Every finding on record at Legacy at Herington

The facility had a census of 31 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness. Findings included: - On 10/29/24 at 8:45 AM, during the initial tour, observation revealed a one three foot by six-inch air vent grill located above the North door entrance to the kitchen was covered with a brownish grease/sticky substance and a gray fuzzy substance blowing directly on the food preparation area. Continued observation revealed two florescent light fixtures, approximately six inches by two feet located in the exhaust hood above the stovetop. One of the florescent covers was missing and exposed the florescent bulb and the other cover was partially affixed to the light fixture. On 10/29/24 at 09:15 AM, observation revealed nine ceiling-mounted fluorescent light fixtures approximately 10 inches by three feet located on the ceiling. The fixtures had metal pull chains affixed to the fixtures with a brownish-gray fuzzy substance affixed to the chains, the fixtures were located directly above the food preparation area and the dishwashing area. On 10/31/24 at 12:10 PM, Maintenance Staff U verified the dirty register grill, and the dirty overhead fluorescent light pull chains and verified the fluorescent bulb located in the stove hood was not encapsulated and should have a cover on the fixture. Maintenance Staff U verified the cover on the other fluorescent light was partially coming off the fixture. The facility's Sanitization policy, dated October 2008, stated the food service area should be maintained in a clean and sanitary manner. All kitchen areas and dining areas should be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The food service manager would be responsible for scheduling staff for regular cleaning of kitchen and dining areas. The facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 31 residents in the facility, who received their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness.

The facility had a census of 31 residents. Based on interviews and record review, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter (Q) 4 indicated no licensed nurse coverage on eight days. The PBJ for FY 2024 Q4 recorded no licensed nurse coverage on the following dates: 07/29/23, 07/30/23, 09/09/23, 09/10/3, 09/11/23, 09/2/23, 09/28/23, and 09/29/23. The PBJ report provided by CMS for FY 2024 Q3 indicated no licensed nurse coverage on eight days. The PBJ for FY 2024 Q3 recorded no licensed nurse coverage on the following dates: 05/12/24, 05/13/24, 05/15/24, 05/16/24, 05/17/24, 05/18/24, 05/19/24, and 05/22/24. The PBJ report provided by CMS for FY 2024 Q1 indicated no licensed nurse coverage on six days. The PBJ for FY 2024 Q1 recorded no licensed nurse coverage on the following days: 10/01/24, 10/05/24, 10/06/24, 10/07/24, 10/09/24, and 10/12/24. A review of the facility licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 10/29/24 at 09:00 AM, Administrative Staff A stated that there was maybe a time when someone was not sending in the correct information and verified the above dates as being reported incorrectly. Administrative Staff A stated that there was always a licensed nurse in the building and that there were more registered nurses than there used to be. The facility's Reporting Direct Care Staffing Information) Payroll-Based Journal) policy, dated 08/2022, documented that direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. The category of work for each person on the direct care staff (including, but not limited to, whether the individual was a registered nurse, licensed practical nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. Direct care staffing information included staff hired directly by the facility, those hired through an agency, and contract employees. The information on direct care staff turnover and tenure, and the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual). The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 31 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 10/29/24 at 08:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 10/29/24 at 09:40 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had six residents with mechanical soft diets and three with a pureed diet. On 10/31/24 at 02:00 PM, Administrative Staff A verified Dietary Staff BB, the dietary manager, was not certified. The facility's Dietician policy, dated 10/2017, documented a qualified, competent, and skilled dietician would help oversee the food and nutrition services in the facility. A food and nutrition services manager would oversee the production, storage, and delivery of food. The dietician would work closely with the food and nutrition services manager and clinical staff. The dietician or nutritional professional may be a full-time or part-time consultant or an employee, depending on the current requirements of the facility. These requirements are based on: a.assessments and care plans of resident's nutritional needs; and b. the overall facility assessment of the number, acuity, and diagnosis of the resident population The dietician would have the qualifications, competency, and skills to carry out the functions of the food and nutrition services. If a dietician is not employed full time (35 hours per) a director of food service management would be designated the individual would: a.Be a certified dietary manager; or b.be a certified food service manager; or c.be nationally certified in food service management and safety; or d.have an associate (or higher) degree in food service management or hospitality (must be from an accredited institution and include courses in food service or restaurant management) e.meet any state requirements for food services or dietary manager. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 31 residents in the facility. This placed the residents at risk for inadequate nutrition.

The facility had a census of 31. The sample included 12 residents. Based on record review, interview, and observation the facility failed to provide care for Resident (R)26 and R8 in a manner that protected and promoted resident dignity. This placed the residents at risk for impaired psychosocial well-being. Findings included: - On 10/29/24 at 11:15 AM, observation revealed R26 sat in a wheelchair right outside the medication room, in between the dining room and the common hall. Licensed Nurse (LN) G obtained R26's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R26's right index finger. LN G then stated to the resident Your blood sugar reading is 277. Continued observation revealed ten residents were seated in the dining room awaiting lunch to be served, while staff and other residents were in the hallways adjacent to the medication room. Ongoing observation revealed LN G lifted R26's shirt and administered insulin (a hormone that lowers the level of glucose in the blood) shot in the resident's abdomen. On 10/30/24 at 04:00 PM, Administrative Nurse D stated staff should not check residents' blood sugar or give the residents insulin injections in a common area; staff should take the residents to their room or to a private area. The facility's Residents Dignity policy, dated February 2021, documented each resident would be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The residents are treated with dignity and respect at all times and their privacy is respected at all times. The facility failed to promote care for R26 in a manner to maintain and enhance dignity and respect placing the resident at risk of impaired psychosocial well-being. 32360 - The Electronic Medical Record (EMR) for R8 recorded diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), a need for assistance with personal care, heart failure, hypertension (high blood pressure), and cardiac arrhythmia (improper beating of the heart, whether irregular, too fast, or too slow). The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R8 had moderately impaired cognition. R8 required partial assistance with upper and lower dressing and showers. R8 required supervision with personal hygiene, mobility, and transfers. R8's Care Plan, dated 08/01/24 and initiated on 06/26/23, documented R8's need for assistance with grooming and personal hygiene and directed staff to encourage care in the morning, afternoon, and at bedtime. On 10/29/24 at 10:32 AM, observation revealed R8's hair was disheveled and greasy. R8 had dried food on her sweatshirt. On 10/29/24 at 03:41 PM, observation revealed that R8's hair was disheveled and greasy. Her chin hair was approximately one-half inch long, and her sweatshirt had dried food on it. On 10/30/24 at 08:29 AM, observation revealed that the front of R8's hair was disheveled, and it was flattened to the back of her head. R8 had chin hair approximately one-half inch long. On 10/3124 at 10:43 AM, Certified Nurse Aide M stated staff should make sure R8's hair was combed before she was brought out of her room. On 10/31/24 at 11:00 AM, Administrative Nurse D stated that staff were to make sure R8's hair was combed and should make sure she was shaved during her showers. The facility's Dignity policy, dated 02/22, documented that each resident should be cared for in a manner that promoted and enhanced his or her sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. Residents are to be treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights and are groomed as they wish to be groomed. The facility failed to promote dignity for R8 when they did not adequately provide grooming assistance before bringing the resident out to the common area. This placed the resident at risk for impaired dignity.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R)25's facility-initiated discharge to the hospital. This placed R25 at risk for impaired rights. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded that R25 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Care Area Assessment (CAA), dated 06/05/24, recorded R25 had MDD, a craniotomy (an operation in which a small hole is made in the skull or a piece of one from the skull is removed to show part of the brain) on 04/21/24 and was alert and oriented with intermittent confusion. R25 had a history of depression and received medications for the diagnosis that were monitored monthly by the pharmacist. R25's Care Plan, dated 10/29/24 recorded R25 received antipsychotic medication for the diagnosis of MDD, and staff monitored for side effects and effectiveness every shift. The care plan documented a gradual dose reduction (GDR) review would be completed by the pharmacist and physician per facility protocol. The Physician's Order, initial order date 08/29/24, directed the staff to administer Seroquel (antipsychotic) 100 milligrams (mg), twice daily for a diagnosis of MDD. On 06/06/24 at 09:28 AM, the late entry nurse's note, documented on 06/05/24 at 06:20 PM, R25 was observed trying to sharpen a shaving razor with a red door hanger. The Certified Nurse Aide alerted the nurse. The nurse assessed the resident and asked him if he wanted to hurt himself and he stated, Why not. Staff notified the primary care physician and received an order to send the resident to the emergency department for an evaluation. R25 was evaluated at the hospital and returned to the facility at 02:00 AM the hospital documented that the resident stated he did not want to hurt himself he wanted to go home and thought if he went to the hospital, they would discharge him and he would not return to the facility. The facility continued 15-minute checks and continued to seek mental health services and/or acute mental health hospitalization . On 06/07/24 at 12:41 PM, the nurses' notes documented that R25 was transported to a behavioral health hospital for an inpatient stay and psychiatric evaluation. R25's clinical record lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 10/30/24 at 01:00 PM, Social Services X stated the facility sent a report monthly to the LTCO that included the residents who were discharged home but stated she had never included residents who were discharged to the hospital. Social Service X stated she had been in the position for two years and was not aware she needed to send that information to the LTCO. Upon request, the facility did not provide a policy regarding the discharge of a resident or the Ombudsman notification policy. The facility failed to notify the LTCO of R25's facility-initiated discharge to the hospital. This placed the resident at risk for impaired rights.

The facility had a census of 31 residents. The sample included 12 residents, with one reviewed for toileting. Based on observation, record review, and interview, The facility failed to revise the care plan to address the toileting needs of one resident, Resident (R) 2. This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), pain in the thoracic spine (the middle section of the spine, located between the cervical spine (neck) and the lumbar spine (low back), and hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland). The Annual Minimum Data Set (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 was independent with mobility and ambulation. R2 required supervision with showers, upper and lower body dressing, transfers, toileting, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and occasionally incontinent of the bowel. R2's Quarterly MDS, dated [DATE], documented R2 had severely impaired cognition. R2 was independent with mobility, toileting, and ambulation. R2 required supervision with showers, upper and lower dressing, transfers, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and bowel. The Quarterly Bowel and Bladder Assessment, dated 08/08/24, documented R2 had no decline in incontinence and was always incontinent of bowel and frequently incontinent of bladder. R2's Care Plan, dated 08/09/24 and initiated on 11/13/23 documented R2 required one-person assistance with toileting, and directed staff to provide peri-care with every incontinent episode. Staff were to ensure she had an unobstructed path to the bathroom. The care plan lacked direction to staff that R2 required toileting after every meal. On 10/30/24 at 09:20 AM, observation revealed R2 walked with Certified Nurse Aide (CNA) O down the hallway. R2 stated, I have to go to the bathroom, oh, I'm going in my pants! CNA O told R2 staff would change her pants and told her not to worry. CNA O told R2 staff would take her into the shower room and get her cleaned up. R2 told staff she did not think she would have a bowel movement in her pants and asked staff to please get her to a bathroom. On 10/31/24 at 10:43 AM, CNA M stated R2 required assistance with toileting before and after meals. On 10/31/24 at 12:30 PM, Administrative Nurse E stated staff should assist R2 with toileting before and after meals. On 10/31/24 at 3:00 PM, Administrative Nurse D stated staff were aware R2 required toileting assistance before and after meals and confirmed the care plan should reflect that. The facility's Care Plans-Comprehensive policy, dated 11/10, documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and concerns. Identifying problem areas and their cases and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events, and complex clinical decision-making. The care planning interdisciplinary team was responsible for the review and updating of the care plan if there was a significant change, a desired outcome was not met, a resident was readmitted to the facility from the hospital, and at least quarterly. The facility failed to revise R2's Care Plan with directions to staff on when to assist R2 with her toileting needs. This placed R2 at risk for impaired care due to uncommunicated care needs.

The facility had a census of 31 residents. The sample included 12 residents, with four reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing and toileting for Resident (R)2. This placed the resident at risk for poor personal hygiene and related complications. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), pain in the thoracic spine (the middle section of the spine, located between the cervical spine (neck) and the lumbar spine (low back), and hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland). The Annual Minimum Data Set (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 was independent with mobility and ambulation. R2 required supervision with showers, upper and lower body dressing, transfers, toileting, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and occasionally incontinent of bowel. R2's Quarterly MDS, dated [DATE], documented R2 had severely impaired cognition. R2 was independent with mobility, toileting, and ambulation. R2 required supervision with showers, upper and lower dressing, transfers, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and bowel. The Quarterly Bowel and Bladder Assessment, dated 08/08/24, documented R2 had no decline in incontinence and was always incontinent of bowel and frequently incontinent of bladder. R2's Care Plan, dated 08/09/24 and initiated on 06/29/23, directed staff to encourage bathing two times per week, inspect her skin during showers, and alert the nurse of any skin issues. The care plan directed staff to reassure R2 that she would not get pneumonia (infection of the lungs) from taking a bath or shower and that staff would try to keep her warm throughout. The update dated 11/13/23 documented R2 required one-person assistance with toileting, and directed staff to provide peri-care with every incontinent episode. Staff were to ensure she had an unobstructed path to the bathroom. The care plan lacked direction to staff that R2 required toileting after every meal. R2's September 2024 Bathing Record and October 2024 Bathing Record, documented R2 requested showers on Wednesday and Saturday dayshift and documented R2 had not received a bath or shower the following days: 09/29/24-10/11/24 (14 days) 10/14/24-10/29/24 (16 days) The EMR documented R2 refused a shower on 10/02/24, 10/05/24, and 10/09/24. On 10/29/24 at 12:53 PM, observation revealed R2 had very disheveled hair. On 10/30/24 at 09:20 AM, observation revealed R2 walked with Certified Nurse Aide (CNA) O down the hallway. R2 stated, I have to go to the bathroom, oh, I'm going in my pants! CNA O told R2 staff would change her pants and told her not to worry. CNA O told R2 staff would take her into the shower room and get her cleaned up. R2 told staff she did not think she would have a bowel movement in her pants and asked staff to please get her to a bathroom. On 10/31/24 at 10:43 AM, CNA M stated R2 would tell staff she was cold and didn't want a shower, but staff would continue to ask her. CNA M said that when R2 refused a shower, she would tell the charge nurse. CNA M stated R2 required assistance with toileting before and after meals. On 10/31/24 at 12:30 PM, Administrative Nurse E stated R2 often refused her shower because she got cold very easily. Administrative Nurse E further verified the facility had not offered different types of bathing. On 10/31/24 at 3:00 PM, Administrative Nurse D stated R2 did not like to shower and thought there had been an incident in her life relating to being in water. Administrative Nurse D stated R2 did not like her hair combed and when staff combed her hair, she would often take her hands and mess up her hair. Administrative Nurse D stated staff were aware R2 required toileting assistance before and after meals and the care plan should reflect that. The facility's Activities of Daily Living (ADL), Supporting policy, dated 03/18, documented the residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition grooming, and personal and oral hygiene. Residents would receive appropriate support and assistance with bathing, dressing, toileting, and grooming to prevent and/or minimize functional decline. If residents with cognitive impairment resist care, staff would attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care. Approaching the resident in a different way or different manner, or just another staff member speaking with the resident may be appropriate. The facility failed to provide cognitively impaired R2 with consistent bathing opportunities and alternatives that incorporated her needs and preferences. The facility further failed to assist R2 with toileting after meals. This placed her at risk for poor hygiene and related complications.

