Every finding on record at Heritage Gardens Health and Rehabilitation Center

The facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to consistently provide activities on the weekends, the facility identified 28 residents with moderately impaired or severely impaired cognition. This deficient practice had the risk of a decline in physical, mental, and psychosocial well-being and independence for these residents. Findings included: - A review of the facility's Activity Calendars for April and May 2025 that revealed no scheduled activities were listed for the weekends. On 05/21/25 at 09:42 AM, during the Resident council meeting the residents stated there was no consistent if any weekend activities provided by the staff. On 05/22/ 25 at 09:47 AM, Certified Nurse Aide (CNA) M stated on some Sundays church groups would come to the facility and provide church services for some of the residents. CNA M stated sometimes visitors would come and provide music for the residents. On 05/22/25 at 10:03 AM, Licensed Nurse (LN) G stated the nursing staff would put a movie in at times for the residents to watch on the weekends. On 05/22/25 at 10:25 AM, Activity Staff Z stated there were not any scheduled activities on the weekends. Activity Staff Z stated there was an administrative staff member assigned to each weekend, and they could initiate activities. Activity Staff Z stated she felt some activities occurred while the staff assisted the residents with their activities of daily living. The facility's Activities policy dated 08/31/19 documented it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility-sponsored group and individual activities and independent activities would be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the community.

The facility identified a census of 54 residents, eight residents on a puree-textured diet. Based on observation, record review, and interviews, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals. This deficient practice placed eight residents at risk for complications related to nutritional impairment. Findings included: - On 05/21/25 at 11:05 AM, Dietary Staff CC placed cooked pork chops into the food processor and then started the machine. Dietary Staff CC then added several scoops of gravy into the food processor. Dietary Staff CC checked the consistency of the pork chops. Dietary Staff CC then added several more scoops of gravy into the food processor with the cooked pork chops. Dietary Staff CC checked the food consistency and then placed the pureed pork chops into a pan. Dietary Staff CC stated he added four cups of gravy into the food processor with cooked pork chops. On 05/22/25 at 10:17 AM, Dietary Staff/Social Service BB stated Dietary Staff CC should have followed the recipe for pureed pork chops. Dietary Staff BB stated what Dietary Staff CC had added to the pureed pork chops had added more calories to the food and had not diminished the nutritional value of the food. The facility's undated Texture and Consistency-Modified Diets) policy documented the food and nutrition services department would be responsible for preparing and serving the diet as ordered, including the texture and fluid consistency. The policy directed care would be taken to serve the foods and fluids as ordered on the consistency-altered diet or fluids.

The facility identified a census of 46 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 9 and R36 nasal cannulas and BIPAP masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 05/21/25 at 09:19 AM, R9 laid on her bed on her right side, R9 had her nasal cannula in her nares. R9's BIPAP mask laid directly on the bedside table, and an oxygen nasal cannula laid in the seat of her wheelchair. R9's BIPAP and oxygen nasal cannula were not stored in a sanitary manner. On 05/21/25 at 10:01 AM, R36's oxygen nasal cannula was wrapped around the handle of the oxygen canister in R36's room. R36's nasal cannula was not stored in a sanitary manner. On 05/22/25 at 09:46 AM, Certified Nurse's Aide (CNA) M stated BIPAP masks and nasal cannulas were to be stored in a bag that was dated. On 05/22/25 at 10:02 AM, Licensed Nurse (LN) G stated that BIPAP masks and nasal cannulas were to be stored in a dated plastic bag, not laid on the bedside table or in the residents' wheelchairs. On 05/22/25 at 10:33 AM, Administrative Nurse D stated that BIPAP masks should be stored in a bag and dated; the mask should not be laid over the bedside table. Administrative Nurse D stated nasal cannulas are also stored in a labeled bag when not in use. The facility's Infection Prevention and Control Program reviewed 08/15/22 documented the facility had established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines.

The facility identified a census of 46 residents. The sample included 14 residents, with five reviewed for immunization status. Based on record review and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Residents (R) 36, R2, R35, and R21. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R36's clinical record revealed the PCV23 was pending on 10/29/24, R36's clinical record lacked documentation that the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. Review of R2's clinical record revealed the PCV13 was administrated on 03/24/24. R2's clinical record lacked documentation that the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. Review of R35's clinical record documented R35's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. Review of R21's clinical record revealed that PCV13 was administrated on 02/14/16, R21's clinical record lacked documentation that PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. On 05/22/25 at 10:02 AM, Licensed Nurse (LN) G stated the nurse in charge would ask about immunization on admission, this information would be charted and given to the director of nursing to follow-up. On 05/22/25 at 10:33 AM, Administrative Nurse D stated immunizations were offered on admission and yearly. Administrative Nurse D stated she had delegated immunization tasks to the assistant director of nursing. Administrative Nurse D stated the facility tried to get declination or consent on admission. She stated the information was sent to the pharmacy, and the pharmacy would decide what immunization each resident would need. The facility's Pneumococcal Vaccine dated 12/04/24 documented the facility would offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Each resident would be offered a pneumococcal immunization unless it was medially contraindicated or the resident had already been immunized Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders.

The facility identified a census of 54 residents. The sample included 14 residents, with two for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 38. This deficient practice placed R38 at risk of uninformed choices and miscommunication regarding her care needs and at risk for impaired ability to return to the facility or her same room. Findings included: - R38's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and seizure (violent involuntary series of contractions of a group of muscles). The Annual Minimum Data Set (MDS) dated 08/26/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R38 was dependent on staff assistance for dressing and transfers. The Quarterly MDS dated 04/25/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R38 was dependent on staff assistance for dressing and transfers. R38's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/11/24 documented she required assistance with her activities of daily living. R38's Care Plan, dated 02/29/24 documented she was dependent on staff assistance for transfers and dressing. R38's EMR under the Progress Notes tab revealed on 03/04/25 at 01:18 PM an Alert Note documented R38 was transferred by ambulance to the hospital. On 04/21/25 at 03:45 PM a Nurse's Note documented R38 was admitted to the hospital. On 05/06/25 at 11:10 AM a Nurse's Note documented R38 was transferred to the hospital by ambulance. On 05/21/25 at 09:42 AM, R38 propelled herself from the dining room to her room. On 05/21/25 at 03:45 PM, Administrative Staff A stated the written notification and bed-hold notice were not sent to R38's legal representative for the three facility-initiated transfers to the hospital. Administrative Staff A stated the social service department was responsible for the written notification and the business office was responsible for the bed-hold notice. On 05/22/25 at 10:17 AM, Dietary Staff/Social Service BB stated the written notification to R38's legal representative had been sent for the three facility-initiated transfers to the hospital. On 05/22/25 at 10:22 AM, Administrative Staff B stated she had not sent out a bed-hold notice to R38's legal representative for the three facility-initiated transfers to the hospital and R38 admitted to the hospital. The facility's undated Bed Hold Notice Upon Transfer policy documented at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident and/or the resident representative written notice which specified the duration of the bed-hold policy and addressed information explaining the return of the resident to the next available bed.

The facility identified a census of 46 residents. The sample included 14 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to consistently follow a physician's order for daily weights for Resident (R) 9. This deficient practice placed R9 at risk for delay in treatment and untreated illness. Findings included: - R9s Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of need for assistance with personal care, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), repeated falls, hypertension (high blood pressure), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), muscle weakness, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), difficulty walking, dementia (a progressive mental disorder characterized by failing memory and confusion), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented that R9 required supervision or touching assistance of staff for eating, was independent for dressing and toileting, and required substantial to maximal assistance with showering. The MDS documented R9 received a diuretic (a medication to promote the formation and excretion of urine) during the observation period. R9's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 04/10/25 documented R9's urinary incontinence and indwelling catheter CAA triggered secondary to a level of assistance R9 required with her toileting hygiene and toilet transfers, incontinent episodes. The CAA documented the contributing factors included weakness and impaired mobility. R9s Care Plan dated 02/26/24 documented R9 received diuretic therapy related to congestive heart failure. R9's plan of care documented R9 would have a fluctuation of weight due to diuretic use. R9's plan of care documented nursing staff were to administer diuretic medications as ordered by a physician. The plan of care for R9 documented staff were to administer medication as ordered by the physician and monitor R9 for side effects and effectiveness every shift. R9's EMR under the Orders tab revealed the following physician orders: Torsemide (diuretic) oral tablet 20 milligrams (mg) by mouth two times a day for CHF/edema dated 12/04/24. Obtain daily weights everyday shift dated 12/03/23. On 05/21/25 R9's EMR under the Treatment Administration Record (TAR) revealed an updated order: Obtain daily weights, notify the physician if a gain of 3 pounds in one day or gain of 5 pounds in one week everyday shift. Review of R9's Treatment Administration Record (TAR) from lacked weights for: 02/24/25, 03/01/25, 03/12/25, 03/13/25, 03/14/25, 03/15/25, 03/17/25, 03/18/25, 03/21/25, 03/25/25, 03/30/25, 04/01/25, 04/02/25, 04/03/25, 04/04/25, 04/05/25, 04/06/25, 04/07/25, 04/08/25, 04/09/25, 04/10/25, 04/11/25, 04/16/25, 04/19/25, 04/20/25, 04/21/25, 04/22/25, 04/23/25, 04/24/25, 04/26/25, 05/13/25, 05/14/25, and 05/19/25. R9's EMR lacked consistent documentation for the refusal of daily weights. On 05/21/25 at 09:19 AM, R9 laid on her bed on her right side. R9 had her nasal cannula in her nares. On 05/22/25 at 09:46 AM, Certified Nursing Aide (CNA) M stated nursing would let the CNA staff know if residents needed to be weighed. CNA M stated if the CNA was unable to get a resident's weight, the CNA would try again later in the day and notify the nurse. On 05/22/25 at 10:02 AM, Licensed Nurse (LN) G stated that CNAs obtain daily weights, LN G stated if the CNA did not obtain the weight, it was the nurse's duty to try to obtain the resident's weight per the physician's order. LN G stated if a weight was not obtained, it was the nurse on duty's responsibility to ensure the refusal was documented. On 05/22/25 at 10:33 AM, Administrative Nurse D stated that the day shift CNAs obtained daily weights, if the weight was not obtained the CNAs were to notify the charge nurse. Administrative Nurse D stated if the resident refused, the EMR would reflect that the resident refused. The facility's Provision of Physician Ordered Services dated 02/01/20 documented the facility would maintain a schedule of diagnostic tests in accordance with the physician's orders. The facility would provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality of care.

The facility identified a census of 54 residents. The sample included 14 residents, with three reviewed for pressure ulcer prevention (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 interviews, record reviews, and observations, the facility failed to provide a pressure redistribution cushion for Resident (R) 35's wheelchair. This deficient practice places R35 at risk for preventable skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R35's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and acute kidney failure. R35's Quarterly Minimum Data Set (MDS) dated 04/03/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted he displayed verbal aggression for one to three days during the assessment. The MDS noted he had bilateral lower extremity impairment and used a wheelchair for mobility. The MDS noted he required substantial to maximal assistance with dressing, personal hygiene, oral hygiene, and bed mobility. The MDS noted he required supervision or touch assistance during meals. The MDS noted he was frequently incontinent of bowel and bladder. The MDS noted he had two or more non-injury falls since the last assessment. R35's Dementia Care Aera Assessment (CAA) completed 01/13/25 indicated he was at risk for cognitive loss, incontinence, falls, and skin breakdown. The CAA noted he had difficulties with orientation, memory, and recall. The CAA indicated a plan of care was implemented to minimize the risks related to his cognitive loss. R35's EMR under Assessment revealed a Braden Scale For Predicting Pressure Sore Risk completed on 04/01/25 indicating he was at risk for developing pressure ulcers with a score of 17. R35's Pressure Injury CAA completed 01/13/25 indicated he triggered the potential to develop a pressure ulcer related to his incontinence and reduced level of mobility. The CAA indicated a plan of care was implemented to minimize the risks of developing pressure ulcers. R35's Care Plan initiated 12/29/22 indicated he had a self-care deficit and required assistance with his care needs. The plan noted he required assistance from staff for grooming, toileting, transfers, dressing, personal hygiene, and bathing. The plan noted he was at risk for alterations in skin integrity related to incontinence and the dementia disease process. The plan indicated he was at risk for skin breakdown due to his Braden scale assessment (assessment used to assess the risks of developing a pressure ulcer). The plan instructed staff to apply barrier cream to his buttocks after incontinence episodes. The plan instructed staff to avoid over-drying his skin and to avoid massages over bony prominences. The plan instructed staff to provide frequent turning and repositioning. The plan instructed staff to float the heels of his feet at bedtime and ensure adequate protein intake. The plan instructed the facility to use pressure redistribution surfaces to his bed and wheelchair if indicated. On 05/20/25 at 07:11 AM, R35 sat in his wheelchair in the secondary dining room on the secured unit. An inspection of his wheelchair revealed no cushion or pressure-reducing padding. R35 sat directly on the wheelchair seat. On 05/22/25 at 09:21 AM, R35 sat in his wheelchair next to the window of the secondary dining room on the secured unit. R35's wheelchair had no cushion or pressure-reducing padding. On 05/22/25 at 09:25 AM, Licensed Nurse (LN) G stated R35 had a pressure relieving cushion in his wheelchair in the past. She stated the padding may have been moved due to his incontinence or it caused him to fall. LN G stated that R35 had decreased sensory awareness and reduced mobility. She stated he sat in his wheelchair most of the time. On 05/22/25 at 09:47 AM, Certified Nurse's Aide (CNA) M stated that R35 had a cushion for his wheelchair. She stated he had a lot of incontinence, and it may have been hard to clean the cushion. CNA M stated she was not sure when the cushion was last in his chair. On 05/22/25 at 10:35 AM, Administrative Nurse D stated R35 had been through several wheelchairs due to his mobility issues. She stated his wheelchair was changed back to his original wheelchair due to continued falls. The facility's Pressure Injury Prevention and Management policy implemented 01/2020 indicated the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing existing injuries. The policy indicated the facility would implement preventative interventions for residents at risk or with existing injuries to include pressure redistribution, nutrition, and supportive surfaces.

- R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), epilepsy (brain disorder characterized by repeated seizures), convulsions (involuntary series of contractions of a group of muscles), and transient ischemic attack (TIA - temporary episode of inadequate blood supply to the brain). The admission Minimum Data Set (MDS) dated 12/08/24 documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R28 had limitations in bilateral upper and lower extremities of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R28 was dependent on staff assistance for dressing. He also required substantial to maximum assistance with transfers. The Quarterly MDS dated 03/11/25 documented a BIMS score of six, which indicated severely impaired cognition. The MDS documented that R28 had limited ROM in the bilateral upper and lower extremities. The MDS documented R28 was dependent on staff assistance with dressing and required partial to moderate assistance with transfers. The MDS also documented R28 had two non-injury falls during the observation period. R28's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/28/24 documented he required assistance with activities of daily living, had general weakness, and decreased safety awareness. R28's Care Plan, with an initiated date of 03/02/25 documented staff educated R28 on the use of his call light and was encouraged to use the call light for his needs to prevent further falls. The plan of care with an initiated date of 03/09/25 documented R28 was re-educated on the use of his call light when he needed assistance. The plan of care also documented the staff was educated to ensure that the items R28 needed were within his reach. R28's EMR under the Progress Notes tab revealed on 03/02/25 at 04:09 PM a Nurse's Note documented R28 was found sitting on the floor next to his bed. Review of the Fall Investigation dated 03/09/25 at 03:15 PM, noted R28 was found on the floor on his right next to his bed. On 05/22/25 at 08:24 AM, R28 laid asleep on his bed. R28's bedside table was next to the bed with a urinal on the bedside table. On 05/22/25 at 09:47 AM, Certified Nurse Aide (CNA) M stated everyone had access to the resident's care plans and the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA M stated R28 was a fall risk and did not remember to use the call light and wait for staff assistance. CNA M stated all nursing staff were responsible for the safety of each resident. CNA M said nurses were responsible for ensuring all fall precautions were in place and stated the CNAs would get updates for each resident if there was a new intervention put in place for a specific resident. On 05/22/25 at 10:03 AM, Licensed Nurse (LN) G stated everyone had access to the resident's care plan or their Kardex. LN G stated the resident's fall interventions were placed on their care plans. LN G stated the staff were educated on any new interventions placed on the care plan. LN G stated when a resident had a fall the staff should keep a closer eye on the resident. LN G stated the charge nurse and Administrative Nurse D would review all fall interventions that had been placed on the resident's care plan. On 05/22/25 at 10:22 AM, Administrative Nurse D stated R28 had been educated to use his call light after the fall that had occurred on 03/02/25 and then the staff had been educated after R28 had fallen again on 03/09/25. Administrative Nurse D stated she would ensure the resident's care plan was updated with the current fall interventions. Administrative Nurse D stated everyone had access to the resident's care plan and Kardex. The facility's Accidents and Supervision dated 02/01/20 documented the resident environment remained as free of accident hazards, and each resident received adequate supervision and assistive devices to prevent accidents. The facility would identify hazards and risks, implement interventions to reduce hazards and risks, monitor for effectiveness, and modify interventions when necessary. The facility identified a census of 46 residents. The sample included 14 residents, with three residents sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 21's fall interventions as directed by her care plan and further failed to implement new interventions for R28. This deficient practice placed R21 and R28 at risk of falls and related injuries. Findings included: - R21's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of encephalopathy (a broad term for any brain disease that alters brain function or structure), hypertension (high blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), reduced mobility, contusion of the scalp, fracture of neck of the left femur, fractures o flower end o left radius, obstructive sleep apnea (a common sleep-related breathing disorder where the upper airway collapses, causing brief pauses in breathing during sleep), dementia (a progressive mental disorder characterized by failing memory and confusion), and asthma (a disorder of narrowed airways that causes wheezing and shortness of breath). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R21 was dependent on staff for all activities of daily living (ADL). The MDS documented R21 had two non-injury falls and two injury falls. R21's Falls Care Area Assessment (CAA) dated 12/10/24 documented R21's fall CAA triggered secondary to a history of falling with fracture, and the use of antidepressant medication. R21's CAA documented contributing factors include impaired mobility and generalized weakness. R21's Care Plan dated 11/22/24 documented staff were to ensure R21's call light was within her reach and encourage R21 to use the call light for assistance. R21's plan of care documented staff to respond promptly to R21's request for assistance. R21's plan of care documented R21 should wear appropriate footwear when ambulating or mobilizing in her wheelchair. R21's plan of care documented staff were to follow fall protocol. R21's plan of care documented R21 needed a safe environment with even floors free from spills, and clutter, adequate, glare-free light, a working and reachable call light, and the bed in a low position at night. On 05/20/25 at 07:17 AM, R21 laid on her bed, bed was in a low position, R21's call light was hooked to the wall, R21 was unable to reach her call light. On 05/21/25 at 09:56 AM, R21 laid in the bed on her right side, R21's bed was in a low position. R21's call bell laid on her bedside table, and her call light was hooked to the wall. R21 was unable to reach the call light or the call bell. On 05/22/25 at 09:46 AM, Certified Nursing Aide (CNA) M stated all nursing staff were responsible for the safety of each resident. CNA M said nurses were responsible for ensuring all fall precautions were in place and stated the CNAs would get updates for each resident if there was a new intervention put in place for a specific resident. CNA M stated all residents should have their call lights laid within their reach. On 05/22/25 at 10:02 AM, Licensed Nurse (LN) G stated every nursing staff member was responsible for the care of each resident. LN G stated residents should be asked where the call light should be placed. LN G stated all residents should be able to reach their call light. She stated if the resident was in the bed the resident's call light should not be hooked to the wall. On 05/22/25 at 10:33 AM, Administrative Nurse D stated call lights should be placed within each resident's reach. Administrative Nurse D stated call lights should not be hanging on the wall if the resident was in her room. The facility's Accidents and Supervision dated 02/01/20 documented the resident environment remained free of accident hazards, and each resident received adequate supervision and assistive devices to prevent accidents. The facility would identify hazards and risks, implement interventions to reduce hazards and risks, monitor for effectiveness, and modify interventions when necessary.

