Every finding on record at Good Samaritan - Atwood

The facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to deliver mail to the facility residents on Saturdays. This deficient practice placed the residents at risk for not having reasonable access to send or receive written communications. Findings included: - On 06/16/25 at 08:00 AM, on entrance to the facility, observation revealed a white basket sitting on a desk inside the front entry door, labeled United States Postal Service (USPS), and it contained numerous envelopes. On 06/17/25 at 09:00 AM, during the resident council meeting, a resident verbalized that there was no mail delivery on Saturdays. The resident stated the activity director would deliver the mail Monday through Friday, but there was not a designated person to deliver on the weekends. On 06/18/25 at 10:00 AM, Administrative Nurse D verified the facility does not always deliver the residents' mail on Saturdays, and there was not a designated person assigned to deliver the mail to the residents. The facility's Resident Mail policy, dated 12/19/2024, documented that the facility would ensure resident privacy in written communication and would deliver mail to the resident promptly in the manner specified in the policy. The policy documented that mail and other materials sent to the resident would be delivered within 24 hours of delivery by the post office, and outgoing mail would be delivered to the postal service within 24 hours, except when there is no regularly scheduled postal pick-up service. The policy documented mail would be delivered unopened to the resident. Assistance would be offered to residents who require help in opening or reading their mail, and the mail would be received in a private place of the resident's choice.

The facility had a census of 26 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 25 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - On 06/16/25 at 08:40 AM, observation revealed the kitchen staff finishing the morning meal and preparing the midday meal. Dietary Staff (DS) stated he was the Dietary Manager. DS reported he had enrolled in a Certified course and had just begun the process of becoming a Certified Dietary Manager. The facility's Director of Food and Nutrition Services Job Orientation and Training policy, dated 12/16/24, documented to ensure consistent and proper training is provided to new directors of food and nutrition (DFN) services. All new DFNs would complete the DFN job orientation and training (JOT) program within three months of their hiring date. All learners completing the DNF JOT program are given adequate time to do so. The JOT will be a priority upon hire for the first two weeks on the job.

he facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 23 gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed the resident at risk for possible exposure to infection. Findings included: - On 6/17/25 at 9:20 AM, observation revealed License Nurse (LN) G had finished R23's nebulizer breathing treatment and was observed washing the resident's nebulizer and did not wear a gown while cleaning the nebulizer mouthpiece. On 06/18/25 at 08:00 AM, observation revealed Certified Nurse Aide (CNA) M assisted the resident to change his shirt while seated in his wheelchair. Continued observation revealed CNA M lacked gloves or a gown. Observation revealed PPE was available across the hall from the R23's room and a PPE magnetic sign, approximately six inches by two inches, that was posted on the resident's door frame with instructions for use of PPE when providing cares for the resident with a G-tube. On 06/18/25 at 08:20 AM, Administrative Nurse D stated the staff should wear PPE for EBP when providing care for R23. Administrative Nurse D verified that a plastic container with PPE equipment was located in the hallway, and it contained supplied PPE for three of the residents who required EBP. Administrative Nurse D stated she would have an in-service and inform staff of the usage and requirements for a resident who required PPE for infection control due to EBP. The facility's Enhanced Barrier Precautions policy, dated 04/06/25, documented EBP was used to prevent the spread of infection and communicable diseases to residents, employees, and visitors through infection prevention and control practices. Enhanced Barrier Precautions expand the use of personal protective equipment beyond situations in which exposure to blood and bodily fluids was anticipated and refer to the use of a gown and gloves during high-contact resident care activities that provide an opportunity for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. EBP is used for residents with chronic wounds and residents with indwelling medical devices, including feeding tubes, even if the resident is not known to be infected or colonized with MDRO. High contact resident care activities include transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with the resident in the therapy gym, changing linens, device care or use, and wound care. EBP are intended to be used for the duration of the resident's stay. For residents on EBP for a wound or indwelling medical device only, precautions can be discontinued if the wound resolves or the device is removed. The policy documented the facility would: post clear signage indicating the type of precautions and required PPE. And clearly indicate the high-contact resident care activities that require the use of a gown and gloves. The facility would provide education to residents and visitors on the importance of hand hygiene, especially when entering and exiting the residents' rooms and the facility. Position a trash can and laundry receptacle inside the resident's room and near the exit to discard PPE after removal, prior to exiting the room, or before providing care for another resident in the same room, or bag and remove trash and soiled laundry immediately. The facility would incorporate process surveillance to determine adherence and the need for additional training and education.

The facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and prepare food in a sanitary manner for the residents who resided in the facility and received meals from the facility's kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 06/16/25 at 08:40 AM, during initial tour of the facility's kitchen, observation revealed in the dry storage room, a case of [NAME] Pears (six #10 size cans) sitting directly on the floor, and a box of oatmeal cream pies also sat directly on the floor. Further observation revealed in the walk-in freezer a bag of sliced zucchini sitting directly on the floor of the freezer, along with a box of frozen buns. Dietary Staff (DS) BB reported that the delivery truck had come during the past week, and the supplies on the stock room floor should have been put on the shelves. DS BB reported that the zucchini and box of buns had fallen from the shelf and should not be sitting on the floor of the walk-in freezer. The facility's Food-Supply Storage-Food and Nutrition Services policy, dated 03/07/25, documented that all food/supply items are stored six inches off the floor. Stored items did not touch the walls, ceiling, or sewer/waste disposal pipes.

The facility had a census of 26 residents. The sample included 12 residents. Based on observation and interview, the facility failed to serve the midday meal within 45 minutes of the designated time of 11:30 AM. This deficiency placed the residents at risk of an impaired dining experience. Findings included: - On 06/16/25 at 11:18 AM, Dietary Staff (DS) CC placed water, a variety of beverages, and silverware on the dining room tables. Residents entered the dining room independently or with staff assistance. Facility staff assisted the residents with shirt protectors as needed and requested. The staff shared the daily devotional reading and announced the meal was to be roast beef, fried potatoes, and cooked cabbage. On 06/16/25 at 12:16 PM, the first meal from the kitchen was served. On 06/16/25 at 12:35 PM, Resident (R) 7 and R17 had been present in the dining room since 11:30 AM, when DS CC reported the kitchen ran out of roast beef and inquired what the residents would like from the alternative menu. On 06/16/25 at 12:50 PM, R7 and R17 reported they were always served last, and often the meals on the menu ran out. R7 and R17 stated they would have selected the roast beef. A staff member took a plate of roast beef and cabbage to the breakroom. The staff reported that R7 and R17 usually requested hamburgers, and the roast beef had been the end pieces of the roast that were not going to be served to the residents. On 06/16/25 at 12:55 PM, R7 and R17 were served cheeseburgers and fried potatoes. On 06/17/25 at 12:50 PM, the last meal had been served. Residents were present in the dining room at 11:30 AM. The meal menu of broccoli was substituted for cauliflower, which had not been reported or announced to the residents. The other menu item of tomato salad was not available, so DS BB offered tomato soup as an alternative. On 06/17/25 at 03:00 PM, DS BB reported the meals were not plated and ready for meal delivery until other DS CC had placed silverware and drinks on the tables. The facility's Dignity in Dining-Food and Nutrition Services policy, dated 11/05/24, documented that the location would promote dining services for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality, cultural, ethnic, and religious beliefs.

The facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide Resident (R) 18 or their representative the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and failed to provide R27 or their representative the completed CMS Notice of Medicare Non-Coverage (NOMOC) form 10123. This placed the resident at risk of uninformed decisions about their skilled services. Findings included: - Review of the CMS form provided to R18 revealed the resident received the wrong form. R18 received the CMS-R-131 and the CMS 10055 form, but had not received the CMS Form 10123. The resident's skilled services ended on 06/04/25. Review of the CMS form provided to R27 revealed the resident received the wrong form. R27 received the CMS -R-131 instead of the CMS form 10055 and failed to receive the CMS 10123 form. The resident's skilled services ended on 06/08/25. The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The Medicare NOMOC form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. I understand that if Medicare does not pay, I will be responsible for payment, but I can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. A provider must issue advance written notice to enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF). If an enrollee files an appeal, then the plan must deliver a detailed explanation of why services should end. On 06/18/25 at 10:00 AM, Administrative Nurse D verified the facility provided the CMS-R-131 form to R18 and R27, and/or their representative, and failed to provide R18 the 10055 form and failed to provide R27 with the CMS 10055 and the CMS 10123 forms to determine if the residents wished to continue services. The facility's Advance Beneficiary Notices policy, dated 01/14/2023, documented Medicare's limitation on liability requires a provider to notify a Medicare beneficiary in advance of furnishing an item or service that is believed to be likely denied by Medicare in order to shift financial liability to the beneficiary. The Advance Beneficiary Notice of Noncoverage (ABN) informs the beneficiary of potential non-coverage and shift of financial liability for those items or services if Medicare denies the claim. The Medicare Administrative Contractor (MAC) may hold any provider financially liable who either failed to give notice when required or gave invalid notice. A provider who cannot demonstrate adequate advance notice was given to the beneficiary cannot transfer financial liability to the beneficiary. The ABN is to be issued prior to providing any item or service that is usually paid for by Medicare, but may not be paid for in this particular case because it is not considered medically reasonable and necessary. The ABN is evidence of the beneficiary's knowledge about the likelihood of a Medicare denial for the purpose of determining financial liability for expenses incurred for services furnished to a beneficiary for which Medicare does not pay. If Medicare is expected to deny payment, an ABN must be given to the beneficiary in order to transfer financial liability for the services for the following circumstances: Skilled Nursing facility prior to providing therapy services, usually paid for under Medicare Part B, but are no longer considered medically reasonable and necessary. The provider will issue the ABN of non-coverage to appropriately inform the beneficiaries of potential financial liability and to allow the beneficiary the opportunity to request a Medicare demand bill review.

The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to investigate an allegation of sexual abuse and initiate protective measures until an investigation was completed. On 07/24/24 at 09:37 PM Resident (R)1 told her daughter that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. On 07/25/24 R1's representative arrived at the facility and spoke with LN G. LN G told R1's representative she felt R1 may have been dreaming. LN G did not report the allegation to administration for almost 24 hours. R1's representative returned to the facility on [DATE] and spoke with Administrative Nurse D. Administrative Nurse D told R1's representative LN G had already investigated the incident and determined the resident had been dreaming. Administrative Staff A confirmed no further investigation was conducted because she and Administrative Nurse D agreed with LN G's conclusion. The facility's failure to initiate protective measures to prevent further sexual abuse and failure to investigate the abuse allegation placed R1 and all other cognitively impaired residents in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), weakness, and macular degeneration (progressive deterioration of the retina). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was independent with eating and oral care and required moderate assistance from one staff for toileting, transfer, dressing, personal hygiene, and bathing. The MDS recorded R1 had no behaviors including hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Functional Abilities Care Area Assessment (CAA), dated 03/05/24, documented R1 was alert and oriented with a BIMS score of 15. The CAA documented R1 had macular degeneration but was able to see well enough to assist with her activities of daily living (ADLs). The CAA documented R1 was independent with mobility in her wheelchair and at times walked short distances in her room using her walker to go to the bathroom. The facility goal for R1 was for R1 to maintain her independence as much as possible and to provide R1 help when she needed it. The Visual Function CAA, dated 03/05/24, documented R1 had a diagnosis of macular degeneration. The CAA documented R1 was not able to see well enough to read a book but was able to see well enough to safely navigate the halls and feed herself. R1's Care Plan, documented R1 primarily used a wheelchair in the hall and self-propelled herself using her feet or the handrails. R1 could walk in her room with assistance from one staff and her walker. R1 chose to sleep in her recliner and could make position changes in the recliner. The care plan documented R1 required one staff's assistance for dressing, toileting, and transfers. On 07/30/24, a new focus was placed in R1's Care Plan which documented R1 had a behavior symptom related to dreaming. The plan documented R1 would have no evidence of behavior problems of dreaming of men being in her room and minimize the potential for R1's disruptive behaviors of feeling men in her room by having a second person in the room when a male is in the room with R1. The Mood/Behavior Note, dated 07/25/24 at 04:20 AM, documented LN G received a phone call from R1's representative at 10:00 PM on 07/24/24. R1's representative just got off the phone with R1 and R1 stated some man had come into her room, pulled off her covers while R1 sat in her recliner, and tried to get into her pants. R1's representative asked LN G if there were any male staff working and LN G stated no. R1's representative asked if it could have possibly been a male resident. LN G explained there were three male residents down R1's hall but they were at the end of the hallway and were all in bed and no other males were in the facility. R1's representative requested the incident be reported to Administrative Nurse D. LN G explained to R1's representative that she had been down R1's hall multiple times between 09:00 PM and 10:00 PM. LN G explained to R1's representative R1 seemed tired that evening when she received her night meds and breathing treatment and R1 had also been sleeping. R1's representative requested R1 be checked on throughout the night. LN G assured R1's representative staff would do so. LN G went down to check on R1. R1 was on the phone with her representative again. R1 seemed very confused. R1 asked her representative multiple times if it was August yet and R1 repeated the same topic over and over. Later at 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. R1 told LN G that some man came into her room and pulled on her butt hair. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? LN G documented R1 concluded that she had dreamt it. The Other Communication Note, dated 07/30/24, documented the ombudsman came to the facility to visit with R1 regarding R1's representative called and reported a man had been in R1's room and R1 claimed the man had pulled her pants down while she was in her recliner. R1 told the Ombudsman she was molested last night. The ombudsmen asked R1 if she felt safe at the facility. R1 said the staff were taking care of her and she felt safe. The ombudsman then asked R1 about men in her room and R1 said She did not want men in her room. Staff asked R1 about the bath house as the bath aide was a male and R1 said it was fine for him to give her a bath. The ombudsman and staff discussed R1's plan of care and staff stated R1's Care Plan had already been changed to not have males alone in R1's room. The facility was unable to provide an investigation, incident report, and/or witness statements related to the incident. The updated timeline of events provided by the facility on 07/31/24, documented on 07/25/24 (this initial call occurred on 07/24/24) at 10:00 PM, LN G received a phone call from R1's representative. R1's representative had just got off the phone with R1 and R1 had stated some man had come into her room and pulled off her covers while R1 sat in her recliner and tried to get into her pants. At 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? On 07/25/24 at 09:03 PM LN G notified Administrative Nurse D of R1's mood and behavior and her findings of LN G's investigation. On 07/25/24 at 09:05 PM, Administrative Nurse D notified Administrative Staff A of R1's mood and behavior and LN G's investigation and findings. On 07/29/24, sometime in the morning, Administrative Staff A and Administrative Nurse D gave the results of the investigation to R1's representative. On 07/30/24, sometime in the afternoon, the ombudsman visited with the resident and social services. R1's Care Plan was reviewed and updated. On 07/31/24 at 09:45 AM, observation revealed R1 resided in a double occupancy room and sat in a recliner closest to the door with her eyes closed. On 07/31/24 at 09:45 AM, R1 stated that she thought a dirty old man had come into her room and tried to get in her pants, but he was gone now, and it had all been taken care of. R1 stated at the time of the incident she had feared the man coming back into her room. On 07/31/24 at 10:00 AM, R1's representative stated that on 07/24/24 at 09:37 PM she called R1 and R1 told her a dirty old man came into her room and was trying to get into her pants. R1's representative reported R1 slept in her recliner and said she had been dozing when it happened. R1's representative stated she called LN G to report the complaint. R1's representative stated LN G confirmed the were no male employees working that night. LN G told R1's representative she had been down R1's hallway passing medications and had not seen any residents walking in the hall. R1's representative stated LN G told her she would go down and talk to R1 and report the incident to Administrative Nurse D. R1's representative stated she called R1 back and was on the phone with R1 until 10:32 PM and no one came into R1's room. R1's representative stated she drove six hours to the facility on [DATE] and arrived at 05:00 PM and personally talked to LN G. LN G told R1's representative she documented the phone call in R1's chart and said R1 may have been dreaming; LN G said she notified Administrative Nurse D. On 07/31/24 LN G was unavailable for an interview. On 07/31/24 at 10:45 AM, Certified Nurse's Aide (CNA) M stated R1 had brought up the incident to her on Saturday, the weekend after it happened. R1 told CNA M that she had been molested and some man had put his hand down her pants. CNA M asked R1 if she was sure that happened and R1 stated Yes. CNA M stated she could not believe that this really happened to R1, and it must have been a dream or something in R1's mind that she thought really happened. CNA M stated R1 continued to bring up the incident. On 07/31/24 at 11:00 AM, Administrative Staff A stated that she and Administrative Nurse D had reviewed LN G's nurse's note and reviewed her investigation. Administrative Staff A stated R1 later told LN G that it may have been a dream. Administrative Staff A stated LN G reported that she was up and down the hall all evening passing meds and the two men on the hallway were in bed. Administrative Staff A stated the facility had not reported the incident to the state agency. Administrative Staff A stated she and Administrative Nurse D were satisfied with the investigation LN G had performed. Administrative Staff A stated she talked with Administrative Nurse D about having ongoing contact with family members when allegations of this type were reported. Administrative Staff A stated she did not know if there was any investigative report with witness statements related to this incident. Administrative Staff A stated she was notified of R1's allegations on 07/24/24 at 09:05 PM. On 07/31/24 at 11:30 AM, Administrative Staff A presented a handwritten timeline of the events and questioned if the facility was supposed to investigate allegations of abuse if the allegations were just a resident's dream. The facility failed to investigate R1's allegation of sexual abuse and initiate protective measures until an investigation was completed. This deficient practice placed R1 in immediate jeopardy and placed all cognitively impaired residents at risk for unidentified and ongoing abuse. On 07/31/24 at 12:46 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R1. On 07/31/24 at 03:00 PM, the facility submitted a plan with corrective actions to remove the immediacy. The corrective actions included: The facility initiated an investigation on 07/31/24 for allegations of abuse and neglect for R1. The abuse allegation was reported to the appropriate state agency, law enforcement, the facility's Medical Director, and R1's family. Immediate education was initiated for all nursing staff on recognizing and reporting abuse and neglect allegations. All interviewable residents were interviewed to identify any safety concerns. The onsite surveyor verified the implementation of the corrective actions and removal of the immediacy on 07/31/24. The deficient practice remained at a scope and severity of E.

