Every finding on record at Hilltop Lodge Health and Rehabilitation Center

Based on interviews and record review, the facility failed to implement its policy to conduct thorough pre-hire criminal background checks for all staff as required and within the required timeframes. Findings included:- On 06/16/2026 at 09:00 AM, review of staffing for background checks was completed, and documentation revealed the following:Certified Nurse Aide (CNA) O had a hire date of 04/17/2024. CNA O's background check was dated 08/06/2025. The facility was unable to provide the 2024 pre-hire background check upon request.CNA P had a hire date of 01/26/2024.CNA P's background check was dated 06/30/2024. The facility was unable to provide evidence that a background check was completed within the required timeframes. On 06/16/2026 at 09:12 AM, Administrative Staff B stated that the above staff were placed in direct care roles pending their background checks. On 06/16/2026 at 10:46 AM, Administrative Staff A verified that the above CNAs worked on the floor, caring for residents, with the backgrounds checks still pending. Administrative Staff A stated that if the staff's background checks came back with a criminal history, those staff would be pulled from the floor. The facility's undated Employee Background Checks, Reporting Requirements, and Prevention of Abuse, Neglect, and Exploitation (ANE) of Residents Policy documented that the policy sets forth the facility's process for conducting a thorough pre-hire background check of relevant individuals to ensure relevant individuals: Have not been found guilty of ANE or mistreatment or misappropriation of property by a court of law. Do not have a finding in the state nurse aide registry concerning ANE, mistreatment of residents, or misappropriation of resident property, or Do not have disciplinary action in effect taken against their professional license.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to provide the nutritional dietary needs for the residents who received meals from the kitchen.Findings included:- On 01/11/26 at 11:00 AM, Dietary Staff (DS) CC obtained one three-ounce scoop of the cornbread stuffing and placed it in a 12-ounce (oz.) household Bullet blender for the pureed diets. The facility prepared pureed diets for five servings. DS CC blended the cornbread stuffing briefly, then added milk and blended the mixture till smooth. The contents were divided into two stainless steel steam table containers and placed in the oven until time to transfer to the steam tables for serving. The pureed recipe for a portion size of a #8 scoop, which totals four ounces. On 01/11/26 at 11:30 AM, during the serving of the main dining room, DS BB served the regular diet portions of copped buttered carrots with a one-ounce portion controlled scooped spoon and the cornbread stuffing with a one-ounce portion rounded scoop. The regular diet buttered carrot recipe portion was four ounces. On 01/12/26 at 10:52 AM, Activity Staff Z and Administrative Staff A reported supervising the kitchen staff while the Certified Manager was absent from the facility. Both staff verified that DS BB and DS CC should have followed the meal recipes for the correct portion sizes of the buttered carrots and cornbread stuffing. The facility's Dining Manager 2026 Dining RD policy, dated 2026, recipe directed staff to serve four ounces of prepared pureed cornbread stuffing and regular diet chopped carrots of four ounces.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary condition for 66 residents who reside in the facility and receive meals from the facility's kitchen, placing them at risk for foodborne illness. Findings included:- On 01/11/26 at 08:39 AM, during the initial tour of the kitchen with Dietary Staff (DS) BB revealed:A four-quart container of diced pineapples without a label with an open date.Deli-sliced ham and turkey were opened without an open date.A sack of four hard-boiled eggs without an open date.A gallon of liquid cheese, without an open date.A quarter of lime juice with an expiration date of 12/01/25, stored in the refrigerator.A gallon-sized tub of mayonnaise and mustard without an open date.Two bags of chopped lettuce without an open date.The walk-in freezer had a box of chicken breast filets sitting directly on the freezer floor and a sack of opened French fries without an open date. The freezer floor also had a small hand-sized bag of an unlabeled item resting on the floor, which DS BB could not identify.On 01/11/26 at 08:43 PM, DS BB verified that the food items should have been labeled with the date when they were opened, and the freezer floor should not have anything touching it.On 01/12/26 at 09:28 AM, Activity Staff Z reported supervising the dietary department with Administrative Staff A, while the Certified Dietary Manager (CDM) was absent from the facility. Activity Staff Z verified that all open foods should have when-opened dates clearly marked on the containers of storage, and expired foods should be discarded. Administrative Staff A also verified that foods should have the open dates and that foods were not to be stored on the freezer floor.The facility's Food Storage policy, dated 05/2020, documented dairy products of processed/open cheese may be refrigerated for three to four weeks, hard-cooked eggs three to four days, shredded leaf lettuce three to five days, open packages of lunch meats of three to five days, and mustard one year.The facility's Food Safety and Sanitation policy, dated 2017, documented that when a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when food should be discarded.

The facility identified a census of 66 residents. The sample included 18 residents, with one resident reviewed for dignity. Based on observation and interviews, the facility failed to ensure Resident (R) 3 was covered when sitting in her Broda chair (specialized wheelchair with the ability to tilt and recline), with just a brief and a shirt on visible to the door.Findings Included:- R3's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), repeated falls, and dysphagia (swallowing difficulty).The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R3 was rarely or never understood. The MDS documented R3 had impairment of her upper and lower body. The MDS documented R3 needed staff assistance for all activities of daily living (ADL).R3's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 10/15/25 was triggered due to R3 requiring assistance with any of the self-care or mobility activities. The CAA documented R3 was at risk for further decline in functional abilities, falls, contractures, isolation, pressure ulcers, and incontinence. The CAA documented R3 would be referred to therapy.R3's Care Plan, revised 05/28/25, documented the following:03/16/21- R3 had impaired cognitive function related to Schizophrenia.03/16/21- R3 would be able to communicate basic needs daily.03/16/21- Directed staff to approach R3 in a gentle, friendly, and unhurried manner.On 01/13/26 at 07:45 AM, R3 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in her room. R3 had a brief and a shirt on, her legs and brief were visible to the residents walking past her room. R3 had a grey blanket with the call light attached to the blanket, which had fallen down and was on her feet.On 01/13/26 at 07:44 AM, Certified Nurse's Aide (CNA) O stated R3 should be dressed and groomed. She stated it was the expectation of the facility that residents were dressed, covered, and not exposed to other residents.On 01/13/26 at 07:35 AM, Licensed Nurse (LN) I stated the facility should not leave residents uncovered and the call light out of her reach. She stated residents should be dressed or covered and not exposed.On 01/13/26 at 08:41 AM, Administrative Nurse D stated it was the expectation of the facility that residents were dressed and groomed when they were out of bed. She stated residents should never have their briefs exposed unless it was a behavior, and the situation was care planned.The facility's Promoting/Maintaining Residents' Dignity policy, dated 01/01/20, documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in an environment that maintains or enhances residents' quality of life by recognizing each resident's individuality.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to revise the care plan with interventions to prevent falls and injury for Resident (R) 50. Findings included:- R50's Electronic Medical Record (EMR) included diagnoses of unspecified abnormalities of gait and mobility, abnormal posture, muscle weakness, repeated falls, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and a personal history of traumatic fracture (broken bone) unspecified.R50's Annual Minimum Data Set (MDS) dated [DATE] documented R50 had moderately impaired cognition, and experienced no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. The MDS further documented that R50 used a walker and wheelchair for mobility, had no functional range of motion impairments, required substantial to maximal assistance with toileting hygiene, upper and lower body dressing, and was dependent on putting on and taking off footwear and walking ten to 150 feet. R50 required partial/moderate assistance with chair/bed transfers. R50 was frequently incontinent of urine and always continent of bowel, received as-needed pain medication, had shortness of breath or trouble breathing when lying flat, and had two or more falls without injury.The Care Area Assessment (CAA) dated 11/08/25 documented R50 triggered for falls due to multiple falls during the review period. The CAA further documented that R50 was at risk for injury related to his fall risk.R50's Care Plan dated 02/17/21 documented R50 had limited physical mobility related to Parkinson's Disease and had an actual fall with no injury related to unsteady gait. The Care Plan documented that R50 was able to ambulate with his front-wheeled walker/cane independently in his room. He required stand by assistance of one staff member when out of his room. The Progress Notes dated 01/15/25 at 08:34 PM documented that R50 fell while trying to ambulate independently to the bathroom and had no injuries. The facility failed to conduct an investigation for causal factors of the fall.The Progress Note dated 01/31/25 at 05:42 AM documented that R50 was found on the floor around 11:10 PM by two Certified Nurse Aides (CNA). The nurse found no injuries. R50 reported he was trying to turn on the power strip to the television as it came unplugged, he slid down the dresser with his back and fell forward.The Progress Note dated 02/01/25 at 04:18 AM documented that the nurse was called to R50's room at approximately 08:10 PM (the previous evening, 01/31/25), and R50 was lying on his back on the floor. R50 reported he was going to the bathroom and went too close to the door, fell against the door, and slid down the door, landing on his buttocks. The nurse found no signs or symptoms of injuries.The Progress Note dated 05/07/25 at 11:18 AM documented that the nurse was called to R50's room at 10:30 AM. R50 was sitting on his buttocks with his hands on the floor beside him. R50 reported he was getting clothes out, lost his balance, and fell back on his buttocks. No injuries were found. The note further documented that R50 was encouraged to utilize the call light to request assistance with getting clothes out of the dresser drawers.The Progress Note dated 05/16/25 at 04:17 AM documented that a CNA alerted the nurse that R50 was lying on the floor. R50 reported he was trying to get something out of his drawers and did not want to bother the staff, then his knees gave out. No injuries were found.The Progress Note dated 05/19/25 at 06:06 PM documented that the nurse was called to R50's room, as R50 was on the floor of the bathroom. R50 reported he was trying to get briefs from the shelf while in the bathroom due to being incontinent, but the shelf was too high, and he lost his balance. The note further documented that R50 was educated on call light use. No injuries were found.The Progress Note dated 06/15/25 at 09:30 AM, documented a CNA reported to the nurse that R50 was sitting on the floor in front of his recliner. R50 reported getting things for bed, had a four-centimeter abrasion to the left knee, and no other injuries were noted at that time.The Progress Note dated 06/16/25 at 01:23 PM documented that a CNA alerted the nurse that R50 was on the floor. R50 was on the floor in front of his recliner, the call light was in reach, with a sign posted in front of R50 reminding the resident to use the call light. R50 reported he was trying to get Chapstick from the dresser drawer and knew he was to use the call light for assistance with walking, but did not feel like he needed help. No injuries were found.The Progress Note dated 08/02/25 at 04:50 PM documented R50 stated he was checking to see if he had soup on his counter, he lost his balance and fell onto his bottom. No injuries were found at the time.The Progress Note dated 09/12/25 at 08:40 PM documented that a CNA notified the nurse that R50 was on the floor. R50 reported he stood up and turned around to check and see if the pad on his chair was wet and lost his balance. No injuries were found.The Progress Note dated 09/19/25 at 10:47 PM documented that the CNA notified the nurse that R50 was on the floor. R50 reported he stood up and turned around to check and see if his pad on the chair was wet and lost his balance. The walker was beside the chair, and the call light was clipped to his recliner in reach. The note further documented that staff offered dressing for bed and toileting at 06:30 PM, and R50 had refused. No injuries were found.The Progress Note dated 09/27/25 at 04:19 AM documented that the nurse was called to R50's room. R50 reported a fall that happened on 09/26/25 at 05:00 PM. R50 refused vital signs assessments.The Progress Note dated 10/08/25 at 12:49 AM, documented a CNA called the nurse to R50's room, and reported the resident was on the floor. R50 reported he was trying to get his handkerchief from the shelf in front of his recliner. The call light was fastened to the recliner within R50's reach.The Progress Note dated 10/15/25 at 11:34 PM documented that the CNA called the nurse to R50's room. R50 was on the floor in front of his recliner. R50 was last seen about ten minutes before falling, when both the nurse and CNA. R50 reported was going to get his donuts from the top of his dresser. No injury was observed at that time.The Progress Note dated 11/11/25 at 09:20 AM documented while CNA was walking by R50's room, R50 put the power recliner into the standing position, and R50 was wearing slick pajamas and slid down the chair instead of standing. The CNA reported that R50 went to his knees after sliding down. R50 stated he was just trying to stand up to readjust while in the recliner, and instead of standing, slid down when the CNA came into the room. No injuries were documented.The Progress Note dated 12/01/25 at 10:10 AM documented that a CNA was assisting R50 in going through clothes and helping R50 move to a new room. The CNA took some belongings to the new room and when the CNA returned R50 was on the floor. R50 reported he tried to get into his recliner and fell. R50 reported that he hit his head on the wheelchair. A small laceration to the lateral side of his left eyebrow.The Progress Note dated 12/03/25 at 07:30 PM documented that Administrative Nurse D had contacted R50's DPOA regarding frequent falls. R50's room change had been completed on 12/01/25, and he had a fall when a staff member had left the room. The DPOA was very frustrated with the situation and R50's stubbornness. Administrative Nurse D had a face-to-face conversation with R50 related to his safety and the continued lack of use of the call light and waiting for staff assistance. A discussion with R50 about plans for improving his safety and decreasing falls. R50 had a call light and bell at chairside within reach.The Progress Note dated 12/04/25 at 04:00 PM documented that R50 had been assisted from the shower by the CNA. R50 was in a wheelchair while the CNA cleared his recliner. R50 stood up suddenly and fell. No signs of injury. R50 was re-educated by Administrative Nurse D about asking for help with transfers and safety.The Progress Note dated 12/14/25 at 04:12 AM documented while a CNA was assisting with a bathroom need and changing his clothes at 03:30 AM, R50 had an abrasion to the right outer knee and a bruise to the right outer eye. R50 initially denied falling but admitted that he had fallen on 12/13/25 at approximately 05:00 PM. Education provided on always using the call light. R50 reported that he used the call light, the CNA answered it, but did not ask him what he needed to he got up on his own. R50's Care Plan intervention dated 01/15/25 directed staff to frequently offer bathroom privileges. R50's Care Plan intervention dated 05/07/25 documented a non-injury fall, all interventions in place, and directed staff to encourage the resident to ask for assistance prior to getting up. R50's Care Plan intervention dated 09/20/25, documented R50 had a non-injury fall and directed staff to continue to educate R50 on the importance of asking for assistance. R50's Care Plan intervention dated 09/30/25, documented a non-injury fall on 09/26/25, and directed staff to continue education and monitoring. R50's Care Plan dated 10/07/25 documented a non-injury fall. The DPOA was contacted regarding concerns, and the facility would discuss with R50's physician the need for a negotiated risk agreement (An agreement in which a resident waives the facility's liability) for R50. R50's Care Plan intervention, dated 10/15/25, documented that R50 had a non-injury fall, a negotiated risk agreement, and to move R50 closer to the nurses' station. R50's Care Plan dated 11/20/25 directed staff to allow R50 to make decisions about the treatment regimen to provide a sense of control and to educate family and caregivers about possible outcomes of not complying. Encourage participation as much as possible during care. Give a clear expectation of all care activities before any as they occur with each contact. If R50 resists with activities of daily living, reassure him, assure he is safe, leave and return in five to ten minutes, and retry. If possible, negotiate a time for activities of daily living so that R50 could participate in decision-making and return at the agreed timeR50's Care Plan lacked a new intervention to prevent further falls and injuries for the falls that occurred on the following dates: 01/31/25 (one in the AM and one in the PM), 02/01/25, 05/16/25, 05/19/26, 06/15/25, 06/16/25, 08/02/25, 12/04/25, and 12/13/25.On 01/12/26 at 09:28 AM, R50 sat in his recliner with his feet elevated, the call light clipped to the recliner arm. He reported that staff assisted him to the bathroom, and he used the call light to call staff.On 01/12/26 at 09:34 AM, CNA M reported that the staff check R50 often, and every time they go by his room, the staff leave his door open and assist him to the bathroom. She reported the resident does not have a scheduled routine, and it was up to the resident to decide when he needed to go to the bathroom or perform other activities of daily living. CNA M stated that R50 used his call light and was not forgetful.On 01/13/26 at 08:13 AM, Administrative Nurse D reported R50 had numerous falls. She verified the frequent use of educating the resident to call for assistance had been ineffective, and the resident continued to fall. She reported that the staff were to get his clothes ready in the morning and evening to prevent falls, and to make sure he had everything he needed or wanted within his reach. Administrative D reported talking with R50's DPOA, and the DPOA reported that R50 was choosing not to use the call light and was very independent. Administrative Nurse D verified there have been falls that lacked a fall investigation with a root cause analysis or a new intervention added to the Care Plan.The facility's Care Plan Revisions policy, dated 02/01/20, documented that the comprehensive care plan would be reviewed and revised as necessary when a resident experiences a status change. The care plan would be updated with the new or modified intervention.

The facility identified a census of 66 residents. The sample included 18 residents, with three residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41's washcloth or carrot (soft roll, designed to position severely contracted fingers away from the palm of the hand) was applied to his right hand to help prevent the risk of wounds related to his contractures.Findings included:- R41's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dystonia (impairment in muscle tone), dysphagia (swallowing difficulty), traumatic brain injury (a brain injury caused by an outside force), and contracture (abnormal permanent fixation of a joint or muscle).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R41 had impairments of both the lower and upper body. The MDS documented R41 was dependent on staff for all activities of daily living (ADL).R41's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/10/25 triggered due to the R41 needing assistance with all of his self-care or mobility activities. The CAA documented R41 was at risk for further decline in functional abilities, falls, contractures, isolation, pressure ulcers, and incontinence. The CAA documented R41 would be referred to therapy for annual screening.R41's Care Plan documented the following:07/24/24- Directed staff to observe and report changes in routine, decrease functional abilities, and decrease range of motion (ROM).08/31/24- Documented R41 was at risk for skin breakdown.08/31/24 - Directed staff to place a rolled washcloth or carrot in R41's right hand as tolerated.On 01/12/26 at 08:45 AM, R41 laid on his side with his head elevated. R41's hand laid across his lap. R41 had a dressing on his right-hand thumb. R41's hands were clenched; he did not have a washcloth or a carrot in his right hand.On 01/13/26 at 07:50 AM, R41 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in his room. R41 was yelling for a nurse. R41's hands were laid in his lap. R41 had a dressing on his right-hand thumb. R41's hand was clenched shut; he did not have a rolled washcloth or carrot in his hand.On 01/13/26 at 07:44 AM, Certified Nurses Aide (CNA) O stated restorative personnel would normally place a washcloth or a carrot in R41's hand. CNA O stated if the CNAs noticed the washcloth or carrot was not in his hand, we would talk to the nurse and have her place the washcloth.On 01/13/26 at 07:35 AM, Licensed Nurse (LN) I stated it was the nurse assigned to R41's responsibility to place a washcloth or carrot in R41's right hand. LN I stated the washcloth should have been placed in R41's right hand.On 01/13/26 at 07:51 AM, Administrative Nurse D stated a washcloth should have been placed in R41's hand. She stated there was a bandage on his thumb for preventative wound care, due to contractures. Administrative Nurse D stated she expected nursing to place the washcloth in R41's hand.The facility's Restorative Nursing Program policy, which was undated, documented it was the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Physical functioning of all residents would be assessed in accordance with the facility assessment protocol.

The facility had a census of 66 residents. The sample included 18 residents, with three residents reviewed for falls. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent falls and injury for Resident (R) 50, who sustained 18 falls. Findings included:- R50's Electronic Medical Record (EMR) included diagnoses of unspecified abnormalities of gait and mobility, abnormal posture, muscle weakness, repeated falls, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and a personal history of traumatic fracture (broken bone) unspecified.R50's Annual Minimum Data Set (MDS) dated [DATE] documented R50 had moderately impaired cognition, and experienced no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. The MDS further documented that R50 used a walker and wheelchair for mobility, had no functional range of motion impairments, required substantial to maximal assistance with toileting hygiene, upper and lower body dressing, and was dependent on putting on and taking off footwear and walking ten to 150 feet. R50 required partial to moderate assistance with chair/bed transfers. R50 was frequently incontinent of urine and always continent of bowel, received as-needed pain medication, had shortness of breath or trouble breathing when lying flat, and had two or more falls without injury.The Care Area Assessment (CAA) dated 11/08/25 documented R50 triggered for falls due to multiple falls during the review period. The CAA further documented that R50 was at risk for fall-related injuries.R50's Care Plan dated 02/17/21 documented R50 had limited physical mobility related to Parkinson's disease and had an actual fall with no injury related to unsteady gait. The Care Plan documented that R50 ambulated with his front-wheeled walker/cane independently in his room. He required stand by assistance of one staff member when out of his room. The Progress Notes dated 01/15/25 at 08:34 PM documented that R50 fell while trying to ambulate independently to the bathroom and had no injuries. The facility failed to conduct an investigation for causative factors of the fall.The Progress Note dated 01/31/25 at 05:42 AM documented that R50 was found on the floor around 11:10 PM by two Certified Nurse Aides (CNA). The nurse found no injuries, and R50 reported he was trying to turn on the power strip to the television as it came unplugged, he slid down the dresser with his back, and fell forward.The Fall Investigation dated 01/31/25 at 08:10 PM documented that R50 had been encouraged and educated frequently on the importance of asking for assistance before getting up and moving around. The intervention was to continue to encourage the resident to be compliant, and concluded that R50 was very independent and wanted to do as much as he could on his own. The Progress Note dated 02/01/25 at 04:18 AM documented that the nurse was called to R50's room at approximately 08:10 PM (the previous evening 01/31/25), and R50 was lying on his back on the floor. R50 reported he was going to the bathroom and went too close to the door, fell against the door, and slid down the door, landing on his buttocks. The nurse found no signs or symptoms of injuries.The Therapy Screen Progress Note dated 02/03/25 at 09:24 AM documented R50 had fallen twice on 01/31/25, once in the early morning and again approximately at 08:00 PM. R50 had frequent falls due to his desire for independence and often refused to use a proper ambulation device and wait for staff to assist him.The facility failed to conduct an investigation for causative factors of the fall, and the care plan lacked intervention to prevent further falls.The Progress Note dated 05/07/25 at 11:18 AM documented that the nurse was called to R50's room at 10:30 AM. R50 was sitting on his buttocks with his hands on the floor beside him. R50 reported he was getting clothes out, lost his balance, and fell back on his buttocks. No injuries were found. The note further documented that R50 was encouraged to utilize the call light to request assistance with getting clothes out of the dresser drawers.The facility failed to conduct an investigation for causative factors of the fall.The Progress Note dated 05/16/25 at 04:17 AM documented that a CNA alerted the nurse that R50 was lying on the floor. R50 reported he was trying to get something out of his drawers and did not want to bother the staff, then his knees gave out. No injuries found. The Fall Investigation dated 05/15/25 at 10:40 PM documented that R50 continued to be non-compliant with requesting staff assistance with getting things out of drawers or closets, and all interventions were in place to keep the resident free from injury; however, R50 continued with non-compliant behaviors. The Durable Power of Attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) was aware and understood R50's continued stubbornness with requesting assistance.The Progress Note dated 05/19/25 at 06:06 PM documented that the nurse was called to R50's room, as R50 was on the floor of the bathroom. R50 reported he was trying to get briefs from the shelf while in the bathroom due to being incontinent, but the shelf was too high, and he lost his balance. The note further documented that R50 was educated on call light use. No injuries found.The Fall Investigation dated 05/19/25 at 06:00 PM, documented that R50 had a chronic history of non-compliance with fall interventions. R50 was educated to alert staff when needing assistance and would be assessed for the need of portable drawers to be placed in the bathroom for ease of access to incontinent supplies.The Progress Note dated 05/21/25 at 10:37 AM documented that the facility faxed the physician for physical and occupational therapy orders due to increased falls and balance concerns.The Progress Note dated 06/15/25 at 09:30 AM documented a CNA reported to the nurse that R50 was sitting on the floor in front of his recliner. R50 reported getting things for bed, had a four-centimeter abrasion to the left knee, and no other injuries were noted at that time.The Fall Investigation dated 06/15/25 at 09:01 PM documented that R50 was getting things for bed and fell. The note further documented that R50 had a history of falls due to not allowing staff to assist him. R50 and staff were educated on setting out clothing for the resident every morning and evening to prevent falls. R50 was very aware of his independence and laughed at most of the education provided by staff, stating, I know I fall, but I'm not hurt, I will be fine.The Progress Note dated 06/16/25 at 01:23 PM documented that a CNA alerted the nurse that R50 was on the floor. R50 was on the floor in front of his recliner, the call light was in reach, with a sign posted in front of R50 reminding the resident to use the call light. R50 reported he was trying to get Chapstick from the dresser drawer and knew he was to use the call light for assistance with walking, but did not feel like he needed help. No injuries were found.The Fall Investigation dated 06/16/25 at 01:10 PM documented that R50 had a history of not requesting assistance from staff while ambulating or letting staff know that he was ambulating, as he had previously agreed. R50 did not utilize the call light for assistance. The resident had frequent falls due to the mentioned behaviors. Staff to check on the resident frequently to help ensure the resident is safe with ambulation.The Progress Note dated 08/02/25 at 04:50 PM documented R50 stated he was checking to see if he had soup on his counter, he lost his balance and fell onto his bottom. No injuries found at the time.The Fall Investigation dated 08/02/25 at 04:30 PM documented that R50 had been provided a three-drawer cart to store snacks in. R50 kept drawers packed full and not always facing him for convenience. The intervention for staff members is to sort through drawers to ensure safety and to encourage the resident to keep all snacks in the drawer. The conclusion of R50 had been educated multiple times on calling for assistance when needing things, and he continued to do things on his own.The Progress Note dated 09/12/25 at 08:40 PM documented that a CNA notified the nurse that R50 was on the floor. R50 reported he stood up and turned around to check and see if the pad on his chair was wet and lost his balance. No injuries were found.The Fall Investigation dated 09/12/25 at 08:40 PM documented that the root cause analysis was that R50 was getting into his dresser to obtain clothing for the night when he lost his balance, causing him to fall. The investigation documented that the staff were to set out his clothing to assist in the prevention of incidents. The conclusion was that staff were educated on the importance of setting clothes out every evening, as in the care plan. No evidence of abuse, neglect, and/or exploitation.The Fall Investigation dated 09/19/25 at 08:45 PM documented that the root cause analysis was R50 unsteady gait, the call light was pinned to his chair, and he continued to refuse to follow interventions in place. The intervention was to continue education on the importance of asking for assistance with things. The resident continued to refuse to use his call light and asked for assistance. R50 feels he is still capable of doing things for himself.The Progress Note dated 09/19/25 at 10:47 PM documented that the CNA notified the nurse that R50 was on the floor. R50 reported he stood up and turned around to check and see if his pad on the chair was wet, and lost his balance. The walker was beside the chair, and the call light was clipped to his recliner in reach. The note further documented that staff offered dressing for bed and toileting at 06:30 PM, and R50 had refused. No injuries found.The Fall Investigation dated 09/26/25 at 05:00 PM documented that on 09/27/25 at 04:19 AM, while staff were providing care for R50, staff noticed an abrasion to the resident's back on either side of the spine. R50 reported he fell at 05:00 PM the day before and stated, I got myself up. The investigation documented that R50 knows better than to get up on his own. R50 had continually been educated on asking for assistance, and he smiles and laughs when staff come to assess him. R50 had been educated to keep the door somewhat open and refused at times. The intervention was to continue to educate and monitor R50. The conclusion documented at times R50 reports of falling, and this might be more behaviorally related.The Progress Note dated 09/27/25 at 04:19 AM documented that the nurse was called to R50's room. R50 reported a fall that happened on 09/26/25 at 05:00 PM. R50 refused vital signs assessments.The Progress Note dated 09/27/25 at 03:37 PM documented that R50 had a scratch on his back from the previous fall. The Progress Note dated 10/08/25 at 12:49 AM documented a CNA called the nurse to R50's room, and reported the resident was on the floor. R50 reported he was trying to get his handkerchief from the shelf in front of his recliner. The call light was fastened to the recliner within R50's reach.The facility failed to investigate the causative factors of the fall.The Progress Note dated 10/15/25 at 11:34 PM documented that the CNA called the nurse to R50's room. R50 was on the floor in front of his recliner. R50 was last seen about ten minutes before falling, when both the nurse and CNA. R50 reported was going to get his donuts from the top of his dresser. No injury was observed at that time.The Fall Investigation dated 10/15/25 at 11:00 PM documented that R50 had not used his call light and got up on his own, and lost his balance, and this is a historical issue. The intervention was for a negotiated risk agreement and to move R50 closer to the nurses' station. The conclusion of no abuse or neglect, and R50 continued to do his own thing after several attempts from staff to educate him.The Progress Note dated 11/11/25 at 09:20 AM documented while CNA was walking by R50's room, R50 put the power recliner into the standing position, and R50 was wearing slick pajamas and slid down the chair instead of standing. The CNA reported that R50 went to his knees after sliding down. R50 stated he was just trying to stand up to readjust while in the recliner, and instead of standing, slid down when the CNA came into the room. No injuries documented.The Fall Investigation dated 11/11/25 at 09:20 AM documented that R50 continued not to use the call light for assistance. The intervention was to have a care plan meeting to discuss with the DPOA about moving closer to the nurses' station. The conclusion was that R50 continued not use the call light, and staff continue to encourage him to ask for assistance.The Progress Note dated 12/01/25 at 10:10 AM documented that a CNA was assisting R50 in going through clothes and helping R50 move to a new room. The CNA took some belongings to the new room, and when the CNA returned R50 was on the floor. R50 reported he tried to get into his recliner and fell. R50 reported that he hit his head on the wheelchair. A small laceration to the lateral side of his left eyebrow.The Fall investigation dated 12/01/25 at 10:10 AM documented that R50 continued to feel he could transfer himself from the wheelchair to the recliner. The intervention was to discuss the harm that could happen when falling. The conclusion documented that the resident continued to refuse to ask for assistance and use of assistive devices. Staff would continue to educate on the importance of asking for assistance before transferring.The Progress Note dated 12/03/25 at 07:30 PM documented that Administrative Nurse D had contacted R50's DPOA regarding frequent falls. R50's room change had been completed on 12/01/25, and he had a fall when a staff member had left the room. The DPOA was very frustrated with the situation and R50's stubbornness. Administrative Nurse D had a face-to-face conversation with R50 related to his safety and the continued lack of use of the call light and waiting for staff assistance. A discussion with R50 about plans for improving his safety and decreasing falls. R50 had a call light and bell at the chairside within reach.The Progress Note dated 12/04/25 at 04:00 PM documented that R50 had been assisted from the shower by the CNA. R50 was in a wheelchair while the CNA cleared his recliner. R50 stood up suddenly and fell. No signs of injury. R50 was re-educated by Administrative Nurse D about asking for help with transfers and safety.The Fall Investigation dated 12/04/26 at 04:00 PM documented that the root cause analysis was R50 falls due to refusing to practice safety precautions. R50 was aware of this and continues to refuse to comply with most interventions. The intervention was to have a conversation with R50's DPOA about the potential for a negotiated risk agreement due to the resident's continued non-compliance. No abuse and/or neglect associated with the incident.The Progress Note dated 12/14/26 at 04:12 AM documented a CNA was assisting with a bathroom need and changing his clothes at 03:30 AM. The CNA observed R50 had an abrasion to the right outer knee and a bruise to the right outer eye. R50 initially denied falling but admitted that he had fallen on 12/13/25 at approximately 05:00 PM. Education provided on always using the call light. R50 reported that he used the call light, the CNA answered it, but did not ask him what he needed so he got up on his own. The Fall Investigation dated 12/14/25 at 03:50 AM documented immediate intervention of education was done, directing the resident not to get up by himself, to use the call light, and to call again if he did not get what he needed. The root cause analysis was that R50 did not alert staff to his needs, so they could assist, not to get things himself, then fell, causing a minor injury. The intervention was to secure a negotiated risk agreement due to frequent falls. Conclusion of no abuse and exploitation associated with the incident.R50's Care Plan intervention dated 01/15/25 directed staff to frequently offer bathroom privileges. R50's Care Plan intervention dated 05/07/25 documented a non-injury fall, all interventions in place, and directed staff to encourage the resident to ask for assistance prior to getting up. R50's Care Plan intervention dated 09/20/25, documented R50 had a non-injury fall and directed staff to continue to educate R50 on the importance of asking for assistance. R50's Care Plan intervention dated 09/30/25, documented a non-injury fall on 09/26/25, and directed staff to continue education and monitoring. R50's Care Plan dated 10/07/25 documented a non-injury fall. The DPOA was contacted regarding concerns, and the facility would discuss with R50's physician the need for a negotiated risk agreement (an agreement in which a resident waives the facility's liability) for R50. R50's Care Plan intervention, dated 10/15/25, documented that R50 had a non-injury fall, a negotiated risk agreement, and to move R50 closer to the nurses' station. R50's Care Plan dated 11/20/25 directed staff to allow R50 to make decisions about the treatment regimen to provide a sense of control and to educate family and caregivers about possible outcomes of not complying. Encourage participation as much as possible during care. Give a clear expectation of all care activities before any as they occur with each contact. If R50 resists with activities of daily living, reassure him, assure he is safe, leave and return in five to ten minutes, and retry. If possible, negotiate a time for activities of daily living so that R50 could participate in decision-making and return at the agreed timeR50's Care Plan lacked a new intervention to prevent further falls and injuries for the falls that occurred on the following dates: 01/31/25 (one in the AM and one in the PM), 02/01/25, 05/16/25, 05/19/26, 06/15/25, 06/16/25, 08/02/25, 12/04/25, and 12/13/25.On 01/12/26 at 09:28 AM, R50 sat in his recliner with his feet elevated, the call light clipped to the recliner arm. He reported that staff assisted him to the bathroom, and he used the call light to call staff.On 01/12/26 at 09:34 AM, CNA M reported that the staff check R50 often, and every time they go by his room, the staff leave his door open and assist him to the bathroom. She reported the resident does not have a scheduled routine, and it was up to the resident to decide when he needed to go to the bathroom or perform other activities of daily living. CNA M stated that R50 used his call light and was not forgetful.On 01/13/26 at 08:13 AM, Administrative Nurse D reported R50 had numerous falls. She verified the frequent use of educating the resident to call for assistance had been ineffective, and the resident continued to fall. She reported that the staff were to get his clothes ready in the morning and evening to prevent falls, and to make sure he had everything he needed or wanted within his reach. Administrative D reported talking with R50's DPOA, and the DPOA reported that R50 was choosing not to use the call light and was very independent. Administrative Nurse D verified there have been falls that lacked a fall investigation with a root cause analysis or a new intervention added to the Care Plan.The facility's Accident and Supervision policy, dated 10/16/23, documented that the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents, by identification of hazards and risks, evaluation and analysis, implementation of interventions, monitoring and modification, and supervision.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 47 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use. Findings included: - On [DATE] at 09:00 AM, observation of the North Hall Nurse Treatment cart revealed R47's Lantus (long-acting insulin) flex pen was not labeled with an opened date. On [DATE] at 09:05 AM, License Nurse (LN) G verified the nurses should label and date the insulin flex pens with the date opened.On [DATE] at 10:00 AM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened, and the date expired. Administrative Nurse D stated the nurses have a sticker to label the insulin pens with that information. Medlineplus.gov directs open, unrefrigerated Lantus can be used within 28 days; after that time, they must be discarded.The facility's Medication Storage policy, dated [DATE], documented medications would be stored in the medication carts or medication room according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

