Every finding on record at Eureka Nursing Center

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately, to prevent the potential for foodborne bacteria. Findings included:- During an initial tour of the resident kitchenette, on 04/13/26 at 08:07 AM, the following areas of concern were noted in the one facility kitchen:1. The bottom shelf of the worktable holding the food processor had a build-up of food debris and dried-on fluids.2. A cart holding clean serving plates contained food debris.3. A stainless steel shelf holding clean serving pots had a build-up of food debris.4. A plastic trash can next to the steam table had dried-on food and fluids on the lid and sides.5. A large, white plastic container used to store thickener had a clear, sticky substance on top.6. Two reach-in freezers in the dry storage room had food debris scattered on the bottom. Review of the Weekly Cleaning schedule revealed the dietary staff was to clean the bottom of prep tables weekly on Mondays. Review of the Weekly Cleaning schedule lacked a day for dietary staff to clean the inside of the reach-in freezers. On 04/15/26 at 11:07 AM, Dietary Staff BB confirmed the areas of concern need to be cleaned on a more regular basis. The facility policy for Dietary Cleaning Procedures, undated, included: The facility shall store, prepare, and distribute food under sanitary conditions to ensure proper food handling practices to prevent the outbreak of foodborne illnesses.

Based on the record review and interview, the facility failed to provide a baseline care plan for Resident (R) 49. Findings included:- R49's Electronic Medical Record (EMR) documented diagnoses of thyrotoxicosis (excessive amount of thyroid hormone in the body), chronic kidney disease, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), heart failure, and displaced supracondylar fracture with intercondylar extension of the lower end of the right femur (a complex high-energy break of thigh bone just above the knee). The Entry Tracking Minimum Data Set (MDS), dated [DATE], documented that R49 had entered (admitted ) to the facility. R49's MDS, dated [DATE], documented a modification of discharge, return anticipated/end of a Medicare Part A stay. R49's EMR lacked evidence of a baseline care plan. On 04/14/25 at 11:41 AM, upon request for R49's baseline care plan, Administrative Staff A reported the facility lacked a baseline care plan and said she expected the staff to have completed a baseline care plan in the required timeframe. The facility's Resident Centered Care Plan Process dated 03/28/18, documented that a baseline care plan will be developed within 24-48 hours after a resident's admission that will include individualized interventions based on the assessed needs and condition of the resident at the time of admission, and the minimum healthcare information necessary to properly care for the resident.

Based on observation, interview, and record review, the facility failed to provide privacy for Residents (R)4 and R3, while staff performed cares in their rooms. Findings included:1. R5's Electronic Medical Record (EMR) documented a diagnosis of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R5's re-admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He was dependent on staff for bed mobility. R5's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 01/28/26, documented the resident required staff assistance for completion of ADLs due to generalized weakness. R5's Care Plan, dated 01/09/26, instructed staff that he required assistance of one to two staff for bed mobility. R5's EMR from 03/16/26 through 04/12/26 under the TASK tab, revealed he was dependent on staff for bed mobility. On 04/13/26 at 12:57 PM, Certified Medication Aide (CMA) S, CMA R and Licensed Nurse (LN) G provided cares for the resident in his room. The resident rested on his right side naked from his mid chest to his feet. While LN G and CMA S provided cares, CMA R exited and entered the room to gather supplies, without covering the resident. The room lacked a privacy curtain. On 04/13/26 at 12:57 PM, CMA S stated R5 should have been covered before she exited and then re-entered the room. On 04/13/26 at 12:57 PM, CMA R confirmed staff had not covered R5, leaving him mostly naked on his bed, when CMA exited and re-entered the room. 2. R3's EMR documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R3's Quarterly MDS, dated [DATE], documented a BIMS score of six, indicating severe cognitive impairment. She was dependent on staff for bed mobility. R3's Care Plan, dated 09/29/25, instructed staff she required assistance of one to two staff for turning and repositioning in bed. On 04/13/26 at 12:37 PM, CMA S and CMA R and LN G provided peri-care (cleansing of the genitals) for the resident in her room. The residents' bed was directly in front of the window with the blinds open for the duration of the care. On 04/13/26 at 12:57 PM, CMA S stated the window blinds should have been closed before beginning resident care. On 04/13/26 at 12:57 PM, CMA R confirmed the residents' window blinds were not closed before resident cares. On 04/15/26 at 07:51 AM, Administrative Nurse D stated it was the expectation for staff to ensure all residents' privacy while providing cares in their rooms. The facility policy for Promoting/Maintaining Resident Dignity, undated, included: The facility shall maintain resident privacy at all times.

Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 6 and R46 were free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication without an appropriate indication of use. Findings Included:- R6's Electronic Medical Record (EMR) documented diagnoses of insomnia, amnesia (inability to sleep), hostility, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic kidney disease, chronic anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) secondary to blood loss, and low back pain. R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R6 had intact cognition and no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or behaviors. The MDS documented that R6 received an antipsychotic antidepressant (a class of medications used to treat mood disorders) and an anticoagulant (a class of medications used to prevent the blood from clotting). The antipsychotic was received on a routine basis, had no gradual dose reduction (GDR), and no physician documentation of GDR as clinically contraindicated. R6's Psychotropic Drug Use Care Area Assessment (CAA), dated 10/02/25, documented the CAA triggered secondary to the use of psychotropic (affects mood or thoughts) medication, with contributing factors of depression and ongoing use of psychotropic medication. The pharmacist conducted periodic reviews of the medication regimen and provided recommendations, including consideration for dose reductions. R6's Care Plan dated 06/18/25, documented R6 had some issues with his short-term memory and a history of behaviors that included rejection of care and verbal aggression towards staff. The plan further documented that R6's medical record indicated a history of hostility and depression, and he was taking an antidepressant as well as an antipsychotic. The plan directed staff to monitor for side effects and adverse reactions of antipsychotic and psychoactive medications. The Physician Order dated 12/18/25, directed staff to administer quetiapine (antipsychotic) 25 milligrams in the evening, related to hostility. The Pharmacy Consultant Note dated 02/04/26, documented R6's drug regimen and chart had been reviewed for appropriateness regarding diagnosis, monitoring, duplication, duration, dosage, drug-to-drug interactions, drug-disease interactions, allergies, black box warning, Food and Drug Administration (FDA) labeling, off-label indications, and standard of care. The note regarding GDR, documented with recent adjustments, had been made to the psychotropic regimen, and would give four to six months to fully stabilize before entertaining the need for GDR with Trazodone increase on 01/2026. The note lacked a rationale for the continued use of Quetiapine for unapproved use for hostility. R6's chart lacked evidence of physician documentation of the rationale and risks versus benefits regarding the use of quetiapine and lacked documentation of the nonpharmacological interventions that were attempted and unsuccessful prior to initiation of antipsychotic medication. On 04/14/26 at 09:57 AM, R6 was in the hallway. He stopped and talked to staff and other residents. He talked about his spouse's death in December and said the holiday was rough on him. He wished his children would visit more often. On 04/15/26 at 09:02 AM, Certified Medication Aide (CMA) S reported that the only behavior she had witnessed had been a slight sexual comment since his wife died. CMA S reported that R6 corrected his statement. CMA S stated R6 was kind and helped look after the other residents. On 04/15/26 at 10:10 AM, Licensed Nurse (LN) G reported she had not heard or seen R6 exhibit hostility or behaviors. On 04/15/26 at 11:45 AM, Administrative Nurse D reported the pharmacist attempted to ensure the physician had an appropriate diagnosis for the use of quetiapine, but the physician failed to document a rationale for the use. The undated facility's Use of Psychotropic Medication policy documented that psychotropic medications are to be used only when the practitioner determines that the medication is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. The resident's medical record shall include documentation of evaluation and the rationale for chosen treatment options. This includes any indicated documentation of the rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication. Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with the manufacturer's recommendations and/or clinical practice guidelines, clinical standard of practices, medication references, clinical studies, or evidence-based review of articles that are published in medical and/or pharmacy journals. - The Electronic Medical Record (EMR) for R46 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). The Annual MDS, dated 03/31/26, documented R46 had a BIMS score of 14, indicating intact cognition. R46 required partial staff assistance for showers, dressing, and eating. The MDS documented R46 rejected care daily and received antipsychotic and antidepressant medication on a routine basis. R46's 03/17/26 Care Plan included the following interventions for R46: 04/27/21- Attempt to identify a cause of behaviors, assess for pain, offer food, fluids, and toileting. Attempt to visit with me one-on-one as needed. I would like my physician to manage my medications and care. I have refused psychiatric services (specialized medical, behavioral, and therapeutic care focused on diagnosing, treating, and preventing mental, emotional, and behavioral disorders). 10/08/21- I have a history of urinating and having bowel movements in inappropriate places. Should you notice me attempting to do this, please redirect me to a bathroom. 10/19/22- I have episodes of agitation where I curse at staff. When this occurs, remind me that this is inappropriate behavior and attempt cares at a later time as needed. 10/20/22- Staff has reported that they have noticed that there are ties that I have increased agitation with morning cares, at times yelling at staff. 03/19/24- I have a history of making sexually inappropriate comments toward female staff. Should you notice this, please remind me that these comments are inappropriate and are unacceptable. 10/25/24- Administer medications as ordered and monitor for effectiveness and adverse reactions. Notify the physician as indicated. R46's Orders tab of the EMR documented an active order dated 06/10/25 for Zyprexa (an antipsychotic medication), 2.5 milligrams (mg), by mouth, to be administered in the evening, for dementia without behavioral disturbances. The EMR lacked documentation of an appropriate indication for use of R46's prescribed Zyprexa and a risk versus benefit for the continued use of the Zyprexa medication. On 04/14/26 at 08:00 AM, R46 ambulated down the hall with his walker, accompanied by Social Service X. On 04/14/26 at 02:25 PM, Administrative Nurse D stated she was aware that the diagnosis of dementia was not approved by the Centers for Medicare and Medicaid Services (CMS), and she, as well as the pharmacist, had discussed this with the physician, but had not been given a different diagnosis or risk versus benefit for the medication. The facility's Use of Psychotropic Medication policy, undated, documented that the residents only received psychotropic medications when all other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience. The policy documented a clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any other treatments have been clinically contraindicated, a psychotropic medication would be prescribed.

Based on observation and interview, the facility failed to promote dignity for one resident, Resident (R)42, who was using her fingers to get thickened juice out of her cup because staff failed to identify and assist or offer a spoon. Findings included:- On 04/14/26 at 09:20 AM, during a meal observation, R42 sat at a table attempting to drink her thickened juice. She put the glass to her lips and tried to drink it, but it was too thick. After trying to drink it several times without success, R42 dipped her right index finger into the juice to scoop it out to eat it. Dietary Staff CC walked over to her table, turned to the surveyor and said, She likes to make a mess, then proceeded to wipe the table. The surveyor questioned if the resident might do better with a spoon and Dietary Staff CC stated, Ya, I guess I can get her a spoon. Dietary Staff CC provided R42 a spoon, and the resident was able to spoon her thickened juice and eat it.On 04/15/26 at 12:25 PM, Administrative Nurse D stated R42 should have been assisted and given a spoon so she would not have to use her finger.The facility's Promoting/Maintaining Resident Dignity policy, undated, documented that the practice of the facility was to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintained and enhanced the resident's quality of life by recognizing each resident's individuality.

Based on record review and interview, the facility failed to develop an individualized person-centered care plan for Resident 49's stay, which began on 12/17/25 and ended on 01/15/26. Findings included:- R49's Electronic Medical Record (EMR) documented diagnoses of thyrotoxicosis (excessive amount of thyroid hormone in the body), chronic kidney disease, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), heart failure, and displaced supracondylar fracture with intercondylar extension of the lower end of the right femur (a complex high-energy break of thigh bone just above the knee). The Minimum Data Set MDS, dated [DATE], documented that R49 had entered (admitted ) to the facility. R49's admission MDS, dated 12/24/25, documented R49 had intact cognition, required partial/moderate assistance with personal hygiene and upper body dressing, substantial/maximal assistance with bed mobility and transfers, and was dependent on toileting hygiene, lower body dressing, and putting on and taking off footwear. R49 was frequently incontinent of urine, received scheduled pain medication, as-needed (PRN) pain medication, and non-medication interventions for pain. The MDS further documented that R49 had a history of falls with fracture before admission, with major surgery requiring skilled nursing facility (SNF) care. R49 required major surgery for repair of the fractured leg/knee, had a surgical wound and pressure ulcer/injury upon admission. R49 received occupational and physical therapy with the overall goal of being discharged to the community. The Care Area Assessments (CAA) triggered by the MDS, dated [DATE], included functional abilities, urinary incontinence, falls, nutritional status, pressure ulcers, and pain. The CAAs documented that a comprehensive care plan would be initiated. R49's EMR had a Nutritional Care Plan dated 12/20/26, documenting that R49 had a nutritional risk related to decreased appetite, lack of mobility, and wounds. The plan directed staff to monitor weights and provide diet and supplements as ordered. The Progress Note dated 12/17/25 at 04:17 PM, documented the admission of R49 with a right femur fracture, who was alert and oriented, and had a regular diet order. The note further documented that R49 required two staff assistance with transfers with a gait belt. The Progress Note dated 01/15/26 at 06:36 AM documented that R49 was transported by emergency medical services to the hospital emergency room. On 04/14/25 at 11:41 AM, upon request for R49's comprehensive care plan, Administrative Staff A reported the facility lacked a comprehensive care plan and said she expected the staff to have completed a comprehensive care plan in the required timeframe. The facility's Resident Centered Care Plan Process dated 03/28/18, documented within seven days of completion of the initial comprehensive MDS, the interdisciplinary team will develop a comprehensive care plan for each elder that includes measurable objectives and timetables to meet each elder's clinical, nursing, mental, cultural, and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to provide adequate activity of daily living (ADL) cares to Resident (R)5 regarding showering. Findings included:- R5's Electronic Medical Record (EMR) documented a diagnosis of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R5's re-admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He was dependent on staff for showering. R5's Activity of Daily Living Care Area Assessment (CAA), dated 01/28/26, documented the resident required staff assistance for completion of ADLs due to generalized weakness. R5's Care Plan, dated 01/09/26, instructed staff he required assistance of two staff for showering. R5's EMR from 03/16/26 through 04/12/26 (27 days) revealed staff showered the resident four times. The EMR lacked any further documentation of showering or rejection of care. On 04/13/26 at 08:45 AM, R5 sat in his wheelchair in his room. He had dirty, greasy hair. On 04/14/26 at 09:01 AM, R5 sat in his wheelchair in the front commons area. He continued to have dirty, greasy hair. On 04/13/26 at 08:45 AM, R5 stated he does not get enough showers. He said he would like to be showered two or three times per week. On 04/13/26 at 12:57 PM, Certified Medication Aide (CMA) S stated the residents were to be showered at least twice per week On 04/13/26 at 12:57 PM, CMA R stated there was a showering schedule in the nurse's station. Residents were to be showered twice weekly but could be showered more often if they chose. On 04/14/26 at 02:03 PM, Licensed Nurse (LN) G stated residents were to be showered twice weekly. If a resident refused a shower, it would be documented in the EMR. On 04/15/26 at 07:51 AM, Administrative Nurse D stated it was the expectation for residents to be showered twice weekly, depending on their preferences. The facility policy for ADL, undated, included: A resident who was unable to carry out ADLs will receive the necessary services to maintain personal hygiene.

