Every finding on record at Great Plains Post Acute

Based on interview and record review the facility failed to ensure Resident (R) 1 remained free from physical restraint when Certified Nurse Aide (CNA) M placed her hand over Resident (R) 1's mouth to keep her quiet. Findings include:- R1's Electronic Medical Record (EMR) revealed a diagnosis of a wedge compression fracture of the second and third lumbar vertebra (spine bones). R1's Significant Change Minimum Data Set (MDS), dated [DATE], recorded a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition; R1 was dependent upon staff for activities of daily living (ADL) including toileting, showers and mobility with a wheelchair. R1's Quarterly MDS, dated 04/21/2026, revealed a BIMS score of 13 indicating intact cognition. The MDS recorded no other changes from the previous MDS. R1's Care Plan, revised on 04/21/2026, indicated R1 had a behavior of yelling out, crying out, impatient, demanding, manipulative with staff and her family. R1 had limited physical mobility related to weakness and double amputee, mobility is independent with manual wheelchair. The facility's incident investigation, dated 05/21/2026, revealed R1 requested CNA M to transfer her back to bed after the evening dinner. CNA M told R1 that if she went back to bed, staff would not get her back up for the 04:30 PM smoke break. R1 decided to stay up in the wheelchair until after the smoke break and then asked CNA M to transfer her back to bed. R1 became impatient while waiting for assistance from CNA M and another staff member; R1 began hollering. CNA M placed her hand over R1's mouth and told her to be quiet. The facility implemented education for abuse, neglect and exploitation starting 05/21/2026. The investigation recorded Staff performed a skin assessment on R1 and noted no injury. The investigation lacked evidence that a psychosocial evaluation was completed. On 06/15/2026, R1 was no longer in the facility and was also unavailable for a telephone interview. On 06/15/2026 at 12:02 PM, an interview with Administrative Nurse E revealed she had received a call from the Social Service Designee explaining the report from R1 that a staff member had told her that if she laid down, she would not be back up for the next smoke break. Administrative Nurse E returned to the facility and immediately pulled CNA M from duty. Administrative Nurse F said that during her interview with CNA M, CNA M revealed that she had placed her hand over R1's mouth and told her to be quiet. CNA M was placed on suspension until the investigation was completed. The facility policy Abuse and Neglect- Clinical Protocol, dated 2005, abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caregiver, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the residents who resided in the facility and received their meals from the kitchen. Findings included:- On 04/20/26 at 08:35 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 4/20/26 at 09:00 AM, Dietary Staff BB verified the dietary manager was not certified. Staff BB stated the facility had two residents with a pureed diet and eight who required a mechanical soft diet. On 04/20/26 at 03:30 PM, Administrative Staff A verified Dietary Staff BB was not certified. Upon request, the facility failed to provide a Certified Dietary manager policy

Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 106 residents in the facility, who receive their meals from the kitchen. Findings included:- On 04/20/26 at 08:20 AM, during initial kitchen tour, observation revealed the following: One 12 inch by 12 inch air vent grill located above the tri compartment sink area was covered with a brownish greasy/sticky substance and gray fuzzy substance on all four edges of the vent, blowing directly on the cleaning area. Two 24 inch by 24 inch return air vent grill located above the cooking stove area covered had brownish grease/sticky substance and gray fuzzy substance blowing directly on the food preparation and stove cooking area. There was brownish splatter behind the cooking stove on the wall approximately four feet from the baseboard. The baseboard was covered with a brownish greasy substance along the floor area. One 36 inch by 36 inch ceiling mounted air conditioner had a brownish gray fuzzy substance that covered the metal grill. The wall behind the wash sink, and the wall behind the tri compartment sink, had two sections of plaster approximately 12 inches by 12 inches falling off the wall and there was plaster on the floor. On 04/20/26 at 11:00 AM, Dietary Staff BB verified the dirty register grill, the splatters/stains behind the stove, and the plaster coming off the wall. Dietary Staff BB verified she was unsure who was responsible for cleaning the vents and stated the plaster on the walls would be maintenance's responsibility to repair. On 04/21/26 at 12:10 PM, Administrative Staff B verified the dirty register grill, the splatters/stains behind the stove, the plaster coming off the wall, the air conditioner grill with brownish gray fuzz covering the grill. The facility's Maintenance Service policy, dated December 2009, documented maintenance services shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The Sanitation policy dated April 2026, documented the food service area shall be maintained in a clean and sanitary manner. All kitchen, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Food service staff would be trained to maintain cleanliness cleaning their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on observation, interview, and record review, the facility failed to resolve recurring issues reported by the Resident Council. Findings included: - A review of the facility's Resident Council Minutes, from 01/2025 to 03/2026, indicated recurring concerns related to call light response times. The Resident Council Minutes for January 2025, in which 18 residents attended, indicated concerns related to call lights not being answered in a timely manner, and documented the issue would be addressed by nursing administration. The Resident Council Minutes for February 2025, in which 18 residents attended, indicated concerns related to call lights not being answered in a timely manner, and documented the issue would be addressed by nursing administration. The Resident Council Minutes for March 2025, in which 17 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. The Resident Council Minutes for June 2025, in which 17 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. The Resident Council Minutes for September 2025, in which 18 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. The Resident Council Minutes for October 2025, in which 14 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. The Resident Council Minutes for November 2025, in which 14 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. The Resident Council Minutes for December 2025, in which 15 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. The Resident Council Minutes for January 2026, in which 20 residents attended, indicated concerns related to call lights not being answered in a timely manner, and documented the issue would be addressed by nursing administration. The Resident Council Minutes for February 2026, in which 20 residents attended, indicated concerns related to call lights not being answered in a timely manner and documented the issue would be addressed by nursing administration. On 04/22/26 at 10:47 AM, the Resident Council President, Resident (R) 87, reported ongoing concerns with call lights not being answered in a timely manner. R87 stated staff would answer the call lights and inform the residents they would return shortly, but that staff often did not return promptly. R87 said the call light wait time was between 30 minutes to an hour. R87 also stated that when agency staff were on duty, mostly on the second and night shift, longer call light wait times occurred. R87 also confirmed the Resident Council did not have information related to where the state agency reports and Ombudsman information were kept, and felt staff should address the residents by name and not use terms such as Momma and Grandma. On 04/22/26 at 12:32 PM, Activity Staff Z stated that the Resident Council concerns were reported to the department director. Activity Staff Z reported the facility had implemented a program with ancillary staff to assist with resident concerns of call light response, especially around meals and the smoking breaks of the residents. Activity Staff Z verified the lack of documentation informing the Resident Council where to locate the state agency reports and the Ombudsman information. On 04/22/26at 12:38 PM, Administrative Nurse D reported being invited to the Resident Council meeting with the previous facility administrator to address the call light response. The facility initiated a program to assist with call light response and concerns of the residents, especially around mealtimes and smoke breaks. Administrative Nurse D verified that the staff should address the residents by name and not by Momma or Grandma. The facility's Grievances/Complaints policy, dated 04/2017, documented that the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. All grievances, complaints, or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.

Based on observation, interview, and record review, the facility failed to implement alternative communication methods for one resident. Resident (R) 22, who spoke in Bengali.Finding included:- The Electronic Medical Record (EMR) for R22 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), pain, and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear.The Quarterly Minimum Data Set (MDS), dated [DATE], documented R93 had severely impaired cognition. R93 was dependent upon staff assistance for toileting, showers, dressing, and personal hygiene. R93 required substantial staff assistance for mobility and transfers. R93 made herself understood and had unclear speech.R93's 03/23/26 Care Plan included the following interventions:06/14/24- R93 required a translator to communicate and ensure the availability and functioning of adaptive communication equipment. Provide a translator as necessary to communicate with the resident. The translator is in Bengali. Staff should anticipate her needs.On 04/21/26 at 11:40 AM, Certified Nurse Aide (CNA) N and CNA O woke R93 up and told her it was time for lunch. CNA O assisted R93 to a seated position and placed a gait belt around her waist. R93 spoke to the CNAs in her native language and then started to hit them. R93 was transferred into her wheelchair. CNA N stated there was a therapy staff member who had a translator on her phone, but she did not work every day, so it was hit or miss if they were able to understand what R93 needed. CNA O stated R93 would point at different things she needed but did not always know what she needed.On 09/22/26 at 10:30 AM, Licensed Nurse (LN) H stated there were signs posted with translator phone numbers in the rooms of residents who spoke different languages that staff were supposed to use if they need to translate anything. LN H further stated that a family member would also assist if needed, but has said that with R93's dementia, sometimes she does not make sense with what she wants. On 04/22/26 at 10:45 AM, observation of a sign hanging in R93's room on the wall reminded staff that the room had audio and visual equipment, and underneath that sign was another sign with the translator's phone numbers, which was not visible to staff.On 04/22/26 at 01:00 PM, Administrative Nurse D stated that the sign should be accessible to staff so that they are aware there are ways to communicate with R93.The facility's Limited English Proficiency or Impairments in Communication policy, undated, documented that the facility would provide for communication with persons with impairments in communication. They would ensure adequate provisions are made for meeting the communication needs of patients, staff, and others. When a significant portion of the facility (25% or greater) understands one language that was not English, they would provide required written materials in that language to patients.

Based on observation, interview, and record review, the facility failed to provide consistent bathing services as care planned for one sampled resident, Resident (R) 107. Findings included:- The Electronic Medical Record (EMR) for R107 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and obesity (excessive body fat).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R107 had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. R107 was dependent upon staff assistance for toileting hygiene, dressing, mobility, and transfers. The MDS documented R107 did not receive showers during the assessment period.The Annual MDS, dated 04/01/26, documented R107 had a BIMS score of 13, indicating intact cognition. R107 was dependent upon staff assistance for lower body dressing, personal hygiene, and toileting hygiene. The MDS documented R107 did not receive showers during the assessment period.R107's Care Plan, dated 04/13/26, initiated on 03/06/25, documented she preferred showers on Tuesday, Thursday, and Saturday evenings. The care plan lacked documentation that R107 refused her showers.The February 2026 Bathing Record and Shower Sheets documented R107 did not receive a bath or shower for the following days: 02/08/26 - 02/23/26 (16 days)The EMR documented R107 refused her baths or showers on 02/12/26, 02/14/26, 02/17/26, and 02/19/2.The March 2026 Bathing Record and Shower Sheets documented R107 did not receive a bath or shower for the following days: 03/06/26 - 03/18/26 (13 days)The EMR documented R107 refused her baths or showers on 03/12/26.The April 2026 Bathing Record and Shower Sheets documented R107 did not receive a bath or shower for the following days: 04/10/26 - 04/21/26 (12 days)The EMR documented R107 refused her baths or showers on 04/11/26, 04/14/26, and 04/16/26.On 04/21/26 at 07:45 AM, R107's room had Enhanced barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) signage at the room entrance. Certified Nurse Aide (CNA) M and CNA O gowned but did not put on a gown. The CNAs removed R107's incontinence brief, and CNA M started to perform personal care to R107. R107 asked them if she needed to hold up her belly for them to wipe. CNA M stated, Yes, and after she held up her belly, CNA M wiped, and R107 said it hurt. R107 had a small open area under her belly. Licensed Nurse (LN) H was informed of the opening and came in, without a gown, and applied a cream to the area and stated she would get an order for treatment from the physician. The CNAs finished personal care with R107 and got up for breakfast. Upon leaving the room, observation revealed the EBP signage was no longer hanging by the door. CNA M stated she did not think she had to wear the EBP anymore as R107 no longer had a catheter (a tube inserted into the bladder to drain urine into a collection bag). CNA M stated that when R107 refused baths, she was reapproached and offered different times when she could get another bath.On 04/22/26 at 11:30 AM, Licensed Nurse H stated R107 often refused her baths, but they tried to give her a washcloth so that she could wash her face and arms. R107 was a check and change, so she expected staff to perform good peri care to help with her lack of bathing.On 04/22/6 at 01:00 PM, Administrative Nurse D stated she expected staff to continue to offer alternatives to baths or showers.The facility's Activities of Daily Living (ADL) Supporting policy, dated March 2018, documented residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). If a resident refused care and treatment, the resident or representative would be informed of the risks versus benefit of the care and treatment. The residents are offered alternative interventions to minimize decline.

Based on observation, interview, and record review, the facility failed to evaluate the effectiveness of fall interventions for two residents, Resident (R) 29 and R93, who had multiple falls, to prevent further falls. Findings included:- The Electronic Medical Record (EMR) for R29 documented diagnoses of cerebellar ataxia (impaired ability to coordinate movement), autistic disorder (a developmental disability caused by differences in the brain), weakness, restlessness, and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition).The Significant Change Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition. R29 was dependent upon staff assistance for all activities of daily living (ADLs). R29 had no upper or lower functional impairment and had two or more non-injury falls.The Quarterly MDS, dated 04/01/26, documented R29 had severely impaired cognition. R29 was dependent upon staff assistance for all adl's. R29 had no upper or lower functional impairment and had two or more non-injury falls. The Fall Risk Assessments, dated 08/08/25, 10/23/25, 11/22/25, 12/02/25, 03/03/2, 03/19/26, and 04/01/26 documented R29 was at a high risk for falls.R29's 04/13/26 Care Plan included the following interventions for R29:10/10/22- Be sure R29's call light is within reach and encourage them to use it for assistance as needed.11/17/22- Staff to leave and re-approach when R29 was restless during care. 03/14/23- Frequent checks when R29 was in his room unattended07/26/23- Identify if agitated with staff before providing care.03/07/25- Mattress on the floor on the side of the bed.03/30/25- wedges for positioning.06/10/25- Dycem (non-slip mat used for stabilization and gripping to prevent slipping) and place a touchpad call light near the edge of the bed.06/27/25- If he becomes agitated with cares, find a stopping point and complete tasks after he has calmed. If he was agitated, do not transfer.08/08/25- Provide frequent comfort and positioning checks when the resident was in his wheelchair.10/23/25- Ensure the bed brakes are always locked.03/18/26- Offer him an earlier rise time if he is awake.03/03/26-Ensure R29 was cleaned up after a haircut. The Fall Investigation, dated 08/08/25 at 06:00 PM, documented that R29 was in his chair by the nurse's station and was moving around in his chair when he fell over the right side of the chair. R29 was oriented to the person, was unable to explain what he was doing, and he did not sustain any injury. The Fall Investigation, dated 10/23/25 at 06:42 PM, documented R29 was on the floor next to the wall and bed. R29 was oriented to self and could not give a description of what he was doing. R29 was assessed and transferred by two staff members into his bed. Staff were educated regarding locking the bed.The Fall Investigation, dated 03/03/26 at 06:43 PM, documented at 11:55 AM, R29 had an unwitnessed fall with contusion. The nursing staff heard a loud thud and observed R29 on the floor in the hallway in front of the nurse's desk, lying on his stomach by his wheelchair. R29 was assessed and was unable to communicate the sequence of events as he is alert to self and non-verbal. The physician ordered the staff to send R29 to the emergency room for evaluation. The Nurse's Notes, dated 03/15/26 at 09:59 AM, documented the nurse and two support staff attempted to get R29 up. R29 was moaning and thrashing around so much that he got himself out of the sling before barely rising from the bed. R29 was lifted above the bed just far enough to fix the head of the bed wheels. The wheels were somehow flipped almost a full 180 degrees around from where they should have been. After the legs were flipped, R29 was placed back into bed without any further incident at this time. The EMR lacked an investigation regarding this incident.On 04/21/26 at 10:20 AM, Certified Nurse Aide (CNA) M, CNA N, and CNA O gowned and gloved. CNA O placed the sling for the full body mechanical lift (a specialized medical device designed to safely transfer individuals with limited mobility who are unable to bear any weight on their own) under R29. When asked why there were three staff to assist with the lift transfer, CNA N stated the R29 often got anxious and had fallen out of the sling during a transfer, so they felt more comfortable with an extra staff person to assist with the transfer. CNA M and CNA O attached the sling to the full lift and safely transferred him into his reclining wheelchair. R29 was not anxious or agitated during the transfer. CNA N stated they try to keep him out by the nurse's station because he has had falls where he fell over the side of the wheelchair. On 04/22/26 at 10:30 AM, Licensed Nurse (LN) H stated they keep R29 by the nurse's station so that they can keep an eye on him because he has periods of anxiousness and agitation. LN H stated R29 was better with staff that he was familiar with, and that one of his falls occurred after he had received a haircut, and there was some hair inside his shirt that bothered him.On 04/22/26 at 01:00 PM, Administrative Nurse D stated R29 had multiple falls after admission, but with consistent staffing, they know his routine. Administrative Nurse D was unaware that three staff were in the room when he was transferred, as he often got anxious with too much stimulation. Administrative Nurse D verified that the incident on 03/15/26 was a fall and should have been investigated. The facility's Falls and Fall Risk, Managing policy, dated 03/18, documented the staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remains relevant. - The Electronic Medical Record (EMR) for R93 documented diagnoses of weakness, unsteadiness on the feet, and hypertension (high blood pressure).The Annual Minimum Data Set (MDS), dated [DATE], documented R93 had a Brief Interview for Mental Status score (BIMS) of seven, indicating severely impaired cognition. R93 required partial staff assistance for toileting, personal hygiene, dressing, and supervision for transfers and mobility. R93 had no functional impairment and had two or more non-injury falls.The Quarterly MDS, dated 01/07/26, documented R93 had a BIMS score of eight, indicating moderately impaired cognition. R93 required supervision of staff for transfers, toileting, dressing, mobility, and ambulation. R93 had no functional impairment and had one non-injury fall.R93's Fall Risk Assessments, dated 08/23/25, 09/11/25, 11/25/25, and 03/10/26, indicate a high risk for falls.R93's 04/20/25 Care Plan included the following interventions:11/14/20-Be sure R93's call light is within reach and encourage her to use it for assistance as needed.12/27/23-Encourage R93 to use her call light and wait for assistance.02/08/25-Non-skid strips in front of the heater.02/22/25- Non-skid strips in front of toilet.03/09/25- No-skid strips to bathroom entryway.04/03/25- Anti-rollbacks to wheelchair.09/11/25- Care plan meeting with family regarding general decline and increased confusion.09/27/25- Do a 3-night sleep diary11/07/25- Dycem (non-slip mat used for stabilization and gripping to prevent slipping) in wheelchair.03/10/26- Maintenance to assess toilet seat04/10/26- Place a sign in the bathroom to use her call light. The Fall Investigation, dated 09/11/25 at 07:30 AM, documented R93 was on the floor in her room, she was fully clothed, had on shoes, and her coat. When staff asked her what she was doing, she stated, I don't know. R93 was assessed and had no injuries. The care plan intervention was to have a care plan meeting with the family regarding her decline. The Fall Investigation, dated 09/27/25 at 02:33 AM, documented R93 was observed on the floor of her room with the wheelchair behind her, and the brakes were unlocked. R92 did not complain of pain and denied she had hit her head. The care plan intervention was to complete a 3-day sleep diary. The EMR lacked documentation; a sleep diary was completed. The Fall Investigation, dated 10/06/25 at 05:53 AM, documented R93 yelled for assistance and was found on the floor with her feet pointing toward the air conditioner. She stated she leaned too far forward in her wheelchair and slid out. She was assessed for injuries and assisted back to her wheelchair. The immediate intervention was to place a bedside table in front of her when she wants to sit in front of the heater. The care plan lacked documentation of the intervention that was put into place.On 04/21/26 at 10:00 AM, R93 sat on the toilet in her bathroom. Certified Nurse Aide (CNA) M told her that if she was done, she needed to wipe herself. R93 finished, then stated she needed assistance to transfer into her wheelchair. CNA M stated that she could transfer herself. R93 used her left hand to grab the handrail on the wall and started to stand up. She was unsteady and tried to pull up her pants by herself. R92 turned to the right and started to sit down in the wheelchair and almost missed the seat. R93 tried to maneuver her wheelchair out of the small bathroom and asked CNA M for assistance and was told she could get herself to her bed. It took multiple tries to get out of the bathroom, but R93 was able to propel herself to her bed. She again asked CNA M to assist her and was told that we could transfer her. R93 stood up, pivoted to her left, and sat down on the edge of the bed. CNA M stated, You need to scoot back on the bed and take R93's legs and swung them up onto the bed. R93 asked to be covered up, and CNA M covered her with a blanket.On 04/21/26 at 10:15 AM, CNA M stated R93 was supervised with toileting and transfers, and that R93 only asked for assistance because I was in the room watching. CNA M stated she had multiple falls, and there are non-skid strips in the room to prevent her falls.On 04/22/26 at 12:26 PM. Licensed Nurse (LN) H stated R93 was a stand-by assist for falls. Staff are to encourage her to do things for herself, but if she needs assistance, they should help her. LN H verified that a 3-night sleep study had not been completed as per the care plan.On 04/22/26 at 01:00 PM, Administrative Nurse D stated she expected her staff to assist R93 if she requested it. Administrative Nurse D stated the sleep study should have been completed and verified that a family conference was not an appropriate care plan intervention for the resident.The facility's Falls and Fall Risk, Managing policy, dated 03/18, documented the staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remains relevant.

Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R)41 and R13 post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. Findings included:- R41's Electronic Medical Record (EMR) documented diagnoses of PTSD, dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R41's Quarterly Minimum Data Set, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the resident was dependent on activities of daily living (ADLs). The MDS further documented R41 had no physical behaviors. R41's Care Plan, dated 01/13/26, documented R41 had behavioral symptoms including yelling at staff, hitting, refusal of medications and treatment, refusal of meals, and sexually inappropriate behavior. The care plan documented that R41 had PTSD, bipolar and mood disorder and directed staff to administer medications as physician ordered, notify the physician of inappropriate behavior, and provide R41 to express herself. The care plan lacked what the resident's PTSD triggers are and what staff were to do to manage her triggers. The Physician's Order, dated 11/12/25, directed staff to administer Latuda (antipsychotic medication) 20 milligram (mg), one tablet at bedtime for schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). A Nurse's Notes, dated 04/16/26 at 00:00 AM, documented R41 had history of mental and behavioral disorders. The note documented R41 was upset and stated she recently had a care plan meeting, and they stated she had a diagnosis of schizophrenia and underlying mental health conditions. R41 denied any signs or symptoms of depression or anxiety. R41's EMR lacked evidence of a trauma informed care assessment. On 04/21/26 at 03:30 PM, Administrative Nurse D verified resident-specific interventions had not been developed to address R41's PTSD diagnosis on admission to the facility on [DATE]. The facility's Behavioral Health Services policy, dated February 2019, documented the facility would provide all residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services are provided to residents as needed, as part of the interdisciplinary, person-centered approach. Safety training, regarding behavioral health services includes, but is not limited to protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma, and post-traumatic stress disorder. Staff must promote dignity, autonomy, privacy, socialization, and safety as appropriate for each resident and are trained in ways to support residents in distress. Behavioral health services are provided by staff who are qualified in behavioral Health and trauma informed care. - The Electronic Medical Record (EMR) for R13 documented diagnoses of PTSD, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), traumatic brain injury (TBI - an injury to the brain caused by external forces), and panic disorder (a chronic anxiety disorder characterized by unexpected, recurring panic attacks). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R13 required partial staff assistance with toileting hygiene, personal hygiene, and lower body dressing. The MDS documented R13 had no behaviors and received an antipsychotic (a class of medication used to treat major mental conditions that cause a break from reality) and antidepressant (a class of medication used to treat mood disorders) medication regularly. The EMR lacked documentation of a trauma-informed assessment with triggers being completed for R13. The 03/09/26 Care Plan included the following interventions for R13. 06/10/26- R13 had the potential for behaviors due to PTSD, depression, panic disorder, and directed staff to administer medication as ordered, provide opportunities for positive interactions, explain all procedures to R13, allow him to adjust to changes, and monitor for behaviors. The Physician's Order, dated 11/18/25, directed staff to administer brexpiprazole (an antipsychotic medication), 4 milligrams (mg), by mouth, daily for depressive disorder. The Physician's Order, dated 11/18/25, directed staff to administer quetiapine fumarate (an antipsychotic medication), 400 mg, by mouth, at bedtime, for PTSD and depressive disorder. The Physician's Order, dated 11/19/25, directed staff to administer bupropion ER (an antidepressant), 150 mg, by mouth, daily, for depressive disorder. The Physician's Order, dated 12/11/25, directed staff to administer quetiapine fumarate, 0.5 mg, by mouth, for PTSD related to TBI. On 04/21/26 at 09:15 AM, Certified Medication Aide (CMA) R administered R13's medication without concern as he sat outside smoking. CMA R stated she was unaware of any PTSD trigger R13 had. She stated he did not have behaviors, stayed in his room most of the time, and usually just went out to smoke and eat. On 04/21/26 at 12:57 PM, Social Services X stated she did not know she was to complete a trauma assessment and knew he had PTSD but had not asked what his triggers were. Social Services X stated she would have put the triggers on his care plan if she knew what they were. On 04/22/26 at 11:30 AM, Licensed Nurse (LN) H verified there were no PTSD triggers on his care plan and did not know what they were. LN H stated, R13 did not have any behaviors. On 04/22/2 at 01:00 PM. Administrative Nurse D stated that usually, when the social history assessment was completed, it would trigger a trauma assessment and did not know why it did not do that. Administrative Nurse D stated that they would investigate getting it fixed or getting a trauma assessment. The facility's Behavioral Health Services policy, dated February 2019, documented that the facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on observation, interview, and record review, the facility failed to label Resident (R) 46 and R89s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with an opened date and the facility failed to label the tuberculin vial solution with an opened date. Findings included:- On [DATE] at 09:30 AM, observation of the facility's East Hall nurse medication cart revealed the following: R46's Lantus (long-acting insulin) two flex pen was labeled with a date opened, but it was smeared and not able to be read. R89's Novolog (fast-acting insulin) flex pen was not labeled with a date opened or discard date. On [DATE] at 11:00 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and the expiration date and discard the expired insulin pens. Medlineplus.gov directs open, unrefrigerated Lantus and Humalog can be used within 28 days; after that time, they must be discarded. The facility's Storage of Medication policy, dated 11/20, documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The policy documented drugs containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling and storage. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. - On [DATE] at 08:34 AM, during inspection of the west medication room, a multidose vial of Tuberculin Purified Protein Derivative (TB) was found without an open date. Licensed Nurse (LN) G verified the vial had been opened and lacked an open date. LN G verified that the TB solution should be discarded within 30 days of being opened. On [DATE] at 08:54 AM, Administrative Nurse D verified the TB vial should have been dated when put in use. The facility's Storage of Medication, dated 11/2020, documented that drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R)81, which included a plan of care and a description of the services provided, which included contact information, visit frequency, medications, and medical equipment. Findings included:- R81's Electronic Health Record (EHR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R81's Quarterly Minimum Data Set (MDS), dated [DATE], documented R81 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognitive impairment. The MDS document R81 required partial to moderate staff assistance with most activities of daily living (ADLs). The MDS documented that R81 received hospice care services. R81's Care Plan, revised 02/17/26, documented R81 had limited physical mobility due to weakness and instructed staff to assist with ADL care. The plan documented the resident was admitted to hospice services on 10/31/25. The plan directed the staff to assist with ADLs, establish a daily routine, and encourage activities of choice. The plan directed staff to monitor and report increased weakness or tiredness to the physician, encourage rest as needed, and observe the effectiveness of pain medication and obtain modifications as necessary to pain medication orders. The care plan lacked a contact number for hospice, what supplies, equipment, and medications hospice would provide, when hospice staff would be in the building, and what care they would provide. A review of R81's clinical record revealed the resident was admitted to hospice care on 10/31/25. The Hospice Agreement, dated 10/31/26, documented Hospice and the facility would jointly develop and agree upon a coordinated plan of care. On 04/20/26 at 03:30 PM, observation revealed R81 sat in a wheelchair in the hall across from the east nurse's station and had no signs or symptoms of pain. On 04/22/26 at 08:45 AM, Administrative Nurse D verified R81's Care Plan lacked information regarding hospice visits, phone numbers, and medical supplies Hospice services would provide and stated she would add the information. The facility's Hospice Program Policy, revised 07/17, documented the facility would designate social services to coordinate care provided to the resident by the facility staff and the hospice staff.

Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to wear appropriate Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) for one resident, Resident (R) 107. Findings included:- On 04/21/26 at 07:45 AM, R107's room had EBP signage at the room entrance. Certified Nurse Aide (CNA) M and CNA O gowned but did not put on a gown. The CNAs removed R107's incontinence brief, and CNA M started to perform personal care to R107. R107 asked them if she needed to hold up her belly for them to wipe. CNA M stated, Yes, and after she held up her belly, CNA M wiped, and R107 said it hurt. R107 had a small open area under her belly. Licensed Nurse (LN) H was informed of the opening and came in, without a gown, and applied a cream to the area and stated she would get an order for treatment from the physician. The CNAs finished personal care with R107 and got up for breakfast. Upon leaving the room, observation revealed the EBP signage was no longer hanging by the door. CNA M stated she did not think she had to wear the EBP anymore as R107 no longer had a catheter (a tube inserted into the bladder to drain urine into a collection bag). On 04/21/26 at 08:00 AM, Licensed Nurse (LN) H stated, R107 no longer had a catheter and did not require staff to wear EBP during cares but would talk with the Infection Preventionist to make sure they didn't need to wear it anymore.On 04/21/26 at 08:30 AM, the signage for EBP was placed back on R107's door, and staff were reeducated to wear the EBP during care because R107 had multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics).On 04/22/6 at 01:00 PM, Administrative Nurse D stated she expected staff to continue to wear EBP when warranted.The facility's Enhanced Barrier Precautions policy, dated December 2024, documented that EBP was utilized to prevent the spread of multidrug-resistant organisms to residents. EBP employs gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply. Some high contact examples are dressing, bathing, providing hygiene or grooming, changing briefs, assisting with toileting, and transferring.

Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room. Findings included:- On 04/22/26 at 09:49 AM, observation in the laundry room revealed the following:1. Missing floor tile along the front of the two front loader washing machines and behind the washers, approximately five feet (ft) by eight inches (in). 2. Behind the washing machines were two floor grates, approximately two ft by 18 in with grayish-black fuzzy substance on the top of them.3. The right front loader washing machine had numerous different-sized streaks of dried white substance below the door and on the right side.4. Underneath the sink, located in the clean area, had missing tile approximately two ft by 18 in. On 04/22/27 at 09:49 AM, Laundry Supervisor (LS) U verified the above findings and stated maintenance was responsible for cleaning the area, and the tile was supposed to be replaced a year ago. On 04/22/26 at 11:17 AM, Maintenance Supervisor (MS) V verified the above findings and stated he was responsible for cleaning the areas in the laundry room. MS V stated he was aware the tile needed to be replaced and would order some, and it would be no problem to lay it. The facility's Maintenance Service Policy documented the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

The facility reported a census of 105 residents with four residents included in the sample. Based on interview and record review the facility failed to ensure the staff administration of resident's medication met professional standards. The Certified Medication Aide administered Trazodone to Resident (R)2 at the incorrect time, and left R3's medication in her room, without observing the resident consume the medication and staff later found 15 medication cups with one gabapentin (medication used for nerve pain) and one tramadol (medication used for moderate to severe pain) in each cup and also found 19 tramadol pills in R3's drawer. Findings included: - R2's Electronic Medical Record (EMR) dated 05/29/24 indicated the following diagnoses: acute/chronic respiratory failure with hypoxia (persisting for a long period, often for the remainder of a person's lifetime, chronically poor airflow) and type two diabetes (a disease in which the body's ability to produce or respond to the hormone insulins is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). R2's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status score of 10, indicating moderate cognitive impairment. R2 received daily insulin (a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels) in the seven-day, look back period. The Care Plan revised 06/05/24 included R2 received a Trazodone which had a black box warning (BBW) to monitor for adverse events, such as suicidal thoughts and behaviors. The EMR revealed an order dated 06/05/24 for Trazodone 50 milligrams (mg) by mouth at bedtime for insomnia/depression. The Nurses Notes dated 01/05/25 at 05:00 PM revealed R2 had increased exhaustion the last couple of days around noon. The medication cart review revealed the nighttime Trazodone dose was placed with the noon medications and given at noon. The team notified the physician regarding the medication given at the wrong time and received orders to monitor the resident for side effects. The Medication Error report dated 01/15/25 revealed R2's Trazodone 50 mg bedtime dose was in the morning medications which caused R2 increased exhaustion around noon the last couple of days. The report revealed R2 received the Trazodone in the morning and continued to receive the evening Trazodone dose also and noted the Certified Medication Aide (CMA) did not verify the medication prior to administration. During an observation on 03/19/25 at 10:45 AM, R2 was in her bed and alert. During an interview on 03/19/25 at 10:45 AM, R2 said she received her Trazodone at noon and it just made her sleepy. R2 said she did not have any other effects to the medication. During an interview on 03/19/25 on 12:20 PM, Licensed Nurse (LN) G said R2 told staff she was tired a lot so we checked her medication and found the Trazodone in the noon slot instead of the bedtime. We notified the nurse practitioner regarding the medication error and received no new orders and continued to monitor R2 for side effects. During an interview on 03/19/25 at 3:30 PM, Administrative Nurse D revealed they expected the staff to give the current medication at the correct time. The facility's policy Administering Medication revision date April 2019, medications are administered in a safe and timely manner as prescribed. The individual administering the medications checks the label three times, to verify, the right resident, right medication, right dosage, right time and right method before giving the medication The facility failed to ensure the medication administration met professional standards when the Certified Medication Aide administered the evening dose of R2's Trazodone at noon, and staff also administered R2's evening dose of Trazodone. - Resident (R) 3's Electronic Medication Record (EMR) dated 09/21/24 revealed a diagnosis of cerebral vascular disease (a condition that affects blood flow to the brain). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status score of seven indicating severely impaired cognition. The MDS documented R3 received antidepressant medication in the seven-day lookback period. The Quarterly MDS dated [DATE] indicated no changes from the 07/04/24 Annual MDS. The Care Plan revised 04/26/24 indicated R3 had potential alterations in comfort related to arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement) and aging process. The staff were to monitor for side effects of pain medication such as, increase agitation, restlessness, confusion, dizziness, and falls. The Tramadol (opioid pain medication) had a black box warning (BBW) because the use of tramadol exposed users to the risk of opioid addiction, abuse and misuse, which could lead to overdose and death. The EMR orders included an order dated 02/13/25 to administer Tramadol 50 milligrams (mg), by mouth, three times a day for knee pain, and a 10/28/24 order for Gabapentin 100 mg, two tablets by mouth, two times a day for neuropathy. The Nurses Notes dated 01/03/25 revealed the unit manager found 15 medication cups in the resident's room with one gabapentin and one tramadol in each cup. An hour later the roommate reported to staff R3 had more tramadol in her drawer and the staff entered the room and removed 19 more Tramadol. On 01/03/25 the facility completed education regarding medication administration, noting when medication was being prepared and given to residents ensure the residents takes the medication while the medication aide or nurse is present, If the resident refuse to take the medication do not leave the medication in the room, return it to the medication cart. During an interview on 03/19/25 at 11:00 AM, R3 said she had no idea why she had not taken her pills and said she would leave them everywhere. R3 said now the staff watch her take her medication all the time. During an interview on 03/19/25 at 11:25 AM, Licensed Nurse (LN) H said the staff did not watch R3 take her medication and found 15 cups in R3's room with one gabapentin and one tramadol in each cup, and 19 Tramadol in R3's drawer. During an interview on 03/19/25 at 03:30 PM, Administrative Nurse D revealed they expected staff to visualize the residents taking their medications. The facility's policy Administering Medication revision date April 2019, medications are administered in a safe and timely manner as prescribed. The individual administering the medications checks the label three times, to verify, the right resident, right medication, right dosage, right time and right method before giving the medication. The facility failed to ensure the medication administration met professional standards when the Certified Medication Aides did not observe the resident taking the medication and left the medication in her room, to which staff later found 15 medication cups with gabapentin and tramadol medication in each cup and also found 19 tramadol in her drawer.

The facility reported a census of 100 residents with eight residents sampled and one resident reviewed for proper discharge from facility. The facility failed to readmit Resident (R) 77 back into the facility. The likelihood for a serious adverse outcome existed, due to the threat to R77's continuity of care, feelings of insecurity to his safety in not having a place to discharge to after the facility had been providing his care for the past two years and four months. The negative psychosocial impact is significant and traumatic, with R77s history of having to live in a men's shelter. This placed R77 in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR), documented R77 had diagnoses of autistic disorder (is a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), anxiety, and schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions). The 12/11/24 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. R77 required total assistance with all activities of daily living (ADL) eating, dressing, mobility, transfers, bathing, oral care, and toileting. R77 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was said on a daily basis, and R77's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject on a daily basis. No depression or behaviors noted. The 09/11/24 Annual MDS documented a BIMS score of one, which indicated severely impaired cognition. R77 required total assistance with all ADLs. R77 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was said on a daily basis, and R77's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject on a daily basis. No depression noted, R77 had rejected care one to three days in seven day look-back period of 09/05/24 thru 09/11/24. The 09/17/24 Behavioral Symptoms Care Area Assessment (CAA) documented R77 continued to reside in facility at this time. R77 had diagnosis of schizoaffective disorder, and autistic disorder. R77 had cognitive deficits with interventions in place. R77 had multiple behaviors R77 had communication deficits but was usually able to make needs known. R77 planned to remain in facility for long term care. The resident's Care Plan documented the following: On 01/17/23 R77's focus of care plan was placement long-term. 01/25/23 - Staff were instructed to encourage participation in social/recreational activities to promote well-being in long term placement. 01/25/23 - Staff would provide support and encouragement to help resident adjust to long-term placement. 09/28/23 - Staff were instructed to refer for psychiatry/ psychology evaluation and follow-up if indicated. The resident's Care Plan lacked any discharge focus or goals. Review of the Physician Orders documented 10/08/22 - Admit R77 long-term care. Review of R77's EHR lacked a discharge order or a 30-day discharge in writing to R77 and or durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). On 02/10/25 at 12:50 PM Social Service Note revealed Social Service Designee (SSD) X received a follow on a referral she had sent to a local facility on 02/07/24, to accept R77. The reply was they currently did not have room and had a long waiting list. SSD X requested that R77 be placed on waiting list. On 02/21/2025 at 03:19 PM Progress Note revealed R77 had attended therapy and became very lethargic and did not want to participate. Vital signs assessed temperature 100.5 degrees Fahrenheit, pulse 102, blood pressure 168/94. Covid and flu swabs were negative. Administrative Nurse F attempted to straight catheterize (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) resident to obtain urine sample, resident did not have any urine output. Resident was transferred to hospital for evaluation. DPOA, Administrative Nurse B was notified of transfer. Bed hold signed by two nurses and sent with resident. On 02/21/25 at 04:55 PM emergency room Note R77 complaints were abdominal pain, decreased urine output, and lethargy. A computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) was completed and revealed a massive rectosigmoid (the part of the large intestine where the upper rectum meets the lower sigmoid colon) stool burden with associated rectal wall thickening. Findings were concerning for fecal impaction. Would consult a general surgeon on 02/22/25 for possible evaluation under anesthesia. On 02/24/25 the hospital was informed Administrative Staff A was not allowing R77 to be re-admitted back to the facility, as his care level was outside the facility's level of care, due to his falls. The hospital staff documented they contacted Administrative Staff A regarding abandoning the patient (R77) at the hospital, and Administrative Staff A stated they will not be back out to reassess the patient and would not take him back. On 02/25/25 at 03:04 PM, Social Service Note revealed Social Service Designee (SSD) X attempted to contact R77's DPOA to inform them that R77 would not be returning to facility. SSD was not able to leave a voicemail. SSD would continue to contact the family. On 03/04/25 at 10:12 AM phone interview with DPOA revealed he had not spoken to any staff at the nursing facility and that they rarely call him. He reported that he did not have voicemail set up on his phone and most calls come in as spam so he would not answer those calls. DPOA reported that R77 was admitted to the hospital on the 21st of February for a fecal impaction and he has been in contact with the hospital. DPOA reported that he has never received a 30 day notice of discharge and was surprised and upset that nursing facility would not accept R77 back to the facility. On 03/04/25 at10:57 AM phone interview with R77's case manager at hospital reported that she had spoken to Administrative Staff on over the phone last week and was informed that R77 was not allowed to return to the facility as his level of care was outside the facility's level of care and due to his falls. During an interview on 03/04/25 at 12:15 PM, Administrative Nurse F reported that R77 would not be readmitted to the facility. Administrative Nurse F reported the facility did not have the means to take care of him as R77 required more behavioral assistance, he did have a helmet and nice chair to be positioned in, but R77 had several falls. Administrative Nurse F reported that she was not in the meeting when it was discussed to not readmit R77. During an interview on 03/04/25 at 12:22 PM, SSD X reported that R77 would not be coming back to the facility as the facility was unable to meet R77's cares, but we had discussed it prior to discharge with DPOA at a care plan meeting to find placement for R77, and referrals had been sent to other facilities. SSD X reported that the clinical team that consisted of Administrative Staff A, Administrative Nurse B, and Administrative Nurse F decided to not let R77 return to the facility. SSD X reported that no 30 day discharge notice had been given to resident or DPOA. SSD X reported she had tried to call the DPOA, and he did not answer. However, she reported her phone when she called out would show on the receiving end the call would come from Utah. SSD X reported that she had just noticed that not long ago. SSD X reported she had no idea if DPOA knew that R77 was not allowed to come back to the facility. During an interview on 03/04/25 at 01:09 PM, Administrative Staff A and Administrative Nurse B reported the facility had attempts to find an appropriate facility to admit R77 and the documentation would be in the referral notes of SSD X in EHR. Administrative Staff A reported that no 30 day notice was given to resident or DPOA. Administrative Staff A reported that when R77 had a previous admission to a hospital it was recommended that R77 have a seat belt placed on chair and a helmet. Administrative Staff A revealed the facility could not use a seat belt as the facility was a restraint free facility and R77 would not be able to self-release a seatbelt and R77's level of care has increased prior to him going to the hospital on the 21st of February. Administrative Nurse B reported that a conversation between therapy and nursing had occurred. However, no evaluation was completed to see if therapy could assist with finding a seatbelt that he could he use and then R77 went to the hospital. Administrative Nurse B reported that the facility decided not to re-admit R77 back on 02/24/25. Administrative Nurse B reported it was an interdisciplinary team decision, and reported it was not documented in the EHR. On 03/05/25 at 09:30 AM, the admission Coordinator reported the facility currently had a censes of 102 residents with a capacity of 115 to 118 beds (13 to 15 beds available). The admission Coordinator reported that she had accepted R77 back on 02/24/24 around 09:00 AM on the website used between the hospital and facility. admission Coordinator reported that R77 was their resident, and the facility had to accept him back, she was not aware if a bed hold had been completed. However, she reported she knew she had to accept him back. admission Coordinator reported after the facility's morning meeting she had to go back into website and decline R77 as a re-admission as the Administrative Staff A reported the facility would not accept R77 back. The admission Coordinator showed the correspondents on the website between the facility and hospital that showed the above. The facility's policy Transfer or Discharge, Facility-Initiated dated October 2022 documented once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. If the facility does not permit a resident's return to the facility (i.e., initiates a discharge) based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. The facility failed to allow R77 return to the facility after he was in the hospital. The likelihood for a serious adverse outcome existed, due to the threat to R77's continuity of care, feelings of insecurity to his safety in not having a place to discharge to after the facility had been providing his care for the past two years and 4 months. The negative psychosocial impact is significant and traumatic, with R77's history of having to live in a men's shelter. This deficient practice placed all residents who are discharged to the hospital are allowed to return to the facility at risk in immediate jeopardy. On 03/05/25 at 11:40 AM, Administrative Staff A, Administrative Nurse B, Regional Nurse Consultant GG, Regional Nurse Consultant II, and Regional Therapy Consultant HH were provided the Immediate Jeopardy (IJ) template and notified the facility the failure for not allowing R77 to return to the facility that he has lived at for two years and four months. The facility submitted an acceptable plan for removal of the immediate jeopardy on 03/06/25 at 12:21 PM which included the following: Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the alleged noncompliance: 1. Resident R77 is currently not at the facility. 2. DON will conduct an immediate review of all residents currently at the hospital. 3. Facility marketing staff went to assess resident R77 at the hospital. 4. Facility marketing staff requested updated requests for Resident R77. 5. Administrator will educate Admission/marketing, social services, DON and clinical manager on discharge and readmission policies. Specify the action(s) the facility will take to alter the process or system failure to prevent serious adverse outcome from occurring or recurring, and when the action(s) will be complete. 1. Administrator will review and update the facility's policy and procedure related to readmission of resident's post-hospitalization care needs. 2. Administrator and admission/marketing staff will review and improve communication protocols with hospital staff, ensuring that clear and timely decisions are made about resident readmissions. 3. Administrator will educate admission/marketing staff to complete a comprehensive assessment process before making decisions regarding readmission. 4. Administrator will educate admission/marketing staff on the communication with hospital staff. 5. Administrator and admission/marketing staff will review and improve communication protocols with hospital staff, ensuring that clear and timely decisions are made about resident readmissions. Any refusal to readmit should be discussed thoroughly with hospital staff to ensure that all potential solutions or alternatives are explored, and the rationale for the decision is documented. 6. R77 will return to the facility upon completion of hospital discharge planning. The removal plan was verified when R77 returned to the facility on [DATE] at 03:06 PM. The scope and severity remained at a G (isolated, actual harm) scope and severity.

The facility reported a census of 100 residents with eight residents sampled and one resident reviewed for fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move), and constipation (difficulty passing stools). Based on observation, interview, and record review the facility failed to have an adequate system in place to identify the known signs and symptoms of fecal impaction for Resident (R) 77, who was required to have a large stool ball removed from his upper rectum, under anesthesia on 02/25/25 at 10:30 AM at the local hospital. This deficient practice placed all residents at risk in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR) documented R77 had a diagnosis of constipation. The 12/11/24 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. R77 required total assistance with all activities of daily living (ADL) eating, dressing, mobility, transfers, bathing, oral care, and toileting. R77 was always incontinent of bowel. The 09/11/24 Annual MDS documented a BIMS score of one, which indicated severely impaired cognition. R77 required total assistance with all ADLs. R77 was always incontinent of bowel. The 09/27/24 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented due to the resident's diagnosis, interventions included to apply incontinence devices as identified as appropriate for the resident, identify voiding patterns, monitor and document no output, increased pulse, increased temperature, altered mental status, change in behavior, and change in eating pattern. The resident's Care Plan documented R77 had impaired gastrointestinal function related to constipation, and included the following interventions: 10/18/22 - Staff were instructed to administer medications per physician orders. 10/18/22 - Staff were instructed to evaluate the resident for abdominal distention, bowel sounds and abdominal discomfort, after three days of no documented bowel movement. 10/18/22 - Staff were instructed to encourage adequate dietary and fluid intake. 10/18/22 - Staff were instructed to monitor for signs and symptoms and or complaints of gastrointestinal upset, nausea, vomiting, and distention. Review of the Physician Orders lacked any orders for monitoring, or medications for, the resident's bowels. Review of the Bowel Incontinence in the EHR from 02/11/25 through 02/21/25 revealed staff documented R77 was incontinent of bowel movements (BMs) on the following days: On 02/12/25 at 10:59 AM, R77 had a medium bowel movement. On 02/13/25 at 11:18 AM, R77 had a medium bowel movement. On 02/15/25 at 09:25 AM, R77 had a small bowel movement. On 02/18/25 at 12:21 AM, R77 had a small bowel movement. On 02/19/25 at 03:21 AM, R77 had a medium bowel movement. All the BMs documented were charted as normal and formed. For all other days during that time frame no BMs were documented. The 02/21/25 at 03:19 PM Progress Note revealed R77 had attended therapy and became very lethargic and did not want to participate. Staff assessed his vital signs, and the resident had a temperature of 100.5 degrees Fahrenheit, pulse of 102 beats per minute, blood pressure of 168/94 millimeters of mercury (mmHg), and his Covid and flu swabs were negative. Administrative Nurse F attempted to straight catheterize (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) the resident to obtain a urine sample, however the resident did not have any urine output. The facility transferred R77 to the local hospital for evaluation. The 02/21/25 at 04:55 PM emergency room Note revealed R77 complained of abdominal pain, decreased urine output, and lethargy. A computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan was completed and revealed a massive rectosigmoid (the part of the large intestine where the upper rectum meets the lower sigmoid colon) stool burden with associated rectal wall thickening. Findings were concerning for fecal impaction. The Note included they would consult a general surgeon on 02/22/25 for possible evaluation under anesthesia. The 02/25/25 at 10:30 AM Hospital Operative Report revealed R77 required surgery to have a large stool ball removed from his upper rectum under anesthesia. During a phone interview on 03/04/25 at 10:57 AM, R77's case manager at the hospital reported that R77 required the fecal impaction had to be removed while R77 was under anesthesia in the operating room on 02/25/25, as the medications and enemas administered to R77 during his admission from 02/21/25 thru 02/25/25 were not effective. During an interview on 03/04/25 at 11:23 AM, Certified Medication Aide (CMA) R reported that the nurse on duty would have to provide her with instructions to administer an as needed medication for any resident. CMA R reported she would look at the bowel movement report that should be printed every day, and if she noted that a resident did not have a bowel movement in three days she would let the nurse know. During an interview on 03/04/25 at 11:40 AM, Licensed Nurse (LN) G reported she would print out the bowel log every morning from the computer, and if a resident had more than three days of no bowel movement documented she provided the CMA direction to use standing orders of as needed milk of magnesia to be administered. LN G reported if a resident had an as needed medication for constipation already ordered she would provide the CMA direction to administer the ordered medication. Furthermore, LN G reported a small bowel movement documented in EHR would not count as a normal bowel movement. LN G reported the staff should document every day on every shift whether a resident had a bowel movement or no bowel movement. During an interview on 03/04/25 at 12:15 PM, Administrative Nurse F reported that bowel protocol is initiated when a resident did not have a normal bowel movement in three days. Administrative Nurse F reported the facility had standing orders for as needed bowel medications to relieve constipation. Administrative Nurse F reported that small BMs should not count as a normal BM and staff should chart every shift if a resident had a BM or not. Administrative Nurse F reviewed the BM charting in the EHR for R77 and confirmed some shifts were missing documentation and confirmed the resident he had not received any medications to treat constipation in the EHR. Administrative Nurse F reported R77 admitted to the hospital for a fecal impaction. During an interview on 03/04/25 at 01:09 PM, Administrative Staff A and Administrative Nurse B both confirmed R77 admitted to the local hospital with a bowel impaction. Administrative Staff A reported it was a concern that R77 required surgery to remove the fecal ball, but stated the resident was having normal bowel movements. Administrative Staff A and Administrative Nurse B could not answer if a small BM that was documented would count as a normal bowel movement. Administrative Staff A reported the facility did not have a bowel protocol policy and the facility used the standing orders for no BMs in three days. Administrative Nurse B reviewed the bowel movement documented in the EHR charting and reported she was concerned with the lack of charting noted for R77. During an interview on 03/04/25 at 01:49 PM, Certified Nurse Aide (CNA) N reported the resident did not have normal bowel movements right before he was discharged and stated it was a smear or visible mark of BM in R77's brief. CNA N reported she was told to document that as a small BM by the prior Director of Nursing of the facility. CNA N reported she noticed R77's breath started to smell like BM last month and his stool looked like putty and hard clay. CNA N said she reported that to the unknown agency nurse, as CNA N could not recall who the nurse was and stated the facility staffed a lot of agencies. CNA N reported she assisted an unknown, agency CMA to administer milk of magnesia to R77, prior to the transfer to the hospital. The facility lacked a policy for monitoring and documentation of bowel movements. The facility's Standing Orders from team health dated 04/04/24 documented if no BM in three days, give milk of magnesia (a medication is used for a short time to treat occasional constipation) 30 milliliters, by mouth. If no results within 24 hours, administer Lactulose (a synthetic sugar used to treat constipation) 20 milliliters, by mouth, every two hours, maximum three doses. If no results administer a Dulcolax suppository (a rectal medication used to treat occasional constipation) 10 milligrams. If no results administer a Fleets enema (is a saline laxative that provides reliable relief from occasional constipation that is inserted via rectum) once and notify the physician if no results. The facility failed to have an adequate system in place to identify the known signs and symptoms of fecal impaction for Resident (R) 77, who was required to have a large stool ball removed from his upper rectum, under anesthesia on 02/25/25 at 10:30 AM at the local hospital. This deficient practice placed all residents at risk in immediate jeopardy. On 03/04/25 at 06:20 PM, Administrative Staff A, Administrative Nurse B, Regional Nurse Consultant GG, and Regional Therapy Consultant HH were provided the Immediate Jeopardy (IJ) template and notified the facility failure for staff pervasive disregard for R77's dignity, in noting his breath smelled of bowel movement; lack of competent staff, who were incorrectly charting smear BM as small BM and lack of staff identification of R77's lack of urine output; lack of behavioral management and staff neglecting to recognize known clinical signs and symptoms of constipation and fecal impaction; Lack of staff training regarding resident behavioral issues and staff not providing adequate ADL assistance regarding bowel management placed R77s in immediate jeopardy to his health and safety, and placed all residents at risk. The deficient practice at F675 also constituted substandard quality of care at 42 CFR 483.24. The facility submitted an acceptable plan for removal of the immediate jeopardy on 03/04/25 at 08:46 PM which included the following: Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the alleged noncompliance: 1. R77 is currently at the hospital. 2. Clinical managers will interview interviewable residents for last BM, signs and symptoms of constipation, and fecal impaction. 3. CNAs will document BMs before the end of their shifts. 4. Nurses will assess non interviewable residents for signs and symptoms of constipation or fecal impaction. 5. If any residents are identified with constipation and fecal impaction, MD will be notified, and orders will be follow as needed. Specify the action(s) the facility will take to alter the process or system failure to prevent serious adverse outcome from occurring or recurring, and when the action(s) will be complete. 1. DON/designee will educate clinical staff on proper BM documentation, urinary output, signs and symptoms of constipation and fecal impaction. 2. DON/designee will educate CNAs to document BMs on POC before they leave their shift. 3. DON/designee will educate nurses to review POC documentation before end of the shift that CNA has completed BM documentation. 4. DON/designee will educate nurses to review alerts on PCC before the end of the shift. 5. DON/designee will educate Nurses to assess residents with no BMs for 3 days, signs and symptoms of impaction, or abdominal pain; notify MD; and follow physician's orders. 6. DON/designee will educate (in-services mentioned above) clinical staff prior to their next scheduled shift. 7. Unit manager will review POC documentation on daily clinical meeting to ensure compliance with BM documentation, urinary output and necessarily follow up. 8. DON will perform random audit on POC documentation, progress notes, MD notification, and medication administration for residents identified with no BM for 3 days or signs and symptoms of constipation or fecal impaction. 9. If additional discrepancies are identified, they will be corrected immediately according to physician's orders.? The surveyor verified the above corrective actions were implemented while on-site on 03/05/25. This deficient practice remained at a scope and severity of a G (isolated, actual harm).

The facility reported a census of 102 residents. The sample included 21 residents. Based on interview and record review the facility failed to provide adequate supervision for Resident (R) 157 when a tourniquet was left on his arm from a blood draw on a Friday and not found until Monday, a total of 5 days. Findings included: - R157's Electronic Health Record (EHR) revealed a diagnoses transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), and lactic acidosis (excessive accumulation of lactic acid produced by the muscle cells with the breakdown of carbohydrates for energy). The Electronic Health Record (EHR) documented an order dated 01/10/25 for hyponatremia (less than normal concentration of sodium in the blood), hyperkalemia (greater than normal amount of potassium in the blood), and transaminitis (a liver enzyme in the blood) lab tests to be obtained. The Progress Notes documented the following: On 01/09/25 at 12:00 PM, provider noted labs from today were pending. On 01/13/25 at 11:05 AM, Licensed Nurse (LN) J noted was informed that a tourniquet was found on R157's right arm. LN J assessed R157's arm and found it to have a deep blue ring around the upper right arm and reddish discoloration going down the arm. R157 had a brace to his right hand and his skin was not excessively warm. The resident's provider was notified and the facility received new orders for a doppler to his right arm. Mobile radiology was notified. On 02/10/25 at 12:48 PM Licensed Nurse (LN) C revealed their lab vendor left a tourniquet on a resident's arm and did not collect all of the ordered labs. On 02/10/25 at 12:54 PM LN J revealed she completed the assessment on R157's arm, obtained the order for the doppler, and notified mobile radiology. On 02/11/25 at 12:29 PM, Administrative Staff A revealed R157 had lab drawn on a Friday and the tourniquet was found on R157's right arm the following Monday. She confirmed that her expectation would have been that the tourniquet on the resident's arm be found much sooner. The facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 04/2021 documented residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical and chemical restraint not required to treat the resident's symptoms. The facility failed to provide a safe and secure living environment for the residents of the facility by the failure to provide adequate supervision to prevent Resident (R)157 from having a tourniquet left tightly on his arm for five days.

