Every finding on record at Good Samaritan - Ellsworth

Based on record review, observation, and interview, the facility failed to follow the standards of practice for Resident (R) 1 related to weight monitoring and reporting increasing weight and edema with shortness of breath to ensure physician involvement, resulting in an exacerbation of congestive heart failure (CHF-a condition with low heart output in which the body becomes congested with fluid) requiring hospitalization. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of CHF, hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), interstitial pulmonary disease (inflammation and scarring in the tissue around the tiny air sacs in the lungs), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R1 required supervision or touching assistance from staff for most of her activities of daily living (ADLs), received diuretic (a medication to promote the formation and excretion of urine) medication, and required continuous oxygen administration. The Functional Abilities Care Area Assessment (CAA), dated 06/27/2026, documented R1 required standby to minimal staff assistance with ADLs due to safety concerns. The CAA documented R1 had numerous falls at home. The Dehydration/Fluid Maintenance CAA, dated 06/27/2026, documented R1 was diabetic (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and received a low-carbohydrate diet. R1's Care Plan, initiated 06/24/2026, documented R1 had an altered cardiovascular status related to arrhythmia (irregular, too fast, or too slow heartbeat), CHF, hypertension, coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), and peripheral arterial disease (PAD- narrowing of the arteries that supply blood to the extremities). The care plan directed staff to monitor and assess R1 for shortness of breath, chest pain, and dependent edema. The care plan documented R1 was on oxygen via nasal cannula at 2 Liters (L). The care plan documented R1 was only able to take a couple of steps with transfers, required two staff to assist with a walker, and was dependent on two staff for bed mobility. The care plan documented R1 was on the diuretic medication Lasix and directed staff to monitor for complications. The care plan directed staff to weigh R1 weekly. On 07/17/2026, an intervention documented R1 was on a fluid restriction of 2000 milliliters (mL) in 24 hours. On 06/23/2026, the EMR documented R1's admission weight as 208.5 pounds. On 06/26/2026, the EMR documented R1's weight as 213 pounds. The EMR lacked physician notification of R1's weight gain. The Communication/Visit with Physician Note, dated 07/02/2026, documented new orders to increase Lasix to 80 milligrams (mg) daily with daily weights for four days and to inform R1's primary care physician how R1's weight was trending. On 07/03/2026, the EMR documented R1's weight as 214 pounds. On 07/04/2026, the EMR documented R1's weight as 215 pounds. The facility failed to follow the physician's orders to complete daily weights for four days. The Skilled Nurses Note, dated 07/08/2026, documented R1 had 1+ pitting edema (mild level of fluid swelling) in her bilateral lower legs. Staff encouraged R1 to elevate her legs as tolerated. Staff noted R1 had shortness of breath while lying flat and upon exertion. On 07/09/2026, the EMR documented R1's weight as 236 pounds. The EMR lacked physician notification of R1's 27.5 pound weight gain since admission. The Skilled Nurses Note, dated 07/09/2026, documented R1 had 2+ pitting edema (moderate level of swelling) in her bilateral lower legs. On 07/10/2026, the EMR documented R1's weight as 239 pounds. The EMR lacked a physician notification of R1's additional weight gain (a total of 30.5 pounds since admission). The Communication/Physician Visit Note, dated 07/10/2026, documented R1's primary physician was in the facility for a visit and wrote new orders for diabetic medication changes. The note lacked indication the physician was aware of and/or alerted to R1's weight gain. The Skilled Nurses Note, dated 07/11/2026, documented R1 had 2+ pitting edema to her bilateral lower legs. The Skilled Nurses Note, dated 07/12/2026, documented R1 had 2+ pitting edema to her bilateral legs. The Skilled Nurses Note, dated 07/13/2026, documented R1 had 3+ pitting edema (moderate to severe fluid buildup) to her bilateral lower legs. The note documented R1 had shortness of breath with exertion. The Health Status Note, dated 07/14/2026 at 03:15 AM, documented R1 complained of pain in both of her legs and described a sharp, tight feeling. R1 stated she could not sleep and would call 911 if she did not get help. Staff administered Tylenol (pain medication) to R1 and had R1 dangle her feet. R1 moved to her recliner. The EMR lacked evidence of physician notification. The Health Status Note, dated 07/14/2026 at 04:20 AM, documented the nurse talked with R1 about calling the clinic as soon as it opened to get her seen that day. R1 agreed and stated she would try to wait out the pain. R1 was in her recliner around 02:30 AM when the nurse talked to her. At around 04:00 AM, the nurse walked the hall and heard R1 on the phone with Emergency Medical Services after calling 911. The nurse called and talked to Administrative Nurse D, who said to let R1 go to the emergency room (ER) to get checked out. The Emergency Department (ED) Report, dated 07/14/2026, documented R1 admitted to the ED with diagnoses of exacerbation of CHF and edema. R1 stated her legs were swollen, and she felt like they were going to burst. The ED note documented R1's Pro-BNP (blood work to check for CHF) was high at 2120 picograms per milliliter (pg/mL) (normal levels are less than 125 pg/ml under the age of 75 and less than 450 pg/ml over the age of 75). The ED report documented R1 received 500 mL of normal saline, 25 grams of albumin (a major protein that circulates in the blood to help maintain fluid balance), followed by 80 milligrams (mg) of IV Lasix. R1's last echocardiogram (graphic outline of the movements of the heart structures produced by ultrasound) was August of 2023, and her ejection fraction was 55-60 % (normal). A repeat echocardiogram would be ordered outpatient. R1 was dismissed back to the facility. The ED Discharge Instructions, dated 07/14/2026, directed facility staff to initiate daily weights, call R1's provider if R1 gained more than two pounds in one day or five pounds in one week, wear compression stockings during the day, and an echocardiogram had been ordered for the following Thursday. The facility was directed to have R1 follow up with her primary care provider one week after the echocardiogram, monitor her intake and output, and limit R1 to 2000 mL of fluid per day to help prevent fluid overload. The Health Status Note, dated 07/15/2026 at 01:41 AM, documented the Certified Nurse Aide (CNA) reported to the nurse R1 wanted to go to the ER. The nurse asked R1 why she felt she needed an ER visit. R1 stated she could not breathe. R1's oxygen saturation (percentage of oxygen in the blood) was 88% on 2 L of oxygen. The nurse increased the oxygen to 3 L, and R1's oxygen saturation was 93%. The nurse had R1 move to the recliner instead of her bed to help with breathing. The nurse called the on-call provider regarding R1's request to go to the ER. The on-call provider agreed an ER visit was not necessary and ordered DuoNeb (nebulized medication to open airways) as needed four times a day as needed for shortness of breath. The on-call provider was okay with increasing R1's oxygen to 3L. A breathing treatment was given. On 07/15/2026, the EMR documented R1's weight as 249 pounds (a total weight gain of 40.5 pounds since admission). The Skilled Nurses Note, dated 07/15/2026, documented R1 had 3+ pitting edema in her bilateral lower legs. The note documented R1 had shortness of breath with and without exertion. A Late Entry Communication with Physician Note effective 07/15/2026 (entered on 07/17/2026) documented the clinic was called about R1's 10-pound weight gain from 07/10/26 to 07/15/26. The clinic nurse stated she would leave a message for R1's provider. No call back was received. The Skilled Nurses Note, dated 07/16/2026, documented R1 had 2+ pitting edema to her bilateral lower extremities. The EMR lacked evidence of physician notification. The Clinic Referral Note, dated 07/17/2026, documented by Licensed Nurse (LN) G, recorded R1's weight was 249.5 pounds (see weight sheets: 41-pound weight gain since admission). At night, R1 complained of pain 10/10, which was uncontrolled by Tylenol. The note documented, Can we get something stronger and a pain clinic? [R1] could not sleep at night. Can we get something for insomnia? [R1] slept maybe an hour tonight. On 07/17/2026, the Clinic Referral Sheet returned to the facility with orders for R1 to be admitted to the hospital. The Communication with Physician Note, dated 07/17/2026 at 02:34 PM, documented the nurse from the clinic called and reported R1 would be direct admitted to the hospital for CHF. The Hospital Discharge Summary, dated 07/20/2026, documented R1 admitted to the hospital secondary to fluid retention and shortness of breath and found to have kidney injury and exacerbation of her heart failure. R1 received an echocardiogram while in the hospital, which demonstrated extensive cardiac abnormalities, cardiomyopathy, valvular disease, and pulmonary hypertension. R1 began to diurese (the production and excretion of urine) after administration of a Lasix drip and then transitioned to oral Lasix. Metolazone (a diuretic medication) was added, and Spironolactone (a diuretic medication) was increased, all of which were effective in improving R1's diuresis and maintaining her fluid levels. The Discharge Orders, dated 07/23/2026, documented R1 admitted with acute exacerbation of CHF, and should obtain lab work before R1's appointment on 07/29/26. The readmission Note, dated 07/23/2026, documented R1 readmitted to the facility and weighed 229 pounds. (20.5 pounds less than when she went to the ED) On 08/17/2026 at 01:00 PM, observation revealed R1 sat in her wheelchair and visited with a friend. R1 received oxygen via nasal cannula and her lower legs were not swollen. On 08/17/2026 at 01:00 PM, R1 stated she knew something was wrong because her legs were so tight and painful she thought they were going to burst. R1 stated if the nurse was not going to do something about it, she was, so she called 911 because that is her right. R1 stated she did not know her weight had gone up so much. R1 stated the night she could not breathe and wanted to go to the ER, she was told she did not need to go. R1 stated the breathing treatment she had been given did help her breathe. R1 stated her care was much better since her readmission to the facility from the hospital. On 08/17/2026 at 01:30 PM, LN H stated the residents with CHF weights were monitored for weight gain. LN H stated if a resident with CHF had a 2-3 pound weight gain in a day, the nurse would call and fax the physician, and if they did not receive any response by the next day, they would call again. LN G stated if a resident had a weight gain of 5 pounds in a week, the same process would be followed. LN H stated that if a resident had a 15-pound weight gain and nothing was done about it, it meant the CHF process had not been followed. On 08/17/2026 at 02:00 PM, Administrative Staff A denied the facility had not followed CHF policy because R1 had not been diagnosed with CHF until after she had returned from the ED. Administrative Staff A stated R1 had not been admitted with CHF. The Person-Centered Care Policy, dated 12/08/2025, documented the purpose of the policy was to improve resident quality of life and quality of care by honoring their preferences that support individuality, independence, and choice. Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Based on observation, interview, and record review, the facility failed to identify causative factors and implement effective interventions to prevent falls for Residents (R) 17, R25, and R30. Findings included: -R17's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), neurocognitive disorder with Lewy bodies (a type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), visual hallucinations (sensing things while awake that appear to be real, but the mind created), generalized weakness, and unsteadiness on feet. R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severe cognitive impairment, disorganized thinking fluctuations, hallucinations, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and physical behavior symptoms directed toward others, which occurred one to three days of the look-back period. R17 had no functional range of motion impairments, required substantial/ maximal assistance with sitting to lying, lying to sitting on the side of the bed, and was dependent on sitting on the side of the bed, chair/bed-to-chair transfers, toileting transfers, and walking ten to 50 feet. R17 had two or more noninjury falls. The Fall Care Area Assessment (CAA), dated 07/21/25, documented R17 had Parkinson's disease with decreased cognition and safety awareness, had tremors that made ambulation unsafe without assistance, and staff were instructed to assist with ambulation when he was restless. R17's Care Plan had a revision date of 03/24/25 documented that R17 had an actual fall with minor injury related to a history of falling. R17's Event Report documented the following findings: On 05/29/25 at 10:30 AM, R17 was found on the floor and was unwitnessed. R17 stood up, his feet caught on the wheelchair pedal, and he lost balance. The care plan lacked new interventions to prevent further falls. The Event Report lacked a root cause analysis. On 07/23/25 at 11:30 AM, R17 was found on the floor. R17 reported he was trying to reach his walker. The intervention, dated 07/23/25, directed staff to monitor R17 for significant changes in gait, mobility, positioning devices, standing/sitting balance, and lower extremity joint function, and that no changes were determined at this time. The Event Report lacked a root cause analysis. On 07/28/25 at 01:24 PM, a non-nursing staff member observed R 17 standing in his room and reported to the nursing staff. The nurse went to R17's room, where R17 was found on the floor. The wheelchair had one brake locked, and the walker was approximately two feet in front of R17. R17 had reported he had an appointment and was unclear about where he was going at the time of the fall. The intervention, dated 07/28/25, directed staff to try leaving the walker out of sight of R17 to reduce attempts to get up to walk on his own. The Event Report, completed on 08/01/25, lacked a root cause analysis. On 08/07/25 at 04:20 PM, R17 was found on the floor of his room, on the fall mat next to the bed. The call light had not been activated, and he had not been incontinent. R18 reported he was trying to help a baby. Staff reported R17 had been agitated earlier and leaning over in the wheelchair to pick up stuff on the floor. The intervention, dated 08/07/25, was to bring R17 to the commons area or the nurses' station if staff could not stay in the room with him. The Event Report lacked a root cause analysis. On 09/01/25 at 01:15 PM, R17 was found in his room, on the floor in front of his wheelchair, with a bedside table had lunch on it, and R17 had silverware in his hand. The intervention, dated 09/01/25, documented R17's Care Plan was reviewed, and no new interventions were added. The Event Report lacked a root cause analysis. On 09/10/25 at 07:20 PM, R17 was found on the floor, having slid out or rolled out of bed. At 07:15 PM, staff reported R17 was found standing in front of his wheelchair trying to go to bed, so staff put him to bed. The intervention, dated 09/10/25, was to bring R17 to the lobby area for monitoring. The Event Report lacked a root cause analysis. On 09/30/25 at 02:45 PM, R17 was found on the floor in his room. R17 pants were wet and wheelchair brakes were not locked. R17 laughing and joking with staff. The immediate intervention was to educate staff if R17 had not wanted assistance from the staff to get another staff member to care for him. The intervention, dated 09/30/26, directed staff that if R17 did not allow the aide to work with him, to get other staff who he will allow to care for him. The Event Report lacked a root cause analysis. On 10/10/25 at 07:35 PM, R17 was found on the floor in the lobby area and attempted to stand out of the wheelchair. R17 attempted to stand, but the pedals were on and out front, and he tripped and lost balance. The wheelchair was not to be locked. R17 reported he saw someone around the corner, but could not get around the corner in his wheelchair. The staff assisted R17 back into his wheelchair and sat with R17 until bedtime medications were given and then assisted him to bed. The intervention, dated 10/10/25, directed staff to ensure wheelchair pedals are removed/out of the way when R17 was left in the lobby for self-propelling. The intervention, dated 10/30/25, directed staff to review R17's medications or combination of medications that could predispose to falls or increase the risk of injury. The Event Report lacked a root cause analysis. On 11/18/25 at 11:50 AM, R17 was found on the floor of his room. R17's wheelchair was near his feet, and the brakes were unlocked. The care plan lacked a new intervention to prevent further falls. The Event Report lacked a root cause analysis. On 01/03/26 at 12:25 PM, R17 was found on the floor of his room, with his lower body underneath the wheelchair. R17 reported he was looking for a place to eat. The immediate intervention for the staff was to inform R17 when dinner was and to take him to the dining room. The care plan lacked a new intervention to prevent further falls. The Event Report lacked a root cause analysis. On 01/17/26 at 03:34 PM, R17 was found on the floor in his doorway to the hall. R17 reported trying not to fall, but someone had pushed him. R17 was taken to the lobby, where staff could assist him with eating. The care plan lacked a new intervention to prevent further falls. The Event Report lacked a root cause analysis. On 01/17/26 at 02:00 PM, R17 was found on the floor of his room, and the wheelchair brakes were not locked. R17 was unable to say what had happened. R17 was assisted to bed using a mechanical lift. The care plan lacked a new intervention to prevent further falls. The Event Report lacked a root cause analysis. On 02/08/26 at 03:50 PM, R17 was found on the floor of his room. R17 was assisted to his wheelchair and brought to the living room area for snacks and to watch football on the television. The care plan intervention, dated 02/08/26, directed staff to review the status of medical conditions that predispose to falls or that could increase the risk from falls, such as Parkinson's disease, and medication review from the physician. The Event Report lacked a root cause analysis. On 03/23/26 at 12:15 PM, R17 found on the floor in his room, approximately two feet from his wheelchair. R17 reported he was trying to make seven points. Staff education was to reposition the chair. The intervention, dated 03/24/26, documented that the staff was re-educated not to leave R17 in the bathroom by himself and to stay in the room to assist him when finished. The Event Report lacked a root cause analysis. On 04/05/26 at 08:30 AM, R17 was found on the floor of his room, with his lower body lying on the wheelchair pedals. R17 was mumbling and yelling. The care plan, dated 04/05/26, documented an antipsychotic medication change on 03/ 27/26, and R17 had a neurology appointment on 04/18/26. The Event Report lacked a root cause analysis. On 04/26/25 at 01:05 PM, R17 was found on the floor of his room, with his wheelchair at his feet. The Care Plan revision, dated 04/26/26, directed staff to monitor the room floor to ensure the room is free of items and spills. The intervention also directed staff to increase side supports in the wheelchair for better positioning, use pillows if R17 is leaning down in the chair, encourage him to go to bed with positioning devices, and therapy to adjust the wheelchair for improved positioning. The intervention, dated 04/26/26, documented R17's bedtime was 08:00 PM. Staff were to check R17 at 05:45 AM to see if R17 needs toileting, and to encourage R17 to lie down at 01:00 PM. The Event Report lacked a root cause analysis. On 05/20/26 at 02:05 PM, R17 is sitting in his room in a wheelchair, with his feet resting on the foot pedals, leaning to the left without side support. R17's fall mat was under his bed, and he had the television on. On 05/20/26 at 03:33 PM, Certified Nurse Aide (CNA) O, reported staff position R17 with support pillows while he is in bed to keep him from rolling out, had a floor mat next to the bed, checked on him frequently, kept the call light within reach, turn the television on to the channel he liked. CNA O also reported that the staff try to toilet him or make sure he is not incontinent and needs to be changed, to assist him with his meals, and do at least hourly checks on him. On 05/21/26 at 01:00 PM, Administrative Nurse D verified R17 fell often and R17's Care Plan lacked new interventions with each fall. Administrative Nurse D reported the facility had not implemented a root cause analysis for resident falls. The facility's Fall Prevention and Management policy, revised on 04/08/2026, documented if a resident had a fall, the facility would complete the fall tool and identify fall risk factors. The care plan would have appropriate interventions for fall risks, and these interventions would be communicated to staff. - The Electronic Medical Record (EMR) for R25 documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) and dementia with mood disturbance (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severely impaired cognition and required toileting supervision. R25 required partial staff assistance with transfers and was independent with mobility and ambulation. R25 had no functional impairment, was frequently incontinent of urine, had no toileting program, and had one non-injury fall since the prior assessment. The Quarterly MDS, dated 05/01/2026, documented R25 had severely impaired cognition and rejected care one to three days. R25 was dependent on staff for toileting, required partial staff assistance with transfers, and was independent in mobility. R25 had no functional impairment, was frequently incontinent with the bladder and bowel, had no toileting program, and had two or more non-injury falls since the prior assessment. The Fall Risk Assessments, dated 01/09/2026, 01/23/2026, 02/01/2026, 02/09/2026, 02/17/2026, 05/02/2026 and 05/10/2026, documented R25 was a high risk for falls. R25's 05/07/2026 Care Plan included the following interventions for R25: 01/23/2026- One staff provided substantial assistance with toileting and required an insert in his incontinence brief for protection. Staff assist with incontinence care and changing their brief. 08/14/2024- Remind R25 not to bend over to pick up dropped items. Encourage R25 to come out of his room for meals. 04/15/2025- Do not leave folding chairs in his room. 11/03/2025- Observe for injury and check range of motion at the time of the fall. [NAME] his bed frame on the wall, the top of the mattress, or the top of his headboard to ensure the correct bed height. 01/12/2026- Monitor/document/report as needed for 72 hours to the health care provider for pain, bruises, and change in mental status. 01/09/2026- Ensure R25 wore newer shoes, and height placement visible was indicated on the wall so staff can ensure proper bed height. 02/01/2026- Place a board behind his recliner to keep it from sliding backwards. 02/09/2026- Ensure R25 wears appropriate footwear and gripper socks when in bed. 02/17/2026- Place Dycem (non-slip mat used for stabilization and gripping to prevent slipping). 02/13/2026- Monitor him every hour and assist with toileting. 05/02/2026- Monitor R25 every hour at night. 05/09/2026- Electric cord removed from the electric recliner. The Fall Investigation, dated 01/12/2026 at 05:45 AM, documented R25 was on the floor in his room, his pants were down, and he was incontinent of bowel. R25 was alert and confused. R25 had sustained a skin tear and a bruise on his left elbow. The Fall Investigation, dated 02/01/2026 at 03:45 PM, documented R25 was on the floor in his room. He was alert and confused. R25 was incontinent and attempted to ambulate to the bathroom. R25 did not sustain any injury. The Fall Investigation, dated 02/05/2026 at 08:40 PM, documented R25 was on the floor in his room. R25 was alert and confused. R25 was incontinent and attempted to ambulate to the bathroom. R25 did not sustain any injury. The Fall Investigation, dated 02/09/2026 at 02:25 AM, documented R25 was on the floor in the bathroom. He had attempted to sit on the toilet and fell. R25 wore socks, and he slipped. R25 did not sustain any injury. The Fall Investigation, dated 02/17/2026 at 09:10 AM, documented R25 was on the floor in front of his recliner. He was alert and confused. R25 was incontinent with bowel and bladder. His recliner was slightly raised as he tried to stand up and slid out of the recliner with the bed pad underneath him. R25 did not sustain any injury. The Fall Investigation, dated 05/02/2026 at 01:45 AM, documented R25 was on the floor in his room by the bed. He was alert and confused. He was incontinent with urine, he was disoriented, attempted to self-transfer, and fell. R25 did not sustain any injury. The Fall Investigation, dated 05/09/2025 at 01:00 AM, documented R25 was on the floor in his room. He was alert and confused. R25 had used his remote to raise the recliner, lifted it way up, and slid out onto the floor. R25 did not sustain any injury. The Fall Investigation, dated 05/15/2025 at 01:11 AM, documented R25 was on the floor in his room behind his recliner. He was alert and confused. R25 was incontinent of urine and sustained no injury. The EMR lacked documentation of a toileting plan, toileting diary, or toileting assessments after his falls. On 05/20/2026 at 07:40 AM, R25 sat in his recliner. Certified Nurse Aide (CNA) N used the remote to lift the seat of the recliner to assist R25 to stand. CNA N took R25's hands and walked with him into the bathroom. CNA N pulled down his pants, but not his incontinence brief, and he sat down on the toilet. CNA N put on a new incontinence brief, assisted him to stand, removed the soiled brief, and put on the clean brief. CNA N stated he had a lot of falls and that they had to put Dycem in his chair so he would not slip out. CNA N stated R25 did not have a toileting routine, staff just observed him hourly, but if he was asleep, they did not wake him up. On 05/21/2026 at 12:15 PM, Licensed Nurse (LN) H stated staff monitors R25 hourly to prevent falls. She stated he was not on a toileting plan and had discussed taking his blood sugar in the morning due to increased output, but it had not been implemented yet. On 05/21/2026 at 01:30 PM, Administrative Nurse D stated she knew there were issues with resident falls and had started to work on root cause analysis to get a better system in place. Administrative Nurse D stated they would start obtaining R25's blood sugar in the mornings to see if there was a medical reason for his increased output, and staff should assist him with toileting. The facility's Fall Prevention and Management policy, revised on 04/08/2026, documented if a resident had a fall, the facility would complete the fall tool and identify fall risk factors. The care plan would have appropriate interventions for fall risks, and these interventions would be communicated to staff. - The Electronic Medical Record (EMR) for R30 documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition, disorganized thinking, and inattention that fluctuated. R30 required substantial staff assistance with transfers, ambulation, and mobility, and partial staff assistance with toileting. R30 had no functional impairment, and one non-injury fall since the prior assessment. The Quarterly MDS, dated 04/30/26, documented R30 had severely impaired cognition and wandered one to three days. R30 was dependent upon staff for toileting, mobility, and substantial staff assistance for transfers. R30 had no functional impairment and had two or more falls since the prior assessment. The Fall Risk Assessment, dated 08/18/2025, 10/13/2025, 01/13/2026, 02/12/2026, and 04/27/2026 a high risk for falls. The 04/40/2026 Care Plan included the following interventions for R30's falls: 12/10/2024- Review her medical record for medications or combinations of medications that could predispose her to falls or increase the risk of injury from falls 03/04/2025- Leave her room door open during the night for visual checks. 07/19/2025- Ask for other staff to get the items required instead of leaving her unattended when doing cares. 08/16/2025- Instruct staff that she is on 30-minute checks and to make sure they are monitoring her. 08/28/2025- If she is awake during checks, get her up until she is ready to go back to sleep. 01/13/2026-Reviewed the care plan, and no interventions are needed for this fall. 02/12/2026- Use a high back wheelchair for mobility with anti-roll back brakes and not the Broda chair (specialized wheelchair with the ability to tilt and recline). 04/27/2026- Monitor resident every 30 minutes when in bed. The Fall Investigation, dated 08/09/2025 at 10:45 PM, documented R30 was on the floor in her room. R30 had gripper socks, was incontinent of urine, and the door to her room was closed. The care plan lacked documentation a new intervention was put into place. The Fall Investigation, dated 08/16/2025 at 09:50 PM, documented R30 was on the floor in her room. She was alert and confused. R30 sustained a laceration (cut) which measured 0.5 (centimeters) cm to her right ear, a skin tear which measured 1.5 cm x 1.5 cm to her right upper arm, and a bruise to her right ear. The Fall Investigation, dated 08/18/2025 at 10:10 PM, documented R30 was on the floor in her room. She was alert and confused and had attempted to self-transfer. R30 did not sustain any injury. The care plan lacked documentation a new intervention was put into place. The Fall Investigation, dated 08/29/2025 at 11:40 PM, documented R30 was on the floor in her room. She was alert, confused, and attempted to self-transfer. R30 sustained a skin tear to her left great toe. The care plan lacked documentation a new intervention was put into place. The Fall Investigation, dated 10/13/2025 at 01:40 PM, documented R30 was on the floor in the front lobby. R30 was alert, confused, and did not sustain any injury. The care plan lacked documentation a new intervention was put into place. The Fall Investigation, dated 01/13/2026 at 11:15 AM, documented R30 was on the floor in the front lobby. R30 attempted to lean forward in her wheelchair to reach out to the vacuum, and another resident attempted to pull back on her wheelchair, which caused her to slide down to the floor. R30 did not sustain any injury. The Fall investigation, dated 02/12/2026 at 6:40 PM, documented R30 was on the floor in the front lobby. She was alert, confused, and did not sustain any injury. The Fall Investigation, dated 04/27/26 at 04:45 AM, documented staff was unable to open the door to her room. The Licensed Nurse (LN) on duty was able to push her head through the door and saw that R30 was on the floor, wrapped in her blankets from her bed. Staff were able to push the door open, and R30's wheelchair, which had been beside the bed, was now in the center of the room. Staff were able to push open the door and assist R30 off the floor. R30 was alert, confused, and did not sustain any injury. On 05/20/2026 at 08:46 AM, R30 was out in the front lobby in her wheelchair. R30 attempted to stand up several times, and a visitor would tell her to sit back down. On 05/20/2026 at 09:00 AM, Licensed Nurse G stated they try to keep R30 out in the lobby area where she can be visualized due to her impulsiveness to stand up. R30 enjoyed watching television and playing with her fidget toys and fidget board. On 05/20/26 at 12:45 PM, Certified Nurse Aide (CNA) M placed a gait belt around R30's waist and assisted her into the bathroom. R30 grabbed onto the handrail in the bathroom and stood up. CNA M pulled down R30's pants, and R30 turned and sat down on the toilet. CNA M put on gloves and performed personal care. CNA M removed her soiled gloves, sanitized her hands, donned clean gloves, and pulled up R30's pants. CNA M assisted R30 back into her wheelchair. CNA M stated they do hourly checks on her because she will attempt to transfer herself and fall. On 021/21/2026 at 01:30 PM, Administrative Nurse D stated she had started working on a better process for falls and the fall prevention system. She stated that they are working towards the investigation, and risk factors intertwine with a root cause analysis. The facility's Fall Prevention and Management policy, revised on 04/08/2026, documented if a resident had a fall, the facility would complete the fall tool and identify fall risk factors. The care plan would have appropriate interventions for fall risks, and these interventions would be communicated to staff.

The facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 38 residents who reside in the facility and receive meals from the facility kitchen, placing the residents at risk for foodborne illness. Findings included: -On [DATE] at 09:19 AM, during initial inspection of the kitchen observation revealed the walk-in refrigerator and freezer had numerous boxes directly stored on the floor. Dietary Staff (DS) BB reported the facility had received supplies the day prior, staff had not unloaded boxes, and the boxes should not have been stored on the floor. The walk-in refrigerator also contained a bag of carrots, opened with use by date of [DATE]. The white refrigerator in the main kitchen had an open, unsealed bag of chicken patties without a label or contents or use-by date on it. Two cups, one plastic, and one Styrofoam, were stored in the bulk bin of thickener, and the ice machine drainage spout was sitting flush on the drainage grate. On [DATE] at 10:57 AM, observation revealed dietary staff preparing for the noon meal. During the process of plating the meal for serving DS CC donned gloves and started preparing plates for residents in the dining room. DS CC picked up the diet menu card from being pulled from being stored in the service window once, which was placed there by DS DD. DS DD was providing residents with drinks as they entered the dining room. DS CC with wisps or several inches of hair that was not contained in the hair net started to plate the food. She used gloved hands to place chopped lettuce and tomatoes as a garnish for the meal. Throughout the serving process DS CC wiped her hands on her clothing and touched her face, and other surfaces in the kitchen without changing gloves. DS BB, assisting DS CC, wore gloves used to assist with plating and serving food, left the kitchen and when returned continued wearing the same gloves. The kitchen utilized two fans, one fan blew directly on the clean area of the dishwashing machine area, and the other fan directly blew on the food service window. Both fans had grey fuzzy material on the screen and blades. The sanitation test strips in the facility kitchen had expired dates of ,d+[DATE], [DATE], and [DATE]. The drawer, cabinet fronts, equipment, and table legs were sticky to the touch. On [DATE] at 02:10 PM, DS BB stated gloves should have been changed between tasks and serving. DS BB said the fans should be cleaned and she had notified the maintenance department about the ice machine drainage spout. DS BB reported she had not been aware that sanitation test strips had an expiration date and had ordered new ones to come when the next supplies were delivered. The facility's General Sanitation Food and Nutrition policy, dated [DATE], documented that the Director of Food and Nutrition Services director maintains a supply of appropriate test strips and thermometers. The facility's Food Supple Storage policy, dated [DATE], documented the Use By/Use or [NAME] By, phrasing will inform customers that these products should be consumed on or before the listed date on the product. The date label is for perishable products with potential safety implications or material degradation of critical performance, such as nutrition. The facility's Hand Washing and Glove Use Food Nutrition Services policy, dated [DATE], documented that employees do not touch any food with bare hands. Proper utensils such as tissue, spatula, tongs, and single-use gloves should be used for food handling to reduce the risk of cross-contamination. The facility's Ice Machine Use and Maintenance policy, dated [DATE], lacked information regarding drainage air gap space. The facility failed to store, prepare, and serve food under sanitary conditions for 38 residents who reside in the facility and receive meals from the facility kitchen, placing the residents at risk for foodborne illness.

The facility had a census of 38 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required committee members, including the medical director, attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - The facility's QAPI meeting attendance sheets documented the members including the QAPI facilitator, the administrator, the director of nursing, the infection control preventionist, the safety director, the social services designee, the activity director, an environmental services employee, the pharmacist consultant, and the medical director. A review of the sign-in sheets from July 2023 through June 2024 revealed only four members attended the November 2023 meeting. The attendance sheets revealed the medical director did not attend a QAPI meeting during the last quarter of 2023. On 07/02/24 at 01:52 PM, Administrative Staff B verified the medical director did not attend and that there was overall low attendance at the QAPI meeting in November 2023. The facility's 2024 QAPI Plan, dated 01/30/24, stated the Plan was designed to outline a comprehensive and data-driven QAPI program that focuses on improving the outcomes and experiences of the residents. The QAPI plan provides a strategic approach to the prevention, identification, reporting, investigation, analysis, and development of performance improvement activities. The facility failed to ensure the medical director attended QAPI meetings at least quarterly as required which placed residents at risk of unidentified quality care services.

The facility had a census of 38 residents. The sample included 12 residents in which five residents were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)25, R31, and R22 had an approved indication for the use of an antipsychotic-(class of medications used to treat major mental conditions that cause a break from reality), and failed to ensure R25's as needed (PRN) antipsychotic had a stop date. The facility further failed to ensure R32 had a risk versus benefit statement for the continued use of clonazepam (an antianxiety- class of medications that calm and relax people) and paroxetine (an antidepressant class of medications used to treat mood disorders) without a gradual dose reduction. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Psychotropic Drug Use Care Area Assessment (CAA), dated 02/21/24, documented R25 received an antidepressant for depression. It was hard to determine if the resident was depressed. He was not happy with his situation and would hit out at staff when they were giving care. The CAA further documented the monitoring of medication side effects and depression. R25's Care Plan dated 05/20/24 documented R25 received medications with Black Boxed Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) or warnings of adverse consequences. The care plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. R25's Care Plan dated 05/20/24 documented R25 used psychotropic medications related to anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and directed staff to consult with the pharmacy and health care provider to consider dosage reduction when clinically appropriate; monitor for signs and symptoms of anxiety. The Physician Order dated 05/11/24 directed staff to administer Zyprexa (antipsychotic) 2.5 milligrams (mg) by mouth two times a day for anxiety and every six hours as needed for anxiety. The order lacked a 14-day stop date for the PRN dose. R25's EMR recorded Zyprexa 2.5 mg PRN dose was administered on 06/15/24 at 06:45 PM. The Progress Note dated 02/22/24 documented a note to the physician from the facility that R25 had more frequent yelling throughout the day and night; Tylenol PRN seemed ineffective and R25 denied pain. R25's family felt the behaviors were anxiety related, and R25 currently took Zyprexa 2.5 mg daily and Celexa (antidepressant) 20 mg daily. The physician responded by increasing R25's Zyprexa to 2.5 mg twice a day. The Consultant Pharmacist [CP] Progress Notes dated 03/28/24, 04/24/24, 05/28/24, and 06/25/24, lacked evidence the CP identified and reported related to the use of Zyprexa without an approved indication, or a documented physician rationale which included the nonpharmacological interventions which were tried and failed as well as a risk versus benefit for the use of an antipsychotic. The notes also lacked evidence the CP identified and reported the lack of the required 14-day stop date for the PRN Zyprexa. On 06/27/24 at 08:30 AM, observation revealed R25 sitting in the dining room with Certified Nurse Aide (CNA) M sitting next to him. CNA M fed the resident a ground and minced diet of eggs, ground sausage, and a thin liquid supplement. R25 ate without any signs of difficulty. CNA M reported R25 was eating well, but the resident had been in a mood for several days and had not eaten well. On 07/02/24 at 11:07 AM, CNA P reported R25 was not capable of verbalization most of the time. CNA P stated R25 occasionally punched out at the staff, but not hard, and this usually happened during bathing. CNA P reported giving R25 time and space for about 10 minutes and this helped with behaviors. On 07/02/24 at 12:20 PM Administrative Nurse D verified R25's Zyprexa had an unapproved indication of anxiety and the PRN lacked a stop date as required. The facility's Psychotropic Medication policy, dated 12/06/23, documented the purpose of the policy to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. The resident will be free from any chemical restraint imposed for the purpose of discipline or convenience and not be required to treat the resident's medical symptoms. If the physician prescribes an antipsychotic for the resident, a registered nurse must complete the Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in PCC. While the use of PRN psychotropic medication is not encouraged, if a PRN physician order is received, ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to the use of PRN psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. The facility failed to ensure R25 had an approved indication for the use of an antipsychotic and failed to ensure R25's PRN antipsychotic had a stop date. This placed the resident at risk of receiving unnecessary psychotropic medications. - R31's Electronic Medical Record documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), essential tremors, hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) without dyskinesia (inability to execute voluntary movements). R31's Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had severe cognitive impairment, had an acute onset of mental status change, and inattention which fluctuated; R31 had not exhibited behaviors. R31 was independent with functional abilities and mobility. The MDS further documented R31 received an antipsychotic and an antianxiety medication. The antipsychotic was received on a routine basis, had no gradual dose reduction (GDR) attempt, and no physician documented GDR as clinically contraindicated. R31's Care Plan Care Plan, dated 04/14/24, documented R31 used psychotropic medication related to dementia with high anxiety. The care plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. The plan directed to attempt non-medication approaches such as watching television shows, giving ice cream, or providing a quiet place and one-on-one interactions in times of anxiety and agitation. The care plan documented R31 also took medication with a Black Boxed Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The Physician Order dated 09/15/23, directed staff to administer Seroquel (antipsychotic) 12.5 milligrams (mg) by mouth one time a day for anxiety. The Pharmacist Consultant Review, dated 10/10/23, documented R31 had a diagnosis of dementia and received Seroquel for anxiety. Antipsychotics had Boxed Warnings for increased mortality in older adults with psychosis related to dementia. Please attempt a GDR of Seroquel with the end goal of discontinuation. The review also included a note from facility staff that R31 had noted the current dose was not helping with an increase in anxiety and agitation. The prescriber's response directed to start an antidepressant and continue Seroquel. The Pharmacist Consultant Review, dated 11/02/23, documented the order for Seroquel for anxiety and reviewed the diagnosis for the use of antipsychotic medication. The prescriber's response was to continue medication, R31 was tolerating well and had improved symptoms on the medication, The Pharmacist Consultant Review, dated 03/28/24, documented a GDR request for Seroquel, to provide clinical rationale supporting the continued use. The prescriber's response was R31 had severe dementia with agitation, was doing wonderful with treatment, and would attempt to decrease at a later date. The Progress Note, dated 06/02/24 at 10:28 AM, documented R31 had increased episodes of fixation and agitation. R31 had asked approximately 10 times that shift why the air conditioner was on; the nurse attempted explanation and redirection, but R31 continued to ask and attempted to put blankets on the vents in the television area. R31 was agitated with staff and education was provided. R31's EMR lacked evidence of a physician-documented rationale which included the nonpharmacological interventions that were attempted and failed for the continued use of Seroquel with no GDR attempts. On 06/26/24 at 02:52 PM, observation revealed R31 participating in the activity in the dining room. She wore a long sweater and carried a purse while she independently ambulated throughout the facility. On 07/02/24 at 11:23 AM, Certified Nurse Aide (CNA) P reported R31 was easily redirected when she got anxious. CNA P said it was helpful to spend one-on-one time with R31, direct her to her room, and try to resolve what might be making her anxious were also helpful to the resident. On 07/02/24 at 12:33 PM, Administrative Nurse D stated she was aware that the use of Seroquel was not approved for anxiety but R31's physician had not changed or updated the diagnosis or provided the required documentation. The facility's Psychotropic Medication policy, dated 12/06/23, documented the purpose of the policy to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. The resident will be free from any chemical restraint imposed for the purpose of discipline or convenience and not be required to treat the resident's medical symptoms. If the physician prescribes an antipsychotic for the resident, a registered nurse must complete the Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in PCC. While the use of PRN psychotropic medication is not encouraged, if a PRN physician order is received, ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to the use of PRN psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. The facility failed to ensure R31 had an approved indication for the use of an antipsychotic. This placed the resident at risk of receiving unnecessary psychotropic medications. 26768 - R22's Electronic Medical Record (EMR) documented diagnoses of anxiety disorders (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke), acute and chronic kidney failure (condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 had no behaviors. R22 required maximal to total assistance for mobility, dressing, and toileting. R22 received antipsychotic and antidepressant medications (a class of medications used to treat mood disorders). The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/10/24, stated R22 received a small dose of Zyprexa (antipsychotic) for anxiety and Celexa (antidepressant). The CAA documented R22's mood has been stable, and he was doing well. R22 was seen by the tele-psych nurse for medication changes and status. R22's Care Plan, dated 05/14/24, directed staff to allow the resident time to respond due to slower processing of cognition skills. In the presence of behaviors or anxiety, staff were to provide opportunities for positive interaction and attention. The plan directed staff to minimize the potential for the resident's disruptive behaviors by offering tasks that divert attention. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. The Physician Order, dated 05/06/24, directed staff to administer Zyprexa (olanzapine) 2.5 milligrams (mg), two times a day for anxiety. The Physician Order, dated 03/18/2024, directed staff to administer Celexa (citalopram- antidepressant drug) 40 mg, at bedtime, for depression. The Medication Administration Record (MAR)/ Treatment Administration Record (TAR) documented R22 had no behaviors related to depression which included crying, isolation, yelling, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. R22 had no signs of psychosis which included crying, hallucinations, delusions, isolation, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. The Psychiatric Practitioner Note, dated 05/06/24, stated after tapering Zyprexa on 04/04/24, staff reported increased anxiety, excessive sleeping, and agitation. The prescriber increased Celexa to 30 mg after which staff reported some decrease in anxiety. The note stated R22's agitation begins at approximately 03:00 PM, but if identified, staff can calm R22 down most of the time. The practitioner ordered staff to continue Zyprexa 2.5 mg twice daily for mood or anxiety and increase Celexa to 40 mg daily. The Psychiatric Practitioner Note, dated 06/21/24, stated R22 had a significant past psychiatric history. Staff reported increased anxiety, some frustration, and anxiety with communication due to a stroke. Staff reported R22's anxiety levels had improved since he became aware of his schedule in advance. R22 stated he was doing well and not really having too much anxiety. He reported sleeping well and denied nightmares. The practitioner documented diagnoses of mood disorder with depressive features, dementia (a progressive mental disorder characterized by failing memory, and confusion), and generalized anxiety disorder. The note documented to continue to taper Zyprexa during subsequent visits as Kansas only approved the use of antipsychotics for certain diagnoses. The practitioner ordered to continue Celexa 20 mg daily for anxiety or mood. The Consultant Pharmacist Review, dated 11/14/23, questioned the diagnosis of anxiety for the use of Zyprexa. The physician responded- yes and documented anxiety without documenting a rationale for the indication or continued use of the antipsychotic medication. The Consultant Pharmacist Review, dated 12/13/23, recommended a gradual dose reduction (GDR) for Zyprexa and Celexa. The physician responded that R22 was evaluated by the psychiatric practitioner and ordered no changes without psychiatric physician involvement. No risk versus benefit rationale was documented. The Consultant Pharmacist Review, dated 06/06/24, recommended a GDR of Celexa 40 mg. The physician responded this was a recent increase with the in-house psychiatric practitioner, a GDR would be contradictive at this time. No risk versus benefit rationale was documented. On 06/27/24 at 07:31 AM, Licensed Nurse (LN) I administered an injection to R22. R22 stated he ate a good breakfast but couldn't remember exactly what he ate. On 07/01/24 at 01:22 PM, Administrative Nurse D stated R22 was admitted with the diagnosis of anxiety for Zyprexa. She verified anxiety was an inappropriate indication for the use of Zyprexa and stated the physician had not changed it when the Pharmacist Consultant had requested. Administrative Nurse D verified the facility failed to follow up on the pharmacist consultant's recommendations to obtain an appropriate indication for use or a written rationale for the continued use of Zyprexa which included the required documentation. The facility's Psychotropic Medications policy, dated 12/06/23, stated before the administration of non-emergency psychotropic medication the staff must document observations of mood, symptoms, or behaviors that cause the resident distress and or endanger the resident or others and the response to interventions used. The care plan would be updated with non-pharmacological interventions to be used. The policy stated if staff determined that initiating a medication was warranted, staff would contact the physician and describe the behavior, attempted interventions, and recommendations. Staff were to obtain the corresponding diagnosis and medical symptom for the medication from the physician. The policy mood and behavior documentation must continue to monitor the effectiveness of the psychotropic medication. Gradual dose reductions must be done according to federal regulations. The facility should attempt gradual dose reduction of psychotropic drugs during at least two separate quarters during the first year unless clinically contraindicated. Continued use may be contraindicated if it was in accordance with relevant current standard of practice and the physician has documented the clinical rationale for why any attempted dose reeducation would be likely to impair the resident's function or cause psychiatric instability or the resident's targeted symptoms returned or worsened after the most recent attempt at a gradual dose reduction at the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. The facility failed to ensure an appropriate indication or the required physician documentation for the continued use of antipsychotic medication for R32. This placed the resident at risk for unnecessary psychotropic medications and potential adverse effects. - R32's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R32 was independent for mobility, toileting, walking, and dressing. The MDS documented R32 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medications. R32's Care Plan, dated 04/15/24, stated R32 used anti-anxiety medications related to dementia with anxiety disorder and directed staff to monitor and document side effects and effectiveness. Monitor R32 frequently for safety. Offer diversionary activities such as one one-on-one discussions. Offer the use of a rocking chair to ease anxiety. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reductions when clinically appropriate. The Physician Order, dated 10/11/23, directed staff to administer paroxetine (a type of antidepressant medication), 20 milligrams (mg) daily for anxiety. The Physician Order, dated 10/20/23, directed staff to administer clonazepam (antianxiety medication that works by increasing the levels of a calming chemical in your brain) 0.5 mg daily for dementia. The Pharmacist Consultant Review, dated 03/28/24, recommended a gradual dose reduction (GDR) of paroxetine 15 mg daily and clonazepam 0.5 mg daily which the pharmacist wrote had been administered since 10/11/23. The physician declined the recommendation and wrote clinically contraindicated without writing a rationale or risk versus benefit statement. The Physician Visit Note, dated 05/24/24, documented R32 had severe dementia but had adjusted to living in the facility and seemed to be happier. The note recorded there were no changes to R32's medications. On 07/01/24 at 12:55 PM, observation revealed R32 independently ambulated from his room to the commons area and sat for a music activity. He was very polite and calm. On 07/02/24 at 10:15 AM, Administrative Nurse D verified the physician had not written a risk versus benefit statement or rationale for continuing paroxetine and clonazepam. The facility's Psychotropic Medications policy, dated 12/06/23, stated before the administration of non-emergency psychotropic medication the staff must document observations of mood, symptoms, or behaviors that cause the resident distress and or endanger the resident or others and the response to interventions used. The care plan would be updated with non-pharmacological interventions to be used. The policy stated if staff determined that initiating a medication was warranted, staff would contact the physician and describe the behavior, attempted interventions, and recommendations. Staff were to obtain the corresponding diagnosis and medical symptom for the medication from the physician. The policy mood and behavior documentation must continue to monitor the effectiveness of the psychotropic medication. Gradual dose reductions must be done according to federal regulations. The facility should attempt gradual dose reduction of psychotropic drugs during at least two separate quarters during the first year unless clinically contraindicated. Continued use may be contraindicated if it was in accordance with relevant current standard of practice and the physician has documented the clinical rationale for why any attempted dose reeducation would be likely to impair the resident's function or cause psychiatric instability or the resident's targeted symptoms returned or worsened after the most recent attempt at a gradual dose reduction at the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. The facility failed to obtain a written risk versus benefit statement or rationale for the continued use of the psychotropic medications for R32, without attempted GDR, placing the resident at risk for unnecessary psychotropic medications and potential adverse effects.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and, interview, the facility failed to revise the care plan with effective intervention to prevent re-traumatization for Resident (R)2 related to a diagnosis of post-traumatic stress disorder (PTSD-mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of PTSD, epilepsy (brain disorder characterized by repeated seizures), heart failure, weakness, morbid obesity (excessive body fat), and localized edema (swelling). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 used a walker and required substantial/maximal assistance with toileting and upper and lower body dressing. R2 required partial/moderate assistance with personal hygiene. R2 was independent with bed mobility and transfers. The MDS further documented a PTSD diagnosis. R2 received scheduled pain medication, an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), and a diuretic (medication to promote the formation and excretion of urine). The Psychosocial Well-Being Care Area Assessment (CAA), dated 08/01/23, documented R2 had lost a close family member and had feelings of sadness, tearfulness, and loss. R2 stated he had accepted the loss but still had times of sadness. R2's Care Plan, initiated 04/28/21, documented R2 used antianxiety medications related to adjustment issues, his mother's death, and PTSD. The care plan directed staff to monitor anxiety, document side effects and effectiveness of antianxiety, and discuss with R2's health care provider and family if there is an ongoing need for the use of medications. The care plan lacked information regarding triggers and interventions related to R2's PTSD to prevent re-traumatization. The Trauma Assessment, dated 04/30/24, documented the purpose of the assessment was to identify residents who were survivors of trauma, to understand how trauma currently affected functioning, and to determine what triggers may cause re-traumatization. The assessment inquired if the resident had experienced some form of trauma or a stressful event, and R2's assessment recorded an answer of no, despite the diagnosis of PTSD The assessment further inquired how trauma currently affected the person, the trauma symptoms and triggers, support and coping strategies, and care planning. The latter portion of the assessment lacked descriptions and was incomplete. The Progress Note, dated 08/17/23 at 10:07 AM, documented R2 was in attendance at the care conference. The note further documented the review of R2's diet, weight, and activity involvement; there were no medication changes. The note recorded that a talk therapy appointment was set up for each month and the facility would transport R2 to sessions. The Progress Note, dated 05/07/24 at 10:19 AM, documented R2 verbalized feelings related to his emotional state and shared his grief with his caregivers. R2 expressed satisfaction with friendships and an improved mood state. R2 reported fewer episodes of anxiety behavior but had a continued need for 24-hour care in a nursing facility. On 06/27/24 at 02:05 PM, observation revealed R2 in his room, listening to music. R2 reported music helped his mood. On 07/02/24 at 09:57 AM Certified Nurse Aide (CNA) N reported knowledge of R2's PTSD diagnosis but was not aware of the cause or what may trigger the resident. CNA N reported she could tell when something was not right with R2's mood and said she tried to have an upbeat attitude which seemed to be effective. On 07/02/24 at 10:13 AM, Licensed Nurse (LN) J reported R2 was not having behaviors and was generally happy. LN J was not sure what may trigger PTSD for the resident. On 07/02/24 at 11:26 AM CNA P reported she thought R2's PTSD might have come from something experienced in his childhood and said R2 had not exhibited behaviors. On 07/02/24 at 11:19 AM, Administrative Nurse E verified the care plan lacked triggers or coping strategies for staff. On 07/02/24 at 02:28 PM, Administrative Nurse D verified R2 had a PTSD diagnosis which stemmed from a history of COVID-19 and his family member's death. Administrative Nurse D verified the care plan lacked triggers and coping strategies that would benefit the resident. The facility did not provide a care plan policy. The facility failed to ensure the care plan to include triggers that may cause re-traumatization related to R2 's diagnosis of PTSD which placed the resident at risk for impaired care due to uncommunicated care needs.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide nursing care that met the standards of practice for Resident (R) 25 when nursing staff failed to monitor the resident's intake and administer tube feedings per the physician's orders and failed to monitor urine output and report decreased output to the physician. This deficient practice placed the resident at risk for medical complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Nutritional Status Care Area Assessment (CAA), dated 02/21/24, documented R25 had scored a six on the nutritional assessment which indicated he was malnourished. R25 had not been eating while he was hospitalized , so a G-tube was placed; all nutrition and medications were given through the tube. The Feeding Tube Care Area Assessment (CAA), dated 02/21/24, documented that while hospitalized , R25 was not eating; a G-tube was placed, and all nutrition and medications were given via tube. The Dehydration/Fluid Maintenance Care Area Assessment (CAA), dated 02/21/24, documented R25 receives all fluids through G-tube. R25 received water before and after feedings and one other time during the day. Labs were monitored as ordered. R25's Care Plan, dated 05/20/24, documented R25 had an indwelling catheter related to neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and instructed staff to monitor and document for pain or discomfort due to catheter. The plan directed staff to document output and monitor, record, and report to the health care provider for signs and symptoms of urinary tract infections. R25's Care Plan, dated 05/20/24, documented R25 met the criteria for malnutrition related to weight loss. The plan directed staff to monitor R25's weight weekly. R25's Care Plan, dated 05/20/24, documented R25 had nutrition problems related to G-tube feedings and medication. The care plan documented R25 had an order for a puree (smooth creamy constancy) diet and extremely thick liquids. R25 required assistance with eating; staff were to monitor for choking. The plan documented R25 had an order for Two- cal HN 2.0 (liquid nutritional supplement), 237 milliliters (ml) five times a day with 120 ml of water before and after feedings. R25's EMR recorded the following weights: 06/13/24 150.0 pounds (lbs.) 06/20/24 149.0 lbs. 06/27/24 146.8 lbs. The Physician Order, dated 06/14/24, directed staff to administer Two-cal HN 2.0 oral liquid 237 ml via G-tube three times a day related to dysphagia; flush with 120 ml of water before and after feeding. Administer if the resident ate less than 50% of his meal. The Dietary Progress Note, dated 06/26/24 at 09:35 AM, documented R25 had a loss of two pounds (lbs.) since 05/30/24. He received a regular diet with a minced and moist texture and had an oral intake of 51 to 100% at most meals. The tube feeding was changed to Two-cal HN 237 ml three times a day as needed if R25's intake was less than 50% at meals. R25's diet was supplemented with Boost Breeze (nutrition drink) daily at noon and the note recommended to increase the Boost to twice a day. R25's EMR lacked documentation of oral meal intake for 15 of 45 meal opportunities from 06/14/24 through 06/30/24. R25's EMR, including the Medication Administration Record/Treatment Administration Record (MAR/TAR), lacked documentation that staff assessed R25 for the need to administer, or that staff administered R25's physician-ordered Two-cal HN via his G-tube for those 15 of 45 opportunities when meal intakes were not monitored and recorded. R25's EMR under the Tasks for June 2024 recorded a urinary output of less than 30 ml hourly (720 ml) in a 24-hour period indicating minimal kidney function for 15 days in June 2024. R25's EMR lacked evidence the nursing staff identified this irregularity and reported it to R25's physician. On 06/27/24 at 08:30 AM, observation revealed R25 sitting in the dining room with Certified Nurse Aide (CNA) M sitting next to him. CNA M fed the resident a ground and minced diet of eggs, ground sausage, and a thin liquid supplement. R25 ate without any signs of difficulty. CNA M reported that R25 was eating well, but the resident had been in a mood for several days and had not eaten well. On 07/02/24 at 08:02 AM, CNA O reported that R25 required assistance with eating. CNA O stated the dietary staff recorded the intake of the resident. On 07/02/24 at 08:03 AM, Dietary Staff (DS) BB stated the dietary department recorded R25's intake into the EMR and reported to the charge nurse what R25's intake was, especially if the resident did not eat well. On 07/02/24 at 08:30 AM, Licensed Nurse (LN) H reviewed the EMR and stated R25 should have received supplemental G-tube feeding if he ate less than 50%. LN H said R25 continued with physician-ordered flush twice a day. to get water flushes two times a day. On 07/02/24 at 12:20 PM Administrative Nurse D stated R25's meal intakes should have been monitored and recorded and supplemental tube feeding given if the resident ate less than 50%. Administrative Nurse D verified nursing staff had not recorded supplemental feeding and verified it was the nurse's responsibility to ensure the need for supplemental feeding if needed. Administrative Nurse D said R25's urine output should be recorded in the EMR and it was the nursing staff's responsibility to assess for adequate urine output to promote health maintenance. The facility's Intake and Output with Hydration Guidelines policy, dated 05/07/24, the purpose of the policy is to measure fluid intake and/or output when ordered by the medical provider, on residents who receive G-tube feedings or have urinary catheters, to ensure that residents receive sufficient fluid intake to maintain proper hydration and health and to provide staff with ideas for hydration implementation. The policy further documented the facility to maintain acceptable parameters of nutritional status, unless the resident's clinical condition demonstrates that this is not possible or resident preference indicates otherwise and is offered sufficient fluid intake to maintain proper hydration and health. The facility failed to provide nursing care that met the standards of practice for R25 when nursing staff failed to monitor the resident's intake and administer tube feedings per the physician's orders and failed to monitor urine output and report decreased output to the physician. This deficient practice placed the resident at risk for medical complications.