The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported Resident (R)1's allegation of sexual abuse to the Licensed Nursing Home Administrator (LNHA) and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. On 07/24/24 at 09:37 PM, R1 told her representative that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. LN G did not report the abuse allegation until 07/25/24 at 09:03 PM. Administrative Staff A stated the allegation of sexual abuse was not reported to the appropriate state entities because LN G determined the resident had been dreaming. The facility failed to ensure staff reported an allegation of sexual abuse to the LNHA immediately and further failed to report the sexual abuse allegation to the required state entities including law enforcement. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), weakness, and macular degeneration (progressive deterioration of the retina). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was independent with eating and oral care and required moderate assistance from one staff for toileting, transfer, dressing, personal hygiene, and bathing. The MDS recorded R1 had no behaviors including hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Functional Abilities Care Area Assessment (CAA), dated 03/05/24, documented R1 was alert and oriented with a BIMS score of 15. The CAA documented R1 had macular degeneration but was able to see well enough to assist with her activities of daily living (ADLs). The CAA documented R1 was independent with mobility in her wheelchair and at times walked short distances in her room using her walker to go to the bathroom. The facility goal for R1 was for R1 to maintain her independence as much as possible and to provide R1 help when she needed it. The Visual Function CAA, dated 03/05/24, documented R1 had a diagnosis of macular degeneration. The CAA documented R1 was not able to see well enough to read a book but was able to see well enough to safely navigate the halls and feed herself. R1's Care Plan, documented R1 primarily used a wheelchair in the hall and self-propelled herself using her feet or the handrails. R1 could walk in her room with assistance from one staff and her walker. R1 chose to sleep in her recliner and could make position changes in the recliner. The care plan documented R1 required one staff's assistance for dressing, toileting, and transfers. On 07/30/24, a new focus was placed in R1's Care Plan which documented R1 had a behavior symptom related to dreaming. The plan documented R1 would have no evidence of behavior problems of dreaming of men being in her room and minimize the potential for R1's disruptive behaviors of feeling men in her room by having a second person in the room when a male is in the room with R1. The Mood/Behavior Note, dated 07/25/24 at 04:20 AM, documented LN G received a phone call from R1's representative at 10:00 PM on 07/24/24. R1's representative just got off the phone with R1 and R1 stated some man had come into her room, pulled off her covers while R1 sat in her recliner, and tried to get into her pants. R1's representative asked LN G if there were any male staff working and LN G stated no. R1's representative asked if it could have possibly been a male resident. LN G explained there were three male residents down R1's hall but they were at the end of the hallway and were all in bed and no other males were in the facility. R1's representative requested the incident be reported to Administrative Nurse D. LN G explained to R1's representative that she had been down R1's hall multiple times between 09:00 PM and 10:00 PM. LN G explained to R1's representative R1 seemed tired that evening when she received her night meds and breathing treatment and R1 had also been sleeping. R1's representative requested R1 be checked on throughout the night. LN G assured R1's representative staff would do so. LN G went down to check on R1. R1 was on the phone with her representative again. R1 seemed very confused. R1 asked her representative multiple times if it was August yet and R1 repeated the same topic over and over. Later at 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. R1 told LN G that some man came into her room and pulled on her butt hair. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? LN G documented R1 concluded that she had dreamt it. The Other Communication Note, dated 07/30/24, documented the ombudsman came to the facility to visit with R1 regarding R1's representative called and reported a man had been in R1's room and R1 claimed the man had pulled her pants down while she was in her recliner. R1 told the Ombudsman she was molested last night. The ombudsmen asked R1 if she felt safe at the facility. R1 said the staff were taking care of her and she felt safe. The ombudsman then asked R1 about men in her room and R1 said She did not want men in her room. Staff asked R1 about the bath house as the bath aide was a male and R1 said it was fine for him to give her a bath. The ombudsman and staff discussed R1's plan of care and staff stated R1's Care Plan had already been changed to not have males alone in R1's room. The facility was unable to provide an investigation, incident report, and/or witness statements related to the incident. The updated timeline of events provided by the facility on 07/31/24, documented on 07/25/24 (this initial call occurred on 07/24/24) at 10:00 PM, LN G received a phone call from R1's representative. R1's representative had just got off the phone with R1 and R1 had stated some man had come into her room and pulled off her covers while R1 sat in her recliner and tried to get into her pants. At 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? On 07/25/24 at 09:03 PM LN G notified Administrative Nurse D of R1's mood and behavior and her findings of LN G's investigation. On 07/25/24 at 09:05 PM, Administrative Nurse D notified Administrative Staff A of R1's mood and behavior and LN G's investigation and findings. On 07/29/24, sometime in the morning, Administrative Staff A and Administrative Nurse D gave the results of the investigation to R1's representative. On 07/30/24, sometime in the afternoon, the ombudsman visited with the resident and social services. R1's Care Plan was reviewed and updated. On 07/31/24 at 09:45 AM, observation revealed R1 resided in a double occupancy room and sat in a recliner closest to the door with her eyes closed. On 07/31/24 at 09:45 AM, R1 stated that she thought a dirty old man had come into her room and tried to get in her pants, but he was gone now, and it had all been taken care of. R1 stated at the time of the incident she had feared the man coming back into her room. On 07/31/24 at 10:00 AM, R1's representative stated that on 07/24/24 at 09:37 PM she called R1 and R1 told her a dirty old man came into her room and was trying to get into her pants. R1's representative reported R1 slept in her recliner and said she had been dozing when it happened. R1's representative stated she called LN G to report the complaint. R1's representative stated LN G confirmed the were no male employees working that night. LN G told R1's representative she had been down R1's hallway passing medications and had not seen any residents walking in the hall. R1's representative stated LN G told her she would go down and talk to R1 and report the incident to Administrative Nurse D. R1's representative stated she called R1 back and was on the phone with R1 until 10:32 PM and no one came into R1's room. R1's representative stated she drove six hours to the facility on [DATE] and arrived at 05:00 PM and personally talked to LN G. LN G told R1's representative she documented the phone call in R1's chart and said R1 may have been dreaming; LN G said she notified Administrative Nurse D. On 07/31/24 LN G was unavailable for an interview. On 07/31/24 at 10:45 AM, Certified Nurse's Aide (CNA) M stated R1 had brought up the incident to her on Saturday, the weekend after it happened. R1 told CNA M that she had been molested and some man had put his hand down her pants. CNA M asked R1 if she was sure that happened and R1 stated Yes. CNA M stated she could not believe that this really happened to R1, and it must have been a dream or something in R1's mind that she thought really happened. CNA M stated R1 continued to bring up the incident. On 07/31/24 at 11:00 AM, Administrative Staff A stated that she and Administrative Nurse D had reviewed LN G's nurse's note and reviewed her investigation. Administrative Staff A stated R1 later told LN G that it may have been a dream. Administrative Staff A stated LN G reported that she was up and down the hall all evening passing meds and the two men on the hallway were in bed. Administrative Staff A stated the facility had not reported the incident to the state agency. Administrative Staff A stated she and Administrative Nurse D were satisfied with the investigation LN G had performed. Administrative Staff A stated she talked with Administrative Nurse D about having ongoing contact with family members when allegations of this type were reported. Administrative Staff A stated she did not know if there was any investigative report with witness statements related to this incident. Administrative Staff A stated she was notified of R1's allegations on 07/24/24 at 09:05 PM. On 07/31/24 at 11:30 AM, Administrative Staff A presented a handwritten timeline of the events and questioned if the facility was supposed to investigate allegations of abuse if the allegations were just a resident's dream. The facility failed to ensure staff immediately reported R1's allegation of sexual abuse to the LNHA and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. This deficient practice placed R1 in immediate jeopardy. On 07/31/24 at 12:46 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R1. On 07/31/24 at 03:00 PM, the facility submitted a plan with corrective actions to remove the immediacy. The corrective actions included: The facility initiated an investigation on 07/31/24 for allegations of abuse and neglect for R1. The abuse allegation was reported to the appropriate state agency, law enforcement, the facility's Medical Director, and R1's family. Immediate education was initiated for all nursing staff on recognizing and reporting abuse and neglect allegations. All interviewable residents were interviewed to identify any safety concerns. The onsite surveyor verified the implementation of the corrective actions and removal of the immediacy on 07/31/24. The deficient practice remained at a scope and severity of D.