The facility identified a census of 46 residents. The sample included 14 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9's bilevel positive airway pressure (BIPAP - non-invasive ventilation device that provides two different levels of air pressure to assist with breathing) mask and nasal cannula were stored in a sanitary manner. This placed R9 at an increased risk for respiratory infection and complications. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of need for assistance with personal care, diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), repeated falls, hypertension (high blood pressure), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), muscle weakness, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), difficulty walking, dementia (a progressive mental disorder characterized by failing memory and confusion), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented that R9 required supervision or touching assistance of staff for eating, was independent in dressing and toileting, and required substantial/maximal assistance with showering. The MDS documented R9 received oxygen therapy and a non-invasive mechanical ventilator during the observation period. R9's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 04/10/25 documented R9 had impaired functional abilities related to general weakness, impaired balance, impaired gait, and mobility. R9's Care Plan dated 03/28/24 documented R9 required oxygen therapy, and staff were to change oxygen tubing, and rinse the oxygen tank filter every week. R9 plan of care documented nursing staff was to apply oxygen therapy as ordered by the physician. R9's plan of care dated 12/12/24 documented R9 used a BIPAP, and nursing staff were to educate R9 on the importance of wearing her oxygen and BIPAP correctly to ensure adequate oxygenation. R9's Care Plan lacked staff direction for the care of R9's oxygen cannula and BIPAP mask. R9's EMR under the Orders tab revealed the following physician orders: Change BIPAP tubing, mask, and storage bag every month every night shift starting on the 5th and ending on the 5th every month dated 12/05/24. BIPAP to be on at night and off during the day. Settings: IPAP: 10CMH20, EPAP: 5CMH20, Rate: 8 every night shift dated 01/31/24. BIPAP to be on at night and off during the day. Settings: IPAP: 10CMH20, EPAP: 5CMH20, Rate: 8 dated 02/01/2024. Change oxygen tubing, storage bag, and rinse filter every Sunday on continuous oxygen use and as needed (PRN) for PRN oxygen use, date the tubing when changed every night shift every Sunday 11/10/2024. Change and date oxygen tubing weekly on Thursdays every day shift 04/10/2025. Change bubbler on oxygen concentrator every 2 weeks, every day shift every 14 days dated 04/10/2025. On 05/021/25 at 09:19 AM, R9 laid on her bed on her right side, R9 had her nasal cannula in her nares. R9's BIPAP mask was laid directly on the bedside table, and an oxygen nasal cannula was laid in the seat of her wheelchair. R9's BIPAP and oxygen nasal cannula were not stored in a sanitary manner. On 05/22/25 at 09:46 AM, Certified Nurse's Aide (CNA) M stated that BIPAP masks and nasal cannulas were to be stored in a bag that was dated. On 05/22/25 at 10:02 AM, Licensed Nurse (LN) G stated that BIPAP masks and nasal cannulas were to be stored in a dated plastic bag, not laid on the bedside table or in the residents' wheelchairs. On 05/22/25 at 10:33 AM, Administrative Nurse D stated that BIPAP masks should be stored in a bag and dated; the mask should not be laid over the bedside table. Administrative Nurse D stated nasal cannulas are also stored in a labeled bag when not in use. The facility's Continuous positive airway pressure (CPAP - ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and BIPAP cleaning policy documented the facility to clean CPAP and BIPAP equipment by current CDC guidelines and manufacture recommendation to prevent the occurrence or spread of infection.

The facility identified a census of 54 residents. The sample included 14 residents, with three reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related care services for Resident (R) 35 to promote his highest practicable level of well-being. This deficient practice placed the residents at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R35's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and acute kidney failure. R35's Quarterly Minimum Data Set (MDS) dated 04/03/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted he displayed verbal aggression for one to three days during the assessment. The MDS noted he had bilateral lower extremity impairment and used a wheelchair for mobility. The MDS noted he had two or more non-injury falls since his last assessment. The MDS noted he had frequent bowel and bladder incontinence. The MDS noted he required substantial to maximal assistance with dressing, personal hygiene, oral hygiene, and bed mobility. The MDS noted he required supervision or touch assistance during meals. The MDS noted he was frequently incontinent of bowel and bladder. The MDS noted he had two or more non-injury falls since the last assessment. R35's Dementia Care Aera Assessment (CAA) completed 01/13/25 indicated he was at risk for cognitive loss, incontinence, falls, and skin breakdown. The CAA noted he had difficulties with orientation, memory, and recall. The CAA indicated a plan of care was implemented to minimize the risks of his cognitive loss. R35's Care Plan initiated 12/29/22 indicated he had a self-care deficit and required assistance with his care needs. The plan noted he required assistance from staff for grooming, toileting, transfers, dressing, personal hygiene, and bathing. The plan indicated he was moved to the secured unit due to his risk of elopement. The plan noted he wandered the secured unit regularly. The plan instructed staff to keep R35 engaged in activities throughout the day, calmly talk to him, and anticipate his needs. The plan indicated he had aggressive behaviors but lacked interventions for staff to utilize during these behaviors. R35's EMR under Progress Notes revealed a Behavioral Note completed 11/01/24 that he had behaviors of entering peers' rooms. The note revealed that R35 was not redirectable during staff attempts. The note revealed he received medication to help him calm down. The note lacked other non-pharmacological behavioral interventions attempted by staff. R35's EMR under Progress Notes revealed a Behavioral Note completed 11/01/24 that staff found R35 in the unit's secured bathroom on the floor. The note revealed he had a non-injury fall as he attempted to self-toilet himself. The note indicated he had no injuries. R35's EMR under Progress Notes revealed a Behavioral Note completed 01/30/25 indicated R35 was aggressive during staff care and redirection. The note revealed R35 grabbed, punched, pinched, and swung at staff. The note lacked behavioral interventions attempted by staff. On 05/21/25 at 12:20 PM, R35 sat in his wheelchair in the hallway next to the secured unit's dining area. R35 wheeled himself from the dining area to R53's room. R35 entered the room and went to the dresser. R35 opened R53's dresser and looked through his belongings. At 12:25 PM, R35 exited the room and went down the hall to the emergency exit. R35 stopped to look in several other rooms but did not enter the other rooms. On 05/22/25 at 09:30 AM, Licensed Nurse (LN) G stated R35 was difficult to keep engaged in activities due to his severe cognitive impairment. She stated the residents on the secured unit were not to enter pes rooms or the locked areas due to safety concerns. She stated the bathroom, closets, and nursing offices were locked at all times. On 05/22/25 at 09:47 AM, Certified Nurse's Aide (CNA) M stated R35 liked to wander on the secured unit but was not allowed to go into peer's rooms. She stated staff were expected to redirect him and provide activities to distract him. On 05/22/25 at 10:35 AM, Administrative Nurse D stated that R35 loved to wander all over the unit, and at times was difficult to keep him out of other rooms. She stated staff were expected to supervise and provide activities to help maintain his interest. The facility's Dementia Care policy revised 10/2019 indicated the facility would implement strategies and approaches to address triggers and behaviors to minimize the distress in the unit and ensure each resident maintained the highest practicable level of physical, mental, and psycho-social functioning as possible.

The facility identified a census of 50 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to provide adequate supervision and failed to identify and implement interventions to address elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk and attempts for Resident (R)1, who had exit seeking behavior and actual attempts to elope from the facility. This placed the resident at risk for elopement and other preventable accident hazards. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), hypertension (elevated blood pressure), reduced mobility, and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) was checked assessment should be completed but was not completed on the assessment. The Cognitive Loss Care Area Assessment (CAA) dated 09/14/23 lacked triggering. The Psychosocial Well-Being CAA dated 09/14/23 documented staff to see social service assessment and notes. R1's Care Plan initiated 09/12/23 lacked R1's elopement risk or interventions to address R1's wandering and elopement behaviors. R1's Wandering/Elopement Risk Scale assessment dated [DATE] documented R1 scored a 10, which indicated R1 was at risk to wander. The Wandering Risk Scale Note dated 09/12/23 at 11:49 PM documented R1 was ambulatory and had no noted wandering since admit. The Interdisciplinary Team (IDT) Note dated 09/15/23 at 11:54 AM documented R1 was at risk for wandering. The Multidisciplinary Care Conference Note dated 10/04/23 documented R1 had a BIMS score of 13 which indicated intact cognition. The Behavior Note dated 10/08/23 at 05:48 PM documented R1 was trying to walk through the main hallway with only a shirt and a brief on. R1 was told by an unidentified resident to turn around and put some clothes on. R1 returned and put pants on. R1 was observed and heard continuously talking to herself and the conversations did not make sense. The Behavior Note dated 10/15/23 at 02:32 AM documented R1 was walking up and down the halls from door to door trying to push on them. R1 tried opening the doors that lead to the outside of the building. The Behavior Note dated 10/15/23 at 02:35 AM documented R1 was walking the hall when she took off at a full speed run and ran her walker into the door. R1 then turned around and sat on her walker and flung her head downwards. R1 was asked what she was doing but failed to respond. The Behavior Note dated 10/21/23 at 11:29 PM documented R1 was putting her call light and on and off but could not state why. R1 then went out of her room and ran up and down the hall and screamed. R1 was found trying to go out the emergency door. R1 stated she was going away. The Behavior Note dated 10/23/23 at 11:53 PM documented R1 attempted to try to run away as R1 looked at the door to the outside. The Behavior Note dated 10/22/23 at 09:04 AM documented R1 ran up and down the south hall in a shirt and brief. R1 attempted to leave out the south door and set the alarm off to the south door. The Behavior Note dated 10/23/23 at 12:26 PM documented R1 started down the hall and had no shirt on, staff was able to redirect R1 to her room and assisted R1 in dressing. The Behavior Note dated 10/24/23 at 12:41 AM documented R1 was exit seeking all shift. R1 ran up and down the halls and attempted to push open the doors. When staff asked what had happened, R1 stated she was attempting to run away. R1 went into the smoking courtyard and a staff member brought her back into the building. The Behavior Note dated 10/24/23 at 01:22 AM documented R1 came out of her room and ran down the hallway. When R1 was asked what she was doing R1 stated she was leaving. R1 asked where the exit was. The Behavior Note dated 10/24/23 at 02:26 AM documented R1 came out of her room with her shoes on the wrong feet and no walker. R1 proceeded towards the back door. The Behavior Note dated 10/24/23 at 04:21 AM documented the south back door alarm sounded and staff ran to the door and observed R1 closing the door behind her and turned to ambulate on the walk towards the street. R1 was redirected by staff and escorted back into the building and R1's room was moved to the secured unit where R1 could be more easily monitored. The Room Change Note dated 10/24/23 at 02:26 PM documented R1 was notified of a room transfer. The reason for the transfer noted increased wandering. On 11/06/23 at 03:23 PM Certified Nurse Aide (CNA) M stated that R1 liked to stay in her room. CNA M revealed she did not know if R1 was considered a full elopement risk. CNA M stated R1 just laid in bed all the time and was not ambulatory. On 11/06/23 at 03:28 PM Licensed Nurse (LN) H stated R1 was moved to the secure unit because she had behaviors of screaming and running up and down the halls and LN H believed exit seeking also. On 11/06/23 at 03:50 PM Administrative Nurse D stated that R1's Care Plan should have had included that R1 was an elopement risk, and it should have been updated when R1 attempted to elope. Administrative Nurse D stated staff used the care plan to know what care to provide for the residents and without R1's Care Plan reflecting interventions for potential elopement, Administrative Nurse D stated staff would not realize why R1 was on the secure unit or her elopement potential. The facility's Elopements and Wandering Residents policy which lacked a date documented the facility would establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment or risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and managing residents at risk for elopement or unsafe wandering included interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards would be added to the resident's care plan and communicated to the appropriate staff. The facility failed to provide adequate supervision and failed to identify and implement interventions to address elopement risk and attempts for R1, who had exit seeking behavior and actual attempts to elope from the facility. This placed the resident at risk for elopement and other preventable accident hazards.

The facility identified a census of 52 residents. Based on observation, record review, and interviews, the facility failed to post the pertinent state agencies and advocacy groups in a manner that was accessible and clearly visible to residents and/or their representatives. This placed the residents at risk for impaired access to resident advocacy groups and agencies. Findings included: - On 09/18/23 at 11:54 AM the facility had the state agencies and advocacy group contact information posted in the main dining room but not at wheelchair height. The height of the posting was aproximately five feet. The posting text was too small to discern the contact information, right to file a complaint with the state agency and the relevant phone numbers in order to do that. There was a large table against the wall in front of the posting which prevented residents and visitors from approaching the postings in order to see more clearly. On 09/19/23 at 10:06 AM Resident (R) 3 and R11 stated the state agency and advocacy information was difficult to read where it was posted and it was a bit high. On 09/20/23 at 03:49 PM Administrative Staff A stated she was not aware of the resident difficulty to see the information provided on the postings. Administrative Staff A stated she would relocate the posted information to a more accessible and visible location. The facility's Facility Required Postings undated policy documented the facility would post required postings in an area that is accessible to all staff and residents. The facility failed to ensure the required posting for state agency and advocacy groups were posted prominently and readily accessible area to residents and/or their representatives.

The facility had a census of 52 residents. The sample included 15 residents and five Certified Nurse Aide's (CNA) were reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had received yearly performance evaluations and had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's in-service records revealed CNA M, CNA O, and CNA P lacked the required 12 hours of yearly in-service education. The facility was unable to provide yearly performance evaluations for the following CNAs: CNA M hire date of 05/25/22. CNA O hire date of 09/15/21. CNA P hire date of 05/12/22. On 09/19/23 at 12:49 PM Administrative Nurse D stated that she did not have the performance evaluations for CNA M, CNA O, and CNA P. She stated that they were paper copies and that she was unable to locate them. She further stated that she provided all of the in-service education that she had available for the requested CNAs for the requested time. On 09/20/23 at 01:38 PM Administrative Staff A stated that tracking educational hours was a collaborative effort between her and Administrative Nurse D. Administrative Staff A stated that she could not definitively show the required in-service hours for each of the requested CNAs. She stated that she would have to take the deficiency and make sure things were corrected going forward. The facility provided Competency Evaluation dated 12/01/19, documented it is the policy of the facility to evaluate each employee to assure competencies and skills for performing his or her job and to meet the needs of the facility residents. The facility failed to ensure three of the five CNA staff reviewed had received yearly performance evaluations and had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care.

The facility identified a census of 52 residents. Based on observation, record review, and interviews, the facility to ensure staff practiced standard infection control practices regarding appropriate hand hygiene during wound care. The facility also failed to ensure staff disinfected resident's items after dirty items were placed on bedside table where the resident ate her meals. The facility failed to ensure the Infection Preventionist tracked and trended infections within the facility. This had the potential to increase the residents' risk for transmission of infectious disease. Findings included: - On 09/20/23 at 07:32 AM Licensed Nurse (LN) H entered Resident (R) 34's room to obtain a blood glucose level. LN H washed hands and donned gloves, placed a clean barrier onto R34's bedside table next her bed. LN H dropped the lancet onto the floor. She picked the dirty lancet up off the floor and placed the dirty lancet onto the bedside table next to clean barrier. LN H doffed gloves and obtained a new lancet, hand sanitized, then donned new gloves and obtained R34's blood glucose. LN H gathered soiled items and disposed of items into the red biohazard container. LN H cleaned and disinfected glucometer and returned machine to container. LN H failed to disinfect the bedside table after obtaining R34's blood glucose. On 09/20/23 at 09:20AM Administrative Nurse E prepped the wound care supplies and bedside table for R44's treatment. Administrative Nurse E wiped the bedside table down with anti-microbial wipes and placed the wound care supplies directly on the surfaces. Administrative Nurse E and Certified Nurses Aid (CNA) M completed hand hygiene and donned gloves. Administrative Nurse E placed clean barrier towels under R44 and removed her kerlix wrap and gauze on both feet exposing her heels. Administrative Nurse E then touched R44's bed footboard and soiled bed sheet with her gloves. Administrative Nurse E pulled the bedside table containing the wound supplies by reaching underneath the non-sanitized sides of the table. Administrative Nurse E then soaked a gauze pad in antiseptic solution and applied it to R44's right heel wound with the same gloved hands. Administrative Nurse E then changed her gloves without completing hand hygiene and applied Manuka honey (honey-based medication that promotes healing and prevent infections) to R44's right heel. Administrative Nurse E changed her gloves again without hand hygiene. During the wound care, CNA M assisted with holding R44's leg in place. On several occasions, she took photos of the wounds (per R44's request) using R44's phone but did not complete glove changes or hand hygiene in between touching the phone and R44's legs. Review of the facility's Infection Control Log for tracking and trending infections from January 2023 through August 2023, revealed the log lacked documentation of organism identification and the infection being treated and tracking the infections within the facility to identify trending. On 09/20/23 at 12:50 PM Administrative Nurse D and Infection Preventionist D stated she had not started tracking the organism or trending infections at that time. On 09/20/23 at 02:41 PM Licensed Nurse (LN) H stated staff should hand sanitize between residents, when soiled and between gloves changes. On 09/20/23 at 02:51 PM Administrative Nurse D and Infection Preventionist D stated she had not had an in-service with the staff since she was hired two or three months ago. Administrative Nurse D and Infection Preventionist D both said they did education in the moment when needed by observation. Administrative Nurse D and Infection Preventionist D agreed they expected staff to perform hand hygiene during direct care, between residents, and during glove changes. The facility's Hand Hygiene policy date 11/01/19 documented staff involved in direct resident contact would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The facility's Infection Preventionist policy dated 11/01/19 documented the Infection Preventionist was defined as the individual designated by the facility to be responsible for the infection prevention and control program. Responsibilities of the Infection Preventionist include but are not limited to: Develop and implement an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable environment. Establish facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control. Oversight of the facility's antibiotic stewardship program. The facility failed to ensure staff practiced standard infection control practices regarding appropriate hand hygiene during wound care. The facility also failed to ensure staff disinfected R34's bedside table after soiled/dirty item was placed where resident's items after dirty items were placed on bedside table where the resident ate her meals. The facility also failed to ensure the Infection Preventionist tracked trended infections in the facility This had the potential to increase the residents' risk for transmission of infectious disease.

The facility identified a census of 52 residents. The sample include 15 residents. Based on observation, record review, and interviews, the facility failed to promote a safe, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings Included: - On 09/18/23 at 07:05AM walkthrough of the facility revealed a heavy urine smell in the southwest hall and the southeast hallway. On 09/18/23 at 09:23AM an inspection of Resident (R)27's bathroom revealed missing tiles around her toilet. On 09/19/23 at 11:00AM Maintenance Staff U was on the secured unit fixing the wall tiles in the unit. She stated the facility was getting around to completing some minor repairs around the facility. An inspection of the facility's front hallways near the main entrance from 09/18/23 through 09/20/23 revealed ongoing loud beeping from the Call Light system. On 09/19/23 at 09:00AM R29 stated the noise from the call light system did get annoying after hearing them beep all day. She stated staff would eventually play music to cover up the beeping. On 09/20/23 at 03:00PM Administrative Nurse D reported the facility was working to improve resident incontinence through screening and more frequent toileting which would help with odors. She reported staff were expected to check on each resident frequently and assist when needed to reduce the call lights beeping. A review of the facility's Resident Rights policy revised 11/2017 indicated facility was to ensure each resident had a right to care within a safe, clean, and therapeutic environment. The facility failed to maintain a comfortable, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected resident.

