Every finding on record at Horizon Post Acute

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent accidents for Resident (R) 71, who required assistance with bathing. On 04/27/2026 at 08:00 PM, R71 self-propelled himself into an unlocked shower room, then came out and waved down Certified Nurse Aide (CNA) M to request assistance with shaving. CNA M assisted R71 with shaving and then left the resident alone in the shower to complete his own shower. While staff were out of the shower room, R71 slipped and hit his chin on the shower bar. Approximately two hours later, R71 began to feel nauseous. He vomited, reported a headache, and requested to go to the hospital. R71 went to the emergency department, where he was diagnosed with a subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain) and was subsequently placed on a ventilator. The resident returned to the facility on [DATE] on hospice and died in the facility on 05/06/2026. This placed R71 in immediate jeopardy. The facility further failed to identify causative factors for falls and develop and implement interventions to prevent further falls for R68 and R6, and failed to ensure a safe, accident-free environment when staff propelled R8 in his wheelchair without the use of foot pedals. Findings Included:- R6's Electronic Health Record (EHR) documented diagnoses of difficulty in walking, weakness, abnormal posture, lack of coordination, and anxiety. R6's admission Minimum Data Set, dated 05/01/2026, documented a Brief Interview for Mental Status score of 15, which indicated intact cognition. R6's Falls Care Area Assessment (CAA), dated 05/01/2026, documented that he triggered for falls due to daily antianxiety medication use, therefore increasing his risk for falls. R6's Functional Ability CAA, dated 05/01/2026, documented that R6 required partial or moderate assistance with lower body dressing, donning, and doffing footwear. He required supervision or touching assistance with walking and setup, clean-up assistance for meals. He had recently admitted and was working with Physical Therapy, Occupational Therapy, and Speech Therapy for strengthening. The Nursing - Clinical admission Evaluation - V 4.0 - - V 6 dated 04/24/2026 documented R6 was a moderate risk for falls. The Nursing - Clinical admission Evaluation - V 4.0 - - V 6 dated 05/12/2026 documented R6 was a high risk for falls. R6's Care Plan dated 04/25/2026 addressed oxygen therapy to assist with ambulation as indicated. The care plan did not address a fall risk and lacked interventions related to fall prevention. R6's Fall Incident Report dated 05/11/2026 documented R6 had a fall as he was walking in the hall and felt himself going down and tried to use his right hand to prevent a fall that resulted in R6 going to the hospital for shoulder pain. There was no post fall intervention documented. On 06/01/2026 at 01:01 PM, observation revealed R6 ambulated with a walker and one staff assistance including a gait belt. During an interview on 06/03/2026 at 09:38 AM, Certification Medication Aide (CMA)S stated that R6 was not a fall risk as she had checked the care plan before her shift, but said he would call for assistance as he used a portable oxygen tank and a walker. During an interview on 06/03/2026 at 09:45 AM, Licensed Nurse (LN) J stated R6 was a fall risk, and it should be in his care plan as he had a recent fall. LN J was a standby assist due to being off balance and on oxygen. During an interview on 06/03/2026 at 01:45 PM, Administrative Nurse D stated that staff would know if a resident was a fall risk by looking at their care plan, huddle, or during rounds with staff. Administrative Nurse D stated that to ensure resident safety after a fall that it would be investigated as to why it happened, education would be provided, and it would be put in the care plan as a fall precaution. Administrative Nurse D stated that all resident falls should be updated in the resident care plan as a fall risk with an intervention. R6's Electronic Health Record (EHR) documented diagnoses of difficulty in walking, weakness, abnormal posture, lack of coordination, and anxiety. R6's admission Minimum Data Set, dated 05/01/2026, documented a Brief Interview for Mental Status score of 15, which indicated intact cognition. R6's Falls Care Area Assessment (CAA), dated 05/01/2026, documented that he triggered for falls due to daily antianxiety medication use, therefore increasing his risk for falls. R6's Functional Ability CAA, dated 05/01/2026, documented that R6 required partial or moderate assistance with lower body dressing, donning, and doffing footwear. He required supervision or touching assistance with walking and set-up, clean-up assistance for meals. He had recently admitted and was working with Physical Therapy, Occupational Therapy, and Speech Therapy for strengthening. The Nursing - Clinical admission Evaluation - V 4.0 - - V 6 dated 04/24/2026 documented R6 was a moderate risk for falls. The Nursing - Clinical admission Evaluation - V 4.0 - - V 6 dated 05/12/2026 documented R6 was a high risk for falls. R6's Care Plan dated 04/25/2026 addressed oxygen therapy to assist with ambulation as indicated. The care plan did not address a fall risk and lacked interventions related to fall prevention. R6's Fall Incident Report dated 05/11/2026 documented R6 had a fall as he was walking in the hall and felt himself going down and tried to use his right hand to prevent a fall that resulted in R6 going to the hospital for shoulder pain. There was no post fall intervention documented. On 06/01/2026 at 01:01 PM, observation revealed R6 ambulated with a walker and one staff assistance including a gait belt. During an interview on 06/03/2026 at 09:38 AM, Certification Medication Aide (CMA)S stated that R6 was not a fall risk as she had checked the care plan before her shift, but said he would call for assistance as he used a portable oxygen tank and a walker. During an interview on 06/03/2026 at 09:45 AM, Licensed Nurse (LN) J stated R6 was a fall risk, and it should be in his care plan as he had a recent fall. LN J was a standby assist due to being off balance and on oxygen. During an interview on 06/03/2026 at 01:45 PM, Administrative Nurse D stated that staff would know if a resident was a fall risk by looking at their care plan, huddle, or during rounds with staff. Administrative Nurse D stated that to ensure resident safety after a fall that it would be investigated as to why it happened, education would be provided, and it would be put in the care plan as a fall precaution. Administrative Nurse D stated that all resident falls should be updated in the resident care plan as a fall risk with an intervention. The facility policy Fall Prevention Program, dated 02/01/2026 date reviewed/revised 03/10/2026, documented that each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. - R8's Electronic Health Record (EHR) documented diagnoses of pneumonia (an infection in the lungs due to inhalation of food and vomit), sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), altered mental status (state of awareness that was different from the normal awareness of a person), neuropathy and neuralgia (weakness, numbness, and pain from nerve damage, usually in the hands and feet), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (HTN-elevated blood pressure). R8's Modification of admission Minimum Data Set (MDS), dated 12/22/25, documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. R8 required a wheelchair for mobility. The MDS documented that R8 required supervision or touching assistance with a walker and for most of his other activities of daily living (ADL). R8's 12/22/25 Falls Care Area Assessment (CAA) documented R8 is at risk of falls and has an increased risk of falling due to the neuropathy in his bilateral lower extremities. The CAA documented R8's internal risk factors are neuromuscular with neuropathy, perceptual with vision impairment, and cognitive impairment. R8's Quarterly MDS, dated 03/24/26, documented a BIMS score of 14, which indicated no cognitive impairment. R8 was independent with mobility in a wheelchair and independent to supervision or touching assistance for most of his other ADLs. The MDS also documented R8 had one non-injury fall. R8's Care Plan, dated 12/18/25, documented he was at risk for falls due to impaired balance, poor safety awareness, neuromuscular and functional impairment and/ or the use of medications that may increase fall risks related to a history of repeated falls and neuropathy. R8's Fall Risk Evaluation, dated 03/31/26, documented that he was a high fall risk. R8's Rehab Post Fall Evaluation, dated 03/31/26, documented a fall on 03/30/26 at 10:45 PM and further documented R8 used a wheelchair as an assistive device. Observed on 06/01/26 at 08:45 AM, staff pushed R8 in a wheelchair without foot pedals, R8's legs were bent at the knee, and his feet were positioned just above the floor. Observed on 06/01/26/26 at 09:05 AM, R8 transferred himself into bed without assistance. On 06/01/26 at 08:45 AM, Certified Nurse Aide (CNA) QQ reported residents should not be pushed in a wheelchair without foot pedals on their wheelchairs. She knew she had been caught pushing [R8] in his wheelchair without his foot pedals and further reported she knows she is not supposed to do that. On 06/02/26 at 11:50 AM, Licensed Nurse (LN) I reported that staff should find the foot pedals for the wheelchair and use them any time they are pushing a resident in their wheelchair, and further reported that all residents that have wheelchairs also have foot pedals available for use on their wheelchairs. On 06/02/26 at 01:15 PM, Administrative Nurse D reported staff were to use foot pedals when pushing a resident in their wheelchair. The facility fall prevention policy dated 02/01/26, with date reviewed/revised 03/10/26, documents that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on review and interviews, the facility failed to facilitate and ensure the resident council was able to meet regularly. Findings included:- Record review of the Resident Council Meeting revealed the facility had no minutes or meetings for the months of May 2025 through May 2026.On 06/02/26 at 02:00 PM, Resident (R) 3 stated the Resident Council had not met on a regular basis since the new owners acquired the facility. R3 stated the Administrative Staff A conducted a meeting in 02/26. R3 stated she could not remember the actual day of the meeting. R3 stated the activities directors used to facilitate the Resident Council meeting but said the facility had several turnovers in the activity department, and a Resident Council meeting had not occurred.On 06/03/26 at 01:31 PM, Administrative Nurse D stated Administrative Staff A had held a meeting with the residents. She stated the facility had turnover in the activity department. She stated she was unsure if the meetings were happening.On 6/03/26 at 02:11 PM, Administration Staff A stated she had arranged and assisted the residents with one resident council meeting in the past three months. She stated she did not know where the minutes to that meeting could be found. She stated she had not had many grievances filed since she had become the administrator at the facility.The facility's Resident Council Meeting policy dated 02/01/26 documented the facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. This policy provides guidance to promote structure, order, and productivity in these group meetings.

Based on interviews, record reviews, and observation, the facility failed to ensure a safe, clean, comfortable, home like environment. This deficient practice placed the residents at risk for tripping hazards, electrical accidents, respiratory hazards, and decreased comfort. Findings included:- On 06/01/2026 at 07:40 AM, observation revealed the 300 hall had a maintenance storage room unlocked with seven air conditioner units stacked in it.On 06/01/2026 at 07:45 AM, initial tour revealed the following:Observation revealed R8 had a black fuzzy substance on the windowsill on the corner of the right window. The walls had several areas without paint. R8 stated that he did not use the window air conditioner as he was afraid it would blow out dust or some other substance on him.Observation of the 200 hall revealed there was no cover on one ceiling light with two springs approximately ten inches hanging down. The cart with the red cooler on it, with two plastic scoops in a zip lock bag was dirty with pieces of popcorn on the second shelf. The bottoms of numerous doors in the hallway had black substance all over them. The walls above the trim in the hall had white spackle looking substance all over the wall above it. A second light fixture with cover was broken on the right end and was missing a light bulb, so it was dimly lit.Observation of the 500 hall revealed six holes in the wall above the baseboard, and the courtyard door to the outside was not shut. The handrails in the 500 hall had large areas of missing paint with visible dirt on brackets behind the handrails. The second courtyard door was unlocked to the outside. The storage room in the 500 hall had five tall boxes of supplies and one plastic wrapped mattress sitting directly on the floor.Observation of the 100 hall revealed the floor was stained and had brown dirt like substance along the middle of the hallway with a blue popped balloon on the hallway floor. The Hoyer lift was sitting in the hallway against the wall with food debris and other black substances on the foot part.Observation revealed the floor on the right side, next to the activity room and respiratory storage room, had a vent with a black organic-like substance on the wall. The same substance was present in the vent on the 100 hall.On 06/02/26 at 08:40 AM, observation of the dining room revealed a white floor vent towards the northeast wall was covered in dust, and a vent cover was knocked off the bottom of the wall and laid on the dining room floor.During an interview on 06/02/2026 at 08:21 AM, Housekeeping E stated that housekeeping cleans the vents every day in the hallways and in the rooms, along with cleaning the air conditioner units, but they do not change the air conditioner filters. During an interview on 06/02/2026 at 08:25 AM, Maintenance V stated that they do not ever change the air conditioner filters, but they do clean them once a week. He said he would ask if it is charted somewhere, as he does not chart it. He stated that he worked with housekeeping to make sure the cleaning got done, and that he would check with housekeepingOn 06/02/2026 at 08:53 AM, Maintenance V stated staff just implemented a checkoff sheet for housekeeping staff to document on when the cleaning was done.During an interview on 06/03/2026 at 10:15 AM, Maintenance V stated that he received an alert on his phone for issues that needed addressed and it would be addressed immediately. He stated the vents with black substance on them were to be cleaned and monitored every day to make sure it would be gone. He stated that staff have a meeting every two weeks for concerns. Maintenance V stated the vents were addressed by housekeeping.During an interview on 06/03/2026 at 01:40 PM, Administrative Nurse D stated that the expectation for staff to identify cleaning needs or broken equipment should be addressed immediately with See something, say something by informing maintenance when there is an issue or staff is to clean it themselves when they notice it.The facility policy The Safe and Homelike Environment dated 02/01/2026 documented that in accordance with residents' rights, the facility would provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. That included ensuring that the resident would receive care and services safely and that the physical layout of the facility, both inside and outside, maximized resident independence and does not pose a safety risk.

Based on observation, record review, and interviews, the facility failed to ensure staff assisted Residents (R)5 with bathing, and hygiene as needed. Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R5 had an impairment of the extremities on both sides of his lower body. The MDS documented R5 needed set up or clean up assistance with eating and oral hygiene, and dependent on staff for toileting, bathing, and dressing. R5's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 03/09/26 documented R5 triggered for alterations in functional abilities and self-care/mobility due to requiring assistance with activities of daily living (ADLs), set-up assistance for meals, oral care, and total care for self-care needs, such as bathing, toileting, turning, and mobility needs. R5's Care Plan documented:04/21/26-R5 had a self-care deficit and required assistance with ADLs and was incontinent.R5 was a two-person assistance with bathing and showing. Staff would inspect skin during showers, alert nurses to any skin issues, and encourage two baths a week. Staff were to check R5's nails and trim and clean his nails during baths. R5's EMR under Care Report documented R5 preferred days for showers were Monday and Thursday, the Care Report documented a bath on 04/02/26, 04/04/26, and 04/17/26, and no bathing in the month of 05/26. R5's Bath Sheets revealed no bath sheets from 04/01/26 through 05/31/26. R5's EMR lacked any documentation of bathing refusals. On 06/01/26 at 12:05 AM, R5's right hand land on his electric wheelchair. R5's fingernails were long and had a dark brown substance under his fingernails. On 06/02/26 at 08:24 AM, R5's right hand laid on his right side on his abdomen. R5's fingernails were long and had a dark brown substance under his fingernails. On 06/01/26 at 12:05 PM, R5 stated he had only one shower since he had been here in the last two years. He stated staff had told him he was too big for the shower chair. He stated he had received a few bed baths. R5 stated he was unsure when he should get his baths or showers as he doesn't get a shower or a bath. He stated he would wash his hands and try to get his fingernails clean, but he was unable to use his sink. He stated his sink was not cleaned and staff dumped his urine from his catheter bag down his sink, and no one cleaned the sink. On 06/03/26 at 09:46 AM, Certified Medication Aide (CMA)R stated she was hired a couple months ago as the bath aide. Stated she did not chart bathing in the EMR and that she just found out yesterday that she was supposed to chart in TASK for bathing. She stated the facility's process for bathing was that she used a bathing sheet. She stated she asked the residents if they would like a shower. If the resident refused, the refusal was documented on the bath sheet. If there had been several refusals, the bath sheets would be taken to Administrative Nurse D. She stated she did not know what happened after she turned the refusals in to Administrative Nurse D. CMA R stated fingernails were cleaned in the shower. She stated if she was able to trim nails, she would during the residents shower. On 06/03/26 at 09:39 AM, LN I stated she didn't do anything with showers; she stated the facility had a bath aide, and she did showers. LNI stated if a resident refused their shower, the aide takes the sheets to the nurse, the nurse was to talk to the resident and ask again if the resident would like a shower at a different time. LN I stated the shower sheets go to Administrative Nurse D, and she takes care of the refusals. LN I stated all nursing staff could clean a residents fingernails. On 06/03/26 at 01:31 PM, Administrative Nurse D stated in a perfect world, all showers would be given when the resident would like a shower. She stated the facility had a lot of turnover in staffing in the last few months. Administrative Nurse D stated the previous owners had used bath sheets, and the current facility continued with the bath sheets. She stated the facility had hired bath aides in 05/26, and the expectation going forward was that bathing would be performed for each resident and charted in the residents EMR. She stated bathing refusals should be charted in the resident's progress notes. The facility ADLs policy dated 02/01/26 documented the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services would be provided for the following activities of daily living, bathing, dressing, grooming and oral care.

Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 8's medical record. Findings included:- On 06/02/26 at 07:55 AM, Certified Medication Aide (CMA) R left her locked medication cart unattended with the laptop screen unlocked, and R8's personal medical information and medications were visible on the screen. On 06/02/26 at 07:57 AM, CMA R returned to her medication cart. CMA R confirmed she was assigned to that medication cart. CMA R then stated she was not positive if the screen needed to be locked or hidden when she was not at the cart. On 06/03/26 at 09:26 AM, Licensed Nurse (LN) I stated that medication carts and laptop screens should be locked at any time a medication aide or nurse walked away from the cart. On 06/03/26 at 01:32 PM, Administrative Nurse D confirmed that the cart and laptop screen should be locked when the staff member walked away from the cart. The facility's Confidentiality of Personal and Medical Records policy dated 02/01/26 documented this facility honors the resident's right to secure and confidential personal and medical records. This included the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.

Based on interviews, observation, and record review the facility failed coordinate care for Resident (R) 22 following a Preadmission Screening and Resident Review (PASSAR-short series of questions designed to determine whether or not a more in-depth assessment for mental health or mental retardation services is required) which indicated a PASSAR II (an in-depth assessment for the purpose of determining whether the individual requires the level of services provided by a nursing facility or the level of services provided in a specialized program for persons with mental illness or developmental disabilities) was needed. Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Quarterly Minimum Data Set (MDS) dated 04/15/26 documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R22 required staff assistance for setup and cleanup during bathing. R22's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/16/25, documented she had a cognitive deficit and visual hallucinations. R22's Care Plan documented the following interventions: 02/04/26 - Staff would encourage ongoing family involvement.Staff would invite her family to attend special events, activities, and meals.Staff would invite and encourage her to attend activities, offer assistance for locomotion as indicated. Staff would invite her to all scheduled activities. Staff would provide her with in- room activities as needed and desired.Staff would provide her with social interaction opportunities. She enjoyed visits from her family and spending time with her dog. She enjoyed word games, trivia bingo, and ice cream socials. R22's EMR under the MISC tab revealed a PASSAR I, dated 09/11/24, which documented she was indicated for further evaluation. R22's clinical record lacked evidence further evaluation (PASSAR II) was provided.The facility was unable to provide evidence a PASSAR Level II was requested and provided as indicated for R22 as requested on 06/03/26 at 08:15 AM.On 06/02/26 at 08:42 AM, R22 sat in the dining room with a smoker apron on. She sat and watched TV. Her hair was oily and stringy.On 06/03/26 at 01:33 PM, Administrative Nurse D stated the social service department was unable to find any documentation that level two PASSAR assessment was completed as indicated. The facility's Resident Assessment - Coordination with PASARR Program policy dated 02/01/26 documented the facility coordinated assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on observation, record review, and interviews, the facility failed to revise Resident (R) 5's Care Plan to include the care of his catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin.R5's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R5 had an impairment of the extremities on both sides of his lower body. The MDS documented R5 needed setup or cleanup assistance with eating and oral hygiene, and dependent on staff for toileting, bathing, and dressing. The MDS documented R5 had a Foley catheter during the observation period.R5's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 03/09/26 documented R5 triggered for alteration in elimination and the need for an indwelling catheter due to activities of daily living (ADLs). The CAA documented assistance was required with toileting, perineal care, use of a bed pan for bowel elimination needs, and indwelling catheter care, therefore placing him at risk for alterations in elimination needs.R5's Care Plan documented:02/04/26 - R5 was incontinent with bowels and risk for impaired skin, rashes, and irritation in the peri-area. Staff were to check R5 every two hours and assist him with toileting as needed. Staff were to keep R5's call light within his reach to use to notify nursing if R5 needed assistance with toileting or incontinence episodes. Staff to provide loose fitting, easy to remove clothing.R5's Care Plan lacked staff direction for the care of R5's urinary catheter.R5's EMR revealed the following physician orders:Indwelling urinary catheter irrigate with 60 milliliters (mls) of normal saline every shift for catheter care.Complete catheter care, hang catheter to dependent drainage, and keep inside a dignity bag, chart output every shift, every shift for urine retention.On 06/01/26 at 08:10 AM, R5 laid in his bed with his eyes shut. R5's urinary catheter bag was three fours full of yellow urine and hung from R5's bed, R5's catheter tubing was placed under his right leg, and the bag was not secured to the bed, it was dangling from the bed. R5's bag was just dangling. R5 did not have a dignity bag.On 06/03/26 at 09:51 AM, Certified Nurse Aide (CNA) Q stated he would know how to care for R5's urinary catheter by the ADL log located at the nurse's desk. He stated he was unsure of access to the resident's care plan, the CNA's used the logs at the nurse's desk.On 06/03/26 at 09:36 AM, Licensed Nurse (LN) I stated she was unsure of who placed the urinary catheters on the residents care planOn 06/03/26 at 01:31 PM, Administrative Nurse D stated the urinary catheter should be placed on the residents care plan.The facility's Care Plan Revisions Upon Status Change dated 02/01/26 documented It was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that were identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, record review, and interview, the facility failed to implement an activities program to support Resident (R)10's social needs with involvement in both individual and group activities to support his highest psychosocial well-being when staff failed to offer and provide activities of his choice. Findings included:- R10's Electronic Medical Record (EMR) documented from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and senile degeneration of brain (progressive, age-related cognitive decline).R10's Quarterly Minimum Data Set (MDS) dated 05/15/26 documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R10 was rarely or never understood. The MDS documented R10 was dependent on staff for all activities of daily living (ADLs).R10's Care Plan documented the following interventions:02/09/24-Stff to invite R10 to all scheduled activities. Invite and encourage R10 to attend activities, and offer assistance for locomotion as indicated. Staff to provide in-room activities as desired.03/28/25-R10 would be present for activities but does not always participate.05/22/25- Staff was to encourage R10 to participate in activities that promote exercise, physical activity for strengthening, and improved mobility.02/04/26-Staff to provide R10 with orientation to activities, dietary schedule a general daily schedule of the facility.Review of R10's EMR under Reports tab of the Care Records from 03/01/26-06/01/26 revealed one activity of 1:1 visit on 05/04/26.On 06/01/26 at 08:27 AM, R10 laid in his bed on his back with his eyes shut. R10's head of bed was elevated, and his bed was in a low position, with a fall mat next to his bed.On 06/01/26 at 10:40 AM, R10 laid in his bed, with his head elevated with his bed in a low position. R10's eyes were open, and his TV was on.On 06/01/26 at 12:47 PM, R10 laid in bed on his back, with his bed in a low position. R10's eyes were open, and the TV was on.On 06/02/26 at 08:34 AM, R10 laid in his bed with head of bed elevated, legs bent with his eyes open.On 06/02/26 at 12:17 PM, R10 laid on his back in his bed, his eyes were shut. R10's bed was in a low position.On 06/02/26 at 03:22 PM, R10 laid on his back in his bed. R10's eyes were open. R10 had his TV on.On 06/03/26 at 09:52 AM, Administrative Nurse E stated R10 liked to watch TV and listen to music. She stated there had been a lot of turnover in the last few months in the activities department. She stated there used to be an activities person that would do activities in the memory unit. She stated the residents like to watch TV, and when there were activities, the residents would be involved. She stated she was aware there had not been activities in memory care in the last few days.On 06/03/26 at 01:31 PM, Administrative Nurse D stated there had been a lot of turnover in the activities department, and she was not sure how many people there had been in the last few months. She stated she knows the facility was lacking in activities. She stated she was aware there were no activities in the memory unit.The facility's Dementia Care policy dated 02/01/26 documented it was the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia to meet his or her highest practicable physical, mental, and psychosocial well-being.