Based on observation, interview, and record review, the facility failed to evaluate the effectiveness of fall interventions for Resident (R)8, who had multiple falls, and revise with person-centered fall interventions to prevent further falls. Findings included:- The Electronic Medical Record (EMR) for R8 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2 with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS), dated [DATE], documented that R8 had a Brief Interview for Mental Status (BIMS) of four, indicating severely impaired cognition. R8 required substantial staff assistance for toileting, personal hygiene, showers, and lower-body dressing. The MDS further documented R8 required supervision with mobility, transfers, and was non-ambulatory. R8 had no functional impairment, had no falls since the prior assessment, and did not ambulate. The Annual MDS, dated 02/22/26, documented R8 had a Brief Interview for Mental Status of 3, indicating severely impaired cognition. R8 was dependent upon staff or toileting, showers, dressing, personal hygiene, and substantial staff assistance for mobility and transfers. The MDS further documented R8 had no functional impairment, had one non-injury fall, and did not ambulate.The Fall Risk Assessments, dated 02/18/25, 04/28/25, 06/19/25, 07/30/25, 12/12/25, 03/03/26, and 03/08/26 documented R8 was at risk for falls.R8's 02/04/26 Care Plan included the following interventions for R8:04/25/22 - I like to wake up early in the morning, usually around 07:00 AM, and prefer to take a shower every other day in the morning.09/18/24 - Toileting program of prompt and assist at 07:00 AM, 10:00 AM, 01:00 PM, 04:00 PM, 08:00 PM, at night, 04:00 AM, and as needed.04/28/25 - Offer me to lie down after meals, and hourly checks while in bed.06/19/25 - Prompt assist with toileting at 03:00 AM.07/30/25 - Prompt and assist with toileting at 06:00 AM.The Fall Investigation, dated 06/19/25 at 04:00 AM, documented R8 was found lying prone on the floor of her room in front of the bathroom. R8 was unable to explain what happened or what she was doing. There was urine on the floor from the bed to where she was lying. R8 sustained an abrasion (scrape) with a hematoma (collection of blood trapped in the tissues of the skin resulting from trauma). The immediate intervention was to adjust the toileting plan to toilet at 03:30 AM instead of 04:00 AM if awake.The Fall Investigation, dated 07/30/25 at 06:15 AM, documented that staff alerted the nurse that R8 was on the floor in her room. R8 was seated on the floor with her left leg under her beside the bed, with the wheelchair to the left side and the bed to the right, facing the wall. R8 had an old abrasion to the right knee with a little blood, and a small, reddened area was noted beside the left outer knee. R8 was able to move all extremities per normal and was assisted by two staff into her wheelchair. R8 was noted to be incontinent with urine and bowel. The immediate intervention was for staff to prompt and assist with toileting at 06:00 AM.The Fall Investigation, dated 12/25/25 at 05:29 AM, documented R8 was on the floor behind the door with blood coming from her forehead. R8 cried in pain, pressure and ice were applied to her head wound to stop the bleeding. R8's right kneecap was bruised and had two scratches on it. R8 went to the emergency room for evaluation and received sutures to her forehead. The immediate intervention was to prompt and assist with toileting at 05:00 AM. The care plan lacked documentation the intervention was put into place.The Fall Investigation, dated 03/03/26 at 04:15 PM, documented R8 fell in the shower room. She was in the shower chair and began to yell when the Certified Nurse Aide (CNA) assisted her. The nurse was in the shower room with the CNA when the nurse left the shower room to get wipes for R8. When the nurse entered the shower room, R8 was observed lying on her right side outside of the shower. R8 sustained a skin tear that measured 2.5 centimeters (cm) x 0.1 cm on the left forearm. Staff assessed R8, and she was assisted into her wheelchair by five staff members. The intervention was to provide R8 with a shower upon awakening or be given a whirlpool. The care plan lacked documentation the intervention was put into place.The Fall Investigation, dated 03/08/26 at 05:55 AM, documented R8 was found next to her bed on her knees and left arm on the floor. R8 was dressed in a gown and barefoot. R8 was assisted into her wheelchair. The recommended intervention was to have staff position her wheelchair at the bedside, so if she transferred herself, her wheelchair was in a locked and ready position. The care plan lacked documentation the intervention was put into place.On 04/14/26 at 09:07 AM, CNA O placed a gait belt around R8's waist. Certified Medication Aide (CMA) T and CNA O assisted R8 to stand up and pivoted her into her wheelchair. CMA T stated R8 had not had any recent falls. CMA T stated they have to keep a close eye on her because when she wakes up, they must be ready to get her up.On 04/15/26 at 08:30 AM, Administrative Nurse E stated he had not printed the care plan that was kept at the nurse's station for staff to access and update as needed. Administrative Nurse D also stated he had not updated the care plan with current interventions.On 04/15/26 at 09:00 AM, she stated she was unaware that R8's last three fall interventions were not on the care plan. When they close out the investigation, she documents the intervention that was to be put into the care plan. Administrative Nurse E further stated that R8 fell in the shower after she had scooted to the edge of the wheelchair, and the CNA told her to please wait for the nurse to come in, but she did not and scooted out of the wheelchair.The facility's Fall Prevention Program policy, undated, documented that each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility provides interventions that address unique risk factors measured by the risk assessment tool. Interventions would be monitored for effectiveness, and the care plan would be revised as needed.

Based on observation, interview, and record review, the facility failed to adequately monitor R35's amlodipine (antihypertensive (high blood pressure medication). The facility failed to ensure R16 was free from unnecessary medication. Findings included:- R16's Electronic Medical Record (EMR) documented diagnoses of hypertensive (elevated blood pressure) heart disease with heart failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, and dementia (a progressive mental disorder characterized by failing memory and confusion). R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R16 had moderately impaired cognition and had wandering behavior one to three days of the look-back period. R16 was independent with functional abilities and mobility. R6 was occasionally incontinent of urine and always continent of bowel. The MDS further documented that R16 received an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic (a class of medication to treat infections), a diuretic, an opioid (a class of medication to treat pain), and an anticonvulsant (a class of medications used to treat seizures). R16's Care Plan dated 06/16/25, documented R16 had a history of urinary tract infections (UTI) and was at risk for worsening incontinence and UTI due to decreased mobility, impaired memory, and high caffeine intake. The plan further documented that R16 was typically independent for toileting hygiene and transfers. The plan directed staff to monitor/document signs and symptoms of UTI, including pain, burning, blood-tinged urine, cloudiness, no output, deepening or urine color, increased pulse and temperature, urinary frequency, foul-smelling urine, altered mental status, change in behavior or eating patterns. The Physician Order dated 04/30/24, directed staff to administer cephalexin (an antibiotic) 500 milligrams (mg) every morning for UTI prophylaxis (preventative in nature). R16's urinalysis and culture report on 07/11/25 and 12/08/25 resulted in no growth at 48 hours. The urinalysis on 01/18/26 indicated no culture was indicated. R16 remained on cephalexin. The EMR lacked documentation from the practitioner regarding the ongoing use of an antibiotic. On 04/15/26 at 09:05 AM, R16 sat in her room in her recliner with a walker in front of her. She reported feeling well. On 04/15/26 at 10:08 AM, Certified Nurse Aide (CNA) N reported R16 exhibited increased confusion when she had a UTI. CNA N reported R16 was independent with toileting tasks, but checked on her when possible, for changes in R16's urine or behaviors. On 04/15/26 at 11:30 AM, Administrative Nurse D verified that R16 was on prophylactic antibiotics, with no laboratory values to support infection or antibiotic use. The updated facility Unnecessary Drugs policy documented that the indication for initiating, maintaining, or discontinuing medication(s) is determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms to identify and rule out any underlying medical conditions, including assessments of benefits and risks, and the preferences and goals for treatment. The resident's medical record should include documentation of this evaluation and the rationale for the chosen treatment options. - R35's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and hypertensive chronic kidney disease (a condition where long-term, poorly managed high blood pressure caused chronic renal damage). The Annual Minimum Data Set (MDS) dated [DATE], documented R35 had long and short-term memory problems with severely impaired decision-making skills. R35 was dependent upon staff for toileting, showers, personal hygiene, mobility, and transfers. R35 did not receive any high-risk medications. R35's 04/07/26 Care Plan included the following interventions: 04/15/25 – Administer antihypertensive medications as ordered and monitor for side effects and effectiveness, monitor and report as indicated for headaches, visual problems, monitor laboratory results as ordered from the physician, check his blood pressure four times a day, and notify the physician if the systolic blood pressure (SBP-top number, he force your heart exerts on the walls of your arteries each time it beats) was greater than 160/90 millimeters (mm) of mercury (Hg), heart rate (beats) number of times the heart contracts )beats) per minute (bpm) of greater than 90 bpm or less than 50 bpm. R35's Orders tab of the EMR documented an active order dated 04/15/25 for staff to notify the physician if his SBP was greater than 160 mmHg or less than 90 mmHg, pulse greater than 100 bmp or less than 50 bpm. The orders further directed staff to administer amlodipine, 2.5 milligrams (mg), by mouth, in the morning, for the diagnosis of hypertensive chronic kidney disease. The Vital Signs Record, for February 2026, lacked documentation of blood pressure readings for R35. The EMR recorded R35 was administered his amlodipine daily and lacked documentation that a blood pressure was taken. The Vital Signs Record, for March 2026, documented one blood pressure reading because the resident had a fall. The EMR recorded R35 was administered his amlodipine daily and lacked documentation that a blood pressure was taken. The Vital Signs Record for April 2026 lacked documentation of blood pressure readings for R35. The EMR recorded R35 was administered his amlodipine daily and lacked documentation that a blood pressure was taken. On 04/14/26 at 08:02 AM, R35 sat in the dining room eating his breakfast. On 04/14/26 at 01:45 AM, Licensed Nurse (LN) H stated she was not sure why staff were not obtaining his blood pressure regularly, but thought that some residents had been on long-term medication for which they did not take daily blood pressures. On 04/14/26 at 02:45 PM, Administrative Nurse D stated that although the care plan stated four times a day for his blood pressure checks, she did not think that was correct, but stated that staff should check his blood pressure at least monthly to make sure the medication was effective. The facility's Unnecessary Drugs policy, undated, documented that each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest mental, physical, and psychosocial wellbeing free from unnecessary drugs. Information gathered during the initial and ongoing evaluations would be incorporated into the resident's comprehensive care plan that reflected person-centered medication-related goals and parameters for monitoring the resident's condition, including the likely medication effects and potential for adverse consequences.

Based on record review and interview, the facility failed to provide the resident (or their representative) a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) for skilled services when Resident (R) 54's skilled services ended. Findings included:- On 04/14/26 at 09:12 AM, ABN and NOMNC notices were requested for R54, R7, and R19. The facility was unable to provide R54's NOMNC related to the end of the skilled services. R54's start of skilled stay began on 01/04/26 and ended on 02/16/26. On 04/14/26 at 11:55 AM, Administrative Staff A confirmed she had not located the NOMNC for the end or R54's end of skilled services provided by the facility. The facility's undated Advanced Beneficiary Notices policy documented that a NOMNC, Form CMS-10123, shall be issued to the resident/representative when Medicare-covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). This notice is used when all covered services end for coverage reasons and an exhaustion of benefits is not considered a termination for coverage reasons.

Based on observation, interview, and record review, the facility failed to display accurate posted nursing staff hours accessible to residents and visitors. Findings included:- During the survey period of 04/13/26 and 04/14/26, observation revealed the facility did not have posted census and direct care nursing staff hours. On 04/14/26 at 01:47 PM, Administrative Nurse D reported that the nursing hour posting had been posted at the entry of the nursing facility. Administrative Nurse D reported that the administrator had been posting the information, and due to the absence of the administrator, the information had not been posted. Administrative Nurse D stated she had the instructions to provide the information in the usual place upon entry into the facility. The undated facility Nurse Staffing Posting Information policy documented the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time.