The facility had a census of 52 residents. The sample included 15 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. This deficient practice placed the 12 residents at risk for preventable injuries and accidents. Findings Included: - On 09/18/23 at 07:34AM, an inspection of an unsecured utility closet in the north-east hall revealed a sprayer bottle of Shurguard Plus cleaning solution in the lower cabinet. The bottle contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 09/20/23 at 01:43PM Certified Nurses Aid (CNA) N stated all chemical products and cleaning solutions should be securely locked out of reach for the residents. On 09/20/23 at 03:00PM Administrative Nurse D stated staff were expected ensure hazardous chemicals and items were kept out of reach of the residents. She stated the utility closet and storage rooms should always be locked. A review of the facility's Accident and Supervision policy 02/2020 indicated the facility will ensure a safe, functional, sanitary, and comfortable environment for the residents. The policy indicated the facility will identify potential environmental hazards to prevent avoidable injuries, illness, and falls. The facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired independently mobile residents. This deficient practice placed 12 residents at risk for preventable injuries and accidents.

The facility identified a census of 52 residents. The sample included 15 residents with two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R)1. This deficient practice placed R1 at risk unnecessary embarrassment and decreased psychosocial wellbeing. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and insomnia (difficulty sleeping). R1's Annual Minimum Data Set (MDS) completed 07/02/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated a history of wandering behaviors. The MDS indicated she required supervision when walking on the unit. R1's Communication Care Area Assessment (CAA) completed 07/17/23 noted she had difficulty making her needs known and understanding others due to her dementia diagnoses. The CAA indicated staff would continue to utilize best practices for risk of impaired communication. R1's Behavioral Care Area Assessment (CAA) completed 07/17/23 indicated she had wandered within the secured unit. The CAA indicated she was easily redirected when needed. R1's Care Plan initiated 12/28/20 indicated she had an illness that enhanced her confusion and wandering behaviors. The plan noted staff were to engage in active conversation, encourage meaningful activities, and visualize her whereabouts frequently. The plan indicated she had behaviors of following staff around and asked repetitive behaviors. The plan instructed staff to anticipate her needs, and to intervene to protect the rights and safety of others (04/11/21). On 09/18/23 at 12:10PM R27 sat in the dining room of the secured unit of the facility. R27 observed R1 (severely cognitively impaired resident) walking within the dining room. R27 yelled out Don't nobody want to talk to you. As R1 attempted to sit next to R37 (severely cognitively impaired resident). R27 yelled out He [R27] don't want to talk with you, move your butt away from him. R27 got up and shuffled to the center of the room. R27 continued to aggressively order R1 to set your [expletive] down somewhere, nobody wants to talk to you. R1 then sat on the couch next to the television. R1 then stood up again to talk with visitors on the secured unit and walked over to them. R27 again harshly yelled out to R1 leave them alone, they don't want to talk to you, set your butt down. R1 sat down again. R27 continued to yell at R1. Certified Nurse Aide (CNA) M then entered the dining room and instructed R27 not to yell at R1. On 09/18/23 at 01:43PM CNA M stated all the residents should be treated with respect from both staff and other residents. She stated the residents should be closely monitored when in the common areas due to behaviors. She stated R1 sometimes wandered the unit and would get in other resident's personal space. She stated R1 could be easily redirected by staff and provided an activity to keep her busy. On 09/20/23 at 03:00PM Administrative Nurse D stated staff were expected to always monitor the residents on the secured unit for behaviors. She stated residents should not be allowed to order or boss other residents around. She staffs the facility holds training that cover dementia related behaviors and interventions to prevent them. She stated all residents should be supervised when in groups or communal areas. The facility's Dignity policy revised 11/2017 stated that each resident shall be care for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. The facility failed to ensure a dignified care environment for R1. This deficient practice placed R1 at risk unnecessary embarrassment and decreased psychosocial wellbeing.

The facility identified a census of 52 residents with 15 residents included in the sample. The facility identified 26 residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 11 and failed to ensure the SNF ABN form 10055 and the Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 was provided within the required timeframes for R16. This failure placed the residents at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R11's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 06/05/23 and ended on 07/02/23. R11 remained in the facility for custodial care. The facility did not issue the SNF ABN 10055 to R11. Review of R16's EMR documented the Medicare Part A episode began on 03/14/23 and ended on 04/05/23. R16 remained in the facility for custodial care. The SNF ABN 10055 and NOMNC 10123 were given to R16 on the same day that Medicare Part A services ended, 04/05/23. On 09/20/23 at 09:08 AM Social Services X stated that she was responsible for completing the SNF ABN and NOMNC forms for the residents. She stated the NOMNC and SNF ABN forms should be provided to residents 72 to 48 hours prior to skilled services ending. She further stated that she was unable to locate the SNF ABN form for R11 and she believed that it may not have been provided to R11. She stated that residents that stay in the facility should receive both forms. The facility provided Advance Beneficiary Notices policy dated 11/01/19, documented the facility shall inform Medicare beneficiaries of his or her potential liability for payment. The policy further documented to ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided within two days of the last anticipated covered day. The facility failed to ensure the SNF ABN form 10055 was provided to R11 and failed to ensure the SNF ABN form 10055 and the NOMNC form 10123 provided at the end of skilled services were issued with enough time for R16 to make informed choices and appeal the non-coverage decisions. This failure placed the residents at risk for decreased autonomy and impaired right to appeal.

The facility identified a census of 52 residents. The sample included 15 residents with five residents reviewed for care planning. Based on observation, record review, and interviews, the facility failed identify the level of care assistance needed for activities of daily living (ADLs) on Resident (R)44's care plan. This deficient practice placed R44 at risk for ineffective treatment and preventable accidents due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity (severely overweight), and blistering of the left and right heels. R44's Admission Minimum Data Set (MDS) completed 08/26/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required one-person physical assistance with transfers, walking, dressing, toileting, personal hygiene, and bathing. The MDS indicated she was occasionally incontinent of urine and always incontinent of bowel but had no toileting program. The MDS indicated she was at risk 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). R44's Urinary Incontinence Care Area Assessment (CAA) completed 08/29/23 indicated she was occasionally incontinent and would need assistance from care staff to continue to observe continence status. R44's Activities of Daily Living (ADLs) CAA completed 08/29/23 indicated she had impaired ADL function related to general weakness and changing cognitive status. R44's Care Plan initiated 08/19/23 indicated she required ADL assistance related to weakness from her recent hospitalization . The plan noted R44 preferred to be bathed on Tuesday and Fridays during the day shift. The plan indicated she required assistance from one staff for bathing activities. The care plan lacked documentation indicating level of supervision/assistance and staff needed to assist R44 related to bed mobility, meals, grooming, locomotion, and toileting. On 09/18/23 at 11:24AM R44 rested in her bed. R44's room smelled heavily of urine and feces. R44 reported her bathing has been inconsistent since arriving at the facility. She stated she had not received a bath in over a week. R44's hair was greasy and uncombed. Her skin was oily. Her fingernails were dirty and untrimmed. She stated if she wasn't so weak, she would give herself a shower, but she required staff assistance to bathed. On 09/18/23 at 11:24AM R44 rested in her bed. R44's room smelled heavily of urine and feces. R44 reported her bathing has been inconsistent since arriving at the facility. She stated she had not received a bath in over a week. R44's hair was greasy and uncombed. Her skin was oily. Her fingernails were dirty and untrimmed. She stated, if she wasn't so weak, she would give herself a shower, but she required staff assistance to bathed. On 09/20/23 at 01:43PM Certified Nurses Aid (CNA) N stated all staff had access to the care plans. She stated the care plan should reflect how much assistance was needed for each resident during cares, how they transfer, and note special care needs the resident required. On 09/20/23 at 02:00PM Licensed Nurse (LN) G stated all direct care staff had access to the care plan. She stated R44 required staff assistance with bathing, toileting, transfers, dressing, and personal hygiene. She stated R44 was weak during walking and used a wheelchair for mobility. On 09/20/23 at 03:00PM Administrative Nurse D stated staff were expected to review and follow the care plans. She stated the plans were reviewed quarterly and reflected the resident updated care needs. A review of the facility's Care Plans policy revised 02/2020 noted that the care plan must meet the needs of each resident's comprehensive assessment must address areas identified as concerns. The policy noted that the plan must include goals, interventions, and instructions to assist with the resident's treatment. The facility failed to identify the level of care assistance needed for ADLs on R44's care plan. This deficient practice placed R44 at risk for ineffective treatment and preventable accidents due to uncommunicated care needs.

The facility identified a census of 52 residents. The sample included 15 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Resident (R)44 and R33. This deficient practice placed both residents at risk for infections and skin breakdown. Findings Included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity (severely overweight), and blistering of the left and right heels. R44's Admission Minimum Data Set (MDS) completed 08/26/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required one-person physical assistance with transfers, walking, dressing, toileting, personal hygiene, and bathing. The MDS indicated she was occasionally incontinent of urine and always incontinent of bowel but had no toileting program. The MDS indicated she was at risk 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). R44's Urinary Incontinence Care Area Assessment (CAA) completed 08/29/23 indicated she was occasionally incontinent and would need assistance from care staff to continue to observe continence status. R44's Activities of Daily Living (ADLs) CAA completed 08/29/23 indicated she had impaired ADL function related to general weakness and changing cognitive status. R44's Care Plan initiated 08/19/23 indicated she required ADL assistance related to weakness from her recent hospitalization . The plan noted R44 preferred to be bathed on Tuesday and Fridays during the day shift. The plan indicated she required assistance from one staff for bathing activities. The care plan lacked documentation indicating level of supervision/assistance and staff needed to assist R44 related to bed mobility, meals, grooming, locomotion, and toileting. R44's Bathing History report from 08/19/23 through 09/20/23 (32 days reviewed) she received bathing on four occasions (08/22/23, 08/26/23, 08/29/23, and 09/11/23) but had no refusal documented. Report indicated she was scheduled to receive a bath/shower every Tuesday and Friday. On 09/18/23 at 11:24AM R44 rested in her bed. R44's room smelled heavily of urine and feces. R44 reported her bathing has been inconsistent since arriving at the facility. She stated she had not received a bath in over a week. R44's hair was greasy and uncombed. Her skin was oily. Her fingernails were dirty and untrimmed. She stated if she wasn't so weak, she would give herself a shower, but she required staff assistance to bathed. On 09/20/23 at 09:20AM R44 cried and reported to Administrative Nurse E during wound care that staff had not been bathing and toileting her appropriately. R44 stated she finally got bathed by the previous night nurse. She stated it was the first time her hair had been thoroughly washed in months. Administrative Nurse E stated she would check and ensure staff were providing R44 with the required ADL assistance she needed on a consistent basis. On 09/20/23 at 01:43PM Certified Nurses Aid (CNA) N reported each resident was assigned bathing days based on their preferences. She stated the residents would receive bathing twice a week. She stated the direct care staff would complete the baths and document the event in the EMR. She stated if a resident refused a shower the nurse would be notified. She stated the nurse would attempt to get the resident to bath and then document the event as refused in the EMR She stated staff would offer another option or time if the resident was not available for the bathing. On 09/20/23 at 03:00PM Administrative Nurse D stated staff were expected to follow the bathing schedule and notify the nurse if bathing was not completed. She stated each resident had assigned bathing days per their care plan. She stated if a bath was missed the resident should have been rescheduled for anther time or date. A review of the facility's Activities of Daily Living policy reviewed 08/2019 indicated the facility will utilize the comprehensive assessment to provide person-centered intervention for each resident's care needs. The policy indicated the facility will ensure the care plans were implemented, reviewed, and followed. The policy indicated the facility would provide adequate assistance and staff support to maintain and prevent ADLs from declining. The facility failed to provide consistent bathing opportunities for R44. This deficient practice placed R44 at risk for infections and skin breakdown. 41037 - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hemiplegia (paralysis of one side of the body) affecting left side, and muscle wasting and atrophy of multiple sites. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R33 required extensive assistance of two staff members for activities of daily living (ADLs). The MDS documented R33 was dependent on two staff member s assistance for bathing during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R33 was dependent on two staff members for bathing during look back period. The MDS documented R33 was at risk of development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R33's Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/18/23 documented R33 assisted staff at times but preferred to just lay in bed. R33's Care Plan dated 06/09/21 documented R33 preferred her bath/shower twice a week and as necessary on day shift. Review of the EMR under Orders tab revealed physician orders: Please place Inter-Dry (single-use fabric used to absorb moisture between skin folds) between abdominal folds dated 11/03/22. Nystatin powder (medication used to treat fungal infections) apply to affected skin folds topically every 12 hours as needed for redness/yeast dated 02/08/23. On 09/18/23 at 01:33 PM R33 laid on her bed dressed in a hospital gown. R33 stated she did not always receive her scheduled bath/shower. R33 stated she would not refuse to take bath/shower. R33 stated the staff would tell her that there was not always enough staff to provide her with a bath/shower or the staff ran out of time on that shift to provide her with a bath/shower. R33 stated that she felt dirty and nasty when she did not receive her scheduled bath/shower. R33 stated the yeast infection under her right arm and breast would itch and burn when she failed to receive her scheduled bath/shower. R33 stated she was not offered a bath/shower on another nonscheduled day to make up for the missed bath/shower. On 09/20/23 at 02:34 PM Certified Nurse Aide (CNA) O stated sometimes bath/showers were not provided do to staffing. CNA O stated the lack of bathing was passed onto the oncoming shift but was not sure if they had followed up and the bath/shower was provided. CNA O stated alternative bathing was offered if they refused their bath/shower. On 09/20/23 at 02:41 PM Licensed Nurse (LN) H stated the baths were listed on the bath/shower list. LN H stated if a bath/shower was not given as scheduled the next shift should follow up and the bath/shower should be provided. On 09/20/23 at 02:41 PM Administrative Nurse D stated the bath/shower list was reviewed weekly to make changes if needed. Administrative Nurse D stated she would expect the staff to provide bah/shower on the resident scheduled bath days or as needed. Administrative Nurse D stated if a resident refused another CNA would approach the resident and if they continued to refuse the nurse would follow up with resident to find out why for the refusal. The facility's Activities of Daily Living policy reviewed 08/2019 documented the facility would utilize the comprehensive assessment to provide person-centered intervention for each resident's care needs. The facility would ensure the care plans were implemented, reviewed, and followed. The facility would provide adequate assistance and staff support to maintain and prevent ADLs from declining. The facility failed to provide a bath/shower to R33's preference of twice a week. This deficient practice increased the potential for poor hygiene, discomfort, further skin related problems, and low self-esteem for R33.

The facility identified a census of 36 residents. Nine residents resided in 1 of the 2 secured units. Based on record review and interview, the facility failed to protect residents from abuse from resident #2. This deficient practice placed all 9 residents in the secured unit in immediate jeopardy. Findings included: - The electronic medical record (EMR) for resident #2 included [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], documented he/she had long and short-term memory deficits with moderately impaired decision-making abilities. He/she had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) with no other behaviors and required limited to total staff assistance with Activities of Daily Living (ADLs). The quarterly MDS, dated [DATE], documented he/she had long and short-term memory deficits with severely impaired decision-making skills and required supervision to total assistance with ADLs. He/she had no behaviors. The Care Area Assessment (CAA) for cognition, dated 5/15/17, documented he/she had impaired daily decision-making abilities with impulsivity. The behavioral CAA, dated 5/15/17, documented a decreased ability to make him/herself understood and understanding of others. The progress notes, dated 1/15/18 through 4/2/18, documented the resident had multiple incidences of striking out at all residents while in the secured unit. The facility put interventions in place after each incident, however they did not protect the 9 residents in the secured unit from harm during this time period. The intervention, dated 4/5/18, documented staff moved resident #2 to a room outside of the secured unit in a non-secured area. This intervention did not take place until after the resident had struck 2 of the 9 residents on the secured unit. On 4/3/18 at 2:42 P.M., direct care staff O stated resident #2 did not like anyone in his/her room. He/she would flail out when others were around him/her. One direct care staff was present on the floor at all times and staff used walkie-talkies to call for assistance of the nursing staff if they were involved with another resident and could not monitor resident #2. On 4/5/18 at 10:40 A.M., licensed staff I stated the administrative staff met every morning to review incidents from the previous day. Staff updated the care plans at that time. The administrative team stated it was hard to place new interventions for the resident after each incident. On 4/5/18 at 10:57 A.M., administrative staff D stated the Quality Assurance team noticed an increase in resident behaviors when certain staff worked in specific areas and the staff have been moved to other units. To ensure enough staff was available, the facility initiated the walkie-talkie system. On 4/5/18 at 3:25 P.M., licensed staff H stated he/she was the charge nurse for the two secured units. The Certified Nurse Assistants (CNAs) called him/her on the walkie-talkies when they were busy with another resident and when resident #2 needed redirection. The facility's Resident Safety Abuse policy, dated (MONTH) (YEAR), documented residents had the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals. The facility failed to protect 9 residents in the secured unit from repeated abuse by resident (#2). The facility abated the immediate jeopardy on 4/5/18 at 8:30 P.M. when it implemented the following: Resident #2 was moved off the secured unit to another room by the nurse's station on 4/5/18 at 3:45 P.M. The Hospice provider for resident #2 was contacted to find a facility that specialized in [MEDICAL CONDITION]'s chorea. Additionally, the facility contacted 12 other facilities for placement. The facility identified other residents with the potential to be affected by this alleged deficient practice upon admission, quarterly, annually, and at significant change utilizing section E and section G of the MDS. The facility in-serviced staff beginning 4/05/18 at 4:00 P.M. regarding interventions for the resident that was moved to a room outside of the secured unit for the safety of other resident's that were in immediate vicinity and Abuse, Neglect, and Exploitation. All staff would be in-serviced by midnight on 4/05/18. No staff would begin a shift until they had been in-serviced on the material. Additionally, this information would be included in the New Employee Orientation. The alleged deficient practice would be monitored by the Director of Nursing (D.O.N.) and/or Administrator and presented to the QAPI meeting 4/11/18. The deficiency will remain at a scope and severity of an E.

