Every finding on record at Good Samaritan-Liberal

Based on observation, interview, and record review, the facility failed to identify and implement measures consistent with and in accordance with professional standards of practice to prevent the development of and promote the healing of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 9, who developed a facility acquired, unstageable, deep tissue injury to her right heel. The staff failed to monitor skin checks weekly, failed to ensure R9's heels were offloaded, and failed to ensure R9 received the required interventions including a low air loss mattress to prevent pressure ulcer development. Additionally, the facility failed to monitor R1's wound for two weeks. Findings included:- R9's Electronic Medical Record (EMR) revealed diagnoses of leukemia (malignant disease affecting bone marrow) and arthritis (inflammation of a joint characterized by pain, swelling, redness, and limitation of movement). R9's 02/07/2026 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11,which indicated moderately impaired cognition. R9's MDS documented no behaviors or refusals of cares. She was independent with activities of daily living (ADL) including bed mobility to roll left and right, and she required supervision for transfers. R9 was at risk of developing pressure ulcers/injuries, had no skin issues, did not use a pressure reducing mattress and/or cushion, and did not require repositioning. R9's 02/13/2026 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R9 had potential for pressure ulcer development related to immobility, and staff would immediately notify the nurse of any new areas of skin breakdown noted during daily care. R9's 05/08/2026 Quarterly MDS documented a BIMS of five, indicating severely impaired cognition. R9 required supervision/touch assistance for bed mobility. She was at risk of developing pressure ulcers/injuries, had no skin issues, no pressure-reducing mattress, and was on a repositioning program. R9's Care Plan, dated 02/03/2026, revealed staff were instructed that R9 required one staff assistance with bed mobility, as she was not always able to turn side to side. R9's Care Plan, dated 02/13/2026, revealed staff were instructed to notify the nurse immediately of any new areas of skin breakdown, which included: redness, blister, bruises, discoloration, etc. noted during bath or daily care. R9's Care Plan lacked any preventative interventions related to the resident's skin, until 06/17/2026 when staff noted a deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) on right heel. R9's Braden Scale (scale used to predict pressure ulcer risk), dated 02/02/2026, revealed a score of 13, which indicated moderate risk. R9's 06/17/2026 Physician's Orders documented the resident's heels were to be floated when in bed. Heel protectors would be placed on the resident when out of bed every shift for a DTI of the right heel. The staff would apply Skin-prep (liquid skin protectant) to the DTI of the right heel, once a day. R9's Weekly Skin Check in the EMR lacked evidence of skin checks completed on the resident since admission on [DATE] through 06/17/2026. R9's Weekly Skin Check, dated 06/17/2026 at 04:41 PM, documented a skin issue that had not been evaluated. The location of the skin issue was the right heel and identified as a pressure ulcer/injury, unstageable, and presenting as deep tissue injury. The wound was acquired in-house (in the facility). The Weekly Skin Issue, dated 06/17/2026 at 05:07 PM, documented a new wound to R9's right heel. The injury was noted to be an unstageable, deep tissue injury. The wound measured 1.59 centimeters (cm) in length, 1.31 cm in width, and had no depth documented. R9's Weekly Skin Check, dated 06/17/2026 at 10:22 AM, revealed a slight increase in the wound measurement and noted there was no open area; slight redness to the wound margins blanched with immediate return. R9 reported slight pain in the area but stated the pain was not increasing. R9's Weekly Skin Issue, dated 06/24/2026 at 10:46 AM, documented a right heel stable previously deteriorating wound characteristics plateaued. Right heel unstageable pressure injury presenting as deep tissue injury. Wound was acquired in-house on 06/17/2026. The right heel DTI measured a length of 1.54 cm and a width of 2.73 cm; surrounding tissue noted erythema (redness or inflammation of the skin). R9's EMR lacked evidence of a turning and repositioning program. R9's Hospice Binder lacked any progress notes for care or information regarding the resident's wound. R9's EMR lacked nutritional notes related to her wounds. On 06/23/2026 at 07:28 AM, observation revealed R9 was in a low bed, her eyes were closed, and her heels were flat on the bed. On 06/23/2026 at 08:49 AM, Certified Nurse Aide (CNA) M assisted R9 to her bedside commode, R9 wore shoes. On 06/23/2026 at 11:15 AM, R9 lay in bed with no pillow or bootie noted under her heels. Licensed Nurse (LN) H folded a blanket and lifted the resident's right heel off the mattress. On 06/23/2026 at 12:30 PM, R9 was in the dining room having lunch; she had no heel booties on. On 06/24/2026 at 07:50 AM, R9 was in dining room waiting for breakfast; she had no heel booties on. On 06/24/2026 at 09:07 AM, R9 sat in her recliner, she had yellow nonskid socks on with no heel booties noted, she said she was comfortable. R9 reported that the facility or hospice company had not offered her an air mattress for her bed. On 06/24/2026 at 09:45 AM, Administrative Nurse E removed R9's sock and noted a foam dressing on her right heel. Administrative Nurse E reported that R9 was supposed to have just skin prep and did not know who applied the foam dressing. R9 reported that the hospice nurse put it on her heel today. Administrative Nurse E measured and took a picture of the right heel noting the length was 1.54 cm and the width was 2.73 cm with no depth and slight redness that blanched when Administrative Nurse E applied pressure. R9 reported that her heel did have more pain when touched today. On 06/23/2026 at 10:33 AM, LN H reported that a weekly skin assessment was completed and documented in the EMR in the assessments tab. On 06/23/2026 at 11:12 AM, LN H reported that she could not locate any weekly skin check notes in R9's EMR completed prior to 06/17/2026. LN H reported R9 entered as a hospice resident and the weekly skin check must not have been ordered. On 06/23/2026 at 01:00 PM, CNA M reported if a resident had a new skin issue or a bruise, she would report that to the nurse. CNA M reported that R9 did not have heel booties, and she would use a folded blanket under R9's heels when she was in bed. CNA M was unsure whether R9 required turning and repositioning. On 06/23/2026 at 04:30 PM, Administrative Nurse D and Consultant Staff II (Regional Improvement Advisor) were in Administrative Nurse D's office. Administrative Nurse D reported she expected the weekly skin checks to be completed weekly on all residents, including hospice residents. Consultant Staff II reported she also expected weekly skin checks to be completed to avoid skin issues. On 06/24/26 at 08:00 AM, Consultant Staff HH (LN from hospice) reported they did not notice R9 had an issue with her right heel until the second week of June 2026. The facility's policy Wound and Pressure Ulcer Management, dated 07/07/25, documented the purpose was to provide current and consistent standards of practice in wound care management. Wound care management may include the management and treatment of surgical wounds, pressure ulcers, diabetic ulcers, and skin conditions, as well as arterial and venous ulcers. These are the most common types of wounds that occur. Good Samaritan wound care programs, pressure ulcer guidelines and protocols have been developed and implemented to provide quality services to our residents. A comprehensive management program to prevent development of pressure ulcers or other skin conditions (Braden, following interventions identified on care plan, nutritional intervention, specialty surfaces, etc.). - R1's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R1 had no behaviors noted. R1 required a formal assessment for pressure ulcer risk and R1 was identified as at risk for pressure ulcer development. R1 admitted to the facility with a stage three pressure ulcer. R1's Care Plan, dated 05/07/2026, indicated staff were to avoid repositing the resident on their back/sacral area, monitor wound healing daily, and report improvements to the healthcare provider. Staff would clean the resident's sacral wound and left buttock and cover the area with a foam dressing daily, and as needed. Staff would notify the nurse immediately of any new areas of skin breakage, bruises, or discoloration. The Skin Assessment, dated 04/29/2026, indicated a stage three pressure ulcer to the lateral coccyx, which was present at the time of admission with purulent drainage noted. The surrounding skin was pink and blanchable with a length of 2.5 centimeters and 1.5 cm in width with no tunneling noted. Staff were to cleanse the area with normal saline, pat the area dry, and apply foam dressing daily and as needed. The Skin Assessment, dated 05/01/2026, revealed redness around wound bed, no granulation noted, 60 percent slough (a yellowish or white soft stringy or moist material made of dead cells); the area measured 2.5 cm in length and 1.5 cm in width. The Skin Assessment dated 05/03/2026 revealed the no changes to the resident's wound. The Skin Assessment dated 05/06/2026 revealed the wound measured 1/7th cm in length by 1/8th cm in width. The Skin Assessment dated 05/27/2026 revealed the wound measured 1/14 cm in length by 0.74 cm in width. The Skin Assessment dated 06/03/2026 lacked any measurement of the pressure injury. The Skin Assessment dated 06/11/2026 revealed the wound measured 1.33 cm in length and 0.94 cm in width. The Skin Assessment dated 06/18/2026 lacked any measurement of the pressure injury. An observation on 06/24/2026 at 02:30 PM revealed Administrative Staff E cleansed, measured, photographed, and dressed the residents' wounds. On 06/24/2026 at 11:20 AM, an interview with Administrative Nurse E revealed if the measurements were not documented they were not done. On 06/24/2026 at 01:57 PM, an interview with Administrative Staff D revealed wound measurements should be documented and if the wound nurse was unable to complete her duties the nurses were supposed to measure and document the residents' wounds. The facility's policy Wound and Pressure Ulcer Management, dated 07/07/2025, revealed staff were to implement a current and consistent standard of practice in wound care management. Wound care management may include the management and treatment of surgical wounds, pressure ulcers, diabetic ulcers, and skin conditions.

Based on observation, interview and record review the facility failed to prepare and serve food under sanitary conditions to prevent the outbreak of foodborne bacteria.Findings included:- During an observation of meal preparation on 06/23/2026 at 04:15 PM, Dietary Staff CC donned gloves then used the gloved hands to open the refrigerator door, touched a soft round flatbread, added ground chicken, and rolled the contents of the flatbread into a burrito-like structure making a chicken wrap. Dietary Staff CC failed to change gloves and/or wash hands and proceeded to place three of the chicken wraps in a blender.During an interview on 06/24/2026 at 03:40 PM, Dietary Manager BB stated the dietary staff were very nervous during the observation and mistakes were made regarding the use of gloves. Dietary Manager BB stated staff did not utilize gloves or wash their hands properly during the observation.The facility's policy Hand washing and Glove Use Food Nutrition Services, dated 06/24/2026, was intended to provide guidelines regarding hand hygiene and glove use to reduce the risk of cross-contamination when serving highly susceptible populations.

Based on observation, interview, and record review, the facility failed to ensure adequate catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) related care for Resident (R) 18 when staff did not ensure each resident's catheter tubing was secure to prevent pulling or dislodgement. The facility additionally failed to ensure R18 had a diagnosis for the indwelling catheter. Findings included:- R18's Electronic Medical Record (EMR) recorded 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 assistance with personal care.R18's 02/23/2026 admission Minimum Data Set (MDS) documented a BIMS of zero, indicating severely impaired cognition. R18's MDS documented that he required total assistance with toileting hygiene.R18's 03/03/2026 Urinary Indwelling Catheter Care Area Assessment (CAA) documented: R18 was admitted without catheter and then on 02/16/26 catheter was initiated and added to plan of care. R18's Care Plan, dated 02/17/2026, instructed staff that R18 had a 16French/10 milliliter (ml) balloon foley catheter. Change catheter as needed if dislodged, occluded, and unable to clear with irrigation. Staff instructed to monitor for pain or discomfort due to catheter. R18's 04/20/2026 Physician Orders documented 16French/10 ml balloon foley catheter. Change catheter as needed if dislodged, occluded, and unable to clear with irrigation. No directions specified for order. R18's 02/16/2026 Electronic Medication Administration Record (EMAR) documented follow up with primary care provider to reassess continuation of catheter. Recommended to remain in place for one week until Flomax a medication that relaxes the muscles in the prostate and the neck of the bladder, making it easier to urinate) was at its peak. R18's 02/23/2026 EMAR documented initials on the record to reassess no progress note was written that catheter was removed. R18's Provider Notes lacked documentation regarding foley catheter. R18's Progress Note, dated 02/24/2026 at 01:46 AM, documented R18 has a 16French catheter in place.R18's Progress Note, dated 02/25/2026 at 10:51 AM, documented R18 a catheter in place, patent and draining yellow urine to gravity.R18's Progress Note, dated 02/26/2026 at 11:54 AM, documented R18 a catheter in place, patent and draining yellow urine to gravity.R18's Progress Note, dated 03/01/2026 at 11:49 AM, documented R18 a catheter in place, patent and draining yellow urine to gravity.R18's Progress Note, dated 04/20/2026 at 06:28 PM, documented order was requested for catheter to be changed monthly and as needed. Provider ordered it to be changed as needed.On 06/22/2026 at 09:45 AM, R18 was seated in his room in his wheelchair. R18 was unsure why he had a catheter. On 06/22/2026 at 01:01 PM, a phone interview with a family member revealed he was unsure why R18 had a catheter. On 06/23/2026 at 10:37 AM, Certified Nurse Aide (CNA)M and CNA O assisted R18 onto the mechanical lift. R18's catheter bag was leaking urine in the privacy bag. CNA M held the drainage bag higher than the urinary bladder. Licensed Nurse (LN) H knocked on R18's door and was updated by CNA M the bag was leaking as CNA M continued to hold the catheter bag above R18's urinary bladder. R18 was assisted into bed, CNA M checked R18's briefs no catheter anchor was noted holding catheter in place. CNA M reported that she performed catheter care this morning and R18 did not have an anchor then and CNA M reported R18 should have an anchor on, and she did not go to get one from storage this morning. LN H applied an anchor for the catheter to his inner right thigh. R18 reported it would save him a lot of pain from pulling like it was. On 06/23/2026 at 01:00 PM, CNA M reported the catheter bag should always be below the bladder.On 06/24/2026 at 09:45 AM, CNA N reported R18 always had a catheter and was not sure it had ever been removed.On 06/24/2026 at 03:30 PM, LN G reported when R18 was admitted he was to have the foley catheter re-evaluated in one week by the provider and it should be in the progress note why he still had the catheter. On 06/24/2026 at 03:45 PM, Administrative Nurse D reported that R18 should always have an anchor to support his catheter. Administrative Nurse D revealed she expected drainage bag always be maintained below the bladder and was uncertain why R18 had a foley catheter, she reported that they would need to inquire about bladder training and expected any resident who had a foley catheter to have a qualifying diagnosis. The facility's policy Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen, dated 03/02/2026, documented that a resident is not to be catheterized unless the clinical condition demonstrates that catheterization is medically necessary and is not used solely for nurse/physician convenience. Catheter tubing is secured to the resident's leg, coiled on bed with no kinks or obstructions and the rest of the tubing should be in a straight line into urinary drainage bag. Make sure drainage bag and tubing remain below level of catheter and bladder.

Based on observation, interview, and record review the facility failed to monitor and respond to Resident (R) 25's lack of bowel movements for 13 consecutive days. Findings included:- R25's Electronic Medical Record (EMR) revealed diagnoses of constipation (difficulty passing stools) and dementia (a progressive mental disorder characterized by failing memory and confusion).R25's 11/27/2025 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. R25 required maximal assistance with toileting and was always incontinent with bowel movements. R25's 12/07/2025 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R25 was incontinent of bowel and bladder. R25 refuses to use the bathroom and would become extremely angry when offered the toilet, as she prefers to go in her brief. R25's Care Plan, dated 07/29/2014, revealed staff were to teach the resident/family the relationship of constipation to food, medicine, treatment regimen, disease process, and psychosocial factors, and teach the resident/family to identify and avoid causative factors.R25's Care Plan, dated 02/23/2021, revealed R18 wore briefs, and staff were to assist to toilet as requested, check brief, and change at least every two hours and when toileted. R25's Care Plan, dated 03/08/2024, revealed R18 refused to be toileted and was incontinent of bowel and bladder and wore a large wrap brief.R25's Physician Orders documented Milk of Magnesia (stool softener) suspension 1200 milligrams (mg)/15 milliliters (ml), administer 30 ml by mouth, as needed for constipation one time a day, ordered 03/04/2024. R25's Physician Orders documented Bisacodyl (laxative) rectal suppository 10 mg, insert 10 mg rectally every 24 hours as needed for constipation, ordered 08/12/2024. R25's Physician Orders documented Senna (laxative) tablet 8.6 mg, give one tablet by mouth, two times a day related to constipation, may hold for loose stools, ordered 10/30/2024. Review of R25's bowel movement frequency in the EMR dated 06/06/2026 through 06/18/2026 revealed the resident exceeded three days/72 hours without a bowel movement. From 06/06/2026 through 06/18/2026 (13 consecutive days) the record lacked documentation of bowel movements for R25. Review of R25's Electronic Medication Administration Record (EMAR) lacked documentation of the administration of as needed medications to R25 in the 13 consecutive days with no documented bowel movements.Review of R25's EMR revealed the progress notes lacked documentation of monitoring for bowel movements or the lack of bowel movements for 13 consecutive days (06/06/2026 through 06/18/2026). On 06/22/2026 at 09:13 AM, R25 laid in her low bed, declined the interview, and reported she did not feel well but did not state specifics. On 06/23/2026 at 04:30 PM, R25 sat in her wheelchair in the lobby eating a snack.On 06/24/2026 at 11:25 AM, Certified Medication Aide (CMA) R reported the CMAs would receive a list from the nurses on which residents have not had a bowel movement for three days, and the nurse would instruct the CMA to give Milk of Magnesia. On 06/24/2026 at 11:45 AM, Licensed Nurse (LN) G reported the night nurse printed off a 'no bowel movement in three days' list and the nurse would instruct the CMA to administer Milk of Magnesia, if no results then a suppository. LN G reviewed R25's EMAR and EMR for the month of June and verified that R18 had no bowel movements from 06/06/2026 through 06/18/2026 and nothing was documented. LN G reported she was not sure how that could have happened. On 06/24/2026 at 11:55 AM, Administrative Nurse D reported she expected the staff to follow the bowel protocol and revealed she did not know why R25 had no bowel movement documented, or why the staff had not assessed the resident. The facility's policy Bowel & Bladder: Evaluation, Assessment, Toileting Programs, dated 04/30/2026, lacked monitoring bowel movements and follow up if no bowel movement in 72-hours.

Based on interview and record review, the facility failed to inform Resident (R) 6 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:- R6's Electronic Medical Record (EMR) recorded diagnoses of hemiplegia affecting the left side and dementia (a progressive mental disorder characterized by failing memory and confusion).R6's 05/28/2026 Annual MDS documented a BIMS score of six, indicating severely impaired cognition. R6 had no rejection of care during the observation period. R6 received antianxiety (a class of medications that calm and relax people) medications in the look back period. R6's 06/11/2026 Psychotropic Drug Use Care Area Assessment (CAA) documented antianxiety medication for anxiety related to dialysis (a procedure where impurities or wastes are removed from the blood).R6's 06/11/2026 Care Plan documented staff were instructed to monitor R6's condition based on guideline or clinical standard of practice related to use of Ativan (anti-anxiety medication). R6's 06/11/2026 Care Plan documented staff were instructed to monitor target behaviors related to anxiety: agitation, anxiety, tearfulness, and or resistance to care including resistance to going to dialysis. R6's 03/23/2026 Physician Order documented Ativan 0.5 milligrams (mg), give 1 tablet by mouth, one time a day every Monday, Wednesday, and Friday for anxiety, give before leaving for dialysis.R6's EMR lacked a documented progress note or consent for the education regarding risk vs. benefits for the Ativan. On 06/22/2026 at 08:56 AM R6 was seated in her wheelchair with chipped nail polish on all her nails, R6 reported she liked them polished and hoped to get the staff to do them.On 06/24/2026 at 11:00 AM R6 reported no one told her the facility was doing manicures and painting resident nails. R6 got very upset.On 06/24/2026 at 04:00 PM Licensed Nurse (LN) H reported that the nurse would not complete the psychoactive medication consents, she reported that Administrative Nurse D would complete the consent. On 06/24/2026 at 04:10 PM Administrative Nurse D reported that she just completed a psychoactive consent for R6's Ativan on 06/24/2026 and reported that it was a medication that dialysis requested, and she expected the charge nurse to complete a consent when a new psychoactive medication was ordered.The facility's policy Psychotropic Medications, dated 12/09/2025, documented A consent form must be signed for the use of psychotropic medications. The permission for use of psychotropic medications will be used to obtain consent.

Based on record review and interviews, the facility failed to provide form CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form 10055 (SNF-ABN: used to notify Medicare A participants discharging from services of potential charges) and Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) to the resident or their representative for Resident (R) 18.Findings included:- R18's Electronic Medical Record (EMR) documented a Medicare Part A episode beginning 02/17/2026 and ending on 03/09/2026.On 06/22/2026 at 04:30 PM Administrative Staff B reported R18 was unable to sign for the SNF-ABN and the NOMNC as R18 was very confused. Administrative Staff B reported R18 did not have a durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to). Administrative Staff B reported that R18's brother signed all his admission paperwork. During an interview on 06/23/2026 at 3:00 PM with Administrative Staff A revealed the paperwork needs to be signed for NOMNC and SNF.The facility's policy SNF Medicare Part A Advance Beneficiary Notice of Non-Coverage (SNABN), documents Medicare's limitation on liability requires a provider to notify a Medicare beneficiary in advance of furnishing an item or service that is believed to likely be denied by Medicare in order to shift financial liability to the beneficiary. The Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) informs the beneficiary of potential non-coverage and shift of financial liability for those Part A items or services if Medicare denies the claim.

Based on observation, interview, and record review the facility failed to provide a written bed hold policy at the time for transfer for Resident (R) 5.Findings included:- R5's 05/20/2026 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition.The Nurse's Progress note dated 06/18/2026 at 08:49 AM, revealed R5 reported dizziness and inability to bear weight during a transfer to the wheelchair. The note documented that R5 appeared pale in color, blood pressure was 94/54 millimeters of mercury (mmHg), pulse was 255 beats per minute, and oxygen saturation was 67 percent on room air. R5 was placed on five liters of oxygen per nasal cannula, and the staff notified the physician who gave orders to transfer the resident to the emergency room.The Nurse's Progress note dated 06/18/2026 at 01:33 PM, revealed the hospital informed the facility that R5 had been admitted to the Intensive Care Unit for septic shock (system infection).R5's EMR lacked evidence of a written bed hold policy provided at the time of the 06/18/2026 transfer to the hospital.During an interview on 06/24/2026 at 08:25 AM, Administrative Staff B revealed it was the nurse's responsibility to send the bed hold policy with any resident who transferred from the facility to the hospital. Administrative Staff B stated the business office then followed up to make sure the bed hold was sent and said R5's bed hold policy was missed.During an interview on 06/24/2026 at 08:40 AM, Administrative Staff D stated Social Service staff took care of the bed hold. Administrative Staff D said the bed hold policy was not sent every time a resident went to the emergency room because it was not known if the resident would be staying.The facility policy Bed Hold, dated 12/23/2025, would ensure the resident/resident representative is made aware of the facility's bed hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility, and determine if the resident/resident representative wants to hold the bed.

Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 11's Electronic Medication Administration Record (EMAR) was signed off with initials after medications were administered. Additionally, the staff failed to ensure R11 received her medications at the ordered time. Findings included:- R11 's Electronic Medical Record (EMR) revealed diagnoses of spastic hemiplegia affecting left side (paralysis of one side of the body) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R11's 01/07/2026 admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. R1 had no rejection of care during the observation period and received an anticoagulant (a class of medications used to prevent the blood from clotting), a diuretic (a medication to promote the formation and excretion of urine), and a hypoglycemic (a medication to manage high blood sugar levels). R11's 01/11/2026 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) revealed R11 had left-sided weakness/hemiplegia and required one staff assistance with activities of daily living (ADLs). R11's Care Plan, dated 01/14/2026, instructed staff to refer to boxed warnings in the orders or EMAR, or medication reference of choice.R11's 01/01/2026 Physician's Orders documented Furosemide (diuretic) 40 milligrams (mg), givetablet by mouth, one time a day for hypertension (HTN-elevated blood pressure).R11's 01/15/2026 Physician's Orders documented Apixaban (anticoagulant) 5mg, give one table by mouth, two times a day for by mouth two times a day for atrial fibrillation (rapid, irregular heartbeat).R11's 01/15/2026 Physician's Orders documented Losartan Potassium 50 mg, give one tablet by mouth one time a day for hypertension.R11's 01/15/2026 Physician's Orders documented Diltiazem 90 mg, give one tablet by mouth one time a day related to hypertension.R11's 05/20/2026 Physician's Orders documented Sitagliptin 50 mg, give one tablet by mouth one time a day for diabetes.R11's 05/20/2026 Physician's Orders documented metformin 1000 mg, give one tablet by mouth two times a day for diabetes.Review of facility's handout Schedule of Medication Administration Times from the entrance conference on 06/22/2026 documented AM medication pass was 08:15 AM - 09:00 AM. On 06/24/2026 at 07:45 AM, R11 ambulated to the dining room with a gait belt and walker with assistance from Certified Nurse Aide (CNA) N.On 06/24/2026 at 07:50 AM, Licensed Nurse (LN) H reported that Certified Medication Aide (CMA) R had left the facility to take care of a personal matter and would be back soon to administer the morning medications to the residents. On 06/24/2026 at 08:15 AM, CMA R reported that she had administered R11's morning medications and verified that none of R11's medications had been signed off on the EMAR as administered at this time. CMA R reported that she was unsure what time she administered R11's medications and reported she was unable to sign them out when she prepared and administered the medications, as it was not highlighted on the EMAR at that time. CMA R reported she left the facility this morning and had just clocked back in. CMA R reported that she would start the morning medication pass right after she arrived at the facility at 06:00 AM and would sign off the 08:00 AM medications when the EMAR highlighted them in yellow. CMA R reported that the nurses know what she does and probably would not administer the medications again if they assisted with the morning medication pass if she was unable to return to work. LN H and LN G were located at the other medications carts next to CMA R's medication cart, and they both reported that when they administer the resident AM medications right after they arrive at the facility to work, they must go back on the EMAR once the medications are highlighted in yellow to sign the medications off then. LN H reported there was no open medication pass at the facility and reported that the medications should really be given at the scheduled time or one hour before or after and signed off once administered. On 06/24/2026 8:30 AM, Administrative Nurse D reported there was not an open medication administration. Administrative Nurse D reported she expected the LNs and CMAs to administer medication one hour before or after the scheduled time and be signed off once administered.The facility did not provide a policy on Medication Administration.

Based on observation, record review, and interview, the facility failed to ensure residents received assistance with activities of daily living (ADL), including facial hair removal for Resident (R) 18 and assistance with nail care for R18, R6, and R11. Findings included:1. R11's Electronic Medical Record (EMR) revealed diagnoses of spastic hemiplegia affecting left side (paralysis of one side of the body) and assistance with personal care.R11's 01/07/2026 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. R1 had no rejection of care during the observation period and required moderate assistance with personal hygiene.R11's 01/11/2026 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) revealed R11 had left-sided weakness/hemiplegia and required one staff assistance with activities of daily living (ADLs).R11's Care Plan, dated 01/14/2026, instructed staff to provide one staff assistance with grooming due to affected left side.On 06/22/2026 at 08:50 AM, R11 was seated in her room in a recliner, she wore a dirty pink t-shirt with dried food on it. R11 had long fingernails with chipped nail polish, and she reported that she liked long nails, but noted they needed new polish. R11 had two jagged, broken nails on her left hand.On 06/23/2026 at 07:42 AM, R11 was seated in her wheelchair with new clothes on. Her two nails remained jagged on left hand and the nail polish remained chipped.On 06/24/2026 at 07:45 AM, R11 ambulated to the dining room with a gait belt and walker with assistance from Certified Nurse Aide (CNA) N. R11's [NAME] fingernails remained jagged and with chipped nail polish. 2. R6's EMR recorded diagnoses of hemiplegia affecting the left side and assistance with personal care.R6's 05/28/2026 Annual MDS documented a BIMS score of six, which indicated severely impaired cognition. R6 had no rejection of care during the observation period. R6 required set-up assistance with personal hygiene.R6's 06/11/2026 Functional Abilities (Self-Care and Mobility) CAA documented R6 had impaired mobility related to cognitive status.R6's Care Plan, dated 10/31/2024, documented staff were instructed to provide one staff assistance with personal hygiene.On 06/22/2026 at 08:56 AM, R6 was seated in her wheelchair with chipped nail polish on all her nails; R6 reported she liked them polished and hoped to get the staff to do them.On 06/23/2026 at 07:35 AM, R6 sat in the dining room in her wheelchair with chipped nail polish on all her nails. On 06/24/2026 at 07:51 AM, R6 sat in her wheelchair in the dining room with chipped worn-off nail polish.On 06/24/2026 at 11:00 AM, R6 reported no one told her the facility was doing manicures and painting resident nails; R6 became upset.3. R18's EMR recorded 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 assistance with personal care.R18's 02/23/2026 admission MDS documented a BIMS of zero, which indicated severely impaired cognition. R18's MDS documented that he had no rejection of care during the observation period and required total assistance with personal hygiene.R18's 03/03/2026 Cognitive Loss/Dementia CAA documented R18 had impaired cognitive function and/or impaired thought processes, evidenced by impaired decision making and long-term memory loss. Goals included for R18 to be able to communicate basic needs through the review date.R18's 05/26/2026 Quarterly MDS documented a BIMS of 99, indicating severely impaired cognition. R18's MDS documented no behaviors and no rejection of care during the observation period. R18's MDS documented he required maximal assistance with personal hygiene. R18's Care Plan, dated 02/18/2026, documented staff were instructed to provide one to two staff assistance with personal hygiene as he was dependent on the staff. On 06/22/2026 at 09:45 AM, R18 was seated in his room in his wheelchair. Observed very long nails on all his fingers and stubbly facial hair. On 06/22/2026 at 01:01 PM, a phone interview with a family member revealed R18 should have his nails trimmed and his facial hair removed as R18 liked to be well-groomed. On 06/23/2026 at 07:24 AM, R18 was seated in his wheelchair, the long nails remained, and the stubbly facial hair remained.On 06/24/2026 at 09:00 AM, R18 was seated in his wheelchair propelling self. R18's fingernails remained long, and his stubbly facial hair remained.On 06/23/2026 at 08:23 AM, Certified Nurse Aide (CNA) S reported showers and baths were documented in EMR under the tasks. CNA S reported if the resident refused care the charge nurse would be notified and the nurse would check with the resident and document that. CNA S reported that in the EMR under the activities, there was a beauty shop/barber task where staff document for the fingernail care and shaves and note if they were completed or refused. CNA S reported there was no paper form for bathing sheet to be filled out by staff. CNA S reported that she would complete nail care on non-diabetic residents and facial hair removal. She reported that activities generally completed the nail polish with manicures. On 06/24/2026 at 11:50 AM, Licensed Nurse (LN) G reported she expected the CNAs to complete nail care on non-diabetic residents on bath days or as needed. LN G reported the nurse would cut the diabetic residents' nails. LN G expected the resident's facial hair to be removed on bath days or when needed or requested. LN G reported activities should complete the nail polish as needed. She reported the CNAs should let the nurse know when a diabetic resident required their nails to be trimmed.On 06/24/2026 at 01:49 PM, Administrative Nurse D reported there was no place in the EMR/tasks tab for staff to document nail care or facial hair removal. She reported she expected the residents to have their nails polished, cleaned, and trimmed, per their preference, and facial hair removed. She reported that if a resident refused their baths the charge nurse would document that in the progress notes. Administrative Nurse D revealed that the activity for manicures was not held in the normal area of the facility today and that is why R6 may have missed the manicure.The facility's policy Activities of Daily Living, dated 12/10/2025, documented any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure adequate infection control practices related to urinary catheter (tube inserted into the bladder to drain urine) care, hand hygiene, and glove use with intravenous (IV) medication.Findings included:- During an observation on 06/23/2026 at 09:00 AM, Licensed Nurse (LN) H entered Resident (R) 21's room to empty the urinal. After she emptied the urinal, LN H removed her soiled gloves and did not perform hand hygiene before she applied new gloves that were in her pocket. LN H then wore those gloves as she primed the tubing of the IV bag, wiped the IV port with an alcohol wipe, flushed the IV line with normal saline, attached the IV tubing to the end cap, and set the IV pump.During an observation on 06/23/2026 at 10:37 AM Certified Nurse Aide (CNA) M and CNA O applied personal protective equipment (PPE) before entering R18's room to transfer the resident with a mechanical lift. During the transfer R18's indwelling urinary catheter bag began to leak, when staff held the bag above the level of R18's bladder. The bathroom in R18's room did not have soap for hand hygiene and both CNA's left the room, wearing their PPE, to go wash their hands. CNA M returned to R18's room to empty the urinary catheter bag and the bag spout touched the inside of the graduated cylinder. CNA M then wiped the port with alcohol and attached the bag spout. LN H returned to the room to apply a new catheter bag without cleaning the connectors.During an interview on 06/23/2026 at 10:55 AM, LN H revealed she should have wiped the drainage bag and catheter opening before connecting them together and should have washed her hands after removing her gloves, before she hung the IV medication.The facility's undated policy Personal Protective Equipment (PPE) revealed all PPE must be removed prior to leaving the work area and placed in a designated area or container for storage, washing, decontamination or disposal, and staff should discharge all PPE upon completing a task.The facility did not provide a policy for the administration of IV fluids.

Based on observations, record review, and interviews, the facility failed to ensure an environment free of chemical hazards for severely cognitively impaired Resident (R) 26 who had a bottle of 91 percent rubbing alcohol on his tray table. Findings included:- R26's Electronic Medical Record (EMR) revealed diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R26's 05/15/2026 Annual Minimum Data Set(MDS) documented a Brief Interview for Mental Status (BIMS) of zero, indicating severely impaired cognition. R26's MDS documented he required set-up assistance for wheelchair mobility. R26's 05/26/2026 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R26 had impaired cognitive function or impaired thought processes, related to disease processes. R26 had forgetfulness, short term memory loss, resistance to care, and agitation. R26's Care Plan dated 05/29/2025 revealed staff were instructed to minimize the potential of resident behavior problems by modifying environmental factors and daily routine.R26's Progress Note on 05/15/2026 at 02:19 PM documented R26 was alert to self. R26 required one staff assistance with activities of daily living. R26 was able to self-propel in the wheelchair following set up assist from staff. R26 had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) in place due to previous wandering. On 06/22/2026 at 10:19 AM, R26 was in his room lying in his bed. R26 had a bottle of 91 percent rubbing alcohol that was approximately 3/4 full on the tray table. R26 reported that he used rubbing alcohol for the syringes and shots he takes. On 06/23/2026 at 07:22 AM, R26 had a container full of disinfectant wipes open on his table near the television and the same bottle of rubbing alcohol in his room. R26 was in the dining room at this time for breakfast. An observation on 06/24/2026 at 09:17 AM noted the same bottle of rubbing alcohol in his room, R26 was in his wheelchair at the nurse station. On 06/24/2026 10:11 AM, Certified Medication Aide (CMA) R reported she was not sure why R26 had a three quarters full bottle of rubbing alcohol in his room and removed it. CMA R reported the facility did not have bottles of rubbing alcohol. On 06/24/2026 at 03:30 PM, Licensed Nurse (LN) G reported R26 should not have a bottle of rubbing alcohol or disinfectant wipes in his room and reported that the aides should have removed the bottle from his room and reported that to the nurse. On 06/24/2026 at 04:45 PM, Administrative Nurse D reported the residents were not allowed to have unsecured bottles of rubbing alcohol in their room and R26 had friends who liked to bring him in items that he should not have. She expected the staff to notice those items and let the nurse know so it could be removed. The facility did not provide a policy regarding safe storage of chemicals.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free of accident hazards on 01/17/26 at approximately 07:30 AM, when R1 fell from a mechanical lift and struck his head. R1 sustained two hematomas (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the back of his head. Findings included:- R1's Electronic Health Record (EHR) included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following cerebrovascular disease affecting right dominant side, and malignant (cancer) neoplasm (tumor) of the brain. R1's 01/08/26 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated the interview could not be completed. Staff assessed R1 to have a memory problem with moderately impaired cognition. The assessment documented R1 utilized a wheelchair for locomotion and was dependent on staff assistance for all care and transfers. The assessment documented no falls since the previous assessment. R1's Care Plan documented on 10/16/13 R1 was at risk for falls related to a history of stroke with hemiparesis and required assistance for transfers. Interventions dated 10/16/13 directed staff to assist with all transfers and utilize his wheelchair for the primary mode of locomotion. R1's Care Plan dated 04/08/20 documented R1 had an activity of daily living (ADL) self-care performance deficit related to a history of a stroke. Interventions dated 12/27/24 directed staff to utilize a total lift with the assistance of two staff with a large sling. Staff would ensure proper positioning in the sling before bearing weight in the sling. R1's EHR, under the Progress Notes on 01/17/26 at 07:30 AM, Licensed Nurse (LN) G documented a SAFE Event - Incident Report - SPN which revealed staff were transferring R1 from the bed to a wheelchair using a full mechanical lift. During the transfer, R1 fell from the lift and struck the back of his head on the legs of the lift. LN G documented she assessed R1 and identified two hematomas on the back of R1's head. LN G documented R1's mentation was at his baseline, and the resident's physician was notified immediately of the incident. On the Fall Scene Huddle Worksheet, LN G documented R1 fell on [DATE] at 07:30 AM in his room. The fall was witnessed by staff during an assisted transfer. The document did not contain an investigation or determination of the root cause of the fall. A Communication/Visit with Physician on 01/20/26 at 05:12 PM, LN I documented R1 was having neurological checks performed every eight hours due to a fall on 01/17/26. LN I documented during the most recent neurological checks, R1 had labored and shallow respirations, and his level of consciousness had declined from baseline. LN I documented R1's physician was notified. A Communication/Visit with Physician on 01/21/26 at 05:48 AM, documented a late entry for 01/20/26 at 06:46 PM, LN J documented R1's physician was notified and advised staff to encourage fluids. A Communication - Other on 01/21/26 at 05:43 PM, LN I documented R1's level of consciousness had returned to his baseline. Observation of the facility's equipment on 04/21/26 at 02:00 PM with Administrative Staff A revealed the facility had five full-body mechanical lifts, with three lifts currently in service on the clinical floor. Each lift had a rounded metal knob fixed in place at the end of the arm of the lift. Each lift had a pouch that contained two metal arms with two hooks each that could be placed onto or removed from the [NAME] on the arm of the lift, which resulted in four hooks to connect to the sling. Administrative Staff A identified that none of the four available hooks on any of the lifts contained a mechanism to prevent the sling loops from unintentionally coming loose during the transfer. On 04/21/26 at 04:15 PM, CNA M stated that on 01/17/26 at approximately 07:30 AM, she and CMA R had finished performing morning cares for R1 and were preparing to transfer R1 from the bed to his wheelchair to go to the dining area for breakfast. CNA M reported she was standing close to R1 during the lift, and CMA R was manipulating the controls of the lift. CMA M said when R1 was lifted off the bed, the lift was pulled out from the bed to make room for the wheelchair. CMA M reported she turned around to get R1's wheelchair, and she heard CMA R scream. When CNA M turned back around, she saw R1 partially hanging from the lift with his feet in the air and his head on the ground. CNA M said that only two loops of the sling remained connected to the lift. CNA M said she was unsure who utilized the two-way radio to call for help, but LN G came with LN H, then she and CMA R stepped to the hallway to let LN G and LN H care for R1. CNA M was unable to recall what size or color of sling was utilized to transfer R1. On 04/21/26 at 04:55 PM, CMA R stated that on 01/17/26 at approximately 07:30 AM, she was performing morning cares for R1 with CNA M and prepared to transfer R1 from the bed to the wheelchair. CMA R stated she was operating the lift controls, and CNA M was holding onto R1. Once R1 was in the sling and lifted into the air, the lift was pulled back from the bed to allow CNA M to place R1's wheelchair in position. When CNA M let go of R1 and turned around to get R1's wheelchair, R1 suddenly rolled to his side in the sling, and the sling became partially undone, and R1 fell to the ground. CMA R stated she screamed when the fall was occurring because she was unable to go around the lift to keep R1 from falling. CMA R said that R1 appeared to hit his head on one of the legs of the lift, and only three of the four loops of the sling remained connected to the lift. CMA R was unable to recall what size or color of sling was utilized to transfer R1. On 04/21/26 at 02:49 PM, LN G stated that on 01/17/26 at approximately 07:30 AM, she was called to R1's room via the two-way radio system because R1 had fallen. Upon LN G's arrival at R1's room, Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R were with R1, who was found on the ground between the legs of the lift. LN G stated R1 appeared to have slipped out of the sling during the transfer with the lift. R1 was assessed for injuries, and two hematomas were discovered on the back of his head. R1's physician was notified, and the physician instructed LN G to monitor R1 and report any changes. LN G stated that neurological checks were initiated, and a Fall Scene Huddle Worksheet was completed and submitted to Administrative Nurse D. LN G said that the lift and sling that were involved with R1's fall were immediately removed from the clinical floor for maintenance to inspect for any defects or malfunctions. LN G was unable to recall how many loops of the sling remained connected to the lift when she arrived at R1's room. On 04/21/26 at 02:00 PM, Administrative Staff A confirmed the fall report provided by the facility contained only two pages and said the report was all the available documents related to R1's fall on 01/17/26. Additionally, Administrative Staff A stated the fall report did not contain evidence that an investigation was performed or that a root cause of the fall was identified. Administrative Staff A reported that fall investigations were the responsibility of Administrative Nurse D. Administrative Staff A stated during a full body lift transfer, staff were expected to pause for approximately 30 seconds after the resident had been lifted free of the bed or wheelchair to double check the loops on the sling had not unintentionally come undone from the hooks on the lift, then proceed with the transfer if safe to continue. On 04/21/26 and 04/22/26, Administrative Nurse D was unavailable for interview. The facility's SRHP- Safe Resident Handling Program Overview R/S, LTC policy, dated 12/12/25, documented the facility's goal was to maintain a safe living and working environment for residents and employees. The policy documented that caregivers would perform a TIME OUT safety stop while the resident was in a sling and still over the surface of the bed or chair when the straps were taut, but before the resident left a surface to ensure the straps were secure prior to moving away from the surface.

