Every finding on record at Legacy on 10TH Avenue

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program, including implementing necessary repairs so that the facility was free of pests. Findings included:- Review of the Pest Control Service Summary Report dated 07/06/2026 documented an inspection of all interior rodent traps and recorded captures accordingly; two traps were replaced. The summary documented treatment of entryways throughout the facility for control of unwanted invaders, and treated the kitchen sinks, drains, and washbasin for continued roach and fly prevention. The summary documented an inspection of the food storage room was performed due to mouse droppings being found. Upon inspection, an abundance of mouse feces behind the deep freezer and in the corner of the storage room was found. Review of the Pest Control Service Summary Report dated 07/07/2026 documented an inspection of the snap traps and interior devices, with one mouse caught in a snap trap in the kitchen dry storage area. Maintenance UU reported fleas in a resident room, and it was treated appropriately. The summary documented drain flies were noticed at the nurses' station, and gnats were reported in the conference room, and all areas were treated appropriately. Review of the Pest Control Service Summary Report dated 07/09/2026 documented a follow-up visit on the snap traps set out for mice in the food storage area. The summary documented one successful capture recorded. All snap traps were replaced, and upon observation, corrosion at the bottom of the exterior food storage entry door was seen. The area is large enough for rodent entry; a condition had been created for repair. Action required: the door needs to be rodent-proofed on the exterior storage door. The summary suggested repair or replace as needed. Review of the Pest Control Service Summary Report dated 07/23/2026 documented fruit fly presence throughout the kitchen. Staff were spoken to about cleaning the undersides of appliances and along plumbing pipes, which is where the flies were harboring. The kitchen storage room was serviced with one captured mouse. The exterior storage door had been repaired. Review of the Pest Control Service Summary Report dated 08/03/2026 documented treatment to the soiled linen and laundry room for fly control. Review of the TELs Work Order Log revealed the exterior food storage entry door was repaired on 07/21/2026 at 11:38 AM. On 07/29/2026 at 12:06 PM, Resident (R) 9 lay in his bed wrapped in his sheet, leaning towards the window. R9 was bare-chested with blue PRAFO boots (pressure-relieving boots) on his feet. R9 did not awaken when his name was called. His breakfast plate with juice and a Mighty Shake sat on his bedside table. There were multiple flies flying around the plate, juice, and a Mighty Shake. There were also smaller fruit flies landing and flying around over the bedside table. R9 also had two flies landing and crawling on him in his room. On 07/29/2026 at 12:14 PM, Licensed Nurse (LN) G verified that there were fruit flies and flies in the room. On 07/29/2026 at 12:29 PM, Maintenance U stated that he had a complaint about fleas in a resident's room. He reported it to the pest control company. Maintenance U reported that when the pest control company reviewed the room, there was no indication of fleas, but the room was treated for fleas just in case there were in the room. On 07/30/2026 at 12:36 PM, R12 stated that he had been bitten on his head a while ago. R12 stated that he had told the former Director of Nursing about the incident. He reported that since that time, he had not had any further concerns with bugs or pests. On 08/04/2026 at 07:18 AM, the kitchen had a wet floor; a sour odor was smelled in the kitchen; there were two racks that hold trays positioned near the dishwasher, holding multiple trays of dirty dishes and trash. On 08/04/2026 at 07:19 AM, Dietary BB stated that the dishwasher had backed up last night during dinner and that was why no dishes were cleaned. Dietary BB further stated that it also had backed up into the three sinks used to wash the dishes by hand. Upon moving to the dry storage area, Dietary BB stated that when she would go in there to get dry goods, she would notice holes in the bags of food. Dietary BB stated she thought it was from staff poking a hole into the bags, and she would throw it away. She then revealed that she had thrown away a lot of food. On 08/04/2026 at 07:41 AM, Certified Nurse Aide (CNA) P stated that the facility always had a lot of bugs, especially when it rained, and the water would just seep into the dining room. CNA P stated she had even seen maggots in R1's wound. On 08/04/2026 at 07:49 AM, flies were seen flying around in the dining room. Staff were seen swatting at/shooing away flies over the top of breakfast food and drinks that staff were serving to the residents. On 08/04/2026 at 11:18 AM, Maintenance U stated that when he does receive reports about mice or flies in the building, he makes sure to put it into the pest control company, and they are good about coming out to take care of any concerns he reports to them. On 08/04/2026 at 05:20 PM, R9 lay in bed with his blanket wrapped around him and his feet sticking out at the bottom with his Profo boots on both feet. There were a couple of flies flying around R9 and landing on him. On 08/04/2026 at 05:21 PM, Administrative Nurse E verified that R9 had flies landing on him while he laid in bed. Administrative Nurse E stated she would need to let Maintenance U know about the flies. The facility's Pest Control policy, revised October 2021, documented the facility would maintain an effective pest control program.

Based on interviews, observations, and record review, the facility failed to prepare, cook, serve, and store food in a sanitary manner for the 57 residents who lived in the facility. Findings included:- On 07/29/2026 at 10:15 AM, the following observations were discovered in the refrigerator:Uncovered, undated elbow noodles, orange in color in a soup bowl in the refrigerator.A large stainless-steel bowl of yellow pudding that appeared to be hardening was uncovered and undated in the fridge.A steel tub of light brown substance was covered with a torn piece of aluminum foil, unlabeled and undated. Dietary BB stated she had no idea what the light brown substance was. None of the refrigerators or freezers had temperature logs with visible temperatures, Dietary BB stated that she had them in her office on a clipboard. Review of the facility refrigerator /freezer and meal temperatures revealed:July 2026 had no morning or evening temperatures of the Prep Stand-up Freezer.July 2026 had no morning or evening refrigerator temperatures for the milk refrigerator. Review of May through July 2026 Food Temperature Logs revealed temperatures were missed on 06/27/2026 supper, 07/25/26 lunch, 07/25/2026 supper, 07/28/2026 supper, no sheet for 07/08//2026 missing all three meals, and no sheet provided for 07/18/2026 through 07/26/2026 Review of the Low Temperature Dish Machine Temperature Log dated May 2026 revealed no breakfast, lunch or dinner temperature checks on 05/13/2026, 05/14/2026, 05/21/2026, 05/22/2026, 05/23/2026, 05/25/2026, 05/26/2026, 05/27/2026, 05/28/2026, and 05/31/2026. Review of the Low Temperature Dish Machine Temperature Log dated June 2026 revealed no breakfast, lunch, or dinner temperature checks on 06/11/2026 through 06/30/2026. No Low Temperature Dish Machine Temperature Log provided for July 2026. The dry storage room had multiple shelves that were empty. When asked about this, Dietary BB revealed that there had been a concern with mice and they had lost a lot of the dry food supplies. On 08/04/2026 at 07:18 AM, the kitchen had a wet floor; a sour odor was apparent in the kitchen; there were two racks that hold trays positioned near the dishwasher, holding multiple trays of dirty dishes and trash. On 07/29/2026 at 02:30 PM, Dietary BB stated there was a mouse problem. She further stated that the dietary staff had started to move the dry food over into the kitchen. Dietary BB stated the mice were getting into the food. She stated the dry storage areas were deep cleaned twice, and it was discovered the mice were getting in because of a spot on the outside door. It has been fixed, and since then, mice have been caught, and she had not seen any recently. On 08/04/2026 at 07:19 AM, Dietary BB stated that the dishwasher had backed up the previous night during dinner and that was why no dishes were cleaned. Dietary BB further stated that it also had backed up into the three sinks used to wash the dishes by hand. Upon moving to the dry storage area, Dietary BB stated that when she would go in there to get dry goods, she would notice holes in the bags of food. Dietary BB stated she thought it was from staff poking a hole into the bags, and she would throw it away. She then revealed that she had thrown away a lot of food. On 07/30/2026 at 02:35 PM, Administrative Staff A stated that the kitchen staff had been in the kitchen cleaning last night. She stated that she had gone into the kitchen and started to clean off the counters but then told Dietary BB that she needed to address the cleanliness of the kitchen. On 08/04/2026 at 12:33 PM, Administrative Staff A stated she was notified there was a concern in the kitchen about the dishwasher not working, but she was not aware that the dishes were not done. Administrative Staff A stated she guessed she should have dug into that a little deeper when she got the text the previous evening The facility's Food Preparation Service policy, revised October 2021, documented that the temperatures of foods held in steam tables were monitored throughout the meal by food and nutrition services staff. The facility's Food Receiving and Storage policy, revised October 2021, documented that all food stored in the refrigerator or freezer would be covered, labeled, and dated ( use by date). Refrigerated foods must be stored below 41 degrees Fahrenheit (F) unless otherwise specified by law. Functioning of refrigeration and food temperatures would be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.

Based on observations, interviews, and record reviews, the facility failed to implement acceptable infection control practices when staff did not properly store Resident (R) 2's and R3's oxygen tubing and nasal cannula in a sanitary manner. The facility failed to properly store R2 and R3's nebulizers (a device that changes liquid medication into a mist easily inhaled into the lungs) in a sanitary manner. The facility failed to ensure R5's Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) bag was secured in a sanitary manner. The facility failed to ensure staff performed wound care for R1 and R3 in a sanitary manner. The facility failed to ensure that staff performed accu-checks and administered insulin for R1 in a sanitary manner. The facility failed to access and flush R3's nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) tubes in a sanitary manner. Findings included:- On 07/29/2026 at 10:24 AM, R2's Oxygen tubing and nasal cannula were draped over her wheelchair outside of her room and not secured in a bag. On 07/29/2026 at 10:25 AM, R3's nebulizer was placed on the bedside, unbagged and dated 05/26/2026. R3's Oxygen tubing and nasal cannula were coiled up and laid in the concentrator, unbagged. On 07/30/2026 at 10:25 AM, two mattresses leaned against a windowsill, and one of the mattresses had the side seal broken with the inner foam exposed. On 07/30/2026 at 01:48 PM, License Nurse (LN) H gathered supplies (four-by-four gauze, distilled water in a cup, paper tape, and two split gauze dressings ripped open). LN H donned gloves, took the wound care supplies into R3's room, laid them on R3's bed with no barrier under them, and did not put a gown on. LN H confirmed that there were no dates on the dressings she removed from R3's back. The dressing removed from the left nephrostomy tube had dried blood, it was balled up and placed on the bed, next to the clean dressing supplies. LN H took four-by-four gauze, wetted it with distilled water, and wiped the nephrostomy tube to clean it. LN H then re-wiped the skin around the nephrostomy tube with a four-by-four gauze. LN H did not change gloves and did not perform hand hygiene after removing the dirty dressing. After LN H cleaned the left nephrostomy tube LN H attempted to throw the used gauze in the trash and missed, the dirty gauze landed on the floor. LN H picked the dirty gauze up from the floor and attempted to throw it in the trash and again missed. LN H then placed the clean dressing and tape around the nephrostomy tube and initialed and dated the dressing. LN H did not change gloves and did not perform hand hygiene prior to placing the clean dressing on. LN H then attempted to remove the dressing from the right nephrostomy tube but noticed the sterile water was empty. Ln H removed her gloves and went to the treatment cart, poured new sterile water, donned new gloves, and did not perform hand hygiene. LN H then wetted gauze and used it to loosen the dressing edges and then peeled the border gauze dressing from R3's right nephrostomy tube. The dressing removed from the right nephrostomy tube had dried blood on it. LN H threw the soiled dressing into R2's bedside table and made it after one attempt. LN H wetted a four-by-four gauze and wiped around the nephrostomy tube insertion site; she did not change gloves and did not perform hand hygiene. While LN H wiped the area, she turned the gauze repeatedly and continued to wipe the area. The gauze became reddish-brown, and she then threw the soiled gauze in the trash. LN H then grabbed a clean gauze, wetted it, and wiped the nephrostomy tube from the insertion site downward, she did not change gloves or perform hand hygiene. R3 then sat down, and LN H placed the clean dressing over the nephrostomy tube site without changing gloves, and she did not perform hand hygiene. On 08/04/2026 at 08:00 AM, LN G pulled the treatment cart into the dining room, he had a glove on his right hand. LN G took the accu-check machine to R1 and performed a blood sugar check on R1's finger. LN G threw the lancet and used glucometer strip into the sharp's container, then took a new glucometer strip and placed it into the glucometer, went and performed a blood glucose check on a different resident, and never sanitized the glucometer. Once the blood sugar readings were performed, LN G removed insulin pens and alcohol pads from the cart, and he provided the insulin to R1, and the other resident, and LN G never performed hand sanitation. On 08/04/2026 at 10:55 AM, LN G asked R3 if it was ok to flush her nephrostomy tubes, and R3 agreed. LN G pushed R3 into the shower room in her wheelchair. LN G gathered supplies and donned gloves without sanitizing his hands. LN G then took R3's left nephrostomy tube, clamped it, wiped the port with an alcohol pad, attached a normal saline (NS) flush to the port, and pushed in the NS while he explained to R3 what was happening. Once LN G had administered the entire 10 cubic centimeters (cc) of NS, he unclamped the nephrostomy tube. LN G proceeded to the right nephrostomy tube and performed the same procedure. Once he had finished, LN G removed his gloves and washed his hands. On 08/04/2026 at 12:39 PM, R5 was in bed with sheets pulled up on his chest with his eyes closed. R5's catheter was on the floor, and there was no privacy bag covering it. On 07/30/2026 at 08:59 AM, R1 stated that the staff had wrapped up his left ankle and heel to make sure that bugs did not get on it. R1 stated that his wound had maggots in them two different times. R1 stated that the staff had cleaned the maggots from his wounds, but he had been admitted to the hospital, and his left leg had been amputated. R1 expressed that he had become unhappy that he had lost his left leg. On 07/30/2026 at 10:23 AM, Certified Medication Aide (CMA) R verified that R3's Oxygen nasal cannula had not been bagged and was draped on the oxygen concentrator in R3's room. CMA R confirmed that R3's nebulizer sat on her over-bed table unbagged and dated 5/26/2026, said they should have been bagged when not in use. On 07/30/2026 at 10:38 AM, Certified Nurse Aide (CNA) N confirmed that the seal was broken on the mattress and said that it was used as a fall mat. CNA N confirmed that the foam was open to air and that if it were to get soiled in any way, it could not be cleaned. On 07/30/2026 at 02:22 PM, LN H stated she should have placed a barrier between R2's bed and the dressing supplies. LN H stated that she should have changed her gloves when she transitioned between cleaning the soiled area and placing the clean dressing onto R2's nephrostomy sites. On 08/04/2026 at 11:27 AM, CMA R stated that when a resident was on EBP, staff were to wear a gown and gloves when providing care to that resident. CMA R also said that a urinary catheter, or the collection bag should never lie on the floor. On 08/04/2026 at 12:46 PM, Consultant GG confirmed that R5's urinary catheter bag was on the floor. Consultant GG stated that a catheter bag should not have been on the floor. On 08/04/2026 at 01:30 PM, CNA P stated that R1 had had maggots in his wound on his left heel, and that she had seen them and it had happened more than once. CNA P said other staff had seen them as well, and it was reported to administration, but the response was to not say anything about it. On 08/04/2026 at 01:55 PM, LN G stated that he should have put gloves on when he was checking the blood sugars in the dining room. LN G said he should have cleaned the accu-check machine in between residents. He also said that when doing dressing changes or accessing R3's nephrostomy tubes, a gown and gloves should have been worn. On 08/04/2026 at 04:15 PM, Administrative Nurse E stated that she expected staff to wash hands before putting on gloves and when staff changed gloves they should be washing or sanitizing their hands. Administrative Nurse E stated that when a treatment was performed on a resident that required EBP, it was expected that the staff wore gloves and a gown, and the resident rooms had the EBP posted on the door to notify staff what should have been worn. Administrative Nurse E stated that when staff provides treatment, there should have been a clean barrier placed between the supplies and the area it is placed on. Administrative Nurse E also said a trash can should have been placed readily accessible before performing the dressing change, she said that it was inappropriate to throw soiled items across the room into the trash. On 08/04/2026 at 04:41 PM, Administrative Staff A stated she expected staff to follow EBP when providing cares for residents that were on EBP. Administrative Staff A stated that she expected the staff that did morning rounds to have identified the mattress with the broken seal, and the unbagged nebulizers and nasal cannulas. The facility's Urinary Continence and Incontinence Assessment and Management policy, revised October 2024, documented routine maintenance of keeping the tubing free of kinks and dependent loops. The policy directed staff to keep the bag below the bladder level and off the floor during care, transfers, and transport. The facility's Policies and Practices - Infection Control policy, revised October 2024, documented the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment, and to help prevent and manage transmission of diseases and infections. The policy documented all personnel would be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training would be appropriate to the degree of direct resident contact and job responsibilities.

