Every finding on record at Legacy at Salina

Based on observation, record review, and interview, the facility failed to provide a safe, functional environment for residents, staff, and the public when the facility failed to ensure the sidewalks were as free from trip hazards as possible and/or failed to flag or post alert for the trip hazards while awaiting repair. Findings included:- On 06/29/2026 at 08:30 AM, observation revealed the front entrance sidewalk that leads from the street curb parking to the front sidewalk had a crack that extended from one side of the sidewalk to the other side, approximately three foot long with a one inch open area that appeared to have been filled, but had settled, and the open area still remained uneven. Continued observation revealed the front sidewalk approximately 18 feet from the sidewalk that leads to the front door had a three foot long by two-inch-wide gap in the sidewalk that had a concrete patched with an elevated area, causing an uneven walking surface on the sidewalk. Proceeding from there towards the entrance to the facility, another area approximately three feet from the first patched area, measuring three foot long by two-inch-wide gap in the sidewalk had a concrete patch area that elevated, causing an uneven walking surface area on the sidewalk. On 06/29/2026 at 09:00 AM, Maintenance Staff U verified the cracks in the sidewalk and stated he had identified the concern about a week before the visitor fell on [DATE]. Maintenance Staff U stated he had filled the cracks with concrete, but the concrete had settled. Maintenance Staff U verified the facility had obtained bids to replace the sidewalk but was waiting on corporate management to approve the work. On 06/29/2026 at 01:00 M, Administrative Staff A confirmed that the areas of the sidewalk had gaps and changes in height. Administrative Staff A verified a visitor fell related to the cracked sidewalk on 05/01/2026 and sustained an abrasion to their forehead and nose. The visitor was transported to the hospital by emergency medical services and had an examination including X-rays, which verified she did not sustain any further injuries. Administrative Staff A verified Maintenance Staff U had identified the sidewalk gaps in April 2026 and purchased a filler for the gaps at a local hardware store but that did not repair the concern as the material settled into the cracks but did not fill them. Administrative Staff A verified after the visitor fell, Maintenance Staff U filled the gaps and cracks with concrete to even out the uneven surface. Administrative Staff A verified the facility had received a bid to have the sidewalks replaced one week before the visitor fell and had submitted the bid to corporate and was awaiting approval to start the replacement of the sidewalks. Administrative Staff A stated the facility had only one incident of a visitor that had fallen due to a crack in the sidewalk in the first part of May. The facility's Resident Environmental Quality policy, undated, documented it was the policy of the facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The policy documented preventive maintenance schedules, for the maintenance of the building and equipment should be followed to maintain a safe environment.

The facility had a census of 39 residents, with three residents sampled for falls. Based on observation, interview, and record review, the facility failed to ensure staff implemented fall prevention interventions to prevent a fall for Resident (R) 1. On 10/16/25, a Certified Nurse Aide (CNA) rolled R1 to her side in bed, and R1 fell out of bed onto the floor. On 10/17/25, after emergency transport for evaluation of R1's complaints of pain, an X-ray revealed R1 had a right femoral neck (top of the thigh bone) fracture (broken bone), which required surgical repair. Findings included: - R1's Electronic Medical Record included diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) and a closed fracture of the right distal femur (thigh bone).R1's Quarterly Minimum Data Set dated 10/03/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R1 was dependent on staff for most activities of daily living, including bed mobility. R1's Care Plan dated 10/03/23 directed staff to provide two staff assistance with bed mobility, dressing, and transfers. The 04/04/25 update noted a specialty mattress was on R1's bed. The 10/16/25 update directed staff to ensure a perimeter-defined mattress was on her bed. The Fall Risk Assessment dated 08/28/25 documented R1 had no falls, was alert and oriented, and chairbound. The fall risk score was less than 10, indicating a low risk for falls. The facility investigation regarding R1's 10/16/25 fall documented R1 was in bed when Certified Nurse Aide (CNA) M assisted R1 with dressing at 03:30 PM. The investigation noted R1 held the positioning rail while CNA M rolled R1 away from her, to adjust the back of the resident's dress, and R1 rolled out of bed onto the floor. The staff observed R1 on the floor with her legs partially folded under her, R1 was crying and displayed signs of anxiety. Licensed Nurse (LN) G performed a full assessment with no abnormalities noted, no signs of increased pain noted, and documented normal range of motion (ROM) for R1. Staff assisted R1 back to bed with the total mechanical lift and three staff assistance. R1 complained of some pain when the staff removed the lift sling. LN G called the physician requesting X-ray orders. R1 requested to get back in her wheelchair, staff repositioned her and administered pain medication per her request. At that time, staff noted R1 was comfortable with no signs of distress. On 10/17/25 staff called for emergency services transport to obtain an X-ray, which noted a partially impacted right femoral neck fracture (a break in the neck of the thigh bone where the broken ends are jammed together but not fully displaced). R1 admitted to the hospital for surgical repair of the fracture.The Progress Note dated 10/16/25 at 04:20 PM documented the nurse performed a head-to-toe assessment of R1 and no tenderness noted to R1's upper torso. R1 was seated against her bed. Two CNAs and a LN positioned R1 on the total lift sling and used the total lift to transfer R1 to her bed. The LN documented R1's lower extremity ROM was normal for the resident, but R1 complained of right hip pain. The LN assessed R1's ROM and documented no bruising, no redness, and no pain. The Staff repositioned R1 in bed, and then R1 insisted on being in her wheelchair. The nurse obtained vital signs and administered pain medication.The Progress Note dated 10/16/25 at 08:31 PM documented R1 cried earlier in the shift due to pain in her right leg, and the nurse had administered pain medication.The late entry Progress Note dated 10/16/25 at 10:14 PM documented R1 told staff all about her fall. R1 rated her pain at a five out of 10 on the pain scale. The nurse documented no visible injuries and noted the resident was in a low bed, a CNA assisted the nurse with pulling R1 up in bed, and the resident tolerated it well.The Progress Note dated 10/17/25 at 01:23 AM documented R1 had ROM deficits. The LN assessed and attempted ROM, but R1 could not move her legs on her own. R1 said it was painful, but did not yell out or seem in any increased distress than her normal demeanor. R1's legs appeared the same length, and R1 assisted the staff with turning.The Progress Note dated 10/17/25 at 09:16 AM documented the nurse called the physician's office due to R1's increased tearful episodes and complaints of pain related to her 10/16/25 fall. The physician ordered the staff to send R1 to the emergency room for evaluation and treatment for right leg pain.On 10/27/25 at 09:30 AM, R1's bed had a perimeter mattress; however, R1 was not in the building for observation.On 10/27/25 at 09:30 AM, LN H stated the previous mattress on R1's bed before the fall was a plain air mattress.On 10/27/25 at 10:45 AM, LN G stated she was on the telephone when R1 fell out of bed on 10/16/25. LN G said she saw the resident seated on the floor, by her bed, with her legs straight out, and a CNA at her back helping her sit. The resident held onto the bed cane rail on that side of the bed. She verified two staff were to provide cares for R1 and said R1 had an air mattress. She verified the CNA should not have rolled the resident without the assistance of another staff person.On 10/27/25 at 11:11 AM, CNA M stated she did not know R1 required two staff assistance for dressing, but she knew R1 required two staff assistance for transfers. CNA M stated she used the walkie to request assistance to get R1 up and transferred to her wheelchair. CNA M stated all the other staff replied they were busy in other rooms so she thought she could start providing activities of daily living (ADL) cares to R1, such as dressing, while she waited for help. CNA M stated when she finished dressing the resident, she told the resident she was going to roll her over to her side to pull her dress down and place a lift sling under her. R1 grabbed the cane rail and assisted (rolling to her side), but R1 pulled on the rail too much, and when rolled, she slid out of her bed. CNA M said R1 had an air mattress at that time, and R1 was still holding onto the rail when she sat on the floor (after falling out of the bed). CNA M said the other staff came into the room, and the nurses assessed the resident before we transferred her back to bed.On 10/27/25 at 08:22 AM, Administrative Nurse D stated R1 was still in the hospital due to a fractured femur. Administrative Nurse D stated the facility educated CNA M post fall, and with a separate in-service on 10/17/25. On 10/27/25 at 09:35 AM, Administrative Staff A stated CNA M had an in-service regarding falls on 08/23/25, as part of her orientation to the facility. On 10/27/25 at 09:40 AM, Administrative Nurse D stated R1's mattress was a plain air mattress prior to the fall, but post-fall the facility added a concave mattress. Administrative Nurse D stated before the fall, R1 required two staff members for most ADL. Administrative Nurse D verified CNA M was the only staff in R1's room at the time of the fall, and verified CNA M had not followed the care plan. The facility's Fall Prevention Program dated 12/23/21 stated all staff were to be aware of fall interventions for residents and know the residents who were at risk for falls. The facility identified, implemented, and completed the following corrective actions by 10/17/25:1. The facility placed a perimeter mattress on R1's bed on 10/16/25. 2. All nursing staff attended or completed an in-service for the transfer of residents on 10/17/25.The facility completed corrective actions by 10/17/25, prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance, at the scope and severity of a G (isolated, actual harm).

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 41 residents who reside in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.Findings included:- On 09/08/25 at 12:00 PM, observation of the noon meal consisted of ham, scallop potatoes, peas, and fruit salad. Dietary Staff (DS) BB was observed overseeing the preparation of the noon meal. DS BB would also assist staff with taking meal trays to the residents.On 09/09/25 at 11:30 AM, DS BB verified she was not certified but had passed the course and just needed to take the test. DS BB further stated she had many years in the food service industry. On 09/10/25 at 01:00 PM, Administrative Nurse D stated DS BB had taken her course, but there was a waiting period before she could take the test.The facility's Dietician policy, dated 10/17, documented that a food and nutrition services manager would oversee the production, storage, and delivery of food and would work closely with the dietician.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to measure and record daily refrigerator and freezer temperatures for the evening shift. This placed the residents at risk for food-borne illnesses.Findings included:- On 09/08/25 at 08:00 AM, during the initial kitchen tour, the daily temperature logs for the large silver refrigerator and freezer lacked documentation. Temperatures were not taken during the following days on the evening shift:09/01/2509/03/2509/06/25On 09/08/25 at 08:00 AM, during the initial kitchen tour, the daily temperature logs for the small silver stand-alone refrigerator were not taken during the following days on the evening shift:09/01/2509/03/25On 09/08/25 at 08:00 AM, during the initial kitchen tour, the daily temperature logs for the tan refrigerator lacked documentation; temperatures were not taken during the following days on the evening shift:09/01/2509/03/25On 09/08/25 at 08:45 AM, Dietary BB verified the lack of documentation and stated the temperatures were to be taken as directed.The facility's Refrigerator and Freezer policy, dated 10/14, documented the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and would observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures. The monthly tracking sheets would include the time, temperature, initials, and actions taken. The food service supervisor or designated employees would check and record the refrigerator and freezer temperatures daily upon opening and at closing in the evening.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to post signage for six of seven residents regarding the use of enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact cares) to ensure staff were aware. This deficient practice placed all residents of the facility at risk for the spread of infections. The facility also failed to ensure staff changed gloves properly during incontinence care for Resident (R) 44, placing the resident at risk for infection. Findings included: - On 09/09/25 at 09:15 AM, observation in six of seven facility identified resident rooms where EBP protocol was to be followed; no EBP signage was found in the room or on the doorway. On 09/08/25 at 11:10 AM, Administrative Nurse D verified the lack of EBP signage for residents with EBP precautions and stated there should be signage. The facility's Enhanced Barrier Precautions policy, dated 03/25/24, stated signs would be posted indicating the resident required EBP, and personal protective equipment was available. - The Electronic Medical Record (EMR) for R44 documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), malignant neoplasm (tumor) of the upper lobe, right bronchus or lung, secondary malignant neoplasm (tumor) of the brain, hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two. The admission Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition. R44 was dependent upon staff for toileting hygiene, dressing, and transfers. The MDS further documented R44 had a catheter. R44's Care Plan, dated 08/28/25, directed staff to assess the catheter every quarter, and as needed, to assess the need for the catheter, change the catheter as needed, and encourage additional fluids. The care plan further directed staff to monitor and document intake and output as per facility policy, notify the physician of any signs of infection, and provide catheter care per facility policy. The EMR lacked documentation. R44 had an order for the Foley catheter, and the documentation staff monitored intake and output. On 09/09/25 at 02:00 PM, R44 had a catheter, and the drainage bag had a small amount of amber (dark yellow) colored urine. Certified Nurse Aide (CNA) M and CNA P donned gowns and gloves and used a full-body mechanical lift to put R44 into bed. Once in bed, CNA M had R44 roll to her right side and back onto her back so she could remove her pants to do catheter care. CNA M removed R44's incontinence brief, took an incontinence wipe, and provided catheter care. R44 asked CNA M if she had a bowel movement (BM), and CNA M stated she was not sure, but she was not done with care. CNA M removed her gloves and donned a clean pair. CNA M assisted R44 to her right side and began to provide personal care. R44 had started to have a BM, and CNA M provided care and put a clean incontinence brief on her. CNA M did not remove her soiled gloves, CNA M and CNA P put R44's pants back on, and adjusted R44's clothing with the soiled gloves still on. CNA M stated she should have removed the soiled gloves before she put on the clean brief and clothing. On 09/08/25 at 01:45 PM, Licensed Nurse (LN) G stated CNA M should have removed the soiled gloves. On 09/10/25 at 01:00 PM, Administrative Nurse D stated she expected staff to follow facility protocol after providing care. The facility's Personal Protective Equipment-Gloves policy, dated 07/09, documented that gloves must be worn when handling blood, body fluids, secretions, excretions, mucus membranes/ and/or no intact skin. The use of gloves varies according to the procedure involved. The policy further directed staff to wash their hands after they remove their gloves.

