Every finding on record at Good Samaritan - Decatur County

The facility had a census of 18 residents. Based on the interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30) indicated the facility did not have licensed nurse coverage 24 hours a day on the following dates:07/07/24 (SU), 07/27/24 (SA), 07/28/24 (SU)08/11/24 (SU)09/29/24 (SU).Review of the facility's daily nursing staff coverage revealed the facility had licensed nurse coverage 24 hours a day on the above dates, and revealed the facility had adequate licensed nurse coverage.On 10/21/25 at 08:37 AM, Administrative Staff A stated the human resource staff was responsible for submitting the PBJ during that period of time, and she no longer worked for the facility.The facility's Reporting Direct Care Staffing Information (PBJ) Policy, revised May 2024, documented that complete and accurate direct care staffing information would be reported electronically to the Centers for Medicaid, Medicare Services (CMS) through the PBJ system in a uniform format specified by CMS.

The facility had a census of 18 residents. The sample included eight residents. Based on observation, interview, and record review, the facility, in coordination with the licensed pharmacist, failed to provide a system of medication records that enabled periodic, accurate reconciliation and accounting for all resident medications when the emergency medication kit (E-Kit) was unlocked in the medication room. The facility staff failed to label and date Resident (R) 6's Insulin aspart (rapid acting) insulin (a hormone that lowers the level of glucose in the blood) pen (a device for giving insulin shots). This placed the residents at risk for being charged for a medication not administered to them from the e-kit. Findings included:- On 09/23/25 at 08:50 AM, during inspection of the facility medication room with Licensed Nurse (LN) G, revealed that the blue E-Kit sat on the counter to the left of the entrance door was unsecured with a note in between the handles which read Stop!! New E-Kit instructions. For all medications taken from the E-kit on the inventory sheet, fill out the bottom of the inventory sheet completely and relock the E-kit with one lock from inside the E-kit. Antibiotics would not have a card use bottle. Fax the resident's order to the pharmacy and notate on the order sheet: TAKEN FROM E-KIT, as well as the quantity used, so the pharmacy knows how much to bill the resident and reimburse the facility for, as well as to re-lock the E-kit. LN G opened the kit, and it lacked an inventory list for the medications in the kit. Observation revealed that LN G was not able to find the inventory list in the medication room. Further observation revealed Administrative Nurse D entered the medication room, verified the E-kit was unlocked, and stated staff should secure the E-kit with a red zip tie on top of the E-kit whenever they open it and use a medication from it. LN G secured the E-kit with one of the ties.On 09/23/25 at 08:58 AM, LN H verified the facility lacked the inventory list for the E-kit and stated it should be inside the E-kit. LN H stated she would call the pharmacy and ask for them to fax the facility the inventory list. LN H stated the procedure staff should take when they open the E-kit and use a medication from it; they are to take the count off the inventory sheet and fax the pharmacy so they can replace it. LN H stated staff were to relock the E-kit after they use a medication.On 09/23/25 at 03:53 PM, LN G stated she was not required to check the E-kit to ensure it was locked.On 09/23/25 at 03:54 PM, Administrative Nurse D stated she had received the E-kit inventory list. Observation revealed Administrative Nurse D conducted an audit of the E-kit and verified the E-kit was missing one vial of Haldol (antipsychotic- a class of medications used to treat major mental conditions that cause a break from reality), 2 vials of lidocaine (medication used to relieve pain), and 2 ampules (glass capsule containing a liquid, especially a measured quantity ready for injecting) of Phenergan (a medication used to manage and treat allergic conditions, nausea and vomiting, motion sickness, and sedation). Administrative Nurse D verified the facility lacked a system for reconciling the medications inside the E-kit and monitoring it to ensure it was locked.On 09/24/25 at 04:31 PM, Consultant GG stated the pharmacist delivers the E-kit to the facility unlocked, due to they have locks in the medication room. Consultant GG stated he provided an inventory list of the medications, placed it inside the E-kit, but did not provide a sheet to reconcile the medications if staff used a medication from it. Consultant GG stated when staff used a medication from the E-kit, they were to fax the resident orders to the pharmacy so the pharmacy could charge the correct resident for the medication.The facility's Emergency Drug Boxes Policy, revised 12/02/24, documented emergency drug boxes are an extension of the providing pharmacists' store and would be kept locked in the medication room, accessible to licensed nurses and medication aides. When a drug is used from the box, the pharmacist or the pharmacist's agent would be notified according to state-specific regulations. A list of emergency medications, including the amounts, dosages/strengths, would be posted on the outside of the box. The pharmacist was responsible for monitoring expiration dates. Record keeping would be in accordance with the state pharmacy system.

The facility identified a census of 18 residents. The facility had one main kitchen and one main dining room. Based on observation, interview, and record review, the facility failed to ensure that the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). Findings included:- On 09/22/25 at 08:37 AM, during the initial tour of the facility kitchen, Dietary BB stated that she was currently taking the classes to become certified but had not taken her test yet. Dietary BB further stated that the registered dietician came to the facility twice a month to review the residents' diets and address any weight loss.On 09/23/25 at 09:18 AM, Administrative Staff A stated that Dietary BB would soon be taking her test to become a certified dietary manager.The facility lacked a policy for Certified Dietary Manager as requested on 09/24/25.

The facility identified a census of 18 residents. The sample included eight residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 18 had a functional pair of glasses needed for her impaired vision. Findings included:- R18's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN- elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), and a history of falling.R18's Annual Minimum Data Set (MDS) dated [DATE] documented she had adequate vision with glasses or other visual appliances and required corrective lenses. R18 had both short and long-term memory problems. R18 had moderately impaired cognitive skills for daily decision making. R18 was dependent on staff for her ADLs. R18 required the use of a wheelchair for mobility that staff propelled. R18's Functional Care Area Assessment (CAA) dated 02/10/25 documented she had a diagnosis of dementia, and the resident was no longer able to care for herself. R18 required full staff assistance with her self cares. R18 required the use of a full mechanical lift for all transfers, and she was unable to make her own decisions.R18's Care Plan, revised on 05/12/25, directed staff to monitor her visual and auditory impairments. The care plan directed staff to assist with the care and use of her glasses. The care plan directed staff that R18 was to wear her glasses during her awake hours.R18's Order Summary in the EMR Orders tab documented an order dated 06/10/23 for the nurse to ensure the residents' glasses were placed on in the morning and removed at bedtime, and the glasses were to be kept in the medication room. R18's Progress Notes tab documented an 'Administration Record note dated 07/10/25 at 08:17 PM documented the Nurse would ensure R18 had glasses placed on in morning and removed at bedtime and should be kept in med room. R18's glasses are still broken and have not been repaired.R18's Progress Notes tab of the EMR documented an 07/16/25 at 09:11 AM Admin Record (Default Note) that documented the nurse was to ensure the resident had glasses placed on in morning and removed at bedtime and kept in the med room. R18's glasses are broken.On 09/24/25 at 11:00 AM, R18's representative stated that she had not been notified by the facility that R18's glasses were broken. R18's representative further stated that she did have a couple of spare pairs at her house that she could bring to the facility.On 09/23/25 at 08:17 AM, R18 did not have her glasses on. R18 was unable to state where her glasses were.On 09/24/25 at 11:17 AM, Administrative Nurse F stated at the time of R18's glasses being broken, Administrative Nurse D had known the glasses were broken since 07/04/25.On 09/24/25 at 11:45 AM, Administrative Staff A stated she had not been made aware that R18's glasses had been broken since July. Administrative Staff A stated had she known the glasses were broken, she would have made sure that R18's representative was notified and that the glasses were replaced or repaired.The facility's Eye Care- Culture, Eyeglasses, Prosthesis, Services policy dated 10/30/24 documented the purpose of this policy was to ensure the resident has access to proper treatment and assistive devices to maintain visual ability. Staff were to report to the licensed nurse any problems with glasses, such as broken or missing lenses.

The facility had a census of 18 residents. The sample included eight residents, with six reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to obtain blood pressure parameters from the physician for one resident, Resident (R) 1, who received medication to treat hypertension (high blood pressure). Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of hypertension, occlusion and stenosis of the right carotid artery (narrowing and blockage of one of the main blood vessels that run up the right side of the neck), and occlusion and stenosis of the right posterior cerebral artery (narrowing and blockage of the artery of the right side of the brain).The admission Minimum Data Set (MDS) dated [DATE] documented R1 had intact cognition. R1 was independent with activities of daily living and did not ambulate. The MDS further documented R1 received antidepressant (a class of medication that calms and relaxes people), anticoagulant (a class of medications used to prevent the blood from clotting), and hypoglycemic (a medication used to lower blood glucose (sugar) levels in the body) medications daily.R1's Care Plan dated 06/24/25 directed staff to monitor, document, and report to the health care provider signs and symptoms of malignant hypertension, administer medication as ordered, and monitor and document any abnormalities for urinary output.The Physician's Order dated 06/25/25 directed staff to administer metoprolol (used to treat hypertension), extended release (ER), 25 milligrams (mg), by mouth, daily for hypertension. The order lacked blood pressure parameters for the resident.On 09/23/25 at 08:30 AM, R1 sat in her room, on her tablet.On 09/24/25 at 12:16 PM, Licensed Nurse (LN) I stated staff obtained R1's blood pressure daily and verified her metoprolol did not have physician-ordered parameters.On 09/24/25 at 12:30 PM, Administrative Nurse D stated there should be physician-ordered parameters for R1's metoprolol and stated LN I would contact the physician for further direction.The facility's Vital Signs-Blood Pressure policy, dated 04/08/25, directed staff to document the resident's vital signs in the medical record. The policy directed staff to recognize significant changes in blood pressure with position changes, and report to the LN if the resident complained of lightheadedness, dizziness, blurred vision, and/or shallow breathing. The policy further directed staff to note if the resident's pulse was regular or irregular.

The facility had a census of 18 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to date Resident (R) 6's Insulin Aspart (rapid acting) insulin (a hormone that lowers the level of glucose in the blood) pen (a device for giving insulin shots).Findings included:- On 09/22/25 at 03:45 PM, observation revealed in the medication cart, R6's Aspart insulin pen was undated when it was opened.On 09/22/25 at 03:45 PM, Licensed Nurse (LN) G verified R6's insulin pen had been used and was undated to indicate when it was opened. LN G stated staff should date the insulin pen when they open it. LN G discarded the pen in a sharps container (a puncture-resistant, rigid plastic receptacle designed to safely collect and dispose of sharp medical objects like needles, syringes, and scalpels, preventing injuries and the spread of infection).On 09/24/25 at 12:21 PM, Administrative Nurse D stated she expected staff to date an insulin pen when they opened it with the expiration date and opened date.The facility did not provide a policy regarding the storage of insulin pens requested on 09/24/25.

The facility had a census of 18 residents. The sample included eight residents, with one reviewed for hospitalization and one reviewed for discharge. Based on observation, interviews and record review, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) and failed to provide one resident, Resident (R) 20, with written information regarding the facility's bed hold policy when they were transferred to the hospital. The facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) for R22.Findings included: - The Electronic Medical Record (EMR) for R20 documented diagnoses of fracture of the part of the neck of the femur (broken thigh bone), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and chronic kidney disease (moderate kidney damage) stage 3. The admission Minimum Data Set (MDS) dated [DATE] documented R20 had intact cognition. R20 required partial staff assistance for dressing, toileting, transfers, and personal hygiene. The Medicare 5 Day MDS dated 08/13/25 documented R20 had moderately impaired cognition. R20 required substantial staff assistance for showers, lower body dressing, transfers, and toileting. R20's Care Plan dated 06/26/25 directed staff to monitor R20's condition based on clinical practice guidelines or clinical standards of practice, report significant changes to the health care provider, and administer medication as ordered. R20's Progress Note dated 07/13/25 at 09:57 PM documented R20 admitted to the hospital for a transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain). R20's clinical record lacked evidence that the family received bed hold notification or that the Ombudsman was notified of the hospital transfer. R20's Progress Note dated 08/03/25 at 08:06 PM documented R20 admitted to the hospital with stroke-like symptoms. R20's clinical record lacked evidence that the Ombudsman was notified of the hospital transfer. R20's Progress Note dated 08/07/25 at 04:50 PM documented R20 readmitted to the facility after she had received three units of blood. R20's Progress Note dated 08/21/25 at 09:45 AM documented R20 was admitted to the hospital with stroke-like symptoms. R20's clinical record lacked evidence that the family received bed hold notification or that the Ombudsman was notified of the hospital transfer. R20's Progress Note dated 08/25/25 at 12:11 PM documented R20 transferred to another hospital due to her condition having worsened, and she did not return to the facility. On 09/24/25 at 12:27 PM, Administrative Nurse D stated that Administrative Staff B was responsible for the discharge summary. The facility's Bed-Hold policy, dated 12/19/24, documented that at the time of admission, transfer, or therapeutic leave, the facility would provide written information to the resident or resident representative of the duration of the state bed-hold policy. The bed-hold policy would specify the duration, if any, during which the resident was permitted to return and resume residence, the reserve bed payment policy in the plan, and the locations' policies regarding bed-hold periods permitting a resident to return. The policy further documented, the social worker, or designee, would provide the notice of bed hold policy. In case of emergency transfer to the hospital, the facility sent a copy with the resident to the hospital for the resident's representative. The facility's Discharge and Transfer policy, dated 03/28/25, directed staff to complete the discharge summary when the discharge was entered into the medical record. The policy further directed staff to send copies of the transfer to the ombudsman. - R22's Electronic Medical Record (EMR) documented the resident had diagnoses of displaced fractured (traumatic bone break where two ends of the bone separate out of their normal positions) right femur (thigh bone), weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R22's Annual Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R22 was independent with most activities of daily living (ADL). The MDS documented R22 had no plan to discharge. R22's Care Plan revised 07/24/25 documented R22 required one staff assist with ambulation and transfers. The plan documented R22 would remain in the facility, and no discharge was planned at this time. The plan documented R22, or her representative, did not want to be asked about returning to the community on any assessments and refused any community referral. R22's Progress Notes dated 07/31/25 at 11:14 AM documented the resident was transferred to another facility to be closer to her family. The Discharge Summary dated 08/07/25 documented that R22 was discharged on 07/31/25 at 11:15 AM. The summary had the condition of resident when discharged , but lacked a recapitulation of R22's stay and reconciliation of medications. On 09/24/25 at 12:27 PM, Administrative Nurse D stated that Administrative Staff B was responsible for filling out the discharge summary. Administrative Nurse D verified the medication reconciliation section was not completed on the summary and stated it should have been completed. The facility's Discharge and Transfer-Rehab/Skilled, Therapy and Rehab Policy, revised 03/28/25, documented the charge nurse or designated individual would complete the discharge summary. This would be triggered in the resident's medical record when the discharge was entered into the census.

The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and activities of daily living (ADL). Based on record review, observation, and interview, the facility failed to provide sufficient nurse staffing with the appropriate skill sets and competencies to treat Resident (R) 2, R3, R4, R5, and R7 with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life to maintain the highest practicable physical, mental, and psychosocial wellbeing. (Refer to F677) Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R2's Quarterly Minimum Data Set (MDS), dated 03/01/25, documented R2 had a Brief Interview for Mental Status score of 99. The MDS documented R2 had short and long-term memory loss, and R2 was severely cognitively impaired. The MDS documented R2 was dependent on staff for completing all of her activities of daily living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/29/24, documented R2 had a diagnosis of dementia, had memory loss, and required a proxy for health care decisions. The Behavioral Symptom CAA, dated 08/29/24, documented R2 had behaviors of physical aggression towards staff during cares, which placed R2 at risk for injury. R2's Care Plan directed staff to engage R2 in simple, structured activities that were not demanding (09/27/23). The care plan directed staff to ensure R2 wore a bra daily and to smooth her shirt so it was not wrinkled (03/18/25). The care plan directed staff to transfer R2 with a full lift with two staff assistance using the high-backed yellow sling (10/04/24). The care plan directed staff to provide weekly one-on-one visits and manicures, and R2's preferred activities were hymns and devotions (09/27/23). On 04/28/25 at 09:30 AM, observation revealed R2 sat in the activity room after breakfast in her wheelchair with a yellow high-backed lift sling under her. R2's hair had not been combed and was mussed. R2 had dried yellow and brown food particles on the sides of her wheelchair that appeared to be days old. R2's blouse was wrinkled. There was no staff in the activity room, and there was no activity for R2 to enjoy. R2 sat and either looked around the room at the five other residents sitting with her or slept in her wheelchair. On 04/28/25 at 10:30 AM, R2 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R2. R2 slept with her head tilted to her right shoulder. On 04/28/25 at 11:00 AM, someone had brought a cart into the activity room that had cookies, tea, and coffee on it. No one had served R2 a drink or snack. R2 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:30 PM, observation revealed Certified Nurse's Aide (CNA) M rolled R2 back and forth in bed by herself to provide R2 incontinent care. R2 grabbed CNA M's hands and arms to try and stop her. After CNA M left the room, observation revealed R2 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone; she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all of the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R3's EMR documented R3 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R3's Quarterly Minimum Data Set (MDS), dated 03/05/25, documented R3 was rarely/never understood. The MDS documented R3 had short-term and long-term memory loss and had severely impaired cognition. The MDS documented R3 was dependent on staff for all of her activities of daily living (ADL). The MDS documented R3 had physical and verbal behaviors directed towards others for four to six days during the look-back period. R3's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/03/24, documented R3 had diagnoses of dementia and Alzheimer's disease and was severely cognitively impaired. The Psychosocial Well-Being CAA, dated 12/03/25, documented R3 was no longer able to tell of her favorite activity. The CAA documented that R3 received family visits one to two times a week and would attend morning devotions. R3's Care Plan directed staff to reminisce with R3 using photos of family and friends (06/15/22). R3's care plan directed staff R3 preferred to have makeup and perfume on every day (12/08/23). R3's care plan directed R3 required two staff to transfer her with a sit-to-stand lift with the green bordered lift sling. R3's care plan directed staff to assist R3 out of bed at 04:00 PM every day and place R3 in front of the TV (07/14/23), provide weekly one on one visits (12/15/20), and offer weekly visits with the chaplain/attends Catholic mass (12/08/23), and invite and remind R3 of scheduled activities and assist as needed (12/15/20). On 04/28/25 at 09:30 AM, R3 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R3 to enjoy. There was no staff in the room. R3's hair had not been combed that morning and was sticking up on end. R3 did not have a bra on, and her left breast and nipple were showing through the blouse she had on. R3 did not have any makeup on. There were dark brown food particles on the sides of R3's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R3 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R3. R3 slept with her chin on her chest. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. No one had served R3 a drink or snack. R3 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:30 PM, observation revealed CNA N rolled R3 back and forth in bed by herself to provide R3 incontinent care. After CNA N left the room, observation revealed R3 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone; she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all of the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R4's EMR documented R4 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), non-traumatic brain dysfunction (damage to the brain that does not result from an external force, such as a fall or accident), need for assistance with personal care, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS), dated 01/07/25, documented R4 had a BIMS score of three, which indicated severely impaired cognition. The MDS documented R4 was dependent on staff for toileting, bathing, and transfer. The MDS documented R4 required maximum/substantial assistance from staff for ambulation, dressing, and bed mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/24, documented R4 had dementia, memory problems, and required assistance with decision making. The Psychosocial Well Being CAA, dated 07/07/24, documented R4 had been a farmer his whole life and rarely socialized. R4's brother visited a few times a week, otherwise, there was no family involvement. R4's Care Plan directed staff R4 preferred to get up and 07:00 AM, eat breakfast, watch TV, and would like to attend morning activities (03/14/25). The care plan directed R4 required a sit-to-stand lift utilizing the yellow bordered sling with two staff assist for transfers and a wheelchair for mobility (02/27/25). On 04/28/25 at 08:45 AM, observation revealed R4 sat in his wheelchair at a table with breakfast in front of him. R4 sat with his head down, his chin on his chest. R4's pants were stained with food particles, his button-down shirt only had two buttons buttoned, and showed a large portion of his chest and stomach. R4's shirt had a large, old orange stain on the cuff. R4 had coughed up some yellow, bloody phlegm on his shirt. On 04/28/25 at 09:30 AM, R4 sat in his wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R4 to enjoy. There was no staff in the room. R4's wheelchair had dark brown dried food particles on the sides of his wheelchair that appeared to have been there for days. On 04/28/25 at 10:30 AM, R4 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R4. R4 wrung his hands and played with his fingers. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. No one had served R4 a drink or snack. R4 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:40 PM, R4 sat in his wheelchair in his room. The TV was not on, and R4 looked around his room. R4 continued to be in stained, unclean clothing with the large yellow, bloody phlegm on the front of his shirt. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone; she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R5's EMR documented R5 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heartbeat), and a history of falling. R5's Annual MDS, dated 02/14/25, documented R5 had a BIMS score of 99, R5 had short and long-term memory deficits, and R5 made poor decisions and required supervision. The MDS documented R5 was dependent on staff for all of her ADLs. The Cognitive Loss/Dementia CAA, dated 02/14/25, documented R5 had dementia, was unable to make decisions appropriately, and had short and long-term memory loss. The Psychosocial Well Being CAA, dated 02/14/25, documented R5 was unable to describe her favorite activity, and family visited often. R5's Care Plan documented R5's preferred activities were devotions, bible study, group exercises, social events, and current events. The care plan directed staff to reminisce with R5 using photos of family and friends. The care plan documented R5 transferred with a full lift using a red-bordered high back sling and two staff. On 04/28/25 at 09:30 AM, R5 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R5 to enjoy. There was no staff in the room. R5's hair had not been combed that morning and was sticking up on end. There were dried yellow egg particles on R5's shirt and pants, probably from breakfast. There were dark brown food particles on the sides of R5's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R5 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R5. R5 played with the arm protectors on her arms. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. Someone had given R5 a cookie, and R5 broke up the cookie and threw it on the floor. R5 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:20 PM, R5 sat in her wheelchair in a living area off the activity room by herself. No staff were interacting with R5. R5 continued to have clothes covered with dried yellow egg particles from breakfast. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone; she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her for activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were ol[TRUNCATED]