The facility identified a census of 66 residents. The sample included 18 residents. Based on record review, observations, and interviews, the facility failed to ensure oxygen saturation equipment was sanitized after each resident's use and further failed to ensure Resident (R) 45's, and R32's oxygen nasal cannulas, and R48 and R29's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks, and R2'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) masks were stored in a sanitary manner.Findings included:- On 01/11/26 at 08:44 AM, during the initial walk-through of the facility, R45's nasal oxygen tubing laid in his chair. The nasal cannula was not stored in a sanitary manner. On 01/11/26 at 09:56 AM R48's nebulizer mask hung over the bedside table; the mask was not stored in a sanitary manner. On 01/11/26 at 12:10 PM, observation revealed an uncovered oxygen cannula and tubing lying on the oxygen tank cylinder valve in the North Hall dining room while R32 ate lunch. Observation revealed R32 had a nasal cannula and tubing attached to an oxygen concentrator in use. On 01/11/26 at 10:25 AM, R2's CPAP mask laid on his dresser; R2's CPAP mask was not stored in a sanitary manner. On 01/12/26 at 08:16 AM R29's nebulizer laid on her bedside table; R29's nebulizer was not stored in a sanitary manner. On 01/12/26 at 11:50 AM, observation revealed R32's uncovered oxygen cannula and tubing rolled up and placed under the oxygen concentrator handle in the North Hall dining room. On 01/13/26 at 07:44 AM, Certified Nurse Aide (CNA) O stated that all respiratory equipment not in use should be placed in a drawer or in a bag to keep the equipment sanitary. On 01/13/26 at 07:35 AM, Licensed Nurse (LN) I stated all respiratory equipment should be rinsed and laid to dry, and the equipment should be covered while drying. LN I stated the equipment should be placed in a marked bag to ensure the equipment stays clean. On 01/13/26 at 07:51 AM, Administrative Nurse D stated all respiratory equipment that was not in use should be placed in a bag labeled with the resident's name and date. She stated she expected staff to place respiratory equipment in a bag when the equipment was not in use. On 01/13/26 at 09:30 AM, Administrative Nurse D stated the resident's oxygen concentrators and tanks have bags available for staff to store the nasal cannulas and tubing in when not in use, and they should not be left uncovered if not in use. The facility's Oxygen Storage policy, undated, documented oxygen would be administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. The policy documented staff would change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. The policy documented staff would keep delivery devices covered in a plastic bag when not in use.

The facility had a census of 66 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.Findings included:- The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) 2025 Quarter (Q) 1, FY 2025 Q2, and FY 2025 Q3 indicated excessively low weekend staffing and a one-star staffing rating. A review of the facility's staffing and nursing hours of the Quarters listed above revealed adequate staffing coverage. On 01/12/26 at 02:30 PM, Administrative Nurse D stated that there had been the appropriate number of staff that worked; however, it was the salaried nurse staff that did not clock in, so their hours did not calculate that they worked when they filled in for staff. Administrative Nurse D verified the facility always had nurse and aide coverage.The facility's Payroll Based Journal policy, dated 12/19/19, documented that it was the policy of the facility to electronically submit to Centers for Medicare and Medicaid services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format to specifications established by CMS.

The facility identified a census of 69 residents with three residents reviewed for elopements. Based on record review, observation, and interview, the facility failed to identify and implement interventions and failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was cognitively impaired and at high risk for elopement. On 08/08/24 and 10/28/24 the facility assessed and documented R1 was at high risk for elopement but did not implement any interventions or update R1's plan of care to alert staff regarding R1's elopement risk. On 10/30/24 staff last saw R1 at 07:30 AM. At approximately 10:30 AM, the facility received a phone call from a community member stating an elderly man was walking on the grounds of the facility. The facility started a head count and realized R1 was not in the facility. His window was open and R1 had chiseled the wooden blocks that were screwed into the windowsill with a butter knife, allowing him to open and exit the window. While staff performed a search for R1, the facility received a phone call from a farm store indicating R1 was there. The store was 0.3 miles away, a seven-minute walk from the facility. R1 had to cross a busy highway with lots of truck traffic, and up and down two steep ditches to reach the store. When staff got to the store, R1 was talking to the local police and was sharing with the police officer that the facility was holding him captive. R1 returned to the facility at the persuasion of Law Enforcement (LE) but refused assessment. The failure to identify and implement interventions and provide adequate supervision to prevent an elopement for R1, placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented that R1 had diagnoses of frontotemporal neurocognitive disorder (a rare progressive brain disease that affects the frontal and temporal lobes of the brain), dementia (progressive mental disorder characterized by failing memory, and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), homicidal ideations (thoughts of murder), and suicidal ideations (thoughts of suicide). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of eight which indicated moderately impaired cognitive function. The MDS documented R1 was independent with most of his activities of daily living. The MDS lacked any documentation of behaviors. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/30/24, documented R1 had short-term and long-term memory loss and a BIMS score of eight. The CAA documented R1 had diagnoses of dementia and depression and was at risk for isolation and further cognitive decline. R1's Care Plan documented R1 required supervision or touch assistance for ambulation, eating, and bathing (05/24/24). The care plan documented R1 tended to exhibit behavioral issues: being easily agitated, loud, disruptive, and anxious due to dementia. Staff were to anticipate and meet R1's needs, assist R1 in developing appropriate coping skills to alleviate behaviors, explain all procedures to R1, allow him to process and decrease his confusion, and administer medication as ordered (05/24/24). The care plan documented R1 had safety concerns related to a history of falls and staff were to be sure R1's call light was in reach and encourage R1 to use it for assistance and educate R1 about safety reminders (05/31/24). R1's Care Plan lacked any documentation of interventions aimed to protect R1 from wandering or elopement until after the incident on 10/30/24. On 10/30/24, R1's Care Plan recorded a focus created on 10/30/24 with an effective date of 05/24/24 that stated R1 was at risk for elopement. Interventions were created on 10/30/24, effective 05/24/24, which directed staff to educate healthcare decision-makers and staff of elopement potential, triggers, and preventative measures. The plan directed staff to encourage R1's independence, while in the building but to ensure he is supervised while outside. The interventions created on 10/30/24, effective 05/24/24, included keeping R1's information in the elopement book, keeping his routine as consistent as possible, and redirecting when wandering around doors or exits. An intervention created on 10/30/24, effective 05/24/24, directed staff that R1's family must sign him out of the facility before R1 exits the facility. The Elopement/Wandering Risk Assessment, dated 05/24/24, documented R1 had a score of 12 which indicated R1 was a high risk for wandering/elopement. The Elopement/Wandering Risk Assessment, dated 10/28/24, documented R1 had a score of 12 which indicated R1 was a high risk for wandering/elopement. The Morse Fall Scale, dated 10/28/24, documented R1 had a risk score of 35 which indicated R1 was at moderate risk for falls. The Incident Note, dated 10/30/24, documented an assisted living nurse received a phone call at approximately 10:30 AM from a local person regarding an older gentleman outside of the facility. The assisted living nurse contacted the facility, and an immediate head count was performed and R1 was unaccounted for. While the facility staff performed a search of the facility and grounds, the facility received a call from the local farm store across the street stating R1 was at the store. Licensed Nurse (LN) G and LN H went to the store. Upon entering the store, R1 was observed visiting with a police officer. R1 was dressed in a T-shirt, khaki shorts, shoes, and socks. R1 was reluctant to talk to LN G and LN H. The police officer reported R1 felt the facility was holding him captive. The police officer convinced R1 to return with him to the facility, willingly got into the police officer's car, and was transported back to the facility without difficulty. R1 refused to talk to any staff member after his return. R1 was placed on one-to-one (1:1) with staff. R1 told the police officer he had removed the blocks from his window and left through the window. The Wandering Risk Scale Note, dated 10/30/24, documented R1 was able to follow instructions, ambulatory, able to communicate, had a history of wandering, had a medical diagnosis of dementia/cognitive impairment, a diagnosis impacting his gait, mobility, or strength, and wandered aimlessly, and made attempts to exit the facility. The Therapy Screen Note, dated 10/30/24, documented the therapist had been requested to complete an urgent BIMS on R1. R1 was in his room with a Do Not Disturb sign on the door. The therapist entered and introduced themselves and R1 immediately started in erratic conversation about knowing this was going to happen with multiple people coming to his room because of this stuff. R1 presented with hypomanic (a condition that involves a period of extreme mood swings, increased energy, and unusual activity levels) and paranoid thoughts about his family. Empathetic listening and reflection were tried and R1 refused to answer a couple of quick questions. The therapist was able to get R1 to respond to some orientation questions and was unable to state the year, date, day of the week, or town he was located in. The Facility Incident Report, dated 10/31/24, documented an assisted living nurse received a phone call at approximately 10:30 AM from a local person regarding an older gentleman outside of the facility. The assisted living nurse contacted the facility and an immediate head count was performed and R1 was unaccounted for. While the facility staff performed a search of the facility and grounds, the facility received a call from the local farm store across the street stating R1 was at the store. Licensed Nurse (LN) G and LN H went to the store. Upon entering the store, R1 was observed visiting with a police officer. R1 was dressed in a T-shirt, khaki shorts, shoes, and socks. R1 was reluctant to talk to LN G and LN H. The police officer reported R1 felt the facility was holding him captive. The police officer convinced R1 to return with him to the facility, willingly got into the police officer's car, and was transported back to the facility without difficulty. R1 refused to talk to any staff member after his return. R1 was placed on one-to-one staff. R1 told the police officer he had removed the blocks from his window and left through the window. The facility notified R1's primary care physician and responsible party of the situation and no new orders were received. An assessment of R1 will be completed when R1 allows. Maintenance secured the windows in R1's room. Maintenance checked all of the windows in the facility to ensure stoppers were in place. The facility provided education to all staff on elopement and abuse, neglect, and exploitation. The facility completed a new wandering assessment for R1, reviewed and updated the elopement book, updated R1's Care Plan, and had an ad hoc meeting with the medical director. LN I's Witness Statement, dated 10/30/24, documented LN I saw R1 around 07:30 AM walking into the dining room. Certified Nurse's Aide (CNA) N's Witness Statement, dated 10/30/24, documented CNA N talked to R1 at 07:15 AM when he asked CNA N for ointment for his bottom. CNA N stated R1 was in a great mood and joking. On 11/20/24 at 10:00 AM, observation of R1's room revealed the windows were screwed shut from the outside. Observation outside of R1's window revealed a bush, large air conditioning units, and a parking lot full of cars. The most direct route to the farm 0.3 miles away from the facility revealed a busy highway with lots of truck traffic and posted speeds of 30 miles per hour. There were also two steep ditches between the facility and the store. On 11/20/24 at 10:00 AM, Administrative Staff A stated R1 was seen on camera about 10:00 AM and then the Assisted Living facility received a phone call from the hospital about a resident being out. Assisted Living staff then called the facility to inform them about 10:30 AM and a head count was started and realized R1 was not in the facility. R1's window was open and R1 had chiseled the wooden blocks that had been screwed into the windowsill to prevent the windows from opening with a butter knife. Administrative Staff A stated he felt R1's BIMS was not accurate because R1 just would not answer the questions and that R1 was more alert and oriented than the BIMS evaluation showed. Administrative Staff A stated that before the elopement, R1 was allowed outside of the facility to walk around but after this incident, the privilege was taken away Administrative Staff A stated the facility staff followed the elopement policy. On 11/20/24 at 10:15 AM, Administrative Nurse D stated she was unaware R1 did not have an elopement intervention in his care plan prior to the elopement. Administrative Nurse D said that after the elopement on 10/30/24, R1 was placed on 1:1 with staff until R1's windows could be secured. Education with all staff was performed on the Elopement Policy and ANE Policy and audits of elopement risk assessments were completed and any resident with a score of nine or higher was ensured elopement interventions were in their care plan on 10/30/24. On 11/20/24 at 10:30 AM, LN G stated R1 had paranoia and at times was perfectly lucid, and then it was like a switch was flipped and he was accusing his sisters of keeping him captive in a basement and forcing him to take pills. LN G stated R1 was at risk for wandering but he never wandered in the facility. LN G stated she thought R1 had been care planned for elopement before the incident but was not sure. On 11/20/24 at 10:45 AM, CNA M stated she never had any problems with R1. He was independent with all of his ADLs. CNA M stated that R1 would come out, get ice water, and go back to his room. CNA M stated right after the elopement, R1 began to become threatening and had a lot of behaviors. On 11/20/24 at 11:00 AM, CNA N stated she saw R1 the morning he eloped, and he appeared to be in a good mood and was joking with her. CNA N stated she saw R1 at about 07:15 AM that morning. CNA N stated she was unaware if R1 had any wandering behaviors. The facility's Elopements and Wandering Residents Policy documented the facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards or risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. On 11/20/24 at 12:29 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the failure to identify and implement interventions and failed to provide adequate supervision to prevent an elopement for R1 placed R1 in immediate jeopardy. The facility completed the following corrections on 10/30/24: R1 was placed on one-to-one with staff. The facility notified R1's primary care physician and responsible party of the situation. A new wandering assessment was completed for R1. The elopement book was reviewed and updated. R1's Care Plan was updated. An ad hoc meeting was held with the medical director on 10/30/24 at 05:00 PM. E Maintenance secured the windows in R1's room. Maintenance checked all of the windows in the facility to ensure stoppers were in place on 10/30/24. Education was provided to all staff on elopement and abuse, neglect, and exploitation on 10/30/24. All corrections were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance. The scope and severity remained at a J.

The facility had a census of 59 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 02/28/24 at 11:04 AM, a review of the noon meal consisted of butter noodles, pork chops, and yellow squash. On 02/28/24 at 11:04 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had started the certified dietary manager classes. On 02/28/24 at 08:30 AM, Administrative Staff A verified Dietary Staff BB did not have a dietary manager certification. The facility's Director of Food Policy, revised 07/02/21, documented the director of food and nutrition services would be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. The facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the kitchen. This placed the residents at risk for inadequate nutrition.

The facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 55, R17, and R54 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care and R20 lacked an anchor for catheter tubing. These deficient practices placed the residents at risk for urinary tract infections and catheter related injury. Findings included: - R55's Electronic Medical Record (EMR) documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), post hemorrhagic (loss of a large amount of blood in a short period of time) anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), muscle weakness, heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), age related cognitive decline, pain, and the need of assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R55 had intact cognition and verbal behavioral symptoms directed toward others which occurred one to three days of the observation period. R55 had had functional range of motion to one side upper extremity and both lower extremities and required partial/moderate assistance with toileting and dressing. The MDS further documented R55 had an indwelling catheter and was occasionally incontinent of bowel. R55 received scheduled pain medication, insulin (a hormone that lowers the level of glucose in the blood), and high-risk medication of a hypnotic (a class of medications used to induce sleep) class. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 10/31/23, documented R55 had an indwelling urinary catheter. R55 received diuretic (medication to promote the formation and excretion of urine) therapy and required assistance with toilet transfers and hygiene. The Dehydration Fluid Maintenance CAA, dated 10/31/23, documented the CAA triggered due to admission diagnoses of pneumonia (inflammation of the lungs) and urinary tract infection (UTI). R55's Care Plan dated 02/07/24 lacked interventions or direction related to R55's indwelling catheter. The Physician Order dated 10/25/25 directed staff to change the indwelling catheter every 30 days. The Physician Order dated 01/22/24 directed staff to anchor the catheter tubing to prevent injury, provide catheter care, and measure output every shift. The Progress Note dated 01/30/24 at 07:40 AM documented staff initiated a standing order to collect a urine analysis (UA) for a suspected UTI due to R55 had increased confusion, behaviors, and a general complaint of not feeling well. The Progress Note dated 02/20/24 at 10:09 AM, documented the Interdisciplinary Team (IDT) met to discuss and review the resident's indwelling catheter, and the care plan was reviewed; the facility would continue the current plan of care. R55's clinical record revealed R55 received antibiotics to treat a UTI on 12/15/23, 12/29/23, and 01/30/24. On 02/28/24 at 12:00 PM, observation revealed staff brought R55 to the dining room with the catheter drainage bag and tubing dragging on the floor under the wheelchair. On 02/28/24 at 07:45 AM, observation revealed R55 in bed which was low to the floor; the catheter drainage bag rested on the floor mat next to the bed. The facility's Catheter Care Policy, dated 01/09/24, documented it was the policy of the facility to provide catheter care to all residents that have an indwelling catheter to reduce bladder and kidney infections. The facility failed to provide R55 with sanitary indwelling catheter care by allowing the catheter drainage bag to touch the floor. This placed R55 at risk for ongoing complications of UTIs. - R17's Electronic Medical Record (EMR) included diagnoses of a personal history of urinary tract infections (UTI), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), neuralgia (intermittent along the course of a nerve) and neuritis (inflammation of nerves causing pain), unspecified disorders of the bladder, type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic respiratory failure with hypoxia (inadequate supply of oxygen), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) with lower urinary tract symptoms, low back pain, unspecified cirrhosis (chronic degenerative disease of the liver), obesity (excessive body fat) and a need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition. R17 had a functional range of motion impairment of both lower extremities and was dependent on staff for toileting, bathing, dressing of the lower and upper body, personal hygiene, and transfers. The MDS further documented R17 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was frequently incontinent of bowel. R17 had macerated (softening and breaking down of skin as a result of prolonged exposure to moisture, such as sweat, urine, feces, or wounds for extended periods) associated skin damage. R17 had shortness of breath with exertion, sitting, resting, and lying flat. The MDS further documented R17 received medication for pain, an antidepressant (a class of medications used to treat mood disorders), a hypnotic (a class of medications used to induce sleep), a diuretic (medication to promote the formation and excretion of urine) and used oxygen during the observation period. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/01/23, documented R17 was frequently incontinent of urine, required extensive assistance with toileting, and was at risk for skin rashes, breakdown, falls, isolation, and UTIs. The CAA further documented the resident was working with physical and occupational therapies. R17's Care Plan dated 02/08/24, lacked indwelling catheter use and directions for care. The Physician Order dated 01/25/24 directed staff to change the catheter as needed (PRN). R17's clinical record revealed R17 was treated for a UTI on 10/20/23, 11/05/23, 11/15/23, and 01/26/23. On 02/27/24 at 01:47 PM, observation revealed R17 lay in bed and watched TV. The indwelling catheter drainage bag hung on the bedframe at the foot of the bed, without a privacy bag. On 02/28/24 at 07:39 AM, observation revealed R17 lying on his back in the bed. His catheter drainage bag lay directly on the floor, not attached to the bed. Licensed Nurse (LN) H stated the catheter bag should not be lying on the floor and confirmed R17 had a history of UTIs. LN H drained the catheter bag and hooked it to the frame of the bed. On 02/28/24 at 09:24 AM, Administrative Nurse E reported the Interdisciplinary Team (IDT), and nurses were responsible for updating the care plans. Administrative Nurse E verified R17's indwelling urinary should have been care planned. On 02/28/24 at 01:30 PM, Administrative Nurse D verified the indwelling catheter use should be included in R17's Care Plan. The facility's Catheter Care Policy, dated 01/09/24, documented it was the policy of the facility to provide catheter care to all residents that have an indwelling catheter to reduce bladder and kidney infections. The facility failed to provide R17 with sanitary indwelling catheter care by allowing the catheter drainage bag to touch the floor, which placed the R17 at risk for ongoing complications of UTIs and infectious diseases. 32358 - R54's Electronic Medical Record (EMR) documented R54 had a diagnosis of urinary retention (lack of ability to urinate and empty the bladder). R54's Quarterly Minimum Data Set (MDS), dated [DATE], documented R54 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R54 was dependent on staff for toileting hygiene. R54 had an indwelling urinary catheter. R54's Care Plan, revised 01/18/24, documented R54 required partial, moderate assistance with toileting hygiene. The plan documented R54 had an indwelling urinary catheter and instructed staff to provide good perineal (private area) care, anchor the catheter tubing to prevent injury, provide catheter care every shift and as needed (PRN), and monitor, record, and report to the physician if R54 had signs or symptoms of urinary tract infection (UTI-an infection in any part of the urinary system). On 02/28/24 at 08:37 AM, R54 sat on the toilet. Certified Nurse Aide (CNA) N placed the uncovered urinary catheter bag on the floor in front of the toilet and placed a plastic container on the floor without a clean barrier. CNA N used an alcohol pad to wipe the tip of the drainage port, then picked up the catheter bag and opened the port. CNA N drained the clear yellow urine into the container. CNA N used an alcohol pad to wipe the drainage port tip again and reinserted the port into the holder then placed the catheter bag on the floor in front of R54. CNA N then applied gloves, stepped on the bag and tubing with her shoe, then used an alcohol wipe and wiped the catheter starting from the tubing insertion site, down to the connection site. R54 stood up and CNA N, with the same soiled gloves, pulled R54's cloth underwear and pants up, then removed and discarded the gloves. CNA N placed R54's catheter bag in her ungloved hand and followed the resident to his wheelchair. Further observation revealed CNA N placed the uncovered catheter bag on the floor, then picked it up with ungloved hands and fastened it to the right-hand side of R54's walker. CNA N left the room without washing her hands and went into another resident's room. On 02/28/24 at 08:55 AM, CNA N verified she placed the urinary catheter bag on the floor and did not change her gloves or wash her hands after providing catheter care. CNA N stated she was going to hang the catheter on the walker but did not think she could. She said she should have changed her gloves and washed her hands after providing catheter care. On 02/28/24 at 03:28 PM, Administrative Nurse D stated she expected staff to follow infection prevention protocols when providing urinary catheter care. Administrative Nurse D said staff should hang the urinary catheter bag below the level of the bladder and never place it on the floor. Administrative Nurse D stated she expected staff to change gloves between dirty and clean and wash hands immediately after removing gloves. The facility's Hand Hygiene Policy, revised 10/25/2002, documented that staff involved with direct resident contact would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The facility's Catheter Care Policy, revised 01/09/24, instructed staff to apply gloves, provide catheter care to the perineal area, bag and gather all supplies used, discard disposable items in the trash can, assist resident to a comfortable, appropriate position, return room back to the original order and then perform hand hygiene. The facility failed to appropriate catheter treatment and services for R54. This placed the resident at increased risk for UTI and catheter-related complications. 26768 - R20 's Electronic Medical Record documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R20 had no behaviors and received an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and a hypnotic (a class of medications used to induce sleep) medication. The MDS documented R20 was independent with eating and required moderate staff assistance with dressing and bed mobility. R20 was dependent on staff for toileting and transfers. R20's Care Plan, dated 02/07/24, lacked information R20 had a urinary catheter and lacked interventions related to the care of it. The Physician Order, dated 10/15/23, directed staff to change the suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) every month. The Physician Order, dated 10/24/23, directed staff to flush the suprapubic catheter twice a week with 100 cubic centimeters (cc) of normal saline during the night shift every Tuesday and Friday. The Physician Order, dated 11/20/23, directed staff to cleanse the suprapubic site and cover it with a drain gauze dressing and tape daily at bedtime. The Physician Order, dated 01/22/24, directed staff to anchor the catheter tubing to prevent injury and provide catheter care every shift. The Physician Order, dated 01/23/24, directed staff to document catheter output every shift. A review of R20's catheter output documentation in the EMR lacked evidence staff measured and recorded R20's urine output on six shifts from 02/01/24 through 02/28/24. On 02/28/24 at 09:45 AM, observation revealed R20 lay in bed while Administrative Nurse E performed wound care. She ensured the suprapubic catheter tubing was not pinned under the brief but did not ensure an anchor was present to prevent pulling or displacement of the catheter. On 02/29/24 at 07:55 AM, Administrative Nurse D verified staff should have ensured an anchor for the tubing was in place and said it should have been on R20's Care Plan. On 02/29/24 at 08:05 AM, Administrative Nurse E verified a catheter tubing anchor should be in place to prevent R20's suprapubic catheter tubing from getting tugged and causing pain. The facility's Catheter Care policy, dated 01/09/2024, stated the facility would provide catheter care to residents who have an indwelling catheter to reduce bladder and kidney infection. The facility failed to ensure staff measured and recorded R20's urinary output and failed to ensure R20's suprapubic catheter tubing was anchored to prevent pulling or dislodgement. This placed the resident at risk for complications related to an indwelling suprapubic catheter.

The facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 10's had multiple antidepressant (class of medications used to treat mood disorders) medications with a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), R17 lacked blood sugar parameters, R55 lacked an end date for the use of an as needed (PRN) antianxiety (class of medications that calm and relax people), R20's recommended gradual dose reduction of psychotropic (alters mood or thought) medications lacked a physician response, and R38's use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) for unapproved diagnosis. The facility also failed to ensure the physicians acknowledged and responded to the CP recommendations. This placed the residents at risk for inappropriate use of medication. Findings included: - R10's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, hypersomnia (excessive sleepiness or drowsiness), age related physical debility, communication deficit, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), dementia, muscle weakness, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had moderately impaired cognition, and had not exhibited behaviors. R10 required substantial to maximal assistance of staff for activities of daily living (ADL) and mobility. R10 took an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) and an antidepressant (class of medications used to treat mood disorders) with no gradual dose reduction (GDR) or physician documentation the GDR was clinically contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/24/23, documented R10 received antipsychotic and antidepressant medications. R10 was at risk for adverse reactions to medications and the pharmacist reviewed medication on admission and monthly thereafter. R10's Care Plan, revised 10/27/23, documented R10 was prescribed psychotropic medications and was at risk for complications. The care plan directed staff to administer medications as ordered by the physician, monitor for side effects and effectiveness each shift, consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. The care plan further directed staff to discuss with the physician and family regarding ongoing need for use of medication. Staff were to review behaviors, and alternate therapies attempted and their effectiveness, monitor, document, and report any adverse reactions. The Physician Order, dated 10/14/23, directed staff to administer: Aripiprazole (antipsychotic) two milligrams (mg) by mouth in the morning related to bipolar disorder. Duloxetine (antidepressant) 30 mg by mouth every morning related to anxiety disorder. Mirtazapine (antidepressant) 15 mg by mouth at bedtime related to anxiety disorder. Hydralazine (blood pressure medication) 50 mg by mouth two times a day with meals related to anxiety disorder. The Pharmacy Drug Regimen Review dated 10/14/23, documented recommendation to R10's attending physician which noted R10 had an order of mirtazapine that did not have a Food and Drug Administration (FDA) labeled indication and to recommended to reassess the indication for use or a Risk versus Benefit assessment. An order of mirtazapine that was prescribed Off-Label could potentially be considered an unnecessary medication. R10's clinical record lacked evidence the of a physician response. The Pharmacy Drug Regimen Review dated 11/01/23, documented a recommendation to the attending physician that R10 had an order for hydralazine with an indication of anxiety, if applicable change the indication. Hydralazine was not FDA approved for anxiety but benefit to resident outweighs any potential adverse side effects. R10's clinical record lacked evidence the of a physician response. On 02/27/24 at 01:39 PM, observation revealed R10 sat in a wheelchair in the hallway. On 02/28/24 at 01:39 PM, Administrative Nurse D could not verify if the pharmacy recommendations were sent to the physician or if a response from the physician was received regarding R10's medication used for anxiety. Administrative Nurse D verified anxiety was not an approved use those medications. The facility's Medication Regimen Review, dated 01/01/20, documented the drug regimen of each resident is reviewed at least monthly by a licensed pharmacist and included a review of resident's medial chart. Review of the medical record in order to prevent, identify, report, and resolve medication -related problems, medication errors, or other irregularities. The pharmacist shall communicate any recommendations and identify irregularities via written communication withing 72 hours of the review. The pharmacist shall forward to the facility's Consultant Pharmacist for follow up, if indicated. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure the CP identified and reported R10's multiple antidepressants used for anxiety and further failed to ensure the physician acknowledged and responded to the CP recommendations. This placed R10 at risk for inappropriate use of psychotropic medications. - R17's Electronic Medical Record (EMR) included diagnoses of a personal history of urinary tract infections (UTI), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), neuralgia (intermittent along the course of a nerve) and neuritis (inflammation of nerves causing pain), unspecified disorders of the bladder, type two diabetes mellitus, chronic respiratory failure with hypoxia (inadequate supply of oxygen), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) with lower urinary tract symptoms, low back pain, unspecified cirrhosis (chronic degenerative disease of the liver), obesity (excessive body fat) and a need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition. R17 had a functional range of motion impairment of both lower extremities and was dependent on staff for toileting, bathing, dressing of the lower and upper body, personal hygiene, and transfers. The MDS further documented R17 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was frequently incontinent of bowel. R17 had macerated (softening and breaking down of skin as a result of prolonged exposure to moisture, such as sweat, urine, feces, or wounds for extended periods) associated skin damage. R17 had shortness of breath with exertion, sitting, resting, and lying flat. The MDS further documented R17 received medication for pain, an antidepressant (a class of medications used to treat mood disorders), a hypnotic (a class of medications used to induce sleep), a diuretic (medication to promote the formation and excretion of urine), insulin and used oxygen during the observation period. R17's Care Plan, initiated 05/19/23, documented R17 had diabetes mellitus, and directed staff to educate the resident, family, and caregivers as to the correct protocol for glucose monitoring and insulin (a hormone that lowers the level of glucose in the blood) injections and obtain return demonstrations. The care plan lacked parameters for physician notification of low or elevated blood sugar levels. The Physician Order, dated 05/22/23, directed staff to administer by injection insulin glargine (long-acting insulin) solution 15 units subcutaneously (under the skin) at bedtime for diabetes. The Physician Order, dated 05/30/23, directed staff to obtain a blood sugar twice a day (BID) for type 2 diabetes mellitus. The order lacked parameters on when to notify the physician. R17's EMR recorded a postprandial (the timeframe of approximately two hours after eating) blood sugar obtained on 02/02/24 between 07:00 PM and 11:00 PM resulting in a reading of 456 milliliters (ml) per deciliter (dL). (Normal postprandial blood sugar levels for adults with DM are 180 ml/dL or less). R17's medical record lacked evidence of physician notification or assessment of the resident related to the abnormally high blood sugar reading. On 02/28/24 at 01:39 PM, Administrative Nurse D could not verify whether the pharmacy recommendations recommended parameters for R17's blood sugar levels. The facility's Medication Regimen Review, dated 01/01/20, documented the drug regimen of each resident is reviewed at least monthly by a licensed pharmacist and included a review of resident's medial chart. Review of the medical record in order to prevent, identify, report, and resolve medication -related problems, medication errors, or other irregularities. The pharmacist shall communicate any recommendations and identify irregularities via written communication withing 72 hours of the review. The pharmacist shall forward to the facility's Consultant Pharmacist for follow up, if indicated. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure the CP identified and reported the lack of parameters for monitoring related to R17's use of insulin. This placed R17 at risk of complications related to the use of insulin. - R55's Electronic Medical Record (EMR) documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), post hemorrhagic (loss of a large amount of blood in a short period) anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), muscle weakness, heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), age related cognitive decline, pain, and the need of assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R55 had intact cognition and verbal behavioral symptoms directed toward others which occurred one to three days of the look-back period. R55 had had functional range of motion to one side upper extremity and both lower extremities and required partial/moderate assistance with toileting and dressing. The MDS further documented R55 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and was occasionally incontinent of bowel. R55 received scheduled pain medication, insulin (a hormone that lowers the level of glucose in the blood), and high-risk medication of a hypnotic (a class of medications used to induce sleep) class. R55's Care Plan lacked any goals or directives related to R55's use of psychotropic medication. The Physician Order dated 10/25/23, directed staff to administer alprazolam (antianxiety medication) 0.25 milligrams (mg) every eight hours PRN for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and lacked a stop date. The Physician Order, dated 12/12/23, directed staff to administer alprazolam 0.25 mg twice a day for anxiety. R55's EMR revealed the PRN alprazolam was administered nine times in December 2023, four times in January 2024, and once in February 2024. The Pharmacy Drug Regimen Review, dated 12/04/23, recorded a recommendation made to the attending physician that R55's alprazolam did not have an FDA-approved indication. The physician responded the use of alprazolam was for anxiety. The Pharmacy Drug Regimen Review lacked evidence The CP reported the lack of a required end date for the use of PRN alprazolam. On 02/28/24 at 07:45 AM, observation revealed R55 in bed which was low to the floor; the catheter drainage bag rested on the floor mat next to the bed. On 02/28/24 at 01:30 PM, Administrative Nurse D verified the PRN alprazolam had not been addressed by the pharmacist and confirmed it required an end date. The facility's Medication Regimen Review, dated 01/01/20, documented the drug regimen of each resident is reviewed at least monthly by a licensed pharmacist and included a review of the resident's medical chart. Review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The pharmacist shall communicate any recommendations and identify irregularities via written communication within 72 hours of the review. The pharmacist shall forward to the facility's Consultant Pharmacist for follow-up if indicated. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure the CP identified and reported the lack of an end date for R55's PRN psychotropic medication. This placed R55 at risk for inappropriate use of psychotropic medications. 26768 - R20 's Electronic Medical Record documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R20 had no behaviors and received an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and a hypnotic (a class of medications used to induce sleep) medication. The MDS documented R20 was independent with eating and required moderate staff assistance with dressing and bed mobility. R20 was dependent on staff for toileting and transfers. R20's Medication Care Plan, dated 02/07/24, directed staff to administer medications as ordered, monitor labs, and report findings to the Nurse practitioner (NP) or the physician. The plan directed staff to monitor and document for side effects and effectiveness. Staff were to ensure a pharmacy review monthly and arrange for psychiatric consult with follow-up as indicated. The plan directed staff to monitor behavior episodes and attempt to determine the underlying cause. Staff were to encourage the resident to express his feelings appropriately. The Physician Orders included the following: Zolpidem (hypnotic drug), 10 milligrams (mg) at bedtime for insomnia, started 02/03/23. Buspar (antianxiety drug), 10 mg twice daily (BID) for anxiety, started 12/26/22. Duloxetine (antidepressant) delayed release, 30 mg, BID, started 12/26/22. The Consultant Pharmacist Review, dated 04/05/23, documented the consultant pharmacist recommended a gradual dose reduction (GDR) for Buspar, duloxetine, and zolpidem. R20's clinical record lacked evidence the physician responded. The Consultant Pharmacist Review, dated 10/03/23, documented the consultant pharmacist recommended a GDR for Buspar, duloxetine, and zolpidem. R20's clinical record lacked evidence the physician responded. The Consultant Pharmacist Review, dated 02/08/24, recommended a GDR of zolpidem or a trial of melatonin. The physician replied no and documented the resident still required the hypnotic, and the benefit outweighed the risk. On 02/27/24 at 02:27 PM, observation revealed R20 lay in bed with his eyes closed; music played in his room. R20 wore foam boots and had an air mattress on the bed. His urine collection bag hung low on the side of his bed. On 02/28/24 at 02:42 PM, Administrative Nurse D verified the physician had not written a risk versus benefit rationale for the continued use of Buspar, zolpidem, or duloxetine when the pharmacist recommended a GDR or a risk versus benefit rationale on 04/05/23 and 10/03/23. On 02/29/24 at 07:55 AM, Administrative Nurse D verified the facility should have followed through with the physician when he did not answer the pharmacist's recommendations for a GDR or a risk versus benefit rationale. The facility's Use of Psychotropic Drugs policy, dated 01/09/24, stated the indications for use of any psychotropic drug would be documented in the medical record and initiated only after medical, physical, functional, psychosocial, and environmental causes had been identified and addressed. Residents who receive psychotropic drugs would receive gradual dose reductions unless clinically contraindicated. The physician in collaboration with the consultant pharmacist would re-evaluate the use of the medication and consider if the medication could be reduced or discontinued. The facility's Medication Regimen Review policy, dated 01/01/2020, stated the drug regimen of each resident would be reviewed at least monthly by a licensed pharmacist to prevent, identify, report, and resolve potential risks associated with medication. The pharmacist would communicate any irregularities to the facility's Director of Nursing, the physician, and the facility's medical director. The policy stated the pharmacist did not need to document a continuing irregularity in the report each month if the physician had documented a valid clinical rationale for rejecting the pharmacist's recommendation. The facility failed to ensure the physician reviewed and acknowledged the consultant pharmacist recommendations for a GDR with a response and documented rationale. This placed the resident at risk for unnecessary psychotropic medications. 32360 - The Electronic Medical Record (EMR) for R38 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition. R38 was independent will all activities of daily living (ADLs). R38 was continent of bowel and bladder. The MDS recorded R38 had no behaviors and received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antidepressant (a class of medications used to treat mood disorders), and a hypnotic (a class of medications used to induce sleep) medication during the observation period. R38's Care Plan, dated 02/07/24, initiated on 06/10/21, documented R38 received psychotropic (alters mood or thought) medication and directed staff to monitor for side effects. Staff completed the Abnormal Involuntary Movement Scale (AIMS-a rating scale that was designed to measure the involuntary movements that developed as a side effect from antipsychotic medications) assessment, consulted with the pharmacy to consider dosage reduction when clinically appropriate and monitored for behaviors. The Physician's Order, dated 06/15/21 directed staff to administer quetiapine fumarate (antipsychotic), 25 milligrams (mg), by mouth, twice per day, for dementia without behavioral disturbance. Review of the CP's monthly medication reviews for R38 dated 03/06/23-02/26/24, documented the pharmacist had no recommendations related to quetiapine use. R38's EMR lacked evidence of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the ongoing quetiapine use. On 02/28/24 at 08:17 AM, observation revealed R38 wore a stocking cap, and a red sweatshirt which had multiple food stains on it. On 02/28/24 at 03:30 PM, Administrative Nurse D stated R38 did not have an appropriate indication for the use of quetiapine. The facility's Medication Regimen Review, policy, dated 01/01/20, documented the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart and the pharmacist should communicate ay recommendations and identified irregularities via written communication within 72 hours of the review. The policy further documented the staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure the CP identified and reported the lack of an appropriate indication for R38's quetiapine. This placed the resident at risk for unnecessary medications and adverse side effects.

The facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10's antidepressant (class of medications used to treat mood disorders) medications had an approved indication, failed to ensure R55 had an end date for the use of an as needed (PRN) antianxiety (class of medications that calm and relax people), failed to ensure R20's recommended gradual dose reduction of psychotropic (alters mood or thought) medications were addressed, and failed to ensure R38's antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) had an appropriate indication or the required physician documentation. This placed the residents at risk of receiving unnecessary psychotropic medication. Findings included: - R10's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, hypersomnia (excessive sleepiness or drowsiness), age-related physical debility, communication deficit, bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), dementia, muscle weakness, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had moderately impaired cognition, and had not exhibited behaviors. R10 required substantial to maximal assistance of staff for activities of daily living (ADL) and mobility. R10 took an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality) and an antidepressant (class of medications used to treat mood disorders) with no gradual dose reduction (GDR) or physician documentation the GDR was clinically contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/24/23, documented R10 received antipsychotic and antidepressant medications. R10 was at risk for adverse reactions to medications and the pharmacist reviewed the medications on admission and monthly thereafter. R10's Care Plan, revised 10/27/23, documented R10 was prescribed psychotropic medications and was at risk for complications. The care plan directed staff to administer medications as ordered by the physician, monitor for side effects and effectiveness each shift, and consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. The care plan further directed staff to discuss with the physician and family the ongoing need for the use of medication. Staff were to review behaviors, and alternate therapies attempted and their effectiveness, monitor, document, and report any adverse reactions. The Physician Order, dated 10/14/23, directed staff to administer: Aripiprazole (antipsychotic) two milligrams (mg) by mouth in the morning related to bipolar disorder. Duloxetine (antidepressant) 30 mg by mouth every morning related to anxiety disorder. Mirtazapine (antidepressant) 15 mg by mouth at bedtime related to anxiety disorder. Hydralazine (blood pressure medication) 50 mg by mouth two times a day with meals related to anxiety disorder. The Pharmacy Drug Regimen Review dated 10/14/23, documented a recommendation to R10's attending physician which noted R10 had an order of mirtazapine that did not have a Food and Drug Administration (FDA) labeled indication and recommended to reassess the indication for use or a Risk versus Benefit assessment. An order of mirtazapine that was prescribed Off-Label could potentially be considered an unnecessary medication. R10's clinical record lacked evidence of a physician response. The Pharmacy Drug Regimen Review dated 11/01/23, documented a recommendation to the attending physician that R10 had an order for hydralazine with an indication of anxiety, if applicable change the indication. Hydralazine was not FDA-approved for anxiety but the benefit to the resident outweighs any potential adverse side effects. R10's clinical record lacked evidence of a physician response. On 02/27/24 at 01:39 PM, observation revealed R10 sat in a wheelchair in the hallway. On 02/28/24 at 01:39 PM, Administrative Nurse D verified anxiety was not an approved use of R10's depression medications or hydralazine. The facility's Medication Regimen Review, dated 01/01/20, documented the drug regimen of each resident is reviewed at least monthly by a licensed pharmacist and included a review of the resident's medical chart. Review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The pharmacist shall communicate any recommendations and identify irregularities via written communication within 72 hours of the review. The pharmacist shall forward to the facility's Consultant Pharmacist for follow-up if indicated. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure R10 had an appropriate indication for multiple antidepressants. This placed R10 at risk of receiving unnecessary psychotropic medications. - R55's Electronic Medical Record (EMR) documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), post hemorrhagic (loss of a large amount of blood in a short period) anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), muscle weakness, heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), age related cognitive decline, pain, and the need of assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R55 had intact cognition and verbal behavioral symptoms directed toward others which occurred one to three days of the look-back period. R55 had had functional range of motion to one side upper extremity and both lower extremities and required partial/moderate assistance with toileting and dressing. The MDS further documented R55 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and was occasionally incontinent of bowel. R55 received scheduled pain medication, insulin (a hormone that lowers the level of glucose in the blood), and high-risk medication of a hypnotic (a class of medications used to induce sleep) class. R55's Care Plan lacked any goals or directives related to R55's use of psychotropic medication. The Physician Order dated 10/25/23, directed staff to administer alprazolam (antianxiety medication) 0.25 milligrams (mg) every eight hours PRN for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and lacked a stop date. The Physician Order, dated 12/12/23, directed staff to administer alprazolam 0.25 mg twice a day for anxiety. R55's EMR revealed the PRN alprazolam was administered nine times in December 2023, four times in January 2024, and once in February 2024. The Pharmacy Drug Regimen Review, dated 12/04/23, recorded a recommendation made to the attending physician that R55's alprazolam did not have an FDA-approved indication. The physician responded the use of alprazolam was for anxiety. The Pharmacy Drug Regimen Review lacked evidence The CP reported the lack of a required end date for the use of PRN alprazolam. On 02/28/24 at 07:45 AM, observation revealed R55 in bed which was low to the floor; the catheter drainage bag rested on the floor mat next to the bed. On 02/28/24 at 01:30 PM, Administrative Nurse D verified the PRN alprazolam had not been addressed by the pharmacist and confirmed it required an end date. The facility's Medication Regimen Review, dated 01/01/20, documented the drug regimen of each resident is reviewed at least monthly by a licensed pharmacist and included a review of the resident's medical chart. Review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The pharmacist shall communicate any recommendations and identify irregularities via written communication within 72 hours of the review. The pharmacist shall forward to the facility's Consultant Pharmacist for follow-up if indicated. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure R55's PRN psychotropic medication had a 14-day stop date or specific duration with the physician's documented rationale for extended use. This placed R55 at risk for unnecessary psychotropic medications and related side effects. 26768 - R20 's Electronic Medical Record documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R20 had no behaviors and received an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and a hypnotic (a class of medications used to induce sleep) medication. The MDS documented R20 was independent with eating and required moderate staff assistance with dressing and bed mobility. R20 was dependent on staff for toileting and transfers. R20's Medication Care Plan, dated 02/07/24, directed staff to administer medications as ordered, monitor labs, and report findings to the Nurse practitioner (NP) or the physician. The plan directed staff to monitor and document for side effects and effectiveness. Staff were to ensure a pharmacy review monthly and arrange for psychiatric consult with follow-up as indicated. The plan directed staff to monitor behavior episodes and attempt to determine the underlying cause. Staff were to encourage the resident to express his feelings appropriately. The Physician Orders included the following: Zolpidem (hypnotic drug), 10 milligrams (mg) at bedtime for insomnia, started 02/03/23. Buspar (antianxiety drug), 10 mg twice daily (BID) for anxiety, started 12/26/22. Duloxetine (antidepressant) delayed release, 30 mg, BID, started 12/26/22. The Consultant Pharmacist Review, dated 04/05/23, documented the consultant pharmacist recommended a gradual dose reduction (GDR) for Buspar, duloxetine, and zolpidem. R20's clinical record lacked evidence the physician responded. The Consultant Pharmacist Review, dated 10/03/23, documented the consultant pharmacist recommended a GDR for Buspar, duloxetine, and zolpidem. R20's clinical record lacked evidence the physician responded. The Consultant Pharmacist Review, dated 02/08/24, recommended a GDR of zolpidem or a trial of melatonin. The physician replied no and documented the resident still required the hypnotic, and the benefit outweighed the risk. On 02/27/24 at 02:27 PM, observation revealed R20 lay in bed with his eyes closed; music played in his room. R20 wore foam boots and had an air mattress on the bed. His urine collection bag hung low on the side of his bed. On 02/28/24 at 02:42 PM, Administrative Nurse D verified the physician had not written a risk versus benefit rationale for the continued use of Buspar, zolpidem, or duloxetine when the pharmacist recommended a GDR or a risk versus benefit rationale on 04/05/23 and 10/03/23. On 02/29/24 at 07:55 AM, Administrative Nurse D verified the facility should have followed through with the physician when he did not answer the pharmacist's recommendations for a GDR or a risk versus benefit rationale. The facility's Use of Psychotropic Drugs policy, dated 01/09/24, stated the indications for use of any psychotropic drug would be documented in the medical record and initiated only after medical, physical, functional, psychosocial, and environmental causes had been identified and addressed. Residents who receive psychotropic drugs would receive gradual dose reductions unless clinically contraindicated. The physician in collaboration with the consultant pharmacist would re-evaluate the use of the medication and consider if the medication could be reduced or discontinued. The facility's Medication Regimen Review policy, dated 01/01/2020, stated the drug regimen of each resident would be reviewed at least monthly by a licensed pharmacist to prevent, identify, report, and resolve potential risks associated with medication. The pharmacist would communicate any irregularities to the facility's Director of Nursing, the physician, and the facility's medical director. The policy stated the pharmacist did not need to document a continuing irregularity in the report each month if the physician had documented a valid clinical rationale for rejecting the pharmacist's recommendation. The facility failed to ensure a GDR was attempted or the physician documented a rationale for the risks versus the benefits of continued use for R20's psychotropic medications. This placed R20 at risk for complications related to psychotropic medications and unnecessary medications. 32360 - The Electronic Medical Record (EMR) for R38 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition. R38 was independent will all activities of daily living (ADLs). R38 was continent of bowel and bladder. The MDS recorded R38 had no behaviors and received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antidepressant (a class of medications used to treat mood disorders), and a hypnotic (a class of medications used to induce sleep) medication during the observation period. R38's Care Plan, dated 02/07/24, initiated on 06/10/21, documented R38 received psychotropic (alters mood or thought) medication and directed staff to monitor for side effects. Staff completed the Abnormal Involuntary Movement Scale (AIMS-a rating scale that was designed to measure the involuntary movements that developed as a side effect from antipsychotic medications) assessment, consulted with the pharmacy to consider dosage reduction when clinically appropriate and monitored for behaviors. The Physician's Order, dated 06/15/21 directed staff to administer quetiapine fumarate (antipsychotic), 25 milligrams (mg), by mouth, twice per day, for dementia without behavioral disturbance. R38's EMR lacked evidence of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the ongoing quetiapine use. On 02/28/24 at 08:17 AM, observation revealed R38 wore a stocking cap and a red sweatshirt which had multiple food stains on it. On 02/28/24 at 03:30 PM, Administrative Nurse D stated R38 did not have an appropriate indication for the use of quetiapine. The facility's Use of Psychotropic Drugs policy, dated 01/01/20, documented that residents are not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and the medication was beneficial to the residents as demonstrated by monitoring and documentation of the resident response to the medication. Non-pharmacological interventions that have been attempted and the target symptoms for monitoring shall be included in the documentation. The facility failed to ensure an appropriate indication or the required physician documentation for the continued use of R38's antupsychotic, placing the resident at risk for unnecessary side effects.