The facility identified a census of 27. The sample included three residents reviewed for pressure injuries/ulcers. Based on record review and interview, the facility failed to ensure adequate treatment to prevent the worsening of a facility acquired pressure ulcer and failed to promote healing. On 12/15/23, Resident (R) 1, who required assistance from two staff for bed mobility, developed a facility acquired unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer to her left heel. The facility applied heel protectors but did not involve the provider until seven days later. The provider ordered a dressing to the wound, changed every seven days. The wound became stagnant and lacked any signs of healing from 12/22/23 through 03/23/24 when a new treatment was started. The facility also did not measure the wound for two weeks from 03/09/24 through 03/22/24. On 03/29/24, the facility spoke with the dietician and the telehealth wound nurse and received new orders for R1's deteriorating wound but did not involve the physician despite increased wound dimensions and the presence of signs of possible infection including increased drainage and pain, until 04/02/24 when the facility received a new order from the wound nurse and the facility's medical director. On 04/03/24, the facility identified drainage from the wound and a new open area on the inside of the left foot but did not notify the physician. On Saturday, 04/06/24, the facility documented R1 would go for a podiatry referral the following Tuesday. On 04/07/24, R1 was assessed by her provider and sent to the hospital for respiratory issues and wound care. Upon admission to the hospital, R1's left heel wound was necrotic (pertaining to the death of tissue in response to disease or injury) with purulent (producing or containing pus), foul-smelling drainage and had advanced to a Stage 4 pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone) with exposed bone. Further testing revealed R1 had osteomyelitis (local or generalized infection of the bone and bone marrow) of her left heel bone. R1 was sent to a higher level of acute care for wound care and vascular evaluation. The surgeon recommended amputation (surgical removal) of the left lower extremity, above the knee. R1 and her family did not want the procedure. R1 was placed on palliative care and passed away on 04/27/24 at the local hospital. The facility's failure to notify and involve the physician and ensure physician assessment of an evolving, and progressively worsening, facility acquired pressure ulcer placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), moderate protein calorie malnutrition, weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 required moderate staff assistance for bed mobility, maximum staff assistance with sit to stand, chair to bed transfer, toileting, and bathing. The MDS documented R1 did not ambulate. The MDS documented R1 was admitted to the facility with intact skin and was at risk for pressure ulcer development. The MDS documented R1 had a pressure reducing device for her chair, a pressure reducing device for her bed, and was on a turning/repositioning program. R1 was not on a nutrition or hydration program to manage skin problems. The Admission Function Abilities Care Area Assessment (CAA), dated 11/27/23, documented R1 presented to the facility with weakness, poor coordination, impaired balance, and pain related to her MS. The CAA documented R1 had occasional urinary incontinence which was likely due to her immobility. The CAA documented R1 was no longer able to ambulate and due to the progressive neurological nature of her disease process, R1 was not expected to improve. The Admission Pressure Ulcer/Injury CAA, dated 11/27/23, documented R1 was at risk for skin breakdown due to her need for staff assistance for bed mobility, having an at risk Braden (assessment tool used to predict risk for pressure injuries) score, and being on psychotropic (alters mood or thought) medications. The CAA documented R1 had no skin issues oat the time of her admission on 11/21/23. The CAA documented all residents of the facility had mattresses that helped with weight distribution to help prevent skin breakdown from occurring. The CAA documented R1 was on a turning/repositioning program and had a pressure reducing cushion in her wheelchair to help reduce her risk and help maintain her skin integrity. The CAA documented the goal was for R1 to remain free from skin breakdown. The Significant Change MDS, dated [DATE], documented R1's BIMS score was 12, which indicated moderately impaired cognition. The MDS documented R1 had one or more unhealed pressure ulcers. The MDS documented R1 had one unstageable pressure ulcer due to slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue), and this pressure ulcer was not present on R1's admission. The CAA documented R1 had a pressure reducing device for her chair, a pressure reducing device for her bed, was on a turning/repositioning program, and was receiving pressure ulcer care. The CAA documented R1 was not receiving an application of any dressing to her feet with or without topical medications. The Significant Change Functional Abilities CAA, dated 02/27/24, documented R1 required assistance with her activities of daily living (ADL's), had an unstageable pressure ulcer to her left heel, and R1's decline was felt to be due to the progression of her MS; she was not expected to improve. The Significant Change Pressure Ulcer/Injury CAA, dated 02/27/24, documented R1 had an unstageable pressure ulcer to her left heel. She was incontinent, dependent on staff for mobility, and had an at risk Braden score. The CAA documented R1 had an air mattress, was on a turning/repositioning program, and had a cushion to her wheelchair. The CAA documented R1 had MS which was the biggest contributing factor that restricted her mobility. R1's Care Plan directed staff R1 required assistance from two staff for all bed mobility (11/23/23). The care plan directed staff to provide R1 a pressure reducing mattress and cushion and to float her heels (11/23/23). The care plan directed staff to notify the nurse immediately of any new areas of skin breakdown redness, blisters, bruises, or discoloration noted during baths or daily care (12/15/23). The care plan directed staff to provide R1 an air mattress due to R1 refused to get out of bed sometimes and was at risk for further skin breakdown (01/11/24). R1 was non-ambulatory and used a wheelchair with bilateral foot pedals propelled by staff (01/12/24). The care plan directed staff to place an Allevyn (foam dressing) heel dressing and change on bath days; the dressing could be left on for seven days and change as needed (01/24/24). The care plan directed staff R1 required two staff assistance with check and changes with position change (03/27/24). The care plan lacked direction regarding how often R1 was to be repositioned. The care plan directed staff to ensure heel protectors were on R1's feet (03/27/24). The care plan directed staff to perform a Wound Data Collection daily and to inform R1 and her family about any new area of skin breakdown (03/27/24). The care plan directed staff to apply a Xeroform (non-adherent dressing) foam dressing to the left heel and secure with Kerlix (cotton gauze) and paper tape and change daily (03/27/24). The care plan directed staff to avoid positioning R1 on her right side. R1 could be placed on her left side or on her back with heel protectors on and feet elevated as much as possible (04/06/24). The care plan directed staff to apply calcium alginate (a highly absorbent dressing for cavity wounds with moderate to heavy drainage), cover with bordered foam dressing, secure with Kerlix and paper tape and change every day (04/11/24). (This intervention was never performed in the facility as R1 never returned). The Kardex [nursing tool that gives a brief overview of the care needs of each resident] did not address any turning or repositioning program or directives for R1. The Admission Braden Scale, dated 11/21/23, documented R1 a score of 16, which indicated mild risk. The Braden Scale intervention guide recommended frequent turning (e.g., every two hours), maximal remobilization, pressure reduction support surfaces if bed or chair bound, protect heels, manage moisture, manage nutrition, manage friction and shear (the separation of skin layers caused by friction or trauma). If other major risk factors were present advance to next level of risk. On admission, on 11/21/23, R1 had an order for thrombo-embolic deterrent hose (TED-compression stockings) to her bilateral legs, on in the morning and off at night. This order was discontinued on 12/19/23. Review of R1's clinical record lacked evidence the staff who signed off on the application and removal of the TED hose noted any skin changed to R1's left heel. R1's medication Review Report documented an order dated 11/29/23 for house shake nutritional supplements, 120 milliliters with meals. R1's EMR recorded a Physician's Order dated 12/01/23 to start on 12/08/23, for a weekly skin check every Friday. The Skin Observation Tool, dated 12/08/23, documented R1's skin check was completed and had no skin conditions observed. The Skin Observation Tool, dated 12/15/23, documented R1 had an unstageable pressure ulcer to the left medial (inner) heel. The Skin Observation Tool lacked evidence staff notified R1's primary care physician or family of the unstageable pressure ulcer. The Wound Data Collection Tool, dated 12/15/23, documented R1 had an unstageable pressure ulcer with eschar to her left heel that measure 2 centimeters (cm) by 3.5 cm with no depth. The wound bed was covered with 100 percent eschar. The surrounding skin was intact and pink. This was the initial data collection on the pressure ulcer and the pressure ulcer was not present on admission. There was no dressing on R1's left heel wound. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family of the pressure ulcer. The Wound Data Collection Tool, dated 12/16/23, documented R1 had an unstageable pressure ulcer to her left heel. The wound was 100% covered with eschar. No dressing had been placed to the left heel wound. A pressure relieving gel heel protector was placed to R1's left heel. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family. The Wound Data Collection Tool, dated 12/17/23, documented R1 had a pressure ulcer to her left heel with pink blanchable surrounding skin. No dressing was present to the left heel wound. Blue heel protectors were placed to R1's heels. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family. The Wound Data Collection Tool, dated 12/19/23, documented R1 had a pressure ulcer to her left heel which measured 1.5 cm by 2 cm. Eschar covered 100 % of the wound bed. The surrounding skin was pink, intact, and macerated (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, feces, or wound drainage for extended periods). There was no dressing to R1's left heel. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family. The Communication/Visit with Physician Note, dated 12/22/23, documented a new order for Allevyn heel dressing to R1's left heel. Change every seven days or as needed. This Communication/Visit with Physician Note was the first documented evidence of notification to the physician of R1's unstageable pressure ulcer to her left heel, dated 12/22/23, seven days after staff discovered the pressure injury. The Wound RN Assessment, dated 12/22/23, documented R1 had an unstageable pressure ulcer to her left heel. The wound was covered with eschar and had minimal drainage. R1's physician was notified regarding the wound status and a new order for Allevyn heel dressing was ordered. Modifications to R1's interventions were repositioning/turning, support surfaces, nutrition, friction/shear management, and wound treatment. R1's Treatment Administration Record (TAR), dated December 2023, documented an order for Allevyn dressing to the left heel; may be on up to seven days, change as needed, and check twice daily, with a start date of 12/22/23. The Wound Data Collection Tool, dated 12/29/23, documented R1 had an unstageable pressure ulcer to her left heel which measured 3.5 cm by 3.2 cm. The wound bed was covered with 95% eschar and 5% granulation (new tissue formed during wound healing). The record lacked evidence staff notified R1's primary care physician of the increased size of R1's wound. The January 2024 TAR, documented an order for an Allevyn dressing to the left heel. The dressing could stay on up to seven days. Change as needed. Check twice daily with a start date of 12/22/23. The Wound Data Collection Tool, dated 01/03/24, documented R1 had an unstageable pressure ulcer which measured 2.5 cm by 2.5 cm. The wound bed was covered with 95% of eschar and 5% of granulation. The wound had a moderate amount of purulent drainage. The record lacked evidence staff notified R1's primary care physician of the purulent drainage. The Wound RN Assessment, dated 01/03/24, documented R1 had an unstageable pressure ulcer to her left heel. The top layer of the wound was peeling back with pink tissue noted underneath. The note documented to continue the current plan of treatment. The Health Status Note, dated 01/03/24, documented R1 was not safe to transfer with the sit-to-stand lift and would be transferred with a full body lift from then on. The Wound Data Collection Tool, dated 01/09/24, documented R1 had an unstageable pressure ulcer to her left heel which measured 3 cm by 3 cm. There was no dressing present. The wound bed was covered with 100% eschar. The record lacked evidence staff notified R1's primary care physician. The Care Plan Change Note, dated 01/11/24, documented an air mattress was added due to R1 refused to get out of bed some of the time and risk for further skin break down. The Care Plan Change Note, dated 01/12/24, documented the mobility bars were removed from R1's bed. The Wound RN Assessment, dated 01/12/24, documented R1 had an unstageable pressure ulcer to her left heel. The left heel wound was documented as a deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) and the area was hard, with skin flaking off. The underneath skin was healed. The record lacked evidence staff notified R1's primary care physician. The 1-16-24 Clinic Visit documented R1 was seen by her physician with a chief complaint of none recorded. The visit recorded a reviewed problem of a left heel wound with an onset date of 10/27/22 [sic]. The HPI [history of present illness] section recorded the resident was calmy sitting in a chair. She initially voiced no concerns. She did then remark that she had some swelling in her legs and feet. Nursing reported she had recurrent urinary tract infections. The resident denied shortness of breath. The Musculosketal section documented R1 had normal muscle strength and poor tone; she had two plus edema (swelling) to her lower extremities. The document noted R1 had heel protector boots on and a dressing to the right [sic] heel. The note followed this with not removed. The Assessment/Plan section did not address or mention the wound. The Wound RN Assessment, dated 01/19/24, documented R1 had a non-pressure wound with partial thickness tissue loss. The note documented to continue with the current treatment. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 01/19/24, documented R1 had an unstageable pressure wound to her left heel that measured 4 cm by 3.5 cm with dry flaky skin. The wound bed was covered with 100 % eschar. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 01/22/24, documented R1 had a non-pressure wound with partial thickness tissue loss. The noted documented to continue with the current treatment plan. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 01/29/24, documented R1's left heel wound was a non-pressure wound with partial thickness tissue loss. The nurse documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 01/30/24, documented R1 had a pressure ulcer to her left heel which measured 3.75 cm by 3.25 cm and was a deep tissue injury. The wound bed was 100% covered with eschar. The record lacked evidence staff notified R1's primary care physician. R1's February 2024 TAR, documented an order for an Allevyn dressing to the left heel. May be on up to seven days. Change as needed. Check twice daily with a start date of 12/22/23. The Wound Data Collection Tool, dated 02/13/24, documented R1 had a deep tissue unstageable pressure ulcer to her left heel that measured 4.5 cm by 3 cm. The wound bed was 100% covered with eschar and had minimal sanguineous (bloody drainage) drainage. The description of the dressing was a Medihoney (medical-grade honey used to aid wound healing) patch to the wound bed, covered with an Allevyn heel dressing, and secured with paper tape. The record lacked evidence staff notified R1's primary care physician. R1's EMR lacked orders regarding the use of Medi-honey to the wound. The Wound Data Collection Tool, dated 02/19/24 documented R1 had a deep tissue unstageable pressure ulcer to her left heel that measured 3.5 cm by 4.0 cm. Drainage was present on the dressing and leaking around the dressing. The wound bed was 100% covered with eschar. The surrounding skin was pink and macerated. The dressing description described Medihoney pad with an Allevyn dressing secured with tape. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 02/19/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented the wound had smaller measurements with new tissue growth after the eschar sloughed off. The note documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. The Late Entry Communication with Dietitian Note, dated 02/19/24 but created on 04/06/24, documented the dietitian was notified via email of R1's deep tissue injury and recommended to continue current protein supplement with no other recommendations given. The Health Status Note, dated 02/20/24, documented the dressing was changed to R1's left heel due to the dressing being soiled. The 2-20-24 Clinic Visit documented R1 was seen by her physician with a chief complaint of NH [nursing home] 2nd 30 day visit The visit recorded a reviewed problem of a left heel wound with an onset date of 10/27/22. The HPI section recorded the resident was doing better feeding herself and asked how long she will be there. She denied pain. She was wearing heel protectors and denied pain or other concern. Her husband continued to help her. She had gotten over recent pneumonia (inflammatory condition of the lungs). The Musculosketal section documented R1 had normal muscle strength and poor tone; her joints, bones, and muscles showed no contractures (abnormal fixation of joints or muscles), malalignment, tenderness, or bony abnormalities. She had normal movement of all extremities. Extremities: edema (tr to LE but feet in heel protectors.). The document noted R1 had edema and wore heel protectors. The Assessment/Plan section did not address or mention the wound. The Other Progress Note, dated 02/23/24, documented a fax was sent to the clinic to request an order for Vitamin C 500 milligrams (mg) daily for wound healing. The medication was received from the pharmacy. The Wound RN Assessment, dated 02/26/24, documented R1 had an unstageable pressure ulcer. The note documented to continue the current treatment. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 02/27/24, documented R1 had a deep tissue injury unstageable pressure ulcer to her left heel that measured 4 cm by 4 cm with 0.1 cm in depth. The wound bed was covered with 95% of eschar and 5% epithelial (denoting the tissue forming the outer layer of the of the body's surface) tissue. The wound had a moderate amount of serosanguineous (semi-thick blood-tinged drainage) drainage. The dressing description was Medihoney with an Allevyn dressing. The record lacked evidence staff notified R1's primary care physician. The MDS Note, dated 02/27/24, documented the facility had changed R1's Quarterly MDS to a Significant Change MDS due to recent behaviors noted, a decline in the BIMS score, and a 5% weight loss over 30 days. R1 had a long-standing history of MS with complaints of frequent pain. R1 had a pressure ulcer to her left heel and slept on an air mattress. The March 2024 TAR, documented an order for an Allevyn dressing to the left heel. May be on up to seven days. Change as needed. Check twice daily with a start date of 12/22/23. This order was discontinued on 03/22/24. The Wound RN Assessment, dated 03/05/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented to continue with the current plan of care. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 03/08/24, documented R1 had a full thickness pressure ulcer to her left heel that measured 4.4 cm by 4 cm by 0.1 cm. The wound bed was 75% covered with eschar and 25% covered with granulation. There was a moderate amount of serosanguineous drainage present. The noted documented the wound was very tender to the touch. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 03/13/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. R1's clinical record lacked evidence of staff measuring the unstageable left heel ulcer from 03/09/24 through 03/22/24. The 3-19-24 Clinic Visit documented the physician saw R1 with a chief complaint of NH 30 day visit. The visit recorded a reviewed problem of a left heel wound with an onset date of 10/27/22. The HPI section recorded she had a visit with another doctor and had severe dementia based on the results of the Mini-Mental State examination (MMSE). The Physical Examination section lacked assessment the musculosketal or skin. The Assessment/Plan section did not address or mention the wound. The Wound Data Collection Tool, dated 03/22/24, documented R1 had a deep tissue injury that was a full thickness wound to her left heel which measured 5 cm by 4 cm by 0.2 cm. The wound had a moderate amount of serosanguineous drainage that was foul smelling and had leaked out of the dressing. The wound bed was covered with 95% eschar and 5% epithelial tissue. The skin around the wound was denuded (skin that has had the first protective layer removed). The dressing was described as Xeroform with an Allevyn heel dressing. The tool lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 03/22/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented R1's wound was deteriorating evidenced by the wound continued to have a layer of eschar over the top of the wound. The note documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. Review of the Order Audit report for R1 revealed on 03/22/24 Licensed Nurse (LN) I entered an order for Xeroform, foam border dressing, secured with Kerlix and paper tape for pressure ulcer to left heel. Change every dayshift. The order was entered as a prescriber written order by Consultant HH. R1 clinical record lacked documentation when Consultant HH was contacted and lacked a provider visit note regarding the wound or a written order. The March 2024 TAR documented a new dressing order started on 03/23/24 for Xeroform, foam border dressing, secured with Kerlix and paper tape for pressure ulcer to left heel. Change every dayshift. A Late Entry Health Status Note, dated 03/23/24 but created on 04/12/24, documented Xeroform was started to help with wound management. A Clinic Referral (used for Visits to Doctor or Hospital Outpatient) dated 03/26/24 recorded a follow up for R1's upper respiratory infection; imaging of R1's chest and laboratory values were reviewed. The documentation lacked any mention of R1's wound and lacked evidence the wound was visualized or assessed by the provider. The Wound Data Collection Tool, dated 03/29/24 documented R1 had an unstageable pressure ulcer to her left heel that was a full thickness wound and in the middle of the wound was an area of hard eschar tissue. The wound measured 4.5 cm by 4 cm by 0.5 cm. There was heavy purulent foul-smelling drainage which had leaked out of the dressing. The collection tool noted there was the presence of possible complication to the wound as evidenced by a deep tissue injury surrounded the upper part of the left heel wound. R1 grimaced during the dressing change. The wound bed was 100% covered with eschar. The skin surrounding the wound was macerated and erythematous (red). The dressing description was Xeroform foam dressing secured with kerlix and paper tape. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 03/29/24, documented R1 had an unstageable pressure ulcer to her left heel that was deteriorating due to non-healing eschar. The note documented staff notified the wound nurse and the dietitian of the non-healing wound. The note lacked documentation staff notified R1's primary care physician. The Late Entry Health Status Note, dated 03/29/24 but created on 04/12/24, documented the facility staff spoke with the wound nurse and she recommended to continue with the Xeroform with an Allevyn heel protector and secure with tape. The note lacked documentation staff notified R1's primary care physician. R1's April 2024 TAR, documented an order for Xeroform foam border dressing, secured with Kerlix and paper tape for pressure ulcer to left heel, started on 03/23/24 and discontinued on 04/02/24. The Communication with Dietitian Note, dated 04/01/24, documented an email was sent to the dietitian regarding R1's non-healing wound. R1 continued house shakes three times a day with meals. The Communication/Visit with Physician Note, dated 04/02/24, documented new orders were received to add Santyl (an ointment to removed damaged tissue from chronic skin ulcers) to the wound bed, cover with Xeroform and foam bordered dressing, per the wound nurse and the facility's medical director. The Nutrition Status Note, dated 04/02/24, documented the dietitian was consulted regarding a non-healing wound on R1's left heel. R1 was receiving soft and bite sized diet with mildly thickened liquids and health shakes three times a day. Intake was good and R1 was eating greater than 50% of her meals 73% of the time over the past two weeks. R1's current weight was 100 pounds and weight had trended up since her admission in November 2023. R1's previous diagnosis was resolved: inadequate oral intake related to decreased appetite and adjustment to living situation. The dietitian documented R1's current diet and supplements should have been adequate to meet her estimated needs. R1 received a daily multivitamin supplement to optimize micronutrient intake for wound healing. The dietitian recommended to continue the current plan of care. R1's April 2024 TAR documented a new dressing order started on 04/03/24 to cleanse the wound to the left heel with wound cleanser, pat dry, place Santyl ointment on the wound bed; cover with Xeroform and wrap in gauze. Change daily. This order was discontinued on 04/05/24. The Nursing Services Note, dated 04/03/24, documented R1's dressing to her left heel had to be changed due to the dressing being saturated with drainage and the drainage going all the way through all the dressing and Kerlix. The dressing order was followed, left heel protectors were applied, and R1's left heel was floated on two pillows. A new sore was noted on the inside of R1's left foot. The nurse documented she would pass along the information to the day shift. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 04/04/24, documented R1 had an unstageable wound to her left heel and deterioration of the wound was evidenced by eschar tissue covering the top of the wound. The note documented R1's primary care physician was notified of the wounds status and the care plan was updated. Santyl was started to debride the dead tissue. The Wound Data Collection Tool, dated 04/05/24, documented R1 had an unstageable pressure ulcer to her left heel which measured 5.5 cm by 6 cm by 0.4 cm. The wound bed was covered with 75% eschar, 10% slough, and 5% epithelial tissue. There was a moderate amount of serosanguineous drainage. The surrounding skin was macerated and erythematous. The note documented a new treatment of calcium alginate to the wound bed covered with foam border, secured with kerlix and paper tape. R1's April 2024 TAR documented a new dressing change order dated 04/06/24 to cleanse the wound to the left heel with wound cleanser, pat dry, place calcium alginate on wound bed, cover with an Allevyn heel dressing, and secure with tape. (This order was placed on hold after R1 was admitted to the hospital.) The Communication Note, dated 04/06/24, documented due to R1's non-healing wound on her left heel and R1 was being referred to podiatry (foot doctor). An appointment was scheduled for Tuesday, 04/09/24, at the local hospital. The Health Status Note, dated 04/07/24, documented R1 was running a fever and her oxygen saturations were dropping into the low 80 percentiles (normal saturation are 93 percent or above). R1's oxygen was increased to 3.5 liters (L) and R1's oxygen saturation was still low. A mask was placed on R1, and her oxygen saturation came up to 90%. The staff contacted R1's family and they wanted the provider, a physician's assistant, to come down to see R1. The staff contacted R1's provider and he stated he would come to the facility and check on R1. The Health Status Note, dated 04/07/23, documented Consultant GG saw R1 and wanted R1 to be admitted to the hospital for an upper respiratory infection and for wound care. R1 was transferred to the local hospital. The Hospital Health and Physical (H&P), dated 04/07/24, documented R1 admitted with a Stage 4 pressure ulcer to her left heel. The H&P documented R1's left heel ulcer was necrotic and mushy with purulent foul-smelling drainage. The wound measured 6 cm by 6 cm by 0.5 cm. A wound culture obtained, showed R1's wound had Escherichia coli (E. coli-bacteria commonly found in the lower intestine that had a potential for causing infections in the urinary tract with inade[TRUNCATED]