The facility had a census of 38 residents. The sample included 12 residents with three residents reviewed for urinary catheter care. Based on observation, interview, and record review, the facility failed to provide urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care in a manner to prevent urinary tract infections (UTI-an infection in any part of the urinary system) for Resident (R) 22 and R91. This placed the two residents at risk for infections and catheter-related complications. Findings included: - R22's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke), acute and chronic kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hyperlipidemia (condition of elevated blood lipid levels), hypercholesterolemia (greater than normal amounts of cholesterol in the blood), anxiety disorders (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and urinary tract infection. The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 had no behaviors. R22 required maximal to total assistance for mobility, dressing, and toileting and had a urinary catheter. The MDS documented R22 received insulin (a hormone used to regulate blood glucose levels), antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), and antidepressant medications (a class of medications used to treat mood disorders). R22 received psychiatric therapy and a gradual dose reduction (GDR) of the antipsychotic drug had been attempted. The Care Area Assessment (CAA), dated 05/10/24, stated R22 had a Foley (brand name) catheter due to retention, was prone to UTIs, and received a prophylactic (preventative in nature) antibiotic (a medicine that inhibits the growth of or destroys microorganisms). Staff provide catheter care every shift and the catheter is changed as ordered and as needed. R22's Care Plan, dated 05/14/24, stated R22 had a Foley catheter related to urinary retention and surgery, initiated on 05/08/23 and revised on 02/21/24. The care plan directed staff to monitor, and document for pain or discomfort due to the catheter initiated 05/08/23. Use enhanced barrier precautions (EBP -infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care) with care. The plan instructed staff to wear disposable gowns when performing high-contact resident care activities, doff gown and gloves inside the resident room, and complete hand hygiene before leaving the room, initiated 03/29/24, and revised on 06/05/24. R22 has a Foley Catheter 16 French (Fr-size), initiated 05/08/23. The plan directed staff to document output initiated on 02/08/24 and perform catheter care by CNA (Certified Nurse Aide) every shift, initiated on 02/16/24, and revised on 03/29/24. R22 has the potential for UTI related to catheter use and a history of UTIs, initiated on 02/21/24. The plan directed staff to collect specimens for culture and sensitivity as ordered, initiated 02/21/24. R22's EMR documented UTIs with antibiotic medication ordered on 08/31/23, 12/30/23, 01/12/24, 02/14/24, and 04/01/24. The 02/14/24 and 04/01/24 urine cultures documented Carbapenem-resistant Enterobacteriaceae (CRE-resistant bacterial infection), a multi-drug resistant organism (MDRO common bacteria that have developed resistance to multiple types of antibiotics). The Progress Note, dated 06/05/24 at 11:40 AM, documented R22 was readmitted to the facility after hospitalization for UTI and received intravenous (IV-administered directly into the bloodstream via a vein) antibiotics. On 06/26/24 at 02:50 PM, observation revealed R22 in his wheelchair in the hall. CNA N assisted R22 to the common resident bathroom where she performed catheter care by emptying the drainage bag. CNA N donned gloves but no gown set the measuring container on a barrier on the floor, emptied the catheter drainage bag, and used an alcohol wipe on the port. CNA N changed gloves without washing her hands, placed the drainage bag back into a privacy bag under the wheelchair, and took the resident back out to the commons area. On 06/27/24 at 01:02 PM, observation revealed R22 in his wheelchair in the hall with the catheter drainage bag in a privacy bag under the wheelchair. Approximately two inches of catheter tubing dragged on the floor when he self-propelled into the nurse's office. There was a wet area observed on the front of R22's slacks and Licensed Nurse (LN) I placed a towel over the wet spot and wheeled the resident to another area to weigh him, per his request, while four inches of catheter tubing dragged on the floor during the transport. On 06/27/24 at 01:27 PM, observation revealed CNA O took R22 in his wheelchair to his room with the catheter tubing dragging on the hallway floor. On 07/02/24 at 09:32 AM, LN H stated staff were to provide catheter care every shift and said staff should use gowns and gloves. LN H stated staff should not provide care in the common bathroom without EBP. On 07/02/24 at 09:42 AM, Administrative Nurse D verified the catheter tubing should not be allowed to drag on the floor and that staff should not use the common bathroom for catheter care. She stated staff should have used EBP every time they provided any catheter care. The facility's Enhance Barrier Precautions (EBP) Protocol, directed staff to determine if EBP was needed for residents with wounds or indwelling medical devices and all residents infected or colonized with select MDROs. Staff was to set up a personal protective equipment (PPE) station inside the resident's room, notify staff that EBP was needed during high contact care, post signs on resident doors, update the care plan, and educate staff, residents, and family. The facility's Catheter Care policy, dated 02/10/23, stated every effort would be made to keep a resident's catheter covered or out of sight, and catheter tubing should never be allowed to touch the floor. When emptying the catheter bag, place a moisture-resistant barrier beneath the measuring container and avoid placing the container on the floor. When finished draining, clean the drainage port with an alcohol wipe and replace it in the holder. Measure and record the volume, discard the urine in the toilet and wash and dry the container according to facility procedures. The facility failed to provide urinary catheter care in a manner to prevent urinary tract infections R22. This placed the resident at risk for further UTI and other catheter-related complications. - R91's Electronic Medical Record (EMR) documented diagnoses of cervical/neck spine fracture and urinary hesitancy (difficulty starting or maintaining a urine stream). R91 was admitted to the facility on [DATE] following hospitalization for a fall and treatment of a urinary tract infection. R91's Catheter Care Plan, dated 06/25/24, stated R91 had an indwelling urinary catheter related to a neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and directed staff to monitor for pain or discomfort due to the catheter, document intake, and output, and provide catheter care every shift. The care plan stated R91 required enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) related to the indwelling catheter, initiated on 06/26/24. Staff was to don a gown and gloves when performing high-contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care or use, and wound care initiated on 06/26/24. The plan directed staff to doff gown and gloves inside the resident's room and perform hand hygiene, initiated on 06/26/24. On 06/27/24 at 11:57 AM, observation revealed R91 stood in his bathroom and stated he had emptied his urinary leg bag just now in the bathroom. Certified Nurse Aide (CNA) Q assisted R91 to his recliner with a walker, gait belt, and minimal assistance. CNA Q gloved but did not don an isolation gown. She performed peri-care, removed gloves, and assisted R91 to stand and transfer to his wheelchair. On 07/01/24 at 08:35 AM, observation revealed R91 sat in his wheelchair at a dining table independently eating. R91's urinary catheter bag hung under his wheelchair without a privacy bag or cover and yellow urine was visible to other residents in the dining room. On 07/01/24 at 01:50 PM, observation revealed R91 in his room in a wheelchair. CNA M donned gloves, but no isolation gown, set a measuring container directly on the floor with no barrier, removed the catheter drainage bag from under the wheelchair, and set it on the floor. CNA M used an alcohol wipe on the port before and after draining the bag, dropped the alcohol wipe on the floor then picked it up and wiped the inside of the port holder on the bag with the contaminated wipe. CNA N attempted to place the drainage bag back into the privacy bag under the wheelchair, and at one point placed the urine collection bag on the floor while trying to attach the privacy bag under the wheelchair. CNA M removed his gloves and attached the privacy bag, handled the Foley bag, and then emptied the urine container into the toilet. He used hand gel before leaving the room. On 06/27/24 at 03:40 PM, Administrative Nurse D stated EBP should have been initiated for R91's catheter care the day he was admitted (06/25/24) and verified it had not been. On 07/01/24 at 01:57 PM, CNA M verified staff should not set the drainage bag on the bare floor. He was not aware the resident was on EBP for the catheter. On 07/01/24 at 02:00 PM, Administrative Nurse D verified the resident was on EBP and showed the bookmark size EBP sign attached to the doorframe. The resident had a small plastic three-drawer cart in the room with EBP supplies, but no sign to indicate that was what was in it. On 07/02/24 at 09:42 AM, Administrative Nurse D verified catheter tubing should not be allowed to drag on the floor and staff should not use the common bathroom for catheter care. Staff should have used EBP every time they provided any catheter care. The facility's Enhance Barrier Precautions (EBP) Protocol, directed staff to determine if EBP was needed for residents with wounds or indwelling medical devices and all residents infected or colonized with select MDROs. Staff was to set up a PPE station inside the resident's room, notify staff that EBP was needed during high contact care, post signs on resident doors, update the care plan, and educate staff, resident, and family. The facility's Catheter Care policy, dated 02/10/23, stated every effort would be made to keep a resident's catheter covered or out of sight, and catheter tubing should never be allowed to touch the floor. When emptying the catheter bag, place a moisture-resistant barrier beneath the measuring container and avoid placing the container on the floor. When finished draining, clean the drainage port with an alcohol wipe and replace it in the holder. Measure and record the volume, discard the urine in the toilet and wash and dry the container according to facility procedures. The facility failed to provide urinary catheter care in a manner to prevent urinary tract infections and to maintain dignity for R91. This placed R91 at risk for further UTI and other catheter-related complications.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)2 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD-mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for unmet behavioral health care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of PTSD, epilepsy (brain disorder characterized by repeated seizures), heart failure, weakness, morbid obesity (excessive body fat), and localized edema (swelling). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 used a walker and required substantial/maximal assistance with toileting and upper and lower body dressing. R2 required partial/moderate assistance with personal hygiene. R2 was independent with bed mobility and transfers. The MDS further documented a PTSD diagnosis. R2 received scheduled pain medication, an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), and a diuretic (medication to promote the formation and excretion of urine). The Psychosocial Well-Being Care Area Assessment (CAA), dated [DATE], documented R2 had lost a close family member and had feelings of sadness, tearfulness, and loss. R2 stated he had accepted the loss but still had times of sadness. R2's Care Plan, initiated [DATE], documented R2 used antianxiety medications related to adjustment issues, his mother's death, and PTSD. The care plan directed staff to monitor anxiety, document side effects and effectiveness of antianxiety, and discuss with R2's health care provider and family if there is an ongoing need for the use of medications. The Trauma Assessment, dated [DATE], documented the purpose of the assessment was to identify residents who were survivors of trauma, to understand how trauma currently affected functioning, and to determine what triggers may cause re-traumatization. The assessment inquired if the resident had experienced some form of trauma or a stressful event, and R2's assessment recorded an answer of no, despite the diagnosis of PTSD The assessment further inquired how trauma currently affected the person, the trauma symptoms and triggers, support and coping strategies, and care planning. The latter portion of the assessment lacked descriptions and was incomplete. The Progress Note, dated [DATE] at 10:07 AM, documented R2 was in attendance at the care conference. The note further documented the review of R2's diet, weight, and activity involvement; there were no medication changes. The note recorded that a talk therapy appointment was set up for each month and the facility would transport R2 to sessions. The Progress Note, dated [DATE] at 10:19 AM, documented R2 verbalized feelings related to his emotional state and shared his grief with his caregivers. R2 expressed satisfaction with friendships and an improved mood state. R2 reported fewer episodes of anxiety behavior but had a continued need for 24-hour care in a nursing facility. On [DATE] at 02:05 PM, observation revealed R2 in his room, listening to music. R2 reported music helped his mood. On [DATE] at 09:57 AM Certified Nurse Aide (CNA) N reported knowledge of R2's PTSD diagnosis but was not aware of the cause or what may trigger the resident. CNA N reported she could tell when something was not right with R2's mood and said she tried to have an upbeat attitude which seemed to be effective. On [DATE] at 10:13 AM, Licensed Nurse (LN) J reported R2 was not having behaviors and was generally happy. LN J was not sure what may trigger PTSD for the resident. On [DATE] at 11:26 AM CNA P reported she thought R2's PTSD might have come from something experienced in his childhood and said R2 had not exhibited behaviors. On [DATE] at 11:19 AM, Administrative Nurse E reported R2 had experienced a personal history of COVID-19 (highly contagious respiratory virus) and had to be hospitalized far from the facility, due to lack of hospital bed availability. When R2 returned to the facility, a close family member also contracted Covid-19 and died . Administrative Nurse E said R2 began having thoughts that bothered him and had been throwing things. She reported R2 started seeing a counselor which helped. Administrative Nurse E verified the care plan lacked triggers or coping strategies for staff. On [DATE] at 02:28 PM, Administrative Nurse D verified R2 had a PTSD diagnosis which stemmed from a history of COVID-19 and his family member's death. Administrative Nurse D verified the care plan lacked triggers and coping strategies that would benefit the resident. The facility's Trauma Informed Care policy, dated [DATE], documented the purpose of the policy was to provide trauma-informed care and avoid re-traumatization. Trauma-informed care means being intentional by anticipating and avoiding institutional processes and practices that are likely to re-traumatize a resident who has a history of trauma. Staff will ensure that residents who experience trauma receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. The facility failed to ensure R2 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet care, emotional, and psychosocial needs.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to follow up on the Consultant Pharmacist (CP) recommendations regarding antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and psychotropic (alters mood or thought) medication use for Resident (R)22, R32, and R25 and failed to ensure the CP identified and reported the lack of a stop date for R25's as needed psychotropic medication. This placed the three residents at risk to continue receiving unnecessary psychoactive medications without an explanation of why the benefits outweighed the risks. Findings included: - R22's Electronic Medical Record (EMR) documented diagnoses of anxiety disorders (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke), acute and chronic kidney failure (condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 had no behaviors. R22 required maximal to total assistance for mobility, dressing, and toileting. R22 received antipsychotic and antidepressant medications (a class of medications used to treat mood disorders). The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/10/24, stated R22 received a small dose of Zyprexa (antipsychotic) for anxiety and Celexa (antidepressant). The CAA documented that R22's mood has been stable, and he was doing well. R22 was seen by the tele-psych nurse for medication changes and status. R22's Care Plan, dated 05/14/24, directed staff to allow the resident time to respond due to slower processing of cognition skills. In the presence of behaviors or anxiety, staff were to provide opportunities for positive interaction and attention. The plan directed staff to minimize the potential for the resident's disruptive behaviors by offering tasks that divert attention. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. The Physician Order, dated 05/06/24, directed staff to administer Zyprexa (olanzapine) 2.5 milligrams (mg), two times a day for anxiety. The Physician Order, dated 03/18/2024, directed staff to administer Celexa (citalopram- antidepressant drug) 40 mg, at bedtime, for depression. The Medication Administration Record (MAR)/ Treatment Administration Record (TAR) documented R22 had no behaviors related to depression which included crying, isolation, yelling, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. R22 had no signs of psychosis which included crying, hallucinations, delusions, isolation, change in mood, sadness, suicidal thinking, increased sleeping, or other depressive behaviors. The Psychiatric Practitioner Note, dated 05/06/24, stated after tapering Zyprexa on 04/04/24, staff reported increased anxiety, excessive sleeping, and agitation. The prescriber increased Celexa to 30 mg after which staff reported some decrease in anxiety. The note stated R22's agitation begins at approximately 03:00 PM, but if identified, staff can calm R22 down most of the time. The practitioner ordered staff to continue Zyprexa 2.5 mg twice daily for mood or anxiety and increase Celexa to 40 mg daily. The Psychiatric Practitioner Note, dated 06/21/24, stated that R22 had a significant past psychiatric history. Staff reported increased anxiety, some frustration, and anxiety with communication due to a stroke. Staff reported that R22's anxiety levels had improved since he became aware of his schedule in advance. R22 stated he was doing well and not really having too much anxiety. He reported sleeping well and denied nightmares. The practitioner documented diagnoses of mood disorder with depressive features, dementia (a progressive mental disorder characterized by failing memory, and confusion), and generalized anxiety disorder. The note documented to continue to taper Zyprexa during subsequent visits as Kansas only approved the use of antipsychotics for certain diagnoses. The practitioner ordered to continue Celexa 20 mg daily for anxiety or mood. The Consultant Pharmacist Review, dated 11/14/23, questioned the diagnosis of anxiety for the use of Zyprexa. The physician responded- yes and documented anxiety without documenting a rationale for the indication or continued use of the antipsychotic medication. The Consultant Pharmacist Review, dated 12/13/23, recommended a gradual dose reduction (GDR) for Zyprexa and Celexa. The physician responded that R22 was evaluated by the psychiatric practitioner and ordered no changes without psychiatric physician involvement. No risk versus benefit rationale was documented. The Consultant Pharmacist Review, dated 06/06/24, recommended a GDR of Celexa 40 mg. The physician responded this was a recent increase with the in-house psychiatric practitioner, a GDR would be contradictive at this time. No risk versus benefit rationale was documented. On 06/27/24 at 07:31 AM, Licensed Nurse (LN) I administered an injection to R22. R22 stated he ate a good breakfast but couldn't remember exactly what he ate. On 07/01/24 at 01:22 PM, Administrative Nurse D verified the facility failed to follow up on the pharmacist consultant's recommendations to obtain an appropriate indication for use or a written rationale for the continued use of the Zyprexa which included the required documentation. The facility's Drug Regimen Review policy, dated 02/10/23, stated a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. The licensed pharmacist completes the drug regimen review by assessing the medication list and the resident's medical chart to identify potentially significant medication issues and notifies the physician if any discrepancies are found or additional information is needed. The pharmacist would follow up until a response was received from the physician. The pharmacist would review to identify that medication doses and duration are appropriate, medication-related errors, and gradual dose reductions. The pharmacist would complete a Medication Regimen Review summary and ensure the director of nursing services and the physician receive a copy. These reports must be acted upon. The facility failed to follow up on the Pharmacist Consultant's recommendations regarding antipsychotic medication use for R22, placing the resident at risk for unnecessary psychotropic medications. - R32's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R32 was independent for mobility, toileting, walking, and dressing. The MDS documented R32 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medications. R32's Care Plan, dated 04/15/24, stated R32 used anti-anxiety medications related to dementia with anxiety disorder and directed staff to monitor and document side effects and effectiveness. Monitor R32 frequently for safety. Offer diversionary activities such as one one-on-one discussions. Offer the use of a rocking chair to ease anxiety. The plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reductions when clinically appropriate. The Physician Order, dated 10/11/23, directed staff to administer paroxetine (a type of antidepressant medication), 20 milligrams (mg) daily for anxiety. The Physician Order, dated 10/20/23, directed staff to administer clonazepam (antianxiety medication that works by increasing the levels of a calming chemical in your brain) 0.5 mg daily for dementia. The Pharmacist Consultant Review, dated 03/28/24, recommended a gradual dose reduction (GDR) of paroxetine 15 mg daily and clonazepam 0.5 mg daily which the pharmacist wrote had been administered since 10/11/23. The physician declined the recommendation and wrote clinically contraindicated without writing a rationale or risk versus benefit statement. The Physician Visit Note, dated 05/24/24, documented R32 had severe dementia but had adjusted to living in the facility and seemed to be happier. The note recorded there were no changes to R32's medications. On 07/01/24 at 12:55 PM, observation revealed R32 independently ambulated from his room to the commons area and sat for a music activity. He was very polite and calm. On 07/02/24 at 10:15 AM, Administrative Nurse D verified the facility had not obtained a physician-written risk versus benefit statement or rationale for continuing paroxetine and clonazepam as recommended by the pharmacist consultant. The facility's Drug Regimen Review policy, dated 02/10/23, stated a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. The licensed pharmacist completes the drug regimen review by assessing the medication list and the resident's medical chart to identify potentially significant medication issues and notifies the physician if any discrepancies are found or additional information needed. The pharmacist would follow up until a response was received from the physician. The pharmacist would review to identify that medication doses and duration are appropriate, medication-related errors, and gradual dose reductions. The pharmacist would complete a Medication Regimen Review summary and ensure the director of nursing services and the physician receive a copy. These reports must be acted upon. The facility failed to follow up on the Pharmacist Consultant's recommendations regarding psychotropic medication use for R32, placing the resident at risk for unnecessary psychotropic medications. 37450 - R25 ' s Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (a broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Psychotropic Drug Use Care Area Assessment (CAA), dated 02/21/24, documented R25 received an antidepressant for depression. It was hard to determine if the resident was depressed. He was not happy with his situation and would hit out at staff when they were giving care. The CAA further documented the monitoring of medication side effects and depression. R25's Care Plan dated 05/20/24 documented R25 received medications with Black Boxed Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration)or warnings of adverse consequences. The care plan directed staff to consult with the pharmacy and healthcare provider to consider dosage reduction when clinically appropriate. R25's Care Plan dated 05/20/24 documented R25 used psychotropic medications related to anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and directed staff to consult with the pharmacy and health care provider to consider dosage reduction when clinically appropriate; monitor for signs and symptoms of anxiety. The Physician Order dated 05/11/24 directed staff to administer Zyprexa (antipsychotic) 2.5 milligrams (mg) by mouth two times a day for anxiety and every six hours as needed for anxiety. The order lacked a 14-day stop date for the PRN dose. R25's EMR recorded Zyprexa 2.5 mg PRN dose was administered on 06/15/24 at 06:45 PM. The Progress Note dated 02/22/24 documented a note to the physician from the facility that R25 had more frequent yelling throughout the day and night; Tylenol PRN seemed ineffective and R25 denied pain. R25's family felt the behaviors were anxiety related, and R25 currently took Zyprexa 2.5 mg daily and Celexa (antidepressant) 20 mg daily. The physician responded by increasing R25's Zyprexa to 2.5 mg twice a day. The Consultant Pharmacist [CP] Progress Notes dated 03/28/24, 04/24/24, 05/28/24, and 06/25/24, lacked evidence the CP identified and reported related to the use of Zyprexa without an approved indication, or a documented physician rationale which included the nonpharmacological interventions which were tried and failed as well as a risk versus benefit for the use of an antipsychotic. The notes also lacked evidence the CP identified and reported the lack of the required 14-day stop date for the PRN Zyprexa. On 06/27/24 at 08:30 AM, observation revealed R25 sitting in the dining room with Certified Nurse Aide (CNA) M sitting next to him. CNA M fed the resident a ground and minced diet of eggs, ground sausage, and a thin liquid supplement. R25 ate without any signs of difficulty. CNA M reported R25 was eating well, but the resident had been in a mood for several days and had not eaten well. On 07/02/24 at 11:07 AM, CNA P reported R25 was not capable of verbalization most of the time. CNA P stated that R25 occasionally punched out at the staff, but not hard, and this usually happened during bathing. CNA P reported giving R25 time and space for about 10 minutes and this helped with behaviors. On 07/02/24 at 12:20 PM Administrative Nurse D verified R25's Zyprexa had an unapproved indication of anxiety. Administrative Nurse D verified the CP had not reported that the needed Zyprexa did not have a stop date The facility's Drug Regimen Review policy, dated 02/10/23, stated a drug regimen review was performed for each resident at least once a month by a licensed pharmacist. The licensed pharmacist completes the drug regimen review by assessing the medication list and the resident's medical chart to identify potentially significant medication issues and notifies the physician if any discrepancies are found or additional information needed. The pharmacist would follow up until a response was received from the physician. The pharmacist would review to identify that medication doses and duration are appropriate, medication-related errors, and gradual dose reductions. The pharmacist would complete a Medication Regimen Review summary and ensure the director of nursing services and the physician receive a copy. These reports must be acted upon. The facility failed to ensure the CP identified and reported that R25 lacked a 14-day stop for the use of PRN psychotropic medication and lacked an appropriate indication for Zyprexa. This placed the resident at risk for inappropriate use of medications.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for infection control were used when staff provided care for Resident (R) 22 and R91's urinary catheters (tube inserted into the bladder to drain urine into a collection bag). This placed residents at risk for potential infections and cross contamination. Findings included: - On 06/26/24 at 02:50 PM, observation revealed R22 in his wheelchair in the hall. CNA N assisted R22 to the common resident bathroom where she performed catheter care by emptying the drainage bag. CNA N donned gloves but no gown set the measuring container on a barrier on the floor, emptied the catheter drainage bag, and used an alcohol wipe on the port. CNA N changed gloves without washing her hands, placed the drainage bag back into a privacy bag under the wheelchair, and took the resident back out to the commons area. On 07/01/24 at 01:50 PM, observation revealed R91 in his room in a wheelchair. CNA M donned gloves, but no isolation gown, set a measuring container directly on the floor with no barrier, removed the catheter drainage bag from under the wheelchair, and set it on the floor. CNA M used an alcohol wipe on the port before and after draining the bag, dropped the alcohol wipe on the floor then picked it up and wiped the inside of the port holder on the bag with the contaminated wipe. CNA N attempted to place the drainage bag back into the privacy bag under the wheelchair, and at one point placed the urine collection bag on the floor while trying to attach the privacy bag under the wheelchair. CNA M removed his gloves and attached the privacy bag, handled the Foley bag, and then emptied the urine container into the toilet. He used hand gel before leaving the room. On 06/27/24 at 03:40 PM, Administrative Nurse D stated EBP should have been initiated for R91's catheter care the day he was admitted (06/25/24) and verified it had not been. On 07/01/24 at 02:00 PM, Administrative Nurse D verified the resident was on EBP and showed the bookmark size EBP sign attached to the doorframe. The resident had a small plastic three-drawer cart in the room with EBP supplies, but no sign to indicate that was what was in it. On 07/02/24 at 09:32 AM, LN H stated staff were to provide catheter care every shift and said staff should use gowns and gloves. LN H stated staff should not provide care in the common bathroom without EBP. On 07/02/24 at 09:42 AM, Administrative Nurse D verified the staff should have used EBP every time they provided any catheter care. The facility's Enhance Barrier Precautions (EBP) Protocol, directed staff to determine if EBP was needed for residents with wounds or indwelling medical devices and all residents infected or colonized with select MDROs. Staff was to set up a PPE station inside the resident's room, notify staff that EBP was needed during high contact care, post signs on resident doors, update the care plan, and educate staff, resident, and family. The facility failed to ensure EBP for infection control was used when staff provided care for R22 and R91's urinary catheters. This placed residents at risk for potential infections and cross-contamination.