Based on record review and interviews, the facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for Resident (R) 14, R15, R16, R17, R18, R19, R20, and R21. Findings included:- Review of the Trust - Current Account Balance dated [DATE] at 12:27 PM documented 36 total accounts with a balance of $14,739.76 The Trust - Current Account Balance documented R14 had a current trust fund balance of $0.01. R14's Electronic Medical Record (EMR) recorded R14 discharged from the facility on [DATE]. The Trust - Current Account Balance documented R19 had a current trust fund balance of $0.02. R19's EMR recorded R19 discharged from the facility on [DATE]. The Trust - Current Account Balance documented R15 had a current trust fund balance of $100.10. R15's EMR recorded R15 discharged from the facility on [DATE]. The Trust - Current Account Balance documented R16 had a current trust fund balance of $155.53. R16's EMR recorded R16 discharged from the facility on [DATE]. The brackets indicate a negative balance, and the account was overdrawn. The Trust - Current Account Balance documented R18 had a current trust fund balance of $393.05. R18's EMR recorded R18 discharged from the facility on [DATE]. The Trust - Current Account Balance documented R20 had a current trust fund balance of $1362.01. R20's EMR recorded R20 died in the facility on [DATE]. The Trust - Current Account Balance documented R21 had a current trust fund balance of $325.05. R21's EMR recorded R21 discharged from the facility on [DATE]. The Trust - Current Account Balance documented R17 had a current trust fund balance of $3077.69. R17's EMR recorded R17 died in the facility on [DATE]. On [DATE] at 09:57 AM, Administrative Staff B stated she thought a trust fund was to be closed within 30 days of discharge or death. On [DATE] at 10:12 AM, Consultant HH stated that if a resident discharged or expired, their trust fund account should be closed within 30 days of the discharge or expiration date. The facility's Closing Resident Trust Funds policy, revised [DATE], documented when a resident was discharged or otherwise closed their account, the facility would refund their trust balance. The policy documented that residents who were discharged from the facility would have their trust accounts closed without providing a request in writing. The policy lacked a timeline for when the trust accounts needed to be closed by after a resident closes the account and/or discharged from the facility.

Based on observation, record review, and interviews, the facility failed to ensure adequate narcotic reconciliation when nursing staff failed to sign-off and sign-on each shift indicating a complete count of all controlled substances. Findings included:- Review of July east side Licensed Nurse: As Needed (PRN) Narcotic Count Sheet revealed no 0600-1800 (06:00 AM -06:00 PM) Oncoming Nurse signatures for 07/01/2026, 07/17/2026, 07/18/2026, 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/24/2026, 07/26/2026, 07/28/2026, and 07/30/2026. No 0600-1800 Off Going Nurse signatures for 07/01/2026, 07/17/2026, 07/18/2026, 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/24/2026, 07/26/2026, and 07/28/2026. No 1800-0600 Oncoming Nurse signature for 07/29/2026 and no Off-Going Nurse signature for 07/29/2026. On 08/04/2026 at 08:48 AM, Licensed Nurse (LN) H stated that the nurses were supposed to count the narcotics in the medication cart to ensure that the count was correct and sign the book verifying that it was completed. LN H stated that if there is a concern with counting the narcotics, she would notify the Director of Nursing or the Assistant Director of Nursing. On 07/30/2026 at 01:23 PM, LN L stated that when she came on for her shift, she counted the cart. LN L stated that the nurses were supposed to sign that the medications were counted and verify that the count is accurate. LN L stated the oncoming nurse would count the pills, while the off-going nurse would verify the count in the book. If there is ever a discrepancy, LN L would contact the Director of Nursing or the Assistant Director of Nursing. On 08/04/2026 at AM, LN G stated that the nurses had been told to make sure that they are counting the narcotics and signing off on the sheet showing that the count has been completed between the oncoming and off-going nurse. I do not know who reviews the sheets to make sure that everyone is counting off the narcotics like they are supposed to, but he knew of times that administration would come around and tell the nurses to make sure that they are completing this task. On 08/04/2026 at 05:00 PM, Administrative Nurse E stated that the nurses are expected to count the narcotics on the medication carts to verify that the count is accurate and then sign in the narcotic book, signaling the task was completed.

Based on observations, interviews, and record review, the facility failed to complete accurate Minimum Data Set (MDS) assessments for Resident (R) 1, which listed the correct s below the knee amputation (BKA) when staff documented R1's left leg was amputated, though it was the right leg. Findings include:- R1's Electronic Medical Record (EMR) documented diagnoses of chronic heart failure, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), type two, hypertension (elevated blood pressure), constipation, diabetes mellitus type two with foot ulcer, and acquired absence of left leg below the knee. R1's admission MDS dated 06/27/2026 documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated intact cognition. The MDS documented R1 had a diagnosis of acquired absence of the left leg below the knee. R1's Quarterly MDS dated 11/06/2025 documented R1 had a diagnosis of acquired absence of the left leg below the knee. R1's Quarterly MDS dated 02/05/2026 documented R1 had a diagnosis of acquired absence of the left leg below the knee. R1's Quarterly MDS dated 03/27/2026 documented R1 had a diagnosis of acquired absence of the left leg below the knee. R1's Quarterly MDS dated 06/27/2026 documented R1 had a diagnosis of acquired absence of the left leg below the knee. Review of R1's Pre-admission Paperwork dated 07/14/2025 documented R1 had acquired absence of leg below knee, right. On 07/29/2026 at 12:35 PM, R1 self-propelled in his wheelchair from the dining room towards the hallway that his room was located on. R1 had no legs below the knee, but had a bandage wrapped around the stump of his left leg. On 07/30/2026 at 08:59 AM, R1 stated that he had his left leg amputated when he went out to the hospital on [DATE]. On 08/04/2026 at 09:31 AM, Consultant II stated that when R1 was admitted to the facility, it was his right leg that was amputated below the knee. On 08/04/2026 at 04:15 PM, Administrative Nurse E stated that she must have just copied the previous diagnosis on the last MDS and did not look to see which leg was amputated when he was admitted to the facility. The multiple MDS that stated the absence of the left leg below the knee are wrong and will need to be fixed. According to CMS's Resident Assessment Instrument (RAI), revised 10/01/2025, Medicare and Medicaid participating Long Term Care (LTC) facilities are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional and health status. The RAI process is the basis for accurate assessment of each resident. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the residents' current health status, which drives the current plan of care.

Based on observations, record review, and interviews, the facility failed to ensure a dignified care environment for residents during meal service and for residents with catheter bags. Findings included:- On 08/04/2026 at 07:49 AM, an unidentified Resident (R) seated in a Broda chair (specialized wheelchair with the ability to tilt and recline) that was propelled by staff into the dining room with his catheter urine collection bag visible as it hung from the bottom of his wheelchair. The bag lacked a privacy/dignity cover. On 08/04/2026 at 08:15 AM, staff pushed R7 into the dining room with his catheter urine collection bag attached to the arm of his wheelchair. The bag lacked a privacy/dignity cover. On 08/04/2026 at 07:59 AM, Licensed Nurse (LN) G entered the dining room pushing a treatment cart. LN G proceeded to go to R1 and perform an Accu-check (a blood glucose monitoring test) at the dining room table. LN G then walked to a different table and performed a second Accu-check on another resident at a different dining room table. LN G then returned the treatment cart and dialed up insulin (a hormone that lowers the level of glucose in the blood) on two different insulin pens, carried them both in one hand, back to the table of the unidentified resident, and administered the insulin, and then proceeded to R1 and administered the second drawn-up insulin pen in full view of all residents in the dining room. On 08/04/2026 at 11:27 AM, Certified Medication Aide (CMA) R stated that a catheter bag should be covered for privacy. On 08/04/2026 at 12:00 PM, LN K stated that the catheter bag stated that a catheter bag should be covered for privacy. On 08/04/2026 at 01:58 PM, LN G stated that he was caught, and said he should not have done the Accu-checks or given the insulin in the dining room. LN G further stated he hated pulling residents out of the dining room to check the Accu-check and give the resident insulin. On 08/04/2026 at 04:15 PM, Administrative Nurse E stated that Accu-checks or insulin should never happen in the dining room in front of the other residents. On 08/04/2026 at 04:41 PM, Administrative Staff A stated that she expected staff to not perform Accu-checks or administer insulin in the dining room. The facility's Quality of Life - Dignity policy, revised October 2021, documented that each resident would be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. The policy documented staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observations, interviews, and record review, the facility failed to ensure staff treated Resident (R) 8 with dignity when staff became argumentative with him regarding his money. Finding included:- R8's Electronic Medical Record (EMR) documented diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), unspecified intracranial injury with loss of consciousness, and cortical blindness (a condition where the brain has trouble processing and understanding signals sent from the eyes). R8's Quarterly Minimum Data Set (MDS) dated 06/25/2026 documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated mildly impaired cognition. R8's MDS documented that he had no behaviors. R8's Care Plan directed staff to offer verbal and tactile cues for mapping of the facility (revised 03/16/2026). R8's plan of care directed staff to monitor and document for physical and/or nonverbal indicators of discomfort or distress and follow up as needed (initiated 03/16/2026). R8's Care Plan had no focus on outbursts or behaviors. Review of Administrative Staff B's Background Check dated 06/17/2026 revealed no documentation of the existence of any criminal history. Review of Administrative Staff B's Attestation Form: Policy: Abuse Investigation and Reporting signed on 07/09/2026 documented she had read and attested to understanding the listed policy and that the facility had zero tolerance related to any form of abuse, neglect, exploitation, and misappropriation. Review of Abuse Prevention Program policy training dated 07/09/2026 had Administrative Staff B's signature. Observation revealed the following conversation in the hall on 08/04/2026:At 01:00 PM, R8 stood in the hallway visibly upset about not being able to locate his $30.00. R8 asked Administrative Staff B if she ever gave him his money. R8 stated he thought that Administrative Staff B never even gave him his money and said he was s going to ask someone if she ever gave him his money.At 01:02 PM, Administrative Staff B responded to R8 stating that she did give him the money. Administrative Staff B then stated repeatedly that she gave R8 his money, and her voice became louder and [NAME] as she repeated herself.At 01:03 PM, R8 reached into his pockets repeatedly while telling Administrative Staff B that she was not right, because he could not find his money.At 01:04 PM, Administrative Staff B stated that next time R8 asked for money, she was not going to give it to him. As Administrative Staff B told R8 she would not give him his money when he next asked, she stepped towards R8 and had her hand up and was pointing at R8. On 08/04/2026 at 01:04 PM, Licensed Nurse (LN) G and Certified Nurse Aide (CNA) O talked to R8 and attempted to ask him where he last had his money, and if he wanted help looking for the money he had gotten earlier that day. On 08/04/2026 at 01:05 PM, R8 stated that he did not get his money and that Administrative Staff B was not being truthful, because if he had gotten it, it should be in his pocket. On 08/04/2026 at 01:08 PM, Administrative Staff A was alerted to the situation with Administrative Staff B and R8. Administrative Staff A went to the front hallway where Administrative Staff B and R8 were, and had Administrative Staff B go into her office and close the door. LN G and CNA O were able to calm R8 down enough to go and help him look for his $30.00 dollars. On 08/04/2026 at 01:48 PM, CNA O stated that the situation with R8 could have gone better. CNA O stated the situation was escalated with Administrative Staff B and it should have been deescalated. CNA O revealed that R8 was known to get upset easily, and staff know that they have to help calm him down. On 08/04/2026 at 04:41 PM, Administrative Staff A stated she had suspended Administrative Staff B related to her behaviors with R8. Administrative Staff A stated that the incident should not have gone the way that it did, and said Administrative Staff B should never have told R8 that next time she would not give him money when he wanted it. The facility's Quality of Life - Dignity policy, revised October 2021, directed staff to speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. The policy further documented that demeaning practices and standards of care that compromise dignity were prohibited. The policy documented staff were expected to promote dignity and assist residents.