The facility identified a census of 34 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to prevent a fall with major injury to Resident (R) 1. On 12/11/23 at approximately 07:45 AM, Certified Nurse's Aide (CNA) M failed to apply the safety belt in the bath chair. As a result of this failure, R1 sustained a displaced intertrochanteric (area between the greater and lesser hip bone) fracture (broken bone) of the right femur (the bone of the thigh). This deficient practice also placed R1 at risk for pain, decreased mobility, and impaired quality of life. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of three, which indicated severe cognitive impairment. The MDS further documented R1 was dependent on one to two staff for all activities of daily living (ADL) except eating. The MDS documented R1 had a previous fall in the observation period resulting in minor injury. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/21/23, documented R1's functional abilities, continence, and potential for cueing had declined due to his cognition. The Fall CAA, dated 11/21/23, documented R1 had a history of falls and was dependent on staff for mobility and dependent on staff for all of his cares. R1's goal was to be free from falls and free from injuries related to falls. R1's Care Plan directed staff R1 required one staff assistance for bathing. It directed staff to ensure R1 wore appropriate footwear (shoes or gripper socks), keep R1's bed in the lowest position with a fall mat in place. R1's Care Plan directed staff to ensure and provide R1 a safe environment and not leave R1 unattended in his wheelchair. The intervention dated 12/11/23 directed staff to have the safety belt on R1 while in the whirlpool. The Fall Risk Assessment, dated 11/21/23, documented R1 had a fall risk score of 15 which indicated R1 was a moderate risk for falls. The E-Task Documentation in R1's EMR for the month of December documented R1 was dependent on one to two staff for bathing and dressing. The Incident Note, dated 12/11/23, documented the shift nurse was called down to the bath house and R1 laid in front of the door. R1 did not have the bathtub safety belt in place and fell out of the bath chair. Staff completed neurological checks and notified R1's primary care physician. Staff notified R1's responsible party, and R1 was sent to the emergency room due to blood thinner protocols and R1's hip looked out of place. The Care Plan Change Note, dated 12/11/23, documented the new fall intervention would be safety belt on while in bath chair and two staff assistance with getting R1 dressed post bath. A Communication/Visit with Physician Note, dated 12/11/23, documented the local hospital notified the facility R1 would be transferred out to a higher level of care for a right hip fracture. Staff notified R1's responsible party of the transfer by the hospital. R1's emergency room Paperwork, dated 12/11/23, documented R1 had a fracture of the proximal (end closest to the pelvis) end of the right femur and was transferred to a higher level of care. The hospital History and Physical, dated 12/11/23, documented R1 had a fall off of a shower stool and reported pain to his right hip. R1 went to the local hospital where radiographs (x-ray) revealed a displaced intertrochanteric fracture of the right hip. The recommendation was for surgical stabilization of the fracture however R1 did have some significant underlying comorbidities (the simultaneous presence of two or more diseases or medical conditions that may be risk factors for poor outcome). A lengthy conversation was held with R1's responsible party and R1's responsible party opted for surgical intervention due to R1's pain level. The risks versus benefits were discussed with R1's responsible party and a closed reduction with internal fixation was planned for 12/13/23. The Hospital Progress Note, dated 12/12/23, documented R1 rested comfortably in bed but indicated he had pain in the right hip. R1's right leg was shorter than the left leg by approximately two inches and was externally rotated. R1's EMR recorded an Admission/Readmission Note, dated 12/15/23, which documented R1 admitted back to the facility from the surgical unit. R1 slept a lot more, had dysphagia (difficulty swallowing) and moved to level five foods with thin liquids. R1's last bowel movement was 12/15/23. A Health Status Note, dated 12/20/23, documented R1 refused his morning medication and as needed Tylenol (pain medication). R1 denied pain when he was not moving. R1 hollered out, grimaced, and tensed up when the nurse moved his right lower extremity. R1 reported a little pain with movement. R1 continued to refuse pain medication. R1's bilateral (both sides) lower extremities were elevated on a leg elevation pillow; a pillow was folded in half and placed between R1's knees to assist in reducing inward rotation of the right lower extremity. The Whirlpool Spa Manufacturer's Operation Manual, directed staff to use the safety belt at all times to ensure resident and staff safety. On 01/03/24 at 10:25 AM, observation revealed R1 laid in bed with pillows between his legs. R1 was awake but appeared confused and was unable to answer any questions. On 01/03/24 at 10:35 AM, CNA N stated that she was never trained to use the safety belt on residents in the bath chair and she had never used the safety belt on R1 prior to the incident on 12/11/23. CNA N stated that she was trained on using the safety belt on all residents after the incident. On 01/03/24 at 10:45 AM, Administrative Nurse D stated she expected all staff to utilize the safety belt on the whirlpool bathchair when giving residents a bath. Administrative Nurse D stated that all staff had been trained regarding abuse and neglect policy and the bathing policy plus safety procedures. On 01/03/24 at 03:30 PM, CNA M stated she had not used the safety belt on R1 while he was in the bath chair in the whirlpool. CNA M stated that she was trained years ago to use the safety belt. CNA M stated she turned to get R1's clothing and when she turned back around, R1 was sliding off of the bath chair. The facility's Bathing Policy, reviewed 08/29/23, documented bath time should be relaxing and pleasant and is also a time when safety is a primary concern. The use of safety measures and equipment are designed to reduce the risk of injury to residents during a bathing experience. Manufacturer's directions for operating and maintaining equipment should be followed including the use of waist and chest safety belts/straps. The facility failed to ensure an environment free from preventable accident hazards when staff failed to apply the safety belt to R1 while he was in the whirlpool bath chair. As a result of the deficient practice R1 fell and sustained a fracture. This deficient practice also placed R1 at risk for pain, decreased mobility, and impaired quality of life. On 12/20/23 the facility identified and completed the following corrective actions: staff education on Abuse, Neglect, and Exploitation and bathing, whirlpool, and shower clinical skills. All actions were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a G scope and severity.

The facility had a census of 33 residents. Based on observation, interview, and record review, the facility failed to ensure appropriate sanitation of dishware used for preparing and serving residents' meals, and failed to monitor cold temperature storage of resident foods. This deficient practice placed the 33 residents of the facility at risk for food borne illness. Findings included: - On 09/27/23 at 11:25 PM, observation revealed Dietary Staff (DS) CC operated the dishwasher and attempted to test the dishwasher rinse for chemical sanitation. The wash and rinse temperatures were less than 135 degrees Fahrenheit (F). She used Quat sanitizer testing strips which indicated no chemicals. The dishwasher was connected to Ecolab Ultra San (bleach). The Dishwasher Temperature Logs, dated July 2023, documented morning and noon only, lacked evidence staff assessed and monitored temperatures for 21 days. The documentation lacked evidence of chemical sanitation checks. The Dishwasher Temperature Logs, dated August 2023, documented morning and noon only, from 08/11/23 to 08/31/23 lacked evidence staff assessed and monitored temperatures the entire day for 08/11, 08/12, 08/13, 08/18, 08/25, 08/27, and 08/31. The documentation lacked evidence of chemical sanitation checks. The Dishwasher Temperature Logs, dated September 2023, documented temperatures for dishes at breakfast and lunch only. The log documented September 2023 wash temperatures were 120-125 F. and rinse temperatures were 128-135 F. Temperatures for 09/04, 09/09, 9/10, 09/26, and the AM temperature on 09/27 were not assessed and recorded. The log included one evening temperature and no sanitation checks for September. On 09/27/23 at 11:35 PM, observation revealed September 2023 Temperature Logs posted on the front of the walk-in refrigerator and freezer. DS CC stated she did not keep the previous months temperature logs. On 09/27/23 at 12:15 PM, observation revealed there was no thermometer in the refrigerator in the dining room which stored some resident food and snacks. Upon request, staff were unable to provide evidence of temperature monitoring for that refrigerator. On 09/27/23 at 11:30 AM, DS CC verified she did not understand how to check the sanitation for the dishwashing or that the temperature was not hot enough for adequate sanitation. She verified the facility did not have chemical test strips for bleach sanitation for the dishwasher. On 09/27/23 at 12:15 PM, DS CC stated the refrigerator in the dining room was for the nurses to use for resident snacks, foods, and drink; she did not monitor the temperature of that refrigerator. On 09/28/23 at 10:23 AM, Consultant GG stated she performed a quarterly review of the kitchen's temperature logbooks. She stated she educated the dietary manager to ensure staff monitored temperatures but did not educate the dietary manager regarding chemical sanitation. The facility's Ware washing- Mechanical and Manual policy, dated 04/03/23, stated food and nutrition employees were to ensure food preparation equipment, dishes and utensils were effectively cleaned, sanitized to destroy potential disease carrying organisms and stored in a protective manner. Staff were to check compliance for wash and rinse cycles each meal service. High temp: wash 150-165 with rinse 150-180F. Low temp: 120 F plus 50 parts per million (ppm) of sodium hypochlorite (bleach). The policy directed staff to record temperatures and or chemicals level on the temperature log. If the temperatures or chemicals were outside acceptable parameters, employees were to notify the director of food services or maintenance. The facility's Refrigerator/Freezer Temperature Log instruction sheet stated staff were to document and record refrigerator and freezer temperatures for the refrigeration unit twice daily on a separate log for each unit. The temperature logs were to be filed for one year. The facility failed to ensure appropriate sanitation of dishware used for preparing and serving residents' meals, and failed to monitor cold temperature storage of resident foods, placing the 33 residents of the facility at risk for food borne illness.

The facility had a census of 33 residents. Based on observation, interview, and record review the facility failed to employ a full time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 33 residents of the facility at risk for inadequate nutrition or food borne illness. Findings included: - On 09/27/23 at 11:00 AM, observation revealed Dietary Staff (DS) CC prepared the pureed vegetables. On 09/27/23 at 11:15 AM, DS CC verified she was the facility's dietary manager, but was not certified. She stated she was enrolled and taking classes since January 2023. Upon request the facility did not provide a policy for certified dietary manager. The facility failed to employ a full time certified dietary manager to supervise the preparation of meals and sanitation in the facility's kitchen, placing the 33 residents of the facility at risk for inadequate nutrition or food borne illness.

The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired quality of care. Findings included: - The facility's employment records documented six nurse aides were employed at the facility for at least one year. The facility's in-service records documented five of the six nurse aides had not completed the required 12 hours of in-service training annually. The Facility Assessment, dated 03/30/23, stated the facility would provide ongoing education and training for the staff throughout the year on the state required topics and other topics identified by Quality Assurance and Performance Improvement (QAPI). The assessment stated competency verification checklists were created for all staff and training on dealing with behaviors would be provided routinely. On 09/27/23 at 226 PM, Administrative Nurse D verified staff did not have the required amount of in-service education. She stated the in-service listings included competency checks. The facility's Competency and Mandatory Education Requirements policy, dated 05/22/23, stated the company was responsible to provide processes for ongoing education and competency achievement and employees were responsible to attain and maintain competency mandatory education required for their specific job description. The policy stated evidence of ongoing competency was required to be documented. Every department was expected to ensure ongoing competencies and mandatory education requirements that apply to their employees were completed within the designated timeframe and documented. The facility failed to ensure nurse aides employed at least one year completed 12 hours of required in-service education, placing the 33 residents of the facility at risk for impaired quality of care.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the environment remained free of accident hazards related to unlocked chemicals and unsecured hydocollator for five cognitively impaired, independently mobile residents. This placed the residents at risk for preventable accidents and injuries. Findings included: - On 09/28/23 at 07:30 AM, observation revealed an unlocked physical therapy room on the 300 Hall including one unattended hydrocollator (liquid heating device used in physical therapy to heat and store hot packs). On 09/28/23 at 7:35 AM, observation revealed an unlocked chapel room on the 300 Hall included the following items: One gallon-size jug of Superior Loot Formica Contact Adhesive, with the warning label may cause skin and eye irritation, and keep out of reach of children. Three four-gallon buckets of LokWork Resilient Adhesive, with the warning label may cause skin and eye irritation and use with local exhaust ventilation. One 32 ounce plastic bottle of odorless Backyard Grill Lighter Fluid, with the warning label inhalation -may be fatal if swallowed and enters airways, and keep out of reach of children and pets. Two tile floor scraping knives with a four inch wide blade. One eight-inch hand saw. On 09/28/23 at 07:45 AM, Administrative Staff A stated the physical therapy room should always be locked, and the chapel should be locked when the contractors' chemicals were temporarily stored in the room. Administrative Nurse D stated the facility had five cognitively impaired independently mobile residents. The facility's Storage of Equipment Products and Supplies policy, dated 04/14/23, documented all chemicals used for cleaning, sanitizing, disinfecting or for maintaining equipment would be labeled and stored in a manner that eliminates risk of improper use, contamination, inhalation, skin contact or personal injury. The facility's Heat Application policy, dated 11/29/22, documented the hydrocollator unit should be in an area not easily accessed by residents. The unit should be stored in a locked room when not in use. The facility failed to ensure the environment remained free of accident hazards related to unlocked chemicals and unsecured hydocollator for five cognitively impaired, independently mobile residents. This placed the residents at risk for preventable accidents and injuries.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident(R)1's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen, stored in the medication room, with the date openedand discard date. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 10:30 AM, observation of the facility's medication room revealed the following: R1's basaglar (long-acting insulin) flex pen lacked an open date and discard date. On [DATE] at 10:35 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the expired insulin. On [DATE] at 10:45 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the resident's name and discard expired pens. The facility's Storage of Medication policy dated [DATE] documented insulin pens would be clearly labeled with the name of the resident and verify the order, the expiration date, and the number of days the pen has been opened. The facility failed to label, and date the resident's insulin flex pen, with the date opened and discard date, placing the residents at risk for ineffective medication.