The facility had a census of 38 residents. The sample included 12 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic (medication used to treat infections) stewardship protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor the effectiveness of and identified inappropriate extended administration of an antibiotic for Resident (R) 25. This placed the resident at risk for complications related to antibiotic use. Findings included: - R25 ' s Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach), unspecified protein-calorie malnutrition, encephalopathy (broad term for any brain disease that alters brain function or structure), urogenital candidiasis (yeast infection), obstructive and reflux uropathy (blocked or reduce urine flow), urinary tract infection (UTI), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment, disorganized thinking, and an altered level of consciousness present which fluctuated. R25 had not exhibited behaviors. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility. R25 was dependent on staff for eating, oral care, toileting, bathing, upper and lower body dressing, and mobility. The MDS further documented R25 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. He had no pain or pain treatments. R25 had a feeding tube (G-tube) and a mechanically altered diet; he received 51 percent (%) or more of his total calories through tube feeding with a fluid intake of 501 cubic centimeters (cc)/day or more. The resident received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), antibiotic (medication to treat infections), and antiplatelet (medication to prevent blood from clotting). The antipsychotics were received on a routine basis only with no gradual dose reduction (GDR) attempted and no physician-documented GDR as clinically contraindicated. R25 also received speech and occupational therapy. The Dehydration/Fluid Maintenance Care Area Assessment (CAA), dated 02/21/24, documented R25 receives all fluids through G-tube, R25 received water before and after feedings, and one other time during the day. Labs monitored as ordered. R25's Care Plan, dated 05/20/24, documented R25 received antibiotic therapy related to prophylactic (preventative in nature) for urinary tract infection and sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body). The care plan directed staff to monitor the resident condition based on clinical practice guidelines or clinical standards of practice related to the use of Augmentin (an antibiotic). The Physician Order, dated 05/12/24, directed staff to administer amoxicillin-potassium clavulanate oral tablet 875-125 milligrams (mg) by mouth in the morning daily for prophylactically UTI. The order lacked a stop date. R25's clinical record lacked evidence of physician-documented rationale for the extended use of Augmentin and a benefit statement that the benefit outweighed the risk of increased antibiotic resistance. On 07/01/24 at 09:44 AM, observation revealed Certified Nurse Aide (CNA) Q took R25 to his room via wheelchair. CNA Q explained she was going to drain and measure the catheter leg bag. CAN Q donned appropriate PPE for EBP, then she proceeded to drain the leg bag into a measuring device and cleansed the drainage spout before adjusting the drainage bag under R25 ' s pant leg. The urine was straw in color and measured 100 milliliters (ml). CNA Q reported the catheter is drained every shift and staff are to put the drained amount in the EMR. CNA Q stated she would report to the charge nurse if there was no urine in the drainage bag if the urine had a bad odor, or if the resident seemed to have pain in the bladder area. On 07/02/24 at 12:20 PM, Administrative Nurse D stated R25 had been on Augmentin since admission. Administrative Nurse D reported she had provided antibiotic stewardship information and inquired to discontinue the use of the antibiotic, but the physician declined. The facility's Antibiotic Stewardship policy, dated 12/07/23, documented the purpose of the policy was to decrease the incidence of multi-drug resistance organisms (MDROs), to promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use. The facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk for adverse events, including antibiotic resistance when the facility failed to monitor effectiveness and identify the extended use of Augmentin for R25, which placed the resident at risk for complications related to antibiotic use.

The facility reported a census of 32 residents. The sample included five residents reviewed for bowel management. Based on record review and interview, the facility failed to assess bowel function/sounds at onset of abdominal discomfort before staff administered an as needed (PRN) laxative suppository to ensure active bowel sounds to rule out obstruction (a blockage that kept food or liquid from passing through the small or large intestine) for Resident (R) 1, who transferred to the hospital on 07/20/23 and admitted for a bowel obstruction. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 was rarely/never understood. R1 required extensive assistance with two staff for bed mobility; total dependence with two staff for transfers; and total dependence with one staff for locomotion, dressing, eating, toileting, and personal hygiene. R1 was always incontinent (lack of voluntary control over urination or defecation) of bowel. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/06/23, documented R1 had dementia and needed cues/reminders given to her for cares and meals. The Urinary Incontinence and Indwelling Catheter CAA dated 06/02/23, documented R1 was dependent with toileting. The Care Plan dated 11/22/23, documented R1 had an activities of daily living (ADL) self-care performance deficit related to dementia and directed staff to provide check and change cares every two hours and PRN. The Care Plan did not address R1's bowel incontinence or bowel management. The Orders tab of R1's EMR documented an order with a start date of 11/22/22 for bisacodyl suppository 10 milligrams (mg) rectally every 12 hours as needed for constipation and an order with a start date of 03/24/23 for Zofran (antiemetic- medication used to treat nausea and vomiting) four mg every eight hours as needed for nausea. The Tasks tab of R1's EMR documented the following bowel movements for 07/11/23 to 07/20/23: one small and one large on 07/11/23, one medium on 07/12/23, one large on 07/13/23, one small on 07/15/23, one small on 07/17/23, and one medium on 07/18/23. R1's medical record revealed the following: An eAdmin Record note on 07/17/23 at 10:46 AM documented Zofran 4 mg as needed for nausea was given as R1 complained of stomach pain. R1's medical record lacked evidence the nurse assessed R1 when she complained of stomach pain. An eAdmin Record note on 07/17/23 at 12:42 PM documented effectiveness of Zofran 4 mg as needed for nausea was unknown as R1 did not clarify. R1's medical record lacked evidence of a physical assessment after the PRN administration. An eAdmin Record note on 07/19/23 at 12:13 PM documented weekly weight was not done due to R1 was not feeling well and she had been vomiting that morning. An eAdmin Record note on 07/19/23 at 03:28 PM documented as needed bisacodyl suppository was given for constipation. R1's medical record lacked evidence the nurse assessed R1 for bowel sounds to rule out possible obstruction or other complications before administering bisacodyl suppository. An eAdmin Record note on 07/19/23 at 03:37 PM documented R1 stated she was going to throw up. An eAdmin Record note on 07/19/23 at 10:56 PM documented as needed bisacodyl suppository was ineffective and R1 did not have a bowel movement (BM). A Health Status note on 07/20/23 at 10:26 AM documented around 09:30 AM, the nurse asked the Certified Nurse Aides (CNA) if R1 ate any of her meal and they stated she refused to eat anything. The nurse went into R1's room to give morning medications and R1 refused to take them. About 10 minutes later, the bath aide came to the nurse and stated R1 had emesis (vomit) all over her. The nurse went to R1's room and noted the emesis was green in color; R1's abdomen was distended and painful to touch. The nurse had the Director of Nursing look at R1, and they agreed R1 needed to be sent to the Emergency Department (ED) to be evaluated. R1 had not eaten anything in 24 hours and had not had a BM in two days even after getting a suppository on 07/19/23 for constipation. A Communication with Resident/Family on 07/20/23 at 01:03 PM documented R1's representative called to inform the facility that R1 was being transferred to another hospital because the ED found R1 had compacted fecal matter equivalent in size to a 20-week-old baby. The facility provided a History and Physical Reports dated 07/20/23 that documented R1 was taken to the ED that morning due to abdominal distention and pain. A Computed Tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan of her abdomen which showed a massive amount of impacted stool in the rectum resulting in a large bowel obstruction. R1 had not taken in much oral intake due to abdominal pain. On 08/01/23 at 01:19 PM, Licensed Nurse (LN) G stated on 07/17/23, R1 took her meds and ate a little bit of breakfast. The Certified Medication Aide (CMA) later reported R1 stated her stomach did not feel good. LN G stated she had assessed R1 and her bowel sounds were not hypoactive (slow) and R1 never complained of any pain with palpations (assess with touch). She stated assessments were documented under progress note but if the assessment was not in there then she might not have documented it. LN G stated if a resident had not had a bowel movement in three or four days, she assessed them unless they complained of stomach pain before that. She stated she performed a bowel assessment before giving a suppository, but she was bad about documenting it. On 08/01/23 at 01:53 PM, Administrative Nurse D stated he was not notified that R1 had some abdominal discomfort on 07/17/23 but he was notified on 07/20/23 that she was experiencing discomfort, abdominal distention, and nausea. He stated he assessed R1 and observed her abdomen was distended and tender with palpation. Administrative Nurse D stated the nurse would evaluate and administer laxatives based on the assessment. He stated the nurse documented in the progress notes what the evaluation was, how many days it had been since the resident had a bowel movement, the resident's usual bowel pattern, bowel sound assessment, and abdominal palpation assessment. The facility's Bowel and Bladder: Evaluation, Assessment, Toileting Programs policy, last revised 04/26/23, directed an abdominal assessment was complex because of the multiple organs in the abdominal cavity and to perform an effective abdominal assessment, the nurse must know the location of those organs. The prevention of constipation and fecal impaction was critical and failure to accurately assess the abdomen has led to unnecessary death of residents. The policy directed the abdominal assessment began with inspection and followed with auscultation (using a stethoscope to listen to internal organs) which happened prior to palpation and percussion because those activities altered the sound of the bowel sounds. The facility failed to assess bowel function/sounds at onset of abdominal discomfort then administered PRN laxative suppository without assessing to ensure active bowel sounds to rule out obstruction for R1. R1 transferred to the hospital on 07/20/23 where she admitted for a bowel obstruction. The facility completed the following interventions by 07/30/23: All current residents had a Bowel Evaluation completed. Education was completed on constipation and fecal impaction management and prevention. The facility developed a new policy Constipation Prevention and Treatment Guidelines on 07/24/23. This deficient practice was cited at past-noncompliance and existed as a G (isolated, actual harm) scope and severity.

The facility identified a census of 37 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to ensure staff met Resident (R) 1's safety needs during transport to a doctor's appointment. On 04/12/23, Transportation Driver U drove R1 to an appointment out of town, sixty-two miles away. Transportation Driver U buckled R1's wheelchair into the safety hooks but failed to place the lap belt and shoulder harness across R1's body. On the way to the appointment, Transportation Driver U made an abrupt stop to avoid being hit by another car. In the process of braking suddenly, , R1 slid out of her wheelchair and onto the floor of the transport van with her legs going underneath the front seats of the driver's seat. R1 stated her knees hurt. A community member stopped and helped Transportation Driver U place R1 back into her wheelchair. R1 agreed to continue to her appointment and medical staff assessed R1 prior to her procedure at the appointment. Upon R1's return to the facility, the licensed nurse assessed R1 and noted R1 had an abrasion to her right knee and swelling to her right ankle. The facility obtained orders for mobile radiology and the x-ray results confirmed R1 had sustained a non-displaced fracture of the right distal (farthest end of the bone) fibula (the outside bone of the lower leg) at the level of the tibiotalar joint (forms the junction between the distal tibia (inner bone of the lower leg) and the fibula of the lower leg and the talus (the large bone in the ankle). Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of type 2 diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with deficit on the right side of the body, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R1 required extensive assistance of two staff for bed mobility, transfer, dressing, toileting, and personal hygiene. R1 required total dependence on one-to-two staff for locomotion on and off the unit using a wheelchair; and required total dependence on two staff for bathing. The MDS documented R1 had one non-injury fall during the look back period. The Activities of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA), dated 03/13/23, documented R1 required extensive assistance with most of her ADLs and was at risk for decline in her ADLs due to a recent cerebral infarction. The Fall CAA, dated 03/13/23, documented R1 was at risk for falls related to R1 requiring assistance with balance and surface-to-surface transfers. The CAA documented R1 required a sit-to-stand lift for transfers. The Fall Care Plan, revised on 03/16/23, documented R1 would be free of falls through the review date. The care plan directed staff to monitor R1 for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function, remind R1 to make sure she was to the bed before she sat, and encourage R1 to wear non-skid stockings at night and when she had her shoes off during the day. The Falls Tool, dated 04/12/23, documented R1 had a score of twenty, which indicated R1 was a high risk for falls. The Transporting Residents in Wheelchairs Checklist, dated 12/30/22, documented a training for Transportation Driver U on how to properly apply all safety belts in the facility van. The Van Driver Education, dated 04/14/23, documented not buckling a resident into the transportation van was neglect. The Witness Statement, dated 04/14/23, documented R1 stated she was not wearing a seat belt when she was transported in the van to her appointment. The Witness Statement, dated 04/14/23, documented Transportation Driver U had to make an abrupt stop on 04/12/23, which resulted in R1 sliding out of her wheelchair onto the van floor and hitting her right knee and foot. With the help of a passerby, Transportation Driver U got R1 off of the floor of the van and back into her chair. The Facility Incident Report, dated 04/20/23, documented Transportation Driver U transported R1 to an appointment at another facility. R1's wheelchair was hooked into the safety locks of the van but R1 was not buckled in. On the way to the appointment, Transportation Driver U had to make an abrupt stop to avoid being hit by another vehicle. R1 slid out of her wheelchair during the abrupt stop and fell on to the van floor. R1 stated her knees hurt but agreed to continue to her appointment. Medical staff at the hospital assessed R1 prior to her appointment. When R1 returned to the facility, the facility nurse assessed R1 and noted R1 had an abrasion to her right knee and swelling to her right ankle. Due to the swelling in her right ankle, the LN obtained orders for a mobile radiology to perform x-rays, which confirmed R1 had a non-displaced fracture of the right distal fibula at the level of the tibiotalar joint. R1 was fitted for a boot on 04/14/23. On 04/14/23 the van was taken to a maintenance shop to get a new seat belt installed. On 04/18/23 both vans were taken to a mechanic shop for inspection. Corrective actions taken included Transportation Driver U was suspended, appointments were re-scheduled, van drivers were educated on van safety, van drivers were assigned a defensive driving training, van drivers were re-educated on transporting residents in wheelchairs and performed a driver road test before being able to transport residents, and safety audits were performed prior to transportations in the facility vans for four weeks. On 05/23/23 at 10:00 AM, observation revealed R1 sat in her recliner watching TV. R1 had a walking boot to her right lower extremity. On 05/23/23 at 10:00 AM, R1 stated she was in the van in her wheelchair on the day of her appointment. R1 stated the sun was in her eyes so she could not see. R1 stated, suddenly she flew out of her wheelchair and landed on the floor of the van. R1 stated her knees hurt and said a nurse stopped and helped Transportation Driver U put her back in her wheelchair. R1 stated a seat belt was not placed on her after the accident but a lap belt was placed on her for the ride back to the facility. On 05/23/23 at 11:00 AM, Transportation Driver U stated he had not put a seat belt on R1 prior to transporting her to her appointment on 04/12/23. Transportation Driver U stated he thought it was part of resident's rights whether they wanted to wear a seat belt or not. Transportation Driver U stated once he got R1 to her appointment, he looked everywhere for all the parts for the seat belt, so he could make sure R1 was buckled on the way back to the facility. Transportation Driver U stated he found the pieces for the lap belt but could not find all the pieces for the shoulder harness. On 05/23/23 at 11:30 AM, Maintenance Supervisor V stated there was a functioning seat belt in the van at the time of the incident that did not need to be put together to use. Maintenance Supervisor V demonstrated the two different belts in the van that could be used. Maintenance Supervisor V stated he trained Transportation Driver U on transportation and safety, and said he never told Transportation Driver U that it was up to the residents whether they wanted to wear a seat belt or not. On 05/23/23 at 12:00 PM, Consultant GG stated the ankle fracture delayed R1's progress with therapy from her recent stroke. Consultant GG stated prior to the accident R1 walked with a walker and two staff assistance in her room and to and from the bathroom, but after the accident she required a full lift, which delayed her therapy. On 05/23/23 at 12:30 PM, Administrative Nurse D stated all residents riding in the van should be seat belted in as it was a safety issue, and it was the state law. The facility's Vehicle Resource Packet, dated 07/22/22, documented prior to transporting residents in the vehicle for the first time the driver will be instructed on how to use the3 equipment and the vehicle in the proper manner. The driver will then demonstrate the proper manner by using the equipment in a return demonstration. Prior to a driver transporting residents a Transporting Residents in Wheelchairs Checklist shall be satisfactorily completed. This checklist will ensure that the driver has a working knowledge of the wheelchair lift, wheelchair securement systems, and accompanying seat belt systems. All passengers must wear a seat belt. The facility's Fall Prevention and Management Policy, dated 03/29/23, documented the facility would promote resident well-being by developing and implementing a fall prevention and management program, identify risk factors and implement interventions before a fall occurs, and give prompt treatment after a fall occurs. The facility failed to prevent avoidable accidents when, during an abrupt stop while transporting R1 to a doctor's appointment, staff did not apply the safety belts for R1, which resulted in R1 sustaining a non-displaced fracture of the lower leg. All corrective actions were completed on 04/18/23, prior to the onsite survey on 05/23/23, therefore the deficient practice was cited as past noncompliance and existed at a G scope and severity.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a sanitary environment when Resident (R) 15's urinary catheter (a tube placed in the body to drain and collect urine from the bladder) drainage bag and tubing touched the floor int he common areas, creating the risk for communicable pathogens. This deficient practice placed R15 and the other residents using the area at risk for transmission of infectious disease. Findings included: - R15's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (at the bottom of the spine), dementia (group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus (disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), and chronic kidney disease, stage 4 (kidneys are moderately or severely damaged and are not working as well as they should). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R15 required extensive of assistance of one staff for eating, two staff for toileting, bed mobility, and total assistance for dressing, transfers, locomotion and hygiene. The MDS documented R15 had a urinary catheter, and one PU, present on admission, The Catheter Care Plan, dated 02/16/23, stated R15 had a urinary catheter and directed staff to provide catheter care by every shift, monitor and document abnormalities of urinary output, and report significant changes to the health care provider. The care plan documented R15 had a catheter related to infection and directed staff to monitor for and document pain or discomfort due to the catheter and signs or symptoms of discomfort on urination and frequency. The Physician Order, dated 12/19/22, directed staff to insert a urinary catheter, and change the catheter every 30 days. On 03/06/23 at 01:08 PM, observation revealed R15 in a wheelchair in her room with the urinary catheter drainage bag and tubing touching the floor under her wheelchair. Further observation at 01:11 PM, Certified Nurse Aide (CNA) O wheeled R15 in her wheelchair to the therapy room down the 100 hall with approximately six inches of the catheter tubing and the privacy bag dragging on the floor the entire way. On 03/07/23 at 1152 AM, Administrative Staff B wheeled R15, in her wheelchair, from the dining room to her room with the catheter bag and tubing dragging on the floor the entire way. On 03/06/23 at 01:11 PM, Certified Nurse Aide (CNA) O verified staff should not allow the catheter tubing and bag to drag on the floor. On 03/07/23 at 1155 AM, Administrative Nurse D verified staff should not allow a urinary catheter bag or tubing to touch the floor or be dragged on the floor. The facility's Urinary Catheter policy, dated 11/28/2022, stated the drainage bag was to be positioned so that it was not touching the floor. The facility failed to ensure a sanitary environment when R15's urinary catheter drainage bag and tubing touched the floor in common areas, creating the risk for communicable pathogens. This deficient practice placed R15 and the other residents using the area at risk for transmission of infectious disease.