Based on observation, record reviews, and interviews, the facility failed to provide adequate catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) acre for Resident (R) 5 when staff failed to secure the tubing with an anchoring device to prevent pulling and injury and further failed to provide a dignity bag for the urine collection bag. Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin.R5'sSignificant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R5 had an impairment of the extremities on both sides of his lower body. The MDS documented R5 needed setup or cleanup assistance with eating and oral hygiene, and dependent on staff for toileting, bathing, and dressing. The MDS documented R5 had a Foley catheter during the observation period.R5's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 03/09/26 documented R5 triggered for alteration in elimination and the need for an indwelling catheter due to activities of daily living (ADLs). The CAA documented that assistance was required with toileting, perineal care, use of a bed pan for bowel elimination needs, and indwelling catheter care, therefore placing him at risk for alterations in elimination needs.R5's Care Plan documented:02/04/26-R5 was incontinent with bowels and risk for impaired skin, rashes, and irritation in the peri-area. Staff were to check R5 every two hours and assist him with toileting as needed. Staff to keep R5's call light within his reach to use to notify nursing if R5 needed assistance with toileting or incontinence episodes. Staff were to provide loose fitting, easy to remove clothing.R5's Care Plan lacked staff direction for care of R5's urinary catheter.R5's EMR revealed the following physician orders:Indwelling urinary catheter is irrigated with 60 milliliters (mls) of normal saline every sift for catheter care.Complete catheter care, hang catheter to dependent drainage, and keep inside a dignity bag. Chart output every shift, every shift for urine retention.On 06/01/26 at 08:10 AM, R5 laid in his bed with his eyes shut. R5's urinary catheter bag was three quarters full of yellow urine and hung from R5's bed. R5's catheter tubing was placed under his right leg, and the bag was not secured to the bed, it was dangling from the bed. R5 did not have a dignity bag.On 06/01/26 at 12:05 PM, R5's urinary catheter bag laid on the foot pedals of his electric wheelchair. The urinary catheter bag was one quarter full of yellow urine. R5's catheter bag did not have a dignity bag.On 06/02/26 at 08:24 AM, R5's urinary catheter laid on the foot pedals of his electric wheelchair. R5's urinary catheter bag had a trace of urine in the bag. R5 did not have a dignity bag.On 06/02/26 at 12:05 PM, R5 stated the facility had never offered to put his catheter bag in a dignity bag. R5 stated the facility did not have an anchor for his catheter. He stated the nurse offered a piece of paper tape to place across the tubing. R5 stated the tubing for the catheter pulls with the paper tape.On 06/03/26 at 09:51 AM, Certified Nurse Aide (CNA) Q stated R5 did let him know the nurse had put tape on his leg to help secure his catheter tubing. He stated he was unsure if the facility had any anchoring device. CNA Q stated the tubing should be anchored. He stated catheter bags should be hung on the wheelchair, placed below the bladder, and in a blue privacy bag.On 06/03/26 at 09:36 AM, Licensed Nurse (LN) I stated all catheter tubing should be secured with an anchor but stated she was unsure who would be responsible for putting the anchor on the catheter tubing. LN I stated she thought the CNA could also apply the anchor. LN I stated the catheter bag should be secured to the wheelchair or bed and not allowed to dangle from the bed. She stated catheter bags should be in a dignity bag.On 06/03/26 at 01:31 PM, Administrative Nurse D stated she was sure the facility had anchors available for resident's catheter tubing, and an anchor should be applied to secure the catheter tubing. She stated the facility had moved the storage room, and the anchors could have gotten misplaced. Administrative Nurse D stated R5 did not like the staff messing with his catheter as it was always placed at the Veterans clinic. She stated R5 not wanting staff to mess with the catheter was the reason he did not have a dignity bag. Administrative Nurse D stated R5 did not want a dignity bag but acknowledged that it was not in R5's plan of care.The facility's Catheter Care policy dated 02/01/26 documented It was the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

Based on observation, record review, and interviews, the facility failed to provide adequate respiratory care and services for Resident(R) 5, who had a respiratory infection, when staff failed to store R5's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and his nasal cannula in a sanitary manner when not in use. Finding Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin. R5's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R5 had an impairment of the extremities on both sides of his lower body. The MDS documented R5 needed setup or cleanup assistance with eating and oral hygiene and was dependent on staff for toileting, bathing, and dressing. The MDS documented R5 was on continuous oxygen and used CPAP during the observation period.R5's Functional Abilities Self-Care Mobility Care Area Assessment CAA dated 03/09/26 documented R5 triggered for alterations in function abilities and self-care/mobility due to requiring assistance with activities of daily living (ADLs), set-up assistance for meals, oral care, and total care for self-care needs, such as bathing, toileting, turning, and mobility needs.R5's Care Plan documented:04/23/26- R5 was on a pulmonary program related to pulmonary prevention.R5 would tolerate full pulmonary treatment without taking breaks.R5 was to wear oxygen as ordered.R5 was to wear his CPAP every night and at naps as tolerated by residents. Per resident preference, he preferred to sleep with nasal cannula on with his CPAP mask over the nasal cannula.R5's EMR documented the following physician's order:Cephalexin (antibiotic) 500 milligrams (mg) give one capsule by mouth three times a day for infection for seven days dated 05/29/26.Oxygen at three liters/minute (ml/min) via nasal cannula every shift dated 04/28/26.CPAP: application assists residents with application of CPAP every bedtime, confirms settings of 12cmH20, and confirm oxygen is hooked up at 3 lt/min and ensure oxygen tubing is attached to both the unit or mask and concentrator. Assist the resident in creating a proper seal date 04/28/26.CPAP: clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use, dated 04/28/26.CPAP: Empty the reservoir and refill at night as needed until 07/01/26 dated 05/01/26.Once a month, respiratory therapists educate resident on CPAP to review rational for the resident on CPAP reviewing rational for the resident's usage of CPAP, inclusive of applicable diagnosis, fit and adjustment of mask, any titration of pressure, review of one time a day starting on the last day of the month, dated 05/01/26.CPAP: Cleanse the reservoir as needed or weekly on Wednesday on day shift dated 05/01/26.CPAP: Replace mask, tubing, accessories, and device upon degradation as needed or per provider recommendation dated 05/01/26.R5's EMR under Progress Notes dated 05/30/26 documented the following Infection Note; R5 continues antibiotics for respiratory infection, he remains without fever and had no complaints of respiratory distress. The oxygen saturations were 97 percent with oxygen; no signs of adverse reactions were noted.On 06/01/26 at 12:05 PM, R5's CPAP and nasal oxygen tubing laid on his bed. R5's respiratory equipment was not stored in a sanitary container.On 06/02/26 at 08:24 AM, R5's CPAP mask was draped over his CPAP machine on his bedside table; his and nasal oxygen tubing laid on his bed. R5's respiratory equipment was not stored in a sanitary container.On 06/03/26 at 09:51 AM, Certified Nurses Aide (CNA) Q stated respiratory equipment should be stored in a bag and the bag should be pulled shut. He stated it was all the nurse's department to duty to place the respiratory equipment in a bag.On 06/03/26 09:39 AM, Licensed Nurse (LN)I stated she was unsure how the respiratory equipment should be stored. She stated she was a new nurse, and she did not apply the CPAP or nasal cannula for R5. She stated during the day respiratory department takes care of respiratory issues. LN, I stated she would find out from her director of nursing.On 06/03/26 at 01:31 PM, Administrative Nurse D stated all respiratory equipment should be placed in a bag when not in use, and all staff could place the respiratory equipment in the bags.The facility did not provide storage of respiratory equipment as requested on 06/03/26.

Based on observation, record review, and interview, the facility failed to ensure pureed food (food has been ground, pressed, and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding) had been prepared to conserve the nutritive value, palatable flavor for two residents on a pureed diet. Findings included:- On 06/02/26 at 10:29 AM, Dietary CC washed his hands and put on a clean pair of gloves and stated there were two pureed diets in the facility but he would prepare three in case a resident wanted more. On the counter was a clean Robot Coupe food processor with a clean container, blade and lid. Dietary CC obtained a metal container from the warmer oven that contained three smothered pork chops. Dietary CC added the pork chops to the container and turned it on to begin chopping/processing the food. Dietary CC then went back to the oven to obtain the container of gravy. He placed the container of gravy on the counter and obtained a clean ladle to scoop out the gravy with and pour into the top of the lid to add to the chops. Dietary CC turned the Robot Coupe off and removed the lid to the container and scraped the food in the container with a plastic spatula, then placed the spatula on a towel on the counter. The lid was placed back on the container, and the processor was turned back on, and he added another ladle of gravy to the pork chops. Dietary CC then removed the lid and container from the processor and grabbed the spatula to assist in pouring the pureed pork chops into a clean metal container and covered with foil and labeled the food. During the process of the puree of this food item Dietary CC did not refer to the recipe for the smothered pork chops available for him to follow.On 06/02/26 at 10:35 AM, Dietary CC stated that the facility had weekly menus each month that included the recipes for each food and how they should be prepared which included the recipe for pureed foods. Dietary CC stated he had been cooking the food and preparing the pureed food for a little while and knew what to add to thin or thicken a food when needed.On 06/02/26 at 10:36 AM, Dietary BB stated she had been the dietary manager for only two weeks and was still educating staff on proper procedures. Dietary BB stated she would re-educate Dietary CC to ensure that he followed the recipes provided for the purees.The facility's Puree Food Preparation policy dated 02/01/26 documented that puree foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogeneous consistency similar to soft mashed potatoes. Do not use water as an additive to prepare puree foods. Refer to your department's Dietary Services manual for additional policies and procedures. Residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per facility policy and procedure. Puree Food Preparation Guidelines per Serving:(More or less may be used depending on the consistency of the cooked food): Meats: Add one teaspoon beef broth or beef gravy Poultry: Add one teaspoon chicken broth or chicken gravy Fish: Add one teaspoon mayonnaise Noodles: Add one teaspoon margarine Vegetables (leaf, stem, or flower): Add two teaspoon mashed potato flakes Vegetables (root, tuber): Add one teaspoon margarine Fruits (EXCEPT grapes, oranges, grapefruit, bananas, plums): Remove peels, skins, cores, pits, and or seeds. Add one tablespoon food thickener (most watery fruits require a food thickener).

Based on observation, record review, and interview, the facility failed to ensure Resident (R)5's call light was within his reach to enable him to call for staff assistance. Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin.R5's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R5 had an impairment of the extremities on both sides of his lower body. The MDS documented that R5 needed setup or cleanup assistance with eating and oral hygiene and was dependent on staff for toileting, bathing, and dressing. The MDS documented R5 had no falls during the observation period.R5's Falls Care Area Assessment (CAA) dated 03/09/25 documented he had anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), antidepressant (a class of medications used to treat mood disorders) drug use, and assistance required for activities of daily living (ADLs), which placed R5 at risk for falls.R5's Care Plan documented:10/30/23-R5 was incontinent of bowels and was at risk for impairment of skin, rashes, and irritation of the peri-area. Staff were to keep R5's call light within his reach to use to notify nursing to use the toilet or an incontinence episode.04/21/26-R5 was at risk for falls related to impaired balance, poor safety awareness, and the use of medication that increases his fall risk. Staff were to keep R5's call light within his reach as he allows.On 06/01/26 at 08:10 AM, R5 laid in his bed with his eyes shut. R5's call light was at the bottom of his bed, on the left-hand side. R5's call light was out of his reach.On 06/03/26 at 09:46 AM, Certified Nurse Aide (CNA) Q stated call lights should be placed on the bed rail or on the person. He stated staff should let the residents know where they have placed the call light.On 06/03/26 at 09:39 AM, Licensed Nurse (LN) I stated call lights should always be within the resident's reach.On 06/03/26 at 01:31 PM, Administrative Nurse D stated call lights should be where the resident could reach and use the call light.The facility's Accommodation of Needs policy dated 02/02/26 documented facility would treat each resident with respect and dignity and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.

Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 when staff failed to assess the residents dialysis (a procedure where impurities or wastes are removed from the blood) access site within the standards of practice. The facility additionally failed to ensure R2 had an active physician's order that included the time, place, and days of their dialysis clinic treatments. Findings included: - R1's EMR from the Diagnosis tab documented diagnoses of dependent on dialysis and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated 05/04/26 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had received hemodialysis during the observation period. R1's Urinary Incontinence and Indwelling CAA, dated 12/05/25 documented she had had feeling of urinary retention related to dialysis. R1's Care Plan, documented the following interventions: 12/01/25 – The Dialysis provider information. Staff would complete the Dialysis flow sheet daily to observe for shunt access site complications-report abnormalities to physician. Staff would not obtain her blood pressure and no needle sticks from right arm. She had a fluid restriction of 1500 milliliters (ml) daily, with dietary determination for allowance for each shift. Staff would obtain lab work as ordered. Facility would provide transportation to the dialysis provider. Staff would observe her for compliance with treatment regime and would educate her as indicated. Staff would observe shunt site for bleeding and notify the physician if bleeding occurred. Staff would obtain here weights per facility protocol.02/04/26- Dialysis chair times Monday, Wednesday, and Friday at 05:50 AM. R1's EMR under the Orders tab revealed the following physician orders: Dialysis Monday, Wednesday, and Friday. Chair time at 05:50 AM dated 01/12/26. The orders also lacked a physician order for the correct days for dialysis. R1 attended dialysis on Monday, Tuesday, Wednesday, and Friday. Review of the Dialysis Communication Sheets revealed staff assessed R1's access site on dialysis days. R1's EMR lacked evidence staff monitored and assessed the access site on non-dialysis days. On 06/03/26 at 08:30 AM, R1 sat at the dining room table as she finished her breakfast. She sat and talked to another resident before she left for dialysis. On 06/03/26 at 09:37 AM, Licensed Nurse (LN) I stated nursing staff would obtain R1's vital signs and a weight post and pre dialysis. LN I stated R1 attended dialysis every day except Thursday, Saturday and Sunday. LN I stated the nursing staff checked R1's access site on the days she would go out for dialysis. LN I stated she was able to find documentation of R1's access site being checked on Thursday, Saturday, and Sunday. On 06/03/26 at 01:33 PM, Administrative Nurse D stated R1's access site should be accessed and documented on the Medication Administration Record (MAR) or on the Treatment Administration Record (TAR) daily. - R2's Electronic Medical Record (EMR) documented under the Diagnosis tab diagnoses of chronic kidney disease stage 4 (CKD- kidneys are severely damaged and are not properly filtering waste from your blood), Type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R2's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R2 had received hemodialysis during the observation period. R2's Quarterly MDS dated 05/13/26 documented a BIMS score of seven, which indicated a severely impaired cognition. The MDS documented R2 had received hemodialysis during the observation period. R2's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 08/15/25 documented she was incontinent of bladder. She wore incontinence products for protection/dignity. She was dependent on staff for toileting hygiene. She had a diagnosis of DM 2 and CKD stage 4 severe, and bilateral leg amputations (surgical removal of a body part). She received her medications as ordered. R2's Care Plan for dialysis last revised on 08/06/25 documented intervention that directed staff: dialysis days were Tuesday, Thursday, and Saturday at 10:15 AM; a dialysis flow sheet to be completed daily to observe for shunt access site complications-report abnormalities to physician; do not take B/P and no needle sticks in right arm; to be transported to dialysis by facility transportation; observe for compliance with treatment regime and educate resident as indicated; observe shunt site for bleeding-notify physician if bleeding occurs; and weights per facility protocol. R2's Care Plan had not been updated with her current dialysis days of Monday, Wednesday, and Friday with a chair time of 05:15 AM. R2's Care Plan had not been updated with her current outside of the facility transportation provider. R'2 Order Summary in the EMR documented a physician's order dated 10/01/25 to monitor the right arteriovenous fistula (AV-is an abnormal connection between an artery and a vein, allowing blood to flow directly between them while bypassing the tiny capillaries) site for thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt)/bruit (blowing or swishing sound heard when blood flows through a shunt) every shift for shunt. And monitor shunt for signs and symptoms of infection. R'2 Order Summary in the EMR documented a physician's order dated 11/11/25 to remove pressure dressing at bedtime on dialysis days on Monday, Wednesday, and Friday for dialysis. R'2 Order Summary in the EMR documented a physician's order dated 11/13/25 for Pre-Dialysis: Assess thrill/bruit. Chart if present and if absent. Notify dialysis center if absent. Assess access site (SPECIFY LOCATION/TYPE) and document N for normal, B for signs/symptoms of bleeding, or I for signs and symptoms of infection, and notify dialysis for bleeding or signs of infection. Assess cognition and document A for alert, C for confused, or D for disoriented. Please complete prior to dialysis one time a day every Monday, Wednesday, and Fri for hemodialysis related to CKD Stage 4. R'2 Order Summary in the EMR documented a physician's order dated 12/10/25 for Post Dialysis: Assess thrill/bruit. Chart if present and if absent. Notify dialysis center if absent. Assess access site (SPECIFY LOCATION/TYPE) and document N for normal, B for signs/symptoms of bleeding, or I for signs and symptoms of infection, and notify dialysis for bleeding or signs of infection. Assess cognition and document A for alert, C for confused, or D for disoriented. Please complete prior to dialysis one time a day every Monday, Wednesday, and Fri for hemodialysis related to CKD Stage 4. R'2 Order Summary in the EMR documented a physician's order dated 01/15/26, per Dialysis ensure resident is on 960 cubic centimeter (cc) fluid restriction/24hrs every shift for dialysis. R2's Order Summary in the EMR lacked a physician's order specifying the dialysis clinic, the clinic location, the chair time, or the days of dialysis. On 06/03/26 at 11:25 AM, R2 sat in her wheelchair at a table in the dining room waiting for her lunch. R2 stated she had just returned from dialysis and was tired and hungry. R2 stated she goes to dialysis on Monday, Wednesday, and Friday and had to be there by 05:15 AM. On 06/03/26 at 09:45, Licensed Nurse (LN) I stated that R2 had a dialysis book that has the information in it on when she goes to dialysis and what days. LN I stated that R2 should have a physician's order that stated when, where and what days she had dialysis. LN I stated R2's care plan should have where she goes for dialysis and what days and her chair time. On 06/03/26 at 11:20 AM, Administrative Nurse E stated R2 had a dialysis book she takes with her to each dialysis visit. Administrative Nurse E stated the book should have the name of the dialysis clinic, what days she goes, and what her chair time was. Administrative Nurse E stated the physician's order should be in the orders in the EMR. Administrative Nurse E stated R2 went to dialysis on Monday, Wednesday, and Fridays and had just returned from dialysis. On 06/03/26 at 01:32 PM, Administrative Nurse D stated R2's orders tab should have the physician's order for dialysis in the chart that should include the location, days, and chair times for her to go to the clinic. Administrative Nurse D stated R2's care plan should reflect that same information for staff to know. The policy for Hemodialysis dated 02/01/26 documented the facility would coordinate and collaborate with the dialysis facility to assure that: the resident's needs related to dialysis treatments are met; the provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments; documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team; and there was ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The facility will ensure that the physician's orders for dialysis include: the type of access for dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location; the dialysis schedule; the nephrologist name and phone number; the dialysis facility name and phone number; transportation arrangements to and from the dialysis facility; any medication administration or withholding of specific medications prior to dialysis treatments; any fluid restriction if ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing sheet was posted and failed to retain the required 18 months of daily nurse staff posting. Findings included:- On 06/01/2026 at 07:37 AM, observation revealed that there was no nurse staffing sheet posted.During an interview on 06/03/2026 at 01:40 PM, Administrative Nurse D stated that staffing should be posted where it could easily be viewed. Administrative Nurse D stated that the facility did not keep documents of all daily posted nurse staffing from the last 18 months due to high turnover.The facility policy Nurse Staffing Posted Information dated 02/01/2026 documented that it was the policy of the facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time.

Based on observation, record review, and interviews, the facility failed to post the previous state inspection information in a location accessible to residents and visitors. Findings included:- On 06/01/2026 at 07:37 AM, observation revealed that the state agency results book was not available. During an interview on 06/03/2026 at 01:40 PM, Administrative Staff D stated that there is a survey book for the facility, but she did not know where it was. The facility was unable to provide a policy related to past survey results availability.

The facility reported a census of 69 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to maintain an effective pest control program. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - The outside vendor for pest control report dated 02/28/25 documented a captured rodent and suggested to the staff to keep doors closed at all times. The outside vendor for pest control report dated 03/13/25 documented staff members mentioned they saw a mouse; the vendor inspected the bait stations and no rodents were noted. The outside vendor for pest control report dated 03/27/25 documented no concerns from staff and none noted. This was the last date the outside vendor for pest control was at the facility. During an interview on 05/21/25 at 11:45 AM, Housekeeper Staff U reported there were rodents in the facility. She reported that she had to deep clean the residents ' rooms in March 2025 and said she found rodent droppings, dried urine, and found a dead rodent in a resident ' s room. Housekeeper Staff U said she reported that to the housekeeping supervisor and the Administrative Staff A. During an interview on 05/21/25 at 11:55 AM, Licensed Nurse (LN) H reported she had not seen any rodents or heard complaints about them from staff or residents. During an interview on 05/21/25 at 12:00 PM, Certified Nurse Aide (CNA) O reported that he had never seen a rodent in the facility but had seen signs of mice droppings in residents ' rooms recently and reported that to the housekeeper. During an interview and observation on 05/21/25 at 12:40 PM, Resident (R) 2, who had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition, showed the surveyor two dead mice in spring-loaded mice traps in her garbage. R2 said that she caught the mice with the spring-loaded mouse traps that she had placed under her bed the previous night. R2 reported that this was not the first time she had to catch mice in her room. She reported that she was out of the mouse traps and would have to ask the maintenance man for more. During an interview on 05/21/25 at 01:15 PM, Maintenance Supervisor V reported there were rodents in hallway 100, evidenced by mice droppings seen in March 2025. Maintenance Supervisor V reported that all the rooms had been deep cleaned and he had not seen or heard about any rodents since then. Maintenance Supervisor V reported the contracted outside vendor for pest control had been to the facility in March 2025 and reported the outside vendor placed the bait stations around the facility and he would not touch those. He reported that he did not know of any resident having a spring-loaded mouse trap and was shocked to see the two dead mice from R2 ' s garbage can from this morning in spring-loaded mice traps. Maintenance Supervisor V reported he would call the outside vendor for pest control to come out. During an interview on 05/21/25 at 02:20 PM, Administrative Staff A reported the outside vendor for pest control service was canceled due to corporate had not paid the invoices. Administrative Staff A reported the last time the outside vendor for pest control was at the facility was March 2025. Administrative Staff A reported that the unpaid invoices would make it difficult to make sure the center is taken care of. The facility ' s policy Pest Control dated May 2008, documented our facility shall maintain an effective pest control program. The facility would maintain an on-going pest control program to ensure that the building is free of rodents.

The facility reported a census of 69 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - During the initial tour of the facility around 08:30 AM on 05/21/25, observation revealed there was flooring missing at the entrance of the dining room on the 300 hallways. Further observation revealed an area approximately four feet long by one foot wide that was covered with blankets which were saturated with water, and surrounded by cautionary wet floor signs on each side of the blankets. During an interview on 05/21/25 at 08:32 AM, Resident (R) 3, who had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition, reported he was concerned about the floor in front of the dining room that had water laying on top of all the blankets for about two weeks. R3 reported he did not feel safe as it was wet all the time. During an interview on 05/21/25 at 11:45 AM, Housekeeper Staff U reported the floor in the 300 hallway had the boards missing and the water just lying there on top of all the blankets had been like that for about three weeks now. During an interview on 05/21/25 at 02:20 PM, Administrative Staff A reported that the flooring in the 300 hallways had been like that since sometime the previous week. He reported that he had a local plumber out to assess the issue and was told it was a broken pipe that was causing a leak under the floor. Administrative Staff A said he reported that he did not have any paperwork or estimate that showed a local plumber was at the facility. Administrative Staff A reported he had concerns about whether the work would be approved and paid for as the corporate office had not paid many of the facility's invoices since March 2025. The facility's Homelike Environment dated 05/2017, documented that residents are provided with a safe, clean, comfortable, and homelike environment.

The facility reported a census of 69 residents. The sample included four residents reviewed for elopement (when a cognitively impaired resident leaves the safe area or premises without supervision). Based on observation, interview, and record review, the facility failed to implement interventions to mitigate the risk of elopement for Resident (R) 1, when the facility failed to update the facility ' s Elopement Risk Book used to alert staff which residents were at risk for elopement. This deficient practice increased the risk of elopement for the affected residents. Findings included: - R1 's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and traumatic brain injury (TBI-an injury to the brain caused by external forces). R1's Face Sheet in the EHR did not include a photo of the resident. R1's 04/29/25 admission Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 99. The MDS recorded R1 had moderately impaired cognition. The MDS recorded R1 was easily distractible and had difficulty keeping track of what was said. The MDS recorded R1 had behaviors of kicking, yelling, and refusal of care two times during the observation period. The MDS documented R1 required supervision assistance with activities of daily living (ADL) including bathing and ambulation. The MDS recorded R1 was independent with the remainder of ADL. R1 ' s Elopement Risk Assessment dated 04/25/25 recorded a score of three points; five or more points indicate a risk for elopement. R1 ' s Elopement Risk Assessment dated 05/10/25 recorded a score of nine points. R1 ' s Care Plan dated 05/12/25 documented R1 was at risk for injury due to wandering and attempting to elope. The plan noted R1 required the use of a Wander Guard (a bracelet that helps monitor residents who are at risk of wandering) bracelet. The plan instructed staff to complete 15-minute visual checks and place a WanderGuard on R1. R1's Care Plan documented staff were instructed to assist R1 in high-traffic areas when ambulating or in a wheelchair to ensure frequent visualization. The plan directed staff to redirect R1 to an activity that she enjoyed. The plan directed staff to monitor and document any attempts at elopement and report as appropriate. R1's Care Plan directed staff to observe R1's WanderGuard for placement and function every shift and change as needed and complete a wandering/elopement assessment quarterly and as needed. R1 ' s Physician Orders documented an order for a WanderGuard to the left wrist; check every shift for placement and function for elopement risk, dated 05/10/25. R1 ' s Medication Administration Record from 05/10/25 through 05/21/25 documented that staff checked R1's WanderGuard placement and function. R1 ' s Progress Note dated 5/10/2025 at 09:57 AM, documented R1 was last seen at 08:50 AM sitting in the lobby near the front entrance in her wheelchair. The note recorded R1 exited the facility around 09:00 AM when a transportation company opened the facility door. During an interview on 05/21/25 at 08:48 AM, Licensed Nurse (LN) G reported staff knew which residents were at risk for elopement using the Elopement Risk Book located at the nurse's station. During an interview on 05/21/25 at 08:50 AM, LN H reported she was not sure which resident wore a WanderGuard and went on to name three residents she thought had one. LN H reported there was an elopement book at Nurse Station Two and reported that Nurse Station One should have an elopement book as well. LN H reported that she received elopement education a few weeks ago and reported she was not aware of any recent elopements that occurred at the facility. During an observation and interview on 05/21/25 at 08:55 AM, LN G had a white binder in her hand, labeled Elopement Risk Book Station One. LN G said she needed to update the book prior to allowing the surveyor to review the book but then handed the surveyor the book. The book contained handwritten names of residents on the list under the 100/300 hall, with one name crossed off. The book, under the 200 Hall, had one name crossed off the form was dated 01/19/25. LN G reported that she had just written those names on the list and crossed off the other names and the four names that she added to the list did not have a face sheet with residents ' information or pictures in the book. She reported that R1 did have a recent elopement and was one of the residents that she was going to update today. LN G reported the staff did receive training after R1 eloped. LN G reported that the Elopement Risk Book would be used by the staff to see what residents were at risk for elopement and the information needed if a resident did elope. LN G was uncertain if Nurse Station Two had an Elopement Risk Book. During an interview on 05/21/25 at 09:00 AM, Certified Medication Aide (CMA) S reported that there were some residents who wore a WanderGuard, and she believed there was a book at Nurse Station Two but was unsure. CMA S reported she was not aware of any recent elopements that may have occurred. During an observation/interview on 05/21/25 at 09:01 AM, CMA S walked to Nurse Station Two to look for the elopement book, but LN G had just pulled the elopement book off the bookshelf, LN G reported that the white binder labeled Elopement Risk Book Station Two was not updated either. LN G reviewed the lists from each book and noted that the Nurse Station One book had a discrepancy. LN J approached and reported the discrepancy involved a resident whose Wanderguard had been discontinued but said she could not remember when it was discontinued. During an interview on 05/21/25 at 09:10 AM, LN H reported that she was not sure who updated the elopement books located at the nurse's stations. LN H asked Administrative Staff A who updated the elopement books and Administrative Staff A said that the nurse who applied the WanderGuard was responsible to add the resident to the book. Administrative Staff A stated the book was supposed to be reviewed by LN G weekly. During an observation on 05/21/25 at 09:30 AM, R1 had a WanderGuard bracelet on her left wrist while she laid in her bed. During an interview on 05/21/25 at 09:35 AM Medical Director GG reported that he was alerted of an elopement that occurred recently and said he expected the elopement book the staff used to know which residents were at risk for elopement to be current and up to date. During an interview on 05/21/25 at 02:10 PM, Administrative Nurse D expected the elopement books to be current and updated. She reported she expected the elopement books to be reviewed weekly and updated when a change occurred the same day. During an interview on 05/21/25 at 02:13 PM, Administrative Staff A reported an audit was put into place it was to be completed weekly. He expected the Elopement Risk Book to be accurate and current up to date. The facility ' s Elopement/Missing Resident dated 02/06/2023 documented that upon admission each resident would be assessed for the potential for elopement risk. Consideration will be given to the residents with mental disorders. The resident ' s picture will be placed in the Elopement Risk Book with a copy of their face sheet.

