Every finding on record at Good Samaritan - Ellis

The facility identified a census of 37 residents, with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to prevent a hot liquid burn to Resident (R) 1. The facility failed to evaluate the temperature of the liquid from the hot water/coffee machine, relying on a temperature regulator that had failed, and allowed the hot water dispensed from the machine to be too hot.Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), gastroparesis (a chronic digestive disorder where the stomach muscles weaken, slowing or stopping food from moving into the small intestine), epilepsy (brain disorder characterized by repeated seizures), and convulsions (involuntary series of contractions of a group of muscles).The Significant Change Minimum Data Set (MDS) dated 11/13/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R1 had impairment of his bilateral upper and lower extremities. The MDS documented R1 required set-up or clean-up assistance with eating. The MDS documented R1 was dependent on staff for all other activities of daily living (ADL).The Functional Abilities Care Area Assessment (CAA) dated 11/13/25 documented R1, a paraplegia, required total assistance with ADL self-care. The CAA documented R1 was not safe to use his electric wheelchair anymore and was now dependent on a manual wheelchair and dependent on staff for locomotion.R1's Care Plan, initiated 12/05/13, documented R1 had impaired ability to manage hot beverages and soups related to paraplegia (03/10/22). The care plan directed staff to offer R1 foods that were at a liquid state at room temperature (06/15/21). The care plan documented R1 would be free from injury and would safely manage hot beverages, serve soup in a mug, provide cup with lid, and remind R1 about being cautious with hot beverages and soups (03/10/22). The care plan documented R1 was on a full liquid diet (06/15/21). The care plan documented R1 was dependent on two staff and a full lift for transfers (04/09/24).The Communication with Resident/Family Note dated 12/18/25 documented R1's responsible party was notified of the burn incident and wound care performed.The Communication /Visit with Physician Note dated 12/18/25 documented R1's primary care provider (PCP) was faxed regarding spilled chicken broth.The Weekly Skin Observation Assessment dated 12/18/25 documented R1 had a reddened area to his left elbow, which measured 22 centimeters (cm) by 7 cm, and a red area to his left lateral abdomen, which measured 9 cm by 5 cm and 4 cm by 1 cm. Staff applied sterile dressing to cover per facility policy and notified R1's PCP for additional orders.The Urgent Fax dated 12/18/25 documented R1 spilled hot tea on his left elbow and left abdomen. Reddened areas on the lateral abdomen measured 4 cm by 1 cm and 9 cm by 5.5 cm. Reddened area on the elbow measured 22 cm by 7 cm. The areas were flushed with cold water and applied a sterile dressing. Please advise on any additional treatment orders. R1's PCP responded to continue the current treatment for seven days.The Communication with Resident/Family Note dated 12/19/25 documented staff talked with R1 about accidentally dropping his hot beverage on his arm. R1 stated, Yep, I just did that to myself, fell out of my hand. Staff asked R1 if he was okay, and R1 stated he was okay and he was not in any pain. R1 voiced that he did not feel trauma or feel this was a traumatic experience.The Physician Order Fax dated 12/22/25 documented the facility informed R1's PCP the blisters were open. Staff requested an order for burn cream to apply before dressing change, as the dressing change caused R1 pain. PCP responded with an order to apply Silvadene (a topical antibiotic used in partial thickness and full thickness wounds to prevent infection) cream twice a day to the affected areas until healed.The Communication/Visit with Physician Note dated 12/23/25 documented a new order had been received for Silvadene cream to the affected area twice a day and cover with a sterile dressing until healed.The Facility Incident Report, dated 12/23/25, documented on 12/18/25 at 11:55 AM Licensed Nurse (LN) G poured chicken broth for R1 in the dining room and placed it in a cup with a lid. At 11:57 AM, LN G entered R1's room, placed the cup on the resident's bedside table, and exited the room. R1 sat up in his bed with his head elevated. At 12:04 AM, Housekeeping Staff heard R1 yelling for help and entered his room. R1 had spilled chicken broth on himself. The lid was still on the cup; the liquid had spilled out through the straw opening. Housekeeping staff immediately notified Administrative Nurse D, who was coming down the hallway. Administrative Nurse D immediately assessed R1, removed his clothing, and followed the facility's burn policy. The burned areas were treated and dressed per protocol. R1's family and PCP were notified. R1 was able to explain to Administrative Nurse D and Administrative Staff A how the incident occurred. At the time of the incident, R1's care plan indicated R1 was to be served hot liquids in a mug with a lid and reminded to use caution with hot beverages and soups. Following the incident, Administrative Nurse D and Administrative Staff A manually checked the temperature of the hot water from the dispenser. The water temperature measured 159 degrees Fahrenheit (F) immediately after dispensing and decreased to 154 degrees F within a couple of minutes. The initial skin assessment of R1 revealed two red areas on his left lateral abdomen, which measured 9 cm by 5.5 cm and 4 cm by 1 cm, and one red area on the left elbow, which measured 2 cm by 7 cm. A follow-up skin assessment was completed on 12/22/25. At that time, R1 had a small blister on the left elbow that had begun to scab, with no remaining skin concerns noted on the left lateral abdomen.The Health Status Note dated 12/31/25 documented R1 had a healing blister on his left arm.The Communication/Visit with Physician Note dated 01/01/26 documented the request for the discontinuation of wound treatment as the wound had healed.On 01/06/26 at 10:30 AM, observation revealed R1 sitting up in bed at a 45-degree angle with his bedside table over the bed. R1 had a protein drink with a straw in the top on the bedside table. R1 ate a snack. R1's left outer elbow was dark pink in color, where his burn had been, in deep contrast to the rest of his pale skin. R1 stated the day the burn occurred, he had not gotten out of bed for lunch. R1 stated LN G brought the chicken broth in and set it down there (indicating the middle edge of the bedside table closest to his body). R1 stated he reached over the chicken broth to reach for something in the middle of his table and knocked the chicken broth off to the left side. R1 stated he could not grab the cup, and it was leaking hot chicken broth. R1 stated he tried to sop up the liquid with a napkin but could not get it all. R1 stated it was his own fault for not reaching high enough over the chicken broth. R1 stated the burns hurt quite a bit at the time, but now there was nothing on his stomach, and then pointed to the dark pink area on his left elbow and stated, That's all that is left on that one.On 01/06/26 at 11:00 AM, Administrative Nurse D stated the facility did not regularly check the temperatures from the water/coffee pot because it had a temperature regulator on it that was to keep the temperature below 150 degrees. Administrative Nurse D stated they did not realize the temperature regulator was not working until the accident happened with R1, and they measured how hot the liquid was. Administrative Nurse D stated the water/coffee pot was placed out of commission, and the company was sending a new temperature regulator to be put on. Until that time, the kitchen staff was brewing all coffee and hot liquids in the kitchen and tempering them to the appropriate temperature for serving. Administrative Nurse D stated all employees were re-educated regarding the hot liquid policy and resident-specific care plans.The facility's Hot Liquids Policy, revised 04/28/25, documented hot liquids are prepared or brewed at high temperatures to maximize flavor and quality. Temperature affects palatability, which varies from person to person. When self-service of hot liquids is available in the dining room, consider serving liquids at temperatures at or below 150 degrees F, supervise the area, do not overfill the carafes or service containers, and pre-pour liquids whenever possible into drinking cups with lids or per care plan. When serving hot liquids to residents: do not overfill the drinking cup, place liquid away from the edge of the table and near the resident's dominant hand, explain to the resident that a hot liquid is being served, and place the hot liquid in the resident's field of vision. When serving hot liquids to residents with behavior or medical conditions that put them at risk for spills: evaluate the ability of the resident to manage hot liquids independently and provide assistance when needed, allow hot liquids to cool before serving it to reduce the risk or severity of burns, add ice to the hot liquids before serving, if resident agrees, and ensure interventions are added to the care plan from the Hot Liquid Safety focus.The facility completed corrective actions by 12/22/25, which included the coffee/hot water machine placed out of service on 12/18/25. All hot liquids are currently prepared by dietary staff, temperature checked prior to service, and placed in carafes before serving to residents. A hot temperature regulator has been ordered for the coffee/hot water machine and will be installed once received. Staff education was immediately initiated regarding the facility's hot liquid policy and resident-specific care plan requirements and completed on 12/22/25. All residents were audited with all hot liquid interventions listed in their care plan to ensure accuracy and compliance. The dietary staff or the designated representative audits and logs temperatures of all hot liquids prior to service. This was completed prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance and remained at the scope and severity of a G to represent the actual, but isolated harm to R1.

The facility had a census of 34 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when the facility failed to assess Resident (R) 26 for safe use of an electric recliner. Findings included:- R26's Electronic Medical Record (EMR) recorded dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), wedge compression fracture thoracic spine levels 11-12, and muscle weakness. R26's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R26 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded R26 was independent with activities of daily living and had one fall, no injury. R26's Fall Care Area Assessment (CAA) dated 05/05/25 documented R26 was at risk for falls due to use of antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people) medications, and had chronic pain and discomfort due to low back pain. R26's Fall Care Plan dated 12/06/25 documented the resident had a fall on 10/27/25 due to missing the chair in activities. The care plan documented on 12/06/25 R26 slid out of the recliner. The care plan documented staff would educate/instruct the resident on the safe use of assistive devices, as well as looking back to ensure the chair was where she could sit before attempting to sit down. The care plan instructed staff to monitor the resident every hour to ensure safety and encourage her to keep her door open when she is feeling weak/tired from her current respiratory infection. R26's EMR lacked evidence the facility assessed R26 for the safe use of an electric lift recliner since admitting to the facility on [DATE]. The Nurses Note dated 12/06/25 at 06:43 AM recorded R26 had an unwitnessed fall from her electric lift recliner and was observed in the middle of the room on the floor on her right side. R26 stated she slid out of her chair and shimmied across the floor to try to get closer to the door to yell for help. The notes documented R26's oxygen saturation was low, and staff applied oxygen at two liters and increased her saturation from 85% to 90 % (normal is 95-100%). Staff instructed R26 to call for help when getting up to avoid further falls with injury. On 12/10/25 at 07:35 AM, observation revealed R26 sat in her electric lift recliner with feet elevated, and Licensed Nurse (LN) H obtained the resident's vitals. Observation revealed R26's call light was on the right arm of the recliner. On 12/10/25 at 03:00 PM, Administrative Nurse D verified the resident had an electric lift recliner since admission to the facility, and an electric lift chair safety assessment was not completed on R26 for safe use of the chair. Administrative Nurse D verified electric lift recliner assessments should be completed on admission, with a change in condition, and quarterly. The facility's Falls Management policy, dated 10/14/25, documented the facility would promote resident well-being by developing and implementing a fall prevention and management program. The facility would identify risk factors and implement interventions before a fall occurs and would give prompt treatment after a fall occurs. The policy documented if the fall involved a medical device, secure the device and any part of the accessories for follow-up investigation and report to the facility risk department.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility's Consultant Pharmacist failed to identify staff were not obtaining Resident (R) 7's blood pressure before the administration of losartan, as ordered. Findings Included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of hypertension (elevated blood pressure), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat). The Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R7 had intact cognition. The MDS further documented R7 received diuretic (a medication to promote the formation and excretion of urine) medication. The Quarterly MDS dated 10/23/25 documented R7 had intact cognition. The MDS documented R7 received diuretic medication. R7's 10/17/25 Care Plan included the following interventions: 06/15/16 - Directed staff to administer medication as ordered, consult with the pharmacy, and healthcare provider to consider dosage reduction when clinically appropriate. 07/16/24 – Directed staff to monitor, document, and report to the healthcare provider changes in edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and weight changes. The Physician's Order dated 11/15/21 directed staff to obtain weekly blood pressure on Mondays and notify the physician if the systolic blood pressure (SBP- top number, the force your heart exerts on the wall of your arteries each time it beats) was less than 90 millimeters of mercury (mmHg) or more than 180 mmHg. Notify the physician if the diastolic blood pressure (DBP- minimum level of blood pressure measured between contractions of the heart; the bottom number of the blood pressure reading) was less than 50 mmHg or more than 110 mmHg and notify the physician if her pulse was less than 50 beats per minute (bpm) or more than 112 bpm. The EMR lacked documentation staff obtained weekly blood pressures for R7. The Physician's Order for R7 dated 07/16/24 directed staff to administer losartan (hypertension medication), 50 milligrams (mg) by mouth at bedtime for CHF, and only if the blood pressure was more than 130/80 mmHg. The EMR lacked documentation staff obtained R7's blood pressure prior to the administration of losartan. A review of the Medications Regimen Reviews (MRR) by the Consultant Pharmacist (CP) from December 2024 through December 2025 lacked evidence the CP identified and reported the losartan order had been transcribed incorrectly or that her blood pressure was not obtained as ordered. On 12/10/25 at 10:15 AM, R7 sat in her recliner with her feet elevated and talked on the telephone. On 12/10/25 at 10:20 AM, Licensed Nurse (LN) G verified staff did not obtain R7's blood pressure every Monday as ordered and verified that staff administered her losartan medication without knowing if R7's blood pressure was out of parameters. On 12/10/25 at 12:40 PM, Administrative Nurse D stated back in July of 2024 R7 was in the hospital, and when she returned, they received an order to hold the medication and resume it if her blood pressure was more than 130/80 mmHg. The medication was held until 10/24/24, and the order was to administer the losartan medication without blood pressure parameters. Administrative Nurse D further stated the order did not get corrected at that time, but verified staff should have followed the physician's orders as written in the EMR. Administrative Nurse D stated staff should have been obtaining R7's blood pressure weekly as ordered and stated the order did not get populated into the EMR system correctly. Administrative Nurse D stated the Consultant Pharmacist had not made her aware of the irregularities of the losartan order or that R7's blood pressure was not obtained as ordered. The facility's Medication Drug Regimen Review policy, dated 12/02/24, documented a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart. The drug regimen review would identify if the doses and duration were appropriate to each resident's clinical condition, age and comorbidities, and monitoring of medications for efficacy and adverse consequences of the potential medication irregularities, and response to these irregularities. The pharmacist would complete a written report noting any drug irregularities or issues of concern of each resident review, the Quality Assurance and Performance Improvement (QAPI) team would review the medication regimen review at the monthly meetings, and the irregularities would be reported to the medical director and attending physician by the director of nursing or designee.