The facility had a census of 37 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, intervention, and record the facility failed to ensure Resident (R) 34 was free from staff abuse and/or mistreatment when Certified Nurse Aide (CNA) M forcefully took R34's bottle of apple juice from her. This deficient practice placed R34 at risk for injury or impaired psychosocial wellbeing. Findings included: - R34's Electronic Medical Record (EMR) documented diagnoses of pain, atrial fibrillation (an irregular and often very rapid heart rhythm), goiter (the irregular growth of the thyroid gland), hypertension (high blood pressure), rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles) and hearing loss. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 had no behaviors, and no falls. The MDS documented R34 required limited staff assistance for eating, extensive staff assistance for all other activities of daily living and she used a walker or a wheelchair. The Communication Care Area Assessment (CAA), dated 12/20/22, recorded R34 was hard of hearing but directed staff to speak close to R34 and slowly, and she was able to understand. R34 was able to communicate and make her needs known. The Nutrition Care Plan, dated 03/02/23, directed staff to invite R34 to food-related activities and offer food and beverages of choice to encourage intake. R34 was able to feed herself after set-up. The plan directed staff to provide the resident with as many choices as possible which gave the resident control over her environment and care delivery. The Skin Care Plan, dated 03/02/23, stated R34 was a high risk for skin injury and directed staff to use extra caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan directed staff to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, or bruises. The Weekly Skin Assessments, dated 02/09/23, 02/16/23, 02/23/23 all stated no new skin issues. The Incident Investigation, dated 02/26/23, documented on Sunday morning, February 26, 2023, during morning care a CNA noticed a bruise on R34's arm. The CNA asked the resident what happened and R34 reported that during the night shift she had scuffle with CNA M. The morning CNA reported the allegation to the charge nurse immediately. Licensed Nurse (LN) H interviewed the resident who reported to her that CNA M had told her she did not need to finish her apple juice and to drink water instead. R34 reported CNA M tried to take the juice away from her and they fought pretty good, and that was most likely the cause of the bruise. The charge nurse notified administration, who immediately notified CNA M he was suspended until further notice. The investigation documented Administrative Nurse D interviewed R34 and performed a skin assessment to ensure no other areas of concern. The investigation stated the current bruise determined to be unrelated to this incident. The investigation stated Abuse and Neglect education was given to all staff. The undated Witness Statement by CNA M stated he gave R34 a bottle of apple juice and asked her to slow down while drinking. He stated the resident ignored him, so he reached for the bottle to set it down. CNA M stated the resident pulled away moving the bottle away from but he managed to grab the bottle and asked R34 to let go. R34 refused to let go of the bottle and tried to pull the bottle away from CNA M's hand. CNA M documented he informed the resident he would not be able to rush back to her room to get her onto the toilet, but the resident did not care. CNA M documented he tried to get R34 to let go of the bottle and had to slowly move her fingertips from the bottle when she refused. The Weekly Skin Assessment, dated 03/02/23 stated no new skin issues and lacked documentation of the current bruise on the resident's upper right arm. R34's EMR lacked evidence of an assessment of R34 after the allegation of abuse. On 03/01/23 at 01:07 PM, during the interview of the alert and oriented R34, she stated she wanted some apple juice during the night and CNA M brought it. R34 stated after one swallow, CNA M tried to take it away and told her she did not need it. R34 stated we argued and fought over the bottle and it caused a bruise on her right arm. R34 stated CNA M had never abused her before, but had been rude, talking in a demeaning way to her questioning if she really needed to use the commode or assistance with other things, and he left the door open when she was uncovered. On 03/02/23 at 02:57 PM, Administrative Staff A stated Sunday morning February 26th, a staff nurse reported to her that R34 told an aide that her and CNA M had an incident and he grabbed her. She stated LN H interviewed the resident, who identified the staff as CNA M. Administrative Staff A stated the facility suspended CNA M and started an investigation. Administrative Staff A stated the facility had received reports against CNA M from other residents, including one incident that was witnessed by an alert and oriented resident. Administrative Staff A stated she interviewed other residents and staff for any concerns. Administrative Staff A stated the facility removed him from care for any resident who complained but verified there were normally only two aides during night shifts. At 03:12 PM, Administrative Nurse D stated CNA M was argumentative with R34 and he admitted to a scuffle with the resident, and he had stated he peeled her fingertips off the glass. Administrative Nurse D stated it was R34's right to drink the juice and she was not a choking risk. On 03/06/23 at 11:38 AM, Administrative Staff A stated CNA M was still suspended, and the facility had not terminated him yet. She stated the other two occasions of alleged abuse, CNA M had not admitted to the potential abuse so the facility could not substantiate those. On 03/07/23 at 11:07 AM, Administrative Nurse D stated the assessment of R34 after the allegation of abuse was documented in risk management, not the medical record. She stated she sent an email to the State Agency on Sunday, February 26, and reported the incident to police. Administrative Nurse D stated she had assigned all staff education for resident rights, person centered care and abuse, neglect, and exploitation. The facility's Abuse and Neglect policy, dated 10/13/22, stated the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation, The facility would not willingly employ or otherwise engage individuals who have been found guilty of abusing, exploiting or mistreating residents by a court of law or have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, or mistreatment of residents. Upon hire and annually education and training would be provided to employees on abuse and neglect. Alleged or suspected violations of mistreatment, neglect, or abuse including injuries of unknown source would be immediately reported to the administrator or their designated authority. The individuals were to intervene in any situation to protect residents. Remove any individual from the location if necessary for protection. Call local law enforcement. The facility would have evidence that all alleged or suspected violations were thoroughly investigated and would prevent further potential abuse during the investigation. The policy stated if there was an allegation of abuse, neglect, or mistreatment, including injuries of unknown source, and or serious bodily injury, the incident would be reported to the state agency immediately, but not later than two hours, after the allegation was made. If the abuse or neglect was substantiated, the results would be reported to the licensing board or appropriate state nurse aide registry. The facility failed to ensure freedom from abuse for R34 when CNA M caused bruising to the resident's arm when he fought with her over a bottle of apple juice, placing R34 at risk for injury and further abuse.

The facility had a census of 37 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to update the care plan with interventions aimed to prevent further falls for Resident (R) 9, who experienced 11 falls in the past 10 months. This deficient practice placed R9 at risk for further falls and potential injury. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), diarrhea (loose, watery stools that occur more frequently than usual), pain, lesion of sciatic nerve (injury to the nerve that controls the back and sides of the leg), and anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R9 had delusions (unshakable belief in something that is untrue), required limited assistance of one staff for walking in her room, extensive assistance of one staff for walking in the corridor, hygiene, and extensive assistance of two staff for bed mobility, transfers, dressing and toileting. The MDS documented R9's balance was impaired, requiring human assistance to stabilize. R9 had no range of motion impairment, no falls and R9 used a walker. The MDS documented R9 was frequently incontinent of urine and bowel and received diuretic (drug to increase the excretion of water from the body) medication. The Fall Care Area Assessment (CAA), dated 02/06/23, documented R9 required assistance with ambulation, surface to surface transfers and toileting. The Fall Care Plan, dated 12/15/22, documented R9 was at risk for falls related to confusion and a history of falls. The care plan directed staff to instruct the resident to use her walker at all times; remind her not to bend over to pick up dropped items; encourage her to use a grabber or to ask for assistance. The plan diercted staff to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility; monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. R9 required supervision to extensive assist at times, and directed to encourage resident to use her walker as she would walk off without it, initiated 05/06/22. Keep resident's bathroom light turned on with the door cracked enough for the resident to see when she awakened at night to maximize resident safety, initiated 06/01/22. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity, initiated 09/05/22. Review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls, initiated 09/23/22. Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs. Remind staff to follow care plan toileting interventions, initiated 10/30/22. Review resident's history of recent or recurrent falls between 12:00-01:00 AM, toileting plan changed to reflect 12:00 AM, staff education done, initiated 11/07/22. The Fall Risk Assessments, dated 05/03/22, indicated a medium risk for falls, 05/31/22 indicated high, 10/30/22 indicated medium, 12/02/22 indicated high, 01/20/23 indicated high, 02/21/23 indicated high. The Fall Note, dated 05/03/22 at 11:23 PM, documented staff found R9 lying on the floor at 09:30 PM in a hallway next to a wheelchair. R9 was immediately assessed for pain and was able to perform range of motion (ROM) to both upper and lower extremities without assistance and without pain. The nurse performed a neurological check (an evaluation of a person's nervous system) even though the resident denied hitting her head. R9 used her walker and ambulated independently with staff to her room for cares and further skin assessment. The Fall Note, dated 06/01/22 at 01:00 AM, documented at 01:00 AM staff heard R9 yelling help me from her room and found R9 lying on the floor next to her bathroom door. R9 stated she thought she was going to the bathroom but was unsure. She denied pain and was able to perform full ROM to both upper and lower extremities without difficulty or discomfort. She denied hitting her head and had no bumps or bruising noted to her head. Skin check revealed no new areas of concern or bruising at that time. R9 ambulated with her wheeled walker and staff stand by assist to the bathroom where she had a continent void. The nurse noted that her room lighting was very poor and R9 did not have her night light on, nor was the light in her bathroom on. The Fall Note, dated 09/05/222 at 04:50 PM, documented staff heard R9 crying for help and found R9 on the floor on her hands and knees. R9 was oriented to person and place, denied hitting her head, and her walker was in front of her. The Fall Note, dated 09/23/22 at 09:57 PM, documented R9 fell and bumped the back of her head on the employee bathroom door. No further information documented. The Fall Note, dated 10/30/22 at 02:51 AM, documented staff heard a loud noise and found R9 in her room, sitting on the floor up against wall between tv stand and bathroom. The bathroom door was shut with the light on. R9 was groggy and unable to describe what happened. Staff helped R9 to toilet and noted a four-millimeter (mm) abrasion inside, underneath her right elbow, actively bleeding. The nurse cleaned the wound and applied ointment. The Fall Note, dated 11/7/22 at 12:45 AM, documented staff heard R9 yelling for help and found R9 sitting upright on the floor on her buttocks in front of the bathroom door. No injuries noted and no pain or discomfort noted. The Fall Note, dated 12/12/22 at 07:11 PM, documented staff found R9 sitting on the floor in front of the loveseat in the common area. Another resident stated that R9 was standing then just sat in the floor. No injuries, pain or discomfort noted. No interventions were implemented after this incident. The Fall Note, dated 01/26/23, documented at about 01:45 AM, staff found R9 lying on the floor on her right side. No wound, skin tear nor bruises were found at the time of assessment, but R9 reported pain in her right hip on which she had been lying. The nurse notified the physician of the finding and that R9's oxygen level dropped to 71% after the fall. The physician ordered oxygen and breathing treatments, labs and a chest X-ray. No interventions were implemented after this incident. The Fall Note, dated 02/14/23 at 02:51 AM, documented at 02:30 AM, staff heard someone hollering out random words and upon entering R9's room found the resident lying parallel with her bed, on her right side, with blankets wrapped around her body. Upon assessment no new skin issues, no rotation noted to legs or arms, and R9 denied pain. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 12:20 AM, documented staff found R9 ambulating independently in the lobby area when she lost her balance and fell backwards on her bottom. She did not hit her head and no injuries were found. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 08:05 PM, documented staff heard a thud noise and then R9 stated help me, help me. Staff found R9 lying on her right side in the commons area next to her walker and a chair. Upon assessment able to move all extremities independently, no rotation or other injuries noted. R9 stated she hurt all over. No interventions were implemented after this incident. On 03/02/23 at 07:40 AM, observation revealed R9 sat in a high back wheelchair with anti-tip bars at a table in the commons area. Her eyes were closed, glasses on, she wore tennis shoes, and had a wanderguard (elopement) alarm on her left ankle. On 03/07/23 at 01:10 PM, Administrative Nurse D verified the care plan had not been reviewed or revised after each fall with interventions to prevent further falls. She stated staff try to keep R9 independent. The facility's Fall Prevention and Management policy, dated 03/30/22, directed staff to update the care plan with any changes or new interventions and monitor the effectiveness of the interventions. The facility's Comprehensive Care Plan policy, dated 06/09/21, stated in addition to updates during a care plan review, care plans must be revised as the resident's needs or status changed. The facility failed to update R9's care plan after falls to with relevant interventions to prevent falls for R9, who experienced 11 falls in the past 10 months, placing R9 at risk for further falls and potential injury.

The facility had a census of 37 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, intervention, and record the facility failed to ensure staff assessed Resident (R) 34 for physical and psychosocial impact after an incident of staff to resident abuse and/or mistreatment which resulted in a bruise. This deficient practice placed R34 at risk for unidentified injuries and psychosocial impairment resulting from staff to resident abuse (Refer to F600). Findings included: - R34's Electronic Medical Record (EMR) documented diagnoses of pain, atrial fibrillation (an irregular and often very rapid heart rhythm), goiter (the irregular growth of the thyroid gland), hypertension (high blood pressure), rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles) and hearing loss. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 had no behaviors, and no falls. The MDS documented R34 required limited staff assistance for eating, extensive staff assistance for all other activities of daily living and she used a walker or a wheelchair. The Communication Care Area Assessment (CAA), dated 12/20/22, recorded R34 was hard of hearing but directed staff to speak close to R34 and slowly, and she was able to understand. R34 was able to communicate and make her needs known. The Nutrition Care Plan, dated 03/02/23, directed staff to invite R34 to food-related activities and offer food and beverages of choice to encourage intake. R34 was able to feed herself after set-up. The plan directed staff to provide the resident with as many choices as possible which gave the resident control over her environment and care delivery. The Skin Care Plan, dated 03/02/23, stated R34 was a high risk for skin injury and directed staff to use extra caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan directed staff to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, or bruises. The Weekly Skin Assessments, dated 02/09/23, 02/16/23, 02/23/23 all stated no new skin issues. The Incident Investigation, dated 02/26/23, documented on Sunday morning, February 26, 2023, during morning care a CNA noticed a bruise on R34's arm. The CNA asked the resident what happened and R34 reported that during the night shift she had scuffle with CNA M. The morning CNA reported the allegation to the charge nurse immediately. Licensed Nurse (LN) H interviewed the resident who reported to her that CNA M had told her she did not need to finish her apple juice and to drink water instead. R34 reported CNA M tried to take the juice away from her and they fought pretty good, and that was most likely the cause of the bruise. The charge nurse notified administration, who immediately notified CNA M he was suspended until further notice. The investigation documented Administrative Nurse D interviewed R34 and performed a skin assessment to ensure no other areas of concern. The investigation stated the current bruise determined to be unrelated to this incident. The investigation stated Abuse and Neglect education was given to all staff. The undated Witness Statement by CNA M stated he gave R34 a bottle of apple juice and asked her to slow down while drinking. He stated the resident ignored him, so he reached for the bottle to set it down. CNA M stated the resident pulled away moving the bottle away from but he managed to grab the bottle and asked R34 to let go. R34 refused to let go of the bottle and tried to pull the bottle away from CNA M's hand. CNA M documented he informed the resident he would not be able to rush back to her room to get her onto the toilet, but the resident did not care. CNA M documented he tried to get R34 to let go of the bottle and had to slowly move her fingertips from the bottle when she refused. The Weekly Skin Assessment, dated 03/02/23 stated no new skin issues and lacked documentation of the current bruise on the resident's upper right arm. R34's EMR lacked evidence of an assessment of R34 after the allegation of abuse. On 03/01/23 at 01:07 PM, during the interview of the alert and oriented R34, she stated she wanted some apple juice during the night and CNA M brought it. R34 stated after one swallow, CNA M tried to take it away and told her she did not need it. R34 stated we argued and fought over the bottle and it caused a bruise on her right arm. R34 stated CNA M had never abused her before, but had been rude, talking in a demeaning way to her questioning if she really needed to use the commode or assistance with other things, and he left the door open when she was uncovered. At 03:12 PM, Administrative Nurse D stated CNA M was argumentative with R34 and he admitted to a scuffle with the resident and he had stated he peeled her fingertips off the glass. Administrative Nurse D stated it was R34's right to drink the juice and she was not a choking risk. On 03/07/23 at 11:07 AM, Administrative Nurse D verified the assessment of R34 after the allegation of abuse was not documented in R34's medical record. The facility's Abuse and Neglect policy, dated 10/13/22, stated the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy stated if there was an allegation of abuse, neglect, or mistreatment, including injuries of unknown source, and or serious bodily injury, the incident would be reported to the state agency immediately, but not later than two hours, after the allegation was made. If the abuse or neglect was substantiated, the results would be reported to the licensing board or appropriate state nurse aide registry. The facility failed to ensure staff assessed R34 for physical and psychosocial impact after an allegation of abuse which resulted in a bruise. This deficient practice placed R34 at risk for unidentified injuries and psychosocial impairment resulting from staff to resident abuse.

The facility had a census of 37 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to provide care and services to prevent falls for Resident (R) 9, who experienced 11 falls in the past 10 months. This deficient practice placed R9 at risk for further falls and potential injury. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), diarrhea (loose, watery stools that occur more frequently than usual), pain, lesion of sciatic nerve (injury to the nerve that controls the back and sides of the leg), and anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R9 had delusions (unshakable belief in something that is untrue), required limited assistance of one staff for walking in her room, extensive assistance of one staff for walking in the corridor, hygiene, and extensive assistance of two staff for bed mobility, transfers, dressing and toileting. The MDS documented R9's balance was impaired, requiring human assistance to stabilize. R9 had no range of motion impairment, no falls and R9 used a walker. The MDS documented R9 was frequently incontinent of urine and bowel and received diuretic (drug to increase the excretion of water from the body) medication. The Fall Care Area Assessment (CAA), dated 02/06/23, documented R9 required assistance with ambulation, surface to surface transfers and toileting. The Fall Care Plan, dated 12/15/22, documented R9 was at risk for falls related to confusion and a history of falls. The care plan directed staff to instruct the resident to use her walker at all times; remind her not to bend over to pick up dropped items; encourage her to use a grabber or to ask for assistance. The plan diercted staff to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility; monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. R9 required supervision to extensive assist at times, and directed to encourage resident to use her walker as she would walk off without it, initiated 05/06/22. Keep resident's bathroom light turned on with the door cracked enough for the resident to see when she awakened at night to maximize resident safety, initiated 06/01/22. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity, initiated 09/05/22. Review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls, initiated 09/23/22. Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs. Remind staff to follow care plan toileting interventions, initiated 10/30/22. Review resident's history of recent or recurrent falls between 12:00-01:00 AM, toileting plan changed to reflect 12:00 AM, staff education done, initiated 11/07/22. The Fall Risk Assessments, dated 05/03/22, indicated a medium risk for falls, 05/31/22 indicated high, 10/30/22 indicated medium, 12/02/22 indicated high, 01/20/23 indicated high, 02/21/23 indicated high. The Fall Note, dated 05/03/22 at 11:23 PM, documented staff found R9 lying on the floor at 09:30 PM in a hallway next to a wheelchair. R9 was immediately assessed for pain and was able to perform range of motion (ROM) to both upper and lower extremities without assistance and without pain. The nurse performed a neurological check (an evaluation of a person's nervous system) even though the resident denied hitting her head. R9 used her walker and ambulated independently with staff to her room for cares and further skin assessment. The Fall Note, dated 06/01/22 at 01:00 AM, documented at 01:00 AM staff heard R9 yelling help me from her room and found R9 lying on the floor next to her bathroom door. R9 stated she thought she was going to the bathroom but was unsure. She denied pain and was able to perform full ROM to both upper and lower extremities without difficulty or discomfort. She denied hitting her head and had no bumps or bruising noted to her head. Skin check revealed no new areas of concern or bruising at that time. R9 ambulated with her wheeled walker and staff stand by assist to the bathroom where she had a continent void. The nurse noted that her room lighting was very poor and R9 did not have her night light on, nor was the light in her bathroom on. The Fall Note, dated 09/05/222 at 04:50 PM, documented staff heard R9 crying for help and found R9 on the floor on her hands and knees. R9 was oriented to person and place, denied hitting her head, and her walker was in front of her. The Fall Note, dated 09/23/22 at 09:57 PM, documented R9 fell and bumped the back of her head on the employee bathroom door. No further information documented. The Fall Note, dated 10/30/22 at 02:51 AM, documented staff heard a loud noise and found R9 in her room, sitting on the floor up against wall between tv stand and bathroom. The bathroom door was shut with the light on. R9 was groggy and unable to describe what happened. Staff helped R9 to toilet and noted a four-millimeter (mm) abrasion inside, underneath her right elbow, actively bleeding. The nurse cleaned the wound and applied ointment. The Fall Note, dated 11/7/22 at 12:45 AM, documented staff heard R9 yelling for help and found R9 sitting upright on the floor on her buttocks in front of the bathroom door. No injuries noted and no pain or discomfort noted. The Fall Note, dated 12/12/22 at 07:11 PM, documented staff found R9 sitting on the floor in front of the loveseat in the common area. Another resident stated that R9 was standing then just sat in the floor. No injuries, pain or discomfort noted. No interventions were implemented after this incident. The Fall Note, dated 01/26/23, documented at about 01:45 AM, staff found R9 lying on the floor on her right side. No wound, skin tear nor bruises were found at the time of assessment, but R9 reported pain in her right hip on which she had been lying. The nurse notified the physician of the finding and that R9's oxygen level dropped to 71% after the fall. The physician ordered oxygen and breathing treatments, labs and a chest X-ray. No interventions were implemented after this incident. The Fall Note, dated 02/14/23 at 02:51 AM, documented at 02:30 AM, staff heard someone hollering out random words and upon entering R9's room found the resident lying parallel with her bed, on her right side, with blankets wrapped around her body. Upon assessment no new skin issues, no rotation noted to legs or arms, and R9 denied pain. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 12:20 AM, documented staff found R9 ambulating independently in the lobby area when she lost her balance and fell backwards on her bottom. She did not hit her head and no injuries were found. No interventions were implemented after this incident. The Fall Note, dated 02/21/23 at 08:05 PM, documented staff heard a thud noise and then R9 stated help me, help me. Staff found R9 lying on her right side in the commons area next to her walker and a chair. Upon assessment able to move all extremities independently, no rotation or other injuries noted. R9 stated she hurt all over. No interventions were implemented after this incident. On 03/02/23 at 07:40 AM, observation revealed R9 sat in a high back wheelchair with anti-tip bars at a table in the commons area. Her eyes were closed, glasses on, she wore tennis shoes, and had a wanderguard (elopement) alarm on her left ankle. On 03/07/23 at 01:10 PM, Administrative Nurse D verified the care plan had not been reviewed or revised after each fall with interventions to prevent further falls. She stated staff try to keep R9 independent. On 03/02/23 at 07:40 AM, observation revealed R9 sat in a high back wheelchair with anti-tip bars at a table in the commons area. Her eyes were closed, glasses on, she wore tennis shoes, and had a wanderguard (elopement) alarm on her left ankle. On 03/07/23 at 01:10 PM, Administrative Nurse D verified the falls care plan had not been reviewed and new interventions identified and implemented after each fall to prevent further falls. She stated staff try to keep R9 independent. The facility's Fall Prevention and Management policy, dated 03/30/22, directed staff to communicate fall risks and interventions to prevent falls per the 24-hour report, care plan, or meetings. The Fall Scene Huddle Worksheet was to be completed as soon as possible after a fall and used by the QAPI committee for follow up and not part of the medical record. The checklist, included in the policy, directed staff to update the care plan with any changes or new interventions and monitor the effectiveness of the interventions. The facility failed to provide supervision and identify and implement person-centered interventions to prevent falls for R9, who experienced 11 falls in the past 10 months, placing R9 at risk for further falls and potential injury.

The facility had a census of 37 residents. The sample included 12 residents with one reviewed for urinary catheter (a tube placed in the body to drain and collect urine from the bladder). Based on observation, intervention, and record review, the facility failed to ensure Resident (R) 15's urinary catheter drainage bag and tubing did not touch the floor. This deficient practice placed R15 at increased risk for urinary infection related to the use of the catheter. Findings included: - R15's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (at the bottom of the spine), dementia (group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus (disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), and chronic kidney disease, stage 4 (kidneys are moderately or severely damaged and are not working as well as they should). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R15 required extensive of assistance of one staff for eating, two staff for toileting, bed mobility, and total assistance for dressing, transfers, locomotion and hygiene. The MDS documented R15 had a urinary catheter, and one PU, present on admission, The Catheter Care Plan, dated 02/16/23, stated R15 had a urinary catheter and directed staff to provide catheter care by every shift, monitor and document abnormalities of urinary output, and report significant changes to the health care provider. The care plan documented R15 had a catheter related to infection and directed staff to monitor for and document pain or discomfort due to the catheter and signs or symptoms of discomfort on urination and frequency. The Physician Order, dated 12/19/22, directed staff to insert a urinary catheter, and change the catheter every 30 days. The Progress Note, dated 03/01/23 at 02:02 PM, documented Administrative Nurse D recatheterized R15 due to the urinary catheter had been removed during nightshift. The Progress Note, dated 03/03/23 at 11:22 AM, documented R15 was readmitted to the facility after hospitalization for sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), and urinary tract infection (UTI). The note documented R15 was quiet, not verbally responding to questions, and required total assistance with all activities of daily living. On 03/06/23 at 01:08 PM, observation revealed R15 sat in a wheelchair in her room with her urinary catheter drainage bag and tubing touching the floor under her wheelchair. Further observation at 01:11 PM, Certified Nurse Aide (CNA) O wheeled R15 in her wheelchair to the therapy room down the 100 hall with approximately six inches of the catheter tubing and the privacy bag dragging on the floor. On 03/07/23 at 11:52 AM, Administrative Staff B wheeled R15, in her wheelchair, from the dining room to her room with the catheter bag and tubing dragging on the floor. On 03/06/23 at 01:11 PM, Certified Nurse Aide (CNA) O verified staff should not allow the catheter tubing and bag to drag on the floor. On 03/07/23 at 1155 AM, Administrative Nurse D verified staff should not allow a urinary catheter bag or tubing to touch the floor or be dragged on the floor. The facility's Urinary Catheter policy, dated 11/28/2022, stated the drainage bag was to be positioned so that it was not touching the floor. The facility failed to ensure R15's urinary catheter drainage bag and tubing did not touch the floor, placing R15, who had a history of UTI and sepsis, at increased risk for urinary infection related to the use of the catheter.