The facility identified a census of 102 residents with 21 sampled, which included one resident 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 to implement care plan interventions to prevent the development of facility-acquired, stage 3 pressure ulcers/injuries (full thickness pressure injury extending through the skin into the tissue below) for Resident (R)14. Findings include: - Review of R14's diagnoses from the Electronic Health Record (EHR) documented: anorexia (lack or loss of appetite), metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (progressive mental disorder characterized by failing memory, confusion). The 11/27/24 Quarterly MDS documented a BIMS score of two, which indicated severely impaired cognition. R14 required set up assistance from staff for eating, supervision of staff for bed mobility, and he was independent with transfers. The MDS noted R14 had no pressure ulcer injuries or skin concerns. The 01/26/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. R14 required total staff assistance with activities of daily living (ADLs) including toileting hygiene, bathing, dressing, bed mobility, and transfers. R14 was incontinent of bladder and bowel frequently. The MDS indicated R14 received tube feedings and had an unplanned weight loss of five percent (%) or more in the last month or loss of 10% or more in last 6 months. R14 was at risk for pressure ulcers and had no pressure ulcer/injuries or skin concerns noted on the assessment. The 02/04/25 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R14 readmitted from the hospital with a diagnosis of metabolic encephalopathy. R14 was noted to have dysphagia (swallowing difficulty) and moderate malnutrition. Interventions would include to apply moisturizer to his skin as needed, not massaging over bony prominences, and the use of mild cleansers for care. The staff would provide frequent incontinent care and prompt removal of wet/damp clothing or sheets as need and provide the resident with pressure relieving devices. The 02/03/25 Care Plan documented interventions initiated 08/04/21 and revised 02/24/23, as follows: Staff were instructed to apply moisturizer to R14's skin as needed, instructed not to massage over bony prominences, and use mild cleansers for peri care/washing. Staff were instructed to minimize extended exposure of the resident's skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets as needed. Staff were instructed to monitor, document, and report to the provider changes in R14's skin status. Staff were instructed to provide a pressure relieving/reducing device on the resident's bed and wheelchair. The Physicians Orders dated 02/03/25 documented the following: 01/20/25 - May have Wound nurse consult; Complete Braden Score (pressure ulcer score) weekly times four. 01/21/25 - Complete a weekly skin evaluation every Saturday during evening shift. 01/31/25 - Wound care to the right and left medial (towards the middle) buttocks. Staff were to cleanse open areas to both of R14's inner buttocks with normal saline (NS- saline water solution for medical use), apply Xeroform (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) to wound bed, cover with Calcium Alginate (a highly absorbent wound dressing made from seaweed) and secure the area with a foam boarder for full thickness skin loss on each medial buttock. The dressing would be changed every Monday, Wednesday, Friday, and as needed if soiled, saturated, or missing. The 01/20/25 at 05:41 PM Readmission Evaluation documented R14 had bruises and identified R14's coccyx had areas of friction present. Administrative Nurse D informed LN I (wound nurse) of the findings and pictures of the areas were taken. The evaluation further noted R14 had incontinence of bowel movement upon readmission to the facility and the Mepliex (absorbent, bordered foam dressing) on the resident's coccyx was removed. The 01/20/25 at 06:45 PM Skin/Wound Note documented a bruise on R14's left inner arm and left hand, from readmission. The 01/20/25 at 09:26 PM Braden Scale assessment documented R14 had a score of 17, which indicated the resident was at risk for skin breakdown. The 01/28/25 at 11:16 AM Skin Evaluation/Assessment documented no new skin concerns. The Progress Note dated 01/31/25 at 11:07 PM documented R14 had open areas to the right and left medial buttocks. Staff notified LN I (wound nurse) and the provider, with no new orders received. The 02/04/25 at 10:40 AM Skin/Wound Evaluation was not completed by LN I, who opened the evaluation, and it remained in progress on 02/11/25. Review of the EHR from 01/31/25 thru 02/11/25 lacked measurements of the open areas to the resident's buttocks. During an observation on 02/03/25 at 02:52 PM R14 was in his bed with the television on, and the head of bed elevated. R14 was positioned on his buttocks. During an observation on 02/04/25 at 05:07 AM R14 was in his bed low to floor, fall mat in place head of bed elevated, and he was positioned on his buttocks. During an observation on 02/04/25 at 07:27 AM, LN Y completed wound care on R14. Observation revealed three open areas on the resident's medical buttocks. One open area on left medial buttock had a red wound base that extended through all the skin layers. The two open areas on the right medial buttock had a deep, reddish crater that has extended through all skin layers. LN Y reported she would not measure the areas as the wound nurse measured the pressure ulcers. During an observation on 02/04/25 at 01:59 PM, the facility applied an air mattress to R14's bed by an outside vendor. The Physicians Orders dated 02/04/25 instructed staff to apply a low air loss mattress to the resident's bed for skin management and set it according to resident's weight. Staff were to check the setting and function every shift for mattress monitoring. During an observation on 02/10/25 at 12:15 PM R14 was in his bed low to floor, fall mat in place head of bed elevated, and he was positioned on his buttocks. During an interview on 02/10/25 at 12:49 PM Certified Nurse Aide (CNA) AA, observed exiting R14's room, reported she had provided incontinent care to R14 and left him on his back as he had no positioning pillows or devices in the room, and he had no repositioning on his care plan. CNA AA reported R14 had a dressing on his buttocks. During an interview on 02/03/25 at 11:52 AM, LN I wound nurse reported she could not call R14's Guardian/Conservator (is a person who manages the day-to-day life of another person, while a conservator is a person who manages the financial affairs of another person) as his old Guardian had been removed in 12/24 in the EHR. The court appointed a new guardian/conservator as the death of the original guardian occurred. LN I said a required consent was needed before the facility wound consultant company would assess R14's wounds. LN I reported the nurse who first assessed R14's wounds on 01/31/25 received an order and treatment from the provider. During an interview on 02/03/25 at 03:25 PM, LN I reported the camera was not working the day she looked at R14's wound, but another nurse may have taken a picture. LN I reported she wanted a wound protocol at the facility, and she was fairly new to this position. LN I reported R14 should be repositioned off of his back at least every two hours. LN I stated R14 should have an air mattress on the bed, and she was not sure why he did not have an air mattress but would look into that. LN I reported R14 had a Stage 3 pressure ulcer on each buttock and R14 did not have any skin breakdown when he readmitted to the facility on [DATE]. During an interview on 02/10/25 at 12:51 PM, Administrative Nurse E reported R14 should have had positioning devices in place to reposition R14 off his buttock and be repositioned by staff at least every two hours. During an interview on 02/10/25 at 04:10 PM, Administrative Nurse D reported R14 developed a facility acquired pressure ulcer since his readmission on 01/20/25. Administrative Nurse D reported R14 should have had positioning devices in his room to use when staff repositioned him in bed. Administrative Nurse D reported staff were not to leave the resident on his back in bed and noted he should be turned side to side. Administrative Nurse D said R14 did not have an air mattress applied to his bed until the afternoon of 02/04/25, as the facility had to wait for an air mattress to be delivered. The facility's Pressure Ulcer/Skin Breakdown- Clinical Protocol dated 03/2014 documented the nursing staff and attending physician would assess and document on individuals significant risk factors for developing pressure ulcers, for example immobility, recent weight loss and history of pressure ulcers. The facility failed to implement interventions to prevent the development of three facility-acquired, stage 3 pressure injuries for R14. The facility further failed to regularly assess, monitor, and document R14's wounds after staff initially identified the resident's wounds had developed. These failures resulted in preventable wounds to R14's buttocks and placed him at an increased risk for further development of pressure injuries skin conditions.

The facility reported a census of 102 residents with 21 sampled. Based on observation, interview, and record review the facility failed to ensure staff assessed Resident (R) 409 after a fall on 01/27/25 and failed to document the fall and/or the resident's status after the fall until the resident transferred to a local hospital and was diagnosed with multiple fractures (broken bones). Findings included: - R409's Physician's Orders dated 01/09/25 revealed the resident had a diagnosis of unspecified fracture of the left femur (broken bone). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 11 indicating moderately impaired cognition. The resident had no behaviors exhibited, required a wheelchair for mobility and required substantial/maximal assistance with all activities of daily living (ADL). The Care Area Assessment[s] dated 01/15/25 for Cognitive Loss/Dementia and Falls revealed R409 admitted from hospital after falling at home and sustaining a left femur (thigh bone) fracture and left clavicle (collarbone) fracture. The Care Plan revision dated 01/21/25 revealed R409 had a risk for falls related to confusion gait/balance problems, incontinence, weakness, and a recent fall with femur and clavicle fracture. The Care Plan intervention dated 01/21/25 revealed the resident required the use of anti-roll back brakes to the wheelchair, a fall mat beside the bed, frequent checks, and staff would monitor/document the resident's pain level. Staff would ensure the surgical incision to the resident's left femur had a dressing in place until she could be seen by the orthopedic physician. Review of the facility Investigation Notes dated 02/05/25 revealed on 01/27/25 at 04:30 PM a local hospital notified the charge nurse, Licensed Nurse (LN) J, R409 had a right-side fracture of the pelvis. The nurses' notes lacked any reports of the resident falling or any indication of pain since the last recorded incident on 01/16/25. Upon further investigation by the facility, R409's roommate reported R409 fell while attempting to stand from her unlocked wheelchair. Staff alerted the nurse of the fall, and she assessed R409, then all three of the staff members lifted the resident from the floor. The resident was transported to the nurse's station. The investigative note documented on 01/27/25 the facility attempted to contact the Licensed Nurse working on the shift when R409 fell to write a statement regarding the resident's record lacking a fall assessment or documentation the facility's fall protocol was followed. Observation on 02/03/25 at 02:54 PM revealed R409 was in her wheelchair with her left arm in a sling and no facial grimace or signs of pain noted. Interview with Certified Nurse Aide (CNA) R on 02/10/25 at 11:25 AM revealed the resident was on fall precautions as she always tried to get up out of her bed. CNA R reported she heard the resident sustained a fracture of the pelvic area the last time she fell . Interview with CNA S on 02/11/25 at 12:50 PM revealed if a resident fell staff were to report it to the charge nurse, and not move the resident until an assessment was completed. During an interview on 02/10/25 at 02:20 PM Administrative Nurse D revealed she expected for all nurses to assess a resident with each fall, notify the provider, responsible party, and nurse manager. Administrative Nurse D stated she would re-educate any nurse who did not provide appropriate care to residents. The facility policy Fall and Fall Management dated March 2018 revealed facility staff will identify interventions related to resident's specific risk factors and causes to try to prevent the resident from falling and to try to minimize complications from the fall. The facility failed to assess R409 after a fall on 01/27/25. The facility further failed to document the fall and/or the resident's status after the fall until the resident transferred to a local hospital and was diagnosed with multiple fractures.

The facility identified a census of 102 residents, with 21 sampled, and one resident reviewed for weight loss. Based on observation, interview, and record review, the facility failed to monitor the weight loss and failed to develop care plan interventions to address the weight loss for cognitively impaired Resident (R) 14, who had an identified weight loss of 20.54% in one month. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R14's diagnoses from the Electronic Health Record (EHR) documented, anorexia (lack or loss of appetite), metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (progressive mental disorder characterized by failing memory, confusion). The 11/27/24 Quarterly Minimum Data Set (MDS) documented a BIMS score of two, which indicated severely impaired cognition. R14 required set up for eating and no weight loss noted. The 01/26/25 Significant Change (MDS) documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. R14 required total staff assistance with activities of daily living (ADL). The MDS indicated R14 received tube feedings and had an unplanned weight loss of five percent (%) or more in the last month or a loss of 10% or more in the last six months . The 02/04/25 Nutritional Status Care Area Assessment (CAA) documented R14 readmitted from the hospital for a diagnosis of metabolic encephalopathy. R14 was noted to have dysphagia (swallowing difficulty) and moderate malnutrition. Due to R14's diagnosis, interventions included to monitor R14's weights per protocol, observe for chewing or swallowing problems, provide the diet and consistency per provider orders, and nothing by mouth (NPO a medical abbreviation used to indicate that a patient should not consume any food, liquids, or medications orally). The CAA also noted to refer R14 to speech therapy for a speech/swallowing evaluation. The 02/03/25 Care Plan documented interventions for R14 which included: 08/04/21 - Staff instructed to observe R14 for chewing or swallowing problems and to offer alternatives of comparative nutritional value. 10/14/21- Staff instructed to refer to speech therapy for a speech/swallowing evaluation. Staff were to provide the diet and consistency, per physician order - puree, double portion meat portions. 07/11/23 - Staff to provide Ensure plus once daily. 01/01/25 - Staff instructed to monitor R14's weights, per protocol. The Physicians Orders dated 01/30/25 documented: 01/20/25 - Speech therapy evaluation and treatment as indicated 01/21/25 - NPO diet. 01/21/25 - Administer Mirtazapine (antidepressant medication) tablet 7.5 milligram (mg), give 7.5 mg, via feeding tube at bedtime for appetite. 01/21/25 - Complete admission and weekly weight for four weeks. 01/24/25 - Provide Glucerna 1.5 Cal (brand name of a family of tube feeding formula that was a calorically dense formula with specialized blend of low glycemic {release glucose slowly into the bloodstream, resulting in a gradual and moderate rise in blood sugar} and slowly digestible carbohydrates), administer one carton every four hours and flush with 30 milliliters of water after each feeding. Review of weights in the EHR from 06/17/24 until 02/07/25 documented the following weights for R14: 06/17/24 at 11:12 AM weighed 162.6 pounds (lbs.). 07/02/24 at 01:22 PM weighed 167.0 lbs. 08/08/24 at 08:06 AM weighed 162.2 lbs. 08/19/24 at 01:06 PM weighed 165.5 lbs. 09/03/24 at 01:29 PM weighed 160.6 lbs. 10/01/24 at 08:56 AM weighed 163.2 lbs. 12/17/24 at 04:59 PM weighed 167.0 lbs. 01/09/25 at 10:56 AM weighed 137.2 lbs. 01/20/25 at 08:27 PM weighed 137.2 lbs. (a 17.10% loss since 08/19/24 and a 20.54% loss since 12/17/24). 02/07/24 at 05:00 PM weighed 155.2 lbs. (18 days since the prior weight). The 01/09/25 (unknown time) Provider Progress Note included the provider saw R14 and Administrative Nurse E reported the resident had a recent weight loss noted. It was reported R14 also had decreased intake/appetite overall, as well as increased weakness/fatigue and an overall change in condition. The provider ordered a Chest X-ray, labs, and Mirtazapine 7.5 mg tablet, give one tablet orally, at bedtime for appetite stimulant. The 01/11/25 at 04:05 PM Progress Note revealed R14 looked different than what was normal for him. Vital signs included a blood pressure of 98 millimeters of Mercury (mmHg) systolic over 56 mmHg diastolic, and a pulse of 105 beats per minute. R14 refused oxygen monitoring, and his breathing was labored. The staff called the Physician and received an order to send R14 to the hospital . The 01/202/25 at 05:41 PM, Progress Note revealed R14 was readmitted to facility from the hospital. The 01/21/25 (unknown time) Provider Progress Note revealed the provider assessed R14 and adjusted R14 to NPO at that time, until evaluated by speech therapy in the facility. The 01/23/25 at 09:38 AM Dietary Progress Note revealed Consultant Staff JJ (Registered Dietician) received consult for tube feeding. R14's current body weight was 137.2 lbs., indicating underweight, with an ideal body weight of 148 lbs. The recommended tube feeding order included Glucerna 1.5 Cal, one carton every four hours, with a goal of gradual weight gain to R14's ideal body weight. The staff were to monitor tube feeding tolerance, residuals, and weights. The 01/26/25 (unknown time) Provider Progress Note included Speech therapy planned to evaluate R14 today to determine if he was safe for PO intake . During a review on 02/11/25 of the EHR, lacked a documented speech evaluation. During an observation on 01/30/25 at 01:20 PM, noted sign in R14's room which read NPO. During an observation on 02/10/25 at 09:10 AM, R14 was in his bed on his back with the head of bed elevated. R14 put his hand up to his mouth as if he was holding a utensil, when R14 was asked with a note written do you want to eat food R14 shook his head yes. R14 used a white board to communicate with staff as he was deaf. During an observation on 02/10/25 at 03:32 PM, R14 was observed by surveyor to have a weight completed by Certified Nurse Aide (CNA) R, CNA AA, and Administrative Nurse E. Staff utilized a mechanical lift scale which had been zeroed out. Weight revealed 141.0 pounds. During an interview on 01/30/25 at 01:20 PM, R14 reported he would eat food when he asked for the food. During an interview on 02/04/25 at 02:04 PM, Certified Nurse Aide (CNA) O reported R14 would ask her for something to eat, and she knew he could no longer eat. During an interview on 02/10/25 at 12:51 PM, Administrative Nurse E reported she had not witnessed the weight obtained on 02/07/25 for R14. Administrative Nurse E said CNA O reported the weight of 155.2 lbs. to her, and she documented that weight in the EHR. During an interview on 02/10/25 at 01:02 PM, Therapy Staff II (Director of Therapy) reported Therapy Staff LL (Speech Therapist) completed an evaluation for R14 and R14 had not started speech therapy. During an interview on 02/10/25 at 03:45 PM, Consultant Staff II reported she attempted to contact Consultant Staff LL, who completed R14's evaluation, as the evaluation could not be located. Consultant Staff II reported the speech evaluation was written on a piece of paper. During an interview on 02/11/25 at 01:17 PM, Consultant Staff LL reported she had completed a speech evaluation on R14 on 01/27/25 the last day she worked at the facility. Additionally, Consultant Staff LL reported she wrote the evaluation on a piece of paper, as she did not know to complete the evaluation in the EHR. Consultant Staff LL reported she texted Consultant Staff II the evaluation was completed, and she recommend R14 to start speech therapy. Consultant Staff LL reported she could not locate the locate the handwritten speech evaluation and reported that was a concern During an interview on 02/10/24 at 04:10 PM, Administrative Nurse D reported R14 had a speech evaluation completed and she did not know the evaluation could not be located. Administrative Nurse D stated it was reported by Consultant Staff II the evaluation was written on a piece of paper. Administrative Nurse D expected the evaluation to be completed and documented in the EHR. Administrative Nurse D expected R14 would have started speech therapy already. Administrative Nurse D reported she expected weights to be completed for all residents, per the physician orders. Administrative Nurse D confirmed R14 had a significant weight loss, and the weight loss was unacceptable. Administrative Nurse D confirmed the weight loss and tube feeding was not documented on the care plan in a timely manner. During an interview on 02/10/25 at 04:46 PM, Consultant Staff JJ (Registered Dietician) reported a virtual weight loss meeting occurred once a month with the interdisciplinary team (IDT) for weight loss that triggered for every single resident. Consultant Staff JJ confirmed R14 had a significant weight loss of 18% in one month and she had recommended weekly weights on 02/04/25. Consultant Staff JJ expected staff to obtain weights as ordered. She also reported the Speech Therapist had completed an evaluation for R14; however, she had not received a copy of the speech recommendations. The facility's undated policy Evaluation Therapy Plan of Care documented an evaluation by Speech-Language Pathologist required professional skills to make clinical judgement about conditions for which services were indicated based on objective measurement, and subjective evaluation of patient performance and abilities. Initiate the evaluation 24 hours after the order was obtained or next business day. The facility's policy Weight Assessment and Intervention dated 03/2022 documented resident's weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and intervals established by the IDT. Any weight change of 5% or more would be re-weighed the next day to confirm weight. If 5% weight change was confirmed the Registered Dietician would be notified in writing by nursing. One month weight loss of greater that 5% was severe. The facility failed to monitor weight loss and care plan weight loss interventions for cognitively impaired R14, who had a severe weight loss of 20.54% in one month. This deficient practice had the potential to negatively affect the resident's physical well-being.

The facility identified a census of 102 residents, which included 57 residents with active trusts held by the facility. Based on observations, interviews, and record review, the facility failed to provide quarterly statements for the 57 residents with trust accounts in the facility. Findings included: - Review of Trust Transaction History of all 57 residents who had active trusts held by the facility revealed no quarterly statements available for review. During an interview on 02/11/25 at 10:19 AM Administrative Staff PP revealed the facility maintained trust funds for 57 residents in the facility. Administrative Staff PP revealed quarterly statements were printed out and hand delivered to residents that had high cognitive functioning or mailed to the residents' representatives if the resident had low cognitive functioning. The facility was unable to provide documentation, which indicated quarterly statements were given to the 57 residents of the facility. The facility did not provide a policy related to management of trust funds. The facility failed to provide quarterly statements of each resident's personal funds entrusted to the facility on the resident's behalf.

The facility reported a census of 107 residents with one resident reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a safe environment on 12/10/23 when a facility staff member gave their personal vaping pen (an electronic device shaped like a pen that is used to inhale vapor when vaping), (which allegedly contained tetrahydro cannabinol [THC], an illegal psychoactive substance) to cognitively intact Resident (R) 1, who had a known history of substance abuse. R1 used the staff members vape pen (a device using marijuana that vaporize the active molecules in concentrated marijuana oil) and was found by staffR1 unable to function and required transfer to the emergency room for evaluation. This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of the 08/05/21 Physicians Orders revealed R1 had diagnoses of alcohol abuse (a spectrum of unhealthy drinking behavior) and psychoactive substance abuse (substance that when taking in or administered into one's system affect mental processes). The Annual Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. R1 was independent with all Activities of Daily Living (ADL). The 06/22/23 Activities of Daily Living [ADL] Care Area Assessment indicated R1 was independent with all ADLs. The Quarterly MDS dated [DATE] indicated no change in cognition or ADL status. The Care Plan dated 12/10/23 revealed R1 had a history of substance abuse and demonstrated ineffective coping skills related to a history of drug and alcohol abuse. R1 reported on 12/10/23 he had consumed THC via a vape pen. Staff educated R1 on illegal substance use and smoking policies on 12/16/23. Intervention addition previously on 08/17/21, instructed the staff to encourage participation in recommended support groups. Staff to provide enhancement of the resident's self-esteem, confidence, and self-acceptance. Accept responsibility for the consequences of his behavior. The Nurses Notes indicated on 12/10/23 at 04:20 AM, staff found R1 on the floor of his room between the wheelchair and his bed. R1 could not support his own weight and an unidentified Certified Nurse Aide (CNA) had to provide support. R1 showed generalized weakness over his entire body. Staff used a full body mechanical lift to transfer R1 back to his bed. A Nurses Notes dated 12/10/23 at 04:22 AM, indicated R1 showed confusion, was lethargic, barely able to hold himself up or keep his eyes open. R1 was sweating profusely and had no core strength present with generalized weakness. The staff attempted to give fluids to R1, but he was drooling and unable to hold the cup of fluid. The Nurses Notes dated 12/10/23 at 06:49 AM, documented staff transferred R1 to an acute hospital by Emergency Medical Services (EMS) for an evaluation. The resident returned to the facility on [DATE] at 10:57 AM with no new orders. Review of the emergency room Physician Report, dated 12/10/23 at 07:02 AM, documented the chief complaint was Marijuana use and hit head. The notes explained the resident with a significant past medical history of diabetes and hypertension.who presents after [hitting (inhalation into the lungs) a vape pen]. He stated he hit the vape pen at least three times in the past three days. He has had significant symptoms after inhaling the contents of the vape pen, such as transient (lasting only for a short time) hearing loss, palpitations (hard, fast, or irregular heartbeat), and severe fatigue. He stated this morning (12/10/23) he fell three times and hit his head on the heater in his room due to his disorientation . R1 denied alcohol or other substance abuse. The physician documented she highly advised that the resident stop using the vape pen and he agreed and understood. R1's history included drug use with Methamphetamines (past meth use, no intravenous [IV] drug use). A Urine Drug Monitoring Screen Test, obtained on 12/12/23 at 08:00 PM and reported results on 12/15/23, revealed the resident's urine was positive for Marijuana Metabolites at 20 nanograms (ng/ml), with notation to See Note A. Note A documented, The results are presumptive, based only on screening methods, and they have not been confirmed by a definitive method. Healthcare Providers needing interpretation assistance, please contact us at [phone number] . The facility 12/19/23 self-investigation report of the incident contained a typed and signed statement by Administrative Nurse A. The statement, dated 12/19/23 at 09:30 AM, documented the nurse spoke with a physician at the laboratory that conducted a urine drug screen on the resident on 12/12/23. Clarification received that test results indicated that Marijuana Metabolite was present in the specimen, but the test did not distinguish between THC or CBD (chemical found in marijuana) use or a level of the drug in the urine, only that the drug present in the specimen. [Doctor] also stated that marijuana may be detected in a urine drug screen for up to 90 days after use. A handwritten statement by Licensed Nurse (LN) G, undated, documented that on the afternoon into the early evening of 12/09/23, R1 did not appear to have any alteration from his baseline health status other than complaining of his ears feeling clogged in the afternoon but later reported his ears felt better. An undated, handwritten statement by LN I, documented she was the charge nurse on duty with the incident of 12/09/23-12/10/23. She explained being called to R1's room at 04:00 AM, that the resident fell out of bed trying to get to the bathroom, which was not usual for R1. Earlier in the shift the nurse also noted changes with R1 and his demeanor. The resident slept a lot more during the shift than he normally would. The resident stated he had ringing in his ears and could barely hear anything earlier in the shift but then his hearing came back. During that time the resident was sweating profusely to which the nurse checked his vital signs and blood glucose (sugar), which were all normal at that time. After the assessment, R1 was back in bed and called the nurse back into the room. R1 wanted to disclose he knew what was going on with his health and that he needed to come clean because he did not want to die. R1 then explained he had all of these things going on with his health because he was vaping someone's THC pen but he did not want to say whose pen it was. He did not want to get anyone in trouble. The nurse asked R1 if he got if from a resident or a staff member, and R1 stated it was from a staff member. The nurse then asked how much he took. R1 stated he vaped three to four times, but they were pretty big hits. R1 then reported he got it from Laundry Staff U, but he did not want to get her in trouble. LN I then asked if this was the only time this happened and he stated, No he did it two days in a row and lost hearing the first day, but the side effects were not as bad as now. LN I asked where the vape pen was now and R1 explained Laundry Staff U took it back and still had it. LN I then notified the facility supervisors of the situation. An undated, handwritten statement by LN G, documented the prior charge nurse (LN I) reported R1 informed LN I he had hit a vape THC pen three times the prior day around 03:00 PM. LN G talked with R1 about the incident. The nurse asked R1 when he had hit the vape pen and R1 stated the day before (12/09/23) around 03:00 PM as well as on 10/08/23 at an undetermined time with two puffs from the pen at that time. The resident reported to LN G that a member of facility staff let him puff on the pen and then took it back. R1 reported Laundry Staff U provided the vape pen to him. The room lacked a visible vape pen at that time. An undated, handwritten statement from Laundry Staff U, documented denial of giving a vape pen to R1. However, she did explain that R1 asked for a pen three times, but she did not share her pen with R1. On 12/19/23, a phone call to Laundry Staff U phone number, revealed no answer, and the surveyor left a message to call the surveyor back. However, no return call from Laundry Staff U came through 12/20/23. Review of the facility timeclock record for Laundry Staff U revealed she was on duty in the facility as follows: Friday, 12/08/23, in at 05:46 AM and out at 02:26 PM. Saturday, 12/09/23, in at 06:06 AM and out at 02:58 PM. Sunday, 12/10/23, in at 05:47 AM and out at 02:00 PM. Monday, 12/11/23, in at 06:00 AM and out at 02:00 PM. Another typed and signed statement by Social Service Designee (SSD) X, dated 12/13/23, documented interview of the resident related to the vape pen and marijuana incident. The typed statement included, .stated that he smoked the vape pen with Delta 8 [Delta 8 THC is a cannabinoid that occurs naturally in cannabis, but it is not extracted directly from the plant] around 03:00 PM and shortly afterwards he fell asleep. [R1] stated that once he woke up around 04:00 AM the next morning he couldn't feel his fingers or push himself out of bed. [R1] stated that he fell on the floor several times and hit his head on the air conditioning (AC) unit while trying to get up. [R1] stated that while he was on the floor a nurse aide found him on the floor and called the paramedics. He was later admitted to the hospital. On 12/19/23 at 08:20 AM, R1 sat in the hallway, in his wheelchair and was not very talkative. On 12/19/23 at 09:25 AM, R1 returned from smoking outside. R1 self-propelled his wheelchair to his room. Interview with R1, on 12/19/23 at 09:35 AM, revealed on the day of the incident the Housekeeping Staff U told R1 their personal vape pen had THC in it, but R1 did not believe her and used it anyway. R1 further explained he took a nap at 3:00 PM and woke up about 04:00 AM. R1 said he fell to the floor and hit his head on the vent by the bed. R1 also indicated he was not able to drink anything or support himself and the facility staff sent him to the hospital. R1 revealed the hospital did not check R1 for THC. Interview with R1, on 12/19/23 at 03:15 PM, revealed he did use a vape pen at the facility before this incident. He explained there was a group of residents (would not reveal which residents) in one room (would not reveal which room) that passed a vape pen around for each to use and share. He did not know what was in the vape pen, but he explained he used marijuana and methamphetamine (illegal drugs) before admission into the facility. Interview with Administrative Staff A and Administrative Nurse D on 12/19/23 at 11:00 AM revealed the facility used the Abuse and Neglect Policy and expected staff to not use drugs before coming to work and staff were not to share their personal items with other staff or residents. They expected the staff to follow the company's policy. The facility policy dated 07/23 for, Reporting Abuse to Facility Management documented It is the responsibility of the employees, facility consultants, attending physicians, visitors and family members to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source. The facility failed to ensure a safe environment for R1 who had a known history of substance abuse, when a facility staff member gave their personal vaping pen, allegedly containing THC, to R1. R1 used the pen and staff found the resident lethargic and required EMS transfer to the ER for evaluation. The facility collected a urine sample from R1 to test for THC on 12/12/23 with results that indicated marijuana metabolite. The facility was provided the Immediate Jeopardy (IJ) Template on 12/19/23 at 04:11 PM, reviewed with Administrative Staff A and Administrative Nurse D regarding a facility staff member that provided their personal vaping pen allegedly containing THC to a cognitively intact Resident 1, who had a known history of substance abuse. R1 used the staff members vape pen and had been found later unable to function. Staff had to have R1 transferred to the hospital for evaluation and placed R1 in immediate jeopardy. There was the likelihood for serious adverse outcome due to staff member providing their own personal vape which contained alleged THC to a resident with known history of substance abuse. The facility provided an acceptable plan of removal of the immediate jeopardy on 12/19/23 at 05:00 PM. The plan included: a special resident council meeting to educate the residents on substance abuse, smoking policy to include vape pens not sharing of smoking material and used only during smoking time in the designated smoking area. If any suspicious activity or illegal activity report to the charge nurse immediately. Staff education initiated on 12/19/23 at 05:30 PM for the following: Accidents-Substance Use Disorder (SUD) undated, Policy. Safety for resident with substance use disorder. Warning signs of substance use disorder. Review of the Drug and Alcohol Policy Handbook, undated. Staff shall not share smoking paraphernalia or drugs with resident that are not prescribed to the residents. All residents smoking paraphernalia must be kept locked up and used only at the designated smoking times in the designated smoking area, this includes vaping pens and e-cigarettes. The survey team validated the immediate jeopardy was removed on 12/20/23 at 11:00 AM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of a D following the removal of the immediate jeopardy.