The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). The facility failed to implement acceptable infection control practices when staff failed to properly store Resident (R) 48 and R60's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) in a sanitary manner. This deficient practice placed the residents in the facility at risk for infectious diseases. Findings Included: - On 02/11/25 at 03:35 PM, observation revealed R60 had an unbagged oxygen tubing and nasal cannula that was attached to the oxygen canister. The tubing and nasal cannula laid in the seat of the wheelchair. The wheelchair was located in the hall outside of the resident's room with residents and staff walking up and down the hall. On 02/13/25 at 12:25 PM, observation revealed R48 unbagged oxygen tubing and nasal cannula that was attached to the oxygen canister. The tubing and nasal cannula laid in the seat of the wheelchair in the resident's room, while staff walked in and out of the R48's room. On 02/13/25 at 09:30 AM, Administrative Nurse D stated the oxygen tubing and cannulas should be stored in a bag when not in use. On 02/13/25 at 02:30 PM, Administrative Staff A stated the last maintenance supervisor was no longer with the facility and the facility was unable to locate or retrieve the information regarding the legionella water testing or water management regarding, if or when it had been completed and the testing results. Administrative Staff A had the information material for the water management process however lacked documentation the process was completed. Upon request, the facility failed to provide a policy related to the sanitary storage of oxygen or catheter tubing. The facility's Water Management policy dated October 2022, documented that the facility handles and maintains its water supply in accordance with recommendations from the Center for Disease Control, (CDC), The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE0, Environmental Protection Agency (EPA), and Food and Drug Administration (FDA). Guidelines. 1. The facility would demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in the building water system through a documented water management program. The facility's approach to controlling waterborne microorganisms will be consistent with nationally accepted standards of the CDC, ASHRAE, and the EPA. 2. Facilities hot water distribution systems serving resident care areas would be continuously recirculated. 3. Facilities would complete an assessment of the water system annually. a. Assessment data would identify where Legionella and other opportunistic waterborne pathogens could grow and spread. b. Assessment would include interventions performed by the facility if risk is identified to prevent the growth of opportunistic waterborne pathogens as well as how the facility would monitor them. 4. Facilities would contact the state's public health authority in the event of a suspected or confirmed case of healthcare acquired legionellosis, or another waterborne pathogen. 5. Facilities would follow CDC guidelines in the collection of cultures in the event it is recommended by the state's public health authority in response to potential/confirmed outbreaks of legionella or other opportunistic waterborne pathogens. 6. Facilities would follow the state's local health authority recommendations in response to outbreaks which may include re-mediating the pathogen reservoir and adjusting control measures as necessary. The facility failed to store R48's and R60's oxygen tubing and nasal cannula in a sanitary manner. The facility further failed to implement a water management program to test and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents who ate in the main dining room and resided in the 400 hall. This deficient practice placed the residents who ate in the main dining room at risk for impaired health and well-being; and the residents who resided in the 400 hall at risk for falls. Findings included: - On 02/11/25 at 11:29 AM, in the dining room and the 400 hall revealed the following issues: 1) The floor, approximately 18 inches (in) wide by five feet (ft) long, half an inch deep, located in front of the shower room on the 400 hall, had missing flooring down to concrete. The main dining room had the following: 1) The four floor vents with grayish-black fuzzy substance. 2) The two window air conditioners had the same substance. 3) The windows all around the dining room had numerous different-sized streaks of grayish-black areas on them. 4) Below the window air conditioner had approximately five ft by three in, of missing mopboard on the left side of the floor air vents and approximately three ft by three, missing mopboard on the right side of the floor air vent. 5) The area located below the shelf where the iced tea was kept had approximately one ft by three ft mopboard sticking out from the wall. 02/13/25 at 02:30 PM, Administrating Staff A verified the above issues in the dining room and the 400 hall and stated the facility had no maintenance staff at this time, so he was responsible for fixing the environmental issues. Administrating Staff A stated if staff had an environmental concern, they would place it in the Technology Enhanced Learning System (TELS) system (a web-based technology designed to tackle the day-to-day challenges of building operations) on the computer. The facility's Quality of Life-Homelike Environment Policy, revised May 2017, documented the facility staff and management should maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a clean, sanitary, and orderly environment. The facility failed to provide a sanitary environment in the main dining room and the 400 halls. This deficient practice placed the residents who ate in the main dining room at risk for impaired health and well-being. And the residents who resided on the 400 hall were at risk for falling.

The facility reported a census of 68 residents, with five sampled, including three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to ensure Resident (R)1, who was totally dependent on staff for cares, had been repositioned timely and his brief changed timely after bowel and/or bladder incontinent episodes. Furthermore, the facility failed to monitor R1's skin weekly, conduct weekly wound assessments, and provide wound treatments as ordered. R1 developed an unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on 05/20/24. The facility did not identify the wound until 06/03/24 and failed to assess the wound until 06/05/24. R1's wound progressed to a stage four pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone). R1 developed additional skin issues to his left outer ankle, left ear, upper right abdomen, and second and third digit of his right hand. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Down's Syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), and muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], assessed R1 with a short-term and long-term memory loss and impaired decision making. He did not reject care and was dependent on staff for bed mobility, transfers, and toileting, and required a wheelchair for mobility. R1 was always incontinent of bowel and bladder and at risk for developing pressure ulcers/injuries. He had two Stage 2 pressure areas (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) that were not present on admission and/or reentry. R1 required a pressure reducing device for his chair and bed and was not on a turning/repositioning program. He received nutrition or hydration interventions to manage skin problems, application of nonsurgical dressings and ointments/medications other than to his feet. R1 received hospice services. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/12/24, revealed R1 had a memory problem making his decisions regarding tasks of daily life severely impaired. The Urinary Incontinence and Indwelling Catheter CAA dated 01/12/24, revealed R1 was incontinent of bowel and bladder, wore incontinent products, and was dependent on staff for all aspects of toileting needs. The Pressure Ulcer/Injury CAA dated 01/12/24, revealed R1 was at risk for skin breakdown and had two stage two pressure ulcers to his left hip. R1 was dependent on staff for all aspects of bed mobility and had a pressure relieving mattress on his bed and a pressure relieving cushion to his chair. R1 required pressure relieving boots while in bed. The Licensed Nurse (LN) was to do a weekly/PRN (as needed) skin assessment and certified staff were to observe skin daily with cares. The staff were to report any new skin areas to the primary care provider for review. R1 recently changed hospice providers and was back on hospice services. The Quarterly MDS dated [DATE], for R1 revealed no change to his memory recall or decision making. R1 did not reject care and continued to be dependent on staff for bed mobility, transfers, toileting, and required a wheelchair for mobility, and had no range of motion impairments, and was frequently incontinent of bladder and always incontinent of bowel. R1 continued to be at risk for developing pressure ulcers/injuries and had one stage two pressure area which was not present on admission/reentry, and one unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) which was not present on admission/reentry. R1 required a pressure reducing device for his chair and bed and was not on a turning/repositioning program. He received nutrition or hydration interventions to manage skin problems, required pressure ulcer/injury care, and application of nonsurgical dressings and ointments/medications other than to feet. R1 continued to receive hospice care. The Care Plan dated 07/25/24 for R1 revealed the following: On 11/21/23 the plan revealed R1 had a potential for impaired skin integrity and was at risk for pressure ulcers. The staff were to utilize pressure reduction equipment, turn and reposition R1, used a cushion in his wheelchair/recliner, specialty mattress to the bed and utilized a ROHO cushion (pressure relief cushion that is made of soft, flexible air cells). Staff were to monitor and document location, size and treatment of skin injury and report any abnormalities, failure to heal, signs and symptoms of infection, maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine or feces), to the physician as indicated. The plan further revealed R1 was incontinent of bowel and a risk for impaired skin, rashes and irritation to the peri-area. The staff were to check R1 every two hours and assist with toileting as needed and provide peri-care immediately after incontinent episodes. R1 was totally dependent on staff for bed mobility, required a mechanical lift and two staff to assist with all transfers. R1 required staff to check and change his brief and provide peri-care with every incontinent episode as he allowed. An update on 06/17/24, revealed R1 had a pressure ulcer, stage two, to his right rear iliac crest (the curved area at the top of the hip bone) and left outer ankle related to his diagnosis of terminal illness. The goal was for his pressure ulcer to heal without complications through the end of the next review date. The Registered Dietician was to consult with any ongoing skin concerns and the staff were to encourage good nutrition/hydration to promote healing and follow the dietary interventions as recommended/ordered. The staff were to perform weekly skin/treatment documentation in accordance to the wound nurse assessment and plan of care recommended, and R1 was to be seen by the wound clinic as ordered. An update on 06/19/24, revealed R1 had an acute wound infection and staff were to administer antibiotics as ordered, treatments as ordered, and encourage dietary/fluid intake. The Orders tab included an order dated 04/30/24, instructing staff to assess R1's skin assessed weekly and obtain a set of vital signs for R1, on the day shift on Monday. The staff were to chart the assessment under the weekly skin evaluation. The hospice Skilled Nursing Visit Note dated 05/17/24 at 09:15 AM, revealed Consultant II documented there was a urine odor and R1's brief, gown, bed pad, and linens were all saturated with urine. R1 had a concerning area to his buttocks and a foam dressing applied to protect the skin and prevent breakdown. The visit note included Consultant Staff II communicated with Administrative Nurse D and CNA's regarding the condition of R1. The Assessments tab for R1 lacked a Weekly Nursing Skin Assessment on 05/20/24, the scheduled date the staff were to complete it. The hospice Skilled Nursing Visit Note dated 05/20/24 at 11:10 AM by Consultant Staff II, revealed R1 had an unstageable pressure ulcer to his upper medial buttocks. The wound bed was 50 percent (%) black, 15% yellow, and 35% red in color and measured 4.5 centimeters (cm) length, by 2.0 cm width, by 0.2 cm deep with a moderate amount of serosanguinous (semi-thick blood-tinged drainage) drainage. The note revealed the wound was new and appeared to be unstageable, the physician consulted and advised a treatment, and Consultant Staff II provided the care per orders. Consultant Staff II communicated with the facility nurse (did not specify name) and R1's durable power of attorney regarding his condition. The Progress Notes dated 05/21/24 at 03:27 PM, for R1 revealed a nutrition/dietary note by Dietary Staff BB. The note revealed per Administrative Nurse D, R1's skin had healed and currently intact, no order changes. The facility failed to notify Dietary Staff BB of R1's pressure area. The Weekly Nursing Skin assessment dated [DATE], documented R1 had no alterations in skin integrity. (This was seven days after the hospice identified an unstageable wound to R1's upper medial buttocks.) The hospice Skilled Nursing Visit Note dated 05/27/24, revealed R1 lacked a dressing to his wound and Consultant Staff II provided wound care as ordered and communicated with the facility staff nurse (name not specified) regarding his condition. The hospice Skilled Nursing Visit Note dated 05/30/24, revealed Consultant Staff II provided wound care as ordered to R1 and coordinated care with LN G. LN G discussed her frustration with Consultant Staff II about staff not communicating if R1's dressing had become dislodged and left open to air. Consultant Staff II provided education to facility staff to frequently reposition and provide peri-care. Consultant Staff II confirmed with LN G that the facility nurse would replace R1's dressing if it should be dislodged or the facility would call hospice to take care of it. The Weekly Nursing Skin assessment dated [DATE], revealed R1 had an unstageable pressure area to right iliac crest (rear) and Administrative Nurse D and hospice were notified. The assessment lacked measurements and characteristics of the pressure area. The hospice Aide Visit Note dated 06/03/24, revealed the aide notified Consultant Staff II that R1's entire brief, outfit, linens, and mattress were soaked with urine when the aide arrived at 10:11 AM. The hospice Skilled Nursing Visit Note dated 06/03/24, revealed the upper medial buttocks wound was 10% red, 80% yellow, and 10% black, measured 3.5 cm by 2.5 cm by 0.1 cm, and the wound had declined in appearance since the last visit. Consultant Nurse II continued to educate staff (lacked names) to frequently reposition R1 and provide peri-care to prevent further skin breakdown and improve skin integrity. The Treatment Administration Record (TAR) dated June 2024 included a treatment order for R1's lower medial back region on 06/04/24. The facility failed to have a treatment order in place for R1's pressure area until 15 days after onset of the area on 05/20/24. The Weekly Pressure Wound assessment dated [DATE] (two days after the facility identified the pressure area, however hospice had identified on 05/20/24), revealed R1 had an unstageable pressure ulcer to his right iliac crest (rear) which measured 4.0 cm by 2.0 cm by 0.1 cm, had a moderate amount of serosanguineous and purulent drainage with slight odor. The wound was covered with 100% slough (dead tissue, usually cream or yellow in color), the surrounding skin macerated (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces), the wound had deteriorated, and lacked an onset date. The facility failed to document wound characteristics until two days after they had identified the area. The hospice Skilled Nursing Visit Note dated 06/06/24, revealed R1's wound had 85% eschar and 15% slough, with a large amount on sanguineous (bloody) drainage with mild odor. R1 was lying on his back upon arrival at 10:40 AM, saturated with urine, and his wound to the lower medial back significantly declined. The staff had been educated extensively by Consultant Staff II on importance of changing and repositioning R1 every two hours being careful to offload the wound, but unsure of how well this is being carried out. Consultant Staff II consulted with the physician and sent a picture of the wound progression, who then changed the treatment orders to the wound. The hospice Chaplain Visit Note dated 06/07/24 revealed Consultant Staff JJ spoke with members of the hospice team [specified names] about the issue of neglect from the facility. The hospice Medical Social Worker Note dated 06/07/24, revealed R1's durable power of attorney (DPOA) posted several signs in R1's room reminding staff to reposition him, change any wet briefs, and offer him drinks when they were in his room. R1's DPOA noticed a new open area to his outer left ankle, photographed the area, and forwarded it to a hospice nurse for review and follow up. The Weekly Nursing Skin assessment dated [DATE], revealed R1 had a pressure area to his right iliac crest measuring 5.5 cm by 3.5 cm. The assessment lacked documentation of any skin issues to R1's left outer ankle, which R1's DPOA had discovered three days prior. The Progress Note dated 06/11/24 at 02:06 PM, by Administrative Nurse D revealed there was a meeting held on 06/11/24 regarding care concerns. Hospice voiced concerns with him being changed on a regular basis and laying on his back too often. R1 had a current wound on the rear ischium (part of the hip bone or over the hip bone area). The facility assured hospice that R1 was on a current every two-hour repositioning schedule and on an air mattress. New hourly checks to be completed for R1 to prevent him from becoming soiled or saturated in his brief and the staff would ensure facility staff repositioned R1 hourly. The Weekly Pressure Wound assessment dated [DATE], revealed R1 had a right iliac crest (rear) unstageable pressure ulcer, lacked onset date, and measured 5.5 cm by 3.5 cm by 0.1 cm, continued to be covered with 100% slough, had moderate amount of purulent (producing or containing pus) and serosanguineous drainage with slight odor, with surrounding skin macerated. This was an increase in size from the prior assessment on 06/05/24. The assessment lacked documentation about R1's left outer ankle, discovered by R1's DPOA five days prior. The Progress Note dated 06/14/24 at 03:26 PM, revealed R1 had a new open area found on his left outer ankle, which was an old pressure area that re-opened. The staff cleaned the area, applied triple antibiotic ointment, and covered with a border gauze dressing. A new wound care order was in place for daily wound care. The facility failed to identify the area until seven days after R1's DPOA discovered the area. The Weekly Pressure Wound assessment dated [DATE] revealed the same measurements and wound assessment as 06/05/24 of the right iliac crest (rear) unstageable pressure ulcer. The assessment revealed a new stage two pressure ulcer to R1's outer left ankle, a previous area which reopened, and measured 0.3 cm by 0.3 cm by 0.1 cm. The hospice Skilled Nursing Visit Note dated 06/16/24 revealed Consultant Staff GG arrived at facility at 11:04 AM, the facility requested a visit due to an increased odor coming from R1's wound. The facility nurse (lacked name) accompanied Consultant Staff GG to R1's room. The old dressing had a moderate amount of serosanguineous fluid, and the wound had an increased amount of necrotic (pertaining to the death of tissue in response to disease or injury) tissue compared to two days ago. Consultant Nurse GG contacted the physician and received new orders for wound treatment, change dressing daily, and start Cipro (antibiotic), 500 milligrams (mg), by mouth, twice daily, for two weeks. The hospice Skilled Nursing Visit Note dated 06/17/24 with arrival time of 04:30 PM, revealed Consultant Staff II attempted to coordinate care with LN J, who said she did not have time to talk, when trying to inquire if R1's wound care had been done as R1 was eating supper. LN J then stated it had been done. LN J admitted that she knew her, and the staff, must do better with changing and checking R1 routinely. Consultant Staff II discussed R1's care with Administrative Nurse D, who believed R1 was doing well. Consultant Nurse II showed Administrative Nurse D image of wound from the previous day, discussed status of it, and having the provider that comes to the facility debride (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) the wound if the physician would give the order for it. Consultant Staff II consulted with the physician and R1's DPOA who agreed with the plan, and orders received. The hospice Skilled Nursing Visit Note dated 06/18/24 revealed Consultant Staff II assessed R1's upper medial buttock wound which was covered with 90% eschar (dead tissue) and 10% slough (dead tissue, usually cream or yellow in color). The wound measured 6.5 cm by 5.0 cm. The wound center Progress Note dated 06/19/24 revealed R1 had a pressure ulcer to the right inferior buttock, wound debrided with post debridement measurements of 3.57 cm by 2.95 cm by 0.3 cm, and the post debridement wound stage was a stage three pressure injury (full thickness pressure injury extending through the skin into the tissue below). The hospice Skilled Nursing Visit Note dated 06/19/24 revealed Consultant Staff II arrived as the practitioner just finished debridement of R1's wound, obtained image of wound, and sent to provider for orders since eschar removed. Orders received and Consultant Staff II relayed visit information to LN G, then visited with Administrative Nurse D. Consultant Staff II had visited with R1's DPOA about staff concerns and agreed the implemented checklist should be revised to be done every two hours and plan solidified with Administrative Nurse D for revision to reflect documentation of care to every two hours. The facility failed to provide checklists prior to 06/19/24. The Hourly/Frequent Checks log for 06/19/24 revealed R1 was on his right side at 08:00 AM until turned to left side at 11:00 AM (three hours), where he remained on his left side until he was turned to his back at 02:00 PM (three hours). R1 was on his left side for three hours from 10:00 PM to 01:00 AM when turned to his right side, where he remained until 04:00 AM (three hours) when staff turned him to his left side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/20/24 revealed R1's wound care was now three times weekly, and no daily visits warranted. R1 was wet and Consultant Staff II provided peri-care, changed brief, and provided wound care. The Weekly Pressure Wound assessment dated [DATE] revealed the same measurements and wound assessment as 6/12/24 and 06/14/24 for R1's unstageable pressure ulcer to right iliac crest (rear). The facility failed to document current wound characteristics. The Hourly Frequent Checks for R1 dated 06/21/24 revealed R1 was on his right side at 11:00 AM and on his left side at 02:00 PM (three hours). R1 was on his right side at 01:00 AM and the log lacked documentation until 04:00 AM (three hours) to indicate he was on his left side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/22/24, revealed Consultant Staff II did an as needed (PRN) visit due to R1's dressing on his wound being saturated. The dressing changed yesterday afternoon for R1 had become completely saturated with wound drainage. Consultant Staff II contacted the physician and orders changed to daily until the wound improved. Consultant Staff II provided wound care per orders and communicated the new change to the DPOA and the facility. The Hourly Frequent Checks for R1 dated 06/22/24 revealed he was on his left side at 11:00 AM and every hour after that until 04:00 PM (five hours) when he was on his right side. R1 was on his right side at 09:00 PM and on his left side at 12:00 AM (three hours later). The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/23/24 revealed Consultant Staff GG arrived at the facility at 06:29 PM and returned to R1's room with an aide from the facility. R1 laid on his back with his brief saturated with urine. The Hourly Frequent Checks for R1 dated 06/23/24, revealed the staff documented he was on his left side at 08:00 PM, 09:00 PM, 10:00 PM, 11:00 PM lacked documentation, and at 12:00 AM. The log lacked R1 moved to right side until 01:00 AM (five hours later). The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/24/24, revealed R1's upper medial buttock pressure ulcer, now labeled as a stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone), included an assessment of the wound to have a large amount of yellow-green drainage with a foul odor and measured 5.5 cm by 4.0 cm by 0.5 cm. Consultant Staff II arrived at the facility at 02:30 PM and noted R1's protective underwear saturated with urine. Consultant Staff II noted wound malodorous after doing peri-care, brief change, and wound care, and contacted the physician regarding this with new orders received for wound care. The Hourly Frequent Checks for R1 dated 06/24/24 revealed R1 was on his left side at 08:00 AM, 09:00 AM, and 10:00 AM (three hours), and on right side at 11:00 AM, 12:00 PM, and 01:00 PM (three hours). R1 was on his left side at 04:00 PM, 05:00 PM, and 06:00 PM (three hours) and on his right side at 07:00 PM, 08:00 PM, and 09:00 PM (three hours), and on his back at 10:00 PM, 11:00 PM, and 12:00 AM (three hours). At 01:00 AM, 02:00 AM, and 03:00 AM (three hours) R1 was on his left side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/25/24 revealed Consultant Staff II arrived at facility at 04:30 PM and facility LN K came into the room to look at R1's wound because she had not seen it. The note revealed the upper medial buttocks wound had tunneling (a portion of a wound that extends deeper into the tissue than the surface creating a channel or tunnel) at 11 o'clock position at 0.6 cm, and at six o'clock position that measured 0.4 cm. The tunneling had not been present on the prior assessments. The hospice Skilled Nursing Visit Note dated 06/26/24, revealed Consultant Staff II arrived at 01:50 PM, facility staff finished feeding him lunch, she then conducted her assessment and provided wound care. The note revealed odor continued to be faint but improved. LN G reported the dressing had come off the evening shift and they had only applied a wet-to-dry dressing, which was still intact upon arrival, and had some strikethrough from drainage. Further skin assessment showed a new area to the inner aspect of the left elbow that measured 0.6 cm by 0.4 cm by 0.1 cm, and a new area to his left ear wound measured 0.9 cm by 0.5 cm by 0.1 cm with blood drainage, which appeared to be associated with some pressure from the oxygen tubing in combination with him resting on the left side of his face. The physician advised treatments to the areas. Consultant Staff II labeled both areas as stage two pressure areas. Consultant Staff II communicated with staff nurse (lacked name) regarding R1's condition. The Hourly Frequent Checks dated 06/26/24, revealed R1 was on his right side at 06:00 AM, 07:00 AM, 08:00 AM, 09:00 AM (four hours) until he was on his left side at 10:00 AM. He remained on his left side at 11:00 AM, 12:00 PM, 01:00 PM (three hours) until he was on his right side at 02:00 PM. R1 was on his right side 11:00 PM through 01:00 PM (three hours) and on his left side at 02:00 AM, 03:00 AM, and 04:00 AM (three hours) until 05:00 AM when he was on his right side. The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/27/24 revealed Consultant Staff II the dressing to R1's inner aspect of his left elbow dislodged. The facility failed to identify R1's dressing was not intact. The Weekly Pressure Wound assessment dated [DATE] for R1 revealed unstageable pressure area to right iliac crest with the same measurements and wound characteristics as the assessment on 06/12/24, 06/14/24, and 06/21/24. The left ankle had the same measurements as the assessment on 06/14/24 and 06/21/24. The facility failed to document R1's current wound characteristics. The TAR dated June 2024 for R1 revealed documentation of 9 indicating other, see progress note for the wound care to right buttock on 06/28/24. The Progress Notes lacked an entry for 06/28/24 to indicate why the staff did not provide wound care to the right buttock. The Hourly Frequent Checks dated 06/28/24 for R1 revealed he was on his right side at 06:00 AM, 07:00 AM, 08:00 AM, and 09:00 AM (four hours) on his left side at 01:00 PM until 04:00 PM when on his right side (three hours). The log revealed R1 was on his right side at 11:00 PM, 12:00 AM, and 01:00 AM (three hours), and on his left side at 02:00 AM, 03:00 AM, and 04:00 AM (three hours). On 06/29/24 the log revealed R1 was on his left side at 11:00 PM, 12:00 AM, and 01:00 AM (three hours), and on his right side at 02:00 AM, 03:00 AM, and 04:00 AM (three hours). The facility failed to reposition R1 every two hours. The hospice Skilled Nursing Visit Note dated 06/30/24, revealed Consultant Staff MM arrived at the facility at 01:40 PM and R1 was lying flat on his back, his brief very saturated in urine. The Hourly Frequent Checks dated 06/30/24 for R1 revealed he was on his left or right side for three hours at a time on five different occasions. The facility failed to reposition R1 every two hours. The Weekly Nursing Skin assessment dated [DATE] for R1 revealed he had a pressure area to his right iliac crest and left outer ankle. The assessment lacked any areas to his left ear or the inner aspect of his left elbow. The hospice Skilled Nursing Visit Note dated 07/01/24 revealed R1's wound to his left ear had scabbed over, and Consultant Staff II had concern that the wound to his lower back was tunneling. The upper medial buttock wound measured 6.0 cm by 3.0 cm by 0.5 cm, with tunneling 1.5 cm at nine o'clock and ten o'clock and 3.5 cm tunneling to 11 o'clock and twelve o'clock. The wound had large amount of serosanguineous and yellow-green drainage with mild odor. The inner elbow stage two pressure area measured 0.8 cm by 0.5 cm by 0.1 cm and improved. The Hourly Frequent Checks dated 07/01/24 revealed R1 was up for supper at 05:00 PM, 06:00 PM, and 07:00 PM (three hours). R1 was on his right side at 01:00 AM, 02:00 AM, 03:00 AM (three hours). The facility failed to reposition R1 every two hours. The facility lacked Hourly Frequent Checks for R1 on 07/02/24. The TAR dated July 2024 lacked documentation the staff provided wound care to R1's right buttock on 07/02/24 per physician order. The Hourly Frequent Checks dated 07/03/24, which was on the blank backside of another log, revealed R1 was on his left side for three hours on three occasions, and on his right side for three hours on one occasion. The facility failed to reposition R1 every two hours. The Weekly Pressure Wound assessment dated [DATE], for R1 revealed no changes in the measurements for the right iliac crest and the left ankle. The wound characteristics for the right iliac crest had not changed since 06/05/24. The wound assessment lacked the wound to the inner aspect of the left elbow. The facility failed to document current wound characteristics. The hospice Skilled Nursing Visit Note dated 07/07/24, revealed Consultant Staff MM arrived at 04:30 PM and R1 was lying in bed on his back, incontinent of bowel and bladder and his brief saturated with urine. The TAR dated July 2024 revealed R1 had a weekly skin assessment performed on 07/08/24. However, the Assessment tab lacked a Weekly Nursing Skin Assessment for 07/08/24. The facility failed to perform a weekly skin assessment per physician order. The Weekly Pressure Wound assessment dated [DATE] revealed no changes in the measurements for the right iliac crest and the left ankle. The wound characteristics for the right iliac crest had not changed since 06/05/24. The facility failed to document current characteristics of R1's wounds. The hospice Medical Social Worker Visit Note dated 07/12/24, revealed Consultant Staff KK arrived at 10:50 AM, revealed R1's DPOA also present during visit. R1 found in a soiled brief, and his bedding and pads soiled with wound drainage. The hospice Skilled Nursing Visit Note dated 07/12/24, revealed Consultant Staff MM arrived at 03:40 PM and staff reported R1's dressing was coming off and saturated before lunch today, so they changed it. The note included orders received to insert a 16 French urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) to dependent drainage to assist with wound healing. Consultant Staff MM inserted the urinary catheter. The hospice Skilled Nursing Visit Note dated 07/14/24, revealed Consultant Staff HH arrived at 09:55 AM for R1's visit. Consultant Staff HH provided wound care. The old dressing had drainage that saturated the dressing with a copious (large) amount of purulent drainage with foul odor. Consultant Staff HH updated the facility staff nurse, LN L, on R1's wound care. The Weekly Pressure Wound assessment dated [DATE], revealed R1 had one wound present to his sacral area that was unstageable and measured 6.0 cm by 3.0 cm by 0.5 cm with prior measurements of 5.5 cm by 3.5 cm. The wound had serosanguineous and purulent drainage of a large amount and with slight odor. The wound bed was covered with 25% slough and had 76 to 100 % granulation tissue (new tissue formed during wound healing) with the surrounding skin macerated. The wound had tunneling/undermining of 1.5 cm at nine and ten o'clock, and 3.5 cm and 11 and 12 o'clock, the wound had deteriorated. The assessment lacked any other wounds. The hospice Skilled Nursing Visit Note dated 07/23/24, revealed R1's stage four pressure ulcer to his upper medial buttock measured 8.0 cm by 5.8 cm by 0.5 cm with 3.0 cm undermining at 12 o'clock and 3.5 cm at seven and nine o'clock, with a large amount of serosanguineous drainage. The Weekly Pressure Wound assessment dated [DATE], for R1 revealed the same measurements to the unstageable sacrum pressure ulcer as the week prior with no changes to the wound characteristic assessment. The assessment revealed wound deteriorated and lacked any other pressure wounds. The facility failed to document current wound characteristics. The hospice Skilled Nursing Visit Note dated 07/27/24, revealed Consultant Staff HH arrived at 08:55 AM and checked in with LN NN, who voiced no concerns. The note revealed new skin issues identified of a stage one pressure ulcer (pressure wound which appears reddened, does not blanche, and may be painful but is not open) to his second finger of his right hand with an onset date of 07/25/24 and a pressure ulcer, lacked stage, to his third finger of his right hand with an onset date of 07/25/24. On 07/29/24 at 11:10 AM, observation revealed R1 laid in bed on an air mattress tilted to his right side with the head of the bed elevated approximately 45 degrees, lacked clothing to upper body and lower body covered with a sheet, hands appeared contracted (abnormal permanent fixation of a joint or muscle), and a urinary catheter drainage bag hung from the right side of the bed frame. From the light fixture in the room above R1's bed were two notes. The first note read DO NOT LEAVE [specified resident] ON HIS BACK! Please, he has a buttock wound. Per his family - contact them for concerns. Thank you for helping us take good care of [specified name]. The second note revealed Check and change my brief regularly, also turning me often, do not let me set in urine or feces as this breaks down my fragile skin and it's pretty disgusting. Observation on 07/29/24 at 11:25 AM, revealed CNA N, CNA P, and CNA O entered R1's room to provide cares and get him up in the high back wheelchair. CNA N moved R1's high back wheelchair into the room, which has a pommel cushion (cushion with a raised section to assist in preventing a pe[TRUNCATED]