The facility had a census of 31 residents. The sample included 12 residents, with one reviewed for pain. Based on observation, record review, and interview, the facility failed to adequately respond to Resident (R)2's complaints of pain. This placed R2 at risk for unresolved pain and discomfort. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), pain in the thoracic spine (the middle section of the spine, located between the cervical spine (neck) and the lumbar spine (low back), and hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 required supervision for showers, personal hygiene, upper and lower dressing, and oral hygiene. The MDS documented R2 had no scheduled or as-needed pain medication. R2's Care Plan, dated 08/09/24 and initiated on 06/29/23, directed staff to administer pain medications as ordered, attempt and document any use of non-pharmacological interventions used, evaluate the effectiveness of pain interventions or medications, monitor and document pain level every shift, and notify the physician if interventions are unsuccessful. R2's Pain Assessment, dated 08/08/24, documented R2 complained of mild pain daily and did not receive scheduled or as-needed pain medication. The Physician's Order, dated 10/03/19, directed staff to assess R2's pain every shift, before and after administering pain medication, and document what non-pharmacological interventions were attempted. The Physician's Order, dated 05/26/24, directed staff to administer Tylenol (pain medication), 500 milligrams (mg), by mouth, every four hours, as needed, for pain. The Physician's Order, dated 10/20/24, directed staff to apply Biofreeze (topical pain analgesic), 10%, to R2's back, every eight hours, as needed for pain in the thoracic spine. The Physician's Order, dated 10/25/24, directed staff to administer acetaminophen (pain medication), 650 mg, two tablets, by mouth, three times per day for pain. A review of R2's Medication Administration Record (MAR) for October 2024, documented the scheduled acetaminophen was to be given at 08:00 AM, 02:00 PM, and 08:00 PM. On 10/30/24 at 07:45 AM, observation revealed Certified Nurse Aide (CNA) N assisted R2 into the dining room for breakfast. R2 stated she did not understand why her back hurt so much when she stood up. Ongoing observation revealed at 08:30 AM, CNA N stood R2 up from the dining table and R2 stated Oh my God, my back hurts so much. CNA N assisted R2 into the commons area and R2 sat down into a chair. Continued observation revealed at 09:20 AM, R2 ambulated down the hall with CNA O and stated again that her back hurt. On 10/30/24 at 09:25 AM, Certified Nurse Aide (CNA) N verified she had not informed the nurse that R2 had complained of back pain. On 10/30/24 at 09:30 AM, Certified Medication Aide (CMA) R stated she was unaware R2 had back pain as staff had not told her. CMA R further stated she had been on vacation for the last two weeks and was unaware R2 had a scheduled pain medication. On 10/30/24 at 09:35 AM, Administrative Nurse E stated the CNA staff should report to the CMA or the nurse when R2 had pain. On 10/30/24 at 10:00 AM, Administrative Nurse D stated R2 had as-needed pain medication and had recently been started on scheduled medication but often refused it. Administrative Nurse D further stated that CNA staff still should report to the charge nurse or CMA that R2 had pain. The facility's Pain-Clinical Protocol, dated 03/18, documented that nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. The staff and physician would identify the characteristics of pain such as location intensity, frequency, pattern, and severity. The physician would order appropriate non-pharmacologic and medication interventions to address the individual's pain. The facility failed to adequately respond to R2's complaints of pain. This placed R2 at risk for unresolved pain and discomfort.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 25's antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality) medication. The facility further failed to ensure the CP identified and reported irregularities in R14's blood sugar monitoring. This placed the residents at risk for physical decline, ineffective medication regimen, and side effects from unnecessary medication. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Care Area Assessment (CAA), dated 06/05/24, recorded R25 had MDD, and had a craniotomy (an operation in which a small hole is made in the skull or a piece of one from the skull is removed to show part of the brain) on 04/21/24 and was alert and oriented with intermittent confusion. R25 had a history of depression and received medications for the diagnosis that were monitored monthly by the pharmacist. R25's Care Plan, dated 10/29/24 recorded R25 received antipsychotic medication for the diagnosis of MDD, and staff monitored for side effects and effectiveness every shift. The care plan documented a gradual dose reduction (GDR) review would be completed by the pharmacist and physician per facility protocol. The Physician's Order, initial order date 08/29/24, directed the staff to administer Seroquel (antipsychotic) 100 milligrams (mg), twice daily for a diagnosis of MDD. R25's EMR lacked a documented physician rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. The Consultant Pharmacist's Monthly Medication Review for R25 on 06/20/24, 07/29/24, 08/29/24, and 09/19/24 lacked evidence of a recommendation for an appropriate indication for the continued use of Seroquel. On 10/30/24 at 08:30 AM, observation revealed the resident sat at the dining room table. Continued observation revealed Certified Medication Aide (CMA) M administered the resident's morning medications which included the Seroquel. On 10/30/24 at 10:10 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of MMD which was not an approved indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis and continues to document MDD. On 10/30/24 at 10:10 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of MMD which was an inappropriate indication for the medication. Administrative Nurse D stated the pharmacist completed monthly reviews of the facility residents and alerted her of concerns and recommendations. The facility's Pharmacist Services-Role of the Consulting Pharmacist dated 2007, recorded the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The pharmacist would provide a report of activities, findings, and recommendations to the administrator and the director of nursing on a monthly basis, and render the required services in accordance with local, state, and federal laws, regulations, and guidelines; nursing care center policies and procedures; community standards of practice; and professional standards of practice. The facility failed to ensure the CP identified and reported the inappropriate indication for the continued use of the antipsychotic medication Seroquel. This placed R25 at risk for unnecessary antipsychotic medication with side effects. 32360 - The Electronic Medical Record (EMR) for R14 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), venous insufficiency (poor circulation), hypertension (high blood pressure), and dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition. R14 was independent with toileting, personal hygiene, mobility, upper and lower dressing, and transfers; R14 did not ambulate. The assessment revealed R14 received hypoglycemic (low blood sugar) medication. The Quarterly MDS, dated [DATE], documented R14 had severely impaired cognition. R14 required supervision for toileting, personal hygiene, upper and lower dressing, and set-up assistance with mobility and transfers. The MDS documented R14 received hypoglycemic medication. R14's Care Plan, dated 08/02/24 and initiated 08/14/23, directed staff to administer diabetic medication as ordered, monitor and obtain blood glucose levels as ordered, and report any signs and symptoms of hypoglycemia and hyperglycemia (high blood sugar). The Physician's Order, dated 03/19/24, directed staff to administer Novolog (a rapid-acting insulin that helps lower blood sugar), five units (U), subcutaneous (SQ-beneath the skin), before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 milliliters (ml) per deciliter (dl) or over 350 mm/dl. The order was discontinued on 09/12/24. The Diabetic Monitoring Record, dated August 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 08/05/24 at 05:00 PM-366 mm/dl 08/13/24 at 05:00 PM- 396 mm/dl 08/14/24 at 11:00 AM-370 mm/dl 08/27/24 at 07:00 AM-360 mm/dl 08/30/24 at 11:00 AM-366 mm/dl The Physician's Order, dated 09/12/24, directed staff to administer Novolog, six U SQ, before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 ml/dl or over 350 mm/dl. The Diabetic Monitoring Record, dated September 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 09/13/24 at 07:00 AM-395 mm/dl 09/30/24 at 11:00 AM-388 mm/dl The Diabetic Monitoring Record, dated October 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 10/04/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/18/24 at 07:00 AM- 407 mm/dl 10/19/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/21/24 at 07:00 AM-413 mm/dd The CP Medication Regimen Review for the months of August and September 2024 lacked evidence the CCP identified and reported the out-of-parameter blood sugars. On 10/30/24 at 07:40 AM, observation revealed Certified Medication Aide (CMA) R administered R14's medication without difficulty. On 10/30/24 at 09:43 AM, Administrative Nurse E stated she did not know why there were blanks in the blood sugar documentation and said staff should follow the physician's orders. On 10/30/24 at 10:00 AM, Administrative Nurse D stated she thought the order was changed a few months ago to notify the physician if the blood sugar was over 400 ml/dl but verified the order did not get documented in the EMR. Administrative Nurse D said she would contact the physician to get a new order. Administrative Nurse D further stated the CP had not notified her of the errors. The facility's Consultant Pharmacist Services Provider Requirements policy, dated 11/17, documented the Medication Regimen Review (MRR) for each resident was completed at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. The pharmacist communicates to the responsible prescriber, the facility's medical director, and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. They communicate recommendations for changes in medication therapy and the monitoring of medication therapy. The facility failed to ensure the CP identified and reported irregularities in R14's blood sugar monitoring. This placed the resident at risk for physical decline, ineffective medication regimen, and side effects from unnecessary medication.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for Resident (R) 18 and failed to notify the physician of blood sugars outside of physician-ordered parameters for R14. This placed the residents at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (ER) for R18 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), a need for assistance with personal care, and constipation (difficulty passing stools). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition. R18 required supervision with toileting, upper dressing, and personal hygiene. R18 required set-up assistance with mobility, transfers, and ambulation. The MDS documented R18 was always continent of bowel. The Quarterly MDS, dated [DATE], documented R18 had severely impaired cognition. R18 required supervision with personal hygiene. He was independent with toileting, mobility, transfers, and ambulation. The MDS documented R18 was always continent of bowel. R18's Care Plan, dated 08/01/24, initiated on 02/01/23 documented R18 had impaired cognition and directed staff to cue, orient, and supervise as needed. The update, dated 0508/23, documented R18 was independent with toileting. The update, dated 08/04/23, directed staff to monitor R18 for constipation and administer medication as directed. R18's Quarterly Bowel Assessment, dated 07/24/24, documented R18 had no abnormalities in bowel status and was always continent of bowel. The Physician's Order, dated 04/07/23, directed staff to administer Milk of Magnesia (MOM-a laxative), 1200 milligrams (mg) per milliliters (ml), 30 ml by mouth every 24 hours as needed for constipation. R18's Bowel Monitoring Record, dated July 2024, documented R18 did not have a bowel movement for the following days: 07/03/24-07/11/24 (nine consecutive days) R18's Medication Administration Record, dated July 2024 lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. R18's Bowel Monitoring Record dated August 2024 documented R18 did not have a bowel movement for the following days: 08/05/24-08/10/24 (six consecutive days) 08/18/24-08/21/24 (four consecutive days) R18's Medication Administration Record dated August 2024 lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. R18's Bowel Monitoring Record, dated September 2024 and October 2024 documented R18 did not have a bowel movement for the following days: 09/20/24-09/26/24 (seven consecutive days) 09/28/24-10/03/24 (seven consecutive days) 10/05/24-10/08/24 (four consecutive days) 10/21/24-10/31/24 (11 consecutive days) The Medication Administration Record dated September 2024 and October 2024 lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. On 10/30/24 at 08:00 AM, observation revealed R18 ambulated with the use of her walker to the entrance door and tried to open it to go outside where a male resident was outside with staff. R18 thought the resident was her husband and wanted to be outside with him. On 10/30/24 at 09:30 AM, Administrative Nurse E stated R18 was independent with toileting and staff asked her if she had a bowel movement. Administrative Nurse E acknowledged R18 was not a good historian due to her cognition and may not remember if she had a bowel movement or not. Administrative Nurse E said staff should have administered the MOM for the extended time periods with no recorded bowel movement. On 10/30/24 at 09:400 AM, Administrative Nurse D verified staff did not provide any interventions to R18 when she did not have a bowel movement. Administrative Nurse D stated R18 was able to take herself to the bathroom but may not remember if she had a bowel movement or not so staff should have completed a bowel assessment on her. On 10/31/24 at 10:43 AM, Certified Nurse Aide (CNA) M stated R18 required assistance with toileting. CNA M said that if R18 had not had a bowel movement, she would tell the nurse. The facility's Standing Order protocol, directed staff to administer MOM 30 ml on day four. If no results on day five, administer bisacodyl (a laxative), 5 mg, and if no results, on day six, administer a Fleets enema (introduction of a solution into the rectum for cleansing or therapeutic purposes), do a bowel assessment. If no results, contact the physician. The facility failed to monitor and provide the ordered interventions for bowel management for R18. This placed the resident at risk for impaction and physical decline. - The Electronic Medical Record (EMR) for R14 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), venous insufficiency (poor circulation), hypertension (high blood pressure), and dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition. R14 was independent with toileting, personal hygiene, mobility, upper and lower dressing, and transfers; R14 did not ambulate. The assessment revealed R14 received hypoglycemic (low blood sugar) medication. The Quarterly MDS, dated [DATE], documented R14 had severely impaired cognition. R14 required supervision for toileting, personal hygiene, upper and lower dressing, and set-up assistance with mobility and transfers. The MDS documented R14 received hypoglycemic medication. R14's Care Plan, dated 08/02/24 and initiated 08/14/23, directed staff to administer diabetic medication as ordered, monitor and obtain blood glucose levels as ordered, and report any signs and symptoms of hypoglycemia and hyperglycemia (high blood sugar). The Physician's Order, dated 03/19/24, directed staff to administer Novolog (a rapid-acting insulin that helps lower blood sugar), five units (U), subcutaneous (SQ-beneath the skin), before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 milliliters (ml) per deciliter (dl) or over 350 mm/dl. The order was discontinued on 09/12/24. The Diabetic Monitoring Record, dated August 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 08/05/24 at 05:00 PM-366 mm/dl 08/13/24 at 05:00 PM- 396 mm/dl 08/14/24 at 11:00 AM-370 mm/dl 08/27/24 at 07:00 AM-360 mm/dl 08/30/24 at 11:00 AM-366 mm/dl The Physician's Order, dated 09/12/24, directed staff to administer Novolog, six U SQ, before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 ml/dl or over 350 mm/dl. The Diabetic Monitoring Record, dated September 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 09/13/24 at 07:00 AM-395 mm/dl 09/30/24 at 11:00 AM-388 mm/dl The Diabetic Monitoring Record, dated October 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 10/04/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/18/24 at 07:00 AM- 407 mm/dl 10/19/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/21/24 at 07:00 AM-413 mm/dd On 10/30/24 at 07:40 AM, observation revealed Certified Medication Aide (CMA) R administered R14's medication without difficulty. On 10/30/24 at 09:43 AM, Administrative Nurse E stated she did not know why there were blanks in the blood sugar documentation and said staff should follow the physician's orders. On 10/30/24 at 10:00 AM, Administrative Nurse D stated she thought the order was changed a few months ago to notify the physician if R14's blood sugar was over 400 ml/dl but verified the order did not get documented in the EMR. Administrative Nurse D said she would contact the physician to get a new order. The facility's Diabetic Care policy, dated 11/20, documented that the provider would order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. The policy directed staff to follow the provider's orders for blood glucose monitoring. The facility failed to notify the physician when R14's blood sugar was out of the physician-ordered parameters. This placed the resident at risk for unnecessary medication side effects and other related complications.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)25's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R25 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Care Area Assessment (CAA), dated 06/05/24, recorded R25 had MDD, and had a craniotomy (an operation in which a small hole is made in the skull or a piece of one from the skull is removed to show part of the brain) on 04/21/24 and was alert and oriented with intermittent confusion. R25 had a history of depression and received medications for the diagnosis that were monitored monthly by the pharmacist. R25's Care Plan, dated 10/29/24 recorded R25 received antipsychotic medication for the diagnosis of MDD, and staff monitored for side effects and effectiveness every shift. The care plan documented a gradual dose reduction (GDR) review would be completed by the pharmacist and physician per facility protocol. The Physician's Order, initial order date 08/29/24, directed the staff to administer Seroquel (antipsychotic) 100 milligrams (mg), twice daily for a diagnosis of MDD. R25's EMR lacked a documented physician rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. On 10/30/24 at 08:30 AM, observation revealed the resident sat at the dining room table. Continued observation revealed Certified Medication Aide (CMA) M administered the resident's morning medications which included the Seroquel. On 10/30/24 at 10:10 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of MMD which was not an approved indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis and continues to document MDD. The facility's Antipsychotic Medication Use policy, dated December 2016, recorded antipsychotic medication may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. The policy documented the residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for appropriateness and indications for use. The interdisciplinary team would complete a preadmission screening for mentally ill and intellectually disabled individuals if appropriate or use of the antipsychotic medication at the time of admission and or within two weeks at the initial MDS assessment to consider whether or not the medication can be reduced, tapered, or discontinued. In addition to the diagnoses antipsychotic medications would generally only be considered if the following conditions are also met; the behavioral symptoms present a danger to the resident and others and the symptoms are identified as being due to mania or psychosis or behavioral interventions have been attempted and included in the plan of care, except in an emergency. The facility failed to ensure R25 did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use placing R25 at risk for adverse side effects.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)6, R14, and R26s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with opened and discard dates. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 10/29/24 at 09:00 AM, observation of the facility's treatment cart revealed the following: R6's Basaglar (long-acting insulin) flex pen was not labeled with an open or discard date. R14's Lantus (long-acting insulin) flex pen was not labeled with an open or discard date. R26's Basaglar flex pen was not labeled with an open or discard date. On 10/29/24 at 08:35 AM, License Nurse (LN) G verified the nurses should label and date the insulin flex pens with the date opened and the expiration date. On 10/30/24 at 08:30 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the date opened and the expiration date. Medlineplus.gov directs open, unrefrigerated Lantus (basaglar and glargine) can be used within 28 days; after that time, it must be discarded. The facility's Storage of Medication policy, dated November 2020, documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to date the insulin flex pens with the opened and discard dates placing the residents at risk for ineffective medication.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for three residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life. Findings included: - On 10/30/24 at 10:00 AM, observation revealed the lunch meal included cheesy macaroni hamburger helper, carrots, pears, and garlic bread. On 10/30/24 at 10:30 AM, observation revealed Dietary Staff (DS) CC prepared three pureed diets. DS CC placed three servings of cheesy macaroni hamburger helper in the Robot-coup blender (a food processor) and added four ounces of beef base. DS CC blended the macaroni to a thin consistency and emptied the blended food into a metal pan and placed the pan into the hot water well in the hot holding cart. Observation revealed DS CC then placed three - four-ounce servings of pears in the Robot coup, with four squirts of simply thick easy mix and blended the food to a pureed texture. DS CC emptied the pureed pears into three bowls, covered them with aluminum foil, and placed them on a serving tray. Observation revealed DS CC then placed three -four-ounce servings of carrots in the Robo-t coup blender including the butter juice from the cooked carrots and blended the food to a pureed texture. DS CC emptied the pureed carrots into a metal pan and placed the pan in the hot water well in the hot holding cart. On 10/31/24 at 11:00 AM, DS BB verified DS CC did not provide the pureed diet residents with the same nutritional diet as the other residents. DS BB verified DS CC did not puree rolls or a biscuit with added milk to the pureed texture and stated DS CC was nervous and just forgot to do that. The facility's Pureed Diet policy, dated January 2014, documented a pureed diet is designed for individuals with moderate to severe dysphagia, and for individuals with poor dentition, minimal or no ability to chew. The general diet or other appropriate diet is modified in consistency by pureeing foods to a smooth consistency. Some foods may need to be thickened after they are pureed to achieve desired consistency. Add the number of pureed diets plus one to the food processor, and give a quick start. If bread/dinner rolls/crackers are on the menu for the general diet, this can be added to the meat or vegetable. If general diets get butter on their bread or roll, add butter to the bread/roll. Puree until proper final consistency is reached the food should be pudding consistency and not run when plated. Cover, label with serving size, and place in appropriate hot or cold areas. The facility failed to provide food prepared by methods that conserve nutritive value and flavor while preparing a pureed diet for three residents. This placed the affected residents at risk for impaired nutrition.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation and interviews, the facility failed to display current daily nursing staff hours. Findings included: - On 10/29/24 and 10/30/24, observation revealed the posted nurse staff hours were dated 10/28/24 and did not display the correct daily nursing staff information. On 10/31/24 at 12:30 PM, Administrative Nurse E stated the night shift nurse was responsible for posting the daily nurse staffing hours and verified the nurse hours for 10/29/24 and 10/30/24 had not been posted. The facility's Posting Direct Care Daily Staffing Numbers policy, dated 07/16, documented the facility would post, daily for each shift, the number of nursing personnel responsible for providing direct care to residents. When computing hours of direct-care staff working split shifts, count only the total number of hours the individual was scheduled to work for the shift information being posted. The facility failed to display current daily nursing hour information as required.

The facility identified a census of 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 1 and R2 were able to exercise their right to receive visitors of their choosing at the time of the residents' choice. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and weakness. The Annual Minimum Data Set (MDS) dated [DATE], documented that R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of six which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 10/06/23, documented R1 had cognitive deficits and was able to make her wants and needs known to staff. R1's Care Plan dated 06/26/23, documented R1 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan documented an intervention, revised 11/22/23, that directed the facility to encourage ongoing family involvement and invite R1's family to attend special events, activities, and meals. On 04/03/24 at 02:58 PM, R1 sat in a chair in the day area next to other residents. On 04/03/24 at 12:11 PM, R1's representative stated she worked at the facility on 02/29/24 because the facility needed help. She relayed she had a situation on that date with R3 and Administrative Staff A. She said on 03/22/24, she visited R1 in the morning and then received a call that afternoon from Administrative Staff A and Administrative Nurse D. R1's representative stated the facility administrative staff told her that she had been found guilty of abuse by the State Agency (SA) and stated she could not visit R1 anymore unless she made an appointment with the facility and the visitation had to be away from other residents and had to be supervised by facility staff. R1's representative stated she called the SA and the Long-Term Care Ombudsman (LTCO) for further information. She stated R1 liked it when she visited at lunchtime, so she arrived at the facility on 04/02/24 at lunchtime and sat with R1. R1's representative stated Administrative Staff A went into the dining room, placed a hand on her (the representative's) shoulder, and directed R1's representative to leave or the facility would have her escorted out. R1's representative stated three law enforcement officers came in and one of them went into where she was visiting her mom. R1's representative stated she tried to keep the situation calm so R1 would not get upset. She said 04/02/24 had been her first visit since 03/22/24. On 04/03/24 at 03:00 PM, Administrative Nurse D stated the facility worked with the LTCO to set up visitation and said he was in the facility on 04/02/24 when R1's representative walked into the building at around 11:15 AM, before her scheduled visitation time at 01:00 PM. R1 was in the dining room along with the LTCO and R1's family sat with her. Administrative Nurse D confirmed that Administrative Staff A called law enforcement at that time. When the law enforcement officers arrived, they spoke to R1's representative outside. Administrative Nurse D stated R1's representative was supposed to call Administrative Staff A or Administrative Nurse D to schedule a visitation time and the facility offered to set up an empty room as a visitation room so R1 and her representative would both be comfortable. On 04/03/24 at 03:10 PM, Licensed Nurse (LN) G stated the only visitation restriction she knew of was for R1's representative. LN G said R1's representative was supposed to call ahead of time and schedule a visitation. On 04/03/24 at 03:15 PM, Administrative Nurse D stated the only abuse or neglect she could make out about R1's representative might be that R1's representative shared information with R3 or that she smoked in her car while R3 vaped outside. She stated she did not see R1's representative as a threat to the residents. Administrative Nurse D stated she did not think there should be restricted visitation and that R1's representative posed no threat but because of an email received from the SA, the facility staff were upset and did not know what to do. She stated she did not call the SA to clarify the email. On 04/03/24 at 03:51 PM, Administrative Staff A stated R1's representative made a complaint against her because of an incident on 02/29/24 with R3 and R1's representative and Administrative Staff A. Administrative Staff A stated she had left the state when the investigation was going on and when the facility received an email from the SA that mentioned substantiated neglect, the facility was instructed by corporate to set up restricted visitation for R1 related to R1's representative. Administrative Staff A stated the facility did not clarify the information with the SA before restricting R1's rights. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to ensure R1 was able to exercise her right to receive visitors of her choosing at the time of her choice. This deficient practice placed R1 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of unsteadiness on feet and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. It was very important to R3 that the family was involved in discussions about her care and very important for R3 to do her favorite activities. The Quarterly MDS dated [DATE], documented R2 had a BIMS score of 15 which indicated intact cognition. The Psychosocial Well-Being Care Area Assessment (CAA) dated 11/14/23, documented that R2 reported little interest or pleasure in doing things. R2's Care Plan dated 11/15/23, documented R2 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan directed the facility encouraged ongoing family involvement and invited R2's family to attend special events, activities, and meals. On 04/03/24 at 10:56 AM, R2 sat up in her bed and conversed with the surveyor. She stated the facility told her husband he could not come up to the dining room and if he went into the dining room, the facility would call law enforcement. She stated her husband no longer feels comfortable coming to the facility and she felt like her visitation was restricted. R2 stated she felt uncomfortable in the facility and her husband made her feel comfortable. R2 began crying. On 04/03/24 at 03:15 PM, Administrative Nurse D stated that R2's family was paying to eat at the facility, and Administrative Staff A gave him his money back and told him he could not eat at the facility anymore. She stated a dietary staff member felt uncomfortable with R2's family being in the dining room in the evenings because of an outburst that occurred. She stated R2's family was told he could not go into the dining room with R2 and that he had to wait until R2 was done eating. On 04/03/24 at 03:51 PM, Administrative Staff A stated R2's family wanted three meals a day and was told he could pay for food. They had set it up where R2's family was paying for meals. She stated last week, dietary staff came into her office crying because R2's family told her he wanted seconds and dietary staff told him all of the residents had not been fed yet. She stated R2's family got mad when he did not get seconds. Administrative Staff A stated she told R2's family that he could visit but he was not allowed in the dining room and R2 and he could eat in the living room if he brought food. She stated the facility gave R2's family the money back that he paid for meals and said to just call it even, but he was not to eat at the facility. She denied giving any alternative options before restricting visitation. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to ensure R2 was able to exercise her right to receive visitors of her choosing at the time of her choice. This deficient practice placed R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.