The facility identified a census of 104 residents. The sample included 23 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 95, who was at risk for pressure ulcers (a 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), received the proper care and treatments to avoid the worsening of a deep tissue injury (DTI - a purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) and the new development of a stage three (full-thickness) pressure injury/ulcer to her sacral/coccyx (small triangular bone at the base of the spine) area. This deficient practice also placed R95 at risk for further skin breakdown and complications from wound infection. Findings included: - The electronic medical record (EMR) for R95 documented diagnoses of hypertension (HTN-an elevated blood pressure), type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), neuropathy (weakness, numbness, and pain from damage to the nerves usually in the hands or feet), and a pressure ulcer. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R95 had a Brief Interview for Mental Status (BIMS) score of two which indicated severely impaired cognition. R95 required extensive assistance of one staff for her activities of daily living (ADLs). R95 was at risk for and had a pressure ulcer. The Pressure Ulcer Care Plan initiated 01/20/23 directed staff to apply moisturizer as needed to skin. Staff were to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets. Staff were to monitor R95's nutritional status, monitor intake and record. Staff werr to monitor/document/report to physician changes in skin status. Staff was to provide resident with pressure relieving/reducing device on bed and on her chair R95 was to be turned and repositioned every two to four hours as tolerated and as needed. The Alteration in Skin Integrity Care Plan initiated 01/27/23 directed staff to evaluate wound weekly and as needed, document wound measurement, wound bed, appearance, odor drainage, and surrounding tissue. Staff were to monitor/document/report to physician as needed any changes in skin status. Staff werr to ensure R95 had a Prevalon boot (a specialty boot that keeps the heel elevated off the mattress to relieve pressure) to the right foot while in bed as resident allowed. The plan did not address the wound treatments or include updated interventions when the existing wound worsened or when a new facility acquired pressure injury was noted. The RN: Wound Assessment (Initial) effective 01/20/23 and signed on 01/24/23 recorded R95 admitted with two wounds. Wound one was a surgical incision to the mid lower back. Wound two was a suspected DTI to the right heel, which measured 5 centimeters (cm) width x3 cm length. The assessment documented the wound treatment was Sureprep (liquid skin protectant) to the heel every shift and application of a Prevelon boot to the right foot when the resident was in bed. The assessment recorded the following interventions would be implemented: repositioning, heels raised while in bed, pressure relieving wheelchair seat cushion, specialty mattress, labs as ordered, protein supplements as ordered, additional supplements as ordered, resident education, resident, and representative education. Under the additional comments section, it directed staff should apply Calmoseptine (skin barrier) ointment to R95's buttocks, sacrum, and coccyx every day for wound prevention. A LN: Weekly Skin/Braden Scale for Prediction Pressure Sore Risk assessment dated [DATE] documented R95's skin was intact with no impairment resulting in a low-risk determination. The Wound Documentation notes dated 02/28/23 through 03/07/23 recorded the right heel DTI measured 2.5 cm x 3 cm and directed all interventions continued. A new Physician Order was initiated on 03/18/23 to cleanse the right heel with wound cleanser and apply Sureprep to the periwound (skin surrounding the wound bed). Cut Aquacel AG (antimicrobial wound dressing) to fit wound bed, and cover with gauze dressing. Change once daily on Mondays, Wednesdays, and Fridays and as needed (PRN) for saturation, soiling or unscheduled removal. The treatment was scheduled as PRN. Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for March 2023 revealed the above dressing was not administered until 03/31/23. The late entry Wound Documentation note marked as effective for 03/20/23 recorded the right heel wound remained a DTI and measured 2.7 cm x 2 cm with no depth. The late entry Wound Documentation notes marked as effective for dates 03/21/23 and 03/28/23 recorded the right heel wound was still a DTI which measured 3 cm x 2 cm with a new finding of a depth of 0.1 cm. Review of the MAR/TAR for March 2023 revealed R95 wore her Prevalon boot every shift with no refusals recorded and staff applied Calmoseptine to R95's buttocks once a day. R95's clinical record lacked evidence the resident refused or removed her boot. On 04/03/23 the Wound Documentation note recorded the resident was assessed by the wound care provider. The note recorded R95 had a DTI which measured 3 cm by 3 cm by 0.1 cm. The wound care specialist Progress Note dated 04/03/23 recorded an initial visit for R95's right heel wound. The report documented R95 had a stage three pressure injury to the right heel which measured 3cm x 3 cm x 0.1 cm. There was a small amount of serosanguinous (drainage with small amount of blood present) drainage. The note documented staff reported to the wound care provider R95 frequently removed her Prevalon boots. The note recorded contributing conditions were dementia, impaired mobility, and noncompliance. The wound care specialist Progress Note dated 04/17/23 recorded a stage three pressure ulcer to the right foot. The note documented staff reported the resident frequently removed her boot. R95's representative was present and tried to explain to R95 the importance of keeping the boot on. The wound care specialist Progress Note dated 04/24/23 recorded a stage three pressure ulcer to the right foot. The note documented staff reported the resident was wearing her boot more. The wound measured 3 cm x 6 cm x 0.1 cm. The wound was debrided (medical removal of dead, damaged, or infected tissue) on this date. Review of the MAR/TAR for March 2023 revealed R95 wore her Prevalon boot every shift with no refusals recorded and staff applied Calmoseptine to R95's buttocks once a day. R95's clinical record lacked evidence of refusals/noncompliance. The LN: Weekly Skin Monitoring Report dated 05/03/23 documented previously noted skin alteration right heel with no new skin issues noted. The LN: Weekly Skin Monitoring Report effective 05/17/23 signed on 05/19/23 inaccurately documented R95's skin was intact. The unsigned and unlocked LN: Weekly Skin Monitoring Report effective 05/17/23 created on 05/19/23 documented R95 had a previously noted skin alteration to her right heel with a treatment in place. A late entry Wound Documentation note dated 05/21/23 documented R95 had a stage three pressure wound to her sacral/coccyx area. The wound care specialist Progress Note dated 05/22/23 documented R95's stage three wound to the right heel. It further recorded an initial evaluation of a second wound to R95's coccyx. The note diagnosed stage three pressure ulcer with measurements of 2 cm by 1.5 cm by 0.1 cm depth. There was a moderate amount of drainage noted. The note recorded a treatment plan and documented the coccyx ulcer was healable and the goal was to heal through aggressive means as fast as possible. A provider Encounter Note dated 05/22/23 documented Advanced Practice Registered Nurse (APRN) JJ assessed R95 due to weight loss and overall decline. The note recorded Consultant JJ discussed hospice with R95's representative. The note further documented R95's representative expressed concern regarding he right heel ulcer. Consultant JJ spoke with the wound nurse who reported the wound healed well with no complications. There was a new area of concern on the resident's sacrum which was followed by the wound specialist and the note documented Consultant JJ would await the recommendations. The wound care specialist Progress Note dated 06/01/23 recorded R95 had a stage three pressure ulcer to her right heel which measured 2 cm x 1.5 cm x 0.1cm. The note recorded a stage three pressure wound to R95's coccyx which measured 2 cm x 2.5cm x 0.1 cm with moderate drainage. The area was debrided that day however the resident did not tolerate well. The wound care specialist note recorded the wound was healable, with a goal to heal by aggressive means as fast as possible. A Encounter Note dated 06/06/23 at 05:50 PM documented the facility wound nurse requested Consultant JJ assess R95's worsening sacral ulcer. Consultant JJ noted that the wound specialist followed this wound. Consultant JJ noted the wound could be a [NAME] terminal ulcer (KTU- an ulcer which develops and progresses very rapidly during active dying process). The note recorded the wound care specialist did follow the resident in-house and it appeared that the sacral ulcer was new as of 5/22/23 and nursing reported that it has worsened in appearance. Wound orders were adjusted, and the resident was started on prophylactic doxycycline (a medication used to treat infections). The wound nurse reported a wound culture was obtained. Consultant JJ recorded the resident's representative was notified that day of concern for KTU and what that indicated and recommended hospice/palliative care. A 06/13/23 Primary Physician Note for R95 documented skin- pink, warm and dry, sacral ulcer stage three, appears consistent with [NAME] ulcer. A 06/23/23 Primary Physician Note for R95 documented the wound culture results were available at that time for the sacral ulcer and antibiotic medications were prescribed to treat an infection. The note documented the wound appearance was previously concerning for [NAME] ulcer and nursing would continue to monitor. On 06/28/23 at 10:06 AM R95 laid in her bed. She had a right heel boot on her right foot and a low air loss mattress on the bed. On 06/29/23 at 02:32 PM Licensed Nurse (LN) H stated weekly skin assessments were done by the nurse on staff each week. LN H stated the wound nurse did weekly assessments as well as the wound dressing changes. On 06/29/23 at 03:38 PM LN I stated when R95 was admitted to the facility there had been a different wound nurse that was no longer with the facility. LN I stated R95 was non-compliant with wearing her Prevalon boot and repositioning. LN I stated weekly skin assessments should be done by the nurses and the wound care nurse does a weekly assessment of wounds as well as the wound dressing changes. LN I stated the wound specialist came to the facility weekly and made rounds with the wound nurse. On 06/29/23 at 04:02 PM Administrative Nurse D stated R95 admitted with a deep tissue wound to the heel and did not have an open area so R95 was not referred to wound specialist at that time. Administrative Nurse D stated she could not say why new interventions had not been put in place to prevent further wound breakdown. Administrative Nurse D stated at that time up until March or April the facility had a different wound nurse than the current wound nurse. Administrative Nurse D stated R95 had been non-compliant with wearing the boot and other treatments, but R95 did start seeing the wound specialist in April when the wound became worse. Administrative Nurse D stated the nurses do weekly skin checks and those should be documented in R95's chart. Administrative Nurse D stated R95 should be seen weekly by the facility wound nurse. Administrative Nurse D stated treatments and the care plan should be updated as needed for R95 if the wound had not been improving and the physician should have been notified if the wound was not improving. Administrative Nurse D could not say why a nurse would have charted on a weekly skin assessment that R95's skin was intact as she has had noted open wounds to her right heel and coccyx area for several weeks. Administrative Nurse D stated she would be educating the nurse staff on proper documentation for skin monitoring. The facility policy Skin and Pressure Injury Prevention revised 03/13/23 documented: The facility would assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice. Assess the resident on admission/re-admission for existing pressure/injury risk factors utilizing the Braden Risk Assessment. Repeat the Braden Risk Assessment weekly for four weeks then quarterly, annually or change in resident skin status/integrity. Braden should be completed for new onset illness. Conduct a comprehensive skin assessment upon admission/re-admission, including skin integrity and areas of impaired circulation/mobility due to pressure from positioning or medical devices. Weekly skin monitoring done by a licensed nurse. Staff inspect the skin when performing or assisting with personal cares or ADLs. Identify any signs of developing pressure injuries. General prevention should include frequent position change based on individual needs; determine need for a special low air loss air mattress; a cushion for chair; use draw sheet to move from side to side and up in bed; positioning devices should be monitored to prevent pressure; protect bony prominences as needed. The facility failed to ensure staff had appropriate wound interventions and documented accurate skin assessments to prevent the further decline of R95's right heel pressure wound and the development of a stage three pressure ulcer/wound to her sacral area, healable per the wound care specialist and later (16 days after development) determined to have the potential for a KTU. This deficient practice also places R95 at risk for further skin damage/wounds and complications from wound infection.

The facility had a census of 104 residents. The sample included 23 residents. Based on observation, record review, and interview the facility failed to recognize, evaluate, manage, and treat Resident (R) 305's pain. This deficient practice resulted in uncontrolled pain which also placed the resident at risk for impaired mobility and diminished quality of life. Findings included: - The Electronic Medical Record (EMR) documented R305 had diagnoses of end stage renal disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), chronic pain syndrome, acute pain due to trauma, muscle weakness, fracture (broken bone) of second lumbar (lower back) vertebra (small bones forming the backbone), and altered mental status. The Admission Minimum Data Set (MDS), dated [DATE], documented R305 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS indicated R305 required dialysis. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 06/21/23, documented R305 admitted from a long-term acute care hospital with a diagnosis of end stage renal disease. The CAA further documented R305 was recently involved in a motor vehicle accident and sustained a L2 (second lumbar vertebra) fracture (broken bone) and had multiple upper extremity soft tissue damage. The CAA indicated he required assistance with activities of daily living (ADL) and worked with therapy services. The Pain CAA dated 06/21/23, directed staff to administer medications as ordered and to monitor for signs and symptoms of pain with each interaction. The CAA documented if R305 appeared to be in pain, staff would utilize appropriate non-pharmacological and pharmacological interventions, and notify the physician if interventions were unsuccessful, or if current complaint was a significant change from R305's past experience of pain. It directed staff to reposition R305 frequently and utilize non-pharmacological pain interventions to promote comfort. The Care Plan dated 06/15/23, documented R305 required hemodialysis related to end stage renal disease. An intervention dated 06/15/23, documented R305 attended dialysis three times a week on Mondays, Wednesdays, and Fridays. The Care Plan dated 06/15/23, documented R305 required assistance with activities of daily living related to confusion, fracture, limited mobility, and pain. An intervention dated 06/15/23, documented R305 required extensive assistance of two staff members for bed mobility. An intervention dated 06/21/23, documented R305 required total dependence of two staff and the use of a Hoyer (total body mechanical lift) lift for transfers. The Care Plan dated 06/26/23, documented R305 had alteration in comfort related to his diagnoses. The plan directed staff to administer R305's medications as ordered. The plan directed staff to monitor for signs and symptoms of pain with each interaction and if the resident appeared to be in pain, to utilize appropriate nonpharmacological and pharmacological interventions. The plan further directed staff to notify R305's physician if intervention were unsuccessful R305's EMR recorded a Physician Order for oxycodone (medication used to treat pain) 5 milligrams (mg) by mouth, every four hours as needed, for moderate to severe pain dated 06/14/23 and a Physician Order for Tylenol 325 MG two tablets every six hours as needed for pain, dated 06/14/23. Review of the Medication Administration Record (MAR) for June 2023 revealed R305 received one dose of oxycodone on 06/15/23, 06/16/23, 06/17/23, 06/18/23, 06/19/23, 06/23/23, 06/26/23, 06/28/23, and 06/29/23. The MAR further documented R305 received a second dose of oxycodone 5 MG by mouth on 06/19/23 as a one-time order. No other doses of oxycodone were administered. The MAR recorded one administration of Tylenol for pain on 06/25/23. The MAR lacked evidence staff assessed effectiveness of the medication. Review of the MAR for June 2023 revealed staff documented a pain evaluation each eight-hour shift. The evaluations and administrations documented on the MAR revealed the following: On 06/15/23 on the morning shift, 06:00 AM -02:00 PM, R305 reported a pain level of four. The PRN medication was noted as administered on 05:24 PM for a pain rating of four. The evening shift, 02:00 PM though 10:00 PM, recorded R305's pain as zero. On 06/16/23 the MAR recorded a pain assessment was unable to be completed as the residnet was out of the facility though the MAR recorded the pain medication as administered at 08:28 AM with a pain score of seven. The evening shift and night shift, 10:00 PM to 06:00 AM, both recorded R305 had no pain. On 06/17/23 all three shifts recorded R305 had no pain though the MAR recorded pain medication was administered on that day at 05:47 PM with a pain score of five. On 06/18/23 all three shifts recorded a pain score of zero however, the pain medications was recorded as administered that morning at 08:16 AM with a pain score of five. On 06/19/23 the morning pain assessment revealed R305's pain was a zero though the MAR recorded pain medication was administered at 09:57 AM and a one-time dose at 11:09 AM. The evening shift recorded a pain score of six, with no associated pain medication administration. On 06/21/23 the MAR documented R305 had a pain score of four in the morning shift, and two in the evening shift and night shift with no pain medication administered. On 06/22/23 the morning shift recorded a pain score of two and the evening shift a pain score of three; no pain medication was administered. On 06/25/23 the pain assessments recorded R305 had no pain all three shifts though The MAR recorded R305 received Tylenol for a pain score of six at 12:11PM. On 06/27/23 the MAR recorded R305 had no pain and received no pain medication that day. A Nursing Progress Note dated 06/19/23, documented R305 requested, and received as needed oxycodone 5 mg before dialysis and he left for his dialysis appointment. The note further documented R305 returned to the facility because he refused to go to dialysis because of pain. Staff notified the physician and obtained an order for a one-time dose of oxycodone 5 mg and administered the dose to R305. The note documented R305 then agreed to have dialysis and was scheduled for a later time that day. A Comprehensive Care Path SPN note dated 06/28/23, documented R305 received physical therapy, occupational therapy, and speech therapy and R305 received pain management after therapy. The note further documented R305 stated pain levels were not tolerable with current interventions. R305's clinical record lacked evidence the staff notified the physician, or if alternative interventions implemented. On 06/26/23 at 10:08 AM R305 sat in his wheelchair in his room. R305 appeared restless and attempted to reposition himself in his wheelchair several times. His leg was shaking, he was letting out small moaning sounds as if in pain and breathing heavily. R305 stated he was in the worst pain in his lifetime and he was not sure if he had received anything for pain during the morning. He stated the pain medication did help when he took them. He also reported he was late for his dialysis appointment and wanted to ask staff why transport had not picked him up. On 06/26/23 at 10:14 AM R305 rolled in his wheelchair out into the hallway, just outside of his door. He began asking why he was not taken to his dialysis appointment and stated he was an hour late for his appointment. R305 continued to appear restless while seated in his wheelchair, his leg continued to shake, he continued to [NAME] heavily, and made sounds as if in pain. Staff members walked past R305 in the hallway without acknowledging him. An unknown staff member stated she would ask the nurse to come speak with him regarding his dialysis appointment. Licensed Nurse (LN) K approached R305 and stated transport was running behind and his dialysis appointment was rescheduled for a later time, and then walked away. She returned and pushed him in the wheelchair down the hallway. R305 asked if someone could do something for his pain and LN K stated she had already given him a pain pill while he was working with physical therapy and having breakfast. On 06/27/23 at 09:16 AM R305 was in his room working with therapy staff. R305 asked for pain medication and stated he needed something to help with his pain. On 06/28/23 at 08:16 AM staff assisted R305 down the hallway in his wheelchair. R305 was shifting his weight around in his wheelchair and appeared uncomfortable, making slight moaning sounds as if in pain. On 06/29/23 at 07:18 AM R305 sat in his wheelchair in his room. He appeared uncomfortable, shifting his weight around in his wheelchair and made noises as if in pain. R305 stated every time staff got him up into his wheelchair, his pain became unbearable. He stated staff do not bring him anything to help with his pain. He reported he thought it would help if staff would give him pain medication before getting him up in his chair and before doing therapy. On 06/29/23 at 11:43 PM Consultant HH stated R305 often complained his pain was 9 to 10, out of 10, with 10 being the worst. She stated R305 was resistant to therapy due to increased pain levels and he often complained of pain throughout the day. She further stated she had to take the resident to the desk to request pain medication and request was not always immediately addressed by nursing. On 06/29/23 at 11:43 PM Consultant II stated on the previous day, R305 rated his pain 11 out of 10 and refused to participate in therapy with her, unless he was given something to help with his pain. She stated R305 received therapy about three times per day and each session lasted around 30 to 45 minutes. On 06/29/23 at 02:33 PM LN H stated she saw staff assessing R305 before getting him out of bed, but she was not sure how often it was done. She stated R305 was confused and further stated it could be an issue for him when notifying staff about his pain before it became unbearable. On 06/29/23 at 04:04 PM Administrative Nurse D stated staff should assess residents for pain, offer to reposition them, and asking them about their pain if a resident is noted to be restless, uncomfortable, or moaning as if they are in pain. She stated it would not be appropriate for staff to walk by a resident displaying these behaviors and not acknowledge them. The facility's Pain Management Policy revised on 07/2019, documented the facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. It further documented identifying potential causes for a resident's pain, evaluating alleviating and or exacerbating factors and to review effectiveness of past and current treatment. The facility failed to recognize, evaluate, manage, and treat R305's pain, who had severe cognitive impairment, and displayed both visible signs and verbal complaints of pain. This deficient practice resulted in uncontrolled pain which also placed the resident at risk for impaired mobility and diminished quality of life.

The facility census totaled 105 residents, with 38 included in the sample, and seven 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 to do weekly skin assessments from 12/21/21 to 02/08/22 to monitor Resident (R) 69's skin and identify the development and prevent worsening of two avoidable pressure ulcers, a stage III (full-thickness skin loss potentially extending into the subcutaneous tissue layer) on the right heel and an unstageable (full-thickness tissue loss in which the base of the ulcer is covered by slough, non-viable yellow, tan, gray, green or brown tissue, and/or eschar, dead or devitalized tissue, ulcer in the wound bed) to the left heel. Findings included: - R69's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/16/22 Significant Change in Status Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident was totally dependent for all care and received scheduled pain medication and as needed for frequent pain rated seven out of 10 on a scale of 0 - 10, with 10 being the most severe pain. The resident had a stage III and an unstageable pressure ulcer with treatment. The 02/16/22 Care Area Assessment (CAA) revealed the resident was dependent on staff for all needs and worked with therapy services. The resident had a significant change recently with two new pressure ulcers to both heels and a treatment order was in place. The 10/23/21 Care Plan revealed the resident required total assistance of two staff for daily care related to musculoskeletal impairment and [CONDITION(S)]. Approaches included for staff to encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use a bell to call for assistance, and weekly skin inspection to monitor for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The Alteration in Skin Integrity Care Plan dated 02/10/22 revealed R69 had actual pressure ulcers to both heels related to pressure and impaired mobility. Approaches included to assess the wounds weekly, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue. The staff were to float the resident's heels and monitor the dressing daily to ensure it was clean/dry/intact. Monitor/document/report to the physician as needed (PRN) changes in skin status including appearance, color, wound healing, signs of infection, wound size (length, width, and depth), and stage. The staff were to provide the resident with pressure relieving/reducing devices on the bed and in the chair and refer to the wound care specialist, as needed. The Weekly Skin Assessments dated 11/14/21, 11/16/21, 11/18/21, 11/22/21, 11/28/21, 12/02/21, 12/06/21, 12/14/21, and 12/21/21 revealed the resident's skin was warm, dry, and pink. The record lacked evidence of further skin assessments documented between 12/21/21 and 02/08/22, almost 50 days later, when breakdown was found on both heels on 02/08/22. The resident wore rigid plastic boots to prevent foot drop (inability or difficulty in moving the ankle and toes upward). The 02/08/22 In-House Acquired Pressure Ulcer Investigation revealed the resident wore rigid plastic (Prafo) boots on both feet to treat foot drop due to [CONDITION(S)]. The record lacked documented evidence the staff removed the Prafo boots to check for skin breakdown. The 02/09/22 at 05:49 PM Wound Documentation Note: Wound assessment/measurements revealed R69 with a stage III right heel wound which measured 1.5 centimeters (cm) in length and width, and had a depth of 0.1 cm. The wound had a small amount of serosanguineous exudate (semi-thick reddish drainage) present. The resident had an unstageable pressure ulcer to his left heel which measured 2.0 cm in length and width and had a depth of 0.1 centimeter (cm). (The wound assessment note lacked a description of the appearance of the wounds and the skin surrounding the wounds.) The 02/16/22 at 04:39 PM Wound Documentation Note: Wound assessment/measurements revealed R69 continued with a stage III pressure ulcer to the right heel which measured 1.0 cm in length and width, and had a depth of 0.1 cm. The resident also had a suspected deep tissue injury (A pressure-related injury to subcutaneous tissues under intact skin) noted to the left heel which measured 2.0 cm in length, 1.5 cm in width, and 0.1 cm in depth. (The wound assessment note lacked a description of the appearance of the wounds and the skin surrounding the wounds.) Observation on 04/18/22 at 10:30 AM revealed the resident laid in bed watching television. The resident had his legs elevated on pillows with Prevalon boots (soft padded pressure relieving boots) on both feet. The resident laid on his back with pillows to each side, elevating him slightly. The resident was awake and voiced no concerns. Observation on 04/18/22 at 04:00 PM Wound Nurse F entered R 69's room and asked resident permission to do his wound care. The resident agreed and she proceeded to gather her supplies needed. With gloved hands the nurse removed the sheet from the resident's feet. Both feet were elevated with Prevalon boots in place. She then removed the right boot and the dressing from the heel exposing a stage 3 pressure wound approx 2.5cm on the heel. The wound had fresh bleeding in the wound bed. The nurse cleaned the wound with gauze and wound cleaner. She then removed her gloves and used hand sanitizer before re-gloving. She then placed a piece of calcium alginate and covered with a bordered gauze. She then disposed of the supplies used and removed her gloves. She then used hand sanitizer and donned clean gloves and repeated the procedure to the left heel. A stage II open wound approximately 2.5 cm was present with fresh bleeding from wound. Following treatment, staff replaced the Prevalon boots on both feet and placed the legs on pillows. During an interview on 04/18/22 at 04:20 PM, Certified Medication Aide (CMA) O reported the resident admitted with a wound on his sacrum. She did not think he came with the wounds to his heels. She did not know when the other wounds appeared. The wound nurse provided his treatments and the staff always keep boots on him. During an interview on 04/19/22 at 01:30 PM, CMA K reported the resident was quadriplegic and was dependent upon the staff for his care. CMA K said the staff provided repositioning, by putting pillows at his sides to relieve pressure to sacral area. Staff elevated his legs and heels, and he always wore Prevalon boots. During an interview on 04/18/22 at 4:00 PM, Licensed Nurse (LN) F reported the resident admitted with a wound to his coccyx, which healed, but the resident now had two pressure ulcers on each heel. She reported the resident wore rigid plastic boots at all times to prevent foot drop. After the wounds appeared the resident was changed to Prevalon boots to prevent further breakdown. The areas are looking pretty good and healing and both have good blood flow. On 04/20/22 at 07:25 AM, LN H reported the resident was to have a weekly skin check and those were entered into the computer when completed. Those assessments are under the assessment tab in the Electronic Medical Record (EMR). On 04/20/22 at 07:30 AM, Administrative Nurse C confirmed no skin assessments were completed between 12/21/21 and 02/09/22. The resident was in the hospital the end of March, but she saw the wounds were identified in February. The wound nurse provided care for the wounds now. Administrative Nurse C stated R69 admitted with a large wound on his sacrum which healed, but she thought maybe after the one wound healed the nurses just did not do anymore weekly skin checks. On 04/20/22 at 04:10 PM, Administrative Nurse B confirmed there were no skin assessments completed between 12/21/21 and 02/08/22. During a phone call on 04/20/22 at 01:39 PM, Physician I stated he was made aware of the resident's condition and the fact there were no skin assessments since 12/21/21 and the wounds were discovered on 02/08/22. Physician I stated if someone would have been looking at his feet, they would have seen the sores develop. The 04/2019 Wound-Ulcer policy documented licensed staff would complete a head to toe skin assessment weekly and as needed. The skin assessment would be documented on the EHR skin assessment. Any unusual findings would be reported to the Registered Nurse for evaluation. Staff was to consult wound care providers when appropriate. The licensed nurse could initiate wound treatment following the facility skin/wound treatment protocol. The facility failed to do weekly skin assessments to the resident from 12/21/21 to 02/08/22, to monitor R69's skin and identify the development and prevent worsening of two avoidable pressure ulcers, a stage III on the right heel and an unstageable to the left heel.