The facility had a census of 33 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, interview, and record review the facility failed to involve the physician and Registered Dietician (RD) in an adequate timeframe after Resident (R) 26 experienced a large weight loss in 11 days in April 2023. This deficient practice placed R26 at risk for further weight loss or health issues. Findings included: - R26's Electronic Medical Record documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), pain, anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), and adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R26 was independent with eating, required staff supervision for transfers, walking, hygiene, limited staff assistance with dressing, bed mobility, and extensive staff assistance with toileting. The MDS documented R26 had no range of motion impairment, weighed 145 pounds (lbs.) and had no swallowing or dental problems. The Nutrition Care Area Assessment (CAA), dated 04/18/23, did not trigger. The Significant Change MDS, dated [DATE], documented R26 required extensive staff assistance with eating. The MDS documented R26 weighed 118 lbs. and was not on a physician prescribed weight loss program. R26's Nutrition CAA, dated 07/19/23, stated R26 had a significant unplanned weight loss, which placed him in the underweight category. R26 was able to feed himself at times, and at other times he needed significant help from staff to get him to eat or help him to eat more. The facility felt this to be related to R26's decline in cognition. The resident had been sitting at the assisted table so that staff could assist and prompt him to eat and had been referred for hospice. The Significant Change MDS, dated [DATE] documented R26 was on hospice and weighed 115 lbs. R26's Nutrition Care Plan, dated 05/02/23, directed staff to provide house shakes at meals. R26's Nutrition Care Plan, updated 08/23/23, directed he was independent with eating (04/18/22). It listed interventions to provide house shakes at meals (04/26/23), and weigh weekly (07/21/23). A revision on 08/10/23 directed staff to seat R26 at the assisted table and encourage him to eat on his own and provide assistance if needed (08/10/23). The Physician Order, dated 04/18/22, directed staff to provide a regular diet, regular texture, thin consistency. The Dining Assessment, dated 04/17/23, stated no problems, no referrals. The Physician Order, dated 04/25/23, directed staff to provide a regular diet, regular texture, thin consistency. R26's EMR listed the following weights: 03/28/23 145.0 lbs. 04/04/23 146.5 lbs. 04/14/23 145.0 lbs. 04/25/23 123.5 lbs. The Physician Order, dated 04/25/23, directed staff to provide a regular diet, regular texture, thin consistency. The Weight Warning, dated 04/26/23 at 09:42 AM, stated R26's weight was 123.5 lbs., which was a 10.0 percent (%) decrease. The Progress Note, dated 04/27/23 at 11:35 AM stated R26 had recent weight loss and staff started house shake three times per day with meals. R7's clinical record lacked evidence staff notified the physician or RD of R26's significant weight loss. The Registered Dietician Assessment, dated 06/28/23 (60 days later), documented R26 was referred to the RD by the Dietary Manager (DM) due to ongoing low body weight. R26 was due for a quarterly review. R26 received a regular diet with good intake and a health shakes three times daily. His current weight was 123 lbs. on 06/27/23 and the resident remained stable since mid-April. The current diet and supplements were adequate to meet the resident's estimated needs. The assessment documented the RD recommended to continue the current plan of care with weight loss interventions in place. On 09/26/23 at 07:55 AM, observation revealed R26 independently ambulated with his walker into the dining room. Certified Nurse Aide (CNA) M assisted him to sit down. R26 fed himself and consumed all of his oatmeal, cinnamon/raisin toast with jelly, and scrambled eggs. On 09/26/23 at 01:28 PM, Administrative Nurse D verified staff did not notify the RD or physician of the significant weight loss in April. She verified the RD did not assess R26 until two months after the weight loss occurred. Administrative Nurse D stated R26's physician saw the resident on 06/14/23 but did not comment on the significant weight loss. On 09/26/23 at 01:37 PM, Dietary Staff (DS) BB stated she provided R26 with 120 milliliters (ml) Ensure (liquid supplement) at every meal. She stated sometimes the nurses told her to give the resident two Ensure. She stated she documented the Ensure together with all R26's fluids during the meal. She stated the resident had a good appetite, and sometimes would eat an additional serving. On 09/28/23 at 08:58 AM, DS CC stated R26's weight was stable in March. She stated staff started giving R26 the house shakes and protein powder in his food in late April. On 09/28/23 at 09:12 AM, Administrative Nurse E stated staff printed all the residents weights weekly and any resident weight loss was discussed at the weekly risk meetings. Administrative Nurse E said on 06/14/23, R26's physician saw him but did not write anything about the weight loss. Administrative Nurse E said R26's orders at that time included house shakes. The facility's Nutrition and Hydration policy, dated 04/12/23, stated staff were to accurately and consistently assess a resident's nutritional status on admission and as needed. The policy directed staff to recognize, evaluate and address the needs of the resident at risk or already experiencing impaired nutritional status and notify the physician as appropriate in evaluating and managing causes of the resident's nutritional risks and impaired nutritional status. The facility failed to involve the RD and physician in an adequate timeframe after R26 experienced a significant weight loss of in 11 days which placed R26 at risk for further weight loss or health issues.

The facility had a census of 33 residents. The sample included 12 residents with two reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide personal grooming assistance and cares for Resident (R) 28. This placed the resident at risk for poor hygiene and impaired dignity Findings included: - R28's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental dosirder characterized by failing memory and confusion,) psychosis (any major mental disorder characterized by a gross impairment in reality perception,) major depressive disorder (disorder which causes persistent feeling of sadness,) and anxiety (mental or emotional reaction characterized by apprehensio, uncertanity and irrational fear.) R28's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status score of two indicating severe cognitive impairment. The MDS recorded R28 required extensive assistance of one staff for personal hygiene, and total staff dependence for bathing. The Activities of Daily Living Care Plan, dated 07/20/23, directed R28 required one staff to provide the resident with total assistance with bathing. R28's Bathing Report documented the resident received a bath/shower two times a week. The Bathing Report documented the resident received a whirlpool on the following days: 08/28/23 08/31/23 09/04/23 09/07/23 09/14/23 (one bath in a week) 09/18/23 09/21/23 09/25/23 On 09/25/23 at 11:30 AM, observation revealed R28 sat in a wheelchair in the commons area with a visitor at her side. R28 had a grey chin hair approximately one-half inch long and visible and R28's hair was uncombed. On 09/28/23 at 10:15 AM, Administrative Nurse E verified the residents had scheduled bath/shower days and the aides documented in the electronic health records. Administrative Nurse E verified the resident had a razor that was not working and a new electric razor was just recently purchased. Administrative Nurse E said she was unsure how many days passed where the aide had not shaved R28. Administrative Nurse E verified the facility recently hired a bath aide that would be responsible for the residents bathing and personal grooming. The facility's, Bathing policy, dated 08/29/23, documented the staff would provide the residents bath to promote cleanliness, general hygiene, stimulate circulation of the skin, comfort, relaxation, and well- being. Staff would perform hand hygiene, oral care, hair care, and apply deodorant and observe and report any skin conditions to the licensed nurse. The facility failed to provide the necessary personal grooming care for R28, placing the resident at risk for poor hygiene and impaired dignity.

The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure the results of the most recent survey (the last standard survey, extended surveys, or subsequent complaint suveys with citations) results were available for public review. - On 09/26/23 at 08:30 AM, surveyors reviewed the Survey Result Binder in the plastic storage container on the East wall close to the Administrator's office. The facility failed to ensure the Statement of Deficiencies (SOD) from the 10/12/23 complaint survey which resulted in a citation was available for review. On 09/26/23 at 08:32 AM, Administrative Staff A verified the 10/12/22 complaint survey SOD was not in the survey binder. Administrative Staff A then retrieved the results and added them to the binder. Upon request, the facility did not provide a policy for posting of the survey investigation results. The facility failed to make available in a readily accessible area the last complaint survey SOD available for public review, placing, the residents, staff and visitors at risk for receiving inaccurate survey information.

The facility had a census of 31 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to assess and identify risks for Resident (R)1, who was severely cognitively impaired, regarding the use of side rails and further failed to place bolsters (a long thick pillow that is placed under other pillows for support) as required to prevent entrapment when side rails and an air mattress were used concurrently. On [DATE] facility staff placed side rails on R1's bed, already equipped with an air mattress, to assist R1 with bed mobility. The facility did not place a bolster per policy to protect R1 from entrapment. On [DATE] R1 experienced a significant change and was placed on hospice services. R1, who required extensive assistance of two staff for bed mobility, was not reassessed for the safe continued use of the side rails and no bolster was placed at that time. On [DATE] at 04:10 AM, staff found R1 on the floor leaning against her bed on her knees. R1's head was between the mobility bar and air mattress. R1's right hand was around the mobility bar. The right side of R1's face was against the air mattress and the left side of her neck was against the mobility bar. Staff assessed R1 and she1 was deceased . Staff failed to assess and identify safety risks for R1's use of side rails and failed to implement safety precautions for the concurrent use of side rails with an air mattress. This placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated R1 had severe cognitive impairment. The MDS documented R1 was totally dependent on two staff for transfers, locomotion, and bathing. R1 required extensive assistance of two staff for bed mobility, dressing, eating, toileting, and personal hygiene. The MDS documented R1 had a stage 3 pressure ulcer, had a pressure reducing device for her chair, a pressure reducing device for her bed, was on a turning/repositioning schedule, and received pressure ulcer care. The Activities of Daily Living (ADL's) Care Area Assessment (CAA), dated [DATE], documented R1 required assistance with all of her activities of daily living, had weakness and limited range of motion, poor balance and coordination, and significant pain. R1 was placed on hospice care as her condition was not expected to improve. The Fall CAA, dated [DATE], documented R1 was at an increased risk for falls due to needing staff to assist and stabilize R1 during change of position. The CAA further documented R1 was unable to maintain sitting balance on her own and relied on staff for transfers using the full body lift. The Activities of Daily Living Care Plan, revised [DATE]/, directed staff to position R1 up in bed with two staff assist using a turning/repositioning sheet, turn R1 from side to side with two staff assist using an assist sheet, and to transfer R1 using a full boy lift with two staff assist. The care plan documented R1 used mobility bars to assist with rolling from side to side. The Fall Care Plan, revised [DATE], directed staff to ensure a fall mat was at R1's bedside at all times when R1 was in bed and to ensure the bed was lowered to the floor. The Pressure Ulcer Care Plan, revised [DATE], documented R1 was provided an air mattress to her bed to assist in the healing of pressure ulcers and to prevent new pressure ulcers from occurring. The Progress Note, dated [DATE], documented R1 was given an air mattress to promote wound healing and prevention of new pressure ulcers. The Physical Device and Restraint Review, dated [DATE], documented mobility bars were placed to R1's bed to enable R1 to assist with bed mobility. The Progress Note, dated [DATE] documented R1 was admitted to hospice services with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR lacked any documentation that a new Physical Device and Restraint Review, assessment, or other safety assessment was completed after R1 had a significant change in condition. The Care Conference Note, dated [DATE], documented R1 had a significant change in status, was on hospice services, and there were no changes made to the plan of care besides adding hospice services. R1's EMR recorded an Incident Note, dated [DATE] at 04:10 AM, which documented the Certified Nurse's Aide (CNA) reported to the nurse on duty that, while performing rounds, R1 was found on the floor. The nurse entered R1's room and found R1 on her knees with her head between the bed and the mobility bar, with her right hand holding onto the mobility bar. R1's right side of her body was leaning against her bed. Vital signs were performed and R1 was pronounced dead in the facility. R1's oxygen was still in place, fall mat was in place, bed was in lowest position, call light was attached to R1's blankets. R1 was last checked at 02:00 AM. On [DATE] at 10:30 AM, Licensed Nurse (LN) G stated that she had placed the air mattress to R1's bed on [DATE] and she did not know the facility's policy regarding concurrent use of air mattress and mobility bars required a bolster to be placed. On [DATE] at 10:45 AM, CNA M stated R1 had been on an air mattress and had mobility bars attached to her bed. CNA M stated there had not been a bolster to R1's bed to prevent entrapment between the air mattress and the mobility bars. CNA M stated that she was unaware of the facility's policy, which directed the use of an air mattress and mobility bars together required a bolster to be used. On [DATE] at 10:45 AM, CNA N stated R1 had been on an air mattress and had mobility bars attached to her bed. CNA M stated there had not been a bolster to R1's bed to prevent entrapment between the air mattress and the mobility bars. CNA M stated that she was unaware of the policy that concurrent use of an air mattress and mobility bars also required a bolster to be used. On [DATE] at 11:00 AM, Administrative Nurse D stated R1 was found with her right side of her face was against the air mattress and the left side of her neck was against the mobility bar and R1 was found to be deceased . Administrative Nurse D verified that the facility's policy documented if an air mattress was used concurrently with mobility bars, a bolster should have been applied to the air mattress. Administrative Nurse D verified a bolster had not been placed to R1's air mattress on [DATE] when the mobility bars were attached to R1's bed. On [DATE] at 02:30 PM, CNA O stated when he found R1 on [DATE] her neck was in between the mattress and the mobility bar and she was gray in color and not breathing. CNA O stated when he and his co-worker were in R1's room at 02:00 AM for turning and check and change, R1 was positioned on her left side and R1 was fine at that time. On [DATE] at 05:30 PM, CNA P stated when he found R1 on [DATE], R1 was on her knees with her head and neck in between the mobility bars and her right hand clutching the mobility bar like she was trying to get out. CNA P stated at 02:00 AM checks R1 was alive and not having any pain or difficulty breathing. On [DATE] R1's primary care physician was contacted regarding R1's death and did not return the phone call. The facility's Bed Safety Including Bed Rails, Side Rails, Assist Bars, policy, revised [DATE], documented bed rail/side rail/assist bar usage will occur only when: medical necessity is supported by resident assessment and data collection documentation allowing resident to assist or be independent with bed mobility or transfer. When the total bed environment i.e. bed frame, mattress bed rail/assist bar device and overlays have been inspected and verified to be free of entrapment risk. Informed consent is obtained from resident or responsible party and then documented in the medical record. Prior to use of bed rails, safety rails, grab bars, and assist bars and Physical Device and Restraint Assessment UDA will be completed. Mattress overlays are discouraged but if a specialty mattress (i.e., air or foam mattress) is added to the bed configuration, bolsters are required. The facility failed to assess and identify safety risks for R1's use of side rails and failed to implement safety precautions for the concurrent use of side rails with an air mattress. This placed R1 in immediate jeopardy. The facility implemented corrective measures to include education to staff regarding the use of side rails, which included assessment and identification of risks and safety needs, the need for bolsters when air mattress used with side rails and audited all residents with side rails and/or air mattresses to ensure safety. The corrective actions were completed by prior to the survey on [DATE]; the deficient practice was cited as past noncompliance.