The facility identified a census of 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to inform Resident (R) 1 and R2 and/or their representative of their visitation rights and any visitation restrictions placed on them. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and weakness. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of six which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 10/06/23, documented R1 had cognitive deficits and was able to make her wants and needs known to staff. R1's Care Plan dated 06/26/23, documented R1 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan documented an intervention, revised 11/22/23, that directed the facility to encourage ongoing family involvement and invite R1's family to attend special events, activities, and meals. Upon request, the facility was unable to provide evidence a notice was issued to R1's durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) stating that her visitation was restricted, what the restrictions were and why. On 04/03/24 at 02:58 PM, R1 sat in a chair in the day area next to other residents. On 04/03/24 at 12:11 PM, R1's representative stated she worked at the facility on 02/29/24 because the facility needed help. She relayed she had a situation on that date with R3 and Administrative Staff A. She said on 03/22/24, she visited R1 in the morning and then received a call that afternoon from Administrative Staff A and Administrative Nurse D. R1's representative stated the facility administrative staff told her that she had been found guilty of abuse by the State Agency (SA) and stated she could not visit R1 anymore unless she made an appointment with the facility and the visitation had to be away from other residents and had to be supervised by facility staff. R1's representative stated she called the SA and the Long-Term Care Ombudsman (LTCO) for further information. She stated R1 liked it when she visited at lunchtime, so she arrived at the facility on 04/02/24 at lunchtime and sat with R1. R1's representative stated Administrative Staff A went into the dining room, placed a hand on the representative's shoulder, and directed R1's representative to leave or the facility would have her escorted out. R1's representative stated three law enforcement officers came in and one of them went into where she was visiting her mom. R1's representative stated she tried to keep the situation calm so R1 would not get upset. She said 04/02/24 had been her first visit since 03/22/24. On 04/03/24 at 03:00 PM, Administrative Nurse D stated the facility worked with the LTCO to set up visitation and said he was in the facility on 04/02/24 when R1's representative walked into the building at around 11:15 AM, before her scheduled visitation time at 01:00 PM. R1 was in the dining room along with the LTCO and R1's family sat with her. Administrative Nurse D confirmed that Administrative Staff A called law enforcement at that time. When the law enforcement officers arrived, they spoke to R1's representative outside. Administrative Nurse D stated R1's representative was supposed to call Administrative Staff A or Administrative Nurse D to schedule a visitation time and the facility offered to set up an empty room as a visitation room so R1 and her representative would both be comfortable. On 04/03/24 at 03:10 PM, Licensed Nurse (LN) G stated the only visitation restriction she knew of was for R1's representative. LN G said R1's representative was supposed to call ahead of time and schedule a visitation. On 04/03/24 at 03:51 PM, Administrative Staff A stated the facility did not send a notice out to R1's DPOA, informing him of R1's restricted visitation. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to notify R1 and/or her DPOA of her restricted visitation as required. This deficient practice placed R1 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of unsteadiness on feet and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. It was very important to R3 that the family was involved in discussions about her care and very important for R3 to do her favorite activities. The Quarterly MDS dated [DATE], documented R2 had a BIMS score of 15 which indicated intact cognition. The Psychosocial Well-Being Care Area Assessment (CAA) dated 11/14/23, documented R2 reported little interest or pleasure in doing things. R2's Care Plan dated 11/15/23, documented R2 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan directed the facility encouraged ongoing family involvement and invited R2's family to attend special events, activities, and meals. Upon request, the facility was unable to provide evidence a notice was issued to R2 and her representative that her visitation was restricted. On 04/03/24 at 10:56 AM, R2 sat up in her bed and conversed with the surveyor. She stated the facility told her husband he could not come up to the dining room and if he went into the dining room, the facility would call law enforcement. She stated her husband no longer feels comfortable coming to the facility and she felt like her visitation was restricted. R2 stated she felt uncomfortable in the facility and her husband made her feel comfortable. R2 began crying. On 04/03/24 at 03:15 PM, Administrative Nurse D stated R2's family was paying to eat at the facility, and Administrative Staff A gave him his money back and told him he could not eat at the facility anymore. She stated a dietary staff member felt uncomfortable with R2's family being in the dining room in the evenings because of an outburst that occurred. She stated R2's family was told he could not go into the dining room with R2 and that he had to wait until R2 was done eating. On 04/03/24 at 03:51 PM, Administrative Staff A stated R2's family wanted three meals a day and was told he could pay for food. They had set it up where R2's family was paying for meals. She stated last week, dietary staff came into her office crying because R2's family told her he wanted seconds and dietary staff told him all of the residents had not been fed yet. She stated R2's family got mad when he did not get seconds. Administrative Staff A stated she told R2's family that he could visit but he was not allowed in the dining room and R2 and he could eat in the living room if he brought food. She stated the facility gave R2's family the money back that he paid for meals and said to just call it even, but he was not to eat at the facility. She denied giving any alternative options before restricting visitation. She stated she should have given a notice to R2 or her representative regarding her restricted visitation. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to notify R2 and/or her representative of her restricted visitation as required. This deficient practice placed R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.

The facility identified a census of 30 residents. The sample included three residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3 was treated with dignity. This deficient practice placed R3 at risk for impaired psychosocial well-being and decreased dignity and self-worth. Findings included: - The Diagnoses tab of R3's Electronic Medical Record (EMR) documented a diagnosis of nontraumatic intracerebral hemorrhage (an emergency condition in which a blood vessel in the brain ruptures and causes bleeding inside the brain). The Significant Change Minimum Data Set (MDS) dated [DATE] documented that R3 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 02/26/24, documented R3 had physical and verbal behaviors directed at staff. R3's Care Plan dated 11/15/23, documented R3's preference to vape (using a device to inhale an aerosol, typically one containing nicotine) while at the facility and directed staff to observe R3 to make sure the smoking policy was followed correctly. R3's Care Plan dated 01/12/24, documented R3 had impaired communication related to aphasia (condition with disordered or absent language function) and directed staff to allow time for R3 to respond to communication and observe for nonverbal cues with communication. In a statement typed by Administrative Nurse D on 03/12/24, R3 stated he was in his wheelchair in front of the building where he vapes because Licensed Nurse (LN) H took him outside. He stated LN H was throwing her cigarette away at her car when Administrative Staff A came outside and went over to LN H's car. R3 stated Administrative Staff A asked LN H why she brought R3 outside because it was not important at that time and Administrative Staff A needed coverage on the floor, not outside smoking. R3 stated LN H sat next to him and stated she wished Administrative Staff A did not talk to her that way and that R3 had just as much of a right as anyone else. R3 stated the interaction between Administrative Staff A and LN H made him feel insecure and unimportant. R3 stated a nurse helping a resident is important and the nurses were supposed to make the residents a priority. Licensed Nurse (LN) H's notarized Witness Statement on 03/13/24 stated on 02/29/24, she took R3 outside for his scheduled vape time and since her car was parked next to the area, she took the opportunity to sit in her car with the door open and have a smoke herself. She stated Administrative Staff A went to the parking lot and asked her what she was doing outside. LN H stated she brought R3 out to vape and was taking a short break herself. LN H stated Administrative Staff A then said R3's vaping was not a priority and LN H must not be too busy if she had time to bring R3 outside. LN H stated the conversation happened in front of R3 and he was upset and stated to LN H that Administrative Staff A should not have said that in front of him. On 04/03/24 at 11:22 AM, R3 lay in bed. He stated on 02/29/24, LN H took him outside to vape and Administrative Staff A came outside to confront LN H. R3 said Administrative Staff A stated his vaping was not a priority. R3 stated that the comment made him feel terrible, belittled, unwanted, and not important. On 04/03/24 at 03:51 PM, Administrative Staff A stated on 02/29/24, LN H took R3 outside and he was sitting by the front while she was in her car. She stated she went outside and asked LN H why she was smoking and told her she would not be able to get to R3 from her car if he started rolling away. Administrative Staff A stated she did not know how R3 heard the whole conversation. She stated she would not have said vaping was not important but if a resident heard that, it would be hurtful. The facility's Dignity policy, revised in February 2021, directed residents to be treated with respect and dignity at all times and the facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. The facility failed to ensure R3 was treated with dignity. This deficient practice placed R3 at risk for impaired psychosocial well-being and decreased dignity and self-worth.

The facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse. On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and caalled her a derogatory name.This deficient practice placed R1 at risk for psychosocial impairment due to the verbal abuse. Findings included: - R1's Electronic Medical Record documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and need for assistance with personal care. The Quarterly Minimum Data Set, (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of two staff with all activities of daily living (ADL's) with the exception of eating. The MDS documented R1 had four to six days during the look back period of exhibiting verbal behaviors directed towards others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/13/23, documented R1 had moderately impaired cognition. The ADL CAA, dated 05/13/23, documented R1 required two staff assistance with toileting, bed mobility, and transfers. R1 required one staff assistance for all other ADL's. The Behavioral Care Plan, revised 06/19/23, R1 had behaviors of being combative, having negative verbalizations, resisting cares, screaming out, and attention seeking. The care plan directed staff to minimize the potential for R1's disruptive behaviors by offering tasks which divert attention, redirect R1 by trying to assist her, and attempt to use positive reinforcement. CNA M's Witness Statement, dated 09/19/23, documented R1 started yelling at CNA M the previous night and raised her hand at CNA M so CNA M had enough and started yelling back at R1. CNA M stated R1 had verbally and physically abused her a number of times and CNA M had walked away. CNA N's Witness Statement, dated 09/19/23, documented CNA N stated she and CNA M were getting R1 back to her recliner when R1 started swatting at CNA M. CNA M was not nice to R1 about it and CNA M started yelling and cussing at R1 and going back and forth with R1. CNA M stated I swear if you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N stated she had never heard or saw anyone talk or handle a resident that way. CNA N stated she should have reported the incident to the nurse but was not sure what to do as she had not been in this kind of situation before. The undated Facility Incident Report, documented CNA N e-mailed Human Resources GG on 09/19/23 and reported while providing night cares to R1 on 09/18/23, R1 began having behaviors and started swatting at CNA M. CNA M became upset with R1 and told R1 If you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N admitted that she was unsure of how to go about reporting the issue and should have reported to the charge nurse after the incident immediately. Human Resources GG notified all parties. On 09/20/23 at 10:30 AM, observation revealed R1 sat in her recliner watching TV. R1 had a blank expression on her face and had her call light in hand with her thumb depressing the call light. R1 stated that no one had ever been mean to her at the facility, no one had ever yelled at her at the facility, and she received good care at the facility. On 09/20/23 at 11:00 AM, Human Resources GG stated he had received an e-mail from CNA N the morning of 09/19/23 telling him of an incident between CNA M and R1. CNA N stated that she should have reported the incident as soon as it happened to her charge nurse, but she wasn't really sure what to do but knew she had to do something. Human Resources GG stated CNA M worked the 02:00PM to 10:00 PM shift on 09/19/23 so he called CNA M in early and suspended her until the investigation was completed. CNA M told Human Resources GG that she had enough of being abused by R1 and nothing was being done about R1's behavior. Human Resources GG stated all staff at the facility had been trained multiple times regarding abuse and neglect but there was another education scheduled on 09/22/23 between shifts and signage had been placed in the work areas regarding staff needing to call the facility administrator immediately when any allegations of abuse or neglect occurred. On 09/20/23 at 11:30 AM, Administrative Nurse D stated that she expected all staff to know and understand the abuse and neglect policy and adhere to it. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 02/06/23, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint no required to treat the resident's medical condition. This includes prohibiting facility staff from taking acts that result in personal degradation including the taking or using photographs or recordings in nay manner that would demean or humiliate a resident and prohibits using any type of photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Training will educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, misappropriation of resident property and exploitation, and dementia management and resident abuse prevention. The facility failed to ensure R1 remained free from verbal abuse. This deficient practice placed R1 at risk for psychosocial impairment due to the verbal abuse.

The facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported verbal abuse to the facility administrator (LNHA). On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and called her a derogatory name. CNA N did not report the incident until 09/19/23 in an e-mail to the Human Resources GG. This deficient practice placed R1 at risk for further mistreatment and psychosocial impairment. Findings included: - R1's Electronic Medical Record documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and need for assistance with personal care. The Quarterly Minimum Data Set, (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of two staff with all activities of daily living (ADL's) with the exception of eating. The MDS documented R1 had four to six days during the look back period of exhibiting verbal behaviors directed towards others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/13/23, documented R1 had moderately impaired cognition. The ADL CAA, dated 05/13/23, documented R1 required two staff assistance with toileting, bed mobility, and transfers. R1 required one staff assistance for all other ADL's. The Behavioral Care Plan, revised 06/19/23, R1 had behaviors of being combative, having negative verbalizations, resisting cares, screaming out, and attention seeking. The care plan directed staff to minimize the potential for R1's disruptive behaviors by offering tasks which divert attention, redirect R1 by trying to assist her, and attempt to use positive reinforcement. CNA M's Witness Statement, dated 09/19/23, documented R1 started yelling at CNA M the previous night and raised her hand at CNA M so CNA M had enough and started yelling back at R1. CNA M stated R1 had verbally and physically abused her a number of times and CNA M had walked away. CNA N's Witness Statement, dated 09/19/23, documented CNA N stated she and CNA M were getting R1 back to her recliner when R1 started swatting at CNA M. CNA M was not nice to R1 about it and CNA M started yelling and cussing at R1 and going back and forth with R1. CNA M stated I swear if you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N stated she had never heard or saw anyone talk or handle a resident that way. CNA N stated she should have reported the incident to the nurse but was not sure what to do as she had not been in this kind of situation before. The undated Facility Incident Report, documented CNA N e-mailed Human Resources GG on 09/19/23 and reported while providing night cares to R1 on 09/18/23, R1 began having behaviors and started swatting at CNA M. CNA M became upset with R1 and told R1 If you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N admitted that she was unsure of how to go about reporting the issue and should have reported to the charge nurse after the incident immediately. Human Resources GG notified all parties. On 09/20/23 at 10:30 AM, observation revealed R1 sat in her recliner watching TV. R1 had a blank expression on her face and had her call light in hand with her thumb depressing the call light. R1 stated that no one had ever been mean to her at the facility, no one had ever yelled at her at the facility, and she received good care at the facility. On 09/20/23 at 11:00 AM, Human Resources GG stated he had received an e-mail from CNA N the morning of 09/19/23 telling him of an incident between CNA M and R1. CNA N stated that she should have reported the incident as soon as it happened to her charge nurse, but she wasn't really sure what to do but knew she had to do something. Human Resources GG stated CNA M worked the 02:00PM to 10:00 PM shift on 09/19/23 so he called CNA M in early and suspended her until the investigation was completed. CNA M told Human Resources GG that she had enough of being abused by R1 and nothing was being done about R1's behavior. Human Resources GG stated all staff at the facility had been trained multiple times regarding abuse and neglect but there was another education scheduled on 09/22/23 between shifts and signage had been placed in the work areas regarding staff needing to call the facility administrator immediately when any allegations of abuse or neglect occurred. On 09/20/23 at 11:30 AM, Administrative Nurse D stated that she expected all staff to know and understand the abuse and neglect policy and adhere to it. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 02/06/23, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint no required to treat the resident's medical condition. This includes prohibiting facility staff from taking acts that result in personal degradation including the taking or using photographs or recordings in nay manner that would demean or humiliate a resident and prohibits using any type of photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Training will educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, misappropriation of resident property and exploitation, and dementia management and resident abuse prevention. The facility failed to ensure staff immediately reported verbal abuse to the facility administrator. This deficient practice placed R1 at risk for further mistreatment and psychosocial impairment.