The facility reported a census of 43 residents with five residents sampled and two residents reviewed for abuse. Based on observation, interview, and record review the facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident sexual abuse, when independently mobile Resident (R) 2 (who had a history of hypersexual behaviors directed toward staff to include groping, sexual inuendo/comments, and attempting to pull staff into bed with him) grabbed R1's breast on 09/30/24, without her consent. This failure placed R1 in immediate jeopardy due to the lack of facility response and reasonable person concept regarding sexual assault, and the negative impact to R1's psychosocial well-being and feelings regarding her safety. The facility also failed to thoroughly investigate two employee-to-resident abuse allegations which involved R10 when several bruises were documented on 10/03/24 and the facility did not investigate as potential abuse and/or report to the state agency or local police of the multiple bruises of unknown origin. This failure placed the residents at risk for abuse and continued negative impact on their physical, mental, and psychosocial well-being. Findings Included: - Review of the Electronic Health Record (EHR), documented R2 had a diagnosis of vascular dementia (a chronic condition that occurs when the brain's blood supply is interrupted, damaging brain tissue and causing a decline in thinking, memory, and behavior). The 06/18/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R2 had a total mood severity score of one, which indicated minimal depression. R2 required total dependence with activities of daily living (ADL), with bathing. R2 required maximal assistance with dressing, transfers, personal hygiene and toileting. R2 was independent with wheelchair mobility and he had 1-3 days rejection of care. The 07/02/24 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R2 triggered due to his behavior of rejection of care. R2 had a diagnosis of dementia, his cognition would worsen if he became ill and typically would improve once well again. R2 had impulsivity and could have increased agitation and aggression, which could result in unsafe behaviors and the potential for injury, or difficulty with performance of ADLs. The 07/02/24 Behavioral Symptoms CAA documented R2 triggered related to refusal of cares and noted this did not place others at risk. The 10/15/24 Quarterly MDS documented R2 had a BIMS score of 14, which indicated intact cognition. Review of R2's behaviors revealed one time he wandered and one time he refused care , which were documented in the seven day lookback period. R2 was independent with wheelchair mobility and received an antianxiety (class of medications that calm and relax people) medication daily. The 11/04/24 Care Plan documented the following: 04/15/19 - Staff were instructed to provide redirection and reorientation if R2 had a decline in cognition in the late afternoon and evening as needed. 03/21/21 - R2 could have increased agitation with education or redirection. Staff were instructed to notice the increased agitation and provide R2 with one-on-one and allow him space. 03/25/21 - Staff were instructed to identify cause of behaviors, assess for pain, offer food, drinks or toileting. 06/17/21 - Staff were instructed to provide reminders and redirection when R2 was inappropriate with behaviors of pulling staff into bed with him and he would try to kiss them. 08/08/24 - R2 had episodes of increased agitation/aggression. Staff instructed to administer Memantine (is a medication commonly used to treat moderate to severe dementia and Buspirone (is a medication commonly used to treat anxiety disorders) per orders. The facility provided Care Plan dated 11/04/24 and not uploaded in the EHR included handwritten interventions, which documented staff were instructed to provided one-on-one supervision for 24 hours, dated initiated 09/30/24 and discontinued on 10/01/24. The 11/04/24 Care Plan lacked any interventions related to a sexual abuse incident directed toward a female resident on 09/30/24. R2's Physician Orders documented an order for Memantine 10 milligram (mg) tablet, give one tablet by mouth, two times a day for vascular dementia, date ordered 06/11/24; and Buspirone HCI tablet 5mg, give one tablet by mouth, two times a day for anxiety/agitation, date ordered 07/18/24. The Physician Orders lacked any documentation directing staff to monitor for behaviors of anxiety/agitation. The Progress Note dated 04/11/24 at 01:17 AM revealed R2 grabbed at a staff member's neck and squeezed while staff attempted to obtain vital signs. The Progress Note on 07/03/24 at 09:48 AM, Certified Nurse Aide (CNA) reported R2 had been sexually inappropriate when he slapped/spanked a CNA on the buttock. The CNA informed R2 that was inappropriate behavior, and Nurse discussed with R2 that was inappropriate and R2 laughed and verbalized and understanding. The Progress Note on 07/16/24 at 02:30 PM revealed R2 wandered up and down the hallways, attempted to open doors, and threw water on the floor. R2 attempted to grab/smack the CNA on the buttock. R2 was informed his behaviors were inappropriate and staff assessed the resident for immediate needs. R2 requested coffee and it was provided. R2 unzipped his pants and told staff to look at it. Nurse called provider for orders. The Progress Note on 07/19/24 at 02:42 PM revealed R2 inappropriately touched staff. The Progress Note on 08/02/24 at an unknown time revealed R2 inappropriately touched staff when care provided that morning. The Progress Note on 09/02/24 at 03:22 PM revealed R2 grabbed his belt, undid his pants in the dining room, and he asked the staff member if she would like a sneak peek. The staff member excused herself and reported R2's behavior to the nurse. The Progress Note on 09/30/24 at 12:45 PM revealed R2 had his arm across R1 and held on to her breast. Staff removed R2 from dining room immediately and assisted him to his room. When R2 was asked by staff why he touched R1 he stated, she liked it, and she didn't say no. R2 was educated by staff that if he was not given verbal consent to touch anyone, then he should not touch them. R2 shook his head and looked down. The facility placed immediate interventions, which included R2 being educated of inappropriateness of touching other residents in that way and placed the resident on 24-hour one-on-one supervision. The progress notes from 09/30/24 thru 11/04/24 lacked any Social Service Designee (SSD) notes regarding the incident on 09/30/24. During an observation on 11/04/24 at 11:00 AM, R1's room was located directly across the hallway from R2's room. R1 sat in her recliner watching television in her room. During an observation on 11/04/24 at 11:48 AM, R2 sat in the dining room at a table as he waited for his lunch. During an interview on 11/04/24 at 11:00 AM, R1 reported that R2 had grabbed her left breast when she was leaving the dining room after lunch. R1 reported she was in shock, scared, uncomfortable, and embarrassed during the incident. She reported she did not know why he grabbed her breast and was glad that someone assisted her that day. R1 reported she tried not to think about how R2 grabbed her, but when she did it bothered her emotionally. R1 had tears in her eyes when she spoke of the incident. R1 reported she was not afraid of R2 at this time and could not recall if a room change was offered to her. R1 reported that R2 had never entered her room and she would not pay attention to R2 anymore. R1 was asked about the male resident mentioned on her care plan, and R1 reported he was just a friend and said she liked him and he was funny, and it was not R2. During an interview on 11/04/24 at 11:48 AM, R2 reported he was by himself in the dining room most of the time and that it did not bother him, he reported he could see everyone in the dining room and could see when they would come in and leave the dining room. During an interview on 11/04/24 at 11:58 AM, Certified Nurse Aide (CNA) G reported R2 would wander independently in his wheelchair throughout the facility. CNA G reported R2 liked to flirt with female staff and asked staff to sit on his lap. CNA G revealed she was never grabbed or touched inappropriately by R2. CNA G reported she did not know R2 had touched a female resident's breast. CNA G revealed she would report any type of abuse seen, heard of, or suspected of to Administrative Staff A or Administrative Nurse C immediately. During an interview on 11/05/24 at 02:35 PM, CNA H confirmed that R2 did not have interventions about sexual abuse on his care plan. CNA H reported that R2 would grab at the staff and make inappropriate sexual comments towards the female staff, she reported that she would go into his room with another staff member to assist with cares. CNA H reported that she would chart in EHR when a resident had a behavior and let the nurse know. During an interview on 11/04/24 at 12:06 PM. Administrative Nurse D reported the resident's care plan in the EHR was current and updated with the care plans printed in the care plan book located at the nurse's station. Administrative Nurse D confirmed R2's care plan in the book had a 09/30/24 intervention of one-on-one for 24 hours handwritten on it and was discontinued on 10/01/24. She confirmed R2's care plan lacked any documentation about sexual assault to a female resident and/or any additional interventions regarding the incident. During an interview on 11/04/24 at 12:50 PM, Dietary Staff J reported she was the one that witnessed R2, grab at R1's breast. She reported that she would have not seen R2 grab R1's breast if she had not moved towards the entrance of the dining room to clean tables. Dietary Staff J reported R1 self-propelled her wheelchair towards the exit of the dining room like R1 would normally do. She thought that R1 and R2 were just talking to each other until she was able to see what occurred. Dietary Staff J reported that R1 had a horrified look on her face and was frozen as R2 had his hand on her breast. Dietary Staff J reported that she immediately separated the residents and assisted R1 to the nurse. Dietary Staff J reported that R2 liked to propel himself around in the dining room and stopped and talked to the residents, mostly the female residents. Dietary Staff J pointed at R2 who had stopped in front of R8 in the dining room to talk to her. Dietary Staff J reported she had received Abuse, Neglect and Exploitation (ANE) education in the first week of October 2024. During an interview on 11/04/24 at 01:30 PM, R4 hesitated to comment on the question Do you feel safe here? R4 asked what the other residents had stated when the surveyor asked them the same question. R4 was educated that the interviews would not be discussed with other residents. R4 reported she was ok here; she was asked if she could be more specific. She reported that the staff would take good care of her, and no staff or resident had abused her. R4 reported that R2 was very grabby and handsy towards other female residents and female staff and liked to flirt with women. R4 reported she did not want R2 to get into trouble. She reported that R2 had never touched her, but she has seen it happen to other women and it bothered her. R4 reported that she did not report this to staff here as she worried she would get kicked out if she caused any trouble for other residents. During an interview on 11/04/24 at 02:02 PM R2 sat in his wheelchair in his room and watched television. When asked about the incident with R1, R2 stated she was that type of woman and she wanted to be touched, if I didn't touch her someone else would have. R2 reported he liked to flirt with women, and he would never touch a woman unless she asked to be touched. R2 reported he was told that touching R1 was not appropriate and to never do it again. R2 then reported that he was mad about the facilities education with him, because they took her side and not his. During an interview on 11/04/24 at 02:29 PM, Licensed Nurse (LN) F reported she was the nurse on the day R2 touched R1's breast. LN F reported that R2 never explained to her why he grabbed at R1, that R2 only stated she never told him no. LN F confirmed that R2 had a history sexual behavior towards the female staff as he would grab at them and make sexual innuendos to the female staff, and staff would tell R2 that was inappropriate behavior. LN F reported to the best of her knowledge R2 was placed on one-on-one supervision for 24 hours and received education noting that touching R1 was inappropriate behavior. During an interview on 11/04/24 at 04:34 PM, Administrative Staff A reported SSD K spoke to R2 about consent and LN F educated R2 about consent before touching other residents, the inappropriate behavior that occurred, and informed R2 not to do it ever again. Administrative Staff A reported the interventions they placed was to prevent R2 from that behavior occurring again. Administrative Staff A reported R2 had never inappropriately touched a resident before and further stated it only happened that one time. During an interview on 11/04/24 at 04:40 PM, SSD K reported R1 was care planned on 10/30/24 regarding a relationship with another male resident as she would be affectionate and want to hold hands and rub his arm. SSD K confirmed it was not R2. SSD K confirmed that R1 had moderately impaired cognition with a BIMS of 10. SSD K reported R2 would not speak to her about the incident. SSD K reported she never went back to talk to him after that day about the inappropriate behavior. SSD K reported she could not recall if R1 was offered a room change as R1 felt safe and confirmed that R1 lived right across the hallway from R2. SSD K reported she visited with R1 several times after the incident and R1 told her she felt safe and had no concerns. SSD K reported she was not aware that R4 was bothered about R2's behaviors of grabbing at others and reported that R4 had never reported her concerns. On 11/05/24 at 11:00 AM Administrative Staff A reported she had the one-on-one supervised signed record for R2 that started on 11/04/24 and Administrative Staff A reported she and Administrative Nurse B had not signed the record on 11/04/24 for the times they had completed one on one supervision for R2. Administrative Staff provided another form that showed initials on them and asked if she could write on the record now for the times, they both had supervised him. The surveyor briefly scanned the form she held and said it was up to her if she wanted to record now on the 11/04/24 one-on-one record, which she did. During an interview on 11/05/24 at 11:05 AM, Nurse Consultant L reported the incident between R1 and R2was not a sexual abuse incident. Nurse Consultant L reported the relationship that R1 and R2 had was just not understood by state agency. Nurse Consultant L reported that R1 did not yell out for help when he touched her breast and that R1 had reported she was not afraid of R2. Nurse Consultant K confirmed that R2's care plan should have been updated after the incident and continued to state it was not sexual abuse. On 11/05/24 at 11:20 AM, Administrative Staff A provided an updated copy of the resident's care plan with a focus area dated 11/04/24, instructing staff to know R2 had a history of inappropriate female contact. On 11/04/24 the facility reinitiated one-on-one supervision for R2. R2 had a room change, which occurred on 11/05/24. During an interview on 11/05/24 at 01:00 PM, Administrative Staff A reported well just looking at it at face value R2 said he would not do it again and he had not since that day, and his room was changed today. R2 continued one-on- one supervision. Administratve Staff A confirmed with a medication change the nurses would assess the medications effectiveness and would continue to monitor his behaviors. During an interview on 11/05/24 at 01:10 PM, Therapy Staff N reported he had the ANE education and stated that he knew that the education was about R1 being touched by R2 and reported that was sexual assault on R1. He was able to state how to report and the different types of abuse correctly. During an interview on 11/05/24 at 02:17 PM, Administrative Staff A reported the staff would monitor behaviors and it would be reported to the charge nurse. The charge nurses use a CUE book (a handwritten communication book for all the nursing staff to review) kept at the nurses' station. The facility policy Abuse Neglect and Exploitation dated May 2023 documented the facility has developed and implemented this policy and procedure to prohibit abuse, neglect, and exploitation. The residents will be free from physical, verbal, emotional, sexual abuse, neglect, and exploitation. Annual training required by all staff on how to report and recognize abuse. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault, or fondling of any part of the body, or any other form of sexual activity with a resident. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident sexual abuse, when independently mobile R2 (who had a history of hypersexual behaviors directed toward staff to include groping, sexual inuendo/comments, and attempting to pull staff into bed with him) on 09/30/24 he grabbed R1's breast without her consent. This failure placed the residents in immediate jeopardy due to the lack of the facility response and reasonable person concept to sexual assault, and the negative impact to R1's psychosocial well-being and feeling safe. On 11/04/24 at 05:52 PM, Administrative Nurse B and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and notified that the facility failure to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident sexual abuse and the lack of the facility response and reasonable person concept to sexual assault, and the negative impact to R1's psychosocial well-being and feeling safe, placed R1 in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 11/05/24 at 02:45 PM which included the following: 1. R2 was placed on a one on one at approximately 08:30 PM on 11/04/24 and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges. 2. To ensure the psychosocial well-being of R1, a follow-up interview was conducted on 11/04/24. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints. The surveyor verified the facility implemented the above corrective measures on-site on 11/05/24 at 02:15 PM. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan. Administrative Staff A sent an email on 11/05/24 at 03:16 PM with several 15 minute check forms attached for R2 and reported that 15 minute checks were put into place on 10/01/24, after the one on one supervision was discontinued, and the 15 minute checks continued up until 11/04/24 when the facility received the IJ template and placed R2 back on one-on-one supervision; However, at no time during the onsite investigation were the 15-minute checks spoken of in interviews or documented or uploaded in the EHR, and no 15 minute checks were mentioned in the facility's investigations or in the IJ removal plan. - The Electronic Health Records (EHR) documented Resident (R) 10 had the following diagnoses that included 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), depression and need for assistance with personal care. The 02/07/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R10 had a total mood severity score of three, which indicated minimal depression and she had behaviors documented one to three days of hitting, swearing, pushing, yelling, grabbing, pinching, and refused care. R10 was totally dependent on staff for assistance with activities of daily living (ADL) such as toileting hygiene, transfers, personal hygiene, bed mobility, and dressing and required moderate assistance with bathing. R10 was independent with wheelchair mobility and eating. The 02/21/24 Behavioral Symptoms Care Area Assessment (CAA) documented R10 triggered related to rejection of care. R10 would become verbally and physically aggressive with staff. Behaviors would typically occur in the morning but resolved after care was provided. The 02/21/24 Cognitive Loss/Dementia CAA documented R10 triggered related to a BIMS score of three and she would wander daily. R10 had a history of cerebral infarction and had a diagnosis of dementia ((progressive mental disorder characterized by failing memory, confusion). R10 had forgetfulness and had forgotten her husband passed away. The Care Plan documented the following: Staff were instructed to provide Tubi-grips (elasticated tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema and tissue protection) applied in morning to both upper extremities and removed at bedtime, date initiated 04/01/21. Staff were instructed to provide two staff assist for all transfers; date initiated 02/03/24. Staff were instructed to re-approach R10 in 10 minutes if she was in a safe position if she became physically and verbally aggressive with staff, date initiated 06/04/24. Staff were instructed to use warm wipes when personal care was provided, date initiated 10/03/24. The Care Plan lacked any documentation noting R10 was at risk for bruising. Review of the Facility Reported Incident dated 10/03/24, alleged Certified Nurse Aide (CNA) Q used profanity and was forceful when dressing R10 on 10/01/24. CNA Q was suspended on 10/01/24. Review of the Facility Reported Incident dated 10/07/24, R10's family member reported to Administrative Staff A on 10/03/24 that during a family visit on 09/29/24 R10 was assisted to the bathroom and reported to family member after she was toileted, she had been hit. CNA G was suspended on 10/03/24 and CNA Q remained on suspension from 10/01/24. The 09/30 /24 at 12:11 PM Progress Note revealed R10 had a blood draw on 09/26/24 as lab results were received. The 09/30/24 at 01:16 PM Weekly Skin Assessment completed by Administrative Nurse C revealed R10 had bruising noted on her left elbow a measured bruise, 3.0 centimeters (cm) length by 3.0 cm width, back of left hand a measured bruise, 0.6 cm length by 0.5 cm width, back of left hand a measured bruise, 3.0 cm length by 2.5 cm width, on left wrist a measured bruise, 0.5 cm length by 0.8 cm width and on her left upper back of arm a measured bruise, 1.0 cm length by 0.8 cm. R10 noted to have scattered areas of bruising to her left upper arm. The left elbow area and the larger of the bruises on her left hand both appeared to be in the healing process with faded or yellow colored edges. The smaller bruised areas appear to be newer. The 10/02/24 at 04:22 PM Progress Note revealed R10 was visited by Social Service Designee (SSD) K and she was asked if she felt safe at the facility, R10 stated well I guess and reported her needs were met. R10 was in a good mood during the visit. The 10/03/24 at 03:56 PM Progress Note revealed a weekly skin assessment was completed by Administrative Nurse B and Licensed Nurse (LN) I on this date. The 10/09/24 at 12:30 PM Progress Note revealed LN I assisted with a discharge skin assessment when R10 was toileted. LN I noted R10 continued to have areas of discoloration to both upper arms which was consistent with the last skin assessment completed by LN I and Administrative Nurse B. No new skin issues noted. The Progress Notes reviewed from 09/30/24 through 10/09/24 lacked any documentation of any nurse assessment completed on R10 after the10/01/24 incident. Review of the written Complaint Investigation Witness Statement dated 10/02/24, by LN O revealed R10 was assessed by LN O on 10/01/24, noted R10 had a flat affect when spoken to, did not want to talk about the incident and did not want to get up and dressed. LN O noted scattered bruising on both upper arms, which were purple in color, some areas were noted to be yellow in color on the edges of the bruises. The 09/26/24 at 03:45 PM Weekly Skin Assessment completed by LN I revealed no skin concerns noted and R10 had trace edema (swelling resulting from an excessive accumulation of fluid in the body tissues) of both lower extremities' ankle region. The 10/03/24 at 11:54 AM Weekly Skin Assessment signed by Administrative Nurse B on 10/03/24 revealed R10 had 15 bruised areas documented on the assessment. Left wrist had a measured bruise, 1.2 cm by 1.5 cm, left wrist had a measured bruise, 1.3 cm by 1.0 cm, left forearm had a measured bruise 1.5 cm by 3 cm, left hand had a measured bruise 101cm (later corrected to measure 1.1cm) by 0.7 cm, left wrist had a measured bruise, 1.0 cm by 0.5 cm and another measured bruise on left wrist measured 1.0 cm by 0.8 cm. Right upper arm had a measured bruise 1.0 cm by 1.0 cm, left forearm had a measure bruise 2.0 cm by 3.1 cm, left hand had a measured bruise, 4.5 cm by 3.3 cm, right wrist had a measured bruise 6.0 cm by 4.8 cm, left upper arm had a measured bruise, 0.6 cm by 0.8 cm, right hip had a measured bruise, 0.7 cm y 1.1 cm, right upper arm had a measured bruise, 1.2 cm y 0.8 cm, right calf had a measured bruise, 1.4 cm by 1.0 cm and left upper arm had a measured bruise, 1.5 cm by 1.3 cm. R10 had three scratched areas noted on the right shin that measured, 1.5 cm by 0.2, 4.2 cm by 0.5 cm and 5.1 cm by 1.3 cm. LN I documented right upper arm had light fading bruise, left upper arm very faint bruise and purple bruise, right hip purple with faded edges and right calf very light faded bruise. The 10/04/24 at 12:23 PM, Non Pressure Sore Assessment competed and signed by Administrative Nurse C revealed R10 had a bruise on left that measured 4.5 cm by 3.3 cm, date of onset10/01/24 and was a new wound. A bruise on left hand that measured 1.1 cm by 0.7 cm, date of 10/01/24 which had improved. A bruise that measured 2.0 cm by 3.1 cm, date of onset 10/01/24 which had improved. A bruise that measured on left forearm, 1.5 cm by 3.0 cm, date of onset 10/01/24 which had improved. Plan of care updated for all areas. The 10/04/24 at 12:29 PM Non Pressure Sore Assessment completed and signed by Administrative Nurse C revealed R10 had a measured bruise on left wrist, 1.3 cm by 1.0 cm, date of onset was 10/01/24 and was a new wound. A measured bruise on left wrist, 1.0 cm by 0.5 cm, date of onset 10/01/24 and had improved, right upper arm had a measured bruise, 1.2 cm by 0.8 cm, date of onset 10/01/24 which had improved. A bruise on left upper arm measured, 0.6 cm by 0.8 cm, date of onset 10/01/24 which had improved. Plan of care updated for all areas. The 10/04/24 at 12:32 PM Non Pressure Sore Assessment completed and signed by Administrative Nurse C revealed R10 had a measured bruise on left upper arm measured 1.5 cm by 1.3 cm date of onset, 10/01/24 was a new wound. R10 had a bruise on right hip that measured 0.7 cm by 1.1 cm date of onset 10/01/24 w had improved. R10 had a measured bruise on right calf, 1.4 cm by 1.0 cm date of onset 10/01/24 and had improved. R10 had a measured abrasion (scraping or rubbing away of skin) on right shin, 5.1 cm by 1.3 cm date of onset 10/01/24 had improved. All the areas noted had plan of care updated. The 10/04/24 at 12:38 PM Non Pressure Sore Assessment completed and signed by Administrative Nurse C revealed R10 had a measured abrasion on right shin, 1.5 cm by 0.2 cm, date of onset 10/01/24 had improved and plan of care updated. Additionally, a measured abrasion on right shin, 4.2 cm by 0.5 cm date of onset 10/01/24 had improved and plan of care updated. During an interview on 11/04/24 at 03:35 PM, Certified Nurse Aide (CNA) P reported she was the CNA that reported CNA Q for abuse toward R10 the morning of 10/01/24. CNA P reported CNA Q used profanity toward R10 when she attempted to dress R10. CNA P reported that R10 tried to bite at CNA Q and that is why CNA Q had pushed R10 down in bed and pulled on R10's arms while she continued to use profanity. CNA P reported she left R10's room to look for Administrative Nurse C, when Certified Medication Aide (CMA) R stopped CNA P and asked her what was wrong. CNA P did not explain what had happened she stated, I'm done. CNA P reported that LN O located her a couple minutes later at the nurse's station and CNA P explained what had happened in R10's room to LN O. CNA P reported that LN O escorted CNA Q out of the facility approximately around 11:35 AM. CNA P reported that she did complete ANE education the first week of October 2024. During an interview on 11/04/24 at 04:00 PM, CNA G reported that she was suspended for the allegation of abuse that R10 made a comment to her family of being hit in the leg when she was toileted by CNA G and CNA Q on 09/29/24 during a visit. R10's family did not report this until 10/03/24. CNA G reported that CNA Q no longer worked at the facility. CNA reported she was allowed to come back to work on 10/04/24 but had to complete the ANE training before she could work. During an interview on 11/05/24 at 02:15 PM, Administrative Nurse B made no comment when questioned origin of several bruises and if there had been an investigation of the several bruises noted investigated noted on the weekly skin assessment in EHR that was completed by her and LN I on 10/03/24. During an interview on 11/05/24 at 02:15 PM, Administrative Nurse C reported she thought the bruises were reported on the facility investigation report and she read out loud from the facility report #0983 a head to toe assessment performed with noted bruising on back of hands from lab draws on a prior day, with no signs of mishandling or physical maltreatment. Administrative Nurse C confirmed there was no progress note or skin assessment documented in R10's EHR after the 10/01/24 incident until 10/03/24 when a skin assessment was completed by Administrative Nurse B. The questioned was asked again how R10 received several bruises that were noted on the 09/30/24 and 10/03/24 weekly skin assessments. Administrative Nurse C reported she was unsure how R10 received all of the bruises that were documented, except for one bruise that was located on R10's right wrist from a blood draw on 09/26/24. During an interview on 11/05/24 at 02:15 PM, Administrative Staff A reported that R10 was independent with her wheelchair mobility, and she would bump into objects and walls at times. The weekly skin assessments from 08/01/24 through 09/26/24 in EHR were reviewed and confirmed documentation of no skin issues noted on any of the assessments. Administrative Staff A reported that the bruises were of unknown origin and the facility lacked an investigation for the bruises. During an interview on 11/05/24 at 02:35 PM, CNA H reported if a new bruise or skin issue was noted she would report that to the charge nurse. CNA G also revealed she would document in the EHR in the bathing task section any skin issues noted. During an interview on 11/05/24 at 02:38 PM, CNA G reported if a new bruise, skin tear or wound was observed that she had not observed before she would notify the charge nurse. During an interview on 11/05/24 at 02:40 PM, LN E reported if a staff member repor [TRUNCATED]