The facility had a census of 89 residents, with 13 residents selected for sample. Based on observation, interview and record review, the facility failed to have a system in place to protect all residents from potential abuse from three current residents known to have a history of criminal prosecution for sexually related charges and who currently were listed on the Sex Offender Registry for the State of Kansas. (Resident #8, 9, 10) Failure to have a system in place to protect all residents placed the residents in immediate jeopardy. Findings included: - Resident #8's clinical record included a resident profile which noted admission to the facility on [DATE]. The 12/23/18 Quarterly MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 15), no [MEDICAL CONDITION] or behaviors, the ability to accomplish transfers with supervision of one staff only, and independence with ambulation. The 6/27/17 Care Plan included the 12/31/18 intervention, Resident exhibits behavior symptoms such as sexually inappropriate comments. Determine cause of behavior and remove resident. Document all behaviors. Attempt to identify patterns to target interventions. Notify MD (medical doctor) of inappropriate behavior. The care plan lacked information related to the resident's lifetime requirement to remain on the Sex Offender Registry for the State of Kansas. Record review also revealed information related to resident to resident sexual allegations made against resident #8 as follows: 12/27/18: The facility reported an incident to the State Survey and Certification hotline which described an encounter between resident #8 and a severely cognitively impaired resident of the opposite gender. Staff witnessed resident #8 kiss the other resident on the mouth. According to the complaint intake, resident #8 reported he/she believed the other resident had the ability to consent and therefore felt the kiss was appropriate. When told the resident lacked the ability to consent, resident #8 reported he/she understood. 12/31/18: Described a staff report of resident #8 making a comment about a cognitively impaired resident of the opposite gender who got into resident #8's bed during the night. Resident #8 described the encounter with the resident as good. The facility investigation revealed the resident was joking when he told the nurse of the encounter. There was lack of sufficient evidence to substantiate the allegation. On 2/11/19, the State Survey and Certification Complaint Hotline received two anonymously reported allegations of sexually inappropriate behavior which named resident #8 as the alleged perpetrator (person accused of wrongdoing) in both incidents involving two cognitively impaired residents. One allegation referred to resident #8's rape of a same sex resident. The other allegation referred to the incident the facility reported on 12/31/18 as described previously. Administrative Staff A was advised of the allegation of rape on 2/12/19 at 9:00 a.m. and the police were immediately notified. During an observation on 2/12/19 at 12:50 p.m., resident #8 moved about in his/her bed independently. The resident answered all questions appropriately and showed no signs of cognitive impairment. During an interview on 2/12/19 at 12:50 p.m., resident #8 reported a desire to move into an apartment but expressed frustration about the lack of housing available for convicted felons. The resident then reported the State of Kansas currently requires him/her to remain on the Sex Offender Registry for an offense which occurred more than [AGE] years ago. A check of the State of Kansas Sex Offender registry found at kbi.ks.gov/registered offender revealed resident #8 had a lifetime requirement to remain on the registry. During an interview on 2/12/19 at 1:00 p.m., Administrative Nurse B reported she knew of resident #8's current status on the Sex Offender registry for Kansas. Nurse B denied knowledge of the specific reasons the resident was on the list. At surveyor request, Nurse B used the previously mentioned website to locate current information on the resident's status and reported the case involved aggravated indecent liberties with a child from several years ago. During an interview on 2/12/19 at 1:10 p.m., Administrative Staff A reported an awareness of resident #8's placement on the Sex Offender registry. According to Staff A, the prior corporate owners of the facility did not require background screenings on residents prior to admission. The corporation who assumed ownership 12/1/18 require the screening but only for newly admitted residents. Administrative Staff A also confirmed the decision was made to not provide other staff such as direct care staff with the registry status information because they wanted the resident to be care for and treated fairly. During an interview on 2/12/19 at 1:20 p.m., Direct Care Staff J reported he/she heard from someone that resident #8 was on an offender registry but lacked information about the type of registry. Staff J also reported staff did not monitor or supervise the resident any differently than other residents because we don't really know anything about what (he/she) did so we don't know what to watch for. During an interview on 2/12/19 at 1:45 p.m., Direct Care Staff K denied knowledge of resident #8's inclusion on a Sex Offender registry. Staff K then provided a name of another current resident (#10) who he/she believed was on the registry. During an interview on 2/12/19 at 2:24 p.m., Social Services Staff I reported knowledge of resident #8's long standing inclusion on the Sex Offender Registry and reported the resident told him/her about being on the registry. According to Staff I, the resident reported the reason for placement on the registry was an incident which involved a child several years ago. Social Services Staff I confirmed the Sex Offender Registry information was not included on the resident's plan of care and staff may not be aware of this information. Staff I named 3 current residents (#8, 9, 10) who are included on the Sex Offender registry for the State of Kansas. According to Staff I, that information is not included on the care plan and direct care staff may not be aware of the registry placement for these 3 residents. The facility's 09/2012 Abuse/Behavior policy lacked guidance related to management of residents with known inclusion on criminal registries, including the State of Kansas Sex Offender registry. The facility's 1/23/17 Resident Prisoner and Sex Offender Policy included a process to screen potential new admissions but lacked guidance related to screening of existing residents. The policy included, Upon admission of a resident directly from prison or a resident who is on the Sex Offender Registry, the Interdisciplinary Care Team shall be made aware of the resident's circumstances to appropriately plan for the safe admission and care of the resident and others during his or her stay. These measures shall be clearly expressed in the resident's care plan so that other staff members may be made aware and shall ensure such practices are followed appropriately. The facility failed to have a system in place to protect all residents from potential abuse from residents #8, a known sex offender currently required to register on the Kansas Sex Offender registry. Failure to have a system in place to protect all residents placed facility residents in immediate jeopardy. - Resident #9's clinical record included a resident profile which noted admission to the facility on [DATE]. The resident's 12/21/18 Quarterly MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 15), the need for supervision only with transfers and an ability to walk without staff assistance. The resident's care plan lacked any information related to his/her sexual history and inclusion on the State of Kansas Sex offender registry. A check of the State of Kansas Sex Offender registry found at kbi.ks.gov/registeredoffender revealed resident #9 was currently included on the registry for for electronic solicitation of a [AGE] year old child. According to the registry listing, the resident must remain on the registry for a total of [AGE] years after conviction. During an observation on 2/12/19 at 2:00 p.m., resident #9 moved about the facility independently using a motorized scooter. The resident responded appropriately to questions and displayed no evidence of cognitive impairment. During an interview on 2/12/19 at 1:10 p.m., Administrative Staff A reported an awareness of resident #9's placement on the Sex Offender registry. According to Staff A, the prior corporate owners of the facility did not require background screenings on residents prior to admission. The corporation who assumed ownership 12/1/18 require the screening but only for newly admitted residents. Administrative Staff A also confirmed the decision was made to not provide other staff such as direct care staff with the registry status information because they wanted the resident to be care for and treated fairly. During an interview on 2/12/19 at 1:20 p.m., Direct Care Staff J denied knowledge of resident #9's inclusion on the State of Kansas Sex Offender registry. During an interview on 2/12/19 at 1:45 p.m., Direct Care Staff K denied knowledge of resident #9's inclusion on a Sex Offender registry. Staff K then provided a name of another current resident (#10) who he/she believed was on the registry. During an interview on 2/12/19 at 2:24 p.m., Social Services Staff I reported knowledge of resident #9's inclusion on the Sex Offender Registry. Social Services Staff I confirmed the Sex Offender Registry information was not included on the resident's plan of care and staff may not be aware of this information. Staff I named 3 current residents (#8, 9, 10) who are included on the Sex Offender registry for the State of Kansas. According to Staff I, that information is not included on the care plan and direct care staff may not be aware of the registry placement for these 3 residents. The facility's 09/2012 Abuse/Behavior policy lacked guidance related to management of residents with known inclusion on criminal registries, including the State of Kansas Sex Offender registry. The facility's 1/23/17 Resident Prisoner and Sex Offender Policy included a process to screen potential new admissions but lacked guidance related to screening of existing residents. The policy included, Upon admission of a resident directly from prison or a resident who is on the Sex Offender Registry, the Interdisciplinary Care Team shall be made aware of the resident's circumstances to appropriately plan for the safe admission and care of the resident and others during his or her stay. These measures shall be clearly expressed in the resident's care plan so that other staff members may be made aware and shall ensure such practices are followed appropriately. The facility failed to have a system in place to protect all residents from potential abuse from resident #9, a known sex offender currently required to register on the Kansas Sex Offender registry. Failure to have a system in place to protect all residents placed the residents in immediate jeopardy. - Resident #10's clinical record included a resident profile which noted admission to the facility on [DATE]. The 1/9/19 Quarterly MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 15, the need for extensive assistance of two staff for transfers, and an inability to ambulate. The resident's 10/23/18 care plan lacked any information related to his/her sexual history and inclusion on the State of Kansas Sex offender registry. A check of the State of Kansas Sex Offender registry found at kbi.ks.gov/registeredoffender revealed resident #10 was currently included on the registry for for the sexual assault/rape of a [AGE] year old. During an interview on 2/12/19 at 1:10 p.m., Administrative Staff A reported an awareness of resident #10's placement on the Sex Offender registry. According to Staff A, the prior corporate owners of the facility did not require background screenings on residents prior to admission. The corporation who assumed ownership 12/1/18 require the screening but only for newly admitted residents. Administrative Staff A also confirmed the decision was made to not provide other staff such as direct care staff with the registry status information because they wanted the resident to be care for and treated fairly. During an interview on 2/12/19 at 1:20 p.m., Direct Care Staff J denied knowledge of resident #10's inclusion on the State of Kansas Sex Offender registry. During an interview on 2/12/19 at 1:45 p.m., Direct Care Staff K confirmed an awareness of resident #10's inclusion on the Sex Offender registry. Staff K denied knowledge of why the resident was required to be on that registry. During an interview on 2/12/19 at 2:24 p.m., Social Services Staff I reported knowledge of resident #10's inclusion on the Sex Offender Registry. Social Services Staff I confirmed the Sex Offender Registry information was not included on the resident's plan of care and staff may not be aware of this information. Staff I named 3 current residents (#8, 9, 10) who are included on the Sex Offender registry for the State of Kansas. According to Staff I, that information is not included on the care plan and direct care staff may not be aware of the registry placement for these 3 residents. The facility's 09/2012 Abuse/Behavior policy lacked guidance related to management of residents with known inclusion on criminal registries, including the State of Kansas Sex Offender registry. The facility's 1/23/17 Resident Prisoner and Sex Offender Policy included a process to screen potential new admissions but lacked guidance related to screening of existing residents. The policy included, Upon admission of a resident directly from prison or a resident who is on the Sex Offender Registry, the Interdisciplinary Care Team shall be made aware of the resident's circumstances to appropriately plan for the safe admission and care of the resident and others during his or her stay. These measures shall be clearly expressed in the resident's care plan so that other staff members may be made aware and shall ensure such practices are followed appropriately. The facility failed to have a system in place to protect all residents from potential abuse from resident #10, a known sex offender currently required to register on the Kansas Sex Offender registry. Failure to have a system in place to protect all residents placed the residents in immediate jeopardy. The facility abated the immediate jeopardy on 2/13/19 at 9:59 p.m. when they took the following corrective action: o Completed a house wide audit of current residents on sex offender status. o Completed ANE interviews with residents throughout the facility - no new reports of ANE were identified o Completed skin assessments/physical assessments on all residents who were unable to be interviewed due to cognitive status. o Completed staff education face to face prior to the start of their next scheduled shifts. Education included informing staff of the revised policy related to screening of residents for sexual offender status, the names of current sex offenders residing in the facility and the location of the newly developed notebooks which included information about the sex offenders. o Updated care plans for all residents identified as registered sex offenders including offense status, safety measures implemented and any restrictions noted from the registry o Developed notebooks for staff reference which included current residents included on Sex Offender registries, the nature of their offenses, and any restrictions noted from the registry. After abatement, the deficiency remained at a scope/severity F.

The facility had a census of 89 residents with 13 residents selected for sample. Three sampled residents experienced falls. Based on observation, interview and record review, the facility failed to ensure 3 of 3 residents who experienced falls received adequate supervision to prevent additional falls. (Residents #1, 4, 5) Findings included: - Resident #5's clinical record included a [DIAGNOSES REDACTED]. The 10/2/18 Quarterly MDS (Minimum Data Set) identified the resident with no cognitive impairment, the need for extensive assistance of two staff for bed mobility, functional limitations in range of motion on one side of the lower extremities, and no falls since the prior assessment. The 12/17/18 Significant Change MDS identified the resident with no cognitive impairment, total dependence on two staff for bed mobility and one fall with major injury since the prior assessment. The 12/4/18 care plan noted the resident's total dependence on two staff for bed mobility. The MDS defined bed mobility as how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture. The 12/10/18 Fall Risk Assessment identified the resident with a moderate risk for falls. Staff recorded the resident's weight as 312 lbs (pounds) on 12/10/18. Progress Notes included: 12/10/18 at 1:15 a.m.: Described a fall from bed which occurred while a direct care staff member performed peri-care (cleansing of the genital/rectal area). According to the note, the resident fell off the bed and onto the metal base of the bedside table. The resident immediately complained of pain to the right knee. The physician ordered X-rays and the note referred to a subsequent [DIAGNOSES REDACTED]. The facility's investigation of the incident revealed Direct Care Staff G failed to utilize another staff member to assist with perineal care as directed by the care plan. During care, the resident rolled out of bed and onto the floor and fractured his/her right leg. According to Direct Care Staff G's statement, resident #5 preferred female staff and another female staff member was not available so he/she provided the care without assistance. During an observation on 2/6/19 at 1:30 p.m., Direct Care Staff E and F prepared to change resident #5's incontinence brief. The resident required assistance of two staff to roll side to side in bed in order to facilitate removal and replacement of the brief. During an interview on 2/6/19 at 1:30 p.m., Direct Care Staff E reported resident #5 required assistance of two staff for bed mobility prior to the fracture. During an interview on 2/5/19 at 1:30 p.m., resident #5 reported he/she fell from the bed recently. According to the resident, staff raised the bed up real high and rolled him/her into a side lying position. The resident reported he/she rolled onto the bedside table, the table collapsed, and the resident fell to the floor, injuring the right leg. During an interview on 2/6/19 at 1:50 p.m., Licensed Nurse C reported the facility honors resident preferences for caregivers as related to gender and, if two females are not assigned to the unit, staff should just borrow someone from the other side for a few minutes. During an interview on 2/6/19 at 2:30 p.m., Administrative Nurse B reported the aides considered bed mobility as pulling the resident up in bed but not turning the resident side to side such as required during perineal care. During an interview on 2/6/19 at 2:30 p.m., Administrative Staff A reported the facility took immediate corrective action to prevent further similar incidents. Staff A provided evidence of actions taken which included immediate suspension of Direct Care Staff G, education of 63 staff members on 12/10/18 and 12/11/18 as related to following the care plan, assistance with bed mobility, and how to ensure staff honored the resident's preferences for caregiver gender by asking for assistance from the other nursing unit. Additionally, Administrative Staff A provided dated sign in sheets for QAPI (Quality Assurance Performance Improvement) meetings held on 12/10/18, 12/11/18, 12/21/18 and 1/18/19 for the purpose of addressing the 12/10/18 incident and implementing appropriate systems to ensure similar incidents did not occur in the future. The facility's 09-2015 Fall - Clinical Protocol lacked guidance related to staff following the resident's care plan. The facility failed to provide resident #5 with adequate supervision to prevent accidents when staff failed to provide care as directed by the care plan and the resident subsequently rolled off the bed and fractured his/her leg. The facility implemented corrective action beginning on 12/10/18 as follows: o Immediately suspended the staff member involved in the incident. o Completed staff education to 63 staff members on 12/10/18 and 12/11/18 to address following the care plan, assistance with bed mobility, and how to ensure staff honored the resident's preferences for caregiver gender by asking for assistance from the other nursing unit. o Immediately conducted a QAPI meeting on 12/10/18 to develop a plan to ensure similar incidents did not occur in the future. The facility conducted additional QAPI meetings related to this incident on 12/11/18, 12/21/18 and 1/18/19. The G (harm level) finding was corrected on 12/11/19 and was considered past noncompliance, however the deficient practice remained at a D. - Resident #4's clinical record included a 12/20/18 Quarterly MDS (Minimum Data Set) which identified the resident with moderate cognitive impairment (Brief Interview for Mental Status score of 12), the ability to walk in his/her room with supervision of one staff member, impaired balance moving from seated to standing and only able to stabilize with staff assistance, impaired balance in surface to surface transfers and only able to stabilize with staff assistance, no limitations in range of motion to the arms or legs, use of a walker and wheelchair, and two or more non-injury falls since the prior assessment. Resident #4's 7/10/18 care plan identified the residents as at risk for falls due to impaired balance, poor coordination, unsteady gait, [MEDICAL CONDITION] (progressive nervous system disorder that affects movement) and a history of falls. The 12/14/18 Fall Risk Assessment identified resident #4 as high risk for falls. Progress Notes included the following entries related to falls: 12/25/18 at 5:00 a.m.: Described an unwitnessed fall in the resident's bathroom. The resident stated he/she tried to use the bathroom and fell . The resident did not sustain any injury as a result of the fall. The Fall Investigation concluded the resident fell because he/she failed to ask for assistance to the bathroom. The facility failed to consider the need to toilet as the root cause/causal factor which contributed to the fall. Staff reviewed/revised the care plan on 12/25/18 with the intervention educated to use call light and ask for assistance when transferring. The care plan lacked evidence of development/implementation of fall prevention strategies based on the root cause of the 12/5/18 fall which was related to the need to toilet. 12/26/19 at 9:00 a.m.: Described an unwitnessed fall which occurred when the resident attempted to reach for his/her cane and fell to the floor. The fall was not related to toileting as in the 12/25/8 fall. The resident received a laceration (cut) to the head which required transfer to the emergency room and placement of sutures (stitches). Staff reviewed/revised the care plan after the 12/6/19 fall to include an intervention to keep the resident's cane and wheelchair within reach. 12/30/18 at 3:00 p.m.: Described an unwitnessed fall which occurred when the resident reported he/she got up to get some money, lost his/her balance and fell to the floor. The resident did not sustain any injury in the fall. According to the 12/30/18 fall investigation, staff determined the root cause/causal factor as found to be getting up without assistance. The investigation noted care plan interventions were in place and followed at the time of the fall. The care plan lacked evidence of review/revision with interventions based on causal factors after the 12/30/18 fall. During an observation on 2/6/19 at 7:45 a.m., resident #4 walked a short distance in the hallway assisted by Therapy Staff H. The resident walked with a slow, shuffling gait. After ambulating approximately 10 feet, staff assisted the resident to the wheelchair for transportation to another location. During an interview on 2/6/19 at 7:45 a.m., Therapy Staff H reported the resident recently started therapy again, in part due to frequent falls. During an interview on 2/6/19 at 11:30 a.m., Administrative Nurse B reported he/she expected staff to complete assessment of causal factors after each fall. Nurse B also reported the resident fell on [DATE] when he/she tried to ambulate to the toilet. The fall on 12/26/18 occurred when the resident attempted to reach his/her cane, therefore the two falls did not have a common cause. The facility's 09-2015 Falls - Clinical Protocol policy lacked specific guidance related to completion of root cause/causal factors after each fall with subsequent development/implementation of new interventions based on the root cause. The facility failed to provide resident #4 with supervision to prevent accidents when staff failed to assess for causal factors/root cause after each fall and then develop/implement interventions based on the causal factors. - Resident #1's clinical record included a [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE]. The Fall Risk Assessment completed on 12/23/18 identified the resident as high risk for falls. The 12/21/18 Baseline Care Plan noted the resident's fall history prior to admission and the family's reports the resident fell twice daily at home. The care plan also identified the resident as alert, lethargic (an abnormal state of sleepiness/drowsiness) and confused. Progress Notes included: 12/22/18 at 7:20 a.m.: A Late Entry described an unwitnessed fall on 12/21/18 which occurred when the resident reported he/she attempted to go to the bathroom without assistance of staff. The Fall Investigation noted the resident's attempts to toilet independently prior to the fall. The intervention implemented after the fall was to place a scoop mattress on the bed rather than address the resident's toileting needs. Staff reviewed/revised the care plan to include placement of a scoop mattress on the resident's bed and to educate the resident to use the call light for help. 12/23/18 at 4:00 p.m.: Described a witnessed fall near the nurse's station which occurred when the resident attempted to stand from a seated position in the wheelchair. The resident complained of hip pain after the fall and was subsequently diagnosed with [REDACTED]. The resident was transported to the facility on [DATE] after [DIAGNOSES REDACTED]. During an interview on 2/6/19 at 11:30 a.m., Administrative Nurse B reported he/she expected staff to complete root cause analyses/assessment of causal factors after falls. According to Nurse B, the resident's fall on 12/3/18 was unrelated to his/her need to toilet. The facility's 09-2015 Falls - Clinical Protocol policy lacked specific guidance related to completion of root cause/causal factors after each fall with subsequent development/implementation of new interventions based on the root cause. The facility failed to provide resident #1 with supervision to prevent accidents when staff failed to assess for causal factors/root cause after each fall and then develop/implement interventions based on the causal factors.

The facility census totaled 62 residents. The sample included 6 residents reviewed for accident hazards outside of the facility. Based on observation, interview, and record review the facility failed to identify accident hazards and potential for serious injury for one resident with functional limitations which placed the resident at risk for immediate jeopardy related to accidents. The resident fell and sustained a sprained ankle after he/she left the facility and walked 1.1 miles during the early morning hours before sunrise on 7/14/17 without the facility's knowledge. (#1) Findings included: - Review of the physician's progress note dated 6/15/17 revealed the resident was evaluated for unsteady gait, seizures, cerebral vascular accident (CVA/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), memory loss, seizures, and leg spasms. Review of the physician order [REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 13 (cognitively intact). The MDS revealed the resident walked and transferred independently, had unsteady gait and had functional limitation to one upper and lower extremity. Review of the activities of daily living (ADL) care area assessment (CAA) dated 8/18/16 revealed the resident required assistance of staff to compete his/her ADLs daily, the resident remained alert and oriented most days since admission, and the resident required a wander guard (an alarm system that alerts the staff of a resident attempt to leave the building unsupervised). Review of the fall CAA dated 8/19/16 revealed the resident required 15 minute checks for safety to reduce his/her risk for falls. Review of the return to the community CAA dated 8/19/16 revealed the resident wished to return to the community and the facility indicated resident #1 may try to leave the facility. The facility placed a wander guard bracelet on the resident related to cognitive and mobility impairments. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact). The MDS revealed the resident ambulated, transferred, and walked independently. The resident walked with unsteady gait and had functional limitation to the one upper and lower extremity. Review of the resident's activity care plan last revised on 6/6/17 revealed the resident liked to leave the facility on leave of absences (LOA) approved by the physician. The care plan directed the staff to monitor the resident for effects related to heat, extended amount of time outdoors, and observe and report signs and symptoms of over exposure to heat. A care plan revision on 7/14/17 revealed a LOA order obtained, education completed and he/she verbalized understanding, and he/she would follow the LOA protocol. Review of the resident's fall care plan last revised 6/6/17 revealed the resident was at risk for falls and had a history of [REDACTED]. [REDACTED]. Review of the social service progress note dated 4/20/17 at 2:30 p.m. revealed the resident scored a 12 (moderate cognitive impairment) on his/her BIMS. The resident was oriented x 3 (person, place, and time). The resident made his/her own decisions but always included his/her family with decision making on significant issues. Review of the nurse's progress note dated 7/13/17 at 9:12 p.m. revealed the resident came to the nurse's station at 2:30 p.m. and revealed he/she intended to leave the facility. The resident wrote smoke shop on the sign out book. The resident failed to return. The facility contacted the resident's family member and he/she agreed to contact the resident. The facility notified the resident's family member he/she left the facility at 2:45 p.m. and had not returned. The note revealed the resident was at someone's house in the south part of Wichita. Review of the physician's orders [REDACTED]. Review of the wunderground.com weather application revealed on 7/13/17 at 1:53 p.m. listed the temperature at 97 degrees Fahrenheit (F) with a heat index of 102.2 degrees F, 3:53 p.m. listed the temperature at 100.9 degrees F with a heat index of 104.6 degrees F, and at 4:53 p.m. listed the temperature at 100 degrees F with heat index of 103 degrees F. Further review revealed a chance of thunderstorms with wind speed listed 31-38 miles per hour (MPH) at 6:31 p.m. on 7/13/17. Information provided by the facility documented the resident traveled approximately ten miles when he/she left the faciity on [DATE]. The speed limits on the roads between the facility and south part of Wichita range from 30 to 60 miles per hour. Review of the Map Quest application revealed six highly traveled intersections between the facility and the south part of Wichita. Review of the nurse's progress note dated 7/14/17 at 3:12 a.m. revealed the resident returned to the facility at 11:00 p.m. escorted by a family member. The family member requested the facility not to allow the resident to leave the building. Staff informed the family member the resident could leave the building on his/her own accord. The facility contacted the physician and the physician gave the order for LOA PRN(as needed). Staff informed the family member of the physician's new orders. The note failed to indicate the resident's condition upon his/her return to the facility. Review of the nurse's progress note dated 7/14/17 at 6:25 a.m. revealed staff identified the resident was not in his/her room at 5:45 a.m. The Wichita Police Department called the facility at 6:10 a.m. and informed the facility the resident was found down the street and refused to return to the building. The facility contacted the physician and family. Review of the nurse's progress note dated 7/14/17 at 11:35 a.m. revealed a staff member spoke with the resident regarding him/her not following the facility LOA policy. The resident revealed he/she intended to go to a friend's house and exercise. The resident revealed he/she understood the facility required him/her to sign out prior to a LOA but the resident revealed he/she left the building without signing out anyway. Review of the nurse's progress note dated 7/14/17 at 12:54 p.m. revealed the resident stated he/she fell when out of the building on a LOA and scraped his/her hand. The resident had a 0.4 centimeter (cm) x 0.4 cm reddened non-open area to the left hand. The resident revealed he/she was a few blocks away from the facility when he/she fell . Staff notified the resident's family and physician. Review of a fall investigation dated 7/14/17 revealed the resident told the facility staff he/she fell while out of the building on a LOA. The facility identified the resident left the facility around 5:45 a.m. to 5:55 a.m. and the local Police Department (PD) and Emergency Medical Services (EMS) found him/her. The PD called the facility between 6:00 a.m.-6:10 a.m. and reported they had the resident and returned him/her to the facility. The investigation failed to identify the location of the resident when the PD and EMS located him/her. The facility determined a wet sloped sidewalk to be the casual factor of the fall. The staff identified a 0.4 centimeter (cm) x 0.4 cm scrape to the left hand. The resident complained of pain to his/her left ankle later in the day. The facility notified the doctor and an x-ray revealed no acute fracture. The resident sustained [REDACTED]. Review of the wunderground.com weather application revealed on 7/14/17 at 4 a.m. through 6 a.m. the area had heavy rain and thunderstorms. Observation on 7/18/17 at 3:51 p.m. revealed the resident walked in the corridor without assistive devices. The resident had unsteady gait and functional limitations to the left arm and leg. Interview on 7/18/17 at 9:15 a.m. with resident #1's family member revealed he/she picked up his/her family member from a house on a busy street approximately 8 miles away from the facility on 7/13/17. He/she revealed the resident reported he/she had been robbed while out of the facility on 7/13/17. The family member revealed he/she returned the resident to the facility at 8:00 p.m. He/she revealed the resident left the facility again at sometime between 8:00 p.m. and 4:00 a.m. The family member revealed he/she received a text message around 4 a.m. from his/her family member which stated he/she fell , hurt his/her ankle, could not get up, and required help. The family member revealed he/she slept through the text alert and was awakened by a phone call from the resident's friend at 5:30 a.m. to inform him/her the resident needed help. The family member revealed he/she called 911 and requested help for his/her family member. He/she revealed the police department informed him/her the resident fell on a sloped sidewalk approximately 1.1 miles from the facility at a busy intersection. Interview with resident #1 on 7/18/17 at 11:04 a.m. revealed he/she left the building about 5 days ago, and walked to the south part of Wichita. The resident revealed he/she was robbed and the person took the last $7.00 he/she had. The resident revealed he/she required his/her family member to come pick him/her up because he/she was too tired to make it back to the facility. The resident revealed he/she left the facility at some point after his/her family member returned him/her to the building that evening and fell on the side walk and hurt his/her hand. The resident could not remember the date or the time he/she left the facility or where he/she intended to go when he/she left the building. Interview with direct care staff B on 7/18/17 at 11:25 a.m. revealed the resident had long-term memory impairment. Staff B revealed he/she did not think it was safe for resident #1 to be walking around unsupervised outside of the facility related to his/her impaired decision making ability and the resident's unsteady gait related to the effects of his/her stroke. Interview on 7/19/17 at 6:24 a.m. with licensed nursing staff C revealed he/she worked the morning the police department called and informed the facility the resident fell while out of the building. Staff C revealed the facility did not know the resident left the building until the police department called and informed them. Staff C revealed he/she felt the resident was unsafe to be outside of the facility in the middle of the night. Staff C revealed the traffic on the road outside the facility was heavy at all hours of the day and night with a speed limited of 40 mph and the location of the facility was not in a safe neighborhood especially at night. Interview on 7/19/17 at 2:20 p.m. with therapy staff D revealed the facility admitted the resident for therapy after he/she suffered a CVA in (MONTH) (YEAR). Staff D revealed the resident failed to make progress and no longer received therapy. Staff C confirmed the resident had impaired function to the left arm and leg related to the CVA. Staff D revealed he/she believed the resident could have walked approximately 8 miles from the facility but believed it was not safe and would not advise the resident walk that far unsupervised. Interview on 7/18/17 at 1:30 p.m. with administrative staff A revealed resident #1 was alert, oriented and deemed safe to leave the facility unattended. Staff A revealed physician E wrote the clarification orders for the resident's leave of absence because the resident's family member requested the resident not be allowed to leave the facility without someone attending him/her for his/her safety. Staff A revealed the building informed the family member he/she could not make those decisions yet because the resident was cognitively intact and physician E agreed. Staff E confirmed he/she did not know the resident walked approximately 8 miles from the facility on 7/13/17, did not know long he/she was away from the facility, and had no idea the resident had been robbed. Staff A revealed the resident had not signed out of the facility between 7/13/17 at 8:00 p.m. and 7/14/17 at 4:00 a.m. Staff A revealed he/she observed the resident in bed in his/her room at 3:30 a.m. on 7/14/17 during a facility drill. Staff A revealed the resident's wander guard bracelet had been discontinued shortly after his/her admission related to him/her no longer being considered a risk of leaving the building without staff's knowledge. Staff A confirmed the resident had physical impairments to his/her left arm and leg and was at risk for falls related to the limitations. Interview on 7/24/17 at 12:35 p.m. with administrative staff A revealed the facility held a care plan meeting with the resident and his/her family last week. Staff A revealed the family reported he/she received a text around 4:07 a.m. on 7/14/17 from the resident which stated he/she fell , could not get up and hurt his/her ankle. Staff A revealed he/she attempted to check the resident's phone to determine a possible time he/she was out of the facility and could not obtain information prior to 7/16/17. Staff A revealed the resident reported he/she left the facility for approximately an hour from the time he/she left the building and was returned by police/EMS. Interview on 7/18/17 at 11:35 a.m. with physician E revealed he/she deemed the resident competent and safe to leave the facility on a LOA. Physician E revealed the resident admitted to the facility for residual effects of a CVA and functional limitations to his/her left side causing unsteady gait. Physician E revealed the facility could not be responsible for the decisions the resident made that affected his/her safety when he/she was outside of the facility. Review of the Leave of Absence policy dated 3/2010 revealed the purpose of the policy was to obtain physician permission for a leave of absence from the center. The policy directed the staff to document the patient's condition at the time of leave, date and time of patient return, including changes in condition and conversation with the patient/authorized representative, physician, and administrator as indicated if the patient does not return to the center at the anticipated time of return. The facility failed to identify the potential risk for injury for resident #1 while out of the facility unsupervised. The resident left the facility without the facility's knowledge, fell and laid on the ground until the resident made contact with his/her family member and the family member alerted police the resident needed assistance, which placed the resident in immediate jeopardy for harm related to leaving the facility and potential for injuries outside the facility. The facility abated the immediate jeopardy on 7-23-17 at 2:00 PM by implementation of the following corrective actions: The facility changed the exit door codes on 7/19/17. The facility provided current residents and/or resident representative education on the therapeutic leave policy, process via live/phone conversation and/or mail. Follow up phone calls were completed to validate receipt of education and understanding of information. The facility completed evaluations for resident #1 to determine mental, physical and emotional capabilities to be able to leave the facility unsupervised. The facility also completed evaluations on other residents to ensure ability for leave of absence (LOA), with appropriate care plan and interventions and physician orders. Each time a resident requests a therapeutic LOA the facility will review the care plan for identification / evaluation of the residents cognitive and physical abilities including the resident's safety awareness to determine if resident is safe to be unsupervised for LOA. The facility completed training for all facility staff on 7/23/17 regarding the LOA policy and procedures for LOA. The facility also reviewed and revised the facility LOA policy. After abatement, the deficient practice remained at a scope/severity of a D.