Based on record review, interview, and observations, the facility failed to identify Resident (R) 5's unwitnessed fall resulting in a head injury as an allegation of abuse or neglect and report to the State Agency (SA) as required. Findings include:- R5's Electronic Medical Record (EMR) documented diagnoses of traumatic subdural hemorrhage without loss of consciousness, hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), 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. R5's admission Minimum Data Set (MDS) dated 07/01/2026 documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R5's MDS documented physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others one to three days during the look back period. R5 required partial to moderate assistance with toilet transfers, oral hygiene, and bed mobility. R5 required substantial to maximal assistance with upper and lower body dressing, putting on and taking off his footwear. R5 was dependent with toileting, shower/bathing himself, and personal hygiene. R5 required supervision or touch assistance to sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, tub/shower transfer, walk 50 feet (ft) with two turns, walk 150 ft, walk 10 ft on uneven surfaces. R5's MDS documented that R5 was unable to determine his fall history prior to admission, but R5 had falls since admission of two or more, with one injury that was not major. R5's Delirium Care Area Assessment (CAA) dated 07/01/2026 documented R5 had evidence of fluctuating delirium symptoms that warranted interventions to identify and treat underlying causes, maintain a safe environment, provide frequent reorientation, monitor cognition and behavior, and promptly notify the provider of significant changes in cognition. R5's Cognitive CAA dated 07/01/2026 triggered but lacked analysis. R5's Behavioral Symptoms CAA dated 07/01/2026 documented R5 demonstrated behavioral symptoms, including wandering, that required individualized interventions. R5's Falls CAA dated 07/01/2026 triggered but lacked analysis. R5's Behavioral Symptoms Care Plan initiated 06/19/2026 directed staff to identify and address unmet needs that may contribute to wandering behaviors. Staff was directed to monitor R5's whereabouts routinely. R5's Fall Risk Assessment dated 06/19/2026, completed post-fall, documented a score of 19.0, high risk for falls. R5's Care Plan initiated on 06/22/2026 and revised on 07/06/2026 documented he was at high risk for falls related to a history of falls, wandering behavior, cognitive impairment, impaired safety awareness, and use of antidepressant medication that may contribute todizziness, sedation, or impaired balance.Interventions dated 06/22/2026 directed staff to anticipate and meet the resident's needs; educate the resident and his caregivers about safety reminders and what to do if a fall occurs; ensure his call light was within reach and encourage him to use it for assistance as needed; respond promptly to all requests for assistance; provide standby assistance during ambulation, especially for longer distances or when R5 appeared fatigued; offer R5 a wheelchair to sit in when he was becoming fatigued. Staff were to follow facility fall protocol.Interventions dated 07/02/2056 documented R5 was provided with non-skid socks and anti-rollback to his wheelchair.Interventions dated 07/06/2026 included the following:Staff were directed to investigate each fall to identify contributing factors and update interventions based on findings.Staff were to encourage regular toileting and respond promptly to requests for assistance to reduce unassisted attempts to ambulate, and to encourage R5's participation in strengthening, balance, and mobility activities as recommended by rehabilitation services.An intervention dated 07/07/2026 directed staff to perform orthostatic blood pressure and pulse measurements (with the patient in the supine, sitting, and standing positions) to assess low blood pressure and possible blood pooling in the lower extremities resulting in dizziness for three days.Interventions dated 07/17/2026 documented non-skid strips were placed beside his bed, and a visual sign call don't fall was placed in his room. R5's EMR documented the following: The Nursing Progress Note dated 06/29/2026 04:28 PM documented that staff alerted the nurse that R5 was found lying on the floor in the hall with blood coming from the back of his. R5 laid in a supine (lying on the back) position on the floor of the hallway, with his walker in front of him. R5 was not responding to verbal stimuli but responded to tactile stimuli. R5 was unable to cooperate with neurological checks, indicating a change in his level of cognition. R5 was sent out to the hospital via emergency medical services (EMS). The Nurses Progress Note dated 06/30/2026 12:19 AM documented R5 returned to the facility, and staff assessed R5's occipital lobe (back of the head) with a laceration that had five staples in place. R5 denied any pain and was restless, not remaining in bed. R5 sat with a Certified Nurse's Aide (CNA) in the hall; the CNA was to provide immediate assistance if R5 began to wander again. On 08/04/2026 at 04:41 PM, Administrative Staff A stated that she had called her corporate support and was told that this concern was not reportable because she had reviewed the camera footage of the fall. Administrative Staff A then stated that she had investigated the fall first and then determined it was not reportable. Administrative Staff A further stated that she spoke to a different corporate support individual and learned that an allegation of neglect is something that should be reported as well. The facility's Abuse Investigation and Reporting policy, revised August 2024, documented that all allegations of resident abuse (including physical, mental, emotional, verbal, and/or sexual abuse), neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse), and any reasonable suspicion of a crime shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management.

Based on record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) within 14 days of the assessment reference Date (ARD) as required. Findings included:- R4's Electronic Medical Record (EMR) documented diagnoses of severe protein-calorie malnutrition, paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), hypertension (elevated blood pressure), convulsions, and malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of upper lobe, right bronchus or lung. R4's Quarterly Minimum Data Set (MDS) with an ARD of 03/12/2026 documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS was not completed until 03/31/2026 (19 days). On 08/04/2026 at 04:15 PM, Administrative Nurse E stated she was the one who completed the MDS. She verified that R4's quarterly assessment was not completed within the 14-day window. According to CMS's Resident Assessment Instrument (RAI) guidelines, CMS's RAI instructed staff that the MDS must be completed within 14 days of the ARD.

Based on observation, record review, and interviews, the facility failed to identify and implement adequate fall interventions to prevent falls for Resident (R) 5, who had multiple falls. Findings included:- R5's Electronic Medical Record (EMR) documented diagnoses of traumatic subdural hemorrhage without loss of consciousness, hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), 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. R5's admission Minimum Data Set (MDS) dated 07/01/2026 documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R5's MDS documented physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others one to three days during the look back period. R5 required partial to moderate assistance with toilet transfers, oral hygiene, and bed mobility. R5 required substantial to maximal assistance with upper and lower body dressing, putting on and taking off his footwear. R5 was dependent with toileting, shower/bathing himself, and personal hygiene. R5 required supervision or touch assistance to sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, tub/shower transfer, walk 50 feet (ft) with two turns, walk 150 ft, walk 10 ft on uneven surfaces. R5's MDS documented that R5 was unable to determine his fall history prior to admission, but R5 had falls since admission of two or more, with one injury that was not major. R5's Delirium Care Area Assessment (CAA) dated 07/01/2026 documented R5 had evidence of fluctuating delirium symptoms that warranted interventions to identify and treat underlying causes, maintain a safe environment, provide frequent reorientation, monitor cognition and behavior, and promptly notify the provider of significant changes in cognition. R5's Cognitive CAA dated 07/01/2026 triggered but lacked analysis. R5's Behavioral Symptoms CAA dated 07/01/2026 documented R5 demonstrated behavioral symptoms, including wandering, that required individualized interventions. R5's Falls CAA dated 07/01/2026 triggered but lacked analysis. R5's Behavioral Symptoms Care Plan initiated 06/19/2026 directed staff to identify and address unmet needs that may contribute to wandering behaviors. Staff was directed to monitor R5's whereabouts routinely. R5's Fall Risk Assessment dated 06/19/2026, completed post-fall, documented a score of 19.0, high risk for falls. R5's Care Plan initiated on 06/22/2026 and revised on 07/06/2026 documented he was at high risk for falls related to a history of falls, wandering behavior, cognitive impairment, impaired safety awareness, and use of antidepressant medication that may contribute todizziness, sedation, or impaired balance.Interventions dated 06/22/2026 directed staff to anticipate and meet the resident's needs; educate the resident and his caregivers about safety reminders and what to do if a fall occurs; ensure his call light was within reach and encourage him to use it for assistance as needed; respond promptly to all requests for assistance; provide standby assistance during ambulation, especially for longer distances or when R5 appeared fatigued; offer R5 a wheelchair to sit in when he was becoming fatigued. Staff were to follow facility fall protocol.Interventions dated 07/02/2056 documented R5 was provided with non-skid socks and anti-rollback to his wheelchair.Interventions dated 07/06/2026 included the following:Staff were directed to investigate each fall to identify contributing factors and update interventions based on findings.Staff were to encourage regular toileting and respond promptly to requests for assistance to reduce unassisted attempts to ambulate, and to encourage R5's participation in strengthening, balance, and mobility activities as recommended by rehabilitation services.An intervention dated 07/07/2026 directed staff to perform orthostatic blood pressure and pulse measurements (with the patient in the supine, sitting, and standing positions) to assess low blood pressure and possible blood pooling in the lower extremities resulting in dizziness for three days.Interventions dated 07/17/2026 documented non-skid strips were placed beside his bed, and a visual sign call don't fall was placed in his room. R5's EMR documented the following: The Incident Follow Up Note dated 06/19/2026 04:08 PM documented R5 was lowered to the floor by staff because R5 had walked down the hallway fast and ran into the wall. Staff noticed that R5 was getting tired as R5 started to go to the ground, and staff assisted him to the ground. R5 sustained a skin tear to the right outer hand, and treatment was applied. The Nursing Progress Note dated 06/29/2026 04:28 PM documented that staff alerted the nurse that R5 was found lying on the floor in the hall with blood coming from the back of his. R5 laid in a supine (lying on the back) position on the floor of the hallway, with his walker in front of him. R5 was not responding to verbal stimuli but responded to tactile stimuli. R5 was unable to cooperate with neurological checks, indicating a change in his level of cognition. R5 was sent out to the hospital via emergency medical services (EMS). The Nurses Progress Note dated 06/30/2026 12:19 AM documented R5 returned to the facility, and staff assessed R5's occipital lobe (back of the head) with a laceration that had five staples in place. R5 denied any pain and was restless, not remaining in bed. R5 sat with a Certified Nurse's Aide (CNA) in the hall; the CNA was to provide immediate assistance if R5 began to wander again. The Event: Falls Note dated 06/30/2026 09:02 PM documented at 06:15 PM, staff could be heard yelling; upon investigation, it was discovered that staff had lowered R5 to the floor due to him getting up without his walker, and he became unsteady on his feet. The Event: Falls Note dated 07/01/2026 at 04:13 PM documented at approximately 02:45 PM, R5 was heard yelling for help. R5 was found laying on his left side on the floor. R5 stated he hit his head and his left arm hurt. R5 had non-slip socks on. R5 was sent out to the hospital for evaluation related to being on a blood thinner. The Nursing Progress Note dated 07/02/2026 07:54 PM documented R5 continued to wander aimlessly up and down the hallways without assistance. R5's gait was unsteady at times, and he had no awareness of safety issues. The Event: Falls Note dated 07/05/2026 at 07:24 PM documented R5 was on the floor in the dining room. R5 was observed lying face down on the floor. The note documented that R5's back of his head was bleeding; he had skin tears to bilateral knees, left hand, left wrist, and his forehead. R5 was assisted to a sitting position, and pressure was applied to all areas. R5 was sent to the hospital due to being on a blood thinner. The Event: Falls Note' dated 07/06/2026 at 11:45 PM documented R5 had an unwitnessed fall at 11:45 PM, and he was transported to the hospital. Another unidentified resident had informed staff that R5 was on the floor. R5 had been walking down the hall and fell. The Event: Falls Note dated 07/09/2026 at 08:01 AM documented R5 was found on the floor lateral to the bed. R5 claimed his left shoulder hurt, which is the side of his body that he fell out of the bed on. R5 claimed he hit his head and that it hurt. R5 was sent to the hospital for evaluation and treatment. The Nursing Progress Note dated 07/09/2026 documented R5 had returned from the hospital and was extremely anxious, trying to wander with a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) in. The Electronic Medication Administration Record (EMAR) - Administration Note dated 07/09/2026 at 08:37 PM documented orthostatic blood pressure every shift for three days. Review of R5's July EMAR documented on 07/07//2026 was blank for 6 PM to 6 AM; 07/08/2026 documented only a sitting blood pressure of 134/70 with the lying, sitting, and standing blood pressure documented and not applicable (NA) on 6 AM to 6 PM, 6 PM to 6 AM documented a two which is a refusal; 07/09/2026 6 AM-6 PM documented a five which is a hold, see progress note and 6 PM to 6 AM documented a two which is a refusal; on 07/10/2026 6 AM to 6 PM documented a two which is a refusal. The Social Services Progress Note dated 07/09/2026 at 09:32 PM documented a care plan meeting to discuss other options for placement of R5. The note documented nursing and therapy agreed that R5 would do better in a Memory Care Unit that is smaller and less stimulating. The note documented interventions were being made to try to assist R5's care and the falls he has had. The TMC Physical Therapy (PT) Note dated 12:00 AM documented R5 had a fall that afternoon and was assisted. R5 fell into his wheelchair as he attempted to get out to go to the bathroom. On 08/04/2026 at 11:15 AM. R5 lay in bed on his back; the top sheet was pulled part of the way up on his chest. R5 had an uncovered catheter bag that lay on the floor and was visible from the doorway. R5's call light was coiled up and lying on the nightstand out of R5's reach. There were no non-skid strips on the floor in R5's room, nor a visual sign in place stating, call don't fall. R5 had a wheelchair in the bathroom, and a Broda (special wheelchair with the ability to tilt and recline) right outside of the bathroom door just beyond the foot of R5's bed. On 08/04/2026 at 11:17 AM, Consultant GG verified that R5 could not reach his call light, that there were no non-skid strips in his room, or the visual sign that stated, call don't fall. Consultant GG stated that he probably required more help after this recent hospitalization, but therapy could not start yet due to awaiting insurance approval. On 08/04/2026 at 01:38 PM, CNA P stated that she could not see a resident's care plan and that she knew how to take care of a resident due to what was passed on in report. On 08/04/2026 at 01:48 PM, CNA O stated that R5 had used a walker and staff needed to make sure that he had his walker, because R5 had a habit of trying to walk without his walker. CNA O stated it was like he forgot he could not walk without it. CNA O further stated that if staff saw R5 up walking, staff were supposed to walk with him. CNA O revealed that when R5 had first come to the facility, staff were walking with him, with a gait belt on, and he took off walking very fast and ran into a wall head-on. CNA O stated after that, staff tried to get him to sit in a wheelchair because he would get tired and just stop wherever he was. CNA O stated that he knew how to take care of R5 because he could get onto his cell phone and pull R5 up and see what interventions R5 had. CNA O retrieved a facility cell phone and proceeded to go to R5 and attempted to pull up his interventions. When CNA O found R5, R5's profile was paused, and he was unable to pull up R5's interventions. On 08/04/2026 at 11:27 AM, Certified Medication Aide (CMA) R stated that if a resident fell, she would not leave the resident and she would call for the nurse or send another staff member to get the nurse. CMA R revealed that she could not access a resident's care plan and that she relied on report to inform her of changes with the resident's care. On 08/04/2026 at 12:00 PM, Licensed Nurse (LN) K stated that if a resident fell, she would go and assess the resident for injuries, check vital signs, assess range of motion on the resident's extremities, if the resident had no injuries, LN K would get the resident up and start fall precautions. If a resident had an injury or was bleeding, she would apply pressure and send the resident out to the hospital for further evaluation and treatment. LN K further stated that the nurses could update a resident's care plan, but it was usually completed by the administrative nurses. On 08/04/2026 at 04:15 PM, Administrative Nurse E stated that the nurses could update the care plan on the floor, but it was mainly Administrative Nurse E that did the updating. She stated that the staff on the floor should know how to get access to a resident's interventions on a facility cell phone with the [NAME] program. On 08/04/2026 at 05:11 PM, Administrative Nurse E stated that the staff can see R5's interventions on the facility cell phones. Administrative Nurse E attempted to pull up R5's profile and found that it had been paused. Administrative Nurse E stated she thought it was paused because of her and to give her one moment as she stepped away. Upon returning, Administrative Nurse E stated that she had not unpaused R5's profile when he was readmitted to the facility on [DATE]. On 08/04/2026 at 04:41 PM, Administrative Staff A stated she expected the staff to follow a resident's care plan, and that an intervention should be added to the care plan after a fall. Administrative Staff A further stated that the floor staff could see a resident's interventions on the facility task documentation point of care program. The facility's Falls and Fall Risk, Managing policy, revised October 2021, documented based on previous evaluations and current data, the 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. The policy documented that the staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If a systemic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions; to try one or a few at a time, rather than many at once. The policy documented that if falling reoccurs despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remains relevant. The policy documents that staff would monitor and document each resident's response to the interventions intended to reduce falling or the risks of falling.