The facility reported a census of 40 residents, with four residents sampled, including two residents reviewed for accidents related to smoking. Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure a safe environment free from accident hazards for all residents in the facility on [DATE] at approximately 01:20 PM when cognitively impaired Resident (R) 1 used a cigarette lighter to start a fire in her room; R1 set fire to her recliner. The facility smoke alarm sounded and Certified Nurse Aide (CNA) M and CNA N used the fire extinguisher to put out the fire. All residents were evacuated from the building and Law Enforcement (LE) arrived at the facility and inspected R1's room with Licensed Nurse (LN) G for the source of the fire. The inspection revealed R1 had multiple lighters in her room as well as other items belonging to other residents including medical equipment and scissors. The facility's failure to provide adequate supervision to ensure a safe environment free from accident hazards placed R1 and the other affected residents in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) documented R1 had diagnoses which included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), unspecified dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, difficulty in walking, other abnormalities of gait (manner or style of walking) and mobility, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebrovascular disease (stroke) affecting the dominate side. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment documented R1 displayed behaviors that included rejection of care for one to three days and noted R1 had no wandering during the seven-day look-back period. R1 utilized a wheelchair and required partial/moderate assistance with shower/bathing, setup to cleanup assistance with eating, and was otherwise independent with her activities of daily living (ADL) such as walking, grooming, toileting, dressing, and eating. R1 was independent with wheelchair locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated [DATE] documented R1 had impaired cognitive function or impaired thought processes related to dementia and she experienced confusion and behaviors. The Behavioral Symptoms CAA dated [DATE] documented R1 had behavior symptoms including hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) that included claims of missing or stolen items from her room. The Quarterly MDS dated [DATE] documented a BIMS score of four which indicated severely impaired cognition. The assessment documented no behaviors or wandering during the seven-day look-back period. R1 was independent with wheelchair locomotion. R21's Care Plan, documented the following: R1 had impaired cognitive function or impaired thought processes and instructed staff that R1 required supervision/assistance with all decision-making. The plan documented R1 had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) in place in her seat cushion, due to her refusal to leave it on, initiated on [DATE] and revised on [DATE]. An intervention initiated on [DATE] and revised on [DATE], documented R1 had the potential for elopement (when a resident leaves a safe area without the knowledge and supervision of staff) related to dementia and instructed staff to use a WanderGuard to alert staff to R1's movements. A Progress Note dated [DATE] at 03:43 PM by Licensed Nurse (LN) H documented a Certified Nurse Aide (CNA) in the resident's hall noticed a glare coming from R1's room as she was walking down the hallway. Upon entering R1's room, R1 had a piece of paper in her hand and was in her wheelchair facing a fire next to her recliner. The note documented that as the fire was being extinguished, staff evacuated all the residents out of the building; the Fire Department (FD) arrived and ensured the fire was extinguished. The note documented R1 reported to LN H and the FD that she was just in her wheelchair next to the bed looking out of her window and said she did not have any knowledge of a fire. The facility's investigation documented the following statements: CNA M's Witness Statement dated [DATE] documented on [DATE] at approximately 01:30 PM, CNA M walked past R1's room and observed a fire flicker; she entered R1's room and observed R1 seated in the wheelchair facing a fire next to the recliner. The statement noted CNA M removed R1 from her room and ran to alert additional staff about the fire, then returned to extinguish the fire with CNA H. CNA H's Witness Statement dated [DATE] documented CNA M removed R1 from her room and voiced there was an actual fire in R1's room. CNA H notified the rest of the staff via the two-way radio and alerted staff it was not a drill and there was a real fire. The statement noted CNA H then grabbed a fire extinguisher and with the assistance of R2's representative, utilized the fire extinguisher to put out the fire. The statement noted once the fire was extinguished, CNA H opened the window to the outside, and then assisted the rest of the staff in evacuating residents out of the building. A Witness Statement dated [DATE] from R2's representative documented the fire alarm was going off and they found the fire and assisted CNA M to remove R1 from the room with the fire, provided CNA H with instructions on how to use a fire extinguisher, and assisted CNA H to extinguish the fire which included the movement of furniture and opening of windows. LN H's Witness Statement dated [DATE] documented after the fire alarms began to sound, staff were notified via the two-way radio of a fire on R1's hall. The statement noted LN H ran to the location of the fire and found CNA H extinguishing the fire and directed the staff to evacuate residents out of the building. LN H then notified the FD, Administrative Staff A, and Administrative Nurse D. The statement noted after the arrival of the FD, staff waited with the residents outside for clearance from the FD prior to taking the residents back inside the facility. Observation of R1's room on [DATE] at 09:30 AM, revealed the room was under restorative reconstruction with two contractor staff present. There was damage and charring observed to the carpeting and the tile underlayment. Observation of photos provided by the contractor staff revealed linear charring damage to the flooring with soot marks up the wall and on the ceiling. During an observation on [DATE] at 10:33 AM, R1 sat in a wheelchair in the common area. R1 was unable to be interviewed due to cognitive issues. CNA N was unavailable for an interview on [DATE] at 12:35 PM. During an interview on [DATE] at 12:38 PM LN G revealed prior to the incident, R1 did have wandering behaviors. LN G stated on [DATE] from approximately 01:15 PM to 01:20 PM, LN G assisted R1 to the bathroom and R1 requested to be left in her wheelchair facing her recliner. LN G said that after the fire was extinguished and the FD cleared the residents to return inside the facility, LN G and LE obtained permission to search R1's room. LN G said there was extensive damage to the right side of R1's recliner and the floor with mild damage to the privacy curtain and R1's recliner contained a lighter that was wedged between the right side of the seat cushion and the right arm of the recliner. LN G said that further searching of R1's room revealed nine additional lighters in pockets that were attached to R1's wheelchair, multiple pens, one pair of standard scissors, one pair of bandage scissors, medical equipment, and multiple other items that belonged to other living and deceased residents. During an interview on [DATE] at 08:14 AM, Administrative Staff A revealed an emergency ad hoc resident council meeting was held on [DATE] where the resident council voted to transition to a non-smoking campus effective [DATE] that included a non-smoking policy for staff. Administrative Staff A revealed the facility did not know where R1 obtained the lighter and said R1 was not known to have wandering behaviors. Administrative Staff A said that after the incident, a search of R1's room revealed R1 had multiple lighters in her room as well as other items that belonged to other residents, including medical equipment and other devices. Administrative Staff A said LE removed the lighters and retained them as evidence for potential criminal charges of arson. Administrative Staff A revealed that during the crisis, the staff performed their duties appropriately and evacuated the residents out of the facility. Administrative Staff A revealed that an ad hoc QAPI (quality assurance process improvement) was held on [DATE] to implement a process improvement plan (PIP) related to the incident that changed the process for existing smoking residents where staff would accompany the smoking residents outside, light the resident's cigarette, and then return into the building and immediately secure the lighter. Administrative Staff A revealed R1 was immediately placed on 1:1 observation and obtained a referral to a behavioral health unit (BHU) and was admitted to the BHU on [DATE] and returned to the facility on [DATE]. Administrative Staff A revealed that on [DATE] all resident's representatives were notified that any items brought into the facility for the residents need to be logged into the resident's inventory sheet so staff could ensure no unsafe items made it into the resident's rooms. The facility's undated policy, Safety and Health, Risk Management documented that all employees were responsible to ensure the safety program was effective. On [DATE] at 04:00 PM Administrative Staff A and Administrative Nurse D were provided with the Immediate Jeopardy (IJ) Template and were informed that the inadequate supervision of R1 who started a fire in the facility with a lighter placed the residents in IJ. The facility's corrective measures, fully completed on [DATE], included the following, which were verified by the surveyor on-site during the investigation. 1. R1 was placed on 1:1 observation immediately after the incident pending admission to an off-site BHU. 2. An ad hoc QAPI meeting was held on [DATE] and changed the process by which residents were allowed to smoke which included staff were to accompany smoking residents outside, light the resident's cigarettes, then immediately return inside to secure the lighter in the nurse's cart. 3. All staff were re-educated that items brought in for residents by families must be placed on the residents' inventory log to ensure unsafe items do not enter the facility, completed [DATE] at 05:00 PM. 3. All residents' families were notified that all items brought into the facility need to be reviewed and placed on the inventory log to ensure that unsafe items do not enter the facility, completed [DATE] at 08:30 PM. 4. R1 was admitted to off-site BHU on [DATE] at 06:45 AM. 5. An ad hoc resident council meeting was held on [DATE] where the residents voted to adopt a non-smoking policy on the facility campus, effective [DATE]. All corrections were completed prior to the onsite survey; therefore, the deficient practice was cited as past noncompliance and remained at a scope and severity of L.

The facility reported a census of 37 residents with 17 residents sampled, which included three residents reviewed for abuse and neglect. Based on observation, interview, and record review, the facility deprived Resident (R) 7 care when the facility failed to ensure call lights were working appropriately to address the care needs of all residents residing on one of the four halls. On 07/16/24, during initial screening, multiple residents reported issues with call light response times and the surveyor observed a 42-minute call light response time for R 7. The facility reported they had issues with the call light system for months and used staff at the nurses' station to watch the system; however, on 07/17/24 at 07:25 AM, no staff were at the nurses' station watching the call light system. This failure placed the residents in immediate jeopardy. In addition, the facility failed to ensure staff identified and responded appropriately to all allegations of abuse and reporting for R21 who had a large bruise across her chest. On 07/16/24, R21's family member stated the facility reported to her that R21 had a bruise located across her lower chest. Furthermore, the facility failed to respond appropriately to R17 allegations of sexual assault. This failure which placed the residents at risk for abuse and continued negative impact on their physical, mental, and psychosocial well-being. Findings Included: - Resident (R) 7's Electronic Health Record (EHR) revealed diagnoses, which included metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), muscle weakness, anxiety disorder, and history of falling. The 12/07/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R7 had a total mood severity score of two, indicating minimal depression. R7 was independent with eating. R7 required supervision assistance with activities of daily living (ADL), with dressing personal hygiene, transfer, and mobility. R7 required maximal assistance with bathing and toileting. R7 was occasionally incontinent of bladder. R7 had no falls. The 06/07/24 Quarterly MDS documented a BIMS score of 15, indicating intact cognition. R7 was independent with eating, oral care, personal hygiene, and upper body dressing. R7 required supervision with toileting and bathing and required moderate assistance with transfers. R7 had no falls. The 12/07/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment documented R7 had bladder incontinence related to his benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) and weakness. The 07/18/24 Care Plan documented R7 had an ADL self-care performance deficit. The Care Plan instructed staff to provide R7 with required one staff assistance for transfers between surfaces and were instructed to use a walker and a gait belt dated 06/13/24. The Care Plan included the staff to provide a call light and place within R7's reach, dated 01/03/23. The 05/24/24 Physician Order included the staff were to ensure R7's tab alarm was working every day, due to frequent falls. Review of R7's Progress Notes from 01/01/24 to 07/18/24 lacked documentation regarding call lights. On 07/16/24 at 09:20 AM, R7 stated staff took a long time to answer his call light. R7 stated it could take the staff over 45 minutes to answer. On 07/16/24, observation revealed R7's call light was on at 09:18 AM, and staff failed to answer the call light until 10:00 AM, a total of 42 minutes. On 07/16/24 at 09:59 AM, Certified Nurse Aide (CNA) M stated she answered the call light for R7 a couple of minutes ago and had forgot to shut it off. CNA M entered R7's room and canceled the call light. Resident (R) 27's Electronic Health Record (EHR) revealed diagnoses, which included after care following a joint replacement surgery, presence of unspecified artificial knee joint, low back pain and migraines. The 05/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R27 had a total mood severity score of 00, indicating no depression. R27 was independent with eating, oral care, toileting, dressing, personal hygiene and mobility. R27 required supervision assistance with activities of daily living (ADL) with bathing. R27 was frequently incontinent of bladder. R27 had pain occasionally with the worst pain level of 10. The 07/03/24 Entry MDS documented a BIMS of 15, and no depression. R27 required moderate assistance with her ADLs with lower dressing, footwear, transfers, and standing. The resident was non ambulatory and required maximal assistance with toileting and bathing. R27 was occasionally incontinent of bladder and documented frequently complained of pain with the worst pain level of nine. The 05/20/24 Functional Abilities Care Area Assessment documented R27 was awaiting knee surgery and was not ambulatory. The 05/20/24 Pain CAA documented R27 had chronic pain related to her diagnosis. The Care Plan reviewed on 07/18/24, documented R27 had recent surgery on her right knee and instructed staff to provide the resident with required one staff assistance with dressing, toileting, transfers, and incontinent care, dated 07/01/24. The 07/13/24 Physician Orders included Hydrocodone-Acetaminophen Oral Tablet, 10-325 milligram (mg) tablet, one tablet, by mouth, five times a day scheduled at the following times, 12:00 AM, 06:00 AM, 12:00 PM, 04:00 PM and 08:00 PM for chronic pain. The Progress Notes reviewed from 06/27/24 to 07/19/24 documented the following: On 06/27/24 at 02:47 PM, R27 readmitted from the hospital after she received a right total knee replacement. On 06/29/24 at 04:42 PM, R27 complained of right knee pain rated at a 10. No medication had been delivered from pharmacy and no answer from the physician. R27 requested to go to emergency room and was transferred. On 06/29/24 at 06:36 PM, R27 returned from the hospital, she had received pain medications and returned with a script and stated her a pain level was five. On 07/03/24 at 06:12 PM, R27 rated her pain at 10, she stated she had scheduled pain medication and stated it worked for her. . On 07/06/24 at 10:56 AM, R27 noted to have redness, warm and pain to her left lower leg. R27's physician made aware waited on new orders. On 07/06/24 at 02:33 PM, Physician had not called facility back with new orders. R27 requested to go to the hospital if the facility did not hear back from the physician. On 07/06/24 at 03:28 PM, R27 was sent to hospital, evaluated in emergency room and was admitted with cellulitis (skin infection caused by bacteria). On 07/12/24 at 05:24 PM, R27 readmitted at 12:30 PM and rated her pain at a seven out of 10. On 07/13/24 AT 04:31 PM, received a new physician order to increase hydrocodone-acetaminophen 10-325 mg changed from four times a day to five times a day per physician. During an interview on 07/16/24 at 12:34 PM, R27 stated her call light did not always work, the light above the door in the hallway did not light up, and staff told her the call light did not activate their pager. R27 stated she had to yell loudly for staff to come assist her and stated this occurred on all three shifts and would at times, have to wait over 45 minutes for staff to answer her call light. On 07/16/24 at 04:00 PM, R27 yelled out the surveyor's name from her room when the surveyor walked by her room. R27 was in her bed. R27 had a frown on her face of discomfort and stated that her call light had been on for over 20 minutes, and no staff had answered it yet. R27 stated she was in pain and needed pain medication. During an interview on 07/16/24 at 04:01 PM, CNA N stated the C hall call lights did not alarm to all of the pagers and the call light system had not been working correctly for several months. During an interview on 07/16/24 at 04:05 PM, Licensed Nurse (LN) G and LN H both confirmed R 27's call light was activated 20 minutes prior when they observed the call light computer screen located in the nurses' station. LN G and LN H stated the call light system has not worked properly for months. During an interview on 07/16/24 at 04:35 PM, Administrative Nurse D stated the call light system had just been looked at recently by a company and had been working properly. Administrative Nurse D expected the aides to always have a working pager and walkie talkie on them when working. On 07/16/24 at 04:35 PM, Administrative Staff A, confirmed she would look into the call light system and update the surveyor. On 07/16/24 at 05:30 PM, CNA O stated she had a pager, but it was not on. CNA O then stated the pager battery was dead. On 07/16/24 at 05:30 PM, CNA P stated she had the float pager on her and had received alerts from A, B, and D hall call lights. Observation with CNA P of her pager history revealed no C hall call lights were received to her pager. On 07/16/24 at 05:30 PM, CNA N stated she always carried a call light pager. On 07/16/24 at 05:30 PM, CNA M stated she did not have a pager on her. CNA M stated she gave the C hall pager to another aide at 04:30 PM today. On 07/16/24 at 05:35 PM, CMA R stated she received the C hall pager at 04:30 PM and cleared the history off the pager. CMA R stated the call light system on C hall did not always work, but the nurses have the call light screen in the nurses' station and would call the staff on the walkie talkies to assist the residents when residents would activate their call light. Observation on 07/16/24 at 05:35 PM, revealed R27 activated her call light, the alert went to the C hall pager, but did not go to any other pager, including the float pager. During an observation on 07/16/24 at 05:40 PM, the call light computer screen in the nurses' station with a history of the longest call light activated time was 62 minutes. Administrative Staff A confirmed that was not an acceptable time for a resident's call light to go unanswered. Administrative Staff A stated the call light should also go to the float pager and confirmed R27's call light did not go to that pager at 05:35 PM. Review of the call light reports from 07/15/24 documented the following extended call light response times: Room C-38, the call light was on for 43 minutes, 36.8 minutes, and 89.42 minutes. Room B-21, the call light was on for 51.17 minutes. Room B-26, the call light was on for 30 minutes. Room B-27, the call light was on for 65.58 minutes. Room A-7, the call light was on for 43 minutes, and Room B-19, the call light was on for 33 minutes. Review of the call light reports from 07/16/24 documented the following extended call light response times: Room A-7, the call light was on for 32 minutes, 36.15 minutes. Room B-23, the call light was on for 31 minutes. Room B-21, the call light was on for 61 minutes. Room B-27, the call light was on for 51 minutes. Room C-37, the call light was on for 47 minutes, 56 minutes, and 43 minutes. Room C-38, the call light was on for 42 minutes. Room D-23, the call light was on for 46 minutes, and Room A-8, the call light was on for 38 minutes. On 07/16/24 at 06:05 PM, Administrative Staff A stated the facility call light plan was the facility would have a staff member at the nurses' station to monitor the call light computer screen and notify staff members by walkie talkie when a call light had been activated. Administrative Staff A stated she contacted the call light company for instructions to re-program the float pager later in the evening as the company was not available to assist at the time of the call. On the morning of 07/17/24 at 07:25 AM, observation of the facility nurse's station revealed no staff were present at the nurse's station to monitor the computer screen for call lights. On 07/17/24 at 07:30 AM, CNA Q stated she did not have a pager but had a walkie talkie. CNA Q stated she was the bath aide and did not need to carry a pager. On 07/17/24 at 07:40 AM, LN I stated the Administrator re-programmed the float pager last night, and all staff were to have a pager and a walkie talkie. LN N stated no one educated or alerted them that a staff member was to watch the call light computer screen. On 07/17/24 at 08:05 AM, B hall CNA MM lacked a call light pager, however had a walkie talkie on her. On 07/17/24 at 08:05 AM, A hall CNA NN had her call light pager and walkie talkie on her, and the pager history showed the call lights activated on the A hall earlier in the morning. On 07/17/24 at 08:05 AM, C and D hall CNA M had both C and D hall call pagers and a walkie talkie on her. CNA M stated she had cleared the history on both the pagers that morning. On 07/17/24 at 08:05 AM, CNA Q stated she now had the float pager on her, and the float pager had no history on it. On 07/17/24 at 08:11 AM, R27 activated her call light. The call light did activate the pager for C hall and float pager, but it did not vibrate or sound when activated per CNA M and CNA Q. CNA M stated the pager should sound or vibrate. On 07/17/24 at 08:35 AM, Administrative Staff A stated she gave verbal education last night after the float pager was re-programmed and stated the aides were to carry the float pager so there would be two working pagers for the call lights being activated. Administrative Staff A stated she did not complete a written education. The facility Call Light policy, dated 08/01/23 documented staff were to ensure the resident always had a method of calling for assistance and would promptly answer resident's call lights. On 07/17/24 at 06:14 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for the failure to provide needed services to residents due to the lack of a functioning call system in place to address the care needs of all residents. The facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at 07:54 AM which included the following: 1. All residents were immediately checked on to address any needs. Continual resident rounding was conducted to monitor and assess resident needs until all pagers were verified functioning appropriately. 2. All pagers were checked to ensure they were functioning properly, and all CNAs and CMAs were checked to ensure they were wearing their functioning pagers. 3. Immediate education was conducted with all CNAs, CMAs, and Charge nurses to ensure all CNAs, CMAs an assigned Charge nurse were wearing their pager during their shift. 4. Walkie talkies will be implemented for increased communication for resident care needs. Walkie talkies will be carried by all nursing staff during their shift to assist in call light response time. 5. Call light company contacted on 07/16/24 and corrected float pager, ensuring this pager received resident call lights from all hallways. What systematic changes were implemented to ensure deficient practice does not recur: 1. Walkie talkies will be carried by all nursing staff during their shift to assist in call light response time. 2. Order was placed for additional pagers. When additional pagers arrive to facility, all nursing staff will carry pagers including Nursing Leadership, during their shift to assist in call light responses. 3. At beginning of each shift, a huddle will be conducted by the charge nurse to ensure all CNAs & CMAs are carrying pagers on their person. 4. Nursing home leadership will implement Angel Rounding, a resident rounding interview and observation system to ensure resident care needs are addressed including call light response times The surveyor verified the facility implemented the above corrective measures on-site on 07/18/24 at 04:00 PM. The deficient practice remained at a scope and severity level of an E, following the implementation of the removal plan. - The Electronic Health Records (EHR) documented Resident (R)21 had the following diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following an intracranial hemorrhage (a type of stroke that causes bleeding in the head), lack of coordination and traumatic brain injury (TBI-an injury to the brain caused by external forces). The 02/15/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition, the depression not scored and lacked staff interview. R21 had behaviors that included hitting and yelling. R21 required supervision for eating and oral care. Moderate assistance with activities of daily living (ADLs), with toileting hygiene, showering and dressing. R 21 required maximal assistance with transfers, personal hygiene, and bed mobility. R21 was dependent on staff for wheelchair mobility. R21 was always incontinent of bladder. The resident had no falls. The 02/15/24 Functional Abilities Care Area Assessment (CAA) documented R21 was dependent on staff with all ADLs. The 05/17/24 Quarterly MDS documented a BIMS score of 99, and the depression was not scored. R21 had behaviors of yelling and hitting. R21 required total dependence of staff for toileting, showering, dressing, hygiene, transfers, and dressing. R21 required maximal assistance for oral care and bed mobility. R21 required supervision for eating. R21 was frequently incontinent of bowel and bladder. On 07/17/24 the Care Plan documented R21 required a full lift with two persons assist, dated 03/21/24. Staff instructed to complete weekly skin assessment by licensed nurse, document the findings and report concerns to the physician, dated 08/03/22. On 07/17/24 the Physician Orders documented to complete weekly skin assessments, document the findings and report concerns to the physician, ordered on 06/29/23. The Progress Notes reviewed 01/01/24 to 07/18/24, documented the following: On 03/21/24 at 08:58 PM, R21 had an old bruise noted across her lower chest area, under arms and left shoulder area. Bruised areas were various colors of purple and yellow. The bruise determined to be from inappropriate gait belt (belt used to help transfer or stabilize during activity) used by staff. Review of the Skin Observation in EHR dated 03/18/24, documented R21's skin check was completed - no skin conditions observed/skin condition resolved. The Skin Observation in EHR dated 03/25/24, documented skin check was completed - no skin conditions observed/skin condition resolved. On 07/16/24 at 12:02 PM, R21 seated in her wheelchair in the main dining room eating her lunch. Noted a personal alarm on wheelchair attached to the handle of the wheelchair and clipped to R21's shirt. On 07/16/24 at 12:40 PM, R21 seated in her wheelchair yelling out come here a few times and waving her right arm. On 07/16/24 at 12:47 PM, a phone interview with R21's family member stated she received a phone call from the facility on 03/21/24 at 10:00 PM from a staff nurse and was notified that R21 had a bruise on her chest, and that it might have been caused by a gait belt. The family member stated they went to the facility the next day and observed a large bruise located on R21. The bruise was across the chest from armpit to armpit, with several different colors of healing. The family member stated they spoke to the Administrator that was no longer employed there and the SSD, and asked why she is just being notified of a bruise that looked to be healing. The family member stated that the Administrator would have the Director of Nurses call her about the bruise. The family member stated she talked to Administrative Nurse D on 03/25/24 and was informed the bruise was caused by a gait belt and that R21 was now a full body mechanical lift to avoid using a gait belt. On 07/17/24 at 05:30 PM, Administrative Staff A was requested to locate incident reports that was requested by a surveyor earlier in the morning from Administrative Nurse D. Administrative Staff A was notified that R21 had a bruise across her chest noted on 03/21/24. On 07/17/24 at 05:35 PM, Administrative Staff A stated that no investigation was completed, that the bruise occurred when family transferred R21 by themselves. Administrative Staff A stated there was a progress note in the EHR. The progress notes reviewed with Administrative Staff A and confirmed there was no progress note that mentioned the family caused the bruise. On 07/18/24 at 09:30 AM, no documentation received about the above concern from Administrative Staff A or Administrative Nurse D. On 07/18/24 at 04:00 PM, Social Service Staff X could not recall a conversation about a bruise on R21. On 07/22/24 at 02:40 PM, Administrative Nurse D stated there was no investigation or report completed about the bruise on R21 as the thought it was caused by a gait belt. Confirmed no staff education completed after the bruise was noted. Administrative Nurse D stated the skin observations should have included the bruise. The facility policy dated 07/06/23 Abuse and Neglect documented the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse and reporting for this resident that had a large bruise across her chest. 36881 - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear) , need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization , the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on 05/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse nor neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD and the DON were employed during the time of the sexual assault allegation by R17 and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse as they should. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they 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 other officials in accordance with state law, including to the state survey and certification agency. The facility failed to ensure R17 remained free from sexual abuse when they failed to acknowledge an allegation, initiate an investigation, report the allegation to law enforcement and/or the state agency, and protect her from further abuse after she alleged, she was sexually assaulted by two men in her room at the facility.

The facility reported a census of 37 residents with 17 sampled for review. The sample included one cognitively intact dependent Resident (R) 17 for reporting an allegation of abuse. Based on observation, interview, and record review, the facility failed to report an allegation of sexual assault when R17 reported a sexual assault by 2 male perpetrators on 05/16/24. On 05/24/24 the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24 the resident readmitted to the facility. The hospital notified the facility of resident's report of sexual assault 05/24/24 and on discharge 5/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, did not report to the state agency, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to the surveyor during survey. This failure placed the resident in immediate jeopardy and at risk for continued negative impact on her physical, mental, and psychosocial well-being. Findings included: - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear), need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization , the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on 05/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse nor neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD and the DON were employed during the time of the sexual assault allegation by R17 and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse as they should. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they 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 other officials in accordance with state law, including to the state survey and certification agency. The facility failed to report, allegations of abuse/sexual assault to the appropriate state agency to ensure protection of the R17 as well as the other residents of the facility. This failure placed the resident in immediate jeopardy and at risk for continued negative impact on her physical, mental, and psychosocial well-being. On 07/18/24 at 03:30 PM, Administrative staff A was provided the Immediate Jeopardy (IJ) template for the failure to respond appropriately to R17's allegations of sexual assault. The IJ was first to exist on 05/16/24, and the facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at which included the following: 1. On 07/16/24, R17 was assessed for any abuse, neglect, or trauma. 2. All nursing staff education initiated on 07/16/24 for Recognizing and Reporting Abuse and Neglect Allegation by the Clinical Learning and Development Specialist. 3. Trauma Informed care assessment completed on 07/17/24 and R17's care plan was updated to reflect new trauma informed care interventions. 4. On 07/17/24, Law enforcement contacted and R17 interviewed. 5. Nursing Home Leadership were educated on Recognizing and Reporting Abuse and Neglect Allegation conducted by Regional Clinical Services Director on 7/18/24. 6. All above education will be completed by 7/18/24 or prior to next working shift. By 7/18/24, facility will review all residents at risk for Trauma informed care and address care plan interventions as needed. 7. Angel Rounding (leadership resident rounding touchpoint) will be initiated 7/18/24 to identify areas of concern and ensure resident safety. The surveyor verified the facility implemented the above corrective measures on -site on 07/22/24. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan.

The facility reported a census of 37 residents with 17 sampled for review. The sample included one cognitively intact dependent Resident (R) 17 reviewed for investigating an allegation of abuse related to sexual assault. Based on observation, interview and record review, the facility failed to thoroughly investigate R17's allegations of sexual assault and failed to protect R17 from potential further sexual abuse. The resident reported sexual assault by 2 male perpetrators on 05/16/24. On 05/24/24 the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24 the resident readmitted to the facility. The hospital notified the facility of resident's report of sexual assault 05/24/24 and on discharge 5/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24 when R17 reported the sexual assault to the surveyor during survey. This failure placed the resident in immediate jeopardy and at risk for continued negative impact on her physical, mental, and psychosocial well-being. Findings included: - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear) , need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization , the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on 05/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse nor neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD and the DON were employed during the time of the sexual assault allegation by R17 and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse as they should. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they 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 other officials in accordance with state law, including to the state survey and certification agency. The facility failed to ensure R17 remained free from sexual abuse when they failed to acknowledge an allegation, initiate an investigation, report the allegation to law enforcement and/or the state agency, and protect her from further abuse after she alleged, she was sexually assaulted by two men in her room at the facility. The facility failed to report and thoroughly investigate reported allegations of abuse/sexual assault to the appropriate state agency to ensure protection of the R17 as well as the other residents of the facility. The facility failed to thoroughly investigate R 17's allegations of abuse/sexual assault to ensure safety and protection of the R17 as well as the other residents of the facility. On 07/18/24 at 03:30 PM, Administrative staff A was provided the Immediate Jeopardy (IJ) template for the failure to respond appropriately to R17's allegations of sexual assault. The IJ was first to exist on 05/16/24, and the facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at which included the following: 1. On 07/16/24, R17 was assessed for any abuse, neglect, or trauma. 2. All nursing staff education initiated on 07/16/24 for Recognizing and Reporting Abuse and Neglect Allegation by the Clinical Learning and Development Specialist. 3. Trauma Informed care assessment completed on 07/17/24 and R17's care plan was updated to reflect new trauma informed care interventions. 4. On 07/17/24, Law enforcement contacted and R17 interviewed. 5. Nursing Home Leadership were educated on Recognizing and Reporting Abuse and Neglect Allegation conducted by Regional Clinical Services Director on 7/18/24. 6. All above education will be completed by 7/18/24 or prior to next working shift. By 7/18/24, facility will review all residents at risk for Trauma informed care and address care plan interventions as needed. 7. Angel Rounding (leadership resident rounding touchpoint) will be initiated 7/18/24 to identify areas of concern and ensure resident safety. The surveyor verified the facility implemented the above corrective measures on -site on 07/22/24. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan.

The facility reported a census of 37 residents, with 17 residents sampled, which included four residents reviewed for Trauma Informed Care. Based on observation, interview, and record review, the facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to a trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed R17 in Immediate Jeopardy (IJ) and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being. Findings included: - Review of Resident (R) 17's undated Physician Orders, documentation included diagnoses of traumatic subdural hemorrhage (bleeding in the brain due to trauma), anxiety disorder, (mental or emotional reaction characterized by apprehension, uncertain and irrational fear), need for assistance with personal care, lack of coordination, and problem related to care provider dependency. The Annual Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident did not exhibit behaviors. She reported feeling down, depressed, or hopeless for two to six days of the look back period and noted the resident would isolate socially at times. The resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation and/or cares one to three days of the look back period. She received antidepressant medication (class of medication used to treat depression). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/12/24, included the resident had impaired cognitive function, impaired thought processes, experienced confusion, and behaviors. The Care Plan, (CP), dated 07/09/24, included interventions initiated on 04/17/24, which instructed staff to provide a translator as necessary to communicate with the resident and further documented the majority of facility staff spoke Spanish. An intervention initiated 04/17/24 instructed staff to monitor/record/report to R17's health care provider as needed when the resident had feelings such as labile mood or agitation, felt threatened by others or thoughts of harming someone. During an interview on 07/16/24 at 01:02 PM, R17 spoke in Spanish to Dietary Staff (DS) BB, who translated the interview to English on behalf of the resident. R17 stated two men sexually assaulted her in the facility. She said she had bruises and bite marks across her breast and abdomen when she made the report to the nurses (at the facility). Upon inquiry, she stated the nurses did not respond to her report of assault nor assess her for injury. She said she was in her room at the facility when the two men forced her on the bed and that was where it happened. The resident sat in her wheelchair, cried, and pointed towards her bed while describing the event. She was anxious, tearful, and her hands were trembling. She reported nobody did anything in response to her allegation. She confirmed law enforcement had not talked with her and she did not feel safe in the facility. During an interview on 07/16/24 at 01:50 PM, DS BB stated she remembered hearing something about the resident (R17) reporting she was assaulted in the facility to someone at the local hospital, but that was a couple of months ago and she was not sure of the details. DS BB stated she did not recall any staff education (regarding resident abuse) provided by the facility at the time. Review of the Electronic Medical Record (EMR) Progress Notes (PN), dated 05/16/24 at 05:00 PM, revealed R17 complained of bilateral (both) breast pain due to a sexual assault that occurred at the facility a long time ago according to the resident. She did not recall when it happened. The resident had never reported any abuse since she admitted to the facility. She stated the people who assaulted her bit her at that time and she had several bruises on her breast and abdomen. The nurse performed a skin assessment, and the assessment was within normal limits. The nurse notified the Director of Nursing (DON), Social Services Designee (SSD), and Personal Care Physician (PCP) of the situation. The EMR PN dated 05/24/24 at 04:30 PM, documentation included the facility nurse spoke to the hospital nurse who reported the resident (R17) admitted from the emergency room (ER) on 05/22/24 for complaints of left sided chest pain. The hospital nurse informed the facility they made an adult protective service (APS) report due to the resident's complaint of sexual assault. The facility would follow up with the resident's PCP and to determine if a consult with cardiologist was required. The EMR PN dated 05/24/24 at 05:42 PM, documented upon return to the nursing facility, the resident was very aggressive and complained much of the night. She refused to have her call light turned off after cares. She banged on the door, yelled, and cried. The EMR PN dated 05/29/24 at 07:46 AM, revealed during a recent hospitalization , the resident (R17) reported to ER staff that she was being sexually abused at the nursing home. Review of the facility EMR documentation above revealed the resident (R17) reported sexual assault by two male perpetrators on 05/16/24. On 05/24/24, the resident went to the hospital for chest pain and reported to hospital staff she was sexually assaulted in the facility. On 05/29/24, the resident readmitted to the facility. The hospital notified the facility of the resident's report of sexual assault on 05/24/24 and on discharge on 05/29/24. The facility failed to respond to R17's allegation of abuse, investigate the allegation of abuse, and did not notify law enforcement until 07/16/24, when R17 reported the sexual assault to a state agency surveyor during a recertification survey. Review of the facility Grievance Log for 04/01/24 through 07/16/24 lacked identification of any allegation of abuse or neglect regarding R17. During an interview on 07/17/24 at 02:44 PM Administrative Staff A confirmed the grievance logs did not include any report of sexual assault for the resident as noted in the 05/16/24 progress notes. The facility followed up on the reported sexual assault on 07/16/24 (approximately two months after the resident originally reported the allegation) when the surveyor brought it to her attention. Administrative Staff A reported she started at the facility as the Administrator on 06/10/24 and she was not aware of the report until 07/17/24. Administrative Staff A said she expected the Social Worker/SSD to track resident grievances, but the SSD informed her she did not maintain the grievance log as it was kept in the old Administrators office. She reported the SSD, and the DON were employed during the time of the sexual assault allegation by R17, and the facility failed to respond to the resident's allegations of abuse on three different occasions. Administrative Staff A reported the facility should report, investigate, and notify law enforcement of allegations of sexual assault to ensure protection of the resident making the allegation, as well as the other residents of the facility. On 07/17/24 at 02:49 PM, Social Service Staff X stated she was just aware of the resident's allegation of abuse related to sexual assault. She stated the staff should protect the resident first then report any allegations of abuse to their supervisor and the state agency, initiate an investigation, and notify law enforcement. The nursing staff should assess the resident for injury, call the physician, family, and law enforcement. The facility should provide education for the staff and also question other residents and staff to get clarification on how they feel about their safety. Social Service Staff X confirmed the allegations of abuse were not reported or investigated when staff were made aware of the allegations on 05/16/24, 05/24/24, and 05/29/24. The facility failed to respond to the resident's allegation of abuse. The facility policy Abuse and Neglect policy, dated 07/06/2023, documentation included the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including but not limited to, location employees, and/or other residents. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origins will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services and both also have the authority to call law enforcement. The location will have evidence that all alleged or suspected violations are thoroughly investigated, and they 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 other officials in accordance with state law, including to the state survey and certification agency. The facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. On 07/18/24 at 03:30 PM, Administrative staff A was provided the Immediate Jeopardy (IJ) template and were notified the facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed R17 in immediate jeopardy and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being. The IJ was first to exist on 05/16/24, and the facility submitted an acceptable plan for removal of the immediate jeopardy on 07/18/24 at which included the following: 1. On 07/16/24, R17 was assessed for any abuse, neglect, or trauma. 2. All nursing staff education initiated on 07/16/24 for Recognizing and Reporting Abuse and Neglect Allegation by the Clinical Learning and Development Specialist. 3. Trauma Informed care assessment completed on 07/17/24 and R17's care plan was updated to reflect new trauma informed care interventions. 4. On 07/17/24, Law enforcement contacted and R17 interviewed. 5. Nursing Home Leadership were educated on Recognizing and Reporting Abuse and Neglect Allegation conducted by Regional Clinical Services Director on 7/18/24. 6. All above education will be completed by 7/18/24 or prior to next working shift. By 7/18/24, facility will review all residents at risk for Trauma informed care and address care plan interventions as needed. 7. Angel Rounding (leadership resident rounding touchpoint) will be initiated 7/18/24 to identify areas of concern and ensure resident safety. The surveyor verified the facility implemented the above corrective measures on -site on 07/22/24. The deficient practice remained at a scope and severity level of a D, following the implementation of the removal plan.

The facility identified a census of 37 residents. Based on observations, record reviews, and interviews the facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. This deficient practice placed the residents at risk for decreased quality of care, quality of treatment, and sense of well-being. Findings included: - The facility failed to ensure an effective quality assessment and performance improvement (QAPI) program as evidenced by the number of deficient practices, elevated scope and severity, and substandard quality of care found onsite as followed. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, which included Resident 17's allegation of sexual assault. The facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA - a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required by federal regulations. The facility failed to investigate all allegations of resident-to-resident abuse, failed to protect residents from further incidents of abuse. The facility failed to recognize a significant change in a resident's physical condition and perform a Comprehensive Minimum Data Set (MDS) assessment within the required 14-day period of the resident's change in condition. This deficient practice had the potential to lead to uncommunicated needs and placed the resident at risk for further deterioration of his physical, mental, and psychosocial well-being. The facility failed to accurately complete the Minimum Data Set (MDS) for five sampled residents, as required by the federal regulations. The facility failed to develop a comprehensive person-centered care plan for one of the 17 residents sampled. The facility failed to revise fall care plans with interventions for three residents for one of the 17 residents sampled. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of 17 sampled residents related to Restorative Nursing Program to ensure his quality of life. The facility failed to ensure an environment as free from accident hazards as possible when facility failed to thoroughly document and place fall mat for R 21 as directed in the care plan. The facility failed to ensure a safe transfer for R36, when staff utilized a full body mechanical lift, without a second staff member present. This deficient practice could potentially result in a mechanical lift transfer accident. The facility failed to acknowledge and respond appropriately to R17's allegations of sexual assault and her display of behaviors, which align to a trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed R17 in Immediate Jeopardy (IJ) and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being. The facility failed to provide scheduled pain medication for R 8 as ordered by the physician. The facility failed to respond to pharmacist's recommendation to complete an Abnormal Involuntary Movement Score to evaluate the effects of the R 21's psychotropic medications. The facility failed to serve the residents of the facility food, which was palatable, attractive, and served at the appropriate temperature. The facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report Registered Nurse (RN) coverage on 29 dates between January 1, 2023 and 09/30/23. The facility failed to have an effective administration to identify and develop corrective action plans for potential quality deficiencies as found on the current survey. This deficient practice placed the residents at risk for decreased quality of care, quality of treatment, and sense of well-being.