The facility census totaled 62 residents. The sample included 6 residents reviewed for accident hazards outside of the facility. Based on observation, interview, and record review the facility failed to identify accident hazards and potential for serious injury for one resident with functional limitations which placed the resident at risk for immediate jeopardy related to accidents. The resident fell and sustained a sprained ankle after he/she left the facility and walked 1.1 miles during the early morning hours before sunrise on 7/14/17 without the facility's knowledge. (#1) Findings included: - Review of the physician's progress note dated 6/15/17 revealed the resident was evaluated for unsteady gait, seizures, cerebral vascular accident (CVA/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), memory loss, seizures, and leg spasms. Review of the physician order [REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 13 (cognitively intact). The MDS revealed the resident walked and transferred independently, had unsteady gait and had functional limitation to one upper and lower extremity. Review of the activities of daily living (ADL) care area assessment (CAA) dated 8/18/16 revealed the resident required assistance of staff to compete his/her ADLs daily, the resident remained alert and oriented most days since admission, and the resident required a wander guard (an alarm system that alerts the staff of a resident attempt to leave the building unsupervised). Review of the fall CAA dated 8/19/16 revealed the resident required 15 minute checks for safety to reduce his/her risk for falls. Review of the return to the community CAA dated 8/19/16 revealed the resident wished to return to the community and the facility indicated resident #1 may try to leave the facility. The facility placed a wander guard bracelet on the resident related to cognitive and mobility impairments. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact). The MDS revealed the resident ambulated, transferred, and walked independently. The resident walked with unsteady gait and had functional limitation to the one upper and lower extremity. Review of the resident's activity care plan last revised on 6/6/17 revealed the resident liked to leave the facility on leave of absences (LOA) approved by the physician. The care plan directed the staff to monitor the resident for effects related to heat, extended amount of time outdoors, and observe and report signs and symptoms of over exposure to heat. A care plan revision on 7/14/17 revealed a LOA order obtained, education completed and he/she verbalized understanding, and he/she would follow the LOA protocol. Review of the resident's fall care plan last revised 6/6/17 revealed the resident was at risk for falls and had a history of [REDACTED]. [REDACTED]. Review of the social service progress note dated 4/20/17 at 2:30 p.m. revealed the resident scored a 12 (moderate cognitive impairment) on his/her BIMS. The resident was oriented x 3 (person, place, and time). The resident made his/her own decisions but always included his/her family with decision making on significant issues. Review of the nurse's progress note dated 7/13/17 at 9:12 p.m. revealed the resident came to the nurse's station at 2:30 p.m. and revealed he/she intended to leave the facility. The resident wrote smoke shop on the sign out book. The resident failed to return. The facility contacted the resident's family member and he/she agreed to contact the resident. The facility notified the resident's family member he/she left the facility at 2:45 p.m. and had not returned. The note revealed the resident was at someone's house in the south part of Wichita. Review of the physician's orders [REDACTED]. Review of the wunderground.com weather application revealed on 7/13/17 at 1:53 p.m. listed the temperature at 97 degrees Fahrenheit (F) with a heat index of 102.2 degrees F, 3:53 p.m. listed the temperature at 100.9 degrees F with a heat index of 104.6 degrees F, and at 4:53 p.m. listed the temperature at 100 degrees F with heat index of 103 degrees F. Further review revealed a chance of thunderstorms with wind speed listed 31-38 miles per hour (MPH) at 6:31 p.m. on 7/13/17. Information provided by the facility documented the resident traveled approximately ten miles when he/she left the faciity on [DATE]. The speed limits on the roads between the facility and south part of Wichita range from 30 to 60 miles per hour. Review of the Map Quest application revealed six highly traveled intersections between the facility and the south part of Wichita. Review of the nurse's progress note dated 7/14/17 at 3:12 a.m. revealed the resident returned to the facility at 11:00 p.m. escorted by a family member. The family member requested the facility not to allow the resident to leave the building. Staff informed the family member the resident could leave the building on his/her own accord. The facility contacted the physician and the physician gave the order for LOA PRN(as needed). Staff informed the family member of the physician's new orders. The note failed to indicate the resident's condition upon his/her return to the facility. Review of the nurse's progress note dated 7/14/17 at 6:25 a.m. revealed staff identified the resident was not in his/her room at 5:45 a.m. The Wichita Police Department called the facility at 6:10 a.m. and informed the facility the resident was found down the street and refused to return to the building. The facility contacted the physician and family. Review of the nurse's progress note dated 7/14/17 at 11:35 a.m. revealed a staff member spoke with the resident regarding him/her not following the facility LOA policy. The resident revealed he/she intended to go to a friend's house and exercise. The resident revealed he/she understood the facility required him/her to sign out prior to a LOA but the resident revealed he/she left the building without signing out anyway. Review of the nurse's progress note dated 7/14/17 at 12:54 p.m. revealed the resident stated he/she fell when out of the building on a LOA and scraped his/her hand. The resident had a 0.4 centimeter (cm) x 0.4 cm reddened non-open area to the left hand. The resident revealed he/she was a few blocks away from the facility when he/she fell . Staff notified the resident's family and physician. Review of a fall investigation dated 7/14/17 revealed the resident told the facility staff he/she fell while out of the building on a LOA. The facility identified the resident left the facility around 5:45 a.m. to 5:55 a.m. and the local Police Department (PD) and Emergency Medical Services (EMS) found him/her. The PD called the facility between 6:00 a.m.-6:10 a.m. and reported they had the resident and returned him/her to the facility. The investigation failed to identify the location of the resident when the PD and EMS located him/her. The facility determined a wet sloped sidewalk to be the casual factor of the fall. The staff identified a 0.4 centimeter (cm) x 0.4 cm scrape to the left hand. The resident complained of pain to his/her left ankle later in the day. The facility notified the doctor and an x-ray revealed no acute fracture. The resident sustained [REDACTED]. Review of the wunderground.com weather application revealed on 7/14/17 at 4 a.m. through 6 a.m. the area had heavy rain and thunderstorms. Observation on 7/18/17 at 3:51 p.m. revealed the resident walked in the corridor without assistive devices. The resident had unsteady gait and functional limitations to the left arm and leg. Interview on 7/18/17 at 9:15 a.m. with resident #1's family member revealed he/she picked up his/her family member from a house on a busy street approximately 8 miles away from the facility on 7/13/17. He/she revealed the resident reported he/she had been robbed while out of the facility on 7/13/17. The family member revealed he/she returned the resident to the facility at 8:00 p.m. He/she revealed the resident left the facility again at sometime between 8:00 p.m. and 4:00 a.m. The family member revealed he/she received a text message around 4 a.m. from his/her family member which stated he/she fell , hurt his/her ankle, could not get up, and required help. The family member revealed he/she slept through the text alert and was awakened by a phone call from the resident's friend at 5:30 a.m. to inform him/her the resident needed help. The family member revealed he/she called 911 and requested help for his/her family member. He/she revealed the police department informed him/her the resident fell on a sloped sidewalk approximately 1.1 miles from the facility at a busy intersection. Interview with resident #1 on 7/18/17 at 11:04 a.m. revealed he/she left the building about 5 days ago, and walked to the south part of Wichita. The resident revealed he/she was robbed and the person took the last $7.00 he/she had. The resident revealed he/she required his/her family member to come pick him/her up because he/she was too tired to make it back to the facility. The resident revealed he/she left the facility at some point after his/her family member returned him/her to the building that evening and fell on the side walk and hurt his/her hand. The resident could not remember the date or the time he/she left the facility or where he/she intended to go when he/she left the building. Interview with direct care staff B on 7/18/17 at 11:25 a.m. revealed the resident had long-term memory impairment. Staff B revealed he/she did not think it was safe for resident #1 to be walking around unsupervised outside of the facility related to his/her impaired decision making ability and the resident's unsteady gait related to the effects of his/her stroke. Interview on 7/19/17 at 6:24 a.m. with licensed nursing staff C revealed he/she worked the morning the police department called and informed the facility the resident fell while out of the building. Staff C revealed the facility did not know the resident left the building until the police department called and informed them. Staff C revealed he/she felt the resident was unsafe to be outside of the facility in the middle of the night. Staff C revealed the traffic on the road outside the facility was heavy at all hours of the day and night with a speed limited of 40 mph and the location of the facility was not in a safe neighborhood especially at night. Interview on 7/19/17 at 2:20 p.m. with therapy staff D revealed the facility admitted the resident for therapy after he/she suffered a CVA in August 2016. Staff D revealed the resident failed to make progress and no longer received therapy. Staff C confirmed the resident had impaired function to the left arm and leg related to the CVA. Staff D revealed he/she believed the resident could have walked approximately 8 miles from the facility but believed it was not safe and would not advise the resident walk that far unsupervised. Interview on 7/18/17 at 1:30 p.m. with administrative staff A revealed resident #1 was alert, oriented and deemed safe to leave the facility unattended. Staff A revealed physician E wrote the clarification orders for the resident's leave of absence because the resident's family member requested the resident not be allowed to leave the facility without someone attending him/her for his/her safety. Staff A revealed the building informed the family member he/she could not make those decisions yet because the resident was cognitively intact and physician E agreed. Staff E confirmed he/she did not know the resident walked approximately 8 miles from the facility on 7/13/17, did not know long he/she was away from the facility, and had no idea the resident had been robbed. Staff A revealed the resident had not signed out of the facility between 7/13/17 at 8:00 p.m. and 7/14/17 at 4:00 a.m. Staff A revealed he/she observed the resident in bed in his/her room at 3:30 a.m. on 7/14/17 during a facility drill. Staff A revealed the resident's wander guard bracelet had been discontinued shortly after his/her admission related to him/her no longer being considered a risk of leaving the building without staff's knowledge. Staff A confirmed the resident had physical impairments to his/her left arm and leg and was at risk for falls related to the limitations. Interview on 7/24/17 at 12:35 p.m. with administrative staff A revealed the facility held a care plan meeting with the resident and his/her family last week. Staff A revealed the family reported he/she received a text around 4:07 a.m. on 7/14/17 from the resident which stated he/she fell , could not get up and hurt his/her ankle. Staff A revealed he/she attempted to check the resident's phone to determine a possible time he/she was out of the facility and could not obtain information prior to 7/16/17. Staff A revealed the resident reported he/she left the facility for approximately an hour from the time he/she left the building and was returned by police/EMS. Interview on 7/18/17 at 11:35 a.m. with physician E revealed he/she deemed the resident competent and safe to leave the facility on a LOA. Physician E revealed the resident admitted to the facility for residual effects of a CVA and functional limitations to his/her left side causing unsteady gait. Physician E revealed the facility could not be responsible for the decisions the resident made that affected his/her safety when he/she was outside of the facility. Review of the Leave of Absence policy dated 3/2010 revealed the purpose of the policy was to obtain physician permission for a leave of absence from the center. The policy directed the staff to document the patient's condition at the time of leave, date and time of patient return, including changes in condition and conversation with the patient/authorized representative, physician, and administrator as indicated if the patient does not return to the center at the anticipated time of return. The facility failed to identify the potential risk for injury for resident #1 while out of the facility unsupervised. The resident left the facility without the facility's knowledge, fell and laid on the ground until the resident made contact with his/her family member and the family member alerted police the resident needed assistance, which placed the resident in immediate jeopardy for harm related to leaving the facility and potential for injuries outside the facility. The facility abated the immediate jeopardy on 7-23-17 at 2:00 PM by implementation of the following corrective actions: The facility changed the exit door codes on 7/19/17. The facility provided current residents and/or resident representative education on the therapeutic leave policy, process via live/phone conversation and/or mail. Follow up phone calls were completed to validate receipt of education and understanding of information. The facility completed evaluations for resident #1 to determine mental, physical and emotional capabilities to be able to leave the facility unsupervised. The facility also completed evaluations on other residents to ensure ability for leave of absence (LOA), with appropriate care plan and interventions and physician orders. Each time a resident requests a therapeutic LOA the facility will review the care plan for identification / evaluation of the residents cognitive and physical abilities including the resident's safety awareness to determine if resident is safe to be unsupervised for LOA. The facility completed training for all facility staff on 7/23/17 regarding the LOA policy and procedures for LOA. The facility also reviewed and revised the facility LOA policy. After abatement, the deficient practice remained at a scope/severity of a D.

The facility census totaled 82 residents with 22 included in the sample. Four residents were reviewed for abuse, neglect, and exploitation. Based on observations, interviews, and record review the facility failed to protect all residents from physical abuse related to resident #95 who had a history of [REDACTED]. This deficient practice placed (all or all on unit) residents in the facility in immediate jeopardy. The facility also failed to report an incident of abuse between resident #95 and #20 within 24 hours of occurrence as required. Findings included: - Review of resident #95's undated, signed physician order [REDACTED]. irrational fear), and [MEDICAL CONDITION] (MS-progressive disease of the nerve fibers of the brain and spinal cord). Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident understood others and could make him/herself understood. The resident had a brief interview for mental status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident had no signs of [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness), hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and no physical behavior directed toward others. The resident had verbal behavior symptoms directed toward others 1-3 days of the 7 day observation period that did not significantly interfere with the resident's participation in activities or social interactions and did not impact others. The resident did not reject care or wander. The resident required limited assistance of 1 staff with all cares except supervision with eating, locomotion, and personal hygiene. The resident used a walker and wheelchair for mobility. The resident received antipsychotic and antidepressant medications daily during the 7 day observation period. Review of the quarterly MDS dated [DATE] revealed the resident spoke clearly and could make him/herself understood and his/she understood others. The resident had a BIMS score of 6, indicating severe cognitive impairment. The resident had disorganized thinking that fluctuated in frequency and severity. The resident had verbal symptoms directed toward others and rejected cares 1-3 days of the 7 day observation period. The resident received antipsychotic and antidepressant medications daily for 7 days of the 7 day observation period. Review of the Cognitive Loss Care Area Assessment (CAA) and the Behavior CAA dated 10/21/16 revealed the resident became frustrated over his/her TV (television) not working 1 time during the observation period. The resident had behaviors of banging on the wall with his/her fist and calmed down with assistance from staff. Review of the Activities of Daily Living (ADLs) CAA dated 10/21/16 revealed the resident had a recent progressive balance and cognitive decline. He/she had a [DIAGNOSES REDACTED]. The resident attempted to get up and ambulate unassisted, however he/she fell during the attempt. Staff encouraged the resident to use the call light for assistance, but the resident had cognitive impairment. Review of the [MEDICAL CONDITION] CAA dated 10/21/16 revealed the resident received [MEDICATION NAME] and [MEDICATION NAME] due to increased outbursts toward others. The resident became angry quickly and was difficult to calm down by staff or family member interventions. The resident had increased safety needs due to outbursts when staff attempted to provide needs related to the reason he/she was angry. The resident calmed down after the situation resolved normally or with medication use. Review of the care plan dated 2/23/16 revealed verbal outbursts with aggression related to cognitive impairment, communication disorders/visual impairment and [MEDICAL CONDITION] disorder. Approaches included: 2/23/16- Allow the resident time to respond to directions or requests. 2/23/16- Approach the resident slowly and slightly on the side. 2/23/16- Gain the resident's attention before speaking or touching. 7/15/16- Administer the resident's medications as ordered. 9/26/16- Ensure there were no knives at resident's meal table. 10/24/16- If strategies were not working to calm the resident, leave, if safe to do so, and reapproach later. 11/10/16- Visual observation by staff when resident went out of his/her room. 2/14/17- Redirect the resident to an appropriate location. 2/14/17- Attempt to minimize excess stimulation. 3/3/17- one-on-one supervision at all times while providing the resident privacy when alone in his/her room per his/her preference. The resident ate meals in lounges or the private dining room. 3/3/17- Staff placed an indicator on the resident's door to remind him/her of the location of his/her room. Review of the progress notes revealed the following: 9/9/16 at 6:18 PM the resident had an outburst in the dining room, screaming and swinging. The resident grabbed the butter knife from the table and held it in his/her hand and pointed it towards another resident. The nurse intervened immediately. Later during the day, the resident calmed down. Emergency Medical Services (EMS) transferred the resident to a local hospital for evaluation and returned to the facility later in the day for the resident's physician to review medications. 9/9/16 at 11:48 PM noted that earlier in the day the nurse stood at the medication cart and heard a scream from the dining room. The nurse looked up and saw the resident with a butter knife in his/her hand swinging the knife. The nurse ran to the resident to calm him/her down and dietary staff told the nurse that the resident stated that he/she was going to kill another resident. The nurse got the butter knife away from the resident and had another aide sit with the resident while he/she ate. 11/10/16 at 11:11 AM the resident got very agitated before breakfast. When the nurse asked what was wrong he/she yelled and went towards another resident's room. The resident yelled shut up and started moving down the hallway into another resident's room. Staff redirected the resident from the other room and then the resident went down the hallway in his/her wheelchair at a fast pace. The resident turned around and started swinging his/her arms around. One resident said good morning to the resident and he/she turned and yelled shut up to him/her. The nurse followed behind the resident to ensure safety of the resident and other residents. 11/10/16 at 3:17 PM the progress note revealed the resident had a neurologist appointment and the neurologist noted the resident needed to be seen by psychologist for uncontrolled behavior problem/anger. 11/24/16 at 8:58 AM the resident came out of his/her room with a remote control in his/her hand and went into another resident's room. This nurse told the resident he/she could not be in that room so he/she backed his/her chair out while yelling and cursing. The resident then went into another resident room and both residents in that room, as well as this nurse told the resident he/she could not go in that room either. The resident then backed his/her chair out of the room and continued to yell, curse, and throw his/her arms around. The resident then went back into his/her room and shut the door. 2/9/17 at 7:30 PM the resident walked out of his/her room, yelling I want my show back! I want my show back! The resident continued walking to the next room, pushed the resident's shut door open, began swinging his/her arms yelling about his/her show to the staff assisting another resident. Staff attempted to redirect the resident but he/she continued yelling and swinging his/her arms. The nurse redirected the resident out of the room, reassured him/her that staff would help him/her with his/her TV then walked back to the resident's room as he/she continued to yell. Staff assisted the resident to find the channel and then he/she sat on the bed and watched TV. 2/10/17 at 4:15 AM SW informed the resident had gone into resident rooms, which frightened a resident. 2/13/17 1:11 PM the nurse contacted a psychiatric clinic for a screen regarding the resident's behavior. The psychiatric clinic said they would not evaluate the resident because they had completed evaluations of the resident in the past and did not feel the resident was harm to him/her or others and did not damage property, therefore he/she did not meet the requirements to conduct another evaluation. The psychiatric clinic staff suggested the facility contact the police when the resident displayed outbursts of behavior. 2/13/17 at 12:30 PM staff monitored the resident every 15 minutes. The resident had entered the room next to him/her unannounced (resident # 17's room). Resident #17 did not want the resident in his/her room. When staff tried to redirect the resident, he/she became easily agitated and verbally aggressive with confrontation. The progress notes revealed the resident remained on 15 minute checks through 2/20/17 and then staff started hourly checks which continued until 2/28/17 at 4:00 PM and staff monitored the resident per standard of care. (checked the resident every 2 hours) Review of the progress notes dated 3/2/17 at 9:58 PM revealed at 7:00 PM staff heard the resident yelling. Two nurse aides (direct care staff I and an unidentified direct care staff) responded see why and found resident #95 in resident #20's room yelling get out to resident #20. Resident #20 stated the other resident grabbed him/her by the arm and then tried to reach for his/her neck before backing up. Resident #95 went back to his/her room and then the nurse spoke with resident #20. The nurse tried to talk to resident #95 but he/she had his/her door barricaded shut and started yelling at the staff so staff left him/her alone. The nurse then called administrative nursing staff A about the situation and Staff A instructed the staff at the facility to call 911, EMS, and the resident's family member. Staff reported to the Police Department that staff called EMS to have the resident transported to the hospital per emergency discharge order from the resident's physician for increased aggressive behavior. EMS lacked a medical reason to transport the resident to the hospital so he/she remained in the facility. The record lacked evidence that the facility notified the State complaint hotline of the incident as required. 3/3/17 at 6:34 AM Staff monitored the resident one-on-one. Review of the progress notes revealed the resident remained on one-on-one observations during the survey process. Observation on 3/8/17 at 2:59 PM revealed the resident sat in the activity where staff provided nail care. Staff sat at a table beside the resident. The resident had a calm appearance and just watched the other residents in the area. Observation on 3/13/17 at 12:58 PM revealed the resident propelled his/her wheelchair down the west hall with direct care staff F right beside him/her and visiting about the trees blooming. During an interview on 3/9/17 at 8:41 AM resident # 20 reported resident #95 came into his/her room [ROOM NUMBER] different times. (Unable to say the exact dates of when this occurred) The first time resident #95 raised h*** saying the TV belonged to him/her and argued and then a staff member came in and took him/her out of the room. The second time resident #95 came in someone was right behind him/her and got him/her out. The 3rd time resident #95 stood at the end of resident #20's roommate's bed and said he/she came in to finish what he/she started last week, so just wait until I get through with you. Resident #20 reported he/she then got up off the bed and as he/she stood, resident #95 grabbed hold of both his/her arms hurting them and then he/she grabbed resident #20's neck with both hands. Resident #20 stated he/she pushed the other resident away with both hands and then a staff came in and made him/her (resident #95) leave the room. Resident #20 reported it happened a couple of weeks ago and he/she still did not feel safe in the facility. The resident stated the other resident (#95) was supposed to be moving but it did not happen. The resident reported he/she felt safe when he/she thought the other resident was leaving. Resident #20 reported he/she could still could see the other resident as he/she passed the door or in the hall. Resident #20 reported he/she started to have nightmares again about an individual that had physically abused him/her and had not had nightmares, prior to the incident with resident #95, in a lot of years. During an interview on 3/7/17 at 2:38 PM direct care staff JJ sat in a chair outside of the resident's room with the door shut. Staff JJ stated the resident's behavior was unpredictable and he/she could be fine for weeks and then all of a sudden get angry. Staff JJ stated when he/she had those moods he/she went into other resident rooms and scared them. During an interview on 3/6/17 at 4:37 PM direct care staff KK stated the resident had behavior problems and went into other resident rooms. Staff KK stated he/she stayed by the resident to make sure he/she did not go into any other resident rooms. During an interview on 3/6/17 at 5:08 PM direct care staff I reported when he/she worked last week, he/she heard yelling and thought it was resident #95 and another resident, but it was resident #95 and resident #20. Resident #20 stood by the bed telling resident #95 to get out of his/her room. When staff tried to get resident #95 out of the room he/she grabbed for the air mattress box attached to the end of the bed and tried to throw it. Staff separated the residents and resident #20 stated the other resident came into the room and grabbed his/her arm and tried to choke him/her. Staff I stated the staff now provide one-on-one supervision for resident #95. During an interview on 3/9/17 at 8:55 AM direct care staff F stated the resident yelled and flung his/her arms ran down the hall and he/she yelled, cussed and ran over staff when he/she had a bad day. Staff F stated he/she did not know of any specific interventions the facility did to prevent resident abuse from happening in the first place but the facility is doing the one-on-one now to keep it from happening again. Staff I stated the resident had altercations in the past with other residents. Staff I said there was an incident in the dining room where he/she threatened other residents with a table knife, he/she has run into staff, doors, and other things if they were in his/her way. During an interview on 3/9/17 at 9:03 AM direct care staff M reported the resident had outbursts, threw things and wandered in other resident rooms and messed with their stuff. Staff M stated he/she knew the resident #95 went into resident #20's room and he/she tried to choke him/her. During an interview on 3/6/17 at 4:54 PM licensed nursing staff H reported the resident needed one-on-one supervision because of some things that happened before the weekend. Staff H stated the resident went into another resident's room and grabbed his/her leg and tried grabbing his/her throat. During an interview on 3/13/17 at 12:48 PM administrative nursing staff LL reported a psychiatric nurse saw resident #20 after the incident to help with his/her memories of abuse and the resident voiced having nightmares only 1 time and did not complain of them again. During an interview on 3/9/17 at 6:12 PM administrative staff B reported that the facility had the psychiatric nurse come and talk to resident #20 after the incident and started resident #95 on the one-to-one observations right after the incident Review of the abuse policy dated 2016 revealed the purpose of the prevent process was to reduce patient risk, mitigate harm, identify root cause and associated factors and minimize the opportunity of recurrence. Resident protection actions included immediately removing the resident from contact with the alleged abuser during the investigation. If the alleged abuser is not an employee, measures are taken to provide a safe secure environment for the resident. Actions might include room change, daily schedule change, visitor restrictions and reporting to other agencies or law enforcement. The policy also revealed if no serious bodily injury occurred it must be reported within 24 hours of forming the suspicion. The facility failed to protect residents from physical abuse related to resident #95 who had a history of [REDACTED]. The facility also failed to report an incident of abuse between resident #95 and #20 within 24 hours of occurrence. This situation put resident #20 in immediate jeopardy. The facility abated the immediate jeopardy on 3/13/17 by the implementation of the following corrective actions: Ongoing monitoring to include 10 resident interviews which will be completed by the administrator / designee weekly for a month, then monthly for 2 months to ensure residents felt safe. The psychiatric physician would validate the discontinuation of one-on-one supervision prior to discontinuation. The Interdisciplinary Team was educated on 3/13/17 by the administrator on the process for the discontinuation of the one-on-one supervision and moved resident #95 to another area of the facility so resident #20 felt safe. Resident #95's care plan will be reviewed quarterly and with change of condition to include behavioral issues and interventions. Interdisciplinary team (IDT) will review resident behaviors weekly time 3 weeks then monthly times 2 months to ensure resident protection is initiated and plan of care and Kardex are up to date and reflect appropriate interventions. After abatement, the deficient practice remained at a scope/severity of an F.