The facility identified a census of 40 residents. The sample included 5 residents reviewed for abuse, neglect and/or exploitation. Based on observation, record review and interview, the facility failed to provide an environment free from verbal and physical abuse when resident #2 repeatedly verbally and physically abused residents #3, #4 and #5. This deficient practice placed the residents in immediate jeopardy. Findings included: - The October/ November 2017 electronic medical record for resident #2 documented [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 which indicated severely impaired cognition and he/she had no behaviors during the assessment period. The resident fed him/herself, required limited assistance with most activities of daily living (ADLs) such as transfers, dressing, and toileting, and ambulated in a wheelchair and at times without the wheelchair on his/her own. The quarterly MDS dated [DATE] documented a BIMS score of 8 which indicated severely impaired cognition. He/she did not display any behaviors and his/her level of assistance did not change from the 5/25/17 assessment. The resident required limited assistance of one staff with ADL's, used a wheelchair and would transfer him/herself without seeking staffs assistance. The admission Care Area Assessment (CAA) dated 5/25/17 for cognition documented the resident had a changing cognitive status and needed assistance with ADLs. The care plan revised 8/24/17 directed staff to assess the resident's functional level, observe/assess changes with the use of [MEDICAL CONDITION] medications (medications for mental disorders), explain procedures, offer simple instructions, encourage the resident to participate in activities, use a calm gentle approach, praise accomplishments, and administer pain medications as needed. The care plan lacked documentation related to any behaviors exhibited by the resident. Review of the nurse's progress notes dated 10/23/17 at 9:25 P.M. documented the resident tried to kick a window out, pulled the hair of resident #3, scratched the arm of resident #4 and verbally abused resident #5, calling him/her names and swearing. The resident bit him/herself on the right arm while he/she kicked and hit. Staff sent the resident to the hospital (no time noted) but he she returned the same day without any new orders. Review of the EMR, nurses progress notes, and care plan for resident #3 dated 10/23/17 lacked documentation and/or interventions, related to the resident #2's abuse . Review of the EMR, nurses progress notes, and care plan for resident #4 dated 10/23/17 lacked documentation and/or interventions, related to resident #2's abuse. Review of the EMR, nurses progress notes, and care plan for resident #5 dated 10/23/17 lacked documentation and/or interventions, related to resident #2's abuse. The nurse's note on 10/24/17 documented the resident had another episode in which he/she hit, kicked, and cursed at staff and residents while he/she ran into the walls and doors. He/she obtained a skin tear. The nurses noted dated 10/24/17 continued with a follow up report that recorded the behavior of kicking, hitting occurred 1 to 3 days in the last 7 days, screaming at others, occurred 1-3 days in past 7 days, the resident significantly intruded on the privacy of others, placed others at significant risk for physical injury and significantly disrupted the living environment. The nurse's note dated 10/27/17 at 1:10 P.M. the resident became very agitated went to another resident's room and got into his/her bed. The nurse's note dated 10/29/17 at 4:57 P.M. documented the resident had hallucinations (sensing things while awake that appear to be real, but the mind created) and saw a person who was not there. The clinical record lacked documentation that staff notified the resident's physician of these occurrences. On 10/31/17 at 8:02 A.M. the resident sat calmly in the dining room. He/she had a bandage on his/her right arm. On 10/31/17 at 8:25 A.M. direct care staff CC stated the resident started to get aggressive and/or agitated after lunch. Staff CC stated the resident and resident #5 had frequent altercations. Staff CC stated he/she worked from 6 A.M. to 2 P.M. these occurrences were usually after lunch. Staff CC further stated he/she thought the residents had sundowners-like syndrome (a neurological phenomenon associated with increased confusion and restlessness in patients with [MEDICAL CONDITION] or some form of dementia), and so his/her behaviors did not really start till that time (2:00 P.M.). On 10/31/17 at 8:25 A.M. licensed nursing staff I stated the resident had excessive behaviors and could be verbally abusive and aggressive towards staff. Staff I further stated when the resident argued with another resident, staff redirected the resident with talking and or watching a television show. On 10/31/17 at 2:00 P.M. administrative licensed nurse C stated there were multiple resident to resident altercations between the resident and residents #3, #4 and #5. Staff C confirmed the lack of documentation of these incidents. The facility's policy titled Resident Safety Abuse Policy, revised September 2017, documented residents had the right to be free from abuse by anyone, including, but not limited to, the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friend, or other individuals. The facility failed to provide an environment free from abuse when resident #2 repeatedly verbally and physically abused residents #3, #4, and #5. This deficient practice placed the residents in immediate jeopardy. The facility abated the immediate jeopardy when it implemented the following on 10/31/17 at 7:45 P.M.: In-service all licensed nursing staff about incident reporting and investigation policy and procedures to be completed by 11/2/17; administrative nursing staff C, licensed nursing staff H and administrative staff A to do daily audit reviews of incident reporting and administrative staff A to follow up on the investigation reporting protocol for 5 weeks - any negative trends will be brought to the Quality Assurance and Performance Improvement (QAPI) meetings; resident #2 was sent out for an evaluation on 11/1/17, returned on 11/1/17 and is currently on one on one until an evaluation and possible placement could be obtained; all newly hired employees will be in serviced during orientation on Abuse, Neglect and Exploitation, admission and readmission documentation and the incident and investigating protocol policy. The deficiency remained at the scope and severity of a G.

The facility identified a census of 40 residents. The sample included 5 residents. Based on record review, and interview, the facility failed to perform comprehensive assessments, continued monitoring, and initiate emergency medical response in a timely manner for 1 resident (#1); staff found the resident unresponsive with difficulty breathing and a low pulse oximetry (a process that measures the amount of oxygen in the blood) and subsequently hospitalized on [DATE]. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's closed record [DATE] physician's orders [REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with a Brief interview for Mental Status score of 4 which indicated severely impaired decision making skills. The Mds noted the resident had disorganized thinking skills that was continuously present and did not fluctuate. The resident fed him/herself after set up and required extensive assistance of one staff member with most activities of daily living (ADLs) such as, transfers to a wheelchair, dressing, toileting and personal hygiene, and received oxygen therapy. The quarterly MDS dated [DATE] documented staff assessed the resident with short and long term memory impairment and severely impaired decision making skills. He/she required limited to extensive assistance of one staff member with ADLs and received oxygen therapy. The Care Area Assessment (CAA) dated [DATE] for cognition documented a history of [MEDICAL CONDITION] disorder (a mental disorder) as well as [MEDICAL CONDITIONS] (commonly known as a stroke) anxiety and depression. The resident had noted confusion and needed reorientation, had multiple psychotic co-morbidities (each additional disorder or disease), as well as mood altering medication. The resident recently transitioned off of hospice services (palliative care for terminal patients). The Care Area Assessment (CAA) dated [DATE] for ADL's documented the resident needed assistance with Adls and was unable to ambulate. The [DATE] Care Area Assessments (CAA) lacked documentation the resident used supplemental oxygen. The POS recorded an order dated [DATE] for oxygen (O2) at 2 liters per minute, (L/m) and to titrate (regulate) to keep O2 saturation (available O2 in the blood) greater than 90 percent (%) (normal levels are 94 to 100%). The nurse's progress notes dated [DATE] at 11:56 A.M. recorded staff transferred {the resident} to the emergency room /acute care hospital at 11:45 A.M. due to his/her pulse (heart beat) was 45 beats per minute (bpm), (normal is 60 to 100 bpm) and the resident had confusion and dizziness. Review of the resident's closed record documented the resident was diagnosed with [REDACTED]. The direct care staff assignment sheet dated [DATE] documented the resident used a wheelchair, required 1 person assistance with ADLs, and used supplemental oxygen (O2) at 3 L/m, titrated to keep his/her oxygen saturation level above 90%. The assignment sheet recorded the resident reported when he/she wanted his/her oxygen. The direct care staff assignment sheet lacked documentation of the new pacemaker. The care plan dated [DATE] directed staff to redirect and reorient the resident when needed, assess changes in level of consciousness (L(NAME)), monitor his/her vital signs, note changes in his/her functional level, and notify the physician of any changes. The care plan documented the resident used supplemental oxygen and directed staff to note the characteristics of his/her respiratory status. The care plan lacked documentation of the new pacemaker. The clinical record documented the resident's oxygen saturation level was 90% on [DATE] at 5:13 A.M. The nurse's progress notes dated [DATE] at 5:46 P.M. recorded {the resident} returned from the hospital following an episode of [MEDICAL CONDITION]. The clinical record lacked documentation related to assessment of the resident upon return from the hospital on [DATE], including an assessment of his/her pacemaker insertion site. Review of the nurse's note dated [DATE] at 8:45 P.M. documented staff transferred{the resident} to the emergency room /acute care hospital by ambulance for an evaluation due to his/her oxygen saturation level was 44% (very low) and through the use of increased O2, was up to 78%. The nurse's progress notes dated [DATE] at 2:15 P.M. recorded when licensed nursing staff H started his/her shift at 2 P.M., direct care staff X called him/her to the resident's room immediately. At that time, the resident's O2 saturation was at 44%. Licensed nurse H turned the oxygen concentrator to 5 L/m. The resident's oxygen saturation level increased slightly. This note documented the resident had cyanotic (a bluish color to the skin or mucous membrane that is usually due to a lack of oxygen in the blood), and his/her skin was clammy (unpleasantly damp and sticky or slimy to touch). Licensed nurse H waited few minutes after increasing the O2 to 5 L/m, but there was not any change. He/she obtained an oxygen cylinder and turned it to 25 L/m, and after period of time, the residents O2 saturation climbed to 78%. The cyanosis and clamminess had diminished, but the O2 saturation would not increase further. Licensed nurse H documented he/she could hear fluid in the resident's lungs upon auscultation (listening). Staff sent the resident to the Emergency Department (ED) for an evaluation. The time lapse from the time direct care staff X informed the nurse of resident's difficulty breathing and the time EMS arrived was 1 hour and 15 minutes (75 minutes). Review of the hospital's final case summary dated [DATE] recorded the resident was admitted on [DATE], and he/she died on [DATE] at 9:47 A.M. from acute and chronic hypoxemia (an abnormally low concentration of oxygen in the blood) and hypercapnia (a condition of abnormally elevated carbon [MEDICATION NAME] levels in the blood) [MEDICAL CONDITION] due to healthcare acquired pneumonia and [MEDICAL CONDITION]. On [DATE] at 11:53 A.M. direct care staff CC stated the resident's health was declining and was sent to the hospital multiple times. On [DATE] at 4:22 P.M. direct care staff O stated he/she worked on [DATE] from 2:00 P.M. to 6:00 P.M. He/she stated upon his/her arrival to the unit; he/she received report from the direct care staff the resident's lips were a little blue. Staff O checked on the resident, and noted the resident's clothes were wet from sweating and his/her lips were bluish. Staff O checked the resident's pulse oximetry and the O2 saturation was 44%. He/she notified the licensed nurse H of the low O2 sat and the resident's difficulty breathing. Staff O further stated licensed nursing staff H did not immediately respond to what he/she reported, so he/she went back to the resident's room, and found him/her unresponsive. He/she turned the O2 concentrator up to 5L/m. Staff H entered the room with a different oxygen tank and delivered O2 through the nasal cannula in his/her mouth and gradually the resident's O2 saturation rose. Licensed Nurse H then called for EMS. On [DATE] at 3:00 P.M. licensed nurse H stated this resident was on continuous O2 at 3 l/m. The resident had an order to check the O2 saturation level every shift and it was documented in the Treatment Administration Record (TAR). Staff H stated the resident had been hospitalized recently for a pacemaker insertion. At the start of the shift, direct care staff O reported the resident's fingers were cyanotic. When direct care staff O checked the resident's O2 saturation, it was 44% Staff H stated he/she turned the O2 up to 4 l/min, then to5 l/m. The O2 saturation was in the 70's, but would not increase any further. Staff H further stated he/she obtained a different oxygen cylinder, and administered O2 at 25 L/m. Staff H further stated he/she notified the resident's significant other and the physician, and summoned the ambulance. On [DATE] at 3:22 P.M. licensed nurse H acknowledged he/she might have told direct care staff he/she would check on the resident soon. Staff H stated he/she had just received report from the previous nurse that this resident was fine. On [DATE] at 4:38 P.M. licensed nurse H stated he/she waited to call the resident's physician when the resident's O2 saturation was so low, because he/she thought the O2 saturation level would rise with additional oxygen. He/she acknowledged the physician should have been notified sooner. On [DATE] at 2:00 P.M. administrative nursing staff C acknowledged the lack of documentation of nursing assessments for this resident. He/she stated he/she expected nursing staff to complete a full assessment and update the care plan upon the resident's return to the facility. He/she further acknowledged if a direct care staff reported to the charge nurse that a resident had a problem, the charge nurse should have immediately assessed the resident. He/she also acknowledged 25 L/m of oxygen was not appropriate for this resident. Staff C further stated staff did not summon the ambulance in a timely manner. On [DATE] at 4:24 P.M. physician x stated the resident had pneumonia and was admitted to the hospital on [DATE]. The resident returned to the facility, and developed [MEDICAL CONDITION], and was sent back to the hospital and equipped with a pacemaker on [DATE]. The hospital discharged the resident back to the facility. The facility's policy Nurse Charting Guidelines, revised [DATE], documented acute conditions (identified through observation or by way of a 24 hour report) may require initial and follow up documentation based on the nursing assessment. With any changes in condition, always document a detailed nurse's note describing a resident's change in condition along with a description of the prudent actions taken. The facility's policy Nursing and Readmission Worksheet, revised [DATE], directed staff to perform a comprehensive skin and body assessment, and complete admission nurses notes, including date, time, method of transport, who accompanied the resident, conditions, allergies [REDACTED]. The facility failed to perform a post - hospitalization assessment (after a pacemaker implant), monitor the resident's condition, notify the resident's physician of a change in the resident's condition, and secure emergency services in a timely manner for this cognitively impaired, dependent resident who experienced a hypoxic episode (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level). This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy when it implemented the following on [DATE] at 7:45 P.M.: On [DATE] the facility took immediate action to prevent further incidents. Licensed nursing staff H had been suspended; In-serviced licensed nursing staff on the assessment of residents upon admission and re¿admission; Follow-up and auditing of records will be done by licensed nursing staff and administrative nursing staff C; Ten daily chart reviews will be conducted for 5 weeks to determine if assessments are completed and follow through, any negative trends will be brought to the Quality Assessment and Performance Improvement (QAPI) meetings; All newly hired employees will be in serviced during orientation on admission and readmission documentation; On ,[DATE] immediate action was taken to prevent further incidents. The RN nurse involved had been immediately identified suspended and terminated from employment.