The facility identified a census of 32 residents. The sample include 17 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to transfer R7 as required by R7's plan of care. On 04/21/23 R7, who required extensive assistance of two staff and a full body lift, slipped forward in her wheelchair. Certified Nurse Aide (CNA) N called out to non-CNA staff (Dietary Staff CC) to assist with repositioning R7 in the wheelchair. CNA N and Dietary Staff CC lifted R7 by her upper arms and pulled R7 back in the wheelchair without the use of the full body lift. During this action, R7's left shoulder made a loud popping noise, which CNA O, who sat at a nearby table, heard. None of the three staff, CNA N, CNA O, or Dietary Staff CC reported the incident to the charge nurse or Administrative Nurse D. On 04/24/23, R7's left shoulder was swollen and painful. An X-ray (radiographic image of a bone) revealed R7 had a left proximal (closer to the point of attachment) humerus (upper arm bone) fracture (broken bone). The facility's failure to provide appropriate assistive care with the required number of staff and necessary equipment, and failure of staff to inform the licensed nurse of the incident to provide appropriate assessment and follow-up, placed R7 in immediate jeopardy. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), muscle weakness, cerebrovascular disease (dysfunction of the blood vessels within the brain), major depressive disorder (major mood disorder), abnormal gait, and fracture of left shoulder. A review of R7's Quarterly Minimum Data Set (MDS) completed 01/27/23 noted she had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS noted she required extensive assistance from two staff for transfers and bed mobility. The MDS indicated she required supervision for meals. R7's Annual MDS completed 04/26/23 indicated she required extensive assistance for bed mobility and was totally dependent on two staff for all transfers. The MDS indicated she had no falls. R7's Cognitive Loss Care Area Assessment (CAA) completed 04/27/23 indicated she had a BIMS of 11 with impairment related to her stroke (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The CAA noted she refused cares at times, but staff should re-approach later. R7's Activities of Daily Living (ADLs) CAA completed 04/27/23 indicated she required a sit-to-stand lift (assistive mechanical lift) until she had her shoulder fracture, and then required a Hoyer lift (full body mechanical lift) with two staff assistance. R7's Fall CAA completed 04/27/23 indicated she was a high fall risk due to her cognitive deficit and balance deficits. A review of R7's Care Plan revised 08/29/22 indicated she was a high fall risk related to impaired mobility and seizure disorder. The plan noted she required a Hoyer lift with two staff members for transfers (07/05/19), was not able to self-propel her wheelchair (07/05/19) and required extensive assistance for long distances. She was independent after set-up assistance for meals. The plan indicated R7 made continual complaints about the facility not having enough staff (09/01/21). The plan instructed staff to encourage positive things when R7 had negative complaints (09/01/21). The plan noted R7 had a new fall intervention added on 05/04/23 that instructed staff the keep a gait on her wheelchair (05/04/23). A review of a Facility Reported Incident completed on 04/24/23 noted R7 complained about left shoulder pain to staff and was sent out for emergency medical treatment at an acute care facility. The report indicated R7 had a left shoulder fracture from an injury of unknown origin. A review of a Witness Statement completed on 04/24/23 by CNA N indicated R7 was in the dining room during dinner service on 04/21/23. CNA N noted R7 slid down her chair and no other staff were available to assist her with R7. CNA N noted she called out to Dietary Staff CC to assist her. The statement indicated both staff pulled R7 up in her wheelchair. The statement noted CNA N heard a popping noise from R7's left shoulder as staff lifted her. The statement lacked documentation related to notifying the nurse or physician at the time of incident. A review of a Witness Statement completed on 04/24/23 by CNA O indicated she assisted other residents in the dining room on 04/21/23 at the time of R7's injury. The statement indicated CNA O heard a popping noise as CNA N and Dietary Staff CC pulled R7 up in her wheelchair. The statement indicated no other direct care staff were in the area for assistance. The statement lacked documentation related to notifying the nurse or physician at the time of incident. A review of a Witness Statement completed on 04/24/23 by Dietary Staff CC noted he assisted CNA N with pulling R7 up in her wheelchair. A review of a Witness Statement completed on 04/24/23 by Licensed Nurse (LN) G indicated she was the charge nurse on duty during the incident resulting in R7's injury on 04/21/23. The statement indicated LN G was not notified of the incident or possible injury. A review of R7's EMR revealed no nursing notes, assessments, or fall investigations completed between 04/21/23 through 04/23/23. A review of R7's EMR revealed a Progress Note on 04/24/23 at 02:32AM indicated R7 had swelling and discomfort to her left shoulder. The note indicated R7 reported she heard a pop while being transferred on 04/21/23. The note indicated an x-ray confirmed a left shoulder (humerus) fracture. On 05/18/23 at 09:45AM observation revealed R7's left shoulder was stabilized with a sling. R7 wore her night clothes. R7 stated she was still in bed due to not having enough staff to get her out of bed when she wanted. She stated it takes two staff and the mechanical lift to get her out of bed. She stated, on 04/241/23, she sat at the table and slid out of the chair. She stated staff stopped her from falling and pulled her up in her chair. She stated she heard a pop in her shoulder but did not feel pain until the next day. On 05/23/23 at 10:20AM CNA N stated on 04/21/23 she went to the dining area to assist with meal services. She stated only two CNAs were working the dining room. She stated the other direct care staff (CNA O) sat with the high-risk table with the meal-assisted residents. She stated R7 began sliding out of her wheelchair. CNA N said she yelled to CNA O for help, but CNA O could not leave the high-risk residents unassisted. She continued to yell out for help attempting to prevent R7 from sliding further but direct care staff were available. She stated Dietary staff CC came over to assist her with R7. She stated as R7 was pulled up in her wheelchair she heard a loud pop coming from R7's shoulder. CNA N stated she asked R7 if R7 was okay and R7 insisted she was and wanted to finish her meal. She stated after the meal she found the charge nurse and reported the incident. She stated she urged the facility to send R7 for emergency treatment, but it did not occur. She reported the facility only had two direct care staff and a nurse working the floor that day. She reported she did not have access to R7's care plan or Kardex to review how she transferred. On 05/18/23 at 12:55PM Administrative Nurse D reported she was notified by R7 on 04/24/23 that R7's shoulder hurt from an incident that occurred on the past Friday (04/21/23). Administrative Nurse D stated R7 slid out of her chair and staff attempted to reposition her in the wheelchair. She stated CNA N and Dietary staff CC stood on both sides of R7 and pulled her up by pulling her upwards by her arms. Administrative Nurse D stated she was not aware of the injury or incident until the following Monday (04/24/23). Administrative Nurse D stated did not know how R7 could have slid out of her chair. She stated R7 could not move or change positions easily. She stated staff may have placed R7 too close to the edge of the chair during transfer. Administrative Nurse D reported all staff should follow each resident's care planned transfer requirements. She stated the direct care staff were required to notify the nurse if an injury or fall occurred. She stated the nurse would have assessed R7 and notified the doctor if any injuries were suspected. She did not know why this did not occur on 04/21/23. Administrative Nurse D reported agency staff do not have access to the Kardex (condensed report created from care planned information) or care plan but were paired with facility staff to ensure they have the care information needed. A review of the facility's Abuse, Exploitation, and Neglect Prevention policy revised 02/2023 indicated all incident related to suspected abuse will be investigated and reported to the investigative agency. The policy indicated the facility will provide a safe and supportive environment for all residents with the deployment of trained and qualified staff to meet the care planned needs of each resident. A review of the facility's Mechanical Lift policy revised 07/2017 indicated all staff will be trained and follow the safe lifting guidelines related to each resident's care planned needs for transfers. The facility's failure to provide appropriate assistive care with the required number of staff and necessary equipment, and failure of staff to inform the licensed nurse in order to provide appropriate assessment and follow-up, placed R7 in immediate jeopardy for neglect. On 05/19/23 the facility completed the following corrections to remove the immediacy: All staff identified as part of the incident regarding R7 were placed on indefinite suspension and will not have any contact with the residents effective immediately as of 05/18/23 at 05:18 PM. All staff were re-educated on prevention of abuse to include neglect and appropriate reporting according to facility policies, and state and federal regulations. After removal of the immediacy, the deficient practice remained at a scope and severity of a G to represent the actual harm to R7.

The facility identified a census of 32 residents. The sample include 17 residents with five residents reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 7 remained free from preventable accidents when the facility staff failed to transfer R7 as required by R7's plan of care. On 04/21/23 R7, who required extensive assistance of two staff and a full body lift, slipped forward in her wheelchair. Certified Nurse Aide (CNA) N called out to non-CNA staff (Dietary Staff CC) to assist with repositioning R7 in the wheelchair. CNA N and Dietary Staff CC lifted R7 by her upper arms and pulled R7 back in the wheelchair without the use of the full body lift. During this action, R7's left shoulder made a loud popping noise, which CNA O, who sat at a nearby table, heard. None of the three staff, CNA N, CNA O, or Dietary Staff CC reported the incident to the charge nurse or Administrative Nurse D. On 04/24/23, R7's left shoulder was swollen and painful. An X-ray (radiographic image of a bone) revealed R7 had a left proximal (closer to the point of attachment) humerus (upper arm bone) fracture (broken bone). The facility's failure to provide appropriate assistive care with the required number of staff and necessary equipment to prevent avoidable accidents placed R7 in immediate jeopardy. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), muscle weakness, cerebrovascular disease (dysfunction of the blood vessels within the brain), major depressive disorder (major mood disorder), abnormal gait, and fracture of left shoulder. A review of R7's Quarterly Minimum Data Set (MDS) completed 01/27/23 noted she had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS noted she required extensive assistance from two staff for transfers and bed mobility. The MDS indicated she required supervision for meals. R7's Annual MDS completed 04/26/23 indicated she required extensive assistance for bed mobility and was totally dependent on two staff for all transfers. The MDS indicated she had no falls. R7's Cognitive Loss Care Area Assessment (CAA) completed 04/27/23 indicated she had a BIMS of 11 with impairment related to her stroke (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The CAA noted she refused cares at times, but staff should re-approach later. R7's Activities of Daily Living (ADLs) CAA completed 04/27/23 indicated she required a sit-to-stand lift (assistive mechanical lift) until she had her shoulder fracture, and then required a Hoyer lift (full body mechanical lift) with two staff assistance. R7's Fall CAA completed 04/27/23 indicated she was a high fall risk due to her cognitive deficit and balance deficits. A review of R7's Care Plan revised 08/29/22 indicated she was a high fall risk related to impaired mobility and seizure disorder. The plan noted she required a Hoyer lift with two staff members for transfers (07/05/19), was not able to self-propel her wheelchair (07/05/19) and required extensive assistance for long distances. She was independent after set-up assistance for meals. The plan indicated R7 made continual complaints about the facility not having enough staff (09/01/21). The plan instructed staff to encourage positive things when R7 had negative complaints (09/01/21). The plan noted R7 had a new fall intervention added on 05/04/23 that instructed staff the keep a gait on her wheelchair (05/04/23). A review of a Facility Reported Incident completed on 04/24/23 noted R7 complained about left shoulder pain to staff and was sent out for emergency medical treatment at an acute care facility. The report indicated R7 had a left shoulder fracture from an injury of unknown origin. A review of a Witness Statement completed on 04/24/23 by CNA N indicated R7 was in the dining room during dinner service on 04/21/23. CNA N noted R7 slid down her chair and no other staff were available to assist her with R7. CNA N noted she called out to Dietary Staff CC to assist her. The statement indicated both staff pulled R7 up in her wheelchair. The statement noted CNA N heard a popping noise from R7's left shoulder as staff lifted her. The statement lacked documentation related to notifying the nurse or physician at the time of incident. A review of a Witness Statement completed on 04/24/23 by CNA O indicated she assisted other residents in the dining room on 04/21/23 at the time of R7's injury. The statement indicated CNA O heard a popping noise as CNA N and Dietary Staff CC pulled R7 up in her wheelchair. The statement indicated no other direct care staff were in the area for assistance. The statement lacked documentation related to notifying the nurse or physician at the time of incident. A review of a Witness Statement completed on 04/24/23 by Dietary Staff CC noted he assisted CNA N with pulling R7 up in her wheelchair. A review of a Witness Statement completed on 04/24/23 by Licensed Nurse (LN) G indicated she was the charge nurse on duty during the incident resulting in R7's injury on 04/21/23. The statement indicated LN G was not notified of the incident or possible injury. A review of R7's EMR revealed no nursing notes, assessments, or fall investigations completed between 04/21/23 through 04/23/23 . A review of R7's EMR revealed a Progress Note on 04/24/23 at 02:32AM indicated R7 had swelling and discomfort to her left shoulder. The note indicated R7 reported she heard a pop while being transferred on 04/21/23. The note indicated an x-ray confirmed a left shoulder (humerus) fracture. On 05/18/23 at 09:45AM observation revealed R7's left shoulder was stabilized with a sling. R7 wore her night clothes. R7 stated she was still in bed due to not having enough staff to get her out of bed when she wanted. She stated it takes two staff and the mechanical lift to get her out of bed. She stated, on 04/241/23, she sat at the table and slid out of the chair. She stated staff stopped her from falling and pulled her up in her chair. She stated she heard a pop in her shoulder but did not feel pain until the next day. On 05/23/23 at 10:20AM CNA N stated on 04/21/23 she went to the dining area to assist with meal services. She stated only two CNAs were working the dining room. She stated the other direct care staff (CNA O) sat with the high-risk table with the meal-assisted residents. She stated R7 began sliding out of her wheelchair. CNA N said she yelled to CNA O for help, but CNA O could not leave the high-risk residents unassisted. She continued to yell out for help attempting to prevent R7 from sliding further but direct care staff were available. She stated Dietary staff CC came over to assist her with R7. She stated as R7 was pulled up in her wheelchair she heard a loud pop coming from R7's shoulder. CNA N stated she asked R7 if R7 was okay and R7 insisted she was and wanted to finish her meal. She stated after the meal she found the charge nurse and reported the incident. She stated she urged the facility to send R7 for emergency treatment, but it did not occur. She reported the facility only had two direct care staff and a nurse working the floor that day. She reported she did not have access to R7's care plan or Kardex to review how she transferred. On 05/18/23 at 12:55PM Administrative Nurse D reported she was notified by R7 on 04/24/23 that R7's shoulder hurt from an incident that occurred on the past Friday (04/21/23). Administrative Nurse D stated R7 slid out of her chair and staff attempted to reposition her in the wheelchair. She stated CNA N and Dietary staff CC stood on both sides of R7 and pulled her up by pulling her upwards by her arms. Administrative Nurse D stated she was not aware of the injury or incident until the following Monday (04/24/23). Administrative Nurse D stated did not know how R7 could have slid out of her chair. She stated R7 could not move or change positions easily. She stated staff may have placed R7 too close to the edge of the chair during transfer. Administrative Nurse D reported all staff should follow each resident's care planned transfer requirements. She stated the direct care staff were required to notify the nurse if an injury or fall occurred. She stated the nurse would have assessed R7 and notified the doctor if any injuries were suspected. She did not know why this did not occur on 04/21/23. Administrative Nurse D reported agency staff do not have access to the Kardex (condensed report created from care planned information) or care plan but were paired with facility staff to ensure they have the care information needed. A review of the facility's Accidents and Incidents-Investigating and Reporting policy, revised July 2017, provided by the facility, revealed all accidents and incidents involving residents occurring on the premises shall be investigated and reported to the Administrator. The policy noted the facility was in compliance with current rules and regulations governing accidents and/or incidents involving medical devices. The policy did not address prevention of avoidable accidents. A review of the facility's Mechanical Lift / Transfer policy revised 07/2017 indicated all staff will be trained and follow the safe lifting guidelines related to each resident's care planned needs for transfers. The facility failed to ensure R7 remained free from preventable accidents when the facility staff failed to transfer R7 as required by R7's plan of care. The facility's failure to provide appropriate assistive care with the required number of staff and necessary equipment to prevent avoidable accidents placed R7 in immediate jeopardy. On 04/26/23, prior to the onsite survey, the facility completed the following corrective actions: Education was provided to involved staff regarding reporting of concerns, and appropriate transfers using appropriately trained staff. Staff re-education related to prevention of accidents and/or hazards. Staff re-education on safe transfers, use of the gait belt and Hoyer lift when needed/care planned. Competency checks were completed for all relevant staff on Hoyer transfers, repositioning, and gait belt use. The surveyor verified the implemented corrective actions prior to arrival onsite on 05/18/23, and therefore deemed the deficient practice past non-compliance, existed at the scope and severity of J.

The facility had a census of 19 residents. The sample included 3 residents reviewed for neglect. Based on record review and interview, the facility failed to provide appropriate care as ordered by the physician for Resident (R)1, when his surgically closed pressure ulcer re-opened and required hospitalization and additional surgery. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Admission Minimum Data Set, (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status, (BIMS) of 12, indicating he was moderately cognitively impaired. The MDS documented the resident required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene, locomotion on and off the unit, extensive assistance of one staff for bathing, supervision after staff set-up, did not ambulate, and used a wheelchair for mobility. The MDS documented the resident was at risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) had no unhealed pressure ulcers, had a surgical wound, and had Moisture Associated Skin Damage (MASD). R1's Admission MDS, dated [DATE], documented the resident had a BIMS score of 11, indicating he was moderately cognitively impaired. The MDS documented the resident required extensive assistance of two staff for bed mobility, transfers, toileting, extensive assistance of one staff for locomotion on and off the unit, personal hygiene, bathing, total assistance of one staff for dressing, ate independently after staff set-up, and did not ambulate. The MDS documented the resident had an unhealed Stage 3 (full thickness loss, subcutaneous fat may be visible, but bone, tendon, muscle is not exposed) pressure ulcer on his coccyx (small triangular bone at the base of the spine). The MDS documented the resident used a wheelchair for mobility. R'1s Pressure Ulcer/Injury Care Area Assessment, (CAA) documented the resident required assistance with Activities of Daily Living, (ADLs) and he had a Stage 3 pressure ulcer. The CAA documented the resident was at risk for skin breakdown due to decreased mobility, and licensed staff would perform a full head to toe skin assessment weekly. The 01/21/21 Physician Orders, upon discharge from the hospital, directed staff to offset R1 to one side while lying in bed or in his wheelchair, turn and reposition frequently, notify the physician if he had redness, nausea and/or vomiting, increased swelling, foul smelling drainage from the wound, any questions or uncertainty, and to schedule a follow up appointment in two weeks for suture removal. The note directed staff to apply [MEDICATION(S)] (wound dressing) to the sacral surgical wound and cover with Duoderm, (wound dressing), change every 72 hours for wound healing, and check the dressing every day. R1's Skin Observation Tool, dated 01/21/21 documented the resident had a dressing on his buttocks with sutures and redness around the wound. The Medical Record lacked documentation staff performed a skin assessment for the week of 01/24/21-01/30/21. R1's Skin Observation Tool, dated 02/04/21 documented the sutures were intact on the sacrum area, redness around the wound, the surgical area on the coccyx continued to drain, and appeared to be healing. The drainage had not been documented on previous skin observations. The observation took lacked information as to the nature or description of the drainage and did not include measurements of the wound. R1's Skin Observation Tool, dated 02/11/21, documented sutures remained on the sacrum and lacked information about the description of the wound or measurements. R1's Braden Scale Assessment, (tool used to assess risks for developing pressure ulcers) dated 10/20/20 and 01/21/21 documented he was at high risk for developing pressure ulcers. The hospital History and Physical, dated 02/16/21 at 05:24 PM, documented the resident had a sacral decubitus ulcer (open wound to skin and underlying tissue resulting from prolonged pressure on the skin) had dehisced (rupture or splitting open of a surgical wound) and was open. The History and Physical documented the resident was a direct admit to the hospital for surgical care of the wound. The Consult Note, dated 02/17/21 at 10:51 AM, documented R1 had a surgical closure of his wound on 01/18/21 and was discharged back to the facility on [DATE]. The note documented R1 had not returned to Physician GG's office to have the sutures (used to close wounds on skin or other tissues) removed, and by the time Physician GG saw R1, the sutures had eroded through to the wound's base. When the sutures were removed, the wound had a railroad track pattern where the rubber bolsters (device used to support and cushion under sutures to reduce tension) had eroded through the skin. The note documented the wound was a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable skin, muscles, tendon, ligament, cartilage, or bone) that measured 4.0 centimeters (cm) by 1 cm x 1 cm. The Operative Report, dated 02/18/21, documented Physician GG performed debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue), washout, and applied a wound vac to the sacral decubitus ulcer. The report documented the wound measured 4.1 cm x 2.5 cm x 1.5 cm. The Pathology Report, dated 02/17/21, documented R1's wound culture from his sacrum area had large amounts of [CONDITION(S)]-resistant staphylococcus aureus (MRSA-an infection that is difficult to treat because of the resistance to some antibiotics). The Nurse's Note, dated 01/22/21 at 03:34 AM, documented R1 returned from the hospital on 01/21/21 with a dressing over sutures on his sacral area. The note documented staff should change the dressing daily and as needed, offset the resident when in bed or wheelchair, and reposition frequently. The Nurse's Note, dated 02/05/21 at 4:32 PM, documented R1 had a surgical wound on his coccyx and received treatment. The Nurse's Note, dated 02/17/21 at 11:25 AM, documented on 02/15/21, Licensed Nurse (LN) G, contacted R1's physician regarding suture removal and they directed her to contact the surgeon's office. R1's family representative contacted LN G to ask who removed the sutures. LN G explained the sutures were still present, and R1's family representative replied they should have been removed two weeks after his dismissal on 01/21/21. LN G documented she had no knowledge of that and would check on it. The note documented after LN G reviewed the discharge orders, there was no mention of a follow up appointment, and LN G contacted Physician GG's office and was told R1 had not missed any recent appointments, but a two week follow up should have been scheduled for suture removal. LN G scheduled an appointment for R1 on 02/16/21 at 02:00 PM (12 days after the sutures should have been removed). The Nurse's Note, dated 02/22/21 at 10:18 AM, documented following the confusion last week on 02/15/21, when LN G came to Administrative Nurse D, and asked when R1's sutures should be removed, Administrative Nurse D directed LN G to contact Physician GG's office about the suture removal. A call initiated by Physician HH and Physician GG on 2/17/21 regarding the appointment the facility should have scheduled with Physician GG's office to remove the sutures. The note documented Administrative Nurse D started an investigation about why the appointment was missed. Administrative Nurse D spoke with LN G and she stated the interim DON (Director of Nursing) took the admission packet with all orders and entered them into the resident's electronic record. LN G found the packet of admission paperwork from the hospital reviewed it with Administrative Nurse D. The packet included the history and physical, and lab results from the hospitalization but no discharge instructions, and none of the pages had been noted. The note documented later that day, Administration Nurse D located additional pages of the admission packet and discovered the medication list had been noted by the interim DON but the pages with the directions for wound care and to schedule a follow up appointment were not noted. Administrative Nurse D noted the admission checklist only had the medication list attached, not the discharge instructions with the order to schedule a follow up appointment to have sutures removed. R1 required readmission to the hospital for surgical intervention of his wound. On 02/22/21 at 04:00 PM, Physician GG stated he dismissed R1 from the hospital back to the facility on [DATE] and his surgically closed wound on his coccyx looked good. Physician GG stated he wrote on the discharge orders staff should call to schedule a two week follow up appointment for suture removal. Physician GG stated he became aware the sutures had not been removed on 02/15/21, which he doubled checked himself for verification, and an appointment was scheduled for 02/16/21. At that time the resident's wound had re-opened, the skin had eroded around the sutures, and he performed surgery to clean up the wound. Physician GG stated the resident would require more surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] On 02/23/21 at 10:20 AM, LN G stated she worked on 01/21/21 when R1 readmitted to the facility from the hospital. LN G stated she performed admission vital signs for R1, and the DON took the admission packet, including discharge orders, and told her she would take care of it. LN G stated she never saw the orders regarding suture removal. LN G stated R1's wound had sutures and she had not noticed any open areas, drainage, or infection in the wound. LN G stated on 02/15/21 she noted the wound looked different; it was open, and she could see orange-colored things that looked like plastic straws in the bottom of the wound. LN G stated she contacted Physician GG's office and scheduled an appointment for R1 on 02/16/21. On 02/23/21 at 02:00 PM, Administrative Nurse D stated LN G approached her on 02/15/21 regarding R1's sutures and when they should have been removed. Administrative Nurse D directed LN G to contact Physician GG's office and schedule the appointment. Administrative Nurse D started an investigation and found the orders had not been noted or processed, and a two week follow up appointment for suture removal had not been scheduled. Administrative Nurse D stated staff did not follow the facility's policy and she would expect a licensed nurse to note the orders and process them. On 02/23/21 at 03:45 PM, Administrative Staff A stated staff had not followed the facility's policy for R1 by failing process physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Admission to the Facility, policy dated August 2020, documented the admitting nurse should add physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Skin Integrity, Pressure Injuries, Nursing Protocol, dated August 2020 documented the resident would receive care, consistent with professional standards of practice to present pressure injuries and would not develop pressure injuries unless the individual's clinical condition demonstrates that there were unavoidable, and the resident with pressure ulcers would receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. The facility failed to note Physician GG's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's surgically closed wound re-opened and required admission to the hospital for additional surgery and treatment. On 02/22/21, the facility began education for licensed nurses on the Facility Admissions and Orders policy's as well as Pressure Ulcer Injuries. Each licensed nurse received a copy of the policy's and signed a form that stated they had received this information. The facility scheduled a mandatory staff in-service on 02/25/21 regarding wound prevention. The deficient practice remains at a scope and severity of a G. The facility's Removal Plan was approved on 02/22/21 at 04:34 PM.