The facility had a census of 34 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for one resident. The facility failed to obtain weekly blood pressures as ordered for Resident (R) 7, who received hypertension (high blood pressure) medication.Findings included:- The Electronic Medical Record (EMR) for R7 documented diagnoses of hypertension, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat).The Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R7 had intact cognition. R7 was dependent upon staff for toileting hygiene, dressing, and transfers. The MDS documented R7 required set-up staff assistance for oral hygiene, showers, and personal hygiene. The MDS further documented R7 received diuretic (a medication to promote the formation and excretion of urine) medication.The Quarterly MDS dated 10/23/25 documented R7 had intact cognition. R7 required substantial staff assistance for upper body dressing, personal hygiene, mobility, and was dependent upon staff for transfers. The MDS documented R7 received diuretic medication.R7's 10/17/25 Care Plan included the following interventions:06/15/16 - Directed staff to administer medication as ordered, consult with the pharmacy, and healthcare provider to consider dosage reduction when clinically appropriate.07/16/24 - Directed staff to monitor, document, and report to the healthcare provider changes in edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and weight changes.The Physician's Order dated 11/15/21 directed staff to obtain weekly blood pressure on Mondays and notify the physician if the systolic blood pressure (SBP- top number, the force your heart exerts on the wall of your arteries each time it beats) was less than 90 millimeters of mercury (mmHg) or more than 180 mmHg. Notify the physician if the diastolic blood pressure (DBP- minimum level of blood pressure measured between contractions of the heart; the bottom number of the blood pressure reading) was less than 50 mmHg or more than 110 mmHg. And notify the physician if her pulse is less than 50 beats per minute (bpm) or more than 112 bpm.The EMR lacked documentation that staff obtained weekly blood pressures.The Physician's Order dated 07/16/24 directed staff to administer losartan (hypertension medication), 50 milligrams (mg) by mouth at bedtime for CHF. Take only if the blood pressure is more than 130/80 mmHg.The EMR lacked documentation R7's blood pressure was taken before administering the bedtime dose of the losartan in October 2025, November 2025, and December 2025.On 12/10/25 at 10:15 AM, R7 sat in her recliner with her feet elevated and talked on the telephone.On 12/10/15 at 10:20 AM, Licensed Nurse (LN) G verified that staff did not obtain R7's blood pressure every Monday as ordered and verified that her losartan medication was administered without knowing if the blood pressure was out of parameters.On 12/10/25 at 12:40 PM, Administrative Nurse D stated back in July of 2024 R7 was in the hospital, and when she returned, they received the order to hold the medication and resume it if her blood pressure was more than 130/80 mmHg. The medication was held until 10/24/24, and the order was to administer the losartan medication without blood pressure parameters. Administrative Nurse D further stated the order did not get corrected at that time but did verify that staff should have followed the physician's orders as written in the EMR. Administrative Nurse D stated that staff should have obtained her blood pressure weekly as ordered and stated the order did not get populated into the EMR system correctly.The facility's Medication Administration Including Scheduling and Medication Aides policy, dated 04/08/25, documented that the medication was to be administered correctly and in a timely manner. A provider's order for any medication was required and must include the diagnosis, name of medication, route, frequency, and stop order if indicated.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to employ a full-time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 35 residents of the facility at risk for inadequate nutrition or food-borne illness. Findings included: - On 03/05/24 at 810 AM, observation revealed Dietary Staff (DS) DD and EE served breakfast to the residents in the dining room. On 03/05/24 at 08:35 AM, Administrative Staff A verified the Dietary Manager was not certified. The facility's Food and Nutrition Services policy, dated 01/02/24, stated the person in charge of the food and nutrition department is responsible for department operation and must meet one of the following criteria: A Certified Dietary Manager (CDM) by the Association of Foodservice and Nutrition Professionals. A Certified Food Service Manager (CFM) by the International Foodservice Executives Association. Similar national certification food service management and safety from a national certifying body. An associate's or higher degree in food service management from an accredited institute of higher learning. The Dietary/Food Service managers must meet state requirements and receive frequently scheduled consultations from a Registered Dietician. The facility failed to employ a CDM or the equivalent to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 35 residents of the facility at risk for inadequate nutrition or food-borne illness.

The facility had a census of 35 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on the following days: 01/14/23, 02/05/23, 02/26/23, and 03/19/23. The PBJ report for FY 2023 Quarter 3 indicated no licensed nurse coverage on 04/08/23, 04/30/23, 05/20/23, 05/21/23 and 06/11/23. A review of the facility's licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 03/06/24 at 11:30 AM, Administrative Nurse D verified the facility failed to submit accurate nursing hour data for the PBJ. She verified the nurse clock-in hours for all the days. The facility's Nursing Service Staff, policy, dated 10/30/23 documented the facility would provide appropriate staff for resident care in the nursing service department. The facility would use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, except when waived by state regulations. The charge nurse would delegate the responsibility to nursing personnel for direct nursing care of residents on the basis of staff qualifications, workload, size and physical layout of the unit or location, and the individual needs of the residents. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 35 residents. Based on record review and interview, the facility failed to ensure one of the five Certified Nurse Aides (CNA) employed at the facility for at least one year completed the minimum 12 hours of in-service training per year and lacked a system for accurately tracking CNA education. Findings included: - A review of the facility's CNA Training Records for CNA staff who had been employed at the facility for over one year revealed a lack of 12-hour in-service training for CNA M, hired 02/15/22. The records recorded that CNA M completed 4.5 hours. On 03/06/24 at 02:20 PM, Administrative Nurse D stated the facility had not monitored the completion of CNA in-service hours and verified that one of the five CNAs lacked the 12 hours of yearly in-service training. Upon request, the facility did not provide a policy for nurse aide in-service continuing education. The facility failed to ensure one of the five CNA staff reviewed completed the minimum 12 hours of in-service training per year and lacked a system for accurately tracking CNA education.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered an injection to Resident (R) 2 beside the front entry to the facility and in view of other residents and when residents were served meals in Styrofoam bowls instead of regular dinnerware. This placed the residents of the facility at risk for impaired dignity. Findings included: - On 03/05/24 observation during the lunch meal service revealed staff provided Styrofoam bowls for baked beans and desserts. On 03/07/24 at 12:52 PM, observation revealed Licensed Nurse (LN) G obtained a finger stick blood sugar from R2 and then administered insulin (a hormone that lowers the level of glucose in the blood) in R2's abdomen, by the front entry with one male resident nearby and a resident watching from the dining room. On 03/05/24 at 12:17 PM, DS BB stated the facility used the Styrofoam bowls because the beans would run into the other foods and the facility only had large bowls. 03/07/24 at 12:00 PM, Dietary Staff (DS) CC stated the facility used Styrofoam bowls for desserts for at least the past year. On 03/07/24 at 01:23 PM, Consultant GG said Styrofoam should only be used in emergencies such as if the dishwasher was not working or for residents on isolation precautions. On 03/07/24 at 01:00 PM, LN G verified she should not have administered the insulin injection in an area where others could see R2's exposed abdomen. On 03/11/24 at 10:30 AM, Administrative Nurse D stated the facility did not have enough bowls because some were thrown away or broken. Administrative Nurse D verified staff should not be using Styrofoam bowls for regular meal services. The facility's Dining Service Standards policy, dated 07/21/23, directed staff to not use stained, chipped, or worn dishes or glassware and not use disposable dishware unless it was appropriate to an individual's needs. The facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered insulin to R2 in view of other residents and when residents were served meals on disposable dinnerware. This placed the residents at risk for impaired dignity.

The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to ensure the residents' dinnerware was not broken or chipped. This placed the 35 residents at risk for unsafe food service. Findings included: - On 03/07/24 at 12:00 PM, Dietary Staff (DS) CC served meals in the facility kitchen. Observation revealed a stack of plates with four chipped plates which DS CC used during the meal service. On 03/07/24 at 01:23 PM, Consultant GG verified the chipped plates could be a safety or sanitation concern and said chipped dinnerware should not be used. The facility's Dining Service Standards policy, dated 07/21/23, directed staff to not use stained, chipped, or worn dishes or glassware. The facility failed to ensure the residents' dinnerware was not broken or chipped. This placed the 35 residents at risk for unsafe food service.