The facility reported a census of 70 residents. The review included 14 facility self-reported incidents with allegations of resident-to-resident abuse, between the dates of 11/10/21 and 04/21/23. Based on observation, interview, and record review the facility failed to provide a safe and secure living environment for the residents of the facility with the failure to accurately investigate, assess, and implement adequate immediate interventions to prevent the continued abuse of resident-to-residents, following these 14 incidents reviewed. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse. Findings included: - During the onsite health resurvey, the following 14 facility reported incidents regarding allegations of resident-to-resident abuse, occurring between 11/10/21 and 04/21/23, were reviewed. Each lacked evidence of a thorough investigation, witness statements, resident interviews, and identification of causal factors to implement interventions to prevent further resident to resident altercations/abuse. 1. The 05/22/22 Resident to Resident Facility Self-Investigation documented on 05/21/22 R170 and R9 were roommates, and they hit each other with a grabber. R9 went to R170's side of the room, with a grabber in his hand and hit his roommate in the head. R170 grabbed the grabber and hit R9 back. R170 went to the emergency room for sutures to his head. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 05/22/22 Progress Note documented on 05/21/22 at 11:30 PM the nurse entered the room and R9 sat on the floor yelling at R170, that he needed to move out of his house. R9 made several attempts to crawl towards R170. The staff moved R9 to a different room and R9 denied pain upon assessment. R170's 05/22/22 Progress Note documented R170 went via ambulance to the emergency room and returned at 03:01 AM with nine sutures to the laceration on his head. 2. The 01/10/23 Resident to Resident Facility Self-Investigation documented on 01/09/23 R25 propelled her electric wheelchair over R18's foot causing fractures of two phalanges (digital bones in the feet) of his right foot. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R25 lacked documentation of the incident on 01/09/23. R18's 01/09/23 Progress Note documented the nurse heard screaming in the foyer. When the nurse arrived, staff stated R25 ran over R18's right foot with her mechanical chair. The nurse documented swelling and bleeding to R18's right big toe. Pressure and ice were applied and R18 complained of pain and staff administered an analgesic. The staff received an order for an X-ray of R18's foot/toes. R18's 01/09/23 Progress Note documented results of the x-ray revealed possible minimally displaced fractures involving the middle phalanges of the second and third toes. The staff received an order from the provider for R18 to be non-weight bearing on the right foot and to keep the toes immobilized. 3. The 11/10/21 Resident to Resident Facility Self- Investigation documented on 11/10/21, R2 was walking down the hall and put his leg out to trip R171. The investigation lacked resident interviews, identification of causal factors, and witness statements. Review of the investigation dated 11/10/21 documented an incomplete investigation with no interventions to protect residents and prevent the abuse from recurring. The 11/10/21 Progress Note documented staff were in hall two, talking, when they heard R171 state that R2 had kicked her. R2 stated I just wanted to trip her to staff. R2 continued to walk down the hall and into his room. 4. The Resident to Resident Facility Self-Investigation dated 12/13/21 documented on 12/07/21 R172 was following R178 and R178 turned and hit R172. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 12/07/21 Progress Note documented staff reported R172 followed R178 and at one-point R172 hit R178 and then R178 punched R172 in the neck. The staff redirected R178 without incident. 5. The Resident to Resident Facility Self- Investigation dated 05/03/22 reported R178 punched R175 in the dining room area when the resident stood up from the table. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note dated 05/01/22 documented R178 punched R175 in the dining room area when the resident stood up from the table. At 05:28 PM staff were monitoring R178 for Risperdal (antipsychotic) and discontinued Buspar (antianxiety) and Trazadone (antidepressant) medications. The progress note revealed R178 hit another resident in the head. 6. The Resident to Resident Facility Self- Investigation dated 02/16/23 reported R178 pinned R21 to the wall and punched her in the chest. R21 in turn scratched R178 right hand. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 02/16/23 Progress Note documented an unidentified Certified Nurse Aide on hall four, reported to the Licensed Nurse, she saw R178 pin a female resident to the wall in the hallway. R21 screamed at R178 telling him to stop. R178 then punched R21 in the chest and she in return scratched his hand. The nurse went to hall four to assess what happened. Scratches and bleeding were noted to R178's right hand. 7. The 05/02/22 Resident to Resident Facility Self-Investigation documented on 05/01/22, R173 grabbed R174's arms and shook her hard. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 05/01/22 Progress Note for R173 documented R173 grabbed another resident and shook her violently. The Progress Note documented an incident of R173 punched another resident the day before this incident. The facility did not report the prior day incident mentioned in the 05/01/22 Progress Note to the state Agency as required 8. The Resident to Resident Facility Self-Investigation dated 06/14/22 documented on 06/14/22, R4 struck R176, then R176 struck R4. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 06/14/22 Progress Note documented R4 and R176 argued, and the staff attempted to intervene, but the residents struck one another. Documentation lacked determination or declaration of who struck first. R4 and R176 were assessed for injuries and escorted to their respective rooms without further incident. 9. On 08/01/22 the Resident to Resident Facility Self-Investigation dated 08/02/22, documented R4 struck R34, again. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 08/02/22 Progress Note documented R4 punched another resident in the face. The residents were removed to a safe environment and assessed them, with no injuries found on either resident. The facility sent R4 via EMS to the Behavioral Health Unit (BHU) for evaluation related to his behavior. The EHR lacked additional information. 10. The 09/01/22 Resident to Resident Facility Self-Investigation documented on 08/30/22, R4 struck R51. The investigation revealed R4 thought R51 called him a bad name, so R4 struck R51. The EHR lacked documentation related to this incident. The investigation lacked resident interviews, identification of causal factors, and witness statements. 11. The 12/08/22 Resident to Resident Facility Self-Investigation documented on 12/08/22 R31 pushed R21 causing her to fall. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 12/08/22. 12. The 01/02/23 Resident to Resident Facility Self-Investigation documented on 01/02/23 R31 pushed R177. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 01/02/23. 13. The 02/15/23 Resident to Resident Facility Self-Investigation documented on 02/15/23 R57's spouse reported R57 had a bruise. Through investigation of video recordings, it was determined R31 entered R57's. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 02/15/23. 14. The Resident to Resident Facility Self-Investigation dated 04/21/23 documented on 04/21/23 R21 entered R57's room and allegedly assaulted R57 which resulted in minor injuries to R57 which required bandages. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Notes lacked documentation of the incident on 04/21/23. On 05/01/23 at 10:00 AM Administrative Staff A reported she did not interview the other residents because the residents were confused, and most of the incidents occurred on the unit, and it would not do any good. She relied on the nursing staff to monitor for further behaviors and completed notifications. She did not know she had to complete a full investigation on a facility reported event . The facility's 03/03/22 Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, documented residents must not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, or other individuals. The policy documented all allegations of abuse should be reported to the administrator immediately. Additionally, the policy documented all allegations of abuse shall be reported to the appropriate state agency no later than two hours after the allegation was made and allegations that result from a crime must be reported to law enforcement no later than 24 hours after the incident. The policy included the administrator would complete documentation of the allegation as follows: 1. Review documentation in EHR (including assessment if allegation resulted in injury) 2. Assess resident for injury if allegation involves physical abuse. 3. Provide notifications to primary care provider and responsible party. 4. Attempt to obtain witness statements from all known witnesses. 5. Preserve physical evidence (if applicable). The policy documented the facility shall implement measures to prevent further potential abuse from occurring. Due to the number of resident-to-resident altercations and lack of thorough investigations and preventative measures to protect residents from abuse, placed the residents in immediate jeopardy. On 04/27/23 at 02:45 PM, Administrative Staff A was informed of the immediate jeopardy status and provided the Immediate Jeopardy Template for failure to provide a safe environment free from abuse. The facility failed to ensure residents were free from resident-to-resident abuse from 11/10/21 through 04/21/23, involving 19 residents. After each abuse incident, the facility did not implement any interventions to prevent further abuse. This had the potential to affect all 70 residents. The facility provided an acceptable plan for removal of the IJ on 04/27/23 at 06:00 PM which included the following: 1. All staff educated on abuse policy, forms of abuse, and the steps for reporting alleged abuse. The surveyor verified the implementation of the corrective actions onsite on 05/02/23 and the deficient practice remained at an G scope and severity.

The facility reported a census of 70 residents. The review included 14 facility self-reported incidents with allegations of resident-to-resident abuse, between the dates of 11/10/21 and 04/21/23. Based on observation, interview, and record review the facility failed to conduct a thorough investigation of the allegations of resident-to-resident abuse and failed to take appropriate corrective actions to protect residents from further abuse. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse. Findings included: - During the onsite health resurvey, the following 14 facility reported incidents regarding allegations of resident-to-resident abuse, occurring between 11/10/21 and 04/21/23, were reviewed. Each lacked evidence of a thorough investigation, witness statements, resident interviews, and identification of causal factors to implement interventions to prevent further resident to resident altercations/abuse. 1. The 05/22/22 Resident to Resident Facility Self-Investigation documented on 05/21/22 R170 and R9 were roommates, and they hit each other with a grabber. R9 went to R170's side of the room, with a grabber in his hand and hit his roommate in the head. R170 grabbed the grabber and hit R9 back. R170 went to the emergency room for sutures to his head. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 05/22/22 Progress Note documented on 05/21/22 at 11:30 PM the nurse entered the room and R9 sat on the floor yelling at R170, that he needed to move out of his house. R9 made several attempts to crawl towards R170. The staff moved R9 to a different room and R9 denied pain upon assessment. R170's 05/22/22 Progress Note documented R170 went via ambulance to the emergency room and returned at 03:01 AM with nine sutures to the laceration on his head. 2. The 01/10/23 Resident to Resident Facility Self-Investigation documented on 01/09/23 R25 propelled her electric wheelchair over R18's foot causing fractures of two phalanges (digital bones in the feet) of his right foot. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R25 lacked documentation of the incident on 01/09/23. R18's 01/09/23 Progress Note documented the nurse heard screaming in the foyer. When the nurse arrived, staff stated R25 ran over R18's right foot with her mechanical chair. The nurse documented swelling and bleeding to R18's right big toe. Pressure and ice were applied and R18 complained of pain and staff administered an analgesic. The staff received an order for an xray of R18's foot/toes. R18's 01/09/23 Progress Note documented results of the x-ray revealed possible minimally displaced fractures involving the middle phalanges of the second and third toes. The staff received an order from the provider for R18 to be non-weight bearing on the right foot and to keep the toes immobilized. 3. The 11/10/21 Resident to Resident Facility Self- Investigation documented on 11/10/21, R2 was walking down the hall and put his leg out to trip R171. The investigation lacked resident interviews, identification of causal factors, and witness statements. Review of the investigation dated 11/10/21 documented an incomplete investigation with no interventions to protect residents and prevent the abuse from recurring. The 11/10/21 Progress Note documented staff were in hall two, talking, when they heard R171 state that R2 had kicked her. R2 stated I just wanted to trip her to staff. R2 continued to walk down the hall and into his room. 4. The Resident to Resident Facility Self-Investigation dated 12/13/21 documented on 12/07/21 R172 was following R178 and R178 turned and hit R172. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 12/07/21 Progress Note documented staff reported R172 followed R178 and at one-point R172 hit R178 and then R178 punched R172 in the neck. The staff redirected R178 without incident. 5. The Resident to Resident Facility Self- Investigation dated 05/03/22 reported R178 punched R175 in the dining room area when the resident stood up from the table. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note dated 05/01/22 documented R178 punched R175 in the dining room area when the resident stood up from the table. At 05:28 PM staff were monitoring R178 for Risperdal (antipsychotic) and discontinued Buspar (antianxiety) and Trazadone (antidepressant) medications. The progress note revealed R178 hit another resident in the head. 6. The Resident to Resident Facility Self- Investigation dated 02/16/23 reported R178 pinned R21 to the wall and punched her in the chest. R21 in turn scratched R178 right hand. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 02/16/23 Progress Note documented an unidentified Certified Nurse Aide on hall four, reported to the Licensed Nurse, she saw R178 pin a female resident to the wall in the hallway. R21 screamed at R178 telling him to stop. R178 then punched R21 in the chest and she in return scratched his hand. The nurse went to hall four to assess what happened. Scratches and bleeding were noted to R178's right hand. 7. The 05/02/22 Resident to Resident Facility Self-Investigation documented on 05/01/22, R173 grabbed R174's arms and shook her hard. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 05/01/22 Progress Note for R173 documented R173 grabbed another resident and shook her violently. The Progress Note documented an incident of R173 punched another resident the day before this incident. The facility did not report the prior day incident mentioned in the 05/01/22 progress note to the state Agency as required. 8. The Resident to Resident Facility Self-Investigation dated 06/14/22 documented on 06/14/22, R4 struck R176, then R176 struck R4. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 06/14/22 Progress Note documented R4 and R176 argued, and the staff attempted to intervene, but the residents struck one another. Documentation lacked determination or declaration of who struck first. R4 and R176 were assessed for injuries and escorted to their respective rooms without further incident. 9. On 08/01/22 the Resident to Resident Facility Self-Investigation dated 08/02/22, documented R4 struck R34, again. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 08/02/22 Progress Note documented R4 punched another resident in the face. The residents were removed to a safe environment and assessed them, with no injuries found on either resident. The facility sent R4 via EMS to the Behavioral Health Unit (BHU) for evaluation related to his behavior. The EHR lacked additional information. 10. The 09/01/22 Resident to Resident Facility Self-Investigation documented on 08/30/22, R4 struck R51. The investigation revealed R4 thought R51 called him a bad name, so R4 struck R51. The EHR lacked documentation related to this incident. The investigation lacked resident interviews, identification of causal factors, and witness statements. 11. The 12/08/22 Resident to Resident Facility Self-Investigation documented on 12/08/22 R31 pushed R21 causing her to fall. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 12/08/22. 12. The 01/02/23 Resident to Resident Facility Self-Investigation documented on 01/02/23 R31 pushed R177. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 01/02/23. 13. The 02/15/23 Resident to Resident Facility Self-Investigation documented on 02/15/23 R57's spouse reported R57 had a bruise. Through investigation of video recordings, it was determined R31 entered R57's. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 02/15/23. 14. The Resident to Resident Facility Self-Investigation dated 04/21/23 documented on 04/21/23 R21 entered R57's room and allegedly assaulted R57 which resulted in minor injuries to R57 which required bandages. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Notes lacked documentation of the incident on 04/21/23. On 05/01/23 at 10:00 AM Administrative Staff A reported she did not interview the other residents because the residents were confused, and most of the incidents occurred on the unit, and it would not do any good. She relied on the nursing staff to monitor for further behaviors and completed notifications. She did not know she had to complete a full investigation on a facility reported event. The facility's 03/03/22 Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, documented residents must not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, or other individuals. The policy documented all allegations of abuse should be reported to the administrator immediately. Additionally, the policy documented all allegations of abuse shall be reported to the appropriate state agency no later than two hours after the allegation was made and allegations that result from a crime must be reported to law enforcement no later than 24 hours after the incident. The policy included the administrator would complete documentation of the allegation as follows: 1. Review documentation in EHR (including assessment if allegation resulted in injury) 2. Assess resident for injury if allegation involves physical abuse. 3. Provide notifications to primary care provider and responsible party. 4. Attempt to obtain witness statements from all known witnesses. 5. Preserve physical evidence (if applicable). The policy documented the facility shall implement measures to prevent further potential abuse from occurring. Due to the number of resident-to-resident altercations and lack of thorough investigations and preventative measures to protect residents from abuse, placed the residents in immediate jeopardy. On 04/27/23 at 02:45 PM, Administrative Staff A was informed of the immediate jeopardy status and provided the Immediate Jeopardy Template for failure to provide a safe environment free from abuse. The facility failed to ensure residents were free from resident-to-resident abuse from 11/10/21 through 04/21/23, involving 19 residents. The facility failed to conduct a thorough investigation of the allegations of resident-to-resident abuse and failed to take appropriate corrective actions to protect residents from further abuse. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse. The facility provided an acceptable plan for removal of the IJ on 04/27/23 at 06:00 PM which included the following: 1. All staff educated on abuse policy, forms of abuse, and the steps for reporting alleged abuse. The surveyor verified the implementation of the corrective actions onsite on 05/02/23 and the deficient practice remained at an F scope and severity.

The facility reported a census of 70 residents. The review included 14 facility reported incidents with allegations of resident-to-resident abuse, between the dates of 11/10/21 and 04/21/23. Based on observation, interview, and record review, the facility failed to provide a safe and secure living environment for the residents of the facility with the failure to report the incidents in a timely manner as required, following 11 of these 14 incidents reviewed. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse. Findings included: - During the onsite health resurvey, the following 14 facility reported incidents regarding allegations of resident-to-resident abuse, occurring between 11/10/21 and 04/21/23, were reviewed. Each lacked evidence of a thorough investigation, witness statements, resident interviews, and identification of causal factors to implement interventions to prevent further resident to resident altercations/abuse. 1. The 05/22/22 Resident to Resident Facility Self-Investigation documented on 05/21/22 R170 and R9 were roommates, and they hit each other with a grabber. R9 went to R170's side of the room, with a grabber in his hand and hit his roommate in the head. R170 grabbed the grabber and hit R9 back. R170 went to the emergency room for sutures to his head. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 05/22/22 Progress Note documented on 05/21/22 at 11:30 PM the nurse entered the room and R9 sat on the floor yelling at R170, that he needed to move out of his house. R9 made several attempts to crawl towards R170. The staff moved R9 to a different room and R9 denied pain upon assessment. R170's 05/22/22 Progress Note documented R170 went via ambulance to the emergency room and returned at 03:01 AM with nine sutures to the laceration on his head. The facility reported the incident to the State Agency (SA) on 05/24/22, three days after the incident. 2. The 01/10/23 Resident to Resident Facility Self-Investigation documented on 01/09/23 R25 propelled her electric wheelchair over R18's foot causing fractures of two phalanges (digital bones in the feet) of his right foot. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R25 lacked documentation of the incident on 01/09/23. R18's 01/09/23 Progress Note documented the nurse heard screaming in the foyer. When the nurse arrived, staff stated R25 ran over R18's right foot with her mechanical chair. The nurse documented swelling and bleeding to R18's right big toe. Pressure and ice were applied and R18 complained of pain and staff administered an analgesic. The staff received an order for an X-ray of R18's foot/toes. R18's 01/09/23 Progress Note documented results of the x-ray revealed possible minimally displaced fractures involving the middle phalanges of the second and third toes. The staff received an order from the provider for R18 to be non-weight bearing on the right foot and to keep the toes immobilized. The facility reported the incident to the SA on 01/10/23, one day after the event occurred. 3. The 11/10/21 Resident to Resident Facility Self- Investigation documented on 11/10/21, R2 was walking down the hall and put his leg out to trip R171. The investigation lacked resident interviews, identification of causal factors, and witness statements. Review of the investigation dated 11/10/21 documented an incomplete investigation with no interventions to protect residents and prevent the abuse from recurring. The 11/10/21 Progress Note documented staff were in hall two, talking, when they heard R171 state that R2 had kicked her. R2 stated I just wanted to trip her to staff. R2 continued to walk down the hall and into his room. The facility reported the incident to the SA on 11/12/21 at 11:26 AM, two days after the incident. 4. The Resident to Resident Facility Self-Investigation dated 12/13/21 documented on 12/07/21 R172 was following R178 and R178 turned and hit R172. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 12/07/21 Progress Note documented staff reported R172 followed R178 and at one-point R172 hit R178 and then R178 punched R172 in the neck. The staff redirected R178 without incident. The facility reported the incident to the SA on 12/13/21 at 02:28 PM, six days after the incident. 5. The Resident to Resident Facility Self- Investigation dated 05/03/22 reported R178 punched R175 in the dining room area when the resident stood up from the table. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note dated 05/01/22 documented R178 punched R175 in the dining room area when the resident stood up from the table. At 05:28 PM staff were monitoring R178 for Risperdal (antipsychotic) and discontinued Buspar (antianxiety) and Trazadone (antidepressant) medications. The progress note revealed R178 hit another resident in the head. The facility reported the incident to the SA on 05/03/22 at 08:32 AM, two days after the incident. 6. The Resident to Resident Facility Self- Investigation dated 02/16/23 reported R178 pinned R21 to the wall and punched her in the chest. R21 in turn scratched R178 right hand. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 02/16/23 Progress Note documented an unidentified Certified Nurse Aide on hall four, reported to the Licensed Nurse, she saw R178 pin a female resident to the wall in the hallway. R21 screamed at R178 telling him to stop. R178 then punched R21 in the chest and she in return scratched his hand. The nurse went to hall four to assess what happened. Scratches and bleeding were noted to R178's right hand. The facility reported the incident to the SA on 02/17/23, one day after the incident. 7. The 05/02/22 Resident to Resident Facility Self-Investigation documented on 05/01/22, R173 grabbed R174's arms and shook her hard. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 05/01/22 Progress Note for R173 documented R173 grabbed another resident and shook her violently. The Progress Note documented an incident of R173 punched another resident the day before this incident. The facility did not report the prior day incident mentioned in the 05/01/22 Progress Note to the state Agency as required The facility reported the incident to the SA on 05/03/22, two days after the incident. 8. On 08/01/22 the Resident to Resident Facility Self-Investigation dated 08/02/22, documented R4 struck R34, again. The investigation lacked resident interviews, identification of causal factors, and witness statements. The 08/02/22 Progress Note documented R4 punched another resident in the face. The residents were removed to a safe environment and assessed them, with no injuries found on either resident. The facility sent R4 via EMS to the Behavioral Health Unit (BHU) for evaluation related to his behavior. The EHR lacked additional information. The incident was reported to the SA on 08/02/22, one day after the incident. 9. The 09/01/22 Resident to Resident Facility Self-Investigation documented on 08/30/22, R4 struck R51. The investigation revealed R4 thought R51 called him a bad name, so R4 struck R51. The EHR lacked documentation related to this incident. The investigation lacked resident interviews, identification of causal factors, and witness statements. The incident was reported to the SA on 08/30/22 at 08:29 PM one day before the incident was dated. 10. The 12/08/22 Resident to Resident Facility Self-Investigation documented on 12/08/22 R31 pushed R21 causing her to fall. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 12/08/22. The facility reported the incident to the SA on 12/14/22, six days after the incident. 11. The 01/02/23 Resident to Resident Facility Self-Investigation documented on 01/02/23 R31 pushed R177. The investigation lacked resident interviews, identification of causal factors, and witness statements. The Progress Note for R31 lacked documentation of the incident on 01/02/23. The facility reported the incident to the SA on 01/03/23, one day after the incident. On 05/01/23 at 10:00 AM Administrative Staff A reported she did not interview the other residents because the residents were confused, and most of the incidents occurred on the unit, and it would not do any good. She relied on the nursing staff to monitor for further behaviors and completed notifications. She did not know she had to complete a full investigation on a facility reported event. The facility's 03/03/22 Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, documented residents must not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, or other individuals. The policy documented all allegations of abuse should be reported to the administrator immediately. Additionally, the policy documented all allegations of abuse shall be reported to the appropriate state agency no later than two hours after the allegation was made and allegations that result from a crime must be reported to law enforcement no later than 24 hours after the incident. The policy included the administrator would complete documentation of the allegation as follows: 1. Review documentation in EHR (including assessment if allegation resulted in injury) 2. Assess resident for injury if allegation involves physical abuse. 3. Provide notifications to primary care provider and responsible party. 4. Attempt to obtain witness statements from all known witnesses. 5. Preserve physical evidence (if applicable). The policy documented the facility shall implement measures to prevent further potential abuse from occurring. Due to the number of resident-to-resident altercations and lack of timely reporting of incidents, this placed the residents in immediate jeopardy. On 04/27/23 at 02:45 PM, Administrative Staff A was informed of the immediate jeopardy status and provided the Immediate Jeopardy Template for failure to provide a safe environment free from abuse. The facility failed to ensure residents were free from resident-to-resident abuse from 11/10/21 through 04/21/23, involving 19 residents. After each abuse incident, the facility did not report the incidents in a timely manner to the SA as required. This had the potential to affect all 70 residents. The facility provided an acceptable plan for removal of the IJ on 04/27/23 at 06:00 PM which included the following: 1. All staff educated on abuse policy, forms of abuse, and the steps for reporting alleged abuse. The surveyor verified the implementation of the corrective actions onsite on 05/02/23 and the deficient practice remained at a F scope and severity.