The facility reported a census of 43 residents with five residents sampled and one resident reviewed for sexual abuse. Based on observation, interview, and record review the facility failed to ensure staff protected residents from sexual abuse, when independently mobile Resident (R) 2 (who had a history of hypersexual behaviors directed toward staff to include groping, sexual inuendo/comments, and attempting to pull staff into bed with him) grabbed R1's breast on 09/30/24, without her consent. This failure placed R1 and other female residents in immediate jeopardy due to the facility did not place interventions to protect R1 and other female residents who resided in the facility, from R2's unwanted sexual abuse/assault. This failure placed the residents at risk for abuse and continued negative impact on their physical, mental, and psychosocial well-being. Findings Included: - Review of the Electronic Health Record (EHR), documented R2 had a diagnosis of vascular dementia (a chronic condition that occurs when the brain's blood supply is interrupted, damaging brain tissue and causing a decline in thinking, memory, and behavior). The 06/18/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R2 had a total mood severity score of one, indicated minimal depression. R2 required total dependence with activities of daily living (ADL), with bathing. R2 required maximal assistance with dressing, transfers, personal hygiene and toileting. R2 was independent with wheelchair mobility, and he had 1-3 days of behavior when he rejected care. The 07/02/24 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R2 triggered for this CAA due to his behavior of rejection of care. R2 had a diagnosis of dementia, his cognition would worsen if he became ill and typically would improve once well again. R2 had impulsivity and could have increased agitation and aggression, which could result in unsafe behaviors and the potential for injury, or difficulty with performance of ADLs. The 07/02/24 Behavioral Symptoms CAA documented R2 triggered for this CAA related to refusal of cares and noted this did not place others at risk. The 10/15/24 Quarterly MDS documented R2 had a BIMS score of 14, which indicated intact cognition. Review of R2's behaviors revealed one time he wandered and one time he refused care, which were documented in the seven-day lookback period. R2 was independent with wheelchair mobility and received an antianxiety (class of medications that calm and relax people) medication daily. The 11/04/24 Care Plan documented the following: 04/15/19 - Staff were instructed to provide redirection and reorientation if R2 had a decline in cognition in the late afternoon and evening as needed. 03/21/21 - R2 could have increased agitation with education or redirection. Staff were instructed to notice the increased agitation and provide R2 with one-on-one and allow him space. 03/25/21 - Staff were instructed to identify cause of behaviors, assess for pain, offer food, drinks or toileting. 06/17/21 - Staff were instructed to provide reminders and redirection when R2 was inappropriate with behaviors of pulling staff into bed with him and he would try to kiss them. 08/08/24 - R2 had episodes of increased agitation/aggression. Staff instructed to administer Memantine (is a medication commonly used to treat moderate to severe dementia and Buspirone (is a medication commonly used to treat anxiety disorders) per orders. The facility provided Care Plan dated 11/04/24 and not uploaded in her included handwritten interventions, which documented staff were instructed to provided one-on-one supervision for 24 hours, dated initiated 09/30/24 and discontinued on 10/01/24. The 11/04/24 Care Plan lacked any interventions related to a sexual abuse incident directed toward a female resident on 09/30/24. R2's Physician Orders documented an order for Memantine 10 milligram (mg) tablet, give one tablet by mouth, two times a day for vascular dementia, date ordered 06/11/24; and Buspirone HCI tablet 5mg, give one tablet by mouth, two times a day for anxiety/agitation, date ordered 07/18/24. The Physician Orders lacked any documentation directing staff to monitor for behaviors of anxiety/agitation. The Progress Note dated 04/11/24 at 01:17 AM revealed R2 grabbed at a staff member's neck and squeezed while staff attempted to obtain vital signs. The Progress Note on 07/03/24 at 09:48 AM, Certified Nurse Aide (CNA) reported R2 had been sexually inappropriate when he slapped/spanked a CNA on the buttock. The CNA informed R2 that was inappropriate behavior, and Nurse discussed with R2 that was inappropriate and R2 laughed and verbalized and understanding. The Progress Note on 07/16/24 at 02:30 PM revealed R2 wandered up and down the hallways, attempted to open doors, and threw water on the floor. R2 attempted to grab/smack the CNA on the buttock. R2 was informed his behaviors were inappropriate and staff assessed the resident for immediate needs. R2 requested coffee and it was provided. R2 unzipped his pants and told staff to look at it. Nurse called provider for orders. The Progress Note on 07/19/24 at 02:42 PM revealed R2 inappropriately touched staff. The Progress Note on 08/02/24 at an unknown time revealed R2 inappropriately touched staff when care provided that morning. The Progress Note on 09/02/24 at 03:22 PM revealed R2 grabbed his belt, undid his pants in the dining room, and he asked the staff member if she would like a sneak peek. The staff member excused herself and reported R2's behavior to the nurse. The Progress Note on 09/30/24 at 12:45 PM revealed R2 had his arm across R1 and held on to her breast. Staff removed R2 from dining room immediately and assisted him to his room. R2 stated to nurse she liked it, and she didn't say no when staff asked R2 why he touched her and if he had consent to touch R1 in that area. R2 was educated by staff to know if he was not given verbal consent to touch anyone, then he should not touch them. R2 shook his head and looked down. The facility placed immediate interventions, which included R2 being educated of inappropriateness of touching other residents in that way and placing the resident on 24-hour one-on-one supervision. The progress notes from 09/30/24 thru 11/04/24 lacked any Social Service Designee (SSD) notes regarding the incident on 09/30/24. During an observation on 11/04/24 at 11:00 AM, R1's room was located directly across the hallway from R2's room. R1 sat in her recliner watching television in her room. During an observation on 11/04/24 at 11:48 AM, R2 sat in the dining room at a table as he waited for his lunch. During an interview on 11/04/24 at 11:00 AM, R1 reported that R2 had grabbed her left breast when she was leaving the dining room after lunch. R1 reported she was in shock, scared, uncomfortable, and embarrassed during the incident. She reported she did not know why he grabbed her breast and was glad that someone assisted her that day. R1 reported she tried not to think about how R2 grabbed her, but when she did it bothered her emotionally. R1 had tears in her eyes when she spoke of the incident. R1 reported she was not afraid of R2 at this time and could not recall if a room change was offered to her. R1 reported that R2 had never entered her room and she would not pay attention to R2 anymore. R1 was asked about the male resident mentioned on her care plan, and R1 reported he was just a friend and said she liked him, he was funny, and it was not R2. During an interview on 11/04/24 at 11:48 AM, R2 reported he was by himself in the dining room most of the time and that it did not bother him, he reported he could see everyone in the dining room, and could see when they would come in and leave the dining room. During an interview on 11/04/24 at 11:58 AM, Certified Nurse Aide (CNA) G reported R2 would wander independently in his wheelchair throughout the facility. CNA G reported R2 liked to flirt with female staff and asked staff to sit on his lap. CNA G revealed was never grabbed or touched inappropriately by R2. CNA G reported she did not know R2 had touched a female resident's breast. CNA G revealed she would report any type of abuse seen, heard of, or suspected of to Administrative Staff A or Administrative Nurse C immediately. During an interview on 11/05/24 at 02:35 PM, CNA H confirmed R2 had no interventions about sexual abuse on his care plan. CNA H reported that R2 would grab at the staff and make inappropriate sexual comments towards the female staff, she reported that she would go into his room with another staff member to assist with cares. CNA H reported that she would chart in EHR when a resident had a behavior and let the nurse know. During an interview on 11/04/24 at 12:06 PM. Administrative Nurse D (MDS Nurse), reported the resident's care plan in the EHR was current and updated with the care plans printed in the care plan book located at the nurse's station. Administrative Nurse D confirmed R2's care plan in the book had a 09/30/24 intervention of one-on-one for 24 hours handwritten on it and was discontinued on 10/01/24. She confirmed R2's care plan lacked any documentation about sexual assault to a female resident and/or any additional interventions regarding the incident. During an interview on 11/04/24 at 12:50 PM, Dietary Staff J reported she was the one that witnessed R2, grab at R1's breast. She reported that she would have not seen R2 grab R1's breast if she had not moved towards the entrance of the dining room to clean tables. Dietary Staff J reported R1 self-propelled her wheelchair towards the exit of the dining room like R1 would normally do. She thought that R1 and R2 were just talking to each other until she was able to see what occurred. Dietary Staff J reported that R1 had a horrified look on her face and was frozen as R2 had his hand on her breast. Dietary Staff J reported that she immediately separated the residents and assisted R1 to the nurse. Dietary Staff J reported that R2 liked to propel himself around in the dining room sometimes and stop and talk to the residents, mostly the female residents. Dietary Staff J pointed at R2 who had stopped in front of R8 in the dining room to talk to her. Dietary Staff J reported she had received Abuse, Neglect and Exploitation (ANE) education in the first week of October 2024. During an interview on 11/04/24 at 01:30 PM, R4 hesitated to comment on the question Do you feel safe here? R4 asked what the other residents had stated when the surveyor asked them the same question. R4 was educated that the interviews would not be discussed with other residents. R4 reported she was ok here; she was asked if she could be more specific. She reported that the staff would take good care of her, and no staff or resident had abused her. R4 reported that R2 was very grabby and handsy towards other female residents and female staff and liked to flirt with women. R4 reported she did not want R2 to get into trouble. She reported that R2 had never touched her, but she has seen it happen to other women and it bothered her. R4 reported that she did not report this to staff here as she worried she would get kicked out if she caused any troubles for other residents. During an interview on 11/04/24 at 02:02 PM R2 was seated in his wheelchair in his room and watching television. When asked about the incident with R1, R2 stated she was that type of woman and she wanted to be touched, if I didn't touch her someone else would have. R2 reported he liked to flirt with women, and he would never touch a woman unless she asked to be touched. R2 reported he was told that touching R1 was not appropriate and to never do it again. R2 then reported that he was mad about the facilities education with him, because they took her side and not his. During an interview on 11/04/24 at 02:29 PM, Licensed Nurse (LN) F reported she was the nurse on the day R2 touched R1's breast. LN F reported that R2 never explained to her why he grabbed at R1, that R2 only stated she never told him no. LN F confirmed that R2 had a history sexual behavior towards the female staff as he would grab at them and make sexual innuendos to the female staff, and staff would tell R2 that was inappropriate behavior. LN F reported to the best of her knowledge R2 was placed on one-on-one supervision for 24 hours and received education noting that touching R1 was inappropriate behavior. During an interview on 11/04/24 at 04:34 PM, Administrative Staff A reported SSD K spoke to R2 about consent and LN F educated R2 about consent before touching other residents, the inappropriate behavior that occurred, and informed R2 not to do it ever again. Administrative Staff A reported the interventions they placed was to prevent R2 from that behavior occurring again. Administrative Staff A reported R2 had never inappropriately touched a resident before and further stated it only happened that one time. During an interview on 11/04/24 at 04:40 PM, SSD K reported R1 was care planned on 10/30/24 regarding a relationship with another male resident as R1 would be affectionate and want to hold hands and rub his arm. SSD K confirmed it was not R2, she reported that R1 liked to be affectionate with some men, she reported that is not why she thought R2 grabbed R1's breast though. SSD K confirmed that R1 had moderately impaired cognition with a BIMS of 10. SSD K reported R2 would not speak to her about the incident. SSD K reported she never went back to talk to him after that day about the inappropriate behavior. SSD K reported she could not recall if R1 was offered a room change as R1 felt safe and confirmed that R1 lived right across the hallway from R2. SSD K reported she visited with R1 several times after the incident and R1 told her she felt safe and had no concerns. SSD K reported she was not aware that R4 was bothered about R2's behaviors of grabbing at others and reported that R4 had never reported her concerns. On 11/05/24 at 11:00 AM Administrative Staff A reported she had the one-on-one supervised signed record for R2 that started on 11/04/24 and Administrative Staff A reported she and Administrative Nurse B had not signed the record on 11/04/24 for the times they had completed one on one supervision for R2. Administrative Staff provided another form that showed initials on them and asked if she could write on the record now for the times, they both had supervised him. The surveyor briefly scanned the form she held and said it was up to her if she wanted to record now on the 11/04/24 one-on-one record, which she did. During an interview on 11/05/24 at 11:05 AM, Nurse Consultant L reported the incident between R1 and R2 was not a sexual abuse incident. Nurse Consultant L reported the relationship that R1 and R2 had was just not understood by state agency. Nurse Consultant L reported that R1 did not yell out for help when he touched her breast and that R1 had reported she was not afraid of R2. Nurse Consultant K confirmed that R2's care plan should have been updated after the incident and continued to state it was not sexual abuse. On 11/05/24 at 11:20 AM, Administrative Staff A provided an updated copy of the resident's care plan with a focus area dated 11/04/24, instructing staff to know R2 had a history of inappropriate female contact. On 11/04/24 the facility reinitiated one-on-one supervision for R2. R2 had a room change, which occurred on 11/05/24. During an interview on 11/05/24 at 01:00 PM, Administrative Staff A reported well just looking at it at face value R2 said he would not do it again and he had not since that day, and his room was changed today. R2 continued one-o one supervision. With a medication change the nurses would assess the medications effectiveness and would continue to monitor his behaviors. During an interview on 11/05/24 at 01:10 PM, Therapy Staff N reported he had the ANE education and stated that he knew that the education was about R1 being touched by R2 and reported that was sexual assault on R1. He was able to state how to report and the different types of abuse correctly. During an interview on 11/05/24 at 02:17 PM, Administrative Staff A reported the staff would monitor behaviors and would be reported to the charge nurse. The charge nurses use a CUE book (a handwritten communication book for all the nursing staff to review) kept at the nurses' station. The facility policy Abuse Neglect and Exploitation dated May 2023 documented the facility has developed and implemented this policy and procedure to prohibit abuse, neglect, and exploitation. The residents will be free from physical, verbal, emotional, sexual abuse, neglect, and exploitation. Annual training required by all staff on how to report and recognize abuse. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault, or fondling of any part of the body, or any other form of sexual activity with a resident. The facility failed to ensure staff protected residents from sexual abuse, when independently mobile R2 (who had a history of hypersexual behaviors directed toward staff to include groping, sexual inuendo/comments, and attempting to pull staff into bed with him) on 09/30/24 he grabbed R1's breast without her consent. This failure placed R1 and other female residents in immediate jeopardy due to the facility did not place interventions to protect R1 and other female residents who resided in the facility, from R2's unwanted sexual abuse/assault. This failure placed the residents at risk for abuse and continued negative impact on their physical, mental, and psychosocial well-being. On 11/04/24 at 05:52 PM, Administrative Nurse B and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and notified that the facility failure to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident sexual abuse and the lack of the facility response and reasonable person concept to sexual assault, and the negative impact to R1's psychosocial well-being and feeling safe, placed R1 in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 11/05/24 at 02:45 PM which included the following: 1. R2 was placed on a one on one at approximately 08:30 PM on 11/04/24 and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges. 2. To ensure the psychosocial well-being of R1, a follow-up interview was conducted on 11/04/24. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints. The surveyor verified the facility implemented the above corrective measures on-site on 11/05/24 at 02:15 PM. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan. Administrative Staff A sent an email on 11/05/24 at 03:16 PM with several 15 minute check forms attached for R2 and reported that 15 minute checks were put into place on 10/01/24, after the one on one supervision was discontinued, and the 15 minute checks continued up until 11/04/24 when the facility received the IJ template and placed R2 back on one-on-one supervision; However, at no time during the onsite investigation were the 15-minute checks spoken of in interviews or documented or uploaded in the EHR, and no 15 minute checks were mentioned in the facility's investigations or in the IJ removal plan.