The facility identified a census of 40 residents. The sample included 3 residents. The facility identified 1 cognitively impaired independently mobile resident, with a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without staff knowledge) and identified 6 residents at risk for elopement. Based on observation, interview, and record review, the facility failed to provide supervision for resident #1, a cognitively impaired independently mobile resident assessed as an elopement risk, to prevent the resident from leaving the facility without the facility staff knowledge on 3/23/16 at approximately 11:00 P.M. The facility staff notified the local law enforcement of the missing resident on 3/24/16 at 1:20 A.M. The local law enforcement found the resident on 3/24/16 at 5:10 A.M. approximately 500 feet (2 blocks) from the facility (approximately 6 hours later). This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of the clinical record revealed an acute care hospital admission note dated 7/25/14, that documented resident #1 had eloped from a dementia unit (special locked unit for residents with the progressive mental disorder characterized by failing memory) of a long-term care facility. The clinical face sheet documented the facility admitted the resident on 8/18/14. A physician note dated 8/19/14 at 6:08 P.M., documented the facility admitted the resident from a Geri-psych unit, felt well, and wondered why he/she was here. The resident put a chair through the window at his/her previous facility when he/she was trying to get to the town his/her child resided. The physician's order [REDACTED]. it was untrue), hallucinations (sensing things while awake that appear to be real, but the mind created), and verbal or physical outbursts, general emotional distress, restlessness, pacing, and shredding paper or tissues) and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The physician order [REDACTED]. The elopement risk assessment dated [DATE] documented the resident ambulated independently, exhibited consistent poor safety judgement, had a history of [REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] recorded the resident with a BIMS (brief interview for mental status) score of 4, which indicated severe cognitive impairment. The resident exhibited disorganized thinking, inattention, verbal and other behaviors, rejected care, and experienced delusions. The resident wandered on 4 to 6 days of the assessment period. The resident required supervision and/or cueing with ambulation in and out of the facility and experienced no falls during before or during the assessment period. The care plan for behaviors dated 2/24/16, documented the resident had a self-care deficit, was very confused, had multiple psychological issues and required close supervision, and had a history of [REDACTED]. The care plan for falls dated 2/24/16 identified the resident at risk for falls with knee pain and an unsteady gait. The care plan directed staff to encourage the resident to ask for assistance, anticipate his/her needs, and to check his/her comfort level every 2 hours. The care plan for special needs dated 2/24/16 identified the resident was a high risk for elopement, had slight tremors in his/her hands. The resident was alert, confused, required close supervision, and staff stayed with the resident when off the unit for an activity. The resident resided in the SCU for safety. Nursing note (NN) dated 3/22/15 at 4:36 A.M., documented the resident had short and long-term memory impairment. The resident was alert to him/herself, uncooperative, apathetic, anxious, irritable and his/her long term memory was impaired at all times in the evening. The resident was unable to recall after 5 minutes, unable to recall the long past, had difficulty making decisions in new situations, made poor decisions, and required cues and supervision when making decisions. NN dated 3/22/16 at 11:42 A.M. recorded the resident constantly wandered the entire shift. The resident had been going in and out of other resident rooms, taking their clothing, bedding, and anything else he/she could get. When staff attempted to get the other resident items back, the resident stated, ____ ya ' ll, I ' m getting out of here . Staff frequently checked and redirected the resident throughout the shift. NN dated 3/23/16 at 6:42 P.M documented the resident yelled he/she needed to get out of here and get to another town about a lawsuit. NN dated 3/24/16 timed 3:42 A.M. recorded the resident eloped from the facility special care unit. Nursing staff documented at 1:20 A.M. staff could not find the resident on rounds and searched the facility. The facility staff notified the local law enforcement, at 1:30 A.M., the resident had eloped from the facility special care unit. NN dated 3/24/16 timed 9:41 A.M. documented local law enforcement found the resident at approximately 5:00 A.M. The law enforcement report dated 3/24/16 documented the facility reported the missing resident at 1:20 A.M. and they arrived at the facility at 2:17 A.M. The report revealed the resident punched the window screen out of the window in the south-west dining room of the SCU between 11:00 P.M. (3/23/16) and 1:20 A.M. (3/24/16). Law enforcement staff located the resident approximately 5:10 A.M. approximately 2 blocks from the facility, and notified emergency medical services (EMS). EMS transported the resident to an acute hospital. The facility provided investigation dated 3/24/16 documented administrative nursing staff D arrived at the area where law enforcement found the resident, who appeared to have fallen. The resident wore gray pants down around his/her thighs, was unable to get up, cold, breathing heavily, and exhibited mumbling speech. According to Wunderground.com on 3/23/16 at 10:52 P.M., the temperature was 64 degrees Fahrenheit, overcast skies, with west-south-west wind of 15 miles per hour (MPH). At 4:09 A.M. a temperature of 39 degrees Fahrenheit, a wind chill (defined for temperatures 50 degrees Fahrenheit or lower, the perceived decrease in air temperature felt by the body on exposed skin due to the flow of air) of 28.8 degrees, and west-northwest wind gusts of 26.5 MPH. At 4:22 A.M. a temperature of 37.9 degrees Fahrenheit, wind chill 27.3 degrees Fahrenheit, and west-northwest wind gusts of 28.8 MPH At 4:49 A.M. a temperature of 37.4 degrees Fahrenheit, wind chill 27.8 degrees Fahrenheit, and west-northwest wind gusts 27.6 MPH At 4:52 A.M. a temperature of 37 degrees Fahrenheit, wind chill 26.2 degrees Fahrenheit, and wind gusts west-northwest 28.8 MPH. NN dated 3/24/16 timed 10:46 A.M. documented the acute care hospital admitted the resident to the intense care unit with the [DIAGNOSES REDACTED]. The low body temperature affects the brain, making the victim unable to think clearly or move well) and lactic acidosis and a rectal temperature of 96.1 degrees Fahrenheit. (According to the National Library of Medicine, a normal body rectal temperature ranged from 97 to 99 degrees.) Review of the resident ' s acute care hospital record documented on 3/24/16, the resident was last known to be well indoors at 11:00 P.M. last night. Apparently, at some point the resident was able to leave the home building and found several blocks away from the nursing home early this morning. The resident of advanced age was hypothermic. Laboratory reports revealed lactic acidosis (lactic acid produced in muscle cells and red blood cells form when the body breaks down carbohydrates to use for energy when oxygen levels are low. Lactic acidosis results when the lactic acid builds up in the blood stream faster than can be removed, when oxygen levels in the body drop). The laboratory reported also revealed some signs of dehydration (when the body does not have as much water and fluid, as it should) and the hospital admitted the resident to intensive care for active rewarming, hydration, and close monitoring. The hospital discharge summary dated 3/25/16 at 8:19 A.M. documented the [DIAGNOSES REDACTED]. Observation on 4/6/16 during the door check tour from 3:10 P.M. to 3:25 P.M. with maintenance staff, the dining room windows in the SCU revealed screws with bumpers placed approximately 5 inches inside the window rail, preventing the window from opening widely. At 3:25 P.M., maintenance staff T revealed, staff placed the bumper screws inside with window frames after the resident ' s elopement on 3/23/16. Observation on 4/7/16 at 2:20 P.M. revealed according to the law enforcement report, the law enforcement staff found the resident, lying on the ground, approximately 500 feet from the facility, between and local business and a 4-plex resident. On 4/6/17 at 1:00 P.M. direct care staff Q reported the resident packed his/her belongings every day and waited for his/her (family) to pick him/her up. On 4/6/16 at 12:45 P.M., licensed nursing staff H reported most of the residents in the SCU were elopement risks. Licensed nursing staff reported staff checked the residents in the SCU about every 2 hours with toileting, do a head count and room check when they cannot find a resident. On 4/6/16 at 5:30 P.M., licensed nursing staff I revealed he/she made rounds in the SCU on 3/23/16 at approximately 10 P.M. and observed the resident walking the halls. Licensed staff entered the unit again at 11:15 P.M. to administer medications to an unsampled resident, however did not observe the resident at that time. At approximately 1:20 A.M., direct care staff O reported he/she could not find the resident and licensed staff entered the SCU and attempted to locate the resident. Licensed staff revealed, direct care staff O reported the window had been open in the dining room earlier in the evening and the window screen torn, he/she then observed the window screen, which appeared to have been punched out. Licensed nursing staff revealed he/she notified the local law enforcement at approximately 1:30 A.M. and the facility staff continued to search the building. Direct care staff N called additional staff to assist in the search around the perimeter and local area, as well as law enforcement and firefighters. Licensed nursing staff revealed at approximately 5:10 A.M. another staff member notified him/her that law enforcement located the resident and emergency medical services were transporting the resident to an acute care hospital for treatment. On 4/7/16 at 6:45 A.M. direct care staff O revealed he/she observed the resident dressed in grey sweat pants, grey sweatshirt, socks, tennis shoes and a ball cap, walked the hallway in the SCU on 3/23/16 at 10:00 P.M. The resident often packed a bag and sit in a chair to report his/her (family) was coming to get him/her. At approximately 11:00 P.M. direct care staff reported, he/she helped an unsampled resident, heard the water running in the resident ' s room, and turned off the faucet. Staff reported between 11:00 P.M. and midnight, when the licensed nurse entered the unit, he/she went out to the long-term care staff toilet. When he/she returned and opened the SCU door, cold air pulled from the unlit dining room. Staff turned the light on and found a dining room window open 10 to 12 inches with the screen torn from around the bottom and right side of the frame, flapping in the wind. Direct care staff reported it was a really cold night and he/she thought it was strange to find the open window and that maintenance should probably work on the torn window screen. Direct care staff reported he/she shut the window and continued rounds and checking residents in rooms. Direct care staff notified the charge nurse at approximately 1:20 A.M. when he/she could not find the resident. On 4/7/16 at 7:35 A.M., administrative nursing staff D revealed the facility did not keep a wander alert book with at risk resident ' s information. On 4/7/16 at 7:45 A.M., administrative nursing staff D reported the MDS coordinator completed the wandering/elopement assessments on admission and quarterly. When staff E was not here, the charge nurse completed the assessment using good nursing judgement to determine the elopement risk. On 4/7/16 at 8:15 A.M., administrative nursing staff E reported he/she completed the elopement wandering assessments, and although a resident wandered in the building independently, it did not mean the resident was at risk for elopement. Administrative nursing staff E revealed he/she documented on the resident ' s care plan with interventions if the resident was a high risk for elopement. Administrative nursing staff E revealed there were no lists available for staff to identify residents assessed as elopement risk and staff had to look in each individual care plan to know the resident was an elopement risk. On 4/7/16 at 9:05 A.M., administrative nursing staff E revealed he/she identified all the residents at risk for elopement on their care plans, and all the residents in the SCU were at risk for elopement. Administrative nursing staff E reported staff completed a summary on the wandering/elopement risk assessment for why the resident was or was not at risk for elopement. On 4/7/16 at 12:05 P.M., licensed nursing staff J reported the resident continually said he/she was leaving (the facility). On 4/7/16 at Now 2:45 P.M., administrative nursing staff D revealed he/she was unaware the resident ' s record documented the resident broke out a window in the unit at another long-term care dementia unit before he/she admitted to this facility. On 4/7/16 at 3:45 P.M. administrative nursing staff E reported he/she was auditing each resident ' s elopement assessment, looking for and completing a summary, and then would be able to provide a list of residents assessed as elopement risk. At 5:45 P.M., administrative staff provided a list of 6 residents assessed as elopement risk, 5 residents in the SCU and one in the long-term care unit. On 4/7/16 at 6:45 P.M., direct care staff P revealed the resident packed his/her bag and belongings up every day and came out to the living room to wait for his/her family to pick him/her up. Review of the facility provided Elopement and Wandering Management policy dated 8/2015 lacked directions to staff how to fill out an elopement assessment. The facility lacked a policy that directed staff how to clearly assess and determine the residents at risk for elopement. The facility failed to provide sufficient supervision to this cognitively impaired independently mobile resident, with an elopement history, from leaving the facility without the staff knowledge of the elopement or the resident ' s location for over 6 hours. The resident experienced hypothermia and required treatment in a hospital intensive care unit. The facility ' s failure to provide adequate supervision placed the resident in immediate jeopardy for injury or harm. The facility abated the immediate jeopardy on 4/11/16 at 2:30 P.M. when the facility: 1. Reassessed all residents and updated residents found at risk for wandering and elopement. In addition the facility updated resident care plans to indicate exit seeking and elopement risk. 2. Upon admission, the facility would assess any resident with a history of exit seeking or elopement, identify on the residents care plan the elopement risk, and place a Wanderguard on the resident for 30 days to determine the elopement/wandering pattern. 3. Maintenance staff continued to test all exit alarm/secured doors weekly to prevent any possible elopement/escape from the exit doors. 4. The facility fixed all windows in the memory secure unit to open only 4 to 5 inches and performed weekly checks of windows in the memory care unit. 5. The facility staff monitored any resident meeting exit/elopement criteria in Person at Risk (PAR), for 4 weeks, care plans were updated to identify the risk of exit seeking/elopement and Wanderguard put in place as needed. 6. Developed and implemented an elopement risk policy, elopement risk assessment and missing resident elopement policies. 7. Inserviced all staff on elopement risk policy, elopement risk assessment, and missing resident elopement policies. 8. The administrator and quality assurance committee would review any negative findings or trends reported by the interdisciplinary team. The deficient practice remained at the scope and severity of a G.

The facility identified a census of 43 residents. The sample included 26 residents, with 4 residents sampled for nutrition. Based on observation, record review, and staff interview, the facility failed to implement timely interventions to avoid significant weight loss of 13.4 lbs weight loss or 7% in one month and 30.6 lbs weight loss or 17% in two months for 1 (#65) resident. Findings included: - The physician's orders [REDACTED].#65 documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] noted short term and long term memory problems and severely impaired cognitive skills, and required supervision with set up for eating. The resident weighed 184 pounds, was 62 inches tall, with no weight loss. The Care Area Assessment (CAA) dated 12/17/15 documented the resident was a recent admit to the facility and was unable to always communicate. The CAA for nutrition noted the resident had behaviors and did not always respond when spoken to. It failed to identify eating concerns. The CAA for Activities of Daily Living (ADLs) did not trigger. The care plan dated 12/23/15 noted staff were to speak slowly and clearly to the resident, assist with ADLs, allow him/her to accomplish as much for himself/herself; provide ordered diet of regular finger food diet and to offer replacement food if he/she seemed to not like what is served. The resident's weights from the clinical record were 183.8 pounds (lbs) on 12/15/15, 170.4 lbs (13.4 lbs weigh loss or 7% in one month) on 01/13/16 and 153.2 lbs on 02/12/16 (30.6 lbs weight loss or 17% in two months). The dietician assessment dated [DATE] noted the resident had lost 4.9 percent (%) of his/her admission weight in 30 days. He/she recommended fortified foods. Although the dietician was in the facility on 2/12/16, staff failed to notify the dietician of continued weight loss and was not included on the list for the dietician to review. The clinical record lacked evidence of interventions to prevent further weight loss after the resident continue to lose weight. A physician's orders [REDACTED]. Observation on 02/29/16 at 12:15 P.M. the resident slept while he/she sat at the dining room table. Observation on 02/29/16 at 12:30 P.M. dietary staff EE sat a plate of food in front of resident. Staff EE called the resident's name, but he/she did not awaken. Staff EE did not make further attempts to wake the resident. Observation on 02/29/16 at 12:50 P.M. the resident woke up, but did not make any attempt to eat or feed himself/herself. Observation on 02/29/16 at 01:00 P.M. staff sat down beside the resident and assisted him/her to eat the food that had cooled off for 30 minutes. Observation on 03/03/16 at 8:16 A.M. the resident was served lunch. He/she ate one-fourth of a banana and a few bites of dry, sugary cereal. Interview on 03/03/16 at 11:19 A.M. direct care staff P stated the resident usually fed himself/herself, but required assistance at times. He/she stated the Certified Dietary Manager (CDM) reviewed the resident's weights for accuracy. Interview on 03/03/16 at 1:58 P.M. licensed nursing staff J stated the resident was losing weight. He/she said the resident received fortified foods. Interview on 03/03/16 at 2:45 P.M. certified dietary manager DD stated he/she was responsible for reviewing the resident's weights. He/she verified the resident was losing weight and was on fortified foods. Fortified foods included bigger portions and added calories to snack foods. He/she said the residents who have had a significant weight loss were marked for the dietician to see, and should have been on the list for the dietician to review in February 2016. Staff DD confirmed the dietician did not review resident #65's record. Interview on 03/03/16 at 6:42 P.M. administrative nursing staff D stated the resident lost weight. When the dietician recommended fortified foods or supplements, the order was sent to the physician for approval and the CDM was responsible for ensuring the orders are obtained. Interview on 03/07/16 at 11:13 A.M. consultant dietician JJ stated the CDM developed a list of residents with significant weight loss for him/her to review each month. She expected a resident with significant weight loss to be on the list. Interview on 3/8/16 at 9:50 A.M. certified dietary manager DD stated food intake logs were only kept on residents during the MDS observation period. If the resident received fortified foods, dietary staff reported percentage of intake to him/her. He/she stated there was not a food intake log for this resident. Physician II was unavailable for interview on 03/07/16. The facility's policy Persons at Risk - Weight Loss, revised August 2015, revealed interventions were developed for residents with a 5% or more weight loss in one month. The facility failed to implement dietician recommendations timely as evidenced by the dietician recommended fortified foods on 1/27/16 and the order was not received until 2/12/16. The facility failed to notify the dietician of continued weight loss or implement measures to prevent further weight loss for this cognitively impaired resident.