Based on observations, interviews, and record review, the facility failed to provide catheter (tube inserted on the bladder to drain urine) care and services consistent with the standard of care for Resident (R) 7 when staff failed to ensure his urine collection bag was maintained below the level of his bladder. Findings included:- R7's Electronic Medical Record (EMR) documented diagnoses of difficulty in walking, lack of coordination, and neuromuscular dysfunction of the bladder. R7's Annual Minimum Data Set (MDS) dated 04/30/2026 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. R7 required partial to moderate assistance with toilet hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, bed mobility, sit-to-lying, and lying-to-sitting on the side of the bed. R7 required substantial to maximal assistance with sit-to-stand, chair/bed to chair transfers, toilet transfers, and shower/tub transfers. R7's MDS documented that he had an indwelling catheter. R7's Urinary Incontinence Care Area Assessment (CAA) dated 04/30/2026 documented R7 had a suprapubic catheter (catheter surgically inserted into the bladder through the abdominal wall) related to neuromuscular dysfunction. R7's Catheter Care Plan, initiated on 05/31/2021, directed staff to monitor and document any pain or discomfort related to his catheter. The plan of care directed staff to check the catheter tubing for kinks. R7's Care Plan lacked direction for maintaining the catheter bag below the level of the bladder to ensure flow to gravity. Review of R7's Progress Notes from 05/01/2026 to 08/06/2026 lacked any documentation of R7's catheter bag placement or R7 refusing to allow staff to move his catheter bag. On 08/04/2026 at 08:15 AM, staff pushed R7 into the dining room with his catheter bag attached to the arm of his wheelchair, and above the level of his bladder. Facility staff did not address the catheter bag on R7's wheelchair and walked away. On 08/04/2026 at 11:27 AM, Certified Medication Aide (CMA) R stated that catheter bags should not be at the level of a resident's waist, but they needed to be below that. On 08/04/2026 at 12:00 PM, Licensed Nurse (LN) K stated that the catheter bag should be below the resident's waist and their bladder. LN K further stated that a catheter bag should never be raised, as that had the potential to cause a urinary infection. On 08/04/2026 at 04:15 PM, Administrative Nurse E stated that catheters should not be at waist height. The facility's Policies and Practices - Infection Control policy, revised October 2024, documented the objectives of our infection control policies and practices were to prevent, detect, investigate, and control infections in the facility. The facility's Urinary Continence and Incontinence - Assessment and Management policy, revised October 2024, documented routine maintenance was to keep tubing free of kinks and dependent loops. The policy directed staff to keep the bag below bladder level and off the floor during care, transfers, and transport.

Based on observations, interviews, and record review, the facility failed to provide necessary respiratory care and services for Resident (R) 2, when R2's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was staff failed to provide education and assistance for use and failed to store the CPAP in a sanitary manner. Findings included:- R2's Electronic Medical Record (EMR) documented diagnoses of heart failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), need for assistance with personal care, chronic respiratory failure with hypoxia (inadequate supply of oxygen), pulmonary hypertension (an increase in blood pressure within the pulmonary arteries), and a history of falling. R2's admission Minimum Data Set (MDS) dated 02/23/2026 documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R2 used oxygen; the MDS did not document use of CPAP while she was a resident. R2's Functional Abilities Care Area Assessment (CAA) dated 02/23/2026 documented R2 had the potential for alteration in activities of daily living (ADL) status due to her history of COPD, respiratory failure, diabetes, and morbid obesity. R2's Quarterly MDS dated 07/13/2026 documented a BIMS score of 13, which indicated intact cognition. The MDS documented R2 used oxygen and a CPAP while she was a resident. R2's Care Plan initiated on 02/03/2026 directed staff to monitor for signs and symptoms of respiratory distress and report to the medical director as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (the collapse of a lung or part of a lung), hemoptysis (when blood is coughed up from the lung), cough, pleuritic pain (inflammation of the lining of the chest wall), accessory muscle usage, and skin color. The care plan directed staff that R2's oxygen setting per nasal prongs was at four liters (L) continuous. R2's Care Plan lacked interventions related to R2's CPAP machine. Review of R2's Order Listing Report documented the following orders:CPAP at night one time a day for COPD, ordered 01/30/2026, discontinued 02/11/2026.CPAP settings 8 centimeters (cm) with nasal pillow, ordered 02/17/2026, discontinued 03/03/2026.CPAP settings 8 cm with nasal pillows, ordered 04/02/2026, discontinued 06/04/2026.Assist resident to use CPAP at bedtime. Please chart refusals at bedtime for obstructive sleep apnea (OSA), ordered 02/06/2026, discontinued on 02/11/2026.Assist resident to use CPAP at bedtime. Please chart refusals at bedtime for OSA, ordered 04/02/2026, discontinued 06/04/2026.Soak CPAP mask weekly in one-to-one vinegar-water solution every night shift every Monday, ordered 04/02/2026, discontinued 06/04/2026. Review of R2's May Treatment Administration Record (TAR) dated 2026 documented R2 wore her CPAP 30 out of 31 nights and refused one time. R2's CPAP mask was soaked four out of four times. Review of R2's June TAR dated 2026 documented R2 wore her CPAP one out of three nights and was hospitalized on the two nights she did not wear her CPAP. R2's CPAP mask was soaked on 06/01/2026. Review of R2's July TAR dated 2026 lacked documentation of any CPAP order. Review of R2's Admit/Readmit Screener: Respiratory dated 04/06/2026 at 05:05 PM documented R2 had a CPAP. Review of R2's Admit/Readmit Screener: Respiratory dated 07/03/2026 at 09:34 AM documented R2 did not have a CPAP. The Electronic Medication Administration Record (EMAR) Note dated 06/10/2026 at 01:02 AM documented to assist resident to use CPAP at bedtime and please chart refusals. The CSC Skilled Evaluation Note dated 06/11/2026 at 01:43 AM documented R2 slept intermittently. R2 had humidification with her oxygen via her CPAP. The Behavior Note dated 06/15/2026 at 11:43 PM documented R2 asked why no one has been using her CPAP for the past week. The nurse responded with I don't have an answer for that, but once you're laid down, comfortable and ready to sleep, just call for me and I will come hook you up to your CPAP myself. The note documented R2 said no and was informed that should she change her mind, just let staff know. The Discharge (Transition) Summary: Social Services Note dated 07/14/2026 at 06:25 PM documented that she would reach out for durable medical equipment (DME) supplies. The supplies needed were oxygen, a wheelchair, a CPAP machine, and a shower chair. Review of R2's Hospital Discharge Paperwork dated 07/13/2026 documented R2's readmission risk was assessed as high. On 07/29/2026 at 10:24 AM, R2's CPAP mask hung off of her nightstand, lying on the floor behind the headboard of her bed, uncovered. On 07/29/2026 at 11:57 AM, R2's CPAP was in the same position as noted at 10:24 AM. On 07/30/2026 at 10:20 AM, R2's CPAP machine sat on her nightstand, with her mask hanging off the side, lying on the floor behind the headboard of her bed, uncovered. On 07/30/2026 at 11:40 AM, Administrative Staff A confirmed that R2's CPAP was lying on the floor behind the headboard of her bed. On 08/04/2026 at 07:07 AM, R2's CPAP was no longer sitting on the nightstand in her room. On 08/04/2026 at 10:54 AM, R2 sat in her wheelchair with her nasal cannula to receive her oxygen. R2 stated that she had not seen her CPAP recently and was unsure what happened to it. R2 stated that she would have used the CPAP more if the staff or someone had shown her what to do with it. R2 further stated that she was trying to stay out of the hospital and using the CPAP would help her do that. On 08/04/2026 at 08:51 AM, Certified Medication Aide (CMA) R stated she did not realize R2's CPAP was gone. CMA R stated that she thought if R2 was not on her oxygen, she needed her CPAP. On 08/04/2026 at 08:52 AM, Licensed Nurse (LN) G stated he did not know why R2's CPAP was gone, but he was not the one who usually put it on her because he did not work nights. On 08/04/2026 at 12:16 PM, Administrative Nurse E stated the nurses had probably already discontinued R2's CPAP order. Administrative Nurse E revealed that the facility rented that CPAP machine for R2, and R2 did not wear the CPAP. Administrative Nurse E stated R2 had been educated on how to wear the CPAP. Administrative Nurse E further stated that R2's son had encouraged her to wear it. The facility's undated CPAP/Bi-Level Respiratory Care policy documented that obstructive apnea was a sleep disorder that occurred when the airway was obstructed or blocked and, as a result, no air moved into or out of the lungs. The policy documented and/all use of CPAP or Bi-level respiratory care procedures required specific physician orders, and the ordered level of air pressure to keep the airway open during sleep may not be changed without consulting the ordering physician, with resultant change in settings ordered.