The facility had a census of 41 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) 4's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R4 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.Findings included:- R4's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R4's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R4 had severely impaired cognition. The MDS recorded R4 required limited assistance with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period.The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/14/25, recorded R4 received antipsychotic medication.R4's Care Plan dated 08/14/25 recorded R4 received antipsychotic medication for the diagnosis of irritability and anger/physical aggression. The care plan documented the facility would administer antipsychotic medications as ordered by the physician, and staff would monitor for side effects and effectiveness every shift and consult with the pharmacist to consider dose reduction when clinically appropriate.The Physician's Order initial order date 08/01/25 directed the staff to administer Seroquel (antipsychotic medication) 25 milligrams (mg), 25 mg three times a day for diagnoses of irritability and anger.R4's EMR lacked a documented physician rationale, which included unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits statement for the Seroquel use.On 09/09/25 at 09:33 AM, observation revealed R4 was standing in her room and changing her clothes. Continued observation revealed Licensed Nurse (LN) H administered the residents' morning medications, which included Seroquel 25 mg. On 09/09/25 at 02:30 PM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of irritability and anger. Administrative Nurse D verified that the pharmacist had identified the inaccurate diagnosis of the Seroquel, and the facility had been working with the physician to get the appropriate diagnoses for the residents on antipsychotic medications. The facility's Medication Management policy, dated July 2022, recorded that the residents would not receive medications that were not clinically indicated to treat a specific condition. Antipsychotic medication would be prescribed at the lowest possible dosage for the shortest amount of time and were subject to gradual dose reduction and review. The residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff would gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risk to the resident and others. The attending physician would identify, evaluate, and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Residents who were admitted from the community or transferred from a hospital and who were already receiving antipsychotic medications would be evaluated for the appropriateness and indications for use. The interdisciplinary team would complete PASARR (preadmission screening for mentally ill and intellectually disabled individuals,) if appropriate: re-evaluate the use of 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, based on assessment of the resident's symptoms and overall situation, the physician would determine whether to continue, adjust, or stop the existing antipsychotic medication. Antipsychotic medication would generally be used for the following conditions/diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statical Manual of Mental Disorders: Schizophrenia, Schizoaffective disorder, Schizophreniform disorder, Delusional disorder, Mood disorder (bipolar disorder, depression with psychotic features, and treatment refractory major depression), Psychosis in the absence of dementia, Mental illnesses with psychotic symptoms and/or treatment-related psychosis or mania, Tourette's Disorder, Huntington's Disease, Hiccups not induced by other medications or Nausea and vomiting associated with cancer or chemotherapy. Residents and/or representatives would be informed of the recommendations, risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use. The staff would observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications.

The facility had a census of 41 residents. The sample included 12 residents, with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to report to the state agency the allegation of abuse and neglect when R4 slapped another resident. This placed the residents at risk for ongoing abuse and/or mistreatment. Findings included: - R4's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R4's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R4 had severely impaired cognition. The MDS recorded R4 required limited assistance with most activities of daily living (ADL). The MDS recorded R4 received antipsychotic medication during the observation period and had a wander guard/elopement alarm that was used daily.The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 05/14/25, recorded R4 was alert to self with confusion noted.The Behavioral CAA, dated 05/14/25, recorded R4 had been noted to wander during the look back period, had a wander guard for safety, and staff would redirect as she tolerated. R4's Care Plan, dated 08/14/25, recorded R4 received antipsychotic medication for the diagnosis of irritability and anger/physical aggression. The care plan documented R4 had the potential to be physically/verbally aggressive, as evidenced by R4 hitting, kicking, biting, and spitting on other residents, screaming out, and using profanities. The care plan directed staff to administer medications as ordered, use interventions before agitation escalates, guide her away from the source of distress, engage calmly in conversation, request a psychiatric evaluation, remind R4 to verbalize knowledge of angry, physically aggressive behaviors, and discuss alternatives to those behaviors. If the resident's response was aggressive, staff were to walk calmly away and approach R4 later, making sure the other residents were safe.The 04/20/25 at 05:14 PM, Nurse's Notes, documented another unidentified resident wandered into R4's room, loud yelling was heard, and the other unidentified resident walked out of the room holding her face. The unidentified resident agreed R4 hit her in the face, and she was removed from R4's room. The note documented all parties were safe at the time. The 04/21/25 at 01:00 PM, Nurses Notes, documented the interdisciplinary team met to discuss the incident, and it was determined the intervention was adequate at this time.The 04/21/25 at 11:38 PM, Nurses Notes, documented the resident had kept to herself, and there were no reports or observations of any resident contact. R4 was at the nurse's station numerous times, joking and laughing. Review of R4's EHR lacked evidence the investigation, including witness statements, was reported to state. Upon request, the facility was unable to provide the investigation related to the event that was sent to the state.On 09/09/25 at 09:33 AM, observation revealed R4 was standing in her room and changing her clothes. Continued observation revealed Licensed Nurse (LN) H administered the residents' morning medications, which included Seroquel (antipsychotic medication) 25 mg. On 09/09/25 at 02:00 PM, Administrative Nurse D stated she was not employed by the facility on the date the incident occurred and was unable to find if the information was sent to the state. Administrative Nurse D said the facility did conduct an investigation, and it was documented in the nurse's notes that the interdisciplinary team met and documented the incident with interventions.On 09/09/25 at 02:30 PM, Administrative Staff A verified the facility had not reported to the State agency when the incident occurred.The facility's Abuse Prevention, Identification, Investigation and Reporting policy, dated 07/08/24, recorded that 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 not required to treat the resident's medical symptoms. 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. The risk for abuse may increase when a resident exhibits behavior(s) that may provoke a reaction by staff, residents, or others, such as: verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating, physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects, sexually aggressive behaviors such as saying sexual things, inappropriate touching/grabbing, talking, touching, or rummaging through others' property, wandering into others' rooms/space, and resistive to cares and services. An example of injuries that could indicate abuse included, but were not limited to, injuries that were non-accidental or unexplained, such as bruises, bite marks, scratches, skin tears, and lacerations with or without bleeding, including those that are in locations that would unlikely result from an accident. The policy documented that all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation should be reported immediately to the Administrator. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation shall be reported to the appropriate state entity not later than two hours after the allegation is made, if the events that cause the allegation involved neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation, but do not result in serious bodily injury. If there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility. The Elder Justice Act requires the matter must also be reported to law enforcement. The state entities are to be notified of a resident-to-resident physical contact that occurs. Which includes but is not limited to where residents are hit, slapped, pinched, or kicked and result in physical harm, pain, or mental anguish, is considered resident-to-resident abuse.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to promote an environment free of hazards for Resident (R) 7, who smoked cigarettes but was not assessed timely for safe smoking practices by the facility, and kept his smoking materials in his nightstand beside his bed. This placed the resident at risk for avoidable injuries and fire-related hazards.Findings included:- R7's Electronic Medical Record recorded 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), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), unsteady gait, and weakness.R7's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R7 used a wheelchair and was dependent on staff for toilet hygiene and personal hygiene. The MDS documented the resident required substantial to maximal assistance to shower/bathe self, sit to stand transfers, and chair to bed transfers. R7's Fall Care Area Assessment (CAA), dated 04/17/25, documented R7 was at risk for falls and utilized a wheelchair for mobility. The CAA documented R7's balance was unsteady, and he was diagnosed with a stroke with deficits, and had a grab bar on the upper portion of his bed to aid in independence with bed mobility.R7's Activities of Daily Living (ADL) Care Plan, dated 09/05/25, directed staff to assist the resident to use a wheelchair and he could self-propel short distances, with staff to propel long distances. The care plan recorded R7 required assistance with ADLs due to impaired balance during transitions.R7's Smoking Care Plan, dated 09/05/25, documented R7 preferred to smoke and did not want a smoking cessation program. The care plan stated the facility would complete a smoking assessment quarterly and as needed, and make sure the facility's smoking policy would be followed correctly to ensure R7 and others' safety. The care plan stated the resident could smoke in a designated smoking area. Staff would report any incidents of smoking and/or non-compliance with the smoking policy to Social Services, the Director of Nursing, or the Administrator. The Smoking Safety Screen dated 11/25/24, documented R7 required assistance to get to and from the smoking area, but could light his cigarettes and put them out without assistance. The assessment documented that the resident smoked 2-5 times a day and could light his own cigarettes. He was safe to smoke without supervision. R7's clinical record lacked evidence the facility had recently assessed R7 for safe smoking practices, including safe storage of smoking materials. On 09/10/25 at 12:45 PM, observation revealed R7 lying in bed on his right side with his eyes closed. On 09/08/25 at 04:00 PM, Social Service (SSD) X stated R7 smoked with staff and kept his cigarettes in a nightstand in a locked box with a key he kept on a necklace around his neck. SSD X verified the resident also had two packages of cigarettes in his nightstand that were not locked up. On 09/09/25 at 09:20 AM, Administrative Nurse D verified R7 did smoke with staff to assist him and verified the last smoking assessment the facility had completed was on 11/24/25, and the facility was to complete quarterly assessments and as-needed assessments. Administrative Nurse D verified the resident was not to keep his smoking materials in his room and was unaware he had the cigarettes and lighter in a locked box in the room.The Tobacco policy, dated 09/21/23, documented the facility would establish and maintain safe resident tobacco/smoking/electronic cigarettes, vape use practices. All persons coming onto the facility property and/or buildings would comply with this policy. When the resident requested to smoke, they would be evaluated for safe smoking upon admission and quarterly. Any tobacco use/smoking-related privileges, restrictions, and concerns shall be noted in the care plan, and all persons caring for the resident shall be alerted to these issues. The facility may impose tobacco use/smoking/electronic cigarettes/vape restrictions at any time if it is determined that the resident cannot do so safely with the available levels of support and supervision. Tobacco/smoking, including electronic cigarette/vape materials, for all residents will be secured by the facility when not in use. Tobacco/smoking areas would be designated by the facility and identified by signage. Any resident with restricted tobacco use/smoking/electronic cigarette/vape privileges requiring monitoring shall have direct supervision by a staff member, family member, visitor, or volunteer, always while using tobacco/smoking.

The facility had a census of 41 residents. The sample consisted of 12 residents, with two reviewed for urinary catheters (tubes inserted into the bladder to drain urine into a collection bag). Based on observations, record review, and interview, the facility failed to obtain an order for the urinary catheter for one resident, Resident (R) 44, and failed to monitor urinary catheter output for R44 and R35. This placed the residents at risk for catheter-related complications. Findings included:- The Electronic Medical Record (EMR) for R44 documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), malignant neoplasm (tumor) of the upper lobe, right bronchus or lung, secondary malignant neoplasm (tumor) of the brain, hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two. The admission Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition. R44 was dependent upon staff for toileting hygiene, dressing, and transfers. The MDS further documented R44 had a catheter. The Urinary Catheter Care Area Assessment (CAA), dated 09/01/25, documented R44 had a diagnosis of urinary retention. R44 had an indwelling Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) for bladder elimination. R44 was to have catheter care done every shift, and input and output monitored per the facility protocol. R44 was dependent upon staff for toileting hygiene tasks. R44's Care Plan, dated 08/28/25, directed staff to assess the catheter every quarter, and as needed, to assess the need for the catheter, change the catheter as needed, and encourage additional fluids. The care plan further directed staff to monitor and document intake and output as per facility policy, notify the physician of any signs of infection, and provide catheter care per facility policy. The EMR lacked documentation R44 had an order for the Foley catheter, or documentation staff monitored intake and output. On 09/09/25 at 02:00 PM, R44 had a catheter, and the drainage bag had a small amount of amber (dark yellow) colored urine. Certified Nurse Aide (CNA) M and CNA P donned gowns and gloves and used a full-body mechanical lift to put R44 into bed. Once in bed, CNA M had R44 roll to her right side and back onto her back so she could remove her pants to do catheter care. CNA M removed R44's incontinence brief, took an incontinence wipe, and provided catheter care. R44 asked CNA M if she had a bowel movement (BM), and CNA M stated she was not sure, but she was not done with care. CNA M removed her gloves and donned a clean pair. CNA M assisted R44 to her right side and began to provide personal care. R44 had started to have a BM, and CNA M provided care and put a clean incontinence brief on her. CNA M did not remove her soiled gloves, CNA M and CNA P put R44's pants back on, and adjusted R44's clothing with the soiled gloves still on. CNA M stated she should have removed the soiled gloves before she put on the clean brief and clothing. CNA M stated she had drained the catheter bag earlier. When asked when she had documented the output, she stated that she didn't; she had told the nurse the amount. On 09/08/25 at 01:45 PM, Licensed Nurse (LN) G verified there was no order for R44's catheter. On 09/09/25 at 02:30 PM, LN G stated that staff did not document the output from catheters and that she has the CNAs tell her if the resident does not have any output. On 09/09/25 at 03:00 PM, Administrative Nurse D stated she would make sure she had the nurse call the physician for an order for a catheter. Administrative Nurse D further stated that there should be documentation of urinary output when a resident has a catheter. On 09/10/25 at 01:00 PM, Administrative Nurse G stated she expected staff to follow facility protocol after providing care. The facility's Catheter Care, Urinary policy, dated August 2022, documented staff were to review the resident's care plan to assess for any special needs of the resident. The policy documented staff were to review and document the clinical indications for catheter use and for ongoing need. The policy documented staff were to follow facility procedures for documented input and output. - R35's Electronic Medical Record (EMR) documented diagnoses of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and a history of bladder cancer. R35's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R35 required moderate staff assistance with toileting and had a urinary catheter. R35's Care Plan, dated 06/19/25, stated R35 had a urinary catheter and directed staff to monitor and document intake and (urinary) output as per facility policy. The care plan stated enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) would be used during high contact activities. R35's medical record lacked documentation of urinary output for the past 30 days. On 09/09/25 at 02:00 PM, Certified Nurse Assistant (CNA) O assisted R35 to ambulate to his bathroom. CNA O donned a gown and gloves and emptied the urinary leg bag of approximately 100 milliliters (ml) of urine. She used an alcohol wipe to disinfect the port. When asked where she documented the output, she replied that there was no place to document it, so she did not. On 09/09/25 at 02:10 PM, Administrative Nurse D verified the lack of urinary output documentation and stated staff should document the output when the resident has a catheter. The facility's Urinary Catheter Care policy, dated August 2022, directed staff to follow the facility procedure for measuring and documenting input and output.