The facility reported a census of 48 residents, with 13 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure resident safety for one of the six residents, during transfer of Resident (R) 30. On 04/11/24, staff used the facility shower chair to transport R30 and in doing so the wheel on the chair broke, the resident to fell forward to the floor, and sustained a fractured tibia (one of two long bones in the lower leg). In addition, on 06/04/24 the facility staff did not ensure a safe transfer for R30 into his electric wheelchair (which had exposed metal) while using the mechanical lift, which resulted in a laceration on his anterior (front) lower leg, that required sutures. Findings included: - Review of Resident (R)30's medical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), polyneuropathy (malfunction of nerves in multiple areas of the body), and right above the knee amputation (surgical removal). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident had impairment on one side of his lower extremity and no impairment in his upper extremities. The resident was dependent on staff for transfers, donning and doffing footwear, and bathing. The resident utilized a wheelchair for mobility. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 11/07/23, assessed the resident required staff assistance for ADL and a previous near fall when a strap on the mechanical lift broke, but staff were able to lower him to the floor without injury. The resident was at risk for difficult transfers due to his right above knee amputation. The Care Plan, revised 04/10/24, instructed staff to assist the resident with bathing and to ensure his sock and shoe were on prior to getting him out of bed and prior to all transfers. Staff utilized the mechanical lift for transfers. The care plan lacked a revision to include the physician's order (05/23/24) for use of a controlled ankle movement (CAM) boot except for skin checks and range of motion. A Nurses' Note, dated 04/11/24, revealed staff transported the resident out of the shower room in a shower chair, and the left front wheel did not swivel, which caused it to fold backward, and the chair tipped forward, at which time the resident fell forward out of the chair and sustained a fractured left tibia, which required a cast. The Facility Investigation dated 04/11/24, revealed the shower chair left front wheel did not swivel, which caused it to fold backward when staff turned the chair and provided forward momentum, which caused the chair to tip forward, and the resident fell forward. The immediate intervention included staff education to transfer residents into the shower chair in the shower room and not transport residents in the shower chair from their room to shower room. The undated Safety/Maintenance Information for the shower chair, used in the incident, instructed staff to check the following monthly: Check the pipe and fittings for hairline fractures. 1. Check all junctures to make certain the pipe and fittings do not pull apart. 2. Clean and lubricate casters [wheels] monthly to avoid rust and wheel lock up. The Shower Chair Safety Maintenance Log documented maintenance completed on 04/15/24. The facility did not provide documentation that staff completed the safety and maintenance inspections prior to 04/15/24. A Physician's Order dated 05/23/24, revealed the removal of R30's cast and instructed staff to ensure R30 wore a CAM boot in place of the cast. The order instructed staff to remove the CAM boot for range of motion and skin inspection. Furthermore , the Interdisciplinary Team Review dated 06/04/24 at 07:25 AM, revealed nursing staff transferred the resident with a mechanical lift into his wheelchair, and the resident sustained an approximate 7.5 cm (length) by 6.3 cm (width) by 0.3 cm (depth) full thickness laceration to his left lower extremity. The resident's wheelchair lacked padding over an exposed piece of metal, and the resident's shin sustained a laceration from the exposed metal. R30 transferred to acute care and received sutures to the laceration. Observation and interview with R30 on 07/09/24 at 04:40 PM revealed he leaned onto his right side, in his electric wheelchair. R30 stated staff pushed him in a shower chair across the shower room threshold, and the wheel broke, and he fell forward onto the floor, and sustained a fracture in his left leg. R30 stated he had a cast on the leg for approximately 60 days, and then after the cast removed, he had a CAM boot applied. R30 stated staff should apply the boot before transferring him into his electric chair, but one time staff did not, and he received a laceration on his shin from an exposed area of sharp metal on his chair. R30 stated now the area is padded, and a cushion placed for protection. During an observation on 07/10/24 at 11:45 AM, Certified Nurse Aide (CNA) N and CNA M transferred R30 from his bed to his electric chair with a full body mechanical lift. The resident did not have the CAM boot on prior to the transfer and staff applied the CAM boot after the transfer of R30, as he sat in his electric chair. During an interview on 07/10/24 at 09:16 AM, CNA N stated after R30's fall out of the shower chair, staff must transfer the resident in the shower room. During an interview on 07/10/24 at 03:30 PM. Administrative Nurse E reported the resident obtained a laceration to his anterior shin from contact with a sharp piece of metal on his chair. The resident required several sutures, but the area was now healed. Administrative Nurse E stated she expected staff to ensure to pad the chair appropriately. Administrative Nurse E stated the resident received therapy services for wheelchair positioning. During an interview on 07/11/24 at 12:02 PM, Administrative Nurse D revealed she expected staff to apply the CAM boot prior to transfer for protection of his leg and confirmed the care plan was not updated to include the CAM boot. During an interview on 07/11/24 at 12:15 PM, Administrative Staff A revealed the facility changed the policy for transporting residents in the shower chair after R30's fall. During an interview on 07/11/24 at 01:25 PM, Maintenance Staff U revealed he did perform monthly safety inspections of the shower chairs beginning 04/15/24, after the incident with the shower chair on 04/11/24. The facility's policy for Resident Showers dated January 2023, instructed staff that based on the resident's function and preferences, the resident may be transported to the shower room in a shower chair provided the manufacturer's instructions allow and dignity is maintained during transport. The facility's policy for Resident Showers revised 04/11/24, instructed staff to assist the resident to the shower room and help the resident sit on the shower chair . An Immediate Staff Reeducation dated 04/11/24, instructed staff to transport residents to the shower room via their wheelchair and then transfer onto the shower chair. The facility policy Accidents and Supervision dated 03/23/24, instructed staff to provide supervision and assistive devices to prevent accidents, which included identifying hazard, evaluating, and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility failed to ensure resident safety during two transfers of Resident (R)30. On 04/11/24, staff used the facility shower chair to transport R30 and in doing so the wheel on the chair broke, the resident to fell forward to the floor, and sustained a fractured tibia. In addition, on 06/04/24 the facility staff did not ensure a safe transfer for R30 into his electric wheelchair (which had exposed metal) while using the mechanical lift, which resulted in a laceration on his anterior (front) lower leg, that required sutures.

The facility reported a census of 48 residents. Based on observation, interview, and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight continuous hours on 08/21/23, 08/22/23, 08/23/23, 08/30/23, 09/01/23, 09/04/23, 09/06/23, 09/08/23, 09/18/23, 09/20/23, 10/01/23, 10/04/23, 10/28/23, 12/01/23, 12/04/23, 12/13/23, 12/20/23, 12/23/23, 12/24/23, 12/24/23, 12/25/23, 12/26/23, 01/01/24, 01/03/24, 01/06/24, 01/07/24, 01/08/24, 01/10/24 and 01/12/24, a total of 29 days, as required. The facility may permit the DON to serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This placed the residents in the facility at risk for unsupervised nursing care and services. Findings included: - Review of the Payroll Based Journal (PBJ) for 04/01/23 through 03/31/24, revealed the facility did not have the required eight consecutive hours of RN coverage, as required, on 08/21/23, 08/22/23, 08/23/23, 08/30/23, 09/01/23, 09/04/23, 09/06/23, 09/08/23, 09/18/23, 09/20/23, 10/01/23, 10/04/23, 10/28/23, 12/01/23, 12/04/23, 12/13/23, 12/20/23, 12/23/23, 12/24/23, 12/24/23, 12/25/23, 12/26/23, 01/01/24, 01/03/24, 01/06/24, 01/07/24, 01/08/24, 01/10/24 and 01/12/24. Review of the Daily Staff Postings from 04/01/23 through 03/31/24, revealed the facility lacked Registered Nurse (RN) coverage on 29 days. On 07/11/24 at 10:01 AM, Administrative Staff A confirmed the facility lacked RN coverage on the days indicated on the PBJ report. The facility utilized the Facility Assessment for required RN coverage. The facility failed to ensure eight consecutive hours of RN nursing coverage to ensure adequate nursing cares provided to the residents of the facility for a total of 29 days.