The facility identified a census of 53 residents with 5 residents sampled. Based on observation, interview, and record review, the facility failed to protect residents from resident to resident sexual abuse when staff failed to protect the residents from unwelcomed sexual advances which placed all female residents in immediate jeopardy. In addition staff failed to protect all residents from resident-to-resident physical abuse when resident (#4) pushed resident (#5), a cognitively impaired resident and caused a fall. Findings included: - The facility admitted resident #1 on 3/18/15, with [DIAGNOSES REDACTED]. Review of the clinical record revealed an acute care hospital discharge summary dated 2/23/15 that documented the resident with inappropriate behavior towards staff and grabbing inappropriately. Review of the admission Minimum Data Set assessment dated [DATE] documented the resident with a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. The resident exhibited behaviors of: [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness); hallucinations (seeing things while awake that appear to be real, but the mind created); delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue); physical behaviors on 4 to 6 days of the assessment period (such as hitting, kicking, pushing, scratching, grabbing, abusing other sexually); and other behaviors not directed at others (such as physical hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, and disruptive sounds) occurred 1 to 3 days of the assessment period. The resident wandered frequently 4 to 6 days of the assessment period and significantly intruded on the privacy of activities of others. The resident required supervision with ambulation and locomotion on and off the unit. Review of the Care Area Assessment (CAA) dated 3/31/15 for activities of daily living documented the resident required close monitoring and had a hard time understanding staff due to a [DIAGNOSES REDACTED]. The initial care plan dated 3/18/15 documented the resident had dementia and behaviors, independently walked with a walker, and directed staff not to leave the resident unattended when off the Secure Care Unit. The plan of care recorded the resident with a potential for anxiety, restlessness and agitation and directed staff to provide one to one assistance during cares, assist the resident to activities, allow the resident to vent his/her feelings, remove the resident from situation, and provide a quiet area for the resident. Review of the comprehensive plan of care dated 3/31/15 recorded the resident with confusion, disorientation, forgetfulness, and impulsivity. Staff added on 4/3/15, social services staff to provide one to one visits as needed. Explain to the resident what behavior was acceptable, praise for the acceptable behaviors, and redirect the resident for inappropriate behaviors. Staff would monitor for changes in behaviors, make referrals, and report the changes to the charge nurse immediately. Staff added on 4/7/15, to redirect the resident when he/she asked to go to bed with him/her. If the resident grabbed staff in an inappropriate place, tell him/her very firmly it was inappropriate and not to do that, document behaviors, and notify the physician. The resident received [MEDICATION NAME] (an antipsychotic medication) twice daily for behaviors. The facility psychiatrist would see the resident after discussion with the resident ' s family about sexual behaviors. Nursing admission assessment dated [DATE] timed 9:20P.M. documented the resident had poor short and long-term memory, made poor decisions, and required cues and supervision from staff for decisions. Nursing note dated 3/20/15 at 2:54 P.M., documented staff observed resident standing next to a female resident ' s bed with pants down around his ankles and holding his (genitals), and asked the if he/she liked that . Staff redirected the resident to put his pants on. As the resident began to walk out of the room and passed nursing staff, he/she reached out to grab another resident and started rubbing his/her hand up and down the resident ' s leg. Staff told the resident again that the behavior was inappropriate and asked him/her to go to his/her room and wait for breakfast. The resident walked to his/her room and stopped at the door where a female resident sat outside his/her door. The resident reached out and attempted to grab the female resident ' s breast. Staff again redirected the resident. Staff documented the resident walked back to his/her room from breakfast and observed the resident enter another female resident 's room and close the door. Staff immediately entered the resident ' s room and observed resident #1 getting into bed with the female resident. Staff redirected the resident to his/her room. Social services staff spoke with the resident and when he/she left the unit, staff observed the resident walked up the hallway, looked into a female resident ' s room, and started to enter the room. Nursing note dated 3/20/15 at 2:55 P.M. recorded a physician order to increase the medication [MEDICATION NAME] dose to 100 milligrams twice daily for behaviors. On 3/22/15 at 10:59 A.M. a behavior note recorded an assessment that the resident ' s behavior put others at significant risk for physical injury, significantly intruded on privacy or activity of others, significantly disrupted care, or the living environment. Staff documented the resident went into the television room and began rubbing on another resident inappropriately. The staff separated the residents. The resident stated that he/she understood that he/she was not to touch other people. Direct care staff assisted the resident with dressing and the resident grabbed at the staff ' s private areas. Staff informed the resident not to do this and resident stated he/she was not doing anything. Nursing note dated 3/23/15 timed 10:47 A.M. recorded the resident was alert, had difficulty following directions, impaired cognition, cooperative but forgetful, unable to recall after 5 minutes, made poor decisions, required cues and supervision from staff when making decisions. Review of activity notes dated 3/27/15 at 9:03 A.M. documented the resident admitted to the special care unit with sexually inappropriate behaviors. Nursing notes dated 4/2/15 at 9:24 A.M. recorded a physician order to decrease the medication [MEDICATION NAME] due to change of condition, the resident experienced balance difficulty, falls, and spent more time lying in bed sleeping with malaise (vague uneasy feeling of body weakness, distress or discomfort). Social service note dated 4/3/15 timed 12:55 P.M. documented staff transferred the resident from the secure care unit to the general nursing home hall. Review of a psychiatry notes on 4/7/15 documented a physician consult due to the resident ' s increase of sexual behaviors and grabbing and fondling residents. The physician ordered the following medication changes for the resident ' s [DIAGNOSES REDACTED].M. and 4 P.M., 2) increase [MEDICATION NAME] (antidepressant medication) to 100 milligrams each morning, and 3) start [MEDICATION NAME] XR (medication to treat moderate-to-severe dementia) 7 milligrams every morning. On 4/8/15 at 5:30 P.M. a primary care physician order added the medication [MEDICATION NAME] ([MEDICATION NAME] medication) 0.625 milligrams every morning. Nursing note dated 4/18/15 timed 11:10 A.M. documented at 9:15 A.M. the resident #1 pushed resident #2 in a wheelchair into another resident room. Staff observed resident with the resident ' s #2 shirt above the breast, resident #1 sitting on a bed with pants down and one hand on his/her (genitals) and the other hand down resident #2 pants. Staff asked resident #1 to leave and then relocated the resident #1 to the special care unit for closer monitoring. Review of resident #2 ' s Minimum (MDS) data set [DATE] documented the resident with short- and long-term memory impairment, severely impaired decision-making skills, and totally dependent on staff for all activities of daily living. Nursing note dated 4/20/15 timed 1:32 P.M. documented resident #1 was asking and making sexual gestures to staff and residents, was easily redirected but did not remember. Nursing note dated 4/21/15 timed 11:55 P.M. documented staff discharged resident #1 by ambulance to an acute care hospital emergency room . On 4/24/15 a witness statement by direct care staff M documented he/she pushed resident #2 out of the dining room into the hallway at approximately 9 A.M. Direct care staff M left resident #2 to answer a call light and when he/she returned resident #2 was gone from the hallway. Direct care staff M reported he/she would not have left resident #2 in the hallway had he/she known resident #1 was anywhere around. Observation on 4/27/15 at 1:10 P.M. direct care staff O pushed the resident in his/her whellchair into his/her room. While direct care staff O and Q transferrd the resident with a gati belt and extensive assistance to the bed the resident mumbled and hummed but was not understandable. On 4/24/15 at 1:30 P.M. licensed nursing staff K reported resident #1 required some assistance with a few activities of daily living and the resident was moved off the special care unit due to some residents requiring more care. Staff could easily redirect resident #1 when he/she exhibited sexual behaviors and had managed other residents with medications for that disorder. On 4/24/15 at 1:37 P.M., administrative nursing staff D revealed, the facility admitted resident #1 on 3/18/15 to the special care unit. On 4/2/15, the facility moved the resident to the general hall after he/she had sexually inappropriate behaviors with an unsampled female resident with the same behaviors on the unit. Administrative nursing staff reported it would help to separate the residents and moved resident #1 away from the unsampled resident onto the general hall. Administrative nursing staff D reported on 4/18/15 A.M. at approximately 9:30 A.M. licensed nursing staff reported the resident was sexually inappropriate with resident #2. Administrative nursing staff D reported he/she told the staff to move the resident back to the special care unit for closer observation by staff, complete incident/investigation reports, and notify the families of the resident. Administrative nursing staff D failed to notify the administrator or the police department at this time and followed up with the investigation on 4/21/15 (3 days after the incident). During an interview on 4/24/15 at 1:45 P.M. administrative staff A reported he/she notified the police on 4/21/15 between 9:13 and 9:30 A.M., on Tuesday, when he/she was told of the resident-to-resident sexual abuse on 4/18/15. On 4/24/15 at 1:50 P.M. Social Services staff X reported that during the admission process, the interdisciplinary team reviewed the resident ' s medical history and all information received and based on a team decision decided on admission. The resident came from another facility with hospice services. Hospice services reported the resident had sexually inappropriate behaviors, made sexual gestures to staff and groped and grabbed at them and as long as staff told him/her, the behavior was inappropriate he/she would stop. The resident was groping at my private area and I told him/her it bothered me, and he/she quit. Social services staff X reported he/she knew of one incident prior to 4/18/15 when the resident was in the doorway of a residents room at about 7:00 A.M. Nursing staff requested that I talk to the resident. I told the resident the unsampled resident was not cognitive enough to understand the actions. The resident said, as long as he/she shook his/her head that was a yes. The resident could not retain information. I was unaware of another incident when the resident got into bed with a resident. Staff informed me on Tuesday 4/21/15 about the sexual incident that occurred on 4/18/15. I contacted the families/responsible parties and started the transfer process for the resident. On 4/24/15 at 2:45 P.M., administrative nursing staff D reported the facility had not investigated or reported to the state agency the two incidents of resident-to-resident sexual incidents on 3/20/15 and 3/22/15 that involved the resident when he/she resided in the special care unit as staff witnessed the incidents. On 4/24/15 at 3:05 P.M. licensed nursing staff L reported the resident #1 was disoriented on admission, walked with a walker, and staff knew he/she had inappropriate sexual behaviors. The resident stood in front of me once asked if I worked here. When I said yes, he/she asked, Do you service? When I said I did not service, the resident said it was too bad I did not service. When the resident displayed sexual behaviors, I told him/her the behaviors were inappropriate. The resident understood but could not recall the information 10 to 15 minutes later. Licensed nursing staff L revealed the staff completed incident investigations and reports for resident-to-resident incidents and always called the report to the director of nursing. On 4/24/15 at 3:10 P.M., licensed nursing staff J reported the resident could not remember who staff were or how to find his/her room. During an interview on 4/24/15 at 3:35 P.M. resident #6 revealed in the television room, a resident that rubbed on his/her arm and placed his/her hands on my arm. When I said his/her hands were cold, the resident attempted to move his/her hands under my upper clothing. Resident #6 revealed he/she reported the incident to a staff member, however, did not remember who or when he/she reported. Resident #6 revealed he/she was afraid of the resident and staff moved the resident (#1)from the general hall back to the special care unit and then transferred the resident out of the building. On 4/24/15 at 5:15 P.M. administrative nursing staff D reported the facility expected staff to separate residents from conflict and make the residents safe. Administrative nursing staff D revealed when staff moved the resident to the special care unit, all staff knew to keep an eye on the resident, and the special care unit had more staff per patient ratio. On 4/27/15 at 12:45 P.M. licensed nursing staff G revealed he/she explained to the resident the sexual behavior was inappropriate and to leave the room. Licensed nursing staff G reported he/she notified the director of nursing by phone and then staff transferred the resident back to the special care unit. Licensed nursing staff G reported he/she attempted to notify the family/responsible party of both residents. On 4/27/15 at 1:45 P.M. direct care staff O reported resident #1 was grabby with staff and other residents on the special care unit. The unsampled resident in the unit would not know to refuse. On 4/27/15 1:55 P.M. direct care staff P reported an unsampled resident in the special care unit would go along with any sexual interaction and would not be able to refuse the resident ' s sexual behaviors due to his/her cognitive impairment. On 4/27/15 at 3:06 P.M. direct care staff N reported staff found residents #1 and #2 in an unsampled resident ' s room with the door closed. Resident #1 sat on the bed with pants down and one hand on his/her (genitals) and the other hand down the resident ' s pants with his/her shirt above the breast. Resident #2 sat in a wheelchair with his/her head turned away and facial grimacing. Direct care staff N reported he/she stayed with resident #2 and resident #1 stood up and pulled up his/her pants. Direct care staff N reported staff knew the resident had sexually inappropriate behaviors. Review of the facility policy Resident Safety Abuse Statement dated 7/2012 directed the facility maintained a work and living environment that was professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental, or sexual), neglect, corporal punishment, and involuntary seclusion and misappropriate of property. The policy directed that residents were not subjected to abuse by anyone including other residents. The facility provided resident safety to each resident when: a. prospective employees were screened. b. new employees were oriented. c. on-going education was provided for all employees. d. the care and treat of residents was provided. e. the staff members were supervised f. the reporting, investigation, and appropriate response to any suspected and/or substantiated violation was completed. Each new employee was informed of their responsibility to immediately report any violation or alleged violations. Should a resident become hostile or unmanageable in any way that would jeopardize his/her safety or the safety of others, the licensed nurse must immediately implement the Unmanageable Residents Policy. The supervisor on duty would IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source to the facility Administrator. The Administrator would report reasonable suspicious of a crime to law enforcement per federal regulation. The Administrator shall also report all alleged violations to appropriate regulatory agencies per state statute and federal regulations. Staff notified the resident ' s family as soon as possible. The Unmanageable Residents Policy revised 3/2015 recorded licensed nursing staff would provide for safety of all residents in the event a resident who became hostile or unmanageable resident in any way that would jeopardize his or her safety or the safety of others. Unmanageable residents were not retained by the facility. After consultation with the administrator, discharge proceedings were implemented as instructed by the attending physician or medical director and in accordance with current laws and regulations governing such discharges. The facility failed to protect residents from resident to resident sexual abuse when Resident (#1), identified with sexual inappropriate behavior and staff failed to protect all female residents in the special care unit from unwelcomed sexual advances. The facility further failed to protect female residents in the general population when he/she was moved off of the special care unit which placed all female residents in immediate jeopardy from 3/20/15 to 4/21/15 when the IJ was corrected when Resident #1 was discharged . The facility abated the immediate jeopardy on 4/25/15 at 10:30 A.M. when: 1. The facility transferred resident #1 out of the facility on 4/21/15 at 11:55 P.M. 2. The facility reported the incident to the law enforcement on 4/21/15 between 9:13 and 9:30 A.M. 3. The facility completed inservice of all staff on the policy for Abuse Neglect and Exploitation dated 7/2012 and facility policy Unmanageable Residents dated 3/2015, training on Reporting Abuse, Neglect and Reasonable Suspicion of a Crime, Incident reporting and Investigation Procedure, Root Cause Analysis Diagram, Notification of Director of Nursing, and Notification of Administrator. This inservice for all employees was completed on 4/25/15 at 10:30 A.M. - The facility admitted resident #4 on 3/3/15 with [DIAGNOSES REDACTED]. fragmentation of thought), and impulse control disorder (a psychiatric disorder characterized by failure to resist a temptation, urge, or impulse that may harm oneself or others). The admission Minimum Data Set Assessment ((MDS) dated [DATE], recorded the resident with a BIMS (Brief Interview for Mental Status) score 99, which indicated the resident could/would not interview. Staff assessed the resident with short- and long-term memory loss, moderately impaired decision-making skills, and indicators of [MEDICAL CONDITION] (inattention). This same MDS recorded the resident with verbal behaviors directed toward others (such as threatening others, screaming at others, cursing at others) occurred 4 to 6 days of the assessment period. Other behavioral symptoms not directed toward others (such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred daily during the assessment periods. Behaviors significantly interfered with the residents care and participation in activities or social interactions. The behaviors significantly intruded on the privacy or activity of others and significantly disrupted care of the living environment. The resident rejected care 4 to 6 days of the assessment period and exhibited wandering behavior daily and significantly intruded on the privacy of activities of others. The care area assessment for behaviors dated 3/16/15 documented the resident with behaviors, impulsivity, and poor safety awareness. The initial plan of care dated 3/3/15 directed staff to assist the resident with activities of daily living. Social services plan to allow the resident to vent, provide one to one visits, teach the resident relaxation techniques, and make referrals as necessary. The comprehensive plan of care dated 3/24/15 recorded the resident had the potential for disruptive interactions (disrupts verbally), [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] ' s disease with a history of behaviors, verbal outbursts, puts out his/her middle finger and flips off. The care plan directed staff to: 1) Administer medications as ordered [MEDICATION NAME] a new oral mediation as the resident refused the [MEDICATION NAME] injections. 2) Certified Nursing Assistant to count verbal outbursts, report to the nurse, and maintain safety of other residents and other staff. 3) Praise the resident for positives, redirect when he/she was becoming agitated. 4) Provide assurance with safety of the resident and those around him/her. The care plan identified the resident with socially inappropriate behaviors, mood changes and isolating behaviors. This plan directed staff to: 1) Provide one to one cares and assist to activities of interest as the resident had a history of [REDACTED]. 2) Offer reassurance using a calm tone. 3) Provide gentle encouragement. 4) Remove from situations; provide quiet area for the resident if he/she was upset or being loud or agitated offer diversion. This plan of care further recorded the resident had a habit of putting out his/her middle finger to everyone he/she met. Staff redirected if the other residents are taking offense to this behavior. Staff tried to redirect the resident ' s behavior. The resident was very quiet, liked to stay in his/her room and watch TV in his/her recliner. Staff invited the resident to activities. The resident had a habit of walking back and forth to the private dining room. The resident preferred to eat at the desk in the front hallway and would not go into the main dining room. The resident exhibited a behavior of yelling out of control and refused to change his/her clothing when wet and soiled. Staff reapproached the resident as needed. Nursing notes dated 3/3/15 timed 2:21 P.M. documented the facility admitted the resident from another nursing facility. Nursing note dated 3/3/15 timed 3:33 P.M. recorded the resident received the medication [MEDICATION NAME] (antipsychotic medication) for socially inappropriate/disruptive behavior: flipping off staff and peers. Nursing notes 3/3/15 timed 4:26 pm, recorded the resident alert, nonverbal for the most part with unsteady gait due to disease, up independently, which placed the resident at risk for falls, no history of frequent falls known. Nursing note on 3/3/15 at 10:00 P.M. recorded the resident received the psychoactive medication [MEDICATION NAME][MEDICATION NAME] behavioral symptoms of slapping, delusions, and extreme fear. The staff would allow the resident to vent his/her feeling, help figure out resident likes and dislikes, divert his/her attention when behavior occurred, would monitor resident behaviors, make adjustments as needed, and report to the physician. Nursing note dated 3/4/15 at 8:38 P.M. recorded staff assisted the resident as needed, encouraged, supervised, monitored activity, and must intervene in social interactions. At times, the resident was easy going and friendly. The resident exhibited behaviors of flipping off staff and other residents every time he/she saw someone on the 6 A.M. to 6 P.M. shift. Nursing note dated 3/4/15 at 8:40 P.M. documented the resident ' s daily decision-making skills were poor, and he/she required cues and supervision. Nursing note dated 3/8/15 at 2:59 P.M. recorded the resident with repetitive physical movement, rocking back and forth. This morning at breakfast the resident was sitting in the conference room and became agitated with this nursing staff and began to yell, (obscenity) and when I tried to redirect the resident one to one with conversation, the resident jumped up out of the chair and lunged at me and approached me and was swinging his/her arms at me. I left the area and he/she went back to sit down in his/her chair and began to flip other residents off with his/her middle finger saying (obscenity). The certified medication aide (CMA) who was working with me approached resident to redirect one to one and the resident became increasingly agitated with the CMA and lunged at this staff. The CMA also left the area. The resident got up and slammed the door that divided the main dining room and conference room. Staff contacted the physician and received a one time order for a medication. Resident had two more incidents of yelling at staff while sitting in the conference room. The resident finished his/her morning meal and went back to his/her room. A behavior note dated 3/9/15 at 7:21 A.M. documented the resident walked into the library and another resident was sitting in a chair beside the chair this resident normally sat in. The resident started flipping off the other resident and went to sit down but was leaning towards the other resident due to his/her unsteady gait. The other resident put his/her arm out to stop this resident from falling onto him/her. This resident became irritated and continued to flip the other resident off close to his/her face while yelling, I ' m not touching him/her! I ' m not touching him/her! Nursing staff got the resident seated and asked this resident, please put his/her arm down. The resident yelled No! I don ' t have to! He/she touched me! Staff asked the other resident if he/she would mind moving to another location and he/she agreed. After other resident left the room, this resident continued sitting quietly in the chair. The resident had not had any other behaviors besides this one of flipping everybody off that he/she sees or passed by. A behavior note dated 3/12/15 at 11:29 A.M. documented a late entry for 3/11/15. The resident came to movie and popcorn activity. When entering dining room, the resident flipped peers off with the middle finger. This writer asked resident to please not do that. The resident continued doing so. Staff explained to resident that if he/she continued, he/she would have to leave the dining room if he/she did not stop flipping off his/her peers and staff with his/her middle finger. Staff asked the resident several times and he/she refused to do so. This writer then told the resident that he/she could not attend the movie and popcorn activity and staff asked the resident to leave the dining room. The resident ran out of the dining room yelling and using foul language toward this writer. Staff was not able to redirect the resident. A behavior note dated 3/12/15 at 11:35 A.M. recorded the resident refused care. Staff asked the resident if they could help him/her change his/her pants as the pants had a wet area from urine on the front. The resident screamed, I already did! The certified nursing assistant (CNA) reported the resident had feces all over him/herself and the bed earlier today and did agree to shower. However, the resident would not allow anyone near him/her now. The resident screamed and yelled, slamming his/her door, still sticking his/her middle finger up at everyone when coming out of his/her room for meals and yelling loudly at staff when they try to provide cares. This behavior occurred multiple times daily. The resident ' s behavior was very upsetting to other residents. A behavior note dated 3/12/15 at 10:38 P.M. recorded the resident continued flipping off every person (staff or peers) that he/she encountered while walking from his/her room to the library and back. The staff approached the resident several times asking if they could assist him/her with changing his/her pants because he/she had a wet area on them. The resident would begin yelling at staff. Staff also laid out a pair of pants for him/her to change into when he/she returned to his/her room. The resident grabbed the pair of pants and threw them in his/her closet yelling, I ' m not changing! At approximately 6:30 P.M., the CNA was successful in getting the resident to change into clean pants. About 20 minutes later, the resident urinated in his/her pants again. The staff again offered to help the resident change, but the resident became agitated and started yelling. Staff laid out a pair of pants and informed the resident that he/she could change into them whenever he/she was ready. The resident has ambulated down to the library a couple times since then and continued to refuse clean pants. Staff will continue to encourage the resident to change clothing. A behavior note dated 3/13/15 at 9:14 A.M. recorded a late entry for 3/12/15 at about 4 P.M. The CNA asked the resident if he/she could help him/her change his/her pants as he/she had urinated on them several times after his shower, and the resident refused to change into dry clothes. The resident started yelling, screaming, and was out of control. Nursing staff raised his/her voice and said, (Name) stop yelling right now, or you will not be able to stay here. Nursing staff feared the resident was going to hit the CNA. The resident then walked down the hall to his/her room, turned around and yelled out to staff saying, obscenity . Nursing staff instructed the CNA to keep away at this time, so the resident could calm down, and to reapproach the resident later. The CNA reported to nursing staff he/she was afraid of the resident. The resident continued to stick up his/her middle finger at staff and residents as he/she walked up and down the hallway. A behavior note dated 3/31/15 at 12:43 P.M. documented the resident continued walking up and down halls flipping off everyone he/she met. Staff observed another resident had yelled at the resident a couple times today about not doing that. The resident continued. Staff was unable to redirect the resident' s behaviors. On 4/2/15 at 1:51 P.M. the physician examined the resident and reviewed the plan of care with no new orders. Social service notes dated 4/3/15 at 12:57 P.M. recorded a near miss for a resident-to-resident incident due to the resid