The facility reported a census of 37 residents. Based on record review and interview, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal [PBJ], related to licensed nursing coverage 24 hours/day and excessively low weekend staffing. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 3, 2023 (April 01-June 30), revealed a lack of License Nurse (ON) for 24 hours/seven days a week, 24 hour/day on the following dates: On 05/06/23 Saturday (SA), On 05/07/23 Sunday (SU), On 05/14/23 (SU), On 05/27/23 (SA), On 06/03/23 (SA), On 06/04/23 (SU), On 06/11/23 (SU), and On 06/18/23 (SU). Review of the PBJ Staffing Data report for FY Quarter 4 (July 01-September 30,2023), FY Quarter 01 (October 01-December 31,2024, and FY Quarter 2 (January 01-March 31, 2024, revealed excessively low weekend staffing. Review of the daily staffing sheets from May 2023 through March 2024, revealed equal staffing on the weekends as during the week. On 07/23/24 at 08:57 AM, Administrative Nurse D reported the Administrator compiles the staff hours for the PBJ and transmits the data to CMS. Administrative Nurse D confirmed the inaccurate staff hours reported on the PBJ for the Quarter 3, 2023 and the inaccurate excessive low weekend staffing reported on the PBJ. The facility lacked a policy for accuracy of the PBJ. The facility reported a census of 37 residents. Based on record review and interview, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal [PBJ], related to licensed nursing coverage 24 hours/day and excessively low weekend staffing.

The facility reported a census of 37 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - Observation of the kitchen and food storage areas on 07/16/24 at 08:27 AM revealed the following areas of concern: One sealed 5-pound bag of cake mix, approximately half used, without an open date. One bag of un-sealed corn bread mix. The refrigerator outside of the kitchen contained an opened orange juice container, one opened gallon of milk and a half gallon of chocolate milk without open date. Observation of the kitchen and food storage areas on 07/17/24 at 04:30 PM revealed the following: Three coated frying pans with several scratch marks. Six cutting boards that had several scratches. Both kitchen ovens had a burnt substance on the bottom. The chest freezer had ice cream with the lids removed and six of the cups had freezer burn. An open bag of barbecued pork which was undated. An open ten-pound bag of frozen vegetables that was undated. Interview on 07/16/24 at 08:27 AM with Dietary Staff BB revealed that she expected staff to label the date on opened food items. Interview on 07/17/24 at 04:30 PM with Dietary Staff BB confirmed the above concerns of kitchen and freezer storage undated items was unacceptable. The Food-Supply Storage-Food and Nutrition Services Policy dated 07/09/20 revealed food that had been opened or prepared, were to be placed in an enclosed container, dated, labeled, and stored properly. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 40 residents, with four residents sampled, including three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision- making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)2. The facility staff knew R2 was an elopement risk and R2 had been upset and voiced she wanted to go home. The facility staff then left R 2 unsupervised near the front entrance. The facility staff had knowledge the front doors had malfunctioned and did not require a code to be entered to open the door, however, reported the WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) still functioned. On 03/19/24 at 07:10 PM, R2 exited the facility via the front doors without staff awareness and the WanderGuard system failed to alarm. Facility staff did not know R2 eloped until a neighbor brought her to the front entrance at 07:24 PM, fourteen minutes later. This deficient practice placed R2 in immediate jeopardy. Findings included: - The Medical Diagnosis tab in the electronic medical record (EMR) for R2 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), altered mental status, restlessness and agitation, and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R2 with a short-term and long-term memory loss and impaired decision making. The Significant Change MDS dated [DATE] assessed R2 with a Brief Interview of Mental Status (BIMS) score of zero, indicating severe cognitive impairment. R2 used a wheelchair for mobility. The Cognitive Loss/Dementia Care Area assessment dated [DATE] revealed R2 had a diagnosis of Alzheimer's disease and required staff to give one command at a time, cue to task at hand, speak in simple direct sentences, and repeat as needed. The Care Plan dated 03/07/24, revealed R2 was at risk for elopement related to increased wandering and a WanderGuard used to alert staff to movement when close to the exit doors. The staff were to check the WanderGuard daily to ensure it was in place. The care plan indicated R2 had a behavior symptom related to her dementia as evidenced by wandering. Staff were to minimize R2's potential for wandering behaviors by offering toileting, snacks, and interaction which may divert attention or prevent wandering behavior. The Elopement Risk assessment dated [DATE] assessed R2 as an elopement risk. The Physician Order tab included an order dated 04/14/22 for R2 to have a WanderGuard in place and to check for placement every day. The Work History Report dated 12/02/23 through 03/31/24 revealed the magnetic exit locks, doors, locks, and gates (elopement) testing and inspection (receivers) task completed by Maintenance Staff U on 03/13/24. The report lacked an area to document if there were any issues. The Progress Note dated 03/19/24 at 07:38 PM, revealed R2 had been hanging around the front lobby and crying, demanding that she goes home. R2 was able to get out of the front door because of the broken lock, and a visitor brought her back into the building. The Progress Note dated 03/20/24 at 01:22 AM, revealed R2 eloped from the building during shift change, the door lock was broke, and entry/exit was possible with no staff mediation. R2 had been crying in the lobby area demanding she go home. The WanderGuard system did not sound, however, R2 had a WanderGuard in place and returned to the facility uninjured, accompanied by a person from a nearby residence. R2 had told the neighbor she was from the facility. R2 was in her wheelchair with her orthopedic boot (device used to protect broken bones and other injuries of the lower leg, ankle, or foot) on her right lower extremity. Licensed Nurse (LN) G assessed R2 for injuries and R2 returned to her room. The Progress Note dated 03/20/24 at 10:39 AM revealed R2 eloped at approximately 07:10 PM last evening. On 03/27/24 at 01:37 PM, observation of the area R2 traversed after she exited the facility revealed a sidewalk in front of the facility that went around to the south side, an area of the sidewalk on the south side had an uneven surface approximately two inches all the way across, and an area of dirt/grass around a tree for approximately 25 feet from the facility sidewalk before reaching a paved area in front of the neighbor's residence. R2 traveled approximately 140 feet from the front entrance to the neighbor's residence without staff knowledge. On 03/27/24 at 01:44 PM, observation revealed R2 resting in her bed with a WanderGuard bracelet in place to her left ankle. On 03/27/24 at 01:45 PM, when R2 asked if she had gone outside after supper last week, she stated no it was cold, cold, cold. On 03/27/24 at 01:29 PM, Maintenance Staff U stated he checked the doors every week or two, whenever it came due in the electronic system, and did not recall any door malfunctions with his last door check completed prior to R2's elopement on 03/19/24. Maintenance Staff U stated he checks each WanderGuard used, weekly. Maintenance Staff U stated the WanderGuard system works fine and when checked the day after the elopement, the system was fine and so was R2's WanderGuard device. On 03/27/24 at 02:00 PM, Certified Medication Aide (CMA) R stated on 03/19/24 she worked 04:00 PM to 10:00 PM and R2 had been upset all day, had been asking staff to take her out, and she last saw R2 around 06:20 PM or 06:30 PM and R2 was crying. CMA R stated she provided R2 reassurance and that was the last time she had seen R2. CMA R stated there was a meeting at 07:00 PM for CMAs and Certified Nurse Aides (CNA) on 03/19/24, which she said she was approximately 10 minutes late getting to, and she never heard an alarm sound around the time R2 eloped. On 03/27/24 at 02:53 PM, CNA M stated she was on duty on 03/19/24 when R2 eloped. CNA M last saw R2 around 06:50 PM to 07:00 PM at the nurse's station talking to LN G and the resident was crying and saying she wanted to go home. CNA M stated R2 started crying after supper, and she observed her starting to walk and reminded she was not supposed to be up walking and needed to sit down (due to recent foot surgery). CNA M stated at one-point R2 was just past the fishpond headed to the front door and she moved R2. R2 had tried to call a friend or family and when they did not answer, it made R2 cry more and she kept saying she wanted to go home. CNA M stated after assisting other residents to lay down, she and CNA N sat in a chair at the fishpond area to chart and a guy had entered the facility and had R2 outside. They brought R2 inside and took to her to the nurse's station. On 03/27/24 at 03:07 PM, CNA N stated she was on duty on 03/19/24 when R2 eloped. CNA N stated R2 had been upset off and on and was talking about going home. CNA N stated she attempted to keep an eye on her and around 07:00 PM, she observed R2 in the hallway and entering her room. CNA N assisted another resident, then helped another staff member with cares, and did not have a chance to see if R2 was still in her room. CNA N stated after that she was in the fishpond area and a young man came in the facility and appeared to be looking for someone, she stood up to hear him better and observed R2 outside with the young man's mother, who said R2 told them she came from here. CNA N stated she brought R2 inside and then to the nurse and informed the nurse of the elopement. CNA N stated she did not hear the WanderGuard system sound when R2 eloped, which was usually a loud sound able to be heard down the hall when in a room. CNA N stated she knew the door was not locking and did not require a code to open since the previous week and as far as she knew it had been fixed. On 03/27/24 at 03:18 PM, Maintenance Staff V stated the magnetic lock was shut off to the door because the circuit board in the keypad was bad, which did not affect the Wanderguard system as it required to be shut off with a switch at a different location. On 03/27/24 at 03:50 PM, Administrative Nurse D stated she expected the staff to do one-to-one with R2 when she was upset that evening, on 03/19/24, and saying she wanted to go home. On 03/27/24 at 04:07 PM, LN G stated from the time she arrived for duty on 03/19/24 at 06:00 PM until she went to obtain vital signs at 07:00 PM, R2 was sitting in the nurse's office door. R2 was crying, wanted to call her aunt who did not answer and that caused R2 to start cussing and demanding to be taken home. LN G stated she told R2 this was where she lived, asked her to calm down, and said she could go to her room. LN G stated another CNA (she could not recall which CNA) moved R2 to the fishpond area to see if she would calm down and that was when LN G went down the hall to obtain vital signs. LN G stated around 07:20 PM, she came back to the nurse's desk to document the vital signs and did not know R2 was gone. LN G stated CNA N informed her a man brought R2 back to the facility from his house. LN G stated she assessed R2 for injuries in her room and tried to get her interested in the television. LN G stated she did not hear the WanderGuard system alarm and stated at the time the magnetic locks were broken; however, the WanderGuard system had been functioning because the day before R4 tried to get out and it sounded. LN G stated R2's WanderGuard was in place to her ankle and R2 did not verbalize wanting to go home after she returned to the facility. LN G stated there were not any extra WanderGuards to replace R2's, so she locked the exterior door so nobody could go in or out without her unlocking it. LN G stated the door had been malfunctioning and it allowed anyone to go in or out without entering a code on the keypad. On 03/27/24 at 04:44 PM, observation revealed R2 propelled her wheelchair independently using her left leg. Her right leg had an orthopedic boot in place and her foot rested on the pedal of the wheelchair. On 03/27/24 at 04:45 PM, Administrative Nurse D moved R2 up to the front door, informed R2 there would be a loud noise, and opened the door. When the WanderGuard system sounded, R2 placed her hand up to her ears. On 03/28/24 at 08:42 AM, Maintenance Staff U stated when he checked the WanderGuard devices on 03/13/24, all of the devices worked. On 03/28/24 at 09:25 AM, observation of the facility video footage (lacked audio) dated 03/19/24 at 07:09 PM, revealed R2 propelled herself in the wheelchair from the hall she resided on and went to the front door using both hands to push the door open, and she exited the facility at 07:10 PM. R2 did not cover her ears when she left the facility. There was no further activity at the front door until 07:24 PM, when a male opened the door and came inside and looked around and at 07:25 PM, he exited the door with two staff behind him. One of the staff, CNA N, observed punching a code on the keypad on the exterior prior to exiting. On 03/28/24 at 09:40 AM, Administrative Staff A stated on the video footage from another camera, she could see R2 standing up and pushing her wheelchair to the neighbor's house. The facility policy Elopement dated 07/11/23 revealed measures would be put into place to minimize risk of elopement that were individualized to resident needs and identified on the care plan. The facility failed to provide adequate supervision and a safe environment to cognitively impaired R2, identified as an elopement risk, who was upset and voiced wanting to go home, and eloped from the facility in her wheelchair on 03/19/24 at 07:10 PM for 14 minutes, without staff knowledge. On 03/28/24 at 01:10 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure to provide adequate supervision when R2 was upset and voiced wanting to go home and eloped from the facility on 03/19/24 at 07:10 PM. The immediate jeopardy was determined to first exist on 03/19/24 at 07:09 PM, and the surveyor verified the facility identified and implemented corrective actions completed on 03/20/24 at 08:30 PM, when the facility completed the following: 1. The facility locked the front door and checked R2's WanderGuard for functioning and sounding the alarm properly on 03/19/24 at 07:30 PM. 2. Nursing conducted a full assessment of R2 on 03/19/24 at 07:35 PM. 3. Maintenance checked R2's WanderGuard receiver and tested okay along with checking with resident at front door sounding the WanderGuard system on 03/20/24 at 09:00 AM. 4. Nursing completed elopement risk assessments on all residents, checked all care plans of residents at risk for elopement to ensure interventions in place for exit-seeking symptoms, and updated the Treatment Administration Record to check twice daily to ensure the WanderGuard is in place on 03/20/24 at 10:00 AM. 5. The Director of Nursing conducted the Preventing Elopement Focus Audit on 03/20/24 at 11:00 AM. 6. Maintenance contacted technician to reset the magnetic lock keypads on 03/20/24 at 12:00 PM. 7. The facility had a Quality Assurance Performance Improvement meeting on 03/20/24 at 01:00 PM. 8. Maintenance replaced circuit board so the magnetic lock would automatically lock and open with a keypad on 03/20/24 at 08:00 PM. 9. The facility staff were educated to make a radio communication when a resident was exit seeking and make sure resident was comfortable, needs met, diversional activities offered, and kept in view during this time on 03/20/24 at 08:30 PM. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility census totaled 34 residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review the facility failed in multiple areas of pressure ulcer care by the failure to measure/monitor pressure ulcers and implement/evaluate interventions to reduce pressure in a timely manner for cognitively impaired, dependent Resident (R)1. The resident developed multiple, recurrent, and avoidable stage II (partial thickness skin loss, presenting as a shallow open ulcer with a red-pink wound bed) pressure ulcers to her left elbow, stage II pressure ulcer to her sacrum (large triangular between the two hip bones), deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) to both heels, and a stage IV (deep wound that reaches the muscles, ligaments, or bones) pressure ulcer to her right elbow. R1's right elbow pressure ulcer required the use of a negative-pressure wound vacuum (decreases air pressure around a wound to assist healing), developed a [CONDITION(S)]-resistant staphylococcus aureus ([CONDITION(S)], type of bacteria resistant to many antibiotics) infection, which required intravenous (inserted into a vein) antibiotics and hospitalization . These failures placed R1 in immediate jeopardy, and placed two other residents, identified with pressure ulcers, at risk. Findings included: - R1's 04/11/22 pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/25/21 Quarterly Minimum Data Set (MDS) noted R1 was at risk of developing pressure ulcers, and noted she had no unhealed pressure ulcers. The 01/25/22 Annual Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 99, indicating the interview could not be completed. The resident was totally dependent on one-to-two staff for activities of daily living (ADL) and was always incontinent of bowel and bladder. R1 was at risk for pressure ulcers, had one or more unhealed pressure ulcers, and three stage II pressure ulcers, which were not present upon admission/reentry. R1 received a pressure reducing device for her chair and bed, was on a turning and repositioning program, received pressure ulcer care, and received antibiotics once in the seven-day look back period. The 04/18/22 Quarterly MDS revealed R1 was at risk for developing pressure ulcers and had unhealed pressure ulcers. The MDS documented R1 had two stage II pressure ulcers (one present upon admission/reentry), one stage IV pressure ulcer (present upon admission/reentry), and one unstageable pressure ulcer (wound covered with a thick layer of tissue preventing the base from being seen and preventing the wound from being staged) with a nonremovable dressing (present upon admission/reentry). The 07/18/22 Quarterly MDS revealed R1 was totally dependent on staff for ADL care. R1 had an indwelling catheter and was always incontinent of both bowel and bladder. R1 had three stage II pressure ulcers, one stage IV pressure ulcer, and one unstageable DTI. R1 received antibiotics six days in the seven-day look back period. The 01/25/22 Pressure Ulcer Care Area Assessment (CAA) documented R1 developed a pressure ulcer to her coccyx, where she had a pressure ulcer before. Her heels became mushy and did not respond to offloading or use of skin prep to toughen the skin. The 01/25/22 Nutritional Status CAA documented R1 had three stage II pressure ulcers. The 06/2022 through 07/04/2022 Braden Scale Assessment documented R1 was at risk for skin breakdown. The 04/22/21 Care Plan documented staff was to monitor the location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff was also required to turn and reposition R1 in bed and chair every two hours and provide pressure relief to both heels. The 11/13/21 Wound Data Collection (tool used by the facility to collect detailed information related to each wound, including measurements) documented a new sacral pressure ulcer (present on readmission to the facility), measuring 1.4 centimeters (cm) in length by 1.6 cm in width. R1 also had a new right elbow pressure ulcer (present on readmission) measuring 1.5 cm by 1.5 cm. The EMR lacked documentation of the measurements, appearance, and treatments of the right elbow pressure ulcer between 11/21/21 and 01/31/22. The 11/24/21 Wound Data Collection documented worsening of the sacral wound that extended into the left buttocks, measuring 6 cm by 2 cm with maceration. The 12/14/21 Wound Data Collection documented worsening of the sacral wound, measuring 6 cm by 2 cm by 1 cm deep. The EMR lacked documentation of the measurements of the sacral pressure ulcer between 12/15/21 and 02/11/22. The 02/01/22 Wound Data Collection documented a new facility acquired pressure ulcer on R1's right elbow, measuring 1 cm by 1 cm. The 02/12/22 Wound Data Collection documented the first measurements of the sacral pressure ulcer since 12/14/21 at 5.6 cm by 1 cm. The 02/20/22 Wound Data Collection documented a new facility acquired left elbow pressure ulcer, measuring 2.5 cm by 3 cm. The 02/24/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 04/11/22 Wound Data Collection documented R1 returned with a wound vacuum to her right elbow; her sacral wound measured 5.9 cm by 5 cm. She had a new facility acquired right heel pressure ulcer measuring 2 cm by 1.5 cm, and a new non-facility acquired left heel pressure ulcer measuring 3 cm by 2.3 cm. The 04/11/22 Care Plan instructed staff were to complete the following pressure ulcer care instructions for a stage II pressure ulcer on the sacrum, stage IV pressure ulcer on the right elbow, stage II pressure ulcer on the left elbow, a DTI on the left heel and a stage II pressure ulcer on the right heel: keep skin clean and dry, use lotion on dry skin; turn R1 from side to side every two hours while in bed and chair; use heel protectors to ensure pressure relief for heels, and an air mattress for pressure relief; elevate R1's heels and elbows off the bed; and the licensed nurse was to complete weekly skin observations. The 04/11/22 through 04/14/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Ensure staff checked the wound vacuum to R1's right elbow, with continuous negative pressure at 125 millimeters of mercury (mmHg), every shift, for intact seal and operating correctly (discontinued on 06/21/22). Cleanse R1's right heel wound with saline, apply a foam dressing, and pressure relief measures every day shift (discontinued on 04/21/22). Assess left heel DTI daily, keep clean and dry, and float heels, every day shift (discontinued on 04/21/22). Cleanse R1's sacral wound with normal saline (NS), cover with Duoderm dressing (ultra-thin dressing to provide flexible and comfortable wound care) and change every Monday, Thursday, and Saturday (discontinued on 04/21/22). The 05/05/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/08/22 and 05/09/22 Progress Note documented the wound vacuum was not working. The 05/09/22 Wound Data Collection lacked documentation of the left heel pressure ulcer measurements and any documentation of the sacral pressure ulcer. The right heel pressure ulcer increased in size, measuring 5.5 cm by 4 cm. The 05/11/22 Progress Note documented the wound vacuum was not working. The 05/16/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Wound care of the right and left heels, keep clean and dry, cleanse with saline, pat dry, cover with foam dressing every day shift, as needed, if soiled, or comes off (discontinued on 05/24/22). 2. Wound care of the sacrum, cleanse with sterile saline, pat dry, apply [MEDICATION(S)] Ag, cover with adhesive foam every day shift, and as needed for if dressing soiled or comes off (discontinued on 07/07/22). The 05/24/22 Wound Data Collection documented both right and left heel pressure ulcers were healed, and the sacral pressure ulcer measured 0.6 cm by 0.7 cm. The 05/31/22 Wound Data Collection documented an increase in size of the sacral wound, measuring 0.7 cm by 0.7cm, with a depth of 0.2cm. The 05/31/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/01/22 Progress Note documented R1 went to the hospital for placement of a Central Line (an intravenous line inserted into a large vein typically in the neck or near the heart that allows IV fluids to transfuse faster than standard IVs and are used to deliver medicines to sicker patients) to receive IV antibiotics. The 06/07/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/21/22 Wound Data Collection documented the completion of the wound vacuum for the right elbow. The 06/22/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/28/22 Wound Data Collection documented a new facility acquired DTI pressure ulcer on R1's right heel, measuring 5.3 cm by 3.5 cm; a new facility acquired stage II pressure ulcer on the left heel, measuring 3.6 cm by 3.3 cm, an existing stage II pressure ulcer on the sacrum, measuring 4.4 cm by 3.2 cm, and an existing stage IV pressure ulcer on the right elbow, that lacked measurements. The 06/29/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Right Plantar Wound: Cleanse wound, apply [MEDICATION(S)] (used to help with wound healing), [MEDICATION(S)] Ag, and cover with Convamax dressing (ultra-absorbent dressing designed to address moderate to heavy drainage that standard dressings can't address) daily, one time a day (discontinued on 07/07/22). The 07/07/22 and 07/14/22 Skin Observation Assessment documented R1 had a right elbow wound, sacral wound, and wounds to both heels, with treatment as ordered by the wound care clinic. The 07/08/22 and 07/09/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff were to apply silver alginate to both heels and cover with adhesive foam pads every morning, apply [MEDICATION(S)] and silver alginate to the sacrum and cover with adhesive sacral foam pad every morning, and to not remove the Grafix dressing (designed for application directly to wounds and surgical sites to cover tendons and bones) applied to right elbow until doctors' appointment on 07/12/22, and ensure the dressing stayed clean, dry, and intact each morning (discontinued on 07/18/22). The 07/16/22 Wound Data Collection documented a new facility acquired stage II pressure ulcer on R1's left elbow, measuring 1.2cm by 1.2cm. The 07/18/22 Care Plan documented staff was to turn R1 from side to side every two hours. Staff was also to complete the following pressure ulcer care instructions for a stage II pressure ulcer on the sacrum, stage IV pressure ulcer on the right elbow, stage II pressure ulcer on the left elbow, a DTI on the left heel and a stage II pressure ulcer on the right heel: keep skin clean and dry, use lotion on dry skin; turn and position R1 every two hours while in bed and chair; staff were to use heel protectors to ensure pressure relief for heels, and an air mattress for pressure relief. On 07/22/22, the care plan was updated, notifying staff to monitor location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 07/22/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/2022 through 07/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Sacral: June 20 and 21. Right Heel July 6 and 7. Right Elbow July 14. Bilateral Heels: July 14, 18, 21, and 22. Weekly assessment July 21. The 07/22/22 Care Plan update instructed staff to monitor location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/25/22 at 03:00 PM of R1's bedroom noted a turning schedule posted on the wall above the resident. At 03:00 PM, according to the posted schedule, R1 was scheduled to be on her left side though R1 laid on her back sleeping, with a wedge underneath her left side, elbow guard padding on both elbows, and soft hand braces on both hands. R1 had heel protector boots on both heels and a U-shaped wedge to her legs. On 07/26/22 at 09:30 AM R1 sat in her wheelchair, in the atrium with other residents. Both of R1's elbows were in elbow guards and both heels were in heel protectors. On 07/26 at 01:30 PM R1 laid on her back in bed with heel protector boots on and she wore elbow guards to both elbows. Interview on 07/25/22 at 03:10 PM with Transportation Staff E revealed she placed the hand guards on R1's hands to prevent R1's nails from digging into the palm of her hands, and to help prevent R1 from picking at the dressings on her body. Interview on 07/25/22 at 03:50 PM with Certified Nurse Aide (CNA) G revealed R1 was last turned in bed at 02:00PM on the previous shift. CNA G stated she tries to follow the turning schedule posted above R1's bed, but that R1 did not always like to lay on her right side because of her right elbow wound. R1 always wore the elbow and heel protectors, even when R1 was sitting in the wheelchair. CNA G said R1 could not use the call light, so the staff checked on R1 every two hours and completed peri-care and catheter care as needed. CNA G said the staff used the U-shaped wedge to help float R1's legs and heels. Interview on 07/27/22 at 11:30AM with CNA H revealed staff turned and positioned R1 every two hours. The staff also checked R1 for incontinence and cleaned her, as needed with catheter care and peri-care. CNA H stated the staff checked R1's skin during her baths and notified the nurse of any changes and pressure ulcers. CNA H said R1 did have pressure ulcers on her heels and elbows and used heel and elbow protectors to prevent further break down. CNA H stated R1's heels were healing, but started to get worse and did not know why. Interview on 07/26/22 at 01:42 PM with Licensed Nurse (LN) F revealed the staff checked on R1 every two hours. The LN on each shift was responsible for completing wound care and wound measurements weekly, and responsible for documenting this weekly in the Wound Data Collection. LN F said when a resident returned to the facility from the wound care center, the LN completed a progress note about what occurred at the wound care center, including any wound measurements, and placed any new orders. R1 did have a central line for IV antibiotics because of her right elbow wound. R1 had a wound vacuum placed before she received the central line. LN F stated R1 picked at anything on her body that she could reach, and would remove her dressings, but it never caused R1 to develop an infection. Interview on 07/25/22 at 02:30 PM with Social Services Designee (SSD) D revealed R1's family requested a meeting with SSD D and Administrative Nurse B to discuss concerns the family had related to the care R1 was receiving at the facility. R1 went to the wound clinic weekly to receive specialized treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . SSD D stated in the most recent visit to the wound clinic, they found wounds on both of R1's elbows. The family showed pictures and videos of R1's wounds to SSD D and Administrative Nurse B, to which Administrative Nurse B had no response. SSD D stated that Administrative Nurse B told the family of R1 that she [Administrative Nurse B] did not know that R1's wounds were that bad. SSD D also stated that only the Licensed Nurses (LN) were able to complete wound care and dressing changes per the provider orders. On 07/27/22 at 12:55 PM, LN F stated she measured R1's wounds that morning (07/27/22). LN F said R1 had a healing, right elbow stage IV pressure ulcer, the size of a nickel, with a dressing in place. LN F said R1's left elbow was a stage II pressure ulcer and the size of a dime, with a dressing in place. R1's left heel was a stage II pressure ulcer and the size of a dime, but open to air. LN F stated R1's right heel was healing. Interview on 07/25/22 at 02:55 PM with Administrative Nurse B revealed the facility did not have a designated wound nurse and said the charge nurse on each shift was responsible for completing dressing changes and wound care for each resident. Administrative Nurse B stated R1 was no longer going to the wound care center for wound treatment. Interview on 07/26/22 at 04:30 PM with Administrative Nurse B revealed R1 could not move herself in bed and required staff assistance for all ADLs. R1's sacral and heel wounds started when she was at the hospital [date unknown] and they never healed. Administrative Nurse B said the wounds would get better and then worse. On 07/12/22, R1's right heel opened up and bled while R1 was at the wound care clinic and her right heel had scabs that may have come off. R1 developed the left elbow wound from lying in bed. Administrative Nurse B said R1's wound care orders changed each week when she returned from the wound care clinic, and she a wound vacuum on her right elbow, but said that treatment was completed. Administrative Nurse B stated the seal on the wound vacuum would break (preventing the vacuum from working properly), and the staff could not to fix it. When this happened, staff removed the wound vacuum dressing and covered R1's right elbow with gauze and notified the wound care clinic the next day. Administrative Nurse B stated R1 was incontinent of bowel, causing her sacral wound to become soiled and require multiple dressing changes throughout the day. The loose stool also caused maceration and eventually caused the sacral wound to open back up. Licensed Nurses were responsible for completing weekly wound assessment including measurements of each wound, but the wound care clinic did complete their own measurements and sent the documentation to the facility. Administrative Nurse B stated that the facility would use the measurements from the wound care clinic as the weekly measurement. R1 used elbow guards for the previous two weeks and Administrative Nurse B stated R1's elbows did not get worse in that time. R1 also used heel protectors for the previous few months, which helped prevent R1's heels from getting worse. The 04/26/22 Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy documented the licensed nurse was to record the type of wound and the degree of tissue damage, including the location of the area, the measurements, and the ulcer/wound characteristics. When a pressure ulcer was present, the licensed nurse was to complete daily monitoring with documentation noted above and the pressure ulcer was to be assessed at least weekly, to include measurements, characteristics, and treatments. The facility failed in multiple areas of pressure ulcer care by failing to measure/monitor pressure ulcers and implement/evaluate interventions to reduce pressure in a timely manner for cognitively impaired, dependent R1. These failures placed R1 in immediate jeopardy, and placed two other residents, identified with pressure ulcers, at risk. On 07/27/22 at 08:05 PM, the facility provided an acceptable plan for removal of the immediate jeopardy, when the facility implemented the following: 1. The facility measured and assessed all of R1's wounds and conducted skin observation on all residents to assess for any new skin issues, on 07/27/22. 2. The facility implemented a wound tracking tool to monitor progression of wound and interventions. 3. The facility educated the nursing staff on the pressure ulcer policies, including documentation, assessments, measurements, care plans, and wound prevention measures. 4. The facility educated the CNA staff including resident rights, repositioning, pressure ulcer development and expectation of documentation of cares. 5. The facility assigned the nursing staff Pressure Injuries, Assessment and Prevention required completions before next working shift. The surveyor verified the implementation of the removal of the immediacy plan while onsite on 07/28/22 at 04:00 PM. The deficient practice remained a G (actual harm, that is not immediate jeopardy) scope and severity, following removal of the immediate jeopardy.

The facility census totaled 40 residents. Based on observation, interview, and record review the facility failed to update interventions to prevent/heal pressure wounds, failed to document turning and repositioning consistently per the facility expectation, and failed to notify resident #1's physician for 11 days to obtain orders for wound treatment/management when he/she admitted to the facility with a pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) to his/her coccyx (small triangular bone at the base of the spine), right heel and developed a pressure injury to his/her left heel at the facility. Findings included: - Review of resident #1's electronically signed physician orders [REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. The resident required extensive assistance of 2 staff for bed mobility and transfers. The resident received as needed (PRN) pain medication and frequently rated his/her pain at a 7 on a scale of 0 to 10, with 10 being the most severe. The resident had a risk for pressure ulcers but had no pressure ulcers noted. The resident required pressure reducing devices for his/her chair and bed, repositioning/turning program, surgical wound care and application of ointment/medications, other than to feet. Review of the discharge minimum data set ((MDS) dated [DATE] revealed the resident had a BIMS of 7, which indicated severely impaired cognition. The resident's bed mobility and transfer status were unchanged from the last assessment. The resident was at risk for pressure ulcers and had one stage 2 (Partial-thickness skin loss with exposed dermis) pressure ulcer upon admission. The resident required a pressure reducing device for his/her chair/bed, and application of ointment/medications other than to feet. Review of the activity of daily living (ADL) care area assessment (CAA) dated 4/1/19 revealed the resident required two-person pivot transfer for toileting and dressing. The resident required assistance of two staff for transfers, toileting, dressing, and bed mobility at times. Review of the pressure ulcer CAA dated 4/1/19 revealed the care area triggered due to the resident's decreased activity/mobility and urinary incontinence. The resident had no skin issues at the time of the assessment. The facility staff would monitor the resident for changes in his/her skin such as: redness, breakdown, tenderness, signs and/or symptoms of infection and would report to the nurse. The staff cue and reposition the resident and kept the resident's skin clean and dry. Review of resident's care plan dated 3/25/19 revealed the following interventions: 3/25/19 - Staff would reposition the resident as necessary to prevent skin breakdown. Staff would also prevent 90-degree flexion to prevent circulation problems. 4/6/19 - The staff would turn the resident from side to side for bed mobility. The resident could move him/herself side to side. He/she needed cueing not to cross his/her legs. 4/6/19 - The resident required extensive assistance of two staff for bed mobility to position from lying to sitting up in bed. 4/6/19 - The resident could lay down if staff brought his/her legs up onto the bed. 4/26/19 - The staff would know the resident had a pressure ulcer to his/her sacral area and a deep tissue injury to his/her heel related to incontinence, poor nutrition, immobility and infection. 4/26/19 - The staff would avoid positioning the resident on his/her buttocks. 4/26/19 - The staff would provide pressure relieving/reducing device on the resident's bed and/or chair. 4/26/19 - The staff would notify the nurse immediately of any new areas of skin breakdown, which included: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. 4/26/19 - The staff would encourage resident to eat protein rich foods, such as: meat, fish, poultry, dairy and legumes. 4/29/19 - The resident had an ADL self-care performance deficit related to a healing left [MEDICAL CONDITION] and confusion and weakness. The resident's care plan lacked interventions related to the deep tissue injury on the resident's heel, which included offloading the pressure on the resident's heels or protective boots on the resident's feet. The care plan further lacked evidence the resident had pressure injury to both the left and right heel. Review of the physician order [REDACTED]. Review of the physician order [REDACTED]. The staff would document the skin assessment findings and report concerns to his/her physician, every Friday on day shift. Review of Braden Scale assessments dated 3/25/19, 4/1/19, 4/8/19 and 4/26/19 revealed the resident had a high risk for skin breakdown. Review of the resident's bed mobility documentation dated 4/10/19-4/13/19, 4/18/19-4/23/19, and 4/26/19-5/8/19 lacked evidence the staff repositioned the resident every 2 hours. Review of the resident's record revealed he/she discharged home on[DATE] against medical advice. Review of hospital discharge summary dated 4/18/19 revealed the resident admitted to the hospital from home on 4/14/19 and discharged back to the facility on [DATE]. The resident left the facility against medical advice, went home on 4/13/19, fell and was transported from his/her home back to the hospital. The facility staff would prevent bed sores by changing the resident's position frequently and use a pillow below both feet, so his/her left foot could heal. Review of the resident's clinical record dated 4/18/19 lacked evidence of any measurements or assessment of an area, which would need to heal on the resident's left foot and/or any notification to the resident's physician regarding his/her left foot. The resident's care plan further lacked any updates related to an area on his/her left foot. Review of the progress note dated 4/18/19 at 4:12 PM revealed the resident admitted to the hospital from home where he/she laid on the floor for hours before being discovered. Review of hospital discharge summary dated 4/26/19 revealed resident [MEDICAL CONDITION] (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases [MEDICAL CONDITION] can lead to the medical emergency, septic shock). The resident readmitted to the facility with pressure ulcers noted to both feet and sacral region, identified as unstageable. The hospital recommended a follow-up appointment with a physician on 4/30/19 at the wound clinic. Review of admit/re-admit note dated 4/26/19 at 3:41 PM revealed the resident was hospitalized or received services at the hospital related to his/her wounds and the facility would monitor wound care. Review of admission/readmission note dated 4/26/19 at 9:42 PM revealed the resident had a deep tissue injury to the left foot and a stage 2 pressure ulcer to the sacral region. Review of registered nurse wound assessment dated [DATE] revealed the resident had a wound to his/her coccyx (small triangular bone at the base of the spine). The note stated the resident's physician was notified. The resident's record lacked evidence the resident's physician responded to the notification with wound management orders. Review of the wound documentation note dated 4/26/19 revealed the resident had a wound to the coccyx, present on admission, which measured 0.5 centimeters (cm) x 0.7 cm and a wound to his/her right heel noted as 100% eschar (dead tissue), which measured 2 cm x 1 cm. Review of wound data documentation dated 4/27/19 revealed the wound dressings to the resident's coccyx and right heel were clean, dry and intact. The resident would follow with wound care clinic on 4/30/19. The report from the hospital nurse revealed dressings were to be left intact and changed as needed until the follow up appointment. The writer would change as needed and wait for the resident's physician to give orders regarding the wound. Review of wound data documentation dated 4/28/19 revealed a left heel wound noted with no description or measurements. Review of the resident's clinical record dated 4/30/19 lacked any evidence the resident went to an appointment at the wound care clinic. Review of wound data documentation dated 5/2/19 revealed the resident had a wound to the right heel, which measured 1.5 cm x 2 cm, with 100% [MEDICATION NAME] (new skin growing in a superficial wound) wound bed. The resident had a wound to his/her left heel, which measured 3 cm x 2 cm with 100% eschar noted. The resident's record lacked evidence the resident's physician was notified of the wound on his/her left heel. The note further lacked any evidence of the wound to the resident's coccyx. Review of wound data documentation dated 5/8/19 revealed the resident's right heel had eschar, which measured 1.7 cm x 1 cm with minimal drainage. The resident's left heel measured 4 cm x 4 cm with 50% granulation (pink-red moist tissue that fills an open wound, when it starts to heal) tissue, 50% eschar and minimal drainage noted. The wound documentation lacked evidence his/her coccyx wound was measured or healed. Review of the registered nurse wound documentation dated 5/8/19 revealed the resident had a suspected deep tissue injury to the right heel, which decreased in size and a suspected deep tissue injury to the left heel. Review of physician communication note dated 5/8/19 at 10:52 AM revealed the resident had wounds to his/her left and right heels. The right heel wound was present on re-admission from hospital. The resident was seen by general surgery, while in hospital for area on his/her heel. The resident had an appointment with the wound center on 5/9/19. Observation of the resident at 1:15 PM on 5/8/19 revealed direct care staff A wheeled the resident to his/her room and retrieved assistance from direct care staff B to assist in laying the resident in his/her bed. Both staff assisted the resident to lay in bed and removed the resident's shoes. Both of the resident's heels had foam dressings in place. Staff A and Staff B positioned the resident's legs on the blanket and as the resident repositioned to his/her left side his/her heels touched the bed. Staff B placed pressure relieving boots on the resident. Observation of the resident on 5/8/19 at 3:23 PM revealed direct care staff C and direct care staff D asked the resident if he/she was ready to get out of his/her bed. The direct care staff placed non-slip socks and shoes on the resident's feet. Observation at 9:02 AM on 5/9/19 revealed licensed nurse E assisted direct care staff F to lay the resident in bed, so he/she could assess the resident's wounds. The resident's left heel had hard black eschar in the middle with surrounding thin eschar and a red/purple colored area, which measured 4 cm x 3.5 cm. The area to the left heel was covered with foam border. The resident's right heel had hard brown eschar, which measured 1.25 cm x 1cm. The resident's coccyx was healed and had a foam border in place to protect the area. Interview with direct care staff B on 5/8/19 at 12:57 PM revealed the resident was repositioned every 2 hours based on his/her risk for pressure injury/skin issues. Staff documented repositioning on the facility computer charting system. Staff B stated every time the staff repositioned the resident it should be logged as a new entry on the computer documentation system to show it was done. Staff B stated they repositioned the resident, however it was hard to come back and chart it. Staff B stated he/she looked at the Kardex to find what cares to provide the resident, but there were times the Kardex didn't match the resident's care plan. Interview with direct care staff A on 5/8/19 at 1:31 PM revealed staff were supposed to reposition the resident every 2 hours, but there were times staff were vey busy and were short staffed, so they try to do every 2 hours. Staff A stated he/she charted on the computer every time he/she repositioned the residents. Staff A stated he/she used pillows and blankets to elevate the resident's legs and float his/her heels. Staff A did not know about heel protectors for the resident, because they were not there the week before. Interview with licensed nurse G on 5/8/19 at 4:04 PM revealed the resident readmitted from the hospital with pressure areas to his/her coccyx (with a little slough in the wound bed), the right heel (small eschar), and the left heel did not have any wounds on it. Staff G noted the resident had the area to the left heel on 5/2/18 and marked it as a suspected deep tissue injury because they were waiting on wound care to give an exact staging of the wound. Staff G stated the resident would go to wound care on 5/9/19. Staff G stated the resident's care plan should have all of the pressure prevention interventions in place and should be updated as needed. The interventions in place before the resident had the pressure injuries were repositioning with cueing and assistance. Staff G stated he/she was not sure what caused the resident's pressure injury to his/her left heel. Staff G reported the resident was going to the wound care center in a few days, because it was the earliest appointment they had. Interview with administrative nurse H on 5/9/19 at 9:45 AM revealed the resident readmitted to the facility with wounds to his/her coccyx and right heel. Staff H stated a few days after the resident returned to the facility the staff identified a wound to his/her left heel. Staff H did not know why the hospital note dated 4/18/19 talked about a wound to the left heel. Resident's wounds were measured weekly by the registered nurses who assessed and dressed them. The interventions in place related to pressure ulcers were for staff to reposition the resident every 2 hours, encourage repositioning, avoid positioning on his/her back, and know the resident preferred his/her right side. Staff H verified the facility would assess the resident's wounds per facility policy was added to the resident's care plan on 5/8/19. Staff H further verified the pressure relieving heel protectors were added to the resident's care plan on 5/8/19 (11 days after he/she returned to the facility from the hospital with pressure injuries to his/her heels). Staff H stated the facility should have something for direct care staff to document repositioning him/her every 2 hours, that should be added to his/her tasks on the computer. If a resident had a wound he/she expected measurement of the wounds, nurse assessment of the wound and a notification to the doctor for treatment and wound care orders. Staff H stated they were waiting on a wound clinic appointment to figure out what they would be doing for the resident's wounds. Staff H expected an as needed dressing change order to be in place. Interview with physician I on 5/9/19 at 11:38 AM revealed he/she received a note 5/8/19 about the resident's pressure areas to the coccyx, right heel, and left heel, but he/she was unaware the resident had any pressure injuries before then. He/she stated he/she would have been the physician notified for any change to this resident, and he/she was not notified on any date before 5/8/19. Physician I would have expected nursing staff to notify him/her and obtain wound care and pressure prevention orders if pressure injuries were identified. Physician I stated he/she would have put all the proper orders in place for the resident. Review of the Skin Assessment, Pressure Ulcer Prevention and Documentation Requirement policy revised 3/19 revealed all 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 would be documented in the resident's legal medical record. If a pressure area was identified staff would notify the physician/practitioner of the ulcer and the resident's condition to obtain orders for treatment. Staff would inquire whether the physician/practitioner felt it was clinically necessary to see the resident. The facility failed to update interventions to prevent/heal pressure wounds, failed to document turning and repositioning consistently per the facility expectation and failed to notify resident #1's physician for 11 days to obtain orders for wound treatment/management when he/she admitted to the facility with a pressure injury to his/her coccyx/right heel and developed a pressure injury to his/her left heel at the facility.