The facility reported a census of 48 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illnesses to the residents of the facility. Findings included: - Observation, on 07/09/24 at 08:55 AM, revealed the following areas of concern in the dry goods pantry: One sealed 10 -pound (lbs.) bag of macaroni that lacked an opened date. Observation, on 07/09/24 at 09:00 AM, revealed half of meat sandwich in a zip lock bag without a date on the bag. A sealed zip locked bag with four, half emptied squeeze bags of icing that measured approximately a half of cup, dated 02/02/24. The icing squeeze containers had no expiration dates noted. Interview, on 07/09/24 at 09:00 AM, with Dietary Staff BB confirmed the areas of concern. Observation, on 07/10/24 at 11:10 AM, revealed an open garbage can that was full with garbage in the kitchen near the food preparation station. Interview, on 07/10/24 at 11:40 AM, with Dietary Staff B confirmed that garbage can should be closed at all times. Observation, on 07/10/24 at 02:00 PM, during the environmental tour with Dietary Staff BB, revealed the following areas of concern: The top oven contained several areas of bubbled burned food debris on the bottom of the inside. Two large fry pan contained multiple scratches in the cooking surface. One large white cutting board had multiple scratches and several gouges noted on both sides of the board. Two white rubber spatulas had cracks and chips on the outer surfaces. During an interview on 07/02/24 at 02:30 PM, Dietary Staff BB confirmed the areas of concern. The facility failed to provide a policy on food storage. The facility failed to store, prepare, and serve food in a sanitary manner to prevent potential foodborne illness for the residents.

The facility reported a census of 48 residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 16 dates between April 1, 2023 and March 31, 2024. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 3 2023 (April 1-June 30) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 04/01/23, Saturday (SA), On 04/02/23, Sunday (SU), On 04/09/23, SU, On 04/15/23, SA, On 04/16/23, SU, On 04/23/23, SU, On 04/29/23, SA, On 04/30/23, SU On 05/07/23, SU, On 05/13/23, SA, On 05/14/23, SU, On 05/21/23, SU, On 05/27/23, SA, On 05/28/23, SU, On 06/24/23, SA, On 06/25/23, SU. On 07/11/24 at 10:01 AM, Administrative Staff A stated the information on the PBJ regarding not having 24-hour Licensed Nursing available seven days a week, for 16 dates, was inaccurate. The facility utilized the Facility Assessment for their policy for completion of the PBJ. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 16 dates between April 1, 2023 and March 31, 2024.

The facility reported a census 48 residents. Based on observation, interview, and record review, the facility failed to provide a clean home-like and sanitary environment for the 11 residents who resided in the special care unit. Additionally, the facility failed to provide a sanitary environment for two residents who had cracked fall mats with uncleanable surfaces in their rooms. Findings included: - On 07/11/24 at 01:25 PM, an environmental tour with Maintenance Director U revealed: On the special care unit, an odor of urine existed throughout the special care unit and extended approximately 10-12 feet beyond the locked doors to the main hallway. On 07/11/24 at 01:30 PM, Maintenance Director U reported the odor of urine in and around the special care unit was due to a resident who would urinate in random places and nursing staff have performed multiple interventions to combat the smell of urine. On 05/21/24 at 09:50 AM, Administrative Nurse E revealed multiple interventions had been attempted to mitigate the smell of urine historically back to September of 2022 with varying degrees of success. Administrative Nurse E confirmed that the pervasive odor of urine did not provide a sanitary home-like environment for the 11 residents who lived on the special care unit. The facility failed to provide a policy related to the elimination of urine odors. The facility failed to provide a clean home-like and sanitary environment for the 11 residents who resided in the special care unit. 28560 - Observation, during the initial tour of the facility on 07/09/24 at 10:48 AM, revealed Resident (R)2 had a fall mat by her bed that contained multiple cracks and areas of worn surface. Observation, during the initial tour on 07/09/24 at 11:11 AM, revealed (R) 20 had two fall mats on each side of her bed. The mats had numerous cracks and worn areas that made the area uncleanable. Interview, on 07/10/24 at 11:57 AM, with Administrative Nurse E, confirmed the fall mats for R20 and R2 were worn and cracked, making sanitation difficult and actual effectiveness of the mats decreased. The facility lacked a policy for fall mat maintenance. The facility failed to ensure a sanitary, safe and homelike environment for these two residents with cracked and worn fall mats.

The facility reported a census of 48 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for three sampled residents, Resident (R)2 and 28 related to antiplatelet medication use, and R34 related to contractures (abnormal permanent fixation of a joint or muscle) not documented as impairments under section G and section GG on the MDS assessments. This placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R28 had the following diagnoses that included atherosclerotic heart disease (also known as coronary artery disease [CAD- abnormal condition that may affect the flow of oxygen to the heart]) and hyperlipidemia (condition of elevated blood lipid levels). The 04/01/24 Annual MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 was independent for all cares except bathing which required supervision and setup. The assessment documented R28 received an anticoagulant medication (a class of medication that prevents or reduces the ability for blood to form clots) and did not receive an antiplatelet medication (a class of medication that prevents or reduces the ability of platelets [a type of blood cell] to stick together). The 04/01/24 Care Area Assessment (CAA) lacked documentation related to anticoagulant or antiplatelet medication use. The 01/04/24 Quarterly MDS documented a BIMS score of 15 which indicated intact cognition. R28 was independent for all cares except bathing which required minimal assistance. The assessment documented that R28 received an anticoagulant medication and did not receive an antiplatelet medication. The 07/11/24 Care Plan documented on 11/09/22, for staff to hold aspirin (an antiplatelet medication) for all dental procedures. The Physician Orders revealed aspirin tablet, 325 milligrams (mg), to be given by mouth, every morning for CAD, ordered 04/02/22. The 04/01/24 to 07/11/24 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented appropriate administrations of aspirin but lacked any documentation of any anticoagulant medications. The Progress Notes reviewed from 04/01/24 to 07/11/24 lacked any documentation related to anticoagulant or antiplatelet medication use. On 05/21/24 at 11:32 AM, Administrative Nurse F confirmed the above information and stated that it was a clerical error in documenting an antiplatelet medication as an anticoagulant. Her expectation was for all MDS assessments to be accurate. Additionally stated that the facility did not have a policy for MDS completion and used the Resident Assessment Instrument (RAI) manual as a guide. The facility failed to accurately complete the MDS for R28 related to antiplatelet medication use. This placed the resident at risk for uncommunicated care needs. 50659 - The Electronic Health Records (EHR) documented R2 had the following diagnoses that included anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The 12/26/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R2 was independent with eating and wheelchair mobility. R2 required moderate assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing. R2 was frequently incontinent of bladder. The assessment documented R2 received an anticoagulant medication (a class of medication that prevents or reduces the ability for blood to form clots) and did not receive an antiplatelet medication (a class of medication that prevents or reduces the ability of platelets [a type of blood cell] to stick together). The 12/06/23 Care Area Assessment (CAA) lacked documentation related to anticoagulant or antiplatelet medication use. The 05/21/24 Quarterly MDS documented a BIMS score of 12, which indicated moderately impaired cognition. R2 was independent with eating and wheelchair mobility and required moderate assistance with ADL's. R2 received an anticoagulant medication and did not receive an antiplatelet medication. The 07/10/24 Care Plan lacked any intervention for aspirin. The Physician Orders revealed aspirin tablet enteric coated, 81 milligrams (mg), to be given by mouth, every morning, for heart health, ordered 05/08/24. The 04/01/24 to 07/11/24 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented appropriate administrations of aspirin but lacked any documentation of any anticoagulant medications. The Progress Notes reviewed from 04/01/24 to 07/11/24 lacked any documentation related to anticoagulant or antiplatelet medication use. On 05/21/24 at 11:32 AM, Administrative Nurse F confirmed the above information and stated that it was a clerical error in documenting an antiplatelet medication as an anticoagulant. Her expectation was for all MDS assessments to be accurate. Additionally stated that the facility did not have a policy for MDS completion and used the Resident Assessment Instrument (RAI) manual as a guide. The facility failed to accurately complete the MDS for R2 related to antiplatelet medication use. This placed the resident at risk for uncommunicated care needs. - The Electronic Health Records (EHR) documented R34 had the following diagnoses that included arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 08/02/23 Annual MDS documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition and a total severity score of two, indicating minimal depression. R34 required extensive assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing. R34 required supervision for eating. R34 was frequently incontinent of bladder. No impairments or contractures of upper extremities captured on the MDS. The 08/02/23 Functional ADL Care Area Assessment (CAA) documented R34 required assistance with ADL's related to arthritis and weakness. The Quarterly MDS, dated [DATE], documented a BIMS score of 12, indicating moderately impaired cognition. No behaviors, no impairments of upper extremities. The Care Plan dated 07/10/24, revealed R34 had a right -hand contracture (abnormal permanent fixation of a joint or muscle) and arthritis. Therapy provided the resident with a hand splint and a carrot (a specialized splint used in therapy for managing hand contractures.) Right resting hand splint to be applied every morning and remove at sleep. The Physician Orders dated 07/10/24 lacked any documentation of hand splint of hand carrot to be applied. The 04/01/24 to 07/11/24 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of hand splint to be applied. The Progress Notes reviewed from 04/01/24 to 07/11/24 lacked any documentation related to contractures or hand splint and carrot. On 07/09/24 at 01:22 PM, R34 is seated in her wheelchair at the nurse's station with a left hand brace on her left hand and a soft carrot splint in her right hand. On 07/10/24 at 07:37 AM, On 07/10/24 at 07:37 AM, R34 seated in the dining room and lacked placement of the left hand splint and the right hand soft carrot. On 07/10/24 at 09:35 AM, Licensed Nurse G (LN) and Certified Nurse Aide (CNA) MM assisted R34 to her recliner. R34 had the soft carrot splint on her right hand, however lacked a left hand splint. On 07/10/24 at 09:43 AM, LN G stated R34 has refused to wear the left hand splint and stated it is as tolerated. LN G stated staff were required to carry Jot sheets that have all the care needs for each individual resident, and they are updated as care is changed. On 07/10/24 at 09:59 AM, CNA M stated the nurse or therapy should apply the hand splints. CNA M reported the jot sheet lacked anything regarding the splint. On 07/11/24 at 02:00 PM, Administrative Nurse F confirmed the above area of concern of impairment not captured on the MDS's. Her expectation was for all MDS assessments to be accurate. Additionally stated that the facility did not have a policy for MDS completion and used the Resident Assessment Instrument (RAI) manual as a guide. The facility failed to accurately the MDS for R34 related to contractures not documented as impairments under section G and section GG on the MDS assessments. This placed the residents at risk for uncommunicated care needs.

The facility identified a census of 48 residents, which included 13 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident. Resident (R) 47 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission, as required. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - R 47's Electronic Health Record (EHR) revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety, and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 11, indicating moderately impaired cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors noted. R47 was independent with activities of daily living (ADLs). R47 required supervision with verbal cues when ambulating independently in the facility. R47 was continent of bowel and bladder. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/22/24 did not trigger. The Cognition CAA documented R47 had a BIMS of 11 and the resident was no longer safe to live alone in her home. The Care Plan dated 07/09/24, lacked staff interventions to provide person-centered care. Review of the Progress Notes from 05/15/24 to 07/09/24 lacked a documentation in regard to completion of a care plan. On 07/09/24 at 10:03 AM, R47 was in her room and anxious when speaking, wringing her hands together and kept moving around her room. On 07/09/24 at 11:30 AM, Administrative Nurse F stated R47 admitted to the facility on [DATE] and verified R47's person-centered care plan was not developed within seven days of the required MDS. The facility's policy for Comprehensive Care Plans, dated 03/28/24 documented: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs identified in resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDS. The facility failed to develop a comprehensive person-centered care plan for one resident. R47 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