The facility census totaled 70 residents, with 18 in the sample, including one resident reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure staff provided adequate supervision and followed the resident's fall prevention interventions to prevent further falls for Resident (R) 18, including one fall which resulted in a fractured (broken bone) right femur (thigh bone) and surgical repair. Findings included: - R18's diagnoses from the Electronic Health Record (EHR) documented anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The 07/19/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R18 required extensive assistance of one staff for bed mobility, dressing, and personal hygiene, and extensive assistance of two staff for transfers. R18 had no falls since the prior assessment. The 02/23/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition. R18 required extensive assistance of two staff for all activities of daily living. The MDS further noted R18 had no falls since the prior assessment. R18 required surgery to repair a fracture to the pelvis, hip, leg, or ankle. The 01/25/23 Care Plan documented R18 was at risk for falls. The Care Plan directed staff to follow facility fall protocol. The Care Plan directed staff to use a body pillow for positioning and mattress perimeters for R18 as of 09/19/22. The Care Plan lacked an intervention for the fall on 12/25/22. Review of the Fall Investigation dated 12/25/22, documented at 01:41 PM, R18 turned on his call light and the responding CNA entered the room, then left the room to gather linens to change R18's bed. While the CNA was out of the room, R18 rolled off the bed, which resulted in a fracture to his right femur. The investigation noted the bed was not at an appropriate height. The investigation lacked witness statements, identification of causal factors, and resident interviews. Review of Progress Note dated 12/25/22, documented a CNA reported to the nurse he had been in the room changing R18's linens, he stepped out of the room to get linens, and R18 rolled out of the bed while he was outside of the room. R18 had a laceration to the right side of his head and a skin tear to his right hand. R18 complained of pain to his right hip. The staff obtained his vital signs and the nurse cleaned the wounds and did not move R18 until emergency service (EMS) staff arrived to assess R18. EMS staff and a Licensed Nurse lifted R18 from the floor to a stretcher. R18 complained of pain to his right leg. R18 transferred via ambulance to the hospital for further evaluation. Review of Progress Note dated 12/27/22, documented R18 returned from the hospital around 03:00 PM, via gurney, transported by an outside transportation services. R18 had a suprapubic (a urinary catheter that is inserted through a small incision in the lower abdomen) catheter in place. R18 had confusion and his speech was not clearly understood. R18 had an incision to his right hip due to a surgical procedure. R18 had a dressing covering the incision with an order to leave the dressing in place until his follow up appointment, and the staff were to apply ice intermittently to his right hip for discomfort, as needed. The staff were to use a mechanical lift for transfers of R18, with the assistance of two staff. Review of the Fall Scene Investigation Questionnaire dated 12/25/22, documented the CNA had answered the questions of toileting time and noted a urinary catheter in place, R18 was incontinent at the time of fall, had no footwear in place, noted the last time R18 had eaten was at lunch, noted R18 was changed at 01:45 PM, and seen at lunch, at noon. Furthermore, the CNA documented R18's call light was on, R18 told him nothing, and the fall happened because R18 rolled to the floor. On 04/26/23 at 03:25 PM, observed R18 lying in his bed, in the regular height position, with no mattress perimeters or body pillow in place. He rested with his eyes closed and awoke at the calling of his name. On 04/26/23 at 03:25 PM, R18 reported on the morning of 12/25/22, he had just woke up and rolled over, right onto the floor. R18 stated he did not think anyone was trying to hurt him. On 05/01/23 at 08:36 AM, Certified Nurse Aide (CNA) D reported in the event of an incident or altercation, staff should report to the nurse immediately and stated several fall interventions that the facility used. She did not know of any fall interventions needed for R18. On 04/27/23 at 04:40 AM, Licensed Nurse (LN) N reported with a fall, she assessed the resident, provide any first aid needed, call for EMS if needed, make a thorough progress note, and notify management, provider, and family. LN N reported the nurse was responsible for putting an intervention in place to prevent further falls. On 04/27/23 at 10:30 AM, Administrative Staff A revealed she expected staff to notify her immediately of incidents. She confirmed the nurse should make a complete progress note to include the entirety of the incident and any interventions put into place. Administrative Staff A confirmed no witness statements, identification of causal factors, or resident interviews were completed for R18's 12/25/22 fall which resulted in a fracture. The facilities 12/23/21 Fall Prevention Program policy documented falls could result in injury and the very least, emotional trauma. The facility role was to assure they identified the residents at risk for falls and assure the facility had individualized preventive approaches in place to assist with the prevention of future falls. The facility failed to provide adequate supervision and assistive devices to prevent accidents, when R18 fell out of bed on 12/25/22, which resulted in a right femur fracture and required surgical repair. - Environmental tour of the facility, on 05/01/23 from 02:00 to 04:00 PM, with maintenance staff Z, revealed the following resident accessible areas contained the following areas/items with accident hazards to the residents of the facility. The 100 Hallway had two bulbs in each of four of the hallway ceiling lights, lacked any type of protective coverings to protect in case of broken glass any resident that may be walking under them if they broke. Maintenance staff Z verified the light bulbs lacked the protective coverings they should have. The large courtyard between hallways 100 and 300, contained a large cement pad in the middle. The cement was approximately 12 by 12 feet, and all edges were raised above the ground level, approximately 4 to 6 inches. These areas could cause any resident in the courtyard to trip and fall onto the cement pad. On the 200 Hallway a residents shower/toilet room on this hallway contained a shower with walls coming out to the front. The front corners of the shower contained tiles which were broken and cracked off in several areas along them. This presented a accident hazard for lower leg injury to any resident using this shower and coming in and out of the shower area. The same shower/toilet area contained metal grab bars for stability to get on and off of the toilet. One side grab bar was loose when grabbed, which could potentially cause a resident that might grab it to lose balance and fall. Maintenance staff Z verified the broken tiles and the loose grab bar could cause accidents to the residents. The 400 Hallway contained the facility special care unit with a resident census of 9. An unlocked residents' shower/toilet room contained multiple resident care items and personal belonging stored in the room's shower areas. The contents stored included pictures, suitcases, clothes, a wheelchair, two large plastic barrels, window blinds against the wall, decor items, and an oxygen tank caddy. This room was so full of items that it created a accident hazard for any of the 9 residents if they wandered into the room and tripped on the items. The special care unit's activity/snack room area contained a sink with cabinets along one side wall of the room. A large storage cabinet just inside this room doorway, stood open. The cabinet held a spray bottle of Spic and Span Disinfectant, to keep out of the reach of children hazard label. The same open cabinet contained a plastic open topped container, that held multiple different types/colors of fingernail polish. These should be kept out of the reach of children also. These hazardous chemicals were accessible to all 9 residents on the special care unit with impaired cognition. The 500 Hallway's southeast exit door entered into a courtyard. On this day the facility had a group of workers cleaning up this courtyard of old metal and tree limbs/trash. On 4/27/23 observation revealed the courtyard contained multiple old mechanical lifts and other old metal equipment, but today at this time they were removed. The courtyard did contain a cement pad, approximately 3 by 3 feet, which was raised along all the edges approximately 2 to 4 inches. Any resident in the courtyard could easily trip on this accident hazard. The facility failed to provide necessary housekeeping and maintenance services to maintain a safe environment for the residents of the facility.

The facility reported a census of 67 residents, with 11 of those residents identified at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff), and three sampled. Based on observation, record review, and interview, the facility failed to provide adequate supervision to cognitively impaired Resident (R)1, who exited the facility without staff knowledge, on 04/04/23. R1 removed the cardboard staff used to cover the window he broke out on 04/03/23, and exited the facility through the broken window on 04/04/23. R1 exited in an area located one-to-two blocks from a heavily traveled, four lane street, with a speed limit of 40 mile per hour. A community member notified the facility R1 was across the street in a fenced-in yard. This deficient practice placed this resident in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of Alzheimer's Disease (a progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), restlessness, and agitation. The 12/09/22 Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 with short-term and long-term memory problems and moderately impaired decision-making abilities. R1 wandered one-to-three days of the seven-day assessment period, required supervision for walking in and out of his room, was independent in locomotion on and off of the unit, and his balance was not steady during transitions, but he was able to stabilize without staff assistance. R1 did not require a wander/elopement alarm. The Annual MDS dated [DATE] for R1 revealed no changes to his memory or decision making. R1 rejected care one to three days and wandered four to six days of the seven-day assessment period. He required supervision for walking in and out of his room and for locomotion on and off of the unit. R1 had no changes in his balance, continued to not require a mobility device, or a wander/elopement alarm. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/07/23 revealed R1 wandered around the memory care unit frequently and into other resident rooms, at times could be easily redirected, and rejected care at times. The ADL [Activities of Daily Living] Functional/Rehabilitation Potential CAA dated 03/07/23 revealed he required assistance with decision making and increased assistance with cares. R1 wandered around the memory care unit frequently and into other resident rooms. The Care Plan dated 02/08/23 revealed R1 had an alteration in thought process related to his Alzheimer's Disease, was at risk for elopement, and did exit seek. He resided on the locked memory care unit, however, when agitated, he had managed to get the fire door into the building open. Staff were to monitor him when wandering the hallways. The Elopement risk assessment dated [DATE] revealed R1 was at risk for elopement. The Progress Note dated 04/03/23 at 02:30 PM revealed the staff notified Administrative Staff A R1's window in his room was broken and the staff covered the window with cardboard. Administrative Staff A called a window company to repair. The Progress Note dated 04/04/23 at 09:48 PM revealed the staff had safety concerns for R1 who was outside of the facility. The facility staff assisted R1 back into the facility, he resisted at first, but other staff members were able to assist in his return to the facility. R1 transferred to the hospital at 09:15 PM. On 04/06/23 at 01:34 PM Licensed Nurse (LN) G stated she was on duty when R1 eloped from the facility. She said she was not his nurse but received a phone call from a lady who said she saw a person outside and wondered if it was our resident. The lady was on the second balcony of her apartment and saw him at a gate. LN G stated she hung up the phone, ran down out the 300 hall exit door, and saw R1 inside a fenced area next to the apartments. LN G stated he went down where a sign was to the south, approximately a block away, and went through the opening there, which was the only one she could find to get in the fenced area. LN G stated she had a Certified Nurse Aide (CNA) drive her car down the block, into the fenced in yard area, to bring R1 back. LN G stated R1 did not say why he left or what he was doing, and he could walk around on his own, without any assistive devices. On 04/06/23 at 01:40 PM observation revealed a paved parking area approximately 15 feet from R1's bedroom window, and the staff found the resident in a fenced in area across the street. The window had been repaired and a dresser was in place in front of the window. Located approximately one-to-two blocks north from the parking lot by his bedroom window, was a heavily traveled four-lane street with speed limit of 40 miles per hour. R1's bedroom was not in a fenced in area of the facility. On 04/06/23 at 02:38 PM LN H stated she was the charge nurse on duty on 04/03/23 when the R1's window was broken, and on 04/04/23 when R1 eloped. LN H stated on 04/03/23 a housekeeper told her about R1's broken window, and she was in the middle of an admission, so she reported the broken window to Administrative Staff A. Administrative Staff A put cardboard up over the window until someone could replace the window. R1 stayed in the same room while the cardboard was in place. LN H stated R1 was very confused, not able to hold a conversation, and not able to say why he broke out the window. LN H verified the cardboard was still in place the day R1 eloped, and staff informed her he eloped when she came back from break. LN H stated R1 would walk back and forth in the hall and try to open doors. On 04/06/23 at 02:53 PM CNA M stated he was not aware R1's window was broken, and he was exit seeking the day he eloped on 04/04/23. CNA M stated he stayed on the hall when the call came that someone was outside. CNA M stated most of the time when R1 walked or try to get out the door, he tried to get R1's attention from getting out. On 04/06/23 at 03:01 PM CNA N stated she was working on the memory care unit on 04/04/23 when R1 eloped, and it was common for R1 to be at a door trying to get out. CNA N stated she had seen him kick at a door before and he was exit seeking frequently but not every day. CNA N stated she did not know the window in his room had been broken out, until after the call came that he was outside. CNA N stated she watched him walk to his room after dinner, which was around 05:30 PM. CNA N stated R1 could stand up on his own and walk, he would walk to his room, close the door and lay down, and could get up out of bed on his own. She stated there were two aides on the hall at the time the facility received the call and so she left the unit to try and help bring him back in. CNA N stated one of the other CNA's drove her car over to him, he was standing at the fence mumbling, and was resistant at first, then R1 got in the car. On 04/06/23 at 03:12 PM Administrative Staff A stated on 04/03/23 a housekeeper was cleaning and noticed R1's window was broken out. The window was on the outside and a banana peel was outside too. Administrative Staff A stated the glass was cleaned up and cardboard was put up until the facility could get the glass company to repair. Administrative Staff A stated R1 was not in his room when staff found the broken window and thought maybe he broke it trying to throw out the banana peel. Administrative Staff A stated the facility did not move R1 into a different room while awaiting the window repair, and the next day when he eloped, he had removed the cardboard from the window, so she believed he eloped out of the window. On 04/10/23 at 10:18 AM Administrative Staff A stated she observed video camera footage and R1 entered his room at 07:13 PM. Administrative Staff A stated the facility did not implement any new interventions for R1 after the staff placed the cardboard over the broken window. On 04/10/23 at 10:30 AM Administrative Nurse D stated the facility did not implement any new interventions for R1 after the staff placed the cardboard over the broken window. On 04/10/23 at 11:00 AM Administrative Staff A stated the facility received the call that R1 was outside on 04/04/23 at 07:18 PM (five minutes after he had gone to his room) and R1 returned to the facility at 07:30 PM. The facility policy Elopement/Missing Resident dated 01/11/22 revealed upon admission each resident will be assessed for the potential for elopement risk. Consideration will be given to the resident's prior history of wandering, whether the history and assessment indicates impaired decision making and/or impaired cognition and the ability to be mobile by walking or use of wheelchair or similar device. When a resident is identified as having wandering behavior on admission, appropriate interventions will be implemented and documented in the resident's plan of care. Residents who develop wandering or exit-seeking behavior after admission will be reassessed and appropriate interventions will be included in the plan of care at the time of identification of the wandering or exit-seeking behavior(s). On 04/10/23 at 03:30 PM Administrative Staff A was informed R1 was in immediate jeopardy and provided the Immediate Jeopardy Template for failure to provide adequate supervision for this cognitively impaired, and at risk for elopement resident, R1, after he broke out his window in his bedroom on 04/03/23 and eloped from the facility out of the broken bedroom window on 04/04/23. This placed R1 in immediate jeopardy. The facility completed implementation of the following corrective measure on 04/05/23 at 10:00 PM: 1. Facility implemented one-to-one with R1 upon return until he was sent out to the behavioral unit on 04/04/23. 2. Elopement assessments were completed on all residents residing on the memory care unit on 04/05/23. 3. The facility repaired the window by installation of plexiglass on 04/05/23. 4. The facility will move R1 to a room that is in the locked enclosed courtyard upon return to the facility. 5. The facility educated staff on 04/05/23 on managing difficult behaviors and elopement by 10:00 PM. 6. The facility completed a quality assurance meeting with the medical director on 04/10/23. The deficient practice was deemed past non-compliance due to the implemented corrective actions and existed at a J scope and severity.

The facility had a census of 60 residents with 15 residents in the sample and three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to prevent the development of a stage 4 (sore that extends below the subcutaneous fat into deep tissues like bone) pressure ulcer (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) for dependent Resident (R)52, who admitted to the facility with intact skin. The facility further failed to monitor and assess the facility acquired pressure ulcer on R52's coccyx (small triangular bone at the base of the spine). Findings included: - R52's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge- return anticipated Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be completed. R52 had short-term memory problems and did not have any pressure ulcer/injury. The Significant Change MDS dated [DATE] revealed a BIMS score of four, which indicated severely impaired cognition. R52 required extensive assistance from staff for bed mobility and toilet use, and limited assistance from staff with eating. R52 was frequently incontinent of bladder and bowel. R52 weighed 108 lbs. (pounds), was 61 inches tall, and experienced weight loss, but was not on a physician prescribed weight-loss program. R52 had one unstageable pressure wound and utilized a pressure reducing device for her chair and bed. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 07/28/21 revealed R52 triggered for urinary incontinence due to decrease mobility and was at risk for skin breakdown due to being occasionally incontinent of bowel and bladder. The Pressure Ulcer/Injury CAA dated 07/28/21 revealed R52 triggered for pressure ulcer/injury due to periods of incontinence of bowel and bladder, increased weakness, and needed extensive assistance with repositioning. The Care Plan dated 08/03/21 revealed R52 had an alteration in skin related to an open area on her coccyx that was a chronic, unstageable pressure injury. Interventions included for staff to encourage good nutrition and hydration in order to promote healthier skin. Staff would turn and reposition every two hours and as needed (PRN). The licensed nurse would perform a weekly skin assessment. Staff would cleanse the area, pat dry, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes) to peri wound (tissue surrounding a wound), apply SilvaKollagen Gel (a silver antimicrobial collagen gel with hydrolyzed collagen which supports autolytic debridement) to wound bed, apply collagen, cover with dry dressing, and change the dressing three times a week. The 06/01/21 Admission Summary Progress Note revealed R52's skin was intact. The 06/13/21 Health Status Note revealed R52 had a small open area at the top of her coccyx, which measured 1-centimeter (cm) x 3-millimeter (mm) x 1mm. The 06/17/21 Weekly Skin Evaluation revealed the resident had a dime sized, stage 2 wound to the sacrum. The Weekly Skin Evaluation further had a notice in red letters stating: NOTE: If an open area, proceed to appropriate skin condition report. (A skin condition report was not completed.) An order dated 06/18/21 to apply skin prep to open area on coccyx each shift and as needed (PRN) after incontinence, every shift for skin integrity, and every eight hours as needed. Discontinued on 06/23/21. An order dated 06/23/21 for weekly skin assessments. An order dated 06/24/21 to cleanse right buttock wound with wound cleanser, apply skin prep to wound edge, apply cut to size alginate (a multipurpose type of wound dressing), cover with foam dressing, change Monday through Thursday till healed. Discontinued 06/25/21. An order dated 06/26/21 to cleanse right buttock wound with wound cleanser, apply skin prep to wound edges, apply dime size Santyl (a sterile enzymatic [MEDICATION(S)] ointment) to wound bed, apply cut to size Xeroform (a fine mesh gauze occlusive dressing impregnated with [MEDICATION(S)]) to wound bed, cover with border dressing, change daily. Discontinued on 08/01/21. The 07/21/21 Social Services Note revealed R52 signed on to hospice care to care for R52's wounds. An order dated 07/22/21 for House Supplement Shake (nutritional supplement drink) 4 ounces (oz). Review of the Hospice Visit Note Report on the following dates revealed: 07/27/21- Sacral wound measured 2.7cm x 2.5cm. 08/02/21- Sacral wound measured 2.7cm x 2.5cm. 08/09/21- Applied sacral wound treatment. 08/12/21- Treatment to coccyx replaced. An order dated 08/04/21 Cleanse sacral wound with wound cleanser, lightly pat dry, apply skin prep to wound edges, apply SilvaKollagen gel to wound bed, cover with cut to size collagen, cover with dry dressing, hospice to change Monday and Friday, our staff to change dressing on Wednesday, one time a day every Wednesday for sacral wound. Discontinued 08/05/21. The 08/05/21 Health Status Note revealed R52's Durable Power of Attorney (DPOA) only wanted hospice to assist with wound care for a two-week period of time between 07/24/21 - 08/06/21, then the facility would provide care similar to before signing on to hospice. An order dated 08/06/21 Cleanse sacral wound with wound cleanser, lightly pat dry, apply Santyl to wound bed, cover with cut to size collagen, over with dry dressing, change dressing Monday-Wednesday-Friday. Discontinued 08/18/21. An order dated 08/19/21 Cleanse buttock open area with wound cleanser, pat dry, apply Santyl to wound bed, cover with cut to size Xeroform, cover with folded 4x4 (sterile dressing), cover with border gauze, change daily. Discontinued 09/12/21. The 08/20/21 Nutrition/ Dietary Note written by Registered Dietician (RD) J revealed R52 had an open area on her coccyx and recommend adding MedPass (nutritional supplement liquid) 120 milliliters (ml), BID for extra calories. The 08/24/21 Activities Note revealed new orders to consult [local wound center] to evaluate and treat the wound on the resident's coccyx. The 09/03/21 Nutrition/Dietary Note revealed RD J again recommended adding MedPass (nutritional supplement liquid) 120 ml, BID for extra calories. The 09/07/21 Health Status Note revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 09/12/21 Weekly Skin Condition Report revealed the resident had a stage three pressure wound to the sacrum, which measured 4.0cm long (l) by 1.4cm wide (w) x 1.7cm depth (d). An order dated 09/12/21 to consult [local wound center] (specialized wound care provider) to evaluate and treat the resident's coccyx wound. An order dated 09/12/21 Coccyx wound, flush open area with normal saline/wound cleanser, pat dry, apply skin prep peri wound. Then apply Santyl to wound bed (thickness of a nickel), pack loosely with alginate. Cover with boarder gauze. Change BID (for excess drainage) and PRN if soiled, damp or dislodged. An order dated 09/12/21 to flush the open area to the resident's coccyx with normal saline and wound cleanser, pat dry, apply skin prep to the peri wound, apply Santyl to wound bed (thickness of a nickel). Staff were to pack the wound loosely with alginate (a multipurpose type of wound dressing) and cover with boarder gauze. Staff would change the dressing twice daily (BID) (for excess drainage) and PRN if soiled, damp, or dislodged. An order dated 09/14/21directed staff to consult hospice to evaluate and treat R52. The 09/15/21 [local wound center] Progress Note revealed an initial coccyx wound encounter, which measured 3.2cm l x 1.5cm w x 1cm d. The resident had bone exposed with undermining noted at 11:00 (on a clock scale) and ending at 6:00 with a maximum distance of 1.6 cm. The wound was noted with copious (abundant) amounts of serosanguineous (semi-thick reddish drainage) drainage. Weekly Skin Evaluations were completed on 06/28, 07/12, 07/19, 07/26, 08/02, 08/09, 08/16, 08/30, and on 09/20/21. (Staff did not complete a Weekly Skin Condition Report which allowed for more in-depth documentation of wound measurements, description of the wound condition, treatment followed, and intervention(s) used.) Review of the September 2021 Electronic Treatment Administration Record (ETAR) revealed the record lacked evidence staff completed weekly skin assessments on 09/06/21 and 09/27/21. Staff did not complete the physician ordered BID wound treatments on the following dates: 09/14, 15, 16, 17, 18, 21, 22, 26, 27, and 09/28/21. Staff further failed to complete wound care at all on 09/23/21. Observation on 09/30/21 at 09:30 AM revealed staff took R52 in her wheelchair from the dining room to her bedroom and placed her in bed on her left side. R52 went to sleep. At approximately 12:00 PM on 09/30/21 staff brought R52 to the dining room for lunch and she had a pressure relieving cushion in her wheelchair. Observation on 10/05/21 at 02:09 PM, Licensed Nurse (LN) H changed R52's dressing to her coccyx. LN H wore gloves and removed the old bordered dressing. The wound was clean, had no sign of infection, no drainage, and no foul odor. LN H used wound cleanser to clean the wound and patted the area dry with gauze. LN H applied skin prep around the peri-wound area, applied Santyl to the wound bed, and packed the wound with calcium alginate. LN H stated there was no bordered gauze available, so he covered the wound with an ABD (highly absorbent sterile dressing) pad and taped the edges. LN H stated there was another wound care company that came in to measure R52's wounds. Interview on 09/30/21 at 09:20 AM, Certified Nurse Aide (CNA) O stated R52 had a sore on her coccyx and the nurses changed the dressing one to two times daily. CNA O stated staff repositioned R52 every two hours and she had a cushion in her wheelchair. CNA O stated R52 had only a standard mattress on her bed and staff packed pillows under her. Interview on 10/04/21 at 04:01 PM, CNA V stated R52 had a sore on her coccyx that was always dressed. CNA V stated R52 would lay down in her bed when she was not in the dining room. CNA V stated R52 had a cushion in her wheelchair and a regular mattress on her bed. Interview on 10/05/21 at 07:30 AM, LN P stated measurements for open sores should be documented in the Skin Condition Report. LN P stated R52 started on hospice care 07/23/21 and was taken off 08/13/21. LN P stated hospice should have documented R52's wound measurements in the hospice communication notebook. LN P stated she could not find any wound measurements beside the Skin Condition Report dated 09/12/21. LN P stated the [local wound center] had not been in to see R52 or anyone since there had been COVID in the building. LN P stated the nursing staff taking care of R52's wound should have documented wound measurements. LN P stated there was no air mattress used for R52 because she moved around a lot in her bed and there was a possibility of this being a fall hazard. LN P stated all mattress used were anti-pressure mattresses. Interview on 10/05/21 at 01:33 PM, Administrative Staff A stated she expected nursing staff to document wound measurements at least on a weekly basis. Interview on 10/06/21 at 11:03 AM, Administrative Assistant M stated Nurse Practioner N stated [local wound center] was on the case to treat R52's wound. In an interview on 10/07/21 at 02:34 PM, Physician Y stated he expected the facility to keep track of the wound measurements in order to follow the progression of the wound. The Pressure Injury/Skin Breakdown- Clinical Guidelines policy revised October 2010 revealed, The nursing staff will complete an evaluation of the skin weekly. The Pressure Injury Treatment Guidelines policy revised November 2017 revealed, Document on the tools provided by the community .information in accordance with the facility policy and professional standards of practice. The facility failed to prevent the development of a stage four pressure ulcer for dependent, Resident (R)52 who admitted to the facility with intact skin. The facility further failed to monitor and assess the facility acquired pressure ulcer on R52's coccyx/sacral area.