The facility had a census of 37 residents with 5 residents selected for sample who all required assistance with transfers. Of the five sampled, three residents experienced falls/accidents with major injury within the past 3 months. Based on observation, interview and record review, the facility failed to provide 1 of 5 sampled residents with adequate supervision to prevent accidents when staff failed to utilize two staff for a mechanical lift transfer as directed by the care plan. The cognitively impaired, dependent resident fell forward during the transfer and received a laceration of the head which required placement of sutures/staples (Resident #1). The facility also failed to assess 2 of 3 residents with recent falls for causal factors after each fall and failed to develop/implement appropriate fall prevention interventions based on causal factors of each fall (Residents #2 and #3). The facility also failed to provide 3 of 5 residents who required assistance with transfers with adequate supervision and assistive devices (use of a gait belt, proper placement of waist strap on the sit to stand lift) to prevent accidents (Residents #1, 2, 4). Findings included: - Resident #1's clinical record included a medical [DIAGNOSES REDACTED]. The 1/7/19 Quarterly MDS (Minimum Data Set) identified the resident with long and short term memory problems, severely impaired decision making abilities, the need for extensive assistance of two staff for transfers, an inability to ambulate, impaired balance in moving from surface to surface and only able to stabilize with staff assistance. The resident had no falls since the prior assessment. The current undated care plan noted the resident's need for assistance of two staff for transfers with a mechanical lift. A 1/9/19 Progress Note at 7:12 a.m. described an incident in which one staff member assisted the resident with the sit to stand lift. According to the note, the resident leaned forward during the process and hit his/her head on the bar of the lift. The resident sustained [REDACTED]. Staff sent the resident to the hospital emergency room for evaluation of the wound. A 1/9/19 Progress Note at 9:00 a.m. described the resident's return to the facility with 3 stitches (closure of a wound with surgical thread) to the head. The facility's investigation included a description of the incident which occurred on 1/9/19 when Direct Care Staff I attempted to secure the straps on the sit to stand lift in preparation to transfer resident #1 from the bed to the wheelchair. During the process of securing the strap, Direct Care Staff I reported he/she must have pulled too hard which resulted in the resident's head striking the bar on the lift. According to the investigation, the resident received a cut to the head which appeared to be deep and continued to bleed despite application of pressure to the area. During an observation on 2/19/19 at 3:30 p.m., Direct Care Staff D and Direct Care Staff E prepared to transfer resident #1 from the wheelchair to the bedside commode via a sit to stand lift. Staff placed the waist belt loosely around the resident's waist but failed to tighten it prior to raising the resident upward. When staff raised the resident, the loose waist belt rose high on the chest/upper back which then moved the resident shoulders upward to the level of the ears and placed increased pressure on the axillary (under arm) areas. Direct Care Staff E failed to raise the resident to a level at which he/she could adequately bear weight on the legs to take the pressure off the axillary region, instead stopped the lift with the resident's buttocks positioned far behind his/her feet with the knees bent at a 90 degree angle in a position in which the resident could not bear weight on the lower extremities. The resident lacked the ability to follow simple commands and verbalize his/her needs during the transfer. During an observation on 2/20/19 at 9:00 a.m., Direct Care Staff F and Licensed Nurse C transferred resident #1 from the wheelchair to the bedside commode via a sit to stand mechanical lift. Direct Care Staff F placed the waist belt securely around the resident's waist. Licensed Nurse C then failed to raise the resident to a level where he/she could adequately bear weight on the legs, stopping instead at a level where the resident's buttocks were positioned far behind his/her feet with the knees bent at a 90-degree angle. During an interview on 2/19/19 at 2:00 p.m., Administrative Nurse B reported some residents only required assistance of one staff with a sit to stand lift and others required assistance of two staff. Although requested, Administrative Nurse B could not provide manufacturer information specific to the sit to stand lift in use by the facility that approved of assistance of only one staff person when transferring a totally dependent resident. During an interview on 2/19/19 at 3:30 p.m., Direct Care Staff E reported resident #1 has always been a two person assist with transfers with the lift. According to Staff E, one staff assisted the resident when he/she fell forward onto the bar of the lift and gashed his/her head. During an interview on 2/20/19 at 9:00 a.m., Direct Care Staff F reported staff consistently used assistance of two staff to transfer resident #1 with the sit to stand lift. The facility's Policy and Procedures/Required Forms for Mechanical Lift/Transfer with a revision date of 5/13 included, .Mechanical lift transfers should be completed by two staff members that are either licensed or certified . The facility failed to provide resident #1 with adequate supervision to prevent accidents when staff failed to utilize two staff for a mechanical lift transfer as directed by the care plan. The cognitively impaired, dependent resident fell forward during the transfer and received a laceration of the head which required placement of 3 sutures/staples. The facility also failed to use appropriate technique when transferring resident #1 with a sit to stand mechanical lift. - Resident #4's clinical record included an 11/27/18 Quarterly MDS (Minimum Data Set) which identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of 4, the need for extensive assistance of two staff for transfers, and functional limitations in range of motion on both sides of the lower extremities. The undated care plan directed staff to transfer the resident with assistance of two staff and a sit to stand mechanical lift. During an observation on 2/20/19 at 10:20 a.m., Direct Care Staff G and Direct Care Staff H prepared to transfer resident #4 from the wheelchair to the bedside commode via a sit to stand mechanical lift. Staff H placed the waist strap loosely over the resident's breasts/chest area. Staff H failed to tighten the strap prior to raising the resident upward. When Direct Care Staff G raised the resident, the loose belt raised high up on the chest/upper back which then moved the resident's shoulders upward and placed increased pressure on the axillary (under arm) areas. After transferring the resident onto the commode, staff released the waist strap. After toileting, staff again secured the waist strap loosely over the resident's breasts/upper chest area. At surveyor request and for safety purposes, Direct Care Staff G moved the waist strap to the proper location around the resident's waist and secured it snugly. Staff G then raised the resident to a standing position. During an interview on 2/20/19 at 10:30 a.m., Direct Care Staff G reported the transfer was much easier after he/she tightened the waist strap and placed the strap around the waist rather than over the upper chest area. The facility's 7/16 Policy and Procedures/Required Forms for Mechanical Lift/Transfers lacked guidance related to placement of the waist belt/strap when using the sit to stand lift. The facility failed to use appropriate technique/placement of the waist strap when staff transferred resident #4 with the sit to stand mechanical lift. - Resident #2's clinical record included a 1/28/19 Quarterly MDS (Minimum Data Set) that identified the resident with long and short term memory problems, severely impaired decision making abilities, dependence on assistance of one staff for transfers, impaired balance and the need for staff assistance to stabilize, no limitations in range of motion in the upper or lower extremities, use of a wheelchair, an inability to ambulate, and one non-injury fall since the prior assessment. The care plan included the 2/9/16 intervention, Resident requires 1 staff participation with transfers with a gait belt. The care plan also identified the resident as at risk for falls. Fall Risk Assessments completed on 12/11/18, 2/7/19 and 2/11/19 identified the resident as high risk for falls. Progress notes included a 12/11/18 entry at 8:46 p.m. which described an unwitnessed non-injury fall in which staff found the resident on the floor next to his/her bed. The 12/11/18 Fall Investigation lacked evidence staff completed an assessment of causal factors after the fall. Staff identified the factors that may have contributed to the fall as unknown cognitive impairment. During an observation on 2/19/19 at 1:15 p.m., Direct Care Staff G transferred resident #2 from the wheelchair to the bed by wrapping his/her arms around the resident's waist and lifting the resident from the wheelchair onto the bed. Staff G failed to use a gait belt during the transfer. During an interview on 2/19/19 at 4:30 p.m., Administrative Nurse B reported staff should use gait belt for all resident transfers. The facility's (MONTH) 2012 Gait (Transfer) Belt policy and procedure directed staff to use gait belts to safely stabilize a transfer. The (MONTH) (YEAR) Fall Prevention and Management policy and procedure defined root cause analysis as a method for identifying the causes of a problem so that the best solutions can be identified and put into place. The policy and procedure lacked specific guidance related to completion of a root cause analysis/assessment of causal factors after each fall The facility failed to complete an assessment of causal factors after resident #2's 12/11/18 fall and then develop/implement appropriate interventions based on the causal factors. The facility also failed to complete a safe transfer for resident #2 when staff failed to use a gait belt during a transfer with assistance of one staff member. - Resident #3's clinical record included a 1/5/19 Quarterly MDS (Minimum Data Set) which identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 13), the need for extensive assistance of one staff for transfers and ambulation within his/her room, no functional limitations in range of motion in the upper or lower extremities, impaired balance in all areas and only able to stabilize with staff assistance, use of a walker as an assistive device and no falls since the prior assessment. The undated care plan identified resident #3 as at risk for falls and included numerous fall prevention interventions, including the 1/19/19 intervention to encourage the resident to push his/her call light for assistance and the 2/8/19 intervention to remind the resident not to transfer without staff assistance and to use the call light. A 1/18/19 Fall Risk Assessment identified the resident as high risk for falls. Progress notes dated 1/18/19 at 4:00 p.m. described an unwitnessed non-injury fall in which the resident reported he/she attempted to ambulate out of the bathroom and fell . The 1/18/19 fall investigation lacked an assessment of causal factors/root cause analysis of the fall. The section of the form entitled, Summarize factors that may have contributed to this incident remained blank. After the fall, staff updated the care plan with an intervention to encourage to use call light rather than an intervention related to the root cause of the fall. Progress notes dated 1/19/19 described an unwitnessed, non-injury fall in which staff found the resident sitting on the floor beside his/her recliner. The 1/19/19 Fall Investigation noted the fall occurred when the resident reached over to pick up dentures, became dizzy and fell to the floor. The investigation lacked evidence of development/implementation of fall interventions related to causal factors of the falls. Progress Notes dated 1/30/19 described an unwitnessed fall in which the resident received a minor scrape to his/her back. The 1/30/19 Fall Investigation lacked evidence staff assessed for causal factors/root cause analysis of the fall and then developed/implemented fall prevention interventions based on causal factors. The Potential Root Cause section of the form remained blank. Progress notes dated 2/1/19 at 8:25 p.m. described an unwitnessed fall in the resident's room in which the resident received facial lacerations which required transfer to the hospital and placement of 12 stitches. The 2/1/19 Fall Investigation section entitled, Summarize factors that may have contributed to this incident included resident has no regard for safety. Removed (his/her) alarm. Believes (he/she) can self transfer. The section of the form used for Potential Root Cause included, impulsive, forgetful, self transferring without thinking of falling. Progress Notes dated 2/14/19 at 1:21 p.m. described an unwitnessed, non-injury fall which occurred when the resident attempted to ambulate independently to the bathroom. According to the note, Resident again strongly encouraged to use call light to ask for assistance when needing to go to the bathroom. The 2/14/19 Fall Investigation lacked evidence staff assessed for causal factors of the fall. The Potential Root Cause section of the form remained blank. During an observation on 2/20/19 at 9:30 a.m., Direct Care Staff F assisted resident #3 to transfer from the wheelchair to the toilet. The resident had the ability to follow simple commands and verbalize his/her needs. During an interview on 2/20/19 at 9:20 a.m., resident #3 reported a desire to remain independent and stated, I don't like to bother anyone. The resident confirmed an awareness staff wanted him/her to call for assistance prior to ambulation and stated, I won't do it. These tumbles are my fault and I know that. I need to do better. During an interview on 2/20/19 at 9:30 a.m., Direct Care Staff F reported the resident frequently refused to call for help prior to ambulation or reaching for something on the floor. According to Staff F, all staff look in on the resident frequently as they pass by his/her room in case the resident needs something. The (MONTH) (YEAR) Fall Prevention and Management policy and procedure defined root cause analysis as a method for identifying the causes of a problem so that the best solutions can be identified and put into place. The policy and procedure lacked specific guidance related to completion of a root cause analysis/assessment of causal factors after each fall. The facility failed to complete an assessment of causal factors after each of resident #3's falls and then develop/implement appropriate interventions based on the causal factors.

The facility census totaled 42 residents. The sample included 3 residents reviewed for resident-to-resident abuse. Based on observation, interview, and record review the facility failed to identify patterns of abuse exhibited by resident #1, directed towards cognitively impaired residents with wandering behaviors. On 8/28/18 resident #1, identified as alert and oriented, slapped cognitively impaired resident #2 and on 9/1/18 resident #1 slapped cognitively impaired resident #3 on the hand. This deficient practice paced resident's #2 and #3 in immediate jeopardy. Finding included: - Review of resident #1's clinical record revealed the following Diagnoses: [REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. He/she had no behavioral indicators during the look back period and was independent with activities of daily living (ADL). Review of resident #1's care plan initiated on 7/3/14 and last revised 9/11/18 on revealed resident #1 had behavioral symptoms with a history of verbal and physical aggression. The care plan directed the staff to intervene as necessary to protect the rights and safety of others, divert the resident's attention, remove him/her from pending situations and reinforce instructions to call staff when he/she required assist with another resident who wandered. Review of the nurse's progress notes dated 8/28/18 at 6:45 p.m. revealed resident #4 called the facility nurse's station and reported resident #1 had an unwanted guest in his/her room and he/she could hear a commotion. Resident #1 reported resident #2 wandered into his/her room and when he/she tried to make resident #2 leave an altercation occurred. Resident #1 reported resident #2 squeezed and tried to break his/her hand. Resident #1 admitted he/she slapped resident #2 to make the other resident release his/her hand. Resident #1's left hand was swollen, an ice pack was offered and declined by the resident. . Review of resident #2's record revealed the following Diagnosis: [REDACTED]. Review of resident #2's MDS dated [DATE] revealed a BIMS score of 5 (severe cognitive impairment). The MDS indicated the resident wandered within the facility 1 to 3 days in the assessment look back period. Review of resident #2's care plan initiated 4/19/17 and revised on 6/25/18 revealed the resident exhibited behavior symptoms related to his/her cognitive deficit. The care plan directed the staff to intervene as necessary to protect the rights and safety of others and leave the resident alone to calm down if he/she was not in danger and did not endanger other residents. Review of resident #2's nurse's progress notes dated 8/28/18 at 6:45 p.m. revealed resident #4 called the facility nurse's station and reported resident #1 had an unwanted guest in his/her room and he/she could hear a commotion. Resident #1 reported resident #2 wandered into his/her room and when he/she tried to make resident #2 leave an altercation occurred. Resident #1 reported resident #2 squeezed and tried to break his/her hand. Resident #1 admitted he/she slapped resident #2 to make the other resident release his/her hand. The resident #2 was medicated with intermuscular anti-anxiety medication after the incident. Review of the 8/28/18 facility investigation revealed at 6:10 p.m. resident #2 propelled him/herself down the hall where resident #1 resided. Resident #2 turned his/her wheelchair around in front of resident #1's door. Resident #1 attempted to exit his/her room and caught his/her motorized wheelchair on resident #2's wheelchair. Resident #1 freed his/her motorized wheelchair and wheeled away from resident #2 who continued to propel him/herself past resident #1's door. Resident #1 turned his/her motorized wheelchair around and placed him/herself in front of (blocking) resident #2. Resident #2 attempted to propel past resident #1 which caused him/her to wheel into resident #1's room. Resident #1 attempted to remove the other resident from his/her room but was unsuccessful and both residents ended up together in resident #1's room. Resident #4 heard the altercation and called the nurse's station and reported resident #1 had an unwanted visitor and he/she could hear a commotion in the room. The staff responded and observed resident #2 as he/she squeezed resident #1's hand. After the staff separated the residents, resident #1 reported he/she had slapped resident #2 to make him/her let go of his/her hand. Observation of the video footage on 10/9/18 at 11:35 a.m. revealed during the incident on 8/28/18, resident #1 propelled him/herself down the hall where resident #1 resided. Resident #2 appeared to be turning his/her wheelchair to propel back up the hall way towards the common area when resident #1 exited his/her room (in a motorized wheelchair). The resident's wheelchairs became entangled with each other. Resident #1 maneuvered his/her motorized wheelchair to free him/herself from the resident #2's wheelchair. Resident #1 was observed as he/she wheeled away from resident #2 and resident #2 continued to propel him/herself in front of resident #1's door. The video footage showed resident #2 did not try to enter resident #1's room. Resident #1 turned his/her motorized wheelchair around and placed him/herself in front of the other resident's wheelchair which forced resident #2 into his/her room. The video showed resident #1 grabbed the handles of resident #2's wheelchair and pulled forcefully to remove him/her from the room. Resident #1 could not remove resident #2 from the room and wheeled into the room with resident #2. The video showed staff entering resident #1's room approximately 5 minutes after the altercation started. Staff removed resident #2 from resident #1's room and the video further showed him/her to be agitated and struck the staff multiple times. The facility investigations revealed staff talked with resident #1 about his/her behavior and instructed him/her to call staff for assistance if he/she had a resident in his/her room and requested a psych evaluation for resident #1 to determine his/her underlining anger and behavior. The resident slapped resident #2 in the face twice and struck him/her multiple times on his/her with a rubber wheelchair handle on 8/28/18 and on 9/1/18 slapped resident #3 as he/she reached out towards resident #1's hand and stated What a beautiful ring. During an interview on 10/9/18 at 4:30 p.m., resident #1 reported resident #2 came into his/her room and he/she attempted to make resident #2 leave and resident #2 attacked him/her. Resident #2 grabbed his/her hand and pulled his/her fingers apart until he/she thought they were broken. Resident #1 stated the facility had a bunch of mentally retarded people that roamed around and went to other resident's rooms without permission and he/she was tired of people without a brain coming in his/her room. Resident #1 admitted he/she slapped resident #2 at least twice with an open hand in the face and struck him/her multiple times on the back of his/her hands with a rubber wheelchair handle he/she had pulled off resident #2's wheelchair during the altercation. Resident #1 revealed he/she would hit any resident without a brain who entered his/her room again. Resident #1 stated besides the only other thing we can do is kill them and referred to resident #2, and #3 by name, and stated do you think I can plead insanity? Interview on 10/9/18 at 9:38 a.m. with direct care staff C revealed resident #1 had a bad attitude directed at all cognitively impaired residents. Staff C revealed resident #1 complained about resident #2 and #3 all the time and referred to those residents as retarded and too stupid to be around normal people. Staff C revealed resident #1 had been involved in a past incident with resident #6. Staff C revealed resident #1 yelled in resident #6's face and taunted him/her until resident #6 punched resident #1 then resident #1 rammed his/her electric chair into resident #6's legs and pinned him/her against the wall before the staff intervened. Staff C revealed the facility instructed the staff to redirect the residents that wandered away from resident #1's room. Staff C denied knowledge of any other interventions initiated to protect the cognitively impaired resident who wandered in the facility. Interview on 10/9/18 at 3:15 p.m. with direct care staff D revealed he/she responded to a call for assistance over the walkie talkie. Staff D revealed he/she observed resident #2 in resident #1's room with the oxygen tank and tubing from the back of resident #2's wheelchair, on the floor between the two residents. Staff D revealed he/she observed resident #2 as he/she squeezed resident #1's left hand and fingers while the resident yelled at resident #2 to stop. Staff D revealed resident #1 admitted he/she slapped resident #2 because he/she would not let go of his/her hand. Staff D removed resident #2 from the room and separated the residents for safety. Staff D revealed resident #1 talked about resident #2 and #3 frequently and made the statement that mentally retarded people shouldn't be allowed to live in the facility because they are stupid and have no brain. Staff D reported resident #1 told staff and other residents frequently he/she would hit the mindless residents if they entered his/her room prior to the incident on 8/28/18 and made the same statement after the incident. Staff D revealed the facility directed staff to monitor and redirect the resident who wandered out of other resident's rooms. Staff D denied knowledge of any specific interventions implemented to protect resident #2 from resident #1. Interview on 10/8/18 at 2:55 p.m. with administrative nurse B revealed the video footage of the incident on 8/28/18 between resident #1 and resident #2and appeared resident #2 attempted to make a U-turn and continue to propel him/herself past resident #1's door. Staff B revealed the video showed resident #1 wheeled away from resident #2 and turned around purposely and confronted resident #2. Resident #1 positioned his/her motorized chair in front of resident #2 and pushed him/her into his/her room where the altercation took place. Staff B revealed the facility completed an investigation and educated the staff to redirect residents who wandered to prevent them from entering other resident's rooms, educated resident #1 to call for staff assist and directed him/her not to address the situation him/herself, and referred resident #1 for a psych evaluation. Staff B revealed the facility considered the idea of using stop signs or the mesh stop sign banners to deter the residents who wander out of other residents rooms, but the facility failed to implement any safety measure to deter the residents that wander from entering resident #1's room before the incident on 8/28/18 or after the incident occurred. Staff B confirmed the facility was aware of resident #1's verbal threats to physical harm resident #2 and #3 if they entered his/her room prior to resident #2 being abused by resident #1. Interview on 10/10/18 at 9:30 a.m. with the administrative staff A revealed the facility was aware of resident #1's aggression towards residents with cognitive impairment, that wandered. Staff A was aware the facility failed to implement any interventions after the incident on 8/28/18 when resident #1 physically abused resident #2 and on 9/1/18 when resident #1 physically abused resident #3. Review of the facility Abuse policy last revised 10/2018 revealed the resident had the right to be free from abuse. The resident shall not be subjected to abuse by anyone, including but not limited to location employees, other residents, consultants, volunteers and employees of other agencies serving the resident, family members or legal guardians. Alleged or suspected violations which involved any mistreatment, neglect, exploitation or abuse including injuries of unknow origin would be reported immediately to the administrator and to other officials in accordance with state law, including the State survey and certification agency. The policy directed the staff to: Intervene in any situation to protect the residents. Remove any individual from the location if necessary for the protection of the residents or employees, including but not limited to employees, visitors, contractors, or family members. Call local law enforcement for assistance with interventions necessary for the protections of the residents and employees. Call 911 for any emergency. The facility would have evidence that all alleged or suspected violations are thoroughly investigated and would prevent further potential abuse during the ongoing investigation. The abuse/neglect policies and procedures did not guarantee that abuse would never occur. To prevent such occurrences, all reasonable measures within the facilities control would be taken. The facility failed to prevent resident-to-resident abuse from resident #1 identified with a history of abuse, for cognitively impaired residents #2. The facility's failure to identify abuse resulted in a resident to resident altercation on 8/28/18 when resident #1 slapped resident #2, a cognitively impaired resident who wandered, twice in the face and struck several times on his/her hands with a rubber wheelchair handle. This deficient practice placed resident #2 in immediate jeopardy. - Review of resident #1's record revealed a [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. He/she had no behavioral indicators during the look back period and was independent with activities of daily living (ADL). Review of resident #1's care plan initiated on 7/3/14 and last revised on 9/11/18 revealed resident #1 had behavioral symptoms with a history of verbal and physical aggression. The care plan directed the staff to intervene as necessary to protect the rights and safety of others, divert the resident attentions, remove him/her from situations and reinforce the instructions to call staff when he/she required assist with another resident who wandered. Review of resident #1's nursing progress notes dated 9/1/2018 at 6:30 p.m. revealed a member of the direct care staff reported he/she responded to a body alarm (a device to alert staff to a resident attempt of unassisted transfers or ambulation) and witnessed resident #3 ambulating without assist to his/her wheelchair. Staff assisted resident #3 back to his/her wheelchair as resident #1 exited his/her room and positioned his/her motorized wheelchair next to resident #3's wheelchair so the two residents faced each other. Resident #3 reached his/her left hand out to touch resident #1's left hand and stated, what a beautiful ring, then resident #1 struck resident #3 on the back of the hand with his/her opened hand. Review of the nurse's progress note dated 9/5/2018 10:49 p.m. revealed resident #1 presented to Administrative Nurse B's office and complained of all the mentally retarded people coming in my room. Nurse B reinforced instructions for resident #1 not to intervene him/herself, directed resident #1 to call for staff assist if the resident entered his/her room and alert staff when he/she observed a resident wandering on his/her hall rather than intervening him/herself. Administrative staff B informed resident #1 facility staff would make every effort to keep the residents who wandered out of his or her room. Review of resident #3's record revealed the following Diagnoses: [REDACTED]. Review of resident #3's MDS dated [DATE] revealed the resident had short and long-term memory loss with severely impaired decision-making abilities. The resident had verbal and physical behaviors directed at others 1-3 days, wandered behaviors 4 to 6 days, and significantly intruded on the activities and privacy of others during the assessment look back period. Review of resident #3's behavioral care area assessment (CAA) dated 8/27/18 revealed the resident propelled him/herself around the facility. The resident propelled him/herself up and down the hallways and at times entered other resident's rooms. Review of resident #3's care plan initiated on 8/31/17 revealed the resident exhibited behavioral symptoms which included wandering in his/her wheelchair through-out the building without purpose or direction. The care plan directed the staff to intervene as necessary to protect the rights and safety of others and to redirect the resident when behaviors occurred. Review of the facility investigation report dated 9/1/18 revealed resident #1 approached resident #3 in the hallway outside of his/her room. The resident positioned his/her motorized wheelchair next to resident #3's wheelchair so the two-residents faced each other. Resident #3 reached out to look at resident #1's ring and stated, what a beautiful ring and resident #1 slapped resident #3 on his/her left hand. The residents were separated and resident #1 was educated not to slap other resident and to allow the staff to handle the situation. The facility failed to implement any new interventions to prevent further episodes of aggression and physical abuse directed towards residents with cognitive impairment who wandered. 10/8/18 at 3:45 p.m. observation of resident #1 revealed the resident accelerated his/her motorized wheelchair as he/she approached the common area of the facility. The resident was forced to stop and back up the wheelchair to get around resident #3. Resident #1 stated, get the hell out of the way and navigated the wheelchair around resident #3 and continued down the hall to the designated smoking area. Resident #3 propelled him/herself through the commons area and down a hall he/she did not reside on looking in each room he/she passed. Observation on 10/9/18 at 11:32 a.m. of the facility's video footage of the incident on 9/1/18 revealed resident #3 propelled his/herself down the hall in the direction of resident #1's room. Resident #3 wheeled to the end of the hall and used the exit to for leverage and stood up which activated his/her body alarm. Direct care staff member E responded to the alarm and redirected the resident. Resident #1 exited his/her room in his motorized wheelchair and maneuvered the chair next to resident #3's wheelchair and positioned him/herself to face him/her. Resident #3 reached out his/her left hand and resident #1 slapped his/her hand. Staff E separated both the residents and escorted resident #3 off the hall. Interview on 10/9/18 at 9:38 a.m. with direct care staff C revealed resident #1 had a bad attitude directed at all residents with cognitive deficits. He/she revealed resident #1 complained about resident #2 and #3 all the time and referred to those residents as retarded and too stupid to be around normal people. Staff C revealed resident #1 was involved in an incident in the past with resident #6. Staff C revealed resident #1 yelled in resident #6's face and taunted him/her until resident #6 punched resident #1, then resident #1 rammed his/her electric chair into resident #6's legs and pinned him/her against the wall before the staff intervened. Staff C revealed the facility instructed the staff to redirect the residents that wandered away from resident #1's room. Staff C denied knowledge of any other interventions initiated to protect the cognitively impaired resident who wandered in the facility. Interview on 10/9/18 at 5:02 p.m. with direct care staff E revealed he/she responded to resident #3's body alarm outside resident #1's room. Resident #3 was agitated and physically aggressive with staff E while he/she attempted to redirect resident #1. Staff E revealed resident #1 yelled out of his/her room at resident #3 to sit down and act right. Staff revealed resident #1 exited his/her room in his/her motorized wheelchair and positioned him/herself next to resident #3's wheelchair. Staff E revealed resident #1 and resident #3 faced each other and resident #3 reached out his/her left hand and commented resident #1's ring was beautiful. Resident #1 slapped resident #3's hand for no reason. Resident #3 did not act aggressive toward resident #1 or attempt to take resident #1's ring. Staff E denied knowledge of new interventions to treat resident #1's aggression and verbal and physical abuse directed at residents with cognitive impairment who wandered. Interview on 10/8/18 at 2:55 p.m. with administrative nurse B revealed the video footage of the incident on 9/1/18 between resident #1 and resident #3 revealed resident #3 appeared to be wandering and did not attempt to enter resident #1's room and there was no reason for resident #1 to exit his/her room. The investigation revealed resident #3 stated what a beautiful ring while he/she reached for resident #1's hand and resident #1 reached out and slapped resident #3 with an open hand. Staff B revealed the facility completed an investigation and educated staff to redirect residents who wandered to prevent them from entering other resident's rooms, educated resident #1 to call for staff assist and directed him/her not to address the situation him/herself, and referred resident #1 for a psych evaluation. Staff B revealed the facility considered the idea of using stop signs or the mesh stop sign banners to deter the residents who wandered out of other resident's rooms, but the facility failed to implement any safety measure to prevent resident #1 from physically abusing resident #3. Interview on 10/10/18 at 9:30 a.m. with the administrative staff A revealed the facility was aware of resident #1's aggression towards residents with cognitive impairment that wandered. Staff A was aware the facility failed to implement any interventions to reduce the risk of or prevent resident #2, #3, and #5 from entering resident #1's and failed to implement interventions to prevent resident #1 from verbal and physical abuse directed towards those cognitively impaired residents. Review of the facility Abuse policy last revised 10/18 revealed residents had the right to be free from abuse. The resident shall not be subjected to abuse by anyone, including but not limited to location employees, other residents, consultants, volunteers and employees of other agencies serving the resident, family members or legal guardians. Alleged or suspected violations which involved any mistreatment, neglect, exploitation or abuse including injuries of unknow origin would be reported immediately to the administrator and to other officials in accordance with state law, including the State survey and certification agency. The policy directed the staff to: Intervene in any situation to protect the residents. Remove any individual from the location if necessary for the protection of the residents or employees, including but not limited to employees, visitors, contractors, or family members. Call local law enforcement for assistance with interventions necessary for the protections of the residents and employees. Call 911 for any emergency. The facility would have evidence that all alleged or suspected violations are thoroughly investigated and would prevent further potential abuse during the ongoing investigation. The abuse/neglect policies and procedures did not guarantee that abuse would never occur. To prevent such occurrences, all reasonable measures within the facilities control would be taken. The facility failed to identify resident-to-resident abuse and prevent actual abuse of the residents in the facility identified as cognitively impairment and who wandered. On 9/1/18 a resident to resident altercation occurred between resident #1 and #3. Resident #1 forced resident #3 into his/her room where resident #1 slapped resident #3 in the face twice and struck resident #3 on his/her hands several times with a rubber wheelchair handle. This deficient practice placed resident #3 in immediate jeopardy. The facility abated the immediate jeopardy on 10/12/18 at 1:02 p.m. when they: 1. The physician for resident #1 was contacted and an order for [REDACTED].>2. The leadership team developed a 24-hour monitoring system for resident #1 until he/she was transferred to the behavioral health unit for evaluation. 3. A Root cause analysis was completed by the leadership team on 10/12/18 which determined resident #1 became agitated when other residents who did not reside on that hall came onto his/her hall. 4. The facility completed all staff training: Preventing, Recognizing and Reporting Abuse and Handling Aggressive Behaviors. 5. The staff will monitor and review all behaviors and incidents daily and when an incident occurred which involved an aggressive resident the Behavior Management Committee would meet and discuss the facility's plan of action. 6. All incidents or concerns will be brought to Quality Assurance and Performance Improvement (QAPI) meeting monthly for review. The deficient practice remained at the scope and severity of an D.

The facility census totaled 42 residents. The sample included 3 residents reviewed for resident-to-resident abuse. Based on observation, interview, and record review the facility failed to identify patterns of potential abuse and protect cognitively impaired residents with wandering behaviors from resident-to-resident abuse from resident #1. The facility identified 4 cognitively impaired residents with wandering behaviors who were at risk for potential abuse and failed to protect 2 of 4 residents from actual abuse (#2, #3). On 8/28/18 resident #1 slapped cognitively impaired resident #2 in the face twice and struck the resident several times on the resident's hands with a rubber wheelchair handle and on 9/1/18 resident #1 slapped cognitively impaired resident #3 on the hand. This deficient practice placed all 4 residents, identified as cognitively impaired and who wandered, in immediate jeopardy. (#2, #3, #5, #7) Finding included: - Review of resident #1's clinical record revealed the following Diagnoses: [REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. He/she had no behavioral indicators during the look back period and was independent with activities of daily living (ADL). Review of resident #1's care plan initiated on 7/3/14 and last revised on 9/11/18 revealed resident #1 had behavioral symptoms with a history of verbal and physical aggression. The care plan directed the staff to intervene as necessary to protect the rights and safety of others, divert the resident's attention, remove him/her from pending situations and reinforce instructions to call staff when he/she required assist with another resident who wandered. Review of the 8/28/18 facility investigation revealed at 6:10 p.m. resident #2 propelled him/herself down the hall where resident #1 resided. Resident #2 turned his/her wheelchair around in front of resident #1's door. Resident #1 attempted to exit his/her room and caught his/her motorized wheelchair on resident #2's wheelchair. Resident #1 freed his/her motorized wheelchair and wheeled away from resident #2, who continued to propel him/herself past resident #1's door. Resident #1 turned his/her motorized wheelchair around and placed him/herself in front of resident #2. Resident #2 attempted to propel past resident #1 which caused him/her to wheel into resident #1's room. Resident #1 unsuccessfully attempted to remove the other resident from his/her room and both residents ended up together in resident #1's room. Resident #4 heard the altercation and called the facility nurse's station and reported resident #1 had an unwanted visitor and he/she could hear a commotion in the room. The staff responded and observed resident #2 as he/she squeezed resident #1's hand. After the staff separated the residents, resident #1 reported he/she slapped resident #2 to make him/her let go of his/her hand. Observation on 10/8/18 at 3:45 p.m. revealed resident #1 accelerated his/her motorized wheelchair as he/she approached the common area of the facility. The resident was forced to stop and back up the wheelchair to get around resident #3. Resident #1 stated, get the hell out of the way and navigated the wheelchair around resident #4 and continued down the hall to the designated smoking area. Resident #4 propelled him/herself through the commons area and down a hall he/she did not reside on, looking in each room he/she passed. Observation on 10/9/18 at 11:35 a.m. of the video footage of the incident revealed resident #1 propelled him/herself down the hall where resident #1 resided. Resident #2 appeared to turn his/her wheelchair to propel back up the hallway towards the common area, when resident #1 exited his/her room. The resident's wheelchairs became entangled with each other. Resident #1 maneuvered his/her motorized wheelchair to free him/herself from the resident #2's wheelchair. As resident #1 wheeled away from resident #2, resident #2 continued to propel him/herself in front of resident #1's door. The video footage showed resident #2 did not try to enter resident #1's room. Resident #1 turned his/her motorized wheelchair around and placed him/herself in front of the other resident's wheelchair which forced resident #2 into his/her room. The video showed resident #1 grabbed the handles of resident #2's wheelchair and pulled forcefully to remove him/her from the room. Resident #1 was unable to remove resident #2 from the room and wheeled into the room with resident #2. The staff entered resident #1's room approximately 5 minutes after the altercation started. Staff removed resident #2 from resident #1's room and observed him/her to be agitated and the resident struck the staff multiple times. The investigations dated 9/28/18 revealed the facility talked with resident #1 about his/her behavior and instructed him/her to call staff for assist if he/she had a resident in his/her room, and requested a psych evaluation for resident #1, to determine his/her underlining anger and behavioral outbursts. Interview on 10/9/18 at 4:45 p.m. with resident #1 revealed resident #3 wandered in and out of everyone's in the facility's room. He/she said resident #3 came into his/her room on 10/8/18 in the evening after supper. He/she said resident #3 knocked off his/her knick-knacks and stole something from him/her however, the resident could not identify any missing personal property. Resident #1 revealed on 9/1/18 at 6:45 p.m. resident #3 propelled him/herself down the hall and he/she stopped in front of resident #1's room. Resident #1 believed resident #3 intended to come into his/her room. Resident #1 said resident #3 stood up and activated his/her body alarm. Direct care staff E responded to resident #3's body alarm. Resident #1 stated resident #3 was agitated and struck out at direct care staff E. Resident #1 exited his/her room and positioned his/her motorized wheelchair next to resident #3's wheelchair so each resident faced each other. Resident #1 said resident #3 reached out to steal the ring off his/her finger so he/she slapped the resident's hand. Resident #1 revealed staff E redirected resident #1 to his/her room and staff E wheeled resident #3 down the hall. Resident #1 stated resident #3 continued to wander through-out the facility and entered other resident's rooms, without permission. Resident #1 stated he/she would hit any resident without a brain who entered his/her room again. Resident #1 stated besides, the only other thing we can do is kill them and referred to resident #2, #3, and #5 by name, and stated, do you think I can plead insanity? Interview on 10/9/18 at 9:38 a.m. with direct care staff C revealed resident #1 had a bad attitude directed at all residents with cognitive deficits. He/she stated resident #1 complained about resident #2, #3, #5 and 7 all the time and referred to those residents as retarded and too stupid to be around normal people. Staff C said resident #1 was in an incident a couple of years ago with resident #6. Staff C revealed resident #1 yelled in resident #6's face and taunted him/her until resident #6 punched resident #1, then resident #1 rammed his/her electric chair into resident #6's legs and pinned him/her against the wall before the staff intervened. Staff C revealed the facility instructed the staff to redirect the residents that wandered away from resident #1's room. Staff C denied knowledge of any other interventions initiated to protect the cognitively impaired resident who wandered in the facility. Resident #1 made comments to other resident in the facility about slapping any one of the mentally challenged residents if they came into his/her room and he/she fired up groups of other residents and encouraged the other residents to physically harm other residents. Interview on 10/9/18 at 3:15 p.m. with direct care staff D revealed resident #1 talked about resident #2, #3, #5 and #7 frequently and made the statement that mentally retarded people should not be allowed to live in the facility because they were stupid and had no brain. He/she revealed resident #1 told staff and other residents frequently he/she would hit the mindless residents if they entered his/her room before the incident on 8/28/18 and had made the same statement after the incident. Staff D revealed the facility directed the staff to monitor and redirect the resident who wandered out of other resident's rooms. Staff D denied knowledge of any interventions implemented to protect the resident who wandered from resident #1. Interview on 10/9/18 at 5:02 p.m. with direct care staff E revealed he/she responded to resident #3's body alarm outside resident #1's room. Resident #3 was agitated and physically aggressive with staff E while he/she attempted to redirect the resident #1. Staff E revealed resident #3 yelled out of his/her room at resident #3 to sit down and act right. Staff revealed resident #1 exited his/her room in his/her motorized wheelchair and positioned him/herself next to resident #1's wheelchair. Staff E revealed resident #1 and resident #3 faced each other and resident #3 reached out his/her left hand and commented resident #1's ring was beautiful. Resident #1 slapped resident #3's hand for no reason. Resident #3 did not act aggressive towards resident #1 or attempt to take resident #1's ring. Staff E denied knowledge of new interventions to treat resident #1's aggression and verbal and physical abuse directed at residents with cognitive impairments, who wandered. Interview on 10/8/18 at 2:55 p.m. with administrative nurse B revealed he/she watched the video footage of the incident on 8/28/18 between resident #1 and resident #3. He/she revealed it appeared resident #2 attempted to make a U-turn and continued to propel him/herself past resident #1's door. He/she revealed the video showed resident #1 wheeled away from resident #3 and turned around purposefully and confronted resident #3. Resident #1 positioned his/her motorized chair in front of resident #2 and pushed him/her into his/her room where the altercation took place. Staff B revealed the facility completed an investigation and educated the staff to redirect residents who wandered to prevent them from entering other resident's rooms, educated resident #1 to call for staff assist and directed him/her not to address the situation him/herself, and referred resident #1 for a psychological evaluation. Staff B revealed the facility considered the use of stop signs or the mesh stop sign banners to deter the residents who wander out of other residents rooms but the facility failed to implement any safety measure to deter the residents that wander from entering resident #1's room before the incident on 9/1/18 or after the incident occurred. Staff B confirmed the facility was aware of resident #1's verbal threats to physical harm resident #2, #3, and #5 if they entered his/her room before resident #1 slapped resident #3 on his/her left hand on 9/1/18. Administrative staff B confirmed the facility failed to prevent physical abuse of resident #3 by resident #1. Staff B confirmed he/she knew of resident #1's verbal threats to hit or slap other residents prior to the incident on 8/28/18 and failed to implement new interventions to prevent resident #1 from abusing another resident. Interview on 10/10/18 at 9:30 a.m. with administrative staff A revealed the facility knew of resident #1's aggression towards residents with cognitive impairment that wandered. Staff A knew the facility failed to implement any interventions to reduce the risk of or prevent resident #2, #3, and #5 from entering resident #1's room and failed to implement interventions to prevent verbal and physical abuse directed towards those residents by resident #1. Review of the facility's Abuse policy last revised 10/2018 revealed the resident had the right to be free from abuse. The resident should not be subjected to abuse by anyone, including but not limited to location employees, other residents, consultants, volunteers and employees of other agencies serving the resident, family members or legal guardians. Alleged or suspected violations which involved any mistreatment, neglect, exploitation or abuse including injuries of unknow origin will be reported immediately to the administrator and to other officials in accordance with state law, including the State survey and certification agency. The policy directed the staff to: Intervene in any situation to protect the residents. Remove any individual from the location if necessary for the protection of the residents or employee, including but not limited to employees, visitors, contractors or family members. Call local law enforcement for assistance with interventions necessary for the protections of the residents and employees. Call 911 for any emergency. The facility would have evidence that all alleged or suspected violations were thoroughly investigated and would prevent further potential abuse while the investigation occurred. The abuse/neglect policies and procedures could not and did not guarantee that abuse would never occur. To prevent such occurrences, all reasonable measures within the facilities control would occur. The facility failed to identify the potential for abuse and protect residents in the facility identified with cognitively impairment and who wandered from resident-to-resident abuse by resident #1. Following resident-to-resident altercations on 8/28/18 and 9/1/18 between resident #1 and resident #2 and #3, the facility failed to implement effective interventions to protect cognitively impaired resident who wandered from further abuse. The facility's failure placed the cognitive impairment residents and who wandered in immediate jeopardy related to abuse. (#2, #3, #5, #7) The facility abated the immediate jeopardy on 10/13/18 at 1:02 p.m. when they: 1. The facility contacted the physician for resident #1 and he/she ordered and an inpatient psychiatric evaluation. 2. The leadership team developed a 24-hour monitoring system for resident #1 until the facility transferred him/her to the behavioral health unit for evaluation. 3. The facility completed a root cause analysis by the leadership team on 10/12/18 which determined resident #1 became agitated when other residents, who did not reside on that hall, came onto his/her hall. 4. The facility required all staff to complete the following training: Preventing, Recognizing and Reporting Abuse and Handling Aggressive Behaviors. 5. The staff will monitor all behaviors and incidents daily and reviewed daily and when an incident occurred which involved an aggressive resident the Behavior Management Committee would meet and discuss the facility's plan of action. 6. All incidents or concerns will be brought to Quality Assurance and Performance Improvement (QAPI) meeting monthly for review. The deficient practice remained at the scope and severity of an E.