The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with the resident's right to a dignified existence by ensuring the residents were well groomed, clean, and dressed appropriately for the day. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for impaired dignity and psychosocial impairment. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R2's Quarterly Minimum Data Set (MDS), dated 03/01/25, documented R2 had a Brief Interview for Mental Status score of 99. The MDS documented R2 had short-term and long-term memory loss, and R2 was severely cognitively impaired. The MDS documented R2 was dependent on the staff for completing all of her activities of daily living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/29/24, documented R2 had a diagnosis of dementia, had memory loss, and required a proxy for health care decisions. The Behavioral Symptom CAA, dated 08/29/24, documented R2 had behaviors of physical aggression towards staff during cares, which placed R2 at risk for injury. R2's Care Plan directed staff to engage R2 in simple, structured activities that were not demanding (09/27/23). The care plan directed staff to ensure R2 wore a bra daily and to smooth her shirt so it was not wrinkled (03/18/25). The care plan directed staff to transfer R2 with a full lift with two staff assistance using the high-backed yellow sling (10/04/24). The care plan directed staff to provide weekly one-on-one visits and manicures, and R2's preferred activities were hymns and devotions (09/27/23). On 04/28/25 at 09:30 AM, observation revealed R2 sat in the activity room after breakfast in her wheelchair with a yellow high-backed lift sling under her. R2's hair had not been combed and was mussed. R2 had dried yellow and brown food particles on the sides of her wheelchair that appeared to be days old. R2's blouse was wrinkled. There was no staff in the activity room, and there was no activity for R2 to enjoy. R2 sat and either looked around the room at the five other residents sitting with her or slept in her wheelchair. On 04/28/25 at 10:30 AM, R2 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R2. R2 slept with her head tilted to her right shoulder. On 04/28/25 at 01:30 PM, observation revealed Certified Nurse's Aide (CNA) M rolled R2 back and forth in bed by herself to provide R2 incontinent care. R2 grabbed CNA M's hands and arms to try and stop her. After CNA M left the room, observation revealed R2 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R3's EMR documented R3 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R3's Quarterly Minimum Data Set (MDS), dated 03/05/25, documented R3 was rarely/never understood. The MDS documented R3 had short-term and long-term memory loss and had severely impaired cognition. The MDS documented R3 was dependent on staff for all of her activities of daily living (ADL). The MDS documented R3 had physical and verbal behaviors directed towards others for four to six days during the look-back period. R3's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/03/24, documented R3 had diagnoses of dementia and Alzheimer's disease and was severely cognitively impaired. The Psychosocial Well-Being CAA, dated 12/03/25, documented R3 was no longer able to tell of her favorite activity. The CAA documented that R3 received family visits one to two times a week and would attend morning devotions. R3's Care Plan directed staff to reminisce with R3 using photos of family and friends (06/15/22). R3's care plan directed staff R3 preferred to have makeup and perfume on every day (12/08/23). R3's care plan directed staff that R3 required two staff to transfer her with a sit-to-stand lift with the green bordered lift sling. R3's care plan directed staff to assist R3 out of bed at 04:00 PM every day and place R3 in front of the TV (07/14/23), provide weekly one on one visits (12/15/20), and offer weekly visits with the chaplain/attends Catholic mass (12/08/23), and invite and remind R3 of scheduled activities and assist as needed (12/15/20). On 04/28/25 at 09:30 AM, R3 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R3 to enjoy. There was no staff in the room. R3's hair had not been combed that morning and was sticking up on end. R3 did not have a bra on, and her left breast and nipple were showing through the blouse she had on. R3 did not have any makeup on. There were dark brown food particles on the sides of R3's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R3 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R3. R3 slept with her chin on her chest. On 04/28/25 at 01:30 PM, observation revealed CNA N rolled R3 back and forth in bed by herself to provide R3 incontinent care. After CNA N left the room, observation revealed R3 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R4's EMR documented R4 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), non-traumatic brain dysfunction (damage to the brain that does not result from an external force, such as a fall or accident), need for assistance with personal care, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS), dated 01/07/25, documented R4 had a BIMS score of three, which indicated severely impaired cognition. The MDS documented R4 was dependent on staff for toileting, bathing, and transfer. The MDS documented R4 required maximum/substantial assistance from staff for ambulation, dressing, and bed mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/24, documented R4 had dementia, memory problems, and required assistance with decision making. The Psychosocial Well Being CAA, dated 07/07/24, documented R4 had been a farmer his whole life and rarely socialized. R4's brother visited a few times a week, otherwise, there was no family involvement. R4's Care Plan directed staff R4 preferred to get up at 07:00 AM, eat breakfast, watch TV, and would like to attend morning activities (03/14/25). The care plan directed R4 required a sit-to-stand lift utilizing the yellow bordered sling with two staff assist for transfers and a wheelchair for mobility (02/27/25). On 04/28/25 at 08:45 AM, observation revealed R4 sat in his wheelchair at a table with breakfast in front of him. R4 sat with his head down, his chin on his chest. R4's pants were stained with food particles, his button-down shirt only had two buttons buttoned, and showed a large portion of his chest and stomach. R4's shirt had a large, old orange stain on the cuff. R4 had coughed up some yellow, bloody phlegm on his shirt. On 04/28/25 at 09:30 AM, R4 sat in his wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R4 to enjoy. There was no staff in the room. R4's wheelchair had dark brown dried food particles on the sides of his wheelchair that appeared to have been there for days. On 04/28/25 at 10:30 AM, R4 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R4. R4 wrung his hands and played with his fingers. On 04/28/25 at 01:40 PM, R4 sat in his wheelchair in his room. The TV was not on, and R4 looked around his room. R4 continued to be in stained, unclean clothing with the large yellow, bloody phlegm on the front of his shirt. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R5's EMR documented R5 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heartbeat), and a history of falling. R5's Annual MDS, dated 02/14/25, documented R5 had a BIMS score of 99, R5 had short and long-term memory deficits, and R5 made poor decisions and required supervision. The MDS documented R5 was dependent on staff for all of her ADLs. The Cognitive Loss/Dementia CAA, dated 02/14/25, documented R5 had dementia, was unable to make decisions appropriately, and had short and long-term memory loss. The Psychosocial Well Being CAA, dated 02/14/25, documented R5 was unable to describe her favorite activity, and family visited often. R5's Care Plan documented R5's preferred activities were devotions, bible study, group exercises, social events, and current events. The care plan directed staff to reminisce with R5 using photos of family and friends. The care plan documented R5 transferred with a full lift using a red-bordered high back sling and two staff. On 04/28/25 at 09:30 AM, R5 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R5 to enjoy. There was no staff in the room. R5's hair had not been combed that morning and was sticking up on end. There were dried yellow egg particles on R5's shirt and pants, probably from breakfast. There were dark brown food particles on the sides of R5's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R5 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R5. R5 played with the arm protectors on her arms. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. Someone had given R5 a cookie, and R5 broke up the cookie and threw it on the floor. R5 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:20 PM, R5 sat in her wheelchair in a living area off the activity room by herself. No staff were interacting with R5. R5 continued to have clothes covered with dried yellow egg particles from breakfast. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast, the food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated that the administrative staff never came out of their offices to assist with resident care. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R6's EMR documented R6 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R6's Quarterly MDS, dated 01/01/25, documented R6 had a BIMS score of three, which indicated severely impaired cognition. The MDS documented R6 was dependent on staff for most of her ADLs. The Cognitive Loss/Dementia CAA, dated 07/01/24, documented a cognitive deficit, short-term and long-term memory loss, and required assistance with decision-making. R6's Care Plan documented R6 would express satisfaction with activities and would come and go during morning activities, manicures, and parties/programs. The care plan directed staff R6 required a full lift with two staff assistance for transfer and bed mobility using the yellow bordered sling. R6's care plan documented R6 used a wheelchair for mobility and could propel short distances. The care plan directed staff R6 enjoyed watching sports on TV, enjoyed bingo, and liked social hour and group exercises. On 04/28/25 at 09:30 AM, R6 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R6 to enjoy. There was no staff in the room. R6's hair had not been combed that morning and was sticking up on end. There were dried yellow egg particles on R6's shirt and pants, probably from breakfast. There were dark brown food particles on the sides of R6's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R6 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R6. R6 slept with her chin on her chest. On 04/28/25 at 09:35 AM, Certified Nurse ' s Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R7's EMR documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), failure to thrive, muscle weakness, and dysphagia (swallowing difficulty). R7's Annual MDS, dated 01/29/25, documented R7 had a BIMS score of 99. The MDS documented R7 had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making. The MDS documented R7 was dependent on staff for toileting, bathing, donning and doffing footwear, and personal hygiene. The MDS documented R7 required substantial/maximum assistance for dressing, transfer, and bed mobility. The Cognitive Loss/Dementia CAA, dated 01/29/25, documented R7 had dementia and short and long-term memory loss. The CAA documented R7's communication was slow, and R7 would often not respond; R7 could sit in silence for long periods. R7's Care Plan directed staff to engage R7 in simple, structured activities that avoided overly demanding tasks such as sorting or folding and directed staff to reminisce with R7 using photos of family and friends (04/29/22). The care plan documented R7 had a self-care performance deficit and required extensive staff assistance for ADLs (05/18/22). The care plan directed staff R7's preferred activities were devotions, bingo, watching TV, and visits (11/07/23). The care plan directed staff to turn on R7's TV in her room when R7 chose not to participate in organized activities 11/07/23). On 04/28/25 at 09:35 AM, observation revealed R7 sat in a recliner in her room with the lights off and the TV off. R7 leaned clear to the recliner's left and over the side. R7's water pitcher was too far away for her to reach to get a drink of water. R7's hair was standing up on end, and her clothes appeared to have been slept in. On 04/28/25 at 10:35 AM, observation revealed, R7 sat in the same position as previously. R7 did not have any activities going on in her room to enjoy. On 04/28/25 at 11:15 AM, R7 continued to sit in the same position; continued to lean clear to the left side of her chair, over the armrest, in an uncomfortable position. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. On [TRUNCATED]

The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with appropriate ADL care for each resident to maintain a dignified existence and quality of life to maintain the highest practicable physical, mental, and psychosocial wellbeing. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for an undignified existence and a decline in their mental and psychosocial well-being. (Refer to F725) Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R2's Quarterly Minimum Data Set (MDS), dated 03/01/25, documented R2 had a Brief Interview for Mental Status score of 99. The MDS documented R2 had short and long-term memory loss, and R2 was severely cognitively impaired. The MDS documented R2 was dependent on the staff for completing all of her activities of daily living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/29/24, documented R2 had a diagnosis of dementia, had memory loss, and required a proxy for health care decisions. The Behavioral Symptom CAA, dated 08/29/24, documented R2 had behaviors of physical aggression towards staff during cares, which placed R2 at risk for injury. R2's Care Plan directed staff to engage R2 in simple, structured activities that were not demanding (09/27/23). The care plan directed staff to ensure R2 wore a bra daily and to smooth her shirt so it was not wrinkled (03/18/25). The care plan directed staff to transfer R2 with a full lift with two staff assistance using the high-backed yellow sling (10/04/24). The care plan directed staff to provide weekly one-on-one visits and manicures, and R2's preferred activities were hymns and devotions (09/27/23). On 04/28/25 at 09:30 AM, observation revealed R2 sat in the activity room after breakfast in her wheelchair with a yellow high-backed lift sling under her. R2's hair had not been combed and was mussed. R2 had dried yellow and brown food particles on the sides of her wheelchair that appeared days old. R2's blouse was wrinkled. There was no staff in the activity room, and there was no activity for R2 to enjoy. R2 sat and either looked around the room at the five other residents sitting with her or slept in her wheelchair. On 04/28/25 at 10:30 AM, R2 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R2. R2 slept with her head tilted to her right shoulder. On 04/28/25 at 11:00 AM, someone had brought a cart into the activity room that had cookies, tea, and coffee on it. No one had served R2 a drink or snack. R2 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:30 PM, observation revealed Certified Nurse's Aide (CNA) M rolled R2 back and forth in bed by herself to provide R2 incontinent care. R2 grabbed CNA M's hands and arms to try and stop her. After CNA M left the room, observation revealed R2 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that it was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all of the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R3's EMR documented R3 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R3's Quarterly Minimum Data Set (MDS), dated 03/05/25, documented R3 was rarely/never understood. The MDS documented R3 had short-term and long-term memory loss and had severely impaired cognition. The MDS documented R3 was dependent on staff for all of her activities of daily living (ADL). The MDS documented R3 had physical and verbal behaviors directed towards others for four to six days during the look-back period. R3's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/03/24, documented R3 had diagnoses of dementia and Alzheimer's disease and was severely cognitively impaired. The Psychosocial Well-Being CAA, dated 12/03/25, documented R3 was no longer able to tell of her favorite activity. The CAA documented that R3 received family visits one to two times a week and would attend morning devotions. R3's Care Plan directed staff to reminisce with R3 using photos of family and friends (06/15/22). R3's care plan directed staff R3 preferred to have makeup and perfume on every day (12/08/23). R3's care plan directed R3 required two staff to transfer her with a sit-to-stand lift with the green bordered lift sling. R3's care plan directed staff to assist R3 out of bed at 04:00 PM every day and place R3 in front of the TV (07/14/23), provide weekly one on one visits (12/15/20), and offer weekly visits with the chaplain/attends Catholic mass (12/08/23), and invite and remind R3 of scheduled activities and assist as needed (12/15/20). On 04/28/25 at 09:30 AM, R3 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R3 to enjoy. There was no staff in the room. R3's hair had not been combed that morning and was sticking up on end. R3 did not have a bra on, and her left breast and nipple were showing through the blouse she had on. R3 did not have any makeup on. There were dark brown food particles on the sides of R3's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R3 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R3. R3 slept with her chin on her chest. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. No one had served R3 a drink or snack. R3 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:30 PM, observation revealed CNA N rolled R3 back and forth in bed by herself to provide R3 incontinent care. After CNA N left the room, observation revealed R3 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that it was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all of the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R4's EMR documented R4 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), non-traumatic brain dysfunction (damage to the brain that does not result from an external force, such as a fall or accident), need for assistance with personal care, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS), dated 01/07/25, documented R4 had a BIMS score of three, which indicated severely impaired cognition. The MDS documented R4 was dependent on staff for toileting, bathing, and transfer. The MDS documented R4 required maximum/substantial assistance from staff for ambulation, dressing, and bed mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/24, documented R4 had dementia, memory problems, and required assistance with decision making. The Psychosocial Well Being CAA, dated 07/07/24, documented R4 had been a farmer his whole life and rarely socialized. R4's brother visited a few times a week, otherwise, there was no family involvement. R4's Care Plan directed staff R4 preferred to get up and 07:00 AM, eat breakfast, watch TV, and would like to attend morning activities (03/14/25). The care plan directed R4 required a sit-to-stand lift utilizing the yellow bordered sling with two staff assist for transfers and a wheelchair for mobility (02/27/25). On 04/28/25 at 08:45 AM, observation revealed R4 sat in his wheelchair at a table with breakfast in front of him. R4 sat with his head down, his chin on his chest. R4's pants were stained with food particles, his button-down shirt only had two buttons buttoned, and showed a large portion of his chest and stomach. R4's shirt had a large, old orange stain on the cuff. R4 had coughed up some yellow, bloody phlegm on his shirt. On 04/28/25 at 09:30 AM, R4 sat in his wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R4 to enjoy. There was no staff in the room. R4's wheelchair had dark brown dried food particles on the sides of his wheelchair that appeared to have been there for days. On 04/28/25 at 10:30 AM, R4 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R4. R4 wrung his hands and played with his fingers. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. No one had served R4 a drink or snack. R4 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:40 PM, R4 sat in his wheelchair in his room. The TV was not on, and R4 looked around his room. R4 continued to be in stained, unclean clothing with the large yellow, bloody phlegm on the front of his shirt. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that it was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated there were times when the activity staff was gone; she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R5's EMR documented R5 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heartbeat), and a history of falling. R5's Annual MDS, dated 02/14/25, documented R5 had a BIMS score of 99, R5 had short and long-term memory deficits, and R5 made poor decisions and required supervision. The MDS documented R5 was dependent on staff for all of her ADLs. The Cognitive Loss/Dementia CAA, dated 02/14/25, documented R5 had dementia, was unable to make decisions appropriately, and had short and long-term memory loss. The Psychosocial Well Being CAA, dated 02/14/25, documented R5 was unable to describe her favorite activity, and family visited often. R5's Care Plan documented R5's preferred activities were devotions, bible study, group exercises, social events, and current events. The care plan directed staff to reminisce with R5 using photos of family and friends. The care plan documented R5 transferred with a full lift using a red-bordered high back sling and two staff. On 04/28/25 at 09:30 AM, R5 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R5 to enjoy. There was no staff in the room. R5's hair had not been combed that morning and was sticking up on end. There were dried yellow egg particles on R5's shirt and pants, probably from breakfast. There were dark brown food particles on the sides of R5's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R5 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R5. R5 played with the arm protectors on her arms. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. Someone had given R5 a cookie, and R5 broke up the cookie and threw it on the floor. R5 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:20 PM, R5 sat in her wheelchair in a living area off the activity room by herself. No staff were interacting with R5. R5 continued to have clothes covered with dried yellow egg particles from breakfast. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that it was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided [TRUNCATED]

The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with a resident-centered activities program that incorporated the resident's interests, hobbies, and cultural preferences to maintain or improve the resident's physical, mental, and psychosocial well-being. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for decline in meaningful interaction, meaningful activities, and psychosocial well-being. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R2's Quarterly Minimum Data Set (MDS), dated 03/01/25, documented R2 had a Brief Interview for Mental Status score of 99. The MDS documented R2 had short and long-term memory loss, and R2 was severely cognitively impaired. The MDS documented R2 was dependent on the staff for completing all of her activities of daily living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/29/24, documented R2 had a diagnosis of dementia, had memory loss, and required a proxy for health care decisions. The Behavioral Symptom CAA, dated 08/29/24, documented R2 had behaviors of physical aggression towards staff during cares, which placed R2 at risk for injury. R2's Care Plan directed staff to engage R2 in simple, structured activities that were not demanding (09/27/23). The care plan directed staff to ensure R2 wore a bra daily and to smooth her shirt so it was not wrinkled (03/18/25). The care plan directed staff to transfer R2 with a full lift with two staff assistance using the high-backed yellow sling (10/04/24). The care plan directed staff to provide weekly one-on-one visits and manicures, and R2's preferred activities were hymns and devotions (09/27/23). On 04/28/25 at 09:30 AM, observation revealed R2 sat in the activity room after breakfast in her wheelchair with a yellow high-backed lift sling under her. R2's hair had not been combed and was mussed. R2 had dried yellow and brown food particles on the sides of her wheelchair that appeared to be days old. R2's blouse was wrinkled. There was no staff in the activity room, and there was no activity for R2 to enjoy. R2 sat and either looked around the room at the five other residents sitting with her or slept in her wheelchair. On 04/28/25 at 10:30 AM, R2 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R2. R2 slept with her head tilted to her right shoulder. On 04/28/25 at 11:00 AM, someone had brought a cart into the activity room that had cookies, tea, and coffee on it. No one had served R2 a drink or snack. R2 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:30 PM, observation revealed Certified Nurse's Aide (CNA) M rolled R2 back and forth in bed by herself to provide R2 incontinent care. R2 grabbed CNA M's hands and arms to try and stop her. After CNA M left the room, observation revealed R2 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all of the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R3's EMR documented R3 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R3's Quarterly Minimum Data Set (MDS), dated 03/05/25, documented R3 was rarely/never understood. The MDS documented R3 had short-term and long-term memory loss and had severely impaired cognition. The MDS documented R3 was dependent on staff for all of her activities of daily living (ADL). The MDS documented R3 had physical and verbal behaviors directed towards others for four to six days during the look-back period. R3's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/03/24, documented R3 had diagnoses of dementia and Alzheimer's disease and was severely cognitively impaired. The Psychosocial Well-Being CAA, dated 12/03/25, documented R3 was no longer able to tell of her favorite activity. The CAA documented that R3 received family visits one to two times a week and would attend morning devotions. R3's Care Plan directed staff to reminisce with R3 using photos of family and friends (06/15/22). R3's care plan directed staff R3 preferred to have makeup and perfume on every day (12/08/23). R3's care plan directed R3 required two staff to transfer her with a sit-to-stand lift with the green bordered lift sling. R3's care plan directed staff to assist R3 out of bed at 04:00 PM every day and place R3 in front of the TV (07/14/23), provide weekly one on one visits (12/15/20), and offer weekly visits with the chaplain/attends Catholic mass (12/08/23), and invite and remind R3 of scheduled activities and assist as needed (12/15/20). On 04/28/25 at 09:30 AM, R3 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R3 to enjoy. There was no staff in the room. R3's hair had not been combed that morning and was sticking up on end. R3 did not have a bra on, and her left breast and nipple were showing through the blouse she had on. R3 did not have any makeup on. There were dark brown food particles on the sides of R3's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R3 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R3. R3 slept with her chin on her chest. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. No one had served R3 a drink or snack. R3 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:30 PM, observation revealed CNA N rolled R3 back and forth in bed by herself to provide R3 incontinent care. After CNA N left the room, observation revealed R3 had a dark brown food ring around her mouth that had not been cleaned from lunch. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all of the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R4's EMR documented R4 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), non-traumatic brain dysfunction (damage to the brain that does not result from an external force, such as a fall or accident), need for assistance with personal care, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS), dated 01/07/25, documented R4 had a BIMS score of three, which indicated severely impaired cognition. The MDS documented R4 was dependent on staff for toileting, bathing, and transfer. The MDS documented R4 required maximum/substantial assistance from staff for ambulation, dressing, and bed mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/24, documented R4 had dementia, memory problems, and required assistance with decision making. The Psychosocial Well Being CAA, dated 07/07/24, documented R4 had been a farmer his whole life and rarely socialized. R4's brother visited a few times a week, otherwise, there was no family involvement. R4's Care Plan directed staff R4 preferred to get up and 07:00 AM, eat breakfast, watch TV, and would like to attend morning activities (03/14/25). The care plan directed R4 required a sit-to-stand lift utilizing the yellow bordered sling with two staff assist for transfers and a wheelchair for mobility (02/27/25). On 04/28/25 at 08:45 AM, observation revealed R4 sat in his wheelchair at a table with breakfast in front of him. R4 sat with his head down, his chin on his chest. R4's pants were stained with food particles, his button-down shirt only had two buttons buttoned, and showed a large portion of his chest and stomach. R4's shirt had a large, old orange stain on the cuff. R4 had coughed up some yellow, bloody phlegm on his shirt. On 04/28/25 at 09:30 AM, R4 sat in his wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R4 to enjoy. There was no staff in the room. R4's wheelchair had dark brown dried food particles on the sides of his wheelchair that appeared to have been there for days. On 04/28/25 at 10:30 AM, R4 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R4. R4 wrung his hands and played with his fingers. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. No one had served R4 a drink or snack. R4 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:40 PM, R4 sat in his wheelchair in his room. The TV was not on, and R4 looked around his room. R4 continued to be in stained, unclean clothing with the large yellow, bloody phlegm on the front of his shirt. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that it was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated that there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today, but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activities provided to the residents were old, redundant, and the activity calendar was rarely changed to meet residents' activity needs. On 04/28/25 at 03:30 PM, Administrative Staff A stated she felt staffing was appropriate for the facility. Administrative Staff A stated she expected staff to make sure all the residents' needs were provided for to ensure the residents' dignity. Administrative Staff A verified that not all the activities on the activity calendar met all the residents' needs for activity. The facility's Nursing Services Staff Policy, revised 10/29/24, documented the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and induvial plans of care and considering the number, acuity, and diagnoses of the facility's resident population. The facility must provide services with the sufficient number of staff to provide nursing care to all residents. - R5's EMR documented R5 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heartbeat), and a history of falling. R5's Annual MDS, dated 02/14/25, documented R5 had a BIMS score of 99, R5 had short and long-term memory deficits, and R5 made poor decisions and required supervision. The MDS documented R5 was dependent on staff for all of her ADLs. The Cognitive Loss/Dementia CAA, dated 02/14/25, documented R5 had dementia, was unable to make decisions appropriately, and had short and long-term memory loss. The Psychosocial Well Being CAA, dated 02/14/25, documented R5 was unable to describe her favorite activity, and family visited often. R5's Care Plan documented R5's preferred activities were devotions, bible study, group exercises, social events, and current events. The care plan directed staff to reminisce with R5 using photos of family and friends. The care plan documented R5 transferred with a full lift using a red-bordered high back sling and two staff. On 04/28/25 at 09:30 AM, R5 sat in her wheelchair in the activity room with five other wheelchair bound residents. There was no activity for R5 to enjoy. There was no staff in the room. R5's hair had not been combed that morning and was sticking up on end. There were dried yellow egg particles on R5's shirt and pants, probably from breakfast. There were dark brown food particles on the sides of R5's wheelchair that appeared to be days old. On 04/28/25 at 10:30 AM, R5 sat in the same position. Someone had placed hymnals to play on the iPad. No staff were in the room interacting with R5. R5 played with the arm protectors on her arms. On 04/28/25 at 11:00 AM, someone brought a cart into the activity room with cookies, tea, and coffee on it. Someone had given R5 a cookie, and R5 broke up the cookie and threw it on the floor. R5 went from 09:30 AM to lunchtime without anything to drink while in the activity room. On 04/28/25 at 01:20 PM, R5 sat in her wheelchair in a living area off the activity room by herself. No staff were interacting with R5. R5 continued to have clothes covered with dried yellow egg particles from breakfast. On 04/28/25 at 09:35 AM, Certified Nurse's Aide (CNA) M stated there were not enough CNAs working on the floor for the day shift or evening shift to make sure all resident cares were completed. CNA M stated that over half of the residents were full lifts or sit-to-stand lifts that required two staff, and by the time the staff got all the residents up, there was not enough time to take care of morning personal hygiene before breakfast. CNA M stated she did not know about the activities for that morning. She knew that after breakfast, the wheelchair bound residents were brought into the activity room, and usually, some kind of activity would occur. On 04/28/25 at 10:00 AM, CNA N stated she was responsible for the restorative program. CNA N stated there was not enough staff to make sure the residents were cared for the way they were supposed to be. CNA N stated that when she first started at the facility, the facility was one of the best, and she recommended to her family to place family members who required care in the facility. CNA N stated that it was not the case anymore, and her family was thinking about pulling her family members out of the facility. CNA N stated there were times when the activity staff was gone, she would cover for her, but she was not aware that there was no activity staff on duty for the day. CNA N stated that overall, the activities were subpar. On 04/28/25 at 11:10 AM, CNA O stated there were not enough CNAs on shift to take care of the residents responsibly. CNA O stated that two CNAs on the floor to take care of all the residents did not leave any extra time to take care of personal hygiene for residents, and a lot of the time, when they finally got everyone out to breakfast food was cold. CNA O stated that just one extra CNA would make a world of difference. CNA O stated administrative staff never came out of their offices to assist with resident care. CNA O stated she did not know anything about activities. On 04/28/25 at 01:30 PM, Activities Staff/Social Services Staff Z stated she was in charge of activities and social services and was allowed three and a half hours a day for each position. Activities Staff Z stated she was gone on Friday and today but had a replacement staff member covering for her activities. It was explained to Activities Staff Z that there was no observed staff who took her place that day. Activities Staff Z stated that a normal morning would be for devotions to be read to residents, hymnals played for residents, an exercise group, and a social hour group. Activities Staff Z stated a folding group was also on the schedule for residents who like to fold clothing protectors, but Activity Staff Z stated a lot of those residents had passed on. Activities Staff Z stated she did not make changes to the activity schedule often. Activity Staff Z stated a Catholic priest was scheduled to come into the facility to meet with Catholic residents, but would not come into the facility and had not since COVID. Activity Staff Z stated the Catholic priest was hard to talk to and admitted she had not tried to get anyone but the local pastor to come in for the spirituality of the residents, and admitted the Catholic residents would not want to meet with him. On 04/28/25 at 02:30 PM, Administrative Nurse D stated she had been fighting corporate on staffing for a while, and she would not drop her staffing numbers anymore. Administrative Nurse D stated she thought staffing was okay for staff to take care of the needs of the residents. Administrative Nurse D became emotionally upset when the resident's conditions and activity involvement were described to her. Administrative Nurse D stated she would expect the nursing staff to take care of all the residents' ADLs and personal hygiene needs and not leave them in the condition they were found in. Administrative Nurse D verified that over half of the fourteen residents required a full lift or sit-to-stand lift for transfers, which required two staff for the transfers. Administrative Nurse D stated she was not aware Activity Staff Z was going to be gone today. Administrative Nurse D admitted that the activit[TRUNCATED]