The facility had a census of 35 residents. The sample included 14 residents with three reviewed for weight loss. Based on observation, interview, and record review the facility failed to identify and implement interventions to prevent weight loss for Residents (R) 14. This deficient practice placed the resident at risk for further weight loss or health issues. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), epilepsy (brain disorder characterized by repeated seizures), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), and pain. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R14 had impaired range of motion (ROM) in all four extremities and required staff set up for meals however she fed herself. The MDS documented R14 had no swallowing or dental issues and weighed 176 pounds (lbs.). The Nutrition Care Area Assessment (CAA), dated 12/18/23, stated R14 had a potential nutritional problem related to moving into a nursing home. R14 was able to feed herself and let staff know her likes and dislikes. R14's Care Plan, dated 12/12/23, stated R14 was able to feed herself independently, but had a potential nutritional problem related to moving into a nursing home. The care plan directed staff to weigh R14 weekly, invite her to food-related activities, and offer food or beverages of her choice to encourage intake. The Physician Order, dated 12/12/23, directed staff to provide a regular diet, and regular texture and stated she needed her food cut up for her. The Dietician Assessment, dated 12/18/23, documented R14 weighed 175.6 lbs. and her intakes were all adequate, mostly 51-100%. The Registered Dietician (RD) recommended adding meal fortification to R14's diet order. R14's EMR lacked documentation that staff added the fortified foods as recommended by the RD. The Progress Note, dated 03/06/24 at 09:31 AM, documented the nurse requested a dietary supplement drink for R14 due to weight loss and refusing meals. The Physician Order, dated 03/06/24, directed staff to provide R14 with Ensure (dietary supplement) twice daily. On 03/05/24 at 12:10 PM, R14 received her meal and staff sat by her and encouraged her. R14 decided to sit at a different table and staff moved with her. R14 ate a few bites of her meal before leaving the dining room. On 03/06/24 at 08:30 AM, observation revealed R14 sat in her wheelchair at a dining table while Certified Nurse Aide (CNA) O encouraged her to eat and drink. R14 stated her stomach was bothering her and she could not eat anymore. R14 requested tea without ice. CNA O informed the nurse who questioned the resident and then brought R14 a Boost (supplement) drink. On 03/06/24 at 08:39 AM, Licensed Nurse (LN) G stated R14's family brought in Glucerna (liquid protein) supplements and LN G stated she would get an order for more. She stated R14's representatives informed staff they gave R14 Glucerna when she would not eat. LN G stated R14 would only eat grilled cheese sandwiches when she was first admitted , but now she likes roast beef and mashed potatoes. On 03/07/24 at 01:55 PM, CNA N stated staff gave R14 a supplement if she did not eat well but was not sure if the supplement was scheduled. She stated R14 ate very little at meals and staff offered her other foods but R14 would complain of stomach pain instead of taking an alternative food. On 03/07/24 at 02:05 PM, LN G stated staff notified the physician and RD of R14's weight loss that week. LN G stated R14 could feed herself, but staff ended up feeding her like her family used to. On 03/07/24 at 10:08 AM, Administrative Nurse D verified staff had not obtained R14's weights weekly and said staff should have notified the physician and the RD earlier than two weeks after the significant loss, Administrative Nurse D said the facility should have started a supplement when the resident refused to eat meals. The facility's Weight and Height policy, dated 09/18/23, stated all residents were weighed at a minimum of weekly for the first four weeks following admission and then monthly thereafter. Residents at risk would be weighed weekly and the facility would immediately inform the resident, consult with the resident's physician, and notify the resident's representative. The policy directed staff to record the weights and if the weight varied by more than three percent, reweigh the resident and document. The licensed nurse was to notify the Dietary Manager (DM) within 24 hours regarding any significant weight change as defined by: five percent in 30 days, 7.5 percent in 90 days, and 10 percent in 180 days. The licensed nurse should immediately notify the medical provider regarding any significant weight change. The facility failed to provide fortified foods to prevent weight loss for R14. This deficient practice placed R14 at risk for further weight loss or health issues.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 31 residents who resided in the facility and received their food from the facility kitchen when the facility failed to ensure dietary staff followed hand hygiene and failed to ensure clean and sanitary food prep areas. This placed the 31 residents at risk for foodborne illness. Findings included: - On 8/24/22 at 11:30 AM observation in the kitchen revealed the following: During serving of the noon meal, Dietary Staff (DS) BB applied gloves, touched her face, steam table, and undercounter fridge door handle. Then, with the same contaminated gloves, took two grilled cheese sandwiches from a plastic bag, and placed them in a frying pan. The mopboard around the kitchen floor had numerous brown stains of various sizes The kitchen ceiling had eight ceiling tiles with numerous different sized brown stains. Three ceiling fluorescent light fixtures had numerous bugs and brown particles. The pipes located underneath the three-well sink had brown and black particles. On 08/24/22 at 11:45 AM, DS BB verified the above issues in the kitchen. The facility's Hand Hygiene and Use of Gloves Policy, revised 12/2018, documented staff should wear gloves when working on a single task and touch any food item. Gloves must be removed and hands must be washed every time staff touch anything other than the food item they are working on. Any time staff hands or gloves are contaminated by touching any non food surface including other utensils or any part of their body and if they are changing food item tasks. The facility's undated Cook To Do List, documented tasks for the morning and night cook to complete each day, but did not include cleaning light fixtures and replacing ceiling tiles. The facility failed to prepare and serve food in accordance with professional standards for food service safety. This placed the 31 residents, who resided at the facility and received food from the facility kitchen at risk for receiving a foodborne illness.

The facility had a census of 31 residents. The sample included five residents. Based on observation, record review, and interview the facility failed to provide ongoing communication to the resident council group about their rights and location of State Long Term Care Ombudsman (LTCO-an official appointed to investigate individual's complaints against maladministration), State Survey Agency (a group which assess whether nursing homes are operating with a quality of care that is in line with standards, applicable laws, and industry regulations) information and the location of the last survey report. This placed the residents at risk for impaired dignity due to decreased autonomy. Findings included: - The Resident Council Minutes, from 08/03/21 to 08/04/22 documented one resident right was reviewed with resident council minutes. The minutes lacked documentation regarding LTCO and State Survey Agency contact information or the last state survey location. On 08/25/22 at 10:00 AM, Resident (R) 4, R7, R8, R11, and R28 attended the resident council meeting with the surveyor and all stated they did not know where the LTCO, State Survey Agency contact information, and last State Survey report was kept. All five of the residents stated staff did not review resident rights with them during the resident council meetings. On 08/25/22 at 10:58 AM, Social Service X verified staff did not review the above information and stated she asked the residents at the resident council meetings if they were being treated ok. The facility failed to provide ongoing communication regarding resident rights, contact information for State LTCO and State Survey Agency, and information regarding lcoation of the last state survey report. This placed the resident at risk for being uninformed of their rights.

The facility had a census of 31 residents. The sample included 14 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions for accidents for one sampled resident, Resident (R) 24, who had multiple falls and failed to use two staff when transferring R27 with a full mechanical lift (used to assist with transfers and movement of individuals who require support for mobility). This placed the residents at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R24 documented diagnoses of [CONDITION(S)] (a disorder of the brain that can be caused by disease, injury, drugs, or chemicals), benign neoplasm of cerebral meninges (brain tumor), [CONDITION(S)] (a neurological disease marked by sudden recurrent episodes of sensory disturbances and loss of consciousness), and mood disorder (the emotional state or mood is distorted or inconsistent with the circumstances and interferes with the ability to function). R24's Admission Minimum Data Set (MDS), dated [DATE], documented R24 had intact cognition and required limited assistance of one staff for transfers, ambulation in her room, dressing, toileting, and personal hygiene. The MDS further documented R24 had unsteady balance, no functional impairment, had no falls, and received therapy. The Quarterly MDS, dated [DATE], documented R24 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, and toileting. The MDS further documented R24 had unsteady balance, upper and lower functional impairment, had two non-injury falls, and received restorative therapy. The Fall Risk Assessments, dated 03/07/22, 04/21/22, 05/29/22, 06/07/22, 07/12/22, and 08/06/22 documented R24 a high risk for falls. The Fall Care Plan, dated 01/04/22, documented R24 was at risk for falls related to her brain tumor and [CONDITION(S)] ([CONDITION(S)] disorder) and directed staff to remind R24 not to bend over and pick up dropped items, encourage the use of her grabber, and educate the resident on the causes of falls. The update, dated 03/06/22, directed staff to ensure the resident's floor in her room remained clean so that she was not tempted to bed over and pick it up. The update, dated 05/20/22, directed staff to have a fall mat next to R24's bed. The update, dated 05/28/22, directed staff to ensure a padded call light was on the resident and reinforce the use and educate the resident on safe use of assistive devices. The update, dated 05/31/22, directed staff to review R24's bowel and bladder continence status and establish a toileting plan based on resident needs. The care plan lacked interventions related to a toileting plan. The Fall Investigation, dated 03/06/22 at 01:09 PM, documented R24 was on the floor in her bathroom and stated she fell after she tried to pick up a small piece of paper off the floor in the bathroom. The investigation documented R24 did not receive any injury. The Fall Investigation, dated 05/20/22 at 04:19 PM, documented R24 was on the floor next to her bed and staff educated her to use her call light. The investigation documented R24 did not receive any injury. The Fall Investigation, dated 05/28/22 at 12:11 PM, documented staff lowered R24 to the floor after finding her in the bathroom by the toilet and the resident was weak and shaky. The investigation further documented staff reeducated resident on the use of the call pad. The Fall Investigation, dated 05/29/22 at 10:30 PM, documented R24 was in the bathroom on the floor with her pajama bottoms and attends pulled halfway down. The investigation further documented R24 had no safety awareness, impaired memory, and did not sustain any injury. The clinical record lacked evidence a toileting plan was established and implemented based on the residents needs in an effort to prevent further falls. The Fall Investigation, dated 07/12/22, at 04:45 PM, documented R24 was on the floor by the bathroom door and was incontinent of urine. The investigation further documented R24 did not use her call light for assistance and did not sustain any injury. The Fall Investigation, dated 08/06/22, at 07:11 AM, documented R24 was on the floor in her room, She stated she had tried to unplug her nightlight and fell . On 08/25/22 at 09:00 AM, observation revealed Certified Nurse Aide (CNA) N asked R24 if she wanted to go for a walk and R24 was slow to respond and whispered yes. CNA N placed a gait belt around the resident and assisted her to stand up in front of her walker. Further observation revealed R24 had a steady gait but required cueing from CNA N to not run into objects along the way. CNA N assisted the resident into a chair in the commons area in front of the television. On 08/25/22 at 09:00 AM, CNA N stated the resident had a lot of falls but was doing better as R24 had a fall mat and a flat call light. On 08/25/22 at 09:35 AM, Licensed Nurse (LN) H stated the resident had a history of a brain tumor and her cognition was not good. LN H further stated she was better than she used to be but will get up on her own because she cannot remember to use her call light. The facility had given her a flat call light that when she started to get up, she would roll over it alerting staff that she had been trying to get up. On 08/29/22 at 11:35 AM, Administrative Nurse D stated, they review falls at the risk meeting and are good at new interventions for residents who falls and would review falls in the clinical morning meetings. The facility's Fall Prevention and Management policy, dated 03/30/22, documented each resident would have a fall prevention and management program to promote resident well-being. The program would identify risk factors and would implement interventions before a fall occurs, give treatment after a fall occurred, prevent further injury, and provides guidance for documentation. The facility failed to follow R24's care plan for falls which directed a resident specific toileting plan should be developed and failed to identify and implement resident centered interventions for falls placing the resident at risk for further falls. - The Electronic Medical Record (EMR) for R27 documented diagnoses of [CONDITION(S)] (paralysis characterized by motor or sensory loss in the lower limbs and trunk), left side [CONDITION(S)] (paralysis of one side of the body), and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R27 had moderately impaired cognition and was dependent upon two staff for transfers and toileting, extensive assistance of two staff for bed mobility and dressing. The MDS further documented the resident had upper and lower functional impairment and used a wheelchair for mobility. The Care Plan, dated 04/19/17, directed staff to use the total lift with two staff for transfers. On 08/25/22 at 12:30 PM, observation revealed Certified Nurse Aide (CNA) M roll the full mechanical lift toward the bed, attach the sling to the lift, raised the resident into the air. Further observation revealed as R27 was raised up, he started to swing around because there was not another aide to control the movement of the resident in the sling. R27 stated, watch my feet, watch my feet! as his feet hit the hydraulic lift (part that lifts the sling bar mechanism into the air). Continued observation revealed CNA M lowered the resident into his electric wheelchair. He was in a slouched position because he was not centered or further back into the seat. On 08/25/22 at 12:30 PM, CNA M stated she should have asked the nurse to assist her with the use of the mechanical lift but she did not. CNA M further stated it was the policy of the facility to use two staff with the full mechanical lift but there wasn't enough staff. CNA M stated she was going to go get a second person to assist her to position R27 in his wheelchair better. On 08/25/22 at 12:40 PM, Licensed Nurse (LN) H stated residents who required the use of a full mechanical lift should always have two staff assistance. On 08/29/22 at 11:30 AM, Administrative Nurse D stated CNA M was trained to use two staff when transferring a resident with a full mechanical lift. The facility's Mobility Support and Positioning policy, dated 05/03/22, documented two or more employees are required for using total lift and assist devices when transferring a resident from surface to surface. The facility failed to use two staff when using a full mechanical lift for R27. This placed the resident at risk for injury.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to treat Resident (R) 16 with dignity when staff applied [MEDICATION(S)] gel (a topical medication used to treat arthritis pain) on her shoulders, twice, at the dining room with two other residents present. This placed the resident at risk for an undignified dining experience. Findings included: - R16's Electronic Medical Record (EMR) documented she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had a Brief Interview of Mental Status (BIMS) score of seven, which indicated severe impaired cognition. The MDS documented R16 required extensive staff assistance with activities of daily living (ADLs) except supervision with eating. R16 received scheduled and as needed (prn) pain medications during the seven day look back period. The Anti-Anxiety Care Plan, revised on 06/27/22, documented R16 received an antianxiety (medication used to treat anxiety) medication. The Right Shoulder Arthritis Pain Care Plan, revised on 06/27/22, documented R16's identified level of pain she tolerated was a five on a scale of 0-10. The care plan instructed staff to report to the nurse if R16 complained of pain or discomfort. The care plan documented R16's pain was aggravated by movement and instructed staff to administer pain medications as ordered. The Physician Order, dated 08/02/22, instructed staff to apply 2 grams [MEDICATION(S)] gel 1%, topically, to R16's shoulders, four times a day for right shoulder pain. On 08/24/22 at 08:20 AM, observation revealed Licensed Nurse (LN) I applied [MEDICATION(S)] gel to R16's shoulders at the dining room table with two other residents present. On 08/25/22 at 11:30 AM, LN I applied gloves, took [MEDICATION(S)] gel out of a medication cup and applied on the resident's shoulders at the dining room table with two other residents present. On 08/24/22 at 08:20 AM, LN I verified she applied R16's [MEDICATION(S)] gel on her shoulders at the dining room table and stated she always applied it at the dining room table. On 08/29/22 at 10:36 AM , LN J stated she would not apply R16's [MEDICATION(S)] gel on her shoulders in the dining room; she would take R16 to her room. On 08/29/22 at 12:07 PM, Administrative Nurse D stated staff should not apply Volteran gel on R16's shoulders in the dining room; staff should take her to her room. The undated Resident's Rights For Skilled Nursing Facilities Policy, documented the resident had a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. The facility failed to treat R16 with dignity when staff applied her Volteran gel to her shoulders, twice, at the dining room table with two other residents present. This placed the resident at risk for an undignified experience.