The facility census totaled 82 residents with 22 included in the sample. Four residents were reviewed for abuse. Based on observations, interviews, and record review the facility failed to ensure residents were free from physical abuse from resident #95 who physically abused resident #20 and created an environment of fear due to his/her yelling, banging on walls, and threatening behaviors. This situation placed resident #20 in immediate jeopardy. Findings included: - Review of resident #95's undated, signed physician order [REDACTED]. irrational fear), and [MEDICAL CONDITION] (MS- progressive disease of the nerve fibers of the brain and spinal cord). Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident understood others and could make him/herself understood. The resident had a brief interview for mental status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident had no signs of [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness), hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and no physical behavior directed toward others. The resident had verbal behavior symptoms directed toward others 1-3 days of the 7 day observation period that did not significantly interfere with the resident's participation in activities or social interactions and did not impact others. The resident did not reject care or wander. The resident required limited assistance of 1 staff with all cares except supervision with eating, locomotion, and personal hygiene. The resident used a walker and wheelchair for mobility. The resident received antipsychotic and antidepressant medications daily during the 7 day observation period. Review of the quarterly MDS dated [DATE] revealed the resident spoke clearly and could make him/herself understood and understand others. The resident had a BIMS score of 6, which indicated severe cognitive impairment. The resident had disorganized thinking that fluctuated in frequency and severity. The resident exhibited verbal symptoms directed toward others and rejected cares 1-3 days of the 7 day observation period. The resident received antipsychotic and antidepressant medications daily for 7 days of the 7 day observation period. Review of the Cognitive Loss Care Area Assessment (CAA) and the behavior CAA dated 10/21/16 revealed the resident became frustrated over his/her TV (television) not working 1 time during the observation period. The resident exhibited behaviors of banging on the wall with his/her fist and calmed down with assistance from staff. Review of the Activities of Daily Living (ADLs) CAA dated 10/21/16 revealed the resident had a recent progressive decline in balance and cognition. He/she had a [DIAGNOSES REDACTED]. The resident attempted to get up and ambulate unassisted, however he/she fell during the attempt. Staff encouraged the resident to use the call light for assistance, but he/she had cognitive impairment. Review of the [MEDICAL CONDITION] CAA dated 10/21/16 revealed the resident received [MEDICATION NAME] (antidepressant medication) and [MEDICATION NAME] (antipsychotic medication) due to increased outbursts toward others. The resident became angry quickly and was difficult to calm down by staff or family member interventions. The resident had increased safety needs due to outbursts. The resident calmed down after the situation resolved normally or with medication use. Review of the care plan dated 2/23/16 revealed verbal outbursts with aggression related to cognitive impairment, communication disorders/visual impairment and [MEDICAL CONDITION] disorder. Approaches included: 2/23/16- Allow the resident time to respond to directions or requests. 2/23/16- Approach the resident slowly and slightly on the side. 2/23/16- Gain the resident's attention before speaking or touching. 7/15/16- Administer the resident's medications as ordered. 9/26/16- Ensure there were no knives at resident's meal table. 10/24/16- If strategies were not working to calm the resident, leave, if safe to do so, and reapproach later. 11/10/16- Visual observation by staff when resident went out of his/her room. 2/14/17- Redirect the resident to an appropriate location (when in other resident rooms). 2/14/17- Attempt to minimize excess stimulation. 3/3/17- one-on-one supervision at all times while providing the resident privacy when alone in his/her room per his/her preference. The resident ate meals in lounges or the private dining room. 3/3/17- Staff placed an indicator on the resident's door to remind him/her of the location of his/her room. Review of the progress notes revealed the following: 9/9/16 at 6:18 PM the resident had an outburst in the dining room, screaming and swinging. The resident grabbed the butter knife from the table and held it in his/her hand and pointed it towards another resident. The nurse intervened immediately. Later during the day, the resident calmed down. Emergency Medical Services (EMS) transferred the resident to a local hospital for evaluation and returned to the facility later the same day for the resident's physician to review medications. 9/9/16 at 11:48 PM noted that earlier in the day the nurse stood at the medication cart and heard a scream from the dining room. The nurse looked up and saw the resident with a butter knife in his/her hand swinging the knife. The nurse ran to the resident to calm him/her down. Dietary staff notified the nurse that the resident stated that he/she was going to kill another resident; staff got the butter knife away from the resident and had another aide sit with the resident while he/she ate. 11/10/16 at 11:11 AM the resident got very agitated before breakfast. When the nurse asked what was wrong, the resident yelled and went towards another resident's room. The resident yelled shut up and started moving down the hallway into another resident's room. Staff redirected the resident from the other room and then the resident went down the hallway in his/her wheelchair at a fast pace. The resident turned around and started swinging his/her arms around. One resident said good morning to the resident and he/she turned and yelled shut up to him/her. The nurse followed behind the resident to ensure safety of the resident and other residents. 11/10/16 at 3:17 PM neurologist progress note indicated the resident needed seen by a psychologist for uncontrolled behavior problem/anger. 11/24/16 at 8:58 AM the resident came out of his/her room with a remote control in his/her hand and went into another resident's room. This nurse told the resident he/she could not be in that room so he/she backed his/her chair out while yelling and cursing. The resident then went into another resident room and both residents in that room, as well as this nurse told the resident he/she could not go in that room either. The resident then backed his/her chair out of the room and continued to yell, curse, and throw his/her arms around. The resident then went back into his/her room and shut the door. 11/24/16 at 2:00 PM the resident became very agitated regarding his/her television and came out to the nursing station and began to yell and scream. The resident attempted to go behind the nurse's station, the nurse called his/her name and the resident yelled and struck the nurse on his/her left forearm. The resident continued to yell and scream down the hallway, in his/her wheelchair, while making multiple attempts to strike staff. 2/9/17 at 7:30 PM the resident walked out of his/her room, yelling I want my show back! I want my show back! The resident continued walking to the next room, pushed the resident's shut door open, began swinging his/her arms yelling about his/her show to the staff assisting another resident. Staff attempted to redirect the resident but he/she continued yelling and swinging his/her arms. The nurse redirected the resident out of the room, reassured him/her that staff would help him/her with his/her TV then walked back to the resident's room as he/she continued to yell. Staff assisted the resident to find the channel and then he/she sat on the bed and watched TV. 2/10/17 at 4:15 AM SW informed the resident had gone into resident rooms, which frightened a resident. 2/13/17 at 12:30 PM staff monitored the resident every 15 minutes. The resident had entered the room next to him/her unannounced (resident #17's room). Resident #17 did not want the resident in his/her room. When staff tried to redirect the resident, he/she became easily agitated and verbally aggressive with confrontation. 2/13/17 1:11 PM the nurse contacted a psychiatric clinic for a screen regarding the resident's behavior. The psychiatric clinic said they would not evaluate the resident because they had completed evaluations of the resident in the past and did not feel the resident was harm to him/her or others and did not damage property, therefore he/she did not meet the requirements to conduct another evaluation. The psychiatric clinic staff suggested the facility contact the police when the resident displayed outbursts of behavior. The progress notes revealed the resident remained on 15 minute checks through 2/20/17 and then staff started hourly checks which continued until 2/28/17 at 4:00 PM and staff monitored the resident per standard of care. (visual checks every 2 hours) Review of the progress notes dated 3/2/17 at 9:58 PM revealed at 7:00 PM staff heard the resident yelling. Two nurse aides (direct care staff I and an unidentified direct care staff) responded see why and found resident #95 in resident #20's room yelling get out to resident #20. Resident #20 stated the other resident grabbed him/her by the arm and then tried to reach for his/her neck before backing up. Resident #95 went back to his/her room and then the nurse spoke with resident #20. The nurse tried to talk to resident #95 but he/she had his/her door barricaded shut and started yelling at the staff so staff left him/her alone. The nurse then called administrative nursing staff A about the situation and Staff A instructed the staff at the facility to call 911, EMS, and the resident's family member. Staff reported to the Police Department that staff called EMS to have the resident transported to the hospital per emergency discharge order from the resident's physician for increased aggressive behavior. EMS lacked a medical reason to transport the resident to the hospital so he/she remained in the facility. Nursing note dated 3/3/17 at 6:34 AM revealed staff monitored the resident one-on-one. (1 staff remained with the resident at all times). Review of the notes from 3/3/17 to 3/14/17 revealed the resident continued to remain on one-on-one staff observations/supervision. Observation on 3/8/17 at 12:36 p.m. revealed the resident sat quietly in the lounge eating his/her lunch with a staff member sitting to the side of him/her. Observation on 3/8/17 at 2:59 PM revealed the resident sat calmly while watching other residents in the activity where staff provided nail care. Staff sat at a table beside the resident. Observation on 3/9/17 at 7:54 AM revealed the resident sat up in his/her bed as direct care staff assisted the resident to eat his/her meal. Observation on 3/13/17 at 12:58 PM revealed the resident propelled his/her wheelchair down the west hall with direct care staff F right beside him/her. During an interview on 3/9/17 at 8:41 AM resident # 20 reported resident #95 came into his/her room [ROOM NUMBER] different times. (unable to say the exact dates of when this occurred). The first time resident #95 raised h*** saying the TV belonged to him/her and argued and then a staff member came in and took him/her out of the room. The second time resident #95 came in someone was right behind him/her and got him/her out. The 3rd time resident #95 stood at the end of resident #20's roommate's bed and said he/she came in to finish what he/she started last week, so just wait until I get through with you. Resident #20 reported he/she then got up off the bed and as he/she stood, resident #95 grabbed hold of both his/her arms hurting them and then he/she grabbed resident #20's neck with both hands. Resident #20 stated he/she pushed the other resident away with both hands and then a staff came in and made him/her (resident #95) leave the room. Resident #20 reported it happened a couple of weeks ago and he/she still did not feel safe in the facility. The resident stated the other resident (#95) was supposed to be moving but it did not happen. The resident reported he/she felt safe when he/she thought the other resident was leaving. Resident #20 reported he/she could still could see the other resident as he/she passed the door or in the hall. Resident #20 reported he/she started to have nightmares again about an individual that had physically abused him/her and had not had nightmares, prior to the incident with resident #95, in a lot of years. Interview with resident #17 on 3/9/17 at 11:32 AM revealed the resident from next door (resident #95) came into his/her room several times over the past two months. The first time, the resident's roommate spotted resident #95 and told him/her to get out of their room. Resident #95 then started yelling back at the roommate cussing until staff led him/her away. The second time was more recent and resident #95 came into the resident's room while he/she was sleeping in his/her wheelchair and touched his/her knee. The resident reported he/she hollered and staff came and got the other resident out of his/her room. The resident did hear the incident between resident #95 and resident #20 and stated resident #95 told the other resident to get out of his/her room and proceeded to touch him/her. Resident #17 stated he/she did not feel safe here with the resident #95 in the next room. He/she stated it was just a matter of time before resident #95 hurt someone or someone else hurt resident #95. During an interview on 3/6/17 at 4:37 PM direct care staff KK stated the resident had behavior problems of yelling, hitting things, and going into other resident rooms so he/she just watched the resident to make sure that he/she did not go into any other resident rooms. During an interview on 3/6/17 at 5:08 PM direct care staff I reported when he/she worked last week, he/she heard yelling and thought it was resident #95 and another resident, but it was resident #95 and resident #20. Resident #20 stood by the bed telling resident #95 to get out of his/her room. When staff tried to get resident #95 out of the room he/she grabbed for the air mattress box attached to the end of the bed and tried to throw it. Staff separated the residents and resident #20 stated the other resident came into the room and grabbed his/her arm and tried to choke him/her. Staff I stated the staff now provide one-on-one supervision for resident #95. During an interview on 3/7/17 at 2:38 PM direct care staff JJ sat in a chair outside of the resident's room with the door shut. Staff JJ stated resident #95's behavior was unpredictable and he/she could be fine for weeks and then all of a sudden get angry. Staff JJ stated when the resident got in those moods he/she went into other resident rooms and scared them so that was why staff are doing one-on-one with him/her. During an interview on 3/9/17 at 8:55 AM direct care staff F stated the resident yelled and flung his/her arms ran down the hall and he/she yelled, cussed and ran over staff when he/she had a bad day. Staff F stated he/she did not know of any specific interventions the facility did to prevent resident abuse from happening in the first place but the facility is doing the one-on-one now to keep it from happening again. Staff I stated the resident had altercations in the past with other residents. Staff I said there was an incident in the dining room where he/she threatened other residents with a table knife, he/she has run into staff, doors, and other things if they were in his/her way. During an interview on 3/9/17 at 9:03 AM direct care staff M reported the resident had outbursts, threw things and wandered in other resident rooms and messed with their stuff. Staff M stated he/she knew the resident #95 went into resident #20's room and he/she tried to choke him/her. During an interview on 3/6/17 at 4:54 PM licensed nursing staff H reported the resident needed one-on-one supervision because of some things that happened before the weekend. Staff H stated the resident went into another resident's room and grabbed his/her leg and tried grabbing his/her throat. During an interview on 3/13/17 at 12:48 PM administrative nursing staff LL reported a psychiatric nurse saw resident #20 after the incident to help with his/her memories of abuse and the resident voiced having nightmares only 1 time and did not complain of them again. During an interview on 3/9/17 at 6:12 PM administrative staff B reported that the facility had the psychiatric nurse come and talk to resident #20 after the incident and started resident #95 on the one-to-one observations right after the incident. During an interview on 3/9/17 at 3:23 PM administrative licensed nursing staff A reported when the facility knew about resident #95 going into other resident rooms the nursing staff increased supervision. Staff also put a blue sign on his/her room thinking he/she had confusion. When resident #95 went into resident #17's room the second time is when IDT decided to put resident #95 on one-on-one supervision. Staff A reported the nurses documented in the progress notes when the staff provided one-on-one supervision and if the resident had any negative behaviors. Staff A stated the resident would remain on one-to-one supervision until he/she moved into the group home. Staff A stated for resident #20 staff had Nurse Practitioner XX visit with the resident and the facility's licensed social worker could also visit with the resident when needed. Staff A and administrative staff B assured resident #20 that he/she would be safe and staff would provide one-on-one supervision for the other resident. Prior to the incident on 3/2/17 resident #95 had been on one-on-one supervision for going into resident #17's room and had a verbal altercation with the resident. Resident #95 did not have behaviors and so the IDT determined to decrease the observations and eventually they went form one-one-one to 15 minute observations, to hourly observations and the every 2 hour observations. So prior to going into resident #20's room staff monitored the resident just like any other resident. Review of the abuse policy dated 2016 revealed the most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to abusive behavior. The facility screened potential and new admissions to determine whether the patient had a personal history of or was at risk for developing abusive actions or aggressive behaviors toward others. If the resident had such a history or presented such a risk, the center reviewed the resident's status to determine if the resident was appropriate for admission and if the center could meet the resident's needs The facility failed to ensure resident #20 remained free from physical and mental abuse by the failure to effectively monitor/supervise resident #95. This deficient practice placed resident #20 in immediate jeopardy. The facility abated the immediate jeopardy on 3/13/17 when the facility completed training for all staff related to Abuse, Neglect and Misappropriation of Patient Property and Behavior Guide with a special focus on identification of and interventions for residents who reported they felt unsafe in the facility, as well as completion of an audit of Behavior Assessments for all residents on 3/10/17 and a plan to continue to review resident behaviors and protect residents related to those behaviors, and to ensure the plan of care and Kardex related to such were up to date and reflected appropriate interventions. The deficient practice remained at a scope/severity of a G.

The facility census totaled 87 residents with 10 included in the sample. Based on observation, interview, and record review, the facility failed to assess causal factors of falls and develop individualized interventions to prevent further falls for 1 of 3 residents reviewed for accidents #9. This resulted in fall with a fractured right wrist for resident #9. The facility also failed to ensure the resident environment remained as free of accident hazards as possible by the failure to securely store chemicals and tools, and keep the floor free of trip hazards. Findings included: - Review of resident #9's admission MDS (minimum data set) dated 10/14/15 (completed 10/27/15) revealed a BIMS (brief interview for mental status) score of 5, indicating severe cognitive impairment. The resident rejected cares 1-3 days of the 7 day observation period. The resident required limited assistance of one staff for bed mobility, toileting, and extensive assistance of two or more staff for transfers. Staff were unable to determine the resident's fall history prior to admission, but the resident did not fall after admission. The resident did not have any range of motion (ROM) impairment, and was not steady, but able to stabilize without staff assistance for all balance activities during transitions and walking. The resident used a walker and a wheelchair for mobility. Review of the quarterly MDS dated [DATE] (completed 2/1/16) revealed no change in cognition or rejection of cares behavior. The resident required supervision of one person for bed mobility, transfers, and toileting, and limited assistance of one staff for walking in the room and corridor. The resident had one non-injury fall since the previous assessment. There were no changes in ROM, balance during transitions and walking, or mobility devices. Review of the ADL (activities of daily living) Functional/Rehabilitation Potential CAA (care area assessment) dated 10/27/15 revealed the resident admitted for skilled therapy following hospitalization for recent progressive balance and cognitive decline. He/she had multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) and needed some assist for many ADLs. He/she got up and walked unassisted, however he/she did fall, though it did not specify dates or how often. Staff encouraged the resident to use the call light to call for assist, but the resident had cognitive impairment and impaired eyesight. Staff would care plan to assist resident #9 with ADLs when needed for safety. Review of the Fall CAA dated 10/27/15 revealed the resident continued to work with therapy for gait strengthening. Staff would provide interventions for fall prevention per plan of care for safety. Review of the Behavioral CAA dated 10/27/15 revealed the resident tried to get up to ambulate on his/her own and did not use the call light to ask for assistance. Review of the resident's care plan, initiated 10/8/15, revealed the resident had cognitive loss as evidenced by a BIMS score of 5 on admission related to MS and a history of developmental delay (failure to progress at a normal rate of development). The resident had an increased fall risk due to history of falls. Interventions directed staff to: 10/8/15- Encourage the resident to transfer and change positions slowly. Keep commonly used articles within easy reach. Provide assist to transfer and ambulate as needed. 10/10/15- Approach the resident from the side or front when attempting to speak with him/her. 10/27/15- Ensure the resident used a walker for ambulation and ensure staff were present with him/her for ambulation. Provide education about the risks of not complying with a therapeutic regimen. Be aware the resident could be non-compliant with treatment/care related to cognitive impairment, get up without assistance to ambulate, and result in falls. Provide patient/representative education to include safe ambulation, self-care techniques, medications, treatments, and daily activity plan. Attempt to keep frequently used items within easy reach. Encourage the resident to wear glasses. 10/28/15- Place the resident's wheelchair near his/her bedside to encourage the resident to use the wheelchair to go to the bathroom rather than trying to walk. 10/29/15- Provide a wide bed for the resident to use. 11/04/15- Labs per physician orders. 12/12/15- Perform a bladder diary (diary to track urinary voiding patterns). Ensure the resident wears proper footwear/non-skid socks and shoes. Reinforce the need to call for assistance. 12/24/15- Evaluate the resident's wheelchair for brake extensions. 12/26/15- Complete a medication review. 12/28/15- Do not leave the resident alone in a wheelchair in his/her room. Assist him/her to bed or to a more visible area such as the nurse's station as resident allows. Review of a fall investigation dated 10/10/15 revealed the resident walked down the west hallway with his/her walker by him/herself, missed steps and fell to the floor. A direct care staff came from the side to talk to him/her and the resident fell . The nurse aide witnessed the fall, but could not reach the resident before he/she fell . Staff placed a new intervention to approach the resident from the side or front when attempting to speak to him/her. Review of a nurse's note dated 10/16/15 revealed the resident continued to be non-compliant with use of the call light and asking for assistance with ambulation. The resident had a fall risk but continued to attempt to walk by him/herself. The nurse continued to educate the resident on safety awareness. Review of a fall investigation dated 10/28/15 revealed the resident stated he/she tried to get out of bed to get to the closet. Staff saw the resident 15 minutes prior lying in bed with his/her eyes closed. The resident turned on his/her call light and when the direct care staff went to check on him/her, he/she was on the floor. No injuries were sustained. The resident stated he/she tried to get a shirt out of the closet and fell . Staff encouraged the resident to use his/her wheelchair for ambulation. Staff assisted the resident back to bed and added a new intervention to place the resident's wheelchair at the bedside to encourage the resident to use the wheelchair rather than try to walk. Review of a fall investigation dated 10/29/15 revealed a resident came to the nurse's station and reported resident #9 was on the floor. Staff found the resident lying on his/her back on the floor with some redness to the left elbow. Staff saw the resident 45 minutes prior sitting in the wheelchair at the nurse's station. The resident stated he/she tried to get out of bed to change his/her clothes. The resident had 2 pairs of pants on half way up to his/her knees. Staff encouraged the resident to use his/her call light . The resident stated he/she did not need any help and to go away. Staff added a new intervention for a wide bed and did not identify this as the second time the resident fell related to attempting to get clothing and get dressed. Review of a fall investigation dated 11/4/15 revealed the resident stated he/she tried to get out of bed to get dressed and fell . Staff saw the resident at 12:55 AM laying in bed. At 1 AM, the nurse heard the resident yell out and went and found him/her on the floor. The resident acted combative and refused a full assessment. No injury. Staff encouraged the resident to use his/her call light when he/she wanted to get up, which the resident agreed to but also stated he/she could take care of him/herself. Staff added a new intervention for labs per physician order [REDACTED]. Review of a fall investigation dated 12/12/15 revealed staff heard the resident yelling for help and a nurse found the resident on the floor. Review of the timeline of events, at 5:30 AM, the resident fell in his/her room and staff assisted him/her to get dressed and put him/her back to bed and put the call light in reach. At 6 AM, the resident yelled out and staff found him/her on the floor again. The summary of critical information revealed the resident stated he/she was getting up to get dressed, even though staff had already dressed him/her. The nurse assessed and the resident did not have any injuries. Staff educated the resident about using the call light if he/she wanted to get up. Staff placed non-slip socks on the resident's feet to also aide in safety. Staff added a new intervention for non-skid socks and shoes and still did not address the resident's pattern of falling while attempting to get dressed. Staff also did not investigate each of the falls on this date separately to determine root cause analysis of each fall. Review of a nurse's note dated 12/12/15 revealed at around 5:30 AM the nurse and another staff heard resident #9 yell out. Upon arriving to the resident's room, staff found him/her on the floor laying on his/her back. The resident stated he/she tried to use the toilet and fell . The resident's left wrist had swelling but no redness. Staff notified the physician at 6:00 AM and received new orders for Tylenol (pain reliever) 650 mg (milligrams) every 4 hours as needed (PRN), Tramadol 50 mg every 4 hours PRN for 1 month, and x-ray to the left wrist. Review of a nurse's note dated 12/12/15 revealed staff received a radiology report stating the resident had an acute (recent) fracture of the radius (arm bone). Staff notified the physician and the physician ordered staff to send the resident to the emergency room . Review of a nurse's note dated 12/12/15 revealed at 10:45 AM, resident #9 returned to the facility with a confirmed left wrist fracture. The resident needed a follow-up appointment with an orthopedic (bone) surgeon in 7 days. Review of a fall investigation dated 12/13/15 revealed at 10:20 AM staff found the resident lying on the floor in the bathroom face down. The resident reported he/she walked to go use the bathroom when he/she lost his/her balance and fell . The resident denied injury and had a splint to his/her left upper extremity in place. Staff educated the resident to use his/her call light and ask staff for assistance with cares. The resident stated he/she tried to go to the bathroom and did not ask for help because he/she could do it him/herself. The resident had poor safety awareness and was very impulsive. Staff added a new intervention for labs per the physician order. Review of a nurse's note dated 1/1/16 revealed resident #9 returned to the facility from having his/her right arm pinned. Observation on 2/9/16 at 11:32 AM revealed the resident self-propelled his/her wheelchair through the commons area by the nurse's station. Observation on 2/11/16 at 10:02 AM revealed the resident sat on his/her bed with his/her wheelchair within reach. The resident's clothes were stored hanging up in a closet and not within easy reach of a wheelchair. The call light sat within reach. Interview with the resident on 2/23/16 at 1:35 PM revealed the resident he/she was headed to his/her room to watch some tv or something. The resident did not remember any falls. Interview with direct care staff D on 2/23/16 at 6:04 AM revealed the resident had a risk of falls. Staff D reported staff lowered the resident's bed, but the resident put it back the way he/she wanted it. Staff D stated, staff also watched resident #9, tried to remind him/her not to get up by him/herself, and made sure the wheelchair stayed close to him/her. Interview with direct care staff M on 2/23/16 at 1:31 PM revealed the resident had an increased fall risk because he/she could not ambulate very well and kind of walked sideways, which was not safe. Staff M reported he/she did not know of any recent falls for the resident or of any falls with injury. Staff M reported to reduce the resident's fall risk, staff lowered the bed and tried to always be with him/her when he/she transferred. Staff M reported the resident did not remember to use his/her call light even if staff reminded him/her. Interview with licensed nursing staff H on 2/22/16 at 4:45 PM revealed staff had to remind resident #9 to use his/her call light, make sure his/her bed remained in a low position at all times, and always check on him/her on a routine basis, whether he/she sat watching tv or laying in his/her bed. Staff H reported he/she thought the resident fractured something in his/her left hand. Staff H reported resident #9 went to the doctor, who did a surgery, and now the resident had a splint to wear. Staff H reported sometimes the resident was compliant, and sometimes he/she was not. When a fall happened, staff H reported the nurse assessed the resident, obtained vitals, completed neurological checks (to check for brain and nerve functioning), and notified the doctor, family, and nurse on call. Then, per staff H's report, the unit manager followed up on whatever he/she had to do with the fall stuff, which had something to do with what happened at the time of the fall, whether or not the resident had shoes or socks on, if the floor was slippery, and/or if the call light was within reach. Interview on 2/23/16 at 4:45 PM with administrative staff L revealed he/she knew staff moved the resident closer to the nurse's station on 11/18/15 due to falls, and he/she thought that had helped his/her fall pattern. Staff L reported the purpose of the fall investigation was to try and do a root cause analysis of the falls and to look for patterns to attempt to prevent further falls. In regards to the resident's fall with a fracture, staff L reported that happened on 12/12/15 after his/her first fall at 5:30 AM as his/her wrist was swollen after that. Staff L confirmed the resident fell twice that day within 30 minutes. Staff L confirmed staff had not identified the pattern of the resident falling was related to attempts to get clothes out of the closet or get dressed. Interview with physician extender N on 2/23/16 at 12:37 PM, revealed according to past records, resident #9 had MS or some kind of neurological defect that went untreated for [REDACTED].#9 had an increased risk of falls and had the fall with a wrist fracture. Staff N reported the resident was young and thought he/she had enough strength to walk around. Staff N reported he/she did not think the resident had the strength or coordination to be able to walk and make it to where he/she needed to go. Mentally, staff N reported the resident could not remember to call someone for help and did not think 100% of the time to use the call light. Staff N reported he/she felt more frequent checks and/or if he/she had a roommate that could help kind of keep an eye on him/her would help prevent further falls. Staff N also reported he/she thought maybe if there were multiple residents in the room, staff might check on him/her more frequently. The facility failed to provide a policy regarding falls as requested on 2/23/16. The facility failed to investigate falls to determine causal factors and patterns and implement appropriate interventions to prevent a fall resulting in a wrist fracture for resident #9. - Observation on 2/8/16 at 2:21 PM revealed room 121 unlocked and full of construction materials including: saw blades, miscellaneous tools, canvas laid out over 1/3 of the floor presenting a trip hazard, a wallpaper holder/cutting device, 5 gallon bucket full of water, multiple large 5 gallon buckets with lids on them, a container of wall base adhesive with a warning to keep out of reach of children, construction adhesive with a warning to keep out of reach of children, 5 one gallon paint cans with a warning to keep out of reach of children 1 can of Kilz brand paint with a warning to keep out of reach of children At that time, direct care staff O attempted to close the door and confirmed the door would not latch and lock. Observation revealed tape over the latching mechanism. Staff O removed the tape from the latch and the door still would not latch and lock. Interview on 2/8/16 at 2:22 PM with direct care staff O revealed the door to the room containing construction supplies was never unlocked, but it looked like a construction worker had placed a piece of tape over the latching piece of the door so it would not latch. Reported there were lots of things inside the room that were dangerous for residents. Staff O reported he/she would go find maintenance staff. At 2:24 PM, staff O reported he/she went and let someone know about the door and the maintenance staff would be there right away to fix it. On 2/8/16 at 2:35 PM, maintenance staff P came to room 121 and reported he/she thought the carpet layer may have put the tape over the latch mechanism when he/she brought boxes of carpet tiles in. Staff P reported the staff always kept the door locked to keep residents out of there for safety reasons. The facility failed to provide a policy regarding chemical storage as requested on 2/22/16. The facility failed to store chemicals securely to ensure the resident environment remained as free of accident hazards as possible.