The facility identified a census of 31 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from abuse and/or neglect. On 02/09/24, Certified Nurse Aide (CNA) M forcefully grabbed R1's wrist, took the glass of orange juice out of R1's hand, and slammed the orange juice on the table. Then CNA M aggressively grabbed R1's wheelchair to start moving her, and R1 put her foot down on the floor. CNA M yelled at R1 and aggressively placed R1's feet on the foot pedals. Social Services X attempted to intervene, but CNA M ignored Social Services X and continued to try and wheel R1 out of the dining room. CNA M treated R1 in a manner that did not uphold the resident's sense of self-worth and individuality. This deficient practice placed R1 at risk for physical harm, pain, and mental anguish. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 was unable to complete the Brief Interview for Mental Status (BIMS). R1 had short-term and long-term memory loss. The MDS documented R1 had exhibited physical and verbal behaviors directed towards others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/29/23, documented R1 had short-term and long-term memory loss and was only alert to herself. The Behavioral Symptoms CAA, dated 08/29/23, documented R1 had behaviors associated with dementia and had sundowning (a state of confusion occurring in the late afternoon and lasting into the night) episodes. The CAA documented R1 was frequently frightened when staff approached her and would hit, bite, and scratch staff during care as a means of communicating her fear. The CAA documented R1 required slow, calm movements, allowing R1 to process before a task was performed. R1's Care Plan directed staff to ensure her safety from potential inappropriate threats or behaviors regarding her impaired cognitive function (01/10/24). The plan directed staff R1 required one staff assistance with bathing, and the assistance of one staff with a sit-to-stand lift for transfers and was dependent on staff for eating. The plan directed staff R1 had the potential to be resistant to care and become frightened, striking at staff, pinching, and/or biting. R1's Care Plan directed staff that before beginning any care, staff were to speak calmly to R1 explaining the task that would be done. Staff were directed to move slowly with R1 with each task. If she became overwhelmed and began to exhibit behaviors, staff were to ensure R1's safety, leave the room, and change caregivers (10/25/23). The plan directed staff to provide R1 with a calm, quiet setting at mealtimes (09/13/23). The Facility Incident Report, dated 02/15/24, documented on 02/09/24 around 09:30 AM, CNA M was in the main dining room trying to remove R1 from the dining room after breakfast. CNA M removed a glass of orange juice from R1's hand and placed the glass firmly on the table. As CNA M tried to move R1's wheelchair, R1 placed her foot on the floor. CNA M picked up R1's legs abruptly and placed her legs on the wheelchair foot pedals. Social Services X approached CNA M and told CNA M to stop pushing R1's wheelchair. Social Services X said she would provide R1 transportation out of the dining room while CNA M stepped outside. R1 was immediately separated from CNA M. The police were notified and came to the facility. Staff performed a skin assessment on R1 with no bruising or reddened areas noted. A second skin assessment was completed two hours later with no bruising or reddened areas noted and no unusual complaints of pain noted. R1's Care Plan was reviewed. CNA M was interviewed, her witness statement gathered, and CNA M was suspended pending investigation. The report did not indicate that any abuse prevention training was provided after the incident occurred. CNA M's Witness Statement, dated 02/09/24, documented she was getting ready to take R1 out of the dining room. CNA M tried to put R1's feet back on the foot pedals as R1 tried to grab and pinch CNA M's side. CNA M stated she moved R1's hand away. R1 then tried to throw her orange juice at CNA M so CNA M took the cup away from R1 and slammed it down on the table. CNA M went back to try and put R1's foot on the foot pedal and R1 kicked at CNA M. CNA M stopped R1 from kicking her and put R1's foot back on the foot pedal. Social Services X told CNA M to leave, and that Social Services X would get R1. CNA M took Social Services X's direction, left R1, and stepped outside for a minute. Licensed Nurse (LN) G's Witness Statement, dated 02/09/24, documented LN G was in the dining room around 09:30 AM giving another resident their medication. LN G heard a loud bang and looked up and observed CNA M taking her hand away from a glass on the table. CNA M yelled something at R1, but LN G could not quite make out what was said. CNA M then proceeded to yell Stop in R1's face as she aggressively picked up R1's left leg and slammed it down on the foot pedal. R1 then went to reach for CNA M, as she was bent down in front of R1. Before R1 could grab CNA M, CNA M abruptly grabbed R1's left arm and forcefully moved it away from CNA M to the other side of R1's wheelchair. Social Services X told CNA M she needed to step away from R1. CNA M ignored Social Services X and grumbled something under her breath. Social Services X then removed R1 away from CNA M. Social Services X's Witness Statement, dated 02/09/24, documented at approximately 09:30 AM CNA M was in the dining room taking R1 out from the dining room after breakfast. CNA M was very rough with R1. Social Services X saw CNA M pull R1 away from the table and CNA M was again very rough with R1. CNA M aggressively lifted R1's legs and feet onto the foot pedals. CNA M pushed R1's hand back against R1's chest and shoved the wheelchair. Social Services X told CMA M to take a break. CNA M pushed the wheelchair about ten feet and then stopped. Social Services X again told CNA M to take a break. Social Services X transported R1 to the activity room and reported the incident to Administrative Staff A. Dietary Staff BB's Witness Statement, dated 02/09/24, documented Dietary Staff BB was cleaning up in the dining room when CNA M came to get R1 out of the dining room. R1 would not put her feet up on the foot pedals. CNA M grabbed R1's legs and threw R1's feet up on the pedals. CNA M then grabbed R1's wrist to grab the cup out of R1's hand and slammed the cup down on the table. Social Services X told CNA M to take a breath and walk away. Social Services X took R1 to where she needed to be. On 02/28/24 at 10:30 AM observation revealed R1 lying in bed sleeping. On 02/28/24 at 12:30 PM observation revealed R1 sat in her wheelchair at the lunch table. R1 said she was having a bad day and requested to be left alone. R1 then shut her eyes and sat quietly. On 02/28/24 at 10:20 AM, Administrative Staff A stated she considered the event to be abuse. Administrative Staff A asked CNA M if she knew what she did was wrong, and CNA M stated yes, she knew it was wrong. Administrative Staff A stated the abuse was witnessed by three other staff members. Administrative Staff A stated Social Services X was visibly shaken about the incident. Administrative Staff A stated the facility did not tolerate abuse and CNA M had subsequently quit. On 02/28/24 at 11:00 AM, Dietary Staff BB stated CNA M slammed R1's legs down onto the foot pedals and was right in [R1's] face. Dietary Staff BB stated CNA M yelled something at R1, but she could not hear what was said. CNA M then grabbed R1's wrist forcefully, took the glass of orange juice out of R1's hand, and slammed it down on the table. Dietary Staff BB stated Social Services X told CNA M to go take a break and at first CNA M ignored her then Social Services X repeated herself and CNA M left. Dietary Staff BB stated she knew what she saw was wrong. On 02/28/24 at 12:00 PM, Social Services X became tearful when asked about the incident that occurred in the dining room on 02/09/24. Social Services X stated she felt so bad for R1 because R1 did not have the cognitive capacity to understand. Social Services X stated CNA M grabbed R1's arm forcefully, took the orange juice out of R1's hand and slammed the cup down on the table, and then shoved R1's arm back into her chest. CNA M then grabbed both of R1's legs and aggressively put her legs on the foot pedals. CNA M was shoving at the wheelchair and Social Services X told her to go take a break. CNA M said, I don't have time for this. Social Services X again told CNA M to take a break. CNA M left the dining room and Social Services X took R1 to the activity room, put on music for her to listen to, and then reported the incident to Administrative Staff A. The facility's Abuse and Neglect Policy, revised 07/06/23, documented that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility failed to ensure R1 was free from staff to resident abuse when R1 was treated in a manner that did not uphold her sense of self-worth and individuality and was handled with aggressive force. The situation dehumanized R1 and placed her at risk for physical harm, pain, and mental anguish. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R1's severe cognitive impairment and inability to self-identify and express her feelings regarding the event.

The facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 was free from abuse when R2 touched R1 in a sexually inappropriate manner. R1, who was severely cognitively impaired, was unable to consent. This deficient practice placed R1 at risk for continued abuse and impaired psychosocial well-being. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The MDS documented R1 required substantial assistance with bed mobility and was totally dependent on staff for transfer, bathing, toileting, dressing, and personal hygiene. R1's Care Plan, dated 05/18/22, directed staff to monitor, document, and report any changes in cognitive function, specifically changes in decision making ability, memory, recall, awareness, difficulty expressing herself, difficulty understanding others, level of consciousness and mental status. The care plan directed staff to supervise R1 with all decision making, keep consistent care routines, and only present one thought, idea, question, or command at a time. The Communication with Physician Note, dated 12/05/23, documented staff notified R1's primary care provider by phone that a male resident touched R1 inappropriately. The provider gave no further orders. The Communication with Family Note, dated 12/05/23, documented staff notified R1's representative that R1 was involved in an incident where a male resident touched R1 inappropriately. Staff informed R1's representative the incident was a reportableevent, and the facility would be doing an investigation. R1's representative verbalized understanding. An Other Progress Note, dated 12/06/23, documented the previous day at 07:30 PM, Certified Nurse Aide (CNA) M reported to Licensed Nurse (LN) G that R2 was observed touching R1 inappropriately and CNA M removed R1 from the situation. The facility administrator was called. Staff checked R1 for any visible signs; there were no marks on R1's right breast where R2 was observed touching R1. CNA M's Witness Statement, dated 12/05/23, documented CNA M walked out of another resident's room and saw R1 sitting in her wheelchair at the corner by the basement door. R2 was with R1 and it initially appeared that R2 held R1's hand and talked to her. CNA M noted the motion of R2's hand did not look right as CNA M got closer and then she realized R2 was rubbing R1's breast in a sexual manner. CNA M grabbed R1's wheelchair and puller her away from R2 and told R2 she would take care of R1 now. CNA M stated that she startled R2 and then he proceeded to walk back to his own hall. CNA M then reported the incident to LN G. LN G's Witness Statement, dated 12/05/23, documented LN G passed medications down the 300 hall. At approximately 07:15 PM, R2 walked with his walker down the 300 hall. At 07:30 PM CNA M reported to LN G she witnessed R2 touching R1's breast and reported she removed R1 from the common area where R1 sat by the television. CMA M reported to LN G she saw R2 touching R1's right breast and holding R1's hand. CNA M took R1 away from R2. LN G called Administrative Staff A to report the incident. After speaking to Administrative Staff, A, LN G and CNA M took R1 to her room and checked to see if there were any marks; no skin alterations were noted. R2's Witness Statement, dated 12/08/23, documented R2 said he was coming up the hall and R1 blocked the hallway so R2 moved her chair over to get by. R2 stated nothing ever happened. R2 said he was just dumbfounded. The Facility Incident Report, dated 12/11/23, documented on 12/05/23 at around 07:30 PM R2 had his hand on R1's breast, stimulating her nipple. The residents were at the nurse's station in the main common area watching TV. The residents were immediately separated by staff. and staff notified the police around 07:45 PM. A skin assessment and trauma assessment were completed with no injuries or redness noted. Administrative Staff A, Administrative Nurse D, R1's primary care physician, and R1's representative were notified. The care plans were reviewed and updated. Behavioral health was notified of a doctor's order for R2 to be assessed. R2 was placed on 15-minute checks during the first twenty-four hours and when out of his room R2 was monitored within visual line of site. The state Long-Term Care Ombudsmen was notified and scheduled for a visit on 12/11/23 or 12/13/23. Staff held a care plan meeting for R2 on 12/08/23 with changes made to his care plan to encompass the path that he took from his room to and from the dining room; his puzzles that he liked to work on in the small dining room were moved to an area where visual monitoring of his actions could occur. R1 was observed for any trauma demonstrated in her behaviors, meal time, or changes in her baseline. On 12/11/23 at 11:00 AM, observation revealed R1 sat in the common area by the nurse's desk people watching. R1 was not able to hold a conversation. On 12/11/23 at 11:30 AM, observation revealed R2 ambulating throughout the facility. R2 had just returned from an outing On 12/11/23 at 10:00 AM, Administrative Staff A stated R2 was found stimulating R1's nipple repeatedly through R1's clothing with no skin to skin contact in the common area by the nurse's desk. Administrative Staff A stated that R1 and R2 were immediately separated and a head to toe assessment was completed on R1 and no harm was found. Administrative Staff A stated it was the facility's responsibility to protect all of the residents from any form of abuse. On 12/11/23 at 10:30 AM, Administrative Nurse D Administrative Nurse D stated R2 was found in the dining room fondling a female resident's breast. Administrative Nurse D stated interventions were placed in R2's care plan to keep him away from female residents and visually observe R2 when he was out of his room. On 12/11/23 at 04:00 PM, CNA M stated when she saw what R2 did to R1 and she knew it was wrong and just reacted and got R1 away from R2. CNA M stated she notified her charge nurse and they took R1 to her room and performed a skin assessment. The facility Abuse and Neglect Policy, reviewed 07/06/23, documented the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to location employees, other residents, family members or legal guardians, friends or other individuals. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator the following employees have the authority delegated by the administrator, Director of Nursing Services and/or supervisor of social services, to intervene in any situation to protect residents, Remove any individual from the location if necessary for the protection of residents or employees, Call local law enforcement for assistance with interventions necessary for the protection of residents and employees, and Call 911 for any type of emergency assistance. The facility failed to prevent an incident of resident to resident abuse to R1. This deficient practice placed R1 at risk for further abuse, and impaired psychosocial functioning.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 32 residents who resided in the facility and received meals form the facility kitchen. This placed the residents at risk for impaired nutrition. Findings included: - On 11/28/23 at 10:35 AM, review of the noon meal consisted of Salisbury steak, tomato soup, grilled cheese sandwich, and cinnamon apples. On 11/28/23 at 10:35AM, observation revealed Dietary Staff BB was in the kitchen and oversaw the preparation of the noon meal. On 11/28/23 at 10:35 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had started the classes but had not completed them. On 11/28/23 at 4:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Organizational Structure -Food and Nutrition Services Policy, revised 12/18/22, documented the person who has overall responsibility for food and nutrition services at locations offering rehabilitation /skilled care services would be designated at the director of food and nutrition services to ensure that centers for Medicare and Medicaid (CMS) minimum education requirements are reflected. The facility failed to employ a full time certified dietary manager for 32 residents who resided in the facility. This placed the residents at risk for not inadequate nutrition.