The facility had a census of 59 residents. The sample included 19 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 54 with dignity, when staff failed to cover his urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) urine collection bag with a privacy bag leaving the urine visible to other residents and guests in the facility. This placed the resident at risk for impaired dignity. Findings included: - R54's Electronic Medical Record (EMR) documented R54 had a diagnosis of urinary retention (lack of ability to urinate and empty the bladder). R54's Quarterly Minimum Data Set (MDS), dated [DATE], documented R54 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R54 was dependent on staff for toileting hygiene. R54 had an indwelling urinary catheter. R54's Care Plan, revised 01/18/24, documented R54 required partial, moderate assistance with toileting hygiene. The MDS documented R54 had an indwelling urinary catheter and instructed staff to provide good perineal (private area) care, anchor the catheter tubing to prevent injury, provide catheter care every shift and as needed (PRN), and monitor, record, and report to the physician if R54 had signs or symptoms of urinary tract infection (UTI-an infection in any part of the urinary system). On 02/27/24 at 11:10 AM, observation revealed R54 ambulated down the hall from his room to the dining room with his urinary catheter bag hanging on the right side of his walker without a privacy bag. R54 sat at the dining room table and ate lunch; R54's urine collection bag remained uncovered, with 12 other residents able to view it. On 02/28/24 at 03:28 PM, Administrative Nurse D stated she expected staff to make sure R54's urinary catheter bag was in a privacy bag. The facility's Promoting/Maintaining Resident Dignity Policy, revised November 2017, documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The facility staff failed to treat R54 with dignity when staff failed to cover his urinary catheter bag with a privacy cover. This placed R54 at risk for impaired dignity.

The facility had a census of 59 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to provide a safe environment in Resident (R) 37's room, when staff placed crinkled duct tape between the floor carpet seams. This placed the resident at risk of preventable accidents and an unhomelike environment. Findings included: - On 02/27/24 at 09:30 AM, observation revealed in R37's room between the carpet seam had gray duct tape running from the bed to the south wall. Observation revealed that the middle of the duct tape was crinkled up approximately one foot (ft). On 02/28/24 at 10:57 AM, Maintenance Staff (MS) U verified the above finding and stated the flooring needed to be replaced. He said he planned on getting a requisition to the administrator but had not got around to it yet. On 02/28/24 at 04:23 PM, Administrative Nurse D stated she was unaware of the issue with the duct tape on the carpet and said that she would look at it. On 02/29/24 at 09:56 AM, Administrative Nurse D stated the flooring needed to be replaced and agreed the issue with the duct tape could be a trip hazard. The facility's Resident Environmental Quality Policy, revised in November 2017, documented preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. The facility failed to provide a safe environment for R37 when staff placed duct tape between the seams of the carpeting in his room. This placed the resident at risk of preventable accidents and an unhomelike environment.

The facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 11 and R18 remained free of neglect and abuse. This deficient practice placed R11 and R18 at risk for injury and impaired physical and psychological well-being due to abuse, neglect, and/or mistreatment. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), dementia (progressive mental disorder characterized by failing memory, confusion), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), unsteadiness on feet, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and a need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R11 had intact cognition and no behavioral symptoms. R11 had a functional range of motion impairment of one side upper extremity, used a walker and a wheelchair, and required partial to moderate assistance with toileting, upper body dressing, and personal hygiene. The MDS further documented that R11 required substantial/maximal assistance with chair, bed, and toilet transfers. R11 had occasional incontinence of urine and was always continent of the bowel. The Functional Activities of Daily Living Care Area Assessment (CAA), dated 08/16/23, documented R11 had deconditioned and was at risk for further decline in activities of daily living (ADL), falls, contractures (abnormal permanent fixation of a joint or muscle), isolation, 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), and incontinence. R11's Care Plan, dated 02/14/24, documented R11 needed assistance with ADLs and directed staff to provide substantial maximal assistance with toileting hygiene and partial moderate assistance with upper body dressing and toilet transfers. The Resident/Family Concern/Grievance Form documented that the date of the concern was 01/16/24. The nature of concern documented R11 used the call light around 11:00 PM when she was in the bathroom without a shirt or pants on. She waited for assistance until almost midnight, then used her cell phone to call a family member to report her call light had not been answered. R11's family member reported they called the facility, but the call was not answered. The form documented Certified Nurse Aide (CNA) P was rude and being snotty and threw a shirt at R11 then left without helping the resident at all. The form further documented that Administrative Nurse D educated staff on 01/25/24 regarding answering the phones and staff attitude; CNA P would not assist R11, and another CNA would take care of R11. Staff were counseled. On 02/27/24 at 12:10 PM, observation revealed R11 ate lunch in her room while she sat in her recliner. On 02/28/24 at 09:13 AM, R11 reported she had been in the bathroom (unsure of the specific date) with the call light for approximately one hour when Certified Nurse Aide (CNA) P had been very rude to her and threw a shirt at her and left the room without assisting the resident. R11 stated she needed assistance due to shoulder pain. R11 stated she was not fearful of staff. On 02/28/24 at 01:44 PM Administrative Nurse D stated she received the grievance on 01/16/24 and discussed the incident with the Interdisciplinary Team (IDT) but had not interviewed R11. Administrative Nurse D reported she instructed CNA P not to work with R11 due to their personality differences. Administrative Nurse D verified they did not get statements from the staff working the night of the incident or do any further investigation of the incident Administrative Staff A and Administrative Nurse D verified it was an incomplete investigation and confirmed the allegation listed on the concern form was not reported to the State Agency. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 11/06/17, documented to ensure the proper management of conduct between residents and the staff to facilitate the resident's right to be free from abuse, neglect, and misappropriation of resident's property, and to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the resident's right to be free from abuse, neglect, and misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility failed to ensure R11 remained free from neglect and abuse when staff failed to provide the necessary care and services required by R11 and threw a shirt at her. This placed the resident at risk for continued neglect and abuse. 32360 - The Electronic Medical Record (EMR) for R18 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), edema (swelling), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (the kidneys have mild to moderate damage). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition. R18 required extensive assistance from two staff for transfers, toileting, dressing, personal hygiene, and bed mobility. R18 had lower functional impairment on both sides, unsteady balance, and did not ambulate. The Quarterly MDS, dated [DATE], documented R18 had severely impaired cognition. R18 was dependent on staff for transfers, toileting, dressing, and personal hygiene, and required substantial/maximum assistance for bed mobility. The MDS further documented that R18 had upper and lower functional impairment on both sides and did not ambulate. R18's Care Plan, dated 02/21/24, initiated on 04/15/21, directed staff to use a Hoyer (total body mechanical lift) and two staff for transfers. The plan directed R18 had fragile skin, staff were to educate her caregivers on causative factors and measures to prevent skin injury. The Weekly Wound Observation Tool, dated 01/28/24, documented a raised area of discoloration across the entire width of R18's chest including over her right breast, which measured approximately seven centimeters (cm) x 7.5 cm. The Nurse's Note, dated 01/29/24 at 04:36 PM, documented a large, raised hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) was noted to R18's right chest area approximately 10 cm in diameter. There was some greenish-yellow resolution to the bruising around the hematoma. R18 also had dark purple bruising to the underside of her right breast extending into her sternum (the long flat bone located in the central part of the chest) and downward towards her diaphragm (the muscle that separates the chest cavity from the abdomen) across the whole girth of R18. The note further documented the injury was possibly consistent with a gait belt (an assistive device used to help safely transfer someone from a sitting to a standing position) used during transfers, and staff were educated on the proper transfer technique for this resident to prevent injury. R18's EMR lacked documentation that an investigation was completed related to the bruising's origin, or to the use of a gait belt on a resident who required a Hoyer lift. The Nurse's Note, dated 01/30/24 at 09:50 AM, documented R18 had bruising to her chest under her breast, likely from the use of a gait belt. Staff were educated on proper technique and would monitor the bruise until healed and update the physician as needed. The Weekly Skin Check, dated 02/07/24, documented the bruising to R18's chest and upper abdomen continued to show improvement. R18's EMR lacked documentation that an investigation was completed related to the bruising's origin, or to the use of a gait belt on a resident who required a Hoyer lift. On 02/28/24 at 08:47 AM, observation revealed R18 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline). Certified Nurse Aide (CNA) M lifted R18's sweatshirt to display where the bruising was and that the bruising had resolved. CNA M stated she was unsure how R18 received the large bruise but said she thought someone transferred R18 with a gait belt. CNA M and CNA N placed a blue sling under the resident, attached it to the Hoyer lift, raised R18 into the air, and transferred R18 to her bed. Further observation revealed CNA M rolled R18 to her right side to remove the sling. CNA M told R18 she was going to check to see if the resident's incontinence brief was wet. CNA M pulled down R18's pants. Continued observation revealed a dark purple bruise on R18's right hand, multiple bruised areas of varying colors on her left leg, and a large wet area on the back of her sweatshirt from ointment that had been administered to a reddened area on her back. CNA M and CNA M placed a dry brief on R18, and covered her up, but did not change the wet, soiled shirt. On 02/28/24 at 9:33 AM, Licensed Nurse (LN) G stated that the staff thought the bruised area was from an improper transfer with a gait belt. LN G said R18 always required a lift transfer and LN G did not know about the bruises on R18's leg and hand. On 02/28/24 at 03:30 PM, Administrative Nurse D stated the facility did not complete an investigation, nor report to the State Agency, about the large, bruised area on R18. Administrative Nurse D said she thought that an agency staff transferred R18 with a gait belt instead of the Hoyer. Administrative Nurse D also stated she was unable to find documentation that education regarding safe, appropriate transfers was provided to the staff. The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy, undated, documented the facility should develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and establish policies and procedures to investigate any such allegations, Training must include education on those activities which constitute abuse and neglect, procedures for reporting relevant incidents, dementia management, and resident abuse prevention. The facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. The facility must report the results of all investigations to the administrator or his or her designated representative and other officials in accordance with State law, within five working days of the incident. The facility failed to ensure R18 remained free from abuse and/or neglect when staff failed to provide the necessary care and services during a transfer which caused injury. This placed the resident at risk for further injury and unidentified abuse and neglect.

The facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to report to the State Agency (SA) allegations of verbal and physical abuse and neglect for Resident (R) 11 and R18. This placed the residents at risk for ongoing abuse, neglect and mistreatment. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), dementia (progressive mental disorder characterized by failing memory, confusion), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), unsteadiness on feet, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and a need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R11 had intact cognition and no behavioral symptoms. R11 had a functional range of motion impairment of one side upper extremity, used a walker and a wheelchair, and required partial to moderate assistance with toileting, upper body dressing, and personal hygiene. The MDS further documented that R11 required substantial/maximal assistance with chair, bed, and toilet transfers. R11 had occasional incontinence of urine and was always continent of the bowel. The Functional Activities of Daily Living Care Area Assessment (CAA), dated 08/16/23, documented R11 had deconditioned and was at risk for further decline in activities of daily living (ADL), falls, contractures (abnormal permanent fixation of a joint or muscle), isolation, 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), and incontinence. R11's Care Plan, dated 02/14/24, documented R11 needed assistance with ADLs and directed staff to provide substantial maximal assistance with toileting hygiene and partial moderate assistance with upper body dressing and toilet transfers. The Resident/Family Concern/Grievance Form documented that the date of the concern was 01/16/24. The nature of concern documented R11 used the call light around 11:00 PM when she was in the bathroom without a shirt or pants on. She waited for assistance until almost midnight, then used her cell phone to call a family member to report her call light had not been answered. R11's family member reported they called the facility, but the call was not answered. The form documented Certified Nurse Aide (CNA) P was rude and being snotty and threw a shirt at R11 then left without helping the resident at all. The form further documented that Administrative Nurse D educated staff on 01/25/24 regarding answering the phones and staff attitude; CNA P would not assist R11, and another CNA would take care of R11. Staff were counseled. On 02/27/24 at 12:10 PM, observation revealed R11 ate lunch in her room while she sat in her recliner. On 02/28/24 at 09:13 AM, R11 reported she had been in the bathroom (unsure of the specific date) with the call light for approximately one hour when Certified Nurse Aide (CNA) P had been very rude to her and threw a shirt at her and left the room without assisting the resident. R11 stated she needed assistance due to shoulder pain. R11 stated she was not fearful of staff. On 02/28/24 at 01:44 PM Administrative Nurse D stated she received the grievance on 01/16/24 and discussed the incident with the Interdisciplinary Team (IDT) but had not interviewed R11. Administrative Nurse D reported she instructed CNA P not to work with R11 due to their personality differences. Administrative Nurse D verified they did not get statements from the staff working the night of the incident or do any further investigation of the incident Administrative Staff A and Administrative Nurse D verified it was an incomplete investigation and confirmed the allegation listed on the concern form was not reported to the State Agency. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 11/06/17, documented to ensure the proper management of conduct between residents and the staff to facilitate the resident's right to be free from abuse, neglect, and misappropriation of resident's property, and to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the resident's right to be free from abuse, neglect, and misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility failed to report R11's allegations of abuse, neglect and mistreatment to the SA as required. This placed the residents at risk for ongoing abuse, neglect and mistreatment. 32360 - The Electronic Medical Record (EMR) for R18 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), edema (swelling), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (the kidneys have mild to moderate damage). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition. R18 required extensive assistance from two staff for transfers, toileting, dressing, personal hygiene, and bed mobility. R18 had lower functional impairment on both sides, unsteady balance, and did not ambulate. The Quarterly MDS, dated [DATE], documented R18 had severely impaired cognition. R18 was dependent on staff for transfers, toileting, dressing, and personal hygiene, and required substantial/maximum assistance for bed mobility. The MDS further documented that R18 had upper and lower functional impairment on both sides and did not ambulate. R18's Care Plan, dated 02/21/24, initiated on 04/15/21, directed staff to use a Hoyer (total body mechanical lift) and two staff for transfers. The plan directed R18 had fragile skin, staff were to educate her caregivers on causative factors and measures to prevent skin injury. The Weekly Wound Observation Tool, dated 01/28/24, documented a raised area of discoloration across the entire width of R18's chest including over her right breast, which measured approximately seven centimeters (cm) x 7.5 cm. The Nurse's Note, dated 01/29/24 at 04:36 PM, documented a large, raised hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) was noted to R18's right chest area approximately 10 cm in diameter. There was some greenish-yellow resolution to the bruising around the hematoma. R18 also had dark purple bruising to the underside of her right breast extending into her sternum (the long flat bone located in the central part of the chest) and downward towards her diaphragm (the muscle that separates the chest cavity from the abdomen) across the whole girth of R18. The note further documented the injury was possibly consistent with a gait belt (an assistive device used to help safely transfer someone from a sitting to a standing position) used during transfers, and staff were educated on the proper transfer technique for this resident to prevent injury. R18's EMR lacked documentation that an investigation was completed related to the bruising's origin, or to the use of a gait belt on a resident who required a Hoyer lift. The Nurse's Note, dated 01/30/24 at 09:50 AM, documented R18 had bruising to her chest under her breast, likely from the use of a gait belt. Staff were educated on proper technique and would monitor the bruise until healed and update the physician as needed. The Weekly Skin Check, dated 02/07/24, documented the bruising to R18's chest and upper abdomen continued to show improvement. R18's EMR lacked documentation that an investigation was completed related to the bruising's origin, or to the use of a gait belt on a resident who required a Hoyer lift. On 02/28/24 at 08:47 AM, observation revealed R18 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline). Certified Nurse Aide (CNA) M lifted R18's sweatshirt to display where the bruising was and that the bruising had resolved. CNA M stated she was unsure how R18 received the large bruise but said she thought someone transferred R18 with a gait belt. CNA M and CNA N placed a blue sling under the resident, attached it to the Hoyer lift, raised R18 into the air, and transferred R18 to her bed. Further observation revealed CNA M rolled R18 to her right side to remove the sling. CNA M told R18 she was going to check to see if the resident's incontinence brief was wet. CNA M pulled down R18's pants. Continued observation revealed a dark purple bruise on R18's right hand, multiple bruised areas of varying colors on her left leg, and a large wet area on the back of her sweatshirt from ointment that had been administered to a reddened area on her back. CNA M and CNA M placed a dry brief on R18, and covered her up, but did not change the wet, soiled shirt. On 02/28/24 at 9:33 AM, Licensed Nurse (LN) G stated that the staff thought the bruised area was from an improper transfer with a gait belt. LN G said R18 always required a lift transfer and LN G did not know about the bruises on R18's leg and hand. On 02/28/24 at 03:30 PM, Administrative Nurse D stated the facility did not complete an investigation, nor report to the State Agency, about the large, bruised area on R18. Administrative Nurse D said she thought that an agency staff transferred R18 with a gait belt instead of the Hoyer. Administrative Nurse D also stated she was unable to find documentation that education regarding safe, appropriate transfers was provided to the staff. The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy, undated, documented the facility should develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and establish policies and procedures to investigate any such allegations, Training must include education on those activities which constitute abuse and neglect, procedures for reporting relevant incidents, dementia management, and resident abuse prevention. The facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. The facility must report the results of all investigations to the administrator or his or her designated representative and other officials in accordance with State law, within five working days of the incident. The facility failed to identify an injury of unknown origin as an allegation of potential abuse or report to the SA as required. This placed the resident at risk for unidentified abuse or mistreatment.

The facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to fully investigate allegations of abuse, neglect and injuries of unknown origin for Resident (R) 11 and R18. This placed the residents at risk of ongoing abuse, neglect and mistreatment. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), dementia (progressive mental disorder characterized by failing memory, confusion), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), unsteadiness on feet, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and a need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R11 had intact cognition and no behavioral symptoms. R11 had a functional range of motion impairment of one side upper extremity, used a walker and a wheelchair, and required partial to moderate assistance with toileting, upper body dressing, and personal hygiene. The MDS further documented that R11 required substantial/maximal assistance with chair, bed, and toilet transfers. R11 had occasional incontinence of urine and was always continent of the bowel. The Functional Activities of Daily Living Care Area Assessment (CAA), dated 08/16/23, documented R11 had deconditioned and was at risk for further decline in activities of daily living (ADL), falls, contractures (abnormal permanent fixation of a joint or muscle), isolation, 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), and incontinence. R11's Care Plan, dated 02/14/24, documented R11 needed assistance with ADLs and directed staff to provide substantial maximal assistance with toileting hygiene and partial moderate assistance with upper body dressing and toilet transfers. The Resident/Family Concern/Grievance Form documented that the date of the concern was 01/16/24. The nature of concern documented R11 used the call light around 11:00 PM when she was in the bathroom without a shirt or pants on. She waited for assistance until almost midnight, then used her cell phone to call a family member to report her call light had not been answered. R11's family member reported they called the facility, but the call was not answered. The form documented Certified Nurse Aide (CNA) P was rude and being snotty and threw a shirt at R11 then left without helping the resident at all. The form further documented that Administrative Nurse D educated staff on 01/25/24 regarding answering the phones and staff attitude; CNA P would not assist R11, and another CNA would take care of R11. Staff were counseled. On 02/27/24 at 12:10 PM, observation revealed R11 ate lunch in her room while she sat in her recliner. On 02/28/24 at 09:13 AM, R11 reported she had been in the bathroom (unsure of the specific date) with the call light for approximately one hour when Certified Nurse Aide (CNA) P had been very rude to her and threw a shirt at her and left the room without assisting the resident. R11 stated she needed assistance due to shoulder pain. R11 stated she was not fearful of staff. On 02/28/24 at 01:44 PM Administrative Nurse D stated she received the grievance on 01/16/24 and discussed the incident with the Interdisciplinary Team (IDT) but had not interviewed R11. Administrative Nurse D reported she instructed CNA P not to work with R11 due to their personality differences. Administrative Nurse D verified they did not get statements from the staff working the night of the incident or do any further investigation of the incident Administrative Staff A and Administrative Nurse D verified it was an incomplete investigation and confirmed the allegation listed on the concern form was not reported to the State Agency. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 11/06/17, documented to ensure the proper management of conduct between residents and the staff to facilitate the resident's right to be free from abuse, neglect, and misappropriation of resident's property, and to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the resident's right to be free from abuse, neglect, and misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility failed to investigate R11's allegation of abuse and neglect which placed the resident at risk of ongoing abuse and neglect. 32360 - The Electronic Medical Record (EMR) for R18 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), edema (swelling), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (the kidneys have mild to moderate damage). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition. R18 required extensive assistance from two staff for transfers, toileting, dressing, personal hygiene, and bed mobility. R18 had lower functional impairment on both sides, unsteady balance, and did not ambulate. The Quarterly MDS, dated [DATE], documented R18 had severely impaired cognition. R18 was dependent on staff for transfers, toileting, dressing, and personal hygiene, and required substantial/maximum assistance for bed mobility. The MDS further documented that R18 had upper and lower functional impairment on both sides and did not ambulate. R18's Care Plan, dated 02/21/24, initiated on 04/15/21, directed staff to use a Hoyer (total body mechanical lift) and two staff for transfers. The plan directed R18 had fragile skin, staff were to educate her caregivers on causative factors and measures to prevent skin injury. The Weekly Wound Observation Tool, dated 01/28/24, documented a raised area of discoloration across the entire width of R18's chest including over her right breast, which measured approximately seven centimeters (cm) x 7.5 cm. The Nurse's Note, dated 01/29/24 at 04:36 PM, documented a large, raised hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) was noted to R18's right chest area approximately 10 cm in diameter. There was some greenish-yellow resolution to the bruising around the hematoma. R18 also had dark purple bruising to the underside of her right breast extending into her sternum (the long flat bone located in the central part of the chest) and downward towards her diaphragm (the muscle that separates the chest cavity from the abdomen) across the whole girth of R18. The note further documented the injury was possibly consistent with a gait belt (an assistive device used to help safely transfer someone from a sitting to a standing position) used during transfers, and staff were educated on the proper transfer technique for this resident to prevent injury. R18's EMR lacked documentation that an investigation was completed related to the bruising's origin, or to the use of a gait belt on a resident who required a Hoyer lift. The Nurse's Note, dated 01/30/24 at 09:50 AM, documented R18 had bruising to her chest under her breast, likely from the use of a gait belt. Staff were educated on proper technique and would monitor the bruise until healed and update the physician as needed. The Weekly Skin Check, dated 02/07/24, documented the bruising to R18's chest and upper abdomen continued to show improvement. R18's EMR lacked documentation that an investigation was completed related to the bruising's origin, or to the use of a gait belt on a resident who required a Hoyer lift. On 02/28/24 at 08:47 AM, observation revealed R18 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline). Certified Nurse Aide (CNA) M lifted R18's sweatshirt to display where the bruising was and that the bruising had resolved. CNA M stated she was unsure how R18 received the large bruise but said she thought someone transferred R18 with a gait belt. CNA M and CNA N placed a blue sling under the resident, attached it to the Hoyer lift, raised R18 into the air, and transferred R18 to her bed. Further observation revealed CNA M rolled R18 to her right side to remove the sling. CNA M told R18 she was going to check to see if the resident's incontinence brief was wet. CNA M pulled down R18's pants. Continued observation revealed a dark purple bruise on R18's right hand, multiple bruised areas of varying colors on her left leg, and a large wet area on the back of her sweatshirt from ointment that had been administered to a reddened area on her back. CNA M and CNA M placed a dry brief on R18, and covered her up, but did not change the wet, soiled shirt. On 02/28/24 at 9:33 AM, Licensed Nurse (LN) G stated that the staff thought the bruised area was from an improper transfer with a gait belt. LN G said R18 always required a lift transfer and LN G did not know about the bruises on R18's leg and hand. On 02/28/24 at 03:30 PM, Administrative Nurse D stated the facility did not complete an investigation, nor report to the State Agency, about the large, bruised area on R18. Administrative Nurse D said she thought that an agency staff transferred R18 with a gait belt instead of the Hoyer. Administrative Nurse D also stated she was unable to find documentation that education regarding safe, appropriate transfers was provided to the staff. The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy, undated, documented the facility should develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and establish policies and procedures to investigate any such allegations, Training must include education on those activities which constitute abuse and neglect, procedures for reporting relevant incidents, dementia management, and resident abuse prevention. The facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. The facility must report the results of all investigations to the administrator or his or her designated representative and other officials in accordance with State law, within five working days of the incident. The facility failed to investigate the origin of a large bruise on R18's chest, in order to rule out abuse and/or neglect. This placed the resident at risk for unidentified abuse, neglect or mistreatment.