The facility identified a census of 39 residents. The sample included 11 residents. Based on interview, and record review the facility failed to provide interventions to prevent falls for 1 (#17) of 3 sampled for falls who fell and obtained a fracture. Findings included: - Resident #17's [DIAGNOSES REDACTED]. The annual Minimum Data Set 3.0 Assessment (MDS) with the Assessment Reference Date (ARD) of 3-11-12 documented the resident's Brief Interview for Mental Status (BIMS) score of 4 indicating the resident with severely impaired decision making skills, required limited assistance with ambulation, was incontinent of bowel and bladder and had a fall since the prior assessment date. The 3-31-12 Fall Care Area Assessment summary (CAA) documented the resident independent with ambulation and at times staff ambulated with the resident, cueing him/her where to go. The resident's gait was slow and steady and at times the resident used the handrail for ambulation. The 3-7-12 Fall Assessment documented the resident with vertigo or dizziness at times, was incontinent, and received antidepressant medications. The resident had an unsteady gait at times and held onto the bars in the hallway or to furniture to steady his/herself. The resident wore non-skid socks while in bed and shoes during the day, staff assisted the resident to the toilet, had stress incontinence, received an antidepressant which increased the risk for falls, and staff offered assistance if needed for ambulation. The 3-12-12 care plan identified the resident at risk for injury related to his/her dementia and history of falls. The care plan directed staff to observe the resident for unsafe situations and educate the resident on safety with assistance for toileting and encouraged to ask for help. The care plan also directed staff to monitor the resident's gait for unsteadiness, wear non-skid socks when in bed as the resident was independent with toileting. Record review of the nurse's notes on 5-5-12 at 5:00 P.M. documented the resident sat in a chair in the dining room reading a magazine, staff left the room leaving the resident unattended and when staff returned found the resident on the floor. Staff faxed the physician on 5-5-12 at that time and requested the use of a personal body alarm on the resident while out of his/her room. The physician agreed. The updated 5-5-12 care plan directed staff to place a personal body alarm on the resident while out of his/her room. Record review of the nurse's note on 5-30-12 at 7:47 A.M. documented staff found the resident on the floor in his/her room at 5:15 A.M. with a skin tear on the resident's left elbow and his/her left leg with shortness and rotated outward. Staff notified the resident's Durable Power of Attorney (DPOA) and the DPOA asked if the resident had his/her alarm on. The nurse's note documented a message was left for the interdisciplinary team to notify the family the resident needed different shoes and needed clarification on the personal body alarm. The 5-30-12 Fall Assessment documented the resident with incontinence, joint pain, confusion, gait off balance and required one aide for assistance with transfers. The resident had more difficulty speaking, speech garbled and did not make any sense. The resident had poor safety awareness due to dementia and an unsteady gait and needed proper footwear on and a clarification order for the personal body alarm. Record review of the physician's orders [REDACTED]. Record review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) from 5-7-12 through 5-30-12 lacked the intervention for the alarm. Record review of the Notarized witness statement, direct care staff F documented he/she got the resident up and toileted and dressed the resident for the day and placed the resident back in bed at approximately 4:30 A.M., went to another residents room and heard the resident say "oh, oh, oh". At that time direct care staff F went to the resident's room and found the resident on the floor. Record review lacked evidence directing staff to get the resident up and dressed at 4:30 A.M. The care plan directed staff to toilet the resident at midnight and 4:00 A.M. The Certified Nursing Assistant (CNA) assignment sheet for the resident directed staff to toilet the resident at midnight and 4:00 A.M. and lacked interventions to include the use of an alarm for the resident or dress the resident at 4:00 A.M. Record review of the Investigation documented on 5-20-12 at around 4:30 A.M. direct care staff F took the resident to the bathroom because the resident's nightgown was dirty. Staff dressed the resident for the day and laid the resident down in bed with his/her non-skid socks and shoes on. The Hospital History & Physical dated 5/30/12 recorded the resident fell this morning while getting up out of bed. He/she experienced an acute onset of left sided leg pain with shortening and external rotation of his/her left lower extremity. He/she transported to the Emergency Department and was found to have a fractured left hip. During staff interview on 6-13-12 at 9:17 A.M. licensed staff E stated the resident developed a urinary tract infection and on 5-25-12 when he/she notified the family, they asked how the "alarm" was going and licensed staff E told the family he/she was not aware of an alarm used for the resident. Licensed staff E also stated later he/she learned of the order for the personal alarm in the chart and it instructed staff to place the personal alarm on the resident when staff was not around. During staff interview on 6-13-12 at 4:20 P.M. administrative nurse C acknowledged the physician's orders [REDACTED]. During staff interview on 6-13-12 at 5:00 P.M. administrative nurse B acknowledged staff dressed the residents and placed them back in bed and stated staff were in-serviced after he/she was made aware it. During staff interview on 6-14-12 at 1:43 P.M. direct care staff F stated he/she toileted the resident every night per the schedule on the CNA assignment sheet, at 1:00 A.M. and 4:00 A.M. Direct care staff F stated he/she dressed the resident and put the resident's shoes on the bed as usual to prevent the resident from bending over and falling. He/she said staff got the resident up at 4:00 A.M. to toilet him/her and dressed him/her and then the resident went back to bed and usually went back to sleep. Direct care staff F said the resident appeared asleep when he/she left the room to attend to another resident. He/she said about 45 minutes later he/she heard the resident holler "oh, oh, oh" and went to the resident's room and found the resident laying on the floor and was bleeding. Staff called the nurse and the nurse assessed the resident. Direct care staff F was not aware of an alarm for the resident and stated the intervention was not on the CNA assignment sheet. During interview on 6-13-12 at 1:58 P.M. the resident's family stated the resident received a fracture of the femur and required repair of the fracture. The 6/2011 facility provided Fall Assessment and Prevention Protocol documented staff updated the CNA assignment sheet with any new interventions and the appropriate staff person implemented any new resident safety equipment identified through the process. The facility failed to provide interventions as planned to prevent falls. - According to the quarterly Minimum Data Set (MDS) for resident #3 dated 5/28/12 the resident's Brief Interview for Mental Status (BIMS) score was 4/15, which indicated the resident had severe cognitive impairment, had verbal outbursts directed toward others 4 to 6 days but less than daily. The resident needed limited to extensive assistance with Activities of Daily Living (ADLs), and had no falls. The care plan for potential for injury as related to falls dated 6/4/12 said staff were to assist the resident out of his/her chair if needed, remind him/her to walk carefully and slowly, monitor that the resident wore non-skid shoes or socks, monitor for any difficulties with walking or unsteadiness, remind the resident to use the roller walker, place a belt or suspenders on him/her if the resident's pants did not have a drawstring to prevent from them falling down. Review of the fall risk assessment dated [DATE] at 2:12 A.M. noted the resident was at risk for falls due to environmental factors that presented a hazard; the brakes on the bed did not work. Staff listed the fall intervention was to notify maintenance staff to fix the brakes to the bed and encourage the resident to wear shoes or gripper socks when up. The nurses notes dated 5/30/12 at 12:30 A.M. said the staff found the resident in his/her room on the floor. The resident moved the bed when he/she sat down on it. Staff found the resident on the floor, with his/her back against the recliner and with the bed now against the wall. An observation on 6/13/12 at 7:30 A.M. revealed the resident ambulated with a steady gait and use of the roller walker to the dining room. Interview on 6/13/12 at 1:50 P.M. with Direct Care Staff I said the resident had a recent fall but was not considered a fall risk. He/she said he/she could not recall prior to this when the resident had a fall. He/she said the resident used a roller walker, gait was steady and needed cued at times to slow down because he/she tended to walk too fast. Staff I said there were several beds in the facility with brakes that did not work, staff wrote this in the maintenance log so maintenance staff could fix them. Staff I said maintenance placed coasters under any bed that rolled but with any force the the wheels rolled off the coaster. An interview on 6/13/12 with Licensed Nursing Staff G at 2:15 P.M. said the resident's fall was an isolated incident, staff figured the bed rolled toward the wall when the resident tried to get back into bed. He/she said maintenance fixed the bed. The resident wore shoes all day and was to wear the gripper socks at night but he/she was unsure if the resident did this. An interview on 6/13/12 at 3:05 P.M. with Maintenance Staff J said staff did notify him/her after the resident fell and he fixed the bed. He/she said the brakes were functional but very still and needed oiled so staff could lock them. Staff J said he/she also placed coasters under the bed wheels to prevent them from moving. He/she said the bed should not move if the coasters were under the wheels and the wheels were aligned correctly. Staff J confirmed there were no coasters under the bed. He/she said many of the brakes on the beds do not function and he/she used parts from other beds to fix but this supply was running low. An interview on 6/13/12 at 5:40 P.M. with Administrative Staff A said housekeeping staff probably swept up the coasters that maintenance placed under the bed wheels. The facility failed to maintain a safe environment for this cognitively impaired but mobile resident. - The quarterly Minimum (MDS) data set [DATE] for resident #23 recorded the Brief Interview for Mental Status score was 11/15, which indicated the resident had moderate cognitive impairment. The resident needed extensive assistance from staff for walking in the corridor, did not walk in the room, needed limited assistance with bed mobility and personal hygiene, and supervision with transfers. The care plan for fall risk dated 5/2/12 said staff to encourage the resident to use the call light and wait for staff to assist him/her with transfers, use the wheel chair for all locomotion and the resident was able to propel self in the wheel chair. Report to the nurse if the resident complained of pain or required more assistance with transfers and Activities of Daily Living (ADLs). Observation on 6/12/12 at 10:55 A.M. revealed the resident laid in bed on his/her left side, eyes closed and rested quietly. There was a transfer bar on the resident's left side of the bed, the other side of the bed was against the wall. The opening to the transfer bar measured 7 1/4 inches wide by 21 inches long from the top of the inside of the bar to the bed frame where the bar attached to a board that staff placed under the mattress. An interview on 6/13/12 at 1:45 P.M. with Direct Care Staff I said the resident used the transfer bar to the bed with change of position and transfer. An interview on 6/13/12 at 4:55 P.M. with Administrative Nursing Staff C said he/she was not aware the opening was too large and thought that was for side rails only. He/she removed the bar and said he/she would notify therapy for suggestions. According to the Federal Drug Administration Hospital Bed Safety Workgroup as of June 2001 revised the dimension within a side rail to less than 120 millimeters (mm) or 4 3/4 inch. The facility failed to ensure the environment remained free of potential accident hazards.

The facility identified a census of 39 residents. The sample included 11 residents. Based on interview, and record review the facility failed to provide interventions to prevent falls for 1 (#17) of 3 sampled for falls who fell and obtained a fracture. Findings included: - Resident #17's [DIAGNOSES REDACTED]. The annual Minimum Data Set 3.0 Assessment (MDS) with the Assessment Reference Date (ARD) of 3-11-12 documented the resident's Brief Interview for Mental Status (BIMS) score of 4 indicating the resident with severely impaired decision making skills, required limited assistance with ambulation, was incontinent of bowel and bladder and had a fall since the prior assessment date. The 3-31-12 Fall Care Area Assessment summary (CAA) documented the resident independent with ambulation and at times staff ambulated with the resident, cueing him/her where to go. The resident's gait was slow and steady and at times the resident used the handrail for ambulation. The 3-7-12 Fall Assessment documented the resident with vertigo or dizziness at times, was incontinent, and received antidepressant medications. The resident had an unsteady gait at times and held onto the bars in the hallway or to furniture to steady his/herself. The resident wore non-skid socks while in bed and shoes during the day, staff assisted the resident to the toilet, had stress incontinence, received an antidepressant which increased the risk for falls, and staff offered assistance if needed for ambulation. The 3-12-12 care plan identified the resident at risk for injury related to his/her dementia and history of falls. The care plan directed staff to observe the resident for unsafe situations and educate the resident on safety with assistance for toileting and encouraged to ask for help. The care plan also directed staff to monitor the resident's gait for unsteadiness, wear non-skid socks when in bed as the resident was independent with toileting. Record review of the nurse's notes on 5-5-12 at 5:00 P.M. documented the resident sat in a chair in the dining room reading a magazine, staff left the room leaving the resident unattended and when staff returned found the resident on the floor. Staff faxed the physician on 5-5-12 at that time and requested the use of a personal body alarm on the resident while out of his/her room. The physician agreed. The updated 5-5-12 care plan directed staff to place a personal body alarm on the resident while out of his/her room. Record review of the nurse's note on 5-30-12 at 7:47 A.M. documented staff found the resident on the floor in his/her room at 5:15 A.M. with a skin tear on the resident's left elbow and his/her left leg with shortness and rotated outward. Staff notified the resident's Durable Power of Attorney (DPOA) and the DPOA asked if the resident had his/her alarm on. The nurse's note documented a message was left for the interdisciplinary team to notify the family the resident needed different shoes and needed clarification on the personal body alarm. The 5-30-12 Fall Assessment documented the resident with incontinence, joint pain, confusion, gait off balance and required one aide for assistance with transfers. The resident had more difficulty speaking, speech garbled and did not make any sense. The resident had poor safety awareness due to dementia and an unsteady gait and needed proper footwear on and a clarification order for the personal body alarm. Record review of the physician's orders [REDACTED]. Record review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) from 5-7-12 through 5-30-12 lacked the intervention for the alarm. Record review of the Notarized witness statement, direct care staff F documented he/she got the resident up and toileted and dressed the resident for the day and placed the resident back in bed at approximately 4:30 A.M., went to another residents room and heard the resident say oh, oh, oh. At that time direct care staff F went to the resident's room and found the resident on the floor. Record review lacked evidence directing staff to get the resident up and dressed at 4:30 A.M. The care plan directed staff to toilet the resident at midnight and 4:00 A.M. The Certified Nursing Assistant (CNA) assignment sheet for the resident directed staff to toilet the resident at midnight and 4:00 A.M. and lacked interventions to include the use of an alarm for the resident or dress the resident at 4:00 A.M. Record review of the Investigation documented on 5-20-12 at around 4:30 A.M. direct care staff F took the resident to the bathroom because the resident's nightgown was dirty. Staff dressed the resident for the day and laid the resident down in bed with his/her non-skid socks and shoes on. The Hospital History & Physical dated 5/30/12 recorded the resident fell this morning while getting up out of bed. He/she experienced an acute onset of left sided leg pain with shortening and external rotation of his/her left lower extremity. He/she transported to the Emergency Department and was found to have a fractured left hip. During staff interview on 6-13-12 at 9:17 A.M. licensed staff E stated the resident developed a urinary tract infection and on 5-25-12 when he/she notified the family, they asked how the alarm was going and licensed staff E told the family he/she was not aware of an alarm used for the resident. Licensed staff E also stated later he/she learned of the order for the personal alarm in the chart and it instructed staff to place the personal alarm on the resident when staff was not around. During staff interview on 6-13-12 at 4:20 P.M. administrative nurse C acknowledged the physician's orders [REDACTED]. During staff interview on 6-13-12 at 5:00 P.M. administrative nurse B acknowledged staff dressed the residents and placed them back in bed and stated staff were in-serviced after he/she was made aware it. During staff interview on 6-14-12 at 1:43 P.M. direct care staff F stated he/she toileted the resident every night per the schedule on the CNA assignment sheet, at 1:00 A.M. and 4:00 A.M. Direct care staff F stated he/she dressed the resident and put the resident's shoes on the bed as usual to prevent the resident from bending over and falling. He/she said staff got the resident up at 4:00 A.M. to toilet him/her and dressed him/her and then the resident went back to bed and usually went back to sleep. Direct care staff F said the resident appeared asleep when he/she left the room to attend to another resident. He/she said about 45 minutes later he/she heard the resident holler oh, oh, oh and went to the resident's room and found the resident laying on the floor and was bleeding. Staff called the nurse and the nurse assessed the resident. Direct care staff F was not aware of an alarm for the resident and stated the intervention was not on the CNA assignment sheet. During interview on 6-13-12 at 1:58 P.M. the resident's family stated the resident received a fracture of the femur and required repair of the fracture. The 6/2011 facility provided Fall Assessment and Prevention Protocol documented staff updated the CNA assignment sheet with any new interventions and the appropriate staff person implemented any new resident safety equipment identified through the process. The facility failed to provide interventions as planned to prevent falls. - According to the quarterly Minimum Data Set (MDS) for resident #3 dated 5/28/12 the resident's Brief Interview for Mental Status (BIMS) score was 4/15, which indicated the resident had severe cognitive impairment, had verbal outbursts directed toward others 4 to 6 days but less than daily. The resident needed limited to extensive assistance with Activities of Daily Living (ADLs), and had no falls. The care plan for potential for injury as related to falls dated 6/4/12 said staff were to assist the resident out of his/her chair if needed, remind him/her to walk carefully and slowly, monitor that the resident wore non-skid shoes or socks, monitor for any difficulties with walking or unsteadiness, remind the resident to use the roller walker, place a belt or suspenders on him/her if the resident's pants did not have a drawstring to prevent from them falling down. Review of the fall risk assessment dated [DATE] at 2:12 A.M. noted the resident was at risk for falls due to environmental factors that presented a hazard; the brakes on the bed did not work. Staff listed the fall intervention was to notify maintenance staff to fix the brakes to the bed and encourage the resident to wear shoes or gripper socks when up. The nurses notes dated 5/30/12 at 12:30 A.M. said the staff found the resident in his/her room on the floor. The resident moved the bed when he/she sat down on it. Staff found the resident on the floor, with his/her back against the recliner and with the bed now against the wall. An observation on 6/13/12 at 7:30 A.M. revealed the resident ambulated with a steady gait and use of the roller walker to the dining room. Interview on 6/13/12 at 1:50 P.M. with Direct Care Staff I said the resident had a recent fall but was not considered a fall risk. He/she said he/she could not recall prior to this when the resident had a fall. He/she said the resident used a roller walker, gait was steady and needed cued at times to slow down because he/she tended to walk too fast. Staff I said there were several beds in the facility with brakes that did not work, staff wrote this in the maintenance log so maintenance staff could fix them. Staff I said maintenance placed coasters under any bed that rolled but with any force the the wheels rolled off the coaster. An interview on 6/13/12 with Licensed Nursing Staff G at 2:15 P.M. said the resident's fall was an isolated incident, staff figured the bed rolled toward the wall when the resident tried to get back into bed. He/she said maintenance fixed the bed. The resident wore shoes all day and was to wear the gripper socks at night but he/she was unsure if the resident did this. An interview on 6/13/12 at 3:05 P.M. with Maintenance Staff J said staff did notify him/her after the resident fell and he fixed the bed. He/she said the brakes were functional but very still and needed oiled so staff could lock them. Staff J said he/she also placed coasters under the bed wheels to prevent them from moving. He/she said the bed should not move if the coasters were under the wheels and the wheels were aligned correctly. Staff J confirmed there were no coasters under the bed. He/she said many of the brakes on the beds do not function and he/she used parts from other beds to fix but this supply was running low. An interview on 6/13/12 at 5:40 P.M. with Administrative Staff A said housekeeping staff probably swept up the coasters that maintenance placed under the bed wheels. The facility failed to maintain a safe environment for this cognitively impaired but mobile resident. - The quarterly Minimum (MDS) data set [DATE] for resident #23 recorded the Brief Interview for Mental Status score was 11/15, which indicated the resident had moderate cognitive impairment. The resident needed extensive assistance from staff for walking in the corridor, did not walk in the room, needed limited assistance with bed mobility and personal hygiene, and supervision with transfers. The care plan for fall risk dated 5/2/12 said staff to encourage the resident to use the call light and wait for staff to assist him/her with transfers, use the wheel chair for all locomotion and the resident was able to propel self in the wheel chair. Report to the nurse if the resident complained of pain or required more assistance with transfers and Activities of Daily Living (ADLs). Observation on 6/12/12 at 10:55 A.M. revealed the resident laid in bed on his/her left side, eyes closed and rested quietly. There was a transfer bar on the resident's left side of the bed, the other side of the bed was against the wall. The opening to the transfer bar measured 7 1/4 inches wide by 21 inches long from the top of the inside of the bar to the bed frame where the bar attached to a board that staff placed under the mattress. An interview on 6/13/12 at 1:45 P.M. with Direct Care Staff I said the resident used the transfer bar to the bed with change of position and transfer. An interview on 6/13/12 at 4:55 P.M. with Administrative Nursing Staff C said he/she was not aware the opening was too large and thought that was for side rails only. He/she removed the bar and said he/she would notify therapy for suggestions. According to the Federal Drug Administration Hospital Bed Safety Workgroup as of June 2001 revised the dimension within a side rail to less than 120 millimeters (mm) or 4 3/4 inch. The facility failed to ensure the environment remained free of potential accident hazards.