The facility had a census of 35 residents. The sample included 3 residents reviewed for neglect. Based on observation, interview, and record review the facility failed to follow a written physician's orders [REDACTED].#1's lab was obtained at a local hospital, determined to have a critical Hemoglobin (protein molecule in red blood cells) level of 3.9 (normal range: male-13.5-17.5 g/dl (grams per deciliter of blood), female-12-15.5 g/dl), was transferred via helicopter to another hospital, and placed in the ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]. This deficient practice placed Resident #1 in immediate jeopardy. The facility failed to follow physician's orders [REDACTED].#2, between 12/17/18 and 12/31/18. Lab obtained on 1/2/19 revealed the resident had a critical low Potassium level, resulting in treatment at the medical clinic. The facility failed to follow physician's orders [REDACTED].#3, on the date ordered or using a specific catheter directed by the physician, as ordered, after he/she was urinating blood. Findings included: - Resident #1's 10/31/18 (POS) physician's orders [REDACTED].), presence of cardiac pacemaker (a small device that's placed in the chest or abdomen to help control abnormal heart rhythms), presence of prosthetic heart valve (a device implanted in the heart of a patient with valvular [MEDICAL CONDITION]), [MEDICAL CONDITION] (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and long term (current) use of anticoagulants (blood thinner medications). The Medicare-60 day (MDS) Minimum Data Set assessment, dated 11/30/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 11, indicating moderately impaired cognition, with no behaviors. The MDS recorded the resident required total 1 staff assistance for bathing, required extensive assistance of 2 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and limited assistance of 1 staff for eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had functional limitation in (ROM) Range of Motion on one side in lower extremities, and used a wheelchair for mobility. The MDS recorded the resident was frequently incontinent of bladder, always incontinent of bowel, and received anticoagulant medication. The 10/10/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident was admitted from an acute care hospital and required extensive to total staff assistance for ADLs. The 10/29/18 care plan, updated on 12/10/18, recorded the resident received [MEDICATION NAME] (anticoagulant medication) for anti-clotting benefits related to his/her prosthetic heart valve. The care plan directed staff to monitor the resident for bleeding, check his/her PT/INR ([MEDICATION NAME]/International Normal Ratio-test to determine how long it takes blood to clot) as ordered by the physician, and report lab results to the resident's primary physician. The 12/5/18 at 12:18 PM, physician's orders [REDACTED]. The 12/5/18 at 6:00 PM, nurse's note recorded the facility sent the resident to the local hospital to obtain blood laboratory tests. (5 hours and 42 minutes after order was written) The 12/5/18 at 8:25 PM, nurse's note recorded facility staff were informed the resident was transferred via helicopter to another hospital with a Hemoglobin level of 4. The local hospital emergency room note, dated 12/5/18, documented the resident came to the emergency room for evaluation of his/her [MEDICAL CONDITION]. The note documented the resident was brought to the hospital from the nursing home initially for outpatient lab that evening, that was ordered around 12:30 PM that afternoon. The note documented upon completion of the lab, it was found the resident had a critical Hemoglobin level of 3.9 mg/dl, and transferred to the emergency room for further evaluation and treatment. The note recorded the resident's condition was discussed with another physician at another hospital, who agreed to accept the resident. The resident transferred in critical condition to the other hospital via helicopter for further evaluation and treatment. The 12/10/18 at 1:47 PM, Social Services note recorded the resident was taken to the local hospital emergency room [DATE] and then transferred to another hospital via helicopter. The note recorded the resident had a [DIAGNOSES REDACTED]. The 12/12/18 at 6:02 PM, Social Services note recorded the resident discharged from the hospital and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 1/29/19 at 9:30 AM, observation revealed the resident lying in bed watching television, head of the bed elevated approximately 45 degrees, and no signs of pain or discomfort. On 1/29/19 at 2:18 PM, Nurse G stated on 12/5/18, he/she accompanied Physician GG while he/she assessed residents at the facility. Nurse G stated he/she gave Physician GG's orders for the resident to Nurse H, who took the orders home with him/her when he/she left at 6:00 PM. Nurse G stated Physician GG telephoned him/her at home wondering why Resident #1's lab had not been completed, the order was written at 12:18 PM and processed at 6:45 PM. Nurse G stated when labs were ordered, they were processed and placed in the computer, then a copy of the order was made and sent with the resident to the hospital for the lab to be drawn. Nurse G stated they had to check the Lab tab on the computer to see if there were any labs that needed to be completed. On 1/30/19 at 11:15 AM, Physician GG stated on 12/5/18, he/she was at the facility assessing his/her residents, and wrote orders for several residents. Physician GG stated the nurse that was given the orders, took the orders home with him/her. Physician GG stated Resident #1 looked pale and anemic, so Physician GG ordered NOW (immediate) labs to be done, it was investigated and found the nurse did not note the lab orders and took the orders home with him/her. Physician GG stated Resident #1 had an active GI bleed and received [MEDICATION NAME] (blood thinner) due to having a prosthetic heart valve, which required his/her INR to be higher at 2.3-2.5. Physician GG stated the resident was evaluated at another hospital two or three times with repeated issues, he/she stabilized and then worsened. Physician GG stated the facility obtains weekly PT/INR labs which are addressed by another hospital each time. Physician GG stated when he/she ordered the NOW labs, the resident was in critical condition, if the labs would have been obtained sooner, it would have been good. On 1/30/19 at 1:47 PM, Administrative Staff A stated the nurse in question did not process orders timely or during his/her shift. Administrative Staff A stated the facility was trying to explore multiple lab options. The facility's Recognizing Signs and Symptoms of Abuse/Neglect policy, dated (MONTH) (YEAR), documented the facility will not condone any form of resident abuse or neglect. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The facility failed follow a written physician's orders [REDACTED].#1, who was determined to have a critical Hemoglobin level, was transferred via helicopter to another hospital, and placed in the ICU with a [DIAGNOSES REDACTED]. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 1/31/19 at 12:52 PM, when the facility completed staff education on the updated lab policy for obtaining NOW lab orders. The deficient practice remains at a scope and severity of a G. - Resident #2's (POS) Physician order [REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 11/2/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating moderately impaired cognition, and no behaviors. The MDS recorded the resident required total 2 staff assistance for bathing, extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, extensive assistance of 1 staff for locomotion on the unit, personal hygiene, and supervision with setup help only for eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, used a wheelchair for mobility, and was frequently incontinent of bowel and bladder. The 11/2/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident admitted from an acute care hospital for strengthening following a spinal fracture (breaks in the bones of the spinal column) and [MEDICAL CONDITION] urinary tract infection [MEDICAL CONDITION] (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases [MEDICAL CONDITION] can lead to a medical emergency of septic shock). The CAA recorded the resident required two staff assistance for ADLs. The 9/12/18 care plan, updated 12/10/18, recorded the resident required staff assistance with ADLs and directed staff to prompt or encourage the resident with ADLs, remind him/her about personal hygiene, and provide assistance as needed. The 12/1/18 at 9:00 PM, nurse's note recorded the resident was unable to remain standing when transferred with a sit-to-stand lift (mechanical lift designed to secure patients during transfers from a seated position to a standing position). The note recorded staff encouraged the resident to stand multiple times, but he/she would not stand and stated, my legs can't hold me up. The note recorded staff did not feel it was safe to transfer the resident with the sit-to-stand lift, so staff quickly assisted the resident into bed with a full lift (a mechanical device designed to lift patients safely) without incident. The 12/4/18 (routine) CMP (Complete Metabolic Panel-test that measures levels of certain substances in your blood) documented a critical low Potassium 2.5 mmol/L (millimoles per liter), (normal range 3.5-5.1). The 12/4/18 at 2:51 PM, nurse's note recorded staff received orders to send the resident to the emergency room for a critical Potassium level. The 12/5/18 a 3:50 PM, Social Services note recorded the resident was admitted to the local hospital for critically high Potassium (should be critically low), with no discharge plans. The 12/9/18 at 4:03 PM, nurses note recorded the resident returned from the local hospital per wheelchair with staff. The note recorded the resident was in good spirits, denied pain, and voiced no complaints. The note recorded staff assessed the resident and obtained vital signs and blood sugar. The 12/13/18 at 9:00 AM, physician's orders [REDACTED]. The medical record lacked documentation a BMP was obtained on 12/17/18, 12/24/18, or 12/31/18. The 1/2/19 at 3:10 PM, nurse's note recorded Nurse Practitioner HH called the facility regarding the resident's lab results. The note recorded the resident's Potassium was low critical at 2.6 and directed staff to send the resident to the clinic. The note recorded staff transferred the resident to the clinic in his/her wheelchair. The 1/2/19 at 5:10 PM, nurse's note recorded the resident returned to the facility at that time, after he/she received Potassium Chloride 20 (meq) milliequivalents at the clinic. The note recorded the following new physician orders: 1) Potassium Chloride 20 meq (PO) by mouth (BID) twice a day. 2) recheck BMP weekly- next due on 1/9/19. 3) weekly weight and vital signs (blood pressure, heart rate, respirations, temperature, oxygen saturation) and report values in written communication, weekly, regardless if normal or not. The 1/2/19 at 4:50 PM, physician's orders [REDACTED]. Nurse Practitioner HH documented that was the reason he/she wrote orders for weekly vital signs, weight, and BMP. Nurse Practitioner HH further documented, this should have been caught earlier, please bring the resident to the clinic, so he/she can be assessed. The note recorded Nurse Practitioner HH wrote new orders for Potassium Chloride 20 meq (BID) twice a day, and first dose given in the office today, 1/2/19 at 4:50 PM, and BMP weekly, next due on 1/9/19. On 1/29/19 at 12:18 PM, observation revealed the resident sat in his/her wheelchair in the dining room. After the resident finished lunch, staff assisted him/her back to his/her room, as the resident visited with staff during the transfer. On 1/29/19 at 2:42 PM, Nurse I stated when the physician ordered lab, they were printed, immediately placed in the computer, and then the resident was sent out to the hospital right away for the lab to be drawn. Nurse I stated he/she was working when Nurse Practitioner HH reported the resident's lab had been ordered twice, but it was not getting done. Nurse I stated the 12/13/18 order to obtain weekly BMPs was not noted, it was scanned into the system but not noted. Nurse I stated Medical Records was responsible for making sure orders were noted. Nurse I stated the facility's system was: the first nurse noted the order, the second nurse double checked it, Medical Records was the third check, and they scan the order into the computer, in this case the system failed all 3 checks. Nurse I stated he/she spoke to Administrative Staff A regarding labs not completed as ordered, and other than checking the Labs tab on the computer, staff have no way to know if a lab order has been completed. Nurse I stated Nurse Practitioner HH talked to administration at the facility regarding labs not being obtained, there was discussion about putting the lab orders on the treatment record, but nothing had been done yet. On 1/30/19 at 10:33 AM, Nurse Practitioner HH stated the resident had a [DIAGNOSES REDACTED]. Nurse Practitioner HH stated the resident was now receiving an oral Potassium supplement to maintain his/her levels, and his/her other medications were checked to see if they contributed to the low Potassium levels. Nurse Practitioner HH stated on 12/4/18, he/she assessed the resident at the facility, and noted the resident was due for his/her routine lab, so he/she had the resident's BMP obtained that day. Nurse Practitioner HH stated he/she had the resident sent to the hospital to have the lab drawn, his/her Potassium level was critically low so he/she was admitted and remained hospitalized until 12/9/18. Nurse Practitioner HH stated on 12/13/18, he/she ordered a weekly BMP and a full set of vital signs, and the labs were not obtained. Nurse Practitioner HH stated he/she received a communication note regarding a different issue, so he/she asked where the resident's BMPs were, because they were not obtained. Nurse Practitioner HH stated, as a result of staff not obtaining the labs as ordered, the resident suffered from extreme muscle weakness and increased confusion even with his/her [DIAGNOSES REDACTED]. Nurse Practitioner HH stated on 1/2/19, he/she noted the facility had not obtained the resident's BMP for 12/31/18, so Nurse Practitioner HH asked staff to have the resident sent to the clinic for a follow up. Nurse Practitioner HH stated the resident had a BMP drawn that day which showed his/her Potassium level was low, so he/she administered oral Potassium to the resident at the clinic. Nurse Practitioner HH stated he/she wrote on the resident's paperwork, that was sent back to the facility with the resident, that the resident received Potassium while at the clinic, and the facility staff still proceeded to give the resident another dose when he/she returned to the facility. Nurse Practitioner HH stated following these incidents, he/she went to the facility on [DATE], and provided education to some of the administration regarding how to ensure labs were completed. Nurse Practitioner HH stated he/she would write orders, they were noted but not completed, he/she asked if the orders needed to be written in a different way and was told the facility had plans in action to keep incomplete lab orders from happening, including having staff go over all the orders, and ensure the orders were documented in the computer. On 1/30/19 at 1:47 PM, Administrative Staff A stated the facility was trying to explore multiple lab options. Administrative Staff HH stated Nurse Practitioner HH came to the facility and discussed Resident #2's low Potassium issues, how lab orders look in the computer, and how to check if the order was completed. The facility's Recognizing Signs and Symptoms of Abuse/Neglect policy, dated (MONTH) (YEAR), documented the facility will not condone any form of resident abuse or neglect. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The facility failed to follow physician's orders [REDACTED].#2, between 12/17/18 and 12/31/18. Lab obtained on 1/2/19 revealed the resident had a critical low Potassium level, resulting in treatment at the medical clinic, placing the resident at risk for increased muscle weakness and confusion. - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 1/1/19, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating moderately impaired cognition, with no behaviors. The MDS recorded the resident was totally dependent on 2 staff assistance for bathing, required extensive assistance of 2 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, extensive assistance of 1 staff for locomotion off the unit, and supervision with setup help only for eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, used a wheelchair for mobility, and frequently incontinent of bowel and bladder. The MDS recorded the resident received anticoagulant (blood thinner) medication. The 10/3/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident required extensive assistance for ADLs, transfers, and toileting needs. The 10/3/18 Urinary Incontinence CAA recorded the resident required extensive staff assistance with toileting and was frequently incontinent of urine. The 12/10/18 care plan recorded the resident received anticoagulant therapy ([MEDICATION NAME]) and directed staff to obtain labs as ordered, report abnormal lab results to the physician, and report signs and symptoms of anticoagulant complications. The care plan recorded the resident had urinary incontinence and directed staff to assist the resident to the toilet or check and change upon awakening, before and after meals, at bedtime, and PRN (as needed). The care plan recorded the resident required extensive assistance of two staff with toileting, but often refused assistance, and directed staff to continue to offer and encourage the resident to allow staff to assist with toileting, changing briefs, and pericare. The 1/23/19 at 12:25 PM, nurse's note recorded staff faxed the resident's physician regarding the resident passing blood in his/her urine. The 1/23/19 fax to the physician recorded the resident was passing some blood clots with urination that afternoon, a recent urinalysis (UA-test to check for bacteria in the urine) was completed with no growth or orders. The fax noted after 30 minutes, no further bleeding had occurred and asked the physician to please advise. The 1/23/19 at 3:40 PM, response by Nurse Practitioner HH recorded he/she had contacted the facility on 1/23/19 at 3:38 PM, spoke with Nurse K, who informed Nurse Practitioner HH the resident was passing blood in his/her urine again. Nurse Practitioner HH gave new orders as follows: 1) UA with urine culture and sensitivity (a test that can detect bacteria in your urine and test to find the right medication to treat the infection). 2) CBC with Auto Diff (Complete Blood Count with Automated Differential-a broad screening test to check for such disorders as [MEDICAL CONDITION], infection, and many other diseases). 3) CMP (Complete Metabolic Panel-blood test that [MEDICATION NAME] a person's metabolism). 4) PT/INR ([MEDICATION NAME]/International Normal Ratio-test to determine how long it takes blood to clot), order attached and at the front desk of the hospital. The 1/23/19 at 4:00 PM, nurse's note recorded the resident was urinating red urine, the physician was notified and directed staff to take the resident to the clinic for lab to be drawn. The note recorded staff were unable to collect a urine sample at that time and would take the urine sample to the lab when available. The 1/24/19 at 8:26 AM, nurse's note recorded the facility received a return fax from the physician with the following orders: UA with urine culture and sensitivity, CBC with auto diff, CMP, PT/INR, order at the front desk of the hospital. The 1/24/19 fax to the physician recorded staff attempted twice to straight cath (a tube-shaped medical device that is used to remove urine from a person's bladder if he or she is having trouble voiding naturally) the resident to obtain the UA, met resistance, and was unable to get the catheter past the prostate (surrounds the tube that carries urine away from the bladder and out of the body). Please advise, as the resident was unable to urinate in a cup at the time of trying to obtain urine. The 1/25/19 at 11:34 AM, response from Nurse Practitioner HH, documented in the future please attempt to use the condom (urinary incontinence device consisting of a flexible sheath that fits over the genitalia just like a condom, and is then attached to a tube that drains the urine into a urinary storage bag) to obtain the specimen. Also, please contact the clinic prior to attempting a straight catheter. The note further documented, if a specimen was collected with the condom please send the specimen to the hospital lab so a urinalysis could be completed, as there was already an order for [REDACTED].>The 1/25/19 at 1:47 PM, nurse's note recorded Nurse Practitioner HH sent an order to the facility to use a condom to obtain a UA specimen, and directed staff to please contact the clinic prior to attempting a straight catheter. On 1/29/19 at 9:40 AM, observation revealed the resident sat quietly in his/her wheelchair beside the nurse's station, no attempt to interact with other staff or residents in the area, and no signs of pain or discomfort. On 1/30/19 at 10:33 AM, Nurse Practitioner HH stated Resident #3 had regular PT/INR labs drawn, his/her lab results came back abnormal. Nurse Practitioner HH stated nursing staff had orders to obtain a monthly PT/INR, and if one of the lab results was abnormal, nursing staff drew the lab weekly, until the results came back normal, then went back to drawing the lab every 2 weeks. Nurse Practitioner HH stated he/she then ordered a UA because the resident was urinating blood and was on [MEDICATION NAME]. Nurse Practitioner HH stated he/she never received the urine sample, nursing staff attempted to catheterize the resident twice instead of using the condom as ordered. Nurse Practitioner HH stated nursing facility staff did not contact the doctor until they were unable to catheterize the resident twice, and the resident had an enlarged prostate. Nurse Practitioner HH stated on 1/23/19 the resident was urinating blood, and staff informed Nurse Practitioner HH the resident's most recent UA was ok. Nurse Practitioner HH stated he/she spoke with the registered nurse on duty and he/she wrote new lab orders to obtain a CBC, CMP, PT/INR, and a UA due to the resident urinating blood. Nurse Practitioner HH stated the facility sent the resident's blood work to him/her on 1/23/19 and again on 1/24/19, and staff had attempted to catheterize the resident twice with no result. Nurse Practitioner HH stated he/she saw the blood work lab results on 1/24/19 and sent written orders to obtain the UA again. Nurse Practitioner HH stated he/she contacted Administrative Staff A and was told that the order for the UA was noted but was never placed into the computer. The facility's Recognizing Signs and Symptoms of Abuse/Neglect policy, dated (MONTH) (YEAR), documented the facility will not condone any form of resident abuse or neglect. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The facility failed to follow physician's orders [REDACTED].#3 on the date ordered or using a condom catheter, as ordered, after he/she was urinating blood, placing the resident at risk for increased bleeding, and infection.