The facility identified a census of 59 residents with 24 residents who elected a full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest) status. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures as indicated by her full code status. At 11:08 AM on [DATE], staff entered R1's room and identified R1 was not breathing. Staff applied oxygen, but noted R1 had no vital signs at that time. The Registered Nurse on duty, LN G, called the emergency room (ER) at the local hospital and spoke with a physician who LN G referred to as R1's primary care physician (PCP). LN G reported she received instruction from the physician, Consultant GG, not to initiate any resuscitative measures as Consultant GG was coming to the facility to assess R1. Facility staff failed to provide CPR to R1, who had a full code status, and failed to activate Emergency Medical Services upon identification of the emergent situation. R1 died in the facility. The deficient practice placed R1, and all residents with a full code status, in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Wernicke's encephalopathy (degenerative brain disorder caused by the lack of vitamin B1), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated R1 was unable to complete the interview, however the MDS documented R1's short-term and long-term memory were intact. The MDS lacked any documentation regarding R1's activities of daily living (ADL) and the assistance and support R1 required. The Cognitive Loss Care Area Assessment (CAA), dated [DATE], documented R1 had a BIMS score of three, which indicated severe cognitive impairment. The CAA documented R1 required assistance with ADLs. The CAA documented R1 was at risk for isolation, depression, and further cognitive decline. The Mood State CAA, dated [DATE], documented R1's depression score increased in total severity and R1 was at risk for further decline in mood, weight loss, and agitation. R1's Care Plan, dated [DATE], documented R1 was a full code, wanted full resuscitation (CPR), and R1's wishes would be honored. R1's Care Plan documented R1 required one to two staff assistance for all of her ADLs and was dependent on staff for meeting her emotional, intellectual, physical, and social needs. The Physician's Orders, tab of R1's EMR documented an order, dated [DATE], noting R1 was a full code. The Notes tab of R1's EMR revealed the following: The Nurse's Note dated [DATE] at 10:03 AM documented upon initial assessment that morning at the beginning of the shift, R1 rested in bed without signs or symptoms of distress or discomfort. R1 took fluids well but made no effort to assist with holding the cup. R1 drank a large amount of fluids with staff assistance. A short time later, staff provided morning cares. Staff transferred R1 to the recliner, which she was opposed to, but staff encouraged her and explained that sitting upright would help to prevent drainage and coughing. Staff observed R1 numerous times and R1 displayed no respiratory distress or cough. The note further documented that up to the time of the note, R1 rested without signs and symptoms of discomfort in the recliner. R1 drank fluids well but had poor food intake. The Nurse's Note, dated [DATE], documented staff entered R1's room to provide cares at approximately 11:08 AM and noted R1 was not breathing. Staff immediately alerted other staff members and placed oxygen on R1. Staff assessed R1 for vital signs and brought the crash cart into R1's room. Staff observed mottling (blotchy, red-purplish marbling of the skin near the end of life caused by slow blood circulation) to R1's bilateral (both sides) lower extremities and upward into her abdomen. R1's hands were cool and her face was pale. LN G was present in the room and called the ER and spoke to an ER nurse who informed LN G the physician, Consultant GG, was present at the desk. After notification, Consultant GG ordered staff not to initiate any procedures as she planned to go to the facility. Consultant GG arrived at the facility three to five minutes later and directed staff not to initiate CPR. The Authorization to Release and Embalm, dated [DATE], documented R1 expired on [DATE] at 11:00 AM. In Certified Nurse Aide (CNA) M's undated Witness Statement, CNA M noted at approximately 11:00 AM she and two nurses ran into R1's room. Upon entering, staff presumed R1 dead. She stated LN G commented This is a blessing and expressed that R1 was a full code but CPR was not performed because R1 constantly expressed that she was in a lot of pain and LN G stated again that it was a blessing. Staff brought the crash carts into R1's room, but nothing was done. The statement documented LN G told everyone to make it look like they did something. CNA M stated after about ten minutes of being in R1's room, LN G checked for heart sounds and stated R1 had no heart sounds and went on the say she already knew that. CNA M documented LN G then tossed a mouth-to-mouth resuscitation pack to LN H and jokingly told LN H she could start CPR and mouth-to-mouth resuscitation. LN G took the pack back and stated she was just joking. CNA M s documented LN H stated LN G was the one driving the train. While CNA M performed postmortem (after death) care with another CNA, LN H came back into the room. CNA M documented she told LN H that R1's body was still warm, and CPR should have been done since R1 was a full code. CNA M documented LN H responded that she thought that herself, but Consultant GG said to stop everything they were doing. CNA M documented she told LN H that they did not do anything to begin with. In CNA N's Witness Statement dated [DATE], CNA N documented she came into work on the North Hall and received report that R1 was coughing and had a slight fever throughout the night. She stated LN H asked her and another CNA to get R1 into her recliner. About thirty minutes later, she and the other CNA performed morning cares for R1, dressed her, and got her up with the full lift. CNA N documented R1 complained of shortness of breath and kept saying help me. Once R1 was in the recliner, she did not sound as raspy and harsh and she no longer complained of shortness of breath, but she breathed heavily. CNA N documented she gave R1 the call light and asked if R1 felt better, and R1 stated she did feel a little bit better. After leaving R1's room, CNA N reported R1's breathing situation to LN H. After everyone was up for lunch, CNA N asked LN H if it would be okay to lay R1 down before lunch. LN H said yes and instructed CNA N to elevate R1's head a bit more. CNA N documented she and another CNA entered R1's room and noticed R1 was white and purple. CNA N checked R1's pulse at her neck and wrist and there was no pulse. CNA N notified LN H that R1 was not breathing. CNA N and LN H reviewed the code list by the nurse's station and identified R1 was a full code. LN H ran to R1's room while CNA N retrieved the crash cart. CNA N documented she took the crash cart to R1's room and LN G was with her. She stated LN G put the oxygen mask on R1 and said she needed the Ambu-bag (handheld tool that is used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths). CNA N retrieved the South hall's crash cart. and returned to R1's room accompanied by CNA O. CNA M documented LN G was on the phone when she entered the room. LN G looked on the South crash cart for an Ambu-bag while LN H held the oxygen mask on R1. LN G stated the facility did not have an Ambu-bag and said the doctor said to stop, they were done. CNA N stated she walked out of R1's room and did not return. In CNA O's Witness Statement dated [DATE], CNA O documented she and CNA N ran to R1's room with the crash cart. LN H had the breathing mask on R1, and LN G was on the phone with the doctor. CNA O documented when LN G got off the phone, she directed staff not to start compressions on R1 as the doctor was on the way. LN H and LN G took the oxygen mask off R1. CNA O documented the doctor showed up and CNA O went back to the South hall. LN H's Witness Statement dated [DATE], documented staff entered R1's room at approximately 11:08 AM to provide cares and noted R1 was not breathing. CNA N immediately alerted other staff members, who went to R1's room. Staff started R1 on oxygen and checked R1 for vital signs. LN H documented she was unable to obtain a pulse or blood pressure reading for R1. Staff brought the crash cart to the room. LN H documented R1 had mottling to her bilateral lower extremities and upward into her abdomen. R1's hands were cool, and her face was pale and white. LN H documented LN G was present and called the ER and spoke with the ER nurse. The ER nurse told LN G that the doctor was right next to her, and the ER nurse relayed the information to the doctor. LN H documented that the doctor directed LN G not to start resuscitative measures and the doctor was coming over to the facility. LN H documented Consultant GG arrived to R1's room right away and directed staff not to initiate anything. LN G's Witness Statement, dated [DATE], documented LN H called the phone at the South nurse's desk at approximately 11:08 AM and asked LN G to come quick. LN G documented she ran down the hall and observed CNA N pushing the crash cart down to the north hall. LN G documented she arrived in R1's room and saw R1 in the recliner. CNA N was sent after the South crash cart due to the fact the North crash cart had inadequate equipment. LN G documented she called the ER while LN H placed oxygen on R1. LN G documented the call to the ER was made from her personal cell phone at 11:09AM. LN G documented R1 was a blue dusky color and had absent pulse and respirations; R1 had mottling from her feet to her upper chest, and was cool to touch. LN G spoke to the ER nurse and told her that R1 was found with no pulse, dusky color, and cool skin with mottling from feet to the upper abdomen. LN G told the ER nurse she was not sure how long R1 had been deceased . LN G documented the ER nurse sat directly next to R1's primary care physician (PCP) and further documented staff were told not to start anything and R1's PCP would be right over. LN G documented she was uncertain of the exact time the physician arrived at the facility, but it was fairly directly after the phone call. LN G documented she made a sarcastic comment to LN H that LN H could start mouth to mouth because of the lack of equipment on the crash cart. LN G stated neither crash cart had an Ambu- bag or suction set up. LN G documented Consultant GG entered the room and listened to R1 with her stethoscope then pronounced R1 dead. On [DATE] at 09:30 AM, LN H stated staff had not performed CPR on R1 because the physician said not to. LN H stated that CNA M was very upset about not performing CPR on R1 and called the police. LN H stated that she received education about performing CPR on residents with full code status immediately if found without pulse or respirations. On [DATE] at 10:15 AM, CNA M stated that she was shocked when R1 was found without a pulse and respirations and the staff did not perform CPR. CNA M stated R1 still had quality of life and the staff owed it to her to honor her wishes to have CPR performed to try to save her life. CNA M stated that she voiced her concerns to LN H and LN H stated she agreed that CPR should have been performed on R1. CNA M stated she called the police to report the lack of action and the police came to the facility and took her statement. On [DATE] at 10:45 AM, Consultant GG stated that she was not R1's primary care physician. Consultant GG stated she was the on-call coroner (an official who investigates violent, sudden, or suspicious deaths) on [DATE]. Consultant GG stated she was sitting in the emergency room when LN G called and spoke to the ER nurse about the situation with R1. Consultant GG stated that she never told the facility not to start CPR or to stop anything that they had already initiated. Consultant GG stated she told staff she would be over to the facility to pronounce R1's death. Consultant GG stated that she recorded 11:00 AM as the time of death. On [DATE] at 12:30 PM, Administrative Nurse D stated CPR should have been initiated on R1 immediately by the staff on [DATE] when they identified R1 was pulseless and without respiration while other staff called 911, R1's primary care physician, and R1's family. The facility's Cardiopulmonary Resuscitation Policy, dated [DATE], documented it is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). The facility will follow current AHA guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to arrival of the emergency medical services; and in accordance with the residents advanced directives; or in the absence of advanced directives or a DNR order; and if the resident does not show obvious signs of clinical death (e.g., rigor mortis [recognizable signs of death, characterized by stiffening of the limbs], dependent lividity [gravitational pooling of blood to lower dependent areas resulting in a red/purple coloration], decapitation [removal of the head], transection [cut in half], or decomposition [decay of the body]). The facility staff failed to provide CPR to R1, who had a full code status, and failed to activate Emergency Medical Services upon identifications of the emergent situation. R1 died in the facility. The deficient practice placed R1, and all residents with a full code status, in immediate jeopardy. The facility implemented the following corrective actions in the approved immediacy removal plan: 1. Reviewed policies and procedures related to code status. 2. 100% Audit of code status completed in the facility [DATE]. 3. Staff were re-educated on facility policies by 10:00 PM on [DATE] by the Director of Nursing or designee regarding the following: CPR (including immediate initiation when appropriate) and Communication of Code Status. 4. Any staff member that did not attend training on [DATE] was not permitted to work until training was complete. 5. A Quality Assurance and Performance Improvement (QAPI) meeting in response to the immediacy was conducted which included the Medical Director. On [DATE], the above corrective actions were verified by an onsite inspection. After removal of the immediacy, the deficient practice remained at the scope and severity of a G.

The facility identified a census of 62 residents with three residents reviewed for abuse, neglect, and exploitation. The facility failed to provide adequate supervision and failed to implement interventions to prevent an incident of resident to resident abuse from occurring when Resident (R) 2 struck R1 in the face. On 04/24/23 at approximately 12:00 PM, R2 was exiting the dining room and stopped at a table and touched R1 on the shoulder. R2 asked R1 how he was doing. R1 said cursed, and commanded R2 not to touch him. R2 drew his hand back and hit R1 on the right side of the face with enough force to shift R1's body in his wheelchair. R1 and R2 were separated immediately afterwards. Staff escorted R2 back to his room. Staff escorted R1 to his room, assessed for injuries and obtained vital signs. R1 had a reddened area on the right side of his face that was painful; staff applied ice as R1 would allow. The facility did not notify R1's Durable Power of Attorney (DPOA) about the altercation with injury. At approximately 02:30 PM, R1's DPOA came to visit him. R1 was sleeping in bed and R1's DPOA shook his leg to wake him up. When R1 woke up, he placed his hands over his head and shrunk back away from his DPOA in fear. As a result of the resident to resident abuse, R1 had an abrasion on his face, discoloration around his eye and on his face, as well as residual fear evidenced by demonstration of protecting his head and face and recoiling from physical contact from his DPOA. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Wernicke's encephalopathy (a degenerative brain disorder), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1's Brief Interview for Mental Status was unable to be completed and R1 had short-term and long-term memory problems. The MDS documented R1 required extensive assistance of two staff for all Activities of Daily Living (ADL's) except for eating. The MDS further documented R1 had one to three days during the look back period of verbal aggression and rejection of care. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/16/23, documented R1 had a diagnosis of Alzheimer's Disease, an altered mood state, and required extensive assistance with his daily cares. The Behavior Care Plan, dated 04/12/23, documented R1 had the potential to be verbally aggressive related to his diagnosis of Wernicke's encephalopathy and directed staff to intervene if R1 became agitated, guide R1 away from the source of distress, engage R1 calmly in conversation, and if R1's response was aggressive, walk away calmly and approach R1 at a later time. The Psychosocial Well-Being Care Plan, dated 04/30/23, documented R1 had ineffective coping and did not like to be touched by other residents or people because R1 was physically and emotionally bullied by his peers as a child. Encourage others to respect R1's boundaries. The Incident Note, dated 04/24/23 at 11:42 AM, documented R2 walked by R1 while leaving the dining room and R2 touched R1 on the shoulder and asked R1 how he was doing. R1 told R2 not to touch him and cursed at R2. A moment later R2 raised his right arm and slapped R1 hard across the right side of his face causing R1's body to shift in his wheelchair. R1 was assessed and his vital signs were obtained. A reddened area was noted to R1's right cheek and he had some pain. A neurological assessment was completed and showed no deficiencies. R1 visited with staff and other residents per his normal routine. An ice pack was provided to R1 which he was able to place to his own face but only tolerated the ice pack for a few minutes. R1 stayed in his wheelchair by the nurse's desk. The Witness Statement, dated 04/24/23 at approximately 11:30 AM, documented Certified Nurse's Aide (CNA) M heard R2 yelling and looked to see R2 yelling at R1 to quit using the Lord's name in [NAME]. R1 looked confused and CNA M never heard any profanity being used by R1. CNA M then saw R2 scream and bend down with his body. R2 then stood up and was behind R1 and hit R1 with his right fist. R2 then raised his cane in his left hand. CNA M approached R2 and took R2's arm and turned him away from R1 and yelled for help. The Witness Statement, dated 04/24/23, documented Speech Therapist GG was assisting another resident in the dining room with therapies. Speech Therapist GG heard CNA M yelling R2's name and saying no. Speech Therapist GG saw R2 standing behind R1 yelling at R1. CNA M was running towards R2. R2 raised his right arm and slapped R1 on the right side of his face extremely hard causing R1's body to shift completely to the left side of his wheelchair. R2 was led out of the dining room by multiple staff while R2 continued to yell. Speech Therapist GG did not hear R1 say anything to R2 to provoke him. Speech Therapist GG stated the resident she was performing therapy with said she did not feel safe in the dining room. The Communication with Family Note, dated 04/24/23 at 02:26 PM, documented R1's sister/DPOA stopped by to visit R1. At this time DPOA was unaware of the incident that had taken place in the dining room. The nurse visited with R1's DPOA about the incident in detail and what interventions were completed after the incident. The nurse apologized to R1's DPOA for not calling her right away as staff were tending to the incident and assessing R1 for any changes in condition, pain, or concerns following being slapped in the face. The DPOA was able to address the reason R1 reacted the way he did when he was touched by R2 as he had been bullied by his peers as a child due to his small stature. The Nurse's Note, dated 04/25/23 at 08:13 AM, documented R1 had a small, reddened area to his upper right cheek from the incident the day before. R1 did not recall the incident per his normal mentation. The Incident Report, dated 04/26/23, documented R2 walked by R1 when leaving the dining room and placed his hand on R1's shoulder and asked R1 how he was doing. R1 cursed at R2 and told R2 not to touch him. A moment later, R2 raised his right arm and slapped R1 hard across the right side of R1's face and causing R1's body to shift in his wheelchair. R2 was directed back to his room and placed on one on one supervision until the trigger was identified. The triggers for R2 were determined as rejection from others. R2 lacked understanding of boundaries and personal space and often greeted others by touching them on the shoulders while approaching them. R1 was assessed and vital signs were obtained. A reddened area to his right cheek with pain was noted. A neurological assessment was completed with no deficiencies noted. R1 visited with staff and other residents. An ice pack was provided to R1 which he can place to his face, but he only tolerated it for a few minutes. R1 stayed in his wheelchair by the nurse's desk for close to an hour visiting with others while the nurse kept visual contact with him. R1 then wanted to go to his room to lay down for a nap and staff took R1 to his room and laid him down. Further evaluation and follow-up was done with R1 and R2 and no obvious signs of concerns regarding the psychosocial well-being was evident at the time. R1 no longer retained memory of the recent events and R2 was aware of his actions and will continue to need monitoring of his behavior. A message was left with R2's geri-psych provider who oversaw R2's psychotropic ( used to alter mood or thought) medications to evaluate R2 for further treatment. Corrective actions taken were: R1 and R2 were separated immediately, R2 was placed on one-to-one supervision until trigger was identified, the primary care physicians and DPOA's were notified, care plan for both residents were updated, and R2's geri-psych provider was contacted, and new medication orders were received for R2. On 05/01/23 at 11:00 AM, observation revealed R1 laid in his bed covered up and turned to the wall. R1 woke up when this surveyor knocked on the door. R1 was confused and was unable to converse with this surveyor. There was no bruising or redness noted to the right side of R1's face. On 05/01/23 at 10:38 AM, R1's DPOA stated that she was upset with the facility because she had to find out about the incident in the dining room when she came to the facility at 02:30 PM on 04/24/23. R1's DPOA stated she went into R1's room and R1 was sleeping in his bed which is not abnormal for him. She stated she touched R1's leg to wake him up and R1 jerked up, covered his head with his hands, and shrank away from her like he was scared of her. She said R1 had the start of a black eye, a red abrasion to the right side of his face, and four finger-imprints on the right side of his face. R1 complained that his head hurt and he did not know if he had dreamt it but he thought someone had hit him. R1's DPOA stated the administrator and the director of nursing told her that if her brother had not been using the Lord's name in [NAME], then R2 would not have hit him. R1's DPOA stated her brother did not deserve to be hit by R2 regardless if he used the Lord's name in [NAME] or not. R1's DPOA was worried about the close proximity of R1 and R2's room as they are only three doors away and R2 was ambulatory. On 05/01/23 at 11:10 AM, CNA N stated R1 was not a problem in the dining room. R1 was able to eat independently. CNA N stated R1 occasionally would get verbally aggressive with cares but otherwise he was no problem. CNA stated that R2 had been having more and more outbursts in the dining room and had been throwing plates and glasses in the dining room and at staff. CNA N stated that R2 was not always easily redirectable and could be scary. On 05/01/23 at 10:30 AM, Administrative Nurse D stated that R2 had become more and more of a problem at the facility with more frequent outbursts. Administrative Nurse D stated R2 refused to take his psychiatric medications because he did not like how the medications made him feel. Administrative Nurse D stated that the facility had tried to find a more appropriate placement for R2 but has not had any success. Administrative Nurse D stated that after this incident she told R2 that he was going to have start taking his medications if he wanted to stay at the facility due to his hallucinations and paranoia. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2017, documented it is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' rights to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility failed to provide a safe, adequate, supervision and interventions to prevent an incident of resident to resident abuse when R2 struck R1 forcefully in the face resulting in discoloration, an abrasion as well as a psychosocial harm as evidenced by physical manifestations of fear.

The facility identified a census of 66 residents. Based on record review and interview, the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to detect and respond to changes in a resident's condition. On the evening of 10/10/22 at 07:52 PM Resident (R)1 had a blood pressure (BP) of 82/60 millimeters of Mercury (mmHg). R1's clinical record lacked evidence of further assessment and physician notification in response to the abnormally low BP. R1's clinical record lacked evidence licensed nursing staff assessed R1's BP from the abnormal low on 10/10/22 through the morning of 10/15/22. On 10/15/22 at 10:36 AM R1's BP was again abnormally low at 82/54 mmHg and R1's clinical record lacked evidence of physician notification and evidence nursing staff initiated any follow up assessment or actions related to the abnormal finding. During this timeframe, 10/14/22 through 10/16/22, R1 was noted with dizziness, nausea, and vomiting. On the afternoon of 10/16/22, approximately six days from the initial abnormal finding, LN H notified R1's physician of R1's condition which included nose bleeds, nausea and vomiting, and new bruising, but failed to report the abnormal blood pressures. Nursing staff did not reassess R1's blood pressure on 10/16/22 or 10/17/22. On 10/17/22, R1's physician assessed him and then sent R1 directly to the emergency department. R1 admitted to the hospital for dehydration. The licensed nursing staff failure to detect, thoroughly assess, and respond to changes in the resident's condition, placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of heart failure (a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve, which indicated moderately impaired cognition. The MDS further documented R1 required limited to extensive assistance of one staff to perform all activities of daily living (ADL) and a diagnosis of hypertension. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/02/22, documented staff were to monitor R1 for signs and symptoms of acute mental status changes to help treat the underlying condition. The Activities of Daily Living CAA, dated 10/02/22 documented staff were to assist R1 with ADL cares as needed, anticipating cares, so that care needs are effectively met. Therapy services were to be used as needed to help increase functional mobility. The Renal Failure Care Plan, dated 10/06/22, directed staff to monitor R1 for signs and symptoms of hypovolemia (abnormally low circulating blood volume). The High Blood Pressure Care Plan, dated 10/06/22, directed staff to monitor R1 for headache, visual changes, lethargy, irritability, and nausea and vomiting. The Admission Note, dated 09/26/22, documented R1 was admitted to the facility and had a sitting blood pressure of 131/83 mmHg (normal range for adults is 120/80) The Vital Signs, dated 09/29/22, documented R1's blood pressure was 113/76 mmHg. The Vital Signs, dated 10/07/22, documented R1's blood pressure was 110/61mmHg lying. The Vital Signs, dated 10/10/22, documented R1's blood pressure was 82/60 mmHg (lying down), taken by LN G. R1's clinical record lacked evidence of further assessment and/or physician notification in response to the abnormally low BP and lacked evidence the low BP was reported to R1's physician. The Nurse's Note, dated 10/11/22, documented R1 had complained of being lightheaded when standing/ambulating. The Vital Signs, dated 10/15/22, documented R1's blood pressure was 82/54 mmHg (lying), taken by LN G. R1's clinical record lacked evidence the staff reported the abnormal BP reading to the physician, and lacked evidence nursing staff initiated any follow up assessment or actions related to the abnormal finding. The Communication with Physician Note, dated 10/16/22, documented LN G contacted R1's primary care physician and left a message with his nurse reporting R1 with symptoms of nose bleeds, nausea and vomiting, and new bruising, but did not indicate the nurse reported the abnormal blood pressures. The EMR for R1 lacked evidence of blood pressures on 10/16/22 and 10/17/22. The hospital's History of Present Illness, dated 10/17/22, documented R1 was seen in the clinic that day with recurrent nausea and vomiting. R1 was clinically dry (dehydrated) and sent to the emergency room for intravenous (given directly into the bloodstream via a vein) fluids. R1's metabolic profile showed acute renal (kidney) insufficiency which was felt to be on the basis of dehydration. R1 admitted to the acute hospital for intravenous fluid resuscitation. On 11/17/22 at 10:30 AM, Consultant GG stated R1 had nausea and vomiting and dizziness for five days prior to his admission to the hospital on 10/17/22, and the facility failed to help R1. Consultant GG stated R1 voiced these complaints to her over the phone, prior to his admission to the hospital. On 11/17/22 at 11:30 AM, LN I stated skilled residents at the facility get assessments and vital signs performed by the nurse in charge, every shift. LN I stated if she had a resident that had a blood pressure 82/60 mmHg she would recheck the blood pressure and notify the physician, or the emergency room if the blood pressure was still low, and assess the resident for symptoms. On 11/17/22 at 03:00 PM, LN G stated R1 had dizziness and nausea and vomiting. LN G stated R1 did not trust himself to go to the bathroom by himself because he felt unsafe, and he was using his call light to ask for assistance when he needed to get up in his room. LN G stated she had not called R1's primary physician regarding the low blood pressures she had documented because the facility did not have blood pressure parameters to call the physicians. LN G stated looking back she should have used her critical thinking skills and called R1's physician regarding the low blood pressures. On 11/17/22 at 03:30 PM, Administrative Nurse D verified R1, as a skilled resident in the facility, should have had his vital signs taken twice a shift with assessments, and said the nurse who documented the low blood pressures should have re-assessed R1 and contacted R1's primary care physician. The facility's Notification of Changes Policy, dated 02/01/20, documented the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include significant change in resident's physical, mental, or psychosocial condition such as deterioration of health, mental or psychosocial status that may include life-threatening conditions or clinical complications. The facility's undated Vital Signs Policy, documented vital signs are indicators of health status, including temperature, pulse, blood pressure, and respiratory rate. Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing, and interpreting routine vital signs, and notifying the physician of abnormal findings. Vital signs shall be performed at least daily for resident's receiving skilled services. The facility failed to ensure licensed nursing staff possessed the skills, and knowledge necessary to detect and respond to changes in a resident's condition. Staff failed to detect, thoroughly assess, and respond to changes in the resident's condition which placed R1 in Immediate Jeopardy. On 11/18/22 the facility removed the Immediate Jeopardy by completing the following actions: 1. All nursing staff received education on changes of conditions, physician notification of changes and vital sign parameters. 2. All residents were reviewed for irregularities in condition or vital signs. 3. The incident was reviewed was reviewed by the facility's Quality Assurance and Performance Improvement team. The deficiency remained at a scope and severity of a D after implementation of the corrective actions.