The facility identified a census of 39 residents with a sample size of 7 residents. Based on record review and staff interview the facility failed to provide timely services and treatment to one sampled resident (#5), for urinary tract infection, and an abscess to his/her back. Findings included: - Resident #5 a closed record review had [DIAGNOSES REDACTED]. Further record review revealed the resident also had a [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) admission assessment with an assessment reference date of [DATE] listed the resident's Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment, and listed the resident's functional status as independent in all activities of daily living (ADLs) except toilet use, and personal hygiene required the supervision of 1 staff member. The resident was occasionally incontinent. The Care area assessment (CAA) for urinary incontinence dated [DATE] stated the resident had a history of [REDACTED]. He/she wore incontinent undergarments that staff assisted with changing as needed. The staff cued the resident to the location of the bathroom. The care plan dated reviewed on [DATE] listed staff to assist the resident to the bathroom as needed, and to provide cues to the location of the bathroom. Review of the care plan revised on [DATE] for potential for tissue integrity impairment, directed nurses to assess skin status. Nurse aides to inspect skin with bathing and toileting, and report changes. A nurses note (NN) dated [DATE] at 8:02 P.M. revealed staff sent a fax to the attending physician, of red casts to the resident's urine with small clots, and requested an order to obtain a urinalysis. On [DATE] at 8:02 P.M. staff reveived and noted orderes to obtain a urinalysis (UA), and culture and sensitivity (C&S) if indicated. Staff notified the family/guardian regarding the new order. Review of the medical record revealed on [DATE] an order, not timed, for possible blood in the urine with clots, obtain UA and C& S if indicated. NN dated [DATE] at 8:15 P.M. listed the resident's blood pressure was (B/P) of ,[DATE]. NN dated [DATE] at 4:42 AM (3 days after staff received the order) facility staff inserted a straight catheter,and was unable to obtain UA after 2 separate attempts. Staff met resistance at 5 inches, and the resident complained of discomfort, and begged for staff to discontinue the procedure. A small amount of blood was on the tip of the catheter after the second attempt. Staff would contact the medical doctor (MD) for further orders. Care plan note dated [DATE] may obtain clean catch urine. Interview on [DATE] at 4:45 P.M. with licensed staff B stated the physician in charge of this resident preferred a straight catheter attempted first to obtain the urine, then if staff were unable to get a sample, obtain an order for [REDACTED]. Licensed staff B further confirmed the urine sample was not obtained until the 9th of November. (5 days after staff obtained the order). The report from a local hospital lab dated [DATE] listed the UA results of 3 plus bacteria, 4 plus mucus, the color yellow and hazy, and positive for protein. Interview on [DATE] at 4:05 P.M. licensed staff A stated he/she worked the floor on [DATE], this resident's family member came and asked me if I knew about the spot on the resident's back. Together with licensed staff C and the family member we looked at the area on the resident's back. There was a big red area on his/her back with a raised area the size of a golf ball in the center. The area measured about ,[DATE] centimeters (cm) on the reddened area, and in the center of the area was maybe a .5 cm white scab. The skin in the area was shinny like a pimple. You could barely touch it, because it was painful to the resident.There were 2 smaller areas on either side of the resident's spine that looked like filled up blackheads. We were going to get a culture of the site but the culture swab was expired, so we were going to get new swab to get a culture of the site in the morning. Licensed staff C suggested to put a warm wash cloth on the area to relieve some of the pressure. If we pushed on the area it hurt the resident. We informed the nurse assigned to the resident, in the special care unit, what happened. We did not dress the area. I did not document any information in the medical record. The next morning the family came to the facility and took the resident to the hospital. Interview on [DATE] at 4:30 P.M. licensed staff C stated he/she was in the dining room on [DATE] assisting residents with the evening meal. Resident #5's family member came to him/ her and said there was an area on the residents back and when he/she hugged the resident, and he/she grimaced in pain. Licensed staff A and I went back to look at the site, and I went to get a culturette, but it was expired. The area was on the resident's mid back, the center was golf ball size and the surrounding area was reddened ,[DATE] inches in diameter around the area. The site was not draining. We applied moist heat to relieve some of the pressure. I had to leave the facility, and I did not document in the medical record. I reported it to the nurse in charge of the resident. The next day the family took the resident to the hospital. Interview on [DATE] at 2:50 P.M. licensed staff D stated I believe it was Wednesday night [DATE] the family member of resident #5 came to visit, we were in the middle of supper. Licensed staff A and C looked at that area on his/her back, and were going to call the physician and get an order for [REDACTED]. At 4:38 P.M. on [DATE] licensed staff D stated again he/she did not see the site or look at it after staff A and C had. The resident was in bed and the site had a dressing on it. Since staff A and C saw this site an said they would follow up on it I did not document on it in the resident's medical record. Interview on [DATE] at 2:15 P.M. with direct care staff G stated he/she would report to the nurse any skin issues, falls or any resident that did not feel well. Direct care staff looked at the resident's skin for dry skin, skin tears, or anything irregular. Staff document this information on the the direct care assignment sheet, and told the nurse. Interview on [DATE] at 2:30 P.M. with licensed staff E stated staff called him/her in during baths if there were concerns and he/she did a skin assessment at that time. Interview on [DATE] at 4:45 P.M. with licensed staff B confirmed there was no documentation describing the area on the resident's back until [DATE] when the family removed the resident from the facility to take him/her to the hospital. His/ her expectation was for the staff to document what they observed at the time and to notify the physician of the findings. Licensed staff B further stated there was an internal investigation going on as to who did not do what. Staff started the investigation the morning of the 10th after the family took the resident to the hospital. Staff determined the certified staff knew about the areas and reported them to the nurse. Certified staff were told they were fatty tumors. Licensed staff B further stated there was no documentation on the [DATE] admission record that the resident came with these bumps on his/her back. There was no documentation of changes in the area or that the direct care staff notified the charge nurse of the area. There is no documentation that the charge nurse looked at the area, and from there it gets fuzzy. The investigation was almost completed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. for a temperature of 100.6 degrees Fahrenheit with temperature of 99 degrees Fahrenheit at 8:00 P.M. A NN dated [DATE] and timed 10:10 AM listed at 9:05 AM the resident's family transferred the resident to a local hospital by car for evaluation of a lesion on his/her mid back. Review of the hospital progress notes for this resident dated [DATE] and timed at 1:42 P.M. listed the urinalysis showed the resident with a urinary tract infection, positive for bacteria, leucocytosis, start antibiotics and await culture and sensitivity results. The back abscess versus cyst: incision and drainage performed in the emergency department, cultures pending. Consult wound care and place on antibiotics. Review of the wound consultation report from the hospital dated [DATE] at 2:28 P.M. listed hospital staff saw the patient at the bedside, staff removed the dressing from the incision and drainage of the abscess/cyst to the midline thorasic back. The incision was a 2 centimeter X incision across a raised erythemic area. The drainage was sanguineous, the surrounding skin was swollen red erythemic 2 centimeters surround the incision and drainage site. Review of the transfer orders dated [DATE] revealed the resident required 5 days of intravenous antibiotics in the hospital for care of a UTI and [MEDICAL CONDITION]/abcess of the trunk. The facility failed to identify, assess, and provide timely treatment for [REDACTED].

The facility had a census of 38 residents. The sample size was 9 residents. Based upon observation, record review and interview the facility failed to ensure that 1 (#112) of 3 residents for falls received supervision and interventions to prevent accidents resulting in a hip fracture. Findings included: - Review of resident #112's Physician order [REDACTED]. Review of the nurse's notes documented the resident admitted from another nursing facility to this facility on 12/27/11 at 3:04 PM. Review of the resident's admission Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 1/17/12 identified the resident scored a 1 (severely impaired cognition) on the Brief Interview for Mental Status, did not display any behaviors, required extensive staff assistance with bed mobility, dressing, transfers, toilet use, personal hygiene, did not walk in room or corridor, and was dependent upon staff for locomotion on unit. The MDS recorded the resident did not have a fall in the last month prior to his/her admission to the facility, had not fallen in the 2-6 months prior to his/her admission, had not sustained a fracture related to a fall in the 6 months prior to admission, and had fallen once since admitted to the facility or prior assessment. The MDS recorded the resident utilized a wheelchair, was not steady, able to stabilize with staff assistance when moved from seated to standing position, turning around, moving on and off toilet, and surface to surface transfers. The resident's care area assessment for pressure ulcers dated 1/23/12 documented the resident had a [DIAGNOSES REDACTED]. The resident's care plan dated 12/27/11 addressed the resident had an self care deficit related to Alzheimer's, impaired physical mobility related to decreased endurance manifested by a history of falls, required standby assistance during transfers, utilized a rolled walker and was confused at times. The resident's care plan included an entry dated 1/7/12 that documented the resident was transferred to a local hospital via ambulance due to a fall the resident sustained [REDACTED]. on 1/7/12. An entry to the resident's care plan dated 1/14/12 documented the resident was observed on the floor in his/her bedroom, and had no apparent injuries. An entry to the resident's care plan dated 1/16/12 documented the facility applied a personal body alarm and the resident was to utilize the personal body alarm at all times. The care plan lacked fall interventions prior to the resident's fall on 1/7/12 and 1/14/12. A nurse's note dated 1/7/12 timed 7:55 A.M.. documented staff observed the resident on the floor at 5:00 A.M., the resident complained of severe right hip pain, the resident was very confused, restless due to a [DIAGNOSES REDACTED]. A nurse's note dated 1/7/12 timed 11:11 A.M. documented the resident admitted to a local hospital with a [DIAGNOSES REDACTED]. A discharge transfer referral with an admission date of [DATE] documented on 1/7/12 the resident had a surgical procedure of a right hip "endo." The resident's admission resident assessment dated [DATE] timed 4:00 P.M. (date resident returned to the facility after the right hip fracture) documented the resident had a [DIAGNOSES REDACTED]. A nurse's note timed 9:21 P.M. dated 1/14/12 (2 days after the resident readmitted to the facility with the right hip fracture) documented staff observed the resident on the floor at 3:55 P.M. with no apparent injuries, the resident did not have on non-skid socks and these interventions were immediately implemented: Gripper socks and/or appropriate footwear, and the resident repeatedly tried to get up in his/her room independently so staff placed a personal body alarm on the resident. The note documented staff reminded the resident to utilize the call light to ask for assistance when transferring or moving about in his/her room, and the resident forgot he/she was unable to ambulate independently. A physician's orders [REDACTED]. On 2/1/12 at 7:20 A.M. the resident's personal alarm activated. Observation revealed the resident's room located 2 rooms from the end of the hall, and no staff in the vicinity. The observation also revealed the resident's personal safety alarm was faintly heard at the nurse's station but was heard down the hall leading to the dining room. The resident's personal safety alarm alarmed from 7:20 A.M. until 7:30 A.M. (a duration of 10 minutes), and at 7:30 A.M. licensed nurse A entered the resident's room. Observation revealed the resident in bed and the alarm detached from the resident, and licensed nurse A reconnected the alarm. The observation revealed the resident not in a low bed, the head of the resident's bed up approximately 30 degrees, and the bed not in the lowest possible position. During interview with licensed nurse A at that time (7:30 A.M.) the licensed nurse stated he/she was down the hall leading to the dining room administering medication and did not hear the alarm until he/she rounded the corner leading to the hall where the resident resided. On 2/1/12 at 12:25 P.M. the resident sat in his/her wheelchair at the dining room table and the resident's personal safety alarm was not attached. At 12:35 P.M. licensed nurse B confirmed the resident's personal alarm was not attached. During interview with licensed nurse B at that time he/she stated the staff should keep the resident's personal alarm attached at all times. On 2/1/12 at 2:40 P.M. the resident was not in a low bed, the bed was approximately 6 inches from the floor. During interview with administrative nursing staff C at that time the nurse confirmed the resident was not in a low bed and stated he/she did not know if the resident's bed could be lowered. During interview with administrative nursing staff C on 2/1/12 at 3:40 P.M. the nurse stated the resident had a history of [REDACTED].). Administrative nursing staff C confirmed the resident's clinical record lacked evidence the facility implemented interventions until after the resident fell on [DATE] (after the right hip fracture and after the resident had sustained another fall after the hip fracture). The facility failed to implement interventions for this resident with a history of falls prior to admission until the resident sustained [REDACTED]. The facility also failed to ensure the personal safety alarm was attached at all times per the physician's orders [REDACTED].

The facility had a census of 43 residents. The sample included 15 residents. Based upon observation, record review and staff interview the facility failed to ensure that 1 (#2) of 1 residents sampled for pressure ulcers did not develop a pressure ulcer unless the individual's clinical condition demonstrated that the pressure ulcer was unavoidable and also failed to ensure the resident received the necessary treatment and services to promote healing. Findings included: - Review of resident's #2 Physician order [REDACTED]. The POS included the resident received a mechanical soft, no added salt, controlled "carb" diet, small portions with nectar thickened liquids and 1 scoop of Resource [MEDICATION NAME] Powder at noon with the lunch meal. The resident's Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 3/13/11 recorded the resident scored 5/15 on the Brief Interview for Mental Status (a score of 5 indicated the resident had severely impaired cognitive skills), required limited staff assistance with bed mobility, transferring and dressing, extensive staff assistance with toileting and personal hygiene, independent with walking in the room/corridor and locomotion on unit and required physical help from the staff in part of the bathing activity. The MDS 3.0 recorded the resident's weight at 223 pounds, no or unknown weight loss and at risk for the development of pressure ulcers. The MDS 3.0 coded the resident had an unhealed Stage III pressure ulcer not present upon admission that measured 4.0 centimeters in length, 3.0 centimeters in width with a depth of 2.0 centimeters. The MDS 3.0 recorded the resident utilized pressure reducing device for his/her bed, no pressure reliving device in his/her chair and on a turning/repositioning program. The resident's Annual MDS 3.0 with an ARD of 12/19/10 identified the resident scored 8/15 on the BIMS (a score of 8 indicated the resident had mildly impaired cognitive skills), at risk for the development of pressure ulcers, no unhealed pressure ulcers, had a pressure relieving device on his/her bed, no pressure relieving device in his/her chair and on a turning/repositioning program. The resident's Care Area Assessment (CAAs) dated 12/21/10 documented the resident had a [DIAGNOSES REDACTED]. The resident's care plan dated 6/15/11 addressed the resident had an open area on his/her coccyx. Interventions included staff would turn/reposition the resident every 2 to 21/2 hours and as needed, staff would report to the charge nurse if the dressing was not on, staff placed a pillow behind the resident's back when in bed and the resident able to position his/her self from side to back. The care plan documented the resident received small portions at meals and staff provided night time (HS) snacks to the residents. The resident's Braden Scale for predicting pressure sore risk dated 9/23/10, 12/15/11 and 6/09/11 recorded the resident scored a 19. According to the legend a score of 19 indicated the resident not at risk for the development of pressure ulcers (a score of 16 or less indicated risk of pressure ulcer development). Review of the resident's Skin and Body Assessment revealed an entry dated 2/4/11 that read: staff observed the resident had a Stage III pressure ulcer on his/her coccyx that measured 2.0 centimeters (cm) wide by 3.0 cm long with a depth of 1.0 cm and the area tender to touch. Further measurements of the Stage III on the resident's coccyx included: 3/4/11: 2.0 cm wide X 3.0 cm long with a depth of 1.0 cm 4/8/11: 1.6 cm wide by 2.5 cm long with a depth of 0.7 cm 5/6/11: 1.4 cm wide by 2.3 cm long with a depth of 0.8 cm 6/3/11: 1.1 cm wide by 2.1 cm long with a depth of 0.7 cm 6/10/11: 1.1 cm wide by 2.0 cm long with a depth of 0.7 cm The resident's clinical record lacked evidence that the facility had monitored the resident's skin for reddened and/or open areas. The skin and body assessment 6/6/11 entry documented the resident had a Stage II on his/her right inner buttock and the rounded area measured 1.5 centimeters, appeared to be from the tape that covered the other area and the facility obtained a new treatment order. A wound clinic consultation note dated 2/23/11 transcribed at 4:15 P.M. documented the resident had a Stage III "sacral decubitus ulcer" that measured 2 cm by 2 cm by 2 cm with rolled edges and a chronic appearance, with good granulation bed with recommendation of "perhaps a wound vac". The resident's clinical record lacked evidence the facility had followed up on the recommendation for a wound vac. A wound clinic note dated 6/6/11 documented the resident's wound care offloading included a mattress and wheelchair cushion. On 3/18/11 the facility received a physician order [REDACTED]. On 4/15/11 the facility received a physician's orders [REDACTED]. According to the resident's 5/11 and 6/11 MAR "kitchen provides." During interview with dietary staff B on 6/16/11 at 12:15 P.M. this writer requested a list of residents that received protein powder from the dietary department. The staff reported the dietary department did not provide protein powder to any resident. During interview with licensed nurse F on 6/16/11 at 12:25 PM the staff reported the dietary department provided the protein powder and that he/she would speak with the dietary department. During interview with licensed nurse F on 6/16/11 at 1:25 P.M. the staff reported he/she had spoken with the dietary staff, dietary department had the order to provide the protein powder to the resident during the lunch meal and the dietary department did not provide the powder powder as ordered. A dietary progress note dated and signed by a registered dietician on 12/8/10 (no time recorded) documented the resident weighed 227 pounds the same as a year ago, the resident's buttock reddened and intact and staff needed to monitor the resident's snack and meal consumption. The resident's dietary progress note dated and signed by a Registered Dietician on 3/9/11 and timed 3:30 P.M. documented the resident had a Stage II "decub" on his/her coccyx and started [MEDICATION NAME] (1 packet) on a two week trial basis. The dietician recommended the resident received [MEDICATION NAME] until the wound healed. The dietary progress note completed by a registered dietician on 4/13/11 (no time recorded) documented the resident continued to receive the [MEDICATION NAME] twice a day (BID) until 4/17/11 (end of trial basis) and the resident continued to consume 100% of meals. A dietitian's review note dated 6/17/11 (no time recorded) documented the resident continued to have a Stage II "decub" on his/her coccyx,[MEDICATION NAME] had been changed to [MEDICATION NAME] per protocol, and the resident received 1 scoop of [MEDICATION NAME] daily at lunch. The note also documented the dietician recommended to increase the [MEDICATION NAME] to one scoop twice a day, 500 milligrams of Vitamin daily and 220 milligrams of Zinc Sulfate daily for 30 days. The note also included the resident's intake was good and the resident's weight remained stable. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the resident's MAR indicated [REDACTED]. Review of the resident's weights revealed the resident's weights stable (the resident weighed 227 pounds on 2/2/11 and 228 pounds on 5/31/11). A laboratory dated 2/8/11 recorded the resident's [MEDICATION NAME] level as 4.1 grams/deciliter (g/dL) normal reference range (3.4-4.0 g/dL) and the resident's protein level as 7.7 g/dL normal reference range (6.4-8.3 g/dL). During interview with licensed nurse C on 6/15/11 at 8:46 A.M. the staff reported the licensed nursing staff did not discover the resident's facility acquired Stage 3 pressure ulcer until it had progressed to a Stage 3 pressure ulcer. On 6/15/11 at 10:34 A.M. the resident attended an activity in the dining room and sat in a chair without a pressure relieving device. Observation of staff serving the lunch meal on 6/15/11 from 11:30 A.M. until 12 noon revealed the resident received small portions which consisted of 6 ounces of Wisconsin cheese soup, 1/2 ham, lettuce and tomato sandwich and 3 crackers. The observation also revealed the resident did not receive the scoop of [MEDICATION NAME] during the lunch meal. Observation at 12:15 P.M. revealed the resident consumed 100% of the lunch meal. On 6/15/11 at 1:30 P.M. licensed nurse A assisted the resident to the bathroom. Observation revealed the resident incontinent of urine and without a dressing on the resident's coccyx pressure ulcer. Further observation revealed the resident had a Stage III pressure ulcer on his/her coccyx that measured approximately 2 cm in length, 1 cm in width and a depth of .5 cm. The observation also revealed the resident had an open area on his/her right buttock that measured approximately 1 cm by 1 cm. During interview with the licensed nurse at that time the nurse reported the open area was caused by tape. On 6/15/11 at 2:40 P.M, 3:07 P.M. and 3:25 P.M the resident sat in a dining room chair without a pressure relieving device. At 3:33 P.M. direct care staff C and D walked the resident from the dining room to his/her room and toileted the resident. Direct care staff C reported the resident was incontinent of urine. On 6/15/11 at 3:40 P.M. and 4:00 P.M. the resident sat in the recliner in his/her room and observation revealed the recliner did not have a pressure relieving device. On 6/16/11 at 12:30 P.M., 1:40 P.M. 2:00 P.M. and 2:16 P.M. the resident sat on the couch in the activity room. On 6/16/11 at 2:30 P.M. direct care staff E walked the resident to the bathroom, the resident inwas continent of urine and the pressure ulcer dressing was not securely intact. On 6/20/11 at 6:00 A.M., 6:15 A.M., 6:30 A.M., 6:45 A.M. the resident sat in the recliner in his/her room with no pressure relieving device in place. During interview with licensed nurse C on 6/20/11 at 1:58 P.M. the staff confirmed the resident's recliner did not have a pressure reliving device. The facility failed to treat a pressure ulcer until it was a Stage III, failed to ensure the resident had a pressure relieving device in his/her recliner, failed to provide the protein powder as physician ordered, and failed to provide [MEDICATION NAME] in a timely manner. This failure placed this resident at risk for the development of additionally pressure ulcers and did not promote healing.