The facility had a census of 39 residents. The sample included 22 residents, of which 6 residents were reviewed for hydration and nutrition. Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional and hydration status for 4 of 6 sampled residents. Resident #15, had severe weight loss of 10.44% in 21 days. Resident #32, had weight loss and no interventions. Resident #34 and #37, failed to consume the recommended daily fluid intake. Findings included: - Resident #15's physician's orders [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 10/01/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 9 (moderately impaired cognition) and no behaviors. The MDS recorded the resident required extensive staff assistance with transfers, setup assistance and supervision with eating, and was unable to walk. The MDS further recorded the resident weighed 122 pounds, had no chewing or swallowing problems, and no recent weight loss. The 10/01/18 admission (CAA) Care Area Assessment for (ADLs) Activities of Daily Living function recorded the facility admitted the resident from the hospital on [DATE], after surgery for [REDACTED]. The CAA recorded the resident was alert, able to make his/her needs known, and required extensive staff assistance with most ADLs. Continued review of the CAA revealed the resident had not triggered problems or risks for nutritional status. The 10/02/18 care plan recorded the resident received a regular diet with thin liquids, and a goal for weight to remain stable. The care plan directed staff to monitor the resident's meal intake, and to involve the (RD) Registered Dietician as needed. The 09/24/18 Nursing Admission Evaluation and progress note lacked documentation staff obtained the resident's weight on admission. The 09/27/18 at 5:15 PM, nursing note recorded the resident had no [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) in his/her lower extremities. The 10/01/18 Admission (CDM) Certified Dietary Manager Nutrition Assessment recorded the resident received a regular diet, required staff setup assistance at the meals, ate and drank independently, and weighed 122.6 pounds. The assessment lacked documentation of the resident's food preferences or need for supplements, and the resident had poor meal intake (less than 50%). The facility's weight record revealed the following: 10/03/18 - 122.6 pounds (9 days after admission to the facility) 10/24/18 - 109.8 pounds (12.8 pounds or 10.44% weight loss in 21 days) The surveyor requested staff weigh the resident on 10/24/18, and the resident was discharged to another facility later that day. The resident's medical record lacked documentation the RD completed a nutritional assessment for the resident. Review of the resident's meal intake record from 09/24/18 to 10/23/18 revealed the following information: 0 - 25% intake at 30 meals 26 - 50% intake at 23 meals 51 -75% intake at 14 meals 76 - 100% intake at 23 meals Review of the evening snack report from 09/25/18 to 10/23/18 revealed the resident received a bedtime snack 3 times in 29 days. The 10/10/18 at 12:00 PM, nurse's note recorded the resident was nauseated and vomited food and phlegm (the thick [MEDICATION NAME] substance secreted by the mucous membranes of the respiratory passages). The physician's orders [REDACTED]. Review of the resident's medical record lacked documentation staff notified the physician about the resident's weight loss or poor nutritional intake. On 10/24/18 at 8:27 AM, observation revealed the resident sat in a wheelchair at the dining room table, and ate and drank independently. Continued observation revealed the resident consumed a few bites of scrambled eggs and toast. On 10/24/18 at 11:02 AM, Nurse G stated the resident ate independently, had a poor appetite, and did not receive supplements. Nurse G stated staff usually weigh new admission residents weekly or as ordered by the physician, and administrative nursing monitored the residents' weights. Nurse G stated he/she was not aware the resident had a weight loss. On 10/24/18 at 3:00 PM, Nurse Aide M stated the resident ate and drank independently, had a poor appetite, and he/she was not aware if the resident received snacks or supplements. On 10/25/18 at 7:40 AM, Dietary Manager BB stated the resident received a regular diet, ate independently, had a poor appetite, and did not receive supplements. Dietary Manager BB stated nursing staff should weigh new residents on admission, weighed weekly for several weeks, and nursing monitor the residents' weights. Dietary Manager BB stated staff had not notified the RD of the resident's weight loss and the RD had not completed an initial nutritional assessment. On 10/29/18 at 8:50 AM, Administrative Nurse D stated new residents should be weighed on admission, weighed weekly for several weeks, and nursing staff should monitor the resident's weight. Administrative Nurse D stated staff should notify the RD and physician about the resident's nutritional problems and weight loss. On 10/30/18 at 11:02 AM, (APRN) Advanced Practice Registered Nurse GG stated the resident had no history of fluid retention and no [MEDICAL CONDITION] when he/she assessed at the facility on 10/12/18 APRN GG further stated the facility staff should weigh the resident upon admission and accurately monitor the resident's weight as he/she ordered. APRN GG stated the facility had not notified him/her about the resident's nutritional problems and weight loss. The facility's Weight Intervention Policy, dated 09/2012, directed staff to weigh the resident upon admission, the next day, and weekly for 2 weeks. The policy directed staff to monitor, identify and intervene for weight loss, and weight loss of 5% or more would be reported to the RD and physician. The policy further recorded weight loss greater than 5% in a month is considered severe weight loss. The facility failed to weigh Resident #15 upon admission, monitor his/her weight and implement interventions to prevent severe weight loss, placing the resident at risk for continued weight loss and nutritional problems. - Resident #32's admission (MDS) Minimum Data Set assessment, dated 8/09/2017, recorded the resident scored 11, on the (BIMS) Brief Interview for Mental Status, which indicated the resident had moderate cognitive impairment. The MDS recorded the resident required extensive assistance of 2 staff with bed mobility, transfers, extensive assistance of one staff for locomotion on and off the unit, dressing, toilet use, personal hygiene, and supervision with limited assistance of one staff for eating. The MDS further documented the resident weighed 125 lbs and received a therapeutic diet. The MDS documented no, or unknown, weight loss or gain. The nutritional (CAA) Care Area Assessment, dated 8/31/2018, documented staff encouraged the resident to eat, offered him/her a variety of foods, observed and assessed his/her weight, as ordered, and reported concerns to the primary care physician. The CAA recorded the staff observed/accessed for complications, including skin breakdown, and reported the concerns to the primary care physician. The CAA lacked documentation of the resident's weight. The care plan, dated 8/21/2018, documented the resident required a Heart Healthy Diet, soft texture and thin liquids, staff monitor meal intakes, and the RD to review as needed. The medical record revealed a physician diet order, dated 8/03/2017, for Fat controlled cholesterol (heart healthy diet), and soft texture. The 8/09/2018 Nutrition Assessment completed by the (DM) Dietary Manager recorded the resident's weight was 124.8 lbs, height 62 inches, and he/she received a Fat/cholesterol controlled (heart healthy) diet, and soft texture. The medical records lacked a (RD) Registered Dietician admission dietary assessment until 9/13/2018. (42 days after the resident was admitted to the facility) The weight record revealed the following: 8/02/18- 124.6 lbs 9/03/18- 110.8 lbs( 13.8 lbs weight loss in 30 days) (The facility lacked any weights in the medical record until the Surveyor asked, then the 10/18 weigh was locked on a clipboard in the nurses station, and the 10/24 weight was obtained after the Surveyor requested a current weight) 10/18/2018 115.0 lb 10/24/2018- 115.5 lbs (requested by the surveyor) 10/25/2018- 114.6 lbs The 9/13/2018 RD progress note, documented the resident's weight was 110.8 lbs and he/she had a significant weight loss since admission to the facility, likely due to [MEDICAL CONDITION]. The note documented the resident received a Fat/cholesterol controlled diet, heart healthy diet. The notes documented the resident required the following daily nutritional needs: 1259-1519 calories, 50 grams of Protein, and 1510 (ml) milliliters of fluids. The RD recommended the resident receive a house supplement twice a day between meals, and monitor his/her weights weekly. The medical record lacked documentation of the residents likes/dislikes, and if staff honored his/her preferences. The medical record revealed the facility admitted the resident on 8/02/2018, and he/she discharged from the facility, to the hospital on [DATE]. The physician visit note, dated 9/26/2018 ordered staff to obtain several blood laboratory test, the following lab work for the resident CBC, UA, [MEDICATION NAME], INR, and Chem 20, however lacked any record of the residents weight loss. On 10/24/2018 at 7:30 AM, observation revealed the resident sat in his/her wheelchair at the dining room table after he/she finished eating breakfast. The resident ate french toast, eggs, coffee and an orange and consumed half of his/her meal. On 10/25/2018 at 2:20 PM, Dietary Manager BB verified the resident lost 13.8 lbs pounds in 30 days and verified the lack of RD assessment on admission. Dietary Manager BB verified the lack of RD documented orders for the House shakes twice a day and weekly weights. On 10/29/2018 at 10:20 AM, Nurse Aide O stated the resident did not eat very much of his/her meals and the resident voiced he/she was not hungry. Nurse Aide O verified the resident had an supplement between meal that he/she was aware of, and verified the resident received supplements, it would be delivered from the kitchen with the snacks and staff would record the amount of intake. On 10/29/2018 at 10:00 AM, Administrative Nurse D verified the medical record documented the resident lost 13.8 lbs in 30 days and verified the lack of a Registered Dietician assessment until 9/13/2018. Administrative Nurse D stated the facility prefers to have the RD complete an assessment on a newly admitted resident 7 days after admission, and verified the RD requested weekly weights and order for House shakes twice daily between meals, and staff had not followed through with the orders. The facility's Weight Assessment and Interventions policy dated 9/2012 indicated the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain for their residents. 1) Each resident is weighed upon admission, the next day, and weekly x 2 and unless indicated otherwise, monthly thereafter. 2) Weights will be recorded per facility protocol. 3) Any weight change of 5% or more since the last weight, the resident would be weighed the next day for confirmation. If the weight change is verified, nursing were to notify the Registered Dietician per facility protocol. 4) The threshold for significant unplanned and undesired weight change will be based on the following criteria (where percentages of body weight loss= (usual weight -actual weight)/ (usual weight x 100): 1 month -5% weight change is significant, greater than 5% is severe. 3 months -7.5% weight change is significant; greater than 7.5% is severe. 6 months -10% weight change is significant; greater than 10% is severe. The interdisciplinary team will identify conditions and medications that may cause anorexia, weight gain, or increase the risk of weight loss. The facility failed to implement timely and effective interventions to prevent weight loss for Resident #32, who lost 13.8 pounds, (11.08% in one month), resulting in significant weight loss, and placing the resident at risk for increased health concerns. - Resident #34's (POS) physician's orders [REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 12/1/17, documented the resident had a (BIMS) Brief Interview for Mental Status Score of 15, which indicated intact cognition. The assessment revealed the resident required supervision with set up assistance of all activities of daily living. The assessment further revealed the resident had occasional bladder incontinence. The 12/1/17 (CAA) Care Area Assessment for dehydration did not trigger. The 14-day Medicare MDS, dated [DATE], documented the resident had a BIMS of 12, which indicated moderately impaired cognition. The assessment revealed the resident required extensive assistance of 1 staff for bed mobility, dressing, toileting, personal hygiene, and set-up assistance of 1 staff for eating. The assessment further revealed the resident had occasional bladder incontinence. The 9/19/18 care plan directed staff to monitor and document for signs and symptoms of (UTIs) urinary tract infections. The care plan lack direction to staff on monitoring the resident's fluid intake. The 1/23/18 registered dietician annual assessment recommended the resident consume 1,311 (ml) milliliters of fluid daily. The 9/4/18 physician's orders [REDACTED]. The 9/17/18 physician's orders [REDACTED]. The 9/18/18 at 10:30 AM, nurse's note documented the resident leaned to the left in his/her wheelchair, staff prompted the resident to sit up and he/she continued to lean to the left side. The note further documented the resident was sent to the (ER) emergency room and was admitted for [MEDICAL CONDITION] (systemic reaction of the body to a bacterial infection) and dehydration (reduction in the amount of water in the body). The 9/26/18 at 6:30 PM, nurse's note documented the resident returned to the facility from the hospital. The 10/18/18 physician's orders [REDACTED]. The 10/21/18 at 1:33 PM, nurse's note documented the resident denied discomfort with urination and was drinking adequate fluids. The 10/23/18 physician's orders [REDACTED]. Review of the (MONTH) (YEAR) fluid intake record revealed the resident consumed an average of 947 ml of fluid daily for the month. Review of the (MONTH) (YEAR) fluid intake record revealed the resident consumed an average of 889 ml of fluid daily for the month. Review of the (MONTH) (YEAR) fluid intake record revealed the resident consumed an average of 865 ml of fluid daily for the month. Review of the (MONTH) (YEAR) fluid intake record revealed the resident consumed an average of 950 ml of fluid daily for the month. On 10/25/18 at 9:04 AM, observation revealed, at breakfast, the resident had drank 1- 120 ml glass of juice and did not drink his/her 120 ml glass of water. Further observation revealed staff did not encourage the resident drink his/her water. On 10/25/18 at 12:30 PM, observation revealed, at lunch, the resident drank a cup of coffee and 1-120 ml glass of juice but did not drink the 120 ml of water. Further observation revealed staff did not encourage the resident drink his/her water. On 8/29/18 at 7:39 AM, observation revealed, at breakfast, the resident had drank 1- 120 ml glass of juice and did not drink his/her 120 ml glass of water. Further observation revealed staff did not encourage the resident drink his/her water. On 10/25/18 at 2:08 PM, Nurse Aide M stated the resident did not like to drink water and staff frequently encouraged the resident often. On 10/29/18 at 9:32 AM, Administrative Nurse D stated the resident has chronic UTIs and staff encourage the resident to drink fluids. The (MONTH) (YEAR) facility's Hydration and Prevention of Hydration Policy documented the facility would endeavor to provide adequate hydration and to prevent and treat dehydration. The facility would assess for signs and symptoms of dehydration during daily care. The policy further documented the staff would provide and encourage intake at bedside, snacks and meal fluids on a daily and routine basis a part of daily care. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, activities of daily living status, individual preferences of habits, cognitive, and medical status will be considered in all interventions and physicians will be informed. The facility failed to ensure Resident #34 received adequate hydration, placing the resident at risk for dehydration and UTIs. - This deficient practice also affected Resident #37, who required 2570 (ml) milliliters of fluid of fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 1085 ml fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 1008 ml fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 823 ml of fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 648 ml of fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 591 ml of fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 590 ml of fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 908 ml of fluid daily for the month. Review of the facility fluid intake record for (MONTH) (YEAR) revealed the resident consumed an average of 868 ml of of fluid daily for the month. On 10/23/18 at 10:36 AM, observation revealed staff brought the resident a new jug of water and sat it on the table, out of the resident's reach, and did not offer the resident a drink. On 10/24/18 at 3:30 PM, observation revealed the resident, with eyes closed, in his/her bed and the resident's water jug across the room out of the resident's reach. On 10/25/18 at 2:09 PM, Nurse Aide M stated staff encouraged the resident to drink and offered fluids when providing cares to the resident. On 10/29/18 at 10:15 AM, Administrative Nurse D stated the resident's water jug should be assessable to the resident when he/she was in bed. The (MONTH) (YEAR) facility's Hydration and Prevention of Hydration Policy documented the facility would endeavor to provide adequate hydration and to prevent and treat dehydration. The facility would assess for signs and symptoms of dehydration during daily care. The policy further documented the staff would provide and encourage intake at bedside, snacks and meal fluids on a daily and routine basis a part of daily care. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, activities of daily living status, individual preferences of habits, cognitive, and medical status will be considered in all interventions and physicians will be informed. The facility failed to ensure Resident #37 received adequate hydration, placing the resident at risk for dehydration.