The facility had a census of 60 residents with 15 residents in the sample and three residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to monitor weights regularly, place effective interventions, and follow-up on registered dietician recommendations for nutritional supplementation, which resulted in Resident (R)52 experiencing severe weight loss of 17.73 percent in 108 days between 05/13/21 through 09/03/21. Findings included: - R52's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R52 required limited assistance with eating. R52 weighed 108 pounds was 61 inches tall, and experienced weight loss, but was not on a physician prescribed weight-loss program. The Quarterly MDS dated [DATE] revealed a BIMS score of four, which indicated severely impaired cognition. R52 required limited assistance with eating. R52 weighed 108 pounds, was 61 inches tall, and experienced weight loss, but was not on a physician prescribed weight-loss program. The Nutritional Status Care Area assessment dated [DATE] revealed R52 recently upgraded to a regular diet with regular texture and thin liquids. R52 had no difficulty noted with eating. The Care Plan dated 06/30/21 revealed R52 had a potential for alteration in nutrition and fluid intake related to dementia. R52 required a mechanical soft diet with thin liquids. Interventions included house shakes (nutritional supplement drink) two times daily initiated on 07/28/21, staff would maintain R52's focus by redirecting her to eat at mealtimes, monitor intake of food and fluids, offer diet as ordered, and take R52 to the dining room for meals. The Care Plan dated 07/06/21 revealed R52 had a potential for nutritional problem related to needing increased assistance with meals due to dementia. Interventions included for staff to invite R52 to activities that promoted additional nutritional intake. Staff were to monitor and document refusals to eat, assist with eating as needed, and the registered dietician would evaluate and make diet change recommendations as needed (PRN). A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Order dated 07/27/21 for regular diet, regular texture, thin consistency. Order dated 07/22/21 for house supplement shake, 4 oz. (ounces). Further review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2021- September 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition- Amount Eaten Task in the EHR from 09/07/21 - 10/05/21 lacked any documentation noting the percentage of meals the resident consumed. (Access to this information was limited to the last 30 days.) A Nutrition/ Dietary Note dated 08/20/21 by Registered Dietician (RD) J revealed R52 weighed 108 pounds and triggered for a weight loss of 13.8 lbs. (pounds) or an 11.3 percent weight loss in 90 days. R52 received a regular diet, regular texture, and had meal intakes of less than 50 percent. R52 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EHR revealed a lack of evidence staff implemented Med Pass 120 ml, BID and was recommended by RD J on 08/20/21. A Nutrition/ Dietary Note dated 09/03/21 by RD J revealed R52 weighed 100.2 pounds and had a weight loss of 16 lbs. or a 14.4 percent weight loss in 90 days. R52 received a regular diet, regular texture, and had meal intakes usually of less than 50 percent. R52 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EHR revealed a lack of evidence staff implemented Med Pass 120 ml, BID as recommended by RD J on 09/03/21. Review of the EHR revealed the following weights: 05/13/21 119.0 lbs. 05/19/21 121.8 lbs. No weights available in the Electronic Health Record (EHR) from 05/20/21 through 08/05/21. 08/06/21 108.0 lbs. which indicated a 11.33 percent weight loss in 80 days (a severe weight loss.) No weights available in the EHR from 08/07/21 through 09/02/21. 09/03/21 100.2 lbs. which indicated a 17.73 percent weight loss in 108 days (a severe weight loss.) Observation on 09/30/21 at 8:38 AM revealed R52 had a breakfast of scrambled eggs, a bowl of oatmeal, French toast, sausage, an 8 oz. cup of orange juice, and an 8 oz. cup of milk. Staff assisted R52 with her meal and she consumed approximately 20 percent of her meal, 75 percent of her orange juice, and no milk. No observation that staff offered R52 a supplement during this meal. Observation on 09/30/21 at 12:12 PM revealed staff assisted R52 with her meal and offered her a lunch that consisted of spinach, beans, cornbread, a cookie, an 8 oz. cup of lemonade, and an 8 oz. cup of water. R52 was not very cooperative and consistently wanted to lean forward in her wheelchair. R52 consumed less than 25 percent of her meal, and approximately 50 percent of her lemonade and water. No observation that staff offered R52 a supplement during this meal. In an interview on 09/30/21 at 09:20 AM Certified Nurse Aide (CNA) O stated R52 was totally dependent with feeding. CNA O stated R52 used to feed herself, but in the past month she needed staff help. CNA O stated R52 no longer ate snacks when offered. CNA O stated he thought R52's weight was pretty consistent and did not think she had lost weight recently. CNA O stated R52 was offered Mighty Shakes (nutritional supplement), but trying to get R52 to drink it was a real challenge. CNA O stated R52 could be very stubborn. In an interview on 10/05/21 at 07:30 AM, Licensed Nurse (LN)P stated R52 had not been eating very well. LN P stated if the Registered Dietician recommended Med Pass and weekly weights due to weight loss, staff should have followed up on this recommendation. In an interview on 10/05/21 at 01:33 PM Administrative Staff A stated if the Registered Dietician recommended Med Pass for R52, the facility should follow-up on this recommendation. In an interview on 10/06/21 at 02:50 PM, Registered Dietician J stated she gave her recommendations to the dietary manager to pass on to the Director of Nursing (DON) to follow-up on, but the facility did not have a DON for some time. Registered Dietician J stated she was not sure if the facility could implement an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/06/21 at 11:03 AM, Administrative Assistant M stated Nurse Practitioner N was unavailable for interview, but would pass on what she said. Administrative Assistant M stated Nurse Practitioner N stated she was going to write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Administrative Assistant M, Nurse Practitioner N stated R52 had dementia, many co-morbidities, and was failing in health. The Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol policy revised February 2018 stated, Monitor and document the weight and dietary intake of residents in a format which permits readily available comparison over time .weight loss .greater than 10% is severe .The Interdisciplinary Team, should attempt to identify conditions and medications that may be causing anorexia, weight loss .Identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes .Strategies to increase a resident's intake of nutrients and calories may include .nutritional supplementation .The Physician, with input from the staff, will determine the most appropriate intervals for weight assessments. The facility failed to ensure staff regularly monitored weights and implemented recommendations from the Registered Dietician to help reduce weight loss, which resulted in R52's severe weight loss.

The facility census total 61 residents with three of the ten residents who reside on the Memory Care Unit sampled for wandering and the potential for elopement. Based on observation, interview, and record review the facility failed to properly secure and alarm an exit door in the dining room of the Memory Care Unit which exited to a courtyard with a six-foot wooden privacy fence in which cognitively impaired, independently mobile Resident (R) 5 exited the unalarmed door and climbed over the privacy fence without the staff's knowledge sometime after 08:45 PM on 07/16/21, a Friday night. R5 wandered after dark in a high traffic area with uneven terrain, highly trafficked city streets and large city intersections with speed limits of 40 miles per hour, and several water hazards for over seven hours until R5 was located by the police department approximately two and half miles from the facility, across the street from a very busy city hospital with an attached emergency room . R5 reported pain at a nine out of a 10 (on a one to ten scale) upon assessment when he returned to the facility on [DATE] sometime after 04:20 AM. This failure placed R5 in immediate jeopardy and nine other cognitively impaired residents who reside on the memory care unit at risk. The facility further failed to determine causal factors and develop interventions to prevent further falls for R2, R3, and R4. Findings included: - Review of R5's Transfer/Discharge Orders revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. Review of the Admission assessment dated [DATE] revealed R5 with short and long-term memory loss. The resident was independently ambulatory. Review of the Baseline Care Plan dated 07/12/21 revealed R5 had a history of wandering, was at risk for falls, and required a Wander Guard (alarm system) bracelet to alert staff if R1 attempted to exit the facility unaccompanied by staff. Review of the Wandering and Elopement Evaluation dated 07/12/21 revealed a score of seven (low risk), and staff placed a Wander Guard on R5. Review of the Brief Interview for Mental Status Assessment (BIMS) dated 07/19/21 revealed a score of three, indicating severely impaired cognition. A Progress Note dated 07/12/21 at 10:29 PM revealed R5 was alert to self with confusion and ambulated independently with a steady gait (manner or style of walking). Staff placed R5 on 30-minute checks and monitored for elopement risk. R5 repeatedly packed and unpacked his personal belongings. A Progress Note dated 07/13/21 at 03:15 PM revealed R5 sat in a chair in the dining room, he was able to follow simple commands, answered yes or no questions in present tense, was easily re-directed, and had a Wander Guard bracelet placed on his right wrist. A Progress Note dated 07/16/21 at 09:45 PM revealed Certified Nurse Aide (CNA) P notified the charge nurse R5 disappeared and possibly eloped from the facility via the dining room door in the memory care unit. The staff searched and failed to locate R5 in the facility or in the courtyard. The note revealed staff on the Memory Care Unit last observed R5 at 08:45 PM (on 07/16/21) while staff provided care to other residents. The on-call nurse, administrative staff, R1's family, and the police were notified and the search for R5 began at 10:23 PM (07/16/21). A Progress Note dated 07/17/21 at 06:51 AM revealed R5 was found outside the facility at 04:20 AM and arrived back at the facility at 04:40 AM. The administrative staff stated R5 was found at the [MEDICATION(S)] near Wesley hospital. R5 was alert and oriented to his name with confusion. R5 complained of generalized pain to his extremities from exhaustion and walking, and rated his pain at a nine out of ten on the pain scale of one to ten. R5 stated he left the facility in search of the warm and cold places, and said he was looking for motor parts. R5 presented with redness to his right knee, bruised areas to his right big toe and foot, a skin tear to his right arm, bruises to his right thumb, and scratched areas to his back. R5 received a shower and received Tylenol (pain reliever) for pain. The facility placed R5 on one-on-one supervision, the Wander Guard bracelet remained in place, and functioned properly when tested . The staff assisted R5 to bed and checked on him every 15 minutes, with no distress noted. Review of Wunderunderground historic weather records revealed the low temperature on 07/17/21 was 75 degrees with wind speeds of 15 miles per hour (mph). An observation of R5 on 07/20/21 at 12:50 PM revealed he sat at the dining room table interacting with other residents with the Wander Guard bracelet visible to his right ankle. An observation on 07/20/21 at 12:48 PM with Licensed Nurse (LN) H revealed the door located in the dining room on the Memory Care Unit had a standard household door knob with a twist lock and lacked a wander guard alarm box. LN H said the door had a newly installed two-piece magnetic code alarm installed to the top of the door. When tested at this date and time, LN H stated the magnetic alarm failed to sound three times when opened by LN H from the inside and outside of the facility. The staff summoned Maintenance Staff (MS) Q to the unit and he entered a code key pad on the magnetic lock and the alarm sounded when the door opened and silenced after he entered a code on the alarm box when the door closed, however when staff opened the door again the alarm failed to sound twice at this date and time. MS Q revealed the magnetic code alarm was not in place at the time R5 eloped on 07/16/21 and was installed yesterday (07/19/21) and he was still trying to figure out how the alarm worked. An observation of the Memory Care courtyard on 07/20/21 at 12:50 PM revealed an unsecured push lawn [NAME], a leaf blower, and a gas container which was ¾ full of gas, stored against the building outside the dining room door. A BBQ grill sat next to the wrought iron gate (propane bottle removed), an unassembled gazebo with sharp hard plastic edges, including metal frame pieces, and metal pipes stacked up against the wooden privacy fence which reached 18-24 inches below the top of the six foot privacy fence. The courtyard also had garden hoses strung along the sidewalk, a sprinkler head with a metal stake on the end exposed, two long metal top brace pieces for the gazebo laid on the sidewalk which posed a trip hazard. Just outside the Memory Care Unit courtyard gate a large party tent was on the ground with pooled stagnant water noted in several spots, another garden hose, and a large piece of rolled fencing on the side walk partially unrolled. The employee parking lot located directly outside of the courtyard fence had multiple areas of broken asphalt, uneven terrain, and broken cement parking blocks with exposed rusted rebar. The location of the facility sat on a heavily traveled street with a speed limit of 40 miles per hour to the North, another busy street with an apartment complex sat directly behind the facility to the South, to the East sat an office building with an open lot with uneven terrain, and located to the West of the facility was a child care center with playground equipment including elevated climbing features and on the next block to the west, the local state university. An interview on 07/20/21 at 12:17 PM with Certified Nurse Aide (CNA) R revealed he considered all the residents on the Memory Care unit a risk for elopement. He revealed the facility installed a door alarm to the dining room door on 07/19/21 and he had not witnessed R5 or any other resident attempt to unlock or exit the door during his shift. CNA R revealed the staff provided activities in the dining room to reduce wandering and he left all the doors cracked to the resident's room so he could make frequent visual checks while working up and down the hall. An interview on 07/20/21 at 04:00 PM CNA P revealed he worked the evening shift on 07/16/21 when R5 eloped from the facility. CNA F revealed he last observed R5 at 08:45 PM as he sat at the dining room table and R5 had not exhibited any wandering behavior or attempted to open the dining room door up to that point on his shift. CNA P revealed he left the dining room to provide care to another resident and when he returned R5 was no longer seated in the dining room. CNA P revealed he immediately searched the Memory Care Unit going from room to room and searched the courtyard for R5. He revealed when he was unable to locate R5 inside the facility, or in the courtyard, he notified the charge nurse. CNA P stated the charge nurse came to the Memory Care Unit, conducted a search of the unit, sent staff on foot to search the surrounding area and staff members drove around the surrounding neighborhoods to find R5 without success. CNA P confirmed he received elopement training upon hire at the facility and said he did not know what to do when he identified R5 eloped from the facility. An interview on 07/20/21 at 12:25 PM with LN H revealed R5 was an elopement risk and had a Wander Guard bracelet placed on him upon admission to the facility. LN H revealed the dining room door on the Memory Care Unit did not have a Wander Guard alarm box or any kind of alarm to alert staff when a resident opened the door and exited into the courtyard before R5 eloped. She revealed when a resident exhibited wandering or exit seeking behaviors the staff provided one on one supervision to ensure their safety. An interview on 07/20/21 at 01:30 PM with MS Q revealed the facility did not have a Wander Guard box or an alarm on the dining room door which lead to the courtyard on the Memory Care Unit. He confirmed the only lock on the door prior to the elopement was the standard door knob twist lock, and the items stored in the courtyard including an unsecured lawn [NAME], a plastic container ¾ full of gas, the garden hose and the stacked building material posed a safety hazard to all the residents who used the courtyard. An interview on 07/20/21 at 12:05 PM with Administrative Staff B revealed R5 eloped from the facility on 07/16/21 around 08:45 PM and was not found until approximately 04:15 AM on 07/17/21 about 2.5 miles away from the facility. Administrator B revealed she reviewed the video footage for the night of the elopement and R1 had not exited the Memory Care Unit via the doors to the other unit, which had a Wander Guard alarm box, and the facility believed he unlocked the door in the unit dining room and climbed over the fence in the courtyard located off the Memory Care Unit. She revealed the staff knew R5 was an elopement risk and stated R5 eloped from another facility prior to his admission to the facility. She confirmed the facility placed a Wander Guard bracelet on R5 upon admission, however the facility door he exited was not alarmed with a Wander Guard receiver device. In a follow-up interview on 07/20/21 at 01:00 PM Administrative Staff B confirmed the dining room door only had a standard lock on the door knob prior to the elopement and confirmed the unsafe materials stored in the courtyard including the gas can, lawn [NAME], and the stacked building materials, posed a hazard to R5 and any other resident who entered the courtyard. Review of the Elopement policy last revised November 2017 revealed elopement occurs when a resident leaves the premise or a safe area without authorization. (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility failed to ensure the Memory Care Unit courtyard exit door was secured with a system to prevent the elopement of R5 who left the faciity on a Friday night, 07/16/21 and was not located until over seven hours later, which placed the resident, and the nine other cognitively impaired residents who resided on unit, in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 07/20/21 at 05:47 PM. The facililty implemented an acceptable plan for removal of the Immediate Jeopardy on 07/21/21 at 03:59 PM when the facility installed a temporary alarm to the Memory Care Unit door to alert staff if a resident exit the unit into the courtyard, received estimates and planned to install a Mag-lock to the exit door, and provided elopement training to all staff members, verified by surveyor onsite. The deficient practice remained at a E scope and severity following removal of the immediate jeopardy. - Review of the 06/15/21 provider Progress Note for R2 revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition with no falls documented. R2 did not require staff assistance for bed mobility, transfers, walking in room, and locomotion on/off the unit. He required supervision of staff for walking in the corridors, toileting, and personal hygiene. Review of the Falls Care Area Assessment (CAA) dated 02/17/21 revealed R2 had a diagnosis of depression and used antidepressant medications, which put him at risk for falls. Review of the Quarterly MDS dated [DATE] revealed R2 was rarely or never understood, had both short-term and long-term memory loss, and had two or more falls with minor injury. R2 required extensive assistance of one staff for toileting and was independent for bed mobility, transfers, walking in room/corridors, and locomotion on/off unit. Review of the Care Plan with a revision date of 06/19/21 revealed R2 was at high risk for falls related to recent falls and contained the following interventions: 04/07/21- Ensure the resident wore appropriate footwear (black bedroom slippers) when ambulating. 04/15/21 - The staff were to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage the resident to use the call light for assistance as needed. The resident needed prompt responses to all requests for assistance and to follow the facilty fall protocol. 06/17/21 - On 06/14/21 R2 fell and was sent to the ER for stitches in his head. Review of the Nurse's Progress Notes dated 03/12/21 revealed Licensed Nurse (LN) J went to R2's room at 02:15 AM. The resident sat on his bed with a wound to the right outer eyebrow, noted to be 2.8 centimeters (cm) in length with depth of 0.2 cm, and no other wounds noted. The resident did not remember falling from his bed. The resident received steri-strips to his brow area. The facility did not have a Fall Investigation for the 03/12/21 fall, with injury. Review of the Nurse's Progress Notes dated 04/02/21 revealed LN J went to R2's room at approximately 03:00 AM and found R2 on his right side with his head near the nightstand. The resident had a small cut to the left upper temple measuring 2.5 cm x 0.2 cm, with no blood noted. The resident did not remember falling. The facility did not have a Fall Investigation for the 04/02/21 fall, with injury. Review of the Nurse's Progress Notes dated 06/14/21 at 12:10 AM revealed at approximately 11:15 PM LN J found the resident with a large amount of blood in his hair. LN J noted R2 with a long, gaping wound approximately three inches in length and another approximately 1.5-2 inches in length. The staff applied pressure to the wound to control bleeding and received orders to send R2 to the emergency room (ER) for sutures. Review of the Nurse's Progress Notes dated 06/14/21 at 04:20 AM revealed the resident received 12 staples to his head at the local emergency room . The facility did not have a Fall Investigation for the 06/14/21 fall, with injury. The Care Plan lacked a new fall prevention intervention related to the 06/14/21 fall. Observation on 07/07/21 at 05:20 PM revealed R2 sat at a dining room table, fully dressed, with shoes on. During an interview on 07/08/21 at 09:59 AM, Certified Nursing Assistant (CNA) K stated she did not know of any falls for R2. CNA K stated the staff needed to keep an eye on him because if he was wet, he tried to change himself. CNA K stated she did not know of any fall interventions for R2. During an interview on 07/08/21 at 10:19 AM, CNA L stated R2 was independent with walking and tended to roam the hallways. CNA L said R2 had one fall, which required staples to his head. CNA L stated R2 always needed to wear shoes. CNA L stated R2 was not able to use a call light. During an interview on 07/08/21 at 10:27 AM, LN M stated R2 fell and received staples at the hospital for one of the falls. LN M stated the LNs should complete a fall investigation for each fall to include a root cause analysis and a fall intervention, which should be included in the care plan. During an interview on 07/08/21 at 10:59 AM, Administrative Nurse C expected the care to be updated with a new fall intervention after each fall. During an interview on 07/08/21 at 11:16 AM, Administrative Staff B stated R2 had two falls on 06/13/21. She expected a fall investigation to be completed for each fall to determine the root cause and possible intervention, which expected to be included in the care plan. Review of the facility policy Accidents and Incidents-Investigating and Reporting dated June 2021 revealed accident involving residents should be investigated promptly. The facility failed investigate falls to determine causal factors and develop interventions to prevent further falls for R2. R2 sustained a fall on 06/14/21 which required staples for a laceration at the local emergency room . - Review of the Physician Orders for R3 dated 06/24/21 revealed the following diagnoses: [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing), [CONDITION(S)] (sudden severe confusion, disorientation and restlessness), hypertension (elevated blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), repeated falls. Resident admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) noted as in progress and not completed. Review of the Baseline Care Plan dated 06/25/21 regarding Fall revealed R3 was at risk for falls and the staff were to encourage the resident to use his call light for assistance of staff. Review of the Fall Risk assessment dated [DATE] revealed a score of 15, indicating a high fall risk. Review of the Nurses Progress Notes dated 06/29/21at 01:54 pm revealed Certified Nursing Assistant (CNA) F informed the Licensed Nurse (LN) she witnessed R3 on the floor by his bed. The resident attempted to sit on the bed, and he slid down and fell to the floor, uninjured. Staff assisted R3 to his feet and he walked to his bed without difficulty. Facility staff documented R3 as Alert and oriented with confusion which is resident baseline. The facility did not have a Fall Investigation for the fall on 06/29/21. Review of the Nurses Progress Notes dated 07/03/2021 at 11:25 AM revealed staff found R3 on the floor and he could not say what he was doing prior to the fall or where he was trying to go. Review of the Fall Investigation dated 07/03/21 revealed R3 experienced an unwitnessed fall. The Fall Investigation failed to identify causal factors for the fall or interventions to prevent further falls. Observation on 07/08/21 at 11:00 AM revealed the resident slept in bed, covered with a blanket. The door to his room was open and R3's room was free of clutter. During an interview on 07/07/21 at 03:04 PM CNA F reported the resident was a fall risk, but he was independent. CNA F reported she did not know what fall interventions were in place. During an interview on 07/07/21 at 03:21 PM Licensed Nurse (LN) H revealed the staff provided activities and supervision to prevent falls for R3. LN H said he liked to keep his eyes closed when he walked, so the staff monitored him closely, as that is when he was more likely to fall. LN H said R3 tried to leave the unit with family when they visited, but the staff were able to intervene and prevent him from eloping. LN H said when he falls, most of the time it was because he walked with his eyes closed and his family said he did the same thing at home as well and had frequent falls. LN H said he has never had injuries with his falls. During an interview on 07/08/21 at 11:16 AM, Administrative Staff B reported they expected fall investigations to be completed with each fall to determine root cause and identify interventions. Review of the facility policy Accidents and Incidents-Investigating and Reporting dated June 2021 revealed accident involving residents should be investigated promptly. The facility failed to investigate falls to determine causal factors and develop interventions to prevent further falls for R3. - Review of the 03/14/21 Physician Orders for R4 revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), [CONDITION(S)] (rapid irregular heartbeat), hypertension (elevated blood pressure). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of three, indicating severely impaired cognition. The resident had no falls since admission. Activities of Daily Living (ADLs) were documented as only occurring once or twice during the review period. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of three, indicating severely impaired cognition. The resident required limited assistance of one staff for all ADLs. The resident had one fall with injury since admission. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/28/21 revealed R4 with Alzheimer's disease. Review of the Care Plan dated 03/02/21 regarding Falls revealed the staff were to ensure R4's call light was within reach and to encourage R4 to use the call light for assistance as needed. The resident needed prompt response to all requests for assistance. The Care Plan further instructed the staff to ensure R4 wore appropriate footwear (brown slip-on house slippers or black tie up shoes). Review of the Fall Risk assessment dated [DATE] revealed a score of 24, indicating a high risk for falls. Review of the Nurses Progress Notes dated 06/23/21 revealed R4 was found on the floor on his right side against the wall. He was alert and responsive with confusion and could not recall what happened. R3 had a skin tear and large purple bruising to his right arm/elbow area with a small amount of bleeding. The note lacked any identification of causal factors or interventions. Review of the Nurses Progress Notes dated 07/05/21 at 05:20 PM revealed a CNA advised LN H that a resident in the locked unit (400 hall) was on the floor. LN H rushed to the unit to find R4 laying on the floor with no pants on and dried blood noted on the floor. Resident had an open bleeding skin tear on his left elbow. Review of the Fall Investigation completed on 07/05/21 revealed the resident had an unwitnessed fall. The Fall Investigation failed to identify causal factors for the fall or interventions to prevent further falls. Observation on 07/07/21 at 02:45 PM revealed R4 stood in his room with his pants down to his knees, one sock on his left foot, right foot bare, and no shoes on. R4 had a dressing to his left arm and ambulated to the bathroom by himself. During an interview on 07/07/21 at 03:08 PM Restorative Aide (RA) G revealed the resident needed quite a bit of assistance with cares. RA G said R4 has a bent over gait and does not ambulate well. RA G said when he has fallen, depending on staffing, he has been made a one-on-one by the nurse. During an interview on 07/07/21 at 03:14 PM LN H revealed she was not the nurse on duty when he fell . The last few days R4 has been agitated because of his move to the locked memory care unit. LN H said to prevent falls, we have activities like memory games, television, and anything to keep his mind busy to help prevent him from walking constantly. LN H said walking him around the patio would be a good idea to allow him to get his need for movement out of his system and walking him up and down the hallway also helped. LN H said R4 had a fall a few days ago. Review of the facility policy Accidents and Incidents-Investigating and Reporting dated June 2021 revealed accident involving residents should be investigated promptly. The facility failed to investigate falls to determine causal factors and develop appropriate interventions to prevent further falls.