The facility had a census of 58 residents. The sample included five residents, with three reviewed for wandering and elopement. Based on observation, record review, and interview, the facility failed to ensure a safe and hazard free environment for one of three sampled residents, Resident (R) 1. Cognitively impaired, R1 eloped from the facility through unlocked/unalarmed fire doors on the South hall, entered the unoccupied West hall, opened the West hall exit door, which sounded an alarm in an area that could not be heard by staff, then exited through a door that lead to an area outside of the facility, without staff supervision or knowledge. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Quarterly Minimum Data Set, (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status, (BIMS) score of six, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, limited assistance of one staff for walking in her room and corridor, and no wandering behavior. R1's Cognitive Loss Care Area Assessment, (CAA), dated 06/03/21, documented the resident had a BIMS score of six, a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and mental illness, and was not always able to make her needs known to staff. R1's Elopement Care Plan, dated 06/03/21, directed staff to encourage independence while in the building, but ensure supervision while outside, observe for sign and symptoms of acute illness which may enhance confusion, and provide a picture and description of the resident in the elopement book. The care plan further directed staff to re-direct the resident when she wandered around doors and exits and visualize her whereabouts frequently. R1's Wandering Risk Assessments, dated 05/27/21 and 08/27/21, documented a score of 10, indicating at risk for wandering and elopement. The Nurse's Note, dated 06/27/21 at 09:45 PM, documented exit seeking behavior at 06:55 PM and 07:27 PM through the East door of the North hall. The note documented the alarm sounded and the resident did not go outside the facility. The Nurse's Note, dated 08/27/21 at 02:49 PM, documented R1 had a history of wandering. The note documented R1 had a medical diagnosis of dementia/cognitive impairment and a diagnosis impacting gait/mobility or strength. The resident wandered in the facility with no exit seeking behaviors. The Nurse's Note, dated 09/07/21 at 05:30 PM, documented R1 wandered around the dining room while she visited with staff, asked where her mother was, and staff were able to redirect her. The note documented R1 wandered throughout the facility and into other residents' rooms with persistent confusion. The Nurse's Note, dated 09/08/21 at 07:00 PM, documented staff reported R1 was outside of the Assisted Living, walking East. Upon investigation the resident went through double doors on South Hall, which led to the West Wing. R1 walked up to the far West door that leads to the assisted living and held the door until it released causing an alarm to go off. She then walked out the outside door that separated the nursing facility from assisted living. Staff in the Assisted Living noticed someone walking outside and after a closer look noted the person to be R1. CMA R went outside to assist R1 to the North Wing entrance door, the resident was hesitant to go with her, but did comply. Nursing facility staff assisted R1 into the facility accompanied by CMA R. Staff completed a full skin assessment on R1, and obtained vital signs. All vital signs were within normal limits, no visible signs or symptoms of injury were noted, and resident denied any pain or discomfort. R1 actively looked for a way out. Staff placed R 1 on one on one supervision, notified administrative staff, and witness statements obtained. R1 remained on one on one until directed otherwise. On 09/08/21 the weather, according to wunderground.com, at the time of the elopement was daylight, 84 degrees Fahrenheit, 32% humidity, winds at 6 miles per hour, clear and no precipitation. Staff found R1 in a parking lot outside the assisted living, away from the main street. The parking lot is located on the northeast side of the assisted living/nursing facility. A busy street runs along the East side of the facility that has a convenience store, grocery store, and other businesses. The parking lot is flat and smooth with no holes or large cracks. There is a privacy fence along the north side of the parking lot. On 09/14/21 at 07:50 AM, observation revealed R1 ambulated without her walker from the South hall, through the front lobby, and into the dining room. Further observation revealed the resident did not approach the exit doors. On 09/13/21 at 04:40 PM, Certified Medication Aide (CMA) R stated she worked in the assisted living on 09/08/21. At approximately 06:00 PM, she noticed a woman outside by the assisted living porch. CMA R stated she recognized the woman as R1, so she called the facility as she went out the door to the resident. CMA R stated R1 was in the parking lot and she redirected R1 to the North door of the facility where three staff members were waiting for her. CMA R stated she did not hear any alarm sounding in the assisted living. On 09/13/21 at 04:40 PM, Licensed Nurse (LN) G stated the last time she saw R1 was when R1 wandered around the center area of the South hall on the evening of 09/08/21 at approximately 05:20 PM. LN G stated at approximately 06:15 PM on 09/08/21, a staff member on the North hall reported R1 was at the assisted living. LN G stated the doors that lead from the South hall into the West hall were not locked or alarmed, and there was no plan in place to ensure R1 and other residents would not go to the unoccupied West hall. LN G stated there were administrative offices on West hall, but after 05:00 PM, there was nobody over there. LN G stated she did not hear any door alarms. On 09/13/21 at 05:30 PM, LN H stated on 09/08/21 at approximately 06:15 PM, she was on the phone at the nurse's station in the assisted living and saw a woman outside by the porch. LN H stated she did not recognize the woman at first, but CMA R recognized that is was R1. CMA R went outside and redirected the resident back to the facility. LN H stated she did not hear the West door alarming. The alarm was meant for the skilled staff, so the assisted living staff would not be able to hear it. On 09/13/21 at 06:00 PM, LN I stated staff notified her that R1 eloped and was found outside of the assisted living. CMA R assisted R1 to the North door. LN I stated she assessed R1 and found no injuries, and all her vital signs were within normal limits. LN I stated the resident had a history of wandering and had tried to exit the facility a few times. LN I stated the doors on the South hall that lead to the West part of the facility were closed, but not locked or alarmed, and stated, I guess we never thought anyone would open them and go over to the West side. We didn't have a plan in place to monitor R1 for that.'' On 09/14/21 at 12:10 PM, Administrative Nurse D stated R1 wandered and had exit seeking behavior prior to the elopement. Administrative Nurse D stated staff shut the double doors that lead from the South hall to the West hall, but they were not locked or alarmed, and the facility did not have a system in place to monitor the doors or the West unoccupied hall. On 09/14/21 at 01:30 PM, Administrative Staff A stated it was not safe for R1 and other at-risk residents to have unlocked and unalarmed doors, which led to unoccupied areas of the facility. The facility's undated Elopement and Wandering Residents Policy documented the facility would ensure residents who exhibit wandering behavior, and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care and address the unique factors that contribute to wandering or elopement risk. The policy documented the facility was equipped with door locks and/or alarms to help avoid elopement, and alarms are not a replacement for necessary supervision. The facility would establish and utilize a systematic approach to monitoring and managing residents at risk or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risk, and implement interventions to reduce hazards and risks, monitor for effectiveness and modify interventions when necessary. The facility failed to adequately monitor and supervise cognitively impaired, R1 from potential accident hazards when she eloped from the building, though doors that lead to an unoccupied area of the facility, exited and activated the alarm (which staff could not hear) on another door, and then exited a door that lead outside to a parking lot unsupervised. This placed R1 at risk for potentially serious outcomes, harm, or injury. The facility implemented in-service education for all staff on 09/09/21, regarding residents at risk for wandering and elopement. This education included that staff are responsible to identify which residents are elopement risk, a wandering/elopement book at each nurse's station and the front desk and continue frequent monitoring of elopement risk residents. The education also included for staff to stay with a resident that is exit seeking and provide one on one interaction, redirect them to a safe area, and notify the nurse immediately. This deficit practice was identified as past non-compliance and corrected on 09/09/21.

The facility had a census of 69 residents, with nine residents selected for sample. Based on observation, interview, and record review, the facility failed to ensure one of nine residents the right to be free from neglect. Staff failed to provide care to Resident (R) 1, a resident with severe cognitive impairment who required extensive staff assistance with all activities of daily living, (ADLs), during a 5.25 hour time period. During that time period, the resident experienced urinary incontinence which soaked the incontinence brief and bed linens, experienced bowel incontinence which dried onto the skin of her buttocks and genital area, was not offered or assisted with breakfast, and experienced pain which caused her to cry out with each movement. Findings included: - R1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 07/10/19 Quarterly Minimum Data Set (MDS) identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of 00), and daily physical and verbal behaviors directed toward others. The assessment also identified the resident with the need for extensive assistance of two staff for bed mobility, transfers and toileting, and an inability to ambulate. The resident experienced total bowel and bladder incontinence and did not participate in a toileting program. R1 required staff assistance of one to eat. The resident weighed 136 pounds (lbs ). According to a staff assessment of R1's pain, the resident experienced pain 3-4 days during the 5 day observation period, as evidenced by non-verbal sounds and facial grimacing. R1 received routine pain medication. On 08/07/19 staff submitted a Discharge MDS reporting the resident's unplanned transfer to the hospital. An additional 08/16/19 Entry MDS reported the resident's return to the facility from the hospital . R1's undated care plan described the resident's need for assistance of two staff for most activities of daily living (ADLs), including transfers, bed mobility, dressing, and toileting. The care plan also noted R1's weight loss and need for a mechanical soft diet with fortified foods for breakfast and at bedtime. The care plan directed staff to reposition the resident at least every two hours and more often as needed or requested. The care plan also included a 06/13/19 intervention to offer and encourage toileting every four hours. The care plan lacked information related to R1's recent femur fracture, pain management related to the fracture, and/or continuous use of a long leg immobilizer upon the resident's return from the hospital on [DATE]. Progress Notes dated 08/07/19 at 06:30 PM described R1's fall from a recliner, complaints of pain to her right hip, and subsequent transfer via Emergency Medical Services (EMS) to the local hospital. A later Progress Note dated 08/07/19 at 09:12 PM described a report from the hospital that R1 experienced a [MEDICAL CONDITION] femur and was sent to a larger area hospital for surgical repair. Progress Notes dated 08/16/19 noted R1's return to the facility with an immobilizer placed on the right leg. According to the note, the resident's surgery consisted of intramedullary nailing ((placement of a rigid rod through the femur to stabilize a broken bone)) of the right femur. An 08/16/19 Progress Note at 02:14 PM described communication with the transferring hospital about the need for R1's use of a leg immobilizer until a follow up doctor appointment on 08/30/19, with removal only for short periods of time for showering. Physician order [REDACTED]. According to documentation of weights, R1 experienced a weight loss of 3.43% in the five month time period from 03/07/19 - 08/19/19. During an observation on 08/22/19 at 09:05 AM, R1 lay in bed, turned onto her left side, facing the wall. The resident was awake and appeared to be talking to herself. On 08/22/19 at 11:20 AM, Certified Nurse Aide (CNA N), Certified Medication Aide (CMA) R, and CNA O entered R1's room. The resident lay in the same position as at the time of the 09:05 AM observation, turned onto the left side facing the wall. The resident was dressed in a night gown and was awake and mumbling to herself. CNA N and CMA R prepared to change the resident's incontinence brief and pulled back the upper bed coverings. The bottom bed sheet and soaker pad beneath the resident were wet with urine according to CNA N. The right leg immobilizer was no longer in the correct position with the upper edge placed at the upper thigh level and the opening over the knee. Instead, the top of the immobilizer rested just above the resident's knee. The resident's incontinence brief was totally saturated with urine. Once staff removed the brief, the resident had dried stool on her buttocks and rectal area which required CNA N to scrub the skin to remove the dried stool. Following incontinence care, CMA R unfastened the straps on the leg immobilizer and attempted to move it up on the leg and into the correct position. R1 cried out as CNA N and CMA R manipulated the leg and pulled on the immobilizer. R1 continued to cry out until staff finally got the immobilizer moved up on the leg and into a more appropriate position. Throughout the incontinence care and repositioning to facilitate care, R1 screamed loudly whenever staff turned her or moved the right lower extremity. The resident's screaming continued with each movement of her right lower extremity throughout the transfer with the full mechanical lift from the bed to the geri-chair. Staff continued to provide care in spite of the resident's crying out with each movement of the right leg. Once seated in the gerichair, R1 stopped crying out. During an interview on 08/22/19 at 08:25 AM, CNA Staff M reported the South Hall nursing unit lacked adequate staff to take care of the residents. According to Staff M, South hall is the heavy care hall because so many residents require assistance of two staff. According to CNA M, there are many days when staff are unable to get residents out of bed in time for breakfast, and often residents miss out on hot breakfast because staff are unable to get them to the dining room by the kitchen's cut off time of 09:00 AM. CNA M also reported she has had residents who require assistance with transfers still in bed at 01:00 PM because there was not enough staff to get them up earlier than that. CNA M reported, It's really bad sometimes. The residents suffer when we don't have enough help. During an interview on 08/22/19 at 11:25 AM, CNA N reported staff on the South Hall nursing unit did not have time to provide care to R1 yet that shift and the 11:20 AM interaction was the first interaction of any kind with the resident since staff came on duty at 06:00 that morning, a time period of 5.25 hours. CNA N further stated, No one has done a thing with her, no changing, no turning, nothing. We haven't had time. When questioned further, CNA N reported staff had not offered R1 breakfast that morning either because they did not want to attempt to feed R1 while she lay in bed due to the risk of choking. According to CNA N, We will give her lunch and I'm sure she will eat. She's a good eater usually. During an interview on 08/22/19 at 11:35 AM, CMA R reported she had responsibility for passing medications on the South Hall nursing unit on that date. CMA R reported R1 had orders for administration of Tylenol routinely for pain, with a dose scheduled for 08:00 AM that morning. According to CMA R, she did not administer the resident's morning medications, including the Tylenol for pain, that morning because R1 was still in bed and she worried R1 would choke if she was in bed when she took the medication. During an interview on 8/20/19 at 08:30 PM, Administrative Nurse D reported new owners assumed management of the facility on (MONTH) 1, 2019. Prior to that date, previous owners allowed higher staffing levels than what new owners allowed. In response to the shift in staffing practices, Nurse D reported many staff have complained repeatedly about not having adequate staff to care for the residents. Nurse D also reported residents complain about lack of staffing to meet their needs. According to Nurse D, when asked about specific lapses in care, neither staff nor residents are able to precisely describe what care they are not able to provide or what care they do not receive. Nurse D reported, If they will tell us what they don't have enough staff to do, we will work with them to fix it, but we need specific information about what they need. They haven't given us that. During an interview on 8/22/19 at 12:30 PM, Administrative Nurse D there was no excuse for staff failure to care to R1 for the first 5.25 hours of their shift that morning. Nurse D also reported CMA R should have consulted with the charge nurse prior to making the decision to hold R1's morning dose of pain medication because the resident remained in bed. The facility's undated Abuse, Neglect and Exploitation Policy defined neglect as, The failure or omission by one's self, caretaker or another person to provide goods or services which are reasonable (sic) necessary to ensure the safety and well-being and to avoid physical or mental harm or illness. The facility failed to ensure R1 the right to be free from neglect. Staff failed to provide care to R1, a resident with severe cognitive impairment who required extensive staff assistance with all activities of daily living (ADLs) during a 5.25 hour time period. During that time period, the resident experienced urinary incontinence which soaked the incontinence brief and bed linens, experienced bowel incontinence which dried onto the skin of her buttocks and genital area, was not offered or assisted with breakfast, and experienced pain which caused her to cry out with each movement.

The facility had a census of 69 residents, with nine residents selected for sample. The sample included review of pain management for one resident. Based on observation, interview, and record review, the facility failed to provide adequate pain management to one of one residents . Certified Medication Aide (CMA) R, the staff member designated to administer pain medications, failed to administer Resident (R) 1's scheduled pain medication as ordered/scheduled. Staff then provided care (incontinence care, repositioning of a knee immobilizer, transfer from bed) to R1 and the resident repeatedly cried out in pain during the care. Staff continued to provide care without regard for R1's expressions of pain. Findings included: - R1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 07/10/19 Quarterly Minimum Data Set (MDS) identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of 00), and daily physical and verbal behaviors directed toward others. The assessment also identified the resident with the need for extensive assistance of two staff for bed mobility, transfers and toileting, and an inability to ambulate. The resident experienced total bowel and bladder incontinence. On 08/07/19 staff submitted a partial MDS reporting the resident's unplanned transfer to the hospital. An additional 08/16/19 partial MDS reported the resident's return to the facility from the hospital. R1's undated care plan described the resident's need for assistance of two staff for most activities of daily living (ADLs), including transfers, bed mobility, dressing, and toileting. The care plan also noted R1's weight loss and need for a mechanical soft diet with fortified foods for breakfast and at bedtime. The care plan directed staff to reposition the resident at least every two hours and more often as needed or requested. According to the care plan, R1 often exhibited behaviors during transfers due to paranoia and anxiety. The care plan lacked information related to R1's recent femur fracture, pain management related to the fracture, and/or continuous use of a long leg immobilizer upon the resident's return from the hospital on [DATE]. Progress Notes dated 08/07/19 at 06:30 PM described R1's fall from a recliner, complaints of pain to her right hip, and subsequent transfer via Emergency Medical Services (EMS) to the local hospital. A later Progress Note dated 08/07/19 at 09:12 PM described a report from the hospital which indicated that R1 experienced a [MEDICAL CONDITION] femur and was sent to a larger area hospital for surgical repair. Progress Notes dated 08/16/19 noted R1's return to the facility with an immobilizer placed on the right leg. According to the note, the resident's surgery consisted of intramedullary nailing (placement of a rigid rod through the femur to stabilize a broken bone) of the right femur. An 08/16/19 Progress Note at 02:14 PM described communication with the transferring hospital about the need for R1's use of a leg immobilizer until a follow up doctor appointment on 08/30/19, with removal only for short periods of time for showering. Physician order [REDACTED]. 1) [MEDICATION NAME] (pain medication used to treat moderate to moderately severe pain) 50 milligrams (mg) three times daily for pain management (08/16/19 order) 2) Tylenol (pain medication) 500 mg three times a day for pain management (08/16/19 order) 3) [MEDICATION NAME] (Tylenol) 325 - 2 tablets - every four hours as needed for pain/fever (08/16/19 order) 4) [MEDICATION NAME] (pain medication used to treat moderate to severe pain) 5/325 mg ([MEDICATION NAME] 5 mg and [MEDICATION NAME] 325 mg) every 6 hours as needed for pain (08/16/19 ) During an observation on 08/22/19 at 09:05 AM, R1 lay in bed, turned onto her left side, facing the wall. The resident was awake and appeared to be talking to herself. On 08/22/19 at 11:20 AM, Certified Nurse Aide (CNA) N, CMA R and CNA P entered R1's room. The resident lay in the same position as at the time of the 09:05 AM observation, turned onto the left side facing the wall. CNA N and CMA R removed R1's incontinence brief and provided incontinence care. The right leg immobilizer was no longer in the correct position with the upper edge placed at the upper thigh level and the opening over the knee. Instead, the top of the immobilizer rested just above the resident's knee. CMA R unfastened the straps on the leg immobilizer and attempted to move it up on the leg and into the correct position. R1 cried out as CNA N and CMA R manipulated the leg and pulled on the immobilizer. R1 continued to cry out until staff finally got the immobilizer moved up on the leg and into a more appropriate position. Throughout incontinence care and repositioning, R1 screamed loudly whenever staff turned her or moved the right lower extremity. The resident's screaming continued with each movement of her right lower extremity throughout the transfer with the full mechanical lift from the bed to the geri-chair. Staff continued to provide care without regard for the resident's expressions of pain whenever they moved the right leg. Once seated in the gerichair, R1 stopped crying out. During an interview on 08/22/19 at 11:25 AM, both CNA N and CMA R reported R1's crying out upon movement of the right leg was due to pain. According to CNA N, It's pain. Moving really hurts her. She yells like that all the time when we move her. CMA R also confirmed a belief R1 cried out due to pain upon movement of the recently fractured right leg. During an interview on 08/22/19 at 11:35 AM, CMA R reported she had responsibility for passing medications on the South Hall nursing unit on 08/22/19. CMA R reported R1 had orders for administration of Tylenol routinely for pain, with a dose scheduled earlier that morning. According to CMA R, she did not administer the resident's morning medications, including the Tylenol for pain, that morning because R1 was still in bed and she worried R1 would choke if she was in bed when she took the medication. CMA R also reported she did not administer other prn (as needed) medications for pain that morning. During an interview on 8/22/19 at 12:30 PM, Administrative Nurse D reported CMA R should have consulted with the charge nurse prior to making the decision to hold R1's morning dose of pain medication because the resident remained in bed. According to Administrative Nurse D, staff should have stopped providing care to R1 when the resident cried out in pain, and consulted with a nurse prior to proceeding with care. Attempts to contact Physician GG, R1's primary care physician, were unsuccessful on 09/04/19 due to the physician's planned two week absence. The facility's undated Pain Management policy included, Each and every elder has a right to the assessment and management of pain . The facility failed to provide R1 with adequate pain management when CMA R held the resident's morning dose of pain medication without consulting the licensed nurse, and then staff continued to provide incontinence care, adjustment of a knee immobilizer and a mechanical lift transfer while R1 cried out in pain.

The facility had a census of 73 residents. The sample included 3 residents, with 3 reviewed for accidents. Based on record review and interview the facility failed to provide adequate supervision to prevent accidents for 1 of 3 sampled residents, with a history of falling, who sustained a neck fracture and brain bleed from multiple falls. (#1) Findings included: - Resident #1's 2/5/19 admission (MDS) Minimum Data Set assessment documented the resident had a (BIMS) Brief Interview for Mental Status score of 11, indicating moderately impaired cognition and the resident wandered. The MDS documented the resident required supervision with ambulation and toileting, used a walker for mobility, was occasionally incontinent of urine, and had no falls. The 5/3/19 quarterly MDS documented the resident had a BIMS score of 7, indicating severely impaired cognition, required supervision with ambulation, dressing, and personal hygiene, used a walker for mobility, and had 2 or more falls with no injury. The 2/5/19 (CAA) Care Area Assessment for cognitive loss/dementia documented the resident had memory loss with no formal [DIAGNOSES REDACTED]. The 2/5/19 CAA for Activities of Daily Living documented the resident had poor safety awareness due to his/her decreased cognitive function/forgetfulness. The 2/5/19 CAA for Falls documented the resident had multiple falls at home without injury and staff needed to be aware that he/she was a high fall risk due to his/her history, and was independent with ambulation with his/her walker. The 2/1/19 care plan directed staff to offer/encourage toileting before and after meals and when he/she was restless, ensure the resident wore appropriate footwear, and used his/her walker when ambulating. The care plan documented the resident had frequent falls at home with poor safety awareness (not using walker) which was one reason he/she admitted to the facility. The care plan directed staff to keep the call light within the resident's reach and encourage him/her to use it for assistance as needed. The 2/18/19 update care plan documented to have (OT) Occupation Therapy help with the resident's walker. The 5/6/19 update directed staff to keep the resident's bed in low position during sleeping times. The 5/15/19 update documented (PT) Physical Therapy would see the resident regarding falls. The 5/21/19 update documented the glider rocker was removed from the resident's room and replaced with a non-rocking recliner. The 6/3/19 update documented a double soft call light was placed in the resident's room upon readmission from the hospital. The 6/5/19 update documented the non-rocking recliner was removed and replaced with a high back chair. The 6/6/19 update documented staff started frequent safety checks and moved the resident to a room closer to the nurse's station. The care plan also directed 1 staff to ambulate with the resident each shift with gait belt and walker, and when the resident was restless. The 1/29/19 Morse Fall Scale indicated the resident was a high risk for falling. The 5/6/19 at 5:42 AM, nurse's note documented staff found the resident seated on floor without injury and the physician was notified. The 5/15/19 at 6:10 PM, nurse's note documented at 4:45 PM the resident fell and stated he/she hit his/her head against bed or table and staff notified the physician. The 5/18/19 at 3:45 AM, nurse's note documented at 2:00 AM the resident complained of neck pain and staff administered pain medication. The 5/19/19 at 10:57 PM, nurse's note documented the resident complained of neck pain and staff administered pain medication with little relief. The resident needed to be watched closely and maybe have his/her neck looked at by a doctor. The 5/21/19 at 1:35 PM, nurse's note recorded the resident was found on floor with his/her head resting on side of bed and stated he/she hit his/her head, complained of head/neck pain, staff noted a lump to the back right side of the resident's head/neck, and the physician was notified. The 5/22/19 at 2:49 AM, nurse's note documented the resident complained of neck pain, staff administered pain medication, and when ambulating the resident leaned to the right. The 5/23/19 at 2:35 PM, nurse's note recorded the resident complained of headache and neck pain, staff administered pain medication with some relief. The 5/24/19 at 1:44 PM, nurse's note documented the resident admitted to the hospital with [REDACTED]. The 5/26/19 at 3:09 PM, nurse's note recorded the resident returned to the facility from the hospital and reported he/she was having pain in his/her neck, but was unable to rate or describe the pain. Staff instructed the resident to ambulate in his/her room with a walker and contact guard assistance of 1 staff. The 5/27/19 at 6:25 AM, nurse's note documented at 10:45 PM and 2:30 AM the resident complained of neck pain and staff administered pain medication. The 5/28/19 at 9:24 AM, nurse's note recorded staff notified the resident's primary care physician of the resident's continued complaints of severe left sided head and neck pain with little to no relief from the current pain medication administered. The nurse's note indicated staff requested a stronger pain medication. The 5/29/19 at 11:14 AM, nurse's note documented due to increased complaints of neck pain, not wanting to leave his/her room and yelling at the slightest movement, staff placed a phone call to the resident's primary care physician. The 5/29/19 at 2:20 PM, nurse's note documented the resident complained of neck and head discomfort where the neck, spine and head joined. The resident hollered out at times for help and was reluctant to do anything since head and neck hurt so bad. Physician orders [REDACTED]. The 5/29/19 at 10:09 PM, nurse's note recorded staff administered pain medication and the resident continued to complain of pain to head and top of spine. The 5/30/19 at 8:56 AM, nurse's note documented staff called the resident's primary care physician requesting an X-ray or (CT) cat scan (an X-ray image taken from different angles to create cross sectional images) of the neck as the resident continued to scream out in pain with any movement of his/her neck. The 5/30/19 at 4:20 PM, nurse's note recorded the emergency department telephoned and directed facility to send the resident to the hospital as he/she had a neck fracture. The 6/3/19 at 6:53 PM, nurse's note documented the resident returned to the facility from the hospital with a neck collar, staff assisted the resident into a recliner with unsteady balance, poor gait, and poor safety awareness. The 6/3/19 fall risk assessment documented the resident was a high fall risk. The mini in-service book documented on 6/3/19 the resident readmitted with a soft collar for his/her neck and required frequent visual safety checks (this was not placed on the care plan). The documentation was signed by 2 staff on 6/3/19, but the facility lacked documentation of any other staff education or frequent visual checks were completed. The 6/5/19 at 12:15 AM, nurse's note recorded the resident was found in his/her room seated on the floor between the bed and recliner, and the foot of the recliner was in the up position. The resident had confusion and stated I just don't think this is my room. The resident's non-rocking recliner was removed and replaced with a high back chair. The 6/6/19 at 01:40 AM, nurse's note documented at 6:00 PM the resident was found on the floor in the center hall lying on his/her back with his/her walker just beside him/her. The 6/6/19 at 2:00 PM, nurse's note recorded staff moved the resident to a room closer to the nurse's station. The 6/6/19 at 3:45 PM, nurse's note documented the resident's primary care physician was telephoned and informed the resident's room was moved to a more busy location to help keep a closer eye on the resident as he/she had poor safety awareness, to let the facility know if they needed to find the resident a different facility, and asked for suggestions on how to keep the resident safe. The physician returned the telephone call and requested a chair alarm and the facility stated those were restraints and dignity issues. The mini in-service book documented on 6/6/19 to place the resident in an active place or activity after meals, toilet before and after each meal, ambulate as much as possible with gait belt and walker, to check on the resident every 15 minutes, and relocated the resident to a different room closer to the nurse's station. Two staff signed the documentation on 6/6, 6/7, and 6/8 and the facility lacked documentation any other staff education or completion of 15 minute checks. The 6/7/19 at 12:34 AM, nurse's note documented the resident would yell, help me, help me when left alone, staff would assist the resident and then upon leaving the resident would yell the same thing again. This cycle continued until the resident became tired enough to go to bed. The 6/719 at 11:46 AM, nurse's note recorded the resident was found up twice in his/her room attempting to ambulate independently. Staff educated the resident each time on the use of her call light (per staff interviews the resident did not use his/her call light). The 6/8/19 at 10:49 PM, nurse's noted documented at approximately 10:20 PM an aide found the resident on his/her bathroom floor lying on his/her back up against the laundry basket with his/her head against the wall. The resident was unable to answer questions, speech was garbled, and he/she attempted to stand up and walk. Staff called the primary care physician and he/she ordered to send the resident to the emergency department. When facility staff assisted the (EMS) Emergency Medical Staff with transfer of the resident to the emergency room , he/she vomited in his/her bed. The 6/8/19 at 11:20 PM, nurse's note reported the hospital called and reported the resident had a bleed in his/her head and admitted to the hospital. The 6/12/19 at 6:29 PM, nurse's note documented the hospital called and reported the resident passed away. On 6/25/19 at 8:18 AM, Direct Care Staff M stated the resident was very forgetful after 2 or 3 PM and would often see him/her ambulating without a walker in the hallway and in his/her room. Direct Care Staff M stated on 6/8/19 found the resident in his/her bathroom during the 1-2 hour checks. Direct Care Staff M stated the resident was never on 15 or 30 minute checks and stated he/she would be told during report if a resident was to be checked every 15-30 minutes. Direct Care Staff M verified the resident's care sheet that the staff are given documented the resident was a fall risk, used a cane, and was very confused. On 6/25/19 at 8:55 AM, Direct Care Staff N verified the resident would not use his/her call light, staff would observe the resident in the hallway without his/her walker, and the resident would shuffle his/her feet when ambulating. Direct Care Staff N verified the resident was not on the list of residents who were to be checked every 30 minutes. Direct Care Staff N stated after the resident fell a few times, he/she became verbally aggressive, complained about his/her neck hurting for weeks before staff were told he/she had a neck fracture, and some days when staff would attempt to get him/her up, he/she would scream leave me alone. On 6/25/19 at 9:39 AM, Nurse G verified the resident would be found in the hallway without his/her walker and his/her gait was slightly unsteady. Nurse G stated after the falls, the resident would shuffle his/her feet and his/her memory span became shorter. Nurse G stated after 4 PM the resident was angry and did not want to be reminded to use his/her walker, and it was harder to get him/her to leave his/her room. Nurse G stated to prevent further falls the staff implemented a different call light that when the resident moved, it would go off and the resident was on 15 minute checks after a fall, but not sure which fall. Nurse G verified the computer prompted the nursing staff to document if safety checks were completed each shift, not every 15 minutes. On 6/25/19 at 1:36 PM, Administrative Nurse D verified the resident would ambulate in his/her room and hallway without his/her walker and had several falls in the facility which involved hitting his/her head. Administrative Nurse D stated staff called the resident's physician several times and reported continued pain with the resident's neck. Administrative Nurse D stated staff were directed per mini in-service on 6/6/19 to intervene if resident was found ambulating by him/herself due to several falls and verified the staff who worked on the resident's hall were to review the mini in-service documentation prior to working each day. Administrative Nurse D verified the facility did not have documentation all of the staff reviewed the 6/3/19 and 6/6/19 mini in-services. Administrative Nurse D verified on 6/3/19 staff were directed to complete frequent checks on the resident, which would mean 15-30 minutes, but the record lacked documentation the resident received the 15 or 30 minute checks. Administrative Nurse D stated the resident's physician requested the facility use an alarm to keep the resident safe and the facility declined the alarm usage because the alarm was viewed as a restraint and undignified. On 6/25/19 at 3:42 PM, Consultant Staff GG verified the resident's falls could have been prevented if the resident received more supervision and felt staffing was a concern. Consultant Staff GG stated if the facility knew the resident was ambulating and had a bad memory, he/she needed to have some sort of alarm or precautions in place to alert the staff of when the resident was moving. Consultant Staff GG verified he/she requested the facility use alarms for the resident and the facility stated they could not use alarms. Consultant Staff GG verified 1 of the resident's last 3 falls contributed to her death, the resident's brain had been scanned with the neck fracture on 5/30/19 and he/she did not have a brain bleed at that time. Consultant Staff G stated 1 of the resident's last 3 falls involved the resident's head as the resident's neck fracture worsened from 5/30 to 6/8/19 and the resident had a brain bleed. The facility's Fall Prevention and Management policy, dated 6/12/19, documented the facility would identify residents at risk for falls, develop plans of care that addressed the risk, and implement procedures to assist in preventing falls. The facility would also investigate accidents involving residents sustaining falls to identify possible cause and develop approaches to assist in preventing repeated falls. If the resident sustained [REDACTED]. Notify all direct care staff about fall occurrence and interventions implemented and update resident care sheets to include this information. The facility failed to provide adequate supervision for Resident #1, who had a history of [REDACTED].