The facility had a census of 39 residents. The sample included 3 residents reviewed for neglect. Based on record review and interview, the facility failed to follow a written physician's orders [REDACTED].#1 admitted to the hospital with [REDACTED]. This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - The [DATE] signed physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. Severe cases [MEDICAL CONDITION] can lead to the medical emergency, septic shock, [MEDICAL CONDITION] urinary tract infection,[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus (a type of bacteria resistant to many antibiotics), [MEDICAL CONDITION]/hypertrophy (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) with lower urinary tract symptoms, dementia (progressive mental disorder characterized by failing memory), and [MEDICAL CONDITION] (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness). The physician's orders [REDACTED]. Resident #1's quarterly (MDS) Minimum Data Set assessment, dated [DATE], documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, which indicated he/she had severe cognitive impairment. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing, and extensive assistance of 1 staff for locomotion on and off the unit. The MDS documented the resident was not ambulatory, used a wheelchair for mobility, had a urinary catheter (insertion of a flexible tube into the bladder to drain the urine into a collection bag) and documented the resident had [DIAGNOSES REDACTED]. The MDS lacked documentation the resident [MEDICAL CONDITION]. Resident #1's annual MDS, dated [DATE], documented the resident had a BIMS of 8, which indicated he/she had moderate cognitive impairment. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing, extensive assistance of 1 staff for walking in his/her room and locomotion on and off the unit, and supervision after staff set up for eating. The MDS documented the resident was frequently incontinent of urine, and used a wheelchair and a cane for mobility. The MDS lacked documentation the resident [MEDICAL CONDITION]. The annual (CAA) Care Area Assessment for cognitive loss, dated [DATE], documented the resident had a BIMS less than 13, and he/she was able to make his/her needs known. The urinary incontinence CAA documented the resident was incontinent, staff assisted the resident with incontinent care to ensure he/she remained clean and dry, and staff would prompt the resident to use the restroom when he/she woke up, before and after meals, bedtime, and as needed. The CAA lacked documentation the resident had [MEDICAL CONDITION]. The [DATE] care plan directed staff to report any signs or symptoms of urinary tract infection (persistent urge to urinate, burning, foul smell, cloudy, red, pink, or dark colored urine, elevated temperature, chills) to the resident's physician, provide catheter care every shift, position the urine bag and tubing below the level of the bladder, and record urine output. The care plan further instructed staff to encourage adequate fluid intake, and give antibiotic therapy as ordered. Review of the resident's medical record documented a urinary catheter was placed on [DATE] for difficulty emptying his/her bladder due to [DIAGNOSES REDACTED]. On [DATE] at 2:30 PM, the physician progress notes [REDACTED]. The resident complained of feeling slightly short of breath. The physician directed staff to continue the resident's current medications and treatment, add [MEDICATION NAME] (medication used to treat fluid retention by increasing urine production ([MEDICAL CONDITION]) and swelling, 20 (mg) milligrams, twice a day, and potassium (essential mineral that is important in maintaining fluid and electrolyte balance in the human body, and necessary for the heart, kidneys, and other organs to work normally), 20 (meq) milliequivalent, twice a day, (CBC) complete blood count (laboratory blood test) in two weeks, and staff should obtain a urinalysis and urine culture. The resident's urine output, documented in the medical record, revealed the following output amount for [DATE] to [DATE]: [DATE] 600 (cc) cubic centimeters, [DATE] 725 cc, [DATE] 1,575 cc, and [DATE] 2,750, and 350 cc yellow urine. The record lacked documentation of the color or character of the resident's urine. The [DATE] at 10:09 AM nurse's note documented the resident's urine was dark, and the catheter tubing with sediment (material that settles to the bottom of a liquid). The note documented staff changed the resident's catheter, and a large amount of red, brown, and yellow sediment was noted at the end of the old catheter tip, and the urine was reddish brown and dark in color when staff placed the new catheter. The [DATE] at 11:35 AM, nurse's note documented staff found the resident unresponsive, staff called the nurse to the resident's room. Nursing staff assessed the resident, and his/her vital signs were abnormal: blood pressure ,[DATE] (normal is ,[DATE]), pulse 39 (normal range is ,[DATE] beats per minute), respirations 22 (normal range is ,[DATE] breaths per minute), oxygen saturation 79% on 2 liters of oxygen (normal range is ,[DATE]%), and staff had not checked the resident's temperature. The note documented staff called the ambulance to transport the resident to the hospital. The [DATE] at 1:15 PM, nurse's note documented the hospital staff informed the facility the resident was admitted with a [DIAGNOSES REDACTED]. The [DATE] at 8:55 AM, social service note documented the resident remained in the hospital, and his/her health status was very grave (serious). The [DATE] at 7:44 PM, nurse's note documented the resident was readmitted to the facility, was non-verbal, unresponsive, and had 3+ [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissue demonstrated by application of pressure to the swollen area with a finger which causes an indentation that persists for some time) in his/her arms. The note documented staff were not able to keep the resident's oxygen saturation within normal limits (,[DATE]%), and oxygen was used for comfort care. The note documented the resident was admitted to Hospice services on re-admission, and the Hospice nurse was at the facility when the resident arrived. The [DATE] hospital history and physical documented the resident presented to the emergency room , semi-conscious, with a past medical history of [REDACTED]. The physical exam showed the resident was poorly responsive and lethargic (lack of energy, sluggish). The note recorded the resident's temperature was 97.8, blood pressure was ,[DATE], pulse 63, respirations 21, and oxygen saturation was 100% on 6 liters of oxygen and 96% on 4 liters of oxygen. The note documented the resident had a chronic (persisting for a long period, often for the remainder of a person's lifetime) Foley catheter in place, with very dark colored brown urine. The resident's urinalysis showed 2+ blood (normal is lesss than 3 ), 1+ protein (normal is ,[DATE]), 3+ bacteria (normal is 0), ,[DATE] red blood cells (normal is ,[DATE]), and white blood count was too numerous to count (normal is ,[DATE] and indicative of a urinary infection). The urine culture documented the resident's urine had Escherichia coli (bacteria commonly found in the lower intestine that had a potential for causing infections in the urinary tract). The resident's lactic acid (mainly produced in muscle cells and red blood cells when the body breaks down carbohydrates to use for energy when oxygen levels are low) level was elevated and was consistent [MEDICAL CONDITION]. The note documented the resident received 2,000 (ml) milliters of fluid in the emergency room and was given [MEDICATION NAME] (medication to treat infections), one gram, per IV (intravenous), and admitted to the hospital. The assessment documented the resident admitted [MEDICAL CONDITION], secondary to urinary tract infection, septic shock (significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death). The note lacked documentation the resident had [MEDICAL CONDITION]. The [DATE] hospital laboratory (CBC) complete blood count results documented the resident had an elevated white blood count of 14.6 (normal range is 3XXX,[DATE].5), low red blood count of 4.02 (normal range is 4XXX,[DATE].72), and high lactic acid result of 3.4 (normal range is 0XXX,[DATE].10). On [DATE] at 9:45 AM, Direct Care Staff M, stated on [DATE], the resident seemed weak and would slide down in his/her wheelchair, but his/her eyes were open and he/she talked to staff. Direct Care Staff M stated when he/she checked on the resident later in the morning, he/she was unresponsive and slid half way out of his/her wheelchair. Direct Care Staff M stated he/she, with help from two other staff members, manually transferred the resident back into his/her wheelchair. Direct Care Staff M stated he/she stayed with the resident until the ambulance arrived to transport him/her to the hospital, and the resident remained unresponsive. On [DATE] at 12:44 PM, Direct Care Staff N stated he/she went to the resident's room on [DATE]. He/she was asked to help transfer the resident because he/she was unresponsive and slid part way out of his/her wheelchair. On [DATE] at 3:20 PM, Administrative Nurse D verified the (ARNP) Advanced Registered Nurse Practitioner Consultant II ordered a urinalysis and culture for the resident, on [DATE]. Administrative Nurse D stated he/she received a telephone call on [DATE] from Physician Consultant HH and he/she reported the urinalysis was not obtained as ordered. Administrative Nurse D verified Licensed Nurse G took the physician's orders [REDACTED]. Administrative Nurse D verified staff should have obtained the urine, as ordered, and verified he/she was not aware of the missed test until Physician Consultant HH called on [DATE] and informed him/her. On [DATE] at 3:30 PM, Administrative Staff A stated the facility was notified by Physician Consultant HH the urinalysis ordered for the resident on [DATE] was never obtained, and stated it should have been done that day. On [DATE] at 9:50 AM, Nurse Consultant Staff GG stated the resident was admitted to Hospice care on [DATE], with a [DIAGNOSES REDACTED]. Nurse Consultant Staff GG stated he/she was not aware of [MEDICAL CONDITION] diagnosis. On [DATE] at 10:20 AM, ARNP Consultant II verified he/she saw the resident at the facility on [DATE], and wrote an order for [REDACTED]. On [DATE] at 10:40 AM, Licensed Nurse G stated on [DATE], ARNP Consultant II came to the facility to see the resident, wrote orders for medication changes, and to obtain a urinalysis with culture for the resident. Licensed Nurse G verified he/she had not placed the order in the computer and the urinalysis was never done. On [DATE] at 11:32 AM, Nurse Consultant Staff JJ stated the resident had a history of [REDACTED]. On [DATE] at 12:00 PM, Physician Consultant HH stated the missed urinalysis and culture could have potentially added to the resident's decline and death. Physician Consultant HH verified the resident was admitted to the hospital with [REDACTED]. On [DATE] at 3:30 PM, Administrative Nurse D stated the facility did not have a copy of the resident's death certificate. On [DATE] at 12:30 PM, Consultant Staff KK stated his/her business does not keep a copy of death certificates. The facility's [DATE] Abuse, Neglect and Exploitation policy documented the definition of neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Upon request, the facility did not provide a policy for processing physician's orders [REDACTED]. The facility failed to obtain a physician ordered urinalysis and culture for Resident #1 on [DATE], who became septic, received treatment at the hospital, and died . The facility abated the immediate jeopardy on [DATE] when the facility completed in-service training to all licensed nursing staff on the process of transcribing physician's orders [REDACTED]. The deficient practice remains at a scope and severity of a G.

The facility identified a census of 52 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to provide, accurately transcribe, and administer, a prescribed medication for 1 of 3 sampled residents (#1) when an antibiotic (a type of antimicrobial drug used in the treatment and prevention of bacterial infections) was not given for 7 days as ordered by the physician. The omission of this medication resulted in the hospitalization of the resident for left hand/wrist/arm pain, redness and swelling. Findings included: - Review of the December 2016 electronic physician's orders [REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. The resident required extensive assistance of staff with bed mobility, transfers, toileting, dressing, and personal hygiene. The quarterly MDS dated [DATE] recorded a BIMS score of 6, which indicated severely impaired cognition. The resident required extensive assistance of staff with functional activities of daily living (ADLs), such as bed mobility, transfers, toileting, dressing, and personal hygiene. The psychotropic medication care area assessment (CAA) dated 9/15/16 directed staff to monitor the resident for medication effectiveness and/or medication side effects. The care plan revised on 1/12/17 directed staff to monitor the resident for potential adverse reactions and/or side effects of medications. The care plan lacked documentation to include the resident's past and/or present use of antibiotics. Review of the resident's clinical record documented on 12/23/16 at 9:30 A.M. the resident had his/her left arm assessed at a local clinic. On 12/23/16 after 11:00 A.M., the resident returned to the facility with a physician's note and order for Doxycycline. The physician's note recorded the resident's antibiotic was ordered from a local pharmacy and would be delivered to the facility. Review of the electronic Medication Administration Record [REDACTED].M. The MAR indicated [REDACTED]. Review of the nurse's progress note dated 12/26/16 at 12:30 P.M. recorded the resident's left hand/wrist/arm remained red with swelling and painful to the touch up to the elbow; and on 12/26/16 at 3:53 P.M., he/she was admitted to the hospital for treatment of [REDACTED]. Review of the nurse's progress notes dated 12/29/16 at 7:56 P.M. documented the resident's return from the hospital (3 day stay) and he/she started Bactrim DS 800-160 (an antibiotic used to treat a variety of bacterial infections) one by mouth (PO) twice a day (BID) (until stopped by physician). Review of the hospital discharge notes and transfer orders dated 12/29/16 recorded the resident received intravenous antibiotic therapy (an invasive method of administering medication directly into the bloodstream) while in the hospital for physician diagnosed left arm cellulitis. Review of the facility's medication error report dated 1/3/16 at 8:35 A.M. documented on 12/30/16 (no time noted) direct care staff J reported the resident did not receive the antibiotic medication per the physician's orders [REDACTED]. The facility's investigation dated 1/3/17 documented a signed witness statement from licensed nurse E wherein the resident's order for Doxycycline 100 mg by mouth twice a day for 7 days was incorrectly entered to read Doxycycline 100 mg by mouth twice a day every 7 days. On 1/18/17 at 11:32 A.M., the resident had his/her left arm resting at the elbow on the wheelchair armrest. The resident's left arm was of normal color, although, remained a little swollen. On 1/18/17 at 11:32 A.M., the resident reported his/her left arm swelled and hurt about a week ago. The resident recalled being hospitalized , and stated he/she received intravenous antibiotics. On 1/18/17 at 11:48 A.M., direct care staff J stated he/she reported to a staff nurse the morning of 12/25/16 he/she thought the order was incorrect and needed clarification from the physician. Direct care staff J stated he/she knew this because he/she witnessed the nurse receive the order. On 1/18/17 at 2:50 P.M., administrative licensed nurse C stated he/she was unsure why the medication was not obtained from the emergency kit. On 1/18/17 at 4:48 P.M., licensed nurse D confirmed he/she entered the order for the Doxycycline into the computer incorrectly. On 1/18/17 at 4:54 P.M., licensed nurse E stated he/she was unaware the resident had orders for antibiotics. On 1/24/16 at 9:41 A.M., physician W was not available for comment regarding the resident's missed antibiotic doses. On 1/24/16 at 14:33 P.M., physician W's clinical manager, licensed nurse N stated physician W was not aware the resident did not receive his/her prescribed antibiotic while at the facility and prior to hospitalization on [DATE]. The facility's Administration of Medications policy, revised December 2012, lacked documentation related to transcription on medications into the computer, the omission of resident's medication including antibiotics, and measures to identify investigate and report medication errors. The policy documented if staff had a concern with a medication, staff would contact the resident's attending physician or the facility's medical director to discuss the concerns. The facility failed to ensure the resident received physician ordered antibiotic therapy timely and consistently to prevent hospitalization for this cognitively impaired, dependent resident with a bacterial infection in his/her left arm.

The facility reported a census of 42 residents with one day care resident. The sample included 3 residents reviewed for abuse. Based on observation, interview, and record review the facility failed to provide an environment free of physical abuse from 1 resident (#1) of the sampled residents when this resident hit resident #8 on 12/16/16 and 12/19/16. This deficient practice placed resident #8, an adult day care resident, in immediate jeopardy. Findings included: - The November 2016 physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. He/she did not exhibit behaviors. He/she required extensive assistance with transfers and supervision with locomotion on the unit. The resident used a wheelchair for mobility. The Quarterly MDS dated [DATE] documented the resident had short term and long term memory problems with a moderately impaired decision making ability. He/she experienced behaviors of wandering 1 to 3 days in 7 days of the assessment. The resident required extensive assistance of 2 staff members with transfers and supervision with locomotion on the unit. The Care Area Assessments (CAAs) dated 2/11/16 for cognition documented the resident had dementia and was forgetful. The CAA for psychosocial well-being documented the resident exhibited frustration easily when staff could not understand him/her. The care plan updated 11/30/16 documented resident #1 propelled himself/herself independently at times. He/she experienced intermittent confusion, became tearful, agitated at times, and hit at others. The care plan directed staff to separate the resident with others when the resident struck out at others and to redirect the resident as needed. The care plan lacked interventions and measures to provide safety for other residents after the incidents on 12/16/16 and 12/19/16. The nurse's note dated 12/17/16 at 5:41 PM revealed a late entry for 12/16/16, resident #1 swatted day care resident (#8), and followed resident #8 down the hallway, and kicked at the back of his/her legs. Both residents were separated and monitored for safety. Review of the clinical record lacked documentation of any further interventions implemented to protect resident #8 and other residents from resident #1's physical behaviors. The record also showed evidence staff completed an investigation of the incident or reported it to the State Survey Agency 3 days later on 12/19/16. The nurse's note dated 12/17/16 at 7:47 PM documented resident #1 roamed in the dining room area and tried to eat food off of other residents' plates and took silverware from other residents. The resident also hid snacks in his/her pants. Review of the clinical record lacked documentation of any interventions implemented to protect the residents from resident #1's physical behaviors in the dining room. The nurse's note dated 12/19/16 at 9:33 AM documented resident #1 smacked resident #8 on the hand and arm, told resident #8 to sit down several times at the dining room table, and staff separated the residents . Review of the clinical record lacked documentation of any further interventions implemented to protect resident #8 and other residents from resident #1's physical behaviors in the dining room. The record also lacked evidence staff completed an investigation of the incident or reported it to the State Survey Agency timely as it was not reported until 3 days later on 12/21/16. The facilities investigation for the incident on 12/16/16, dated 12/19/16, documented interventions to include separate dining areas for resident #1 and #8 and for staff to watch resident #1 closely. The care plan lacked these interventions. The facilities investigation for the incident on 12/19/16, dated 12/21/16, documented interventions to include separate dining areas for resident #1 and #8 (duplicated from the incident on 12/16/16) and to increase one on one activities from staff with resident #1. The Risk of Elopement and Wandering assessment dated [DATE] documented the resident was cognitively impaired with poor decision-making skills, the resident ambulated independently with a wheelchair and he/she wandered aimlessly. The Mood and Behavior assessment dated [DATE] documented the resident exhibited wandering and verbal behavior toward others. The Mood and Behavior assessment dated [DATE] documented the resident did not exhibited any behaviors. Direct care staff Q's Witness Statement dated 12/16/16 revealed resident #1 slapped resident #8's hands and scratched his/her arm, and 45 minutes later resident #1 came behind resident #8 and kicked him/her. A Witness statement from an unnamed staff person dated 12/16/16 revealed resident #1 scratched resident #8's wrist. Direct care staff R's Witness statement, undated, revealed resident #1 told resident #8 to sit down aggressively then slapped resident #8 twice when resident #8 patted the resident on the hand. On 12/21/16 at 4:27 PM, resident #1 sat in his/her wheelchair in the hallway. He/she did not answer when greeted. On 12/21/16 at 12:45 PM, direct care staff O stated resident #1 propelled himself/herself in the wheelchair around the facility and went in other residents' rooms. Staff O also stated the resident was difficult to redirect. On 12/21/16 at 1:01 PM, activity staff X stated resident #1 had mood swings and pushed his/her hands forward at times. Staff X also stated the resident often wandered around and he/she did not do any 1 on 1 activities with the resident. On 12/21/16 at 1:13 PM, direct care staff P stated the resident rejected cares and had confusion. Staff P further stated if he/she saw the resident hit someone, he/she would remove the residents from the situation and report to the charge nurse. On 12/21/16 at 1:25 PM, administrative nursing staff D stated the incidents on 12/16/16 and on 12/19/16 should have been reported to the State Agency within 24 hours. Staff D also acknowledged resident #1 had a history of [REDACTED]. On 12/21/16 at 2:02 PM, direct care staff O stated, that on 12/16/16, resident #1 grabbed resident #8's wrist and left a mark on resident #8. Staff separated the residents at that time but no staff monitored them consistently, forty-five minutes later, resident #1 propelled himself/herself behind resident #8 and kicked resident #8's leg. On 12/19/16, resident #1 and #8 sat at the same dining table, when resident #8 reached out for sugar, resident #1 yelled at resident #8, staff did not separate the residents at that time. Staff O stated he/she was not aware any further interventions to be done for these two residents, and he/she further stated resident #1 would hit anyone that was in front of him/her. On 12/21/16 at 2:44 PM, licensed nursing staff H stated he/she heard resident #1 kicked resident #8's leg under the dining table at breakfast on 12/19/16. Staff H also reported if he/she saw a resident to resident altercation, he/she would report to the administration staff and document the incident. On 12/21/16 at 3:07 PM administrative staff B stated resident #1 and #8 were cognitively impaired. Resident #1 became upset easily and staff should bring him/her to the office when he/she was upset. Resident #1 had a history of [REDACTED]. If other residents upset resident #1 or held his/her hands, resident #1 might hit that resident due to his/her impaired cognition and mood swings. On 12/21/16 at 3:40 PM, licensed nursing staff I stated there was not any type of visual check documentation for resident #1, and nursing staff documented the resident's behaviors only as needed. On 12/22/16 at 8:58 AM, administrative nursing staff D confirmed the care plan should have been updated for resident #1 after the incidents on 12/16/16 and on 12/19/16 with more specific interventions to prevent harm to other residents. Staff D further stated the staff should have placed resident #1 and #8 in different dining areas and provided more monitoring of resident #1. The facility's policy, Preventing Resident Abuse, revised November 2016, documented the facility maintained an abuse-free environment. The facility failed to provide protection for resident #8 from physical abuse from resident #1, which resulted in repeated incidents of physical abuse, on 12/16/16 and on 12/19/16. This deficient practice placed resident #8 in immediate jeopardy. The facility abated the immediate jeopardy on 12/23/16 at 10:00 PM, by initiating the following: Resident #1 was placed on 1:1 supervision with staff until he/she was sent to a behavioral health facility for assessment. The facility revised the Abuse, Neglect, and Exploitation Policy to include interventions to protect residents in an incident involving resident to resident abuse. All staff received in-service on abuse and the revised abuse policy. This deficient practice will remain at a scope and severity of D.