The facility had a census of 31 residents. The sample included 14 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to notify Resident (R)11's physician after R11 made the statement she wished she was dead. This placed the resident at risk for further decline of her emotional well-being and delayed mental healthcare treatment. Findings Included: - The Electronic Medical Record (EMR) for R11 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition and was independent with all activities of daily living (ADLs). The MDS further documented R11 had thoughts she would be better off dead or hurting herself never or one day, felt depressed or hopeless two to six days, felt bad about herself never or one day. R11 received antianxiety (medication that calm and relax people with excessive anxiety, nervousness or tension) during the look back period. The Care Plan, dated 06/09/22, documented R11 had depression as evidenced by being tearful, fearful, and she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse's Note,' dated 08/10/22 At 01:39 PM, documented R11 stated she felt homesick and hopeless; she felt that she was a burden to people. The note further documented R11 commented that she wished she was dead but had no plan to hurt herself and agreed she would not do that because she had nothing to hurt herself with. R11 continued to cry and refused her as needed anxiety medication. The EMR lacked documentation the physician or family was notified and lacked follow up documentation or interventions put into place after R11 made the statement she wished she was dead. On 08/24/22 at 08:00 AM, observation revealed R11 ate breakfast in the dining room. On 08/24/22 at 10:00 AM, R11 stated she lived in the facility since June; she missed her mom. R11 further stated she wished her mom could come live with her. R11 stated the facility where her mom lived never let her talk to her mom. On 08/24/22 at 08:00 AM, Licensed Nurse (LN) G stated R11 was upset that her mother did not live at the facility with her but R11 had never made statements of harming herself. On 08/25/22 at 09:30 AM, Certified Nurse Aide (CNA) M stated R11 had behaviors of crying sometimes but had not made comments that she wanted to harm herself. On 08/29/22 at 11:00 AM, Social Service X stated she talked with R11 about the statement but R11 did not have a plan to harm herself. Social Services X further stated she had not documented any of the conversation she had with R11 and verified R11's physician was not notified. On 08/29/22 at 11:30 AM, Administrative Nurse D stated staff should have contacted the physician and family to make both of them aware of the situation. The facility's Notification of Change policy, dated 05/16/22, documented the facility must immediately inform the physician and resident representative when there was a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment, and the safety of individuals in the location was endangered due to the clinical or behavior status. The facility failed to contact R11's physician and family when she made the statement that she wished that she was dead. This placed the resident at risk of further decline of her emotional well-being and delayed mental healthcare treatment.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to immediately respond and investigate a report of alleged inappropriate interaction between a male resident, (R)10 and R11. This placed the residents at risk emotional distress. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition and was independent with all activities of daily living (ADLs). The MDS further documented R11 had thoughts she would be better off dead or hurting herself never or one day, felt depressed or hopeless two to six days, felt bad about herself never or one day. R11 received antianxiety (medication that calm and relax people with excessive anxiety, nervousness or tension) during the look back period. The Care Plan, dated 06/09/22, documented R11 had depression as evidenced by being tearful, fearful, and she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff to discuss with the resident any concerns, fears, or issues regarding health or other subjects. The Nurse's Note, dated 08/22/22 documented an unidentified evening Certified Nurse Aide (CNA) overheard a conversation regarding an interaction with R11 and R10. The CNA stated R10 talked to R11 about the possibility of marriage and a request to have sex with him. The CNA further stated R11 called her brother to ask his permission regarding these issues and ask if it would be ok to start kissing R10. The EMR lacked documentation of any follow up with the incident. On 08/24/22 at 08:00 AM, Licensed Nurse (LN) G stated she was unsure what had happened between the two residents but R11 did not want R10 in her room anymore because he had said something that scared her. LN G said R11 stated R10 gave R11 the creeps. On 08/24/22 at 10:00 AM, R11 stated she hoped that a problem she had, with R10, was taken care of. R11 stated that R10 wanted to marry her. R11 further stated she had told him he would have to wait because she needed to talk to her family a little bit more about it. R11 stated the previous Sunday, which was her birthday, R10 came to her room and wanted to come in; she stated she really did not want him to, but she let him come in anyway. R11 stated he asked her if he could kiss her and she told him that he could kiss her on the cheek. R11 stated it scared her when he asked her to have sex with him. R11 said she hopes R10 will stay away from her. R11 stated she told her nurse what R10 said and was told if he said anything else inappropriate to her, to let the nurse know. On 08/24/22 at 01:40 PM Social Service X stated the two residents had been in a platonic relationship and she was not aware it had progressed. Social Services X further stated the family was aware and was ok with the relationship. Social Service X stated both residents' got flirty with each other and were always in each other's room. Social Service X stated that before she left the facility the previous evening, she saw R11 trying to get R10's attention and did not understand why he would not talk to her. Social Service X further stated she would write a note in the charts and talk to all the staff to make sure they keep both residents out of each other's room. On 08/25/22 at 07:50 AM, LN H stated she was the nurse on the evening of 08/22/22 and that the family had not come for R11's birthday, which upset R11. LN H further stated R11 told her she did not want R10 in her room anymore, so LN H told the staff to make sure R10 did not go in R11's room. On 08/25/22 at 09:30 AM, CNA M stated she had just been told not to let R10 and R11 in each other's room and that the facilty had sent around a notice that staff must sign to show them they read the notice. On 08/29/22 at 11:30 AM, Administrative Nurse D stated they should have put interventions into place immediately after they heard about the situation between R11 and R10, as well documenting that both residents had been talked to and the resident's families as well. The facility's Abuse and Neglect policy, dated 03/31/22, documented each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. If an employee received an allegation of abuse, neglect, exploitation or misappropriation of resident property or witnesses suspected abuse, neglect, exploitation, the employee would take measures to protect the resident, provided the safety of the employee was not jeopardized, the employee would then report the allegation to a supervisor. The facility failed to immediately respond and investigate a report of alleged inappropriate interaction between R10 and R11. This placed the residents at risk emotional distress.

The facility had a census of 31 residents. The sample included 14 residents with one reviewed for hospitalization . Based on observation, record review, and interview the facility failed to provide Resident (R)14 or her representative in writing a notice of transfer to the hospital, which included the reason for transfer, the date, and where R14 was transferred. The facility failed to send a copy of R14's notice for transfer to the hospital to the State Long Term Care Ombudsman. Findings included: - R14's Electronic Medical Record (EMR) documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R14's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R14 required extensive staff assistance with bed mobility, transfers, locomotion on and off unit, dressing and personal hygiene, limited staff assistance with walk in corridor and room and toilet use, and independent with eating. R14's Alteration in Hematological Status Care Plan, revised 06/27/22, instructed staff to monitor/document/report to health care provider as needed (prn)following sign and symptoms of [CONDITION(S)], and encourage/give good oral hygiene post iron administration to prevent staining of the teeth or dentures. The care plan instructed staff to increase observation of the because she was a fall risk. R14's Progress Notes, dated 06/19/22 at 07:54 AM documented the resident was transferred to the hospital. Review of R14's Progress Notes, revealed lack of documentation the resident or representative was provided written notice when R14 was transferred to the hospital on 06/19/22. The facility was unable to provide documentation the Ombudsman was notified in a reasonable amount of time when the resident was transferred to the hospital on 06/19/22. On 08/23/22 at 03:42 PM, observation revealed R14 sat in a recliner in her room with oxygen on at two liters per nasal cannula (flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils). On 08/29/22 at 09:09 AM, Social Service X stated she notified R14's representative by telephone regarding the resident being transferred to the hospital on 06/19/22 but did not give the representative a written copy of the transfer. Social Service X stated she was unaware she was supposed to provide a written notice for R14's transfer to the hospital. Social Service X stated she did send a notification to the Ombudsman when the resident went to the hospital but did not have record of it. On 08/29/22 at 10:36 AM, Licensed Nurse (LN) J stated when a resident was transferred to the hospital the nurse sends the bed hold policy, transfer form, and R14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LN J stated social service staff was responsible for providing R14's representative written transfer information. Upon request the facility failed to provide a resident transfer or ombudsman notification policy. The facility failed to provide R14 or her representative with a written transfer notice, when she was transferred to the hospital. This placed the resident and representative at risk for unknown information regarding transfer.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide Resident (R)14 or her representative with written information regarding the facility bed hold policy, when R14 was transferred to the hospital. This placed R14 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R14's Electronic Medical Record (EMR) documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R14's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R14 required extensive staff assistance with bed mobility, transfers, locomotion on and off unit, dressing and personal hygiene, limited staff assistance with walk in corridor and room and toilet use, and independent with eating. R14's Alteration in Hematological Status Care Plan, revised 06/27/22, instructed staff to monitor/document/report to health care provider as needed (prn)following sign and symptoms of [CONDITION(S)], and encourage/give good oral hygiene post iron administration to prevent staining of the teeth or dentures. The care plan instructed staff to increase observation of the because she was a fall risk. R14's Progress Notes, dated 06/19/22 at 07:54 AM documented the resident was transferred to the hospital. Review of R14's clinical record revealed lack of documentation the resident or representative was provided the facility bed hold policy. On 08/23/22 at 03:42 PM, observation revealed R14 sat in a recliner in her room with oxygen on at two liters per nasal cannula. On 08/29/22 at 09:09 AM, Social Service X stated she notified R14's representative by telephone regarding the bed hold policy but did not document the notification or give the representative a written copy of it. Social Services X stated nursing was responsible for sending the bed hold policy and receiving a signed copy from the R14's representative. On 08/29/22 at 10:36 AM, Licensed Nurse (LN) J stated when a resident was transferred to the hospital the nurse sends the bed hold policy, transfer form, and R14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LN J stated social service staff was responsible for reviewing the facility bed hold policy with the resident's representative and obtaining a signed copy. The facility's Bed-Hold-Rehab/Skilled Policy, revised 12/10/21, documented at the time of admission, transfer or therapeutic leave, the facility would provide written information to the resident or resident representative that specified the following; 1. The duration of the state bed-hold policy, if any, during which a resident is permitted to return and resume residence. 2. The reserved bed payment policy in the state plan. 3. The location's policies regarding bed-hold periods permitting a resident to return. The policy documented In case of emergency transfer the resident's copy of the notice of bed-hold policy would be sent with the other papers accompanying the resident to the hospital. the family member or resident representative, if any, is provided with the notice of bed-hold policy within 24 hours of the transfer. The notice of bed -hold policy should be mailed if family or the resident representative does not come to the facility to receive a copy. The charge nurse is responsible for completion of notification procedures if the transfer occurs at a time the social worker is not at the location. The facility failed to provide R14 or her representative with the bed hold policy when she was transferred to the hospital. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to develop a discharge care plan for Resident (R) 33, to reflect current needs, goals, treatment and discharge preferences. This placed the resident at risk for miscommunication or interruptions in the continuum of care. Findings included: - The Electronic Medical Record (EMR) for R33 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required limited assistance for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The MDS further documented R33 had lower impairment on one side and expected to be discharged to the community. The EMR lacked a discharge care plan for R33. The Nurse's Note, dated 06/12/22 at 11:33AM, documented R33 left the facility with her daughters. R33 was excited, thankful, and happy to be going home. The note further documented the facility did not have therapy information for the resident once she went home but would call the family the following Monday. On 05/29/22 at 11:15 AM, Administrative Nurse E verified the facility had not developed a discharge care plan for the resident. On 05/29/22 at 11L30 AM, Administrative Nurse D stated there should always be a discharge care plan developed for the residents. The facility's Discharge Planning-Rehab/Skilled policy, dated 12/22/21, documented discharge planning was a process that began n admission and involved identifying each resident's goals and needs, developed and implemented interventions to address them, and continuously evaluate them throughout the resident's stay to ensure a success ful discharge. The facility failed to develop a discharge care plan for R33, placing the resident at risk for miscommunication or interruptions in the continuum of care.