The facility had a census of 84 residents. The sample included 3 residents which were reviewed for abuse. Based on observation, record review, and interview, the facility failed to protect and prevent further potential abuse of the residents in the facility, when Dietary Aide CC continued to work and complete his/her shift after staff witnessed him/her abuse a resident. This deficient practice placed the residents who reside in the facility in immediate jeopardy. Findings included: - Resident #1's significant change (MDS) Minimum Data Set assessment, dated 10/11/18, documented the resident had short and long term memory problems with moderately impaired cognition. The MDS indicated the resident required extensive assistance from staff for bed mobility, transfers, dressing and personal hygiene, total assistance from staff for toileting, bathing, locomotion on and off the unit, ate independently after staff set up, unable to ambulate, and used a wheelchair for mobility. The MDS documented the resident had physical behaviors directed toward others. The (CAA) Care Area Assessment for cognitive loss/dementia documented the resident had a [DIAGNOSES REDACTED]. The 10/11/18 care plan directed staff to provide the resident's diet as ordered, thin liquids, and a calm, quiet setting at all meals with adequate eating time. The care plan documented the resident preferred to eat in the south dining room and the directed staff to cue, reorient and supervise the resident as needed. The 12/6/18 at 4:22 PM, nurse's note documented a dietary staff member reported at lunch today, the resident reached for a glass of water on the other side of the table and he/she was grabbed and pushed back into his/her chair. The note documented the resident was unable to communicate any information about the incident. The facility's incident report documented on 12/6/18 at approximately 3:15 PM, Administrative Staff B was notified of a potential abuse incident. The report documented Dietary Staff CC pushed/shoved the resident back into his/her wheelchair and yelled at him/her. The report documented Dietary Staff DD and EE witnessed the incident and Dietary Staff DD notified, by text at 11:04 AM, Dietary Supervisor BB, who brought Dietary CC into his/her office and discussed his/her attitude and offered to send him/her home if needed. At approximately 3:00 PM, Dietary Staff DD and EE verbally reported to Dietary Supervisor BB that Dietary Staff CC shoved the resident into his/her chair and yelled at him/her. The report documented Dietary Staff CC's shift ended and he/she left the facility at 1:50 PM (approximately 3 hours after the incident). Dietary Supervisor BB reported the alleged abuse to Administrative Staff B, who asked Dietary Staff CC to return to the facility and he/she was suspended that day at 4:20 PM. The facility terminated Dietary Staff CC on 12/10/18. On 12/12/18 at 5:00 PM, observation revealed staff pushed the resident, in his wheelchair, to the south dining room for supper, and visited with staff about the food he/she wanted to eat. Further observation revealed staff was pleasant and kind to the resident. On 12/11/18 at 1:45 PM, Administrative Staff B stated on 12/6/18 at approximately 3:15 PM, he/she was informed of potential abuse to Resident #1 by Dietary Supervisor BB. Administrative Staff B stated Dietary Staff DD sent a text message to Dietary Supervisor BB at 11:04 AM that read if you are still in the building you should come down and sit back and see how Dietary Staff CC is treating people. The text message did not mention abuse to a resident. Administrative Staff B verified the actual abuse was reported to Dietary Supervisor BB by Dietary Staff DD and EE at approximately 3:00 PM. Administrative Staff B verified he/she requested Dietary Staff CC return to the facility and suspended him/her at 4:20 PM. Dietary Staff CC was terminated on 12/10/18. On 12/11/18 at 2:10 PM, Administrative Staff A stated he/she was notified of the potential abuse sometime after 3:00 PM on 12/6/18. Administrative Staff A verified Dietary Staff CC was suspended on 12/6/18 and terminated on 12/10/18 after the facility investigated the allegation. Administrative Staff A verified Dietary Staff CC continued to work and finished his/her shift until his/her shift ended and he/she left the facility at 1:50 PM. Administrative Staff A stated Dietary Staff CC should have been sent home immediately and not allowed to finish his/her shift. On 12/12/18 at 2:15 PM, Dietary Supervisor BB stated approximately 60 residents eat in the south dining room on a regular basis and verified Dietary Staff CC worked in that dining room. Dietary Supervisor BB stated after he/she talked to Dietary Staff CC about his/her attitude and behavior (approximate 12:30-1:00 PM on 12/6/18) Dietary Staff CC continued to work in the dining room until his/her shift ended and he/she left the facility at 1:50 PM. Dietary Supervisor BB stated there was one resident that remained in the dining room during the time Dietary Staff CC continued to work. The facility's 12/2016 Abuse Prevention Policy documented the administration would protect residents from abuse by anyone and residents would be protected during abuse investigations. The policy documented employees of the facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. The facility failed to protect the residents who resided in the facility, when Dietary Staff CC allegedly abused a resident, continued to work and finish his/her shift, which placed the residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 12/14/18 after in-service of all staff on the updated abuse, neglect, and exploitation policy. The facility terminated the alleged perpetrator on 12/10/18. The deficient practice remains at a scope and severity of a D.

The facility had a census of 84 residents. The sample included 3 residents which were reviewed for abuse. Based on observation, record review, and interview, the facility failed to provide a safe environment free from abuse for 1 of 3 sampled residents, when Dietary Staff CC yelled at and shoved a resident back into his/her chair. Two dietary staff members witnessed the incident and stated they did not report the incident to their supervisor for 4 hours. This deficient practice placed the resident in immediate jeopardy. (#1) Findings included: - Resident #1's significant change (MDS) Minimum Data Set assessment, dated 10/11/18, documented the resident had short and long term memory problems with moderately impaired cognition. The MDS indicated the resident required extensive assistance from staff for bed mobility, transfers, dressing and personal hygiene, total assistance from staff for toileting, bathing, locomotion on and off the unit, ate independently after staff set up, unable to ambulate, and used a wheelchair for mobility. The MDS documented the resident had physical behaviors directed toward others. The (CAA) Care Area Assessment for cognitive loss/dementia documented the resident had a [DIAGNOSES REDACTED]. The 10/11/18 care plan directed staff to provide the resident's diet as ordered, thin liquids, and a calm, quiet setting at all meals with adequate eating time. The care plan documented the resident preferred to eat in the south dining room and directed staff to cue, reorient and supervise the resident as needed. The 12/6/18 at 4:22 PM, nurse's note documented a dietary staff member reported at lunch today, the resident reached for a glass of water on the other side of the table and he/she was grabbed and pushed back into his/her chair. The note documented the resident was unable to communicate any information about the incident. The facility's incident report documented on 12/6/18 at approximately 3:15 PM, Administrative Staff B was notified of a potential abuse incident. The report documented Dietary Staff CC pushed the resident back into his/her wheelchair and yelled at him/her. The report documented Dietary Staff DD and EE witnessed the incident and Dietary Staff DD notified, by text at 11:04 AM, Dietary Supervisor BB, who brought Dietary CC into his/her office and discussed his/her attitude and offered to send him/her home if needed. At approximately 3:00 PM, Dietary Staff DD and EE verbally reported to Dietary Supervisor BB that Dietary Staff CC shoved the resident into his/her chair and yelled at him/her. The report documented Dietary Staff CC's shift had ended and he/she had left the facility. Dietary Supervisor BB reported the alleged abuse to Administrative Staff B, who asked Dietary Staff CC to return to the facility and he/she was suspended that day at 4:20 PM. Dietary Staff CC finished his/her shift and left the facility at 1:50 PM on 12/6/18 (approximately 3 hours after the incident). The facility terminated Dietary Staff CC on 12/10/18. On 12/11/18 at 1:45 PM, Administrative Staff B stated on 12/6/18 at approximately 3:15 PM, he/she was informed of potential abuse to Resident #1 by Dietary Supervisor BB. Administrative Staff B stated Dietary Staff DD sent a text message to Dietary Supervisor BB at 11:04 AM but the text message did not mention abuse to a resident. Administrative Staff B verified the actual abuse was reported to Dietary Supervisor BB by Dietary Staff DD and EE at approximately 3:00 PM. Administrative Staff B verified he/she requested Dietary Staff CC return to the facility and suspended him/her at 4:20 PM. Dietary Staff CC was terminated on 12/10/18. On 12/11/18 at 2:10 PM, Administrative Staff A stated he/she was made aware of the potential abuse sometime after 3:00 PM on 12/6/18. Administrative Staff A verified Dietary Staff CC was suspended on 12/6/18 and terminated on 12/10/18 after the facility investigated the allegation. Administrative Staff A stated Dietary Staff DD and CC should have immediately reported the abuse to administrative staff when Dietary Supervisor BB was not available. On 12/11/18 at 3:05 PM, Dietary Staff DD stated he/she was serving lunch in the south dining room on 12/6/18, when he/she saw Dietary Aide CC run to Resident #1's table, yell at the resident, grabbed the resident by his/her arm, and slammed him/her back into his/her wheelchair in a forceful manner. Dietary Staff DD stated Dietary Staff CC had been rude to residents and staff all day. Dietary Staff DD verified he/she witnessed the abuse at approximately 11:00 AM, sent a text message to his/her supervisor at approximately 11:04 AM but he/she did not mention abuse to the resident, only that Dietary Supervisor BB should return to the dining room and see how Dietary Staff CC was treating people. Dietary Staff DD verified he/she did not report the abuse to his/her supervisor until 3:00 PM (approximately 4 hours later) and stated he/she should have reported it sooner to someone in administration. On 12/11/18 at 3:35 PM, Dietary Staff EE stated during lunch service in the south dining room on 12/6/18, he/she witnessed Resident #1 reach across table to get another resident's glass of water. Dietary Staff CC ran to Resident #1's table, yelled at and grabbed the resident by his/her arm and shoved him/her into his/her wheelchair. Dietary Staff EE stated he/she did not know what was said in the text message Dietary Staff DD sent to his/her supervisor, and assumed since Dietary Staff DD sent the text message, he/she would not need to report it. Dietary Staff EE stated Dietary Staff CC had been rude all day to residents and staff and his/her tone was gruff. On 12/12/18 at 10:10 AM, Administrative Nurse D stated Dietary Staff CC acted inappropriately and did not follow the facility's policy for abuse, as well as Dietary Staff DD and EE when they did not report the abuse for approximately 3 hours. On 12/13/18 at 10:08 AM, Dietary Staff FF stated he/she had heard Dietary Staff CC be rude to residents and used a harsh tone of voice when he/she spoke to them. The facility's 12/2016 Abuse Prevention policy documented the resident has the right to be free from abuse, neglect, misappropriation of property and exploitation. The policy documented the facility would protect the residents from abuse by anyone, including facility staff. The policy further documented all allegations of abuse should be reported within the timeframe as required by federal requirements and all staff are responsible for immediately reporting potential abuse to their immediate supervisor. The facility failed to provide Resident #1 with an environment free from abuse, when Dietary Staff CC yelled at Resident #1 and forcefully shoved him/her back into his/her wheelchair. This deficient practice placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 12/14/18 after in-service of all staff on the updated abuse, neglect, and exploitation policy with emphasis on reporting procedures. The facility terminated the alleged perpetrator on 12/10/18. The deficient practice remains at a scope and severity of a D.

The facility had a census of 78 residents. The sample included 5 residents. Based on observation, interview, and record review, the facility failed to follow 1 of 5 sampled resident's wishes to have (CPR) Cardiopulmonary Resuscitation (full code, an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation) performed, if needed. This placed Resident #1 in immediate jeopardy when his/her breathing and heart rate ceased. Findings included: - The facility admitted Resident #1 on [DATE], and the resident's medical chart had a green sticker (designating full code) on the outside cover and no DNR (do not resuscitate) or Full Code sticker inside the cover. The medical record lacked further information regarding the code status of the resident. The [DATE] admission checklist, to be completed within 4 hours, instructed staff to review orders, but lacked instruction regarding obtaining the DNR status. The admission resident rights, undated, signed by the resident's representative, stated the resident had a right to make choices about aspects of his/her life that were significant to him/her. The rights documented nursing facilities must maintain written policies and procedures concerning advance directives (medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves), and document in a prominent part of the current medical record whether or not the resident had an advance directive. Provide education for staff concerning the facility's policies and procedures on advance directives. The [DATE] physician's admission orders [REDACTED]. Further review of the physician orders [REDACTED]. The (POS) Physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated [DATE], documented the resident entered the facility from an acute hospital, had moderate cognitive impairment, and had no abnormal behaviors. The assessment documented the resident was independent with eating, and required limited assistance with all other (ADLs) activities of daily living. The assessment documented the resident had shortness of breath with exertion, and received supplemental oxygen therapy. The [DATE] (CAA) Care Area Assessment summary for falls directed staff to ensure the resident's oxygen tubing was not caught or hooked on anything. The [DATE] care plan for oxygen therapy instructed staff to provide (O2) oxygen per nasal cannula (nose piece) at 3 (L) liters per minute, continuously, monitor for signs and symptoms of respiratory distress, and report to the physician, as needed. The [DATE] physician's progress note documented the resident was alert and oriented, able to express himself/herself well, with normal speech, received continuous oxygen at 3L, and required an oxygen mask at night. The [DATE] at 8:20 AM, progress note documented the resident was confused, with slurred speech, and oxygen saturation at 79% (normal range =,[DATE]%). The note documented the oxygen mask was connected to the humidifier with no air coming through. Staff placed a nasal cannula on the resident and oxygen saturation came up to 90% by 8:55 AM. The resident remained in bed with the head of the bed elevated, and at 9:30 AM, the resident was breathing through his/her mouth, and the oxygen saturation dropped into the 80%s. Staff reapplied the oxygen mask on at 4L, and oxygen saturation rose to 95%. The [DATE] at 10:00 AM, progress note documented the resident's oxygen saturation at 94% on 4L per nasal cannula, and when staff turned the oxygen down to 3L, his/her oxygen saturation dropped to 77%. Staff reapplied the oxygen mask on at 4L, the oxygen saturation went to 90%, and staff called the hospital to contact the physician. The note documented the resident had clear normal speech and normal breath sounds. At 11:20 AM, the progress note documented staff received a physician order [REDACTED]. At 12:35 PM, the progress note documented the resident took his/her scheduled medications, and staff brought a room tray to the resident, who was in bed with the head of the bed elevated. Staff later found the resident pale and unresponsive, and staff called 911. The progress notes documented the (EMT) Emergency Medical Technicians arrived and pronounced the resident dead at 12:53 PM. The [DATE] EMT documentation recorded the facility called 911 at 12:44 PM, and the EMTs arrived at the facility 12:46 PM. The EMTs documented staff informed them the resident was unresponsive and breathing very slowly. The EMTs documented the resident pulseless and not breathing at 12:47 PM, and the EMT contacted the physician, for clarification of the code status, who advised them to proceed with DNR status. On [DATE] at 8:15 AM, Nurse A stated staff know the resident's DNR or full code status by the sticker on the chart, in the chart, or in the living will (written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive). Nurse A stated when he/she first checked the resident about 6:30 AM, to administer medication, the resident was sleeping. Nurse A stated the resident responded and asked if the nurse could come back later. Nurse A stated the next time he/she saw the resident was when an aide came and told him/her the resident was not looking right. Nurse A stated he/she instructed the aide to get the charge nurse as the resident was very lethargic (drowsy), and he/she noticed condensation in the oxygen mask, with no air coming out. Staff placed a nosepiece on the resident and connected it directly to the concentrator. Nurse A stated he/she informed the charge nurse what happened, and staff brought a new mask in, checked it, and air was flowing through it. Nurse A stated the resident's oxygen was 79% at the beginning of the incident, and after the resident's oxygen level improved, the charge nurse called the physician and continued with care of the resident. Nurse A stated around lunch time he/she went into the resident's room and the resident seemed exhausted, but responded to questions and asked for lunch and pain medication. Nurse A stated he/she gave the medications, saw the resident had a lunch tray, and was drinking juice. Nurse A stated later, the charge nurse hollered down the hall to meet him/her in the resident's room. Nurse A stated when he/she arrived, the resident was pale, not responding, and he/she asked the nurse if the resident was a DNR or not. Nurse A stated the charge nurse informed him/her, yes, the resident also had a living will (even though the medical record had no order or information the resident requested DNR status). Nurse A stated the nurse called 911 and the EMTs put the resident on a monitor, asked if the resident was a DNR, and the EMTs checked his/her chart. Nurse A stated the EMTs contacted the physician by phone, per procedure, and were instructed to not perform CPR and to determine the time of death. On [DATE] at 9:20 AM, Nurse B stated his/her CPR certification had expired. Nurse B stated he/she visually checked on the resident around 6:15 AM and the resident looked normal and had an oxygen mask on at that time. Nurse B stated at 8:20 AM, an aide reported the resident was confused with slurred speech, so he/she went to the resident's room and found his/her oxygen was 79% with the oxygen mask. Nurse B stated no air was coming through the mask, so staff replaced the mask and the new mask allowed air flow. Nurse B stated the resident was pale, sweaty, he/she was breathing through his/her mouth with big, deep, gasping breaths. Nurse B stated he/she stayed with the resident until oxygen was 94%, and the resident was talking. Nurse B stated when the resident was stable he/she called the physician and the family. Around 11:00 AM, the resident's skin color was good, breathing normal, awake/alert, answered questions appropriately, and he/she asked for lunch. Nurse B stated medications were administered without difficulty, and staff served a lunch tray. Nurse B stated he/she left the resident's room to make a milkshake for the resident and when he/she returned the resident was unresponsive, pale, with no oxygen reading. Nurse B verified the resident's chart had a green dot (which specified full code) on the outside cover, on the inside cover no DNR sticker. Nurse B verified the resident's living will did not document whether the resident requested full code or DNR status. Nurse B stated a resident's code status was not always determined with admission orders [REDACTED]. On [DATE] at 12:05 PM, Nurse Aide E stated about 12:43 PM, the resident was pale, still warm, not breathing, and had no pulse. Nurse Aide E stated staff were rubbing the resident's chest, but the resident did not respond, nor did his/her eyes react to light. Nurse Aide E stated he/she asked if the resident was a full code or DNR, and Nurse B stated he/she was not sure. Nurse Aide E verified the resident's chart did not have a DNR sticker on the inside of the front cover, so he/she was unsure of the code status. He/she handed the chart to the nurse, and Nurse B stated the resident was a DNR. Nurse Aide E stated the EMT requested the resident's DNR or living will and the EMT contacted the physician for further direction as the resident had pulseless electrical activity (clinical condition characterized by unresponsiveness and lack of palpable pulse in the presence of organized cardiac electrical activity). The heart rate flatlined and the physician instructed EMT to declare time of death. On [DATE] at 1:40 PM, Nurse Aide F stated around 7:45 AM, he/she noticed the resident extremely pale and sweaty, and noticed condensation in his/her oxygen mask. Nurse Aide F stated he/she asked the resident questions, but thought the resident was more confused, so he/she ran to get a nurse. Nurse Aide F stated he/she was unsure how long the supplemental oxygen was not working. Nurse Aide F stated staff replaced the mask and the oxygen worked again. Nurse Aide F stated throughout the morning, he/she checked on the resident, who had trouble speaking, kept asking why he/she was so sick, and his/her speech was still somewhat slurred. Nurse Aide F stated at 11:30 AM, staff changed the resident's clothing, and his/her oxygen saturation dropped into the 80s, which the nurse aides reported to the nurse. On [DATE] at 3:00 PM, health information Staff G stated when a new resident was admitted , staff asked the resident or family for the resident's code status, DNR or full code, and had them and the physician sign a form. Staff G stated if the resident chose DNR status, staff placed a copy in the resident's chart and sent a copy to the physician. Staff G stated staff placed a red sticker (DNR) on the outside cover of the chart, and inside the chart cover, another red sticker. Staff G stated if the resident chose full code status, staff placed a green sticker (full code) on the chart cover, and inside the cover, the green sticker stated full code. Staff G stated when the facility admitted Resident #1, the resident or their representative had not specified whether the resident had chosen DNR or full code status, so staff placed a full code sticker on the outside of the resident's chart, but did not place a full code sticker inside the cover. Staff G verified the facility had not received any other documentation stating the resident's code status as a DNR and staff had not followed up to clarify advanced directives and code status with the family or the physician. On [DATE] at 3:15 PM, Administrative Nurse C verified the resident's chart had a green sticker which indicated staff were to provide full code procedure, if needed. Administrative Nurse C verified staff should have provided (CPR) cardiopulmonary resuscitation to the resident. Administrative Nurse C verified the nursing home physician orders [REDACTED]. The facility's ,[DATE] Cardiopulmonary Resuscitation policy stated if a resident is found unresponsive and not breathing normally, a staff member who was certified in CPR would initiate CPR unless: It was known that a DNR order that specifically prohibits CPR exists for the resident. If the resident's DNR status was unclear, staff were to initiate CPR until it was determined that there was a DNR or a physician's orders [REDACTED]. The facility failed to perform CPR for Resident #1, who was found unresponsive, without respirations or pulse, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE], after completion of training of all staff on how and where to find the code status of all residents, when to initiate CPR, and an audit of all resident's charts to ensure correct coding. This deficient practice remained at a scope of G.