The facility identified a census of 33 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and adequate transfer assistance for Resident (R) 1. On 10/17/22 at approximately 05:30 PM, Certified Nurse Aide (CNA) M assisted R1 out of the whirlpool tub. CNA M opened the whirlpool door, pulled the whirlpool chair out of the whirlpool bath, positioned the whirlpool chair next to R1's wheelchair, which was next to the whirlpool bath, and transferred R1. CNA M transferred R1 on her right side. R1 reached out with her left hand to steady herself and used the open whirlpool door which swung back and hit her right hand. This resulted in a displaced fracture of the mid-radius (the outside bone of the forearm) and the distal (furthest away from the body) ulna (inside bone of the forearm). Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), [CONDITION(S)] (paralysis of one side of the body) affecting the right dominant side, and [CONDITION(S)] (condition with disordered or absent language function). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. The MDS documented R1 required extensive assistance of one staff member providing weight bearing support for bed mobility, transfer, walking in room, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS further documented R1 was not steady and had balance issues during transitions and ambulation; she needed staff assistance to stabilize, had functional limitation in range of motion of her upper and lower extremities, and used a walker and a wheelchair for mobility. The Activity of Daily Living (ADL) Care Area Assessment (CAA) was not completed. The Fall CAA, dated 07/13/22, documented R1 required assistance for transfers and mobility. The ADL Care Plan, dated 07/07/22, directed staff to transfer and bathe R1 with assistance of one staff. The Skin Observation Note, dated 10/17/22, documented R1 received a hematoma to her right hand measuring 11 centimeters (cm) by 5.5 cm. The note documented R1 received a blood thinner and the last administration time was 10/17/22 at 08:57 AM. The Skin Observation Note further documented R1 had pulled on the whirlpool tub door with her good hand, it swung back into her weak right hand, and a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) immediately formed. Staff applied an ice pack to the back of R1's right hand and elevated the hand. The Risk Management Note dated 10/17/22 at 10:22 PM, documented an examination was performed regarding R1's hematoma to the top of her right hand from an incident on the previous shift during R1's bath. The area to the top of R1's right hand was significantly bruised. Slight bruising was also noted to R1's wrist as well as a raised bump area to the right wrist. R1 stated Yes, yes, yes, when asked if she had pain and rated her pain eight out of ten (0-10 pain scale with zero indicating no pain and 10 as the worst pain imaginable). Ice was applied to R1's right hand and wrist; the hand was elevated, and pain medication administered. When asked if she wanted to go the emergency room that night for an x-ray or wait until the morning, R1 replied No, no, tomorrow. The Communication Note, dated 10/17/22 at 10:53 PM, documented R1 reported the incident in the bath house at approximately 09:30 PM to 10:00 PM and staff tried to control R1's pain in her right hand/wrist. The Health Status Note, dated 10/18/22 at 12:13 PM, documented R1's staff notified primary care provider of R1's hematoma, pain, and increased swelling to her right hand/wrist and new orders were received to send R1 for x-rays of her wrist and arm. R1 was transported for the x-ray after lunch. The Radiology Report, dated 10/18/22, documented R1 had an acute minimally displaced fracture of the mid radius as well as the distal ulna. The Communication with Resident/Family Note, dated 10/18/22 at 05:10 PM, documented staff notified R1's durable power of attorney (DPOA) of R1's fractures to her right arm. The nurse also received new orders to immobilize the right arm and discuss with R1's DPOA which orthopedic (bone) doctor R1 preferred for consult. The Health Status Note, dated 10/21/22 at 04:34 PM, documented staff received an order for occupational therapy to evaluate R1; a long arm splint was placed on R1's right arm. The instruction given directed to keep the splint dry, cover for showers, keep in a sling unless showering. R1 was to follow up with an orthopedic center on Wednesday, 10/26/22. The Communication/Visit with Physician Note, dated 10/22/22 at 11:40 PM, documented R1 had visual signs of pain three hours after administration of pain medication. Staff called the emergency room for new orders to address the pain. Staff received a new order to administer a one-time extra dose of pain medication. On 10/24/22 at 10:30 AM, observation revealed R1 sat in her recliner with her legs elevated and her right arm in a long brace, supported by an arm sling. R1's fingers to her right hand were purple and swollen. On 10/24/22 at 10:30 AM, R1 could communicate by using one-word answers. When asked if R1's right arm hurt, R1 pointed to her arm in the sling, nodded and said, Hurt, hurt. When asked if R1's was in a lot of pain, R1 pointed to her arm and fingers and said, Yes, yes, yes. On 10/24/22 at 10:45 AM, Administrative Staff A and Licensed Nurse (LN) H assisted with a demonstration on how CNA M transferred R1 from the whirlpool chair to the wheelchair on 10/17/22. CNA M was on R1's right/weak side facing R1 with R1's flaccid right hand behind CNA M. When CMA M stood R1 with the gait belt, R1 reached out with her left hand and grabbed the whirlpool tub door for support and the whirlpool tub door swung back and hit R1's right hand. On 10/24/22 at 12:30 PM, CNA M stated that she was getting R1 out of the whirlpool. R1was seated on the whirlpool chair and she moved the whirlpool chair out right beside the whirlpool tub next to R1's wheelchair. After drying R1 off she applied a gait belt and went to transfer R1 to her wheelchair. CNA M stated she was R1's right/weak side and when R1 stood up she was unsteady and reached out with her left hand to grab a hold of the whirlpool tub door to steady herself and swung the whirlpool tub door back into her right hand. CNA M stated she finished getting R1 dressed and took her back to her room and then reported the incident to LN H. On 10/24/22 at 11:00 AM, Administrative Nurse D verified CNA M should not have transferred R1 to her weak/right side from the whirlpool bath chair. Administrative Nurse D said if the whirlpool bathtub door would have been secured, the broken arm would not have occurred. Upon request the facility could not provide a competency check list verifying CNA M was trained on whirlpool bathing and usage. Upon request, the facility did not provide an accident/occurrence policy. The facility failed to provide a safe environment free from avoidable accidents for R1, which resulted in an injury, and pain.

The facility had a census of 49 residents. The sample included 17 residents of which 2 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to identify causal factors for the development of a facility acquired pressure ulcer and initiate timely interventions to prevent worsening and promote healing, causing the ulcer to increase to a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle, as a result of pressure, or pressure in combination with shear and/or friction) pressure ulcer for 1 of the 2 sampled residents. (#10) Findings included: - Resident #10's quarterly (MDS) Minimum Data Set assessment, dated 9/14/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment revealed the resident required extensive 2 staff assistance for bed mobility, transfers, toilet use, personal hygiene, and had functional impairment of bilateral upper and lower extremities. The MDS further documented the resident had a Stage 1 pressure ulcer. The 7/09/2018 (ADL) Activities of Daily Living (CAA) Care Area Assessment documented the resident required extensive staff assistance with transfers, bed mobility, non ambulatory, and required a motorized wheelchair for mobility. The CAA documented the resident slept on his/her stomach when in bed. The CAA documented the resident had [MEDICAL CONDITION] (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth) which affected his/her ability to control movements and functional range of motion. The pressure ulcer CAA documented the resident at risk for skin breakdown. The quarterly Braden scale assessment for predicting pressure ulcer risk, dated 6/22/2018 and 9/14/2018, documented a score of 15.0 which indicated the resident at risk for pressure ulcer development. The 9/10/2018 care plan directed the staff to keep the resident's skin clean and dry and to reposition the resident with 2 staff. The care plan documented the resident had impaired mobility and was at risk for pressure ulcer development. The care plan lacked documentation and interventions regarding the resident's right elbow pressure ulcer, including pressure relieving treatment. The 9/19/2018 care plan directed the staff to provide elbow protectors to the resident's right elbow to decrease pressure, and to be worn at all times. The skin assessment, dated 8/17/2018, documented the resident had 1 open area noted on his/her right elbow, measuring 1.3 (cm) centimeters by 0.8 cm, and staff were waiting on orders for the skin treatment. The 8/17/2018 fax to the physician, documented the resident had a pressure ulcer to his/her right elbow, staff was unable to apply a dressing due to the location at the bend of the elbow, and no drainage noted. The physician directed staff to cleanse the wound, and apply dynanex cut hydrogel (a gel based wound dressing) gauze to fit the wound, apply barrier cream to surrounding tissue, and cover with a foam dressing The skin assessment, dated 8/21/2018, documented the resident had an unstageable pressure ulcer on his/her right elbow measuring 1.2 cm by 1.5 cm, and staff applied a dynanex cut hydrogel gauze to cover the wound, and applied barrier cream to surrounding tissue with a foam dressing. The skin assessments documented the following for the right elbow ulcer: 8/30/2018 Stage 1, 1.1 cm by 1.3 cm, continued with same treatment. 9/03/2018, 1.0 cm by 1.1 cm, continued same treatment. 9/10/2018, 1.1 cm by 1.0 cm, continued same treatment. 9/17/2018, Stage 2, 1.9 cm by 1.4 cm, improved surrounding tissue, skin red and cool to touch, wound cleanser, hydrogel gauze to the size of the wound, foam pad, and secured with kling dressing. 9/24/2018, Stage 2, 1.4 cm by 0.8 cm improved, continue same wound treatment. The 9/26/2018 at 11:57 AM, nurse's notes documented the physician verified to continue with the hydrogel dressing, off load the resident from applying pressure to his/her right elbow, and requested a nutritional consult. The skin assessment, dated 10/01/2018, documented a Stage 2 pressure ulcer right elbow, increased size, continue same treatment. The 10/03/2018 at 9:43 PM, nurse's note documented the resident weighed 77(lbs) pounds, fluctuating between 71-82 lbs the last 6 months. The note documented the resident received a multivitamin, liquid protein 30 (mls) milliliters once daily, and request to increase the liquid protein to twice daily. The skin assessment, dated 10/09/2018, documented a Stage 2 pressure ulcer right elbow, area improved, 0.7 cm by 0.9 cm, scabbed over, continue with same treatment. The 10/11/2018 at 4:31 PM, nurse's note, documented the nurse administered the nutritional liquid supplement 30(ml) milliliters daily and the resident spit it out and stated I don't want that. The skin assessment, dated 10/15/2018, documented pressure ulcer right elbow, 0.6 cm by 0.7 cm, no odor, no drainage, continue with same treatment. The skin assessment, dated 10/22/2018, documented an unstageable pressure ulcer, right elbow, 0.4 cm by 0.6 cm, no depth, area scabbed over, no pain, no odor or drainage, continue with same treatment. The skin assessment, dated 11/01/2018, documented an unstageable pressure ulcer, right elbow, 0.4 cm by 0.6 cm, scab covering the wound, continue with same treatment. The 11/01/2018 at 1:43 PM, nurse's note dated the resident weighed 71 lbs, and fluctuated between 70-82 lbs during the past 6 months. Resident received treatment to his/her Stage 2 pressure area to the right elbow, and staff provided multi vitamins and liquid protein three times a day for an extra 15 grams of protein. The skin assessment, dated 11/08/2018, documented a Stage 3 pressure ulcer, right elbow, 1.2 cm by 1.5 cm x 0.2 cm, worse, scab gone, noted depth to the wound. Granulation tissue noted to the wound bed, no odor, no drainage, surrounding tissue pink, intact, and blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation), continue with same treatment. The 11/17/2018 physician order [REDACTED]. The skin assessment, dated 11/15/2018, documented a pressure ulcer Stage 2, 0.7 cm by 1.1 cm redness blanchable. No odor, no drainage, cleansed with wound cleanser, applied hydrogel, foam overlap and kerlix to hold in place, continue same treatment. The skin assessment, dated 11/22/2018, documented a Stage 3 pressure ulcer right elbow, 1.1 cm by 1.3 cm by 0.2 cm, no drainage or odor, surrounding tissue pink, intact, and blanchable. Staff reminded the resident to not put pressure to the right elbow, the resident would not allow the staff to apply sheepskin to the arm of his/her wheelchair. The 11/27/2018 occupational therapy evaluation and plan of treatment documented an order to address the patient's position in the electric wheelchair. Resident exhibits exacerbation of reduced static and dynamic balance, decreased postural alignment, reduced functional activity tolerance, and decreased neuromotor control, placing the resident at risk for further decline in function, compromised general health, and decreased participation with functional tasks. Per nursing, the resident presents with safety concerns when seated in the power chair, increased leaning anteriorly/laterally, and unable to return to midline without assistance. Due to the documented physical impairments and associated functional deficits, the resident is at risk for further decline in function, immobility, decreased skin integrity and compromised general health. The 11/28/2018 physician's orders [REDACTED]. The skin assessment, dated 11/29/2018, documented a Stage 4 pressure ulcer, right elbow, 1.3 cm by 1.5 cm by 0.2 cm, continue with current wound orders. Fax sent to the physician to request [MEDICATION NAME] to help promote skin production. No documentation of a new physician order [REDACTED].>On 12/03/2018 the resident was admitted to the hospital for pneumonia. On 12/17/2018 at 9:50 AM, observation revealed the resident sat in a wheelchair in his/her room. Further observation revealed Nurse I removed the dressing from the resident's right elbow, cleansed the wound with wound cleanser, applied deuoderm to fit the area, and an elbow protector over the bandage. Continued observation revealed a 12 inch by 6 inch pillow placed under the resident's arm and the wheelchair arm rest. On 12/17/2018 at 10:10 AM, Nurse I verified the resident leaned to the right and he/she braced him/herself on the right elbow. Nurse I verified the resident developed the pressure ulcer (MONTH) (YEAR) and had gradually gotten worse. On 12/17/2018 at 10:20 AM, Therapy Staff HH stated the resident had an electric scooter and used the right hand to control the wheelchair. The resident had a therapy evaluation completed for positioning on 11/27/2018 and it was determined the resident was leaning and required lateral torso supports. Therapy Staff HH stated the resident had a storage bag attached with velcro on the right side of his/her wheelchair below the arm rest, and the bag and velcro was removed due to the potential of rubbing on the resident's elbow. On 12/17/2018 at 10:30 AM, Administrative Nurse D verified the resident developed the facility acquired pressure ulcer on his/her right elbow on 8/17/2018, which increased to a Stage 4, and the facility had not determined the reason or cause of the pressure ulcer. The 9/2016 facility Pressure Ulcer Policy documented to provide appropriate assessment and prevention of pressure ulcers as well as the treatment necessary. The policy documented each resident would have an initial skin assessment completed by the licensed nurse at the time of admission/readmission. Residents at risk for pressure ulcer development and those with pressure ulcers should be monitored daily for changes in their skin condition. The nursing staff responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurses. The residents who cannot reposition themselves independently, should be repositioned as often as directed by the care plan approaches. The facility failed to identify casual factors for the development of a facility acquired pressure ulcer and initiate timely interventions to prevent worsening and promote healing, causing Resident #10's pressure ulcer to increase to a Stage 4 pressure ulcer, placing the resident at risk for infection, and further skin breakdown.

The facility had a census of 30 residents. The sample included 3 residents who were reviewed for accidents. Based on observation, record review, and interview the facility failed to monitor and account for 2 of 3 sampled residents who walked away unattended while on a facility outing, placing the residents in immediate jeopardy. (#1, #2) Findings included: - Resident #1's 1/12/18 Admission Assessment documented the resident was admitted to the facility from the hospital, after he/she became confused, got lost walking in his/her community, and didn't know where he/she was at. The assessment documented the resident was to receive skilled services related to a change in condition: wandering, anxiety, mood/behavior, incontinence, vital signs, and pain. The assessment documented the resident was unable to find his/her way around familiar areas, had short term memory loss, and may be at risk for elopement. The 1/12/18 Admission Checklist section regarding risk for elopement was not completed. Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 6/29/18, recorded the resident had adequate hearing and vision, was understood, understood others, had a (BIMS) Brief Interview for Mental Status score of 10, indicating moderately impaired cognition, and no behaviors. The MDS recorded the resident required staff supervision with no setup help for locomotion on and off the unit, toilet use, and independent with bed mobility, transfers, walking in room and corridor, and dressing. The MDS recorded the resident's balance was steady, had no functional limitation in (ROM) Range of Motion, used a walker for mobility, was always continent of bowel and bladder, had no pain, and no falls. The 1/19/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident was independent with ADLs, with good balance. The CAA recorded the resident ambulated independently around the facility with staff supervision for location and safety. The 1/25/18, reviewed 6/29/18, ADL care plan recorded the resident had an ADL self-care deficit related to a [DIAGNOSES REDACTED]. The care plan recorded the resident was independent with toilet use, transfers, and ambulation using a (FWW) front wheeled walker. The care plan recorded the resident had potential for elopement related to confusion and being unhappy with placement in the facility. The care plan directed staff to offer to take the resident for a walk outdoors, and provide diversionary activities, such as folding towels, putting together jigsaw puzzles, reading the newspaper, etc. The care plan recorded staff placed a wander guard alarm (a wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person) on the resident to alert staff to the resident's movement, and to provide staff assistance as needed. The care plan directed staff to check placement of the wander guard 3 times per shift, and staff reviewed weekly at the risk meeting. The facility's incident investigation, dated 8/27/18, documented the incident occurred on 8/25/18 at 11:45 AM. The investigation documented facility staff were loading residents into the van after a parade, and in the commotion the resident, along with another resident, #2, wandered away. The resident had a history of [REDACTED]. The 8/25/18 at 12:55 PM nurse's note recorded Administrative Staff A walked in the door at 11:40 AM with the resident, and said the resident was picked up down the street, as staff were loading the van with the wheelchair residents, this resident was confused of what was going on and walked the wrong way down the street. The note recorded the resident stated, I was lost and didn't know where I was going, so I just started to walk. There was no change in the resident's orientation or cognition. Staff notified the resident's physician, family and administrator, and obtained the resident's vital signs, which were within normal limits for the resident. The note recorded staff completed a physical assessment, the resident denied pain, stated he/she felt fine, went to the bathroom and then to the main dining room for lunch. Per the facility report, at the time of the incident, the was daytime, and the weather was sunny and 88 degrees. The staff found the resident, along with resident #2, on Highway 14/Douglas Street that runs through town, which has moderate to heavy traffic. The residents would have passed across a set of railroad tracks, and a bridge crossing the Smoky(NAME)River, they walked from a heavier populated area to a less populated area, the road was paved and smooth. The 8/28/18 Risk for Elopement Assessment documented the resident's family/legal representative had voiced concerns that indicated the resident may try to leave or had wandering tendencies, the resident had verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip or stayed near the exit door. The assessment documented the resident had a history of [REDACTED]. On 8/29/18 at 12:18 PM, observation revealed the resident sat in the living room area, ambulated over toward the exit door setting off his/her wander guard alarm. Observation revealed when staff asked the resident to move away from the door, he/she followed directions without complaint, the resident was aware he/she was setting off the alarm by where he/she was standing and made no further attempts to exit the facility. On 8/28/18 at 4:34 PM, Administrative Nurse D stated the elopement occurred and was reported on Saturday, 8/25/18, staff assessed both residents, including vital signs, with no injuries noted. Administrative Nurse D stated both residents were smiling and laughing, and stated they had a good time, when staff found the 2 residents walking down the street approximately 3 to 3 ½ blocks away from the area where the facility van was loaded. On 8/28/18 at 5:45 PM, Administrative Nurse D's witness statement documented on 8/25/18 he/she received a phone call from the facility informing him/her that 2 residents had walked away from the group at the parade, so he/she drove into town and interviewed all staff members involved. Administrative Nurse D documented Activity Staff Z and AA were loading the big van and Activity Staff AA asked where Residents #1 and #2 were at. Activity Staff Z noticed that Administrative Staff A was already gone and thought maybe the 2 residents went with her/him. Activity Staff Z then called Administrative Staff A, he/she stated that he/she already had the 2 residents and they were headed back to the facility. Administrative Staff A stated he/she was driving and noticed the 2 residents walking, so he/she pulled the van over, there was no room in his/her van, so a local citizen offered to give the residents a ride back to the facility. Maintenance Staff U had gone into town looking for the residents. Administrative Nurse D documented he/she reviewed both resident's care plans and added in new interventions, and a new protocol was being placed for when residents go out of the building. Administrative Nurse D documented the new protocol included that any resident who was at risk for elopement would need to be 1 on 1 and the Activity Director, Social Services and Director of Nursing would decide what the correct ratio for staff to residents would be. On 8/29/18 at 8:55 AM, Administrative Staff A's witness statement documented on 8/25/18 staff and residents left the facility at 8:30 AM to go the city parade, they sat on the corner of Main Street and(NAME)Street/Highway 14. Administrative Staff A documented there were barricades after the bridge approximately 4 blocks away, and barricades right in front of the railroad tracks approximately 50 feet away. Administrative Staff A documented after the parade was finished, around 11:00 AM, and his/her van was loaded with the 3 residents he/she had taken to the parade, he/she went around a 2-block section, past a business on(NAME)Street and over the bridge. Administrative Staff A documented a small distance past the bridge he/she saw Residents #1 and #2 walking hand in hand on the side of the street, so he/she pulled the van over, and a local citizen, who was in front of him/her, also pulled over. Administrative Staff A documented he/she got out of his/her van and confronted the residents and told them they should not be walking. Administrative Staff A documented he/she did not have any room in his/her van, so at 11:31 AM, he/she tried to call Maintenance Staff U and Activity Staff Z, but did not get an answer, so the local citizen transported the residents back to the facility, arriving around 11:35 AM. Administrative Staff A documented when he/she found the residents, Resident #1 was smiling, when he/she was told he/she was not supposed to be walking, Resident #1 stated, Oh. The residents were found approximately 0.4 miles from the facility on(NAME)Street/Highway 14. On 8/29/18 at 9:38 AM, Activity Staff Z's witness statement documented on 8/25/18 around 8:35 AM, he/she took 14 residents and the activity assistant to the parade in the big van. Activity Staff Z stated the group sat at the corner of East Main Street and Douglas/Highway 14, there were barricades close to the railroad tracks about ½ block away from where they sat, the police were in front of the track guiding the parade. Activity Staff Z stated after the parade was finished, around 11:00 AM, Activity Staff Z and AA waited for Maintenance Staff U to go and get the vans, and then we started loading the residents. The witness statement documented Activity Staff Z stated he/she was picking up the same people he/she took down to the parade, he/she had Residents #1 and #2 in his/her van on the way down. Activity Staff Z documented staff were loading the residents, he/she was going to get the residents to put them up on the lift, and Activity Staff AA was taking the more independent residents up in the front, we worked together to get the residents on the van. Activity Staff Z stated he/she loaded 3 residents and saw Activity Staff AA loading the other van. Activity Staff Z documented he/she saw Residents #1 and #2 standing by the raised flower beds beside the vans, so he/she started loading the 4th resident. Activity Staff Z documented Activity Staff AA asked, Where's Resident #1 and Resident #2? Activity Staff Z stated, Aren't they in the van?, Activity Staff AA responded, No. Activity Staff Z documented Administrative Staff A was already loaded and had left, so he/she called Administrative Staff A at 11:35 AM, to see if he/she had the residents, he/she said, Yes, I do now. Activity Staff Z documented he/she finished loading the rest of the residents and brought them back to the facility around 11:45 AM. Activity Staff Z documented when he/she got back to the facility both residents were both acting fine, Resident #1 stated I don't think that I should have done that. Activity Staff Z documented he/she told the resident that he/she was just happy the residents were safe. Activity Staff Z stated both residents liked to walk, and Resident #1 would sometimes make comments that he/she wanted to leave. Activity Staff Z stated when the facility takes the residents on outings, to the zoo or fair, we have a list of every resident and every staff member knows who they are responsible for, we didn't feel like we needed to do that for the parade. On 8/29/18 at 10:17 AM, Maintenance Staff U's witness statement documented on 8/25/18 around 8:30 AM, he/she loaded the resident's wheelchairs into the facility truck, after the wheelchairs were loaded staff took the residents downtown to watch the parade. Maintenance Staff U documented after the parade was finished, around 11:00-11:15 AM, he/she got the vans and then went and got the pickup to load the wheelchairs, when he/she returned with the pickup, Activity Staff Z told him/her there were 2 resident's missing, Residents #1 and #2. Maintenance Staff U documented Activity Staff Z remembered Resident #1 stated he/she wanted Mexican food so Maintenance Staff U went down to the art gallery where Mexican food was being served, went inside and didn't see either resident so he/she went back to where the other residents were being loaded when Activity Staff Z informed him/her staff found and returned the 2 missing residents to the facility. Maintenance Staff U documented he/she felt it was his/her responsibility to help keep track of the residents while they were at the parade. Maintenance Staff U documented the facility had no real plan for designating who was responsible for each resident's whereabouts, all staff were to keep an eye on the residents. On 8/29/18 at 3:23 PM, Administrative Nurse D stated the facility had a list of all the residents who went down to the parade, we just did not keep track of which residents were in each van so we knew which staff member had which residents. The facility's Elopement policy dated (MONTH) 2013, documented the facility will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring and managing residents at risk for elopement. The facility failed to monitor and account for Resident #1 who eloped during a facility outing, and ambulated unattended by staff, down a busy highway for 0.4 miles before he/she was picked up and returned to the facility, placing the resident at risk for injury. The facility abated the immediate jeopardy on (MONTH) 29, (YEAR) at 8:00 PM, when the facility completed a new protocol for activity outings to ensure resident safety. The Administrator, DNS, social worker and activities director will discuss each activity outing prior and decide what appropriate supervision will be needed for reach resident. Also, anyone who has BIMs lower or equal to a 10 and/or at risk for elopement will be a 1 on 1 during activity outings. Training was provided to all staff in the facility regarding the new protocol, policy and procedure of elopement, policy and procedure of activity outings, and policy and procedure of behavioral causes and interventions. Each staff member was contacted individually and educated on above topics, completed a quiz to provide proof of education and acknowledgment of understanding. Education was completed between 8/29/2018 and 8/31/18. The facility will do quarterly elopement drills in facility, DNS will audit 5 staff members weekly for one month then monthly, alternating shifts on what signs and symptoms to look for on exit seeking residents and what to do if an elopement occurs. Administrator will audit any staff member helping with activity outing on staff to resident ratio, weekly risk team meetings will be held to review interventions used with all high risk elopement residents, with all findings brought to monthly QAPI meetings as well. The deficient practice remains at a scope and severity of a D. - Resident #2's Admission (MDS) Minimum Data Set assessment, dated 8/17/18, recorded the resident had adequate hearing and vision, clear speech, was understood, and understood others. The MDS recorded the resident had a (BIMS) Brief Interview for Mental Status score of 6, indicating severe cognitive impairment, and no behaviors. The MDS recorded the resident required staff supervision with setup help only for dressing, toilet use, personal hygiene, and independent with bed mobility, transfers, walking in room and corridor, and locomotion on and off the unit The MDS recorded the resident's balance was steady, had no functional limitation in (ROM) Range of Motion, was always continent of bowel and bladder, had no pain, and no falls. The 8/17/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident was independent with ADLs most all the time, and ambulated and transferred independently. The CAA recorded the resident required no assistive device and he/she had steady gait and balance. The 8/13/18 ADL care plan recorded the resident had a self-care performance deficit related to a [DIAGNOSES REDACTED]. The care plan recorded the resident was independent with ambulation, bed mobility, toilet use and transfers. The 8/27/18 care plan update recorded the resident had potential for elopement related to dementia, confusion, hovering around doors and would question the location of exits. The care plan directed staff to offer to take the resident for a walk outdoors, provide diversionary activities such as putting puzzles together, visiting with others and listening to music. The care plan recorded the resident wore a Wander Guard (a wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person) used to alert staff to the resident's movement and provide staff assistance as needed. The facility's Incident Investigation, dated 8/27/18, documented the incident occurred on 8/25/18 at 11:30 AM. The investigation documented facility staff and residents were getting up after the parade and amongst the commotion the resident, along with resident #1 got lost and walked away. The 8/25/18 at 12:50 PM, nurse's note recorded Administrative Staff A walked in the door at 11:40 AM with the resident and said that he/she had been picked up down the street because as staff were loading the van with the wheelchair residents, this resident was confused of what was going on and walked the wrong way down the street. The note recorded no change in cognition or orientation since the incident, vital signs were within normal limits for the resident, staff notified the resident's physician, director of nursing, administrator, and the resident's family. The note recorded the resident was unsure of what was going on and when asked he/she stated I don't know I was just walking and talking with him/her referring to resident #1 who was standing next to resident #2. The note recorded staff completed a physical assessment without abnormalities found, and the resident denied pain. Per the facility report, at the time of the incident, the was daytime, and the weather was sunny and 88 degrees. The staff found the resident, along with resident #2, on Highway 14/Douglas Street that runs through town, which has moderate to heavy traffic. The residents would have passed across a set of railroad tracks, and a bridge crossing the Smoky(NAME)River, they walked from a heavier populated area to a less populated area, the road was paved and smooth. The 8/13/18 Risk for Elopement assessment documented the resident was not at risk for elopement. On 8/28/18 at 4:13 PM, observation revealed the resident sat in the lobby area with 3 other residents. The resident looked at a magazine and visited with the other residents, no mobility assistive device nearby, a wander guard in place to the resident's right ankle, and he/she made no attempt to get up and leave the facility. On 8/28/18 at 4:34 PM, Administrative Nurse D stated the elopement occurred and was reported on Saturday, 8/25/18, staff assessed both residents, including vital signs, with no injuries noted. Administrative Nurse D stated both residents were smiling and laughing, and stated they had a good time, when staff found the 2 residents walking down the street approximately 3 to 3 ½ blocks away from the area where the facility van was loaded. On 8/28/18 at 5:45 PM, Administrative Nurse D's witness statement documented on 8/25/18 he/she received a phone call from the facility informing him/her that 2 residents had walked away from the group at the parade, so he/she drove into town and interviewed all staff members involved. Administrative Nurse D documented Activity Staff Z and AA were loading the big van and Activity Staff AA asked where Residents #1 and #2 were at. Activity Staff Z noticed that Administrative Staff A was already gone and thought maybe the 2 residents went with her/him. Activity Staff Z then called Administrative Staff A, he/she stated that he/she already had the 2 residents and they were headed back to the facility. Administrative Staff A stated he/she was driving and noticed the 2 residents walking, so he/she pulled the van over, there was no room in his/her van so a local citizen offered to give the residents a ride back to the facility. Maintenance Staff U had gone into town looking for the residents. Administrative Nurse D documented he/she reviewed both resident's care plans and added in new interventions, and a new protocol was being placed for when residents go out of the building. Administrative Nurse D documented the new protocol included that any resident who was at risk for elopement would need to be 1 on 1 and the Activity Director, Social Services and Director of Nursing would decide what the correct ratio for staff to residents would be. On 8/29/18 at 8:55 AM, Administrative Staff A's witness statement documented on 8/25/18 staff and residents left the facility at 8:30 AM to go the city parade, they sat on the corner of Main Street and(NAME)Street/Highway 14. Administrative Staff A documented there were barricades after the bridge approximately 4 blocks away, and barricades right in front of the railroad tracks approximately 50 feet away. Administrative Staff A documented after the parade was finished, around 11:00 AM, and his/her van was loaded with the 3 residents he/she had taken to the parade, he/she went around a 2 block section, past a business on(NAME)Street and over the bridge. Administrative Staff A documented a small distance past the bridge he/she saw Residents #1 and #2 walking hand in hand on the side of the street, so he/she pulled the van over, and a local citizen, who was in front of him/her, also pulled over. Administrative Staff A documented he/she got out of his/her van and confronted the residents and told them they should not be walking. Administrative Staff A documented he/she did not have any room in his/her van, so at 11:31 AM, he/she tried to call Maintenance Staff U and Activity Staff Z, but did not get an answer, so the local citizen transported the residents back to the facility, arriving around 11:35 AM. Administrative Staff A documented when he/she found the residents, Resident #1 was smiling, when he/she was told he/she was not supposed to be walking, Resident #1 stated, Oh. The residents were found approximately 0.4 miles from the facility on(NAME)Street/Highway 14. On 8/29/18 at 9:38 AM, Activity Staff Z's witness statement documented on 8/25/18 around 8:35 AM, he/she took 14 residents and the activity assistant to the parade in the big van. Activity Staff Z stated the group sat at the corner of East Main Street and Douglas/Highway 14, there were barricades close to the railroad tracks about ½ block away from where they sat, the police were in front of the track guiding the parade. Activity Staff Z stated after the parade was finished, around 11:00 AM, Activity Staff Z and AA waited for Maintenance Staff U to go and get the vans, and then we started loading the residents. The witness statement documented Activity Staff Z stated he/she was picking up the same people he/she took down to the parade, he/she had Residents #1 and #2 in his/her van on the way down. Activity Staff Z documented staff were loading the residents, he/she was going to get the residents to put them up on the lift, and Activity Staff AA was taking the more independent residents up in the front, we worked together to get the residents on the van. Activity Staff Z stated he/she loaded 3 residents and saw Activity Staff AA loading the other van. Activity Staff Z documented he/she saw Residents #1 and #2 standing by the raised flower beds beside the vans, so he/she started loading the 4th resident. Activity Staff Z documented Activity Staff AA asked, Where's Resident #1 and Resident #2? Activity Staff Z stated, Aren't they in the van?, Activity Staff AA responded, No. Activity Staff Z documented Administrative Staff A was already loaded and had left, so he/she called Administrative Staff A at 11:35 AM, to see if he/she had the residents, he/she said, Yes, I do now. Activity Staff Z documented he/she finished loading the rest of the residents and brought them back to the facility around 11:45 AM. Activity Staff Z documented when he/she got back to the facility both residents were both acting fine, Resident #1 stated I don't think that I should have done that. Activity Staff Z documented he/she told the resident that he/she was just happy the residents were safe. Activity Staff Z stated both residents liked to walk, and Resident #1 would sometimes make comments that he/she wanted to leave. Activity Staff Z stated when the facility takes the residents on outings, to the zoo or fair, we have a list of every resident and every staff member knows who they are responsible for, we didn't feel like we needed to do that for the parade. On 8/29/18 at 10:17 AM, Maintenance Staff U's witness statement documented on 8/25/18 around 8:30 AM, he/she loaded the resident's wheelchairs into the facility truck, after the wheelchairs were loaded staff took the residents downtown to watch the parade. Maintenance Staff U documented after the parade was finished, around 11:00-11:15 AM, he/she got the vans and then went and got the pickup to load the wheelchairs, when he/she returned with the pickup, Activity Staff Z told him/her there were 2 resident's missing, Residents #1 and #2. Maintenance Staff U documented Activity Staff Z remembered Resident #1 stated he/she wanted mexican food so Maintenance Staff U went down to the art gallery where mexican food was being served, went inside and didn't see either resident so he/she went back to where the other residents were being loaded when Activity Staff Z informed him/her staff found and returned the 2 missing residents to the facility. Maintenance Staff U documented he/she felt it was his/her responsibility to help keep track of the residents while they were at the parade. Maintenance Staff U documented the facility had no real plan for designating who was responsible for each resident's whereabouts, all staff were to keep an eye on the residents. On 8/29/18 at 3:23 PM, Administrative Nurse D stated the facility had a list of all the residents who went down to the parade, we just did not keep track of which residents were in each van so we knew which staff member had which residents. The facility's Elopement policy dated (MONTH) 2013, documented the facility will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring and managing residents at risk for elopement. The facility failed to monitor and account for Resident #2 who eloped during a facility outing, and ambulated unattended by staff, down a busy highway for 0.4 miles before he/she was picked up and returned to the facility, placing the resident at risk for injury. The facility abated the immediate jeopardy on (MONTH) 29, (YEAR) at 8:00 PM, when the facility completed a new protocol for activity outings to ensure resident safety. The Administrator, DNS, social worker and activities director will discuss each activity outing prior and decide what appropriate supervision will be needed for reach resident. Also, anyone who has BIMs lower or equal to a 10 and/or at risk for elopement will be a 1 on 1 during activity outings. Training was provided to all staff in the facility regarding the new protocol, policy and procedure of elopement, policy and procedure of activity outings, and policy and procedure of behavioral causes and interventions. Each staff member was contacted individually and educated on above topics, completed a quiz to provide proof of education and acknowledgment of understanding. Education was completed between 8/29/2018 and 8/31/18. The facility will do quarterly elopement drills in facility, DNS will audit 5 staff members weekly for one month then monthly, alternating shifts on what signs and symptoms to look for on exit seeking residents and what to do if an elopement occurs. Administrator will audit any staff member helping with activity outing on staff to resident ratio, weekly risk team meetings will be held to review interventions used with all high risk elopement residents, with all findings brought to monthly QAPI meetings as well. The deficient practice remains at a scope and severity of a D.