The facility had a census of 32 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to prepare food in accordance with professional standards for food service safety when staff failed to check temperatures of food items prior to serving and failed to ensure clean and sanitary refrigerators and food preparation areas. This placed the residents at risk for foodborne illness. Findings included: - On 11/27/23 at 12:35 PM, observation of the kitchen revealed the white refrigerator's bottom two shelves had numerous different-sized yellow, dried liquid stains and the freezer had numerous undated four-ounce (oz) health shakes. On 11/27/23 at 1:00 PM, observation revealed the white refrigerator/ freezer, located in the activity room on Angle Lane, had numerous undated four oz health shakes and the bottom two shelves had numerous, different-sized red, dried, food and liquid stains. On 11/28/23 at 10:30 AM, observation during follow up to the kitchen revealed an unlabeled, undated, flour and sugar container. On 11/28/23 at 12:30PM, Dietary Staff (DS) BB verified the above observations and stated she had been employed with facility for three weeks and was in the process of making a cleaning schedule. DS BB stated the shakes should be dated, and the flour and sugar bins should be labeled and dated. DS BB said she unaware if dietary was responsible for the refrigerator located in the activity room. The facility's Cleaning Schedule-Food and Nutrition Services, revised 11/27/23, documented the director of food and nutrition services (DFN), senior living dining director or designee is to post written daily, weekly and monthly cleaning assignments in the kitchen areas. Employees were responsible for knowing his or her assigned duty and carrying it out during the designated work shift. The policy listed tasks for staff to complete daily. The facility's Food-Supply Storage-Food and Nutrition Services Policy, revised 05/11/23, documented to ensure food is stored properly products should be consumed on or before the date listed on the package of food items. The facility failed to prepare food in accordance with professional standards for food service safety when failed to ensure clean and sanitary refrigerators and food preparation areas. This placed the residents at risk for foodborne illness. - On 11/28/23 at 11:55 AM during observation of preparation of resident's pureed diets, Dietary Staff (DS) CC placed a container of macaroni and cheese into the microwave, heated on high for one minute, blended, then added unmeasured cold milk. DS CC placed the macaroni and cheese into a container and handed the container to another dietary aide to serve to the resident. After intervention from the survey team, DS CC DS CC stated oh! in response to an inquiry if the macaroni and cheese would be the appropriate temperature and DS CC then checked the temperature of the food item. the temperature of the macaroni and cheese was 112 degrees Fahrenheit (F) so DS CC placed the macaroni and cheese into the microwave for 30 seconds, rechecked the temperature which was 149 degrees F. DS CC then handed it to the dietary manager to serve to the resident. On 11/28/23 at 12:10PM, DS CC began to dish up tomato soup into a resident's bowl until prompted by the survey team to check the temperature of the soup. DS CC stated he sometimes checked food temperatures prior to dishing them up and serving to residents and other times he waited until after the residents were served. DS CC stated it just depended on how quickly the residents needed their meals. DS CC stated he was unaware he was supposed to check the food temperatures prior to serving. On 11/28/23 at 12:00PM, DS BB stated staff should check the temperature of food items prior to serving them. Upon request the facility did not provide a policy regarding checking food temperatures. The facility failed to check food temperatures prior to serving the 32 residents who received their food from the facility kitchen. This placed the 32 residents at risk for foodborne illness.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to assess one of 12 sampled residents, Resident (R)12's cognition on the Minimum Data Set (MDS) assessment. This placed the resident at risk for an inaccurate care plan and unmet care needs. Findings included: - R12's Electronic Medical Record (EMR) documented R12 had diagnoses of hypertension (elevated blood pressure), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R12's comprehensive Admission Minimum Data Set(MDS), dated [DATE] lacked documentation regarding R12's cognition. The MDS documented R12 was independent with activities of daily living (ADLs). R12's Care Plan, revised 10/03/23, documented R12 was independent with ADLs. The plan documented R12 saw a psychologist (expert in the mind and behavior, who help people cope with mental health challenges and improve their well-being), and instructed staff to provide the resident assistance, supervision, and support to identify precipitating factor and stresses but lacked a section regarding her cognition. On 11/27/23 at 04:42 PM, observation revealed R12 sat in a chair in her room and crocheted. On 11/29/23 at 01:41 PM, Administrative Nurse E verified R12's 08/28/23 MDS lacked information regarding R12's cognition in Section C. Administrative Nurse E stated staff failed to get the interview of R12's cognition to her before the assessment reference date (ARD) date so she submitted it without the information. On 11/30/23 at 08:46 AM, Administrative Nurse D stated staff in charge of conducted the interview for R12's cognition should get the information to the MDS coordinator prior to the resident's ARD date. The facility's Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Policy, revised 06/13/23, documented the social worker/ Registered Nurse (RN) coordinator/designated employee should notify interdisciplinary team members of timelines for completion of the Resident Assessment Instrument (RAI) process. The interviews must be conducted during the designated observation period, if any discipline is unable to complete its section the RN coordinator should assign another person to complete this section within the time frame. The facility failed to assess R12's cognition on her 09/12/23 comprehensive MDS. This placed the resident at risk for an inaccurate care plan and unmet care needs.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 21 appropriate activities of daily living (ADL) care, which included incontinence care, for R21 placing the resident at risk for poor hygiene and impaired quality of life. Findings included: - R21's Electronic Medical Record (EMR) documented diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), contracture of left shoulder and left wrist (abnormal permanent fixation of a joint or muscle) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R21 had a Brief Interview of Mental Status (BIMS) score of eight indicating moderately impaired cognition. The MDS further documented R21 required two staff assist with bed mobility, and transfers. R21 was incontinent of bowel and bladder. The Activities of Daily Living Care Area Assessment Summary (CAA), dated 02/11/23, stated R21 required total staff assistance with bed mobility and transfers and was incontinent of bowel and bladder. R21's Care Plan, reviewed on 11/14/23, directed the staff to use a full mechanical lift for all transfers from bed and the wheelchair. The plan directed staff to provide incontinent care and check and change incontinent brief after each meal and as needed. The plan directed to reposition R21 every two hours when R21 was in the wheelchair or bed. On 11/28/23 at 07:40AM, observation revealed R21 sat in her wheelchair at the dining table and ate breakfast. On 11/28/23 at 09:40AM, observation revealed R21 sat in her wheelchair at the dining table. On 11/28/23 at 09:55AM, observation revealed Certified Nurse Aide (CNA) M pushed R21 in her chair to the activity room. CNA M did not provide R21 a check and /or change. On 11/28/23 at 11:10AM, observation revealed CNA M pushed R21 in her wheelchair to the front lobby area near the dining room entrance but did not provide a check or change of the incontinent brief. On 11/28/23 at 11:30AM, observation revealed CNA N pushed R21 in her wheelchair to the dining room. CNA N did not check or change R21's brief. On 11/28/23 at 12:50PM, observation revealed CNA M pushed R21 in her wheelchair to her room. On 11/28/23 at 01:00PM, observation revealed CNA M and CNA N in R21's room. Further observation revealed CNA M attached the full body lift sling to the lift and raised R21 from her wheelchair to her recliner chair. CNA N raised the foot of the recliner and placed a lap blanket on R21. Neither staff member provided a check or change of R21's incontinent brief. On 11/28/23 at 03:50PM, observation revealed CNA M and CNA N in R21's room. Further observation revealed CNA M attached the full body lift sling to the lift and raised R21 from her recliner to her wheelchair. CNA N raised the foot pedals on the wheelchair, placed a lap blanket on the resident and then pushed R21 from her room to the front lobby area near the dining room entrance. On 11/28/23 at 04:45PM, observation revealed CNA M pushed R21 in her wheelchair into the dining room. On 11/29/23 at 09:10AM, CNA O verified R21's incontinent brief should be changed after meals and before transferring her from her bed or recliner to her wheelchair. On 11/29/23 at 11:50AM, Licensed Nurse (LN) G verified R21 was incontinent of bowel and bladder and wore incontinent briefs, which were to be changed by staff. On 11/29/23 at 01:45PM, Administrative Nurse D verified she expected staff to follow the care plan for R21. Administrative Nurse D said R21 should have been checked and changed after meals and before transferring her to and from her wheelchair. The facility's Activities of Daily Living policy dated 11/20/22, stated staff are to provide residents with appropriate treatment and services to maintain activities of daily living for the well-being, for residents who are unable to carry out personal hygiene. The facility failed to provide R21 assistive ADL care and as directed in R21's plan of care. This deficient practice placed the resident at risk for poor hygiene and impaired quality of life.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 21 the necessary care and services for positioning when in the wheelchair, or assessment and care of R21's skin. This deficient practice placed the resident at risk for discomfort and potential skin breakdown. Findings included: - R21's Electronic Medical Record (EMR) documented diagnosis of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiplegia (paralysis of one side of the body),hemiparesis (muscular weakness of one half of the body), contracture of left shoulder and left wrist (abnormal permanent fixation of a joint or muscle) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R21 had a Brief Interview of Mental Status (BIMS) score of eight indicating moderately impaired cognition. The MDS further documented R21 required two staff assist with bed mobility, transfers and positioning. The MDS recorded R21 was at risk for skin breakdown. The Activities of Daily Living Care Area Assessment Summary (CAA), and Pressure Ulcer CAA dated 02/11/23, stated R21 required total staff assistance with bed mobility, transfers and positioning and was at risk for skin breakdown. R21's Care Plan, reviewed on 11/14/23, directed the staff to use a full mechanical lift for all transfers from bed and from wheelchair. R21 was at risk for skin breakdown due to hemiplegia and needed positioning and pressure reducing devices when in the wheelchair. R21's updated Care Plan, on 11/24/23, instructed the staff to use an elbow pillow under R21's left elbow when she was in the wheelchair. R21's Braden Scale (an assessment to determine risk for skin breakdown or pressure ulcers) dated 09/15/23 documented a score of eight which indicated the resident was at very high risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and skin breakdown. The Nurses Notes dated 11/23/23 at 08:00PM, stated R21 had a small open area to the left elbow. Staff cleansed the area and left it open to air. R21's Skin Assessment sheet dated 11/23/23 lacked documentation of the area on the left elbow. On 11/28/23 at 07:40AM, observation revealed R21 sat in her wheelchair at the dining table and ate breakfast. R21's left arm was down in the wheelchair and there was no left elbow pillow present or in use. On 11/28/23 at 09:40AM, observation revealed R21 sat in her wheelchair at the dining table with no left elbow pillow present. On 11/28/23 at 09:55AM, observation revealed R21 pushed in her wheelchair from the dining room by Certified Nurse Aide (CNA) M pushed R21 to the activity room. R21 did not have a left elbow pillow. On 11/28/23 at 11:10AM, observation revealed CNA M pushed R21 in her wheelchair to the front lobby area near the dining room entrance, R21 did not have a left elbow pillow. On 11/28/23 at 11:30AM, observation revealed CNA N pushed R21 in her wheelchair to the dining roomR21 did not have a left elbow pillow. On 11/28/23 at 12:50PM, observation revealed CNA M pushed R21 in her wheelchair to her room with no left elbow pillow. On 11/28/23 at 01:00PM, observation revealed CNA M and CNA N in R21's room. Further observation revealed CNA M attached the full body lift sling to the lift and raised R21 from her wheelchair to her recliner chair. CNA N raised the foot of the recliner and placed a lap blanket on R21 but R21 was not provided a left elbow pillow. On 11/28/23 at 03:50PM, observation revealed CNA M and CNA N in R21's room. Further observation revealed CNA M attached the full body lift sling to the lift and raised R21 from her recliner to her wheelchair. CNA N raised the foot pedals on the wheelchair and placed a lap blanket on the resident. The staff did not provide R21 a left elbow pillow. Staff then pushed R21 from her room to the front lobby area near the dining room entrance. On 11/29/23 at 07:40AM, observation revealed R21 sat in her wheelchair at the dining table. Her left arm was down in the wheelchair with no left elbow pillow present. On 11/29/23 at 11:50AM, observation revealed R21 laid in bed. Per request Licensed Nurse (LN) G preformed a skin assessment of R21's left elbow. R21's elbow had a band aid. LN G removed the band-aid and measured a 0.5 centimeter (cm) by 0.5cm reddened area on R21's left elbow. On 11/29/23 at 12:30PM, LN G verified she was not aware of the reddened area on R21's left elbow. On 11/29/23 at 01:45PM, Administrative Nurse D verified she expected staff to follow the care plan for R21. Administrative Nurse D was not aware of the documentation on 11/23/23 at 08:00PM regarding the area on R21's left elbow. Administrative Nurse D verified she expected the LN staff to assess and document skin concerns on the skin assessment. The facility's Skin Assessment Pressure Ulcer Prevention and Documentation Policy dated 04/26/23, stated staff are to appropriately use prevention techniques for residents at risk for skin breakdown and use of prevention devices to decrease risk of skin breakdown. Documentation on skin assessment of reddened areas, bruises, and pressure ulcers are to be done as needed and weekly. The facility failed to provide a positioning device as care planned for R21 placing the resident at risk for skin breakdown and discomfort.

The facility had a census of 32 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing for the two residents' pureed diets. This placed the residents at risk for impaired nutrition. Findings included: - On 11/28/23 at 10:35 AM, Dietary Staff (DS) CC, with DS BB overlooking, stated the facility had two residents who received pureed diets. DS CC placed two Salisbury steaks into a blender container, blended, then poured unmeasured hot water into the blender and blended to the consistency of mashed potatoes. DS BB placed the pureed Salisbury steak into a container and placed on the steam table. DS BB stated one of the resident's family members brought in some macaroni and cheese. DS CC placed the macaroni and cheese container into the microwave on high for one minute, checked the temperature (149 degrees Fahrenheit [F.]) and then placed it into a blender container. DS CC blended, then added an unmeasured amount of milk and blended to a consistency of mashed potatoes. 11/28/23 at 11:20 AM, DS CC verified he had not used a recipe and stated he had been employed with the facility for one year but was not trained on how to prepare pureed diets. DS CC stated he just used the way his grandmother's food used to look for reference. 11/28/23 at 11:22AM, DS BB verified the facility dietary department lacked pureed diet recipes and said staff should have a recipe to follow. The facility's Blenderized Diet-Food and Nutrition Policy, revised 05/02/23, documented the blenderized diet provided adequate amounts of calories and protein to meet most resident's needs. The dietitian should assess the resident for the nutritional adequacy of this diet for extended use and consider use of a multivitamin and mineral supplement. all menu items served on the blenderized diet must be prepared using a standard recipe. The facility kitchen staff failed to follow a recipe when preparing pureed diet for two residents. This placed the residents at risk for impaired nutrition.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R) 16's bruises of unknown origin on her left arm and left breast area. This deficient practice placed the resident at risk for unidentified and ongoing abuse and/or mistreatment. Findings included: - R16's Electronic Medical Record (EMR) documented diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), difficulty walking, lack of coordination, and healing of left neck femur fracture (hip fracture). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R16 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS further documented R16 required total assist with bed mobility and transfers; R16 used a wheelchair. The Care Area Assessment Summary (CAA) dated 09/17/23, documented R16 had memory loss and was unable to recall accurately. R16's Care Plan, dated 09/17/23, directed the staff to provide total assistance with transfers, bed mobility, dressing, grooming and personal hygiene. The Nurses Notes dated 11/13/23 at 02:05PM, stated the licensed dayshift Charge Nurse received a report from the night shift Certified Nurse Aide (CNA) that R16 had bruises on her left arm and on her left breast. The nurse asked R16 about the bruises but R16 was unable to recall or verbalize where the bruises came from on her left arm and left breast. R16's medical record lacked further assessment or documentation of the bruises on her left arm or left breast and lacked evidence an investigation was completed to rule out abuse. On 11/29/23 at 12:45PM, Administrative Nurse D verified she was not aware of the bruises on R16's left arm and left breast. Administrative Nurse D verified no facility investigation was completed on the bruises of unknown origin. On 11/29/23 at 12:55PM, Administrative Staff A verified no facility investigation was completed on R16's bruises on left arm and left breast. The facility's Abuse, Neglect and Exploitation policy dated 11/23/23, stated the facility is to investigate injuries of unknown origin. The facility failed to investigate R16's bruises on her left arm and left breast, placing the resident at risk unidentified and ongoing abuse and/or mistreatment.

The facility identified a census of 30 residents with three reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure interventions were implemented to prevent Resident (R) 1 from falling out of bed and failed to ensure intervention in place to prevent injuries for R1 who had multiple falls from her bed. As a result, R1 fell out of bed and sustained an acute left hip fracture. This deficient practice also placed R1 at risk for further falls and injuries. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). The Quarterly 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 documented R1 required extensive assistance of one to two staff for bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS recorded the resident had no falls and used a motion sensor alarm daily. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/20/22, documented R1 had a diagnosis of dementia that was evidenced by memory loss and periods of confusion. The Activities of Daily Living Function/Rehabilitation Potential CAA, dated 12/20/22, documented R1 required extensive assistance with all of her activities of daily living except eating. R1 used a sit to stand mechanical lift for transfers and a wheelchair for mobility that staff would push. The Fall CAA, dated 12/20/22, documented R1 was at risk for falls related to R1 being unable to hold her own weight secondary to poor knee condition and dementia. The Fall Care Plan, revised 09/06/23, documented on 03/29/23 staff were to ensure correct bed height. R1's bed was to be in the lowest position when she was lying in bed. Staff were to frequently monitor R1 during the night R1 was properly positioned away from the side of the bed. The intervention dated 06/16/23 documented staff were to use the motion sensor to alert staff to R1's movement and to assist staff in monitoring movement during nighttime hours. The intervention placed on 05/17/23, directed staff to review R1 for significant changes in cognition, safety awareness and decision-making capacity. The intervention on 07/14/23 directed staff to place motion sensor and staff were to check the motion sensor alarm for functionality prior to leaving the room after cares. The interventions on 09/04/23 directed staff to ensure R1 was wearing appropriate footwear of gripper socks when lying in bed at all times and morning staff were to check on R1 at start of shift to assist her out of bed in a timely manner to prevent R1 from attempting to get herself out of bed. It directed staff to ensure a floor mat on the floor while R1 was lying in bed. The Fall Risk Assessment, dated 07/14/23 documented R1 was a high fall risk. The Incident Note, dated 04/13/23, documented a CNA had found R1 lying on the floor next to her bed on her right side. Staff checked on R1 twenty minutes prior. R1 was able to move all of her extremities. R1 complained of generalized pain. R1 was assisted back to bed using a full lift and two staff assist. R1's care plan lacked any interventions put into place regarding this fall. The Incident Note, dated 04/16/23, documented R1 was found out of bed, face down on the floor at the foot of the bed calling for help. R1's forehead was resting on the bed frame, and she was clutching the tubing connected to the air mattress. Staff noted blood on the floor from a skin tear to R1's left elbow, a small bruise on R1's right hand, and scattered bruising noted to R1's left forearm. R1 was transferred back to bed using a full body lift. R1 was incontinent of urine. The Incident Note, dated 05/17/23, documented R1 was found sitting on the floor next to her bed, leaning up against the bed frame. R1 had no immediate injuries, and the bed was in the lowest position. R1 was assisted up and to bed with two-person assistance and the use of a full lift. The note documented R1 was awake most of the night. The CNA heard R1's motion sensor alarm and went in her room and found R1 on the floor. The Incident Note, dated 07/14/23, documented R1 was heard yelling help, and her call light was not on. Staff found R1 on her buttocks with her legs sticking out in front of her, leaning her back against the bed. R1 wore a shirt, a cardigan, a brief, and socks. R1 had a large amount of bowel movement on the bed pad and her brief. The Incident Note, dated 09/03/23, documented the CNA found R1 sitting on the floor with her back against her bed. R1 stated she needed to go find her girls. The Other Progress Note, dated 09/04/23, documented LN G was called to R1's room. R1 was found on the floor with the top part of her head under the bed. R1 was trying to grip the bed to pull herself up. Staff assisted R1 away from the bed. LN G assessed R1 and asked if she had pain anywhere. R1 stated her hip hurt. LN G assessed R1's left hip and the left hip appeared rotated. R1 was transferred to the local hospital by EMS. The Health Status Note, dated 09/04/23, documented the facility received notification R1 was sent to a higher level of care related to a broken left hip. The Witness Statement, dated 09/04/23, documented staff called LN G into R1's room. When LN G entered R1's room, R1 was on the floor with the top part of her head under the bed. R1 was trying to grab the bed to pull herself up. Staff assisted R1 away from the bed. LN G assessed R1 and asked if she hurt anywhere and R1 stated her hip. LN G stated R1's left hip appeared rotated. The Witness Statement, dated 09/04/23, documented CNA M walked to the nurse's station about 02:30 PM to chart. Laundry Staff GG came up to CNA M and told CNA M that R1 was on the floor. CNA M went to R1 and radioed for LN G. R1 was laying on the floor with her head a little under the bed and R1 told CNA M her hip was hurting. The Witness Statement, dated 09/04/23, documented Laundry Staff GG was putting away R1's clothes and R1 was lying in bed with her arms up on the rails. Laundry Staff GG stated R1 looked like she was going to fall out of bed, so she went to get help. Laundry Staff GG stated she was halfway down the hall when she heard R1 say, Help! I fell out of bed. Laundry Staff GG stated R1 kept repeating that. Laundry Staff GG found CNA M and told her what happened. Laundry Staff GG and CNA M hurried to R1's room and R1 was on the floor with her head underneath her bed. On 09/11/23 at 12:30 PM, Laundry Staff GG stated that when she was in R1's room putting her clothes away, R1 was moving in bed and was on the edge of the bed. Laundry Staff GG stated the motion sensor alarm was not alarming. Laundry Staff GG went to get help and before she was halfway down the hall, she heard R1 yelling for help that she had fallen. Laundry Staff GG stated she did not hear the motion sensor alarm alarming. On 09/11/23 at 12:45 PM, CNA M stated Laundry Staff GG came and got her and told her R1 had fallen. Upon arriving to R1's room R1 was on the floor and trying to pull herself up with the mobility bar and her head was underneath the bed. CNA M stated the motion sensor alarm was not sounding. On 09/11/23 at 01:00 PM, LN G stated that when she got to the room R1's head was under the bed, and she was trying to pull herself up with the mobility bar. LN G stated R1's motion sensor alarm was not sounding. LN G verified staff were to make sure the motion sensor alarm was functional after all cares were completed before leaving R1's room. On 09/11/23 at 02:00 PM, Administrative Staff A stated she expected appropriate fall interventions in place for every fall, to prevent future falls. Administrative Staff A stated Administrative Nurse D had investigated the fall and found the motion sensor alarm was working appropriately. The facility Fall Prevention and Management Policy, reviewed/revised 03/29/23, documented the risk for falling for residents in long-term care locations substantially increases due to decreased mobility, frailty, muscle weakness, gait disturbance, and disease progression. In order for fall prevention and management program to be successful there must be accountability from the leadership and caregivers in the location. On admission or readmission, review the applicable documents and any additional admit information for fall risk factors. Complete the Fall Tools UDA for fall screening and identifying fall risk factors. Care Plan the appropriate interventions including personalizing all areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-hour report, care plan, Kardex, daily stand-up meeting, and/or Fall Committee Meetings. The facility failed to ensure interventions were implemented to prevent R1 from falling out of bed and failed to ensure intervention in place to prevent injuries for R1 who had multiple falls from her bed. As a result, R1 fell out of bed and sustained an acute left hip fracture. This deficient practice also placed R1 at risk for further falls and injuries.