Based on interviews, record review, and review of the facility's policy, the facility failed to ensure all contracted staff working in the facility were either fully vaccinated or had an approved exemption prior to providing services at the facility. Specifically, Contract Staff (CS) 7 was contracted by the facility to make residents' beds; however, CS7 was not fully vaccinated and had not applied and been approved for an exemption. The facility's failure placed all residents at risk for the transmission of COVID-19. Findings include: Review of the facility's policy titled, COVID-19 Immunization, Employee-Enterprise, revised 06/13/22 revealed .Definitions .Vaccinated receiving an approved one-dose COVID-19 vaccination (e.g., J&J [[NAME]/Johnson & Johnson]) or receiving both doses of an approved two-dose vaccine (e.g., Pfizer, Moderna) .Contingent worker. An employee who works under contract for an employer. A contingent employee is hired for a specific job at a specific rate of pay Purpose: [NAME] recognizes the importance of creating a safe environment, free of infection/transmission of disease and to protect our patients/residents, employees, licensed independent medical practitioners .Policy: COVID-19 vaccination shall be required for all employees, medical residents, students, volunteers, contingent workers, and vendors unless exempt for medical or religious purposes .or otherwise prohibited by applicable states law .Any medical resident, student, volunteer, contingent worker, or vendor who fails to comply with the COVID-19 vaccination requirements by or before the Enforcement Dates shall be removed from the schedule until such time when such person either receives the COVID-19 vaccination or approved exemption. All employees .as well as all .contingent workers .are solely responsible for ensuring that their staff assigned to work, perform services, or otherwise exercise privileges at [NAME] are fully compliant with all applicable masking, testing, or other communicated safety requirements at all times . Review of an undated facility document titled, Contract Staff, revealed CS7 was listed on the list with the titled of Bed Making. Review of an untitled document on the facility's letter head, dated 07/06/22, revealed [CS7's name] worked for the [facility's name] in [NAME], Kansas for the following dates: [NAME] 14th and 15th, 21st and 22nd, 28th and 29th 2022. July 5th and 6th 2022 . During an interview on 07/06/22 at 12:12 PM, the Infection Preventionist (IP) stated CS7 was tested at a minimum once a week per the facility's policy. The IP also stated the facility was aware CS7 was not vaccinated; however, they were not aware that she did not have an approved exemption until 07/06/22. The IP further stated it was her expectation CS7 would have been either fully vaccinated or had an approved exemption prior to working in the facility for resident and staff safety from COVID-19. During an interview on 07/06/22 at 12:29 PM, the Director of Nursing (DON) stated the facility was aware that CS7 was not fully vaccinated; however, they were not aware that she did not have an approved exemption. The DON also stated when she called the contract company this morning (07/06/22), they informed her they did not have an exemption process. Continued interview revealed CS7 should not have been working in the facility without either being fully vaccinated or having an approved exemption due the CS7's risk of transmitting COVID-19 infection. The DON further stated she was responsible for ensuring all contract staff were either fully vaccinated or exempted and CS7 slipped through the cracks.

The facility had a census of 32 residents. The sample included 3 residents, who were reviewed for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without staff knowledge). Based on observation, record review and interview the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 sampled residents. Resident #1 was a elopement risk with cognitive impaiment, who had a non-functioning wanderguard alarm (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) and exited the facility without staff knowledge, placing Resident #1 in immediate jeopardy for exposure and accident hazards. Findings included: - Resident #1's annual (MDS) Minimum Data Set assessment, dated 05/17/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 2 (severe cognitive impairment) with inattention and memory problems. The MDS also recorded the resident walked independently without a mobility device, had unsteady balance when turning around or transferring, had improved wandering behavior, and was a fall risk with one minor injury fall in the past 90 days. The 05/17/17 (CAA) Care Area Assessment for cognitive impairment and falls recorded the resident was frequently confused due to dementia (progressive mental disorder characterized by failing memory and confusion), had unsteady balance and a history of falls. The 05/17/17 care plan recorded the resident was an elopement risk and directed staff to place a wanderguard bracelet on the resident to alert staff, when the resident was close to an exit door or if the resident eloped through the door. The care plan also recorded the resident walked independently without a mobility device, and had a history of [REDACTED]. Review of the July 2017 (TAR) Treatment Administration Record revealed staff checked and recorded the function of the resident's wanderguard bracelet every night, even though the facility's wanderguard alarm system had not functioned since early June. Review of the facility's 30-day (06/25/17 - 07/25/17) Behavior Monitoring Report revealed the report lacked documentation staff monitored the resident's wandering behaviors each shift. The 07/08/17 at 10:30 PM, nurse's note recorded the resident wandered in the halls and pushed on the exit doors at the end of the halls. The nurse's note also recorded the resident became anxious and easily agitated, when staff attempted to redirect the resident back to his/her room. The facility's Elopement Risk Assessment, dated 07/18/17, recorded the resident had poor decision making skills and safety awareness, and often wandered in the halls and attempted to open exit doors. The assessment recorded the resident followed visitors and attempted to elope from the building, when the visitors exited the facility. The assessment further recorded the resident's family continued to be concerned for the resident's safety and wanted staff to keep a wanderguard bracelet on the resident and monitor the resident closely. The 07/21/17 at 1:12 PM, nurse's note recorded the resident eloped from the facility by following a visitor out the east exit door. The 07/21/17 Elopement Incident Report recorded a hospital employee called the facility to alert staff of a resident wandering outside the facility. Accuweather.com recorded the temperature on 07/21/17 at 1:00 PM in Atwood, Ks. was 97 degrees Fahrenheit. On 07/25/17 at 1:08 PM, observation revealed the resident walked independently without a mobility device on the east resident hall. Continued observation revealed the resident attempted to follow a visitor out the east exit door and staff redirected the resident to return to the living room area near the front entrance. On 07/25/17 at 2:07 PM, observation revealed the east exit door had a keypad alarm code on the right side of the door frame (per multiple staff interviews, the door code was posted in the door window left of the keypad, prior to the resident's elopement), an 8 inch by 8 inch sign on the right side of the door directed visitors Please help us keep our resident safe, wait until the door closes before walking away (no sign to direct visitors to not allow residents out the exit door). Continued observation revealed the east exit door had no wanderguard alarm and the following environmental hazards located outside the east exit door: South: asphalt road/driveway with rough, uneven surface approximately 30 feet wide, then an empty lot with rough terrain approximately 1/2 block across, then Highway 36 (speed limit 35 mph, with high truck traffic). East: asphalt and gravel driveway with rough, uneven surface approximately 50 feet wide, then sloped (unmaintained area) with tall weeds, small trees and scattered construction debris/materials (chunks of concrete, bricks/blocks, lumber), then approximately 1/2 block further, the community lake West: asphalt driveway/road with rough, uneven surface, construction in process with equipment, tools and materials in the area. At approximately 150 feet the road had a steep slope that ended at the community lake about 1 block further. North: (this was the area staff found the resident) gravel driveway with rough, uneven surface approximately 30 feet wide, then a steep slope with trees spaced a few feet apart, fallen branches and large rocks scattered on the ground, then approximately 1/2 block further, the community lake. On 07/25/17 at 1:31 PM, Administrative Nurse A stated, due to construction, the facility moved the main entrance of the facility to the east exit door several weeks ago, and most staff and all visitors entered the building through the east exit door. Administrative Nurse A stated the east exit door required an alarm code to operate the door and the facility posted the alarm code inside and outside the facility for the visitor's convenience to enter and leave the building. Administrative Nurse A stated the facility had not moved the facility's wanderguard alarm system to the east exit door due to financial constraints, and when the resident, who was an elopement risk and wore a wanderguard bracelet, eloped through the exit door, no alarm sounded to alert staff. Administrative Nurse A stated the resident followed a visitor to the east exit door and the visitor allowed the resident to leave the building. Administrative Nurse A stated hospital therapy staff observed the resident wandering in the facility's parking lot from a hospital window (approximately 150 to 200 feet away), and had a hospital nurse alert the nursing home staff. Administrative Nurse A stated the facility had no video security system to confirm the time of the elopement, but an estimated time from witness accounts placed the resident outside 5-7 minutes, before hospital staff alerted the facility of the resident's elopement. Administrative Nurse A further stated the resident was a fall risk due to impaired balance and poor safety awareness. On 07/26/17 at 7:32 AM, Nurse B stated the confused resident walked independently without a mobility device and wandered in the halls at times. Nurse B stated the resident wore a wanderguard bracelet due to a history of attempts to open exit doors and/or follow visitors out of the building. Nurse B stated the door alarm code on the east exit door was posted for all the visitors to use throughout the day, the door had no wanderguard alarm system, and staff had not monitored the door. Nurse B further stated the facility had no system to direct staff to routinely observe the resident. On 07/26/17 at 7:37 AM, Nurse Aide C stated the pleasantly confused resident walked independently without a mobility device and staff frequently redirected the resident, when he/she wandered in the halls. Nurse Aide C stated staff would also redirect the resident, when he/she attempted to follow visitors out the exit door. Nurse Aide C stated all the visitors entered and exited through the east exit door with the posted door for the visitors convenience. Nurse Aide C further stated staff had not monitored the east exit door and was not aware of a system to complete routine observations of the resident. On 07/26/17 at 7:42 AM, Nurse Aide D stated staff frequently cued and directed the confused resident during (ADLs) Activities of Daily Living, and staff often redirected the resident, when he/she wandered. Nurse Aide D stated the resident attempted to open exit doors and follow visitors out of the exit doors. Nurse Aide D further stated staff had not monitored the east exit door or provided routine observations of the resident. On 07/26/17 at 8:31 AM, Nurse E stated the facility used the east exit door as the main entrance, since early June, and the posted door alarm code was for all the visitors to enter and leave the facility. Nurse E stated the resident attempted to open exit doors and follow visitors out of the building, and staff placed a wanderguard alarm on the resident. Nurse E stated a visitor allowed the resident to leave the building out the east exit door and no alarm sounded, because the exit door was not equipped with wanderguard alarm system. Nurse E stated hospital staff observed the resident wandering outside, unsupervised, and alerted facility staff. Nurse D further stated the resident had poor safety awareness and was at risk for falls. On 07/26/17 at 9:01 AM, Administrative Nurse A stated the resident had a history of [REDACTED]. Administrative Nurse A stated the facility had not provided routine visual checks for the resident and/or staff had not monitored the east exit door, prior to the resident's elopement. Administrative Nurse A stated staff were not aware the resident eloped from the building, until hospital staff called to report the resident was wandering on the north side of the building. The facility's Elopement policy, dated April 2016, recorded the facility was responsible for a system to manage/monitor a resident at risk for elopement. The policy also directed staff to identify resident risks and environmental hazards and modify interventions, as needed, for the resident's safety. The facility failed to provide adequate supervision to prevent an elopement for cognitive impaired Resident #1, who was an elopement risk, had a non-functioning wanderguard bracelet, and exited the facility without staff knowledge, placing the resident in immediate jeopardy for exposure and accident hazards. This deficient practice was determined past non-compliance when the facility implemented the following on 07/21/17: As of 7/21/17 staff alone have knowledge of our key code and will be escorting guests in and out of the building. This will remain in place until the installation of the new wanderguard system can be installed at every door with access to the outdoors. As of 7/17/17 a motion sensor alarm was placed on the main entry door. On 7/21/17 staff were educated on policy and procedure for an elopement by Erin Cook, staff development coordinator. Any staff not in attendance at this inservice were educated 1:1. Charge nurse will check proper functioning of sensor alarms at every shift. Results of this audit will be brought to QAPI monthly. A list showing all residents at a high elopement risk will be placed at the nurses station so all staff are aware of the potential risk of elopement. This list will be updated as needed with any admissions, discharges or significant changes. On 7/21/17 Convergint Technologies were notified by administrator, Allie Karas, about the need for wanderguards on every exit with access to the outdoors. On 7/24/17 we held an elopement drill and will continue to have elopement drills quarterly that are coordinated by the administrator. Maintenance will audit to ensure the drills are being completed and bring results to QAPI monthly. We will monitor our process by ensuring all visitors or vendors are allowed entry into the building solely with staff assistance until our wanderguard system is installed. This information will be brought to monthly QAPI meetings and reviewed.