The facility had a census of 31 residents. The sample included 14 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to place interventions on the care plan to prevent falls for Resident (R) 24. This deficient practice placed the resident at risk for further falls due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R24 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Admission Minimum Data Set (MDS), dated [DATE], documented R24 had intact cognition and required limited assistance of one staff for transfers, ambulation in her room, dressing, toileting, and personal hygiene. The MDS further documented R24 had unsteady balance, no functional impairment, had no falls, and received therapy. The Quarterly MDS, dated [DATE], documented R24 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, and toileting. The MDS further documented R24 had unsteady balance, upper and lower functional impairment, had two non-injury falls, and received restorative therapy. The Fall Risk Assessments, dated 03/07/22, 04/21/22, 05/29/22, 06/07/22, 07/12/22, and 08/06/22 documented R24 a high risk for falls. The Fall Care Plan, dated 01/04/22, documented R24 was at risk for falls related to her brain tumor and [CONDITION(S)] ([CONDITION(S)] disorder) and directed staff to remind R24 not to bend over and pick up dropped items, encourage the use of her grabber, and educate the resident on the causes of falls. The update, dated 03/06/22, directed staff to ensure the resident's floor in her room remained clean so that she was not tempted to bed over and pick it up. The update, dated 05/20/22, directed staff to have a fall mat next to R24's bed. The update, dated 05/28/22, directed staff to ensure a padded call light was on the resident and reinforce the use and educate the resident on safe use of assistive devices. The update, dated 05/31/22, directed staff to review R24's bowel and bladder continence status and establish a toileting plan based on resident needs. The care plan lacked evidence of updates which included the toileting plan. The Fall Investigation, dated 03/06/22 at 01:09 PM, documented R24 was on the floor in her bathroom and stated she fell after she tried to pick up a small piece of paper off the floor in the bathroom. The investigation documented R24 did not receive any injury. The Fall Investigation, dated 05/20/22 at 04:19 PM, documented R24 was on the floor next to her bed and staff educated her to use her call light. The investigation documented R24 did not receive any injury. The Fall Investigation, dated 05/28/22 at 12:11 PM, documented staff lowered R24 to the floor after finding her in the bathroom by the toilet and the resident was weak and shaky. The investigation further documented staff reeducated resident on the use of the call pad. The Fall Investigation, dated 05/29/22 at 10:30 PM, documented R24 was in the bathroom on the floor with her pajama bottoms and attends pulled halfway down. The investigation further documented R24 had no safety awareness, impaired memory, and did not sustain any injury. The clinical record lacked evidence a toileting plan was established based on the residents needs in an effort to prevent further falls. The Fall Investigation, dated 07/12/22, at 04:45 PM, documented R24 was on the floor by the bathroom door and was incontinent of urine. The investigation further documented R24 did not use her call light for assistance and did not sustain any injury. The Fall Investigation, dated 08/06/22, at 07:11 AM, documented R24 was on the floor in her room, She stated she had tried to unplug her nightlight and fell . On 08/25/22 at 09:00 AM, observation revealed Certified Nurse Aide (CNA) N asked R24 if she wanted to go for a walk and R24 was slow to respond and whispered yes. CNA N placed a gait belt around the resident and assisted her to stand up in front of her walker. Further observation revealed R24 had a steady gait but required cueing from CNA N to not run into objects along the way. CNA N assisted the resident into a chair in the commons area in front of the television. On 08/29/22 at 11:35 AM, Administrative Nurse D stated, they review falls at the risk meeting and are good at new interventions for residents who falls and would review falls in the clinical morning meetings. Administrative Nurse D further stated, there should be new interventions placed on the care plan for the resident. The facility's Comprehensive Care Plan and Care Conference policy, dated 07/01/22, documented the care plan provided an ongoing method of assessing, implementing, evaluating, and updating the resident's care plan to help to maintain the resident's highest practicable level of function. The facility failed to revise R24's care plan with new resident-centered fall interventions. This placed the resident at risk for further falls and injuries due to uncommunicated care needs.

The facility had a census of 40 residents. The sample included 11 residents. Based on observation, record review and interview, the facility failed to implement interventions to 1 sampled Resident #35, after he/she attempted suicide, and the resident made repeated suicide attempts on 3 more occasions. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #35's (POS) physician order [REDACTED]. be felt from time to time), and major [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing) not due to a substance or known physiological condition, and [MEDICAL CONDITION] disorder ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The significant change (MDS) Minimum Data Set assessment, dated 8/30/18, recorded the resident had severe cognitive impairment, indicated by a (BIMS) Brief Interview for Mental Status score of 2. The assessment recorded the resident required extensive to total assistance of 1 to 2 staff for bed mobility, transfers, dressing, toileting, personal hygiene, and eating. The MDS further recorded the resident had a urinary tract infection in the past 30 days, received scheduled and as needed pain medication, had a life expectancy of less than 6 months and had a non-injury fall. The resident also received [MEDICAL TREATMENT] (treatment for [REDACTED]. The cognitive loss/dementia (CAA) Care Area Assessment, dated 9/6/18, recorded the resident had a [DIAGNOSES REDACTED]. The CAA further documented the resident received hospice services, chose not to continue with [MEDICAL TREATMENT], and refused medications that affected his/her mood. The resident experienced delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and had increased behaviors which consisted of, thinking the building was on fire, easily distracted, and not able to follow conversations. The current care plan, dated 12/18/18, initiated on 5/23/14, documented the resident had depression as evidenced by sadness. The care plan directed staff to monitor, record, and report to the health care provider any suicidal plan, past attempts at suicide, sense of hopelessness or helplessness, and impaired judgment or safety awareness. The care further directed staff to report risky actions such as placing himself/herself at risk for harm to self, and intentionally harming self. The care plan lacked documentation of revisions after the resident's suicide attempts on 9/19/18, 9/24/18, 9/25/18 until 9/26/18 after the resident's 4th suicide attempt. The 9/26/18 care plan update documented the resident at risk for suicide related to refusing to take medications and being on hospice and [DIAGNOSES REDACTED]. The update directed staff to build a relationship of trust through regular 1:1 visits, listen carefully for any suicidal statements (i.e. I'm going to kill myself, the world will be better off without me, I've had enough, I'm a burden) and observe for non-verbal indications of suicidal intent (i.e. giving away possessions, changing his/her will, changing life insurance policy), and report to the charge nurse. The care plan update further directed the staff to monitor resident every 15 minutes for suicide risk. Keep door cracked open to keep resident visible and document every 1 hour. The care update directed staff to remove items from the resident's room that could cause harm, cords and trash bags have been removed from his/her room (resident has a bell to use to call staff), and window blind cords are tied out of reach. The 8/23/18 progress note (untimed) recorded the resident was placed on hospice services. The 9/19/18 at 3:14 AM, progress note recorded the resident placed a bag over his/her head and attempted to tie it. The resident stated he/she was in pain, but refused medications. The note documented the resident settled down, slept the rest of the night and staff checked frequently on the resident. The medical record lacked documentation staff notified the physician after the resident's suicide attempt on 9/19/18. The 9/24/18 at 5:31 AM, progress note recorded staff notified hospice of the resident's self harm behavior, in which the resident had an electrical cord around his/her neck and tried to get trash bags. The note also included a fax was sent to physician. The 9/25/18 at 9:17 PM, progress note recorded staff found the resident wrapping a cord around his/her neck. Four staff members assisted to remove any possible hazards from the resident's room. The 9/26/18 at 12:00 PM, progress note recorded the resident found a cord from a call light in a drawer in his/her room. The note further documented a volunteer heard a noise, peeked into the resident's room, and found the resident lying on the mattress on the floor, with the cord wrapped tightly around his/her neck. The note documented the cord was so tightly wrapped the nurse had to use scissors to cut the cord from around the resident's neck to free it. The note further recorded all cords from blinds were hidden behind the blinds, and all cords of any kind removed from the room, staff completed 10-15 minute checks if the resident was alone, and the door to the hallway would not be closed if he/she was alone. Observation on 1/8/19 at 7:31 AM revealed the resident in his/her room, seated in a wheelchair, facing the bed and verbalizing repetitively grandma. Staff entered and assisted the resident in to his/her bed. On 1/8/19 at 10:29 AM, Direct Care Staff M stated he/she was aware the resident attempted to harm him/herself. If that happened, the staff were to tell a nurse immediately, after making sure the resident was safe. Direct Care Staff M further stated residents were placed on 15-minute checks and staff can fill out a Stop and Watch form, to alert other staff. Staff can also initiate the 15-minutes check on the electronic record. On 1/8/19 at 1:58 PM, Nurse G, reported when a resident had suicidal or self-harm intentions, all items that could be dangerous were removed from the resident's room. Staff would stay 1 on 1 with the resident and notify the DON. Nurse G was aware the resident exhibited self-harm behaviors. On 1/8/19 at 2:05 PM, Administrative Nurse D verified the resident had self-harm behaviors on 9/19/18, and the facility was working with a hospice service for the care and management of Resident #35. He/she reported a physician should be notified immediately when a resident attempted to harm themselves, and he/she verified the facility lacked documentation staff notified the physician until 9/24/18. (4 days later) On 1/9/19 at 3:35 PM, Administrative Staff A verified staff had not completed an investigation or reported to the state agency after Resident #35's self-harm/suicidal attempts. The facility's Suicide Precaution policy, dated 02/2013, directed staff to provide for the safety of residents at risk for suicide and to identify/recognize possible signs of intent to commit suicide. The policy further directed when a resident verbalized suicidal ideation's or intent, the social worker or registered nurse must assess the resident to determine the risk for self-harm, complete the Suicide Risk Assessment, document interventions in the care plan, initiate a monitoring system to watch the resident at intervals no greater than 15 minutes, call the physician, and notify mental health professionals. The policy recorded the facility would attempt to contract with the resident not to harm self, identify a person or plan that will help the resident feel safe immediately, to the extent possible, remove all items that could cause self-injury, and move the resident to a safe location within an unobstructed view of the nurse's station. The policy also directed in the event suicide has been attempted or the resident's potential for self-harm escalates, staff were to contact the physician and make arrangements to have the resident moved to a psychiatric unit or emergency center. If warranted this may include a 911 call to ensure resident safety. If suicide had been attempted, the incident report must be competed and reviewed by a social services or other appropriate staff. Staff would assess the ability of the facility to keep the resident safe. The facility failed to implement immediate interventions after Resident #35 attempted suicide, and the resident made further suicide attempts, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 1/11/19 at 10:40 AM, after in-service of all staff on abuse and neglect policy, suicide precautions, use of Stop and Watch, and understanding and helping the suicidal resident. All licensed staff received education for change of condition notification and incident reporting policy and procedure. The deficienit practice remains at a scope and severtiy of a D.