The facility had a census of 41 residents. Based on observation, interview, and record review, the facility failed to label and date one insulin pen (a hormone that lowers the level of glucose in the blood) after opening for use. This deficient practice placed residents at risk for ineffective or outdated medication. Findings included: - On 09/08/25 at 08:12 AM, the facility's north medication cart held one Novolog (fast-acting insulin) insulin pen, which was unlabeled and undated. On 09/08/25 at 08:12 AM, Licensed Nurse (LN) G verified the insulin pen should have been labeled and dated when opened. On 09/10/25 at 01:25 PM, Administrative Nurse D verified that staff were to label and date insulin pens when opened. The facility's Insulin Administration policy, dated September 2014, directed staff to record the expiration date and time on the insulin vial after opening.

The facility had a census of 41 residents. The sample included 12 residents, with one reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure collaboration between the hospice provider and the facility for one resident, Resident (R) 44, who was admitted to hospice on 08/28/25. This placed the resident at risk of inadequate end-of-life care.Findings included:- The Electronic Medical Record (EMR) for R44 documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), malignant neoplasm (tumor) of the upper lobe, right bronchus or lung, secondary malignant neoplasm (tumor) of the brain, hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two.The admission Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition. R44 was dependent upon staff for toileting hygiene, dressing, and transfers. The MDS further documented R44 required set-up assistance from staff for eating and oral hygiene. The MDS documented R44 required pain medication and was on Hospice services.R44's Care Plan, dated 08/28/25, directed staff to administer medications as ordered, assess respiratory and cardiac status as needed, and encourage family and friends to visit and be supportive of her needs. The care plan documented that hospice was to provide medications, equipment, and supplies due to the resident's terminal diagnosis, and staff were to utilize pressure reduction equipment and procedures as indicated. The care plan directed staff to refer to facility social services and/or hospice social services and the pastor as needed. The care plan lacked documentation of what supplies, medications, and when hospice staff would be in the building.On 09/09/25 at 02:00 PM, R44 had a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and the drainage bag had a small amount of amber (dark yellow) colored urine. Certified Nurse Aide (CNA) M and CNA P donned gowns and gloves and used a full-body mechanical lift to put R44 into bed. Once in bed, CNA M had R44 roll to her right side and back onto her back so she could remove her pants to do catheter care. CNA M removed R44's incontinence brief, took an incontinence wipe, and provided catheter care. R44 asked CNA M if she had a bowel movement (BM), and CNA M stated she was not sure, but she was not done with care. CNA M removed her gloves and donned a clean pair. CNA M assisted R44 to her right side and began to provide personal care. R44 had started to have a BM, and CNA M provided care and put a clean incontinence brief on her. CNA M did not remove her soiled gloves, CNA M and CNA P put R44's pants back on, and adjusted R44's clothing with the soiled gloves still on.On 09/08/25 at 01:45 PM, Licensed Nurse (LN) G stated R44 was on Hospice services, and the nurse comes a couple of times a week, and staff can call if they need to report anything or need them to come to the facility. On 09/10/25 at 01:00 PM, Administrative Nurse D stated the care plan should be specific to the resident's needs and what the facility and hospice would provide.The Hospice Program policy, undated, documented that hospice services were available to residents at the end of life. Coordinated care plans for residents who received hospice services would include the most recent hospice plan of care, as well as the care and services provided by the facility. The coordinated care plan would reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative. The plan of care would be revised and updated as necessary to reflect the resident's current status.

The facility had a census of 41 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter 4 indicated the facility had excessively low weekend staff.On 09/09/24 at 03:30 PM, Administrative Staff A verified the facility would complete the quarterly PBJ data and then would send that information to corporate, then corporate would send that collected information to Prime View, which is a data collection program, and that was the final information that was submitted to the PBJ data. Administrative Staff A verified the facility had adequate staffing during the 2024 Quarter 4 and stated they were unsure how it was incorrectly submitted. The Reporting Direct Care Staffing Information (PBJ) policy, dated August 2022, documented that direct care staffing information is reported electronically to the Centers for Medicare and Medicaid Services (CMS) through the PBJ system. Complete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS. Direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain and maintain their highest practicable physical, mental, and psychosocial well-being. Direct care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees. For auditing purposes, reported staffing information is based on payroll records, invoices, tied back to a contract, or other verifiable information. Data is submitted by the designated personnel with training on the PBJ user interface. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly.

The facility had a census of 40 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1, R2, and R3 remained free of neglect and abuse. Based on the reasonable person concept, this deficient practice resulted in feelings of belittlement for R1, R2, and R3 and placed all three residents at risk of neglect and the potential for a negative psychosocial impact. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urine retention (lack of ability to urinate and empty the bladder). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was dependent on staff with toileting. R1's Care Plan, revised 03/01/25, documented R1 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The care plan instructed staff to assess the resident's catheter quarterly and as needed (PRN) for continued use, change as the physician ordered, monitor and document intake and output, notify the physician of any signs of infection, and use a catheter strap on the catheter. The care plan documented the resident did not use a toilet, bedpan, or bedside commode, access with checking and changing brief, and provide perineal (private area) care with every incontinent episode as R1 allowed. The facility's investigation sheet, dated 02/17/25, documented the charge nurse Licensed Nurse (LN) G called Administrative Nurse D at 06:38 AM on 02/17/25 to report R1 needed to talk to Administrative Nurse D as soon as she came in to work. The investigation documented Administrative Nurse D and Social Service Designee (SSD) X saw R1 as they arrived for work. R1 reported Certified Nurse Aide (CNA) M would not change her the night prior when R1 called CNA M to her room. R1 reported CMA M told her she did not need changed and left the room. R1 reported this to the other aide who came in and changed R1's brief, which was soaked. The investigation documented R1 was afraid of CNA M. The incident report documented CMA M was terminated on 02/18/25. The Witness Statement from LN G documented on 02/14/25 on the 10:00 PM to 06:00 AM shift CNA M answered R1's call light and R1 reported to CNA M she was wet and needed to be changed. CNA M told R1 You are not wet, you have a catheter. The statement documented R1's catheter did leak around it. The Witness Statement noted LN G attempted to educate CNA M, and CNA M stated She [R1] is lying to me [CNA M] and you [LN G] and I [CNA M] did my job. LN G noted CNA M was unable to be educated. On 03/04/25 at 11:00 AM, observation revealed R1 sat in a wheelchair in the living room area of the facility at an activity. On 03/04/25 at 09:13 AM, Administrative Staff A verified LN G's witness statement revealed that R1 had reported to LN G on the night shift starting on 02/16/25 and ending on 02/17/25. Administrative Staff A stated she was unaware the incident was reported to LN G. Administrative Staff A stated the facility would educate LN G on reporting the incident to the administration immediately. On 03/04/25 at 11:14 AM, Administrative Nurse D stated whenever there is an allegation of abuse, the staff should immediately report it to her and Administrative Staff A. Administrative Nurse D verified CNA M was not immediately suspended when the allegation was reported to LN G, and that CNA M should have been. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 03/03/22, documented that upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment the facility would immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. The facility failed to ensure R1 remained free from neglect when staff failed to provide the necessary care and services required for R1's incontinent care and R1 said she was scared of the CNA. Based on the reasonable person concept, this deficient practice placed the resident at risk for neglect and the potential for negative psychosocial impact. - R2's EMR documented R2 had diagnoses of chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), constipation, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), muscle weakness, and neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). R2's Admission Minimum Data Set (MDS), dated [DATE], documented R2 had a BIMS of 15, which indicated intact cognition. The MDS documented R2 required substantial, maximal staff assistance with toileting and had a urinary catheter. The Activity of Daily Living (ADL) Functional / Rehabilitation Potential (CAA), dated 01/19/25, documented R2 required substantial, maximal staff assistance with toileting. The Urinary Incontinence and Indwelling Catheter CAA dated 01/19/25 documented R2 required substantial to maximal staff assistance with toileting hygiene, had a diagnosis of neurogenic bladder, and had a urinary catheter. The CAA instructed staff to provide catheter care every shift and PRN, monitor output, and record in R2's EMR. R2's Care Plan, revised 01/16/25, documented R2 had renal insufficiency and was at risk of fluid overload. The plan instructed staff to obtain lab reports and report any abnormal values to her physician as necessary. The plan documented R2 required one staff assist with toileting and instructed staff to provide perineal care for every incontinent episode and as necessary. The plan documented R2 had a urinary catheter for diagnosis of neurogenic bladder and instructed staff to assess R2's catheter quarterly and PRN to assess the need for continued use, change as physician ordered, encourage additional fluids to aid in the flow of urine, and monitor and document intake and output as facility policy. The Facility's Investigation sheet, dated 02/17/25, documented the investigation discovered CNA M had denied R2 assistance to the bathroom. The investigation sheet documented CNA M had stated to R2 You already have been twice, you don't need to go again. On 03/04/25 at 11:30 AM, R2 sat in a wheelchair in her room and wore pants, which covered her urinary catheter. On 03/04/25 at 11:14 AM, Administrative Nurse D stated whenever there is an allegation of abuse staff should immediately report it to her and Administrative Staff A. Administrative Nurse D verified CNA M was not immediately suspended when the allegation was reported to LN G, and CNA M should have been suspended immediately. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 03/03/22, documented that upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment the facility would immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. The facility failed to ensure R2 remained free from neglect when staff failed to provide the necessary care and services required for R2's incontinent care. Based on the reasonable person concept, this deficient practice resulted in feelings of fear for R2 and placed R2 at risk for further psychosocial harm, intimidation, and neglect. - R3's EMR documented R3 had diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, retention of urine (lack of ability to urinate and empty the bladder), and neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). R3's Quarterly MDS, dated [DATE], documented R3 had a BIMS of 15, which indicated intact cognition. The MDS documented R3 as dependent on staff with most activities of daily living (ADL). R3's Care Plan, revised 01/30/25, documented the following: Staff would know R3 was incontinent of the bladder. Staff were to make sure R3 had an unobstructed path to the bathroom. Staff were to monitor, and document for signs and symptoms of urinary tract infection (UTI - an infection in any part of the urinary system). Staff were to obtain labs as the physician ordered and notify him/her of the results. Staff would know R3 required two staff assist with toileting. The Facility Incident Report dated 02/17/25, documented an investigation was conducted when R3 reported CNA M would not change her incontinent brief when she requested. It was discovered CNA M had not checked or changed R3 ' s brief for her entire eight-hour night shift. On 03/03/25 at 11:45 AM, staff propelled R3 down the hall to her room and no signs or symptoms of incontinence were noted. On 03/04/25 at 09:13 AM, Administrative Staff A verified LN G's witness statement revealed R1 had reported to LN G on the night shift starting on 02/16/25 and ending on 02/17/25. Administrative Staff A stated she was unaware the incident was reported to LN G. Administrative Staff A stated the facility would educate LN G on reporting the incident to the administration immediately. On 03/04/25 at 11:14 AM, Administrative Nurse D stated whenever there was an allegation of abuse staff should immediately report it to her, and Administrative Staff A. Administrative Nurse D verified CNA M was not immediately suspended when the allegation was reported to LN G and that CNA M should have been. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 3/3/2022, documented that upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment the facility would immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. The facility failed to ensure R3 remained free from neglect when staff failed to provide the necessary care and services required for R3's incontinent care. Based on the reasonable person concept, this deficient practice placed the resident at risk for neglect and the potential for negative psychosocial impact.