Based on observations, interviews, and record review, the facility failed to ensure staff possessed the appropriate skills and knowledge to safely provide direct care and nursing services related to Resident (R) 3's nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) tubes when the facility failed to provide training, education and ensure competencies for care of the nephrostomy tubes. (Refer to F880) Findings included:- R3's Orders tab documented the following:Clean around nephrostomy tubes with soap and water in a circular motion, rinse with saline, and work out three to four inches. Wrap dry gauze around the tubes and secure with gauze; cover and secure the tube with tape or an occlusive dressing such as Tegaderm (a transparent film dressing that is synthetic and self-adhesive), change every two days and as needed (PRN). When showering, the areas must be covered by Tegaderm or Opsite (transparent polyurethane film), every day shift; every two days for newly placed nephrostomy tubes for 12 days, ordered 01/08/2024.Empty left nephrostomy tube every shift, report output less than 10 - 15 milliliters (mL) per day, Contact Consultant JJ every shift for monitoring, ordered 01/09/2024, discontinued 08/29/2025.Empty right nephrostomy tube every shift, report output less than 10 - 15 milliliters (mL) per day, contact Consultant JJ every shift for monitoring, ordered 01/09/2024, discontinued 08/29/2025.Enhanced Barrier Precautions related to nephrostomy tubes every shift, ordered 03/262024, discontinued 08/29/2025.Clean nephrology tube site daily with soap and water, place dry gauze over the site and secure with tape; take off dressing to shower every day shift for nephrology tubes, ordered 04/02/2024, discontinued 08/29/2025.Enhanced Barrier Precautions related to nephrostomy tubes every shift, discontinued 06/18/2026.Empty left nephrostomy tube every shift, report output less than 10 - 15 milliliters (mL) per day, contact Consultant JJ every shift for monitoring, discontinued 06/18/2026.Empty right nephrostomy tube every shift, report output less than 10 - 15 milliliters (mL) per day, contact Consultant JJ every shift for monitoring, discontinued 06/18/2026.Enhanced Barrier Precautions related to nephrostomy tubes every shift, ordered 06/23/2026.Empty left nephrostomy tube every shift, report output less than 10 - 15 milliliters (mL) per day, contact Consultant JJ every shift for monitoring, ordered 06/23/2026.Empty right nephrostomy tube every shift, report output less than 10 - 15 milliliters (mL) per day, contact Consultant JJ every shift for monitoring, ordered 06/23/2026.Clean nephrology tube site daily with soap and water, place dry gauze around site and secure with tape; take off the dressing to shower every day shift for nephrology tubes, ordered 06/23/2026.Change left nephrostomy tube dressing every three days; one time a day every three days for new left nephrostomy tube placed on 07/15/2026, ordered 07/15/2026.Flush both nephrostomy tubes with 10 mL of normal saline every shift to keep patent, clamp the drain tube at the blue hub, flush, and then unclamp, ordered 07/15/2026. On 07/30/2026 at 01:48 PM, License Nurse (LN) H gathered supplies: four-by-four gauze, distilled water in a cup, paper tape, and two split gauze dressings ripped open. LN H donned gloves and took the supplies she had gathered into R3's room and laid them directly on R3's bed. LN H did not put a gown on for enhanced barrier precautions (EBP). LN H explained what she was going to do and asked R3 to stand and pull her shirt up to expose the dressings to her back. R3 stood and exposed two four-by-four border gauze dressings that lacked any dates or indication of the age of the dressing. LN H confirmed that there were no dates on the dressings she would be removing from R3's back then removed the dressing from the left nephrostomy tube, which had dried blood on it. LN H balled up the dressing and placed it on the bed beside the clean dressing supplies. LN H then took a clean bordered gauze, wet it with distilled water, then began to wipe around the nephrostomy tube that exited R3's back. LN H continued to wipe around the tube and then went wider around the nephrostomy tube and did not change out the four-by-four gauze until it was folded up and was brown in color; LN H then placed it on the bed next to the clean supplies and the balled-up dirty dressing. LN H took another four-by-four gauze, wet it, and wiped the nephrostomy tube, starting at the opening on the back, pulling outward on the tube. LN H then re-wiped the skin around the nephrostomy tube with the second four-by-four gauze and then balled it up and threw it at the trash can but missed the can. The soiled dressing landed on the floor. LN H retrieved the balled-up dressing and the used four-by-four gauze and repeated throwing them at the trash can but missed those as well. LN H retrieved one clean split gauze and the paper tape and placed the split gauze around the nephrostomy tube and taped it into place with the paper tape, which she dated and initialed. LN H then moved to remove the dressing on the right nephrostomy tube. LN H had trouble getting a hold of the edge of the bordered gauze and was going to wet a four-by-four gauze to wet the dressing but found she had run out of sterile water. LN H doffed her gloves, proceeded to the treatment cart, poured more sterile water into a cup, donned a new pair of gloves without sanitizing or washing her hands, and went back to R3. LN H wet a four-by-four gauze and held it onto the edge of the bordered gauze to loosen the edge of the bordered gauze. After holding the wet four-by-four gauze on the bordered gauze for approximately one minute, LN H proceeded to peel the bordered gauze off of R3's right nephrostomy tube. The skin under the taped area was pulled away by the bordered gauze dressing. The skin around the nephrostomy tube insertion site was red and open. The dressing that LN H removed from the tube had dried blood at the split gauze in the middle of the dressing and at the bottom right corner of the dressing. LN H balled up this dressing and threw it into the trash can under the bedside table. LN H wet a four-by-four gauze and then wiped around the nephrostomy tube insertion site. While LN H wiped the area, she turned the gauze over and over and continued to wipe the area with the gauze becoming reddish-brown in color before throwing that gauze away and retrieving a second gauze, wetting it with sterile water, and then wiping the nephrostomy tube from the insertion site in a downward motion. The skin around the stitches on the right nephrostomy tube was red. R3 then said she could not that she could not stand it any longer. LN H placed a split gauze four-by-four on the right nephrostomy insertion site and let R3 sit down, then proceeded to tape the dressing in place with paper tape to the top and bottom of the dressing, which included the date and LN H's initials on the dressing. LN H gathered the remaining supplies from R3's bed and left the room. On 07/29/2026 at 08:48 AM, LN H stated that she had been shown how to care for R3's nephrostomy tubes by another floor nurse. LN H stated that the facility had never provided any training on how to provide care for R3's nephrostomy tube dressings or flushing the lines. On 08/04/2026 at 10:52 AM, LN G stated that he had an idea on how to care for R3's nephrostomy tubes because he had asked the hospital nurse that was giving report on this last hospitalization. LN G further stated that was the only type of training he had received for R3's nephrostomy tubes; the facility had never given him any training on how to care for R3's nephrostomy tubes. On 08/04/2026 at 04:15 PM, Administrative Nurse E stated that she could not find any training of any kind related to the care of nephrostomy tubes. The facility's Competency of Nursing Staff policy, revised October 2021, documented that all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements by state law. The policy documented the staff development, and training program was created by the nursing leadership, with input from the medical director, and was designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. The policy listed the following factors considered in the creation of the competency-based staff development and training program: an evaluation of the current program to ensure basic nursing competencies; and specialized skills or training needed based on the resident population. The policy documented the facility assessment included an evaluation of the staff competencies that were necessary to provide the level and types of care specific to the resident population.

The facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure there was sufficient nursing staff on the weekends to provide care to each resident's basic and individual needs. Findings included:- A review of the facility's CMS (Centers for Medicare and Medicaid) Payroll-Based Journal (PBJ) Staffing Data Report CASPER Report 1705D for fiscal year (FY) 2026 quarter one data revealed the facility triggered for excessively low weekend staffing.The facility's Facility Assessment, last reviewed on 03/19/26, documented the facility had a capacity of 60 residents. Based on the number of residents and their basic and individual needs the required staffing numbers (optimal/minimum) for each shift on weekdays for day and evening shifts two licensed nurses, two certified medication aides (CMA), and four direct care staff (certified nurse aides); for the night shift: two licensed nurses, two direct care staff. Weekend staffing numbers were two licensed nurses, two certified medication aides (CMA), and four direct care staff; for the night shift: two licensed nurses, two direct care staff. Review of the actual nursing staff working schedules from 10/01/25 to 02/28/26 revealed low weekend staffing (less than the minimum/optimal number of staff per facility assessment) on four of four weekends in October 2025, five of five weekends in November 2025, four of four weekends in December 2025, two of four weekends in January 2026, and four of four weekends in February 2026. On 03/31/26 at 12:51 PM, Licensed Nurse (LN) G stated that typically they try to have two nurses, four nurse aides and two medication aides for each shift on days and evening shift and nights have two nurses and two aides and then on weekends it should be the same. The facility has on-call staff that are called to cover on the weekends. On 03/31/26 at 12:51 PM, Administrative Nurse D stated the facility had an on-call schedule for each weekend and that person would be called if a slot was needed to cover. Administrative Nurse D stated weekends were hard to get staff coverage when there was a call-in and at times management staff would come in to cover if staff were excessively low. Ultimately, each shift for days and evenings and nights should be the same on the weekends as it was during the week. On 03/31/26 at 01:13 PM, Administrative Staff A stated that there was an on-call list for every weekend to call to try to get coverage if there had been call-ins and management staff had to come in to cover at times. The weekends are when there are the most call-ins, and those shifts are hard to get covered but the weekend staffing requirements are the same as during the week and based off what the facility assessment said was the minimal number of staff needed. The facility's Facility Assessment policy, revised July 2024, documented the facility assessment also included a detailed review of the resources available to meet the needs of the resident population. This part of the assessment included: all personnel, including directors, managers, regular employees (full and part-time), contracted staff (full and part-time), and volunteers. There was a breakdown of the training, licensure, education, skill level and measures of competency for all personnel.

The facility identified a census of 54 residents. The facility had one kitchen and a dining area. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to dirty dishes, food storage, and nonworking equipment.Findings included:- During the initial tour on 03/24/26 at 09:10 AM, observation revealed the following:The dietary manager was not wearing a hair net, while in the kitchen area standing by the two-door refrigerator.The floors were sticky and dirty; tiles were missing off the floor next to the dishwasher.There were 17 trays with dried chili, cinnamon rolls and other foods on a tall silver cart, the trays were left from the previous day. The dishwasher sink had standing water. Dietary Staff BB stated the garbage disposal was backed up.The bowls and plates were not stored inverted.The steam table had dried food on the top, and dried food particles of dark brown substance that had run down the front of the table. Underneath the steam table revealed grease and food residue. Next to the steam table was a stainless-steel counter, the counter had dried food spilled down the side of the counter. Under the counter was brown serving trays with dried white substance covering parts of the trays.Dietary Staff BB stated the ovens on the stove did not work, and staff were using the convection oven to bake their food.The kitchen door was propped open.In the two-door refrigerator in the kitchen prep area, observation revealed a bag of sliced turkey that was opened and undated. The turkey was dripping juices on to the bottom shelves.In a single door white freezer, a box of chocolate chip cookie dough was opened and opened to air.In the double refrigerator in the serving area there was chocolate pudding unlabeled and undated, a bag of canned fruit, and small bowls of fruit that were unlabeled and undated.On 03/31/26 at 07:44 AM, a recheck of the kitchen revealed the ice scoop laid on top of the ice machine, the scoop was not in a container. There was no thermometer in the milk cooler. On 03/23/26 at 09:25 AM, Dietary Staff BB stated all foods should be dated and labeled. She stated the garbage disposal was backed up, and maintenance came in a fixed disposal. Dietary Staff BB stated the steam table, and counters should be cleaned often and after each meal. She stated dishes should be inverted. She stated maintenance had been working on ordering parts and fixing the ovens in the kitchen. Dietary Staff BB stated all dishes should be washed and put away and not left overnight. On 03/31/26 at 08:31 AM, Dietary Staff BB stated maintenance had plunged the garbage disposal and it was now in working order. She stated she would get a thermometer in the milk cooler, and a container for the ice scoop.On 03/23/26 at 12:21 PM, Administrative Staff A was unaware the kitchen was not clean. She stated her expectation was all staff follow policies and procedures. She stated the kitchen had employee turnover in the last six months. The facility's Food Receiving and Storage policy undated documented foods would be received and stored in a manner that complies with safe food handling practices.The facility's Sanitation policy undated documented the food service area shall be maintained in a clean and sanitary manner.

The facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Licensed Nurse (LN) on staff had and retained a valid active nursing license. Findings included:- On 03/23/26 the facility report dated 02/17/26 documented Administrative Staff A identified that LN H's nursing license was lapsed since 11/30/25. The facility verified LN H's lapsed nursing license through a search on Nursys (a national database for verification of nurse licensure) website: www.nursys.com and the Kansas State Board of Nursing (KSBN) website at www.kansas.gov/ksbn-verifications/. On 03/23/26 the surveyors conducted a search of the Nursys website and the KSBN and verified that LN H's nursing lapsed on 11/30/25. LN H continued working at the facility with a lapsed license up until 02/17/26.On 03/23/26 at 12:20 PM, Administrative Nurse D stated that human resources (HR) staff were responsible for verifying valid licenses and keeping track of the expiration dates. Administrative Nurse D stated the facility has had some changeover in HR staff recently and it was found that the checking of the nursing licenses and nurse aide registry validations had not been kept up to date.On 03/23/26 at 10:45 AM, Administrative Staff A stated that she had found out after the turnover of three different HR staff in the past six months that nursing license verifications had not been completed for some time. Administrative Staff A stated that Administrative Staff B was now the person that would be responsible for keeping track of licensures and nurse registry verification.The facility's Background Screening Investigations policy dated November 2023 documented for any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license.