The facility had a census of 38 residents. The sample included 3 residents. Based on record review and interview, the facility failed to provide necessary care and services, including assessment/re-assessment, for 1 of the 3 residents, when staff failed to assess a resident who had coffee ground emesis (dark brown vomit the color and consistency of coffee grounds, typically the result of a stomach bleed), an elevated temperature and blood pressure, and died in the facility. (#1) This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated [DATE], documented the resident had a (BIMS) Brief Interview for Mental Status score of 5, which indicated he/she had severe cognitive impairment. The MDS revealed the resident required extensive staff assistance for all (ADLs) activities of daily living, except he/she ate independently. The MDS revealed the resident used a wheelchair for mobility and received oxygen therapy. The cognition (CAA) Care Area Assessment, dated [DATE], documented the resident had a BIMS score of 5 and he/she communicated his/her needs and directed his/her day to day care. The [DATE] care plan directed staff to report any signs or symptoms of changes in the resident's condition to the nurse, including nausea and vomiting. The [DATE] at 10:54 AM, nurse's note stated the resident stayed in bed all morning, his/her blood pressure was running high, the resident took his/her morning medications, and then vomited. The note stated the resident refused to wear his/her oxygen, his/her fingers were blue and cold, and the oxygen saturation was documented as 98%, but did not indicate if this was on room air or on oxygen. The note stated staff educated the resident on wearing oxygen to prevent low oxygen saturation. The note lacked documentation staff re-assessed the resident's blood pressure, notified the resident's physician of his/her high blood pressure and vomiting. The [DATE] at 11:06 AM, vital sign record documented the resident's blood pressure was ,[DATE] (mmHg) millimeter of mercury (normal range is ,[DATE] mmHg). The record documented the resident's blood pressure was ,[DATE] mmHg when staff checked it the same day at 2:08 PM. The next documentation staff checked the resident's blood pressure was on [DATE] at 2:14 PM (3 days after the high reading), and the reading at that time was ,[DATE] mmHg. The clinical record lacked evidence staff re-assessed the resident's blood pressure, or notified the physician of the high blood pressure reading. The [DATE] at 6:45 PM, Medication Administration Record [REDACTED]. The note stated the resident could not take the medications, due to nausea, and he/she had emesis of dark, coffee ground texture. The note stated staff held all morning medications. The clinical record lacked documentation staff assessed the resident, notified his/her physician regarding the resident's nausea and coffee ground emesis, or that staff held his/her medications. The [DATE] at 9:12 PM, vital sign record documented the resident had a temperature of 101.1 degrees (F) Fahrenheit (normal body temperature varies by person, age, activity, and time of day. The average normal body temperature is generally accepted as 98.6. A temperature over 100.4 most often means you have a fever caused by an infection or illness). The clinical record lacked documentation staff re-assessed the resident's temperature, or the resident's physician of the increased temperature. The [DATE] at 11:36 PM, (late entry) nurse's note stated the resident rested in bed and had no complaints, but refused to take his/her medications, food or water, which was not abnormal for the resident. The note lacked documentation staff notified the resident's physician. The [DATE] at 2:30 AM, nurse's note stated the nurse designated a (CNA) Certified Nurse's Aide to check the resident's temperature. The note stated the CNA reported to the nurse that he/she was unsure if the resident was breathing, and the resident had vomited. The note recorded staff found the resident positioned on his/her back, oxygen on, brownish/purple emesis, and loose, mucus stools with bright red blood. The note lacked documentation of the nurse's assessment. The note stated staff notified the resident's physician, received telephone orders to release the body to the mortuary, and notified the resident's family. In a notarized witness statement, dated [DATE], Nurse B stated on [DATE] at approximately 9:00 PM, the aide reported the resident had a temperature of 101.0 degrees F. Nurse B stated he/she immediately checked the resident's medication record, and determined the resident had an order for [REDACTED]. In a notarized witness statement, dated [DATE], Nurse Aide C stated on [DATE], he/she checked the resident's temperature around 8:00 PM, and reported to Nurse B it was 101.1 degrees F. On [DATE] at 10:35 AM, Nurse D stated staff should complete a full assessment any time there is a change in the resident's condition. Nurse D stated he/she would report to the physician immediately if a resident had a high blood pressure reading, temperature, nausea and vomiting. On [DATE] at 11:25 AM, Nurse E stated he/she worked the day shift on [DATE], and the resident had a temperature of 99.3 degrees F after lunch. Nurse E stated he/she did not administer any medication for the temperature because the resident was given routine aspirin that morning, but he/she advised the next shift to monitor the resident and check his/her temperature. Nurse E stated he/she would do an assessment and notify the physician any time there was a change in the resident's condition. On [DATE] at 8:45 AM, Administrative Nurse F stated when he/she came to work on [DATE], he/she was informed of the resident's death, that occurred earlier that morning. Administrative Nurse F stated he/she reviewed the weekend report sheets, and noticed the resident had coffee ground emesis on [DATE], and an elevated temperature on [DATE]. Administrative Nurse F stated he/she could not find any documentation staff assessed the resident for either occurrence, or on [DATE] when the resident vomited and had an elevated blood pressure reading. Administrative Nurse F stated he/she started an investigation of the incident, and sometime between 8:00 AM and 12:00 PM, he/she suspended the two nurses involved, and notified them they would remain suspended until completion of the investigation. On [DATE] at 11:05 AM, Physician G stated he/she expected staff to notify him/her when the resident had a high blood pressure reading, coffee ground emesis, and a temperature. Physician D stated he/she would have ordered staff to send the resident to the emergency room . On [DATE] at 11:50 PM, Nurse H verified he/she worked the night shift on [DATE]. Nurse H received the report that the resident had a fever of 101.1 degrees F, and he/she refused Tylenol. Nurse H stated at approximately 2:30 AM, he/she directed the CNA to check the resident's temperature, and the CNA returned and reported he/she did not think the resident was breathing, and he/she had vomited. Nurse H stated he/she found the resident positioned on his/her back, with his/her oxygen on, and a moderate amount of brownish/purple colored emesis around his/her mouth. Nurse H stated the resident also had loose mucus stools, with bright red blood. Nurse H stated vital signs were unattainable and there was no pulse. Nurse H stated an assessment should have been completed, and the physician notified when there was a change in the resident a few days before. On [DATE] at 12:10 AM, Nurse Aide I stated he/she worked the night shift on [DATE], and at approximately 2:30 AM, the nurse asked him/her to check the resident's temperature. Nurse Aide I stated when he/she went into the resident's room, he/she used a flashlight to check the resident, and found the resident on his/her back, with oxygen on, pale skin, a brownish substance around his/her mouth, his/her hands were cold to the touch, and it appeared he/she was not breathing. Nurse Aide I stated he/she got the nurse and the resident had no pulse. Nurse Aide I stated he/she last saw the resident alive at approximately 12:00 AM during rounds. On [DATE] at 10:25 AM, Nurse A stated he/she worked the evening shift on [DATE], as he/she passed medication in the dining room, and at approximately 5:45 PM, an aide reported to him/her the resident had vomited. Nurse A stated he/she went to the resident's room, and observed what appeared to be coffee ground emesis in the resident's trash can, but he/she was not too worried, because there was no odor to the emesis, and it did not appear to be a large amount. Nurse A verified he/she did not assess the resident, notify the physician or document in the progress notes. Nurse A stated he/she told the next shift to monitor the resident, but stated he/she was overwhelmed that evening, and should have taken the time to complete an assessment, and document in the progress notes. The facility's ,[DATE] policy for Interact-Stop and Watch, stated the policy is used to help identify early, subtle changes in a resident, and to help improve communication between staff members, visitors and the nurse about resident changes in condition. The policy stated if staff identified a change while observing a resident, staff should document in the computer program. The charge nurse should be notified verbally a Stop and Watch should be completed as soon as possible after staff noticed a change, and at a minimum, at the end of the shift. If the nurse determines there was not a change in condition, a progress note must be made documenting the nurse's evaluation of the resident. The facility's ,[DATE] policy for Nursing Documentation Guidelines/Timelines, stated when staff identified a change in condition in a resident, the nurse would use the interact change in condition evaluation to collect the data prior to communicating with the medical provider. The facility's ,[DATE] policy for Notification of Change to the medical provider stated the facility must The facility failed to ensure staff assessed Resident #1, when he/she had an elevated blood pressure reading, vomited coffee ground emesis, an elevated temperature, ultimately died in the facility, and failed to document the change in condition in the medical record, or communicate with the physician, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 9:00 PM, after all licensed nurses, certified nurse aides, and certified medication aides received training on how to identify a change in condition, and how to complete a change of condition evaluation data collection tool. The deficient practice remains at a scope and severity of G.