The facility had a census of 40 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to ensure staff immediately reported an allegation of potential abuse and neglect to the administrator. Resident (R)1 reported an allegation of potential abuse and neglect to Licensed Nurse G, after Certified Nurse Aide M did not provide assistance to R1 for urinary care and R1 had a soaked brief. LN G did not report the incident to administrative staff. This failure placed R1 at risk for continued neglect. Findings Included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urine retention (lack of ability to urinate and empty the bladder). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was dependent on staff with toileting. R1's Care Plan, revised 03/01/25, documented R1 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The care plan instructed staff to assess the resident catheter quarterly and as needed (PRN) for continued use, change as the physician ordered, monitor and document intake and output, notify the physician of any signs of infection, and use a catheter strap-on the catheter. The care plan documented the resident did not use a toilet, bedpan, or bedside commode, access with checking and changing brief, and provide perineal (private area) care with every incontinent episode as R1 allows. The Facility's Investigation sheet, dated 02/17/25, documented Administrative Nurse D was called by charge nurse Licensed Nurse (LN) G at 06:38 AM on 02/17/25 to report R1 needed to talk to Administrative Nurse D as soon as she came in to work. The investigation documented Administrative Nurse D and Social Service Designee (SSD) X went in to see R1 as they arrived for work. R1 reported Certified Nurse Aide (CNA) M would not change her last night when R1 called CNA M to her room. R1 reported CMA M told her she did not need changed and left the room. R1 reported to the other aide who came in and changed R1's brief. R1's brief was soaked. The investigation documented that R1 was afraid of CNA M. The incident report documented CMA M was terminated on 02/18/25. The Witness Statement, from LN G documented on 02/14/25 on the 10 PM - 6 AM shift CNA M answered R1's call light and R1 reported to CNA M she was wet and needed to be changed, and CNA M told R1 You are not wet, you have a catheter. The statement documented that R1's catheter does leak around it. The note documented LN G attempted to educate CNA M and CNA M stated She [R1] is lying to me [CNA M] and to you [LN G], and she did her job. CNA M was unable to be educated. On 03/04/25 at 11:00 AM, observation revealed R1 sat in a wheelchair in the living room area of the facility at an activity. On 03/04/25 at 09:13 AM, Administrative Staff A verified LN G's witness statement revealed R1 had reported to LN G on the night shift starting on 02/16/25- 02/17/25 and stated she was unaware the incident had been reported to LN G. Administrative Staff A stated LN G would be getting educated on reporting the incident to administration immediately. 03/04/25 at 11:14 AM, Administrative Nurse D stated whenever there is an allegation of abuse staff should immediately report it to her and Administrative Staff A. Administrative Nurse D verified CNA M was not immediately suspended when the allegation was reported to LN G and that CNA M should have been. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 3/3/2022, documented that upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment the facility would immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: 1) suspending the employee 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. The facility staff failed to report to the administration immediately a potential allegation of abuse when staff failed to provide incontinent care for R1. Based on the reasonable person concept, this deficient practice placed the residents at risk for neglect and the potential for negative psychosocial impact.

The facility identified a census of 42 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to provide a safe environment for Resident (R) 1 during a transfer. On 07/04/24, Certified Nurse's Aide (CNA) M transferred R1 by herself with the sit-to-stand lift. R1's ankle buckled and R1 fell out of the lift sling and sustained a broken left thumb. This deficient practice also placed R1 at risk for falls, injury, and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 required the use of a manual wheelchair. The MDS documented R1 had not had any falls during the assessment period. The Activities of Daily Living Care Area Assessment (CAA), dated 09/20/23, documented R1 required extensive assistance for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. R1 required total assistance with bathing. The CAA documented R1's balance was unsteady and R1 required a six-to-stand lift (for stabilization) and assistance from two staff for transfers. The CAA documented R1 was alert and oriented with intermittent confusion. The Fall CAA, dated 09/20/23, documented R1 was t risk for falls but had not had any falls during the assessment period. The CAA documented R1's balance was unsteady, and she required two staff assistance with a sit-to-stand lift for stabilization. R1's Care Plan directed staff R1 required two staff assist for bathing, bed mobility, dressing, toileting, and transfer. The plan directed staff to use two staff assist using a sit-to-stand lift to transfer R1. The plan directed staff R1 was a fall risk and to ensure her call light was within reach, follow fall protocols, and to ensure R1 had a safe environment. The Morse Fall Scale, dated 09/28/23, documented R1 had a fall risk score of 55 which indicated R1 was a high risk for falls. The Progress Note, dated 07/04/24, documented Licensed Nurse (LN) G was called to R1's room for a fall to the floor. CNA M used the sit-to-stand lift alone and R1's ankle buckled sideways and R1 slipped to the floor. The fall was witnessed, and R1 had no head injury. LN G found R1 sitting on the floor in her room with her legs between the sit-to-stand lift. R1 complained of right knee pain but denied neck pain, back pain, or other pain. The Progress Note, dated 07/05/24, documented LN H noted R1's left hand was swollen and bruised between her thumb and index finger. LN H contacted R1's primary care physician to obtain an order for a mobile x-ray. The Post Fall Note, dated 07/05/24, documented R1's left hand was swollen and bruised. An x-ray was obtained, and staff awaited results. The Progress Note, dated 07/05/24, documented the x-ray results were received. The impression revealed an irregular lucency (the quality or degree of clarity) at the base of the first metacarpal (thumb) bone may be due to a superimposed acute non-displaced fracture. The results were called to R1's primary care physician. R1's primary care physician returned the phone call and ordered for a thumb spika (splint to secure non-emergency injuries to bones) splint, and ordered staff not use the sit-to-stand lift for transfers. The physician also ordered staff to keep weight off R1's left hand and set a follow up appointment for 07/15/24. Staff notified R1's responsible party who stated she would bring in the spika splint. Staff wereceducated on R1's new transfer status. The Final X-Ray Report, dated 07/05/24, documented an irregular lucency at the base of the first metacarpal bone may be due to superimposed acute nondisplaced fracture. The Progress Note, dated 07/05/24, documented R1's responsible party brought in the spika splint and requested that R1 always be transferred with a full lift even after her fracture was healed to prevent further falls. R1's splint was in place and her pain was being managed by as-needed pain medication. The Post Fall Note, dated 07/06/24, documented R1 had a fracture to her left hand and the pain was being managed with as-needed pain medications. The Post Fall Note, dated 07/07/24, documented R1's pain was being managed by as-needed pain medication. The Post Fall Note, dated 07/07/24, documented R1's left hand splint was in place. R1 had mild bruising and swelling around the thumb and the first digit area. R1's left hand was non-weight bearing. The Progress Note, dated 07/09/24, documented the Interdisciplinary Team (IDT) met that morning regarding R1's prior fall and interventions to prevent future falls. Staff were to ensure R1's feet were properly placed on the sit-to-stand platform. R1's Care Plan was updated, and a mini in-service was posted for staff education. The Progress Note, dated 07/16/24, documented R1's primary care physician ordered the spika splint to be in place twenty-four hours a day/seven days a week except for bathing. A follow up was scheduled in four weeks with an x-ray prior to the appointment. The undated Facility Incident Report documented CNA M transferred R1 with a stand-up lift. R1's foot was unstable and buckled during the transfer. R1 slipped through the sling to the floor. LN G came to assess R1 and found no injury. The fall follow up assessment the next day, LN H observed swelling to R1's hand, notified R1's family and requested an x-ray from R1's primary care physician. The order was received, x-ray completed and revealed a displaced area. R1's primary care physician requested a splint and full lift until R1's left hand was weight bearing. R1's daughter requested continual use of full lift. CNA M was retrained and put on a performance improvement plan and an in-service was given to all staff. Performance improvement plan will be reviewed at Quality Assurance and Performance Improvement (QAPI) to audit for retraining. CNA M's undated Witness Statement documented R1 was on the sit-to-stand lift when the incident occurred. R1's ankles shifted, and the weight was too much for R1 to bear. LN G's Witness Statement, dated 07/16/24, documented she was called to R1's room by CNA M. LN G found R1 out of the sit to stand sling and sitting on the floor with her legs between the lift. CNA M stated she had used the lift by herself and R1's ankle buckled when she slipped to the floor. R1 denied neck, back or head pain but did complain of right knee discomfort. No deformity noted. On 07/16/24, at 10:00 AM, observation revealed R1 was transferred with the full lift from her bed to her wheelchair. R1 had a splint to her left hand. R1 held the left hand with her right hand through the transfer process. On 07/16/24 at 10:15 AM, CNA N stated that he was educated about always having two staff when a mechanical lift was in use. On 07/16/24 at 10:20 AM, R1 stated Oh yes my hand hurts! R1 rated her left-hand pain at medium. R1 stated the pain sometimes made it difficult for her to sleep. On 07/16/24 at 10:30 AM, Administrative Nurse D stated CNA M was a good CNA, but she was relatively new to the position. Administrative Nurse D stated CNA M was just in a hurry to complete the transfer and did not find another staff to assist her. Administrative Nurse D stated that she had counseled with CNA M about the importance of two staff transfers with a mechanical lift. On 07/16/24 at 11:00 AM, Administrative Staff A, verified CNA M did not follow the facility policy and procedure regarding use of mechanical lift. The facility's Using a Mechanical Lifting Machine Policy, dated July 2017, documented at least two nursing assistants are needed to safely move a resident with a mechanical lift. The facility's Safe Lifting and Movement of Residents Policy, dated July 2017. Documented to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident's safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents. The facility failed to provide a safe environment for R1 during a transfer. As a result, R1 fell and sustained a broken thumb. This deficient practice also placed R1 at risk for falls, injury, and pain. The facility identified and implemented immediate corrective actions, which were completed on 07/10/24 which included: CNA M was retrained on proper mechanical lift protocol and placed on a performance improvement plan. An in-service was completed for all employees regarding when using any mechanical lift two staff members must be present per facility policy and failure to do so could result in immediate suspension and/or termination. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a G.