The facility census totaled 54 residents, with three sampled for wandering behaviors. Based on observation, interview, and record review the facility failed to provide appropriate supervision to cognitively impaired Resident (R) 1, identified by the facility as at risk for wandering, exhibited exit seeking behaviors, and had communication deficits. R1 eloped on 09/02/20 through a window in an empty wing of the facility. R1 was out of the facility between the hours of 01:45 PM and 05:00 PM. The facility staff was unaware of R1's absence, until therapy alerted them R1 could not be found between approximately 02:30 PM to 03:00 PM. The facility noted the missing window after conducting an outside perimeter walk after 04:00 PM. The local police department picked up R1 at approximately 03:30 PM, approximately 0.7 miles/3696 feet away from the facility, across several very busy four-lane city roadways with 40 miles per hour speed limits. A concerned citizen reported R1 in a parking lot and he looked in distress. These failures placed R1 in immediate jeopardy. Findings included: - R1's pertinent [DIAGNOSES REDACTED]. disorder, anxiety disorder, dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), heart failure (weak heart muscle), [MEDICAL CONDITION] (condition with disordered or absent language function), personal history of [MEDICAL CONDITION] (TIA- episode of [MEDICAL CONDITION] insufficiency) and cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficits. Review of the 08/05/20 Admission Minimum Data Set (MDS) revealed the staff assessment of R1's mental status indicated modified independence with some difficulty in new situations only. The MDS noted R1 had long/short-term memory problems, inattention, and disorganized thinking. R1's speech was unclear with slurred/mumbled words. He sometimes understood others and responded adequately to simple, direct communication only. R1 understood others, but missed some parts/intents of message. The MDS indicated no wandering during the seven-day review period. The resident's gait was steady, required set-up with supervisionfor walking in the corridor/locomotion off unit, and supervision for locomotion on the unit, with no falls noted. Review of the 08/05/20 [MEDICAL CONDITION] Care Area Assessment (CAA) revealed R1 triggered for [MEDICAL CONDITION] (a sudden severe confusion, disorientation and restlessness) related to inattention and disorganized thinking with no true signs of [MEDICAL CONDITION] at that time. Review of the 08/05/20 Cognitive Loss/Dementia CAA revealed R1 triggered for cognitive loss/dementia related to refusal of BIMS and memory problems. R1's [DIAGNOSES REDACTED]. Review of the 08/05/20 Activities of Daily Living (ADL) CAA revealed R1 triggered due to functional/rehabilitation potential related to staff supervision with some ADLs needed. R1 was fairly independent with ADLs at times, he needed direction to properly complete. Review of the 08/05/20 Behavioral CAA revealed R1 triggered for behavioral symptoms related to rejection of care and behavioral symptoms noted on the MDS. R1 had [MEDICAL CONDITION], dementia and cognitive deficit placing him at risk for noncompliance. Review of the 08/05/20 Fall CAA revealed R1 triggered for falls related to antianxiety medication. Review of 07/30/20 Elopement Assessment identified R1 at high risk for wandering/elopement. Review of the 07/31/20 Fall Risk Evaluation identified R1 was at low risk for falls. Review of the 08/04/20 Care Plan with revision on 08/13/20 revealed R1's alteration in thought process related to history of [MEDICAL CONDITION] ([MEDICAL CONDITION]- stroke, a 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), [MEDICAL CONDITION] (characterized by partial loss of the ability to produce language (spoken, manual, or written), [MEDICAL CONDITION], and behavioral syndromes. Staff cued, reoriented and supervised R1 as needed. Review of 08/04/20 Care Plan with a revision on 08/26/20 revealed R1 was at risk for elopement related to his history of attempts to leave facility unattended and impaired safety awareness. Staff assessed R1 for fall risk. Staff also distracted R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books per the resident's preferences. Staff to identify patterns of wandering such as wandering purposeful, aimless, or escapist, or was resident looking for something or needed more exercise? Staff intervened as appropriate. Staff provided R1 with structured activities including toileting, walking inside and outside, and reorientation strategies including signs, pictures, and memory boxes. Review of 08/04/20 Care Plan with revision on 09/03/20 revealed on 09/02/20 R1 removed a window and went out of the screen. Staff immediately placed the resident on 1:1 staffing (provided to ensure the safety of residents who may be suffering from cognitive impairment, exhibit challenging behavior, or may be at risk of falls or of causing harm to themselves or others) for 09/02/20 and 09/03/20 for the day shift. The windows on hall 500 noted as different from the rest of the building, and maintenance immediately secured the windows. Immediate staff education on elopement completed with all staff prior to returning to work. On 09/03/20 day shift, R1 continued on 1:1 for about half of the day shift, until all windows checked and secured, and alarms placed on both end doors on hall 500. Staff would have eyes on R1 when he moved throughout the facility. Review of 08/04/20 Care Plan with revision 08/13/20 revealed R1 noted at high risk for falls related to gait/balance problems, poor communication/comprehension, psychoactive drug use, and his unawareness of safety needs. Staff anticipated and met the resident's needs, call light within reach, and encouraged the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. Revision on 09/05/20 revealed R1 lost his balance and fell on [DATE] in the hallway and could not describe the incident. Revision on 09/18/20 revealed R1 did not tie his shoelaces and fell on [DATE]. Review of 07/31/20 at 03:52 AM Nursing Note revealed R1 easily agitated during the shift and expressed he wanted to leave the facility. He walked throughout the facility and stared out the front door. R1 noted sitting in dining room with his clothes and a jacket. Review of 08/05/20 at 01:10 PM Nursing Note revealed R1 refused to stay in his room and demanded to be let out to smoke. Review of 08/08/20 at 12:04 AM Nursing Note revealed on second shift (02:00 PM- 10:00 PM) for 08/07/20, R1 ambulated around facility and rummaged through things. Staff noted R1 took a spray bottle that had been given to staff to spray surfaces down (with a cleaning solution in it) with brown liquid noted. Staff asked him what substance was and R1 stated it is my coke. The resident came to the nurse this shift and asked for a coke and root beer which staff provided to him. Review of 09/03/20 at 10:52 AM Nursing Note revealed the facility reported to the State on 09/02/20 at approximately 04:00 PM, as staff could not locate R1. Every worker in the building began an organized search directed by Administrative Staff A, who notified Administrative Nurse B. Staff searched the facility first and found an open window with the screen torn on hall 500. The search broadened to the surrounding area outside. Staff called the police at 04:18 PM, notified them of R1's missing status, and printed out face sheets with R1's picture. At 04:49 PM the police called the facility back and stated to meet them outside. When the police arrived, they stated the college campus police transported R1 at 03:30 PM to R1's family member's home. The police picked R1 up at his family member's house, and at 05:00 PM R1 returned to the facility. LN C immediately assessed R1 for injuries, with none noted. Staff notified R1's legal guardian and physician, and immediately placed R1on 1:1 status. Staff notified maintenance to secure the windows, and the window R1 eloped from was immediately replaced and secured. Immediate staff education and review of the elopement policy completed on 09/02/20 at 05:15 PM with all staff in the facility. All other staff must complete elopement training before reporting to work. Review of signed 09/08/20 Facility Investigation for the 09/02/20 elopement revealed R1 eloped between 01:30 PM and 03:15 PM through a window in room in the 500 hall. Between 02:30 PM and 04:00 PM, staff could not locate the resident. The facility notified the local police at 04:18 PM of R1 as missing, and at 04:49 PM the local police called to say the nearby college campus security picked up R1 and took him to his family member's house at 03:30 PM. Police transported R1 back to the facility at 05:00 PM. R1 spent approximately two hours alone outside the facility and walked across a busy intersection and onto a college campus (also very heavily trafficked area) with two small ponds noted in possible path. R1 traversed approximately 0.7 miles/3696 ft from facility. Per data reported on weather.com for 09/02/20, the high temperature was 82 degrees Fahrenheit (F), with a low of 68 degrees F, and mostly cloudy. Review of notarized statement by police officer M on 09/04/20 revealed between 03:29 PM to 03:48 PM a female notified the officer of a male (R1) walking on a sidewalk near the college campus parking lot. R1 told the officer he wanted to walk to his family member's house, but his speech was hard to understand. The officer assisted R1 to sit in his police car to rest and not fall. The officer noted that due to the heat and R1's inability to move/walk quickly, he transported R1 to the address he provided. At the house, the inhabitants knew R1 and let him in. Later in the day, a call came in for a lost adult (R1), and the officer notified dispatch of R1's location. He transported R1 back to the facility at 05:00 PM. Observation of R1 on 09/24/20 at 12:16 PM revealed he sat in a wheelchair alone at a table in the dining room area. R1 answered staff by waving his hand and did not respond verbally during this observation. At 12:30 PM, R1 pushed himself with his feet backwards in the wheelchair with non-skid socks and slip on shoes. R1 ambulated easily in wheelchair, with no specific destination noted and he tended to look around with no expression. Interview with R1 on 09/28/20 at 03:33 PM, he indicated he did not leave the facility a few weeks ago, but then stated he took off down the road. R1 indicated the police transported him to a family member's house. He indicated he left the facility, but could not tell this surveyor how or indicate how long he was outside the facility. The only recollection of the incident, per R1, was that he needed to make a call when he got to wherever he was going. Interview with Certified Nurse Aide (CNA) D on 09/24/20 at 02:52 PM revealed when R1 first arrived at the facility, he wandered and pushed on doors. He resided in hall 500 when he first arrived for isolation (same hall he eloped from on 09/02/20). After the 14 days, R1 moved to hall 100, and wandered up and down the halls and pushed on the exit doors. CNA D stated his normal daily habit included being in the hallways, in the dining room seated at the tables, or in his room if he wanted to sleep. R1 was curious about the doors to staff. She indicated that R1 fell last week because his slip-on shoe went underneath the wheel of his chair. She stated that R1 was independent with all ADLs and he made his own decisions. She indicated staff were to re-direct and keep an eye on him because he roamed the facility a lot. On 09/02/20, she arrived for second shift at 02:00 PM, and received report at the nurse's station. She indicated she did not remember seeing him on her first rounds while she stocked rooms, completed baths, and check-and-changes. She indicated she went to his room at some point and he was not there. She did not think not finding him was abnormal, due to his wandering. Later in the day at approximately 03:30 PM, Speech Therapy (ST) I notified her R1 could not be found. CNA D searched for R1. The doors to the 500 hall were shut due to no residents resided in that area and the doors were not alarmed. When R1 arrived back at the facility after his elopement, staff were directed to keep an eye on him more often. She indicated no specific time frame was relayed, but was just instructed more often. Staff identified residents as elopement risks by the use of a wander guard or if staff observed a resident wandered. She indicated the nurses usually go room-to-room approximately every hour, and if CNA staff see him out of his room, staff watch him. Interview with CNA E on 09/28/20 at 10:10 AM revealed she did not know R1 was an elopement risk prior to his 09/02/20 elopement. CNAs completed report in the nurse's station and checked on all resident's after the report. She indicated staff kept an eye on him, checked on him when he was out of his room, and always knew R1's location in the facility. Interview with CNA F on 09/28/20 at 10:16 AM revealed staff checked on R1 often, kept eyes on him all the time, in his room or out in the common areas. She indicated R1's had confusion at times. Staff checked on R1 frequently and introduced 1:1 with him last month due to behaviors. She indicated that R1's steady gait sometimes faltered, and he ambulated in the wheelchair. Interview with CNA G on 09/28/20 at 11:13 AM indicated R1 as an elopement risk and often wandered the facility. He stated that interventions for R1's elopement status before his elopement on 09/02/20 included staff checked on him often and when he wandered staff followed and re-directed him. Staff checked on R1 approximately every 15-30 minutes to ensure his safety and location. Interventions since R1 eloped included a wander guard, but he indicated no other interventions he knew of, staff just reported R1's location/wandering at the end the shift. CNA G indicated R1 had obvious confusion. Interview with CNA H on 09/28/20 at 12:30 PM revealed she arrived on 09/02/20 at 02:10 PM for her shift and obtained report from the nurse and aide. She indicated the CNAs completed report in the middle of the hallway to check on each resident room-by-room. She also indicated she always made sure she laid eyes on all of her residents, but residents moved around so often. She did not see R1 in his room, and then ST I asked her where he could find R1 (between 02:00 PM and 03:00 PM). She went to Licensed Nurse (LN) C and told him R1 could not be found. R1 usually stayed in the main area. All employees looked all over the facility for about an hour. When he first arrived at the facility, R1's confusion was apparent, and he pushed on the exit doors. She indicated the LNs sat R1 in the nurse's station sometimes, and he walked around the facility and talked to the other residents. She states there were no other interventions for elopement for this resident. She also added that he eloped easily from the facility because staff, from 12:30 PM to 02:00 PM, completed multiple tasks. Interview with LN C on 09/24/20 at 03:30 PM revealed R1's cognitive status could be alert and oriented, but with confusion at times. R1 rarely pushed on doors to get out. He needed little assistance and considered R1 independent. He indicated staff reported to each other when a shift ended/began and went room-by-room to check residents, but occasionally this scenario did not happen. The day R1 eloped, staff did not do a room-to- room check of residents. R1 usually could be found in the dining room eating, in his room sleeping, and he visited the administrative offices too during the shifts. ST I went to R1's room for therapy and could not locate R1 at approximately 03:00 PM. When R1 returned to the facility, interventions implemented included increased supervision at all times. Staff completed hourly checks for an amount of time, but the facility discontinued these checks. Staff ensured his location now. Interview with LN L on 09/28/20 at 10:26 AM revealed staff knew R1's elopement risk because he exhibited exit seeking and wandered the facility. LN L indicated his elopement status when giving report, and the CNAs completed walking report. LN L indicated R1 did not have a wander guard on admission, and she had no idea he had risk for elopement before his elopement on 09/02/20. LN L indicated before the elopement on 09/02/20, she knew of no interventions for elopement for R1. Interview with Administrative Nurse B on 09/28/20 at 10:37 AM revealed when administrative staff asked the CNAs and LNs on shift, no staff had seen R1. She indicated R1 noted as missing at 04:00 PM when LN N looked for him to complete care and could not locate him. Before he eloped, R1's elopement interventions included the CNAs checked on R1 every couple hours. The care plan included his elopement risk, staff communicated shift-to-shift, and the LNs communicated to the CNAs. When R1 eloped from the facility, he wore a hat, ¾ sleeve shirt, long pants, and tennis shoes. Interview with Administrative Staff A on 09/24/20 at 01:49 PM revealed on 09/02/20 at approximately 01:15 PM she talked to R1 up in the front lobby and he told her he wanted to go home. R1 usually resided in his room sleeping or out with other residents in plain sight. The staff did not complete any extra checks on him for safety because R1 is always just around. Sometimes he napped back in the 500 hall rooms because the area was quiet. Administrative Staff A said R1 removed the sliding part of the window from the track in room [ROOM NUMBER] and broke the screen and eloped from the building. She indicated around 04:00 PM she headed to leave the facility and facility staff notified her of R1's elopement. The facility called the police at approximately 04:18 PM after the findings of the ripped screen and missing window. Staff always visually checked rooms/residents when they walked up and down the halls, several times a shift, but not scheduled. She considered R1 to be low risk for elopement, but she indicated per the elopement assessment completed on 07/30/20 indicated him to be high risk. In the future, monthly maintenance checks for the windows were implemented to ensure the safety of our residents. Interview with Speech Therapist I on 09/24/20 at 04:10 PM revealed he looked for the resident between approximately 02:00 to 03:00 PM. He notified CNA O and looked approximately 10 minutes in all halls and rooms. Staff reported this to Administrative Staff A and then all staff searched. R1 talked about wanting to leave the facility and getting out before he eloped on 09/02/20. He indicated that R1's [MEDICAL CONDITION], moderately impaired cognition, short-term memory issues, and problem-solving skills hindered his safety awareness. Interview on 09/28/20 at 03:10 PM with Maintenance Staff K revealed the secured windows on 500 hall were outdated, and anyone that attempted to remove the window could have easily. Review of the revised 11/2017 Elopement F689 policy revealed for residents requiring increased monitoring of wandering, the LN will initiate Elopement/Wandering supervision for a specific period of time identified in the care plan or physicians orders; moderate or high risk scoring on assessment or wandering not conducive to the safety of the resident. Staff shall promptly report any resident who tries to leave the premises or suspected of being missing to the charge nurse or Director of Nursing (DON). The facility failed to provide adequate/appropriate supervision for a cognitively impaired and independently mobile R1, which allowed him to leave the facility through a window without staff knowledge for over two and a half hours, and local police picked up the resident from a parking lot after a report of a male who looked in distress. R1 traversed over busy four lane roads and intersections heavily trafficked with speed limits of 40 mph. This failure placed R1 in immediate jeopardy.

The facility census totaled 67 residents with 3 residents identified by the facility as at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to implement effective interventions to ensure 1 resident did not leave the facility, without staff's knowledge, wander over 1 mile in heavy traffic areas and accept a ride from a stranger who then transported the resident to a local emergency department. (#1) The resident was unaccounted for approximately 4 hours. This facility failure placed the resident in immediate jeopardy and had the potential to affect three residents deemed at risk for elopement in the facility. Findings included: - The facility admitted Resident #1 on 6/23/17 and staff identified the resident as an elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff) risk upon assessment. Review of the elopement assessment completed on 6/23/17 revealed the resident was alert to self only and able to move him/herself independently. Resident #1 had a history of [REDACTED]. Review of the resident's admission plan of care, dated 6/23/17, revealed staff placed a wander guard (device that sets off an alarm when residents wearing one attempt to exit the building without an escort, as long as the doors are equipped with the wander guard system) bracelet on the residents left ankle. Review of a nursing note dated 6/25/17 at 6:30 AM revealed two licensed staff checked the resident's wander guard to ensure it worked by taking the resident to the front door and setting off the alarm. One of the staff members then took the resident back to his/her room to lay down. A nursing note dated 6/25/17 at 9:40 AM revealed the resident walked up and down the 200 hall and licensed nursing staff D took the resident outside to smoke. Staff D reported he/she stayed with the resident and after smoking 2 cigarettes, escorted the resident to the main dining room to eat around 9:20 AM. Licensed staff D went back to check on the resident and direct care staff advised him/her they could not find the resident in the dining room. Staff started a search of the facility two times and still could not locate the resident. Staff searched the exterior of the building as well. The manager on duty contacted the administrator and local law enforcement. Review of a nurse's note dated 6/25/17 at 2:10 PM revealed a local hospital contacted the facility asking for a current medication list and paper work for the resident. The physician extender at the hospital's emergency department reported a community member found the resident near a very busy highway interchange, with a speed limit up to 65 miles per hour (MPH) and the resident appeared confused. The resident reported he/she lived at that hospital, so the community member took the resident there. Observation on 6/28/17 at 7:55 AM revealed multiple construction vehicles on the busy main street in front of the facility with only 2 lanes open for traffic. The posted speed limit for the street was 30 MPH due to the construction. Observation on 6/28/17 at 8:37 AM revealed door 3 opened with a code, which staff had to enter on the wall-mounted unit next to the door. The door closed by itself rapidly and latched. Out back of the door revealed 2 locked sheds, the employee parking lot, and apartment buildings across the residential street. Traffic on a main commercial road was visible, with approximately 25 different vehicles noted, and approximately 300 feet to the north of the exit. Observation on 6/28/17 between 8:37 AM and 10:23 AM revealed the wander guard panels present on only the front door. Interview with maintenance staff B on 6/28/17 at 12:40 PM revealed the only door equipped for the wander guard was the main door. Interview with direct care staff C on 6/29/17 at 8:40 AM revealed he/she did not remember exactly which day the resident eloped, but he/she worked resident #1's hall the day he/she eloped. He/she took a breakfast tray to the resident and noted the resident was not in his/her room. Staff C reported the resident explored the facility that morning, so he/she performed a quick search for the resident looking in the commons area and the smoking room. After staff C could not locate the resident, he/she advised licensed nursing staff D of his/her inability to locate the resident. After that notification, staff C reported all the staff members searched for the resident and notified the police department and fire department. Staff C thought he/she notified staff D of the missing resident between 9:30 AM-10:00 AM. Interview with direct care staff E (certified to administer medications) on 6/28/17 at 3:35 PM revealed he/she first met the resident the day the resident eloped while he/she administered medications. Around 9:30 AM- 10:00 AM, licensed nursing staff D stated the resident was missing and assigned staff specific halls to search. He/she searched the 200 hall and looked in the closets, under the beds, in the beds, and everywhere for the resident. Interview with licensed nursing staff D on 6/29/17 at 8:16 AM revealed on the day resident #1 left the facility, he/she took the resident along with another resident out to smoke. When returning from the smoke break, staff D looked at his/her watch and it read 9:20 AM. Staff D sat the resident down at a dining room table so he/she could eat some breakfast and staff D continued with his/her duties. Staff D stated at 9:40 AM he/she looked at his/her watch and thought it was time to check on the residents. As he/she left the nursing station, direct care staff C advised him/her that he/she could not locate the resident. At that time, all the staff were advised and performed a facility-wide search. After the search, the resident could not be located, so he/she advised the manager on duty and staff performed another search. He/she stated an environmental staff member reported an unknown person out by door #3, but when shown a picture of the resident, he/she stated they just did not remember. Staff D reported the resident stood in the foyer upon his/her arrival at work that day, so he/she and another licensed nursing staff went ahead and had the resident get close to the front door to set off the wander guard alarm. Staff D reported the wander guard system was only effective for the front door. Interview with licensed nursing staff I on 6/29/17 at 4:51 PM revealed for residents assessed at moderate to high risk for elopement, the first intervention was the placement of a wander guard. If staff noticed exit-seeking behaviors, then increased visual checks would be the next intervention. Interview with administrative nursing staff G on 6/29/17 at 1:40 PM revealed that if staff identified a resident as an elopement risk, then staff would place a wander guard after obtaining an order from the physician and contacting the resident's family. Interview with administrative staff A on 6/28/17 at 12:14 PM revealed through the facility's investigation of the incident, the resident left the building through door 3 (not equipped with a wander guard alarm) and due to a 3 second delay on the door, the resident followed a staff member out of the facility. He/she stated an unknown staff member reportedly saw the resident, but did not know who he/she was and did not think anything about it. Then around 9:40 AM, the direct care staff notified the licensed nursing staff in charge the resident was unable to be located. The facility notified the police and multiple staff members came in to help search for the resident in their personal vehicles until the local hospital notified the facility of the resident's location. During a conversation with administrative staff A on 6/28/17 at 3:55 PM revealed staff notified him/her of the incident at 10:06 AM the day the resident left. He/she went to pick the resident up from the hospital emergency department, after the physician extender evaluated the resident, and resident #1 reported he/she followed a staff member out of the #3 door. When asked about the reliance on the wander guard system, he/she reported there was a double system in place for the monitoring of the door alarms. Staff A used an example of the resident attempting to leave the facility a different day, after the elopement, and the resident attempted to leave via a door which had an audible alarm in place when opened and an alarm in the main lobby area which advised staff the door opened and staff went to check and prevented the resident from leaving the facility. Review of the policy entitled elopement, revised 10/2015, revealed each resident would be evaluated for elopement and wandering risk upon admission and quarterly. Staff were to promptly report any resident who tried to leave the facility or suspected of being missing to the charge nurse. If an employee observed the resident leaving, he/she should attempt to prevent them from leaving, get help, and instruct the charge nurse. If the resident was discovered missing from the facility, staff were to find out if the resident was out on a pass, if not then initiate a search of the facility and premises. If not located then notify the administrator, director of nursing (DON), resident's legal representative, medical doctor (MD), law enforcement, and if needed volunteer agencies. Provide search teams with the resident information and initiate and extensive search of the surrounding area. The failure of the facility to ensure staff implemented effective interventions to prevent resident #1 from leaving the facility placed resident #1 in immediate jeopardy. The facility had only one door equipped to monitor the wander guard with this being the only intervention in place per the admission care plan. The resident was able to follow a staff member out of an exit door, without staff's awareness. There was a 3-second delay on the door the resident exited, which gave the resident enough time to exit prior to the alarm sounding. The facility had a door company come and fix the 3-second delay on door #3 and educated the staff on being aware of their surroundings and making sure that no residents followed them out of the facility on 6/26/17. The deficient practice was identified as past non-compliance and was corrected on 6/26/17.