The facility had a census of 35 residents. The sample included 13 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to identify the risk for pressure injuries and implement preventive interventions for Resident (R)8 who had pressure areas on her buttocks and had a decline in health. As a result, R8 developed a pressure injury to her left heel, which progressed to an open wound. The facility further failed to ensure weekly monitoring of skin conditions in order to assess wound status including wound bed, healing, and effectiveness of treatments for R7 and failed to review and offer treatment options to R31. This deficient practice placed those residents at risk for delayed healing or worsened wounds. Findings included: - The Electronic Medical Record (EMR) documented R8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 required extensive assistance of one staff for bed mobility, transfers, toileting, ambulation, and personal hygiene. The MDS documented R8 had upper functional range of motion impairment on one side. She was not assessed for risk for breakdown, had no skin breakdown, and no turning or repositioning program. The Pressure Ulcer Care Area Assessment (CAA), dated 01/13/22, documented R8 required extensive assistance with bed mobility and transfers. The CAA further documented the resident sat in her recliner all day long, only left her room for meals, and occasionally walked in the halls in the evening. The Braden Scale Assessment, (formal assessment for predicting pressure ulcer risk) dated 02/24/21, documented a score of 21, indicating not at risk for pressure ulcer development. The EMR lacked documentation the facility completed a more recent Braden Scale Assessment. The Pressure Ulcer Care Plan, revised 04/22/22, originally dated 2/28/22, directed staff to educate R8 as to causes of skin breakdown, provide pressure relieving/reducing devices and/or skin protective device, pressure relieving mattress, and pressure relieving cushion in recliner. It further directed staff to notify the nurse immediately of any new areas of skin breakdown. The plan of care recorded the resident had several small open areas to her bilateral buttocks. The care plan lacked documentation R8 had a deep tissue injury (a localized area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and/or shear) that opened on her left heel and lacked interventions to prevent the breakdown on her heel. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Dietician Assessment, dated 05/04/22, documented R8 had a significant change, received medical nutritional supplements, and snacks; R8 had wounds. A Nurse's Note, dated 05/21/22 at 09:04 PM, documented a deep tissue injury to R8's left heel. Skin prep (a liquid film-forming protective barrier) was applied to her heel. Staff provided a foam heel protector on R8's left heel. The note lacked measurements of the deep tissue injury. The Skin Observation Tool, dated 05/27/22, documented R8 had a deep tissue injury to her left heel; a foam dressing was in place and skin prep applied twice daily. R8 had no signs of infection. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The heel was soft and had no redness or drainage. The note directed staff to continue the skin prep, notify the wound nurse if the area opened, and confirm that heel pad was in place. (The order was discontinued on 06/15/22). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The order was discontinued on 06/27/22) The Skin Observation Tool, dated 06/18/22, documented R8's left heel was purple in color and firm around the edges but slightly boggy (soft) in the middle. The Skin Observation Tool, dated 06/21/22, documented R8's left heel was purple in color, firm around the edges, but slightly boggy in the middle. The Skin Observation Tool, dated 06/23/22, documented R8's left heel was purple in color and firm around the edges, but slightly boggy in the middle. The Wound Data Collection Tool, dated 06/27/22, documented R8 had a deep tissue injury, with a small open area in the center, which measured 2.5 cm x 2.0 cm. The middle area was slightly boggy and had a pinpoint open area with sanguineous drainage (leakage of fresh blood produced by an open wound). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order further directed staff to cut and fit xeroform gauze (an fine mesh dressing used to cover wounds to reduce infection) over the center of the wound area that was draining, cover all of wound with an ABD (an extra thick dressing designed to care for moderate to heavily draining wounds), secure with bulkee (elastic bandage wrap) gauze and tape, and change the dressing daily. The Wound Data Collection Tool, dated 07/03/22, documented a loose scab pulled off of the wound to R8's left heel with a small tear drop open area, which measured 2 cm x 1 cm that a red center. The Wound Data Collection Tool, dated 07/07/22, documented a pressure ulcer to R8's left heel which measured 1.0 cm x 1.5 cm x 0.1 cm and had no drainage. The Wound Data Collection Tool, dated 07/11/22, documented a pressure ulcer to R8's left heel. The tool documented the wound was small, approximately 0.5 cm in diameter and shallow. The tissue surrounding the wound was intact, had good color, and no odor or drainage. The Wound Data Collection Tool, dated 07/14/22, documented a pressure ulcer to R8's left heel which measured 0.3 cm x 0.3 cm x 0.1 cm, 100% pale pink wound bed with hypo granulation (not enough tissue to fill the wound bed) tissue, and minimum serous (a thin, watery fluid) drainage; the surrounding skin was fragile and calloused (hardened skin). On 07/12/22 at 09:30 AM, observation revealed Licensed Nurse (LN) G washed her hands, gloved, and removed the old dressing from R8's left heel. Continued observation revealed LN G cleansed the wound with wound cleanser, removed her soiled gloves, and donned a clean pair of gloves. LN G wiped the skin around the wound with skin prep, placed xeroform on the wound bed, covered R8's heel with an ABD pad, and wrapped her foot with gauze wrap. LN G put the heel protector back onto the residents left foot. On 07/12/22 at 09:30 AM, LN H stated R8 had skin breakdown to her buttock intermittently since R8 admitted in January. The area on R8's buttocks was healed since June. LN H stated R8 had a decline in May and stopped getting out of bed. LN H stated when staff discovered the wound on R8's heel, they put a heel protector on her left foot, and skin prep to the area. The heel had a black spot that recently opened. On 07/12/22 at 02:45 PM, Administrative Nurse E stated R8 had sensitive, fragile skin, and her buttocks would break down, and then heal. Administrative Nurse E further stated R8 had a decline and was not getting out of bed. After that decline, staff found the deep tissue injury on R8's left heel. Administrative Nurse E verified that although R8 had the skin breakdown on her buttocks, staff had not implemented the heel protector until after the resident had the deep tissue injury. On 07/14/22 at 10:07 AM, Certified Nurse Aide (CNA) M stated R8 did not have any skin breakdown to her buttocks, but had an open area on her left heel. CNA M further stated R8 did not have the heel protector until after the resident's heel broke down. On 07/14/22 at 11:30 AM, Administrative Nurse D stated staff should have floated R8's heels and should have implemented more interventions to prevent the breakdown on her heel since she already had skin breakdown on her buttocks and her skin was compromised. On 07/19/22 at 08:36 AM, Consultant II stated that he saw R8 during the time she had a decline, and the facility efforts were focused on R8's buttocks wound. Facility staff repositioned her when she was in recliner. Consultant II stated he did not observe any issue on R8's heels when she was in bed. Consultant II stated R8 would have benefitted from proactive measures to prevent heel breakdown. The facility's Pressure Ulcers policy, dated 05/03/22, documented a resident who had a pressure ulcer would receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. The residents would receive appropriate assessments and services to promote and maintain skin integrity. If a resident's clinical condition makes compromise of skin integrity clinically unavoidable, this information would be documented in the medical record. The facility failed to implement preventative interventions to prevent pressure injuries on R8's left heel. As a result of this deficient practice, R8 developed a deep tissue injury which later opened to a pressure ulcer. -The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had moderately impaired cognition, exhibited no behavior symptoms, had no functional range of motion impairment in upper or lower extremities, no nutritional approaches, and at risk for pressure ulcers. The MDS further documented R7 had an unhealed pressure ulcer stage three (full thickness skin loss) not present upon admission, had pressure reducing device for his bed, received nutritional or hydration interventions to manage skin problems, and had pressure ulcer care. The Nutritional Annual Care Area Assessment (CAA), dated 02/25/22, documented R7 had a stage three pressure ulcer located mid spine, nutritional intake is good, had dementia, require cueing to eat, and took nutritional supplement to maintain weight. The Care Plan, dated 04/19/22, lacked skin/wound care problem, goals, or interventions related to the stage three pressure ulcer to his mid spine area. A Skin Observation recorded on 06/01/22 documented the area of intact skin over vertebrae that has been previously open was light pink in color. The Wound Data Collection Tool dated 06/07/22 documented a 3 centimeter (cm) by (x) 3 cm area of fragile skin but no open areas. The mid-spine area was cleansed and patted dry. Skin prep (liquid skin barrier) was applied as well as a transparent dressing. The Wound Registered Nurse (RN) Assessment, dated 06/15/22, documented a stage two pressure ulcer (a sore that has broken through the top layer of skin) with serous (clear) drainage, autolytic debridement (uses the body's enzymes and natural fluids to soften bad tissue) modification to treatment plan. The note lacked measurement of wound size. The Physician Order, dated 06/17/22, directed staff to cleanse mid spine area, pat dry, apply skin prep to periwound (tissue surrounding the wound), cover with small [MEDICATION(S)] (opaque dressing for wounds that is biodegradable, non-breathable, and adheres to the skin) dressing, and reinforce with a transparent film dressing. The order further instructed the dressings to be changed twice a week and as needed. The Wound RN Assessment, dated 06/27/22, documented a healing stage three pressure ulcer decreased in size and continued autolytic debridement. The document lacked wound size. The Wound Data Collection Tool completed on 07/01/22, 07/03/22, 07/05/22, 07/07/22 lacked information regarding the size of the wound, status of healing, presence of drainage, periwound status or treatment information. A Skin Observation completed on 06/22/22, 06/29/22 and 07/06/22 lacked information regarding the size of the wound, status of healing, presence of drainage, periwound status or effectiveness of the treatment. The Wound RN Assessment completed on 07/06/22 recorded a stage two wound but lacked further information. On 07/14/22 at 10:21 AM, observation revealed Administrative Nurse E and Consultant GG remove R7's dressing from the mid spine wound and measure the area. The wound measured 2.5 centimeters (cm) by 2.5 cm with four small open areas. On 07/13/22 at 01:59 PM, Administrative Nurse D stated the resident's skin was checked weekly on bath days by the nurses, and area of concerns should be followed on a weekly basis which should include size, drainage, treatment, stage, and treatment regimen. The facility's Skin Assessment Pressure Ulcer Prevention and Documentation policy, dated 04/26/22, documented id a pressure ulcer is identified, the registered nurse should record the type of wound, and the degree of tissue damage, location, and should be assessed/evaluated at least weekly and documented on the Wound RN Assessment. The facility failed to adequately monitor and assess R7's recurring pressure ulcer to the mid spine which placed the resident at risk for delayed healing and complications related to wounds. -The Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition, no behavioral symptoms exhibited, required supervision and limited assistance with activities of daily living, and had functional range of motion impairment of both side lower extremities. The MDS further documented no nutritional approaches. R31 had a stage three (full thickness skin loss which fat may been seen) and stage four pressure ulcer upon admission/entry or reentry. R31 had a pressure reducing device for bed, nutrition/hydration interventions to manage skin problems, received pressure ulcer/injury care, application of nonsurgical dressing, application of ointment/medications other than to feet. The Pressure Ulcer Care Area Assessment, date 09/05/21, recorded R31 had stage 4 pressure areas on right and left ischium, stage three pressure ulcer to left lower leg, and stage two pressure ulcer to right buttock. The Care Plan, dated 06/27/22, documented R31 had [CONDITION(S)] related to inoperable spinal tumor, two stage four pressure ulcers to left gluteal (pertaining to the buttocks or buttocks muscles) fold and right ischium (part of the hip bone) related to immobility and [CONDITION(S)]. The Care Plan directed staff to encourage repositioning at least every two hours, pay particular attention to ankles, heels and bottom of feet. Educate resident/family as to cause of skin breakdown, including transfers/positioning requirements, good nutrition, and frequent repositioning. Encourage, assist with use of assist bar, trapeze bar to assist with turning. Provide pressure relieving/reducing device on bed and chair. The Physician Order, dated 06/17/22, directed staff cleanse right buttock, pat dry, apply skin prep (liquid skin barrier) to periwound, place Santyl (a sterile enzymatic [MEDICATION(S)] ointment) to wound bed, cut and apply calcium alginate (dressing absorbs drainage) to open wound bed, cover with bordered super absorbent dressing, and change daily. The Wound Data Collection Assessment, dated 05/09/22, documented the right buttock measured 8.5 centimeters (cm) in length by 3.0 cm wide, and 0.1 cm depth, non-healing, increased drainage and had 75 percent (%) slough. The Wound Data Collection Assessment, dated 05/19/22, documented the right buttock measured 16.0 cm in length by 3.0 cm width and 0.1 cm in depth which included four wounds. Inferior wound one measured 2 cm in length by 0.9 cm in width and inferior wound two measured 0.5 cm in length by 1.7 cm in length, middle wound measured 5.5 cm in length by 3 cm wide, and a superior wound 2 cm in length by 0.8 cm in length with 50% granulation and slough. The note included Wound Care Skin Integrity Evaluation which documented discussed management and prevention of infection for wound goals. Unknown if patient is a candidate for surgical interventions, or if he would want this if he were. Facility needed to discuss with physician if patient was a candidate for wound vac (device which applies negative pressure to wound to assist in wound healing). The clinical record lacked evidence R31 was evaluated for surgical intervention and lacked evidence R31 was evaluated for a wound vac to assist with healing. The Physician Order, dated 06/17/22, directed staff cleanse right buttock, pat dry, apply skin prep (liquid skin barrier) to periwound, place Santyl (a sterile enzymatic [MEDICATION(S)] ointment) to wound bed, cut and apply calcium alginate (dressing absorbs drainage) to open wound bed, cover with bordered super absorbent dressing, and change daily. The Wound Data Collection Assessment, dated 06/29/22, documented a stage three pressure ulcer to right buttock which measured 11 cm in length by 4.5 cm in width by 0.2 cm in depth with 30% granulation (tissue formed during wound healing) and slough (dead tissue, usually cream or yellow in color). On 07/12/22 at 11:08 AM, observed Licensed Nurse (LN) H change dressing and provided physician ordered treatment to pressure wounds. R31 assisted nurse by rolling to his side on an air mattress bed. On 07/14/22 at 10:55 AM, Administrative Nurse F verified the pressure ulcer had declined since June 2022 and no new interventions had been placed on the care plan. She also verified the record lacked documentation of education provided regarding to skin care and understanding the risk versus benefit of declined treatment interventions to the resident. On 07/14/22 at 12:42 PM, Administrative Nurse E verified she measured wounds weekly, and was not aware of the recommendation to discuss treatment interventions related to surgical interventions or wound vac treatment. The facility's Wound and Pressure Ulcer Management policy, dated 05/26/22, documented wound care management included the management and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care programs and pressure ulcer guidelines and protocols have been developed and implemented to ensure that quality services are provided to the resident. A comprehensive management program to prevent development of pressure ulcers. The facility's Pressure Ulcer policy, dated 05/03/22, documented a resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcer from developing. The facility failed to discuss treatment plan recommendations with R31, which placed the resident at further risk of unhealed stage three pressure ulcer to his right buttock.

The facility had a census of 40 residents. The sample included 12 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a boney prominence, due to pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development of Resident (R) 13's facility acquired, unstageable pressure ulcer (partial thickness loss of skin and the wound bed is viable) to the left scapula/vertebrae. Findings included: - R13's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had short- and long-term memory loss with severely impaired cognition. The MDS documented the resident required extensive staff assistance with bed mobility and transfers, no pressure ulcers or skin issues. The Pressure Ulcer Care Area Assessment (CAA), dated 05/08/20 recorded the resident tended to walk on the balls of his feet with a slight shuffling gait, ambulated with a walker, had a pressure relieving mattress on his bed, and a pressure relieving pad on his chair. The CAA documented the resident had frequent episodes of bowel and bladder incontinence. The Skin and Wound Care Plan, dated 01/28/2021, recorded the resident had an unstageable pressure ulcer develop due to immobility. The care plan directed the staff to assess and monitor wound healing daily, the registered nurse would assess weekly, and report improvements to the health care provider. The care plan directed the staff to provide the resident pressure relieving/reducing devices on bed (air mattress) and gel cushion in the chair. The 02/05/20, 05/05/20, and 08/07/20 Braden Scale Assessment, (a skin assessment to determine risk for pressure ulcers) documented the resident was not at risk for pressure ulcer development. The 11/13/20 Braden Scale Assessment revealed a score of 12, which placed the resident at risk for pressure ulcers. The Physician Telephone Order, dated 12/08/20, directed staff to apply skin prep two times daily to the resident's red pressure area on the left mid spine. The resident's record lacked further documentation of the resident's pressure area until six days later on 12/11/20. The Wound Evaluation sheet, dated 12/11/20, documented the resident had upper mid vertebrae redness with irritation on the left side of the back, area covered with [MEDICATION NAME] (transparent dressing used to cover and protect wounds). The resident's record lacked orders for the wound until two days later on 12/13/20. The evaluation sheet lacked further description of the wound. The Physician Telephone Order, dated 12/13/20, directed staff to cleanse the small open areas to the resident's left mid spine with wound wash, pat dry, apply skin prep to peri-wound (tissue surrounding the wound), and apply transparent dressing every 48 hours and as needed. The Wound Evaluation Sheet, dated 12/16/20, documented two superficial abraded areas to the left upper back, cleansed with wound wash, skin prep applied to peri wound, Island (sterile, non-adherent, absorbent wound pad that provides a waterproof and bacterial barrier) dressing applied. No measurements documented. The evaluation sheet lacked further description of the wound. The Wound Evaluation Sheet, dated 12/23/20, documented a transparent dressing over area on the left upper back. No measurements documented or description of the wound. The Wound Evaluation Sheet, dated 12/27/20, documented the left scapula open area measuring 2.8 centimeters (cm) x 1.4 cm with necrotic (dead tissue) area in the middle 1.0 cm x 0.7 cm. The evaluation documented treatments of calcium alginate (highly absorbent dressing that promotes healing and the formation of granulated tissue) applied to the wound and covered with foam. The Wound Evaluation sheet, dated 12/30/20, documented the left side of the vertebral column, abraded areas cleansed with wound wash, skin prep to peri wound, and Island dressing over the left back area. The evaluation sheet lacked further description on the wound. The Physician Telephone Order, dated 01/06/21, instructed staff to cleanse with saline wash, apply skin prep to peri wound, apply [MEDICATION NAME] (a dressing that provides a moist and insulated healing environment that protects uninfected wounds while allowing the body's own enzymes to help heal the wound) over area, and change every 72 hours and as needed to open area on left mid spine. The Wound Evaluation sheet, dated 01/06/21, documented the left upper back cleansed, and [MEDICATION NAME] dressing applied. The Wound Evaluation sheet, dated 01/13/20, documented treatments to offload pressure points with pillows, gel pads in wheelchair under bottom and behind back, dressings to open areas as needed. The evaluation sheet lacked further description of the wound. The POS, dated 01/20/20, ordered staff to clean the open area on the left mid spine/left scapula with saline wash, apply skin prep to peri wound, then apply a [MEDICATION NAME] sheet over the area. The physician ordered the dressing to be changed every two days and as needed. The order sheet lacked further documentation of the wound. No additional wound evaluation sheets were noted until 01/22/21, 9 days later. The Wound Evaluation Sheet, dated 01/22/21, documented cleansed with saline wash, skin prep to peri wound, and [MEDICATION NAME] dressing to small open area. The evaluation sheet lacked further description of the wound. On 01/26/21 at 11:40 AM, observation revealed Licensed Nurse (LN) I removed the dressing from the resident's left scapula, cleansed the wound with wound cleanser, the area measured 6.3 cm x 3.0 cm, with dark black eschar (dead tissue covering the wound that eventually sloughs off) then applied a [MEDICATION NAME] dressing to the wound. On 01/26/21 at 02:10 PM, Administrative Nurse D verified the resident developed a facility acquired pressure ulcer on his left scapula/vertebrae approximately four weeks ago. Staff initiated the Geri chair (an upholstered recliner on wheels that can be pushed around like a wheelchair, usually with a removable tray) after he had developed other skin redness on his feet and then he developed the areas on his spine and scapula. They placed gel cushions in the seat and back of the Geri chair. Administrative Nurse D verified the area was pressure related and stated they had contacted therapy last week to evaluate for a new wheelchair or cushion that would suit him better and not cause pressure on his back area which they feel caused the wound to begin with. The facility Skin Assessment Pressure Ulcer Prevention and Documentation policy, dated 11/17/20, documented the facility would appropriately use prevention techniques and pressure redistribution surfaces for those residents at rick for pressure ulcers. The facility would assess residents with regards to skin breakdown, accurately document observations assessments of residents. The residents would have a comprehensive skin inspection completed by a licensed nurse on admission/readmission to identify and skin issues present including, but not limited to, pressure ulcers, and the results would be documented in the medical record. The registered nurse would complete the Braden Scale for Predicting Pressure Sore Risk on all residents quarterly or when the resident has a change of condition that could affect his or her risk of developing an ulcer. The facility would implement treatments and interventions per communication with the physician. The facility failed to provide interventions, weekly measurements and/or weekly monitoring of the wound to prevent the development of R13's facility acquired unstageable left scapula/vertebrae pressure ulcer, placing the resident at risk for infection and further pressure ulcers.