The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 41 residents who received their meals from the facility's kitchens. This placed the residents at risk for foodborne illness. Findings included: - On 01/02/24 at 08:10 AM, observation in the kitchen revealed: One unsealed unlabeled plastic bag of tater tot patties, one unsealed unlabeled plastic bag of tater tots, and one bag of unsealed, unlabeled plastic bag of chicken strips in the white upright freezer. The outside of the refrigerator freezer had numerous different-sized areas of blackish substance. Inside the refrigerator were numerous different-sized specks of food particles on the door shelves, below the bottom drawers, and the top and middle compartments of the door. The walk-in refrigerator had an open box with an uncovered bunch of celery which had a white substance on the bottom of the bunch. On 01/03/24 at 11:30 AM, observation in the kitchen revealed: The walk-in freezer had six undated personal-size deep-dish cheese pizzas and five undated (one-half gallon) different flavored ice cream. The upper cupboard doors above the microwave had numerous different-sized chips in the corkboard towards the bottom of all doors. The bottom cupboard drawers located under the serving window would not open due to broken tracking where the drawers slide in and out. The right lower bottom cabinet below the microwave was missing a piece of the door approximately one inch by 18 inches and would not open. The lazy [NAME] in the right bottom corner cabinet was stuck, Dietary Manager (DM) BB opened it with force and stated he did not know that it was a cabinet. Inside the lazy [NAME], the top shelf and the bottom shelf had numerous different size black specks, The lower cabinet underneath the serving table had the hinge bent which made the cupboard hang uneven. The pipes, approximately five feet long, located underneath the three-sink area had numerous different-sized blackish substances on them. The floor underneath the dishwasher where the clean dishes came out had 11 missing floor tiles approximately 12x12 inches (in). The five fluorescent ceiling lights, approximately three feet by one foot had numerous different-sized specks in them and the one located in the middle of the ceiling above the three sinks and oven hood had burnt-out bulbs. The ice machine drainage pipe located in the dining area by the wall next to the kitchen continuing through the wall into the kitchen was approximately one-half inch down in the drain hole. One unlabeled, undated flour container and one unlabeled, undated sugar container were located in the first room to the right of the entrance to the dry storage by the walk-in refrigerator. On 01/03/24 at 11:50 AM, observation revealed Dietary Staff (DS) DD started dishing up residents' plates. The surveyor stopped her and asked her if she normally checked the temperatures of the food items before serving. DS DD stated it depended on if there were residents in the dining room ready to eat. 01/03/24 at 11:50 AM, DM BB verified the issues in the kitchen and stated staff had a cleaning schedule to follow for each shift. 01/04/24 at 10:33, DM BB stated he expected staff to check food items' temperatures on the steam table right before they served them to the residents. The Kitchen Cleaning Rotation Sheets, dated 2016, documented tasks for morning and evening dietary staff to complete daily, monthly, and annually. The facility kitchen staff failed to store and prepare food in accordance with professional standards for food service safety. This placed the 41 residents who received their food from the facility's kitchens at risk for foodborne illness.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean comfortable, and homelike environment in the dining room. This placed the residents at risk of an unsafe and uncomfortable environment. Findings included: - On 01/02/24 at 11:35 AM, observation in the dining room revealed the floor throughout the dining room had blackish gray build up and the floor tile located next to the heater had an approximately four-inch wide by a nine-inch long missing piece of tile. On 01/04/24 at 10:40 AM, Maintenance Staff (MS) U verified the above findings and stated he had not waxed the dining room floor because the facility was going to replace it, but he did not know when. On 01/04/24 at 10:58 AM, Administrative Staff A verified the dining room floor had not been waxed for a while and stated the facility was going to purchase new flooring, so staff had not waxed the old one. Administrative Staff A said the facility received one estimate but felt like it was high; the facility then had to put the new flooring on hold due to the expense of a recent foundation repair. The facility's Maintenance Service Policy, revised in December 2009, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. The facility failed to provide a safe, clean, comfortable, and homelike environment in the dining room. This placed the residents at risk of an unsafe and uncomfortable environment.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide a safe environment free of chemical hazards for five cognitively impaired independently mobile residents and failed to ensure a safe environment for Resident (R) 33. The deficient practice placed the affected residents at risk for preventable accidents, falls, and related injuries. Findings included: - On 01/03/24 At 08:07 AM observation revealed a bottle of Windex Multi-Surface Cleaner and Lime Away bottles sitting on an open shelf below the fish aquarium. The Lime Away bottle was labeled to keep out of reach of children. On 01/03/24 at 08:09 AM, Administrative Nurse D, stated one of the residents cleaned the aquarium and placed the cleaning agents under the aquarium, and left them there. Administrative Nurse D verified the cleaning agents should not have been left under the aquarium and took them to have them locked up. The facility's Storage Areas, Environmental Services, dated 12/2009, documented cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. The facility failed to provide an environment free of chemical hazards for five cognitively impaired, independently mobile residents who resided in the facility placing the resident at risk for preventable injuries. 32360 - The Electronic Medical Record (EMR) for R33 recorded diagnoses of dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebrovascular accident (CVA-an interruption in the flow of blood to cells in the brain), and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R33 had severely impaired cognition, and required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS further documented R33 had unsteady balance, upper functional impairment on one side, and had falls before admission. The Annual MDS, dated [DATE], documented R33 had severely impaired cognition, dependent upon staff for transfers, substantial to maximum assistance for personal hygiene and dressing, did not ambulate, had no functional impairment, and had no falls. The Fall Risk Assessments, dated 12/19/22, 12/29/22, 08/29/23, and 12/14/23, documented a high risk for falls. The Care Plan, dated 12/01/23, initiated on 12/02/22, documented R33 had visual impairment, impaired balance, poor safety awareness, and was at risk for falls. The care plan directed staff to ensure R33 wore appropriate footwear when ambulating or in a wheelchair and encouraged her to ask for assistance to transfer or ambulate. The Fall Investigation, dated 12/29/22 at 06:45 PM, documented R33 was observed on the floor on her left side beside her wheelchair in the dining room. The investigation further documented R33 stated staff had turned off the lights in the dining room so R33 thought she needed to get out of the dining room. The investigation documented the nurse and two staff assisted R33 up off the floor and transferred her into her wheelchair and assessed her with no injuries. On 01/03/24 at 02:30 PM, observation revealed R33 sat in her wheelchair with a gait belt around her waist in the bathroom. With Certified Nurse Aide (CNA) M on her right side and CNA P on her left, staff assisted her to stand. CNA M pulled down R33's pants and incontinence brief and assisted her to turn and sit down on the toilet. CNA M stated R33 had a walker in the bathroom she did not know where it went; it was usually left in the shared bathroom. CNA P went into the room next to R33's and found R33's walker in another resident's room. CNA P did not sanitize the walker and provided it to R33 then cued R33 to hold onto the walker. R33 held onto the walker and stood up. CNA M performed peri care, removed her gloves and without performing hand hygiene, pulled up R33's pants, walked R33 to her wheelchair, and sat her down. On 01/03/24 at 2:45 PM, CNA M stated R33 used the walker for short distances and had not had any recent falls. CNA M further stated R33 got up on her own a couple of times and fell . On 01/08/24 at 10:41 AM, Administrative Nurse D stated dietary staff turned off the lights on 12/29/23 while R33 was still in the dining room and did not tell anyone that she was still in there. Administrative Nurse D further stated education was provided and a mini-inservice was held regarding the fall. The facility's Falls and Fall Risk Managing policy, dated 12/07, documented that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling., Staff would monitor and document each resident's response to interventions intended to reduce falling or the risk of falling and if the resident continued to fall, staff would reevaluate the situation, and change the current intervention. The facility failed to prevent cognitively impaired R33 from a fall after staff turned off the lights in the dining room and R33 thought she had to get up and leave. This placed the resident at risk for injury.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for two medication storage carts placing the residents at risk for missing medications and unsafe access to medications. Findings included: - On 01/02/24 at 10:39 AM, observation revealed a treatment/medication cart in the living room area was unattended and unlocked. The unlocked drawers contained insulin (a hormone that lowers the level of glucose in the blood) for four different residents. Licensed Nurse H verified the cart should be locked when unattended. On 01/03/24 at 12:09 PM, observation revealed a medication cart in the living room area unattended and unlocked. Certified Medication Aide (CMA) R verified the medication cart should be locked when unattended. On 01/04/24 at 01:00 PM, observation revealed Resident (R) 5 in a wheelchair in the dining room attempting to open drawers on the medication cart. On 01/08/24 at 10:58 AM, Administrative Nurse D stated the medication carts should be locked if staff was not present. The facility's Storage of Medications policy, dated 12/2007, documented compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility failed to store drugs and biologicals in a secure manner placing the residents at risk for missing and unsafe access to medications.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to provide proper infection control practices related to point of care testing for COVID-19 (a highly contagious respiratory virus) and also failed to sanitize a resident's walker after it was used by another resident who had not been feeling well. This placed the residents at risk for infectious disease. Findings included: - On 01/03/24 at 07:45 AM, observation revealed Resident (R)25 stated she did not feel well and refused her medication. At 10:07 AM, observation revealed Certified Nurse Aide (CNA) N placed R33's silver walker in front of R25 and told her to hold onto the walker to stand up. CNA N had R25 pivot turn and sit down in her wheelchair. At 02:30 PM, observation revealed R33 sat in her wheelchair with a gait belt around her waist in the bathroom. With Certified Nurse Aide (CNA) M on her right side and CNA P on her left, staff assisted her to stand. CNA M pulled down R33's pants and incontinence brief and assisted her to turn and sit down on the toilet. CNA M stated R33 had a walker in the bathroom she did not know where it went; it was usually left in the shared bathroom. CNA P went into the room next to R33's and found R33's walker in another resident's room. CNA P did not sanitize the walker and provided it to R33 then cued R33 to hold onto the walker. R33 held onto the walker and stood up. CNA M performed peri care, removed her gloves and without performing hand hygiene, pulled up R33's pants, walked R33 to her wheelchair, and sat her down. On 01/03/24 at 02:20 PM, observation in the conference room revealed Activities Z took a COVID-19 test, waited only five minutes through the directions called for a 15-minute wait time, and then threw the used test into the trash, and left the room. Further observation of the testing area revealed a white notebook with a testing log on top of the small refrigerator, and two used COVID-19 tests with the log on top of the refrigerator. On 01/03/24 at 03:00 PM, Administrative Nurse D stated staff were supposed to get another nursing staff member or another administrative staff member to witness the COVID-19 tests, and then dispose of the test appropriately. Observation revealed Administrative Nurse D then gloved, placed the used tests into the trash, removed the trash bag and removed her gloves but did not sanitize the top of the refrigerator where the used COVID-19 tests had been. On 01/08/24 at 10:44 AM, Administrative Nurse D stated staff should have sanitized R33's walker after it had been used by another resident. The facility's COVID-19 policy guidelines dated, 05/19/23, documented the infection control preventionist should assess, monitor, and ensure compliance with all infection control practices, infections should be line listed on tracking forms, and all employees, consultants, and contractors should be educated related to virus, infection control preventions for early detection and monitoring. The facility would record all test results, both positive and negative, within the organization's tracking system. All COVID-19 testing supplies should be disposed of in biohazardous waste. The facility failed to provide proper infection control practices when testing for COVID-19 and failed to sanitize a resident's walker after it was used by another resident who had not been feeling well. This placed the residents at increased risk for infectious disease.

The facility identified a census of 37 residents. The sample included 13 residents with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide assistance during R14's meals. The facility further failed to identify the unplanned weight loss and implement interventions to prevent further loss. R14 weighed 157.2 pounds on 11/02/21 and 140.8 pounds on 05/06/22 which indicated a significant unplanned weight loss of 10.43 percent (%) in six months. Findings Included: -The Medical Diagnosis section within R14's Electronic Medical Records (EMR ) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (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 ) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), hypertension (high blood pressure), and retention of urine (lack of ability to urinate and empty the bladder). The Annual Minimum Data Set (MDS) dated [DATE] indicated R14 was independent with eating and required setup assistance for meals. The MDS reported that she weighed of 157 pounds (lbs). The MDS indicated that R14 had the ability to hear, understood others, spoke clearly, but had impaired vision. The MDS indicated that she required extensive assistance from two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The report indicated that no weight loss occurred of five percent in one month or ten percent in the last six months . R14's Quarterly MDS dated [DATE] noted a Brief Interview for Mental Status (BIMS) of six which indicated severe cognitive impairment. The MDS indicated that R14 required setup and supervision from one staff for eating. The MDS noted that she spoke clearly, no concerns with hearing, understood others, spoke clearly, and had highly impaired vision. She weighed 141 lbs. with no weight loss of five percent in a month or ten percent in the last six months. R14's Nutrition Care Area Assessment (CAA) dated 11/02/21 recorded that she was on a regular diet and was independent with help and set-up for her meals. The CAA noted that she consumed 76 to 100 percent of her meals. R14's Care Plan revised 03/24/22 indicated she suffered from a self-care deficit related to her medical diagnoses. The care plan stated staff were to encourage her to go to the dining room for meals or to assist her while eating in her room. She required extensive assistance from one staff during meals. Staff were to monitor and report signs of dysphagia (swallowing difficulty), pocketing (holding food in the pockets of the mouth), and potential choking hazards during the resident's meals. Staff should provide a divided plate as needed to assist with her independence (added 04/10/2019) and to encourage finger foods when possible (revised 07/30/21). The care plan lacked interventions for weight monitoring. The care plan lacked interventions related to R14's inability to utilize the eating utensils and difficulty seeing the food being served. R14's Weight Lookback report indicated she weighed 157 lbs on 11/02/21. R14's EMR under the Orders tab revealed a physician's order dated 01/29/20 for a regular diet with regular texture and consistency with instructions for the resident's food to be served on a divided plate. . R14's EMR revealed a Dietary Profile dated 11/01/21 which stated she received regular diet with regular texture and consistency. The resident needed a divided plate and was independent with eating and used regular utensils. The profile noted R14 had good hearing and vision. The profile noted her weight as 152 lbs. A Nutrition/Dietary Note under the Progress Notes tab dated 11/03/21 by Registered Dietician (RD) HH documented R14's weight was stable for the past 180 days. Her current weight was 157.2 lbs and she was considered obese. R14 received a regular diet, ate in her room, and in the dining room. She requested to have her tray set-up and fed herself. R14's appetite was usually 76-100%, but occasionally was 50-75%. R14 was obese but was not concerned with her weight at that time. RD HH recommended to continue the current diet regimen. R14's Weight Lookback report indicated she weighed 149 lbs. on 12/03/21 which represented a 5.22 % loss in 30 days. A Nutrition/Dietary Note under the Progress Notes tab documented by the RD HH dated 12/07/21 which stated R14 needed assistance with meals. The note recorded R14 had a difficult time seeing her food and recommended that she be assisted with her meals to maintain her weight versus the use of finger foods. (R14's Care Plan lacked revision with interventions to address the resident's increased need for assistance). R14's Weight Lookback report indicated she weighed 146.6 lbs. 01/04/22. A Nutrition/Dietary Note under the Progress Note tab documented by Dietary Staff BB on 01/18/22 recorded R14 was on a regular diet and used a divided plate for all meals. R14 ate in her room and in the dining room. R14's appetite was good. Her favorite food was sweet potatoes, eggs, and ice cream. Her current weight was 147 lb. Her body mass index (BMI- measure of body fat based on height and weight) was 28 which indicated she was overweight. The note recorded R14 was happy with her weight and did not want any changes to her diet. R14's Dietary Profile completed by Dietary BB dated 01/18/22 noted that she was on a regular diet with regular texture and consistency with no nutritional supplements. The profile noted that she needed a divided plate. The profile stated that she was independent and did not require eating assistance. The profile noted that the resident's hearing and sight were good. The profile noted that she used regular utensils. The profile noted her weight as 147lbs. R14's Weight Lookback report indicated she weighed 147 lbs. on 02/09/22 which indicated a 6.17 % loss in 90 days. R14's clinical record lacked evidence that staff consulted the RD regarding R14's continued weight loss. A Health Status Note dated 02/11/22 noted that R14 has not been herself. The note stated she had poor appetite, was more tired, and was not making sense when talking. The note stated that she was more confused than normal. A Health Status Note dated 02/20/22 indicated that R14 declined to eat breakfast and lunch with her weight steadily declining for the past three months. The note documented vital signs were normal and staff notified the oncoming. The note lacked documentation that staff notified R14's physician. A Medication Change Note dated 02/21/22 stated R14 seemed to have lost her appetite with the increased trazodone (antidepressant medication) and continued to have anxiety, confusion, and refused to eat. A Health Status Note date 02/21/22 noted that R14 continued to have decreased appetite and drowsiness. The note stated staff rescheduled the trazodone medication to bedtime. A Health Status Note dated 02/22/22 noted that R14 continued to have decreased appetite, anxiety, and refusal to eat related to trazodone. R14's Weight Lookback report indicated she weighed 141.4 lbs on 03/07/22. A Health Status Note dated 03/08/22 noted that R14 continued the trazodone increase with no adverse reactions. The reported noted that she tolerated the medication well. R14's Dietary Profile dated 03/21/22 noted she was on a regular diet with regular texture and consistency with no nutritional supplements prior to admission. The profile noted that she needed a divided plate. She was independent and did not require eating assistance. The profile noted that the resident's hearing and sight were good and she used regular utensils. The profile noted her weight as 141lbs. A Plan of Care Note dated 03/24/22 recorded a care plan meeting was held with R14 and her representative. The note documented R14 reported she liked the food. The note lacked evidence of discussion of R14's weight loss with R14 or her representative. R14's Weight Lookback report indicated she weighed 140.8 lbs. on 05/06/22 which represented a significant weight loss of 10.22% in six months. On Nutrition/Dietary Note dated 05/17/22 under the Progress Notes tab documented R14's treatment team met to discuss her weight decline of 10.4 % in 180 days. The note recorded R14's weight loss was related to her not being able to get food into her mouth. The note stated that not all utensils and finger foods worked for R14. The note documented a recommendation that staff provide R14 encouragement and queuing. R14's clinical record lacked evidence of RD referral and physician notification related to a significant unplanned weight loss. On 05/23/22 at 08:45AM R14 slept in her reclining chair. R14's breakfast plate sat in her lap and appeared untouched. No staff were observed in her room to assist her with her meal. The food was not cut up for R14 to be able to eat the sausage and toast provided. On 05/25/22 at 10:45AM R14 slept in her reclining chair. R14's breakfast plate was sat on her bedside table. The food appeared untouched. R14's roommate stated that staff delivered the food around 09:00AM. On 05/26/22 at 08:03AM R14 slept sitting upright in her reclining chair wearing a clothing protector. She appeared prepped for breakfast and her food was cut up for her to eat, but not covered to prevent it from getting cold. At 08:45AM an unidentified staff entered the room and woke R14 to assist her to eat breakfast. The care staff apologized to the resident and explained, I'm sorry, I forgot you wanted to eat breakfast. Staff then attempted to feed the resident the cold meal before stopping to assist her to the restroom. R14 appeared confused and disoriented but stated that the food was hard to chew and not good. On 05/26/22 at 12:52 PM with Certified Medication Aid (CMA) R reported that residents who required assistance during meals services should not be left alone during meal service. He stated that staff can review the resident's care plan to find out if the resident had a special diet or needs during meal service. CMR R reported that staff weighed the resident each month unless it is in the care plan. On 05/26/22 at 02:04 PM in an interview with Administrative Nurse E, she stated that residents could eat in their rooms if they chose to but staff need to be available to assist them. She reported that residents that require assistance eating should never be left alone during mealtimes and staff should assist them with their meals. She reported that R14 should have had someone in the room assisting her with her meal. On 05/31/2022 at 05:45 PM in an interview with RD HH, she stated that R14 had a gradual decline since last year. She stated that she notified physical therapy that the resident needed assistance during all meals and was told by physical therapy to try finger foods instead. She reported that the weight loss was unplanned and may have been prevented depending on the resident's cognitive state each day. She indicated the resident could not eat by herself and needed to be encouraged to consume her meals. She reported that R14 required physical assistance from staff due to R14 was unable to see the food on her plate, use the utensils, or get the food into her mouth. RD HH said R14 often chose to eat in her room due to her becoming anxious in the dining room to the point of her crying out to leave. The facility's Assisting Impaired Resident with In-Room Meals policy revised 09/2013 stated staff are required to ensure the resident is prepared to receive the meal before serving. The policy stated the resident should be positioned upright and head tipped slightly forward. The policy stated staff are responsible to ensure that food is served at the appropriate temperature. The facility's Nutrition and Hydration policy revised 01/2022 stated that dietary and nursing staff monitor that resident's food intake and tolerance of specific interventions. The policy stated that the facility if committed to ensuring each resident maintains acceptable parameters of nutritional status to maintain proper health. The policy indicated that residents shall be placed on weekly weights. The facility failed to provide assistance during R14's meals. The facility further failed to identify the unplanned weight loss and implement interventions to prevent further loss. R14 weighed 157.2 pounds on 11/02/21 and 140.8 pounds on 05/06/22 which indicated a significant unplanned weight loss of 10.43 % in six months.