The facility had a census of 34 residents. The sample included 14 residents with 5 reviewed for falls. Based on observation, record review, and interview the facility failed complete a root cause analysis for each fall to develop and implement timely and effective interventions to prevent accidents for 3 of the 5 sampled residents who had falls with injuries. (#27, #28, #42) Resident #28 experienced multiple falls, with one resulting in a rib fracture. The facility also failed to ensure the resident environment remained free of accident hazards as possible when staff failed to properly store hazardous chemicals under the bathroom by the dining room, identified on initial tour, which placed 8 cognitively impaired independently mobile residents who was reside in the facility at risk. Findings included: - Resident #28's quarterly (MDS) Minimum Data Set assessment, dated 2/19/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 8, which indicated moderate cognitive impairment, and no behaviors. The MDS indicated the resident independent with most ADLs except required extensive assistance of 1 for bathing, and was independent with set up help only for eating. The MDS indicated the resident was steady at all times except turning around and facing the opposite direction while walking but was able to stabilize without human assistance. The MDS indicated the resident ambulated with a walker and had no falls since the prior assessment. The quarterly MDS, dated [DATE] unchanged except the resident had altered (LOC) level of consciousness. The MDS indicated the resident required limited assistance of 1 staff for most (ADLs) Activities for Daily Living, except independent with no set up for eating, and extensive assistance of 1 for bathing. The MDS indicated the resident was not steady, and only able to stabilize with human assistance for balance during transitions, walking. The resident ambulated with a walker or wheelchair and had one non major injury fall since the prior assessment. The 8/12/15 (CAA) Care Area Assessment for falls stated the resident was at risk for falls related to gait instability and required assistance of 1 staff for transfers and ambulation. The 3/2/16 care plan instructed staff to monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. The care plan instructed staff to ensure the resident ambulates with one person assist, gait belt and walker. The care plan revealed staff added the following interventions after he/she had a fall: 4/22/16 (fall on 4/14/16)-monitor call system to alert staff of resident's movement 4/23/16 (fall on 4/23/16) lacked evidence of care plan review or revision 5/18/16 (fall on 5/8/16)-staff to avoid clothing that is a fall risk due to being too loose The 5/18/16 physical therapy discharge note indicated the resident had not been motivated to push for progress with physical therapy and had met some of his/her goals but reached the maximum potential for other goals. The note indicated the resident declined exercises due to his/her lack of motivation and therapy staff recommended a restorative program. 6/8/16 (fall on 6/8/16) lacked evidence of care plan review or revision 6/23/16 (fall on 6/23/16) lacked evidence of care plan review or revision 6/29/16 (fall on 6/29/16) lacked evidence of care plan review or revision 6/30/16 (fall on 6/30/16) on 7/1/16 physician order [REDACTED]. 7/2/16 (fall on 7/2/16) lacked evidence of care plan review or revision 7/4/16 (fall on 7/4/16) lacked evidence of care plan review or revision 7/12/16 (fall on 7/9/16) staff to assist the resident to his/her room and ensure alarm was on the resident 7/13/16 (fall on 7/9/16) per recommendation of the therapy department, staff to remove the resident's wheelchair from his/her room 7/15/16 (fall on 7/9/6) resident had actual fall with minor injury related to poor balance and cognition deficit (lacked evidence of a care plan review or revision) 7/23/16 (fall on 7/23/16) no documentation of care plan review or revision 7/29/16 (fall on 7/29/16) no documentation of care plan review or revision On 7/31/16 at 12:53 PM, nurse's notes indicated staff found the resident on the floor with a 1 (cm) centimeter skin tear to left forearm, no further injuries and the bed alarm was not working. The 7/31/16 chest and left rib x-ray indicated the resident had an acute (abrupt onset) left 7th rib fracture. On 7/31/16 physician order [REDACTED]. [DIAGNOSES REDACTED]. The facility completed 12 fall tool assessments between 4/4/16 and 7/31/16 which indicated the resident was a high fall risk. Further review of the resident's medical record revealed [REDACTED]. The medical record lacked root cause analysis for each of the resident's falls. On 8/17/16 at 7:45 AM, observation revealed staff propelling the resident from his/her room, in his/her wheelchair, to the dining room. Further observation revealed the resident's fall alarm pinned to the back of the resident's shirt. On 8/17/16 at 3:40 PM, Nurse Aide J stated the resident had frequent falls and the staff moved his/her walker away from his/her reach, so he/she would call for assistance (even though the resident had severe moderate impairment) to get out of his/her bed, applied the fall alarm, and the staff reminded the resident his/she had an ostomy (a combining form used in the names of surgical operations that involve the establishment of an artificial opening into or between the part or parts) of his/her urine/stool and the staff empty both of his/her ostomy bags frequently. Nurse Aide J stated the resident was more confused since he/she returned from the hospital in April of this year. On 8/17/16 at 3:05 PM, Nurse F stated the resident had frequent falls with the nurses checking on him/her hourly, and moved his/her bed closer to the bathroom and the door to his/her room. Nurse F stated the resident used his/her call light more than previously. On 8/18/16 at 2:30 PM, Administrative Nurse A verified the resident's care plan was not updated after each fall or new interventions put in place after each fall. The facility's 7/2015 fall prevention and management policy and procedure indicated after a fall, the resident may experience lifestyle changes due to impaired function, decreased mobility and lost independence. The policy indicated it was the facility's obligation to provide the safest environment possible for the residents. The policy directed staff to implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident and/or monitor the effectiveness of the interventions, modify the interventions as necessary, in accordance with current standard of practice. The facility failed to complete a root cause analysis to determine the cause of each fall to develop and implement timely and effective interventions for cognitively impaired Resident #28 who experienced multiple falls, with one resulting in a fractured rib. - On 8/15/16 at 8:20 AM, observation revealed an unlocked bathroom by the dining room with the following accessible hazardous chemicals: One 24 ounce spray canister of Lysol foaming disinfectant cleaner with warnings to keep out of reach of children, can cause moderate eye irritation, and hazardous to humans/animals. One 14 ounce canister of MARC Fruit medley dry spray air freshener with warnings of harmful or fatal if swallowed, eye and skin irritant. On 8/15/16 at 8:20 AM, Activity Staff N verified the observation and removed the hazardous chemicals. On 8/22/16 Administrative Staff A reported the facility had 8 cognitively impaired, independently mobile residents. The facility's March 2016 policy for storage of supplies directed staff to ensure that all products (chemicals and disinfectants) are labeled and stored in a manner that eliminates risk of improper use, contamination, inhalation, skin contact or personal injury. The policy stated housekeeping products and supplies should not be stored in resident rooms or units and directed staff to store them in a locked cabinet and/or storage room. The facility failed to ensure safe storage of hazardous chemicals, which placed the 8 cognitively impaired, independently mobile residents of the facility at risk for potential harm from the accessible hazardous chemicals. - Resident #27's 8/9/16 Physician order [REDACTED]., social or interpersonal functioning), arthroplasty (the surgical repair of a joint), syncope (fainting or passing out), pain (physical suffering or distress due to injury or illness, something that hurt's the body), and overactive bladder (frequent feeling of needing to urinate). The significant change (MDS) Minimum Data Set assessment, dated 5/3/16, revealed the resident had a (BIMS) Brief Interview for Mental Status score of 10, indicating moderately impaired cognition, required limited assistance of 1 staff for (ADLs) Activities of Daily Living, had poor balance, and 2 or more falls. The quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4, indicating severely impaired cognition, required extensive assistance of 1 staff for (ADLs) Activities of Daily Living, had poor balance, 2 or more falls, shortness of breath with exertion, and used a wheelchair. The cognitive loss (CAA) Care Area Assessment, dated 5/17/16, revealed the resident had a decline in ADLs and urinary continence, recently received physical therapy and occupational therapy services, and participated in a toileting program and restorative nursing program. The falls CAA, dated 5/7/16, revealed the resident had moderately impaired cognition, with signs and symptoms of delirium (sudden severe confusion, disorientation and restlessness) during a clinical observation. He/she had difficulty focusing and following directions. The 6/7/16 care plan directed staff to report changes in the resident's cognitive function to the charge nurse, transfer the resident from a lying to sitting position, then place shoes on the resident's feet prior to the resident getting out of bed. The care plan further directed staff to assist the resident with 1 staff for ambulation using a walker, and with physical hand cues to ensure the resident's hips are centered in the walker. The 5/10/16 update directed staff to toilet the resident every 2 hours while awake, at midnight, and 4:00 AM, due to an increased risk for falls. The care plan further revealed the staff placed a bed alarm on 6/12/15 and a personal alarm on 5/5/16. On 5/9/16 at 4:43 AM, the incident investigation revealed staff found the resident on the floor, on his/her knees facing the bed. The nurse assessed the resident and found no injuries. The resident stood and walked to the bathroom. The physical therapist evaluated the resident on 5/5/16 and determined the resident did not meet the criteria for treatment. Staff changed the resident care plan on 5/5/16, prior to the fall, to add a personal alarm to the care plan. On 5/11/16 at 00:30 AM, the incident investigation revealed staff found the resident on the floor, tangled in his/her covers, and the alarm on. The nurse completed the assessment, found no injuries and found the resident was incontinent at the time of the fall. Staff provided incontinence care, updated the care plan, and stated the resident walked independently in his/her room and directed staff to provide assistance of 1 to walk outside of his/her room. On 5/20/16, the incident investigation revealed the resident fell to the floor after exiting the shower stall. The resident sat on the floor at the entrance of the shower stall as the nurse staff assisted the resident with an abrasion to the left upper back with a reddened, round, raised area surrounding the reddened area to his/her bottom. The investigation described the floor as wet and slippery. Staff did not make a care plan change. The 6/26/16 Falls Data Collection Tool revealed a score of 14, a moderate risk for falling. On 7/26/16 at 11:05 AM, the incident investigation revealed staff found the resident on his/her right side on the floor in front of the electric recliner. The resident stated he/she did not know what happened, although staff noted the recliner seat raised. The nurse's assessment revealed the resident had a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the back of his/her head, and was incontinent of stool. Staff did not complete an assessment of the resident's ability to use the power chair correctly and did not make a care plan change. On 7/29/16 at 9:25 PM, staff responded to the resident's call light and found the resident lying on the floor, diagonal to his/her bed, flat on his/her back. The resident stated he/she hit his/her head. The nurse completed an assessment and 2 staff assisted the resident to walk with a walker into the bathroom. The nurse noted the resident had impaired memory, a gait imbalance, was incontinent, and the alarm did not sound. Staff did not record an investigation and response stating why the alarm failed to sound. The 7/29/16 Falls Tool revealed the resident had moderate cognitive impairment and impaired balance, with a score of 15, moderate risk for falls. The 7/31/16 at 7:40 AM, the incident investigation revealed staff called the nurse to the resident's room. The nurse aide explained he/she attempted to make the bed while the resident brushed his/her teeth. The nurse aide described a crashing noise, reported he/she turned, and observed the resident fall against the wall and hit the side of his/her head on the automatic air freshener on the wall. The facility transferred the resident to the (ER) emergency room for evaluation and treatment for [REDACTED]. Orders received from the ER, directed staff to remove the sutures in 8 days, perform neurological checks every 4 hours for 24 hours, and the physician order [REDACTED]. The physician provided [DIAGNOSES REDACTED]. The 7/31/16 Falls Tool, revealed a score of 15, a moderate risk for falling. On 8/2/16 the physician signed the fall notification from the facility and directed staff to monitor for altered mental status. Review of the medical record revealed staff did not complete a bladder assessment or a 3 day voiding diary since 5/3/16, for the quarterly MDS assessment. The Bladder Incontinence Data Collection Tool on 5/3/16 at 10:21 AM revealed the resident had urine incontinence daily, although not on each shift, leaked urine going into the bathroom, and used the bathroom 2 times a night, per the care plan. Review of the medical record revealed the facility lacked a policy/procedure and documentation of alarm checks to ensure the equipment functioned correctly. On 8/16/16 at 4:26 PM, observation revealed Nurse Aide E assisted the resident to walk down the hallway into the dining room for the evening meal. The resident had steady balance, wore a gait belt, and leaned forward into a wheeled walker. On 8/17/16 at 10:46 AM, observation revealed Nurse Aide G assisted the resident into the bathroom with a gait belt and use of a wheeled walker, cueing the resident to stand from the commode, and he/she stood with minimal assistance. Nurse Aide G cleaned the resident's perineum (the area of the body between the thighs, from the pelvis to the rectum) and adjusted his/her clothing, then allowed the resident to walk from the bathroom independently into the room, not holding the gait belt, using a wheeled walker. Nurse Aide G assisted the resident to walk down to the dining room. On 8/17/16 at 12:50 PM, Nurse H stated staff toileted the resident every 2 hours, provided stand by assistance when the resident walked, and used an alarm for fall prevention related to recent falls. Nurse H stated he/she did not know how the staff checked the alarm system for correct function. Nurse H further stated the nurse performing the investigation should initiate a new intervention as a part of the investigation. On 8/17/16 at 4:30 PM, Nurse Aide G stated the resident required extensive assistance with a gait belt and wheeled walker, and he/she fell recently when an aide was in the room with the resident. Nurse Aide G stated the nurse added an intervention to stay with the resident at all times when in the bathroom or up walking. Nurse Aide G explained the resident remained in his/her close proximity and could be assisted quickly in the room, and did not leave his/her eyesight. On 8/18/16 at 1:50 PM, Nurse Aide I stated the resident needed assistance with brushing his/her teeth, stand by assistance with use of a gait belt and wheeled walker for ambulation, and staff monitor the use of an alarm pad in the resident chair. Nurse Aide I stated he/she did not know who checked the alarm pad system. On 8/18/16 at 4:10 PM, Administrative Nurse A stated the nurse does an investigation and determines the root cause analysis (a method of problem solving) of the fall, and initiates a care plan change based on the findings to prevent future falls. Nurse A further stated the facility initiated a new restorative process, approximately 1 month ago, which is still in development and verified the resident had a decline in ADL's with several falls. Nurse A verified staff transferred the resident to the ER after a recent fall, where the resident received sutures to the left lower ear. Nurse A verified the facility did not have an exact method of checking the resident alarms, and could not state the exact process used. Review of the medical record revealed the facility lacked a policy/procedure and documentation of alarm checks to ensure the equipment functioned correctly. The facility's Fall Prevention and Management policy and procedure, dated July 2015, stated: The risk for falling increases due to decreased mobility, muscle weakness gait disturbance and disease processes. After a fall, a resident may experience lifestyle changes due to impaired function, decreased mobility and lost independence. An avoidable accident means the facility failed to implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident. An unavoidable accident means an accident occurred despite the facility's efforts to monitor the effectiveness of interventions and modify the interventions as necessary, in accordance with current standards of practice. The facility failed to thoroughly investigate Resident # 27's falls, initiate appropriate interventions to identify and prevent future falls, follow care plan interventions to prevent falls, and provide maintenance checks on the equipment to ensure proper function. - The physician order [REDACTED].#42, dated 5/27/16, revealed the following Diagnoses: [REDACTED]., social or interpersonal functioning), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), hyperglycemia (greater than normal amount of glucose in the blood), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), obstruction of duodenum ((an obstruction at the outlet of the stomach), and [DIAGNOSES REDACTED] ulcer (an open sore found in the lining of the beginning of the intestine). The admission (MDS) Minimum Data Set assessment, dated 6/3/16, indicated the resident had severe cognitive impairment, an altered level of consciousness, and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), required limited assistance of 1 staff for some (ADLs) Activities of Daily Living, and extensive assistance of 2 staff for toileting. The MDS further stated the resident had urinary incontinence, poor balance, visual impairment, history of 2 falls, and received antipsychotic and antianxiety medications. The falls (CAA) Care Area Assessment, dated 6/3/16, stated the resident had severe cognitive impairment with agitation and anxiety, grabbed at staff, wandered, had delirium (untrue persistent belief or perception held by a person although evidence shows it was untrue), inattention, difficulty focusing, drowsiness, and frequently dozed off. The resident had occasional episodes of urinary incontinence and visual impairment caused by glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow). The 5/27/16 care plan directed staff to assist the resident to walk short distances with use of a gait belt, wheeled walker and assistance of 1. The care plan further stated the resident required assistance of 1 to 2 staff to use the bathroom, wore resistant shoes that color contrasted with the floor, participated in a restorative program, and had a tabs alarm. On 5/31/16, the incident investigation stated the resident tried to walk independently and fell on the floor in the dining room. The nurse initiated neurological assessments and notified the physician and the family. Staff did not make a care plan change. On 6/1/16 at 8:30 PM, the incident investigation revealed staff found the resident on his/her back beside the recliner, on a carpeted area of the dining room lounge. The nurse assessed the resident and found a bruise to the back of his/her head. The medical record lacked measurements of the bruise. The nurse notified the physician and the family, and completed the investigation. Staff did not make a care plan change. On 6/5/16 at 8:20 AM, the incident investigation revealed staff found the resident after he/she slipped out of bed onto 1 knee. The nurse assessed the resident and found no injuries. Staff did not make a care plan change. On 6/8/16, staff added an intervention on the care plan to apply a gray lap belt to the resident wheelchair, and release the strap every 2 hours. On 6/10/16 at 3:05 AM, the incident investigation revealed the resident attempted to stand up from the toilet independently and fell on to the floor, with no staff present in the bathroom The resident's wheeled walker was close to him and a gait belt around the resident's waist. The nurse assessed the resident and noted a small skin tear to the right elbow area, and he/she cleaned and dressed the skin tear. The resident stood with assistance of 2 staff, and walked back to the recliner in the dining room. Staff did not make a care plan change. Review of the medical record revealed staff did not complete a bladder assessment or a 3 day voiding diary. On 6/10/16 at 9:00 PM, the incident investigation revealed staff found the resident on the floor in front of his/her recliner, with the chair tipped forward, the footrest partially raised and the upper portion of the resident's body remained in the recliner. The nurse assessed the resident and found no injury. The investigation revealed the resident did not hit his/her head, and he/she disconnected the alarm. Staff transferred the resident from the floor to the wheelchair with assistance of 3 staff. Staff did not complete an assessment of the resident ability to use the power chair correctly and did not make a care plan change. The physical therapy discharge note, dated 6/17/16 stated the resident did not meet his/her goal, although he/she reached his/her maximum potential. The note further stated the resident had a very low energy level and he/she fell deeply asleep and the therapist had difficulty arousing him/her. The therapist stated the lack of energy and strength limits his/her ability to perform physically. On 6/19/16 at 6:45 AM, the incident investigation revealed staff found the resident lying on the floor in front of the recliner. The alarm did not sound. He was able to move all extremities without difficulty or pain. The resident reported he/she hit his/her head. The nursing assessment revealed a small bruise with swelling noted to the back of the resident head, with the tissue tender to the touch, and the resident wore improper footwear. The resident stated he/she attempted to get up to find his/her spouse. The nurse initiated neurological assessments and notified the physician /family. Staff did not make a care plan change. The Falls Tool, dated 6/19/16, revealed a score of 16, a high risk for falls, and stated staff used an alarm for fall prevention. Review of the medical record revealed the facility lacked a policy/procedure and documentation of alarm checks to ensure the equipment functioned correctly. The medical record revealed the resident discharged on [DATE], and transferred to another nursing home for a long term stay. There was no opportunity for observation of the resident. On 8/17/16 at 12:50 AM, Nurse H described the resident as restless and stated after falling a few times, staff brought him out of his/her room and transferred him/her into a recliner, to allow increased observation of the resident. Nurse H stated the nurse completing the incident investigation assumed responsibility to add an intervention to the care plan. On 8/17/16 at 4:30 PM, Nurse Aide G stated the resident required extensive assistance from staff, used a walker, had cognitive impairment, repeated him/herself frequently, and had 1 or 2 falls. Nurse Aide G stated staff added an alarm to the care plan, but the resident disconnected the alarm. The care team then added a safety lap belt for fall prevention. Nurse Aide G stated he/she did not know how or when the alarms are checked or who is responsible for doing it. On 8/18/16 at 4:10 PM, Administrative Nurse A stated the nurse does an investigation, determines the root cause analysis (a method of problem solving) of the fall, and initiates a care plan change based on the findings, to prevent future falls. Nurse A verified the facility did not have an exact method of checking the resident alarms, and could not state the exact process used. The facility's Fall Prevention and Management policy and procedure, dated July 2015, stated: The risk for falling increases due to decreased mobility, muscle weakness gait disturbance and disease processes. After a fall, a resident may experience lifestyle changes due to impaired function, decreased mobility and lost independence. An avoidable accident means the facility failed to implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident. An unavoidable accident means an accident occurred despite the facility's efforts to monitor the effectiveness of interventions and modify the interventions as necessary, in accordance with current standards of practice. The facility failed to thououghly investigate Resident # 42's falls, initiate appropriate preventative measures to prevent future falls, follow care plan interventions to prevent falls, and provide mainenance checks on the equipment to ensure proper function.