The facility had a census of 40 residents. The sample included three residents. Based on interview and record review, the facility failed to administer Resident (R) 1 medications in accordance with professional standards of practice when she received R2's medications including: [MEDICATION NAME] (blood pressure) 5 milligrams (mg), [MEDICATION NAME] (blood pressure) 100 mg, Eliquis (anti-coagulant) 2.5 mg, [MEDICATION NAME] (muscle relaxer) 20 mg, [MEDICATION NAME] extended release (opioid - a narcotic pain medication) 60 mg, and [MEDICATION NAME] (anti-convulsant) 600 mg , which caused severe sedation with very low blood pressure (readings lower than 90 millimeters of Mercury (mmHg) systolic (top number) or 60 mmHg diastolic (bottom number) and resulted in R1's hospitalization , which placed R1 in immediate jeopardy. Findings included: - R1's Physician order [REDACTED]. R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff with most Activities of Daily Living (ADLs), and received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) and diuretic (medication to promote the formation and excretion of urine) medications seven of seven days during the lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/06/19, documented the resident had a BIMS score of three related to short term memory loss. The ADL Care Plan, dated 11/25/19, directed one staff to assist the resident with ADLs. R1's Blood Pressure Records from 12/01/19 - 01/15/2020, revealed the resident's blood pressure (BP) ranged from 96/46 millimeters of Mercury (mmHg) - 139/75 mmHg (normal 120/80 mmHg). The Nurse's Note, dated 01/04/2020 at 05:50 PM, documented R1 ate breakfast in the dining room at 09:20 AM and Licensed Nurse (LN) G administered medications to the resident. At 09:24 AM, LN G realized she administered R1 the wrong medications and called the provider. The provider directed staff to administer R1 25 grams (gm) of activated charcoal (charcoal used in emergency treatment of [REDACTED]. The note documented LN G sat next to R1 and frequently monitored her vital signs. At 11:11 AM, staff obtained R1's BP with a reading of 77/58 mmHg and the provider directed staff to administer R1 a 500 milliliter (ml) Normal Saline (salt water) (NS) bolus (a single dose of medication given all at once). The note documented staff started the NS bolus at 12:05 PM, monitored the resident's vital signs every 15 minutes, and the first bolus completed at 02:05 PM. The note documented staff reported to the physician the resident's BP was 89/58 mmHg and the provider directed staff to administer R1 another 500 ml bolus. The note documented the resident was excessively sleepy and her BP's ranged from 78/49 mmHg to 104/57 mmHg. At 04:06 PM, staff called the provider, he directed staff to administer R1 another 1000 ml bolus of NS and continue monitoring the resident's vital signs. Report was given to the next nurse who continued to monitor the resident. The Facility's Investigation, dated 01/04/2020, documented LN G mistakenly administered R1, R2's [MEDICATION NAME] (blood pressure) 5 milligrams (mg), [MEDICATION NAME] (blood pressure) 100 mg, Eliquis (anti-coagulant) 2.5 mg, [MEDICATION NAME] (muscle relaxer) 20 mg, [MEDICATION NAME] extended release (opioid) 60 mg, and [MEDICATION NAME] (anti-convulsant) 600 mg. The investigation documented LN G set up medications for a couple of residents prior to administering them, then inadvertently picked up R2's medications and administered them to R1. The Nurse's Note, dated 01/04/2020 at 10:18 PM, recorded R1 sleepy with no response to verbal or tactile stimuli. The resident had a dry incontinent pad and the NS continued at 250 ml per hour. Staff monitored the resident's vital signs frequently with BP readings at 07:00 PM of 91/71 mmHg and 08:30 PM of 98/48 mmHg. The Nurse's Note, dated 01/04/2020 at 10:30 PM, documented R1 rested in bed with eyes closed and did not react to verbal stimuli. The resident's BP was 103/49 mmHg and she had received 2,250 ml of NS with no urine output. Staff called the provider who directed staff to continue administering the resident 250 ml NS per hour. The Nurse's Note, dated 01/05/2020 at 03:49 AM, documented R1 rested in bed with her eyes closed and did not react to verbal or tactile stimuli. The resident had received 3,250 ml of fluid with no urine output and her current BP was 90/56 mmHg. The Nurse's Note, dated 01/05/2020 at 04:49 AM, documented the resident with no urinary output. Staff called the on-call provider and an order was received for a Foley catheter (tube inserted into the bladder to drain urine into a collection bag). Staff inserted the Foley catheter with immediate urine output (no documentation of amount). The Nurse's Note, dated 01/05/2020 at 08:31 AM, documented R1's BP maintained around 100-110 mmHg systolic (top number) and 60-70 mmHg diastolic (bottom number). Staff called the on-call provider and he directed staff to stop the fluids. Staff noted a small amount of urine in the catheter bag. The Nurse's Note, dated 01/05/2020 at 09:20 AM, documented R1's BP 61/32 mmHg, staff notified the on-call provider and the fluids were restarted. The Nurse's Note, dated 01/05/2020 at 09:50 AM, documented R1's daughter arrived at the facility and the resident did not respond to verbal stimuli. The Nurse's Note, dated 01/05/2020 at 11:10 AM, documented the provider assessed R1 and her BP ranged between 60-70 mmHg systolic and 30-40 mmHg diastolic. The resident responded slightly to pain stimuli (technique used for assessing the consciousness level of a person who is not responding to normal interaction) and the family decided to send the resident to the hospital. The Nurse's Note, dated 01/05/2020 at 12:30 PM, documented Emergency Medical Services (EMS) arrived at the facility, obtained R1's BP at 82/42 mmHg, and R1 did not open her eyes while EMS transferred her down the hall. The Nurse's Note, dated 01/10/2020 at 03:24 PM, documented per family the resident would not return to the facility. The facility's corrective action, dated 01/06/2020, documented the facility gave LN G a final warning for not following policy and procedure of medication administration and a licensed nurse would monitor LN G for her first six shifts back at the facility to verify the procedures for medication administration were followed. All licensed nurses and medication aides were re-educated on the policy and procedure for medication administration prior to working and Administrative Nurse D monitored their first shift scheduled to pass medications following 01/04/2020. On 01/16/2020 at 12:35 PM, Administrative Nurse D stated after LN G administered R1 the wrong medications, she immediately notified the on-call provider and was given orders, staff monitored the resident, and staff kept in contact with the provider. Administrative Nurse G verified LN G did not follow the facility's medication administration policy and procedure. LN G was removed from the medication cart, completed her 12 hour shift on 01/04/2020 and then suspended during the investigation on 01/06/2020. LN G was allowed to return to work on 01/10/2020, received a final written warning for not following the policy and procedure, and was monitored by a licensed nurse for the first 6 shifts she worked. Administrative Nurse D stated R1 was sent to the hospital per EMS at the family's request. On 01/16/2020 at 01:05 PM, LN G stated on 01/04/2020 she set up four or five resident's cups of medications while she was in the dining room passing medications. LN G stated she was bored while waiting for another staff member to come in to supervise the residents. LN G stated she wrote resident names on some of the cups but not all of them. LN G stated she picked up R1's cups and thought it was the correct one because her [MEDICATION NAME] (medication for constipation) was next to it, but there was another resident who also received [MEDICATION NAME]. LN G knew as soon as she got back to her medication cart that she had made a mistake, she called the on-call provider and notified the DON who was in the facility at the time. LN G stated she was given orders to administer R1 activated charcoal and a NS bolus. LN G stated staff monitored the resident throughout the day and night and the provider was updated as needed. LN G stated she was suspended during the investigation and returned to work on 01/10/2020. LN G stated a licensed nurse monitored her when she passed medications and she had worked two shifts since returning to work. LN G stated she also received re-education on medication administration policy and procedures and a final written (disciplinary) notice. On 01/16/2020 at 04:00 PM, Administrative Staff A stated LN G was suspended on 01/06/2020 and returned to work on 01/10/2020. LN G was allowed to complete her shift on 01/04/2020 but she did not pass any more medications. On 01/17/2020 at 01:59 PM, Consultant (C) GG verified LN G notified him the morning of 01/04/2020 of a medication error for R1. C GG stated the medications that were administered to R1 could have contributed to the decline in her blood pressure and her medical condition. C GG stated R1 was not taking any blood pressure medications and the medications R1 was given included two blood pressure medications. The facility's Medication Administration policy, dated (MONTH) 2020, documented pre-setting medications was not an acceptable practice. Medications are administered to the resident according to the Six Rights. All employees passing medications are familiar with action and adverse reaction of medications. Six Rights: right medication, right dose, right resident, right route, right time and right documentation. The policy directed staff to perform three checks: read the label on the medication container and compare with the Medication Administration Record [REDACTED]. The facility failed to ensure staff administered medications in accordance with professional standards of practice for R1 who received R2's medications. This deficient practice caused severe sedation with very low blood pressure and resulted in R1's hospitalization , which placed R1 in immediate jeopardy. The deficient practice was identified as Past Non-Compliance and corrected on 01/06/2020 when the facility removed LN G from medication administration and re-educated all licensed nurses and medication aides on the policy and procedure for medication administration prior to their first shift scheduled to pass medications following 01/04/2020. Each medication administration was monitored by Administrative Nurse D.

The facility identified a census of 40 residents. The sample included 3 residents reviewed for elopement risk. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent leaving the building, for 2 of 3 residents, who eloped from the facility. Resident #1 displayed increased agitation earlier in the day, had prior exit seeking behavior, and exited the facility without staff knowledge. Resident #2 wandered within the facility, with no destination, exited the resident care areas by use of the elevator and entered an unsafe basement area not approved for resident use, without staff knowledge. This deficient practice placed Resident #1 and #2 in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated [DATE], documented the resident had long and short term memory loss, moderately impaired decision making ability, inattention, moderate difficulty hearing, disorganized thinking, was able to make himself/herself understood, and he/she understood others. The MDS documented the resident was independent with (ADLs) Activities of Daily Living, except assistance 1 staff for dressing, had unsteady balance when walking, did not use any assistive devices, range of motion impairment on 1 side of upper extremities, did not wander, and received anti-depressant medication daily. The [DATE], cognitive loss (CAA) Care Area Assessment documented the resident became anxious at times in the afternoon/evening and had moderately impaired decision making skills related to dementia. The behavior CAA documented the resident frequently wandered throughout the day, and became easily agitated with others while speaking, if he/she could not hear the person's answer. The CAA further stated the resident wandered with no specific pattern. The [DATE] care plan directed staff to ensure the resident wore a wander guard pendant (prevents at risk residents from leaving the facility unless they are accompanied), in the form of a necklace, and offer to take the resident for a walk outdoors with assistance of 2 staff. The care plan further directed staff to use the same exit door to leave/re-enter the facility and encouraged the staff to use the east courtyard off the dining room. The care plan directed staff to monitor placement of the pendant necklace and documented the resident was not to leave the facility unattended. Review of the medical record revealed the resident had a history of [REDACTED]. The [DATE] physician orders [REDACTED]. Review of the progress notes and behavior documentation for [DATE] and [DATE] lacked documentation staff accompanied the resident outside for a walk. The [DATE] at 9:32 PM, progress note documented the resident changed during the shift, had his/her head down, his/her balance was off when he/she walked, had not talked to staff, displayed repetitive movements, clapped hands, hit his/her legs, and hit the baby doll. The note further documented the resident did not eat or drink at the evening meal, sat at a table, folded a shirt saver, and repeatedly hit the table with his/her hands. The [DATE] at 2:41 PM, progress note documented the resident continued to have abnormal behavior, with repetitive movements/actions, and he/she flattened a napkin with a cup, while at the dining room table. The note further documented the resident looked at the staff and responded with what, when his/her name was spoken, and was the only word the resident verbalized during the shift. The progress note documented the resident's gait was steady, vital signs were within normal limits, but the resident was unable to communicate his/her needs. On [DATE] at 7:00 PM, K-State Weather Data Library documented the outdoor temperature as 83 degrees Fahrenheit, with wind speed at 10.0 miles per hour in McCook, Nebraska. The K-State Data Library staff reported the normal system used did not report hourly weather for Oberlin, KS and reported the daily high was 77 degrees Fahrenheit and further stated the closest station to draw hourly weather was located in McCook, NE, 28 miles north of Oberlin, KS. The [DATE] at 7:15 PM, incident report documented the nurse heard the door alarm sound, and checked the alarm panel, on the 500 hall. The report further documented a dietary staff member reported to the nurse he/she had observed a resident walk through the dining room into the 500 hall area. Upon entering the 500 hallway, the nurse found the exit door partially open, and radioed for staff assistance at the exit. The incident report documented a nurse aide went out the north side, from the back door, Dietary Supervisor F went out the front door, and found the resident across the street, accompanied the resident back to the building, and when the resident refused to re-enter the building, Dietary Supervisor F sat in front of the building with the resident until Nurse E walked the resident back into the building. Review of the medical record revealed the documentation lacked a physical assessment of the resident and a completed wandering/elopement assessment or handwritten progress note, after the resident returned to the facility. The medical record lacked documentation of an elopement/wandering assessment and no handwritten elopement assessment entries in the progress notes. On [DATE] at 11:00 AM, observation revealed the resident sat in a standard cushioned chair, in the east living room area, initially twirling his/her thumbs in a circular motion around each other, felt the floor with his/her hands all around the base of the chair, looked at the ceiling for several minutes, occasionally said a few words out loud, but did not talk to anyone. Continued observation revealed the resident leaned forward, looked around on the floor, and stood and walked forward, his/her gait was steady, without an assistive device. Observation further revealed a nurse approached the resident, as he/she began to enter another resident's room, took the resident's hand, redirected him/her to sit in the same chair, and gave the resident a cookie to eat. On [DATE] at 1:45 PM, observation revealed the resident walked independently around the west nurse's station and the dining room area, carried a blanket, and wandered without a purpose. Observation further revealed the resident approached staff as they passed by, and attempted to give the blanket to each one. On [DATE] at 2:10 PM, observation revealed the resident, walked independently around the west nursing station and the dining room area, with a baby doll wrapped in a receiving blanket. The resident presented confused, but in a good mood, smiling and talking to the baby doll On [DATE] at 2:35 PM, observation revealed the resident stood by the front entrance, watching the door. As the surveyor entered the building, the door slowly closed and the resident took a few steps toward the door, as the surveyor remained in the area to ensure the resident did not attempt to walk out. On [DATE] at 3:21 PM, observation revealed the 500 hall exit door, had no wander guard device and after the door handle was depressed for 15 seconds, the 500 hall door alarm sounded, and the door released. Observation further revealed Administrative Staff A arrived to check the status of the door after 1 minute and 49 seconds had elapsed. On [DATE] at 3:45 PM, observation revealed the resident entered the 500 hallway, pushed through the double doors and the doors closed behind the resident. Observation further revealed Administrative Nurse B entered the area and redirected the resident as he/she approached the conference room. On [DATE] at 10:30 AM, Dietary Supervisor F documented, in a notarized witness statement, he/she was in his/her office on [DATE], when the door alarm sounded and he/she observed Nurse Aide G walk by quickly. Dietary Supervisor F documented he/she followed Nurse Aide G to the main dining room, where the nurse aide continued on to the 500 hall, and he/she stopped at the front door. Dietary Supervisor F documented he/she stood at the front door and noticed the resident, across the street, walking through the grass, towards the back of a pickup. Dietary Supervisor F documented he/she left the facility, headed toward the resident as the resident stepped out into the street, walked around the pickup, and knocked on the driver's side window of the pickup. Dietary Supervisor F documented he/she crossed the street, talked with the resident, took the resident's hand, and walked the resident back across the street. Dietary Supervisor F further documented the resident did not want to come back into the facility, so the resident and Dietary Supervisor F sat in the chairs on the patio and visited, until the resident was ready to come back in. On [DATE] at 1:30 PM, Nurse D documented, in a notarized witness statement, the alarm panel sounded and indicated it was the 500 exit door. Nurse D documented he/she went to the exit and found the door opened approximately 6 inches, he/she immediately radioed for help at the 500 hall exit, and Nurse Aide G also looked outside. After some time had passed, he/she heard Dietary Supervisor F say on the radio, they (Dietary Supervisor F and the resident) were outside the front door sitting down. Nurse D documented he/she had not heard the wander guard panel sound. Nurse D documented he/she headed to the front door, where Nurse E was also at the front door, and went outside to meet the resident, accompanied by Dietary Supervisor F. Nurse D documented a few minutes passed, the 3 came in the front doors, and he/she silenced the wander guard alarm at the front door. Nurse D documented he/she had previously visualized the resident walking around the building and looking out the doors, but had not observed the resident pushing on the door. On [DATE] at 5:10 PM, Nurse E documented in a notarized witness statement, he/she arrived at the front entrance, on [DATE] at 7:15 PM, following the elopement, and visualized Dietary Supervisor F as he/she walked with the resident up the sidewalk. The witness statement further documented the resident refused to initially return to the inside of the building, and sat outside with Dietary Supervisor F. Nurse E documented the resident agreed to return inside the facility and he/she looked the resident over, saw no obvious injury, but did not document an assessment or vital signs, then notified the resident's responsible party, the physician, and Administrative Nurse B. On [DATE] at 5:25 PM, Nurse Aide G documented, in a notarized witness statement, the resident was agitated, walked around and around the square, going into other resident's rooms, and clarified the resident was able bodied , walked fast, and he/she observed the resident go up to the doors, read the sign, and push on the door until it opened. On [DATE] at 10:15 AM, Nurse H stated the resident was very confused, walked independently, and wandered, which increased in the afternoon to evening. Nurse H further stated the resident walked the entire building, including the 500 hallway, and pushed on the exit door handles. Nurse H stated staff tried to redirect the resident, but it did not last long. On [DATE] at 11:50 AM, Administrative Nurse B verified the nurses had not completed an elopement/wandering assessment on the resident and stated the nurses should follow the same basic process and review the same type of resident information contained on an assessment form, and then enter the result into the medical record/progress notes. Administrative Nurse B further stated the nurses should have assessed the resident for wandering/elopement risk on admission, quarterly, and with a change in status. Administrative Nurse B verified the 2 doors equipped with a wander guard system, were not checked by nursing or maintenance staff for correct function on a regular basis. On [DATE] at 12:20 PM, Nurse C stated the resident resided at the facility a long time, and verified the facility staff were aware of the elopement risk at the time of admission, he/she was care planned on admission for the risk, but not assessed due to staff's prior knowledge of the resident. Nurse C stated the charge nurse checked function of the wander guard pendants on the ,[DATE] shift, the ,[DATE] nurses checked each door to ensure it locked, and further stated staff had not checked the doors using a wander guard device to ensure the wander guard on the door functioned correctly. On [DATE] at 1:50 PM, Nurse Aide I stated the resident wore a wander guard pendant necklace he/she walked the entire building, including the 500 hallway, and went through the double doors without any problem. Nurse Aide I further stated the resident was very confused, pushed on the door handles and opened the doors. On [DATE] at 3:21 PM, Maintenance Supervisor J verified the 500 hall exit door was not equipped with a wander guard and stated he/she had not checked the exit doors with the wander guard system for correct functioning of the wander guard. On [DATE] at 3:25 PM, Administrative Staff A verified the 500 hall door was not equipped with a wander guard system. On [DATE] at 4:55 PM, Nurse E stated the facility had not utilized an elopement/wandering assessment and verified a complete head to toe assessment was not completed or documented, on the resident after re-entering the facility, following the elopement. The ,[DATE] procedure for elopement/missing resident, directed staff to gather at the front desk determine the time the resident was last seen, assign staff for safety checks inside the facility, including the bathrooms, closets, offices, and utility rooms - ,[DATE] hall, ,[DATE] hall, kitchen/town square/500 hall, basement, and outside the facility, staff were directed to divide the town into 4 quadrants, assign a person to each quadrant, driving if possible, start searching closest to the building, working outward. The procedure directed staff to notify the administrator and DON if not present. Call 911 to notify police if the resident was not located within 5 minutes, notify family, begin calling in staff to assist. The elopement procedure directed the charge nurse to complete an incident report after each incident, be it elopement, fall, etc. The procedure further directed staff to follow the triggered (UDAs) User Defined Assessment (computer program that calculates assessments scores, maintains histories, displays instructions, and updates the workflow) - Falls, Vital Signs, Pain Data, and Neurological Check (wander guard assessment was not included) The facility failed to provide adequate supervision for Resident #1, who displayed increased agitation earlier in the day, had prior exit seeking behavior, and exited the facility without staff knowledge, placing the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE], when the facility completed an all staff in-service, which included a review of the elopement policy and procedure, with focus on reporting of elopement, elopement protocol, assessment and prevention, missing resident drill, signage at exit doors, alarm/wander guard function checks, and completion of the Elopement Risk Checklist. The deficient practice remains at a scope and severity of a D. - The physician's orders [REDACTED].#2 had [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated [DATE], documented the resident had severely impaired cognition, physical and verbal behaviors, behaviors toward others, rejected cares, wandered ,[DATE] days of the observation period, required extensive assistance of 2 staff for (ADLs) Activities of Daily Living for transfers, dressing, toileting, limited assistance of 1 staff for walking, hygiene, bed mobility, and supervision with no staff assistance for locomotion on and off the unit. The MDS further documented the resident had poor balance, required staff assistance to regain his/her balance, and used a walker/wheelchair for mobility. The [DATE] behavior (CAA) Care Area Assessment documented the resident was physically and verbally aggressive towards staff, did not allow staff to meet his/her needs when he/she was angry, and slept up to 24 hours, without waking up. The CAA further documented the resident cursed at staff, tried to kick staff, but had not placed the resident or the staff in serious danger. The CAA documented the cause of the behavior triggers was unknown, he/she did not bother other residents, and was fine one minute, then became angry without any reason. The CAA further documented the resident was an elopement risk, and continued to try to go through the exit doors. The [DATE] care plan directed staff to ensure a wander guard pendant (a device that alerts staff when a resident comes close or attempts to open an exit door) was attached to the underside of the resident's wheelchair, and to offer to take the resident for a walk outdoors. The care plan further directed staff to transfer the resident with the assistance of 1 staff, provide weight bearing support to walk with a gait belt, and documented the resident was independent with mobility, in the wheelchair. The care plan documented the resident had a history of [REDACTED]. The [DATE] physician order [REDACTED]. Review of the Treatment Administration Record for March and April revealed nursing staff checked the wander guard on the resident's wheelchair for correct functioning each day, but had not tested the wander guard on the front and back exit door. The [DATE] at 8:42 AM, progress note documented the resident was in a bad mood, cussing, and going up and down the hallway. On [DATE] at 3:15 AM, the incident report documented the east hall nurse aide called on the phone to the west hall nurse aide, because he/she had not observed the resident for a while. The incident report further documented the west hall nurse aide informed the east hall staff the resident was not in the area and all the staff began to look for the resident. The incident report documented 3 staff members checked resident rooms, but did not locate the resident. The report documented 1 nurse aide went downstairs and found the resident in the old activities room, seated in the wheelchair, holding the room door open with his/her leg/foot. The report then documented the nurse and nurse aide assisted the resident upstairs in the elevator, then went back downstairs, locked the elevator in the stop position in the basement, and notified the resident's responsible party and the (DON) Director of Nursing. The nurse documented on the incident report the resident was confused and the elevator was found unlocked. The incident report included a facility review of the [DATE] incident, which documented the resident independently rolled onto the open elevator, rode to the basement, and was found in the old activity room doorway still in his/her wheelchair, within 30 minutes from the time the staff last checked the resident. The review documented education of staff to always place the elevator in the down position, in the basement, after use, to prevent the elevator from opening on its own. The review further documented the elevator company last inspected the elevator on [DATE]. The [DATE] at 3:51 AM, progress note documented the resident was awake during the shift, roamed around the facility in his/her wheelchair, was pleasant and talked to staff. The progress note further documented a nurse aide on the east hall noticed he/she had not observed the resident for a while, then called on the radio to see if the resident was over on the west hall. Staff informed the east hall nurse aide the resident was not on the west hall and staff started searching the rooms for the resident. The progress note documented, staff went down to the basement to search after he/she was not found on the main floor, and located the resident in the door way of the old activities room, holding the door open with his/her leg/foot. A [DATE] invoice from the elevator inspection company, documented the facility reported an operating problem with the passenger elevator. The invoice documented when the company arrived the unit was operating. They adjusted the door open limit switch, and checked the unit to verify proper and safe operation. On [DATE], review of the medical record revealed the documentation lacked a physical assessment of the resident after he/she returned to the main floor of the facility on [DATE]. Further review of the medical record revealed no documentation of a completed elopement/wandering assessment and no handwritten elopement assessment entries in the progress notes. On [DATE] at 11:15 AM, observation of the resident revealed he/she sat in a wheelchair in the hallway, made thumping noises, then propelled forward in the wheelchair, 2 nurse aides approached and accompanied the resident down the hall and asked if he/she needed to use the bathroom. A few minutes later the resident propelled his/her wheelchair independently to the living room area. The resident hovered in the hallway next to the living room area, when a second nurse aide approached and offered the resident coffee, then directed the resident into the dining room. On [DATE] at 2:25 PM, observation revealed the resident wheeled him/herself around in the living room area, by the east hall nurse's station and the dining room entrance. The wander guard pendant was on the underside of the wheelchair. On [DATE] at 3:30 PM, observation of the old activities room in the basement, revealed the room was filled with stored equipment, recliners, beds, wheelchairs, bars, etc., with no organization of the equipment, minimal walking space, with unsecured items/tables leaning, which posed a significant safety risk. Observation further revealed the basement contained many other interconnected rooms, contained a working stove, and numerous unorganized items, also a safety risk. On [DATE] at 12:55 PM, a second tour of the basement revealed the following observations: A locker room with a time clock. A break room with microwave and refrigerator. An open kitchen area down a narrow hallway, had a functioning electric stove, and when the burner knob was turned on, the element began to heat up. A second open storage area with equipment, wheelchairs, walkers, etc., stacked half way up the wall, the area had approximately a 4 to 5 foot wide walkway through the area. The padlocked housekeeping and nursing cages held supplies and were located on the right side of the elevator. An unlocked heavy door opened to the hot water boilers and a locked housekeeping cart. The hallway, going past the cages, lead to the open clean laundry area, then to the soiled laundry area, with accessible laundry chemicals. Further observation revealed the walkway between the laundry carts and the folding table was wide enough for a person to walk through, but not wide enough for a wheelchair to pass through. The water from the sink in the laundry room, accessible by ambulation, fed off the same water line as the washing machines, and tested at a temperature of 166.4 degrees Fahrenheit. The laundry room door opened into the staff breakroom. The following items were found in a cupboard, under the basement kitchen sink : Sta-flo Liquid Starch (gives clothing a crisp stiff appearance), 64 ounces, ½ full, with a warning the liquid could cause irritation to the skin. Rose Mildew Spray (anti-fungal spray for rose bushes,) approximately 12 ounces in a generic bottle, no warning label added. Vinegar, very dark coloring, gallon container, approximately. ,[DATE]th left in the container, could cause mild irritation. On [DATE] at 3:45 PM, Nurse K documented, on a notarized witness statement, the east hall nurse aide on night shift called and wanted to know if he/she observed the resident on the west hall. Nurse K documented the aide was informed the resident was not on the west hall and asked if the resident was on the east hall, the aide stated no, then an aide went to the dining room, 500 hall, and downstairs. The statement documented the aide found the resident downstairs in the activity doorway, in his/her wheelchair, holding the doorway open with his/her foot. Nurse K documented he/she and the nurse aide assisted the resident back upstairs in his/her wheelchair to the main floor. Nurse K documented he/she informed the administrator what happened and documented the elevator process directed staff to lock the elevator after use. On [DATE], Nurse Aide L documented, on a notarized witness statement, the resident sat in the west hall area because he/she wandered through the building at all hours of the day and night and staff left the resident to help another resident. Nurse Aide L documented upon return to the west hall, the resident wandered off, and staff thought the resident returned to the east hall. Nurse Aide L documented, approximately 10 minutes later, staff from the east hall called over the radio asking if the resident was in the area, and staff started a search. Nurse Aide L documented he/she found the resident, in the basement, trying to get unstuck from the old activity room door. Nurse Aide L documented staff overviewed the resident to check him/her for injuries, and the resident did not appear to have any. Nurse Aide L documented staff searched for the resident downstairs, found him/her stuck in his/her wheelchair, in the old activity room doorway, and staff assisted the resident to the upper/main floor. Staff returned to the basement and locked the elevator down on the basement level, because the elevator doors opened and closed periodically on their own. On [DATE] at 3:50 PM, Nurse K stated he/she could not remember the specific date the incident happened, but voiced he/she assessed the resident by looking him/her over, had not checked vital signs because, a person could tell he/she was fine by looking at him/her. Nurse K stated the resident consistently wandered around the building during the night. The nurse verified the elevator door opened by itself at different times, with no person near the elevator door/button. On [DATE] at 6:10 PM, Nurse Aide L stated he/she found the resident inside the activities room in the basement, as the resident attempted to free his/her wheelchair, which was stuck between the wall and the door. Nurse Aide L stated the resident verbalized he/she was glad to see him/her, as the nurse aide freed the resident's wheelchair and foot, which were stuck between the wall and the door. Nurse Aide L stated the resident could not free himself/herself. On [DATE] at 5:15 PM, Administrative Nurse B verified the facility had no specific form to assess a resident for wandering or elopement, or written procedure for staff elevator usage. Administrative Nurse B stated staff were directed to only use the elevator to bring their carts filled with supplies from the basement to the main floor. Administrative Nurse B verified the facility had the laundry department downstairs, along with stock supplies for housekeeping, maintenance, etc. and many of the basement rooms were used for storage. Administrative Nurse B further verified after an incident/elopement, the nurse should perform a head to toe physical assessment, and document the results in the medical record. On [DATE] at 5:45 PM, the Administrative Staff B verified the elevator maintenance staff attempted to repair the elevator several times and could not prevent it from opening and closing on its own, with no one around. Administrative Staff B stated staff were directed to lock the elevator, on the basement level, so it could not be used, following completion of his/her task. The facility's ,[DATE] Elopement /Missing Resident policy and procedure directed staff to gather at the front desk, determine the time the resident was last seen, assign staff for checks inside the facility, including the bathrooms, closets, offices, and utility rooms - ,[DATE] hall, ,[DATE] hall, kitchen/town square/500 hall, basement, and outside the facility. The procedure further directed staff to divide the town into 4 quadrants, assign a person to each quadrant, driving if possible, start searching closest to the building, working outward. The procedure directed staff to notify the administrator and director of nursing, if not present, call 911 to notify police if the resident was not located within 5 minutes, notify family, begin calling in staff to assist. The elopement procedure directs the charge nurse to complete an incident report after each incident, be it elopement, fall, etc. Directs staff to follow the triggered (UDAs) User Defined Assessment (computer program that calculates assessments scores, maintains histories, displays instructions, and updates the workflow) - Falls, Vital Signs, Pain Data, and Neurological Check (wander guard assessment was not included) The facility failed to provide adequate supervision for Resident #2, who wandered within the facility, with no destination, exited the resident care areas by use of the elevator and entered an unsafe basement area not approved for resident use, without staff knowledge, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE], when the facility completed an all staff in-service, which included a review of the elopement policy and procedure, with focus on reporting of elopement, elopement protocol, train staff on the method to engage the elevator from the emergency stop mode, discussion of when the elevator should be used, alarm/wander guard function checks, and completion of the Elopement Risk Checklist. The deficient practice remains at the scope and severity of a D.