The facility had a census of 40 residents. The sample included 3 residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to provide adequate supervision for 1 of the 3 sampled residents, (#1), who eloped from the facility without staff's knowledge, and was found by an off-duty employee, approximately one and one-half blocks from the facility on a busy street. This placed Resident #1 in immediate jeopardy. The facility failed to provide adequate supervision to 1 of 3 sampled resident (#2), who left the facility without staff awareness, placing the resident at risk for an accident. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 5/15/18, documented the resident had short and long-term memory problems. The MDS documented the resident required supervision of 1 staff for bed mobility, transfers, walking in his/her room or corridor, and locomotion on and off the unit, limited staff assistance of 1 for dressing and personal hygiene, supervision with set up for bathing, extensive assistance of 1 staff for toileting, and he/she ate independently after staff set-up. The MDS documented the resident wandered daily and was at significant risk for getting into potentially dangerous places. The 5/15/18 admission (CAA) Care Area Assessment for cognition documented the resident had a [DIAGNOSES REDACTED]. The CAA documented the resident often wandered throughout the facility, attempted to exit two times, and wore a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) to his/her left ankle that staff checked for function each shift. The 5/15/18 admission CAA for behavior documented the resident attempted to exit the facility without success, and staff easily re-directed him/her. The CAA documented the resident wandered through out the facility 5 of 7 days of the look back period. The admission care plan, dated 5/8/18, directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, such as walking inside or outside, pictures and a memory box, food, conversation, television or books. The care plan documented the resident liked to stack (DVD) digital video devices, group activities, and would eat anything on the dietary menu. The care plan documented the resident wore a Wanderguard on his/her ankle. The 5/3/18 admission elopement assessment indicated the resident was at risk for elopement and staff placed his/her picture in the elopement book, and placed a Wanderguard on the resident's ankle. The 8/9/18 elopement risk assessment indicated the resident remained at risk for elopement and continued to wear a Wanderguard. The 8/11/18 at 11:08 PM, nurse's note documented at approximately 6:25 PM, the resident was outside of the building and was brought back inside by staff. Staff offered the resident ice water and snacks, and assisted him/her to the bathroom. Staff completed a head to toe assessment and there were no injuries noted. The note documented the resident's vital signs were normal, he/she denied pain, and there were no signs or symptoms of dehydration, as the resident was noted wearing a winter coat when the outside temperature was 90 degrees Fahrenheit. The note documented staff placed the resident on 15-minute visual checks, and notified the resident's guardian and physician, as well as the facility administrator and director of nursing. The facility's investigation report documented on 8/11/18, between 6:24 and 6:30 PM, off duty Licensed Nurse H observed the resident walking on the corner of a busy street. Licensed Nurse H stopped his/her car, went to the resident, and asked him/her to get into the car so he/she could take the resident back to the facility. The temperature outside was 85-90 degrees Fahrenheit, and staff believed the resident was outside approximately 15-20 minutes. The investigation report documented Licensed Nurse G came on shift at 6:00 PM, and shortly after that, at approximately 6:10 PM, the door alarm sounded, and when Licensed Nurse G opened the door and looked out, he/she did not see any resident outside. The report documented when Licensed Nurse G looked out the door, a large dumpster parked outside the door, could have obstructed Licensed Nurse G's view. On 8/16/18 at 10:40 AM, observation revealed the resident watched television in the south TV room and a Wanderguard in place on his/her left ankle. On 8/20/18 at 1:20 PM, observation revealed staff escorted the resident from the dining room, to his/her room at the south end of the facility. Further observation revealed a Wanderguard on the resident's left ankle, with no exit seeking behavior. On 8/16/18 at 2:00 PM, Direct Care Staff N stated he/she heard the alarm sound for the southwest front door, and he/she announced it overhead (a loudspeaker system to make announcement, notify or summons people in large buildings) to alert staff. Direct Care Staff N stated he/she observed Licensed Nurse G coming up the hall and stated he/she checked the door and there was no one outside. Direct Care Staff N stated he/she shut the alarm off, and at approximately 6:30 PM, he/she observed staff coming in the front door with the resident. Direct Care Staff N stated he/she had witnessed the resident wandering and was at risk for elopement and wore a Wanderguard. On 8/16/18 at 2:15 PM, Licensed Nurse H stated on 8/11/18, he/she clocked out of the facility and left for his/her break at 6:24 PM. Licensed Nurse H stated he/she drove his/her car south from the facility and after he/she turned onto a busy street, he/she noticed the resident standing on the sidewalk. Licensed Nurse H stated he/she pulled the car over, got out and approached the resident, who walked back to the car with him/she, and Licensed Nurse H drove the resident back to the facility. On 8/16/18 at 4:56 PM, Licensed Nurse G stated he/she worked 6:00 PM-6:00 AM on 8/11/18. Licensed Nurse G stated he/she clocked in for his/her shift at few minutes before 6:00 PM, and he/she heard the door alarm sound. Licensed Nurse G stated he/she went to the door that alarmed, opened the door, and looked outside, but did not see any resident. Licensed Nurse G stated he/she continued to the nurse's station to begin his/her shift. Licensed Nurse G stated Licensed Nurse H left for his/her break and returned a few minutes later with the resident. Licensed Nurse G stated he/she had not physically gone outside to search for the resident, and did not perform a head count of the elopement risk residents to make sure they were in the facility. On 8/20/18 at 11:15 AM, Administrative Nurse D stated when a door alarm sounds, he/she would expect staff to go to that door, and physically go outside to search for any resident that may have eloped. Administrative Nurse D stated Licensed Nurse G did not follow the facility's elopement policy and search the outside premises. Administrative Nurse D stated the facility's elopement policy and procedure did not include staff performing a head count of the elopement risk residents to be sure they were in the facility, but he/she would expect staff to check on those residents. The facility's (MONTH) 2007 elopement policy documented if a resident was missing from the facility, staff should determine if the resident was out on authorized leave or pass, and if not, staff should initiate a search of the building and premises. The policy had no documentation for staff when an exit door alarms for no reason. The facility failed to provide adequate supervision for Resident #1, who eloped from the facility and was found one and a half blocks from the facility on a busy street. This placed the resident at risk for harm and injury. The facility abated the immediate jeopardy on 8/20/18, when all staff were educated on the Elopement Policy and Procedure, and elopement drills were performed. The deficient practice remained at a scope and severity of a D. - Resident #2's admission (MDS) Minimum Data Set assessment, dated 7/3/18, documented the resident had a (BIMS) Brief Interview for Mental Status score of 8, which indicated moderately impaired cognition. The MDS documented the resident required limited staff assistance with bed mobility, dressing, toilet use, personal hygiene, supervision with transfers, walk in room and corridor, locomotion on and off unit, and eating. The MDS documented the resident had wandering behavior 1 to 3 days of the 7 day look back period. The 7/3/18 (ADLs) Activities of Daily Living (CAA) Care Area Assessment documented the resident required staff supervision with locomotion on and off the unit and ambulation in room or corridor due to he/she did not know where to go at times and had been noted to exit seek. The CAA documented the resident wore a wander guard (bracelet that sets off an alarm when a resident wearing one attempts to exit the building without an escort) bracelet on his/her left ankle. The 7/3/18 Behavioral CAA documented the resident had a [DIAGNOSES REDACTED]. The CAA documented the resident had a history of [REDACTED]. The CAA directed staff to redirect the resident, offer ice cream, one on one, or doing the resident's hair. The 6/29/18 care plan documented the resident was at risk for elopement, and directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. The care plan documented the resident preferred ice cream and watching the hallmark channel on television. The 6/30/18 at 2:32 PM, nurse's note documented the resident was restless after lunch meal, ambulated to the front door several times, verbally expressed a desire to go home, and staff redirected the resident by giving him/her a task to do. The 8/11/18 at 10:56 PM, nurse's note documented at approximately 6:00 PM, a staff member brought the resident back in from outside, while the nurses were in report. The note documented after the nurses finished report, staff offered the resident ice water and snacks, toileted, brought back to his/her room, where the nurse completed a head to toe assessment, and the resident had no injuries or signs or symptoms of dehydration. The note documented the resident stated He/She was looking for his/her home. The 8/11/18 incident report documented Nurse G came on to work his/her shift at 6:00 PM, at approximately 6:10 PM the southwest front door alarm sounded, Nurse G checked it, by opening the door, looked around, and did not see a resident outside, so the door was cleared. The report documented at around 6:15 PM Nurse Aide M was in another resident's room, at the end of the hall, by the southwest front exit door, heard a noise, went to see where the noise was coming from, and saw the resident on the other side of the door waving at Nurse Aide M, and asked to come into the facility. The report documented the resident was immediately brought into the facility, taken to his/her room, the nurse performed a head to toe assessment, staff offered the resident food and drink, and the resident had no injuries. The report documented the resident was at risk for elopement. The 8/16/18 at 5:15 PM notarized witness statement from Nurse G documented on 8/11/18 Nurse G clocked in for his/her shift a few minutes early before 6:00 PM, the alarm went off shortly after, he/she checked the door, and saw no resident outside at that time. The statement documented Nurse Aide M was coming to check the door as he/she came in, Nurse G informed Nurse Aide M he/she had not observed anyone. The statement documented Nurse G went to the conference room for report, after report he/she was informed of the resident's elopement, completed a head to toe assessment of the resident, and offered the resident water and snacks. The 8/16/18 at 12:30 PM notarized witness statement from Nurse Aide M documented he/she heard the door alarm, started walking back to door 7 (southwest front exit door), and saw Nurse G, who stated he/she had checked the door. The statement documented moments later he/she was assisting another resident, heard someone yell help, help, so he/she went and checked to see who was yelling at the southwest south exit door, when he/she opened the door saw the resident waving his/her hands at the window. The statement documented Nurse Aide M brought the resident inside the facility and asked him/her what he/she was doing and if anything hurt, the resident replied no, stated he/she was looking for home. The statement documented Nurse Aide M showed the resident to his/her room and the resident calmed down and started to color in an activity book. The statement documented the last time Nurse Aide M sawthe resident, prior to the incident, was at dinner around 5:00 PM. On 8/20/18 at 1:38 PM, observation revealed the resident sat on the side of his/her bed, coloring pictures with colored pencils, and a wander guard bracelet observed on the resident's left ankle. On 8/16/18 at 5:00 PM, Nurse G stated on 8/11/18 a little after 6:00 PM an alarm from the door 7 (southwest front exit door), he/she was on the way to the restroom, opened the door, looked around and did not see anyone either way, saw Nurse Aide M coming down the hall and told her he/she had checked the door and there was no one outside. Nurse G stated he/she was not 100% sure of the facility's protocol to go outside the door to check for residents after the door alarmed. Nurse G stated he/she did not take a head count of the residents at risk for elopement, and was not sure if any other staff had conducted one either. Nurse G stated the resident wore a wander guard bracelet but the southwest front exit door had no wander guard alarm. On 8/20/18 at 11:15 AM, Administrative Nurse D stated the charge nurse or another staff member should walk outside the facility to look for residents, when a door alarm sounds. Nurse D stated staff should conduct a head count of residents at risk for elopement, when a door alarm sounds, and they cannot find a reason for it to alarm. The facility's (MONTH) 2007 elopement policy had no documentation, regarding staff direction, when an exit door alarms for no apparrent reason. The facility failed to provide adequate supervision for Resident #2, who left the building without staff awareness, placing the resident at risk for an accident.