The facility census totaled 93 residents with 13 residents included in the sample. Of those 4 residents were reviewed for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices for 2 of 4 sampled residents by the failure to thoroughly assess and implement interventions related to the resident's behaviors, and failed to provide adequate supervision during times when the resident experienced behaviors to prevent a fall with hip fracture for resident #13 The facility also failed to ensure resident #12 had his/her call light within reach as planned. Findings included: - Review of resident #13's Admission/5 day MDS (Minimum Data Set) assessment dated [DATE] revealed the resident's BIMS (Brief Interview for Mental Status Score) and cognitive status were not assessed, hallucinations and delusions dashed (not assessed), and behavioral symptoms not assessed. It identified the resident needed extensive assistance of 2 staff members for bed mobility and transfers, walking in room and corridor, and extensive of one staff member for locomotion on/off the unit. It identified staff were unable to determine if the resident had any falls prior to admission, but experienced one fall with no injury since admission to the facility. Review of the Fall CAA (Care Area Assessment) for the 8/12/13 MDS assessment revealed the resident had one fall out of bed when the resident reached for a trash can to throw up in and leaned too far and fell . It identified the resident at high risk for falls due to confusion, weakness, need for assistance with transfers, and impulsiveness at times. It identified staff planned to care plan for this. Review of the ADL (Activities of Daily Living) CAA for the 8/12/13 MDS assessment revealed the resident needed assistance with all ADLs and received tube feedings as well as trialing oral feedings. It identified the resident needed assistance with all intake and received assistance with wheelchair mobility. The assessment identified the resident was very weak, short of breath with exertion, and got very anxious. The CAA revealed staff planned to care plan to provide for the assistance the resident needed as well as therapy training to improve independence in at least some of the resident's ADLs. Review of the resident's current care plan identified the resident with an ADL self-care deficit as evidenced by need for extensive assist with most ADLs related to disease process (multiple co-morbidities of Hepatitis C (an inflammatory condition of the liver), renal Insufficiency, dementia (progressive mental disorder characterized by failing memory, confusion) and physical limitation) and directed staff to assist with daily hygiene, grooming, dressing, oral care and eating as needed, break ADL tasks into subtasks for easier patient performance, encourage and/or assist to reposition frequently, refer to the therapy plan of treatment in the medical record for more detail, and transfer with a sit-to-stand lift and 2 staff. Initiated on 9/6/13, but created in the record on 9/7/13, the care plan identified the resident with verbal/physical agitation/aggression related to alcohol/drug withdrawal, cognitive impairment and directed to provide medications, attempt to redirect when yelling. It identified the resident exhibited attention seeking behavior (yelling out stating the resident would throw self on floor) and directed staff to redirect the resident and give medications as ordered, and physician aware related to behavioral comments (initiated on 9/6, created 9/7, revised 9/9), check on resident frequently to ensure safety, as resident would attempt to walk and adjust bed controls and resident was a fall risk (initiated 9/6/13 but created 9/12/13), give patient clear, concise explanation of anything about to occur (initiated 9/5/13 but created 9/7/13), and remove from public area when behavior is disruptive/unacceptable (initiated 9/5/13 but created 9/7). The care plan identified the resident at risk for falls due to unsteady/gait (8/6/13) and directed staff to encourage to transfer and change positions slowly, have commonly used articles within easy reach, physician referral related to nausea, provide assist to transfer and ambulate as needed, wide bed/low bed/mats manipulated bed controller at times (created 8/10/13, initiated 8/8/13, and revised 9/11/13.) It identified the resident at risk for adverse effects related to the use of antipsychotic medication, use of antidepressant medication, and use of antianxiety/anxiolytic medication. The resident used citalopram (antidepressant), Ativan (antianxiety medication), Seroquel (antipsychotic medication), Risperdal (antipsychotic medication), and Remeron (antidepressant medication) in the last week, but Risperdal had been discontinued. It directed to completed AIMS (Abnormal Involuntary Movement Scale) testing per facility guidelines, identified the resident with potential for severe adverse reaction and to evaluate the effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs, notify physician of declines related to dosage changes, obtain lab results as ordered and notify physician of abnormal values, provide patient teaching of risks and benefits of medications as needed, psychiatrist consult and follow up as needed, reduce environmental noise/distractions to facilitate sleep, and report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation, ability, lethargy, complaints of dizziness, tremors, etc. The care plan failed to direct staff specifically how often the staff needed to check on the resident, or how to know that frequency was effective in keeping the resident safe, failed to include environmental factors which increased or triggered behaviors, specific non-pharmacological interventions to reduce anxiety, or direction for what staff needed to do when the resident attempted to walk. Review of the facility's Patient Admission/Readmission screen dated 9/5/13 revealed the resident readmitted to the facility from the hospital and included a mental status assessment: inattention - not present, disorganized thinking - not present, altered level of consciousness - not present, psychomotor retardation - not present, cognitive skills for daily decision making - modified independence (some difficulty in new situations). It identified the resident with a history of falls, needed assistance for ambulation, bed mobility, toileting, transfers, and dressing, and needed a walker and a wheelchair for mobility. Review of the Section I: Specific Behaviors (the facility's form for monitoring and tracking behaviors) revealed it identified when the resident readmitted to the facility from the hospital on [DATE], staff monitored for anxiety, yelling out, trying to get out of bed, and walking. The form lacked any direction for staff as to what they should when and if these behaviors occurred, or what interventions staff attempted to help resolve behaviors or redirect the resident. Review of the first nurse's note on 9/6/13 at 3:32 A.M. revealed the resident was cooperative with care and medications, no yelling and no complaints of pain or difficulty breathing. The second nurses note after readmitted d 9/6/13 at 3:53 P.M. revealed staff received an order from the physician at 2:00 P.M. for as needed Tylenol for pain. Review of a third nurses note with an effective date of 9/6/13 at 5:00 P.M., but not created until 9/7/2013 at 3:37 P.M. revealed the resident was alert and oriented to self and able to make needs known to staff. The resident had been yelling and screaming most of the day, and when staff asked the resident what is the matter, the resident reported he/she wanted to get out of bed and walk. Staff gave the resident the call light and encouraged him/her to use it at all times for assistance. The resident responded yes. then within a few minutes, staff heard the resident screaming. A nurse aide went to room and assisted resident to his/her chair, and took the resident to the dining room. The resident did not stay, left the dining room and wanted to go to bed. Staff assisted the resident to bed and lowered the bed to the floor, with floor mats in place and call light at reach, but resident wanted the bed to be higher. The resident later got himself/herself up to his/her chair. The resident sat at the nurses' station, and propelled himself/herself back to the resident's room. The nurses note revealed staff heard screaming and yelling and went to room and noted resident on the floor lying on his/her back. The fourth note created 9/7/13 at 12:25 A.M. but effective as of 9/6/13 at 7:45 P.M. revealed staff found the resident on the floor laying on the resident's back with his/her head facing the door. The resident complained of pain to the right side of his/her cheek, his/her right leg and hip. The nurse received an order from the physician to transfer the resident to the hospital. During an interview with Direct Care staff I at 6:20 P.M. on 9/11/13, he/she reported the resident yelled for help every one to two minutes during the shift prior to the fall on 9/6/13. Staff I reported he/she walked in the resident's room after the resident put on his/her call light, and it surprised him/her to see the resident in the resident's wheelchair. At that time the resident said he/she did it by himself/herself. Staff I assisted the resident back to bed because the resident asked to lay down, but then reported being upset because the bed felt too low. Staff I reported to the nurse who then educated the resident regarding bed safety, but staff I reported it did not help. The nurse directed staff I to keep an eye on the resident. Staff I reported the resident got up on his/her own again, and reported he/she wanted to eat. Staff I revealed the resident received pain medication before dinner, but threw it up on the resident's clothes. Staff assisted the resident to clean up, then assisted the resident to the dining room, where the resident did not stay long, and then reported he/she wanted to lay in bed again. Staff I assisted the resident back to the resident's room, and helped the resident to lay down, and reported he/she had difficulty getting other work done because the resident continued to call and need or want assistance. Staff I reported he/she thought the resident normally needed one person and a gait belt for transfers, and needed staff to check on the resident every 2 hours, but that day, staff I reported he/she used 2 staff and a gait belt to assist the resident. Staff I reported, 5 minutes after he/she assisted the resident to bed the 3rd time and left the room, he/she found out the resident had fallen. During an interview with Direct Care staff Q at 6:30 P.M. on 9/11/13, Staff Q reported he/she did not work with the resident consistently, but had answered the call light when the resident rang. Staff Q reported it normal for the resident to frequently call for help, and thought the resident wanted someone to sit with him/her. Staff Q reported he/she would talk to the resident for a little bit, and when he/she left the room, the resident would call again a few minutes later. During an interview with Licensed Nursing staff R at 5:58 P.M. on 9/11/13, he/she reported when he/she came on that day, he/she received in report the resident had been yelling all day, and the yelling had progressed. The day before, the resident came back from the hospital with normal behavior. But that day, Staff R revealed the resident put on the call light but would still yell out. Staff R checked on the resident multiple times, with the resident voicing a need to use the restroom or other things, but would still yell afterward. Staff R went back into the room after leaving from taking the resident to the restroom, and the resident would ask if staff felt mad at the resident. Staff R confirmed the resident was a fall risk prior to the fall, and at one point, used the controllers and raised the height of the bed. Staff R reported staff provided education about the safety of keeping the bed down. At 4:00 P.M. that day, Staff R walked toward another hall, and saw the resident walking down the hall independently as the resident held onto the handrails. Staff R reported he/she did not know the resident had the ability to walk. Staff assisted the resident to his/her wheelchair and then to the bathroom, and when staff helped the resident back into bed, the resident yelled again, not necessarily for anything but wanted someone to be there. The resident got pain medication at 6:00 P.M. and confirmed it helped at 6:30 P.M. Staff R reported he/she later gave the resident the rest of his/her medication and another staff member assisted the resident to lay down. Staff R reported a staff member found the resident on the floor, and complaining of leg pain. During an interview with Administrative Nursing staff B at 1:30 P.M. on 9/16/13, he/she reported staff used the Patient Admission/Readmission screen to initially assess a resident ' s behaviors, then if they got worse or changed, staff monitored them on the Section I: Specific Behaviors form. Staff B confirmed staff used the care plan as a guide for how to care for the resident, and voiced understanding regarding the care plan not having specific information related to the resident's behaviors. Staff B reported staff increased the amount of supervision for the resident prior to the fall and hip fracture, and reported staff provided every 15 minute checks for the resident. Staff B confirmed the resident transferred himself/herself multiple times without staff assistance that day, and confirmed the resident fell with no staff present in the room. Review of the facility's Falls Practice Guide dated 12/2011 identified the risk for patient falls is potentially greater upon admission and within the first few days post admission to a long term center compared to similar environments. Review of the facility's Mood and Behavior Practice Guide dated 3/2011 revealed, "Range of Interventions -The range of possible interventions includes non-pharmacologic as well as pharmacologic options. Non-pharmacologic approaches used as initial interventions can minimize the need for medication, permit use of the lowest dose, or result in the discontinuation of medication." It also revealed, "Alleviating Symptoms -...Continual attempts to understand and address a symptom's root cause will reveal ways to improve interventions. As effective interventions help the patient, the team will notice a change in the symptom's frequency. Focusing on timely alleviation of a mood or behavior symptom reduces the possibility of the symptoms becoming accepted as unavoidable patient behavior." The facility failed to thoroughly assess and implement interventions related to the resident ' s behaviors, and failed to provide adequate supervision during times when the resident experienced behaviors and ambulated or transferred him/herself several times during the same shift to prevent a fall with hip fracture. - Review of resident #12's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed the resident with a BIMS (Brief Interview for Mental Status) score of 11 (moderate impairment). It identified the resident needed extensive assistance of 1 staff member for bed mobility, and extensive assistance of 2 staff members for transfer. The assessment identified the resident had 2 or more non-injury falls since admission or the prior assessment. Review of the resident's Quarterly MDS dated [DATE] revealed the resident with a BIMS of 11. It identified the resident needed extensive assistance of one for bed mobility, and extensive assistance of 2 for transfers. The assessment again identified the resident had 2 or more falls without injury since the prior assessment. Review of the Fall CAA (Care Area Assessment) for the 1/15/13 MDS revealed it identified the resident had 2 non-injury falls in the last 3 months from the resident's wheelchair in the bathroom while trying to use the toilet. It identified the resident slid out of the wheelchair. The resident had hemiparesis (muscular weakness of one half of the body) and after dialysis (a procedure in which impurities or wastes are removed from the blood), generalized weakness also. The resident needed 2 person extensive assistance to transfer. The assessment revealed staff planned to care plan to prevent falls and fall related injuries. It also noted the restorative program worked with the resident at that time. Review of the resident's fall care plan last revised 8/27/13 revealed it identified the resident at risk for falls due to muscle weakness, right side [DIAGNOSES REDACTED] (paralysis of one side of the body) and impaired mobility and included for staff to ensure the resident had his/her call light clipped to the bed. Review of nurses note dated 7/30/13 at 10:02 p.m. revealed staff found the resident on the floor on his/her knees, with his/her bottom up and face on the floor. When staff asked the resident what he/she was doing at the time of the fall, the resident reported he/she wanted to reach his/her call light. The investigation also revealed the call light clipped to the bed, and the resident seated in his/her wheelchair prior to the fall. When the resident leaned forward to reach the call light, the resident fell to the floor. Observation at 8:43 A.M. on 9/4/13 revealed a staff member pushed the resident into his/her room then left the room and walked down the hall. At 8:45 A.M. observation inside the room revealed the resident sat in a wheelchair with the room light and television off, and the call light clipped on a sheet and covered up underneath the comforter. The resident asked the surveyor for assistance with turning on the television and changing the resident's clothes. The surveyor notified Licensed Nursing staff S who went to the resident's room and closed the door. At 8:54 A.M., observation revealed the resident now watched television in a clean shirt, and had the call light out from under the covers and within reach. Observation on 9/4/13 at 4:13 P.M. revealed Direct Care staff T walked into the resident's room, picked up the resident's call light from the floor, and pinned it to the resident's bed. The resident grabbed on to the light and asked staff T where it had been. Staff T reported he/she thought Licensed Nursing staff C and a physician probably knocked it onto the floor when they left the resident's room. During an interview at 8:42 A.M. on 9/11/13, Direct Care staff E identified the resident was able to use his/her call light for assistance, and confirmed it needed to be within reach. During an interview with Administrative Nursing staff B at 4:38 P.M. on 9/11/13, he/she confirmed staff needed to follow the care plan. Staff B reported he/she had a new staff member working on the hall that day and did notice a concern related to putting call lights within reach. Staff B reported he/she provided education to the staff member because residents needed to have their call lights within reach. Review of the facility's Call Light/Bell Response Policy dated 8/11/06 revealed, "Place call light/bell within patient's reach regardless of patient location such as: in bed, on commode, unaccompanied in sitting area. The facility failed to ensure this cognitively impaired resident with a history of falls had his/her call light available to notify staff if the resident needed assistance.

The facility census totaled 103 residents. The sample included 3 residents sampled for accidents. Based on observation, interview and record review the facility failed to identify and implement interventions to reduce the risk of an accident hazard when one of the three sampled residents (#2) frequently grabbed at the privacy curtains during the time staff provided pericare to the resident. The resident grabbed the privacy curtains on 6-16-13 and fell out of bed sustaining lacerations to the head which required sutures. Findings included: - Review of the significant change MDS (Minimum Data Set) dated 10-3-12 identified resident #2 still needed extensive assistance of 2 staff for bed mobility and transfers and extensive assistance of one staff for personal hygiene. The MDS identified the resident had one non-injury fall since the previous MDS. The quarterly MDS dated [DATE] identified the resident with a BIMS (Brief Interview for Mental Status) of 3, severely cognitively impaired. The MDS again showed the resident required extensive assistance of two staff for bed mobility and transfers, and extensive assist of one staff for personal hygiene. The CAA (Care Area Assessment) dated 10-10-12 identified the resident as a fall risk, due to a history of a fall out of bed. The CAA also identified the resident's non-ambulatory status, confusion, forgetfulness, weakness and use of pain medication as factors that made the resident a risk for falls. The care plan dated 3-26-13 identified a goal to minimize risk for injury related to falls. The interventions included: keep bed in low position, perimeter mattress, provide assistance of 2 to transfer with mechanical lift and reassess fall risk as needed. Review of the interdisciplinary team progress notes dated 6-16-13 at 11:03 p.m. revealed the resident had a fall from the bed at 8:45 p.m. The note continued that due to the large amount of blood loss from a head injury or injuries and the resident's temporary unresponsiveness, the staff sent the resident to the emergency room . Staff noted they immobilized the resident until EMS (Emergency Medical Services) arrived, and someone applied pressure to the side of the resident's head. The note identified Emergency Medical Services transported the resident to the emergency room at 11:15 p.m. Another Interdisciplinary Team progress note dated 6-17-13 at 2:45 a.m. noted the resident returned to the facility via Emergency Medical Services. Staff noted the resident was oriented to person and room. Staff completed an SBAR (Situation, Background, Assessment and Request) on 6-16-13 at 11:27 p.m. The situation included during direct care staff changing the resident, the resident reached out and grabbed the privacy curtain and pulled him/herself out of the bed and onto the floor. Staff noted blood to the resident's head. The background portion of the SBAR identified the resident's cognition and health status had both declined, the resident had no recent falls. The assessment included staff kept the resident immobile pending assessment at the emergency room . The request portion of the assessment included transport of the resident to the emergency room . Review of the facility's investigation report revealed the direct care staff had the resident positioned on his/her side in bed while providing peri-care. The resident reached out for the privacy curtain. The direct care staff held onto the resident and educated and encouraged the resident not to do that due to the fall risk. The resident agreed and let go of the curtain. When the direct care staff continued with peri-care, the resident reached out again and grabbed the privacy curtain with both hands and pulled him/herself to the floor. The direct care staff immediately went to get the nurse, who assessed the resident and noted a laceration to the right forehead. The staff did not move the resident, the physician was notified and gave an order for [REDACTED]. The resident returned to the facility with stitches to his/her forehead and an order for [REDACTED]. A written statement from Licensed Staff A identified Direct Care Staff B had notified Staff A that the dressing to the resident's coccyx needed changed due to soiling. Staff A said before he/she got to the room the resident fell . When staff A went into the room he/she saw a pool of dark blood surrounding the resident's face and when he/she called out the resident did not blink or answer. Staff A gave instructions not to move the resident and had another staff member apply pressure to the laceration to try and stop the bleeding while Staff A called the physician. Staff A noted Staff B had just cleaned the resident when the fall happened and the resident did not have a brief on yet when the fall happened. Direct Care Staff B wrote a statement that he/she prepared to change the resident. Staff B said he/she had turned the resident on his/her side and the resident grabbed for the privacy curtain. Staff B noted the resident did that often. Staff B asked the resident to let go of the curtain and warned the resident, "Your (sic) going to pull yourself out of bed!" Staff B said the resident grabbed again with both hands and fell out of bed. Review of the Emergency Medical Services report revealed that staff said the direct care staff had the bed at the "tallest" position caring for the resident when the resident reached for the curtain and pulled him/herself off the bed, striking his/her head on the floor. Staff reported the resident was unresponsive for potentially a few minutes. Observation on 6-18-13 at 3:40 p.m. revealed the resident in the front lobby with visitors. The resident had a sutured area to his/her right upper forehead. Observation on 6-18-13 at 5:14 p.m. revealed the resident sitting in the dining room. Upon approaching the resident to ask about his/her meal, the resident pointed out he/she had stitches. He/she said he/she fell on the side of the bus. Observation on 6-19-13 at 7:15 a.m. revealed the resident sat in a wheelchair in the hall. The resident immediately pointed out the sutures, again. Interview with Direct Care Staff B on 6-19-13 at 4:35 p.m. regarding the accident/fall on 6-16-13 with resident #2 revealed Staff B was the only staff in the room at the time of the fall. Staff B said he/she usually provided pericare to the resident by him/herself. Staff B said he/she had someone help transfer the resident to the bed with the lift. Staff B said after transfer of the resident to bed, the bed remained in the highest position while Staff B provided pericare to the resident. Staff B said typically the resident grabbed at the (privacy) curtain when he/she was turned to the side facing the curtains within his/her reach. Staff B said he/she estimated the resident grabbed at the curtain about 90% of the time. Staff B also said the resident had an air mattress on the bed at the time of the fall. Staff B said the air mattress was "kind of slick". Staff B said generally he/she pulled the curtain back out of reach of the resident, however this time the staff had just gotten a brief from the closet ( which required pulling the privacy curtain into the reach of the resident so Staff B could open the closet) and did not pull the curtain back out of the resident's reach. Staff B said there was no care plan he/she knew about in regard to how to handle the resident grabbing at the curtain. Interview with Direct Care Staff C on 6-20-13 at 1:50 p.m. revealed he/she had provided care to resident #2 only occasionally and today was one of those days. Staff C said he/she knew the resident pulled at the privacy curtains when staff turned the resident to his/her side. Staff C said he/she always got staff to assist him/her when providing pericare to the resident. Interview with Direct Care Staff B on 6-20-13 at 3:15 p.m. revealed he/she almost always provided pericare to resident #2, without any assistance. He/she said a second person assisted with getting the resident into bed, then the 2nd person usually left the room. Staff B said on the day of the fall, he/she had started providing pericare and the resident grabbed for the curtain. Staff B said he/she held onto the resident and educated the resident about the fall risk related to grabbing at the curtain. Staff B said he/she started cleaning the resident again and that time the resident grabbed at the curtain again and pulled him/herself to the floor and Staff B could not catch the resident. Interview with Licensed Staff A on 6-19-13 at 4:15 p.m. revealed the resident had not had any falls for quite a while until the one "a few days ago". Staff A said he/she knew the resident grabbed at the curtain a lot when the staff rolled him/her to the side. On 6-24-13 Administrative Staff E provided a written statement from Licensed Staff A, which had a date of 6-22-13. The statement said resident #2's fall was the result of the resident taking hold of the privacy curtain and pulling him/herself off the bed, falling on the floor. Staff A said he/she was often asked to assist with the resident's care, and he/she had also done the dressing to the coccyx. He/she said the resident consistently grabbed onto the corner of the bed for support or held the hand of a 2nd staff member when available. Staff A said he/she personally had not seen the resident touch the privacy curtain. Interview with Licensed Staff D on 6-20-13 at 1:45 p.m. revealed Staff D did not normally work on the hall where resident #2 resided, but he/she did work there occasionally. Staff D shared that he/she knew the resident grabbed at the privacy curtains when staff turned him/her on the side to provide care. Interview with Administrative Staff E on 6-19-13 at 5:35 p.m. revealed he/she personally did not know resident #2 grabbed at the privacy curtain until after the accident on the 16 th. Staff E said after the fall the facility had provided a wider bed for the resident and had also put mats on the floor beside the resident's bed. Staff E confirmed there was no perimeter mattress on the resident's bed at the time of the accident. Interview on 6-20-12 at 3:25 p.m. with Administrative Staff E revealed he/she had talked with other staff and had found that direct care staff told him/her that resident #2 reached out frequently for the curtains whenever the staff turned the resident to his/her side. Staff E said he/she had talked to the MDS coordinator and the Social Services Designee and both told him/her they had never heard anything about that. Staff E said he/'she updated the care plan to include moving the curtains so the resident could not reach them due to his/her fear of falling and grabbing at the curtains. Staff E said the facility educated in the behavior inservices to report any behaviors to administrative staff. Staff E said possibly staff did not look at it like a behavior because the resident grabbed at the curtains all of the time. Interview on 6-24-13 at 5:35 p.m. with Administrative Staff E revealed he/she had updated the care plan again to include the need for 2 staff when providing providing pericare, or changing the resident. The facility failed to identify and develop a plan to prevent one resident who grabbed and pulled at the privacy curtains, from pulling him/herself out of the bed and sustaining 2 lacerations to the forehead, which required sutures.

The facility census totaled 110 residents with 4 residents sampled. The sample included the review of 3 residents for the facility provision of therapy services. Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents received the appropriate treatment and services to maintain or improve their walking abilities. The facility failed to reinstate physical therapy services to the residents lower extremities for over 2 months after a physician determined the resident's fractured ankle had healed. (#2) Findings included: - Review of the medical record (both electronic and paper copy) revealed resident #2 came to live in the facility on 12/9/09. In the year 2010, the resident experienced falls on 3/10, 4/10, 5/28, 5/29, 5/31, 6/27, 8/9, 8/15 and 8/17. On most of the falls, the resident attempted independent ambulation or transfers. According to a quarterly MDS (Minimum Data Set--a required assessment) dated 9/24/10, the resident experienced moderately impaired cognition, required extensive assistance from one staff member with bed mobility, transfers, limited assistance from one staff member for walking in their room or in the corridor and supervision with set up help only from staff with locomotion on the unit. The assessment further identified staff did not lift the resident either manually or mechanically and with falls in the past 30 and 31-180 days. On 10/3/10, the resident attempted to transfer independently to the toilet and sustained a fall in the bathroom. The resident suffered a fractured ankle as a result of this fall. Because of the fracture, an orthopedic doctor (bone) ordered staff to apply a boot to the resident's affected ankle and to allow toe-touch weight bearing on the leg until further notice. On 10/22/10, physical therapist C described, in a narrative report, that the resident had been receiving physical therapy at the time of the fall with the resultant ankle fracture on 10/3/10. As a result, therapy updated their goals and now focused on functional transfers (rather than walking), wheelchair mobility, sitting balance, and education on safety and proper technique with the therapeutic boot on the affected leg. The report identified that 2 weeks after the fall the resident's transfer ability improved from requiring moderate assistance from staff to minimal assistance, but continued to have difficulty with standing that required more than 1 attempt to stand. The report finished by identifying the resident required 1 week of extension past the 30 day certification to educate the resident on in-room exercises, to establish a restorative program and train the aides on transfers with the resident. On 11/19/10, the resident saw the orthopedic doctor, who discontinued the specialized boot and ordered the resident to have full weight bearing on the affected foot and leg. On 1/18/11 at 12:52 p.m., observation of the resident revealed they sat in a wheelchair outside of the dining room. The resident stated they had lived in the facility for about a year and had fallen and fractured their ankle not that long ago. The resident said they were tired of sitting in "this thing" (then gestured to the wheelchair) and wanted to walk again, but that staff wouldn't let them. When asked if the staff had told the resident why they couldn't walk, the resident said staff tell them "You've fallen!" Review of an annual MDS, dated [DATE], identified the resident with short-term memory problems, required extensive assistance from 2 staff for bed mobility, transfers, not steady when moving from seated to standing position, did not walk, and with impairment on both sides of the upper and lower extremities. It further identified the resident did not receive any physical, occupation or speech therapies or nursing rehabilitation services to maintain range of motion abilities. The assessment showed the resident now required more staff assistance for bed mobility, transfers and no longer walked. The care plan, dated 1/4/11, instructed staff to transfer the resident with a mechanical lift and 2 staff as needed, monitor and report any declines in the resident's range of motion. On 1/18/11 at 4:05 p.m., Physical Therapist D identified the resident had received physical therapy at the time that they fell in October, but was currently not receiving physical therapy. Staff D said they expected the physician to order physical therapy soon, when they determined the resident could sustain full weight bearing ability on their affected leg. On 1/19/11 at 7:23 a.m., Nurse Aide E stated they had noticed the resident used to stand "pretty good" about 3 months ago, but now didn't stand so well and required total care from the staff. Observation on 1/19/11 at 9:18 a.m., nurse aides E and F transferred the resident from the wheelchair onto the toilet with the use of a mechanical sit to stand lift. On 1/19/11 at 10:40 a.m., Administrative Nurse A stated the staff started to use a mechanical lift on the resident after the fracture because of the limited weight bearing ability on the ankle. When asked why they continued to use it when the resident now had an order for [REDACTED]. On 1/19/11 at 11:45 a.m., Therapist D stated they were unaware that the resident had a decline in their transferring ability, but that the nursing staff notified the physician and received an order that day to do a physical therapy evaluation to determine what needs the resident exhibited. The facility failed to provide the appropriate treatment and services to a resident to maintain or improve the resident's walking abilities. The resident stopped walking after an ankle fracture to allow healing. After the physician determined the ankle healed, the facility failed to resume physical therapy to restore the resident's walking ability for over 2 months.