The facility reported a census of 44 residents with a sample size of 18 residents, the facility failed to attain the identified medically related social services for Resident # 2 for dental services for dentures and this resident suffered a significant weight loss and had difficultly eating, Resident # 18 also required dental services. Findings included: - The signed Physician orders [REDACTED]. The 4-29-11 annual MDS (Minimum Data Set) Assessment indicated resident #2 displayed moderately impaired cognition and required limited assistance of one staff with eating, listed resident's weight at 149 pounds and height at 64 inches, and no weight loss and no difficultly with chewing or swallowing, along with no mechanically altered diet needed. This same MDS contained nothing related to dental issues. Review of the nurses notes revealed that resident #2's upper dentures where lost June 11, 2011. Resident #2's weight record revealed the following weights: June 2011 = 144 July 2011 = 141 August 2011 = 137 The resident's weight loss equaled 7 pounds since the loss of the dentures. Review of the Clinic Referral form dated 8-23-11, signed by the Physician's Assistant (PA) documented the following, " Lost top teeth, nursing home willing to pay half the cost but the (Resident's durable power of attorney) won't pay the other half, this may account for the weight loss, Please ask Social Services to explore other options for the payment of the upper dentures." The significant change MDS (Minimum Data Set) assessment dated [DATE] indicated resident # 2 had a significant weight loss of 5% and listed the resident's weight at 126 pounds, had coughing or choking during meals and need for mechanically altered texture of foods identified. This same MDS contained nothing related to dental concerns. The Care Area Assessments for Nutrition dated 9-19-11 contained the following summary: "Resident has had continuous weight loss in past 180 days. Is on a mechanical soft diet. Resident lost top dentures this quarter which has made it very difficult to chew food. The person who is also the resident's Durable power of attorney and the Social services designee were to work on getting dentures replaced. Resident does receive nutritional supplements twice daily to help with the weight loss. " During an interview with social service staff G on 10-26-11 at 3:40 pm, staff G admitted knowledge of resident # 2's weight loss, missing top dentures. When asked if she had seen the physician order [REDACTED]. When asked what steps she took to explore alternate payment options for the denture replacement, she stated, "I called the residents' Durable power of attorney (DPOA). The 8-23-11 PA order had stated the DPOA was not willing to pay for replacement dentures. Staff G confirmed she had taken no other action to help this resident get replacement dentures. Although the PA wrote an order 8-23-11 that directed Social Services staff to explore other options for paying for the dentures, the clinical record included no evidence that social services looked for alternatives in the 64 days since the order. Review of the weight record for resident #2 indicated the following weights: 9-9-11 = 123 10-21-11 =122 This continued weight loss equaled 13.99% in 180 days. Review of the Dietary care plan review notes on 10-3-11, the Certified Dietary Manager wrote,"Resident's current weight is 123 pounds, showing an 8% weight loss in 30 days. Resident is eating very poorly and is being assisted. Food fortified and Benecal is being added daily, resident eats varied amounts from 25% to 100% and some meals refused or 0% taken." Observation on 10-25-11 at 5:30 pm revealed resident received assistance to eat by direct care staff. The resident did not have any dentures in place and ate very slowly taking over an one and half hours to complete the evening meal. The resident appeared to have difficulty chewing, as resident kept working the food over and over before swallowing. Observation on 10-26-11 at 7:38 am revealed resident sipping coffee per self and then staff assisted resident # 2 to eat. The dietary staff served the resident fortified cereal and the resident took 100% of the supplement. The resident had no dentures in place and took over one and half hours to complete the meal. The resident had difficulty chewing, as resident took a great deal of time with every bite before swallowing. During an interview on 10-26-11 at 1:30 pm with direct care staff P, staff P stated, "Before the resident lost his/her dentures, he/she ate okay and had not lost any weight." During an interview with administrative Nurse A on 10-27-11 at 11:30 am, Nurse A confirmed that the Social services staff did not follow thorough with the PA's order of 8-23-11 to explore alternative payment for new upper dentures. The facility failed to provide medically related social services for resident #2 whose lost upper dentures were not replaced which caused resident difficultly with eating and chewing and the resident lost 27 pounds of weight. - Resident #18 admitted to the facility on [DATE]. The resident's Physician order [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 9/8/11 recorded the resident cognitively intact. The MDS further recorded the resident had no mood or behavior problems and was independent with transfer, walking in the room and in the corridor, locomotion on and off the unit, dressing, eating and personal hygiene and required staff supervision only for bed mobility. The annual MDS dated [DATE] recorded the resident did not have broken dentures. The resident's record lacked a dental care plan. The self care deficit care plan dated 9/15/11 lacked direction for the resident's broken dentures and plan for a formal oral assessment by a dentist. Review of the resident's medical record lacked a dental assessment. Observation on 10/25/11 at 9:57 A.M. revealed the resident had 2 missing teeth on the upper denture. During an interview on 10/25/11 at 9:58 A.M., the resident stated they have lived in the facility for 6 years and had never seen a dentist in that 6 years. The resident further stated their denture was broken when they admitted to the facility. During an interview on 10/26/11 at 3:38 P.M., Social Service staff F stated they did not know if the resident saw a dentist in the last 6 years, but the facility had dental hygienist visits in the facility and they charged $50. Staff F further stated licensed staff was in charge of the dental program. During an interview on 10/27/11 at 11:16 A.M., licensed staff A stated the resident was not seen by a dentist because he/she had limited funding. Licensed staff A further stated the resident's family was informed when the hygienist first started to come to the facility, and they did not get a response from the family. During an interview on 10/27/11 at 10:58 A.M., administrative staff N acknowledged the resident had broken dentures, and the resident admitted to the facility that way. Administrative staff N further stated the resident's family did not take him/her to the dentist, and the facility did not have the resident seen by a dentist because Medicaid did not pay for routine dental care, and the resident's family did not respond to the initial hygienist letter and pay for the care. Administrative staff N further stated nobody at the facility attempted to find alternative sources of funding for the resident to be seen by a dentist, and they did not attempt additional letters to the resident's family and they did not contact Medicaid to see if they would cover the cost of a dental visit. The facility-provided policy entitled Dental/Oral Health Services and Assessments dated 1/09 directed, "The center will provide or obtain from an outside source routine and 24-hour emergency dental services that meet professional standards and principles. Residents will be assisted, when necessary, in making routine and annual appointments, arranging transportation and referral to a dentist in case of lost or damaged dentures." The facility failed to provide for the medically related social services needs of this resident.

The facility identified a census of 44 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to effectively manage pain for resident #15. Findings included: - According to the clinical record, the facility admitted resident #15 on 3/18/09 with a readmission from an acute care hospital on [DATE]. Review of the physician's orders [REDACTED]. Review of the Significant change Minimum Data Set (MDS) 3.0 Assessment, dated 9/1/11, recorded the resident with a BIMS (Brief Interview for Mental Status) score of (14) that documented the resident cognitively intact. This same MDS recorded the resident required extensive assist for staff for all activities of daily living, with functional range of motion Impairment to both lower extremities, on a scheduled pain medication regimen and received pain medications as needed as well as non-medication interventions for pain relief. The review of the resident-pain assessment interview documented the resident experienced occasional pain during the last 5 days of the assessment period, that limited day to day activities. The review documented the resident rated the pain intensity at a score of (4) on a pain rating scale of 0-10, 10 at the worst. Review of the Pain Assessment, dated 9/6/11, recorded that the resident interview indicated pain in the right lower leg, left hip and leg and rated the pain a (6). This assessment recorded the resident's pain affected eating and activities, relieved by medication and lying still and increased by increased activity and treatments. Review of the interdisciplinary team note summary, dated 9/8/11, addressed the resident's alteration in comfort with a goal to have his/her pain controlled. Review of the Care Area Assessment (CAA), dated 9/13/11, recorded the resident with chronic pain related to a history of osteo[DIAGNOSES REDACTED], an open wound to the right shin, left hip abscess and mild pain to right lower leg posterior lateral wound. The CAA further recorded the resident received the pain medication [MEDICATION NAME] 25 microgram patch changed every 72 hours with occasional breakthrough pain present and relieved with the use of PRN (as needed) [MEDICATION NAME] sulfate. Review of the resident's plan of care, dated 9/15/11, recorded staff provided nursing through skilled care for wound assessment, treatment and pain management. This same plan of care addressed the resident's alteration in comfort and directed staff to: - administer medications as per physician orders -observe for signs and symptoms of pain and report to the charge nurse. -offer pain relief measures such as diversional activities, change of position and -monitor for pain and fatigue. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation, on 10/25/11 at 2:15 P.M., revealed the resident lay in bed with an emesis basin on his/her chest. The resident reported, "Not feeling any better than yesterday, no worse and no better." On 10/25/11 at 2:40 P.M., direct care staff F notified licensed nursing staff B the resident still complained of pain. Licensed nursing staff B responded, "The resident cannot receive any more [MEDICATION NAME] until after 3:00 P.M.". On 10/26/11 at 8:50 A.M., the resident used the call light and asked to change position. Direct care staff E and I, assisted the resident to turn in bed, holding the resident's left leg. Direct care staff E asked if the nurse brought a pain pill. The resident stated "yes, but my left leg hurts with every movement". On 10/26/11 at 10:53 A.M., direct care staff E and I worked together to provide the resident with a bed bath. As direct care staff E moved the resident's left leg, the resident breathed out "ohh", quietly under his/her breath with a pained look on his/her face. As direct care staff E and I then transferred the resident with the maxi-lift, from the bed to the recliner, the resident called out, "Watch my foot!", and "ohhh" each time staff raised or positioned the resident's left leg. On 10/26/11 at 1:20 P.M., direct care staff E and I transferred the resident with the maxi-lift, from the recliner back into his/her bed, transferred with lift. The resident continuously moaned during the transfer. On 10/26/11 at 1:35 P.M., licensed nursing staff B and J prepared to change the dressings on the resident's wounds. As licensed nursing staff F moved the resident's left leg, the resident quietly moaned "oww, ah, ah" each time staff moved the resident's leg. Licensed nursing staff J rolled the resident's head of the bed down and the resident stated "It's hard to relax, oh, oh, I want my head up". Staff explained the bed cannot be raised until the treatment was done. The resident stated "It's hard to breathe", and tried to hold him/herself in a more upright position. Licensed nursing staff J told the resident, "It won't be long." The resident replied, "I hope so." As licensed nursing staff B placed a pillow beneath the resident's legs, the resident grimaced and breathed "oh". Licensed nursing staff B asked the resident if he/she was still hurting, the resident replied "Yes and no". Review of the MAR indicated [REDACTED] At 8:20 A.M., 2 milligrams [MEDICATION NAME] given for complaint of left leg/ankle pain and evaluated the pain at 9:00 A.M., relieved from an "8" to a "4". At 10:00 A.M., 2 milligrams [MEDICATION NAME] given for continued complaint of left leg/ankle/pain (unrated). [MEDICATION NAME] placed per schedule. Documentation of the evaluation of the pain medication at 10:30 A.M., revealed the [MEDICATION NAME] did not completely relieve the pain. At 11:45 A.M., 2 milligrams [MEDICATION NAME] given for complaint of left leg pain (unrated). Review of the resident's clinical record on 10/27/11 revealed the resident last received PRN pain medication on 10/26/11 at 11:45 A.M. During an interview on 10/26/11 at 2:15 P.M., licensed nursing staff B revealed the resident last received PRN pain medication at 11:45 A.M. Licensed nursing staff B reported the resident requested pain medication when he/she wanted it and did not request any pain medication prior to the wound care treatment. On 10/26/11 at 4:50 P.M., direct care staff F reported that staff ask the nurse if the resident can have any pain medication before turning or moving him/her. On 10/27/11 at 10:35 A.M., the resident lay quietly in bed and explained, "When I lie still I have no pain, mostly the pain is with any movement and especially my left leg. The resident continued that "Sometimes the pain is (rated at) a 2 and at its worse is a 10". On 10/26/11 at 10:10 A.M. licensed nursing staff B reported that the resident's pain patches are changed every 72 hours and "They sort of wear out on the 3rd day before changing and the resident has more pain then". On 10/26/11 at 2:00 P.M., licensed nursing staff D reported toward the end of the 72 hours of the pain patch, the resident required more PRN pain medication. Licensed nursing staff D reported the staff had not notified the physician, but would have the facility's new physician see the resident on rounds. Licensed nursing staff D continued that the resident's activities declined after the hospitalization , the resident no longer walked and cannot sit on the toilet due to the pain in his/her left leg. Review of the facility provided policy, Pain Data Collection and Management, dated November 2009, directed the purpose "to determine what pain relief interventions can be utilized and established to aid resident in maintaining comfortable level of function in ADLs (activities of daily living), eating, mobility and all other physical activities. This same policy directed that, "Residents identified at high risk for pain will be reviewed weekly, by licensed nursing staff." Review of the clinical record lacked evidence that the staff assessed and reviewed the resident's pain management weekly. Review of the facility provided policy for Pain Management - Resident Assistance, dated January 2009, directed that, "All residents will receive interdisciplinary consultations on assistance in managing pain... Individualized approaches will be developed to address the resident's pain management needs in a holistic manner. The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan. The facility failed to effectively and consistently manage this resident's pain as per the facility policy and the resident's individualized comprehensive care plan through failure to notify the physician timely when ordered pain medication failed to control break through pain. The resident continually experienced break through pain, without adequate relief, on an ongoing basis.

The facility reported a census of 41 residents, with 6 residents included in the sample and 3 reviewed for pain management. Based on observation, interview, and record review, the facility failed to prevent or reduce pain for 1 of the 3 sampled residents by administering pain medication prior to the identified painful dressing changes (#1015). Findings included: - Resident #1015's 10/11/11 physician's orders [REDACTED]. Resident #1015's 11/7/11 Significant Change MDS (Minimum Data Set) Assessment reported severely impaired cognition, the need for staff to provide total assistance with all ADLs (activities of daily living), received scheduled and as needed medications for pain, and received non-medication interventions for pain. On this same MDS, the resident reported occasional pain affected daily activities but not sleep, and rated as 3 on a scale of 0 as none and 10 as worst. The resident's 11/11/11 Pain Assessment reported the resident complained of joint, soft tissue, open areas on the skin, and generalized leg pain overall at a 3 on a scale of 0 for none and 10 for the worst pain. The resident reported the pain at worst as "severe", described the pain as "shooting, nagging, sometimes nauseating, aggravated by movement and (dressing change) treatments", and pain increased when "moved or receiving (dressing change) treatments." The resident reported the pain affected sleeping patterns, daily living, relationships with others and caused irritability, difficulty concentrating on tasks, and appetite. The resident reported a goal to remain alert during the day, sleep comfortably at night, and experience comfort with movement. The resident's MDS triggered multiple care areas to review for the care plan on 11/16/11 which included pain. The resident's 11/16/11 Pain CAA (Care Area Assessment) reported the resident's causal factors as joint pain that increased and affected day to day living, received every three days a [MEDICATION NAME] (a narcotic pain medication) patch 50 mcg. (micrograms) and [MEDICATION NAME] (a narcotic pain medication) 5 mg. (milligrams) every hour as needed for breakthrough pain, at times refused pain medication when offered, had contractures and open areas of the skin that contributed to pain problems. The facility indicated the CAA as pertinent to the resident care and proceeded to care plan the pain interventions. The physician's orders [REDACTED]. to 50 mcg and change every 3 days for pain. The physician's orders [REDACTED]. to 5 mg. every hours as needed for breakthrough pain without a maximum limit. The physician's orders [REDACTED]. Lexi-comp's Geriatric Dosage Handbook, page 861, instructed to use [MEDICATION NAME] as an medication to treat anxiety, nausea, and fever. The handbook lacked information that [MEDICATION NAME] increased the effectiveness of [MEDICATION NAME] or [MEDICATION NAME], or to use [MEDICATION NAME] to treat pain symptoms. The resident's 11/17/11 care plan instructed staff that the resident needed total assistance with all ADLs, observe for signs of pain and report the findings to the charge nurse, to offer pain relief measures like diversional techniques and change of positioning, to change the resident's position at least every 2 hours and also when requested by the resident, and to use two staff members to reposition the resident. Nursing notes between 11/1/11 and 11/30/11 reported 6 occasions when staff performed dressing changes to the resident's multiple open areas without administering pain medication for breakthrough pain prior to the procedure. Nursing notes between 12/1/11 and 12/6/11 reported 2 occasions when staff performed dressing changes to the resident's multiple open areas without administering pain medication for breakthrough pain prior to the procedure. The resident's December 2011 MAR (medication administration record) reported the resident received [MEDICATION NAME] 5 mg. at 3:20 p.m. on 12/6/11 (1 hour and 34 minutes before the dressing change to the left foot). Observations on 12/6/11 at 4:45 p.m. revealed the resident laid in the bed with the head elevated slightly, moaned repeatedly, complained the dressing changes cause pain, and refused the dressing change to the resident's open area between the left 1st and 2nd toes. Administrative Nurse A administered the resident [MEDICATION NAME] at 4:47 p.m. and obtained the resident's permission to perform a dressing change to the resident's open area between the left 1st and 2nd toes. Resident #1015's clinical record lacked documentation that the facility nursing staff offered the resident pain medication prior to initiating the 4:54 pm, painful dressing change procedure on 12-6-11. Observations on 12/6/11 at 4:54 p.m. revealed Administrative Nurse C and Licensed Nurse D performed a dressing change to the resident's open area between the left 1st and 2nd toes. During the procedure the resident moaned, said "ouch, ouch", and grimaced. At 4:56 p.m., Administrative Nurse C moved the right leg and then the left leg, and each time the resident moaned and said "ouch." Neither staff offered the resident pain medication. During an interview on 12/6/11 at 5:04 p.m., Administrative Nurse C reported awareness staff administered the last dose of [MEDICATION NAME] at 3:20 p.m., and stated "we don't need to give (him/her) any more ([MEDICATION NAME]), we just gave (him/her) [MEDICATION NAME] and that will help (him/ her) calm down." During an interview on 12/7/11 at 1:44 p.m., Administrative Nurse A reported the resident refused pain medication on multiple occasions, awareness dressing changes and movement increased the resident's pain level, and confirmed the facility failed to offer pain medication prior to the dressing changes. The facility failed to provide adequate pain management for resident #1015 prior to what the resident described as painful dressing changes in November and December 2011, despite the staffs' knowledge that the dressing changes caused the resident pain.