The facility had a census of 44 residents. The sample included 3 residents reviewed for accidents. Based on observation, record review and interview the facility failed to ensure 1 of 3 sampled residents remained as free of accidents hazards as possible. Resident #1 was not assessed for safety with hot liquids, and received 1st and 2nd degree burns when he/she spilled a cup of hot coffee in his/her lap. Findings included: - Resident #1's signed (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 3/16/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 4, indicating severe cognitive impairment, and no behaviors. The MDS recorded the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toilet use, personal hygiene, bathing, limited assistance of 1 staff for locomotion on and off unit, and independent with 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 in one upper extremity, and used a wheelchair for mobility. The 7/11/16 Cognitive Loss/Dementia (CAA) Care Area Assessment recorded the resident had severe cognition deficits that affected his/her safety, and ability to make clear and consistent rational decisions about his/her care, safety, and life. Contributing factors included [DIAGNOSES REDACTED]. The CAA recorded factors would include: safety concerns, injury related to inability to make sound decisions, exacerbation (an increase in the severity of a disease or its signs and symptoms) of his/her anxiety at times, as his/her dementia progresses, diminished quality of life, with a continued decline in his/her self-care abilities that would put him/her at risk for malnutrition (a serious condition that occurs when a person's diet doesn't contain the right amount of nutrients), and dehydration (a condition that occurs when the loss of body fluids, mostly water, is greater than the amount taken in). The 7/11/16 (ADL) Activities of Daily Living CAA recorded the resident needed extensive staff assistance with his/her ADLs to maintain his/her optimum quality of life, safety, nutritional status, fluid balance, personal hygiene, and all aspects that pertain to his/her care as he/she was unable to perform these functions for himself/herself any longer. The 1/18/17 care plan recorded the resident needed help choosing food he/she liked to eat due to his/her dementia. The care plan recorded the resident, at times, had some difficulty with feeding himself/herself due to his/her arm, and directed staff to assist the resident if he/she was not eating. The 4/23/17 care plan update directed staff to place the resident's coffee and any other hot liquid in a cup with a lid, to help him/her keep from spilling it on himself/herself. The 4/22/2017 at 3:52 PM, nurse's note recorded the resident spilled hot coffee on his/her lap area, and staff immediately applied cold water to the area. The note recorded no redness or warmth was noted, and staff would monitor and chart as needed. The 4/22/2017 at 4:26 PM, nurse's note recorded the resident had a reddened area to both his/her thighs and developed blistering due to previously spilled coffee. Staff initiated cool compresses to the site every hour, and notified the resident's physician. The 4/22/2017 at 9:21 PM, nurse's note recorded the area to the resident's bilateral thighs had increased in raised, fluid filled areas. The fluid filled area to the right thigh was now an open area, and staff applied moist/cold cloths to the site every hour. Staff continued to monitor for changes, and contacted the on call physician for further recommendations. The 4/22/2017 at 9:49 PM, nurse's note recorded the facility received a physician's orders [REDACTED]. The 4/22/2017 at 10:03 PM, nurse's note recorded staff were directed to apply a cool compress to the resident's bilateral thighs every hour, and contact the resident's physician the following Monday if the burns were not resolved. A fax was sent to the resident's physician to notify him/her about the new order and request an order for [REDACTED]. The 4/23/2017 at 1:49 AM, nurse's note recorded the resident returned from the hospital ER with new orders to wash the burned areas gently on a daily basis with mild soap and water, apply Vaseline (petrolatum-jelly based product used to help protect minor cuts and burns), or Vaseline gauze (a fine non-adherent sterile mesh, absorbent gauze containing white petrolatum that remains moist, nontoxic and nonirritating), then cover with non-adherent dressing daily. The note recorded the resident was to follow up with his/her physician for a wound recheck, staff were informed of the new orders, and staff updated the treatment record. The 4/24/2017 at 1:32 PM, nurse's note recorded the resident had multiple red/open areas to his/her bilateral inner thighs, with some fluid filled blisters, staff applied treatment to all areas, and encouraged the resident to drink fluids. The note recorded upon standing, the resident reported pain like a boil (a painful fluid filled area that forms under the skin) to his/her inner thighs, and staff administered pain relievers. The 4/22/17 emergency room report documented the patient was brought to the emergency department by nursing home staff for burns to his/her legs. Staff reported, earlier in the day, the resident spilled a cup of hot coffee on his/her lap. Staff noticed burns to the area when they helped the resident change his/her clothes and bandaged the burned areas at that time. Tonight, staff noted blistering, so the resident transferred to the emergency room to be evaluated. The resident denied any pain to the area. Evaluation of the resident revealed a burn injury (scald burns to upper inner thighs with some bullae (blisters that appear when fluid is trapped under a thin layer of skin) formed). The note directed staff to keep the wounds clean, and wash gently on a daily basis with mild soap and water, then apply Vaseline or Vaseline gauze and cover with a non-adherent dressing. The noted directed staff to have the resident return if there were any signs of infection (purulent drainage (producing or containing pus), increased redness, increased pain) or for any other concerns. The resident's medical record for skin observations recorded the following wound descriptions and measurements: 4/22/17 at 4:20 PM, wound to right thigh (front) with redness and blistered area to thighs, cool compresses initiated. 4/23/17 at 5:32 PM, staff measured the following 7 areas: - right gluteal fold (a fold on the back of the upper thigh that marks the upper limit of the thigh from the lower limit of the buttock), blister measuring 0.8 cm x 1.9 cm - right gluteal fold, blister measuring 0.8 cm x 1.6 cm - right gluteal fold, blister measuring 10.0 cm x 4.2 cm - right gluteal fold, blister measuring 1.0 cm x 2.8 cm - left gluteal fold, reddened/raised area measuring 10.0 cm x 5.0 cm - right gluteal fold, open area measuring 10.8 cm x 4.5 cm - right gluteal fold, open area measuring 9.9 cm x 4.5 cm 4/25/17 at 1:46 AM, the following 7 areas were measured: - right inner thigh, open burned area measuring 3.0 cm x 2.5 cm - right inner thigh, open burned area measuring 9.9 cm x 4.5 cm - right inner thigh, blister measuring 1.0 cm x 2.5 cm - right inner thigh, blister measuring 0.8 cm x 1.8 cm - right inner thigh, blister measuring 0.9 cm x 4.0 cm - right inner thigh, blister measuring 0.7 cm x 1.7 cm - left inner thigh, burn measuring 10.2 cm x 4.9 cm Coffee burn resulted in 2 open areas and 4 intact blisters to right inner thigh; red area with open blister to left inner thigh, new order received and initiated. 5/4/17 at 12:42 AM, right inner thigh, burn measuring 15 cm x 4.5 cm -left inner thigh, burn measuring 10.2 cm x 4.9 cm All fluid filled blisters from the coffee burn have opened and areas are covered with yellow slough (dead tissue separating from living tissue). Peri-wounds remain reddened, dressing changed per order. On 4/26/17, staff completed a hot liquids safety evaluation for Resident #1, (four days after the resident spilled hot coffee on him/herself). The assessment recorded the resident had a BIMS score of 4, his/her mood varied over the course of a day, was easily agitated, frequent impulsive acts, short tempered, weakness/paresis (a weakness of voluntary movement, or partial loss of voluntary movement or by impaired movement) in his/her upper extremities, and loss of mobility/reduced movement in upper extremities. The assessment directed staff to ensure the resident used a cup with a lid, make sure the temperature of his/her liquid did not exceed 180 degrees, only drink hot liquids while sitting at a table, and provide a shirt protector to the resident. On 5/9/17 at 10:30 AM, observation revealed Administrative Nurse A and Nurse B removed the dressings on the resident's burns. Observation revealed the right inner thigh dressing had a large amount of yellow purulent (producing or containing pus) drainage, the left inner thigh dressing had a small amount of yellow watery drainage. Observation revealed Nurse B cleansed the wounds with (WC) Wound Cleanser. Observation revealed the left inner thigh wound measured 3.2 cm x 1.0 cm, the right inner thigh wound measured 5.2 cm x 7.0 cm, and the right top leg wound, measured 1.6 cm x 2.0 cm. Observation revealed Nurse B applied Silvadene (a topical treatment to prevent infections in persons with second and third degree burns) to all the wounds using a clean applicator for each wound, applied Vaseline gauze to each wound, then dressed each wound with Telfa (absorbent cotton pad) and Medipore tape (soft cloth surgical tape). Observation revealed the left gluteal crease area had one red line down the middle, with no open areas. On 5/10/17 at 8:27 AM, observation revealed the resident seated in the dining room in his/her wheelchair for breakfast, an immobilizer (to impede movement) in place to his/her right shoulder/upper arm, and a shirt protector in place. Observation revealed a small tray table attached to the resident's wheelchair in front of him/her with a plate of pancakes, mixed fruit, a glass of juice (uncovered), a glass of apple juice (uncovered), and a 3/4 full cup of coffee (uncovered). Observation revealed the resident independently drank and ate his/her meal. Observation of the dining room revealed only one unsampled resident had lids on his/her drinks, and no other residents in the dining room had lids. Observation revealed Resident #1 was able to freely move his/her right arm to eat his/her food, and consumed all of his/her meal, but not much of his/her coffee. On 5/10/17 at 8:34 AM, observation revealed Housekeeping Supervisor C stopped to talk to a (CNA) Certified Nurse Aide at another table in the dining room. Housekeeping Supervisor C then grabbed a cup with a lid and went over to Resident #1's table, poured the resident's coffee into the cup, placed the lid on top, and gave it back to the resident. Housekeeping Supervisor C stated he/she was not aware the resident needed a lidded cup. On 5/9/17 at 10:20 AM, Administrative Nurse A stated when the coffee incident initially happened, there were no discolored areas on the top of the resident's legs. He/she stated Nurse D poured cold water on the resident's lap right away, but where the resident had sat in the hot coffee, his/her burns were worse to the back of the resident's legs and inner thighs. On 5/9/17 at 1:37 PM, Medication Aide E stated the resident usually does well eating on his/her own, and did not like to be helped. Medication Aide E stated, prior to the incident on 4/22/17, he/she had not observed the resident spill his/her coffee or drinks. Medication Aide E stated he/she was in the dining room on 4/22/17 assisting another resident to leave the dining room. Medication Aide E stated when he/she walked past Resident #1, he/she heard the resident scream, noticed the resident's lap was wet, and realized the resident's coffee cup was empty. Medication Aide E stated he/she and Nurse D poured ice water on Resident #1 to cool him/her off, then assisted the resident to his/her room and removed his/her pants. Medication Aide E stated Nurse D assessed the burned areas, immediately notified the physician, and staff continued to apply cool cloths to the burned areas the rest of the day. Medication Aide E stated Resident #1's care plan now directed staff to provide a lidded cup for the resident's coffee and hot liquids, and had changed to drinking cups with lids for all residents at risk for spilling their drinks. Medication Aide E stated the resident did complain of pain occasionally, but lately it was more of an itch. On 5/10/17 at 10:14 AM, Nurse D stated he/she heard Dietary Aide F, who was in the dining room, say that Resident #1 had spilled his/her coffee. Nurse D stated he/she was in the living room when he/she observed Medication Aide E was at Resident #1's table and started to bring the resident out to Nurse D. Nurse D stated he/she then poured the pitcher of ice water that was on his/her medication cart, on Resident #1's lap and assisted him/her back to his/her room where staff undressed the resident. Nurse D stated when he/she initially assessed Resident #1, there were no red areas on his/her legs. Nurse E then applied cold cloths to the resident's legs, and assisted the resident to change his/her incontinent brief, and then to bed. Nurse D stated approximately 15 minutes later, he/she went back to Resident #1's room to check on him/her, and the resident's legs had turned red. Nurse D stated approximately one hour later, Resident #1's right inner thigh had a blister, so staff placed a cool wash cloth on the blistered area and rechecked an hour later. Nurse D then notified the resident's physician because the resident's wounds had progressively worsened with blisters starting on both legs, the cool washcloths had not helped, and the resident complained of pain, even though he/she had administered pain medications to the resident. Nurse D stated at 9:00-9:30 PM staff sent the resident to the emergency room and he/she did not return from the hospital before Nurse D's shift was over. On 5/10/17 at 9:23 AM, Administrative Nurse A stated not all residents at risk for spilling hot liquids were to have lids on their hot liquids. The facility's intervention was that Resident #1 was supposed to, the residents have a choice. Administrative Nurse A stated the facility had discussed putting lids on for people at risk, and have chosen to cool down the coffee. Administrative Nurse A stated the coffee was now served at 145 degrees Fahrenheit, prior to this incident the coffee was still served at a temperature below 180 degrees. Administrative Nurse A stated he/she hesitated to place a lid on Resident #1's coffee out of fear he/she may not drink it, and staff were cooling the coffee for the resident before this. Administrative Nurse A stated a hot liquid evaluation had not been completed on Resident #1 or any other resident prior to the incident on 4/22/17, and the facility had no policy for it. The temperature of the coffee when checked on 5/9/17 and 5/10/17, ranged between 139 and 145 degrees Fahrenheit. On 5/10/17 at 10:50 AM, Dietary Manager G stated the kitchen staff had not checked the temperature of the hot liquids prior to serving them to the residents until this accident happened, but staff now check the hot liquids temperatures for all the residents, anytime they are served. Dietary Manager G had not identified the appropriate temperature range of the coffee. On 5/10/17 at 1:50 PM, Physician H stated the facility should not have had the temperature of the coffee so hot, and with the resident moving so quick, his/her spilling should have been expected. Physician H stated it could have been, and should have been in Resident #1's care plan, that she was at risk for spilling hot liquids. Upon request, the facility was unable to provide a Hot Beverage Policy that had been developed, prior to this incident. The facility failed to ensure Resident #1 remained as free of accidents hazards as possible, when he/she received 1st and 2nd degree burns after spilling a cup of hot coffee on his/her lap.