The facility identified a census of 33 residents. Based on observation, interview, and record review, the facility failed to provide supervision for 1 resident (#1, a cognitively impaired independently mobility resident), to prevent the resident from exiting the facility without staff knowledge. This placed resident #1 in immediate jeopardy. Findings included: - Review of the physician admission orders [REDACTED]. Review of a nutritional assessment dated [DATE] documented the resident wore glasses for a visual impairment. The admission Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. The resident exhibited disorganized thinking, inattention, heard with minimal difficulty, had unclear speech, sometimes understood by others, and sometimes not understood others. The resident exhibited unsteady balance when turning around or moving on and off the toilet, and was able to stabilize without assistance from staff and ambulated without an assistive device. The resident required staff supervision and cueing with ambulation. The Care Area Assessments dated 12/16/15 triggered for cognition and falls. During an interview on 12/22/15 at 2:00 P.M., administrative nursing staff E reported the CAA included, the facility newly admitted the resident and he/she had lived with family all his/her life. The resident had dementia, forgetfulness, just smiled, grinned, and did not know his /her family ' s name. The resident triggered for cognition, required frequent reorientation, reassurance, and reminders to help make sense of things. The resident cannot hold any conversation, mumbled, or said okay to questions. The resident walked with staff and a slow steady gait and did not know where his/her room was or his/her way around the facility. The facility assessed the resident as an elopement risk as he/she had a history of [REDACTED]. Review of the resident ' s plan of care dated 11/19/15, directed the resident wandered and may attempt to leave the building unsupervised. Staff performed 30-minute visual checks, and encouraged the resident to attend and participate in activities. The care plan directed staff to assess the circumstances such as needing assurance, wanting something and redirection from exit seeking behavior. Interventions added 12/8/15 included one to one supervision through the night (on 12/7/15) and placed a pressure sensor alarm to notify staff that the resident was standing up. Nursing note dated 12/3/15 at 3:34 P.M. documented the resident with increased confusion, had become very difficult to redirect, decreased appetite and got up from his/her seat at meals and wandered the facility. A facility facsimile to the physician dated 12/3/15, recorded the resident had increased confusion, very difficult to redirect, gained focus on one person, was difficult to redirect him/her, and wandered in the dining room at meals. Nursing note dated 12/4/15 at 10:45 A.M., recorded a return facsimile regarding the resident ' s confusion by the physician extender, and directed the physician would see the resident during rounds the next week. Nursing note dated 12/8/15 at 12:45 A.M. recorded staff observed the resident in the dining room at approximately 6:30 P.M. on 12/7/15. At approximately 7:00 P.M. the facility staff observed the resident was not in his/her room or the surrounding area. After a complete facility search of all rooms, restrooms, beds, exterior surrounding area, locked and unlocked areas, staff drove streets looking for the resident. The facility notified the emergency staff and activated the elopement protocol. On 12/7/15 at 7:54 P.M. administrative staff notified the local law enforcement regarding the missing resident. Local law enforcement advised the facility, the resident was next door in the housing apartments with the apartment manager and police officer. Administrative and nursing staff ambulated the resident back into the facility at approximately 8:00 P.M. Nursing staff assessed the resident without any injury and placed the resident on one to one observation with staff. Maintenance staff changed all the door codes. Review of the facility investigation dated 12/8/15, documented the resident wore overalls, a long-sleeved shirt, socks and shoes, and walked out an open door from the facility into an apartment next door. The unidentified apartment resident notified the housing manager, who then notified the police at 6:39 P.M. According to Wunderground.com, the weather on 12/7/15 at 6:58 P.M. revealed a temperature of 40.1 degrees Fahrenheit, calm, without wind. The Civil twilight (when the sun was 6 degrees below the horizon) occurred at 5:34 P.M., nautical twilight (the horizon was clearly visible, but artificial lighting must be used to see objects clearly, with the sun 12 degrees below the horizon). At 6:07 P.M., astronomical twilight was at 6:39 P.M. with no light in the sky (the sun was a full 18 degrees below the horizon and no visible light observed from the sun). The new elopement risk assessment form, dated 12/8/15, assessed the resident with impaired cognition, [DIAGNOSES REDACTED]. The resident had eloped more than once while at home and left the faciity on ce without informing staff. The resident had verbally expressed the desire to go home, packed his/her belongings to go home, and wandered aimlessly with no goal directed. Risk factors included the resident was a recent admission or readmit within past 30 days, and took medications that could increase restlessness. The resident had a history of [REDACTED]. The resident has a (family/sibling) he/she had lived with his/her whole life, often wandered the facility looking for his/her sibling and taking the dementia medication Aricept. The facility identified the resident at risk for elopement/wandering at this time. A physician progress notes [REDACTED]. The physician recommended a wander risk system (a system with bracelets that set off an alarm when residents wearing one attempt to exit the building without an escort). Nursing note dated 12/9/15 at 1:29 P.M. recorded a physician visit with the recommendation for a facility Wanderguard system. Nursing notes dated 12/9/15 at 6:59 P.M. documented facility staff continued monitoring the resident elopement risks. He/she did not attempt to leave facility this shift, however, wandered in the TV room, dining area, and staff continued constant visual checks and the resident ' s pressure alarm while in a chair. Nursing note dated 12/18/15 at 12:53 A.M. documented the resident continued with baseline dementia and ambulated independently. Observation on 12/22/15 at 10:00 A.M. revealed an unlocked door between the facility long-term care-unit television room into a hallway, with a sign please keep door closed on the side of the door with the locked doors access the kitchen, basement, and housekeeping office, and assisted living. Observation revealed the kitchen lacked an exterior door. The housekeeping office door, across the hall, revealed a locked exterior door to a sidewalk and back parking lot. Upon exiting the building from the housekeeping office door, walking around the building on the paved sidewalk to the paved parking lot, into the street, down to the apartment complex located east of the facility, revealed a distance of approximately 470 feet. Observation revealed no paved sidewalk from the facility to the apartment complex located east of the facility. The community hospital located across the street with a hospital speed zone of approximately 25 miles per hour. Observation on 12/22/15 at 9:00 A.M., revealed the resident sat in a chair with a pressure alarm, inside the lobby area, next to the patio exit door in view of facility staff. Observation on 12/22/15 at 11:50 A.M., direct care staff L ambulated hand in hand with the resident, and lead the resident into the dining room with a slow steady gait. Observation on 12/22/15 at 1:30 P.M. the resident sat quietly with eyes closed in a chair in the lobby with a pressure alarm in the chair. During an interview with the resident, on 12/22/15 at 2:15 P.M. when asked if he/she had taken a nap, the resident only mumbled, said okay, and was unable to hold a conversation. A statement from direct care staff M dated 12/8/15, documented the staff observed the resident in the dining room during the evening medication pass. At approximately 7 P.M. staff noticed, the resident was not in his/her room or the living room, and then searched for the resident inside and outside the building. Direct care staff M searched around the side roads and park in his/her vehicle and checked behind the apartment building with a flashlight, when he/she observed the resident walking with staff from the apartments back to the facility. A statement from direct care staff N dated 12/8/15, documented he/she saw the resident in the dining room at approximately 6:35 P.M. with another resident. At approximately 7 P.M. nursing staff were directed to start searching every room, closet, and bathroom, and the assisted living rooms. During an interview on 12/22/15 8:40 A.M., administrative staff A reported staff and residents last saw the resident at approximately 6:30 P.M. Interviewable residents at his/her table in the dining room reported they last saw the resident at 6:30 P.M. when he/she left the dining room and went toward the television room. The housekeeping office door was open with hoses running across the floor from the parking lot, for the hood cleaning crew, then across the hallway into the kitchen. The facility staff surmised the resident went out the housekeeping door, around the building on the sidewalk to the parking lot and down to the apartment housing. A tenant, called the apartment manager that a (gender) walked into his/her apartment. The tenant made that phone call at 6:39 P.M. The apartment manager called the police, but not the facility. The resident walked independently. The facility staff and residents interviewed heard no alarms. During an interview on 12/22/15 at 11:25 A.M. alert and interviewable resident #7 reported resident #1 sat at the same table for the evening meal and on 12/7/15, he/she got up and left the dining room about 6:25 P.M. and did not hear any door alarms sound after that. He/she revealed, resident #1 talked about going home all the time. On 12/22/15 at 11:28 A.M. alert and interviewable resident #6 revealed resident #1 sat at the same dining room table for meals. Resident #6 reported on 12/7/15, he/she left the dining room at approx. 6:30 P.M. Resident #6 revealed he/she and resident #1 got up from the same dining room table at approximately the same time and walked in the opposite direction. Resident #1 walked toward the television room. Resident #6 reported he/she did not hear any door alarms sound after getting up from the table. On 12/22/15 at 10:00 A.M., housekeeping/maintenance supervisor U reported he/she was here to assist with the kitchen vent hood cleaning when he/she came into the building on the evening of 12/7/15. The kitchen had no door to the exterior and the service company, for the kitchen vent hood, had to prop open the housekeeping office door across the hallway to run the big hoses into the kitchen from the parking lot in back of the building. Housekeeping/maintenance supervisor U revealed the nursing staff notified him/her a resident was missing. He/she checked all the doors, found them working with door alarms working correctly, and then changed all the door codes. Review of a statement from a contracted service worker, dated 12/8/15, documented he/she was working on the back service door on 12/7/15 at approximately 7:00 P.M. to 8:00 P.M. and did not see any one leave the building. On 12/22/15 at 11:13 A.M., licensed nursing staff G revealed on 12/7/15 at approx. 6:00 P.M., the resident sat at a dining room table eating with other residents. At approximately 7 P.M. the resident was not in his/her room and nursing staff implemented the elopement procedure. Staff searched inside the facility and the exterior surroundings. No alarms activated to alert staff of the resident ' s exit. The resident had been here approximately one month. He/she had not tried to leave and did not go toward doors, unless he had his/her coat and hat. The resident would tell you he/she was leaving and wanted to go back with his/her sibling. The resident walked around the common areas, and could not find his/her room without staff assistance. On 12/22/15 11:35 A.M., direct care staff O reported the resident was on 30 minute checks before his/her elopement on 12/7/15. The resident had gone to the doors and tried to punch the buttons, but could not push the correct code, and had been talking about going home. The resident was dressed for going outside, but did not have a coat on. Direct care staff O reported he/she did not hear a door alarm the evening of 12/7/15. Direct care staff O revealed he/she checked the shower room, resident rooms, got a flashlight and went around the building, in the field behind the hospital. He/she went into the hospital, described the resident, and asked if they had seen him/her. On 12/22/15 at 11:00 A.M. licensed nursing staff H revealed the direct care staff chart resident location on 30-minute checks. The direct care staff alerted the nurse if they cannot find a resident. Licensed nursing staff H reported the resident was on 30-minute checks. During an interview on 12/22/15 at 11:05 A.M., direct care staff L revealed the resident needed assistance with dressing and his/her (family/sibling) visits often. The resident became upset and wanted to leave when his/her (family/sibling) left. The resident now had a pressure pad alarm to alert staff when he/she gets up from the chair. On 12/22/15 at 11:10 A.M., direct care staff P reported the resident had dementia and cried when his/her (family/sibling) left from a visit. On 12/22/15 at 12:28 P.M. direct care staff Q reported the resident the resident was steady on his/her feet and did not know where his/her room was. During an interview on 12/22/15 at 2:20 P.M. administrative staff A revealed the door between the television room and the hallway was propped open earlier during the day on 12/7/15. Administrative staff A was unsure when the sign Please, keep the door closed , was on the access door. Administrative staff A revealed the facility reassessed all the residents after the elopement event and identified two residents were at risk for elopement. On 12/22/15 at 4:50 P.M. direct care staff R reported the resident gets up to walk and looks for his/her (sibling/family). The facility recently provided inservices on elopements and door alarm procedures. The facility failed to provide supervision and assistive devices for this cognitively impaired independently mobile resident identified as an elopement risk, from leaving the facility without staff knowledge of the elopement or the resident ' s location that placed the resident in immediate jeopardy for injury or harm. The facility corrected the immediate jeopardy on 12/12/15 when: 1) Face-to-face education was provided to all staff regarding all egress doors in the facility, how the alarms worked, and what to do when an alarm was sounding. The facility started education immediately following the incident and completed on December 12, 2015. 2) Staff assessed the resident immediately upon return to the facility. 3) Staff stayed one on one with this resident until staff implemented a pressure alarm pad the following morning. 4) All doors/alarms were checked immediately and found to be in working order. 5) Maintenance supervisor changed door codes immediately. 6) Staff assessed/reassessed all residents for elopement risk. 7) The director of Nursing or Designee would monitor to ensure all residents admitted were assessed for elopement risk. Administrator or Designee would monitor on a weekly basis for eight weeks in the Risk program to trend monthly in the QA Committee Meeting to ensure substantial compliance. 8) The facility implanted the policy Maintenance Service, that directed, maintenance service would be provided to all areas of the building, grounds, equipment while maintaining a safe environment for all concerned. Maintenance personnel would follow established safety regulations to ensure the safety and well-being of all concerned. If it was necessary to keep doors open for service men to perform needed maintenance, someone was assigned to monitor the door continuously until maintenance was completed, to ensure no residents leave the building. Surveyor: Melander, Diana

The facility identified a census of 34 residents. The sample included 3 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices to 1 sampled resident (#2) a cognitively impaired dependent resident, which experienced a preventable fall that resulted in emergency room treatment for [REDACTED]. Findings included: - The undated electronic face sheet recorded resident #2 had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for cognition dated 3/3/15, documented the resident was unable to complete an interview, alert with no verbal response, but does track with his/her eye movement. The staff interview for mental status indicated the resident had both short- and long-term memory deficits, was rarely verbal, required assistance with decision-making, and staff reported the resident appeared to understand what was said at times. The CAAs for falls dated 3/3/15, documented the resident was at risk for falls related to utilization of a sling with a mechanical lift during transfers. The resident required assistance of two staff members for all transfers and did not stand or ambulate. The fall risk assessment indicated resident risk factors as memory deficits, total incontinence of both bowel and bladder, confined to a chair, and disorientation. The quarterly Minimum Data Set Assessment ((MDS) dated [DATE] recorded the resident never understood, knew names and faces of staff, and had severely impaired decision-making. The resident required total assistance of two staff member for all activities of daily living (ADLs) except for one staff with eating. The resident had loss of functional range of motion to both arms and legs, and was always incontinent of bowel and bladder. The fall risk assessment dated [DATE] documented the resident with a total score of (13) which indicated placed the resident was at moderate risk for falls. The transfer/lift/lift-chair assessment dated [DATE], documented the resident was unable to stand or bear weight on both legs, had a history of [REDACTED]. The plan of care for activities of daily living dated 8/25/15 documented the resident with weakness in his/her extremities, contractures in both knees, required assistance of two staff to provide incontinence care, and a full body lift for all transfers. The plan of care for falls dated 8/25/15 directed staff: a) keep the bed in low position when occupied, b) place a mat on the floor beside the bed, c) utilize a sling lift for all transfers, d) position in the Geri-char for safety, e) utilize bolsters on the MA65 mattress (alternating pressure air mattress) to help identify the edge of the bed, and f) utilize body pillows for positioning. Additional interventions added on 10/10/15 directed when rolling the resident side to side in bed for changing incontinence brief with two staff, one staff held onto the resident so he/she was secure in position in bed. Keep the Philadelphia neck collar on the resident at all times and keep forehead laceration with staples clean and dry, with application of antibiotic ointment. Review of a fall note dated 10/9/15 timed 8:26 P.M. documented direct care staff rolled the resident side to side in bed to provide incontinence care. Direct care staff turned to throw an incontinence brief in the trash and the resident fell on to the floor from the top of the mattress, approximately four feet above the floor. The staff assessed the resident with facial grimacing, moaning, and an actively bleeding laceration to the top of his/her head. The staff obtained physician orders [REDACTED]. Nursing note dated 10/10/15 timed 4:33 A.M., documented the resident returned from the hospital emergency room in his/her Geri-chair (a large padded reclinable chair with a wheeled base, designed to assist residents with limited mobility comfort). The resident wore a Philadelphia collar (a neck braced used to which is used to immobilize the head and neck after a cervical fracture) and had 10 staples to the laceration on his/her forehead. Nursing note dated 10/11/15 at 6:43 P.M. recorded the resident continued to wear the cervical (neck) collar, and required a full mechanical lift for transfers. Nursing note dated 10/12/15 at 11:14 A.M. documented the resident had difficulty swallowing due to positioning of his/her head, secondary to hard neck collar. Observation in the dining room on 10/20/15 at 12:28 P.M. revealed the resident wore a cervical neck brace reclined in a Geri-chair with his/her legs pulled up and stiffly bent. Observation of incontinence cares on 10/20/15 at 4:00 P.M. revealed the resident laid on his/her right side, bent knees, arms and legs without active movement (range of motion), on an air mattress with side bolsters, and cushioned fall mat on 1 side of the bed. Direct care staff P and M raised the bed to waist height and performed incontinence care. The resident could not separate his/her knees for care and was unable to lie flat on the bed. Observation revealed the non-verbal resident had approximately 10 surgical staples to his/her upper left forehead with dried blood present. A statement by direct care staff M dated 10/12/15 recorded direct care staff M and Q provided incontinence care to the resident on 10/9/15 with the bed raised. When direct care staff Q turned to dispose of an incontinence brief in the trash, direct care staff M stepped away from the resident and bed, and went to the closet, when the resident ' s bed mattress shifted and he/she fell off the bed onto the floor. On 10/20/15 at 1:44 P.M., direct care staff N reported the resident did not move him/herself and required full care from staff for activities of daily living. During an interview on 10/20/15 at 1:45 P.M. direct care staff M reported two staff provided care for the resident to turn and reposition at all times and the resident did not move or turn him/herself. On 10/20/15 at 2:50 P.M., licensed nursing staff G reported the resident required two staff for all activities of daily living and cares. The resident wore a neck immobilizer, his/her legs and knees were very contracted, and his/her bed contained an air mattress. On 10/20/15 at 3:02 P.M. administrative nursing staff D reported staff made an error during cares that allowed the resident to fall. On 10/27/15 at 10:10 A.M., an interview with direct care staff Q revealed on 10/9/15 at approximately 4:30 P.M. direct care staff Q and M provided incontinence care to the resident. Direct care staff Q reported direct care staff M held onto the resident when he/she provided cares. Direct care staff Q turned to dispose of an incontinence brief, and when he/she turned back around, direct care staff M had stepped away from the resident, the resident fell from the mattress, slid down his/her thigh to the floor from the mattress and cut his/her forehead. The facility lacked a policy to direct staff in safe turning and positioning dependent residents. The facility provided an education checklist for repositioning in bed, lacked direction for staff for safe positioning and turning dependent residents on air mattresses to prevent falls. The facility failed to provide supervision to a severely cognitively impaired totally dependent resident, which allowed the resident to fall from a height of approximately 4 feet (from the bed to the floor), that resulted in treatment at an emergency room . The dependent resident experienced a head laceration that required 10 staples and cervical spine fracture.