The facility had a census of 29 residents. The sample included 16 residents with 1 reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide interventions to prevent the development of pressure ulcers for 1 of 1 residents who developed a facility acquired, Stage III pressure ulcer (an open area that extends into the tissue beneath the skin, forming a small crater, fat may show in the sore but not muscle, tendon or bone). (#25) Findings included: - Resident #25's physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 2/12/15, indicated the resident had moderately impaired cognition, with a (BIMS) Brief Interview for Mental Status score of 12, required limited assistance of 1 staff with bed mobility, transfer, dressing, toilet use, personal hygiene, and extensive assistance of 1 staff with bathing. The MDS indicated the resident was at risk for developing pressure ulcers, was not on a turning/repositioning program, and had pressure reducing devices for the chair and bed. The quarterly MDS, dated [DATE], indicated the resident had a stage III pressure ulcer which measured 2.5 (cm) centimeters x 2.5 cm x 0.1 cm, an infection of his/her foot, was not on a turning/repositioning program, had pressure reducing devices for the chair and bed, and received pressure ulcer care. The 2/12/15 pressure ulcer (CAA) Care Area Assessment stated the resident's skin was intact. He/she required limited assistance with bed mobility, and was at risk to develop a pressure ulcer. The resident had a pressure reducing mattress and cushion for a recliner, had occasional incontinence and mild cognitive loss. The 2/5/15 Braden Scale for Predicting Pressure Ulcer risk revealed a score of 22, which indicated the resident at mild risk for developing pressure ulcers. The 2/5/15 Admit Tool indicated the resident's lower extremities had no irregularities. The 2/26/15 care plan contained no direction to the staff regarding skin care for the resident, although the staff assessed the resident at risk to develop pressure ulcers on 2/5/15. The care plan revealed no revisions regarding skin care for the resident until 5/1/15 when the physician diagnosed the resident with a Stage III pressure ulcer on his/her left foot. The 5/1/15 intervention directed staff to assess, record and monitor the wound healing daily, report improvements and declines to the health care provider and elevate the resident's lower extremities as much as possible. The 4/25/15 at 9:04 PM nurse's notes indicated the resident stated his/her foot hurt, and grimaced and moaned. The resident stated he/she thought his/her shoes were hurting him/her. The resident moaned a little more when the nurse palpated (a technique used in physical examination in which the examiner feels the texture, size, consistency and location of certain body parts with his/her hands) the area outside of the instep, directly behind the ball of the foot and again right before the heel area. The note stated some protrusions (parts that stick out) noted to the bone of the arch but no swelling or redness noted. The 4/26/15 at 5:31 PM nurse's note indicated the staff administered [MEDICATION NAME] (a pain medication) to the resident for foot pain. The note revealed no documentation regarding further assessment of the resident's foot. Review of the medical record revealed a skin assessment had been completed weekly on 4/2, 4/9, 4/16, 4/23 and 4/30 with no documentation of any reddened areas. The 5/1/15 physician's clinic note revealed the resident had a Stage III pressure ulcer (an open area that extends into the tissue beneath the skin, forming a small crater, fat may show in the sore but not muscle, tendon or bone) to his/her left foot, and instructed the staff to administer to the resident, Keflex (an antibiotic) 500 (mg) milligrams, orally twice a day for 10 days. The physician further directed the staff to keep the wound clean, covered, and float the resident's left foot. The 5/5/15 at 10:00 PM nurse's note indicated the resident was started on [MEDICATION NAME] (an antibiotic) 100 mg, orally, twice a day for treatment of [REDACTED]. The weekly wound care progress notes revealed the following: 5/6/15 Measurement 3 cm x 4 cm x observation. Post measurement after [MEDICATION NAME] 3.3 cm x 4.3 cm x 0.1 cm. 5/13/15 Measurement 3.2 cm x 4.2 cm x 0.1 cm. Post measurement after [MEDICATION NAME] 3.3 cm x 4.3 cm x 0.1 cm. 5/20/15 Measurement 1.7 cm x 2 cm x observation. Post measurement after [MEDICATION NAME] 1.8 cm x 2.2 cm x 0.1 cm. 5/27/15 Measurement 1.6 cm x 2.2 cm x 0.1 cm. Post measurement after [MEDICATION NAME] 1.7 cm x 2.2 cm x 0.1 cm. 6/3/15 Measurement 2 cm x 2 cm x 0.1 cm. Post measurement after [MEDICATION NAME] 2.1 cm x 2.1 cm x 0.1 cm. The 5/6/15 Wound Culture Report stated the resident had (MRSA) Methicilin Resistant Staph Aureus) in his/her left foot wound. The 5/6/15 Wound Care Specialist progress note indicated a large amount of serosanguinous (thin, watery fluid and blood) drainage from the wound and directed the staff to float the resident's heels nightly. The 5/11/15 at 12:54 PM nurse's note indicated the facility received a verbal order to start [MEDICATION NAME] (an antibiotic) 1 gram, twice a day, intravenously (infusion of liquid substances directly into a vein) for an infection of the resident's left foot wound. The resident had a PICC (peripherally inserted central catheter) placed to receive extended antibiotic therapy. The 5/27/15 dietary progress note contained no documentation the resident had a pressure ulcer. The 5/29/15 at 4:11 PM nurses note indicated the resident had a pressure ulcer with no dietary supplementation ordered by the physician. The nurse's note further stated the rubbing of the resident's shoes caused the pressure sore to develop and directed the staff to float the resident's heels at bedtime. The medical record revealed no Registered Dietician assessment or interventions since the development of the resident's pressure ulcer. The 5/30/15 laboratory assessment indicated the resident's total protein and [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) were within normal limits. On 6/3/15 (32 days after the staff identified the pressure ulcer) the physician's assistant ordered [MEDICATION NAME] (a nutritional supplement that promotes the healing of pressure ulcers,[MEDICAL CONDITION] surgical wounds) two times a day for the resident. On 6/2/15 at 1:32 PM, observation revealed Nurse A entered the resident's room with supplies for a dressing change. Observation revealed the resident was lying on the bed, he/she sat up on the bed and removed his/her left sock. Nurse A put on gloves and removed the dressing from the resident's left foot while the foot lay directly on the bedspread with no barrier. The dressing had an approximate quarter size yellow colored area on the outside. Nurse A discarded the soiled dressing into the trash at the side of bed. Nurse A removed his/her soiled gloves and applied new gloves. Nurse A measured the open area at 2.5 cm with a circular graph paper, folded the graph in half and laid it on the bedside table with no barrier. The open area had a white pea sized area in the middle with a pink wound bed. Nurse A, with the soiled gloves on, cleansed the open area and then applied calcium alginate and covered with an opsite dressing. Nurse A picked up the clear graph paper and discarded it in the trash, removed his/her gloves and washed his/her hands. The resident placed his/her sock back on his/her left foot and rested the left foot directly on the bed. On 6/3/15 at 7:51 AM, observation revealed the resident lying on his/her right side in bed with his/her left foot on the bed and not elevated. On 6/4/15 at 7:52 AM, observation revealed the resident lying on his/her right side with no socks on his/her feet. Further observation revealed the edges of the dressing on the resident's left foot curled up, and his/her left foot lying directly on the bed and not elevated. On 6/2/15 at 2:01 PM, Nurse A stated the resident had worn white tennis shoes and had complained of his/her left foot hurting before the staff noted the pressure ulcer. On 6/2/15 at 3:07 PM, Administrative Nurse B stated the pressure ulcer came from poorly fitted shoes which were still in the resident's closet. On 6/3/15 at 11:27 AM, Nurse Aide H stated the resident was not supposed to walk outside of the room but he/she had observed the resident in the hallway. Nurse Aide H stated he/she knew the resident had an infection in his/her foot but [MEDICAL CONDITION]. Nurse Aide H stated he/she had witnessed the resident picking at his/her foot dressing. On 6/4/15 at 11:14 AM, Administrative Nurse B verified no documentation in the nurse's notes of an inspection of the resident's left foot when the resident complained of pain in the left foot, prior to the discovery of the pressure ulcer. On 6/8/15 at 11:18 AM, Consultant M stated he/she was unaware the resident had a pressure ulcer, the dietary manager sometimes notified him/her if a resident had a pressure ulcer, and he/she does not receive a printout of residents with wounds. On 6/8/25 at 3:59 PM, Physician Assistant O stated the pressure ulcer on the resident's left foot was caused by constant pressure to that area and could have been caught a lot earlier. The facility's Wound and Pressure Ulcer Management Policy, dated 5/15, stated resident's at risk for pressure ulcer development should be monitored daily for changes in their skin condition. This may occur during the course of the resident's daily care and/or bathing where the CNA should perform a head-to-toe check of the resident's skin, paying particular attention to: bony prominences (heels, tailbone/gluteal fold, shoulder blades, elbows, back of the head, etc). The facility failed to develop and implement effective interventions to prevent the development of pressure ulcers for Resident #25, who developed a Stage III facility acquired avoidable pressure ulcer.

The facility reported a census of 44 residents with 20 sampled for review. The sampled included 4 residents reviewed for weight loss. Based on observation, interview and record review, the facility failed to have a system to ensure residents maintained acceptable parameters for weight unless clinically unavoidable for 2 of the 4 sampled residents. (#5 and #38) Resident #38 experienced a severe weight loss of 11.4% over the period of 6 months. Findings included: - physician's orders [REDACTED]. A 3/23/11 annual MDS (minimum data set) assessment showed resident #38 as alert and oriented, required no assistance with eating, weighed 140 pounds and had a 5% weight loss and was on a physician prescribed weight loss program. On 9/1/11 at 1:41 pm, Case Manager N reported the resident did not have orders for a prescribed weight loss program and that the MDS contained inaccurate information regarding the resident ' s weight loss. A 4/6/11 nutrition care area assessment stated, "Since return from hospital res (resident) is eating better and drinking fluids. Res at times will not eat a lot of what is given to (him/her) but is always offered to have something else. Res does have [MEDICAL CONDITIONS] which could cause (the resident) to have fluid retention at times causing weight to fluctuate at times. Res is going to have protein added to diet to help gain weight " A 5/25/11 review by the registered dietician stated, " Diet order 1500 cal (calorie) no added salt current wt (weight) 135 lbs. Wt continue to decline goes to the dining room for meals and feeds self. Need to fortify foods with margarine or butter. Add gravy to meals. Recommend health shake 3x daily with meals. Will continue to follow. " The record lacked any further assessments by the registered dietician for this resident from 5/25/11 through 8/31/11 (over 3 months). The record lacked evidence of the facility implementing the dietician recommendations to fortify foods with margarine or butter, add gravy to meals and provide health shakes three times daily. A 6/16/11 quarterly MDS assessment showed the resident again had a 5% weight loss. The interdisciplinary assessments and summary reviews included a 6/26/11 dietary manager quarterly review which stated, "Resident weight is 134. This is down 5 lbs in 30 days. Diet is 1500 calorie. Resident eats between 25-100% and drinks average of 340 per meal with 120 cc (cubic centimeters) supplement with noon meal. " The 6/29/11 care plan included the following interventions: o weight weekly, o monitor intake at meals, o report any declines to cn (charge nurse) or provider o health shakes every day o if I don't eat what is served, please offer me other choices o serve me small portions o resident chooses to sleep in please offer breakfast or a milkshake when a wake, A weight record showed the following weights: 3/3/11 - 140 pounds 6/5/11 - 134 pounds 7/26/11 -- 131 pounds 8/30/11 - 124 pounds ( a 5 % weight loss from the previous month, a 7.5 % weight loss from 6/5/11, and an 11.4% weight loss since the 3/3/11 weight) The care plan lacked any updates following the residents continued weight loss. The resident ' s meal intake record from 8/11/11 - 8/31/11 showed on 15 of the 21 days lacked evidence of the monitoring of meal intake for all three meals. The record also lacked evidence that if the resident refused breakfast or slept late that staff offered a milkshake as outlined in the care plan. On 8/31/11 at 5:46 pm, observation of the preparation of the resident ' s meal showed the dietary staff did not fortify the resident ' s food or add protein. The resident received Salisbury steak and mashed potatoes and gravy. The resident consumed all the steak and a few bites of the mashed potatoes. The resident reported he/she did not like the brown gravy. Dietary staff W reported she had not prepared resident 5 ' s meal any different that the other residents and had not fortified the foods. On 8/31/11 at 4 pm, the dietary manager V stated the resident liked the health shakes and cheese. She reported staff should put cheese on the plate at every meal. She stated the facility lacked a system which determined the amount of calories the resident required for weight maintenance and then, based on the resident ' s meal and supplement intake, determined if the resident consumed the appropriate amount of calories. She confirmed the facility had not implemented the dietician ' s recommendations on 5/25/11 and that the dietician had not reviewed the resident ' s continued weight loss in the previous 3 months. In summary, the facility failed to have a system in place to ensure resident ' s consumed the amount of calories needed to maintain weight, to monitor a resident ' s meal intake, to ensure resident ' s with weight loss received the benefit of a review from a registered dietician, and to implement new interventions following weight loss for resident #38. The resident experienced a severe weight loss of 11.4% in 6 months. - Physicians orders from 8/17/11 for resident #5 included the following Diagnoses: [REDACTED]. Hypertension, constipation, pancreatitis, congestion, [MEDICATION NAME] degeneration, pain, [MEDICAL CONDITION] embolism; status [REDACTED]. An 11/24/10 annual MDS (minimum data set showed resident #5 as alert and oriented, weighed 101 pounds and had no weight loss. A 12/5/10 care area assessment for nutrition stated the resident tat well and had no weight loss. A 3/21/11 registered dietician note stated, " Current weight 102 pounds seems to weigh between 102 and 106 pounds. Resident has fortified diet orders. Goes to dining room for meals and feed self. Recommend a health shake daily to provide additional calories. We don ' t want the weight to trend downward. " A 5/21/11 registered dietician noted stated, current weight 100 pounds which indicates a 2 pound weight gain from 98 pounds. Weight gain is good and in fact we would like to see (the resident) continue to gain. Previous note had recommended starting health shakes. Recommend to continue with heal shake as recommended in March. " A 6/1/11 care plan included the following interventions: o Now sitting at nutritional assist table per request due to vision loss o Weigh weekly An 8/3/11 registered dietician noted stated, " Current weight 97 pounds weight continues to trend down. Had recommended health shakes, if not taking health shakes, recommend 2 cal 2 ounces four times daily to provide additional calories. Also recommend fortified foods. " Physician orders [REDACTED]. An 8/18/11 quarterly MDS showed the resident continued to be independent with eating and weighed 96 pounds. The 8//31/11 care plan lacked any updates to reflect the physician orders. A weight record showed the following weights: 3/09/2011-102 pounds 6/02/2011 - 98 pounds 7/28/2011 - 95 pounds 8/30/11 - 98 pounds A Dining Record from 8/11/11 - 8/31/11 lacked evidence of monitoring the resident ' s meal intakes for al three meals on 5 of the 21 days and lacked monitoring of the resident ' s snack intake three snacks a day as ordered and the supplement four times a day as ordered for 21 of the 21 days. On 8/31/11 at 5:30 pm, dietary staff W prepared the resident ' s meal. The resident received Salisbury steak with no gravy, mashed potatoes and one scoop of gravy, peas and pears. The dietary manager V reported at this time that resident ' s on fortified diets should received extra butter on the mashed potatoes and vegetables as well as extra gravy. Dietary staff W reported she had not prepared resident 5 ' s meal any different than the other residents and had not fortified the foods. The resident consumed 80% of the meal and drank 100% of the supplement. On 9/1/11 at the noon meal, the resident received 4 ounces of 2 Cal supplement, chicken casserole, broccoli, mashed potatoes and gravy. During the preparation of the meal, the dietary manager V had to remind the kitchen staff to add extra butter to the resident ' s vegetables. The resident ate 100% of the meal. On 8/31/11 at 4 pm, the dietary manager V stated the facility lacked a system which determined the amount of calories the resident required for weight maintenance and then, based on the resident ' s meal and supplement intake, determined if the resident consumed the appropriate amount of calories. She also stated the facility lacked a system to ensure monitoring of the resident ' s meal and supplement intakes. In summary, the physician and dietician had recommended interventions to improve or maintain resident #5 ' s weight. The facility failed to have a system in place to ensure the interventions were put in place and to monitor the resident ' s caloric intake compared to the resident ' s caloric needs to ensure adequate calories for weight maintenance.