The facility had a census of 58 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to protect all (gender) residents from unwelcome sexual advances from 1 of 1 residents reviewed for behaviors (#66) which placed all (gender) residents in immediate jeopardy. The facility also failed to thoroughly investigate and report sexual behaviors/interactions to a state agency for 1 of 1 residents reviewed for behaviors. - Resident #66's physician's orders [REDACTED]. thought and emotions are so impaired that contact is lost with external reality), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). The quarterly (MDS) Minimum Data Set assessment, dated 12/18/2015, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3. The MDS indicated the resident was independent with bed mobility. The MDS indicated the resident required limited assistance with transfers, walking in room/corridor and walking off the unit. The MDS indicated the resident received antidepressant and antianxiety medications. The 12/28/2015 care plan, directed staff to cue, reorient, supervise, and redirect/reassure the resident as needed. The care plan indicated the resident had a wander guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on his/her left wrist to alert staff to the resident's movement. The care plan directed the staff to check the resident every 30 minutes for his/her location, provide cognitive stimulation and social interaction due to the resident's cognitive deficits, encourage him/her to participate in daily activities, and assist him/her on where to go. No behaviors, or resident to resident altercations documented. On 2/16/2016 at 11:23 AM, observation revealed the resident sat on the side of his/her bed visiting with his/her family member. The resident asked his/her family member what to do next, and his/her spouse stated it would be time to eat in a few minutes. On 2/17/2016 at 10:55 AM, observation revealed the resident stood up from a chair in the entry way to the facility, took two steps toward Resident #49, who was sitting in another chair, then bent down and touched his/her folded hands in his/her lap. Resident #49, who had his/her eyes closed, awoke with a startled appearance. Continued observation revealed no staff in the area. The 10/12/2015 at 9:59 AM, nurse's notes indicated the resident walked up and down the hall pleasantly confused, then stopped and visited with staff and other residents. Resident #66 told the staff, he/she wanted to kiss them on the cheek before he/she went walking again. The staff documented the resident frequently hugs or touches staff (female and male) arms and/or back. The 11/25/2015 at 4:48 PM, nurse's notes indicated the resident walked up behind Resident #49 in the dining room, bent down and kissed him/her on the cheek. Staff redirected and educated the resident that he/she should only kiss his/her spouse. Resident #49 stated he/she did not kiss him/her on the lips, and Resident #66 stated there would be time later when no one was watching. Staff did not provide further interventions. The 11/30/2015 at 8:45 PM, nurse's notes indicated the resident re-arranged lobby chairs to sit beside Resident #49. Observation revealed Resident #66 reached over and touched Resident #49's breast. Staff approached the resident stating that was inappropriate and the resident stated he/she was trying to clean the front of Resident #49's shirt. Staff suggested the resident prepare for bed in his/her room. The resident returned to the lobby without his/her walker and staff encouraged him/her to return to his/her room and walk with the walker. The resident became agitated, an pushed the staff and attempted to hit staff with his/her walker. Staff explained they would have to call his/her family member to explain the incident and the resident became apologetic. Staff did not provide further interventions. The 12/06/2015 at 3:30 PM, nurse's notes stated staff observed the resident in the front lobby with Resident #49 and stated he/she was not romantically or sexually interested in the other resident, but enjoyed visiting with him/her. The 12/06/2015 at 4:24 PM, nurse's notes documented Resident #66 walked up behind Resident #49, who sat in his/her wheelchair in the lobby, and leaned down and kissed him/her on the cheek. Staff did not provide further interventions. The 12/20/2016 at 8:59 PM, nurse's notes indicated the resident finished eating and went over to the next table and told Resident #43 he/she was beautiful and stated he/she was going to kiss him/her. Resident #43 stated he/she did not want to kiss, and Resident #66 stated he/she would not hurt him/her but just kiss. Resident #43 again stated no, that he/she did not want to kiss and staff arrived, redirected the resident to the lobby, and informed him/her that his/her actions were inappropriate. The resident became agitated and informed the staff to mind their own business. The resident continued to approach and be physically forward with, other female residents as the evening progressed. The resident told Resident #52 he/she would look him/her up later on tonight. Staff did not provide further interventions. The 1/02/2016 at 6:23 PM, nurse's notes documented Resident #66 informed Resident #52 what room he/she lived in and to come over to his/her room later on tonight. Resident #66 told Resident #52 he/she was strong and could make it to his/her room later on in the night. Resident #66 asked Resident #52 if he/she had clothes to bring then stated maybe they are not going to need clothes. Resident #66 stated he/she would love to keep Resident #52 warm at night. Staff did not provide further interventions. The 1/03/2016 at 6:10 PM, nurse's notes stated staff observed Resident #66 kissing Resident #52 on the lips. Staff informed the resident that was inappropriate behavior and he/she needed to stop. The resident stated nothing was wrong and staff reminded him/her that they were still married to other people. Resident #66 voiced that he/she was separated from his/her spouse and that their marriage was over. The staff informed the resident they were responsible for his/her well-being and Resident #66 verbalized some profanity at the staff then turned and walked away. Staff did not provide further interventions. The 1/06/2016 at 6:41 PM, nurse's notes documented staff observed Resident #66 in the lobby beside the residents' commons bathroom and visualized him/her leaning over and kissing Resident #52 on the lips. Staff heard the resident making plans to accommodate him/her tonight. Staff interrupted the resident who became very offensive and questioned the staff how kissing someone was wrong. Staff explained to him/her that he/she was still married and the resident became upset and stated his/her marriage was over a long time ago. Staff did not provide further interventions. The 1/16/2016 at 1:32 PM, nurse's notes stated the resident was very agitated, and verbalized he/she did not belong in the facility and was unsure why he/she was still in the building. Resident #66 stated he/she would just walk out if he/she did not get some answers about why he/she does not get to talk to his/her family member. Staff informed the resident his/her spouse lived at a retirement home duplex and attempted to redirect the resident with music, bible, TV, then called his/her family member due to staff not being able to redirect the resident. The resident continued to be agitated, and pacing, and staff administered [MEDICATION NAME] (an anti-anxiety medication) as needed for agitation. The [MEDICATION NAME] was not effective in calming down the resident. The 1/16/2016 at 4:27 PM, nurse's notes documented the staff overheard the resident tell another resident he/she was coming out of a divorce and decided to move on. Resident #66 stated it was a big mistake and he/she had his/her eyes on another resident, but every time he/she wanted to do something with the other resident the staff comes along and interrupts. Resident #66 stated he/she would get his/her gun and take care of a couple of staff walking by. Staff did not provide further interventions. The 1/16/2016 at 6:00 PM, nurse's notes documented Resident #22 motioned for staff to come over where he/she was sitting by Resident #66. Resident #22 told the staff that Resident #66 asked him/her to have sex with him/her. He/she told Resident #66 no but he/she continued on talking about having sex. Staff interceded and Resident #22 walked away. Staff told Resident #66 that it was inappropriate behavior and he/she needed to stop. Resident #66 became verbally threatening to the staff and told the staff he/she would show him/her what inappropriate was. The staff informed the resident to relax and leave the other residents alone. Staff did not provide further interventions. The 1/16/2016 at 9:03 PM, nurse's notes documented the staff spoke with the resident's spouse about the resident becoming verbally and physically aggressive and the family member became very upset and stated he/she had hoped he/she would not do this to others. The family member indicated he/she did not like to come to visit the resident, because each time he/she visited the resident, he/she became more abusive. The resident accused his/her family member of taking the retirement checks, spending them, buying a new car, running around with the opposite sex, and he/she would get his/her gun and put an end to it. Resident #66 stated he/she would end it all and commit suicide. The resident's family member stated he/she was beginning to be afraid of him/her and it was the worst the resident had been. Staff suggested the family member to talk to the Director of Nursing and Social Services about available options. The 1/17/2016 at 12:52 PM, nurse's notes documented staff overheard the resident verbally yelling at another resident to shut his/her mouth. The residents were seated in the foyer in separate chairs and the other resident did not acknowledge being spoken to or being yelled at. Staff redirected Resident #66 and the other resident went to his/her room. Staff overheard Resident #66 stating he/she use to work with the other resident and he/she could not hit the other resident back then but nothing was stopping him/her now, and then the resident walked to the dining room without incident. Staff did not provide further interventions. The 1/17/2016 at 4:08 PM, nurse's notes documented the resident seated in the lobby and asked a Certified Medication aide if they had heard that he/she had been told he/she had been molesting some of the residents at the facility. The resident's spouse was to have a meeting to discuss the incidents. Resident #66 stated he/she would not hurt anyone, and was not aware he/she was doing anything like that, and would try not to do it anymore. The 1/17/2016 at 6:45 PM, nurse's notes documented the resident told staff when he/she was separated from Resident #52 that he/she wanted to buy a gun and end it all and stated his/her family member deserved better than that. The resident stated he/she felt like he/she was in jail and should start acting like that. Resident #66 stated he/she was going to start getting violent with others. The resident stated he/she was old but could still throw people across the room, and if that does not work, he/she would get a gun from someplace and just take care of everybody. Staff administer the resident's as needed medication to prevent further escalation of the situation. Staff did not provide further interventions. The 1/18/2016 at 11:08 AM, nurse's notes documented the facility licensed social worker spoke with the (DPOA) Durable Power of Attorney in regards to the resident's behaviors over the weekend. The contract licensed clinical social worker recommended contacting the physician and start the resident on [MEDICATION NAME] (an antipsychotic medication to treat mood swings from high to low). The nurse faxed the physician in regards to the [MEDICATION NAME]. The contract licensed clinical social worker felt the resident was not a threat to him/herself at this time. The facility licensed social worker visited with another facility in regards to a bed available on the special care unit, and there was not one available. The DPOA did not want the resident transferred to another facility due to the distance, his/her health, and age. The licensed social worker informed the administrator and nurse of this and the staff would continue to monitor. The 1/30/2016 at 4:00 PM, nurse's notes documented the staff observed the resident kissing Resident #52 in the front lobby. Staff informed the resident that it was inappropriate behavior and he/she denied kissing the other residents. Staff did not provide further interventions. The 1/30/2016 at 7:00 PM, nurse's notes indicated the resident sitting in the lobby holding hands with Resident #52. Resident #49 came up to the residents and told Resident #52 to leave his/her spouse alone. Resident #66 got up and out of his/her chair and threatened to hit Resident #49. Resident #66 stated he/she would hit him/her if he/she did not keep his/her mouth shut. Resident #66 was not able to be redirected and staff administered [MEDICATION NAME] 0.5 mg to the resident for agitation. Staff did not provide further interventions. The 2/01/2016 at 7:58 PM, nurse's notes documented Resident #66 sat in the front lobby with Resident #52 and asked staff if they could look the other way so he/she could sneak Resident #52 in his/her room to have sex. Staff informed the resident he/she was married and they could not allow that kind of activity to happen. Resident #66 became upset, short tempered, and stated he/she was not married anymore and his/her spouse took off on him/her last week. Resident #66 later on stopped staff in the hallway and asked how much money it would cost him/her to have sex with them. Staff informed the resident the facility does not allow that and reminded the resident he/she was married. Resident #66 told staff he/she thought the facility was a sex retreat for married couples with open relationships. The resident asked how much he/she would have to pay to have sex with him/her. Staff redirected the resident to the lobby. Staff did not provide further interventions. The 2/06/2016 at 9:22 PM, nurse's notes stated Resident #66 kissed Resident #52. Resident #66 and became agitated when staff informed him/her that Resident #52 did not understand and did not know who Resident #66 was. Resident #66 became upset and proceeded to bump the medication aide into the medication cart and threatened to hit him/her. Staff did not provide further interventions. The 2/08/2016 at 3:01 PM, nurse's notes stated Resident #66 was in the dining room at the beverage/snack bar and walked up to another resident and tried to kiss him/her, and the resident refused. Resident #66 became mad, tossed his/her walker, cursed and left the area. The staff tried to redirect the resident when he/she got mad and left the area. Staff did not provide further interventions. The 2/13/2016 at 9:30 PM, nurse's notes indicated Resident #66 and Resident #45 had an altercation. The staff spoke with the resident and his/her mood improved during that time. Staff administered [MEDICATION NAME] and the resident stated he/she felt better and would go to bed. The nurse posted a nurse aide outside of the door to monitor for any additional altercations. The 2/15/2016 at 4:39 PM, nurse's notes indicated staff spoke with the resident's spouse regarding the resident's incident with the roommate over the weekend and the DPOA wanted the resident in a private room due to his/her dementia with behaviors. On 2/17/2016 at 9:30 AM, Medication Aide G stated Resident #66 likes to kiss and hold hands with other residents and staff have to monitor his/her where about's. The staff tried to redirect him/her, and administer medication if he/she becomes agitated. Staff are unable to redirect the resident during the inappropriate behaviors and interactions. Medication Aide G stated when the resident's family member comes to the facility he knows what he/she is doing and will not display the inappropriate behaviors. On 2/17/2016 at 2:15 PM, Social Service Staff F stated when the facility first admitted the resident, he/she was upset about nursing home placement. In the last few months, he/she had an increase in sexual interactions and altercations with other residents and the facility monitor the resident during the incidents and altercations. The staff notified the DPOA and families if and when the incident was going on. When the two residents' families were notified they responded and stated the residents were cognitively impaired and they did not know what they are doing and it was innocent. Social Service Staff F stated the license social worker followed up with the resident weekly and sent recommendations to the resident's physician. Social Service Staff F stated the resident's family member did not want him/her to go to a special care units, or to the special care locked unit in another facility. On 2/17/2015 at 2:30 PM, Administrative Nurse B stated he/she was aware of the interactions/altercations the resident had with (gender) residents at the facility and verified he/she notified the family members and/or DPOA. Administrative Nurse B stated the resident saws the licensed social worker on a weekly basis he/she had suggested the resident start on [MEDICATION NAME]. The facility failed to get the return fax in a timely manner as of 2/18/2016 the facility still did not have the [MEDICATION NAME] although the physician ordered the medication 32 days after the contract social worker recommended the medication. Administrative Nurse B stated the resident's exit seeking behaviors started shortly after admission to the facility and the inappropriate sexual interactions started in October. On 2/17/2016 at 5:10 PM, Nurse E stated the resident had a fondness for Resident #52. Staff redirected the resident and removed him/her away from Resident #52, and the resident becomes upset. On 2/18/2015 at 12:45 PM, Administrative Staff C stated he/she was not aware of all the nurse's notes and documentation regarding Resident #66's behaviors and interactions with the other residents. On 2/17/2016 at 2:30 PM, Administrative Nurse B verified the resident to resident sexual abuse regarding unwelcome advances and the physical aggression from Resident #66 and verified the incident had stated the facility had not completed any further investigation into the incidents. Administrative Nurse B stated the resident has not had any in patient mental health interventions since the incident and his/her spouse had refused mental health in patient evaluations. Administrative Nurse B verified he/she did not call the incidents into the State agency. The facility's February 2014 Abuse and Neglect policy indicated a resident had the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Resident must not be subject to abuse by anyone, including but not limited to, center staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator and to other officials in accordance with state law, including the state survey and certification agency. In the absence of the administrator from the center, the following individuals have the administrative authority of the administrator for purpose of immediate reporting of alleged violations: the director of nursing services or the director of social services. These designated individuals are delegated the authority by the administrator to: 1) Intervene in any situation in order to protect residents. 2) Remove any individual from the facility if necessary for the protection of residents or staff, including but not limited to employees, visitors, contractors or family members. 3) Call local law enforcement for assistance with interventions necessary for the protection of residents or staff. 4) Call 911 for any type of emergency assistance. 5) Ensure that all residents are not subjected to abuse by anyone, including , but not limited to , location staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. The center will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to the officials in accordance with state law, including to the state survey and certification agency within five working days of the incidents, or sooner as designated by state law. If the alleged or suspected violations is verified, appropriate corrective action will be taken. The facility abated the immediate jeopardy on 2/18/16 after completion of training of all staff regarding the protection of all residents during resident to resident behaviors and implementation of 1 of 1 as needed. The training also included the importance of following the abuse, neglect and exploitation policy, following up with the physician, and protection of residents. The deficient practice was abated to a scope and severity of an F. The facility failed to provided adequate supervision for Resident #66 who displayed sexual behaviors and protect the residents in the facility from resident to resident altercations.