The facility census totaled 49 residents with 3 sampled for accidents. Based on observation, interview and record review the facility failed to ensure 3 of 3 residents received adequate supervision, assistance and assuasive devices to prevent accidents (#1, #2 and #3). Resident #1 had repeated falls (5 falls in 5 months since admission) from the bed when attempting to self-transfer. The facility developed a toileting program and planned for a bed alarm to alert staff when the resident attempted to get up. On 9/27/16 staff failed to toilet the resident as planned at 5:30 AM and failed to ensure the bed alarm was on, in place as care planned and functioned when the resident exited the bed, attempted to ambulate to the bathroom and fell . This fall resulted in a right hip fracture and neck fracture. Findings included: - Review of resident #1's physician's orders [REDACTED]. Review of the admission MDS (minimum data set) dated 4/12/16 revealed a BIMS (brief interview for mental status) score of 9, indicating moderately impaired cognition. He/she required extensive assist by 1 staff for bed mobility, transfers, dressing and toilet use. He/she experienced frequent urinary incontinent episodes and did not have a toileting program. He/she had a history of [REDACTED]. The cognition CAA (care area assessment) dated 4/18/16 indicated the resident had forgetfulness, needed repetitive cueing to assist with tasks. Staff needed to anticipate and meet the resident ' s daily needs. The ADL (activities of daily living) CAA dated 4/18/16 identified the resident with cognitive and musculoskeletal impairment with a history of cerebrovascular accident (the sudden death of some brain cells due to a lack of oxygen when the blood flow is impaired) and right side hemiparesis. He/she could raise his/her right arm above his/her head and had complete range of motion but the right leg was limited. He/she needed repetitive cueing throughout tasks with 1 person assist for transfers and a gait belt. He/she needed to be told to push him/herself up, grab wheelchair arms, turn around and such with repetitive cueing. The fall CAA dated 4/18/16 indicated the resident experienced weakness with poor endurance. The resident experienced increased weakness after dialysis. Staff used a bed alarm to alert staff of the resident's movement. A family member reported the resident fell in previous 30 days and previous 31 to 180 days. The family member did not know the exact circumstances, however, and stated the resident forgets and is not safe. On 4/11/16 he/she fell at dialysis when he/she attempted to self-transfer. His/her sitting balance remained fair to good but he/she could not maintain standing balance without staff assistance. Review of the quarterly MDS dated [DATE] revealed no change in cognition or ADL abilities. He/she continued to experience frequent urinary incontinence and had a toileting program. The resident experienced 2 or more non-injury falls since the prior assessment. He/she received an antidepressant on 7 days of the 7 day observation period which increased the resident's fall risk. Review of the ADL care plan revealed a toileting schedule dated 7/11/16 of 5:30 AM, 9:00 AM, 2:00 PM, 7:00 PM and 9:00 PM. Toilet at approximately 4:00 PM or when he/she returned from dialysis on Monday, Wednesday and Fridays. Transfer the resident between surfaces with 1-2 person assist with a gait belt due to right-sided weakness and need for repetitive simple cueing throughout tasks. Review of the fall care plan dated 4/6/16 revealed staff needed to place a bed alarm to alert staff when the resident attempted to get up. On 4/18/16 staff updated the care plan with Staff needed to assist the resident with all transfers and ambulation, position safely in bed and wheelchair and use pillows as needed to maintain position. The resident fell on [DATE], 5/19/16 and 8/6/16 without review or revision to the care plan for interventions to prevent future falls. Review of the resident ' s medical record between 4/5/16 through 10/17/16 revealed falls with facility investigations as follows: On 4/11/16 the resident was at the dialysis center and attempted to self-transfer as reported by another patient there. The facility indicated the root cause as he/she believed he/she can still walk and transfer independently. There were no interventions listed in the investigation but staff revised the care plan to include staying with the resident until the other facility staff took over. Review of the facility's investigation for the fall on 4/27/16 at 11:00 PM the resident dropped the call light, he/she stood up from the bed and when he/she attempted to sit in the wheelchair, the wheelchair rolled away because the brakes were not locked. The investigation revealed staff had not turned the bed alarm on (planned since 4/6/16). Initial interventions to prevent future falls included for staff to double check the bed alarm, make sure the resident could reach the call light, and always lock the wheelchair. The care plan lacked evidence of a review or revision to prevent future falls. The facility could not provide the investigation for the 5/19/16 fall. Administrative nurse F reported he/she had completed an investigation but he/she could not find it. The facility investigation revealed on 8/6/16 at 6:40 PM the resident fell in the dining room alone and unattended. The resident attempted to maneuver through the dining room independently, got caught up in a dining room chair and leaned forward to attempt to dislodge the chair, and he/she fell forward. The resident sustained [REDACTED]. The fall investigation included an initial intervention to prevent future falls of staff make sure the dining room remained free of clutter and all chairs were out of resident ' s path. Staff failed to revise the care plan with this intervention or address the resident's need for assistance and/or supervision. The facility investigation dated 9/27/16 at 6:30 AM revealed the resident got out of bed and no alarm sounded. The resident used the rolling over bed table as an assistive device to ambulate to the bathroom. Direct care staff B was in the hallway and as he/she approached the resident's room he/she saw the resident standing as he/she attempted to ambulate with the over bed table. Staff B reported he/she made a sound when he/she saw the resident and then the resident partially turned to look at him/her. The resident fell backward and struck the back of his/her head on a bed side table. The investigation indicated staff last toileted the resident at 3:00 AM (the care plan indicated staff were to take the resident to the bathroom at 5:30 AM) and the resident was incontinent of urine at the time of the fall. The bed alarm at the time was in place but turned off. The root cause analysis failed to identify staffs ' failure to follow the care plan for the toileting schedule and the bed alarm being turned off. The analysis identified the resident with unsteady gait, history of falls, and he/she forgot he/she could not walk alone. The initial intervention included an alarm, visual checks, and staff was to put the wheelchair out of reach. On 9/30/16 staff updated the care plan with resident had a neck fracture and planned for a neck collar to be in place. The care plan directed staff to handle the resident gently when moving or positioning to maintain body alignment. The resident also had a right hip fracture from the same fall with surgical repair and staples to the right upper thigh. The care plan already included a bed alarm which staff revised on 9/30/16 to include a chair alarm. Review of the notarized statements included in the facility's investigation failed to mention the alarm not being turned on. The investigation laced statements from the night shift staff. Review of the radiology report dated 9/27/16 revealed an X-ray showed a hip fracture and the cervical CT (computerized X-ray) showed a neck fracture. Observation on 10/18/16 at 10:00 AM revealed the resident rested in bed with his/her eyes closed and the bed in a low position with a mat on the right side of the bed. He/she had a cervical collar in place and the call light in his/her hand. Observation on 10/18/16 at 11:21 AM revealed direct care staff C and direct care staff D assisted the resident to transfer from the bed to the wheelchair with a gait belt. The resident stood with most of his/her weight on the left leg following staff's cueing, took a few steps and pivoted to the chair. The bed alarm did not sound during this transfer. Direct care staff C reported the alarm should sound when the resident is no longer on the sensor pad. He/she pulled back the bed sheet and found a small pad approximately 8 inches by 16 inches the alarm box was not turned on. He/she said the resident needed the longer bed style pad because he/she could scoot off this smaller one and then the alarm was ineffective. Interview on 10/18/16 at 11:25 AM with direct care staff C revealed he/she worked the morning of 9/27/16 and heard a staff member call for help. When he/she responded to the resident's room he/she saw the resident on the floor. Staff C reported the bed alarm with the small type pad was not sounding. He/she reported the last time staff checked the resident for incontinence or repositioned was around 6:00 AM. He/she did not remember if the alarm sounded during care at that time. Interview on 10/18/16 at 12:23 PM with direct care staff B revealed he/she worked the resident's hall during the day hours on 9/27/16. He/she received report from the off-going shift but did not check the resident for incontinence or take him/her to the bathroom. The resident lay in bed at 6:00 AM and the direct care staff from the night hours reported no concerns about the resident. Staff B said the resident had a high risk for falls and needed to have an alarm on the bed which sounded when the resident attempted to get up. Interview on 10/18/16 at 3:53 PM with direct care staff E revealed he/she worked the night shift on 9/26/16 into the morning of 9/27/16. He/she worked a different hall but the staff worked together on rounds to provide resident cares. He/she reported rounds were done at 1:00 AM, 3:00 AM and 5:00 AM. Rounds consisted of toileting the residents that wanted to get up to the bathroom and checking/changing the others. He/she said the resident did not want to get up during the night and staff just checked him/her for incontinence. He/she had changed the resident on the 3:00 AM rounds but did not know about the 5:00 AM rounds. He/she could not remember if the alarm was in place or turned on. He/she said the resident needed the longer bed pad type alarm not the chair pad alarm. Interview on 10/19/16 at 6:58 PM with direct care staff J revealed he/she worked on the overnight hours of 9/26/16. He/she said the resident does not use the call light at night and staff check and change him/her every 2 hours. Staff J reported he/she knew the care plan directed to toilet the resident at 5:30 AM but the resident routinely refused to get up. He/she could not remember whether staff had changed the resident on the 5:00 AM rounds. He/she could not remember if the bed alarm was turned on. Interview with licensed nurse A on 10/18/16 at 10:36 AM revealed he/she was in the nurse ' s area preparing for the day on 9/27/16 when he/she heard a loud thump. He/she found the resident on the floor by the bed with complaints of head/neck pain and no bed alarm sounded. He/she called emergency medical service to transport the resident to the hospital for evaluation. Interview with administrative nurse F on 10/18/16 at 5:00 PM revealed an expectation for staff to follow the care plan. He/she confirmed the care plan directed staff to toilet the resident at 5:30 AM and to have a bed alarm in place and turned on. He/she confirmed the facility's investigation reflected the resident fell on [DATE] and sustained a fractured neck and hip when staff failed to have the alarm on and toilet the resident as planned. Review of the facility's policy titled, Fall Prevention and Management dated 7/2015 revealed a resident's health and well-being can be forever impacted by a fall. It was the facility ' s obligation to provide the safest environment possible for the residents trusted to our care. The policy directed staff to identify actual risk factors and take steps to prevent the fall from occurring again. This included a post-fall investigation to determine the cause of the fall (root cause analysis), identifying risk factors and steps (interventions) to prevent the fall from happening again. The facility failed to ensure staff implemented planned interventions of a bed alarm and toileting program for the resident who had repeated falls. On 9/27/16 staff failed to toilet the resident as planned at 5:30 AM and failed to ensure the bed alarm was on, in place and functioning. The resident exited the bed, attempted to ambulate to the bathroom and fell . This fall resulted in the resident having a right hip fracture and neck fracture. The facility also failed to identify the root cause of the resident ' s fall on 9/27/16 and failed to investigate the fall on 5/19/16. - Review of the quarterly MDS (minimum data set) for resident #2 dated 6/28/16 revealed a BIMS (brief interview for mental status) score of 10 indicating moderately impaired cognition. He/she required limited assistance of 1 staff for bed mobility, transfers, toilet use and personal hygiene but extensive assistance with dressing. He/she did not have a history of falls and received medications that increased his/her fall risk (an antidepressant and diuretic on 7 days of the 7 day observation period). Review of the annual MDS dated [DATE] revealed the no changes in cognition level or ADL (activities of daily living) abilities. Staff marked the resident had not fallen since the last assessment. He/she remained on an antidepressant for 7 days of the 7 day observation period. The cognition CAA (care area assessment) dated 9/30/16 indicated the resident had moderate impaired cognition with ability to recognize family and some staff members. He/she knew the location of his/her room, dining room and facility office where he/she received help to call family. He/she does not use the call light consistently and will seek out staff to make requests. The ADL CAA dated 9/30/16 identified the resident with self-care deficit related to cognitive impairment and body size (difficulty reaching feet). Both these risk factors affect his/her ability to perform personal hygiene and dressing lower extremities. He/she needed limited to extensive assist with ADL's. The fall CAA dated 9/30/16 identified risk factors for the resident of impaired balance while ambulating and when he/she turned while ambulating. He/she had other risk factor of antidepressant use daily. He/she used a wheelchair as his/her primary mode of locomotion. He/she could transfer to the toilet independently with use of the grab bars. The ADL care plan included an intervention dated 12/5/13 for staff to provide the resident with assistance of 1 with a gait belt and walker to transfer between surfaces. He/she is able to do the task at times independently or with stand by assistance. The fall care plan included intervention dated 3/5/14 for staff to educate the resident and family about safety reminders and what to do if a fall occurred. Staff are to monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. On 2/26/16 staff updated the care plan with educate resident and family on safety of assistive devices the resident used. He/she had Dycem (an anti-slip material) placed in the wheelchair to prevent sliding from the wheelchair. On 3/3/16 staff updated the care plan with anti-roll back brakes applied to the wheelchair for fall prevention. review of the resident's medical record revealed [REDACTED]. On 7/20/16 at 4:00 PM staff responded to the resident's scream and found he/she on the floor face down in front of his/her recliner. The resident had multiple cuts and abrasions to face, left elbow and hand. The resident did not know what happened. The lift recliner was in the highest position and he/she sat in the recliner prior to the fall. The resident received sutures in the emergency room to close the laceration on the right forehead. The facility determined the resident raised the lift chair to the highest position, stood up and fell forward. The facility indicated maintenance will evaluate the chair to prevent highest elevation and take off the remote controller. The care plan lacked any information regarding this fall or interventions to prevent future falls. On 10/14/16 at 1:00 PM direct care staff D assisted the resident to dress after bathing. The resident stood with his/her shoes on and holding onto the walker when his/her knees buckled. Staff D used the gait belt for the task and stabilized the resident to lower to the floor without injury. The facility's investigation lacked a root cause for the knee buckling and no interventions were developed to prevent future falls of this nature. The care plan lacked any information about this incident with no changes to the ADL or fall care plan. Observation on 10/18/16 at 10:48 AM revealed the resident seated in a wheelchair in his/her room watching TV. The recliner in the room and the control device on top of the arm rest but staff had unplugged the chair. At 11:13 AM the resident independently propelled his/her wheelchair safely from his/her room to the dining room using his/her feet and the hand rail. Observation on the afternoon of 10/18/16 revealed the resident did not use the recliner. He/she propelled in the wheelchair about the facility and outside for about 30 minutes. Interview on 10/18/16 at 1:45 PM with direct care staff C revealed the resident was at risk for falls and staff assisted him/her to transfer. He/she can use the bathroom independently because he/she used the grab bars. If he/she was feeling weak he/she would call for help. Staff C the 7/20/16 fall happened in the evening because the resident raised the chair up to high. He/she said they were directed to keep the chair unplugged and to help him/her operate the chair if he/she wanted to use it. The fall on 10/14/16 happened after he/she received a whirlpool bath. He/she said the whirlpool chair will move and possibly did which caused him/her to lose his/her balance. He/she said he/she responded to the fall and the walker and gait belt were in use. Interview on 10/18/16 at 2:40 PM with direct care staff H revealed the resident only needed assistance to dress and get in and out of the bed. He/she used the bathroom independently. Staff H did not know about the fall from the recliner and said he/she had never seen the resident use it. He/she did not know about the resident's fall in the bath house and did not know of any changes in his/her care. Interview with administrative nurse F on 10/18/16 at 5:00 PM confirmed the resident had fallen as above and the investigations were incomplete. He/she also confirmed staff failed to update the care plan to prevent future falls. He/she said the recliner was unplugged and staff are to plug it in to operate the controls if the resident wanted to use it but he/she has not used it since the fall. Review of the facility's policy titled, Fall Prevention and Management dated 7/2015 revealed a resident's health and well-being can be forever impacted by a fall. It is the facility ' s obligation to provide the safest environment possible for the residents trusted to our care. The policy directed staff to identify actual risk factors and take steps to prevent the fall from occurring again. This will included a post-fall investigation to determine the cause of the fall (root cause analysis), identifying risk factors and taking steps (interventions) to prevent the fall from happening again. The facility failed to ensure staff completed a root cause analysis for this resident who fell on 2 occasions and failed to develop interventions to prevent future falls. - Review of resident #3's physician orders [REDACTED]. Review of the annual MDS (minimum data set) dated 7/5/16 revealed a BIMS (brief interview for mental status) score of 3, indicating severe cognitive impairment. He/she walked independently in the room with limited assistance to transfer between surfaces but required extensive assistance with dressing, toileting and personal hygiene. Staff provided the resident with a toileting program for management of occasional urinary incontinence. He/she fell twice without injury since the previous assessment. The cognition CAA (care area assessment) dated 7/7/16 revealed the resident had no significant changes, needed assistance to anticipate and meet his/her daily needs. He/she needed cueing to time of day, but could participate in daily decision of simple choices. He/she used the bathroom independently and attempted to meet his/her own needs. The ADL (activities of daily living) CAA did not trigger for a further assessment. The fall CAA dated 7/7/16 identified the resident fell twice since previous MDS, was forgetful and could not remember how to safely use a walker or to use a walker at all times. He/she often transferred him/herself and at times needed limited assistance especially if getting up from a low chair. He/she needed staff to provide reminders to use a walker with all ambulation. The quarterly MDS dated [DATE] included the same cognition. The resident required extensive assistance by 1 staff for bed mobility, transfers, and toilet use and person hygiene with limited assistance for walking. He/she was no longer on a toileting program but still experienced occasional urinary incontinence. He/she fell on ce without injury and once with major injury since the last MDS. Review of the current care plan revealed an ADL plan dated 12/30/15 for resident to ambulate as desired with a front wheeled walker and staff were to remind him/her to scoot in close to the walker. The ADL care plan included toileting schedule dated 8/27/15 directed staff to assist the resident to the bathroom at 10:30 AM, 4:00 PM, 5:30 PM with a revision on 7/8/16 of resident often used the bathroom independently. The fall care plan dated 2/23/16 included for staff to ensure the resident avoided too loose, slippery or too long clothing which increased the resident's fall risk. On 4/9/16 staff added to make sure the resident's walker remained in reach, in sight of the resident, and to prompt him/her to remember to use the walker. Since 1/25/16 staff were to monitor the resident and report to health care provided for signs/symptoms of pain, changes in mental status, sleepiness or inability to maintain posture. Review of nursing notes between 5/1/16 and 10/17/16 revealed the resident fell on [DATE], 5/29/16 and twice on 8/19/16. Review of the facility ' s fall investigations revealed: On 5/2/16 at 7:00 PM staff found the resident on the floor in the center of the room between the couch and bathroom with his/her walker a short distance away and his/her back to the bathroom. The facility identified the root cause as the resident having difficulty with ADLs and was using the bathroom. Staff found the resident with his/her pants around his/her hips. The initial intervention included for staff to assist the resident for all bathroom trips. The care plan lacked an updated and continued with the same toileting schedule in place since 8/27/15. On 5/29/16 at 9:40 AM the resident lost his/her balance when attempting to ambulate out of the hairdressing parlor. The facility's investigation reflected facility staff provided employee education but did not include what education. The investigation failed to include an analysis of the causal factors of the fall, did not identify interventions to prevent further falls, and staff did not revise the care plan. On 8/19/16 at 4:30 AM staff found the resident on the floor close to the bed with his/her walker a distance away and to the left of the resident. The investigation identified staff last toileted the resident at 4:00 AM. The facility identified the root cause as the resident lost his/her balance and the resident had a decreased level of consciousness, diaphoretic (sweating) and pale with cold skin. He/she could not move his/her feet and staff sent the resident to the emergency room for evaluation. The initial intervention included the need for a bed alarm but the care plan lacked this revision. A nursing noted dated 8/19/16 at 10:26 AM indicated the resident returned from the emergency room with a [DIAGNOSES REDACTED]. On 8/19/16 at 4:40 PM staff found the resident on the floor. The resident had been in bed asleep and when he/she woke up he/she stood up without assist. The resident wore regular shoes and had no alarm in place to alert staff. Staff last toileted the resident at 2:30 PM and he/she was incontinent at the time of fall (the toileting schedule included a 4:00 PM toileting). The facility identified the root cause as urgency to toilet with an initial intervention to toilet the resident more frequently and the family requested a bed alarm be placed. Observation on 10/18/16 at 10:10 AM revealed direct care staff G propelled the resident from the chapel to his/her room, unhooked the TABS (an alarm that attached to the resident and then to a box located on another surface) alarm, removed the wheelchair foot pedals and applied a gait belt around the resident's waist. Staff G propelled the resident to the toilet where he/she used grab bars to pull self into a standing position while staff G provided some support by the gait belt. When the resident finished toileting staff G reattached the TABS alarm cord. Observation on 10/18/16 at 2:00 PM revealed the resident rested in bed with a sensor alarm in place. Interview on 10/18/16 at 10:59 AM with direct care staff G revealed the resident was at risk for falls and fell before. The resident needed to have the bed alarm when in bed and then any time he/she sat in a chair or activity he/she needed the TABS alarm attached to his/her person. Staff G said staff assisted the resident to toilet before and after meals or activities. Interview on 10/18/16 at 2:44 PM direct care staff H revealed the resident was a fall risk and currently used a wheelchair because of back pain. He/she said the resident needed to have an alarm on while in bed and when in the chair to let staff know he/she wanted to get up. He/she said when there was a change in the resident he/she found out in report and the care plan. Interview on 10/18/16 at 11:25 AM with licensed nurse A revealed an expectation for staff to follow the care plan. He/she identified the resident as a high fall risk and required alarms on the bed and wheelchair. He/she said before the fall when the resident hurt his/her back the resident was independent. Nurse A could not remember what the care plan interventions were for the falls prior to 8/19/16. Interview on 10/18/16 at 5:00 PM with administrative nurse F confirmed the investigations were not always complete. He/she reviewed the care plan and confirmed the plan lacked interventions for any of the resident ' s 4 falls. Review of the facility's policy titled, Fall Prevention and Management dated 7/2015 revealed a resident's health and well-being could be forever impacted by a fall. The policy directed staff to identify actual risk factors and take steps to prevent the fall from occurring again. This included a post-fall investigation to determine the cause of the fall (root cause analysis), identifying risk factors and taking steps (interventions) to prevent the fall from happening again. Review of the facility's policy titled, Care Plan dated 9/2012 revealed staff will review, evaluate and update the care plan. This plan of care would be modified to reflect the care currently provided for the resident. The facility failed to provide the resident with the planned assistance to toilet and the planned bed alarm to prevent repeated falls. The facility also failed to investigate all falls thoroughly to determine causal factors to prevent further falls.

The facility reported a census of 52 residents, and identified 13 residents at risk for elopement. Three residents were sampled for elopement. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent two of the sampled residents (#1 and #2) from exiting the facility unattended, and ambulating down a gravel road. Resident #1 and #2 were gone from the building for 30 minutes, and staff found the residents on a road with no sidewalks about 3 blocks from the facility. This deficient practice placed resident #1 and #2 in immediate jeopardy. Findings included: - The facility admitted resident #1 on 8/15/16, with a [DIAGNOSES REDACTED]. Review of resident #1's Admission MDS (Minimum Data Set) dated 8/19/16 revealed a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. The resident had verbal behavior symptoms directed towards others and wandered 1 to 3 days during the 7 day observation period. The resident ambulated independently in his/her room and the corridor and was independent with locomotion on the unit. The resident required supervision with locomotion off the unit. Review of the Behavioral CAA (Care Area Assessment) dated 8/19/16 revealed the resident got upset when he/she could not go outdoors. He/she was very verbal and upset he/she could not go outside. Staff were unable to reason with the resident due to his/her cognitive impairment. Staff placed a wanderguard (a bracelet that sets off an alarm when residents wearing one attempted to exit the building) on the resident to alert staff. The resident wandered up and down hallways pushing resident #2 in a wheelchair. The resident went to different doors attempting to leave the facility. Staff were to know the resident's whereabouts and were to invite and encourage the resident to participate in daily activities and provide redirection when he/she wanted to go outside. Review of resident #1's care plan (initiated 8/16/16) revealed resident #1 had a potential for elopement related to a [DIAGNOSES REDACTED]. Staff were to visually check on the resident every 15 minutes (initiated 9/24/16). Review of resident #2's Admission MDS (Minimum Data Set) dated 8/19/16 revealed a BIMS (Brief Interview for Mental Status) score of 13, indicating intact cognition. The resident required limited assistance with one person physical assist for walking in room and corridor, required extensive assistance with one person physical assist with locomotion on the unit and was totally dependent one person physical assist with locomotion off the unit. The resident required the use of a walker and wheelchair for mobility. Review of the ADLs/Functional Status CAA (Care Area Assessment) dated 8/19/16 revealed the resident needed limited to extensive assistance with most tasks. Use of a wheelchair was the resident's primary mode of locomotion. The resident did not propel self but the resident's family member was usually with him/her and he/she pushed the wheelchair for the resident. Review of resident #2's care plan revealed the resident had a potential for elopement. (Date Initiated: 9/24/16) Intervention directed staff to check the resident every 15 minutes. (Date Initiated: 9/24/16) The resident had a Wander Guard used to alert staff to the resident's movement and to assist staff in monitoring movement. (Date Initiated: 9/24/16) The resident had an ADL (activity of daily living) self-care performance deficit related to cognitive impairment and disease process. (Date Initiated: 8/16/16) Interventions included ambulation with 1 person assist with gait belt and walker. (Date Initiated: 8/16/16) Review of the 9/24/16 Incident Note revealed a staff member found resident #1 about 3 blocks from the facility. The resident stated a visitor let him/her out of the building. Staff returned the resident uninjured. The note lacked documentation regarding the weather, terrain, or speed limit of the area the residents traveled. According to wunderground.com, the weather conditions at 12:55 PM on 9/24/16 were 71.6 Fahrenheit temperature with clear skies and winds out of the east northeast at 4.6 miles per hour. Review of the 9/24/16 Incident Note revealed resident #1 attempted to leave the facility and stated, I have to go home to work on my car. Staff easily deterred the resident and he/she did not leave the facility. Review of the 9/24/16 Incident Note revealed resident #1 again tried to leave the facility stating that he/she had to get home to finish raking the leaves. Staff returned him/her to his/her room without incident. He/she did not leave the facility. Review of the 9/26/16 Incident Note revealed staff continued to check on the resident every 15 minutes. The resident did not attempt to leave the facility during the shift. An observation on 9/27/16 at 2:45 PM revealed resident #1 pushed resident #2 in a wheelchair in the hallway. The resident #1 wore a wanderguard and resident #2 had a wanderguard attached to his/her wheelchair. An observation on 9/28/16 at 8:25 AM revealed a sign on the rear (west) exit door stating, Please be alert for residents near exits. If you see any residents attempting exit or if alarm sounds while resident exits the facility, please alert staff. Do not allow residents to follow you out. An observation on 9/28/16 at 9:15 AM revealed resident #1 pushed resident #2 in the wheelchair down A Hall . Physical therapy staff redirected the residents to go with him/her to the front lobby for an activity. Resident #1 wore a wanderguard on his/her right wrist. During an interview on 9/28/16 at 9:23 AM direct care staff E stated resident #1 was at risk for leaving the building. Staff E stated if he/she saw the resident trying to get out of the building he/she would try to redirect him/her and encourage the resident to attend an activity, get him/her a snack or just talk with him/her. Staff E stated the resident was easily redirected. Staff E stated before the resident attempted to exit the building he/she asked staff how to get out of the building, or stated he/she wanted to go home. Staff E stated the resident wore a wanderguard. Staff E stated an alarm went off if the resident attempted to exit the building. The alarm sounded at the affected door and there was also a panel that indicated which door alarm sounded. Staff E stated all staff were supposed to go outside and check for any residents that might have exited the building before resetting the alarm. Staff E stated resident #1 tried to go out of the building every day, and the day the resident exited the building the alarm went off a lot as there were a couple of new admissions to the facility and a lot of visitors did not know how to use the door code, and frequently set off the alarm. Staff E stated the resident exited the building during lunch time when he/she was busy taking care of other residents. Staff E stated he/she responded to the alarm but did not check outside to see if a resident went out before resetting the alarm. Staff E stated he/she thought one of the visitors set off the alarm. Staff E acknowledged he/she should have checked when the alarm sounded to see if a resident went outside. Staff E stated the same day of the incident administrative nurse staff C had a staff meeting concerning door alarms and the importance of checking outside every time the door alarm sounded. Staff E also attended a mandatory in-service later in the week dealing with elopements. Staff E stated he/she did not usually work with the resident but tried to keep a frequent watch over him/her. An interview on 9/28/16 at 9:58 AM direct care staff F stated he/she did not think resident #2 was at risk for elopement since he/she could not walk very well and was mostly in his/her wheelchair. Staff F stated in order for the resident to leave the building someone needed to push him/her in his/her wheelchair. During an interview on 9/28/16 at 12:15 PM direct care staff D stated resident #1 was at risk for eloping. Staff D stated the resident usually went to staff to get help to find the front exit and would tell staff he/she needed to go back home. Staff D stated he/she redirected him/her and the resident did well with redirection. Staff D verified the resident had a wanderguard on since he/she came to the facility. Staff D stated if a door alarm sounded staff were to go to the door alarm panel to check which door alarm was sounding. Staff were to go directly to the door and go outside to check if a resident went outside. Staff D stated all staff were to respond to the alarm. If another staff was at the door staff should verify if the other staff checked to make sure no resident went outside. Staff D stated since the elopement staff completed 15 minute checks on the resident and documented those on the computer kiosk. Staff D stated the facility provided training concerning elopement and door alarms to all staff. During an interview on 9/28/16 at 12:33 direct care staff D stated he/she did not think resident #2 was at risk for elopement unless he/she was with resident #1 and he/she pushed the resident in his/her wheelchair outside. Staff D stated resident #1 was aware of where he/she was and the facility was his/her new home. Staff D stated resident #2 could probably go outside if he/she wanted to but he/she would just have to let staff know this and sign-out in the notebook by the front door. Staff D stated resident #2 would usually went with resident #1 so if resident #1 wanted to go outside he/she would probably go along with this. Staff D stated staff completed 15 minute checks on both resident #1 and #2. During an interview on 9/28/16 at 2:11 PM direct care staff H stated resident #1 was an elopement risk and he/she tried to get out of the exit doors. Staff H stated the resident walked around and asked staff how he/she could go outside to get some fresh air. Staff H stated on 9/24/16 around 1:30 PM as he/she drove to work when he/she noticed resident #1 pushing resident #2 in a wheelchair on the side of a gravel road. He/she then pulled up to the residents with his/her car and asked resident #1 how he/she got out of the facility but the resident did not know and stated he/she was just going for a walk. Staff H stated when staff arrived from the facility he/she took the resident back to the facility in his/her car and the other staff pushed resident #2 back to the facility in the wheelchair. During an interview on 9/28/16 at 2:35 PM direct care staff H stated he/she would not consider resident #2 at risk for elopement since he/she was always sitting in his/her wheelchair and did not walk very well. Staff H stated resident #2 always pushed resident #1 around in his/her wheelchair; and the only way the resident could get out of the facility was if resident #1 took him/her out. During an interview on 9/28/18 at 2:50 PM licensed nursing staff G stated resident #1 was a risk for elopement since the day he/she admitted to the facility. Staff G stated a family member said the resident liked to spend time outside. Staff G stated the confused resident had dementia and the resident voiced he/she wanted to go home and wandered around the facility. Staff G stated he/she never witnessed the resident actively trying to get out of the facility. Staff G stated the resident wore a wanderguard from the day he/she arrived at the facility. Staff G stated if a door alarm activated, all staff were supposed to find out what alarm was sounding and check to see if a resident was trying to exit the building. If staff did not see anyone at the door, staff were supposed to physically go outside and check to see if a resident went outside. Staff G stated on the date of the incident nothing unusual with the resident took place. The resident did not pace around or try to get outside of the building. The resident did ask staff where main street was located. Staff G stated he/she last saw the resident at approximately 12:30 PM eating lunch in the dining room with resident #2. The day of the incident the door alarm went off 6 or 7 times since there were a lot of visitors. Staff G stated the door alarm sounded if the door was held open too long. Staff G stated he/she did not realize the resident went outside of the facility until staff H called him/her on the phone to report he/she found the residents out on the street. During an interview on 9/28/16 at 3:01 PM licensed nursing staff G stated he/she did not think resident #2 was at risk for wandering or eloping on his/her own unless resident #1 pushed him/her in the wheelchair. Staff G stated resident #2 had a wanderguard on his/her wheelchair after the elopement. During an interview on 9/28/16 at 3:29 PM administrative nursing staff C stated he/she expected staff to respond to a door alarm. If there was a resident at the door he/she expected staff to redirect the resident. If staff did not see a resident he/she expected staff to go outside and look to see if a resident exited the building. Staff C stated staff were to reset the door alarm only after staff verified no residents exited the building. Staff C stated there was a system in place to prevent elopements, to include the use of wanderguards and there were elopement policies in place. Staff C stated direct care staff responded to the door alarm but failed to go outside to check if a resident went out the door. Staff C stated since the elopement incident occurred, the facility reeducated staff on elopements, and conducted an unannounced elopement drill. Staff C stated staff found resident #1 pushing resident #2 on the road. During an interview on 9/28/16 at 4:03 PM administrative nursing staff C stated he/she did not think resident #2 needed a wanderguard but since the resident #1 pushed him/her around in the wheelchair and if resident #1 were to remove his/her own wanderguard there would still be one on the wheelchair. During an interview on 9/28/16 at 5:13 PM administrative nursing staff C stated he/she held an unannounced mock elopement drill the following day. Staff C stated he/she and the administrator observed staff respond every time the door alarm was set off and planned to hold mock elopement drills throughout the first month following the incident and on a monthly basis thereafter. Review of the Alarms: Bed, Chair and Door Policy (Revised 1/14) revealed: All staff were responsible for physically checking on the resident when an alarm sounded. The facility failed to provide adequate supervision to prevent the elopement of resident #1, when the resident left the building without staff knowledge of such until staff found the resident walking along a street pushing resident #2 in a wheelchair. This deficient practice placed both residents in immediate jeopardy. The facility abated the immediate jeopardy on 9/29/16 when the facility held mandatory in-services re-educating staff on how to properly respond to door alarms and to visually check to see if any resident had exited the building. This deficient practice remains at the scope and severity of a D.

The facility had a census of 52 residents and 20 of those ambulated independently. Based on observation, interview and record review, the facility failed to provide a safe environment within the beauty shop when water temperatures in the shampoo sink measured 138 degrees Fahrenheit and a key to the locked beauty shop was in a slot next to the door and readily accessible to residents. This failure placed residents in immediate jeopardy related to the risk of significant burns from the hot water. The facility also failed to provide adequate supervision with mechanical lift transfers for 1 of 4 residents reviewed for accidents (#11) when one staff completed the mechanical lift transfer without assistance of another staff person. Findings included: - During initial tour on 4/4/16 at 10:15 a.m., the water temperature at the hair washing sink in the beauty shop measured 138 degrees Fahrenheit. Another survey staff confirmed the excessive temperature of 138 degrees with another thermometer. At the time of the observation the beauty shop was locked but staff kept the key in a slot near the door which was accessible to residents. On 4/4/16 at 10:37 a.m., Maintenance Staff Z used a facility thermometer to measure the water temperature at the hair washing sink in the beauty shop, and obtained a reading of 137 degrees Fahrenheit. During an interview on 4/4/16 at 10:36 a.m., Maintenance Staff Z reported the facility beauty shop had a water heater to heat water for the beauty shop only. According to Maintenance Staff Z, he/she checked water temperatures throughout the facility once weekly and recorded them on a log sheet. Although requested, Maintenance Staff Z could not provide evidence he/she periodically monitored the water temperature within the beauty shop. On 4/4/16 at 2:21 p.m., the water temperature at the hair washing sink in the beauty shop measured 138.4 degrees Fahrenheit. Maintenance Staff Z confirmed he/she did not lower the thermostat on the hot water heater, even though he/she knew the water tested 138 degrees Fahrenheit at 10:15 a.m. on the same day. Staff Z then entered the beauty shop, turned on the hot water faucet, and drained the tank of the hot water supply and lowered the thermostat. Staff Z remained in the beauty shop during this time. On 4/4/16 at 4:32 p.m., after giving the hot water heater time to refill, the water temperature at the sink in the beauty shop measured 113.3 degrees Fahrenheit. Review of water temperature logs for the time period from 11/4/15 to the current time revealed the following: 11/4/15 - 12/22/15: Maintenance staff recorded the water temperature in one room on each of four hallways once weekly. The documentation did not include the specific room in which staff checked the water temperature and included no evidence staff monitored water temperatures within the beauty shop. 12/23/15 - 3/13/16: No documentation of water temperatures obtained in the beauty shop. 3/14/16 - 3/30/16: Maintenance staff recorded weekly water temperature checks in the dining rooms on each hall. The logs included no evidence of monitoring of water temperatures in resident rooms and/or the beauty shop. 3/31/16 - 4/4/16: No documentation of monitoring of water temperatures in the beauty shop in this 5 day time period. According to the Domestic Water Temperature policy dated 3/16, brief exposure to hot water placed residents at substantial risk for burns. The policy directed staff to monitor water temperatures within bathroom, public bathroom and any other areas which had sinks, on a weekly basis or more often if conditions required. The facility directed staff to record the specific location of the temperatures, the date/time of the temperatures, and the name of the person who monitored the temperatures. The facility failed to provide a safe environment for 20 ambulatory residents who could access the beauty shop with the key next to the beauty shop door including when the water in the beauty shop shampoo sink measured 138 degrees Fahrenheit. This failure placed residents in immediate jeopardy related to the risk of significant burns from the hot water. The facility abated the immediate jeopardy on 4/8/16 at 10:20 AM when the facility provided education to all employees, including the hair stylist, regarding hot water temperatures, developed a plan for the monitoring of hot water throughout the facility, and revised their policy regarding the monitoring of water temperatures. This deficient practice remained at a scope and severity of an E. - Review of resident # 11's signed physician orders dated 11/30/15 revealed the following Diagnosis: [REDACTED]. Review of the significant change MDS (minimum data set) dated 6/8/15 revealed the resident had severe cognitive impairment. The resident required extensive assistance of one staff person for transfers. The resident had no functional limitation in range of motion in the upper or lower extremities. The resident used a walker and wheelchair. Review of the quarterly MDS dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of two or more staff for transfers. Review of the Fall CAA (care assessment area) dated 6/8/15 revealed the resident had a history of [REDACTED]. The resident's had impaired balance during transitions. The resident could not ask for help and he/she did not remember to wait for help. The resident had a new [DIAGNOSES REDACTED]. On 2/25/16 the resident ' s care plan was updated and revealed the resident required two staff participation with transfers. Staff used a sit-to-stand mechanical lift (transfer device) to transfer the resident if the residet could put his/her legs off the bed. If the resident could not get his/her legs off of his/her bed, staff were directed to use a total mechanical lift. The resident required a large sling for both the sit-to-stand and total lifts. Observation on 4/6/16 at 7:03 AM revealed the resident lay in bed with his/her eyes closed. Direct care staff Y asked the resident if he/she wanted to get up and he/she opened one eye and started to get up. Staff Y removed a rubber mat (used for prevention of falls) off of the floor and raised the resident's bed. Staff Y dressed the resident and then put a full lift sling under the resident. At 7:11 AM, staff Y pulled the curtain and left the resident's room to get a mechanical lift from the hallway. Staff Y rolled a full mechanical lift into the resident's room and positioned the resident's wheelchair in the middle of the room. Staff Y pushed the mechanical lift to the resident ' s bed side, attached the sling straps to the lift. Staff Y proceeded to raise the resident up from the bed and could not hold onto the resident as he/she moved the lift from the bed to where the wheelchair sat. The resident sat in the sling and moved side-to-side in large movements during the transfer. He/she turned the resident toward the arm of the sling while he/she held the back of the sling in his/her hands. When staff Y rotatedthe resident from side facing to forward facing, his/her feet became hung up on the arm of the sling and wheelchair. Staff Y reached over the wheelchair to position the resident's feet off of the seat of the wheelchair as he/she lowered the resident into the chair. Staff Y moved the lift and positioned the sling under the resident. During an interview with direct care staff Y on 4/6/16 at 11:13 AM revealed he/she provided care to residents based on a care plan located in the facility kiosk. He/she reported he/she received on the job training for use of the lifts by another aide employed by the facility. He/she used the full mechanical lift without another aide frequently. He/she stated he/she often used the sit-to-stand lift by his/herself as well. During an interview with licensed nursing staff D on 4/7/16 at approximately 11:00 AM revealed he/she monitored direct care staff and ensured care planned interventions were implemented by observation of residents/staff. He/she reported both lift types (sit-to-stand and full lift) were to be used by two direct care staff during each transfer. During an interview with administrative nursing staff F on 4/7/16 at 1:16 PM revealed he/she expected direct care staff to use two people when residents were transferred with both the sit-to-stand and the full lifts. Review of the facility policy dated September 2012, for use of mechanical lift revealed the lift was designed to be operated safely by one caregiver but dependent on the situation, facility policy, and based on the patient's condition, two direct care staff might be necessary for proper use of the lift. The facility failed to provide a safe environment for a resident related to improper use of the full mechanical lift.