The facility had a census of 54 residents. Based on observation, interview, and record review, the facility failed to follow the pest control recommendations. Findings included:- The Pest Control Monthly Report dated 02/24/26 documented recommendations with a high priority related to a hole in the wall under the bathroom sink large enough for rodent entry, and the hole needed to be patched. The recommendations documented the hole in the wall was near the floor.On 03/24/26 at 11:32 AM, an observation of Resident (R) 5's room revealed a hole in the wall underneath his sink.On 03/24/26 at 12:05, Maintenance Supervisor U stated the hole remained in the wall. He stated he did not have time to fix the hole in the wall. Maintenance Supervisor U stated the facility had done a mock survey, and the owners did a walk through, and had given him projects that had a deadline. He stated he had traps set up to catch mice and boxes outside to catch mice. He stated the mice had been less since the traps were set and he had fixed the outside of the building.On 03/31/26 at 12:00, Certified Nurses Aide (CNA) N stated when staff see mice or rodents in R5's room or R18's room the CNA would put that information into Facilities Work order System (TELS). She stated the maintenance person gets this information and takes care of any situation.On 03/31/26 at 12:12, Licensed Nurse (LN) G stated she would call the maintenance supervisor to let them know right away there was a problem.On 03/31/26 at 12:25 PM, Administrative Nurse D stated the facility had a program to ensure all rooms and equipment were kept in good condition. She stated rooms were checked weekly.On 3/31/26 at 02:10 PM, Administrative Staff A stated she expected any recommendations to be followed up on immediately.The facility's Pest Control policy undated documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services.

The facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure nurse aides received the required 12 hours of in-service training. Findings included:- On 03/24/25, the record of the required nurse aide in-service training documentation from the past year was requested. The facility was unable to locate the binder that had the sign-in sheets and the education/training provided to nurse aide staff.On 03/24/26 at 12:41 PM, Administrative Staff A stated she was unable to find the in-service binder and has had some staff turnover in the last year, including the staff responsible for making sure the in-services were completed and documentation maintained. She said the facility will be having a skills fair soon.On 03/31/26 at 12:51 PM, Administrative Nurse D stated the director of nurse aides was responsible for ensuring the nurse aides have completed and maintain the documentation for the required in-services. Administrative Nurse D stated the facility has had staff turnover in that position and some of the required in-service documentation was not completed or retained.The facility's Nurse Aide Qualifications and Training Requirements policy dated 08/10/21 lacked information regarding the nurse aides required yearly 12 hours of in-service training/education.

The facility identified a census of 54 residents. The sample included 14 residents. Based on observation and interviews, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.Findings included:- On 03/23/26 at 08:45 AM, during the facility walk through of the East and West Halls, there was a distinct smell of urine. While doing the walk through, up and down each hall revealed several urinals set on bedside tables and on the floors by the beds, some of the urinals did not have lids. The hall foyer entry into the dining room had a distinct urine smell.An inspection was completed in the facility's laundry service room. Laundry was stacked up, and four large grey tubs of laundry sat in the laundry room. The laundry room was in the hall next to the kitchen foyer entry.The floor in the dining area was sticky and dirty, with multiple dried spills.On 03/31/26 at 12:05 PM, Licensed Nurse (LN) G stated she would have a Certified Nurse's Aides (CNAs) help her look for the source of the smell. She stated she would check all the residents who were incontinent. LN G stated she would also get maintenance and housekeeping involved to find the source.On 03/23/26 at 12:25 PM, Administrative Nurse D started the staff should find the source of the odor. She stated staff can give urinals with a lid, or ensure the urine was dumped more often.On 03/23/26 at 12:12 PM, Administrative Staff A stated her goal for the facility was that there were no foul odors in the building, and policies and procedures would be followed. Administrative Staff A stated the facility did have a person in the facility who urinates in other places than the bathrooms. She stated housekeeping keeps clean as soon as it was seen.The facility's Quality of Life-Home Environment policy undated documented residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Clean, sanitary and orderly environment; Pleasant, neutral scents.

The facility identified a census of 54 residents. The sample included four residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect residents from further abuse during the investigation after independently ambulatory Resident (R) 1 took the keys to R2's electric wheelchair, struck R2 with a cane, and tipped R2 over and out of the wheelchair. On 07/04/23, R1, who had a history of hitting other residents, approached R2 while both residents were outside unsupervised. R1 claimed R2 tried to run him over, and forcibly took the keys to the wheelchair. R1 then picked up R2's cane and began striking R2 in the face and head with the cane. The altercation caused R2's wheelchair to tip over and R2 landed on the ground. Both residents then grappled for the cane while on the ground. As a result, R2 sustained severe bruising to his face around his eyes and multiple hematomas to R2's face around and above the left eye, on top of the head, as well as skin tears to his left arm and hand. After the event, the facility offered R1 anger management which he declined, and staff monitored to ensure R1 and R2 remained on opposite sides of the building but placed no further interventions to prevent a reoccurrence, or abuse to other vulnerable residents. The facility failure placed the residents in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of mental disorder (clinically significant disturbance in an individual's cognition, emotional regulation, or behavior), schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms), and signs and symptoms involving cognitive functions and awareness. R1's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded R1 required supervision with setup help for bed mobility, transfers, walk in room and corridor, locomotion on and off the unit, eating, and personal hygiene. R1 required supervision of one staff member physical assistance with dressing and toilet use. R1 was tired or had little energy two to six days during the look back period. The MDS recorded R1 had no behaviors. R1's Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS recorded R1 required supervision with setup help for bed mobility, transfers, walk in room and corridor, locomotion on the unit, eating, dressing, and personal hygiene. R1 required supervision of one staff member physical assistance with toilet use. The MDS recorded R1 was independent with no setup help needed for locomotion off the unit. The MDS recorded R1 had no behaviors. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 11/26/22 documented R1 ambulated with a walker and completed most of his cares independently. The Mood CAA dated 11/26/22 documented R1 scored for depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) with signs and symptoms during the interview for moods. The Behaviors CAA did not trigger. R1's Mood Care Plan intervention initiated 01/20/20 directed staff to intervene before agitation escalated, remove from distress, engage calmly in conversation, and offer alternatives. The intervention dated 09/15/22 documented R1 and an unidentified resident had an altercation which resulted in R1, and the unidentified resident, hit each other. Another intervention dated 03/13/23 documented R1 hit another resident in the face and staff were directed to keep them away from each other for 24 hours. The unidentified resident, that R1 hit, agreed to move rooms. The Nursing Note dated 05/06/23 at 03:00 PM documented R1 was in the cafeteria and physically struck R5. Review of the video revealed R1 followed R5 to the trash cans; there was a verbal altercation which then resulted in R1 hitting/striking R5 multiple times. The Behavior Note dated 05/07/23 at 05:18 PM documented R1 had been calm with no agitation toward other residents. The note further documented R1 believed he did the right thing (defending himself) by hitting another unidentified resident. The Social Services Note dated 05/08/23 at 03:24 PM documented R1 had an altercation with an unidentified resident and R1 was encouraged to stay away from the unidentified resident involved. R1 was encouraged to yell for staff rather than striking out. The Alert Note dated 05/13/23 at 02:08 AM documented R1 hit an unidentified resident in the eye. The Nursing Note dated 07/05/23 at 12:34 AM documented R1 and R2 were on the ground grappling with a cane that belonged to R2. R1 incurred a superficial tear, two abrasions on the top of his scalp and three skin tears to the right arm. The undated Witness Statement, provided by R1, transcribed by Administrative Nurse D, recorded R1 stated he took R2's scooter key because R2 attempted to run over R1. R1 was hit with the cane first by R2, then R1 took the cane and hit R2 with it. R1 pushed R2 backwards and broke R2's scooter and ended up on the ground. The undated Witness Statement, provided by R2, transcribed by Administrative Nurse D, documented R1 grabbed R2's keys, and turned off R2's wheelchair. R1 then took R2's cane and hit R2 in the face and arms, and then pulled R2 out of his wheelchair. R2 hit R1 back in self-defense. Another resident (R3) went and got help. The undated Witness Statement, provided by R3, transcribed by Administrative Nurse D, recorded R1 went outside and started to fight with R2. R1 hit R2 first and then R2 hit back. R3 went and got the nurse after R1 and R2 ended up on the ground. On 07/10/23 at 01:25 PM R2 sat in his wheelchair with a blood-tinged sclera (white of the eye) of the left eye, dark black to deep purple bruising and swelling approximately 1.5 inches around the outside of the eye. R2 had a 3-inch raised area above the left eyebrow with a lighter maroon to a deep purple area encircling the raised area. R2 had kerlix (gauze wrap) wrapped on his left forearm and a one inch squared bordered gauze to the top of R2's left hand. R2 confirmed he had pain related to his injuries. On 07/10/23 at 01:26 PM R2 stated R1 came outside and found him out front and stated, Let's fight. R2 stated that R1 pulled the key out of R2's electric scooter and would not give it back and pushed R2. R2 revealed he told R1 not to touch him. R2 further revealed R1 grabbed R2's cane and started hitting him with it. R1 pushed R2 and ended up breaking R2's wheelchair seat and then R1 and R2 fell to the ground. R2 stated R3, a resident that sat with R2 outside before and when this occurred alerted nursing staff to get R1 and R2 apart and off the ground. R2 stated R1 walked around and bullied other residents. He stated he felt stalked by R1 and said other residents felt the same way. R2 stated he was uncertain the facility would protect him or do anything about R1 bullying and stalking. R2 stated he was also really worried about the other residents in the facility. On 07/10/23 at 01:38 PM R1 laid in his bed. Observation revealed a bruised area under his right eye in the shape of a triangle and a maroon to grey bruise above the bridge of his nose approximately 0.5 centimeters (cm) in width and approximately 2.0 cm in length. R1 stated he was outside for a walk and came upon R2. R1 denied he was specifically looking for R2. On 07/10/23 at 01:45 PM Certified Medication Aide (CMA) R stated R1 and R2 were now kept separated and there were no other precautions in place. CMA R stated she was told about the event after she noted the bruising on R2's face and asked staff what happened. On 07/10/23 at 01:48 PM Certified Nurse Aide (CNA) M stated R1 hit other residents in the past, but R2 had no history of that kind of behaviors. CNA M revealed she had not learned about the event in report, but later, after she noted bruising on R2 and asked about it, she was informed of the incident. On 07/10/23 at 02:38 PM Administrative Nurse D stated R1 and R2 lived on different sides of the building, and they have been told to stay on their sides of the building. She said R1 and R2 were monitored to make sure they stayed on opposite sides of the building. She said staff followed the policy related to the event. On 07/10/23 at 03:16 PM CNA N stated R1 was very aggressive and had a history of going after residents in wheelchairs. The facility's policy Protection of Residents During Abuse Investigations revised October 2021 documented the facility would protect residents from harm, reprisal, discrimination, or coercion during investigations of abuse allegations. The facility failed to take immediate actions to ensure staff identified and implemented immediate and appropriate protective measures to prevent abuse. This placed residents in immediate jeopardy The facility completed the following corrective actions to address the immediacy: R1 was placed on 1:1 at 05:20 PM on 07/10/23. R1 will remain on 1:1 until transferred out for care, discharged from facility or until medical intervention was placed. All staff were educated on recognizing signs and symptoms of abuse, neglect, and exploitation. Staff were educated on facility policy for abuse and resident to resident altercation. Staff were educated on abuse investigation reporting policy and protection of residents during abuse investigations. A licensed social worker met with R1 to discuss possible treatment options and discharge planning. Resident care plans were reviewed and updated with appropriate intervention to address aggression. Implementation of the corrective actions and removal of the immediacy was verified onsite by the surveyor on 07/11/23. The scope and severity remained at the level of E to reflect the risk to R2 and other wheelchair bound residents.