The facility identified a census of 58 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to keep residents from being sexually and physically abused by 1 of 1 residents reviewed for behaviors. (#66) - Resident #66's physician's orders [REDACTED]. thought and emotions are so impaired that contact is lost with external reality), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). The quarterly (MDS) Minimum Data Set assessment, dated 12/18/2015, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3. The MDS indicated the resident was independent with bed mobility. The MDS indicated the resident required limited assistance with transfers, walking in room/corridor and walking off the unit. The MDS indicated the resident received antidepressant and antianxiety medications. The 12/28/2015 care plan, directed staff to cue, reorient, supervise, and redirect/reassure the resident as needed. The care plan indicated the resident had a wander guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on his/her left wrist to alert staff to the resident's movement. The care plan directed the staff to check the resident every 30 minutes for his/her location, provide cognitive stimulation and social interaction due to the resident's cognitive deficits, encourage him/her to participate in daily activities, and assist him/her on where to go. No behaviors, or resident to resident altercations documented. On 2/16/2016 at 11:23 AM, observation revealed the resident sat on the side of his/her bed visiting with his/her family member. The resident asked his/her family member what to do next, and his/her spouse stated it would be time to eat in a few minutes. On 2/17/2016 at 10:55 AM, observation revealed the resident stood up from a chair in the entry way to the facility, took two steps toward Resident #49, who was sitting in another chair, then bent down and touched his/her folded hands in his/her lap. Resident #49, who had his/her eyes closed, awoke with a startled appearance. Continued observation revealed no staff in the area. The 10/12/2015 at 9:59 AM, nurse's notes indicated the resident walked up and down the hall pleasantly confused, then stopped and visited with staff and other residents. Resident #66 told the staff, he/she wanted to kiss them on the cheek before he/she went walking again. The staff documented the resident frequently hugs or touches staff (female and male) arms and/or back. The 11/25/2015 at 4:48 PM, nurse's notes indicated the resident walked up behind Resident #49 in the dining room, bent down and kissed him/her on the cheek. Staff redirected and educated the resident that he/she should only kiss his/her spouse. Resident #49 stated he/she did not kiss him/her on the lips, and Resident #66 stated there would be time later when no one was watching. Staff did not provide further interventions. The 11/30/2015 at 8:45 PM, nurse's notes indicated the resident re-arranged lobby chairs to sit beside Resident #49. Observation revealed Resident #66 reached over and touched Resident #49's breast. Staff approached the resident stating that was inappropriate and the resident stated he/she was trying to clean the front of Resident #49's shirt. Staff suggested the resident prepare for bed in his/her room. The resident returned to the lobby without his/her walker and staff encouraged him/her to return to his/her room and walk with the walker. The resident became agitated, an pushed the staff and attempted to hit staff with his/her walker. Staff explained they would have to call his/her family member to explain the incident and the resident became apologetic. Staff did not provide further interventions. The 12/06/2015 at 3:30 PM, nurse's notes stated staff observed the resident in the front lobby with Resident #49 and stated he/she was not romantically or sexually interested in the other resident, but enjoyed visiting with him/her. The 12/06/2015 at 4:24 PM, nurse's notes documented Resident #66 walked up behind Resident #49, who sat in his/her wheelchair in the lobby, and leaned down and kissed him/her on the cheek. Staff did not provide further interventions. The 12/20/2016 at 8:59 PM, nurse's notes indicated the resident finished eating and went over to the next table and told Resident #43 he/she was beautiful and stated he/she was going to kiss him/her. Resident #43 stated he/she did not want to kiss, and Resident #66 stated he/she would not hurt him/her but just kiss. Resident #43 again stated no, that he/she did not want to kiss and staff arrived, redirected the resident to the lobby, and informed him/her that his/her actions were inappropriate. The resident became agitated and informed the staff to mind their own business. The resident continued to approach and be physically forward with, other female residents as the evening progressed. The resident told Resident #52 he/she would look him/her up later on tonight. Staff did not provide further interventions. The 1/02/2016 at 6:23 PM, nurse's notes documented Resident #66 informed Resident #52 what room he/she lived in and to come over to his/her room later on tonight. Resident #66 told Resident #52 he/she was strong and could make it to his/her room later on in the night. Resident #66 asked Resident #52 if he/she had clothes to bring then stated maybe they are not going to need clothes. Resident #66 stated he/she would love to keep Resident #52 warm at night. Staff did not provide further interventions. The 1/03/2016 at 6:10 PM, nurse's notes stated staff observed Resident #66 kissing Resident #52 on the lips. Staff informed the resident that was inappropriate behavior and he/she needed to stop. The resident stated nothing was wrong and staff reminded him/her that they were still married to other people. Resident #66 voiced that he/she was separated from his/her spouse and that their marriage was over. The staff informed the resident they were responsible for his/her well-being and Resident #66 verbalized some profanity at the staff then turned and walked away. Staff did not provide further interventions. The 1/06/2016 at 6:41 PM, nurse's notes documented staff observed Resident #66 in the lobby beside the residents' commons bathroom and visualized him/her leaning over and kissing Resident #52 on the lips. Staff heard the resident making plans to accommodate him/her tonight. Staff interrupted the resident who became very offensive and questioned the staff how kissing someone was wrong. Staff explained to him/her that he/she was still married and the resident became upset and stated his/her marriage was over a long time ago. Staff did not provide further interventions. The 1/16/2016 at 1:32 PM, nurse's notes stated the resident was very agitated, and verbalized he/she did not belong in the facility and was unsure why he/she was still in the building. Resident #66 stated he/she would just walk out if he/she did not get some answers about why he/she does not get to talk to his/her family member. Staff informed the resident his/her spouse lived at a retirement home duplex and attempted to redirect the resident with music, bible, TV, then called his/her family member due to staff not being able to redirect the resident. The resident continued to be agitated, and pacing, and staff administered [MEDICATION NAME] (an anti-anxiety medication) as needed for agitation. The [MEDICATION NAME] was not effective in calming down the resident. The 1/16/2016 at 4:27 PM, nurse's notes documented the staff overheard the resident tell another resident he/she was coming out of a divorce and decided to move on. Resident #66 stated it was a big mistake and he/she had his/her eyes on another resident, but every time he/she wanted to do something with the other resident the staff comes along and interrupts. Resident #66 stated he/she would get his/her gun and take care of a couple of staff walking by. Staff did not provide further interventions. The 1/16/2016 at 6:00 PM, nurse's notes documented Resident #22 motioned for staff to come over where he/she was sitting by Resident #66. Resident #22 told the staff that Resident #66 asked him/her to have sex with him/her. He/she told Resident #66 no but he/she continued on talking about having sex. Staff interceded and Resident #22 walked away. Staff told Resident #66 that it was inappropriate behavior and he/she needed to stop. Resident #66 became verbally threatening to the staff and told the staff he/she would show him/her what inappropriate was. The staff informed the resident to relax and leave the other residents alone. Staff did not provide further interventions. 1/16/2016 at 9:03 PM, nurse's notes documented the staff spoke with the resident's spouse about the resident becoming verbally and physically aggressive and the family member became very upset and stated he/she had hoped he/she would not do this to others. The family member indicated he/she did not like to come to visit the resident, because each time he/she visited the resident, he/she became more abusive. The resident accused his/her family member of taking the retirement checks, spending them, buying a new car, running around with the opposite sex, and he/she would get his/her gun and put an end to it. Resident #66 stated he/she would end it all and commit suicide. The resident's family member stated he/she was beginning to be afraid of him/her and it was the worst the resident had been. Staff suggested the family member to talk to the Director of Nursing and Social Services about available options. The 1/17/2016 at 12:52 PM, nurse's notes documented staff overheard the resident verbally yelling at another resident to shut his/her mouth. The residents were seated in the foyer in separate chairs and the other resident did not acknowledge being spoken to or being yelled at. Staff redirected Resident #66 and the other resident went to his/her room. Staff overheard Resident #66 stating he/she use to work with the other resident and he/she could not hit the other resident back then but nothing was stopping him/her now, and then the resident walked to the dining room without incident. Staff did not provide further interventions. The 1/17/2016 at 4:08 PM, nurse's notes documented the resident seated in the lobby and asked a Certified Medication Aide if they had heard that he/she had been told he/she had been molesting some of the residents at the facility. The resident's spouse was to have a meeting to discuss the incidents. Resident #66 stated he/she would not hurt anyone, and was not aware he/she was doing anything like that, and would try not to do it anymore. The 1/17/2016 at 6:45 PM, nurse's notes documented the resident told staff when he/she was separated from Resident #52 that he/she wanted to buy a gun and end it all and stated his/her family member deserved better than that. The resident stated he/she felt like he/she was in jail and should start acting like that. Resident #66 stated he/she was going to start getting violent with others. The resident stated he/she was old but could still throw people across the room, and if that does not work, he/she would get a gun from someplace and just take care of everybody. Staff administer the resident's as needed medication to prevent further escalation of the situation. Staff did not provide further interventions. The 1/18/2016 at 11:08 AM, nurse's notes documented the facility licensed social worker spoke with the (DPOA) Durable Power of Attorney in regards to the resident's behaviors over the weekend. The contract licensed clinical social worker recommended contacting the physician and start the resident on [MEDICATION NAME] (an antipsychotic medication to treat mood swings from high to low). The nurse faxed the physician in regards to the [MEDICATION NAME]. The contract licensed clinical social worker felt the resident was not a threat to him/herself at this time. The facility licensed social worker visited with another facility in regards to a bed available on the special care unit, and there was not one available. The DPOA did not want the resident transferred to another facility due to the distance, his/her health, and age. The licensed social worker informed the administrator and nurse of this and the staff would continue to monitor. The 1/30/2016 at 4:00 PM, nurse's notes documented the staff observed the resident kissing Resident #52 in the front lobby. Staff informed the resident that it was inappropriate behavior and he/she denied kissing the other residents. Staff did not provide further interventions. The 1/30/2016 at 7:00 PM, nurse's notes indicated the resident sitting in the lobby holding hands with Resident #52. Resident #49 came up to the residents and told Resident #52 to leave his/her spouse alone. Resident #66 got up and out of his/her chair and threatened to hit Resident #49. Resident #66 stated he/she would hit him/her if he/she did not keep his/her mouth shut. Resident #66 was not able to be redirected and staff administered [MEDICATION NAME] 0.5 mg to the resident for agitation. Staff did not provide further interventions. The 2/01/2016 at 7:58 PM, nurse's notes documented Resident #66 sat in the front lobby with Resident #52 and asked staff if they could look the other way so he/she could sneak Resident #52 in his/her room to have sex. Staff informed the resident he/she was married and they could not allow that kind of activity to happen. Resident #66 became upset, short tempered, and stated he/she was not married anymore and his/her spouse took off on him/her last week. Resident #66 later on stopped staff in the hallway and asked how much money it would cost him/her to have sex with them. Staff informed the resident the facility does not allow that and reminded the resident he/she was married. Resident #66 told staff he/she thought the facility was a sex retreat for married couples with open relationships. The resident asked how much he/she would have to pay to have sex with him/her. Staff redirected the resident to the lobby. Staff did not provide further interventions. The 2/06/2016 at 9:22 PM, nurse's notes stated Resident #66 kissed Resident #52. Resident #66 and became agitated when staff informed him/her that Resident #52 did not understand and did not know who Resident #66 was. Resident #66 became upset and proceeded to bump the medication aide into the medication cart and threatened to hit him/her. Staff did not provide further interventions. The 2/08/2016 at 3:01 PM, nurse's notes stated Resident #66 was in the dining room at the beverage/snack bar and walked up to another resident and tried to kiss him/her, and the resident refused. Resident #66 became mad, tossed his/her walker, cursed and left the area. The staff tried to redirect the resident when he/she got mad and left the area. Staff did not provide further interventions. The 2/13/2016 at 9:30 PM, nurse's notes indicated Resident #66 and Resident #45 had an altercation. The staff spoke with the resident and his/her mood improved during that time. Staff administered [MEDICATION NAME] and the resident stated he/she felt better and would go to bed. The nurse posted a nurse aide outside of the door to monitor for any additional altercations. The 2/15/2016 at 4:39 PM, nurse's notes indicated staff spoke with the resident's spouse regarding the resident's incident with the roommate over the weekend and the DPOA wanted the resident in a private room due to his/her dementia with behaviors. On 2/17/2016 at 9:30 AM, Medication Aide G stated Resident #66 likes to kiss and hold hands with other residents and staff have to monitor his/her where abouts. The staff tried to redirect him/her, and administer medication if he/she becomes agitated. Staff are unable to redirect the resident during the inappropriate behaviors and interactions. Medication Aide G stated when the resident's family member comes to the facility he knows what he/she is doing and will not display the inappropriate behaviors. On 2/17/2016 at 2:15 PM, Social Service Staff F stated when the facility first admitted the resident, he/she was upset about nursing home placement. In the last few months, he/she had an increase in sexual interactions and altercations with other residents and the facility monitor the resident during the incidents and altercations. The staff notified the DPOA and families if and when the incident was going on. When the two residents' families were notified they responded and stated the residents were cognitively impaired and they did not know what they are doing and it was innocent. Social Service Staff F stated the license social worker followed up with the resident weekly and sent recommendations to the resident's physician. Social Service Staff F stated the resident's family member did not want him/her to go to a special care units, or to the special care locked unit in another facility. On 2/17/2015 at 2:30 PM, Administrative Nurse B stated he/she was aware of the interactions/altercations the resident had with (gender) residents at the facility and verified he/she notified the family members and/or DPOA. Administrative Nurse B stated the resident saw the licensed social worker on a weekly basis he/she had suggested the resident start on [MEDICATION NAME]. The facility failed to get the return fax in a timely manner as of 2/18/2016 the facility still did not have the [MEDICATION NAME] although the physician ordered the medication 32 days after the contract social worker recommended the medication. Administrative Nurse B stated the resident's exit seeking behaviors started shortly after admission to the facility and the inappropriate sexual interactions started in October. On 2/17/2016 at 5:10 PM, Nurse E stated the resident had a fondness for Resident #52. Staff redirected the resident and removed him/her away from Resident #52, and the resident becomes upset. On 2/18/2015 at 12:45 PM, Administrative Staff C stated he/she was not aware of all the nurse's notes and documentation regarding Resident #66's behaviors and interactions with the other residents. The facility's February 2014 Abuse and Neglect policy indicated a resident had the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Resident must not be subject to abuse by anyone, including but not limited to, center staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator and to other officials in accordance with state law, including the state survey and certification agency. In the absence of the administrator from the center, the following individuals have the administrative authority of the administrator for purpose of immediate reporting of alleged violations: the director of nursing services or the director of social services. These designated individuals are delegated the authority by the administrator to: 1) Intervene in any situation in order to protect residents. 2) Remove any individual from the facility if necessary for the protection of residents or staff, including but not limited to employees, visitors, contractors or family members. 3) Call local law enforcement for assistance with interventions necessary for the protection of residents or staff. 4) Call 911 for any type of emergency assistance. 5) Ensure that all residents are not subjected to abuse by anyone, including , but not limited to, location staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. The center will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to the officials in accordance with state law, including to the state survey and certification agency within five working days of the incidents, or sooner as designated by state law. If the alleged or suspected violations is verified, appropriate corrective action will be taken. The facility failed to protect residents from resident to resident sexual abuse regarding unwanted sexual advances from Resident #66, verbal abuse, and the resident to resident altercations.

The facility had a census of 57 residents. The sample included 4 residents. Based on observation, interview, and record review the facility failed to provide an environment free of accident hazards for 1 of 4 residents reviewed for accidents. Cognitively impaired Resident #1, who required extensive assistance for toileting, fell from the toilet when left unattended and sustained a laceration to his/her forehead requiring emergency care. Findings included: - Resident #1's significant change (MDS) Minimum Data Set assessment, dated 5/4/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3, and required extensive assistance from 2 staff for bed mobility, transfers, and toilet use. The MDS further indicated the resident's balance was unsteady, only able to stabilize with staff assistance, and had a lower extremity range of motion impairment on 1 side. The MDS indicated the resident frequently incontinent of urine, and had 1 non-injury fall. The 5/4/15 fall (CAA) Care Area Assessment indicated the resident had a fall, on 5/1/15, when he/she transferred independently to the bathroom, which resulted in no injury. The CAA further indicated the resident has dementia (progressive mental disorder characterized by failing memory, confusion), which affected his/her cognition, decision making, and safety measures. The 5/13/15 care plan informed the staff the resident was a fall risk due to an unsteady gait, and impaired balance. The care plan instructed the staff to provide a personal alarm to alert staff of the resident's movement, and to monitor the resident every 30 minutes for restlessness, or frequent attempts to get up. The 5/1/15 fall risk evaluation indicated the resident at high risk for falls. The 5/21/15 at 2:45 PM, nurse's note indicated staff found the resident on the floor, in his/her room, lying on his/her right side. The note further indicated the resident had a laceration, above his/her right eyebrow, which was bleeding and measured 3 (cm) centimeters. The note stated the staff received a physician's orders [REDACTED]. The 5/21/15 at 8:36 PM, nurse's note indicated the resident returned from the emergency room after treatment for [REDACTED]. The note further indicated staff placed chair, bed, and floor alarms due to resident safety concerns. The 5/21/15 emergency room report indicated the resident received 7 sutures to the laceration above the resident's right eyebrow directed staff to remove the sutures in 1 week. Review of the 5/21/15 facility investigation revealed Nurse Aide B had left the resident alone, on the toilet, to check on another resident whose alarm was sounding. On 6/8/15 at 3:51 PM, observation revealed the resident, seated in his/her recliner, with his/her feet elevated and a personal alarm attached. Further observation revealed Nurse Aide B in the room to take the resident for a walk. Nurse Aide B told the resident what he/she was doing, lowered his/her legs, applied a gait belt, and assisted the resident to stand with a walker. Continued observation revealed the resident ambulated with assistance of staff and a walker down the hallway. On 6/8/15 at 3:54 PM, Nurse Aide B verified staff should stay with the resident when he/she used the toilet. On 6/9/15 at 10:00 AM, Nurse C stated last year the facility introduced a new policy which instructed staff, that a resident who had a personal alarm was not to be left alone in the bathroom. Nurse C further stated the facility communicated the new policy through a communication book, and a staff meeting. On 6/9/15 at 11:13 AM, Administrative Nurse A verified staff had left the resident on the toilet alone despite the new policy. Administrative Nurse A verified 6 staff are usually scheduled for the evening shift. Administrative Nurse A verified staff were notified of the policy change in November by mini in-services, in the communication book, verbally informing staff, and during staff in service. On 6/11/15 at 11:30 AM, Nurse Aide B verified he/she was the only nurse aide on the hall at the time of the resident's fall. Nurse Aide B stated he/she had heard another resident's alarm sounding while the resident was on the toilet and felt it was important to check on the other resident. The facility's 11/17/14 Residents' with Chair Alarm Procedure policy instructed staff to remain with a resident in the bathroom if he/she used a personal alarm. The facility failed to provide adequate supervision when staff left Resident #1, on the toilet unattended, and he/she fell and sustained a laceration to his/her forehead requiring sutures to close the wound.

The facility had a census of 58 residents. The sample included 17 residents. Based on observation, record review and interview, the facility failed to develop and implement interventions in a timely manner to prevent pressure sores from developing for 1 of 1 resident reviewed for pressure ulcers, resident #19 who developed an avoidable, unstageable pressure sore on his/her left heel. Findings included: - Resident #19's quarterly (MDS) Minimum Data Set assessment, dated 11/05/2014, indicated the resident had severely impaired cognition, and required extensive assistance of 2 staff with (ADLs) Activities of Daily Living for bed mobility, dressing, toilet use, and personal hygiene and total dependence with transfers. The MDS indicated the resident had no skin conditions, no pressure ulcers, no venous or arterial ulcers, and had a pressure reducing device on his/her bed and chair. The significant change MDS, dated [DATE], indicated the resident had severely impaired cognition, and required extensive assistance of two staff for ADLs. The MDS indicated the resident had a Stage II pressure ulcer on 11/29/2014, had a pressure reducing device to his/her bed and chair, pressure ulcer/surgical wound care, application of non-surgical dressing, and applications of ointments/ medication other than to his/her feet. No measurements of the area. The 12/11/2014 (CAAs) Care Area Assessment indicated the resident had a Stage II pressure ulcer noted on 11/29/2014, and on 12/01/2014, the area measured 5 (cm) centimeters x 5 cm and was dark purple in the center and the borders white. The 9/19/2014 care plan indicated the resident had a potential for pressure ulcer development and was at risk for skin breakdown due to urinary incontinence, dementia, and impaired mobility. The care plan indicated the staff would reposition the resident every two hours and notify the the nurse of any new areas of skin breakdown. The 12/11/2014 updated care plan indicated the resident had an unstageable pressure ulcer develop on his/her left heel with eschar (dead tissue) due to immobility. The 11/24/2014 Braden assessment scale, for predicting pressure sore risk, revealed a score of 13, which indicated he/she was at moderate risk. The 8/29/2014 dietary assessment indicted the resident weighted 167#. the registered dietician recommended the resident received assistance with his/her meal intake, and received a protein supplement, and super cookie once a day. The 12/02/2014 dietary assessment indicated the resident weighed 155 pounds, and he/she had skin issues on his/her left heel. The registered dietician recommended, the resident received assistance with his/her meal intake, a super cookie in the afternoon, multi vitamin, and Prostat (a nutritional supplement with increased protein) 30 (cc) cubic centimeter twice a day to promote healing. The 11/24/2014 at 2:34 PM, nurse's notes indicated the resident arrived at the facility from the hospital for a fractured left hip. The nurse's notes stated the resident had a surgical incision to his/her left hip, did not ambulate, and had bowel and bladder incontinence. The documentation revealed no other skin issues. The 11/25/2014 at 12:56 PM, nurse's notes indicated the resident had capillary refill (is the amount of time it takes for the blood flow/color to return to the skin) less than 3, and slight non [MEDICAL CONDITION] (swelling)noted to the left ankle and foot. The notes indicated the resident required extensive assistance with all (ADLs) Activities of Daily Living. The 11/27/2014 at 3:25 AM, nurse's notes indicated the staff repositioned the resident every two hours or when he/she hollered out for help, and the staff noted the resident had left leg swelling from the knee up. The 11/29/2014 at 9:47 PM, nurse's notes indicated the aides alerted the nurse to the resident's room and verified the resident had an open sore above the left heel. The nurse notes indicated the staff cleaned the area and applied a mini island (non stick [MEDICATION NAME] dressing), and notified the physician of a purple area on the resident's left heel. The clinical records indicated staff informed the Director of Nursing and he/she stated they would look at the area on Monday (two days after the staff identified the area). The nurse applied pressure reliving boots and floated the resident's heels. (The clinical record had no further documentation regarding measurements, or specific characteristics of the open area). The 12/02/2014 physician's orders [REDACTED]. The note stated if the wound opened up, consult with a wound specialist would be advised. The 12/04/2014 at 1:55 PM, nurse's notes indicated the resident left the facility and went to the hospital. Continued review revealed the resident had a venous doppler (ultrasound to evaluate blood flow) that was negative for a venous [MEDICAL CONDITION] (blood clot) in the left lower extremity. The 12/06/2014 physician's orders [REDACTED]. The (TAR) Treatment Administration Record stated on 12/02/2014 to cleanse the left heel with a wound cleanser, apply [MEDICATION NAME] and cover [MEDICATION NAME] dressing (a super absorbent dressing that cushions wounds and traps drainage while protecting the skin) every day for a Stage II pressure ulcer. Further review of the TAR revealed no mention of the sulfadine and bactracin cream as ordered by the physician on 12/02/14. Continued review revealed the physician discontinued the order for sulfadine and [MEDICATION NAME] cream on 12/06/2014. The TAR indicated on 12/07/2014 the physician order [REDACTED]. On 1/07/2015 at 3:45 PM, Administrative Nurse C stated he/she had not see the physician's orders [REDACTED]. Nurse C verified the facility applied [MEDICATION NAME] to the residents wound instead of the physican's treatment order. The left heel pressure ulcer record included the date, length x width, exudate (drainage) amount, and tissue type, which combined produced a total score: 17 is the highest score, decreasing to zero, and the score decreased with healing to a score of zero which indicated a resolved ulcer. 1) 12/01/2014 - 5 x 5, no exudate, no tissue type score 10 2) 12/08/2014 - 4.5 x 5.5, no exudate, no tissue type, score 9 3) 12/15/2014 - 4.5 x 4.8, no exudate amount, tissue type, score 13 4)12/22/2014 - 4.3 x 4.8 no exudate tissue type 4, score 13 5) 12/29/2014 - 4.3 x 4.7, no exudate, tissue type 4, score 13 6) 01/05/2015 - 4.3 x 4, no exudate, tissue type 4, score 13 The 12/23/2014 at 12:48 PM, nurse's notes verified the physician ordered a referral to a wound care specialist physician and the staff scheduled an appointment on January 8th 2015. On 12/31/2014 at 7:25 AM, observation revealed the resident sat in a wheelchair in the living room with a pressure relieving boot on his/her left heel, and the foot appeared shiny and purple. On 12/31/2014 at 10:50 AM, observation revealed the resident lying in bed on his/her back, with pressure relieving boots to both feet with his/her heels floated on a pillow. Nurse H removed the resident's left boot and revealed a black area approximately 4 x 4 cm with the skin cracked open, no drainage noted, no dressings were on or applied to the ulcer and staff had applied [MEDICATION NAME] (antiseptic agent used on the skin/surface to destroy viruses/germs) to the blackened area prior to the observation. On 1/05/2015 at 9:41 AM, Administrative Nurse C stated the resident readmitted to the facility on [DATE], and the pressure ulcer developed on the resident's left heel on 11/29/ 2014. Administrative Nurse A verified the resident had left lower leg [MEDICAL CONDITION] and had worn shoes until staff noted the ulcer. Administrative Nurse A verified he/she did not think the nurses performed an adequate skin assessment of the resident after the hospitalization . Administrative Nurse C verified the other contributing factors to the development of the pressure ulcer included the [MEDICAL CONDITION] in his/her left lower leg and the footwear/shoes the staff put on that did not fit properly. Administrative Nurse C verified the staff failed to float the resident's heels after he/she returned from the hospital with a [MEDICAL CONDITION]. On 1/06/2015 at 11:00 AM, Nurse Aide I verified the resident had a [MEDICAL CONDITION]. Nurse Aide I stated the staff did not float the resident's heels until after the pressure ulcer developed. Nurse Aide I verified the resident had a pressure relieving mattress on the bed after returning from the hospital and recently the physician directed the staff to place pressure reducing boots on both heels when the resident was in bed and on the left heel when he/she was up in the wheelchair. On 1/08/2015 at 1:35 PM, Physician M verified on 12/02/2014 he/she ordered sulfadine and bactracin cream to apply to the left heel wound and the facility failed to follow his/her order for the treatment of [REDACTED]. The facility's 2/2012 Pressure ulcer/Skin prevention policy indicated the staff would assess the residents with regard to risk of skin breakdown, accurately document observation and assessment of the resident, appropriately use preventative techniques and pressure redistribution surface on those residents at risk for pressure ulcers. The residents would have a comprehensive skin inspection done by the licensed nurse on admission/readmission to identify any skin issues present including, but not limited to, pressure ulcers and the results documented. A comprehensive assessment, which included the Resident Assessment Instrument (RAI), would be completed by the registered nurse evaluating the resident's risk factors, the residents condition, and the nature of the pressure to which the resident may be subjected. The assessment should identify which risk factors could be removed or modified. Residents who are unable to reposition themselves independently would be repositioned as often as directed by the care plan approaches. A systematic skin inspection would be made daily by the nursing assistant assigned to the residents at risk for skin breakdown. The nursing assistant responsible for this would report any abnormal findings or signs of skin impairment to the licensed nurse. If the resident developed a pressure ulcer, the physician would be notified and obtain orders for the treatment. The facility failed to develop and implement timely interventions to prevent an avoidable unstageable pressure ulcer to Resident #19's left heel after he/she returned from the hospital with a [MEDICAL CONDITION] and required more assistance with positioning.