The facility had a census of 55 residents. Ten residents lived on the SCU (special care unit) and the sample included four of those residents. Based on observation, interview and record review, the facility failed to provide 2 of 4 sampled residents with adequate supervision and assistive devices to prevent falls. (Residents #1 and #4) Resident #4 experienced multiple falls while he/she lived on the SCU. The facility failed to assess for causative factors of each fall and failed to develop/implement appropriate fall prevention strategies to prevent additional falls. Resident #4 experienced falls on two occasions that required treatment in the hospital emergency room and placement of staples to lacerations on the head. The facility failed to ensure the resident environment remained free from potential hazards when staff stored potentially harmful solutions/items in unlocked, accessible areas within the SCU. The facility failed to ensure 10 residents on the SCU received adequate supervision to prevent accidents and to maintain a safe environment. The facility failed to provide 2 of 4 sampled residents with adequate supervision and assistive devices to prevent falls. (Residents #1 and #4) Resident #4 experienced multiple falls while he/she lived on the SCU. The facility failed to assess for causative factors of each fall and failed to develop/implement appropriate fall prevention strategies to prevent additional falls. Resident #4 experienced falls on two occasions that required treatment in the hospital emergency room and placement of staples to lacerations on the head. Findings included: - Resident #4's clinical record included signed physician's orders [REDACTED]. The 4/13/15 Admission MDS identified resident #4 with long and short term memory problems, moderately impaired decision making abilities, physical and verbal behaviors directed towards others, the presence of wandering behaviors, the need for assistance of one staff member for bed mobility, the need for staff supervision for transfers and ambulation, no functional limitations in range of motion, use of a walker, history of fall in the month prior to admission, no falls since admission, and no skilled therapy or restorative therapy. The 6/8/15 Significant Change MDS (Minimum Data Set) identified resident #4 with long and short term memory problems, severely impaired decision making abilities, inattention and disorganized thinking that was always present, the presence of wandering behaviors, the need for extensive staff assistance with bed mobility, transfers, ambulation, and toilet use, impaired balance in all areas and only able to stabilize with staff assistance, no functional limitations in range of motion of the upper or lower extremities, use of a walker and wheelchair, and participation in skilled physical therapy. CAAs (Care Area Assessments) dated 6/10/15 included: Cognitive Loss: Resident has [DIAGNOSES REDACTED]. Radiology reports subdural hematoma, subacute to chronic right sided subdural hematoma. Impression on 5/29/15 was chronic subdural hematoma bilaterally (both sides of the brain) . Urinary Incontinence: .frequent episodes of incontinence and need for extensive assist with peri care and brief change.resident does not express need to toilet.toilet resident routinely.toilet when restless. Falls: : .History of falls. Resident is often unsteady when ambulating. Is unaware of safety needs. Unable to remember to use walker, or wait for assistance. Does reside on SCU for safety. Wears wanderguard for safety. Currently receives PT (physical therapy) to improve functioning, strength and endurance. Is not always receptive to therapy secondary to cognitive impairment. On 4/27/15 was observed on floor in kneeling position. On 5/18/15 on floor with laceration to back of head. On 5/19/15 documented that resident fell again. On 5/29/15 sent to hospital for evaluation of seizure -[DIAGNOSES REDACTED]. H&P 5/29/15 indicated subdural hematoma with chronic and acute subdural hemorrhage (loss of a large amount of blood in a short period of time). Resident #4's 6/12/15 care plan included: o ADLs (activities of daily living): Requires one person assist with walker and gait belt for ambulation, requires one staff participation with bathing, in able to turn/reposition self, requires 1 staff to dress.Requires 1 assist to use toilet.Resident requires one staff participation with gait belt for transfers. o Falls: Ensure that resident is wearing appropriate, well-fitting non skid footwear, monitor resident for significant change in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. To be assisted with all transfers and ambulation. Personal alarm when up in chair and bed alarm in bed used to alert staff to resident ' s movement and to assist staff in monitoring movement. Fall Risk assessments included the following: o 4/27/15: high risk for falls o 7/18/15: high risk for falls physician's order [REDACTED]. As requested. the facility provided a list of all resident #4's falls since admission on 4/13/15. That list included: o 4/27/15 fall at 4:30 p.m. in the TV room which resulted in a bruise to the right thigh A 4/27/15 Investigation tool described the fall on that date at 4:30 p.m. in which staff found resident #4 on the floor in the TV room with soiled pants down around his/her ankles. According to the document, the resident reported he/she tried to go to the bathroom and did not have a walker. The Fall Risk Evaluation Tool dated 4/27/15 remained entirely blank under the sections for post fall assessment and evaluation, and follow up teaching/training progress notes. In response to the fall, staff determined the root cause was a need to use the restroom and indicated on the Investigation document that staff would offer/suggest toileting on an every 3 hour basis in the future rather than every shift. Review of the 6/12/15 care plan revealed no reviews/revisions to the care plan following the fall to include interventions to toilet every three hours as indicated on the Investigation tool. The 6/12/15 care plan directed staff to toilet resident #4 upon arising, after breakfast, before and after meals and when restless. The care plan included no evidence of development/implementation of additional fall prevention interventions after the fall in an attempt to prevent additional falls. o 5/18/15 fall at 7:50 p.m. in the dining room which resulted in a laceration (wound to the skin) to the head and transfer/treatment to the emergency room for placement of 16 staples to the head. A 5/18/15 Investigation tool described the fall at 7:50 p.m. when staff found resident#4 laying on the floor of the SCU dining room, bleeding from the back of the head. Staff sent the resident to the local hospital for evaluation and treatment of [REDACTED]. Fall Risk Evaluation tools completed on 5/18/15 and 5/19/15 included .restless and frequently active. Unable to keep sitting for any length of time, requiring more 1:1 care. Sections of the tool related to post fall assessments and evaluation remained blank. The section of the form related to teaching/training also remained blank. Review of the fall documents revealed no evidence of assessment for causative factors of the fall, including assessment of the resident's restlessness and frequent activity as described in the fall risk evaluation tool. The facility determined a need to place personal alarms on resident #4 and obtained a therapy screen for strengthening and to improve his/her gait. According to the emergency room physician's documentation dated 5/18/15, the resident received a 9 cm (centimeter) laceration to the back of the head which required placement of 16 staples. o 5/19/15 fall at 1:40 p.m. in the TV room which resulted in a laceration to the head The clinical record lacked evidence of an investigation for the fall and no assessment for causative factors. o 6/22/15 fall at 7:00 a.m. which resulted in no injuries A 6/22/15 Investigation document described the witnessed fall at 7:00 a.m. when resident #4 attempted to sit in a chair and slipped off. Review of the documentation revealed no evidence of assessment for causative factors of the fall and then development/implementation of appropriate interventions to prevent additional falls. o 6/22/15 fall at 4:15 p.m. in the hallway which resulted in a laceration to the head The 6/22/15 Investigation document described resident #4's fall at 4:00 p.m. when staff witnessed the resident fall while walking in the hallway with a walker. The resident struck his/her head during the falls and required transportation to the hospital via ambulance. According to facility documentation, the resident required the placement of sutures to the head laceration. Documentation recorded on a Patient Information form from the hospital on [DATE] noted a laceration to the back of resident #4's head with placement of sutures. A 6/22/15 Fall Risk Evaluation completed after the fall noted resident #4's progressively worsening brain bleed and use of a walker, gait belt and stand by staff assistance to help reduce falls. Sections of the tool related to post fall assessments and evaluation remained blank. The section of the form related to teaching/training also remained blank. o 6/30/15 fall at 3:30 p.m. in the resident's room which resulted in no injuries The facility assessed for causative factors and determined resident #4 might have experienced the fall due to looking for food or fluids or a need to use the bathroom. The facility reviewed/revised the care plan to include use of a wheelchair only and to avoid use of the walker. o 7/1/15 fall at 10:37 p.m. in the resident's room which resulted in no injuries The investigation revealed a partially completed assessment for causative factors that included only that staff found the resident on the floor, he/she may have slid out of bed, and the reason was unknown due to advanced dementia. The facility reviewed/revised the care plan to include use of a video camera in his/her room in order to monitor the resident more closely. o 7/13/15 at 7:59 p.m. in the resident's room which resulted in no injuries The documentation revealed no evidence of assessment for causative factors and no evidence of development/implementation of additional interventions in an attempt to prevent additional falls. o 7/17/15 at 7:00 p.m. in the hallway which resulted in no injuries The clinical record lacked evidence of an investigation related to the fall and no evidence of review/revision of the care plan to include additional interventions in an attempt to prevent additional falls. o 7/18/15 at 11:05 p.m. (did not include injury vs. non-injury or location of fall) The clinical record revealed no evidence of assessment for causative factors and no evidence of development/implementation of additional interventions in an attempt to prevent additional falls. During an observation on 7/28/15 at 8:40 a.m., resident #4 sat in a wheelchair in the dining room. The resident did not have a personal alarm in place as directed by the care plan. Additional observations on 7/28/15 at 9:00 a.m., 10:00 a.m., 10:30 a.m. and 11:07 a.m. revealed no use of a personal alarm on the resident and his/her wheelchair as directed by the care plan. During these observations, the resident had obvious cognitive impairment and lacked the ability to understand verbal communication and to respond verbally in an appropriate manner. The resident made repeated attempts to stand from the wheelchair during these observations. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A reported resident #4 experienced frequent falls since admission to the facility. Upon review of the fall documentation, Nurse A confirmed the clinical record lacked evidence of assessment for causative factors after each of resident #4's falls since admission, and then evidence the facility developed/implemented appropriate fall prevention strategies after each fall in an attempt to prevent additional falls. According to Nurse A, resident #4 received quite a gash to the head in the 5/18/15 fall and required multiple staples to repair the wound. Nurse A also reported staff should ensure resident #4 had a personal alarm in place at all times as directed by the care plan. The facility's Fall Prevention and Management policy and procedure dated July 2015 directs staff to have a proactive approach as related to falls, and to identify a potential risk and take steps to mitigate the risk before actual harm occurs, and to attempt to predict what might cause a resident to fall and what action staff can take to prevent falls. The policy also directs staff to identify actual risk factors for falls and take steps to prevent the fall from occurring again. Using that approach, the policy directs staff to complete a post fall investigation to determine the root causes of the fall (root cause analysis), identify risk factors and take steps (interventions) to prevent the fall from happening again. The facility failed to provide resident #4 with adequate supervision and assistive devices to prevent falls. Resident #4 experienced multiple falls while he/she lived on the SCU. The facility failed to assess for causative factors of each fall and failed to develop/implement appropriate fall prevention strategies to prevent additional falls. Resident #4 experienced a fall on 5/18/15 that required treatment in the hospital emergency room and placement of 16 staples to a laceration on the head. The resident experienced an additional fall on 6/22/15 that required transfer to the emergency room and placement of sutures. - Resident #1's clinical record included signed physician's orders [REDACTED]. The 5/6/15 Significant Change MDS (Minimum Data Set) identified resident #1 with long and short term memory problems, moderately impaired decision making abilities, difficulty focusing attention, the need for extensive staff assistance for bed mobility and transfers, an inability to ambulate, unsteady balance when moving from seated to standing position and only able to stabilize with staff assistance, functional limitations in range of motion on one side of the lower extremities, no falls in the previous month, no falls in the 2-6 months prior to admission, use of antipsychotic medication daily, participation in occupational and physical therapy. CAAs (Care Area Assessments) completed on 5/12/15 included: Falls: .Has Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) that makes mobility difficult, since had hip fracture is requiring more assistance for mobility. Cognitive Loss/Dementia: .has impaired short term and long term memory, moderate impairment in daily decision making and inattention.is requiring more assistance due to recent decline after hip fracture. ADL (activities of daily living): .needs extensive assistance to total dependence needed for care.recent hip fracture and now is more totally dependent on staff for all cares. Falls: Has Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) that makes mobility difficult, since had hip fracture is requiring more assistance for mobility. No falls since readmission from hospital. Resident #1's 7/24/14 Care Plan included: Resident has impaired cognitive abilities related to dementia. Resident has an ADL self care performance deficit related to Parkinson's, recent left hip fracture and needing increased assistance with dressing/ambulation. (revised 4/29/15) Resident has healing fractured left hip. Reposition as necessary to prevent skin breakdown, prevent 90 degree flexion to prevent circulation problems. Resident is at risk for falls related to Parkinson's, recent fracture as evidenced by unaware of safety needs. Fall mat by bed. Position resident toward center of bed. Use body pillow to help maintain position. Bed and chair alarm used to alert staff to resident's movement and to assist staff in monitoring movement. Padded mat on floor by bed. (added 4/10/15 with revisions 4/29/15). As requested, the facility provided a list of each fall resident #1 experienced since 4/1/15. The list included the following: 4/9/15 at 7:45 p.m. described a fall in the resident's room in which the resident did not experience injury. According to the Investigation tool, staff found resident #1 sitting on the floor on his/her buttocks on the mat next to the bed with a walker nearby. Review of the fall investigation revealed no evidence of assessment for causative factors of the fall. After the fall, the facility updated the care plan with the 4/10/15 intervention to position the resident toward the center of the bed and use a body pillow to maintain position. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A confirmed the facility failed to assess for causative factors of all falls in an attempt to prevent additional falls. The facility's Fall Prevention and Management policy and procedure dated July 2015 directed staff to have a proactive approach as related to falls, and to identify a potential risk and take steps to mitigate the risk before actual harm occurred, and to attempt to predict what might cause a resident to fall and what action staff can take to prevent falls. The policy also directed staff to identify actual risk factors for falls and take steps to prevent the fall from occurring again. Using that approach, the policy directed staff to complete a post fall investigation to determine the root causes of the fall (root cause analysis), identify risk factors and take steps (interventions) to prevent the fall from happening again. The facility failed to provide resident #1 with adequate supervision to prevent falls. Resident #1 experienced a fall on 4/9/15. The facility failed to assess for causative factors of the fall in an attempt to prevent additional falls. - During an observation on 7/28/15 at 1:00 p.m., multiple residents of the SCU (Special Care Unit) moved about the dining room, hallway and area around the nurse's desk. At the time of the observation, the two staff members assigned to the unit were both in a room assisting another resident, and therefore the remaining residents lacked supervision. During this observation, resident #4 opened and closed drawers at the nurse's desk, handled the contents of the drawers, and moved items around on the desk top. The contents of the drawers included a tube of Tena Protective Cream with Zinc, a small bottle of nail polish, and a 16 ounce bottle of isopropyl alcohol. Each of the items contained warnings to keep out of reach of children and/or warning to notify the Poison Control Center if swallowed. During the same observation, a bag sat next to the hand sink in the area directly across from the nurse's desk. The bag contained multiple razors and razor blades and was within reach of residents in wheelchairs as well as residents who ambulated in the area. The facility's Environmental Guidelines policy dated August 2012 with a revision date of 12/14 included, Storage areas that contain hazardous materials must be locked. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A reported staff should make sure all potentially hazardous items were locked up in the SCU. The facility failed to ensure the resident environment remained free from potential hazards when staff stored potentially harmful solutions/items in unlocked, accessible areas within the SCU. - Initial tour of the facility's SCU (Special Care Unit) on 7/27/15 at 3:00 p.m. revealed 10 residents lived on the unit. The unit had a locked door for entrance/exit from the unit. Additional observations of the unit revealed the following: 7/28/15 from 7:55 a.m. - 8:13 a.m.: Residents on the SCU lacked supervision during this 18 minute time period. From 4-7 residents sat at tables in the dining room area and/or ambulated in the hallways without staff presence/supervision. At 8:13 a.m., Direct Care Staff C came out of a residents' room and reported he/she was the only staff member present on the unit at that time. According to Staff C, the other staff member working on the SCU that shift was currently off the unit bathing another resident. 7/28/15 from 8:15 a.m. - 8:26 a.m.: Residents on the SCU lacked supervision during this 11 minute time period. From 4-8 residents sat at the dining room table or ambulated in the area. Resident #3 walked around the Nurse's desk, touched items on the desk and moved them about, touched the computer screen/keyboard, and then ambulated into the kitchen area. A non-sampled resident removed leaves from a plant at the nurses's desk and placed the leaves in the trash. Another non-sampled resident picked up a styrofoam cup that contained an unknown liquid from the nurse's desk, looked in the cup, lifted it to his/her mouth, and then put the cup back on the desk without drinking from it. Other residents sat at tables in the dining room area. At 8:26 a.m., Direct Care Staff B returned to the unit with a non-sampled resident. According to Staff B, he/she took the resident over to another hall to give the resident a bath, and that left only one staff member on the unit with the remaining 9 residents. 7/28/15 from 8:28 a.m. - 8:38 a.m.: Residents on the SCU lacked staff supervision during this 10 minute time period. Resident #3 opened and closed kitchen cabinets and drawers and appeared to be in search of something. At 8:31 a.m., resident #3 found a carafe of coffee on the kitchen counter and opened/closed multiple cabinet drawers searching for something. The resident removed a glass from an upper cabinet and poured coffee from the carafe into the drinking glass, filling the glass full to the brim. Resident #3 then ambulated across the dining room to a chair located on the south side of the room, spilling coffee from the cup down the front of his/her blouse and slacks and onto the floor along the way. The resident sat down in the chair with the coffee, took a drink, and then noticed the spilled coffee on his/her clothing. Resident #3 attempted to wipe the coffee off his/her clothing with one hand while he/she held the glass of coffee with the other hand, which resulted in more coffee spilling from the cup. The resident then stood up from the chair and placed the glass that contained the coffee on the table in front of a non-sampled resident who sat at the table. That resident immediately picked up the glass of coffee and started drinking from the cup. Also during this time period, a very frail, unsteady appearing non-sampled resident stood up from a dining room chair, stated he/she was too cool and started to ambulate down the hallway with a very unsteady, wobbly gait. At 8:38 a.m., Direct Care Staff B came out of a resident room, saw the resident ambulating down the hallway, and immediately assisted the resident back to the dining room chair. At surveyor request, Direct Care Staff B then removed the glass of coffee from the non-sampled resident's hand and reported the resident should have only thickened fluids. 7/28/15 from 10:30 a.m. - 11:04 a.m.: Direct Care Staff B took a resident off the unit for a bath and only Direct Care Staff C remained on the unit with the residents. Staff C sat at the nurse's desk looking at a magazine while resident #2 and two other non-sampled residents sat in a TV room around the corner from the nurse's desk and not in visual control from the nurse's desk. One non-sampled resident repeatedly attempted to stand up from the recliner but lacked the strength to do so. At 10:30 a.m., Direct Care Staff C reported he/she didn't know where resident #4 was, and stated he/she was probably in his/her room. Staff C looked in the resident's room and did not find the resident. Another resident then approached Staff C and asked for assistance, so Staff C abandoned the search for resident #4. At 10:34 a.m., four minutes after the initial inquiry about resident #4's location, an unknown noise came from behind a closed door in a resident room. Staff C opened the door and found resident #4 in his/her wheelchair next to a bed, with his/her glasses off and a blanket pulled partially over his/her head. The resident's wheelchair was angled under the bed in such a way that the resident could not move it. Staff C assisted resident #4 out of the room and pushed the resident in the wheelchair to the nurse's desk. Staff C then sat in the chair at the nurse's station. The three previously mentioned residents remained seated in the TV room and out of sight of Direct Care Staff C. At 10:40 a.m., resident #2 stood from his/her seat in the TV room, and walked very unsteadily to the door of the TV room. From Staff C's seat at the nurse's station, he/she could not see resident #2 standing in the doorway. Resident #2 then pulled the door closed to the TV room walked into the area near the nurse's station. Staff C stood up and assisted resident #2 to a chair but did not open the door to the TV room in which two residents remained behind the closed door. Those two residents remained behind the closed door in the TV room for a total of 24 minutes until staff opened the door to the room at 11:04 a.m. at surveyor request. 7/28/15 at 12:20 p.m.: Resident #3 stood at the kitchen sink rinsing dishes. The resident used his/her hands to scrape food from the plates into the trash, rinsed dirty dishes with water and then placed them in cabinets and drawers with other clean items. At 12:24 p.m., resident #3 reached into the trash can and removed a piece of garlic toast and started to eat it. Direct Care Staff B and C and Activity Staff D sat at different dining room tables assisting resident with lunch and/or visiting with them. Although the three staff members sat in the same room, none supervised resident #3 ' s activities in the kitchen sink area. 7/28/15 from 12:57 p.m. - 1:20 p.m.: Direct Care Staff B and C assisted residents with care in a resident room, which left no one to supervise residents in the commons area of the SCU. During this 23 minute time period, resident #4's personal alarm sounded when the resident attempted to stand up from a seated position in the wheelchair. Another resident heard the alarm and went to resident #4's wheelchair to turn the alarm off. Neither Staff B or C stepped out of the room they were in to respond to the sounding alarm. At 1:16 p.m., a non-sampled resident lay in bed in his/her room. Resident #4 had his/her wheelchair next to the other resident's bed and repeatedly banged against the bed and surrounding furniture. Resident #4 appeared to attempt to turn the wheelchair around to leave the room, but lacked the ability to do so. o 7/28/15 at 8:00 p.m.: Direct Care Staff E sat at the nurses station looking at a smartphone while resident #4 sat next to Staff E in the wheelchair facing the wall of the laundry room. Two other non-sampled residents sat in chairs in the dining room, facing away from Staff E. One non-sampled resident sat alone in the TV room which was not in visual contact of the nurses ' station where Staff E sat. Resident #3 was not in any of the common areas of the unit. Suddenly, a resident to resident altercation between two non-sampled residents started when one resident noticed the other resident slept in resident #3's bed. A physical altercation ensued and Staff E jumped up and separated the residents. Staff E called for the licensed charge nurse to come to the unit. When the nurse arrived, he/she took the non-aggressive/victim resident to his/her room for assessment. The other aggressive resident left the commons area and remained unsupervised, in areas of the unit where no staff were present. At 8:15 p.m., two non-sampled residents sat at a dining room table awaiting snacks. One resident received a cup of vanilla pudding. The resident took bites of the pudding with a spoon, and then pushed the pudding cup and spoon to the other resident who started to eat it. Direct Care Staff E and H were in the dining room at the time but neither supervised the residents. Then, Staff H provided one of the residents with thickened juice. The resident took a drink, and then passed the glass of juice to the other resident who immediately started drinking it. In the time period from 8:00 p.m. - 8:40 p.m., resident #3 was not observed anywhere in the SCU. When asked about resident #3's location, Direct Care Staff E stated, (He/she's) probably in (his/her) bed or in (another resident's) room. Staff E made no effort to locate resident #3. At 8:40 p.m., survey staff went room to room in the SCU in an attempt to locate resident #3 who was eventually found in bed in another resident's room. A 4/14/14 sign posted on a closet door across from the Nurse's Desk in the SCU included: Protocol for Neighborhood.The quiet room door is to remain open AT ALL TIMES unless family members are visiting and wish for privacy. If residents are sitting in both quiet room and the dining, staff will need to position themselves as to be able to see both rooms. An additional document dated 5/20/15 from a Communication Meeting included, Both staff members on C Hall (SCU) must not be in the laundry room at the same time. One staff member must be out on the hall to be available to residents. During an interview on 7/28/15 at 11:12 a.m., Direct Care Staff B reported only one staff person remains on the unit when the other aide takes breaks or takes residents off the unit to bathe. According to Staff B, it's difficult for one staff person to supervise the other residents alone, particularly if the remaining staff person needs to be in a resident room with a resident. Staff B confirmed residents lack supervision during those times. During an interview on 7/28/15 at 8:00 p.m., Direct Care Staff E reported staffing on the SCU consisted of one or two staff all the time as well as a medication aide and licensed nurse that cover two units. Staff E reported there are many times when only one staff member is in the unit and is responsible for supervising all residents, and stated, We do ok. I don't think we need more than one sometimes. According to Staff E, staff on the SCU do not call for help from another unit when one staff member must leave the unit, and instead uses only one staff member to care for all residents on the SCU. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A reported staff of the SCU must provide supervision to residents at all times. According to Nurse A, SCU staff should coordinate baths and breaks with staff from other units to ensure coverage in order to adequately supervise SCU residents. The facility failed to adequately supervise 10 residents on the SCU on 7/28/15.

The facility had a census of 55 residents. Ten residents lived on the SCU (special care unit) and the sample included four of those residents. Based on observation, interview and record review, the facility failed to provide 2 of 4 sampled residents with adequate supervision and assistive devices to prevent falls. (Residents #1 and #4) Resident #4 experienced multiple falls while he/she lived on the SCU. The facility failed to assess for causative factors of each fall and failed to develop/implement appropriate fall prevention strategies to prevent additional falls. Resident #4 experienced falls on two occasions that required treatment in the hospital emergency room and placement of staples to lacerations on the head. The facility failed to ensure the resident environment remained free from potential hazards when staff stored potentially harmful solutions/items in unlocked, accessible areas within the SCU. The facility failed to ensure 10 residents on the SCU received adequate supervision to prevent accidents and to maintain a safe environment. The facility failed to provide 2 of 4 sampled residents with adequate supervision and assistive devices to prevent falls. (Residents #1 and #4) Resident #4 experienced multiple falls while he/she lived on the SCU. The facility failed to assess for causative factors of each fall and failed to develop/implement appropriate fall prevention strategies to prevent additional falls. Resident #4 experienced falls on two occasions that required treatment in the hospital emergency room and placement of staples to lacerations on the head. Findings included: - Resident #4's clinical record included signed physician's orders [REDACTED]. The 4/13/15 Admission MDS identified resident #4 with long and short term memory problems, moderately impaired decision making abilities, physical and verbal behaviors directed towards others, the presence of wandering behaviors, the need for assistance of one staff member for bed mobility, the need for staff supervision for transfers and ambulation, no functional limitations in range of motion, use of a walker, history of fall in the month prior to admission, no falls since admission, and no skilled therapy or restorative therapy. The 6/8/15 Significant Change MDS (Minimum Data Set) identified resident #4 with long and short term memory problems, severely impaired decision making abilities, inattention and disorganized thinking that was always present, the presence of wandering behaviors, the need for extensive staff assistance with bed mobility, transfers, ambulation, and toilet use, impaired balance in all areas and only able to stabilize with staff assistance, no functional limitations in range of motion of the upper or lower extremities, use of a walker and wheelchair, and participation in skilled physical therapy. CAAs (Care Area Assessments) dated 6/10/15 included: Cognitive Loss: Resident has [DIAGNOSES REDACTED]. Radiology reports subdural hematoma, subacute to chronic right sided subdural hematoma. Impression on 5/29/15 was chronic subdural hematoma bilaterally (both sides of the brain) Urinary Incontinence: frequent episodes of incontinence and need for extensive assist with peri care and brief change resident does not express need to toilet .toilet resident routinely toilet when restless . Falls: : .History of falls. Resident is often unsteady when ambulating. Is unaware of safety needs. Unable to remember to use walker, or wait for assistance. Does reside on SCU for safety. Wears wanderguard for safety. Currently receives PT (physical therapy) to improve functioning, strength and endurance. Is not always receptive to therapy secondary to cognitive impairment. On 4/27/15 was observed on floor in kneeling position. On 5/18/15 on floor with laceration to back of head. On 5/19/15 documented that resident fell again. On 5/29/15 sent to hospital for evaluation of seizure -[DIAGNOSES REDACTED]. H&P 5/29/15 indicated subdural hematoma with chronic and acute subdural hemorrhage (loss of a large amount of blood in a short period of time) Resident #4's 6/12/15 care plan included: o ADLs (activities of daily living): Requires one person assist with walker and gait belt for ambulation, requires one staff participation with bathing, in able to turn/reposition self, requires 1 staff to dress Requires 1 assist to use toilet .Resident requires one staff participation with gait belt for transfers . o Falls: Ensure that resident is wearing appropriate, well-fitting non skid footwear, monitor resident for significant change in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. To be assisted with all transfers and ambulation. Personal alarm when up in chair and bed alarm in bed used to alert staff to resident ' s movement and to assist staff in monitoring movement . Fall Risk assessments included the following: o 4/27/15: high risk for falls o 7/18/15: high risk for falls physician's order [REDACTED]. As requested. the facility provided a list of all resident #4's falls since admission on 4/13/15. That list included: o 4/27/15 fall at 4:30 p.m. in the TV room which resulted in a bruise to the right thigh A 4/27/15 Investigation tool described the fall on that date at 4:30 p.m. in which staff found resident #4 on the floor in the TV room with soiled pants down around his/her ankles. According to the document, the resident reported he/she tried to go to the bathroom and did not have a walker. The Fall Risk Evaluation Tool dated 4/27/15 remained entirely blank under the sections for post fall assessment and evaluation, and follow up teaching/training progress notes. In response to the fall, staff determined the root cause was a need to use the restroom and indicated on the Investigation document that staff would offer/suggest toileting on an every 3 hour basis in the future rather than every shift. Review of the 6/12/15 care plan revealed no reviews/revisions to the care plan following the fall to include interventions to toilet every three hours as indicated on the Investigation tool. The 6/12/15 care plan directed staff to toilet resident #4 upon arising, after breakfast, before and after meals and when restless. The care plan included no evidence of development/implementation of additional fall prevention interventions after the fall in an attempt to prevent additional falls. o 5/18/15 fall at 7:50 p.m. in the dining room which resulted in a laceration (wound to the skin) to the head and transfer/treatment to the emergency room for placement of 16 staples to the head. A 5/18/15 Investigation tool described the fall at 7:50 p.m. when staff found resident#4 laying on the floor of the SCU dining room, bleeding from the back of the head. Staff sent the resident to the local hospital for evaluation and treatment of [REDACTED]. Fall Risk Evaluation tools completed on 5/18/15 and 5/19/15 included .restless and frequently active. Unable to keep sitting for any length of time, requiring more 1:1 care. Sections of the tool related to post fall assessments and evaluation remained blank. The section of the form related to teaching/training also remained blank. Review of the fall documents revealed no evidence of assessment for causative factors of the fall, including assessment of the resident's restlessness and frequent activity as described in the fall risk evaluation tool. The facility determined a need to place personal alarms on resident #4 and obtained a therapy screen for strengthening and to improve his/her gait. According to the emergency room physician's documentation dated 5/18/15, the resident received a 9 cm (centimeter) laceration to the back of the head which required placement of 16 staples. o 5/19/15 fall at 1:40 p.m. in the TV room which resulted in a laceration to the head The clinical record lacked evidence of an investigation for the fall and no assessment for causative factors. o 6/22/15 fall at 7:00 a.m. which resulted in no injuries A 6/22/15 Investigation document described the witnessed fall at 7:00 a.m. when resident #4 attempted to sit in a chair and slipped off. Review of the documentation revealed no evidence of assessment for causative factors of the fall and then development/implementation of appropriate interventions to prevent additional falls. o 6/22/15 fall at 4:15 p.m. in the hallway which resulted in a laceration to the head The 6/22/15 Investigation document described resident #4's fall at 4:00 p.m. when staff witnessed the resident fall while walking in the hallway with a walker. The resident struck his/her head during the falls and required transportation to the hospital via ambulance. According to facility documentation, the resident required the placement of sutures to the head laceration. Documentation recorded on a Patient Information form from the hospital on [DATE] noted a laceration to the back of resident #4's head with placement of sutures. A 6/22/15 Fall Risk Evaluation completed after the fall noted resident #4's progressively worsening brain bleed and use of a walker, gait belt and stand by staff assistance to help reduce falls. Sections of the tool related to post fall assessments and evaluation remained blank. The section of the form related to teaching/training also remained blank. o 6/30/15 fall at 3:30 p.m. in the resident's room which resulted in no injuries The facility assessed for causative factors and determined resident #4 might have experienced the fall due to looking for food or fluids or a need to use the bathroom. The facility reviewed/revised the care plan to include use of a wheelchair only and to avoid use of the walker. o 7/1/15 fall at 10:37 p.m. in the resident's room which resulted in no injuries The investigation revealed a partially completed assessment for causative factors that included only that staff found the resident on the floor, he/she may have slid out of bed, and the reason was unknown due to advanced dementia. The facility reviewed/revised the care plan to include use of a video camera in his/her room in order to monitor the resident more closely. o 7/13/15 at 7:59 p.m. in the resident's room which resulted in no injuries The documentation revealed no evidence of assessment for causative factors and no evidence of development/implementation of additional interventions in an attempt to prevent additional falls. o 7/17/15 at 7:00 p.m. in the hallway which resulted in no injuries The clinical record lacked evidence of an investigation related to the fall and no evidence of review/revision of the care plan to include additional interventions in an attempt to prevent additional falls. o 7/18/15 at 11:05 p.m. (did not include injury vs. non-injury or location of fall) The clinical record revealed no evidence of assessment for causative factors and no evidence of development/implementation of additional interventions in an attempt to prevent additional falls. During an observation on 7/28/15 at 8:40 a.m., resident #4 sat in a wheelchair in the dining room. The resident did not have a personal alarm in place as directed by the care plan. Additional observations on 7/28/15 at 9:00 a.m., 10:00 a.m., 10:30 a.m. and 11:07 a.m. revealed no use of a personal alarm on the resident and his/her wheelchair as directed by the care plan. During these observations, the resident had obvious cognitive impairment and lacked the ability to understand verbal communication and to respond verbally in an appropriate manner. The resident made repeated attempts to stand from the wheelchair during these observations. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A reported resident #4 experienced frequent falls since admission to the facility. Upon review of the fall documentation, Nurse A confirmed the clinical record lacked evidence of assessment for causative factors after each of resident #4's falls since admission, and then evidence the facility developed/implemented appropriate fall prevention strategies after each fall in an attempt to prevent additional falls. According to Nurse A, resident #4 received quite a gash to the head in the 5/18/15 fall and required multiple staples to repair the wound. Nurse A also reported staff should ensure resident #4 had a personal alarm in place at all times as directed by the care plan. The facility's Fall Prevention and Management policy and procedure dated July 2015 directs staff to have a proactive approach as related to falls, and to identify a potential risk and take steps to mitigate the risk before actual harm occurs, and to attempt to predict what might cause a resident to fall and what action staff can take to prevent falls. The policy also directs staff to identify actual risk factors for falls and take steps to prevent the fall from occurring again. Using that approach, the policy directs staff to complete a post fall investigation to determine the root causes of the fall (root cause analysis), identify risk factors and take steps (interventions) to prevent the fall from happening again. The facility failed to provide resident #4 with adequate supervision and assistive devices to prevent falls. Resident #4 experienced multiple falls while he/she lived on the SCU. The facility failed to assess for causative factors of each fall and failed to develop/implement appropriate fall prevention strategies to prevent additional falls. Resident #4 experienced a fall on 5/18/15 that required treatment in the hospital emergency room and placement of 16 staples to a laceration on the head. The resident experienced an additional fall on 6/22/15 that required transfer to the emergency room and placement of sutures. - Resident #1's clinical record included signed physician's orders [REDACTED]. The 5/6/15 Significant Change MDS (Minimum Data Set) identified resident #1 with long and short term memory problems, moderately impaired decision making abilities, difficulty focusing attention, the need for extensive staff assistance for bed mobility and transfers, an inability to ambulate, unsteady balance when moving from seated to standing position and only able to stabilize with staff assistance, functional limitations in range of motion on one side of the lower extremities, no falls in the previous month, no falls in the 2-6 months prior to admission, use of antipsychotic medication daily, participation in occupational and physical therapy. CAAs (Care Area Assessments) completed on 5/12/15 included: Falls: .Has Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) that makes mobility difficult, since had hip fracture is requiring more assistance for mobility. Cognitive Loss/Dementia: has impaired short term and long term memory, moderate impairment in daily decision making and inattention is requiring more assistance due to recent decline after hip fracture ADL (activities of daily living): needs extensive assistance to total dependence needed for care recent hip fracture and now is more totally dependent on staff for all cares Falls: Has Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) that makes mobility difficult, since had hip fracture is requiring more assistance for mobility. No falls since readmission from hospital. Resident #1's 7/24/14 Care Plan included: Resident has impaired cognitive abilities related to dementia. Resident has an ADL self care performance deficit related to Parkinson's, recent left hip fracture and needing increased assistance with dressing/ambulation . (revised 4/29/15) Resident has healing fractured left hip. Reposition as necessary to prevent skin breakdown, prevent 90 degree flexion to prevent circulation problems. Resident is at risk for falls related to Parkinson's, recent fracture as evidenced by unaware of safety needs Fall mat by bed. Position resident toward center of bed. Use body pillow to help maintain position. Bed and chair alarm used to alert staff to resident's movement and to assist staff in monitoring movement. Padded mat on floor by bed. (added 4/10/15 with revisions 4/29/15) As requested, the facility provided a list of each fall resident #1 experienced since 4/1/15. The list included the following: 4/9/15 at 7:45 p.m. described a fall in the resident's room in which the resident did not experience injury. According to the Investigation tool, staff found resident #1 sitting on the floor on his/her buttocks on the mat next to the bed with a walker nearby. Review of the fall investigation revealed no evidence of assessment for causative factors of the fall. After the fall, the facility updated the care plan with the 4/10/15 intervention to position the resident toward the center of the bed and use a body pillow to maintain position. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A confirmed the facility failed to assess for causative factors of all falls in an attempt to prevent additional falls. The facility's Fall Prevention and Management policy and procedure dated July 2015 directed staff to have a proactive approach as related to falls, and to identify a potential risk and take steps to mitigate the risk before actual harm occurred, and to attempt to predict what might cause a resident to fall and what action staff can take to prevent falls. The policy also directed staff to identify actual risk factors for falls and take steps to prevent the fall from occurring again. Using that approach, the policy directed staff to complete a post fall investigation to determine the root causes of the fall (root cause analysis), identify risk factors and take steps (interventions) to prevent the fall from happening again. The facility failed to provide resident #1 with adequate supervision to prevent falls. Resident #1 experienced a fall on 4/9/15. The facility failed to assess for causative factors of the fall in an attempt to prevent additional falls. - During an observation on 7/28/15 at 1:00 p.m., multiple residents of the SCU (Special Care Unit) moved about the dining room, hallway and area around the nurse's desk. At the time of the observation, the two staff members assigned to the unit were both in a room assisting another resident, and therefore the remaining residents lacked supervision. During this observation, resident #4 opened and closed drawers at the nurse's desk, handled the contents of the drawers, and moved items around on the desk top. The contents of the drawers included a tube of Tena Protective Cream with Zinc, a small bottle of nail polish, and a 16 ounce bottle of isopropyl alcohol. Each of the items contained warnings to keep out of reach of children and/or warning to notify the Poison Control Center if swallowed. During the same observation, a bag sat next to the hand sink in the area directly across from the nurse's desk. The bag contained multiple razors and razor blades and was within reach of residents in wheelchairs as well as residents who ambulated in the area. The facility's Environmental Guidelines policy dated August 2012 with a revision date of 12/14 included, Storage areas that contain hazardous materials must be locked. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A reported staff should make sure all potentially hazardous items were locked up in the SCU. The facility failed to ensure the resident environment remained free from potential hazards when staff stored potentially harmful solutions/items in unlocked, accessible areas within the SCU. - Initial tour of the facility's SCU (Special Care Unit) on 7/27/15 at 3:00 p.m. revealed 10 residents lived on the unit. The unit had a locked door for entrance/exit from the unit. Additional observations of the unit revealed the following: 7/28/15 from 7:55 a.m. - 8:13 a.m.: Residents on the SCU lacked supervision during this 18 minute time period. From 4-7 residents sat at tables in the dining room area and/or ambulated in the hallways without staff presence/supervision. At 8:13 a.m., Direct Care Staff C came out of a residents' room and reported he/she was the only staff member present on the unit at that time. According to Staff C, the other staff member working on the SCU that shift was currently off the unit bathing another resident. 7/28/15 from 8:15 a.m. - 8:26 a.m.: Residents on the SCU lacked supervision during this 11 minute time period. From 4-8 residents sat at the dining room table or ambulated in the area. Resident #3 walked around the Nurse's desk, touched items on the desk and moved them about, touched the computer screen/keyboard, and then ambulated into the kitchen area. A non-sampled resident removed leaves from a plant at the nurses's desk and placed the leaves in the trash. Another non-sampled resident picked up a styrofoam cup that contained an unknown liquid from the nurse's desk, looked in the cup, lifted it to his/her mouth, and then put the cup back on the desk without drinking from it. Other residents sat at tables in the dining room area. At 8:26 a.m., Direct Care Staff B returned to the unit with a non-sampled resident. According to Staff B, he/she took the resident over to another hall to give the resident a bath, and that left only one staff member on the unit with the remaining 9 residents. 7/28/15 from 8:28 a.m. - 8:38 a.m.: Residents on the SCU lacked staff supervision during this 10 minute time period. Resident #3 opened and closed kitchen cabinets and drawers and appeared to be in search of something. At 8:31 a.m., resident #3 found a carafe of coffee on the kitchen counter and opened/closed multiple cabinet drawers searching for something. The resident removed a glass from an upper cabinet and poured coffee from the carafe into the drinking glass, filling the glass full to the brim. Resident #3 then ambulated across the dining room to a chair located on the south side of the room, spilling coffee from the cup down the front of his/her blouse and slacks and onto the floor along the way. The resident sat down in the chair with the coffee, took a drink, and then noticed the spilled coffee on his/her clothing. Resident #3 attempted to wipe the coffee off his/her clothing with one hand while he/she held the glass of coffee with the other hand, which resulted in more coffee spilling from the cup. The resident then stood up from the chair and placed the glass that contained the coffee on the table in front of a non-sampled resident who sat at the table. That resident immediately picked up the glass of coffee and started drinking from the cup. Also during this time period, a very frail, unsteady appearing non-sampled resident stood up from a dining room chair, stated he/she was too cool and started to ambulate down the hallway with a very unsteady, wobbly gait. At 8:38 a.m., Direct Care Staff B came out of a resident room, saw the resident ambulating down the hallway, and immediately assisted the resident back to the dining room chair. At surveyor request, Direct Care Staff B then removed the glass of coffee from the non-sampled resident's hand and reported the resident should have only thickened fluids. 7/28/15 from 10:30 a.m. - 11:04 a.m.: Direct Care Staff B took a resident off the unit for a bath and only Direct Care Staff C remained on the unit with the residents. Staff C sat at the nurse's desk looking at a magazine while resident #2 and two other non-sampled residents sat in a TV room around the corner from the nurse's desk and not in visual control from the nurse's desk. One non-sampled resident repeatedly attempted to stand up from the recliner but lacked the strength to do so. At 10:30 a.m., Direct Care Staff C reported he/she didn't know where resident #4 was, and stated he/she was probably in his/her room. Staff C looked in the resident's room and did not find the resident. Another resident then approached Staff C and asked for assistance, so Staff C abandoned the search for resident #4. At 10:34 a.m., four minutes after the initial inquiry about resident #4's location, an unknown noise came from behind a closed door in a resident room. Staff C opened the door and found resident #4 in his/her wheelchair next to a bed, with his/her glasses off and a blanket pulled partially over his/her head. The resident's wheelchair was angled under the bed in such a way that the resident could not move it. Staff C assisted resident #4 out of the room and pushed the resident in the wheelchair to the nurse's desk. Staff C then sat in the chair at the nurse's station. The three previously mentioned residents remained seated in the TV room and out of sight of Direct Care Staff C. At 10:40 a.m., resident #2 stood from his/her seat in the TV room, and walked very unsteadily to the door of the TV room. From Staff C's seat at the nurse's station, he/she could not see resident #2 standing in the doorway. Resident #2 then pulled the door closed to the TV room walked into the area near the nurse's station. Staff C stood up and assisted resident #2 to a chair but did not open the door to the TV room in which two residents remained behind the closed door. Those two residents remained behind the closed door in the TV room for a total of 24 minutes until staff opened the door to the room at 11:04 a.m. at surveyor request. 7/28/15 at 12:20 p.m.: Resident #3 stood at the kitchen sink rinsing dishes. The resident used his/her hands to scrape food from the plates into the trash, rinsed dirty dishes with water and then placed them in cabinets and drawers with other clean items. At 12:24 p.m., resident #3 reached into the trash can and removed a piece of garlic toast and started to eat it. Direct Care Staff B and C and Activity Staff D sat at different dining room tables assisting resident with lunch and/or visiting with them. Although the three staff members sat in the same room, none supervised resident #3 ' s activities in the kitchen sink area. 7/28/15 from 12:57 p.m. - 1:20 p.m.: Direct Care Staff B and C assisted residents with care in a resident room, which left no one to supervise residents in the commons area of the SCU. During this 23 minute time period, resident #4's personal alarm sounded when the resident attempted to stand up from a seated position in the wheelchair. Another resident heard the alarm and went to resident #4's wheelchair to turn the alarm off. Neither Staff B or C stepped out of the room they were in to respond to the sounding alarm. At 1:16 p.m., a non-sampled resident lay in bed in his/her room. Resident #4 had his/her wheelchair next to the other resident's bed and repeatedly banged against the bed and surrounding furniture. Resident #4 appeared to attempt to turn the wheelchair around to leave the room, but lacked the ability to do so. o 7/28/15 at 8:00 p.m.: Direct Care Staff E sat at the nurses station looking at a smartphone while resident #4 sat next to Staff E in the wheelchair facing the wall of the laundry room. Two other non-sampled residents sat in chairs in the dining room, facing away from Staff E. One non-sampled resident sat alone in the TV room which was not in visual contact of the nurses ' station where Staff E sat. Resident #3 was not in any of the common areas of the unit. Suddenly, a resident to resident altercation between two non-sampled residents started when one resident noticed the other resident slept in resident #3's bed. A physical altercation ensued and Staff E jumped up and separated the residents. Staff E called for the licensed charge nurse to come to the unit. When the nurse arrived, he/she took the non-aggressive/victim resident to his/her room for assessment. The other aggressive resident left the commons area and remained unsupervised, in areas of the unit where no staff were present. At 8:15 p.m., two non-sampled residents sat at a dining room table awaiting snacks. One resident received a cup of vanilla pudding. The resident took bites of the pudding with a spoon, and then pushed the pudding cup and spoon to the other resident who started to eat it. Direct Care Staff E and H were in the dining room at the time but neither supervised the residents. Then, Staff H provided one of the residents with thickened juice. The resident took a drink, and then passed the glass of juice to the other resident who immediately started drinking it. In the time period from 8:00 p.m. - 8:40 p.m., resident #3 was not observed anywhere in the SCU. When asked about resident #3's location, Direct Care Staff E stated, (He/she's) probably in (his/her) bed or in (another resident's) room. Staff E made no effort to locate resident #3. At 8:40 p.m., survey staff went room to room in the SCU in an attempt to locate resident #3 who was eventually found in bed in another resident's room. A 4/14/14 sign posted on a closet door across from the Nurse's Desk in the SCU included: Protocol for Neighborhood The quiet room door is to remain open AT ALL TIMES unless family members are visiting and wish for privacy. If residents are sitting in both quiet room and the dining, staff will need to position themselves as to be able to see both rooms. An additional document dated 5/20/15 from a Communication Meeting included, Both staff members on C Hall (SCU) must not be in the laundry room at the same time. One staff member must be out on the hall to be available to residents. During an interview on 7/28/15 at 11:12 a.m., Direct Care Staff B reported only one staff person remains on the unit when the other aide takes breaks or takes residents off the unit to bathe. According to Staff B, it's difficult for one staff person to supervise the other residents alone, particularly if the remaining staff person needs to be in a resident room with a resident. Staff B confirmed residents lack supervision during those times. During an interview on 7/28/15 at 8:00 p.m., Direct Care Staff E reported staffing on the SCU consisted of one or two staff all the time as well as a medication aide and licensed nurse that cover two units. Staff E reported there are many times when only one staff member is in the unit and is responsible for supervising all residents, and stated, We do ok. I don't think we need more than one sometimes. According to Staff E, staff on the SCU do not call for help from another unit when one staff member must leave the unit, and instead uses only one staff member to care for all residents on the SCU. During an interview on 8/10/15 at 11:00 a.m., Administrative Nurse A reported staff of the SCU must provide supervision to residents at all times. According to Nurse A, SCU staff should coordinate baths and breaks with staff from other units to ensure coverage in order to adequately supervise SCU residents. The facility failed to adequately supervise 10 residents on the SCU on 7/28/15.