The facility had a census of 44 residents. The sample included 13 residents of which 3 were reviewed for nutrition. Based on observation, interview, and record review, the facility failed to develop and implement nutritional interventions, in a timely manner, to prevent significant weight loss for 1 of 3 residents reviewed for nutrition, who lost 11.49% of his/her body weight in the 25 days after admission to the facility on [DATE], and another 5.15% of his/her body weight in 1 week in July. (#53) Findings included: - Resident #53's admission (MDS) Minimum Data Set assessment, dated 6/10/16, indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status score of 14 and had been admitted from an acute hospital. The assessment indicated the resident required limited assistance with eating, and weighed 160(#) pounds. The MDS indicated the resident had no weight loss, no therapeutic or mechanically altered diet, no swallowing problems, and no teeth. The 6/10/16 (CAA) Care Area Assessment for nutrition revealed the resident was at risk for less than adequate nutrition and fluid intake related to he/she required occasional assistance with eating. The summary further stated the resident had no teeth and chose not to wear his/her dentures, was occasionally confused, and would forget to eat or drink. The initial care plan, dated 6/3/16, instructed staff to provide a regular diet, offer food/drink, and weigh the resident on admission and monthly. Review of the medical record on 7/27/16 revealed no comprehensive plan of care for the resident's nutritional needs, even though the resident lost weight during the first month after admission to the facility. The 6/3/16 physician's orders [REDACTED]. The 6/20/16 (RD) Registered Dietician assessment stated the resident received magic cups between meals TID, ate in the dining room and reported a good appetite. However, he/she had weight loss of 14# since admission to the facility. The assessment stated the resident had no teeth or dentures and had chewing or swallowing difficulties. The dietician recommended a mechanical soft diet due to no teeth, chewing/swallowing difficulties, and a 14# weight loss since admission. The 6/20/16 physician order [REDACTED]. Review of the resident's weight record revealed the following: 6/3/16 admission weight 167# 6/8/16 - 160# 6/14/16 - 152.6#, a loss of 14.4# (8.62%) in 11 days since admission. 6/22/16 - 150# 6/28/16 weight 147.8#, a loss of 19.2# (11.49%) in the 25 days since the resident's admission to the facility on [DATE]. Review of the resident's meal intake for June 2016, revealed the resident consumed 0-100% of meals, and refused some meals. Review of the (MAR) Medication Administration Record [REDACTED]. The 6/30/16 blood labwork revealed [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) level normal at 3.8 (normal range is 3.4 to 4.8), and total protein elevated at 8.6 (normal range is 6-8.3) Review of the medical record revealed, on 6/30/16, the resident was discharged from the facility. On 7/12/16, the facility readmitted the resident with a physician's orders [REDACTED]. No re-admission weight documented. On 7/14/16, the resident weighed 151.4#. The 7/14/16 registered dietician's assessment stated the resident's intake varied from 0-100%, and he/she received a magic cup TID for nutritional support. The assessment lacked additional interventions for the resident. The 7/21/16 weight of 143.6# indicated a significant weight loss of 5.15% in one week. Review of the medical record revealed no documentation the staff notified the physician or the registered dietician of the resident's significant weight loss. Review of the resident's meal intake for July 2016, revealed the resident consumed 25-100% of meals. Review of the (MAR) Medication Administration Record [REDACTED]. On 7/25/16 at 11:00 AM, observation revealed the resident sat at the dining room table, waiting for staff to take his/her meal order. Continued observation revealed at 11:30 AM, (30 minutes later) dietary staff took his/her meal order, and at 11:48 AM, dietary staff had not yet served the resident his/her meal when nursing staff asked the resident if he/she was done eating and wheeled the resident from the table. At 11:50 AM, continued observation revealed Administrative Nurse A informed staff the resident had not eaten yet and instructed staff to bring him/her back to the table. On 7/26/16 at 8:25 AM, observation revealed the resident independently ate 100% of a ham/cheese omelet, 2 pieces toast, 360 (cc) cubic centimeters water, with no chewing problems observed. On 7/26/16 at 11:22 AM, observation revealed the resident independently ate 100% of a bowl of ground chicken with gravy, creamed corn and drank 360 cc of ice water. On 7/26/16 at 3:00 PM, observation revealed the resident in bed and no magic cup observed in the room. Further observation revealed staff delivering afternoon snacks on another hall and stated they had already been down the resident's hall to pass snacks. On 7/27/16 at 10:20 AM, observation revealed the resident in bed and no magic cup observed in the room. The resident stated he/she did not receive magic cups or health drinks. On 7/27/16 at 11:25 AM, Administrative Nurse A stated the resident usually drank water, and does not have problems chewing or swallowing on the soft diet. Administrative Nurse A stated the weight report only triggered their attention if a resident lost a significant amount if one resident was reviewed at a time. Administrative Nurse A stated he/she had no further weight meeting notes, for this resident, after 6/8/16. On 7/27/16 at 1:35 PM, Medication Aide K stated the resident received magic cups TID with meals, and staff received them from the kitchen because they need to be refrigerated. Medication Aide K stated he/she documented if staff offered a magic cup, but did not document how much the resident consumed. He/she stated the computer program did not allow staff to document the amount consumed. Medication Aide K stated the resident usually ate a couple of bites of the magic cups, and stated staff have not tried other supplements. On 7/27/16 at 1:50 PM, Dietary Staff C stated the resident received what is on his/her diet card. Observation of the resident's diet card revealed mechanical soft diet/ground meats, and did not include magic cups. Dietary Staff C stated the dietary department did not have an order for [REDACTED]. He/she stated the registered dietician came to the facility on ce per month. Dietary Staff C stated the nurse aides obtained weights, documented in the computer, and the Dietary Staff C and the (DON) Director of Nursing reviewed the weights each week. Dietary Staff C stated if a resident started losing weight, the DON contacted the registered dietician and/or physician for further intervention. He/she verified he/she had not notified the registered dietician of the resident's significant weight loss in July. On 7/27/16 at 2:35 PM, the resident reported staff did not offer him/her supplements or health drinks. On 7/27/16 at 4:23 PM, Medication Aide J stated staff offered the resident a magic cup with meals but he/she refused most of the time. He/she stated staff documented the refusal on the (MAR) Medication Administration Record, [REDACTED]. Observation, at this time, revealed Medication Aide J requested a magic cup from the dietary staff, and at 4:31 PM, Dietary Staff C stated the facility had no magic cups in stock and it would be 2 days before a new shipment arrived. On 8/1/16 at 9:50 AM, Administrative Nurse A verified staff had not completed a comprehensive care plan and should have developed and implemented a care plan for the resident who required meal assistance at times, supplements, mechanical soft foods, and had a significant weight loss. He/she stated staff obtained magic cups from another facility in town. On 8/2/16 at 11:00 AM, Registered Dietician L verified the facility had not notified him/her of the resident's significant weight loss between 7/14/16 and 7/21/16, and had not made him/her aware the resident consumed only 25% of the magic cup supplements. On 8/2/16 at 3:41 PM, Physician's Nurse T stated the facility had not notified the physician of the resident's significant weight loss and poor consumption of the magic cups. He/she stated the physician saw the resident in the office on 7/22/16 and the resident would not allow the physician's staff to weigh him/her. The facility's 9/2008 Weight assessment and Intervention policy directed nursing staff to weigh residents on admission, the next day, and weekly for 2 weeks thereafter. If no weight concerns are noted, weights will be obtained monthly thereafter. The policy directed staff to retake the weight if any weight change of 5% or more since the last weight. If significant weight loss is verified, nursing would immediately notify the dietician in writing. The policy stated the following criteria for significant weight loss as follows: 1 month - 5% weight loss is significant, greater than 5% is severe. 3 months- 7.5% weight loss is significant, greater than 7.5% is severe. The policy instructed staff to address weight loss or impaired nutrition with individualized care plans based on the needs of the resident, functional factors, chewing/swallowing abnormalities and the use of supplements. The facility failed to notify the physician and the registered dietician of the significant weight loss, Resident #53, who had a significant weight loss and poor intake of magic cups, which placed the resident at risk for further impaired nutrition.

The facility had a census of 45 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for 1 of the 3 sampled residents reviewed for accidents, who was left alone on the toilet, fell , and sustained a rib fracture. (#1) Findings included: - Resident #1's annual (MDS) Minimum Data Set assessment, dated 8/11/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 8, which indicated he/she had moderate cognitive impairment. The MDS indicated the resident required extensive assistance from the staff for toileting, limited assistance from the staff for transfers, had unsteady balance and used a walker and a wheelchair for mobility. The MDS revealed the resident had no falls since the prior assessment. The 8/11/14 fall (CAA) Care Area Assessment, indicated the resident required limited to extensive assistance from the staff for transfers, did not ambulate, received psychotropic medications, and he/she could be up with assistance to the toilet. The 8/17/14 care plan stated the resident was at risk for falls, directed the staff to provide extensive assistance of 1 staff for toileting, and the resident occasionally had not used his/her call light for assistance. The care plan further directed the staff to keep the resident's bed in low position, and remind the resident not to stand when he/she felt unsteady. The Morse scale for fall risk assessment, dated 8/11/14, revealed the resident was at high risk for falls. The 9/24/14 at 6:39 AM nurse's notes revealed around 4:25 AM, the (CNA) Certified Nurse Aide notified the nurse the resident was on the floor. The staff found the resident on the floor, in his/her bathroom, lying on his/her left side, with knees bent, and his/her left arm positioned under the resident. The note revealed the staff assisted the resident back into his/her bed, the resident complained of pain all over, a sharp pain in his/her left side, and the resident was transported to the emergency room by ambulance at 5:22 AM. The 9/25/14 at 3:41 PM nurse's notes revealed the hospital nurse informed the facility the resident would be admitted to the hospital for observation, regarding a fracture of the resident's 7th rib. The emergency room report, dated 9/24/14, revealed the resident had a [DIAGNOSES REDACTED]. The hospital consult report, dated 9/24/14, revealed the ambulance brought the resident to the emergency room , after a fall in his/her bathroom, when he/she landed on his/her left side. The resident reported pain with deep inspirations and pain on his/her left side, with most of the pain in his/her chest area. The chest x-ray, dated 9/24/14, revealed a left, 7th rib fracture. On 10/28/14 at 9:10 AM, observation revealed the resident, lying in bed, positioned on his/her left side, with his/her eyes closed. Further observation revealed the bed in the low position, the call light in reach and the room well lit and uncluttered. Observation of the resident's bathroom revealed a grab bar on the wall on the right side of the toilet. On 10/28/14 at 3:25 PM, Licensed Nurse A, verified the staff should not have left the resident alone on the toilet because he/she is a fall risk. On 10/29/14 at 4:50 AM, Nurse Aide A, verified he/she was working when the resident fell . Nurse Aide A verified residents who are at risk for falls should not be left alone while on the toilet. Nurse Aide A did not know if the resident was at risk for falls. The 9/24/14 signed witness statement, revealed Nurse Aide E assisted the resident to the bathroom at approximately 4:15 AM on 9/24/14, left the resident alone, and at approximately 4:25 AM, when in another resident's room, heard the resident screaming. The statement revealed Nurse Aide E found the resident lying on his/her left side on the bathroom floor. On 10/29/14 at 8:15 AM, Administrative Nurse C, verified the resident was a high fall risk and he/she expected the staff to stay with the resident while in the bathroom. Administrative Nurse C verified residents who are at risk for falls, should have a sticker on their chart to identify them as a fall risk. Administrative Nurse AC verified there was no fall risk sticker on the resident's chart, and no way to alert the staff of his/her fall risk. Administrative Nurse C verified the care plan did not identify the resident as a high fall risk, and did not direct the staff to stay with the resident when toileted. The 11/9/12 facility policy for falls and fall risk management revealed the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to ensure staff provided a safe environment, with adequate supervision for Resident #1, who fell while left unattended, in the bathroom, and sustained a rib fracture.