The facility census totaled 67 with 30 residents included in the sample with 3 resident reviewed for accidents. Based on observation, interview and record review the facility failed to monitor the effectiveness of the current fall care plan interventions and initiate new interventions to reduce the risk for fall or risk for injuries related to falls for 2 of 3 (#74 and #8) residents and the facility failed to secure hazardous chemicals to prevent potential exposure to the residents on a hall with 9 independently ambulatory and cognitively impaired residents. Resident #74 sustained tibia/fibula leg fractures. Findings included: - Review of resident #74's admission MDS (minimum data set) dated 5/25/12 revealed the resident was unable to complete a BIMS (brief interview for mental assessment). The resident had short and long term memory loss with moderately impaired decision making ability. The resident had signs and symptoms of delirium including inattention, disorganized thinking, with mood indicators of little interest in doing things,feeling tired or having little energy, poor appetite, trouble concentrating, and moving speaking slowly from 2-6 days per week. The resident was free from behavior indicators, the resident had fallen the past 6 months prior to admission Review resident #74's quarterly MDS dated [DATE] revealed a BIMS score of 15, cognitively intact. The resident had no mood indicators and had behavioral indicator of verbally abuse 1-3 days per week and resistance of care 4-6 days per week. The resident required extensive assist of two staff members for transfers, extensive assist of one staff member for toilet use, personal hygiene, bathing, and limited assistance of one staff member for dressing, and eating. The resident required supervision for locomotion on and off the unit. The MDS indicated the resident had not had not had falls. Review of resident #74's ADL (activities of daily living) CAA (care area assessment) dated 5/31/12 revealed the resident required total assist with hygiene toileting, locomotion and long distance locomotion, had a Foley catheter. The resident required limited assistance of one staff member for dressing, meals, and transfers. The resident was independent with repositioning, and total assist with bathing. Review of the resident's Fall CAA dated 5/31/12 revealed the resident had difficulty paying attention in conversations, mild cerebral speech abnormality, no problems from past history of hip fracture with surgical repair. Review of the resident's care plan dated 1/8/13 identified the resident had a problem with inappropriate behavior related to chronic schizophrenic behaviors updated 1/22/13; the resident was hit by another resident the resident had no injuries and did not retaliate. The care plan was updated on 4/8/13; the resident slapped another resident across the nose. The care plan directed the staff that new or worsening behavior would be documented in the medical record, and on the behavior monitoring sheet for further evaluation and interventions; instruct staff on the resident's behaviors and potential interventions that may be used. Further review of the care plan directed the staff to glean information from other care givers that may be used for potential interventions. The physician will be notified of the new or worsening behavior as well as the family and documented in the record, attempt to determine the behavior trigger if possible with a complete assessment, evaluate behavior documentation for successful interventions and update the care plan as needed. The resident likes to pace the halls, may ambulate as able, SSD (social service director) to follow resident, the resident wears his/her sunglasses in the building, talks to himself/herself, and moved the resident to a different table in the dining room on 4/8/13. Review of resident #74's fall care plan dated 5/18/12 revealed the resident was at risk for falls per The Fall Risk Assessment score of 22 on 8/26/12; the assessment noted a score of 10 or higher indicated the resident was high risk for falls. The care plan was updated on 7/25/12 "actual non-injury fall", 8/10/12 updated with" fall no apparent injury", 8/26/12 "fall found on floor lying beside the bed", 2/7/13 "non injury fall assist to floor", 2/28/13 "fall non injury resident threw self on floor", and on 4/8/13 "threw self out of wheelchair and bed", The care plan directed the staff to place a falling star on the resident's door and head board to identify the resident as a fall risk, fall assessment done on admission, quarterly and with change in condition, resident used a wheelchair for mobility, staff to evaluate medications for risk factors, assess the environment for safety issues and intervene as needed, keep the at risk resident involved in activities of his/her choice, therapy as needed with decline in ADL ability, hip and elbow protectors to help avoid injury. The care plan was revised on 7/30/12 with "Dycem to wheelchair", 8/10/12 "bed and personal alarm on at all times to prevent injury", 7/28/13 "provide the resident with a calm environment" and on 4/8/13 "sent resident to the hospital". review of the resident's medical record revealed [REDACTED]. Review of the investigation report the facility mailed to the State for the reportable event that occurred on 4/8/13 revealed at approximately at 6:00 p.m. resident #74 was open handily struck by another resident and scratched the resident. Resident #74 became agitated and was taken to his/her room by the staff nurse and CNA (Certified Nurse Aide) to allow the resident to calm down. The resident later returned to the dining room to drink coffee and was seated at another table with a different resident. Resident #74 began yelling at the other resident and reached his/her arms towards the other resident. The facility staff attempted to calm the resident without success. The staff removed the resident from the dining room, the resident continued to yell and was arching his/her back and threw himself/herself on the floor. The resident was carried to his/her room by the facility staff and placed in his/her room in bed. Shortly after placing the resident in his/her room the staff heard banging in the resident's room and upon entering the room observed the resident lying on the floor. The resident reported he/she heard something snap in his/her right leg and the resident was found to have a tibia and fibula fracture of the right leg that required surgical repair. Further review of the investigation revealed the resident returned to the facility with continued complaints of pain and swelling continued in left leg. The resident was diagnosed with [REDACTED]. Review of the nurses note dated 4/11/13 at 7:00 p.m. revealed the resident returned from the hospital with purple discoloration to the left outer leg. The lower left leg was slightly swollen, non-pitting, capillary refill 3 seconds, right leg wrapped with ace wrap below knee to ankle and the resident reported pain 5 out of 10 on the pain scale to right ankle. Review of the resident's Nurses Note's dated 4/15/13 at 3:00 p.m. revealed the physician gave new orders to x-ray left lower extremity related to new complaints of left lower leg. Review of resident #74"s History and Physical dated 4/11/13 revealed x-rays of right tibia and fibula and right ankle revealed a distal 3rd spiral, oblique fracture and a distal fibula fracture. Review of the mobile x-ray report dated 4/16/13 revealed views of the tibia and fibula obtained on 4/16/13 revealed an irregular comminuted fracture involving the proximal shaft of the tibia at the level of the metadiaphysis junction. In addition a fracture involving the proximal fibula at the level of the fibular neck and a fracture involving the distal one-third shaft of the tibia. . The review of the fall Investigation report on 4/8/13 revealed the resident was found on the floor in his/her room lying on his/her back facing the door. The resident's right knee was bent with the foot turned inward. The resident revealed he/she was trying to get out of bed but "they took my wheelchair". Further review of report summary revealed resident had increased agitation at dinner, was taken to his/her room after refusing to remain in wheelchair. transferred to bed by direct care staff. New interventions implemented to reduce the resident's risk for further accident- continue to remove resident from area when he/she became agitated, attempt to administer prn (as needed) medication, and provide a calm environment. The facility failed to place the interventions placed on the Fall Investigation report on the resident's care plan. Observation on 4/29/13 at 2:03 p.m. revealed Licensed nurse J assisted the resident with a transfer from the bed to the wheelchair with the assist of a slide board. Staff J placed the body alarm on the resident's wheelchair after the transfer was completed. Staff J and the resident interacted well together. On 4/25/13 at 11:56 a.m. an interview with direct care staff O revealed the resident had a body alarm to his/her wheelchair and bed to alert staff to attempts of unassisted movement. Staff O revealed the staff had been directed to offer the resident a smoke, or turn on the radio in the resident's room and he/she would calm down. Staff O revealed the resident liked to watch TV and the staff used the television to calm his/her agitation as well. Staff O revealed the staff had not been directed by the Licensed Nurses to leave the resident in his/her room unattended with the door closed. On 4/29/13 at 12:01 p.m. an interview with resident #74 revealed he/she had a problem with another resident and struck out at him/her. The facility staff came into the dining room to remove resident #74, the resident revealed he/she was was in the wheelchair and refused to allow the staff to push him/her out of the dining room. The resident revealed he/she was cursing and screaming when 5 to 6 staff members surrounded him/her and lifted him/her out of the chair. Resident #74 revealed he/she was fighting and kicking the staff and the staff members dropped him/her on the floor. Further interview with resident #74 revealed the staff carried the resident to his/her room, placed the resident on the bed, closed the resident's door and failed to place his/her wheelchair in the room. The resident revealed that he/she attempted to get out of the bed to go get the wheelchair when he/she fell and heard a snapping sound in his/her right leg. The resident revealed he/she was laid on the floor for about 20 minutes with the door closed prior to staff returning to check on him/her. The resident revealed the body alarm was attached to his/her bed but did not sound when he/she fell . On 4/30/13 at 9:14 a.m. an interview with Licensed Nurse F revealed 4/30/13 The staff nurses are expected to write an intervention on the resident's care plan after each fall. The Administrative nurses reviewed the fall weekly during the Risk Meeting and reviewed the resident's care plan for accuracy and need for updating after falls. Staff F confirmed the staff failed to update the resident's care plan with a new intervention to reduce the resident fall or risk for falls on 2/7/13, 2/27/13 and 4/8/13. Staff F also confirmed the resident's care plan did not direct the staff to take the resident to his/her room when he/she was severely agitated and leave him/her unattended with the door shut. Staff F confirmed that staff nurses was supposed to write an intervention after each fall. On 4/30/13 at 3:55 p.m. an interview with direct care staff R revealed the resident's behavior was out of control and he/she began cursing and used racial slurs at staff and other resident's in the dining room. Staff R revealed that he/she and two other staff members had been directed by the nurses on a previous occasions to remove the resident and take him to his room to calm down. Staff R revealed three staff members attempted to remove the resident from the dining room but he/she threw himself/herself out of the wheelchair, the three staff members picked the resident up and carried him/her to his/her room, placed the resident in his/her room, left him/her alone and shut the door to allow the resident time to calm down. Staff R confirmed the resident was not assessed by a charge nurse after throwing him/herself on the floor from the wheelchair prior to when the three staff members picked the resident up and carried him/her to the room. Staff R confirmed the resident's wheelchair was left in the dining room and was not placed back in the resident's room until after the resident was found on the floor yelling he/she needed to go to the hospital he/she had broke something. Direct care staff confirmed the resident's body alarm was not sounding when the resident was found on the floor. On 4/30/13 at 4:04 p.m. an interview with Licensed nurse A revealed the first time the resident had the behavioral outburst the staff placed the resident in his/her room and turned the music on and left him/her in the room with the door open to calm down. Staff A revealed the staff have been advised to buy the resident a pop, let the resident smoke, provide one on one or use music to redirect him/her when the resident is having behaviors. Staff A confirmed the staff had carried the resident to his/her room and put him/her on the bed and closed the door. Staff A revealed the resident had been in the room approximately 5 minutes with the door shut before he/she made it to the room with the prn medication for agitation to administer to the resident. Staff A revealed the resident was observed on floor, yelling in pain and screaming to call the paramedics his/her leg was broken. Staff A revealed the resident had previous episodes of agitation in the past and the staff would offer the resident a pop, allow the resident to smoke a cigarette, of sit in his/her room and listen to music to allow the resident time to calm down. Licensed nurse A revealed that he/she was not sure what the care plan directed the staff to do when the resident had episodes of agitation because he/she had never looked at the resident's care plan. On 4/30/13 at 11:37 a.m. an interview with Physician DD revealed with a resident having that kind of behaviors he/she would have recommended 1 on 1 in the room to allow the resident to calm. Staff T revealed leaving the resident in the room alone when he/she was that agitated would not be the option for the resident's safety. Review of the facility's Fall Prevention Policy last revised 9/10/04 revealed Nursing staff document the incident in the "Nurses Notes" portion of the medical record. The documentation will include the notification of the family and physician and any new interventions, which will be put in place to deter further falls. Further review of the policy revealed the facility will provide training to staff regarding the fall prevention program at least annually, including reasons and risk for the falls in the elderly, interventions specific to their discipline to reduce the risk for falls and documentation procedures. The facility failed to evaluate the effectiveness of the current care plan interventions and intimate new interventions after falls to decrease the risk for fall or injuries related to falls. The resident sustained [REDACTED]. - Review of resident #8's Significant Change MDS (minimum data set) dated 12/19/12 revealed a BIMS (brief interview for mental status) score of 15 (cognitively intact). The required total assist of two staff member for transfers, total assist of one staff member for toilet use and bathing, extensive assist of one staff member for personal hygiene, limited assistance of one staff for dressing,set up help for locomotion on and off the unit and eating. The resident was independent with bed mobility and required a wheelchair for locomotion. Review of resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 15, cognitively intact. The resident required total assist of two staff members for transfers, total assist of one staff member for toilet use, and personal hygiene, limited assistance of one staff member for dressing, supervision for locomotion on/off the unit, eating, and remained independent with bed mobility. Review of resident #8's ADL (activities of daily living) CAA (care area assessment) dated 12/31/12 revealed the resident required extensive assist with ADLs. Review of the resident's care plan dated 10/5/12 revealed the resident was at risk for falls per fall risk assessment dated [DATE] with a score of 12 (key revealed a score of 10 or higher was high risk for falls). The care plan directed the staff that the resident had a falling star on the door that indicated the resident was a a fall risk. The resident would have a fall risk assessment done on admission, quarterly, and with change in condition, the resident used an electric wheelchair for locomotion, keep at risk resident involved in activities of choice, Hoyer lift for transfers from bed to wheelchair with staff assist and per family request, the resident family requested the staff not use the green lift (600) pound lift and to have 3 staff members present when using the lift. Review of the state reportable investigation revealed an incident occurred on 10/05/12. The resident was being transferred by lift from bed to wheelchair when lift tilted. The facility staff were unable to stop the resident from falling. The facility nurse assessed the resident and with the help of four staff members transferred resident safely to the wheelchair. Resident #8 complained of pain to his/her right leg an x-ray was done and showed no breaks or fractures. The investigation revealed the resident had gained 88.6 pounds in the 6 months after observed transfer with 600 pound lift was approved, the resident weight was still 80 pounds below the weight restriction on the lift. The facility chose to rent a 1,000 pound lift and use 3 staff members during transfers for the resident's safety. The facility planned to continue to check all lifts per the facility's environmental equipment standards of practice and to provide ongoing staff training. Review of the maintenance record revealed the lift was tested and in working order on 10/3/12. The lift test consisted of the lifts ability to go up and down, the wheels on the lift were clean, and the lift legs were in working order. On 4-24-13 at 10:00 a.m. an interview with resident #8 revealed "the staff lifted me in the lift and as they were trying to lower me into my electronic wheelchair they kept pushing the lift and it broke." The resident revealed that he/she was dropped on his/her right leg onto the foot rest of the wheelchair. The resident revealed the facility had bought a new lift to use for his/her transfers after the fall. Observation on 4/25/13 at 9:30 a.m. direct care staff L and T placed the lift sling under the resident by rolling him/her from side to side in the bed. The resident assisted the direct care staff by holding onto the bed rails and pulling him/herself from side to side. The staff then positioned the lift over the bed, placed the sling straps into sling strap holders and lifted the resident, rolled the resident over to his/her wheelchair and lowered the resident into the wheelchair. The resident did not complain of any pain or show any signs/symptoms of non-verbal pain or fear of being lifted in the sling and rolled in the lift to the wheelchair. On 4/2513 at 7:01 a.m. an interview with direct care staff L revealed he/she was told the lift was broke and the resident was dropped onto the foot rest of his/her wheelchair. Staff L revealed the facility purchased a new lift that accommodated a thousand pounds to lift the resident. Further interview with staff L revealed that all residents that required the use of a lift had to be evaluated and approved by the therapy department for safe use for each resident. On 4/29/13 at 4:33 p.m. an interview with direct care staff U revealed, at the time of the accident, the lift was working well, the legs where out for stability and the wheels were not sticking. Staff U revealed he/she and Direct care staff V had attempted to push the resident in the lift to the wheelchair when the lift flipped. On 4/30/13 at 8:31 a.m. an interview with Administrative nurse G revealed the resident was evaluated by the therapy department to ensure the 600 pound lift was safe for him/her. Staff F revealed the facility was unable to determine why the lift tilted during the transfer but the facility purchased a 750 pound lift for staff to use when the resident was transferred. All staff have received training on the new lift during the skills fair. Staff G revealed the resident no longer required three staff members for transfers. The facility discontinued the assistance of three aides for transfers with the lift when the 750 pound lift was delivered and the lift was deemed safe for the residents use. On 4/30/13 at 8:40 a.m. and interview with Therapy staff member W revealed that all staff were trained on the appropriate use of the lifts in the facility. Staff W revealed that the facility held a skills fair every year that educated all staff on the use of the therapy approved sling and lift for each resident. Staff W confirmed the therapy department had approved the use of the lift for this resident prior to the accident. Staff W revealed that he/she was unsure how the accident happened but thought the staff had used the lift equipment wrong. On 4/30/13 at 9:14 a.m. interview with Administrative nurse F revealed that resident's care plan indicated the resident was to be transferred with the 750 pound lift and the assistance of three staff members. Staff F confirmed the facility had failed to revise the resident's care plan timely to ensure the direct care staff knew how many staff members needed to be present during transfers. Review of the facility's Fall Prevention Policy last revised 9/10/04 revealed Nursing staff will document the incident in the "Nurses Notes" portion of the medical record. The documentation will include the notification of the family and physician and any new interventions, which will be put in place to deter further falls. Further review of the policy revealed the facility will provide training to staff regarding the fall prevention program at least annually, including reasons and risk for the falls in the elderly, interventions specific to their discipline to reduce the risk for falls and documentation procedures. The facility failed to evaluate the effectiveness of the current care plan interventions and initiate new interventions after falls to decrease the risk for fall or injuries related to falls. - Observation on 4-22-13 at 12:30 p.m., revealed a full 480 ml (milliliter) spray bottle of Spic and Span glass and all purpose cleaner sitting on the back of a toilet in a resident bathroom on hall 1. The warning label on the bottle read to keep away from children, harmful if swallowed, or inhaled, keep away from eyes may cause permanent damage. On 4-22-13 at 12:44 p.m., administrative staff G reported the cleaning chemicals were supposed to be kept in locked in the cleaning carts at all times and removed the bottle from the room. On 4-24-13 at 8:31 a.m., maintenance staff C reported the housekeeping staff were supposed to keep all the chemicals locked up in their portable cleaning carts at all times unless they were using them. The carts had been modified with locks for this purpose. On 4-24-13 at 12:15 p.m., housekeeping staff AA reported the cleaning chemicals were supposed to be locked up in the carts and kept away from the residents. Review of the undated facility policy for housekeeping basis rules and chemical storage revealed to make sure chemicals were locked up at all times. Review of the Material safety date sheet for Spic and Span disinfecting all-purpose spray and glass cleaner revealed the potential health effects to exposure were corrosive to the eyes and can cause permanent damage, exposure to the skin may irritate or burn, inhalation may cause mucous membranes(the lining on the inside of the mouth, throat and lungs) irritation, if ingested(swallowed) may cause nausea(feeling sick in the stomach), vomiting(expelling stomach contents), and diarrhea(runny or liquid bowel movements). On 4-24-13, administrative staff G identified 9 independently mobile, cognitively impaired residents lived on the hall. The facility failed to secure potentially hazardous chemicals and reduce exposure to those chemicals for the 9 residents with cognitive impairment that were independently mobile and lived on that hall.

The facility census totaled 66 residents with 31 included in the sample. Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for pain relief for 3 of 4 residents (#42, #59 and #78) sampled for pain and failed to assess and provide positioning devices for 1 of 3 residents sampled for positioning (#81). As a result of the facility's failure to recognize and address resident #42's severe pain the resident's pain compromised their function regarding dining. Findings included: - Resident #42's Minimum Data Set (MDS) re-entry assessment with an Assessment Reference Date (ARD) of 1/22/11 identified the resident with dementia, memory problems, [MEDICAL CONDITIONS], required the total assistance of one staff member with personal hygiene and toilet use, limited assistance with bed mobility and transfers, independent with set up assistance with eating, and experienced no pain. The CAA (Care Area Assessment) dated 11/8/10 assessed the resident as alert with confusion taking meals in the restorative dining room, with an intake of 50% to 75%, pockets food in their mouth, and needs verbal cues to stay on task at meal time. The care plan dated 1/26/11 failed to contain interventions regarding pain. Review of the nurses' notes revealed on 1/26/11 the resident returned from the hospital after treatment for [REDACTED]. On 2/3/11 at 2:00 p.m. the resident complained of lower back pain. Staff contacted the physician and received an order to obtain a UA (urinalysis), may use straight catheter (tube inserted into the bladder). Staff documented they gave PRN medication, Tylenol 1000 mg (milligrams), in the nurses notes but the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 2/7/11 at 2:00 p.m. the nurses notes showed the resident continued with severe back pain. Staff called the physician who said to continue to attempt to get the UA. Again the MAR indicated [REDACTED]. On 2/8/11 at 2:00 p.m. staff obtained the UA per straight catheter, five days after the initial order. The resident continued to have severe back pain on 2-8-11; the staff called the physician who ordered [MEDICATION NAME] 2.5 mg. now and PRN every 4 hours. Review of the MAR indicated [REDACTED]. at 2:00 p.m., on 2/9/11 at 8:00 am and 6:00 p.m. and on 2/10/11 at 8:24 a.m. On 2/11/11 the UA results revealed a UTI with escherichia coli bacteria, white blood cells 20-50 measurement (normal range 0-4), red blood cells 10-20 (range 0-2). On 2/11/11 the physician ordered the antibiotic [MEDICATION NAME] 100 mg. twice a day for 10 days and [MEDICATION NAME] 2.5 mg. every 12 hours for 3 days and then return to PRN. Observations on 2 /10/11 at 7:30 a.m. revealed the resident sat at the dining room table, in their wheelchair, with their breakfast of pureed food in front of them. The resident took one bite of food and then sat and held their left hand on the left side of their back (flank, where the kidneys are located). The nurse failed to identify and respond to the resident's pain. On 2/10/11 at 7:53 a.m. administrative nurse A sat down at the table across from the resident and started feeding the resident's table mate. The nurse encouraged resident #42 to take a bite of food. The resident just sat and continued to hold their back. On 2/10/11 at 8:00 a.m. the resident cried out and moaned and continued to hold their back. Administrative nurse A continued to feed the other resident and encouraged resident #42 to take a bite of food. The resident did not eat. On 2/10/11 at 8:13 a.m. the resident continued to hold their back with their left hand and a fork with the right hand. On 2/10/11 at 8:18 a.m. the resident moaned and held their back, rocked back and forth and said "I can't, I can't." Administrative nurse A continued to feed the table mate and continued to not address resident #42's complaints of pain. On 2/10/11 at 8:19 a.m. certified medication aide (CMA) D gave the resident's table mate their medications and heard resident #42 moan with pain and said "what is going on with you?" On 2/10/11 at 8:26 a.m. (57 minutes since the first observation of the resident with pain) CMA D gave the resident pain medication [MEDICATION NAME] 2.5 mg. and helped them take a drink of milk. When asked the CMA said the resident did have an order for [REDACTED]. Resident #42 continued to not eat. On 2/10/11 9:10 a.m. administrative nurse A moved to the other side of the table and sat down beside resident #42 and fed them. The resident no longer moaned but continued to hold their back. The resident ate 25% of their meal. On 2/10/11 at 10:10 a.m. the resident sat in their wheelchair in their room. When the surveyor asked the resident how they were doing the resident said "terrible, it is worse." On 2/10/11 at 11:11 a.m. the resident returned to their room after a shower, and continue to hold their hand on the flank area of their back. During interview on 2/15/11 at 11:00 a.m. nurse G stated they did not know why the resident started experiencing back pain, but they were giving the PRN medications. They acknowledged the staff had a hard time obtaining the UA. Sometimes they inserted the catheter but the resident had no urine output. (The nurses' notes failed to contain documentation of when the staff attempted to obtain the UA.) During interview on 2/16/11 at 4:00 p.m. administrative nurse F stated they kept a nurse in the dining room at meals to assist with meals but to also supervise other staff to ensure the residents received the assistance they needed and in case a resident had a emergency. The facility failed to recognize and address the resident's complaints of severe pain which compromised their function regarding dining. The resident displayed signs of pain for 57 minutes before they received the PRN (as needed pain medications) on 2/10/11. The facility failed to obtain the UA in a timely manner and administer the PRN pain medications when the resident experienced pain. - The facility's failure to assess and address tooth pain affected resident #59 and failure to assess and address abdominal and back pain affected resident #78. - Observation on 2/8/11 at 2:00 p.m. revealed resident #81 sat in a wheelchair, in the activity room, behind the dining room in front of the TV. The resident's wheelchair had no head support and the resident slept with their head straight back with their chin straight up in the air. Observation on 2/10/11 at 1:20 p.m. revealed the resident in their room asleep in the wheelchair with their head straight back. On 2/14/11 at 2:40 p.m. observation revealed the resident in the wheelchair in their room with their head straight back as they slept. During interview on 2/15/11 at 12:50 p.m. therapy staff N acknowledged they were not aware the resident's head fell back when they fell asleep in the wheelchair and had not assessed the resident for head positioning. Observation on 2/15/11 at 3:00 p.m. revealed a high back wheelchair parked in the resident's room as the resident slept in bed. During interview on 2/16/11 at 4:00 p.m. therapy staff N confirmed after assessing the resident they identified a need for a high back wheel chair to assist the resident with head positioning. The facility failed to assess and implement a positioning device to support the resident's head while in the wheelchair to maintain their highest practicable physical well being.