The facility had a census of 58 residents. The facility identified a total of 32 residents as cognitively impaired and independently mobile. The facility reported two recent elopements from the facility. The sample included both residents involved in the elopements (Residents #1 and #2) as well as one resident with cognitive impairment and the ability to propel him/herself about the facility independently and therefore at risk for elopement (Resident #3). Based on observation, interview and record review, the facility failed to provide 2 of 3 sampled residents with adequate supervision to prevent elopements without staff knowledge as follows: o Resident #1 had multiple medical diagnoses, including a malignant neoplasm (cancerous tumor) of the brain and convulsions. The facility identified resident #1 as an elopement risk when he/she lived on the dementia unit. The resident had the ability to ambulate independently and had extremely limited verbal skills as related to his/her diagnoses. At the request of family and with approval of the physician, the facility moved resident #1 from the locked unit into a room in the main part of the facility. The facility failed to develop and implement appropriate elopement prevention interventions upon transfer to the main part of the facility. Resident #1 left the facility without staff knowledge on 1/15/15, and ambulated 0.12 miles from the facility before a staff member driving by saw the resident and informed the facility of the resident's location. This facility failure to develop/implement appropriate elopement prevention interventions upon transfer from the locked unit placed resident #1 in immediate jeopardy. o Resident #2 had no cognitive impairment and staff provided the resident with door codes so the resident could go outside alone to smoke at will. The facility had no system in place to know when resident #2 went outside or returned inside. On 2/7/15, resident #2 became upset and decided to leave the facility on his/her motorized scooter. The resident exited the building after entering the code on the door alarm, and used the scooter to leave the facility property. After a while, a staff member noticed resident #2 was not in the facility and wasn't outside, and so staff began to search for the resident. Staff found the resident sitting on his/her scooter, in the street, approximately 5 to 6 blocks from the facility (2/5 of a mile), unable to move the scooter forward or backward. The resident reported he/she was "lost and scared" when staff found him/her. Findings included: - Resident #1's computerized clinical record noted admission to the facility in April, 2014 with multiple medical diagnoses, including a malignant neoplasm (cancerous tumor) of the brain, anxiety and convulsions (seizures). Admission physician's orders [REDACTED]." The 4/1/14 Admission MDS (Minimum Data Set) identified resident #1 with unclear speech, "usually understood" by others, "usually understands" what others say, an inability to complete the BIMS (Brief Interview for Mental Status) due to an inability to speak, moderately impaired decision making abilities, no wandering behaviors, the ability to walk with supervision and assistance of one staff person, impaired balance in all areas, functional limitations in range of motion of upper and lower extremities on one side, and enrollment in Hospice services. The 12/18/14 Quarterly MDS identified resident #1 with an inability to complete the BIMS due to lack of verbalization abilities and also noted his/her moderately impaired decision making abilities. According to the assessment, resident #1 had the ability to ambulate without physical assistance of staff, did not use assistive devices of any kind, and had functional limitations in range of motion of the upper and lower extremities on one side. CAAs (Care Area Assessments) dated 4/11/14 noted an inability to complete the BIMS and described resident #1's moderately impaired decision making skills secondary to brain cancer. According the the Cognitive CAA, the resident had the ability to vocalize "yes" or make sounds but lacked the ability to speak other words. According to the ADL CAA, resident #1 required assistance with all care and had limitations of the right arm secondary to brain cancer. Resident #1's 12/18/14 care plan noted his/her "impaired thought processes" as evidenced by difficulty making decisions and expressing him/herself. According to the care plan, the resident had the ability to ambulate independently. The care plan noted resident #1's risk for falls related to right sided weakness, and directed staff to monitor the resident's ambulation and intervene as needed. The care plan also identified resident #1 as an elopement risk due to wandering behaviors and need for placement on the special care unit. The care plan directed staff to "check resident every 15 minutes" as an elopement prevention intervention. A 1/7/15 fax to resident #1's physician described the residents' family member's request to move him/her out of the special care unit. Staff asked the physician for an order to move resident #1 out of the special care unit to the "general floor." Later that same day, the physician faxed back an order to move resident #1 to the "general population." A Progress Note dated 1/8/15 described resident #1's transfer/move from the locked special care unit to a room on "B" hall. Review of the clinical record revealed no evidence of development/implementation of appropriate elopement prevention interventions upon transfer from the locked unit to B Hall even though the facility identified resident #1 as an elopement risk when he/she resided on the special care unit. Additional progress notes included: o 1/14/15: "Resident is frequently wandering facility ad lib, confused and needs redirected to the B hall dining room, and shown to (his/her) room multiple times per shift...." Then, on 1/15/15 at 3:10 p.m. and 3:15 p.m., the following Progress Notes described resident #1's elopement from the facility as follows: o 3:10 p.m.: "Resident found walking outside of facility approximately 1 block away in front of dentist ' s office, unattended. Returned to facility by CNA (certified nurse aide) without difficulty. No s/s (signs/symptoms) of injury, alert and pleasant and cooperative." o 3:15 p.m.: "Resident walked out front door, was a block from center and staff member seen (him/her) and brought (him/her) back to center...." On 1/16/15, the day after the elopement, the facility sent a fax to resident #1's physician which included, "Increased wandering habits exhibited. Resident experienced an episode elopement from facility , walked out the front door and down street to dentist office. No injury or complications. Was only out of facility for 5 minutes unsupervised. Do we need to consider return to special care unit?" The physician responded via fax on that same day with "Yes, cannot risk another elopement. Please return to Special Care Unit." During an observation no 2/9/15 at 3:30 p.m., resident #1 ambulated in C hallway accompanied by staff. The resident ambulated without assistive devices and had some impairment of one upper and one lower extremity. In response to a greeting and a simple question, Resident #1 made noises and said "yea" repeatedly. The resident lacked the ability to communicate his/her needs during that observation. During additional observations on 2/9/15 at 3:45 p.m., 2/10/15 at 8:15 a.m. and 2/10/15 at 11:20 a.m., resident #1 remained on the locked special care unit. During an observation on 2/10/15 at 7:30 a.m., the facility was located in a combination business/residential neighborhood, with a church across the street and slightly left/north of the facility, the back doors of several businesses directly across the street and a parking lot, and a combination of homes and businesses to the right/south of the facility. The dental office where staff found resident #1 on 1/15/15 was at the far end of the block to the right/south of the facility, and not within visualization of the facility. During an interview on 2/9/15 at 5:05 p.m., Direct Care Staff D reported he/she worked on B hall on the evening shift and cared for resident #1 when he/she lived on that hallway. According to Staff D, resident #1 wandered " everywhere" within the entire facility at will, and had the ability to ambulate from hallway to hallway without staff assistance and without assistive devices. Staff D reported all staff tried to monitor resident #1 as closely as they could, but due to the heavy workload on that hallway, stated, "I think (he/she) felt ignored because we couldn't pay much attention to (him/her)." Staff D also reported awareness that resident #1 was an elopement risk but denied knowledge of a certain time frame staff was to check on the resident. Staff D reported the evening shift on B Hall lacked the ability to monitor resident #1 due to the need to provide care to other residents. During an interview on 2/10/15 at 11:10 a.m., Licensed Nursing Staff E reported an awareness of resident #1's needs and care on the special care unit as well as during the brief time he/she lived on B Hall. Staff E reported a need to reorient resident #1 frequently when he/she lived on B hall and show the resident back to his/her room often because the resident got "lost" within the facility. Staff E denied knowledge of a specific time frame for monitoring resident #1's whereabouts as directed by the care plan. Staff E also had no knowledge of the development/implementation of any additional interventions to ensure resident #1's safety and prevent elopement upon transfer from the locked special care unit to B Hall. During an interview on 2/10/15 at 11:58 a.m., Administrative Nursing Staff A reported staff identified resident #1 as an elopement risk at the time of admission and subsequently placed him/her on the locked special care unit. According to Nurse A, staff should check residents identified as elopement risks every 15 minutes, including resident #1. Since resident #1 was already on every 15 minute checks at the time of transfer from the locked special care unit to B Hall, that intervention carried over to B Hall. Nurse A reported there were not any new elopement prevention interventions developed/implemented after resident #1's transfer from the special care unit to B hall in order to keep the resident safe and prevent elopement. Administrative Nurse A also reported resident #1 exited the building without staff knowledge on 1/15/15 at approximately 1:00 p.m. via the main entrance door at the front of the facility. According to Nurse A, video surveillance footage confirmed the door disarmed when visitors exited and then, approximately 60 seconds after the visitors left, resident #1 went through the door which failed to reactivate during that time period, and was then outside. Nurse A reported that a staff member who arrived at the facility 5 to 10 minutes later saw resident #1 standing in front of a dental office and returned the resident to the facility immediately. Nurse A reported that video footage showed resident #1 was out of the facility unsupervised a total of 10 minutes before the staff member returned him/her to the building. During a telephone interview on 2/10/15 at 1:45 p.m., Direct Care Staff C reported he/she drove down the street headed toward the facility on 1/15/15 at approximately 1:00 p.m. and saw resident #1 standing by vehicles parked near a dental office on the corner of the block. Staff C provided the name of the dental office and indicated that office was approximately 1 block from the facility. According to Staff C, he/she went and got resident #1 and returned him/her to the facility without incident. According to mapquest.com, the actual distance between the facility and the dental office where staff found resident #1 was 0.12 miles. The neighborhood was a combination business/residential area with steady vehicle traffic and a speed limit of 25 miles per hour. According to the facilities ' "Elopement" policy dated September 2012, "The center will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring and managing residents at risk for elopement. These include identifying environmental hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. All residents will be assessed for risk of elopement through the pre-admission and/or admission process and as needed. Each center will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan...." The facility failed to provide resident #1 with adequate supervision to prevent elopement. Resident #1 had moderately impaired decision making abilities and staff assessed the resident as an elopement risk. Resident #1 left the faciity on [DATE] via a disarmed front door and walked 0.12 miles through a residential/business area. A staff member drove to the facility and saw the resident standing by cars at a dental office 0.12 miles from the facility, and returned the resident to the facility. The resident remained out of the facility, unsupervised, for a total of 10 minutes. This facility failure placed resident #1 in immediate jeopardy of harm. The facility abated the immediate jeopardy on 2/13/15 by implementing the following measures: 1) Moved resident #1 back to the Special Care Unit (1/16/15) 2) Changed the codes to exit doors on the A and B halls (2/8/15) 3) Completed staff education on "neighborhood" safety and the admission policy for the Special Care Unit (2/11/15) 4) Changed the settings for the front door closure/re-arming of the magnetic lock from 60 seconds to 10 seconds. (2/13/15) 5) Implemented measures to ensure daily monitoring of all door alarms with documentation recorded on logs. 6). Placed motion alarms at the front exit door, at the exit doors on each hallway on which residents lived, and on the West exit by the family dining room. 7) Educated staff on motion alarm use, elopement procedures, door alarms, signage and residents identified as "at risk for elopement." on 2/13/15. 8) Identified all residents at risk for elopement within the facility and made a list of all those residents accessible so all staff were aware. 9) Posted signs at all exit doors advising visitors/families to be aware of residents in the area and to notify staff of any resident who exited the facility. 10) Updated the care plans for all residents identified as "at risk" for elopement. After abatement of the immediate jeopardy, the scope/severity of this deficient practice remains at a "D" level. - Resident #2's clinical record included an 8/1/14 Admission MDS (Minimum Data Set) that identified the resident with moderate cognitive impairment, independence with transfers and ambulation, no functional limitations in range of motion of upper or lower extremities, and use of a walker for ambulation. A 1/19/15 Quarterly MDS identified resident #2 with no cognitive impairment, no wandering behaviors, independence with transfers, need for supervision only for ambulation in the room and corridor, and no balance impairments. CAAs (Care Area Assessments) completed on 8/1/14 after the Admission MDS noted some mild cognitive impairment, independence with ambulation with the walker, and a history of falls with no falls since admission to the facility. The 1/28/15 Care Plan described resident #2 as "forgetful" and noted a risk for falls related to a history of a pelvic fracture. The care plan directed staff to "monitor resident frequently and intervene appropriately to anticipate resident needs and assist to prevent falls." A "Fall Risk Assessment" completed on 1/7/15 identified resident #2 as a "medium risk" for falls. Progress Notes included the following documentation related to resident #2's elopement from the facility without staff knowledge: o 2/7/15 at 1:50 p.m.: "Notified by CNA (certified nurse aide) resident had left property in electric wheelchair. Resident was seen at approximately 1345 (1:45 p.m.) by activity director leaving sidewalk at back of building and going north in street. Staff alerted by activity director when resident did not return in a few minutes. Resident located on South Parkway (name of street) near South Holly Drive (name of street). Returned to facility without incident by staff." o 2/7/15 at 10:23 p.m.: "Resident apologetic about leaving the facility earlier. States (he/she) was mad that someone took teddy bear out of (his/her) room. Denies wanting to leave again. Aware (he/she) remains on 15 minute checks." o 2/9/15 at 5:11 p.m.: "Talked to resident about leaving the center and (he/she) said (he/she) will never do it again, that (he/she) got lost and scared...." During an observation on 2/9/15 at 3:45 p.m., resident #2 ambulated in the hallway with a walker accompanied by an unknown direct care staff member. The staff member entered a code into the door alarm and opened the door. Both resident #2 and the staff member went outside and remained outside together while the resident smoked a cigarette. During an observation and interview on 2/10/15 at 8:05 a.m., resident #2 was alert and oriented and able to verbalize his/her needs and thoughts. Resident #2 reported he/she typically went outside several times daily to smoke and knew the code to the "back door." According to the resident, staff gave him/her the door code a few weeks after admission to the facility and, after he/she knew the code, staff did not typically know when the resident went outside or came back in. Resident #2 described getting angry on Saturday, February 7th, and he/she decided to leave the facility property. After entering the code for the door, resident #2 left the faciity on a motorized scooter via the West back door by the private dining room. Resident #2 reported he/she smoked a cigarette and then decided to leave the property. According to the resident, he/she drove the motorized scooter down the street "a long ways" and then became lost and scared. Resident #2 reported it felt like he/she was lost "forever" until staff found him/her. Resident #2 became tearful when recalling the incident, and stated, "I was just so lost. I didn't know what to do." During an interview on 2/9/15 at 5:05 p.m.. Direct Care Staff D reported the facility has 3 residents who go outside by themselves to smoke several times each day, including resident #2. According to Staff D, those residents know the codes to the doors and go in and out whenever they want. Staff D denied knowledge of any method of knowing when those residents were outside or inside, and stated "We just always think they will stay here and will be ok." During an interview on 2/10/14 at 10:40 a.m., nonsampled resident #4 reported he/she knew the door alarm codes "to a couple of doors" because he/she smoked and went outside without staff supervision at least 3 or 4 times every day. Resident #4 reported an ability to leave the facility via those exit doors "any time of the day or night" without staff knowledge and denied any requirement to notify staff when he/she went outside or came back in. During an interview on 2/10/15 at 11:10 a.m., Licensed Nurse E confirmed resident #2 knew the codes to the door alarms and regularly went outside to smoke by him/herself. According to Nurse E, the facility did not have any method of knowing when residents who smoked went outside or came back inside. Nurse E reported knowledge of resident #2's elopement on 2/7/15, and stated he/she heard the resident got lost "clear over on Holly Street" and didn't know how to get back to the facility. During an interview on 2/10/15 at 11:58 a.m., Administrative Nurse A confirmed resident #2 left the facility and the facility property without staff knowledge on 2/7/15. According to Nurse A, resident #2 knew the code to get out the door so he/she could smoke and, prior to 2/7/15, went outside regularly to smoke independently. Nurse A could not verbalize a facility system that allowed staff to know when residents such as resident #2 went outside and/or came back inside the facility. Nurse A also reported staff located resident #2 several blocks from the facility on 2/7/15 and returned him/her to the facility unharmed. During an interview on 2/10/15 at 1:05 p.m.. Activity Staff F reported he/she sat outside in a personal vehicle on the afternoon of 2/7/15. While sitting in that vehicle, he/she saw resident #2 come outside to smoke. After the resident finished smoking, Staff A reported the resident "headed north" on his/her motorized scooter, driving on the sidewalk for a short distance before exiting the sidewalk in order to drive the scooter down the street. Staff A said he/she watched resident #2 continue to head north on the scooter and thought the resident must plan to go around the block and then come back to the facility. Staff A then went inside the facility, did a few tasks, and then went out the front door of the facility to get the mail. Upon going out the front, Staff A reported he/she didn't see resident #2 on the scooter and decided something was wrong. Staff A then went inside and advised other staff he/she thought resident #2 left the property and staff needed to locate the resident. During an interview on 2/10/15 at 1:50 p.m., Direct Care Staff G reported he/she and another CNA (certified nurse aide) left the facility to search for resident #2 on the afternoon of 2/7/15. According to Staff G, they found the resident several blocks from the facility, sitting on his/her scooter in the street, unable to get out of a "dip" in the street. At the time staff located the resident, Staff G reported the resident was "crying and scared." Staff G then described the location where staff found resident #2 as "way up the street here to the north, then turn left at the stop sign and go west for 2 or 3 blocks. (He/she) was right by that little park up there, right where there's a big dip in the street." On 2/10/15 at 3:00 p.m., the distance from the back door of the facility where resident #2 exited to the "dip" in the street by the park where staff found resident #2 was mapped at 0.4 miles. The facility failed to have a system in place to ensure adequate supervision for residents who they allowed to leave the facility without staff knowledge and/or staff assistance. Resident #2 left the facility property without staff knowledge, traveled 0.4 miles on his/her motorized scooter, before he/she became lost and scared.

The facility had a census of 54 residents with 3 resident sampled for review. Based on interview and record review, the facility failed to ensure 1 of 3 residents sampled received necessary care and services (monitoring bowel function, assessment and timely treatment of [REDACTED]. Resident #1 experienced episodes of constipation and a fecal impaction with rectal bleeding that required hospitalization and suturing of a rectal/anal tear. Findings included: - Resident #1's admission MDS (minimum data set) assessment revealed the resident had severe cognitive impairment and was dependent on 1 person for toilet use and personal hygiene. According to the assessment, the resident had frequent bowel incontinence without constipation. The resident weighed 80 pounds and received nutrition and fluids via tube feedings. An 11/15/13 significant change MDS assessment revealed the resident had moderately impaired cognition and the resident was always incontinent of bowel and experienced constipation. The resident's weight was 79 pounds and continued to receive nutrition and fluids via tube feedings. Resident #1's 11/19/13 dehydration CAA (care area assessment) summary indicated the resident was at risk for dehydration due to being NPO (nothing by mouth). The CAA revealed the resident received all liquids via feeding tube and recently had constipation with an order on 11/16/13 for MOM (milk of magnesia, a laxative) 30 ml (milliliters) every other day. Review of resident #1's nursing care plan prior to 11/26/13 lacked identification of constipation as a problem, goals related to bowel function, and appropriate interventions to prevent constipation and/or fecal impaction. A faxed communication to the physician on 11/15/13 stated, "(resident #1) is going 4-5 days without having a bowel movement. May we have an order to give MOM 30 ml every other day per peg (feeding tube) to help get (his/her) bowels regular?" The physician response approved the order for the laxative. Review of resident #1's physician order [REDACTED]. Review of the November 2013 MAR (medication administration record) revealed the resident received MOM 30 ml per feeding tube on 11/16/13, 11/18/13 and 11/20/13. Review of resident #1's bowel record report revealed the resident had a medium/soft stool on 11/3/13. The report revealed the resident next bowel movement was on 11/7/13, 4 days later which was also medium/soft. The resident's next bowel movement was on 11/12/13, 5 days later, which was small and soft. On 11/16/13, 4 days later, the resident had small, loose, liquid bowel movement. The resident received MOM on 11/16/13. On 11/17/13, the resident had 2 small, soft bowel movements. On 11/18/13. resident #1 had a small and a medium, soft bowel movement. The resident received MOM on 11/18/13. On 11/19/13 the resident had 4 medium bowel movements, 2 were soft and 2 were described as hard. On 11/20/13 the resident had 2 small, one medium soft stool, and one large, hard bowel movement. The resident received a dose of MOM on 11/20/13. A witness statement dated 11/22/13 by direct care staff E revealed that on 11/20/13 at or around 2:00 or 2:15 p.m., resident #1's family asked for staff E to transfer the resident to bed. Staff E stated there was blood in the resident's incontinence brief and asked the resident's family to find a nurse. Direct care staff F entered the room as the charge nurse was "on break". Direct care staff stated that staff F pushed on the resident's stomach as staff E "stimulated" the resident so he/she could "push" the stool out. A witness statement by direct care staff F dated 11/26/13 revealed that resident #1's family met him/her in the hall and stated, his/her mother was "impacted and needed a nurse". Staff F thought the nurse assigned to the resident was at lunch, so he/she went to the room to assist staff E. According to the statement, staff E was gently stimulating the resident rectum to help the resident pass the stool. Staff F further stated that he/she told licensed nurse C what was going on and the nurse stated he/she knew and had given the resident MOM at noon. A nurses note on 11/20/13 at 2:30 p.m. by licensed nurse C stated, "CNA (certified nurse aide) reported to this charge nurse that the resident was very anxious and reaching for (private area). (He/she) further stated that the resident was full of soft stool and that (he/she) had removed a large amount from (him/her). (The CNA) also stated there was some blood in the stool but not a lot. Resident appeared less anxious and more comfortable at this time. No noted distress or signs/symptoms of discomfort, family at bedside. Will continue to monitor." Licensed nurse D's 11/26/13 witness statement revealed direct care staff G called him/her to the tub room on 11/20/13 at around 4:40 p.m. and the resident had blood dripping from the anus on to the floor. The resident had an incontinence brief saturated with blood. He/she notified the director of nursing services and the facility administrator. A nurses note written by administrative nurse B stated, "On 11/20/13 at approximately 5:00 p.m., I was called to the whirlpool room by (licensed nurse D). Resident having rectal bleeding, fresh bright red blood from rectal area." According to note, the resident's physician and family were notified and the facility transferred the resident to the hospital per ambulance. An Xray done after admission to the hospital on [DATE] revealed the resident had fecal material which appeared to be hardened in the left colon. Physician H's 11/22/13 progress note stated, "...admitted with rectal bleeding after digital removal of impacted feces. The patient was given Movi Prep (laxative) yesterday and had a significant bowel clean out. The patient continues with rectal bleeding and is status [REDACTED].Tube feeding on hold, will need further bowel prep for colonoscope." An operative report dated 11/22/13 indicated the resident had a diagnostic colonoscopy with anoscopy and direct suturing of the bleeding site....a bleeding site was found to be posterior 2 cm (centimeters) from the anal verge with evidence of active pumping bleeding site." Review of the clinical record revealed the resident returned tot he facility on 11/25/13. On 11/27/13, the resident had a reoccurrence of rectal bleeding and the facility transferred him/her to the emergency room . According to hospital progress notes, the resident had continued rectal bleeding and the family chose to provide comfort care only. During an interview on 11/26/13 at 3:07 p.m., direct care staff E stated that on 11/20/13, resident #1 was anxious and kept "grabbing" his/her private area. Staff E revealed the resident's family asked him/her to lay the resident in bed and check the incontinence brief. Direct care staff E stated the residents brief had blood in it and he/she asked the resident's family to get a nurse. Staff E stated that direct care staff F entered the room and stated the charge nurse was "at lunch". At that time, staff E stated that she held the residents buttock as staff F pushed on the resident's stomach. Staff E stated the stool the resident expelled was hard, clay consistency. An interview on 11/26/13 at 3:22 p.m. with direct care staff F revealed that he/she reported the incident to licensed nurse C and the nurse did not assess the resident, but indicated that he/she knew the resident had constipation and MOM had been given. During an interview on 11/26/13 at 2:33 p.m., licensed nurse J indicated that if residents did not have a bowel movement for 3 days, then the resident should be on a "bm list". The nurse should give the resident a laxative and monitor the resident for results. Licensed nurse J stated that each resident has orders for "as needed" laxatives and they do not follow any standing orders or bowel protocol to manage constipation. During an interview on 11/26/13 at 3:34 p.m., administrative nurse B stated that the facility does not have standing orders or a written bowel protocol. He/she stated that orders for laxatives are given as needed for the residents by their physicians. Nurse B stated that at the time when resident #1 developed problems with constipation, that the procedure was for the nurses to run a "bm list" daily with residents that went 3 or more days without a bowel movement. Nurse B verified that resident #1 did not have an order for [REDACTED].#1's brief, he/she should have stopped until a nurse was able to assess the resident. Administrative nurse B also verified that resident #1 had a fecal impaction with rectal bleeding on 11/20/13 that required hospitalization and suturing of the bleeding site. Attempts to interview physician H on 11/27/13 were unsuccessful. Attempts to interview physician K, Medical Director of the facility, on 11/27/13 were also unsuccessful. The facility failed to monitor bowel function, assess and treat resident #1's constipation in a timely manner. Resident #1 experienced episodes of constipation and had a fecal impaction with rectal bleeding that required hospitalization and suturing of the bleeding site.