The facility identified a census of 54 residents. The sample included four residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse when independently ambulatory Resident (R) 1 took the keys to R2's electric wheelchair, struck R2 with a cane, and tipped R2 over and out of the wheelchair. On 07/04/23, R1, who had a history of hitting other residents, approached R2 while both residents were outside unsupervised. R1 claimed R2 tried to run him over, and R1 forcibly took the keys to the wheelchair. R1 then picked up R2's cane and began striking R2 in the face and head with the cane. The altercation caused R2's wheelchair to tip over and R2 landed on the ground. Both residents then grappled for the cane while on the ground. As a result, R2 sustained severe bruising to his face around his eyes and multiple hematomas to R2's face around and above the left eye, on top of the head, as well as skin tears to his left arm and hand. The facility failure to prevent R1 from abusing R2 placed R2 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of mental disorder (clinically significant disturbance in an individual's cognition, emotional regulation, or behavior), schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms), and signs and symptoms involving cognitive functions and awareness. R1's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded R1 required supervision with setup help for bed mobility, transfers, walk in room and corridor, locomotion on and off the unit, eating, and personal hygiene. R1 required supervision of one staff member physical assistance with dressing and toilet use. R1 was tired or had little energy two to six days during the look back period. The MDS recorded R1 had no behaviors. R1's Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS recorded R1 required supervision with setup help for bed mobility, transfers, walk in room and corridor, locomotion on the unit, eating, dressing, and personal hygiene. R1 required supervision of one staff member physical assistance with toilet use. The MDS recorded R1 was independent with no setup help needed for locomotion off the unit. The MDS recorded R1 had no behaviors. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 11/26/22 documented R1 ambulated with a walker and completed most of his cares independently. The Mood CAA dated 11/26/22 documented R1 scored for depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) with signs and symptoms during the interview for moods. The Behaviors CAA did not trigger. R1's Mood Care Plan intervention initiated 01/20/20 directed staff to intervene before agitation escalated, remove from distress, engage calmly in conversation, and offer alternatives. The intervention dated 09/15/22 documented R1 and an unidentified resident had an altercation which resulted in R1, and the unidentified resident, hit each other. Another intervention dated 03/13/23 documented R1 hit another resident in the face and staff were directed to keep them away from each other for 24 hours. The unidentified resident, that R1 hit, agreed to move rooms. The Nursing Note dated 05/06/23 at 03:00 PM documented R1 was in the cafeteria and physically struck R5. Review of the video revealed R1 followed R5 to the trash cans; there was a verbal altercation which then resulted in R1 hitting/striking R5 multiple times. The Behavior Note dated 05/07/23 at 05:18 PM documented R1 had been calm with no agitation toward other residents. The note further documented R1 believed he did the right thing (defending himself) by hitting another unidentified resident. The Social Services Note dated 05/08/23 at 03:24 PM documented R1 had an altercation with an unidentified resident and R1 was encouraged to stay away from the unidentified resident involved. R1 was encouraged to yell for staff rather than striking out. The Alert Note dated 05/13/23 at 02:08 AM documented R1 hit an unidentified resident in the eye. The Nursing Note dated 07/05/23 at 12:34 AM documented R1 and R2 were on the ground grappling with a cane that belonged to R2. R1 incurred a superficial tear, two abrasions on the top of his scalp and three skin tears to the right arm. The undated Witness Statement, provided by R1, transcribed by Administrative Nurse D, recorded R1 stated he took R2's scooter key because R2 attempted to run over R1. R1 was hit with the cane first by R2, then R1 took the cane and hit R2 with it. R1 pushed R2 backwards and broke R2's scooter and ended up on the ground. The undated Witness Statement, provided by R2, transcribed by Administrative Nurse D, documented R1 grabbed R2's keys, and turned off R2's wheelchair. R1 then took R2's cane and hit R2 in the face and arms, and then pulled R2 out of his wheelchair. R2 hit R1 back in self-defense. Another resident (R3) went and got help. The undated Witness Statement, provided by R3, transcribed by Administrative Nurse D, recorded R1 went outside and started to fight with R2. R1 hit R2 first and then R2 hit back. R3 went and got the nurse after R1 and R2 ended up on the ground. On 07/10/23 at 01:25 PM R2 sat in his wheelchair with a blood-tinged sclera (white of the eye) of the left eye, dark black to deep purple bruising and swelling approximately 1.5 inches around the outside of the eye. R2 had a 3-inch raised area above the left eyebrow with a lighter maroon to a deep purple area encircling the raised area. R2 had kerlix (gauze wrap) wrapped on his left forearm and a one inch squared bordered gauze to the top of R2's left hand. R2 confirmed he had pain related to his injuries. On 07/10/23 at 01:26 PM R2 stated R1 came outside and found him out front and stated, Let's fight. R2 stated that R1 pulled the key out of R2's electric scooter and would not give it back and pushed R2. R2 revealed he told R1 not to touch him. R2 further revealed R1 grabbed R2's cane and started hitting him with it. R1 pushed R2 and ended up breaking R2's wheelchair seat and then R1 and R2 fell to the ground. R2 stated R3, a resident that sat with R2 outside before and when this occurred alerted nursing staff to get R1 and R2 apart and off the ground. R2 stated R1 walked around and bullied other residents. He stated he felt stalked by R1 and said other residents felt the same way. R2 stated he was uncertain the facility would protect him or do anything about R1 bullying and stalking. R2 stated he was also really worried about the other residents in the facility. On 07/10/23 at 01:38 PM R1 laid in his bed. Observation revealed a bruised area under his right eye in the shape of a triangle and a maroon to grey bruise above the bridge of his nose approximately 0.5 centimeters (cm) in width and approximately 2.0 cm in length. R1 stated he was outside for a walk and came upon R2. R1 denied he was specifically looking for R2. On 07/10/23 at 01:45 PM Certified Medication Aide (CMA) R stated R1 and R2 were now kept separated and there were no other precautions in place. CMA R stated she was told about the event after she noted the bruising on R2's face and asked staff what happened. On 07/10/23 at 01:48 PM Certified Nurse Aide (CNA) M stated R1 hit other residents in the past, but R2 had no history of that kind of behaviors. CNA M revealed she had not learned about the event in report, but later, after she noted bruising on R2 and asked about it, she was informed of the incident. On 07/10/23 at 02:38 PM Administrative Nurse D stated it was weird that R1 was even out front, because he typically never went out front. Administrative Nurse D stated R1 and R2 lived on different sides of the building, and they have been told to stay on their sides of the building. She said R1 and R2 were monitored to make sure they stayed on opposite sides of the building. She said staff followed the policy related to the event. She stated the residents were outside and did not require oversight or staff supervision. She confirmed the area of the occurrence was at the end of the garage, outside of the view of staff. On 07/10/23 at 03:16 PM CNA N stated R1 was very aggressive and had a history of going after residents in wheelchairs. On 07/10/23 at 05:16 PM Administrative Staff A stated the police were called and R1 and R2 had the chance to press charges; both choose not to. The facility's policy Resident-to-Resident altercations revised [DATE] documented facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, DON, and to the Administrator. Make any necessary changes in the care plan approaches to any or all the involved individuals. The facility failed to ensure residents remained free from abuse when R1 took the keys to R2's electric wheelchair, struck R2 with a cane, and tipped R2 over and out of the wheelchair. R2 sustained physical injuries to his face, and pain because of the abuse, as well as the psychosocial impact which included R2's worry for his safety and that of his friends. This placed R2 in immediate jeopardy. The facility completed the following corrective actions to address the immediacy: R1 was placed on 1:1 at 05:20 PM on 07/10/23. R1 will remain on 1:1 until transferred out for care, discharged from facility or until medical intervention was placed. All staff were educated on recognizing signs and symptoms of abuse, neglect, and exploitation. Staff were educated on facility policy for abuse and resident to resident altercation. Staff were educated on abuse investigation reporting policy and protection of residents during abuse investigations. A licensed social worker met with R1 to discuss possible treatment options and discharge planning. Resident care plans were reviewed and updated with appropriate intervention to address aggression. Implementation of the corrective actions and removal of the immediacy was verified onsite by the surveyor on 07/11/23. The scope and severity remained at the level of G to reflect the physical and psychosocial harm to R2.

The facility had a census of 54 residents. The sample included 21 residents. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the facility failed to consistently monitor water temperatures in areas with resident access and failed to ensure the water in Resident (R) 55's bathroom remained at a safe temperature. On 04/18/23 at 10:50 AM, R55 reported an unidentified staff complained to him the water from R55's bathroom sink had scalded the staff. Upon assessment, the temperature of the sink water measured at 143.5 degrees Fahrenheit (F) which was 23 degrees above a safe bathing temperature. At 11:10 AM, Administrative Staff A rechecked the water temperature and verified it was 141 degrees F at that time, which was too hot, per Administrative Staff C. This failure placed R55 in immediate jeopardy. The facility further failed to ensure safe water temperatures in resident rooms when hot water temperatures were above acceptable bathing temperatures at 125-138 degrees F. This placed the affected 12 other residents and placed the residents at risk for burns. Findings included: - On 04/18/23, upon request for the monthly water temperature logs, the facility could only provide water temperature testing for April 2023 (done on 04/12/23), which included 40 resident rooms and included the rooms found to have unsafe temperatures. The log documented a range of temperatures from 106 degrees F to 111 degrees F. Administrative Nurse E reported the facility lost any other documentation of water testing. On 04/18/23 at 10:50 AM, assessment of water temperatures for the sinks in residents' rooms, related to a complaint called into the state agency, revealed the following temperatures: R55's room measured 143.5 degrees F. R51 and R46's shared room measured 135 degrees F. R31 and 44's shared room measured 135 degrees F. On 04/18/23 at 11:10 AM, Administrative Staff C verified the water temperatures with a facility thermometer. Administrative Staff C obtained the following sink water temperatures: R55's room measured 141 degrees F. R51 and R46's shared room measured 133 degrees F. R31 and R44's shared room measured 138 degrees F. On 04/18/23 at 11:14 AM, Administrative Staff C verified the water was too hot and went to the water system and attempted to adjust it. On 04/18/23 at 11:15 AM, an assessment of other resident room sink water temperatures were performed to ascertain the extent of the problem. The following sink water temperatures were found: R26 and R36's shared room measured 138.7 degrees F. R17's room measured 137.7 degrees F. R11's room measured 125 degrees F. R15's room measured 132 degrees F. R32 and R20's shared room measured 134 degrees F. On 04/18/23 at 11:25 AM, assessment of the water temperature in the shower room on the east hall revealed a water temperature of 126 degrees F. On 04/18/23 at 12:56 PM, water temperatures in the affected rooms (listed previously) were assessed again and all measured less than 115 degrees F. On 04/10/23 at 05:10 PM, Administrative Nurse E stated staff used the computer system or paper tickets to report maintenance issues. She stated staff were recently in-serviced on how to report issues. On 04/18/23 at 10:50 AM, R55 stated a staff member complained the water scalded her in the past. He stated he did not use the sink. On 04/18/23 at 11:00 AM, Certified Nurse Aide (CNA) M stated she did not know of the water being too hot in any resident rooms. On 04/18/23 at 03:25 PM, Administrative Staff C and Administrative Nurse E verified the facility adjusted the water temperatures to a lower temperature. The facility's Safety of Water Temperatures policy dated 08/11/21, documented tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) recorded temperatures at 124 degrees F can cause a third-degree burn ( serious burn which affects the outer layer of skin as well as the entire layer beneath and requires immediate medical attention) in three minutes of exposure; temperatures at 127 degrees F can cause third degree burn with one minute of exposure; temperatures at 133 degrees F can cause third-degree burn in 15 seconds of exposure, and water temperatures at 140 degrees F can cause a third-degree burn in five seconds of exposure. The facility failed to ensure the environment remained free of accidents when unsafe hot water temperatures were found in the handwashing sink in R55's room, placing R55 in immediate jeopardy related to potential burns from the hot water. Unacceptably hot water was also found in 12 other resident rooms placing the 12 affected residents at risk for hot water related burns and/or injuries. On 04/18/23 the facility implemented the following corrective measures: 1. The facility administrative staff immediately adjusted hot water temperatures to be below 120 degrees F. 2. Facility consulted plumping professionals to come onsite and evaluate the hot water heaters. 3. Staff received education on safe, acceptable, water temperatures. 4. The facility contracted with a local professional to install additional thermometers to the facility hot water tanks. 5. The facility placed locks on the doors to the hot water heater on the Northeast unit. After removal of the immediacy, the deficient practice remained at the scope and severity of E.

The facility identified a census of 56 residents. Based on record review and interviews the facility failed to prevent a significant medication error when Certified Medication Aid (CMA) R failed to verify the identity of Resident (R) 1 prior to administering medication. On 4/26/21 at 09:22 PM R1 received multiple medications in error, including psychoactive medications (affecting cognition, mood, and/or thoughts). After R1 received the incorrect medications, R1 was unresponsive and in respiratory distress. R1 was sent emergently to an acute care facility, placed on a ventilator for assisted respiration, and admitted to the intensive care unit (ICU). The deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) recorded he admitted to the facility on [DATE] for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Daily Skilled/Manage Care/Progress Note assessment which served as the baseline Care Plan dated 04/23/21 documented R1 was alert and oriented to person, place, and time and required limited assistance of one staff member with most activities of daily living, such as transfers, dressing, toilet use ambulation, and eating. R1's initial baseline Care Plan, dated 04/22/21 consisted of a review of systems; cognition, cardiovascular, breathing, nutrition, mobility, [CONDITION(S)], but lacked any documentation regarding the resident's medications. A nurse's Progress Note, dated 04/27/21 at 05:59 AM documented at 10:27 PM on 04/26/21 CMA R notified Licensed Nurse (LN) G that R1 received another resident's medications. The note recorded R1 received the following medication, prescribed to R3, in error: [MEDICATION(S)] (anticonvulsant) 300 milligrams (mg) [MEDICATION(S)] (medication used to treat and prevent abnormal heart rhythms) 40 mg [MEDICATION(S)] (medication used to treat cholesterol) 40 mg [MEDICATION(S)] (anticonvulsant) 1000 mg [MEDICATION(S)] (supplement used as a sleep aid) 6 mg Requip (medication used to treat symptoms of [CONDITION(S)] disease: limb stiffness, tremors, muscle spasms, and poor muscle control) 2mg [MEDICATION(S)] (an antipsychotic medication used to treat certain mental/mood conditions (such as [CONDITION(S)], [CONDITION(S)], sudden episodes of [CONDITION(S)] or depression associated with [CONDITION(S)] 400 mg. The note further recorded the resident's oxygen saturation (SpO2-the level of oxygen in the blood, normal values 95 % to 98%) was 95 percent (%) on room air. At midnight on 04/26/21 R1' s SpO2 dropped from 95% to 91%. He was given supplemental oxygen at five liters per minute to raise his SpO2 to 95% and subsequently transferred to the hospital at 02:30 AM 04/27/2021 . The hospital emergency room (ER) Admission Report dated 04/27/21 at 03:13 AM documented R1 presented in the ER from a local nursing facility for evaluation of an unintentional drug overdose. R1 accidentally received other patients' medications. He also had a fall out of bed sometime around 8:00 PM. When facility staff checked on R1, he had an altered level of consciousness and was not responding. Emergency Medical Services (EMS) reported a normal glucose (blood sugar level). His Glasgow Coma Scale (GCS) on arrival was three. According to Medical Dictionary.com, the Glasgow Coma Scale is a clinical scale used to reliably measure a person's level of consciousness after a [CONDITION(S)]. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. A person's GCS score can range from three (completely unresponsive) to 15 (responsive). A nurse's Progress Note, dated 04/27/21 at 06:01 AM documented LN G received a call from a pharmacist at the hospital to confirm the medications R1 received. The pharmacist informed LN G R1 was intubated (had a tube inserted into the trachea for ventilation), received vasopressors (medication that tends to raise low blood pressure), and admitted to the ICU. A notarized Witness Statement by CMA R documented on 4/26/21 CMA R passed medications on the East side after dinner. The East side had two admissions during the shift, and there were issues with one of the new resident's medications. CMA R worked with the hospice nurse and the charge nurse to fix the medication problems. At the same time, residents stopped CMA R and asked for things. One of the residents was upset about how staff transferred him. CMA R was in that resident's room and assisted to deescalate the situation. CMA R received the medications for the newly admitted residents. CMA R did not know what the new residents looked like. CMA R assisted other facility staff when R1 fell in the dining room but did not know R1's name at that time. CMA R documented staff called R1 the new guy, and CMA R only met R1 once when he arrived the prior week. CMA R was interacting with R1 and in doing so, accidentally gave R1 the wrong medications. In another notarized Witness Statement, dated 04/27/21, CMA R documented she administered the medications to R1 at 09:22 PM. At 10:27 PM CMA R checked R1's blood pressure (BP). R1 was alert and oriented at that time and his BP was 112/61 millimeters of mercury (mm/HG). His pulse was 71 beats per minute (BPM). CMA R documented it was at that time she realized the medication error and informed the nurse. Interview on 04/28/21 at 2:33 PM, CMA R stated on 04/26/21 there was a lot going on at once, with new admits, and falls and everything. She reported she realized the error when she overhead a Certified Nurse Assistant (CNA) say R1's name. Once she realized the mistake, she informed the nurse right away. During an interview on 04/28/21 at 12:30 PM, Administrative Nurse D stated she expected staff to clearly identify the resident before administering any medications. Administrative Nurse D stated CMA R did not follow the facility policy regarding medication administration. She also said she would expect staff not to attempt to administer medications during periods of chaos or confusion. During a telephone interview, on 04/28/2021 at 03:06 PM, Physician M stated staff notified his nurse practitioner and himself of the medication error in a timely manner. Physician M stated in the event of medication errors, he ensured the resident was stable and monitored for any changes. Physician M stated staff monitored R1 closely and when his condition changed, staff transferred the resident to the hospital for treatment . The facility's Administration of Medications policy revised April 2019 documented all medications were administered in a safe and timely manner as prescribed. The facility's Medication Administration Competency Checklist recorded a six-step verification process to be used by person(s) administering medications which included The Right Resident, received the Right Medication, in the Right Dose, by the Right Route, at the Right Time, in the Right Form. The facility failed to prevent a significant medication error for R1, a cognitively impaired resident, when CMA R failed to verify R1's identity prior to administering medication which resulted in R1 receiving another resident's medication. Subsequently, R1 became unresponsive, suffered respiratory distress and low BP. R1 required emergent care at the hospital where he was placed on ventilator and admitted to the ICU. This failure placed R1 in immediate jeopardy beginning on 04/26/2021 at 09:22 PM when the medication error first occurred. The immediate jeopardy was removed when the facility completed the following interventions on 04/27/21 at 11:00 PM. The Director of Nursing and Staff Development Coordinator educated all facility licensed nursing and certified medication staff including agency staff on the procedure for administering medications, in resident identification and the six right of medication administration. Staff also completed a Medication Administration Competency Checklist and Post-test. The Director of Nursing and Staff Development Coordinator or designee educated all licensed nursing staff including agency staff on the Event Management System policy (which includes medication discrepancy, and notification of physician). A Quality Assurance and Performance Improvement (QAPI) meeting was held with the QAPI Committee and Medical Director via telephone.