The facility identified a census of 44 residents with 18 residents sampled with 1 of the 18 reviewed for pressure ulcers . Based on observation, interview, and record review, the facility failed to assess, plan, implement and provide care to 1 totally dependent resident with pressure ulcers. Findings included: - According to the clinical record, the facility admitted resident #15 on 3/18/09 with a readmission from an acute care hospital on [DATE], with [DIAGNOSES REDACTED]. Review of the Significant change Minimum Data Set (MDS) 3.0 Assessment, dated 9/1/11, recorded the resident with a BIMS (Brief Interview for Mental Status) score of (14) that documented the resident cognitively intact. This same MDS recorded the resident required extensive assist of staff for all activities of daily living, with functional range of motion impairment to both lower extremities, with 2 unstageable pressure ulcers present on readmission. Review of the clinical record revealed a Braden skin assessment, dated 9/6/11, that scored the resident an 11, and indicated a score of (10-12) as high risk. Review of the Care Area Assessment (CAA), dated 9/13/11, recorded the resident with an open area on the lateral/posterior calf currently treated with daily moist to dry dressings. . Review of the resident's plan of care, dated 9/15/11, identified the resident with impaired skin integrity with two open areas on the left hip from draining abscesses, open (pressure ulcer), post debridement, area on the right posterior calf with necrotic tissue and two chronic (stasis ulcers) open areas on the left leg. This plan of care directed staff to provide: -treatment as ordered -nursing through skilled care for wound assessment and treatment, pain management, assessing respiration status and monitoring abscess drainage. -assessment of wound with each dressing change -observe for signs and symptoms of infection -redness, increased drainage, color of drainage, fever and report to physician. -debridement of right calf as indicated -measure area on right posterior calf length, width. -administer medications as per order (alteration in comfort). The plan of care failed to address the resident's right heel pressure ulcer. During an interview, on 10/24/11 at 3:00 P.M., licensed nursing staff I reported the resident's outer right heel ulcer, "was probably about a stage 2 now". On 10/25/11 at 2:15 P.M., licensed nursing staff B reported that staff provided treatment to the resident's lower right leg twice daily and staff kept information as to when the wound needed measuring again on a calendar. Licensed nursing staff B revealed the resident had black eschar around the right heel. Observation, on 10/26/11 at 1:35 P.M., during wound care treatments revealed licensed nursing staff B and J changed dressings on the posterior aspect of the resident's right calf. During the wound care to the right leg, the black area of eschar (approximately 1.0 centimeters in diameter came off the resident's right heel, leaving pink skin with a small red area where the scab last attached approximately 1.0 x 0.8 centimeters in size. Review of the clinical record revealed an interdisciplinary team assessment note, dated 9/19/11, that the open area on back of his/her right leg had improved and continued to receive daily wet to dry dressing changes with debridement of the wound as needed from physical therapy. . Review of the treatment record, revealed measurements to the lower right leg (calf) on 8/29/11, and 10/14/11. Review of the treatment record on 10/25/11 measured the wound to right lateral calf at 8.4 centimeters long by 2.2 centimeters wide by 0.5 centimeters deep with white slough central to wound with black eschar to both ends. Review of the treatment record, revealed measurements to the unstageable right heel ulcer dated 8/29/11. Review of the nursing notes dated 10/4/11 recorded the resident's blackened circular area on the right heel without a dressing. Review of the nursing notes/interdisciplinary team notes lacked evidence of any comprehensive weekly skin assessments on 9/14/11, 9/21/11, 9/28/11, 10/5/11, 10/12/11, 10/19/11 and 10/26/11. Review of the clinical record lacked evidence of consistent weekly assessment of the resident's skin by licensed nursing staff. On 10/26/11 at 10:45 A.M., licensed nursing staff D reported that the charge nurse follows up on the resident skin assessments. On 10/26/11 at 4:50 P.M., direct care staff F revealed that the resident's skin ulcers were present for quite a while and that staff turned the resident every two hours. . On 10/27/11 at 9:15 A.M., licensed nursing staff D revealed, "There is no real schedule for monitoring resident's identified at high risk for skin assessments. Licensed nursing staff D revealed a list that recorded this resident to have weekly skin assessments on Wednesday. Licensed nursing staff D revealed the results of the skin assessments should be recorded in the weekly nursing notes. Review of the facility provided undated policy "Principles for Managing and Treating Pressure Ulcers: Healing Process, directed, "The RN should assess and evaluate the wound status at least weekly for progress towards healing. If progress is not noted in a two week time frame, there may be a need to change interventions that modify/eliminate the risk factors or change to the treatment. At a minimum documenting the evaluation of the healing process and lack of progress should be documented along with the decisions made to continue or change the interventions. Education directed, "Ongoing assessment/monitoring of medical conditions should occur in order to identify changes and to assist the resident in attaining and maintaining skin integrity." The facility failed to accurately and consistently assess and monitor this resident's skin integrity as per the facility policy and as planned, to ensure healing of this residents two identified, unstageable pressure ulcers.

The facility reported a census of 41 resident, with 6 residents included in the sample, and 3 residents reviewed with actual skin breakdown or high potential for skin breakdown. Based on observation, interview, and record review, the facility failed to turn and reposition 2 of the 3 sampled residents (#1001, and 1015) and resident #1001 who had an existing Stage II pressure ulcer on the buttocks developed an additional stage II pressure ulcer)in the buttock crease). Findings included: - Resident #1001's 11/2/11 physician's orders [REDACTED]. The physician's renewed orders contained the original order date of 10/28/11 to treat open areas of the skin with [MEDICATION NAME] Ointment to "AAA" (all areas affected). Resident #1001's 11/3/11 Annual MDS (Minimum Data Set) Assessment reported short and long term memory problems, severely impaired decision making skills, total dependence on staff for all ADL's (activities of daily living), a risk for pressure ulcers but none present, on a turn and reposition program, presence of a pressure relieving device in the chair and bed, and received nutritional and hydration support for the pressure ulcer risk. The resident's 11/4/11 Wound Assessment reported "no open areas to the buttock, very reddened skin, a very superficial open area remains to left buttock measuring 3.2 cm (centimeters) long, 1.1 cm wide, this area is present within the margins of area assessed." The resident's MDS triggered multiple care areas to review for the care plan on 11/10/11 which included pressure ulcers. The resident's 11/10/11 Pressure Ulcer CAA (Care Area Assessment) identified the resident's causal factors as a recent readmission for the hospital to treat a urinary tract infection and [MEDICAL CONDITIONS] (severe diarrhea caused from antibiotic use), history of a healed pressure ulcer, a high score on the Braden Scale (a pressure ulcer risk scale) , and needed staff to provide drinks and food. The facility indicated the CAA as pertinent to the resident care and proceeded to care plan the pressure ulcer interventions. The resident's 11/11/11 care plan instructed staff that the resident needed total assistance with all ADL's, to change his/her position every 2 hours, may be up in a chair for meals only, to turn side to side in bed and keep off of his/her back, use of a pressure relieving device in the chair and bed, to measure area of concern at least weekly and record, and to keep the coccyx (tailbone area) area open to air while in bed. The resident's 11/11/11 Wound Assessment reported "superficial open area remains present although smaller at 2 cm long and 0.8 wide, rest of area assessed remains reddened, but without any other open area." The clinical record lacked Wound Assessments for the coccyx wound on 11/18/11 or 11/25/11. The resident's 11/29/11 Wound Assessment reported a stage II pressure ulcer to buttock 2.6 cm long by 1.0 cm wide by 0 cm deep, 10% [MEDICATION NAME] tissue, 50% granulation tissue, no slough or eschar, no drainage, the surrounding skin as pink, treated with [MEDICATION NAME] ointment, no odor and no pain noted, on a turning and nutrition plan, has a pressure relieving device, and the facility notified the physician. The 11/29/11 assessment indicated the open area increased in length and width from the 11/11/11 assessment. Observations on 12/6/11 at 11:33 a.m. revealed the resident laid in bed on his/her right side. Direct Care Staff E and Direct Care Staff F checked the resident for incontinence while wearing gloves, cleaned the periarea with wet wipes, and removed the urine soiled incontinent pad. Continued observations revealed the resident had 2 open areas to the buttock, one to the left buttock and one to the buttock crease. Continued observations revealed Direct Care Staff E and F transferred the resident to the wheelchair using a mechanical lift, and the resident sat on a gelled pad in the wheelchair to relieve pressure. During an interview on 12/6/11 at 11:36 a.m., Direct Care Staff E reported the charge nurse placed an ointment on the area to treat the open areas daily. Staff E stated the nurses knew of the new pressure ulcer since they see the wounds daily. Staff E identified the open area to the left buttock was the oldest wound, and the open area to the buttock crease existed for approximately 1 1/2 to 2 weeks. Observations on 12/6/11 at 1:21 p.m. revealed the resident laid in bed on his/her left side, covered with a blanket, and call light within reach. Observations on 12/6/11 at 3:31 p.m. revealed the resident remained on his/her left side in bed. Observations on 12/6/11 at 4:00 p.m. revealed the resident remained on his/her left side in bed. Observations on 12/6/11 at 4:25 p.m. revealed the resident remained on his/her left side in bed. Observations on 12/6/11 at 5:15 p.m. revealed Direct Care Staff G and Direct Care Staff H sat the resident upright in bed, dangled the resident's feet on the side of the bed, and transferred the resident to the wheelchair with a gel pad in the seat, which revealed the facility failed to change the resident's position after 2 hours to relieve pressure on the resident's left side (a total 3 hours and 54 minutes later). During an interview on 12/6/11 at 5:25 p.m., Direct Care Staff G reported his/her shift began at 2 p.m. that day, the previous shift failed to report when they repositioned resident #1001 last, and he/she was the only staff on assigned to the Country Reflections hallway until 4 p.m. Observations on 12/7/11 at 7:30 a.m. revealed the resident sat in a wheelchair in an upright position on a gel pad at the dining table. Observations on 12/7/11 at 8:01 a.m. revealed the resident leaning to right side of the wheelchair while staff assisted the resident to eat breakfast. Observations on 12/7/11 at 9:03 a.m. revealed the resident sat in the wheelchair near the Country Reflections hallway nursing station area and continued to lean to the right. Observations on 12/7/11 at 9:59 a.m. revealed the resident remained in the wheelchair, continued to lean to the right, and staff propelled the resident to dining room for a singing activity. Observations on 12/7/11 at 10:34 a.m. revealed the resident remained in the wheelchair, continued to lean to the right, and staff propelled the resident back to the Country Reflections hallway nursing station area. Observations on 12/7/11 at 10:50 a.m. revealed Direct Care Staff F propelled the resident to his/her room, Direct Care Staff E and F transferred the resident to bed using a mechanical lift, laid the resident to the left side, checked the resident for incontinence, noted the incontinent pad as dry, exposed the coccyx area to air, and covered the resident with a blanket. The observation revealed the facility failed to change the resident's position after 2 hours to relieve pressure on the resident's 2 buttock stage II pressure ulcers (a total of 3 hours and 20 minutes later). During an interview on 12/7/11 at 1:44 p.m., Administrative Nurse A confirmed Direct Care Staff G worked alone on the assigned hall, but reported Staff should have asked for help from the Medication Aide on the assigned hall, or from the Charge Nurse or other Certified Nursing Assistant on the other hall. Administrative Nurse A confirmed the facility failed to reposition the resident every 2 hours. The resident's 12/7/11 Wound Assessment reported the stage II pressure ulcer to the left buttock as 1.6 cm long by 0.5 cm wide by 0 cm deep, 100% granulation tissue present, no drainage, surrounding skin intact and pink, treated with [MEDICATION NAME], no odor or pain, on a turning and nutrition plan, and pressure relieving device present. The clinical record lacked evidence of an assessment of the open area to the buttock crease. During an interview on 12/7/11 at 3:23 p.m., Administrative Nurse C reported he/she completed the wound assessment earlier that day with License Nursing Staff I, the staff treated the wound with [MEDICATION NAME] ointment, and did not see a second open area to the buttock crease. During an interview on 12/7/11 at 3:24 p.m., Licensed Nursing Staff I confirmed he/she assessed the resident's buttock earlier that day with Administrative Nurse C and reported he/she did not see a second open area to the resident's buttock crease. Observations on 12/7/11 at 3:29 p.m. revealed Administrative Nurse C assessed the resident's wound with gloved hands and noted a second open area to the resident's buttock crease. During an interview on 12/7/11 at 3:42 p.m., Administrative Nurse C reported the second open area to the buttock crease as a stage II pressure ulcer measuring 1.2 cm long by 0.3 cm wide by 0 cm deep. The facility identified Resident # 1001 with a stage II pressure ulcer to the left buttock. The failed turn and reposition resident #1001 every 2 hours on two separate occasions. The resident developed a second stage II pressure ulcer to the buttock crease. - Resident #1015's 10/11/11 physician's order [REDACTED]. Resident #1015's 11/7/11 Significant Change MDS (Minimum Data Set) Assessment reported severely impaired cognition, the need for staff to provide total assistance with all ADL's (activities of daily living), received scheduled and as needed medications for pain, received non-medication interventions for pain, and per the resident's interview reported occasional pain that affected daily activities but not sleep, rated pain as 3 on a scale of 0 as none and 10 as worst. The resident's 11/11/11 Braden Scale (a pressure ulcer risk scale) reported the resident as high risk with a score of 11, and instructed staff to initiate interventions such as frequent change of positioning on a schedule and use pressure relieving devices. The resident's MDS triggered multiple care areas to review for the care plan on 11/16/11 which included pressure ulcers. The resident's 11/16/11 Pressure Ulcer CAA (Care Area Assessment) reported the resident's causal factors as; required 2 staff to reposition every 2 hours, frequently incontinent of urine and stool related to the inability to sit on commode due to left hip pain and increased the risk of pressure ulcers to the coccyx (tailbone), significant weight loss due to decrease of appetite, Braden scale score of 11 meaning high risk for pressure ulcer, pressure ulcer on right lower leg increased in size as per the last assessment, chronic end stage disease, malnutrition, several pressure ulcers assessed at least on a daily basis, each wound measured weekly and documented, right lower leg evaluated by physical therapy 11/1/11 and will be debrided next week, frequently the resident asked to change position when in pain, pressure relieving device in the bed and chair, poor fluid and nutritional intake which interferes with wound healing, presently no open area to coccyx, admitted with 2 sores to left lower leg. The facility indicated the CAA as pertinent to the resident care and proceeded to care plan the pressure ulcer interventions. The resident's 11/16/11 Wound Assessment reported an unstageable pressure ulcer to the back of the right lower leg measured as 8.7 cm (centimeters) long by 2.8 cm wide by 0.8 cm deep, moderate amount of purulent (cloudy) and sanguineous (bloody) drainage, the wound bed as macerated, red, and hard, no undermining or tunneling, odor present, no pain present, covered with "aquagel." The resident's 11/17/11 care plan instructed staff that the resident needed total assistance with all ADL's, the resident has a pressure relieving device in the chair and in bed, to offer pain relief measures such as diversional techniques and change of positioning, to change the resident's position at least every 2 hours and also when requested by the resident, and to use two staff members to reposition the resident. The resident's 11/23/11 Wound Assessment reported an unstageable pressure ulcer to the back of the right lower leg measured as 9.7 cm (centimeters) long by 1.8 cm wide by 1.8 cm deep (increased since last assessment), moderate amount of serosanguineous (clear and bloody) drainage, the wound bed as macerated, red, and hard, no undermining or tunneling, odor present, no pain present, covered with "aquagel." The resident's 12/1/11 Wound Assessment reported an unstageable pressure ulcer to the back of the right lower leg measured as 9.7 cm (centimeters) long by 3.3 cm wide by 0.7 cm deep (increased in width since last assessment), moderate amount of serosanguineous (clear and bloody) drainage, the wound bed as macerated, red, and hard, no undermining or tunneling, odor present, no pain present, covered with "aquagel." The resident's 12/1/11 Wound Assessment reported a new stage II pressure ulcer to the central back on spine 1.0 cm long by 0.4 cm wide by 0 cm deep, no drainage, [DIAGNOSES REDACTED]tous present, slough present on the wound bed, no undermining/tunneling, no odor or pain, and treated with "copa" dressing. Observations on 12/6/11 at 2:01 p.m. revealed the resident laid in bed on his/her back with the head of the bed elevated slightly. Observations on 12/6/11 at 3:35 p.m. revealed the resident remained in bed on his/her back with the head of the bed in the same slightly elevated position. Observations on 12/6/11 at 4:25 p.m. revealed the resident remained in bed on his/her back with the head of the bed in the same slightly elevated position. Observations on 12/6/11 at 4:47 p.m. revealed the resident remained in bed on his/her back with the head of the bed in the same slightly elevated position. Observations on 12/6/11 at 5:05 p.m. revealed Administrative Nurse C and Licensed Nursing Staff D repositioned the resident to the left side (2 hours and 54 minutes later). During an interview on 12/6/11 at 5:25 p.m., Direct Care Staff G, the staff assigned to resident #1015's hallway, reported his/her shift began at 2 p.m. that day, the previous shift failed to report when they repositioned resident #1015 last, and he/she was the only staff on assigned to the Country Reflections hallway until 4 p.m. During an interview on 12/7/11 at 1:44 p.m., Administrative Nurse A confirmed Direct Care Staff G worked alone on the assigned hall, but reported Staff G should have asked for help from the Medication Aide on the assigned hall, or from the Charge Nurse or other Certified Nursing Assistant on the other hall. Administrative Nurse A confirmed they failed to reposition the resident which placed pressure on the resident's pressure ulcer located to mid back and back of right lower leg for a period greater than 2 hours. The facility failed turn and reposition resident #1015 after 2 hours on his/her back with two existing stage II pressure ulcers, one to the back of the right lower leg and a new one to the central spine.

The facility reported a census of 44 residents with a sample size of 18 residents and 3 of the 18 residents were reviewed for weight loss/nutrition. Based on observation, record review, and interview, the facility failed to provide one of three residents identified at risk for impaired nutrition, with dental services to replace missing dentures and to prevent a severe weight loss of 8% in 30 days and 13.99 % in 180 days. (#2) Findings included: - The signed Physician orders [REDACTED]. The 4-29-11 annual MDS (Minimum Data Set) Assessment indicated resident #2 displayed moderately impaired cognition and required limited assistance of one staff with eating, listed the resident's weight at 149 pounds and height at 64 inches, and no weight loss and no difficultly with chewing or swallowing, along with no mechanically altered diet needed. Nursing notes revealed resident #2 lost his/her upper dentures on 6-11-11. Resident #2's weight record revealed the following weights: June 2011 = 144 July 2011 = 141 August 2011 = 137 The resident's weight loss equaled 7 pounds since the loss of the dentures. Review of the Clinic Referral form dated 8-23-11, signed by the Physician's Assistant (PA) indicated the PA's awareness of the resident's weight loss and the PA's orders included, " Lost top teeth, nursing home willing to pay half the cost but the (Resident's durable power of attorney) won't pay the other half, this may account for the weight loss, Please ask Social Services to explore other options for the payment of the upper dentures." The significant change MDS (Minimum Data Set) assessment dated [DATE] indicated resident # 2 had a significant weight loss of 5% and listed the resident's weight at 126 pounds, coughing or choking during meals and need for mechanically altered texture of foods identified. This same MDS contained nothing related to dental issues. The Care Area Assessments for Nutrition dated 9-19-11 contained the following summary: "Resident has had continuous weight loss in past 180 days. Is on a mechanical soft diet. Resident lost top dentures this quarter which has made it very difficult to chew food. The resident's Durable power of attorney and the Social services designee were to work on getting dentures replaced. Resident does receive nutritional supplements twice daily to help with the weight loss. " Review of the Dietary care plan review notes on 10-3-11, the Certified Dietary Manager wrote,"Resident's current weight is 123 pounds, showing an 8% weight loss in 30 days. Resident is eating very poorly and is being assisted. Food fortified and Benecal is being added daily, resident eats varied amounts from 25% to 100% and some meals refused or 0% taken." During an interview with social service staff G on 10-26-11 at 3:40 pm, staff G admitted knowledge of resident # 2's weight loss, and missing top dentures. When asked if she had seen the physician order [REDACTED]." Staff G confirmed she had taken no other action to help this resident get replacement dentures. Although the PA wrote an order 8-23-11 that directed Social Services staff to explore other options for paying for the dentures, since the DPOA, the clinical record included no evidence that social services looked for other alternatives in the 64 days since the order. The Care Plan dated 10-6-11 identified the concern of altered nutrition and listed the following instructions to staff: ? Assistance of one with eating as allowed ? Offer snacks morning, evening and bedtime ? Record and monitor meal intakes daily ? Fortify appropriate goods Review of the weight record for resident #2 indicated the following weights: 9-9-11 = 123 down 15 pounds since August 10-21-11 =122 This continued weight loss, after the Physician Assistant ordered Social services to find alternatives for purchase of replacement dentures, equaled 13.99% in 180 days. Observation on 10-25-11 at 5:30 pm revealed resident received assistance to eat by direct care staff, resident without any dentures in place, ate very slowly taking over an one and half hours to complete the evening meal. The resident appeared to have difficulty chewing, as resident kept working the food over and over before swallowing. Observation on 10-26-11 at 7:38 am revealed resident sipping coffee per self and then staff assisted resident # 2 to eat. The dietary staff served the resident fortified cereal and the resident took 100% of the supplement. The resident without any dentures in place, took over one and half hours to complete the meal. The resident noted to have difficulty chewing, as resident took a great deal of time with every bite before swallowing. During an interview on 10-26-11 at 1:30 pm with direct care staff P, staff P stated, "Before the resident lost his/her dentures, he/she ate okay and had not lost any weight." During an interview with administrative Nurse A on 10-27-11 at 11:30 am, Nurse A confirmed that the Social services staff did not follow thorough with the PA's order of 8-23-11 to explore alternative payment for new upper dentures and confirmed that the resident lost a significant amount of weight. The facility failed to provide resident # 2, identified at risk for impaired nutrition, with the necessary care and services regarding the lost upper dentures and difficulty with chewing. The resident suffered difficulty chewing and experienced a significant weight loss.