The facility reported a census of 47 residents which included three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 who staff assessed as a fall and elopement risk, remained free from accident hazards when staff failed to properly supervise the resident after assisting R1 out of the front door of the facility. On 03/28/22, Nurse Aide 2 (in training) (NA2) M, entered the front door of the facility to clock in for his shift. R1 was sitting by the door and told NA2 M she needed help to get out of the facility. NA2 M assisted the resident out of the front door and then went back inside to finish checking in for his shift. R1 self-propelled her wheelchair down the sidewalk towards the parking lot which sloped downhill. Her chair quickly rolled towards the end of the sidewalk, veered to the right, and rolled over the curb of the sidewalk. This caused the resident to fall out of her chair and hit her head on the pavement in which she sustained an orbital (eye) fracture requiring a trip to the emergency room for sutures. Findings included: - The Physician Order Sheet (POS), dated 06/02/22, documented R1 with diagnoses of cerebral infarction (stroke) and [CONDITION(S)] (weakness or paralysis) affecting left non-dominant side of the body. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status Score of 4, or severely impaired cognition. The resident required extensive assistance of two staff members for transfers. R1 had range of motion impairment in her upper and lower extremity on one side and used a wheelchair for mobility. The resident had no wandering behaviors during 7-day lookback period or falls since the prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/23/22, instructed staff that the resident had left sided weakness due to a stroke. She required extensive assistance from staff with Activities of Daily Living (ADLs). R1 had severely impaired cognition and depression. The Falls CAA, dated 02/23/22, instructed staff that the resident was a fall risk due to left sided weakness from a stroke. The Care Plan, updated on 04/01/22, documented the following interventions: 1. On 02/24/20, resident documented as a high fall risk due to deconditioning, confusion, and left sided [CONDITION(S)] due to a stroke. 2. On 03/08/21, advised the staff that the resident has a history of sitting by the doors waiting for her mom or dad, or one of her children to pick her up. The staff were to provide gentle redirection should that happen. 3. On 03/29/22, staff advised to assist with propelling the resident's wheelchair while outdoors. A Post Fall Evaluation, dated 03/28/22 at 06:27 PM, documented by Licensed Nurse (LN) G revealed R1 experienced a fall at 06:05 PM, outside the facility in an unsafe area of pavement. The resident was in a hurry/rush at the time of the fall. R1 sustained a head wound to the left eye and temple. Staff sent the resident to the emergency room for treatment. Review of an Elopement Risk Evaluation, dated 02/07/22, revealed a score of 2 or at risk for elopement. An Interdisciplinary Team Review/Investigation, dated 03/28/22, revealed the witnessed incident happened on 03/28/22 at 06:05 PM. R1 was lying on her back on the cement in the parking lot. A bystander and another staff member who witnessed the fall when she arrived at work were with the resident when the nurse arrived to assess the resident. R1 was in her wheelchair and went down over the curb causing the wheelchair to tip the resident out. The nurse then proceeded to call emergency services. Environmental factors that attributed to the fall was an unsafe area of the sidewalk. R1 sustained a head wound to the left temple and eye area. The suspected root cause was R1 was outside the facility self-propelling her wheelchair without assistance. The resident was in the line of sight of two staff members, however she was not in close enough proximity for staff to prevent R1 from propelling herself to an unsafe area of the sidewalk. Review of the hospital's CT [scan that produces images inside the body] Maxillofacial [relating to the jaw and face] without Contrast, dated 03/29/22, revealed comminuted (bone is broken into two or more parts) displaced fractures involving the superior lateral left orbit (eye socket) with overlying hematoma and laceration. A couple of these fracture fragments appear to rest against the left globe (eye). A Skin Only Evaluation, dated 03/31/22 at 11:41 AM by Administrative Staff A revealed the resident had an intact laceration above the left eye with sutures present and edges well approximated. The resident complained of pain and tenderness to the area. The area surrounding the laceration and left eye orbit with bruising in various colors from dark purple to yellow/green. The bandage covered the laceration. A Witness Statement, dated 03/28/22, by NA2 M, revealed he entered the front door of the facility to clock in for his shift at 05:50 PM and was standing at the kiosk in the foyer. R1 told the resident she was trying to get out and asked if he would help her. NA2 M assisted R1 outside the facility through the front door and returned to finish checking in at the kiosk in the foyer. He looked outside after he checked in and saw R1 on the ground and a bystander rushing towards her. NA2 M then ran outside to help, then went back in to get the nurse. A Witness Statement, dated 03/28/22, by Certified Medication Aide (CMA) R, revealed she was pulling into the parking lot of the facility and saw R1 on the sidewalk in front of the building. By the time CMA R got out of her vehicle, R1 reached the end of the sidewalk by the parking stalls, her wheelchair went over a curb, and she fell out of the chair. She witnessed R1 hit her head on the pavement. She ran to the resident and applied pressure to the wound with tissue. The resident sustained a large skin tear and a gash by her eyebrow that was bleeding. The nurse arrived, assessed the resident, and called 911. Observation, on 06/15/22 at 08:49 AM, revealed R1 sitting in her wheelchair and propelling herself around the room. Her room was clean and uncluttered. A fall mat noted by R1's bed. The resident was alert and calm and propelled herself over to a table to pick up a newspaper. Observation, on 06/15/22 at 02:09 PM, revealed R1 sitting in her wheelchair by a large window in her room. She was calm, alert, and watching the birds on the feeders outside her window. Interview, on 06/12/22 at 11:11 AM, Administrative Nurse D reported R1 stopped at the front entrance door and asked NA2 M to assist her outside the facility. He helped her outside and went back in the building to clock in for his shift. While that was happening, R1 propelled her wheelchair down the sidewalk and the chair went quickly down to and over the curb and she was thrown out of her chair. CMA R arrived at the facility and witnessed the resident's fall. The NA2 M alerted the nurse and 911 called. NA2 M was a new aide in training, but he should have supervised the resident outside the facility. R1 went to the hospital where a CT scan discovered an orbital fracture. Interview, on 06/15/22 at 01:20 PM, CMA S reported the resident was a fall and elopement risk. The resident was able to propel herself around the facility in her wheelchair and wandered the facility daily. R1 sat at the front entrance later in the afternoon waiting for her parents to come pick her up from the facility. CMA S stated R1 would try to open the door occasionally and staff were to redirect her to another activity. The resident would comply at times but would always wind up back at the front door. Interview, on 06/15/22 at 02:52 PM, CMA R verified her witness statement and stated she hurriedly got out of her vehicle and tried to reach the resident before she fell to the ground. She stated she got within 10 feet of R1 and saw her fall and hit her head on the pavement. She encouraged R1 to lie still while she applied pressure to her wound and talked to her. The resident remained calm and awake during the whole incident and was with her until emergency services arrived to take her to the hospital. Interview, on 06/15/22 at 03:29 PM, NA2 M verified his witness statement and stated after he let her out of the building, he locked her wheelchair before going back into the foyer. R1 unlocked her wheelchair and propelled herself down the sidewalk. He stated the sidewalk slopes down and the resident's chair went quickly and veered to the right and over the curb of the sidewalk at the parking lot. It happened really fast. He rushed outside and CMA R was already at R1's side helping her. CMA R told him to get the nurse. LN G came out and assessed her and called 911. R1 was awake and calm during the incident. NA2 M was educated by the facility after the fact about resident safety and when it was appropriate to let them out of the building. The facility did not provide a policy for resident accidents and lack of supervision. The facility failed to properly supervise R1 who staff assessed as a fall and elopement risk, after assisting R1 out of the front door of the facility. On 03/28/22, NA2 M, entered the front door of the facility to clock in for his shift. R1 was sitting by the door and told NA2 M she needed help to get out of the facility. NA2 M assisted the resident out of the front door and then went back inside to finish checking in for his shift. R1 self-propelled her wheelchair down the sidewalk towards the parking lot which sloped down-hill. Her chair quickly rolled towards the end of the sidewalk, veered to the right and rolled over the curb of the sidewalk. This caused the resident to fall out of her chair and hit her head in which she sustained an orbital fracture requiring a trip to the emergency room for sutures. This citation was considered to be past non-compliance, when the facility corrected the deficient practice, with implementation and then completion of the following items, on 03/29/22 at 02:00 PM. 1. On 03/28/22 at 06:15 PM (immediately following the incident), the staff member responsible for assisting the resident outside the facility front door and then going back inside, received one to one education with a teachable moment. 2. Education of all facility staff began on 3/28/22 and completed with 100% of staff educated on 03/29/22 at 2:00 PM. The education included review of the facility policy entitled, Safety and Supervision of Residents.

The facility reported a census of 66 residents. The 19 residents selected for review included 10 for review of unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that 1 (#10) of the 10 residents selected for unnecessary medication review, remained free of an unnecessary medication when the resident experienced the presence of adverse reactions, with physical and mental decline in abilities. Findings included: - The medical record of resident #10, documented admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A Braden Scale to assess for pressure ulcer risk, dated 2/24/10, documented a total score of 16. (Mild risk for pressure ulcers of scores 15-18). Another Braden Scale, dated 5/11/10, documented a total score of 15, with mild risk. (The decline documented an increase in moisture from rarely to often moist.) The admission comprehensive assessment, dated 3/6/10, documented short term cognitive impairment, moderately impaired decision making ability, behaviors of being resistive to cares daily, mental function varied over the course of the day, persistent anger with self or others, easily annoyed, anger at nursing home placement, independent with bed mobility, limited assistance of 1 staff to transfer, extensive assistance of 2 staff to walk in the hallway, independent locomotion in a wheelchair in the hallway, occasional bladder incontinence, no pressure ulcers, with abrasions/bruises, and with pressure relieving devices to bed/chair. physician's orders [REDACTED]. However, the medication was only documented as given to the resident one time since ordered for increased anxiety on 6/14/10. On 3/10/10, the physician also ordered, "[MEDICATION NAME], 0.5 mg, every 4 hours PRN anxiety. However, the medication was never documented as given to the resident since the physician ordered it on 3/10/10. The facility staff sent a fax to the physician, dated 5/10/10, which documented, "Resident has been having increasing episodes of anger to staff and others. (He/She) refuses cares and cusses at staff. Yesterday (he/she) even slapped a CNA (certified nurse aide) in the face while (he/she) was trying to help (him/her). Would you review current medications?" The physician returned the fax, dated 5/11/10, with new order, "Add [MEDICATION NAME], 0.25 mg, BID (twice a day). Keep me updated." The quarterly assessment, dated 5/13/10, documented a decline in cognition which included an addition of problems with long term memory, required limited assistance of 1 staff for bed mobility/transfers/walk in hallway, extensive assistance of 1 staff for locomotion in a wheelchair in the hallway, frequently incontinent of bladder, with no skin problems, and used a pressure relieving device to the bed/chair. The facility sent a fax to the physician, dated 5/14/10 at 4:00 PM, which reported the staff found the resident on the floor without injury. The physician returned the fax with documentation, "Okay." The facility again sent a fax to the physician, dated 6/21/10 at 5:35 PM, which reported, "Resident was on floor. No apparent injury noted. Vital signs refused, resident cussing and hitting at staff." The physician returned the fax with new order, "Psych consult." The facility sent another fax to the physician, dated 6/23/10 at 12:45 PM, "Psych PA (Psychiatric physician assistant) for (psychiatric group) recommends increase [MEDICATION NAME] to 0.5 mg BID at 8:00 AM and 3:00 PM, and try [MEDICATION NAME] 0.1 mg at bedtime (with blood pressure every shift times 1 week) for behaviors/agitation." The physician documented on the fax, " OK, as (he/she) ordered." On 7/21/10 at 2:00 PM, licensed nurse B went to the resident's room to provide a skin prep treatment to a blister (pressure ulcer) on the resident's right heel. Observation revealed a clear fluid soft filled blister on the outer right heel,which extended across the backside of the resident's heel. The nurse reported seeing the area approximately 3 days prior and explained the area approximately doubled in size over the last 3 days. The nurse further explained the pressure ulcer developed in the facility following a recent decline in the resident's ability. On 7/26/10 at 9:00 AM, certified nurse aides N and S assisted the resident from the wheelchair onto the bed. The resident would only bear a little weight on the legs to assist the staff during the transfer. The staff positioned the resident on the bed. On 7/26/10, At 4:10 PM, licensed nurse G entered the resident's room and applied skin prep swabs over the resident's right outer heel blister area. The nurse reported no knowledge as to why the pressure ulcer developed on the resident's right heel. Nurse G reported the resident gradually declined since admission to the facility and stated, "It was not a fast decline." The nurse further explained the resident slept more and more and the pressure ulcer probably developed from the resident's heels lying directly on the bed. The nurse further explained the physician changed the resident's medications due to behaviors, however the nurse reported during the night shift the resident did not give the staff any trouble. The nurse stated, "I guess when (he/she) first came in, (he/she) gave the first two shifts a lot of trouble. (He/She) has just slowly declined." On 7/26/10 at 4:50 PM, certified nurse aides P and Q removed a urine saturated incontinent brief and slacks from the resident. The back of the resident's shirt contained urine saturation half way up the resident's back. The nurse aides explained, "Three months ago, the resident could grab the wheelchair and assist to transfer but not now. (He/She) used to be able to turn and move about on the bed until approximately the last month. (He/She) just declined and the staff have to help (him/her) to reposition now. (He/She) only talks now when (he/she) doesn't want us to give the cares. Then (he/she) curses at us. (He/She) used to be worse with behaviors and would get very upset." On 7/27/10 at 7:25 AM, certified nurse aides N and R assisted the resident from the bed and into the wheelchair for the morning meal service in the dining room. When the nurse aide applied the metal footrests to the wheelchair, the resident stated, "I don't need those." The nurse aides explained, "(He/She) used to stand with 1 person but now (he/she) is a 2 person assist. (He/She) changed over the past 2 weeks or so." On 7/27/10 at 8:45 AM, further review of the resident's medical record revealed [REDACTED]. On 7/27/10 at 9:45 AM, administrative staff Y explained the resident refused therapy frequently and declined prior to May, 2010, due to the resident's refusals, when the resident's medications changed and increased. However, staff Y explained the facility staff should have used the PRN medications for behaviors prior to requesting an increase in the resident's antipsychotic medications for behaviors. Staff Y further verified the facility lacked any type of behavior monitoring for the resident's antipsychotic medications. The facility failed to conduct any type of behavior monitoring to assess the resident for adverse reactions to the antipsychotic medications. Furthermore, the facility failed to identify the resident's decline in mental and physical ability and notify the physician for decrease in the medications.

The facility had a census of 66 residents with 19 sampled for review, which included 2 resident's with weight loss. Based on record review and interview, the facility failed to ensure these two sampled residents (#91 and 45) received appropriate care and services to maintain proper nutritional status. Findings: - The facility admitted resident # 91 on March 17, 2010, with [DIAGNOSES REDACTED]. The clinical record identified the resident's height as 71 inches and weight of 120 pounds. The MDS (minimum data set), dated 3/21/10, documented the resident as having short term memory problems, being moderately impaired with decision making, required limited assistance from one staff for most ADL's (activities of daily living), and required only supervision for eating. The admission care plan, dated 3/17/10, instructed staff to provide a regular diet and Nutrashakes three times a day, per physician's orders [REDACTED]. The admission nutrition evaluation, dated 3/22/10, and completed by the registered dietician, documented the resident at 63% of IBW(ideal body weight), and receiving supplemental shakes three times daily. The comprehensive care plan, dated 4/2/2010, addressed potential for weight loss and dehydration and included interventions as follows: "Monitor and record dietary intake; weigh weekly, times four, then monthly and prn (as needed)." Review of the clinical record failed to reveal any weekly weights documented. The SNAR (Skin, Nutrition, and at Risk) Policy and Procedure, dated 3/10, documented, "... # (number)3.) After admission/re-admission, a resident will be weighed weekly for 4 weeks to establish a baseline or identify risks of weight loss/gain. ... #9. The inter-disciplinary team will review the weights ...An inter-disciplinary note will be written (in their medical record) for each resident discussed regarding current interventions provided (including average meal/snack intake, assistive devices used and if assistance is needed with meals,...) effectiveness of the current plan of care, need to adjust plan of care, notification of physician and responsible party of the resident's current status..." Licensed nurse X, on 07/28/10 at 1:30 pm, confirmed the medical record lacked the weekly weights as the SNAR policy and procedure instructed. The nurse reported the notes kept during the facility nutrition meeting included weekly weights for the resident as follows: 3/17/10 -120 # (pounds) (admission weight) 3-22/10 -118 # 3/29/10 -116 # 4/5/10 -112 # ( The resident experienced a significant loss of 6.6% (percent) with a 8 pound loss in less than 3 weeks). The clinical record failed to evidence staff notified the physician for further instructions following this initial significant weight loss. 4/21/10 -101 #, The resident further experienced a total significant loss of 15.8% with a loss of 19# in a little over one month. The clinical record failed to evidence staff notified the physician for further instructions following this continuation of significant weight loss. On 7/28/10 at 1:30 PM, licensed nurse X, further explained during the 4/21/10 nutrition meeting the committee discussed a possible feeding tube, hospice,and the possible addition of [MEDICATION NAME] to the resident's juice. The comprehensive care plan lacked any further update after the initial significant weight loss noted on 04/05/10 until updated on 4/26/10, with interventions including Nutrashakes three times daily (which was already planned), [MEDICATION NAME] to juice twice daily,and Hospice to educate family that current nutritional intake is part of end of life process. (This update occurred 4 days following a 19 pound/15.8% weight loss in a little over one month). The March, 2010, MAR (medication administration record) documented the resident refused the Nutrashakes 23% of the time. (42 times offered with 10 refusals). The April, 2010 MAR indicated [REDACTED]. (90 times offered with 83 times refused). The RD (registered dietician) notes, dated 4/13/10, documented the resident's weight as 120 pounds (inaccurate according to SNAR records), 63% of IBW, as eating 100% of meals and nutritional shakes three times a day. (inaccurate according to documentation on the MAR for March and April, 2010). The diet order revealed a regular diet and documented the resident able to feed self. The RD notes, on 4/27/10, documented the resident's weight as 112, (inaccurate according to SNAR records) and noted a 6.6% weight loss since admission, and as a significant weight loss. The resident received shakes three times a day, had poor food intake, and admitted to Hospice... The medical record contained a fax to the physician, dated 4/14/10 (9 days following the initial significant weight loss), that included notification of decreased oral intake, refusal to eat, and to requested to consult the family regarding different options to use such as a feeding tube or hospice. The fax lacked documentation of the resident's weight or amount of weight loss. The physician documented "If he/she doesn't increase PO (oral) intake we can have Dr.____ insert a peg tube for fluids/nutrition." Interview on 7/28/10, at 1:20 PM, licensed nurse B reported the staff talked to a family member about using a feeding tube or putting the resident on hospice. The family was unsure of what was best, and afraid to do something that would upset the resident's (other) children. The family decided to wait and talk to the resident's son before making a decision. Staff continued to say that the family had then decided they did not want a feeding tube and elected for the resident to go on hospice. The medical record revealed, on 4/23/10 (9 days after communication with the physician), the resident admitted to Hospice Services with a [DIAGNOSES REDACTED]. Certified dietary staff Z stated, on 7/28/10 at 1:45 pm, the documentation concerning the SNAR meetings lacked inclusion in the resident's medical record. The resident's medical record contained the initial evaluation, and notes from the consultant. The staff further explained the resident's medical record lacked the completed meal percentage intake sheets. Staff verified the facility initiated Nutrashakes for the resident upon admission, but failed to attempt other interventions once the resident began refusing the shakes. Nurses Notes, on 3/28/10 at 1230 pm, documented the resident refused to get up for lunch, and yelled 'I don't want to eat.". On 7/28/10 at 2:16 PM, certified staff L, reported the resident as weak without a great appetite, but able to feed themselves for the first week or so after admission, then the resident pushed the plate away and didn't want help from the staff, and did not want to drink the supplements. On 7/28/10 at 2:20 PM, certified staff CC, remembered the resident as being friendly with some confusion. Staff explained the resident ate okay for the first couple of weeks, then started to refuse. The staff attempted to provide health shakes, and other snacks but the resident continued to refuse. The resident's family visited the resident daily. In Summary: The facility failed to address the nutritional needs of this resident, to ensure the resident maintained proper nutritional status as follows: 1. The facility failed to identify significant weight loss when it first occurred on 04/05/10. 2. Failed to notify the physician for further instruction, in a timely manner, of the resident's initial significant weight loss on 04/05/10 and further significant weight loss, on 04/21/10, until 04/26/10. 3. Failed to follow-up with the physician, for further instruction, when the resident began refusing the Nutrashakes and when the family declined a feeding tube. The resident experienced a 19#/15.8% weight loss in a little over one month. - This deficient practice also affected resident # 45. The facility failed to identify weight loss or plan interventions for the weight loss, and also failed to complete weekly weights times four as required by the facility policy and procedure and as planned.