The facility had a census of 86 residents. The sample include 16 residents of which 2 were reviewed for pressure ulcers. Based on record review and interview, the facility failed to provide necessary treatment and services to prevent a pressure ulcer from developing for 1 of 2 sampled residents who developed an avoidable unstageable (intact outer skin with deep tissue injury in which the actual depth is completely concealed), pressure ulcer on his/her left heel. (#51) Findings included: - Resident #51's physician's orders [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 9/15/2016, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 1, indicating severely impaired cognition skills for daily decision making and total dependence of 1-2 staff assistance with (ADLs) Activities of Daily Living, including bed mobility, transfers, toilet use, personal care, and locomotion on and off the unit. The MDS indicated the resident was at risk for developing pressure ulcers and had a pressure reducing device to his/her bed and chair, on a turning/repositioning program, and had no current pressure ulcers. The 9/16/2016 skin (CAAs) Care Area Assessment summary indicated the resident required 2 staff for transfers and was totally dependent on staff for ADLs. The CAA indicated the resident was at risk for pressure ulcers. The 9/08/2016 care plan instructed the staff to assist the resident with transfers and bed mobility to aide in preventing pressure areas, encourage the resident to change position frequently while sitting, and monitor areas where pressure ulcers are known to develop. Review of the care plan revealed no specific interventions regarding preventative measures to decrease the risk of pressure ulcer development to the resident's lower extremities or feet. The care plan lacked evidence of an individualized repositioning program, and lacked documentation of routine skin checks. The 9/08/2016 admission nursing assessment indicated the resident did not have any pressure related skin issues. The 9/20/2016 (RD) registered dietitian dietary progress notes indicated the resident returned from the hospital with a weight of 170 pounds and a poor appetite. Staff were to offer the resident strawberry shakes with meals, and the RD will continue to monitor. The 9/29/2016 Braden scale for predicting pressure ulcer risk was a score of 14. (a score of 12 or less represents high risk) The 10/11/2016 at 1:45 PM, nurse's note indicated staff applied skin prep (a liquid film forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to the resident's left heel every shift for protection. Review of the nurse's notes lacked any other documentation regarding the resident's left heel. The 10/11/2016 weekly wound evaluation flow sheet indicated the resident had a left heel pressure ulcer with pink tissue around the wound margins, approximately 1.5 (cm) centimeters by 0.7 cm, with no depth documented, no drainage, and no odor. The flow sheet revealed the current treatment was skin prep every shift, pressure relieving boots to off load heels, reposition every 2 hours and a low air loss mattress. The 10/17/2016 weekly wound evaluation flow sheet indicated the resident had a left heel pressure ulcer, no measurements documented, and was pink with boggy (tissue that is firm, painful, mushy, warm) [MEDICATION NAME] tissue. The flow sheet revealed the current treatment included pressure relieving boots and lotions. The 10/18/2016 (1 day after the 10/17/2016) weekly wound evaluation flow sheet indicated the resident had a left heel pressure sore, 1.5 cm by 0.5 cm, with pink surrounding tissue and pink wound margins. The flow sheet revealed the current treatment included skin prep every shift, pressure relieving boots, repositioning every 2 hours, and a low air loss mattress. The 10/20/2016 weekly wound evaluation flow sheet indicated the resident had a left heel pressure ulcer, 1.8 by 2.0 cm with pink surrounding tissue and pink wound margins. The current treatment included skin prep every shift, pressure relieving boots, repositioning every two hours, and a low air loss mattress. (The pressure ulcer increased in size, and, and no documentation in the medical record regarding physician notification or change of treatment) The 10/30/2016 weekly wound evaluation flow sheet (10 days after the last evaluation) indicated the resident had a left heel pressure ulcer, 1.2 cm by 1.7 cm with pink wound margins. The flow sheet revealed the current treatment included skin prep every shift, pressure relieving boot, repositioning every two hours and a low air loss mattress. The 10/13/2016 registered dietitian progress note indicated the resident was reviewed due to a wound on his/her left heel, and documented it was not open. Review of the last [MEDICATION NAME] (the liver takes proteins from the foods you eat and turns them into new proteins that circulate to various organs and tissues in your body) level on 7/02/2016 was 2.5 (normal range 3.5 to 5.5). The note revealed the resident's protein requirements are 82-90 (gm) grams per day, and the resident's meals provided 85-95 gm, in addition to strawberry shakes he/she received with meals. Observations were unavailable, as the resident discharged from the facility on 11/01/2016. On 11/15/2016 at 4:10 PM, Nurse J stated the resident required a total body lift for transfers, pressure relieving boots with no socks, on both heels, and staff float his/her heels. Nurse J stated the resident was declining and not eating or drinking very much. On 11/17/2016 at 4:15 PM, Nurse B stated the resident physically declined and required the assistance of 2 staff with ADLs and total body lift for transfers. Nurse B stated the resident had a weight loss and it was hard to get him/her to eat and drink. On 11/17/2016 at 9:00 AM, Administrative Nurse A stated the resident gradually declined before he/she developed a pressure ulcer on his/her left heel. Administrative Nurse A verified the staff placed pressure relieving boots on his/her heels after the pressure ulcer developed. Administrative Nurse A stated the pressure ulcer size had increased and verified the facility did not have the care plan updated with the new interventions after the pressure sore developed. On 11/28/2016 at 8:45 AM, interview with Physician R stated the resident the resident developed the pressure ulcer on the resident's left heel at the facility, and stated the resident had been in the hospital and had a [DIAGNOSES REDACTED]. Physician R verified the staff were to reposition the resident every 2 hours and place pressure reducing boots on the resident feet/heels. Physician R stated the resident could not use his/her arms and so he/she repositioned him/herself using his/her heels/feet. The facility's undated Pressure ulcer prevention policy indicated all residents admitted to the facility would be assessed for the risk of developing pressure ulcers and interventions initiated to prevent impaired skin integrity. Residents that are admitted with or develop pressure ulcers shall receive appropriate monitoring and treatment to promote healing. The facility is committed to providing the resources, staff and education necessary to prevent and treat pressure ulcers. The residents will be assessed for risk of developing pressure ulcers on admission/readmission, then weekly for four weeks, quarterly and upon identification of a significant change in condition. The assessment will be completed within 4 hours of admission or identification of a significant change, the assessment will also include a head to toe skin assessment. The policy further stated recognizing additional risk factors and use clinical judgement when assessing an individual's risk for developing pressure areas. All residents who are bedfast and/or chairfast have an alteration to their intact skin are to be considered at high risk for pressure ulcer development regardless of their risk assessment score. Implement interventions to relieve/reduce pressure in residents. Implement interventions to reduce shear and friction. Reduce /minimize excessive moisture on the skin. Promote nutrition and hydration health. Promote circulation and mobility. Resident will have a head to toe skin assessment by a licensed nurse completed and documenters at least weekly. All direct care staff will observe for changes in skin condition whenever skin is exposed (bathing, toileting, clothing changes) and report any suspicious areas to the charge nurse immediately. The facility failed to develop and implement timely and effective interventions, to prevent the development and worsening of a pressure ulcer for this cognitively impaired, dependent Resident #51 who admitted to the facility without a pressure ulcer and developed an unstageable pressure ulcer.

The facility had a census of 85 residents. The sample included 4 residents, all of which were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide supervision and assistive devices to prevent falls, for 2 of the 4 sampled residents. Resident #1 fell and sustained a fractured ankle when his/her pressure alarm was not implemented as care planned, and Resident #4 fell and sustained a skin tear, abrasions (the scraping or rubbing away of the surface of the skin), and a hematoma (the collection of blood trapped in the tissues of the skin or in an organ) when his/her personal alarm failed to properly function. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 10/14/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 0, which indicated he/she had severe cognitive impairment. The MDS indicated he/she had inattention, disorganized thinking, and unclear speech. The MDS indicated the resident required extensive assistance for all (ADLs) Activities of Daily Living, except for supervision with eating. The resident had unsteady balance which required assistance from the staff to stabilize, and no limitations with his/her range of motion. The document indicated the resident used a wheelchair and a walker, and had 2 falls, one with injury and one without injury. The 10/12/15 Morse Fall scale indicated the resident a high risk for falls. The 10/15/15 care plan stated the resident had short term memory loss and used a merry walker (a walker/wheelchair combination) for mobility. The care plan directed staff to place a personal alarm on his/her wheelchair, a pressure alarm in his/her bed, and to assist with transfers and ambulation as needed to prevent falls. The 8/10/15 fall investigation report stated on 8/9/15, staff found the resident on the floor of his/her room. The resident was unable to describe what happened, and staff noted the resident had been incontinent of bowel and bladder. The report stated the recommendation or new intervention for the resident would be to use a pressure alarm while he/she is in bed. The report lacked documentation of what time the fall occurred and staff failed to complete a root cause analysis for this fall. The 9/28/15 fall investigation report stated staff found the resident sitting on the hallway floor outside of his/her room, with his/her wheelchair in front of him/her. The resident was unable to describe what happened. The report stated staff reviewed the resident's care plan, with no new recommendations or interventions, and would continue the current care plan. The report lacked documentation of what time the fall occurred and staff failed to complete a root cause analysis for this fall. The 12/31/15 fall investigation report stated staff observed the resident on the floor in his/her room. The report stated the resident was unable to describe what happened, and was not able to recall the incident the next day. The report stated the time of the fall to be approximately 3:10 AM. The report listed a pressure alarm while the resident is in bed as a recommendation or new intervention. The staff failed to complete a root cause analysis for this fall. The 1/16/16 at 5:30 AM (late entry), nurse's notes stated at approximately 3:00 AM on 12/31/15, staff found the resident on the floor. The pressure alarm did not sound to alert the staff that the resident was getting out of bed. The note stated the resident had no injury, except facial grimacing and pulling away his/her leg when staff examined the right hip area and the resident transported to the hospital for evaluation. The note stated the hospital called the facility and reported the resident's x-rays were unremarkable, and the resident would return to the facility. The 12/31/15 emergency room report stated the ankle showed no edema (swelling) and the resident would be transferred back to facility and proceed accordingly. An addendum to the report stated as the hospital staff dismissed the resident, facility staff noted he/she had a little swelling to his/her right ankle and resident was brought back into the hospital for an x-ray of his/her right ankle. The x-ray revealed a non-displaced fracture of the right ankle. The report stated a (CAM) controlled ankle movement walking boot was placed on the resident's right ankle, and the resident would be reassessed in the physician's office the following week. The 12/31/15 x-ray report indicated the resident had a right fibula (bone in the lower leg) fracture. The 12/31/15 at 7:30 AM, the nurse's notes stated the resident returned to the facility at 7:45 AM, with a boot in place on his/her right foot/ankle, and with orders for no weight bearing, instructing the staff to keep the resident's right lower extremity elevated, and to place an ice pack on the area 4 times a day, for 30 minutes, for the next 24 hours. The 1/5/16 at 10:55 AM, nurse's note stated the resident returned from an appointment with his/her physician, with orders for the boot to remain in place at all times, except to remove it 2 times a day to check the resident's skin, and to see the physician in 3 weeks, with an x-ray prior to the appointment. On 2/4/16 at 12:30 PM, observation revealed the resident, sat in a wheelchair, with a boot in place on his/her right foot. Nurse Aide A and Nurse Aide B used the full mechanical lift to transfer the resident from his/her wheelchair, to the bed. Nurse Aide A placed 2 pillows under the resident's right lower leg/foot to elevate it. Further observation revealed there was a pressure alarm on the resident's bed, and a green light which indicated the alarm was on. On 2/11/16 at 4:30 AM, Nurse Aide C stated he/she checked the alarm when putting the resident to bed. Nurse Aide C was not aware of who was to check the alarms to be sure they worked. On 2/11/16 at 1:20 PM, Nurse Aide B stated he/she didn't know of anyone specific who checked the residents' alarms to be sure they are turned on and in working order and did not know of any place staff should document the alarm checks. A review of the resident's medical record revealed [REDACTED]. On 2/11/16 at 7:55 AM, Nurse D stated he/she had no idea who was responsible for checking the resident's alarm. Nurse D stated I suppose someone should check them to be sure they're working, but I do not know who. On 2/11/16 at 5:55 AM, Administrative Nurse E verified the pressure alarm on the resident was not on at the time of his/her fall on 12/31/15. Administrative Nurse E verified the nurses are responsible for checking the alarms. Administrative Nurse E verified the facility has no policy regarding who is responsible for checking the alarm. On 2/16/16 at 1:35 PM, Medication Aide H stated he/she had worked the shift when the resident fell and fractured his/her ankle. Medication Aide H stated he/she assumed the 2:00 PM-10:00 PM shift had completed bed checks on the resident, and he/she did not check the resident's alarm. Medication Aide H stated when the resident fell , he/she noticed the bed alarm was unplugged and the cord was under the mattress on the bed. On 2/18/16 at 8:15 AM, Administrative Staff I verified the staff had not completed a thorough investigation, including root cause analysis for the resident's falls. The facility's 11/18/15 Fall Prevention and Management policy states the facility will maintain equipment and assistive devices in safe working order, identify contributing factors for the fall, complete an investigation for each incident that would include, but is not limited to assessment of the environment, equipment, contributing health history, medical history, attire (footwear and clothing), use of restraints, ambulatory status, including use of assistive devices and toileting needs. The facility failed to provide a safe environment for Resident #1, when his/her pressure alarm was not turned on, and he/she fell , and sustained a fractured ankle. - Resident #4's quarterly (MDS) Minimum Data Set assessment, dated 1/3/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 2, which indicated he/she had severe cognitive impairment. The MDS further indicated the resident required extensive assistance from the staff for transfers, total assistance for toileting, and used a wheelchair for mobility. The MDS indicated the resident had unsteady balance and required staff assistance to stabilize, had upper and lower extremity impairment on both sides, and had no falls. The 1/6/16 care plan directed the staff to perform 30 minute visual checks, encourage the cognitively impaired resident to use his/her call light, place a pressure pad in his/her bed, and a personal alarm in his/her wheelchair. The care plan stated the resident required extensive assistance of 2 staff for transfers. The 2/5/16 at 3:30 PM, nurse's notes stated the staff found the resident on the floor in the hallway outside of his/her room, with his/her feet on the leg pedals of the wheelchair. The resident had a 3 (cm) centimeter hematoma on his/her forehead, a 1cm by 1.2 cm abrasion on his/her left knee, a 2.0 cm x 2.5 cm abrasion on his/her right knee, and a 2 cm by 2.5 cm skin tear to the right arm. The note stated the resident's personal alarm was sounding, but was faint. The 1/16/16 Morse Fall Assessment indicated the resident a high risk for falling. On 2/11/16 at 8:25 AM, observation revealed Nurse Aide F and Nurse Aide G, transferred the resident from his/her wheelchair to the beside commode, with use of a gait belt. Further observation revealed a personal alarm in the resident's wheelchair. On 2/11/16 at 8:35 AM, Nurse Aide F stated the resident has a personal alarm in his/her wheelchair to notify staff when he/she tries to get up from the wheelchair. Nurse Aide F stated he/she was not sure who is responsible for checking the alarms. On 2/11/16 at 8:45 AM, Nurse Aide G stated the resident has a personal alarm in his/her wheelchair to alert the staff when he/she tries to get up. Nurse Aide G is not sure who should check the alarms to make sure they are working. On 2/11/16 at 7:55 AM, Nurse D stated he/she had no idea who was responsible for checking the resident's alarm. Nurse D stated I suppose someone should check them to be sure they're working, but I don not know who. On 2/11/16 at 7:45 AM, Administrative Nurse E stated the personal alarm on the resident's wheelchair wasn't in good working order at the time of his/her fall. Administrative Nurse E stated the alarm sounded, but was very faint. Administrative Nurse E stated nurses are responsible for checking the alarms, and stated the facility has no policy regarding who was responsible for checking the alarm. The facility's 11/18/15 Fall Prevention and Management policy states the facility will maintain equipment and assistive devices in safe working order, identify contributing factors for the fall, complete an investigation for each incident that would include, but is not limited to assessment of the environment, equipment, contributing health history, medical history, attire (footwear and clothing), use of restraints, ambulatory status, including use of assistive devices and toileting needs. The facility failed to provide a safe environment for Resident #4, when his/her personal alarm was not working properly, he/she fell , and sustained a hematoma, abrasion and skin tear.

The facility had a census of 91 residents. The sample included 5 residents, 3 of which were reviewed for accidents and high risk for elopement. Based on observation, record review and interview the facility failed to provide appropriate interventions and supervision and a safe environment to prevent accidents or elopements for 2 of the 3 sampled residents. (#1 and #2) Findings included: - Resident # 1 ' s quarterly (MDS) Minimum Data Set 3.0 assessment, dated 8/16/13, indicated the resident had short and long term memory loss and severely impaired decision making. The MDS indicated the resident ' s vision was adequate and he/she wore glasses. The MDS indicated the resident displayed inattention continuously, disorganized thinking and an altered level of consciousness which fluctuated and required extensive to total assistance of 1-2 staff for most (ADLs) Activities of Daily Living. The MDS indicated the resident was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, facing the opposite direction while walking, moving on off the toilet and surface to surface transfers and no functional limitations in range of motion. The MDS indicated the resident had no falls since the prior MDS was completed. The 5/29/13 (most current) care plan stated the resident was at risk for falls and instructed the staff to check the resident frequently for incontinence or the need to go to the bathroom. The care plan stated a clip alarm was used when he/she was in his/her recliner, and to monitor the resident frequently when he/she was up in the wheelchair. The care plan instructed the staff to keep the resident ' s environment free of clutter or obstructions, and to provide limited to extensive assistance with ADLs as needed. The 8/16/13 fall risk assessment indicated the resident was at high risk for falls. The 8/24/13 at 3:00 PM, investigation follow up form indicated the staff found the resident sitting on the floor in front of his/her roommate ' s bed. The resident stated he/she was waiting to play with the kids. The investigation follow up form indicated the resident ' s roommate stated the resident slid off the bed. Further review of the resident ' s medical record revealed no nurse ' s notes or assessment of the resident after the 3:00 PM fall on 8/24/13. The clinical record lacked evidence the facility implemented interventions after this fall to prevent further falls. The 8/24/13 at 8:00 PM, nurse ' s notes indicated a visitor found the resident on the floor in the dining room. When the nurse arrived the resident was away from his/her wheelchair lying supine (lying horizontally on the back and unconscious. The nurse maintained C-spine (held head in proper body alignment) and had other nurse call 911. While waiting for (EMS) Emergency Medical Service, the resident started to come around. The nurse ' s notes indicated the resident was very lethargic (sluggish) and was in and out of consciousness. The resident ' s oxygen saturation was in the low 80s (normal range is 90 - 100. The 8/24/13, hospital ' s History and Physical stated the resident ' s fall was unwitnessed and the facility had returned the resident to his/her room after finding him/her on the floor in the dining room and he/she was difficult to arouse. The resident was hypoxic (inadequate supply of oxygen) at 80% by EMS and 4 Liters of oxygen was applied per nasal cannula. The resident ' s oxygen level was 96% in the emergency room . The resident had a large contusion (bruise) to the right occiput (pertaining to the back of the head) with ecchymosis (bruising), tender to palpation and no skull depression. The resident was alert and oriented x 2, knew he/she was at the hospital and was able to tell the physician his/her name. Further review of the resident ' s medical record revealed the care plan had not been updated since the 8/24/13 falls. Review of the medical record revealed the resident was readmitted to the facility on [DATE] at 11:00 AM. On 8/28/13 at 5:40 PM, observation revealed the well groomed resident seated in a wheelchair, receiving oxygen by a nasal cannula, with staff sitting beside him/her assisting with the evening meal. Observation revealed the resident wore glasses, had a personal alarm attached to the back of his/her shirt, and a portable oxygen tank secured on the back of the resident ' s wheelchair and the oxygen at 1 ? Liters. On 8/29/13 at 9:44 AM, observation revealed the resident had a bruised area, approximately 2 inches in diameter on the back of his/her head. On 8/28/13 at 5:50 PM, Nurse I stated he/she checked the dining room frequently and did not go to break until the residents were all out of the dining room. On 8/28/13 at 5:55 PM, Nurse A stated a nurse aide is to stay in the dining room until every resident is out of the dining room. Nurse A stated he/she tries to check and make sure all of the residents are out of the dining room or a nurse aide is still in the dining room with them. On 8/28/13 at 6:01 PM, Nurse Aide J stated a staff person was to be in the dining room until all the residents were out of the dining room and taken to their rooms. On 8/29/13 at 2:33 PM, Nurse A stated the resident was more alert on 8/24/13 prior to his/her falls. Nurse A stated, on 8/24/13 at around 3:00 PM, the resident had transferred him/herself from his/her wheelchair to his/her roommate ' s bed and the roommate stated the resident had slid off the bed onto the floor. Nurse A stated he/she was working that evening with 2 aides and had called another nurse in to help do treatments. Nurse A stated he/she thought the resident was probably left in the dining room from approximately 6:30 PM until he/she was notified the resident was on the floor in the dining room at 8 PM. Nurse A stated the resident was lying on his/her back with his/her head facing the entrance of the dining room and his/her feet were a ways from the wheelchair. Nurse A stated he/she thought the resident had stood up to walk and had fallen. Nurse A stated the resident ' s skin was gray and the oxygen tubing was too short to reach the resident from the back of his/her wheelchair and the nasal cannula was not in place so the resident was not receiving any oxygen. Nurse A stated the resident was unresponsive for 10-15 minutes and Nurse A felt the resident had possible head injuries and held the resident ' s head in C-spine position and had another nurse call 911, then let EMS take over the resident ' s care upon their arrival. Nurse A stated when EMS checked his/her Oxygen Saturation it was in the low 80 ' s. Nurse A stated the resident had 1 eye which was constricted and the other eye was dilated. Nurse A stated he/she felt the resident, who rarely propels him/herself in the wheelchair, had been left in the dining room since supper. Nurse A stated the emergency room physician called and asked how the resident was laying when found and how long he/she may have laid there. On 9/3/13 at 7:48 AM, Nurse Aide B stated the resident did not independently propel him/herself in the wheelchair. On 9/3/13 at 8:45 AM, Administrative Nurse C verified no nurse ' s notes or assessment regarding the resident ' s fall at 3:00 PM on 8/24/13 had been documented. On 9/4/13 at 4:34 PM, Physician Extender N stated when the resident was sent to the emergency roiagnom on [DATE], it was the first time he/she had met the resident. Physician Extender N stated he/she was concerned about the length of time the resident possibly was on the floor especially in a common ' s area. Physician Extender N stated the resident was incontinent of urine and was " out of it " and was admitted to the intensive care unit due to having bilateral pulmonary emboli. The Physician Extender N stated he/she was not aware the resident had a fall earlier the same day prior to going to the emergency room and also remembered the resident had a large bruise/contusion on the back of his/her head but would not be able to say if the bruise/contusion was from the first or the second fall on 8/24/13. The facility failed to provide adequate supervision to prevent accidents for Resident # 1 who fell at 3:00 PM and staff failed to document an assessment or interventions put into place to prevent future falls. The resident fell again at 8:00 PM in the dining room approximately 1 ? hours after the evening meal when he/she was left in the dining room alone and a visitor found him/her resident lying on the floor in the dining room unresponsive and without his/her oxygen on. - Resident # 2 ' s annual (MDS) Minimum Data Set 3.0 assessment, dated 7/24/13 indicated the resident scored 4, on the (BIMS) Brief Interview for Mental Status, which is severe cognitive impairment. The MDS indicated his/her vision was adequate and he/she wore glasses and displayed disorganized thinking which did not fluctuate. The MDS indicated the resident required extensive assistance of 1 staff for personal hygiene, bathing, limited assistance of 1 staff for toileting and set up with staff supervision for the rest of his/her (ADLs) Activities of Daily Living. The MDS indicated the resident ambulated with a walker and was not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, and turning around facing the opposite direction while walking. The 8/1/13 (CAAs) Care Area Assessment summary stated the resident had trouble with short term memory during interviews for the MDS. The CAAs stated the resident was unable to find words to answer the questions and could not remember what he/she had done with his/her family the prior day. The CAAS stated the resident appeared to understand the context of questions but had difficulty finding words to answer the questions and would comment " just let me think " and would look off in space for a while and then change the subject. The 7/31/13 care plan stated the resident had some cognitive loss/dementia and instructed the staff to encourage him/her to visit with others and inform him/her of meals and activities as needed. The care plan instructed the staff to monitor him/her as he/she ambulated unassisted with a walker, and to instruct him/her on safety of smoking only outside or in the smoke room. The care plan stated the South Hall nurse was to keep the resident ' s cigarettes and give him/her one when he/she requested and to supervise the resident with ambulation and instruct him/her to use a walker on and off the unit. The care plan stated the resident enjoyed going out on the front porch. The 8/21/13 care plan update stated, the resident was a potential wanderer, and had left the facility and grounds. The care plan instructed the staff the resident was on a 30 minute wandering check list and a message was placed on the kiosk. The care plan instructed the staff to monitor the resident when he/she was outside smoking. The 8/14/13 at 4:30 PM, nurse ' s notes stated the resident went outside in front of the facility to smoke a cigarette, which is a usual thing for him/her to do. The notes stated the facility received a call from a convenience store across the street from the facility, stating the resident was there and had crossed the street to get there. The notes stated the resident said he/she walked over to buy a pack of cigarettes, when administrative staff picked him/her up and returned back to the facility. The nursing staff explained to him/her that he/she could not leave the facility without some kind of supervision and the cognitively impaired resident stated he/she was sorry and wouldn ' t do it again. Further review of the resident ' s medical record revealed no elopement assessment was completed on this resident and a Wandering Checklist was started on 8/14/13 at 5:00 PM. Review of the wandering checklist, with 30 minute checks, revealed no documentation on: 8/14/13 from 5:30 PM thorough 8/15/13 at 7:00 PM 8/15/13 at 7:30 PM through 8/17/13 at 8:00 AM 8/15/13 at 1:00 PM through 8/19/13 at 6:00 AM 8/19/13 at 9:00 AM through 8/23/13 at 6:00 AM 8/23/13 at 9:30 AM through 8/29/13 at 4:00 PM On 8/29/13 at 9:00 AM, Administrative Nurse B stated all the exit doors are alarmed to alert the staff when a resident leaves the facility. The facility investigated the incident. On 8/29/13 at 9:10 AM, observation revealed all exit doors had a push button for anyone to use and exit the building. On 8/29/13 at 10:31 AM, observation revealed the resident ambulated in the south hallway with a walker and a slow, steady gait and had his/her glasses on. On 8/29/13 at 10:48 AM, the resident stated he/she goes outside the building to smoke several times a day and knows how to exit the building without staff assistance. He/she stated he/she reads large print but eyesight was getting worse and the resident stated he/she thought he/she could hear a car coming even if he/she couldn ' t see it. The resident stated he/she had gone to a convenience store, across the street from the facility one time, and had not told anyone he/she was leaving. The resident stated the staff had talked to him/her not to do that again. On 8/29/13 at 1:29 PM, Nurse Aide D stated the aides only chart the observations of the wandering residents on the wandering sheet. Nurse Aide D stated the resident had not tried to leave the facility before the incident 2 weeks ago. Nurse Aide D stated the resident walked with a steady gait. On 8/29/13 at 2:10 PM, Administrative Nurse C verified the wandering checklist had missing documentation. Administrative Nurse C stated the office staff also helped to keep an eye on the resident when he/she was outside smoking since there ' s a window in their office where they can see him/her easily. Administrative Nurse C stated the nurse ' s aide ' s chart only on the wandering checklist. On 8/29/13 at 2:20 PM, Administrative Staff H stated, on 8/14/13 when the resident left the facility, the staff had decided the resident had attended the wine and cocktail hour, the 4:00 PM activity, and would have gone outside to smoke between 4:15 and 4:30 PM. On 8/29/13 at 2:55 PM, Nurse A stated the resident had gone outside to smoke at approximately 4:00 PM on 8/14/13 and staff did not know the resident had left the facility ' s property until the convenience store across the street, called and asked if a resident from the facility was missing, as a person with a walker came over to buy cigarettes. Nurse A stated Administrative Staff H drove over to pick the resident up and the resident had no injuries. Nurse A stated it was explained to the resident he/she could not go over to the convenience store to buy cigarettes without some kind of supervision. On 8/29/13 at 2:55 PM, Nurse Aide E stated the aides can chart the wandering 30 minute check list on the kiosk (electronic charting) also. On 8/29/13 at 3:20 PM, Ancillary Staff F stated the resident was observed sitting outside on the front porch the day he/she eloped and went around 4:00 PM, as that was the day of the monthly wine and cocktail hour. Ancillary Staff F stated the resident did not have a glass of wine or a cocktail and no one saw him/her walk towards Casey ' s that afternoon. On 8/29/13 at 3:45 PM, Nurse G stated he/she was unable to print the resident ' s wandering checklist due to lack of information recorded in the report. Nurse G verified the only documentation of the checklist was the hard copy which revealed numerous blanks. The facility ' s 9/3/13 Elopement Policy stated resident ' s identified as being at risk for elopement are accounted for every 30 minutes by staff and documentation noted on an individual flow sheet. Residents without a known history or wandering and/or elopement are to be accounted for at least every 2 hours day and night. The facility identified the time after 4:00 PM as the period when most elopements seem to occur, probably due to Sundowner ' s Syndrome (a condition in which a person tends to become confused or disoriented toward the end of the day). The facility failed to provide adequate supervision for Resident # 2 to prevent further elopements.