The facility census totaled 53 residents with 20 in the sample with three of those residents sampled for weight loss. Based on observation, interview and record review the facility failed to monitor body weight, identify weight loss, and provide interventions in a timely manner to prevent avoidable severe weight loss for residents #2 and #43. Resident #2 lost 11 pounds in 60 days for a 7.9% weight loss. Resident #43 lost 15 pounds in 30 days for a total weight loss percentage of 9.5%. Findings included: - Review of resident #2's signed physician orders [REDACTED]. Review of the annual MDS (minimum data set) dated 7/29/13 revealed the resident unable to complete a BIMS (brief interview for mental status) and staff assessment done to include memory problems both short and long term, and modified independence with decision making. The resident had moderate depression per staff assessment. The resident required dependent on staff for eating, had no swallowing issues with any weight loss noted over last 180 days. Medications included an antidepressant and a diuretic (medication to promote the formation and excretion of urine). Review of the CAA (care area assessment) dated 8/1/13 revealed the following: Cognitive CAA- Resident had a [DIAGNOSES REDACTED]. This affected his/her ability to speak, but not express self. The resident had memory impairments and had trouble with processing things that are asked or said, but if given time and not rushed most of the time could answer simple yes or no questions. Nutrition CAA- The current diet ordered a pureed consistent carbohydrate. The resident ate an average of 12-87% of meals served. Resident's weight 132 pounds, 90 days ago 137 pounds and 180 days ago was 130 pounds. Receives one packet of benecal (high calorie food additive) with meals TID (three times a day). The resident frequently only ate applesauce at breakfast and potatoes at lunch, staff had been able to get the resident to eat soup if he/she won't eat the meal. The resident required assist to eat at meals, a few years ago the resident stopped trying to eat or drink on his/her own and was dependent on staff to do for him/her. No chewing difficulty observed. Review of the care plan with a date of 2/22/13 revealed alteration in nutrition related to diabetes, disease process. The resident had a history of [REDACTED]. Approaches included; serve diet as ordered by the physician, record food intake, spoon feed, snacks in the afternoon and bedtime. Benecal 1 packet TID. Sugar free 2cal 60 ml (milliliters) TID Review of the physician order [REDACTED]. Review of the resident weight record revealed the following weights indicating a severe weight loss of 11 pounds (7.9%) in 60 days: 7/7/13-138.8 7/13/13-121.8 reweight 3 times by 2 different staff 7/28/13-132.0 8/4/13- 134.2 8/11/13- 133.2 8/18/13 131.2 8/31/13- 127.8 9/1/13- 127.8 The clinical record lacked evidence the facility notified the resident's physician of his/her weight loss and failed to notify the dietician. Review of the snack record book on 9/4/13 revealed no sheets for September 2013 in book to track if the resident received snacks as care planned. The snack sheets for August 2013 revealed the resident did not receive snacks in the afternoon or bedtime as planned. Review of the latest dietician note dated 7/25/13 listed a weight of 136.2. The resident's weight decreased 2.6 pounds in one week and 4.4 pounds over 4 weeks with benecal TID with food for additional calories. The resident ate soups mostly at meals. Since resident often chose to eat soup, recommend preparing soup with half and half (half cream, half milk) and benecal when possible. Monitor intake, weights and lab work. The clinical record lacked documentation regarding the weight loss on 7/13/13. Review of the MAR (medication administration record) for August and September 2013 listed the benecal given TID and initialed by the nurse as given though no documentation of how much the resident received. The MAR indicated [REDACTED] Observation on 9/4/13 at 12:20 p.m. revealed the resident sat at the dining table assisted to eat the noon meal. The meal consisted of mashed potatoes and gravy, ground pork with gravy and beets. Observation made of direct care staff adding a tub of benecal to the potatoes and gravy. The resident took small bites of food when offered. 12:50 p.m. revealed the resident ate all the potatoes and gravy containing the benecal supplement, and drank all juice and water. The resident refused the meat letting it run out of his/her mouth. Observation on 9/5/13 at 8:30 a.m. revealed the resident sat in a wheelchair at the dining table. The resident had a plate of pureed food along with a cup of tomato soup. Observation of the direct care staff C revealed the benecal divided between the soup and the applesauce with the resident taking about 3/4 cup of soup and refusing the applesauce. Licensed nurse B confirmed he/she did not know how much benecal the resident actually received. On 9/4/13 at 11:10 a.m. direct care staff C reported the resident ate very little. The resident required assistance and took very small bites. If the resident did not like something he/she just let it run out of his/her mouth. The resident liked tomato soup so staff mixed Benical (high calorie food additive) to the soup and fed the resident the soup. The resident needed much coaxing to eat and would only take a small amount such as if he/she was served mashed potatoes and gravy with the meal that is all he/she would eat with the benical added to the potatoes. During an interview on 9/4/13 at 5:15 p.m. direct care staff O reported the resident usually refused everything but tomato soup at supper. The resident did not eat much but would always eat the soup. On 9/5/13 at 8:05 a.m. dietary staff O stated the direct care staff weigh all residents weekly and enter the weight into the kiosk. If the weight is 5 pounds or more different than the previous weight the kiosk cues the staff to reweigh the resident. Staff O stated he/she got the weights weekly off of the kiosk and reviewed the weights. If a resident has had significant weight loss the resident went on the list for the dietician to review during the monthly visit. If the dietician made recommendations the nursing staff notified the physician for orders. On 9/5/13 at 9:10 a.m. licensed nurse B stated the dietician saw all residents with weight loss monthly. The nurse reported he/she did not monitor the weights and would call the physician if the nurse happened to notice weight loss. The nurse stated he/she really did not have enough time to monitor the weights and unaware of what residents received snacks from the snack cart. During an interview on 9/5/13 at 12:00 p.m. administrative nurse H reported his/her expectations of the charge nurse included monitoring of the weekly weights. The nurses were responsible to report to the physician. Also the facility had weekly meetings to review weight and skin issues. The dietary manager also monitored the weights and made a list for the dietician to see those residents. Administrative nurse H was unaware the nurses did not chart on the amount of supplement taken as ordered. During an interview on 9/6/13 at 11:30 a.m. consultant HH reported visiting the facility 1 time a month to review weight losses, new admits, [DEVICE] (gastrostomy tube- a tube that goes directly into the stomach through the abdominal wall for feeding the resident) feeders, and residents with wounds. Consultant HH reported he/she received a list of residents with weight loss, from dietary staff L and those are the residents he/she reviewed during the visit. Consultant HH confirmed being unaware of the resident's weight loss from 138.8 to 121.8 in a week's time with the resident reweighed 3 times for accuracy of weight. Consultant HH reported he/she would give recommendations to nursing and follow-up the following visit. Consultant HH also reported he/she expected the facility to notify him/her anytime a resident had a significant weight loss. Snacks and nourishment supplements were a problem. Staff needed to monitor residents getting supplements. The program needed to be improved. By not monitoring and acting on significant weight losses Consultant HH stated the facility was putting the residents at risk for harm. On 9/6/13 at 1:30 p.m. an attempt made to contact the resident's physician with a voice message informing that the physician would be out of the office until the following week. On 9/11/13 at 9:53 a.m. a second attempt to notify the resident's physician with a voice message stating the physician was still out of the office. The voice message also stated not to leave a message and to call again when the physician was in the office. Review of the Policy named Monitoring Residents for Impaired Nutrition and Nutritional Risk; updated in August 2012 revealed: Purpose To identify and monitor residents with impaired nutrition or at nutritional risk 1. Residents with impaired nutrition or nutritional risk may be identified by nursing, dietary, and other members of the care plan team. 2. Nursing staff will notify the DDS (director of dietary services) of new signs of nutritional risk... The DDS should be notified of: B. Significant weight change, gain or loss, (3 pounds in one week, 5 percent in 1 month, 7.5 percent in three months, 10 percent in six months). 4. The DDS or designee will review resident weights monthly or more often to identify residents with significant weight loss/gain. Insidious weight loss or gain refers to the gradual unintended, progressive weight change over time. The facility failed to monitor weekly weights to identify significant weight loss, give between meal snacks as care planned and failed to monitor and document the amount of the ordered supplement consumed by the resident for resident #2 with a weight loss from 138.8 on 7/17/13 to 127.8 on 9/1/12 for a severe weight loss of 11 pounds (7.9%) in 60 days. - Review of resident # 43's physicians physical examination completed on 4-11-13 included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), and anxiety (a mental or emotional reaction of irrational fear). Review of the admission MDS (Minimum Data Set 3.0, a required assessment) dated 4-17-13 revealed the resident not able to answer interview questions for mental status. Assessment by staff revealed the resident had short and long term memory problem, with moderately impaired skills for daily decision making. It revealed the resident had physical and verbal behavioral symptoms directed at others which significantly interfered with the resident's care. It also revealed the resident rejected care and wandered daily. The MDS identified the resident needed supervision of 1 staff person for eating; the resident did not have a swallowing disorder, received a mechanically altered diet, and had not lost 5% of weight or 10% weight loss in the past 6 months. The resident received an antianxiety medication 5 out of the past 7 days. Review of the quarterly MDS dated [DATE] identified the resident with short and long term memory deficit, with moderately impaired decision making ability. The assessment revealed the resident had physical behaviors directed toward others, and daily rejection of care with wandering 1-3 of the past 7 days. It revealed the resident needed supervision of 1 staff for eating, had no swallowing problems and did not have weight loss of 5 % in the last month of 10% in the past 6 months. It also revealed the resident received an antidepressant 7 out of the past 7 days and antianxiety medications 2 of the past 7 days. Review of the Cognitive Loss/Dementia CAA (Care Area Assessment) dated 4-22-13 revealed the resident had [MEDICAL CONDITION] would sometimes respond to yes or no questions. Review of the nutritional status CAA revealed the resident received a regular diet with ground meat. The resident had natural teeth with some broken teeth but was able to eat and chew regular food, and served with ground meat. The resident was able to feed self with set up/cueing and encouragement to eat. Intake varied usually 50 - 75% with some 100%. According to a family member the resident had no recent weight loss. The resident did not express any hunger or thirst. Snacks offered in the afternoon and at bed time. The dietitian had not yet seen the resident. Staff L referred the resident to the dietician for admission assessment. Review of the care plan last revised on 7-19-13 revealed a potential for alteration on nutrition with interventions to encourage / cue to feed self, provide set up help, document meal and fluid intake, offer afternoon and bedtime snack, serve diet per doctors' orders, observe for chewing difficulty, provide substitute as needed. Staff encouraged fluids every 2 hours while awake. The care plan was not revised to include the dietitian recommendation for large portions. Review of the nutrition progress note dated 5-23-13 revealed the physician ordered a regular diet with ground meat as tolerated. Weight 157#, 1# gain in 1 week, offer alternate if not eating meal served. Review of the nutrition progress note dated 7-17-13 revealed the physician ordered a regular diet and could have ground meat. Average meal intake for all day was 98%; average fluid intake from meal times for all day was 1210 cc (cubic centimeter). Current weight was 143# and appeared to be up and down 2-3# in 1 week. Review of the nurses notes, physician orders [REDACTED]. The dietitian nutritional assessment dated [DATE] revealed the resident required 1725 calories to maintain weight and 2200 calories to gain weight. Review of the dietitian notes dated 7-25-13 recommended staff to "serve large portions at meals - offer ice cream, pudding or 2 cookies twice a day to prevent weight loss". Review of the resident's dietary card revealed staff were to serve a regular diet with ground meat, water, and juice. It failed to identify the large portions or snacks twice a day. Review of the resident weights revealed the following --- 4-14-13 --- 149.0 4-28-13 -- 152.0 5-13-13 - 155.6 5-18-13 --- 157.0 5-19-13 --- 156.2 6-1-13 --- 142.0 6-19-13 --- 148.0 6-29-13 -- 145.0 7-6-13 -- 145.0 7-13-13 --- 143 7-31-13 ---150.4 8-3-13 -- 148.0 8-11-13 -- 151.0 8-19-13 -- 147.8 8-25-13 -- 148.0 8-31-13 --- 148.6 The physician orders [REDACTED]. Review of the physician order [REDACTED]. Observation on 9-4-13 at 11:38 a.m. the resident received boiled potatoes, ground pork roast with gravy, seasoned beets, fruit cocktail, and creamy fruit salad. He/she also received a glass of orange juice and glass of ice water. The resident ate 95 % of meal, and drank all of his/her fluids. Observation on 9-4-13 at 5:16 p.m. the resident received a bowl of beef stew, piece of corn bread, and a lemon bar. At 5:41 the resident ate all of his/her stew and his/her lemon bar. During an interview on 9-4-13 at 5:45 p.m. direct care staff F reported the dietary staff were to pass snacks. Dietary staff came to the special care unit first and passed snacks, and then they went D hall. He/she also reported the resident usually ate well. Sometimes he/she would eat breakfast last and then eat lunch as well. He/she got peanut butter and jelly snacks in the afternoon, plus he/she would pick something off the snack cart. The resident usually chose a banana or vanilla ice-cream. On 9/5/13 at 8:05 a.m. dietary staff L stated the direct care staff weighed all residents weekly and entered the weight into the kiosk. If the weight was 5 pounds or more different from the previous weight the kiosk cued the staff to reweigh the resident. Staff L stated he/she got the weights weekly off of the kiosk and reviewed them. If a resident had significant weight loss the resident was then put on the list for the dietician to review during the monthly visit or sooner if needed. The physician was also notified of dietician's recommendation. During an interview on 9-5-13 at 3:37 p.m. administrative nursing staff H reported the department heads have a meeting weekly. Nurse H had not had it for the past week but would have it weekly. The staff goes through weights from the previous week if a resident had an extreme loss in the past week the staff brain storm on who needs supplements. Nurse H reported it was his/her responsibility to follow-up on supplement orders. Nurse H reported the facility would get a system in place to follow up on that. Review of the Policy named Monitoring Residents for Impaired Nutrition and Nutritional Risk; updated in August 2012 revealed: Purpose To identify and monitor residents with impaired nutrition or at nutritional risk 1. Residents with impaired nutrition or nutritional risk may be identified by nursing, dietary, and other members of the care plan team. 2. Nursing staff will notify the DDS (director of dietary services) of new signs of nutritional risk. The DDS should be notified of: B. Significant weight change, gain or loss, (3 pounds in one week, 5 percent in 1 month, 7.5 percent in three months, 10 percent in six months). 4. The DDS or designee will review resident weights monthly or more often to identify residents with significant weight loss/gain. Insidious weight loss or gain refers to the gradual unintended, progressive weight change over time. The facility failed to monitor weekly weights as planned to identify significant weight loss, and follow the dietician's recommendations for resident #43 with a weight loss from 157 pounds on 5/18/13 to 142 pounds for a severe weight loss of 15 pounds (9.5%) in less than 30 days.

The facility had a census of 52 residents with 20 residents selected for sample. Based on observation, interview and record review, the facility failed to provide four sampled residents with the necessary care and services (timely, thorough nursing assessments of the resident ' s condition) to attain or maintain the residents ' highest practicable physical well-being. Residents #36 and #37 experienced significant changes in their medical conditions, and nursing staff failed to adequately assess those changes in a timely manner. The medical conditions of both residents deteriorated prior to their transfer to the hospital. Residents #12 and #45 experienced a change in skin conditions and nursing failed to adequately assess those changes in a timely manner. Findings included: - A [DATE] signed physician's order [REDACTED]. The [DATE] Annual MDS (Minimum Data Set) identified resident #37 with moderately impaired decision making abilities and short and long term memory problems. CAAs (care area assessments) completed for resident #37 on [DATE] noted treatment with antibiotics for a urinary tract infection beginning on [DATE] and again on [DATE] for treatment of [REDACTED]. Resident #37 ' s [DATE] care plan directed staff to administer antibiotics as ordered, assess lung sounds, monitor the resident ' s temperature, and notify the physician as needed. Resident #37 ' s clinical record included orders faxed from the physician on [DATE]. Those orders directed staff to begin treatment with an antibiotic and a steroid. The facility provided a notarized witness statement written by Direct Care Staff BB on [DATE]. According to that statement, Staff BB noticed resident #37, " sweating extremely bad " at approximately 9:30 a.m. on [DATE], and immediately notified the charge nurse. A while later Staff BB checked on resident #37 again, and determined the resident had difficulty breathing and worsened sweating. Staff BB then told the charge nurse again about the deterioration in the resident ' s condition. Staff BB noted the charge nurse checked on the resident at approximately 10:40 a.m., approximately 1 hour and 10 minutes after staff first advised him/her of a change in the resident ' s condition. Staff called the ambulance to transport the resident to the hospital but the resident expired at the facility prior to arrival of the ambulance. The facility provided a notarized statement written by Licensed Nursing Staff FF (the charge nurse who worked that day) on [DATE]. According to that statement Staff FF noted increased respiratory rate and frothy sputum (saliva) and elevated the head of the bed. Staff FF reported the resident lacked vital signs at 11:05 a.m. and the EMS (emergency medical service) arrived at approximately 11:07 a.m. (Approximately 2.5 hours after the direct care staff informed the charge nurse of the resident ' s condition.) The facility provided a hand-written video log for [DATE]. According to the video log, Direct Care Staff BB assisted Resident #37 to his/her room at 9:58 a.m. and returned at 10:25 a.m. Direct Care Staff BB returned again with Nursing Staff FF at 10:28 a.m. and the EMS (emergency medical service) arrived at 11:09 a.m. (1 hour and 11 minutes after the staff took Resident #37 to his/her room). According to the facility's February 2005 procedure for, " Notification of Condition Change and Observation, " staff should assess the following areas for residents with a suspected illness/medical condition: o Observe the resident o Vital signs o Pain o Respiratory rate and status o Abdomen o Skin o Lung sounds o Bowel sounds o Palpate abdomen for tenderness o Warmth of skin Review of resident #37 ' s clinical record revealed no evidence of a thorough, timely nursing assessment as directed by facility policy after direct care staff first noted the resident with difficulty breathing and sweating. During an interview on [DATE] at 2:08 p.m., Direct Care Staff BB reported he/she worked [DATE], the day resident #37 became ill. According to Staff BB, he/she informed the charge nurse of the resident ' s change in condition at approximately 9:30 a.m.. Staff BB stated about 10:40 a.m. the resident " was gurgling ...you could hear (him/her). " Staff BB reported he/she told the charge nurse again and the nurse then went to assess the resident. Staff BB reported resident #37 passed away at approximately 11:00 a.m. that morning. On [DATE] at 11:45 a.m., Administrative Nurse B stated he/she had viewed the video log and the aides reported to the charge nurse when Resident #37 needed help. The nurse did not assess the resident ' s condition and appeared to, " not know what to do. " The facility failed to provide resident #37 with the necessary care and services (timely, thorough nursing assessments after a significant change in condition) to maintain the resident ' s highest practicable physical well-being. The resident became ill, direct care staff informed the charge nurse, and the charge nurse failed to assess the resident ' s condition in a timely manner. The resident ' s condition worsened further, direct care staff again informed the charge nurse, and the charge nurse then assessed the resident. The resident expired within 2 hours of the first onset of symptoms that were not assessed, and approximately 30 minutes after the resident ' s condition worsened again. - The [DATE] signed " physician's order [REDACTED]. The [DATE] Quarterly MDS (minimum data set) for Resident #12 revealed the resident ' s cognition severely impaired for daily decision making, at risk for pressure ulcers, but did not have any skin issues. The [DATE] Quarterly MDS for Resident #12 revealed no change in the cognition or skin assessment. The [DATE] CAA (care area assessment) revealed Resident #12 to be at risk for skin breakdown related to total dependence on staff for turning, repositioning and incontinence, however did not have any skin breakdown. The [DATE] care plan revealed Resident #12 had redness, irritation and gaulding in the peri-area. The care plan directed staff to check closely for skin breakdown, provide peri-care after incontinence and to reposition the resident every two hours. " Interdisciplinary Notes " on [DATE] at 9:45 a.m. revealed nursing staff documented the CNA/CMA (certified nurse aide/certified medication aide) reported Resident #12, " having red, [MEDICATION NAME], papular rash starting in the groin area a few days ago now spread to trunk/axillas (underarms). " Further review revealed an order on [DATE] for [MEDICATION NAME] powder (antifungal) to be applied twice daily until the rash healed. The facility faxed the physician on [DATE] to report a red, blotchy rash with blisters on Resident #12 ' s back, arms and peri-area. The clinical record revealed physician appointments for Resident #12 ' s on [DATE], [DATE] for rash to trunk and arms with medications ordered and again on [DATE] with a change in medication. The clinical record revealed communication with the physician on [DATE], [DATE], and [DATE] for the rash and blisters. The facility ' s [DATE] " Pressure Ulcer Practice Guidelines " included: " Initial wound assessments. If during the skin observation areas are identified, then the following documentation is recommended " : 1. Type of wound (pressure, surgical, skin tear, laceration ...burn, skin denudation, etc.); 2. Location (where on the body is it located; 3. Measurements (length, width, depth, and the presence location ...; 4. General appearance/presence of healing. Wound bed characteristics (color, type of tissue ...Description of wound edges and surrounding skin as appropriate ... " 5. Drainage: presence, type, color, odor, appearance and approximate amount of any exudate (drainage); 6. Presence or absences of signs of infections (redness/[DIAGNOSES REDACTED], induration/hardness, [MEDICAL CONDITION]/swelling, warmth, purulent and/or malodorous drainage.) 7. Pain: presence, nature, and frequency of, what alleviates, what aggravates. " Ongoing skin assessments. Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin conditions. Any abnormal findings/changes (redness, rashes, bruises, open areas, etc. should be documented in the Skin Module ... The center should have a system in place for daily observation of pressure ulcers/wounds (with accompanying documentation when a complication or change is identified) ... It is recommended the nursing progress notes reflect the nurse ' s observation and management of wounds from a shift to shift perspective and with each dressing change. At minimum, weekly documentation is recommended to provide a review of the pressure ulcer/wound. Weekly documentation should include the date observed and ... " , the same documentation as the initial wound assessment. Although the [DATE] and [DATE] Quarterly MDS revealed the resident at risk for pressure ulcers and the facility ' s guidelines directed staff to document the seven characteristics of the wound, the clinical record lacked ongoing skin assessments. The clinical record lacked nursing skin assessments, treatment records for the dressing applied to the left hand, and weekly bath skin observations by the aides as directed in the facility ' s Pressure Ulcer Practice Guidelines. Although the record contained multiple entries of physician notification related to Resident #12 ' s rash, a [DATE] " Interdisciplinary Assessments and Summary Reviews " (for the quarterly MDS) for Resident #12 revealed staff documented " No skin breakdown at this time " . Observation of Resident #12 on [DATE] at 12:50 p.m. revealed a gauze dressing/bandage to the resident ' s left hand/wrist and multiple areas of both arms with red circular marks and multiple areas of fluid filled blisters. Observation of Resident #12 on [DATE] at 8:05 a.m. revealed fluid filled blisters on all extremities, under his/her arms, on the chest and in his/her groin area. On [DATE] at 1:12 p.m., Direct Care staff CC applied a cream to the rash/blistered areas. Staff C stated the nursing staff applied the dressing to the left hand/wrist because of large weeping blisters. On [DATE] at 10:29 a.m., Licensed Nursing Staff E confirmed staff had treated the rash/blisters on Resident #12 for several months and it continued to worsen. Staff E verified staff changed the dressing to Resident #12 ' s when needed " to keep the area from draining on everything and keep it clean " . Staff E stated he/she tried to chart skin observations regularly in the Interdisciplinary Notes and that the CNA ' s should report to the charge nurse when they observe a change. On [DATE] at 7:47 a.m., Licensed Nursing Staff H stated nursing staff had relied on the nurse aides to alert the charge nurse if they " noticed something unusual " . Staff H stated they, " will now be doing skin assessments " weekly with each residents bath . The facility failed to provide Resident #12 with the necessary care and services (timely, thorough nursing assessments of the resident ' s condition) to attain or maintain the residents ' highest practicable physical well-being when the resident ' s skin conditions developed and continued to worsen. - The physician's orders [REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 (severe impairment); and had no skin concerns. The care plan dated [DATE] for the potential for impaired skin integrity related to cognitive impairment and incontinence revealed staff provided pericare; checked the skin with cares; reported any redness, irritation, or breakdown to the charge nurse; and assisted to turn/reposition the resident every 2 hours. The electronic bath record for [DATE] revealed the resident received a bath on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and lacked documentation of the bruises on the resident's hands. The electronic skin observation record for [DATE] revealed the lack of documentation of the bruises on the resident's hands. The Nurse's Notes dated [DATE] at 9:50 A.M. revealed the resident wandered in the hallway with a walker; was not easily redirected; when the certified nurses' aide (CNA's) attempted to redirect the resident the resident tried to pinched and scratch the staff; when staff attempted to toilet the resident she/he tried to pinch and hit. The resident was aggressive yesterday morning and hit at staff; staff caught the resident's hand causing a two centimeter skin tear; bruising present around the area this morning; staff would monitor behaviors and if no improvement would notify the provider. Chart review lacked documentation of a skin assessment. Observation on [DATE] at 2:54:10 P.M. revealed the resident had purple bruised marks on both hands. Observation on [DATE] at 7:12 A.M. revealed the resident had purple blotches anteriorly on both hands bilaterally. Staff interview on [DATE] at 1:12 P.M. with Direct Care Staff N stated the resident became combative with cares, and with toileting, hitting her/his hands on the table, and/or toilet. Staff interview on [DATE] at 1:20 P.M. with Licensed Nursing Staff D stated she/he noted the resident had bruising on both hand bilaterally and the CNA informed her/him the resident was combative with care and would strike out her/his hand, hitting either the table or toilet; she/he was not sure staff completed an incident report. Staff interview on [DATE] at 2:32 P.M. with Licensed Nursing Staff D stated staff completed skin assessments annually and the CNA, who provided baths, informed the nurse if there were any problems. Staff interview on [DATE] at 2:58 P.M. with Direct Care Staff L stated the resident could be combative with care and was not sure how the resident received the bruises on her/his hands; staff notified the charge nurse. She/he said if she/he saw any bruising on a resident, she/he notified the charge nurse. Staff interview on [DATE] at 7:05 A.M. with Direct Care Staff O if she/he saw bruising on a resident, she/he notified the charge nurse. Staff interview on [DATE] 7:30 A.M. with Direct Care Staff L stated there were no bath sheets; documentation of baths was done electronically and the electronic form only stated if a bath was given, but with no documentation of skin issues. Staff interview on [DATE] at 10:29 A.M. with Administrative Nursing Staff B stated the CNA providing the bath should inform the charge nurse of the bath so she/he could assess the resident's skin and was not sure if this was done. The facility expected the nursing staff to do skin checks weekly and fill out an incident report for skin bruising/tears. Staff interview on [DATE] at 10:36 A.M. with Licensed Nursing Staff G stated it was her/his expectation that when a CNA reported a bruise to the nurse, she/he would assess/investigate the concern and report to the director of nursing. The policy and procedure with a revised dated of ,[DATE] for Pressure Ulcer Practice Guidelines revealed weekly skin checks were recommended for all residents, especially those identified as "at risk". The facility failed to perform a skin assessment for the dependent resident with bruises. - The review of the admission MDS (minimum data set), for Resident #36, dated [DATE], revealed a BIMS (brief interview for mental status) with score of 2 (moderately impaired). The residents' ADL (activities of daily living) functional status revealed that the resident required extensive assist with all ADL' s and ,[DATE] person assist except in locomotion off the unit the resident was dependent. The MDS revealed that the resident received oxygen therapy. Review of the Cognitive loss/dementia, CAA (care area assessment) dated [DATE] revealed the resident had agitation and behaviors of spitting meds and food out. The care plan with a date of [DATE] included the following interventions: Provide copy of the DNR (do not resuscitate) to medical personnel as needed. On [DATE], the staff revised the care plan to include assist the resident to drink, give medication as ordered, and offer fluid frequently, every 2 hours. Review of the IDP (interdisciplinary progress) notes dated [DATE] at 4:00 p.m., Staff notified the physician the resident had some blood in the urine today and that the right lower leg had some purple discoloration, when the resident was put to bed after lunch the pedal pulses were faint and the feet were cold to touch. Staff revealed that the pink color returned after the resident was placed in bed and warmed. The facility failed to notify the family or director of nursing of the significant change in the resident's condition. The IDP notes indicated the physician was notified, but no route of notification was mentioned and no response from the Physician was documented. Staff failed to do further assessments regarding the purple discoloration of the feet. Review of the IDP notes on [DATE], at 7:30 p.m., revealed the resident had purple discoloration to his/her feet and they were cold to the touch. Staff reported that after applying a warm cloth to the feet and after elevating the feet and legs, the color returned to pink. The staff also reported that after an incontinent episode the resident had some spots of blood in the brief. The staff faxed Physician X at 8:00 p.m. on [DATE] and the physician's office was closed and received no reply. No further follow-up by phone call was made to inform the physician of the change in status. The fax was re-sent again on [DATE] at 9:16 a.m., the physician responded to the fax at 1:15 p.m. [DATE] with orders for stool for occult blood, But he/she failed to address the discoloration of the feet. Staff failed to follow up with the physician and failed to further assess the residents' discoloration of his/her feet. Again staff failed to notify the residents family, and the DNS (director of nursing services), of the change of condition in the residents hands and feet. Review of the IDP notes dated [DATE] at 10:30 a.m. revealed that the nurse was called to the hallway noting the resident's hands and feet were cold, and staff were unable to get an oxygen saturation reading. The vital signs included: blood pressure ,[DATE], pulse 57, respirations ,[DATE] rapid, with gasps. The nurse placed a call to the physician. Review of the IDP notes on [DATE] at 10:30 a.m. revealed that staff H placed a call to the family member to ask if he/she wanted the resident sent to the hospital. The resident's family member stated that he/she wanted a physician to look at him/her if it was an infection and or dehydration and or electrolyte imbalance. Staff documented on [DATE] at 10:45 a.m., that Physician X gave the order to send to the resident to the emergency room . At 10:50 a.m., the EMS (Emergency Medical Service) arrived at the facility. The staff documented " the resident was lethargic and unresponsive". At 11:15 a.m. the facility received a call from the hospital requesting to know if the resident's family had been told about the residents' condition. The nurse documented that Physician X believed that the resident had a blood clot in his leg that had traveled to the lung and requested that the family get to the hospital as soon as possible as the resident was not doing well. The staff took the spouse to the hospital to be with the resident. At 11:47 a.m. The hospital called with the report that the resident had died . On [DATE] at 2:43 p.m., an interview with direct care staff Y revealed that the resident's feet just began to mottle. The nurse sent a fax to the physician and the resident transferred to the hospital and died there. On [DATE] at 4:25 p.m., Administrative nursing staff B reported that the resident had some discoloration to the feet and legs that was present and then was gone after they warmed the extremities up but the nurse on duty faxed the physician at 8:00 p.m. and of course, no one was there. The nurse should have called to inform him/her of the incident. Staff B reported that on [DATE] he/she suggested sending the resident to the emergency room . However licensed Nursing staff H reported that the doctor would want to know what the family's wishes were since the resident had a DNR and had advanced directives, so staff B called the family member first and then the resident was sent to the emergency room per family members request and died there. Administrative nursing staff B planned to come in and do extensive training on the staff for assessments, and what to do in emergent situations. He/she confirmed that the staff should have called the physician. On [DATE] at 12:10 p.m., Administrative nursing staff B reported that upon a change in condition, staff should fill out the change in condition form, and notify the DNS, Physician, and the family he/she confirmed that staff failed to complete the change in condition form for this resident. On [DATE] at 10:41 a.m., an interview with Physician X confirmed the resident was terminal and was only moved to the facility to be close to the family and wife when he died . The resident had a [DIAGNOSES REDACTED]. Physician X revealed that nothing could have helped the resident. The Notification of Change in Resident Status Policy is to provide appropriate notification of change in resident's status. The Center will IMMEDIATELY inform the resident if appropriate and consult with the resident's physician and if known notify the resident's family or legal representative in the following cases; Significant change in the resident's physical, mental, psychosocial status. Procedure for Notification of Condition Change and Observation that the following steps be followed. 1. The Condition Change and Observation (Form #241) is used to collect pertinent data on the resident and his/her condition 5. Document in the IDP (interdisciplinary progress notes) 6. Put the completed form # 241 and put behind the IDP notes 8. Update the care plan Certified Nursing Assistant flow sheet and Medication Administration Record. The facility failed to further assess and monitor resident #36 ' s significant change in condition.

The facility reported a census of 56 residents with 24 residents sampled for review. Based on observation, record review, and interview, the facility failed to monitor one of one resident's bowel movements, which resulted in staff removing a fecal impaction (#10), and failed to monitor one [MEDICAL TREATMENT] resident's weights and blood pressures per physician orders. Findings included: - The 6-15-2009 face sheet [DIAGNOSES REDACTED]. Record review under LAB/XRAY revealed a 9-17-10 KUB (kidneys, ureter, bladder) xray done due to complaints of abdominal pain while an inpatient at a geropsyche unit, which identified a fecal impaction. The Quarterly 9-24-10 MDS (minimum data set), following the resident's hospitalization from [DATE] through 9-21-10, did not record a fecal impaction under H2 of the form. Review of the facility policy for bowel assessment, revised 9-2010, defined constipation as: "If the resident has two or fewer bowel movements during the seven day look back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements)", and defined fecal impaction as: "a large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that the resident is unable to move it from the rectum. Watery stool from higher in the bowel or irritation from the impaction may move around the mass and leak out, causing soiling...often a sign of fecal impaction." The 3-7-2011 Significant Change MDS (minimum data set) identified resident #10 with impaired cognition, extensive assist of one for personal hygiene, toileting, dressing, and on a scheduled pain regimen, received an antipsychotic, antidepressant, antianxiety, and diuretic the last 7 days of the lookback period. The 3-7-11 cognition CAAS (care area assessment summary) identified the resident resided on the special care unit. The ADL (activity of daily living) CAAS identified the resident required limited to extensive assistance with dressing, grooming, and toileting. The urinary incontinence CAAS identified the resident as unable to consistently and appropriately take self to bathroom secondary to cognitive impairment, BM's (bowel movements) not consistently documented every 3 days, however is poor historian and unable to remember when he/she had BM, does receive Senna S (laxative/stool softner) BID (two times per day). Interdisciplinary nursing progress notes dated 3-9-11 identified the resident with "times of resisting eating secondary to complaints of upset stomach." The 3-10-11 care plan for his/her polypoid tumor included observed for signs/symptoms of obstruction including distension, nausea, vomiting, pain, decreased appetite. The 3-10-11 care plan for constipation directed staff to report to change nurse if no bm (bowel movement) in 3 days. Review of the resident's BM log from 2-1-11 through 4-6-11 revealed the following information: * 2-1-11 - 2-11-11 no bowel movement (11 days) MOM (milk of magnesia) given 2 times on 2-2-11 and 2-6-11. Staff recorded no results following this intervention. * 2-17-11 - 2-20-11 no bowel movement and no laxative given * 2-24-11 - 3-10-11 no bowel movement and MOM given only 1 time on 2-26-11 with no results and no further intervention (14 days) * 3-19-11 - 3-26-11 no bowel movement and no laxative given Nurse's notes on 4-6-11 at 10:00 p.m. recorded the following, "Has been on the no BM list x 2 days...MOM given yesterday without [MEDICATION NAME] suppository given this evening and passed a large hard stool but stool remains in the lower colon...removed 3 large hard bm's digitally." The April 2011 MAR (medication administration sheet) revealed no MOM given until 4-12, 4-21, and 4-26-11 with no results charted. The 4-2011 Physician order sheet identified the following for resident #10: * encourage fluid intake * [MEDICATION NAME] 5 mg. (milligrams) at bedtime for dementia (started 2-15-11) * [MEDICATION NAME] 15 mg. at bedtime for depression (started 2-15-11) * [MEDICATION NAME] 20mg. daily for hypertension * Klonopin 0.5mg. every morning and 1 mg. at bedtime for anxiety (increased 2-15-11) * [MEDICATION NAME] 10/325 mg. TID (3 x per day) for pain * Senna S one tab BID (2 x per day) for constipation Review of the 12th Edition of the GERIATRIC DOSAGE HANDBOOK, Semla, Beizer, and Higbee, identified that [MEDICATION NAME], Klonopin and [MEDICATION NAME] all have a high potential for the side effect of constipation. The reference identified [MEDICATION NAME] with [MEDICATION NAME] tendencies including dry eyes, dry mouth, and dry stool. Observation of CNA (certified nurse's aide) Q and CMA (certified medication aide) M on 4-26-11 at 3:00 p.m. assisted the resident to the toilet. Both staff encouraged resident to "push it out, push hard." The resident did not void or pass stool. CMA M asked the resident if he/she wanted a snack or a drink and the resident refused stating, "My belly hurts, I just want to go back to bed." Observation on 4-27-11 at 7:20 a.m. revealed the resident sitting on the toilet with staff present. CMA M asked the resident if his/her bowels moved yesterday and the resident replied, "No, I about blew my head off trying." When staff cleansed the resident, a large amount of tan-colored fecal material remained on the periwipe. The aide commented, "(He/She) might be pushing liquid out around stool, so I will leave (him/her) set a little longer." Interview on 4-27-11 at 7:35 a.m. with CMA M confirmed the resident had difficulty with constipation, did not like to drink fluids very well, and required much encouragement. Interview with CNA GG on 4-27-11 at 9:30 a.m. confirmed the resident "did not know how to push right and is in a terrible state." Interview with licensed nurse FF on 4-27-11 at 4:00 p.m. reported that any nurse can pull the "NO BM List", confirmed if a resident had no bm in 3 days staff should administer MOM, if no bm 24 hours after that, staff administer a suppository, if no bm in the next 24 hours, staff give a Fleets enema and notify the physician. Observation on 4-28-11 at 8:45 a.m. revealed CNA GG asked resident how he/she felt, and the resident responded, "Not good" and rubbed his/her abdomen when asked if he/she had pain. Interview with administrative nurse A on 4-28-11 at 1:20 p.m. confirmed staff did not follow the facility policy and reported the 7-3 charge nurse should print off the NO BM list daily at the end of the shift. In summary, the facility failed to monitor resident #10, with a history of constipation and fecal impaction, on a consistent basis for regular bowel movements. The resident suffered a fecal impaction and staff digitally removed stool on 4-6-11. - On 4/7/11 the physician ordered [MEDICAL TREATMENT] on Monday, Wednesdays, and Fridays, Blood Pressure Parameters of 180/90 and Daily Weights for resident #65. The admission MDS (Minimum Data Set) assessment dated [DATE] identified resident #65 as alert and oriented, limited assistance required with bed mobility, transfers, walking, toileting, personal hygiene, [DIAGNOSES REDACTED]. The 4/22/11 health maintenance care plan for [MEDICAL TREATMENT] identified resident #65 required [MEDICAL TREATMENT] on Monday, Wednesdays, and Fridays and directed staff to encourage rest between meals when tired, allow for periods of rest between activities of daily living, and directed staff not to take blood pressures in left arm because of shunt. Observation on 4/27/11 at 7:20 am revealed nurse N assisted the resident to get ready for [MEDICAL TREATMENT]. Nurse N assisted the resident to his/her wheelchair and then pushed the resident in wheelchair to the dining room. Nurse N stated that the resident eats his/her breakfast and then the facility transports the resident to [MEDICAL TREATMENT] around 8:30 am. The April 2011 MAR (Medication Administration Record) revealed that staff should obtain daily weights before breakfast and before and after [MEDICAL TREATMENT]. The MAR indicated [REDACTED]. The nurses notes on 4/27/11 revealed a Blood Pressure of 203/87. The nurses notes did not identify if the facility had retaken the resident's blood pressure or followed the Blood Pressure Parameters of 180/90 for notifying the physician. During an interview with nurse N on 4/28/11 at 10:01 am she confirmed that staff should notify the physician when blood pressure is above the parameters. During an interview with administrative nurse A on 4/28/11 at 11:45 am she stated that the staff are supposed to weigh the resident before and after [MEDICAL TREATMENT] and confirmed that the record lacked the required documentation. In summary, the facility failed to provide the necessary care and services before and after [MEDICAL TREATMENT] for resident #65.

The facility had a census of 57 residents with 11 sampled for review. Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 sampled resident by failure to recognize and thoroughly address the resident's physical needs after sustaining a fall which resulted in hospitalization with a [DIAGNOSES REDACTED]. Findings included: - Resident #9's 12/30/10 CAAS (care area assessment summary) for cognition stated, "...been living alone until 12/12/10 when hospitalized . Doctor wrote in plan 'cerebral atrophy is noted with severe dementia' being found on floor initiated trip to emergency room and hospitalization . Was unable to tell daughter how (he/she) got on the floor and seemed surprised that (he/she) was on the floor. Is oriented to name....unaware of where (he/she) is." The resident CAAS for falls stated, "...two falls at home prior to admission to hospital. Daughter stated on 12/11/10 when she went to her (mother/father's) house (he/she) was on the floor. (He/she) stated the cat had gotten under the bed and was trying to get the cat. This explanation sounded logical to the daughter. The next day her (mother/father) was lying on the floor and did not even realize (he/she) was on the floor. This is when (he/she) was taken to the emergency room for evaluation and admitted ." The resident's 3/3/11 nursing care plan for potential for injury related to recent illness, cognitive impairment , poor balance, recent falls, and wandering included these interventions: * Transfer with one man assist, gait belt and walker. * Personal alarm on at all times. * To be assisted with all mobility off SCU (Special Care Unit). * Redirect when wandering, divert attention. * Observe when alone and assist. Interventions for concern of Essential Hypertension included the following interventions: * Report to doctor BP (blood pressure) out of perimeters. (Systolic 180 and diastolic 110) * Anti-hypertensives as ordered. BP prior to giving medication and document. Resident #9's 5/24/11 quarterly MDS (minimum data set) assessment revealed the resident had the ability to express ideas and usually understands others. The resident had a BIMS (brief interview for mental status) of 7 which indicated severe cognitive impairment and required limited assistance of 1 person for bed mobility, transfers, walking, and toilet use. He/she required the extensive assistance of 1 person for dressing, personal hygiene, and ate with supervision/set up assistance. Resident #9 had no functional limitations in range of motion and used a walker for mobility. [DIAGNOSES REDACTED]. Nurses notes on 5/27/11 at 0450 written by licensed nurse F stated, "Nurse aid notified charge nurse that (resident) was found on the floor beside (his/her) bed, full head to toe assessment was done, limited range of motion noted on (resident's) left side, no injury noted, (resident) was then assisted to (his/her) bed, was non responsive to verbal stimuli, little response to touch, VS (vital signs) T (temperature) 98.1, BP 208/103, P (pulse) 100, R (respirations) 22." At 0610 the nurse's note continued, "BP 198/100, (resident) non responsive, charge nurse transferred (resident) to emergency room by ambulance." A nurses note at 0820 by the same nurse stated, "emergency room notified charge nurse that (resident) had started vomiting, so they were keeping (him/her) for evaluation." At 0841, licensed nurse F documented notification of the resident's daughter in the nurses note and at 0842 the resident's attending physician had been notified by fax. Review of the nurses notes revealed the initial assessment of the resident after the fall occurred at 0450 with an acute change in the resident's VS/neurological status and transferred to the hospital at 0610, 1 hour and 20 minutes after the initial assessment. A neuro-check flow sheet (neurological assessment tool) initiated on 5/27/11 at 0500 documented the following assessment for resident #9: 0500: Temp: 98.1 Pulse: 103 Resp: 22 BP : 208/103 Not oriented Consciousness: lethargic Pupils: 3mm bilaterally with right pupil reactive and left pupil sluggish. Right arm/leg: weak Left arm/leg: strong. No spontaneous movement or speech. 0515: Temp: 98.1 Pulse: 100 BP: 198/100 No change in above documented neurological status. 0530: Temp: 97.8 Pulse: 101 BP: 192/101 No change in above documented neurological status. 0630: Hospital The resident's 5/27/11 0615 emergency nursing record indicated the resident's Chief Complaint/Injury: "fell out of bed, elevated BP, lethargy and change in mental status, possible head injury". ER (emergency room ) personnel documented VS of Temp: 97.6, P: 98, R: 22 BP: 236/113 with an oxygen saturation of 88% on room air. Initial physician orders [REDACTED]. Resident #9's CT of the head revealed the following indication: "Fall with possible head injury - vomiting, change in level of consciousness" with this impression: "Severe [MEDICAL CONDITION] with massive left-sided cerebral hemorrhage, largely intrparenchymal with additional components of subdural, subarachnoid, and intraventricular hemorrhage. There is substantial associated midline shift to the right." The admission physician's 5/27/11 History and Physical stated the chief complaint of altered mental status [REDACTED]. (He/she) was also noted to have elevated blood pressure of 200/120. A CT scan of the brain done showed a large [MEDICATION NAME] left hemisphere hemorrhage. The patient will be admitted for further management." Physical assessment revealed, "Pupils are equal and reactive to light, but sluggish....There is an obvious focal deficit on the right upper extremity and right lower extremity with zero muscle strength. Deep tendon reflex is increased. The patient does mobilize the left arm and left leg. The patient is not communicating verbally. (The patient) opens (his/her) eyes. The physician's plan stated, "Large left hemisphere [MEDICATION NAME] hemorrhage status [REDACTED]. Patient is a DNR (do not resuscitate). I spoke with family members....Advised the daughter to contact the rest of family members, as the patient has a very poor prognosis." A nurses note on 6/1/11 at 3:00pm stated, "received a call from (the hospital) that the (resident) had passed away". During an interview on 6/15/11 at 7:27am, licensed nurse F state he/she had been called to resident #9's room on 5/27/11 when nursing staff G found the resident on the floor. The resident had been assessed "head to toe" before moving to the bed and had no signs of injury. Nursing staff F stated he/she worked nights and didn't really know the resident's cognitive or physical abilities, however, nursing staff G told the nurse the resident would take him/herself to the bathroom unassisted. Licensed nurse F stated the resident's BP had been high the first time, his/her pupils were sluggish, had weakness on the right side and initiated neuro checks every 15 minutes. After transferring to bed, the resident opened his/her eyes, but did not respond to questions. After the third neuro check, the BP had not come down and noticed the sluggish pupils, licensed nurse F decided to transfer the resident to the hospital via ambulance. An interview on 6/15/11 at 9:46am with licensed nurse H revealed resident #9 had been oriented to self and significant others prior to the fall and would go to the bathroom unassisted. The resident would forget to use the call light and would go without assistance. During an interview on 6/15/11 at 11:30am administrative nursing staff B confirmed nursing staff should notify the physician of any acute changes in resident's condition or assessment findings immediately. He/she also confirmed the resident had a bed alarm on the bed that had been turned off on the night of the fall. In summary, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for resident #9 who after a fall had acute changes in vital signs and neurological status. Licensed nursing staff failed to immediately act or report these changes for 1 hour and 20 minutes when the facility transferred the resident to the hospital with a [DIAGNOSES REDACTED].