The facility reported a census of 66 residents. The 19 residents selected for review included 3 with current pressure ulcers. Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to promote healing, prevent infection and prevent related to pressure ulcers for 4 selected residents. This included 2 (#10 and #47) selected residents who developed avoidable pressure ulcers with actual harm, and 2 (#84 and #76) selected residents with failure to provide necessary treatment and services to promote healing and prevent development of new pressure ulcers. Findings included: - The medical record of resident #10, documented admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A Braden Scale to assess for pressure ulcer risk, dated 2/24/10, documented a total score of 16. (Mild risk for pressure ulcers of scores 15-18). Another Braden Scale, dated 5/11/10, documented a total score of 15, with mild risk. (The decline documented an increase in moisture from rarely to often moist.) The admission comprehensive assessment, dated 3/6/10, documented short term cognitive impairment, moderately impaired decision making ability, independent with bed mobility, limited assistance of 1 staff to transfer, extensive assistance of 2 staff to walk in the hallway, independent locomotion in a wheelchair in the hallway, occasional bladder incontinence. no pressure ulcers, with abrasions/bruises, and with pressure relieving devices to bed/chair. The quarterly assessment, dated 5/13/10, documented no change in cognition, required limited assistance of 1 staff for bed mobility/transfers/walk in hallway, extensive assistance of 1 staff for locomotion in a wheelchair in the hallway, frequently incontinent of bladder, with no skin problems, and used a pressure relieving device to the bed/chair. The current plan of care, dated 7/1/10, included interventions, "Inspect skin head to toe each bath day and observe daily for any red or irritated areas. The current TAR (treatment administration record) for July, 2010, documented a treatment, dated 7/19/10, "Skin prep to blister right outer heel tid." However, the staff failed to document completion of the treatment for [REDACTED]. On 7/21/10 at 2:00 PM, licensed nurse B went to the resident's room to provide a skin prep treatment to a blister on the resident's right heel. Observation revealed a clear fluid soft filled blister on the outer right heel,which extended across the backside of the resident's heel. The nurse reported seeing the area approximately 3 days prior and explained the area approximately doubled in size over the last 3 days. The nurse further explained the pressure ulcer developed in the facility following a recent decline in the resident's ability. At this time, observation revealed the resident's bed lacked any pressure relieving device. 7/26/10 at 8:15 AM, the resident sat in the wheelchair at the dining room table. The resident wore yellow gripper type socks on the feet, which sat with the resident's right heel, with the pressure ulcer blister, directly on the metal foot pedal of the wheelchair. On 7/26/10 at 9:00 AM, certified nurse aides N and S assisted the resident from the wheelchair onto the bed. The resident would only bear a little weight on the legs to assist the staff during the transfer. The staff positioned the resident on the bed, lying on the back, with an ankle ring device directly around the resident's right heel, and not the ankle. Following further questioning, certified nurse aide N moved the ankle ring device to the correct position, on the resident's right ankle, to elevate the heel off of the bed surface. The resident's left heel lay directly on the mattress without any pressure relieving device to the heel or the bed. A pillow remained at the foot of the bed, below the resident's feet, and not in use. At 2:10 PM and 3:30 PM, the resident rested on the back on the bed with ankle ring devices to both ankles, however the resident's knees rested over the top of a pillow which placed the resident's heels directly on the mattress without pressure relieving device. At 4:10 PM, licensed nurse G entered the resident's room and applied skin prep swabs over the resident's right outer heel blister area. The surveyor informed the nurse of the pressure ulcer blister extending across the entire backside of the resident's heel. The nurse then picked up the resident's right heel again and applied more of the skin prep to the backside of the pressure ulcer blister. The nurse reported no knowledge as to why the pressure ulcer developed on the resident's right heel. Nurse G reported the resident gradually declined since admission to the facility and stated, "It was not a fast decline." The nurse further explained the resident slept more and more and the pressure ulcer probably developed from the resident's heels lying directly on the bed. The nurse further explained the physician changed the resident's medications due to behaviors, however the nurse reported during the night shift the resident did not give the staff any trouble. The nurse stated, "I guess when (he/she) first came in, (he/she) gave the first two shifts a lot of trouble. (He/She) has just slowly declined." Physician's orders, dated 3/10/10, ordered, "[MEDICATION NAME], 0.25 mg (milligrams), every 4 to 6 hours PRN (as needed) for anxiety/outbursts. However, the medication was only documented as given to the resident one time since ordered for increased anxiety on 6/14/10. On 3/10/10, the physician also ordered, "[MEDICATION NAME], 0.5 mg, every 4 hours PRN anxiety. However, the medication was never documented as given to the resident since the physician ordered it on 3/10/10. The facility staff sent a fax to the physician, dated 5/10/10, which documented, "Resident has been having increasing episodes of anger to staff and others. (He/She) refuses cares and cusses at staff. Yesterday (he/she) even slapped a CNA (certified nurse aide) in the face while (he/she) was trying to help (him/her). Would you review current medications?" The physician returned the fax, dated 5/11/10, with new order, "Add [MEDICATION NAME], 0.25 mg, BID (twice a day). Keep me updated." The facility sent a fax to the physician, dated 5/14/10 at 4:00 PM, which reported the staff found the resident on the floor without injury. The physician returned the fax with documentation, "Okay." The facility again sent a fax to the physician, dated 6/21/10 at 5:35 PM, which reported, "Resident was on floor. No apparent injury noted. Vital signs refused, resident cussing and hitting at staff." The physician returned the fax with new order, "Psych consult." The facility sent another fax to the physician, dated 6/23/10 at 12:45 PM, "Psych PA (Psychiatric physician assistant) for (psychiatric group) recommends increase [MEDICATION NAME] to 0.5 mg BID at 8:00 AM and 3:00 PM, and try [MEDICATION NAME] 0.1 mg at bedtime (with blood pressure every shift times 1 week) for behaviors/agitation." The physician documented on the fax, " OK, as (he/she) ordered." On 7/26/10 at 4:50 PM, certified nurse aides P and Q reported no cares provided to the resident since the staff came to work at 2:00 PM. The staff removed a urine saturated incontinent brief and slacks. The back of the resident's shirt contained urine saturation half way up the resident's back. However, the nurse aides failed to cleanse the resident's skin on the back following saturation of urine from the incontinence. The nurse aides explained, "Three months ago, the resident could grab the wheelchair and assist to transfer but not now. (He/She) used to be able to turn and move about on the bed until approximately the last month. (He/She) just declined and the staff have to help (him/her) to reposition now. (He/She) only talks now when (he/she) doesn't want us to give the cares. Then (he/she) curses at us. (He/She) used to be worse with behaviors and would get very upset." The resident remained without assistance to change position on the bed for at least 2 hours and 50 minutes and then staff failed to cleanse the urine saturated skin on the resident's lower back following incontinence. On 7/27/10 at 7:25 AM, certified nurse aides N and R assisted the resident from the bed and into the wheelchair for the morning meal service in the dining room. When the nurse aide applied the metal footrests to the wheelchair, the resident stated, "I don't need those." The nurse aides explained, "(He/She) used to stand with 1 person but now (he/she) is a 2 person assist. (He/She) changed over the past 2 weeks or so." On 7/27/10 at 8:45 AM, further review of the resident's medical record revealed [REDACTED]. The medical record lacked any skin assessment or description of the pressure ulcer on the resident's right heel. Furthermore, the medical record lacked any documentation of the physician notification of the resident's new pressure ulcer. At this time, licensed nurse I reported the staff found the resident's pressure ulcer on 7/19/10, and the nurse gave the charge nurse a skin assessment to complete for the chart. Nurse I also reported instructing the charge nurse to notify the physician for an order for [REDACTED]. At 9:45 AM, administrative staff Y reported they talked to the charge nurse from 7/19/10, who explained they put the treatment on the TAR, however the nurse failed to actually notify the physician of the area and failed to request the treatment order from the physician. The nurse also failed to complete the skin assessment to describe the pressure ulcer when found on 7/19/10. At 10:30 AM, licensed nurse I provided a completed wound/skin healing record, dated 7/27/10. The record documented, "...Onset date of the pressure ulcer on 7/19/10... to the resident's right heel... currently measured at 4.7 by 8.6 cm (centimeters)... stage 2... no depth... serous exudate... no odor... surrounding skin color is pink... and no culture obtained..." At 1:10 PM, the resident sat in the wheelchair in the hallway with the yellow gripper socks on. The footrest contained a strap across the back of the pedal attached to a upward protruding metal peg. The resident's right heel sat directly on top of the metal peg area, without any type of pressure relieving device to the heel area. In Summary: The facility failed to; 1.) Assess the resident with decline in ability, to implement interventions and prevent the development of the pressure ulcer. 2.) Notify the physician of the pressure ulcer development and obtain a treatment order, until questioned by the surveyor on 7/27/10. 3.) Provide pressure relieving devices to the resident's bed and wheelchair footrest pedal, until questioned by the surveyor on 7/27/10. 4.) Provide assistance to reposition for at least 2 hours and 50 minutes. 5.) Provide adequate cleansing of the resident's skin following urine saturation up the resident's lower back. The facility staff found the pressure ulcer on 7/19/10. The area doubled in size within 3 days, related to failure of the facility to assess the resident's decline in condition and develop interventions to prevent development of pressure ulcers. - The clinical record identified resident # 47, admitted on [DATE], free of redness or pressure ulcer to the buttocks. A Braden Skin Risk Assessment, dated 6/28/10, scored the resident at 17, with the indicator of 15-18 representing mild risk for development of pressure ulcers. A 7/3/10, comprehensive assessment, identified the resident as cognitively impaired of short term memory, with long term memory intact, and moderately impaired of decision making skills. The assessment further indicated the resident without a history of/or currently with a pressure ulcer, with preventative devices of a pressure relieving device for the bed and chair, and required limited assistance of 1 staff for bed mobility and transferring. Additionally, the assessment identified the resident continent of bowel and bladder. A 7/3/10, resident assessment protocol, identified the resident at risk for pressure areas secondary to the resident's limited mobility. The assessment evidenced, "(The) focus will be to prevent development of any pressure areas by maintaining (a) nutritionally balanced diet and assist (the resident) in changing (his/her) position at least every 2 hours and observe (the resident's) skin for development of any red or irritated areas..." The resident's 7/13/10 care plan, included the potential for pressure areas and instructed staff to: 1) Inspect skin each bath day and observe daily for any red or irritated areas., 2) Assist in changing positions frequently when up in the wheel chair or in bed. 3) Foot care to be done routinely by podiatrist. 4) Lotion dry areas of skin prn (as needed). The care plan failed to include the use of pressure relieving devices in the bed or chair. A 7/21/10, facsimile communication to the resident's physician, contained within the clinical record, included, "Resident has 1.0 cm (centimeter) x 0.6 centimeter open area on right buttock. Stage II, wound bed pink, peri (surrounding) wound pink, no drainage or odor. May we start MVI (Multi Vitamin) 1 daily, Zinc 50 mg (milligrams) daily, Vitamin C 500 mg bid (twice daily), and [MEDICATION NAME] (a protein supplement) 1 packet bid, for 2 weeks to promote wound healing. Started treatment of [REDACTED]." The physician responded, "OK to try!" On 7/22/10 at approximately 9:30 a.m., observation revealed the resident sat in a wheel chair, with a pressure relieving cushion in the seat. The resident, during the stage I interview, reported pain to his/her buttock, "And that the area is very sore." The resident further indicated being unable to sit on it for very long without a lot of pain." On 7/22/10 at 10:30 a.m., the resident sat in a recliner in his/her room without a pressure relieving cushion to the seat of the chair. At 5:00 p.m. on 7/22/10, the resident sat in the television room, in an easy chair, with his/her feet elevated on an ottoman. The chair seat lacked a pressure relieving cushion. The resident appeared to be attempting to shift position, and stated, "I'm hurting on my butt. I have a sore there." Further inquiry, regarding pain medication revealed the resident unaware of the last time staff administered pain medication, but, "I need some now." The resident exhibited signs of discomfort, such as facial grimacing and fidgeting, not observed during previous visits, at various times on 7/21/10 to 7/22/10. Interview, on 7/26/10 at 11:00 a.m., with licensed nursing staff D, reported the resident's wound, "Looks better than compared to when previously observed." The staff member reported a lack of awareness of why the ulcer developed. CNA staff BB, reported on 7/26/10 at 4:11 p.m., that the staff member identified an area, to the resident's buttocks, about 1 week ago, during a bath. The staff member reported that staff are now turning and re-positioning the resident more frequently. The staff member reported the resident requires a pressure relieving mattress to his/her bed, a pressure relieving cushion to the wheel chair and that the cushion should be moved into any chair the resident sat in. Observation of licensed nursing staff C, on 7/27/10 at 2:18 p.m., as staff completed a dressing change to the resident's buttocks, revealed the resident, attempting to reposition him/herself onto their side in bed, revealed the resident and unable to shift his/her position onto his/her side, without extensive assistance of the staff member. After assisting the resident with repositioning, the staff member exposed the resident's right buttock, and removed a dressing, revealing a stage II pressure ulcer. The area appeared free of infection and redness, exhibited a pink wound bed, and measured approximately 1.5 centimeter L (length) x .0.5 cm w (width), with depth undetermined. The staff member indicated, at that time, "The area is improving." The facility failed to maintain pressure relieving devices to this dependent resident's chair, who acquired a pressure ulcer, following admission to the facility, increasing the resident's pain level. - This deficient practice, of failure to provide care and services to prevent and heal pressure ulcers also affected resident's # 76 and 84. The facility failed to maintain pressure relieving devices to the recently healed pressure ulcer on resident #76's left heel. Additionally, the facility failed to provide physician ordered supplements of [MEDICATION NAME] powder (a body building powder), 1 scoop twice daily, and a high protein, lactose free, dietary supplement, ordered to be given 3 times daily, to resident #84 with a non-facility acquired pressure ulcer.