The facility had a census of 39 residents. The sample included 3 residents reviewed for abuse/neglect. Based on record review, interview, and observation, the facility direct care staff failed to immediately report to the facility's administrative staff, witnessed staff abuse toward 1 of 3 sampled residents. (#1) Findings included: - The 9/21/16 physician orders [REDACTED]. system attacks its own), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The quarterly (MDS) Minimum Data Set assessment, dated 7/7/16, indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status score of 13. The assessment revealed the resident required extensive staff assistance with toileting, dressing, and bed mobility and total staff assistance with transfers. The assessment revealed the resident was continent of urine and frequently incontinent of bowel, and received diuretics (medication to promote the formation and excretion of urine). The quarterly MDS, dated [DATE], documented the resident was occasionally incontinent of urine and frequently incontinent of bowel. The 10/11/16 nursing care plan review recorded the resident continued to require assistance with (ADLs) activities of daily living and cares, staff encouraged his/her independence at highest functioning level and to use call light for assist as needed. The resident required total assist of two staff using the total lift for transfers The 10/18/16 care plan for ADLs revealed the resident directed his/her cares. The care plan documented the resident required assistance of 2 staff for toileting, and required a total lift (a mechanical device use to transfer people) to transfer him/her with a high back sling. The care plan further directed staff to provide a commode for the resident's toileting, check on the resident at 5:00 AM or 6:00 AM, at shift change in the morning, and offer him/her use of the commode. The 10/11/16 mobilization support assessment revealed the resident required 2 staff with a total lift for transfers, a wheelchair for locomotion, and he/she was able to propel himself/herself. The assessment directed staff to provide assistance as needed. Review of the nurse notes 9/1/16 through 11/7/16 revealed no documentation regarding behaviors, incontinence, or abuse. The facility's 10/21/16 investigation stated the incident occurred on 10/19/16 and staff failed to report to a nurse or administrative staff until 10/21/16. The investigation revealed the human resources director then notified the (AP) Alleged Perpetrator, Nurse Aide D, by telephone of the allegation and that he/she was suspended until further notice as of 10/21/16. The investigation revealed Nurse Aide H verified resident #1 had activated his/her call light numerous times and requested to use the bathroom. Nurse Aide H reported Nurse Aide D told the resident each time, he/she would have to wait until after lunch. Nurse Aide H reported the resident waited over 3 hours for assistance with toileting and Nurse Aide D yelled at the resident. The investigation revealed resident #1 stated he/she could not hold his/her urine that long, became incontinent of urine, and reported he/she had waited over 2 hours for assistance with toileting. The investigation revealed resident #1 reported Nurse Aide D chastised him/her and then made him/her wear a diaper as punishment. The investigation revealed, upon interview, Nurse Aide C stated after lunch, he/she assisted Nurse Aide D with the resident, who was incontinent. Nurse Aide C stated Nurse Aide D got after resident #1 and said something like you can't tell me that you can't hold your urine, you held it the other day. The undated witness statement by Nurse Aide C revealed the resident used his/her call light during lunch to request assistance to go to the bathroom. Nurse Aide C explained to the resident, staff would help him/her as soon as staff was able. The statement indicated, after lunch, during care, Nurse Aide D told the resident something like you know what, Resident #1, the other day you held it for hours. Now you can't even hold it for less than an hour? This is ridiculous, you could have held it. The 11/7/16 witness statement by Nurse Aide D revealed, on 10/19/16, the resident called to use the restroom in the morning. Nurse Aide D told the resident it would be a while because there were other residents requesting help also. The statement revealed when Nurse Aide D and Nurse Aide C went to the resident to assist the resident, he/she had been incontinent. The statement revealed Nurse Aide D left the room to get the full lift and when he/she came back, they assisted the resident with toileting and Nurse Aide C had laid clean pants and a clean brief on the bed. The statement indicated staff provided care to the resident then assisted him/her back into his/her wheelchair. On 11/7/16 at 1:23 PM, observation revealed Nurse Aides E and F used the full body lift to transfer the resident from the wheelchair to his/her bed. The resident stated he/she did not have to urinate, so the staff transferred the resident back to his/her wheelchair. On 11/7/16 at 11:55 AM, Nurse Aide D stated, on 10/19/16, the resident had a shower and later wanted to use the bathroom. Nurse Aide D stated he/she told the resident it would be a little while, because staff were in the process of toileting other residents. When staff (Nurse Aides C and D) toileted the resident, he/she was incontinent. Nurse Aide D stated he/she and Nurse Aide C transferred the resident to the bed and onto the bed pan, and left the resident so he/she could have privacy. Nurse Aide D stated when he/she returned, Nurse Aide C had already been in the room and had the resident dressed, so he/she and Nurse Aide C assisted the resident to transfer. Nurse Aide D stated he/she did not put a brief on the resident, because he/she was already dressed and ready for the transfer. Nurse Aide D stated while he/she was in the room no one discussed using a brief and he/she could not remember if the resident had a brief on prior to toileting. On 11/7/16 at 1:20 PM, the resident stated Nurse Aide D talked to her/him about the need to wear diapers if he/she could not control his/her urine. Resident #1 stated staff did not call them diapers but that is what they are. On 11/7/16 at 2:46 PM, Nurse Aide C stated resident #1 requested assistance to the bathroom and he/she had to wait until staff could assist him/her. (Review of the facility's call light log for this resident revealed, on 10/19/16, the call light was activated at 11:01 AM, and deactivated at 11:13 AM.) Nurse Aide C stated the resident had a brief on when he/she and Nurse Aide D toileted him/her. The previous director of nursing had told staff to put a brief on the resident when he/she soiled him/herself. Nurse Aide C stated Nurse Aide D, speaking in a loud voice, told the resident some things that could be taken for verbal abuse and another staff down the hall, Nurse Aide H, heard the altercation. Nurse Aide C stated Nurse Aide D told the resident you are [AGE] years old and you are peeing your pants. This is absolutely ridiculous! Nurse Aide C stated Nurse Aide D spoke in a disgusted, irritated voice, loud enough to be heard in the hall. Nurse Aide C reported the resident stated I know, I know. Nurse Aide C stated they provided care and answered other alarms, then later in the shift Nurse Aide C told the nurse that the resident had soiled him/herself, and Nurse Aide D got on the resident. Nurse Aide C verified he/she did not ensure the nurse was aware Nurse Aide D spoke inappropriately to the resident. Nurse Aide C verified he/she should have reported the incident to the nurse, (DON) Director of Nursing, or the administrator. On 11/7/16 at 4:30 PM, Administrative Nurse A stated he/she disciplined Nurse Aide D and provided abuse/neglect education for Nurse Aides C and D after the incident. On 11/8/16 at 9:20 AM, Administrative Staff B stated the facility did not terminate the employee because the resident did not want to have Nurse Aide D fired because he/she was the resident's favorite aide. On 11/8/16 at 9:35 AM, Nurse G verified on 10/19/16, during the day shift, staff did not notify him/her of inappropriate speaking or verbal abuse to the resident. Nurse G stated he/she would have initiated an investigation if staff reported the incident to him/her. On 11/17/16 at 12:00 PM, Administrative Nurse A stated the facility hired Nurse Aide H on 10/14/16, and on that day, completed and signed he/she reviewed and understood the facility's Abuse, Neglect and Exploitation Policy, including being a mandated reporter of any suspected incidents of abuse or neglect. Administrative Nurse A stated Nurse Aide H reported the staff to resident abuse 10/19/16 incident to the facility on [DATE], and quit his/her employment before Administrative Nurse A could obtain a witness statement from the aide, and had been unsuccessful locating him/her. The facility's last abuse, neglect, and exploitation education for all staff was on 8/5/16, and Nurse Aides C and D attended. The facility's 9/2013 Abuse and Neglect policy and procedures, revised 9/2016, stated alleged or suspected violations involving mistreatment, neglect or abuse were reported immediately to the administrator and to other officials in accordance with state law, including the state survey agency. Administration may remove any individual from the facility, if necessary, for the protection of residents or staff. The facility will thoroughly investigate all alleged or suspected violations and will prevent further potential abuse while the investigation is in progress. Results of all investigations were reported to the administrator or designee, and to the state survey agency with 5 working days of the incident. If the alleged or suspected violation was verified, appropriate corrective action was taken. If an employee received an allegation of abuse, neglect or misappropriation of resident property, or witnesses suspected abuse, neglect or misappropriation of resident property, the employee would take measures to protect the resident, and then report the allegation to a supervisor. The charge nurse was notified immediately to assess the situation and complete an initial investigation. If there was an allegation of employee to resident abuse, the facility removed the employee from providing direct care to all residents and placed on suspension pending the results of the investigation. The facility direct care staff failed to immediately report to the facility's administrative staff, witnessed staff abuse toward resident #1, placing the resident at risk for further abuse. The facility abated the immediate jeopardy on 11/16/16 at 8:25 AM, when they suspended the (AP) alleged perpetrator, completed face to face education for all staff regarding the facility's Abuse/Neglect/Exploitation policies, reporting of suspected abuse/neglect/exploitation, including inappropriate use of social media and resident rights. The facility's plan of correction also stated they would follow up weekly with Resident #1 for any adverse effects, conduct 5 resident interviews weekly, audit 7 staff weekly on knowledge of the abuse/neglect/exploitation policy and protocol, and educate and train the administrator, Director of Nursing, Social Services, and Human Resources on abuse/neglect/exploitation investigations. This deficient practice remained at a scope and severity of F.

The facility had a census of 39 residents. The sample included 3 residents reviewed for abuse/neglect. Based on record review, interview, and observation, the facility failed to ensure an environment free of abuse for 1 of 3 sampled residents. Direct care staff member D verbally abused resident #1 while providing care. Direct care staff C was present, and direct care staff H was in the hallway. Neither staff intervened to protect the resident. This placed Resident #1 in immediate jeopardy. Findings included: - The 9/21/16 physician orders [REDACTED]. system attacks its own), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The quarterly (MDS) Minimum Data Set assessment, dated 7/7/16, indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status score of 13. The assessment revealed the resident required extensive staff assistance with toileting, dressing, and bed mobility and total staff assistance with transfers. The assessment revealed the resident was continent of urine and frequently incontinent of bowel, and received diuretics (medication to promote the formation and excretion of urine). The quarterly MDS, dated [DATE], documented the resident was occasionally incontinent of urine and frequently incontinent of bowel. The 10/11/16 nursing care plan review recorded the resident continued to require assistance with (ADLs) activities of daily living and cares, staff encouraged his/her independence at highest functioning level and to use call light for assist as needed. The resident required total assist of two staff using the total lift for transfers The 10/18/16 care plan for ADLs revealed the resident directed his/her cares. The care plan documented the resident required assistance of 2 staff for toileting, and required a total lift (a mechanical device use to transfer people) to transfer him/her with a high back sling. The care plan further directed staff to provide a commode for the resident's toileting, check on the resident at 5:00 AM or 6:00 AM, at shift change in the morning, and offer him/her use of the commode. The 10/11/16 mobilization support assessment revealed the resident required 2 staff with a total lift for transfers, a wheelchair for locomotion, and he/she was able to propel himself/herself. The assessment directed staff to provide assistance as needed. Review of the nurse notes 9/1/16 through 11/7/16 revealed no documentation regarding behaviors, incontinence, or abuse. The facility's 10/21/16 investigation stated the incident occurred on 10/19/16 and staff failed to report to a nurse or administrative staff until 10/21/16. The investigation revealed the human resources director then notified the (AP) Alleged Perpetrator, Nurse Aide D, by telephone of the allegation and that he/she was suspended until further notice as of 10/21/16. The investigation revealed Nurse Aide H verified resident #1 had activated his/her call light numerous times and requested to use the bathroom. Nurse Aide H reported Nurse Aide D told the resident each time, he/she would have to wait until after lunch. Nurse Aide H reported the resident waited over 3 hours for assistance with toileting and Nurse Aide D yelled at the resident. The investigation revealed resident #1 stated he/she could not hold his/her urine that long, became incontinent of urine, and reported he/she had waited over 2 hours for assistance with toileting. The investigation revealed resident #1 reported Nurse Aide D chastised him/her and then made him/her wear a diaper as punishment. The investigation revealed, upon interview, Nurse Aide C stated after lunch, he/she assisted Nurse Aide D with the resident, who was incontinent. Nurse Aide C stated Nurse Aide D got after resident #1 and said something like you can't tell me that you can't hold your urine, you held it the other day. The undated witness statement by Nurse Aide C revealed the resident used his/her call light during lunch to request assistance to go to the bathroom. Nurse Aide C explained to the resident, staff would help him/her as soon as staff was able. The statement indicated, after lunch, during care, Nurse Aide D told the resident something like you know what, Resident #1, the other day you held it for hours. Now you can't even hold it for less than an hour? This is ridiculous, you could have held it. The 11/7/16 witness statement by Nurse Aide D revealed, on 10/19/16, the resident called to use the restroom in the morning. Nurse Aide D told the resident it would be a while because there were other residents requesting help also. The statement revealed when Nurse Aide D and Nurse Aide C went to the resident to assist the resident, he/she had been incontinent. The statement revealed Nurse Aide D left the room to get the full lift and when he/she came back, they assisted the resident with toileting and Nurse Aide C had laid clean pants and a clean brief on the bed. The statement indicated staff provided care to the resident then assisted him/her back into his/her wheelchair. On 11/7/16 at 1:23 PM, observation revealed Nurse Aides E and F used the full body lift to transfer the resident from the wheelchair to his/her bed. The resident stated he/she did not have to urinate, so the staff transferred the resident back to his/her wheelchair. On 11/7/16 at 11:55 AM, Nurse Aide D stated, on 10/19/16, the resident had a shower and later wanted to use the bathroom. Nurse Aide D stated he/she told the resident it would be a little while, because staff were in the process of toileting other residents. When staff (Nurse Aides C and D) toileted the resident, he/she was incontinent. Nurse Aide D stated he/she and Nurse Aide C transferred the resident to the bed and onto the bed pan, and left the resident so he/she could have privacy. Nurse Aide D stated when he/she returned, Nurse Aide C had already been in the room and had the resident dressed, so he/she and Nurse Aide C assisted the resident to transfer. Nurse Aide D stated he/she did not put a brief on the resident, because he/she was already dressed and ready for the transfer. Nurse Aide D stated while he/she was in the room no one discussed using a brief and he/she could not remember if the resident had a brief on prior to toileting. On 11/7/16 at 1:20 PM, the resident stated Nurse Aide D talked to her/him about the need to wear diapers if he/she could not control his/her urine. Resident #1 stated staff did not call them diapers but that is what they are. On 11/7/16 at 2:46 PM, Nurse Aide C stated resident #1 requested assistance to the bathroom and he/she had to wait until staff could assist him/her. (Review of the facility's call light log for this resident revealed, on 10/19/16, the call light was activated at 11:01 AM, and deactivated at 11:13 AM.) Nurse Aide C stated the resident had a brief on when he/she and Nurse Aide D toileted him/her. The previous director of nursing had told staff to put a brief on the resident when he/she soiled him/herself. Nurse Aide C stated Nurse Aide D, speaking in a loud voice, told the resident some things that could be taken for verbal abuse and another staff down the hall, Nurse Aide H, heard the altercation. Nurse Aide C stated Nurse Aide D told the resident you are [AGE] years old and you are peeing your pants. This is absolutely ridiculous! Nurse Aide C stated Nurse Aide D spoke in a disgusted, irritated voice, loud enough to be heard in the hall. Nurse Aide C reported the resident stated I know, I know. Nurse Aide C stated they provided care and answered other alarms, then later in the shift Nurse Aide C told the nurse that the resident had soiled him/herself, and Nurse Aide D got on the resident. Nurse Aide C verified he/she did not ensure the nurse was aware Nurse Aide D spoke inappropriately to the resident. Nurse Aide C verified he/she should have reported the incident to the nurse, (DON) Director of Nursing, or the administrator. On 11/7/16 at 4:30 PM, Administrative Nurse A stated he/she disciplined Nurse Aide D and provided abuse/neglect education for Nurse Aides C and D after the incident. On 11/8/16 at 9:20 AM, Administrative Staff B stated the facility did not terminate the employee because the resident did not want to have Nurse Aide D fired because he/she was the resident's favorite aide. On 11/8/16 at 9:35 AM, Nurse G verified on 10/19/16, during the day shift, staff did not notify him/her of inappropriate speaking or verbal abuse to the resident. Nurse G stated he/she would have initiated an investigation if staff reported the incident to him/her. On 11/17/16 at 12:00 PM, Administrative Nurse A stated the facility hired Nurse Aide H on 10/14/16, and on that day, completed and signed he/she reviewed and understood the facility's Abuse, Neglect and Exploitation Policy, including being a mandated reporter of any suspected incidents of abuse or neglect. Administrative Nurse A stated Nurse Aide H reported the staff to resident abuse 10/19/16 incident to the facility on [DATE], and quit his/her employment before Administrative Nurse A could obtain a witness statement from the aide, and had been unsuccessful locating him/her. The facility's last abuse, neglect, and exploitation education for all staff was on 8/5/16, and Nurse Aides C and D attended. The facility's 9/2013 Abuse and Neglect policy and procedures, revised 9/2016, stated alleged or suspected violations involving mistreatment, neglect or abuse were reported immediately to the administrator and to other officials in accordance with state law, including the state survey agency. Administration may remove any individual from the facility, if necessary, for the protection of residents or staff. The facility will thoroughly investigate all alleged or suspected violations and will prevent further potential abuse while the investigation is in progress. Results of all investigations were reported to the administrator or designee, and to the state survey agency with 5 working days of the incident. If the alleged or suspected violation was verified, appropriate corrective action was taken. If an employee received an allegation of abuse, neglect or misappropriation of resident property, or witnesses suspected abuse, neglect or misappropriation of resident property, the employee would take measures to protect the resident, and then report the allegation to a supervisor. The charge nurse was notified immediately to assess the situation and complete an initial investigation. If there was an allegation of employee to resident abuse, the facility removed the employee from providing direct care to all residents and placed on suspension pending the results of the investigation. The facility failed to ensure this dependent resident an environment free of verbal abuse when a staff member, spoke inappropriate comments in a loud, disgusted, voice, to the resident while providing care and another staff member present did not intervene on the resident's behalf. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 11/16/16 at 8:25 AM, when they suspended the (AP) alleged perpetrator, completed face to face education for all staff regarding the facility's Abuse/Neglect/Exploitation policies, reporting of suspected abuse/neglect/exploitation, including inappropriate use of social media and resident rights. The facility's plan of correction also stated they would follow up weekly with Resident #1 for any adverse effects, conduct 5 resident interviews weekly, audit 7 staff weekly on knowledge of the abuse/neglect/exploitation policy and protocol, and educate and train the administrator, Director of Nursing, Social Services, and Human Resources on abuse/neglect/exploitation investigations. This deficient practice remained at a scope and severity of G.

The facility reported a census of 43 residents with 3 residents sampled for accidents. Based on observation, interview, and record review, the facility failed to ensure 1 of the 3 sampled residents received adequate supervision and assistive devices to prevent accidents which resulted in resident #1 sustaining injuries to his/her nose, forehead, and right elbow after the resident fell forward out of a wheelchair propelled by staff without foot pedals in place. The resident required emergency room treatment which included suturing of a laceration to the resident's nose. Findings included: - Resident #1's 3/29/12 Annual MDS (Minimum Data Set) reported short and long term memory problems with disorganized thinking and inattention. This MDS reported the resident needed total assistance of 2 staff for transfers and locomotion on/off the unit. This MDS also reported the resident used a wheelchair for mobility and experienced no falls since the last assessment period. Resident #1's 6/21/12 Quarterly MDS reported short and long term memory problems with disorganized thinking and inattention. This MDS reported the resident needed total assistance of 2 staff for transfers and locomotion on/off the unit and used a wheelchair for mobility. This MDS reported the resident experienced falls since the last assessment period but failed to indicate the amount or type of falls. Resident #1's 9/13/12 Quarterly MDS reported short and long term memory problems with disorganized thinking and inattention. This MDS reported the resident needed total assistance of 2 staff for transfers and locomotion on/off the unit. This MDS also reported the resident used a wheelchair for mobility and experienced no falls since the last assessment period. Resident #1's 4/4/12 ADLs (Activities of Daily Living) CAA (Care Area Assessment) Summary reported the resident resisted care and lacked understanding of directions from staff due to Alzheimer's Disease and a severe self-care deficit. Resident #1's 4/4/12 Falls CAA Summary reported the resident had a mobility deficit related to a hip fracture, experienced unsteady balance and gait, and a fall risk assessment indicated he/she displayed a high risk to fall. The Falls CAA reported the resident used a wheelchair for long distance mobility. Resident #1's care plan, last reviewed on 11/12/12, instructed staff that the resident used a wheelchair for long distance mobility and that the resident resisted cares at times due to dementia. The care plan included a handwritten intervention indicating "foot pedals" dated 10/22/12 and "keep foot pedals on wheelchair when transferring resident" dated 11/13/12. Review of the resident's 11/13/12 "Incident Report", documented by Licensed Nursing Staff E, revealed at 6:55 p.m., resident #1 fell "face first" on the ground in the hallway after propelled by Direct Care Staff D in a wheelchair without foot pedals. The incident report indicated that Staff D called for assistance and Licensed Nursing Staff F responded. Staff F noted blood coming from open areas on the resident's forehead, nose, and right elbow. The incident report indicated Staff F continued to assess the resident as Staff E educated Staff D that "the resident needed foot pedals on at all times". The incident report indicated Staff D reported the foot pedals "didn't fit on the wheelchair" and Staff E reported the ill-fitting foot pedals to maintenance. The incident report indicated Staff E notified the on-call nurse practitioner by phone, the attending physician by fax, the administrator, and the resident's family. Staff sent the resident to the emergency room for treatment. Review of the local emergency room 's report on 11/13/12 at 7:29 p.m. revealed resident #1 arrived with lacerations to the nose and forehead due to a fall from his/her wheelchair. The report indicated the emergency room staff sutured a 1.2 centimeter laceration on his/her nose and sent the resident back the facility with instructions on how to care for the sutures and other lacerations. Resident #1's nursing notes on 11/13/12 at 10:50 p.m. indicated the resident returned to the facility with 3 sutures on his/her nose, a bandage on his/her forehead, and steristrips on the right elbow. The nursing notes further indicated the "top layer of skin off on tip of nose". The clinical record indicated staff performed neurological assessments starting at 10:50 p.m. on 11/13/12 until the day shift on 11/16/12. Review of a previous complaint (Complaint #KS 306) with an exit date of 10/16/12 investigated the facility's failure to individualize resident care plans related to repositioning and use of foot pedals on wheelchairs, including resident #1. As a result of the complaint investigation, the POC (plan of correction) for deficiencies written included a plan to update and individualize comprehensive care plans for each resident to meet their needs as identified in the comprehensive assessment related to repositioning and use of foot pedals on wheelchairs. The POC reported the facility planned to identify other residents having potential to be affected by the same deficient practice by 11/13/12. During an observation on 12/3/12 at 3:14 p.m., resident #1 laid on his/her back in bed covered with a blanket with a blackened scab area to his/her mid-forehead and bridge of nose. Further observations revealed multiple small, pea-sized shaped, dark purple marks across the resident's right and left cheeks. During an observation on 12/3/12 at 5:24 p.m., Direct Care Staff G propelled resident #1 in the hallway in a wheelchair with the resident's feet and legs fitted into bilateral padded foot pedals. During an observation on 12/17/12 at 12:21 p.m., resident #1 sat at a dining room table in his/her wheelchair with the resident's feet and legs fitted into bilateral padded foot pedals. During an interview on 12/3/12 at 4:59 p.m., Direct Care Staff G reported resident #1 "definitely needed foot pedals" while in his/her wheelchair for safety due to confusion, difficulty following directions, and tended to resist care from staff. Staff G reported resident #1 lacked sufficient strength to hold up his/her legs when propelled by staff over long distances in his/her wheelchair and that resident #1 never propelled his/her own wheelchair. During an interview on 12/3/12 at 4:15 p.m., Administrative Staff A reported at the time of the incident on 11/13/12, resident #1's care plan failed to accurately inform staff to use foot pedals while in a wheelchair. Staff A reported the facility included this resident with the plan of correction for deficiencies written for a complaint investigation (Complaint #KS 306) and he/she delegated to Staff C to revise all residents' care plans to be individualized related to foot pedals. Staff A reported Administrative Nursing Staff C failed to enter "use foot pedals" correctly into the computer care plan, resulting in failure to show the revision on direct care staff computers. Staff A reported Staff C failed to write the intervention on the paper care plan on 10/22/12 but back-dated the 10/22/12 entry after the revision on 11/13/12. Staff A reported he/she and maintenance staff checked the foot pedals for proper fit on 11/14/12 and found no issues. During an interview on 12/17/12 at 12:39 p.m., Administrative Nursing Staff B verified the resident fell out of the wheelchair because staff failed to use foot pedals. During an interview on 12/17/12 at 4:13 p.m., Licensed Nursing Staff E reported resident #1 lacked the ability to follow directions and needed foot pedals at all times while in the wheelchair. Staff E reported the care plan on the computer and paper lacked an intervention to use foot pedals while in the wheelchair and he/she added the intervention on 11/13/12. During an interview on 12/18/12 at 9:53 a.m., Nurse Practitioner H reported staff notified him/her of resident #1's fall on 11/13/12 with injuries to the face and right elbow and he/she gave an order to send the resident to the emergency room for treatment. The facility failed to ensure resident #1 received adequate supervision and assistive devices to prevent accidents which resulted in the resident sustaining injuries to his/her nose, forehead, and right elbow after falling forward out of a wheelchair propelled by staff without foot pedals in place. The resident required emergency room treatment which included suturing of a laceration to the resident's nose.