The facility identified a census of 56 residents. The sample included three residents who received mechanical soft diets (foods that are physically soft, with the goal of reducing or eliminating the need to chew the food). Based on record review and interviews, the facility failed to ensure a mechanical soft menu was followed for Resident (R)1. On [DATE] at approximately 5:50 P.M. R1 received uncut and non-soft Brussel sprouts with the evening meal. R1 experienced choking and required the [MEDICATION NAME] maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe). R1's skin color turned blue, R1 underwent cardio-pulmonary resuscitation (CPR-chest compression used to restore blood circulation in a person whose heart stops) and was transported to an area hospital. The deficient practice placed R1 in Immediate Jeopardy. Findings Included: - The Electronic Medical Record (EMR) identified R1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. R1 required extensive assistance of one to two staff with most activities of daily living (ADLs), except eating. The MDS recorded R1 required set up and supervision with meals, received a mechanically altered diet (a diet that required change in texture of food or liquids). The Nutrition Care Area Assessment (CAA) dated [DATE] documented R1 was on a mechanical soft diet and was able to feed himself for the most part. R1 had [MEDICAL CONDITION] (a progressive disease of the nervous system, marked by muscle rigidity and tremors) and needed limited assistance at times. The EMR, under the Orders tab, recorded an order, dated [DATE] for a regular diet, mechanical soft, ground texture, and nectar consistency fluids. R1's Care Plan revised on [DATE] documented R1 ate a mechanical-soft diet. The Care Plan added on [DATE], the resident needed increased supervision since readmission with meals, set-up and may need to assistance to get started to eat. The Care Plan also directed staff to monitor and document any signs and symptoms of dysphagia, such as pocketing (food-holding food in cheeks), choking, coughing, drooling, holding food in mouth, and repeated attempts at swallowing. The nurse's Progress Note dated [DATE] at 8:14 PM documented Certified Nursing Aide (CNA) N notified Licensed Nurse (LN) G that R1 choked while eating dinner. LN G ran from the west side to find the resident sitting upright in a wheelchair in the hallway. LN G began the [MEDICATION NAME] on R1 in the wheelchair until R1 began turning blue in the face, became unconscious, and his whole body was limp. At that point, LN G checked for a radial pulse, had staff assist R1 to the floor and began CPR. LN G and another staff member performed CPR until Emergency Medical Technicians (EMT's) arrived, took over, and transported the resident to the hospital. Review of the Menu, noted as Week 11, dated [DATE] documented Brussel sprouts were to be substituted with green beans for mechanically altered diets. According to https://www.NationalDysphagiaDiet.com for mechanical soft diets, vegetables should all be soft, well-cooked, should be less than ,[DATE] inch and should be easily mashed with a fork. This source advised residents with mechanical soft diets to avoid cooked corn and peas. broccoli, cabbage, Brussel sprouts, asparagus or other fibrous, non-tender or rubbery cooked vegetables. In a notarized Witness Statement, signed [DATE], Dietary Cook BB documented, I cooked the food they gave me according to menus given. In a notarized Witness Statement, signed [DATE] CNA M documented she had just taken a resident dinner when CNA N ran into the room and said R1 was choking and ran out of the room. CNA M ran after CNA N to R1, who was in a wheelchair on the East side day area. CNA M told CNA N to get the nurse. LN G arrived and began the [MEDICATION NAME]. Staff then lowered R1 to the floor, initiated, and and continued CPR until EMTs arrived. In a notarized Witness Statement, signed [DATE], LN G documented she ran from the West side to find R1 in a wheelchair in the hallway. LN G immediately began the [MEDICATION NAME] while the resident was in a wheelchair. R1 became unresponsive, face turned blue, and his pulse was absent. Staff moved R1 to the floor and performed until emergency medical services (EMS) arrived, took over, and transported R1 to the hospital. In a notarized Witness Statement, signed [DATE] CNA N documented she was assisting another resident and as she turned to walk down the hall, she saw R1 up in the wheelchair gasping for air with R1's hands by his neck. CNA N immediately stopped to start the [MEDICATION NAME] maneuver. CNA N could not help R1 alone and yelled for help. An unidentified aide that CNA N was walking with ran over quickly to assist. CNA N ran to get the nurse and anyone else that could help. In a notarized Witness Statement, signed [DATE], CNA O documented CNA N came to the west side to get the nurse because R1 was choking. CNA O and CNA N observed LN G performing the [MEDICATION NAME] maneuver, on R1, but no object came out. CNA O and CNA N assisted R1 to the floor, and staff started chest compressions. CNA O recorded the EMTs retrieved a Brussel sprout from the resident. CNA O documented Administrative Nurse D asked CNA O to cut open a Brussel sprout to see if it was hard, and it was hard. Review of the Hospital emergency room Report dated [DATE] revealed R1 experienced cardiopulmonary arrest (heart cessation) and acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (lack of oxygen) due to an aspiration event (a condition in which foods, or fluids are breathed in through the windpipe). Interview on [DATE] at 2:08 P.M Dietary Manager (DM) DD provided a copy of the menu for [DATE] and stated Brussel sprouts in any form were not on the mechanical soft diet menu. DM DD stated 'I'm not really sure what happened, if a page of the menu fell out or what exactly happened. We have since revamped how menus are done. In an interview on [DATE] at 12:02 P.M. Administrative Nurse D stated on [DATE] at approximately 5:51 PM she received notification R1 had a choking episode, went unresponsive, and was sent to the hospital. Administrative Nurse D stated it was unclear why staff served R1 Brussel sprouts, but green beans were the alternative and the green beans were available in the kitchen. On [DATE] at 1:09 PM Physician HH stated staff notified him of the occurrence in a timely manner and he indicated the situation would be reviewed in the facility's Quality Assurance program. The facility did not provide a policy specific to mechanical soft diets. The facility failed to ensure staff served a mechanical soft diet to R1 with a documented swallowing problem and a physician ordered mechanical soft diet which led to a choking episode, breathing cessation, and [MEDICAL CONDITION]. This deficient practice placed R1 in Immediate Jeopardy on [DATE] at 5:50 P.M. The Immediate Jeopardy was removed when the facility completed the following on [DATE] at 2:30 PM. The facility immediately identified the event and the need for staff education for accurate diet textures served to residents. The facility completed an audit of diet orders. An audit of diets for all residents at mealtimes by dietary and nursing and audits were taken to morning meeting to follow up with any other clinical/dietary needs. The facility placed books at the nurse station with diet education. The facility placed a list of diet orders at each nursing station. The kitchen will have clipboard with the following information mechanical diet highlight, menus, recipes, spreadsheet for each menus to prevent errors if recipes missing, and thickened liquids diets. Based on the completion of corrective measures on [DATE] at 2:30 PM, the deficiency was cited at past non-compliance.

The facility identified a census of 49 residents. The sample included 3 residents reviewed for elopement risk (when a resident leaves the facility without staff knowledge). Based on record review and interview, the facility failed to ensure 1 resident (#1) received adequate supervision to prevent elopement when the resident exited the facility's enclosed smoking area on 5/25/18 at undetermined time (last seen at approximately 4:36 AM) walked 6.1 miles in a suburban metropolitan area, and was returned to the facility by facility staff. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The electronic medical record (EMR) for resident #1 included [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented the staff assessed the resident with long and short-term memory problems. He/she had inattention, disorganized thinking which did not fluctuate, hallucinations (sensing things while awake that appear to be real, but the mind created), and delusions(untrue persistent belief or perception held by a person although evidence shows it was untrue). He/she wandered daily and required supervision with locomotion. The quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. He/she had hallucinations, delusions, inattention and disorganized thinking which did not fluctuate. He/she wandered 4 to 6 days of the 7- day period. He/she required supervision for locomotion. The Behavioral Care Area assessment dated [DATE] documented he/she had a history of [REDACTED]. The elopement care plan dated 8/14/17 documented he/she was at risk for exit seeking due to impaired cognitive function and impaired thought processes related to his/her diagnoses. Staff alerted the nurse if the resident attempted to leave the building. A revision on 1/12/18 documented the staff performed 1 on 1 observations 24 hours a day. Review of the licensed nurse's progress note dated 5/25/18 at 6:42 AM documented staff saw the resident near the nurse's station at approximately 4:15 AM. At approximately 4:50 AM the staff were unable to locate the resident. At 5:45 AM the administrator notified the facility that staff found the resident. The resident stated he/she wanted to go to the group home. The EMR documented the following elopement assessments: 5/3/17 at low risk, 7/19/17 low risk, 8/17 moderate risk, 9/20/17 high risk, 1/8/18 high risk, 4/19/18 high risk, and 5/17/18 high risk. Review of the facility obtained witness statements documented licensed staff G observed the resident near the nurse's station and then walk back to his/her room about 4:15 AM on 5/25/18. Licensed staff H was told by staff the resident wasn't in the building about 4:30 AM on 5/25/18. Direct care staff N observed the resident talking to a nurse around 3:50 AM to 4:00 AM and could not find him/her around 4:30 AM on 5/25/18. Direct Care Staff O accompanied the resident to the smoking patio. He/she left the resident to answer a call light and upon return to the patio the resident was gone. According to the K-State Weather Data Library the on 5/25/18 at 4:30 AM the outside temperature was 66 degrees Fahrenheit (F) with fog in the area at 4:00 AM. On 5/30/18 at 7:50 AM the resident was in his/her room accompanied by staff. A wander-guard bracelet was present on his/her left ankle. On 5/30/18 at 9:30 AM administrative staff A stated all staff received education on elopements and 1 on 1 care directives during orientation. The staff also received an in-service on elopement and 1 on 1 care on 5/10/18. Direct care staff O attended the in-service. Administrative staff A investigated the incident and found staff left the resident unattended on the smoking patio on 5/25/18 at 4:36 AM, during which time direct care staff O answered a call light. Direct staff O came back within 5 minutes and the resident was gone. The staff notified him/her by 4:45 AM and staff searched the facility grounds. The police were notified. Facility staff located the resident at 5:35 AM and returned to the facility with him/her. The facility's undated 1 on 1 Directives statement documented the staff member must be within 10 feet of the resident. The staff must walk to and from places with the resident. The nurse must always be aware which staff member was assigned to the 1 on 1 and always know the location of the resident. The facility's elopement policy dated (MONTH) (YEAR) documented the facility staff promptly report, to the charge nurse or director of nursing, any resident who tries to leave the premises or was suspected of being missing. The facility failed to ensure 1 resident (#1,) with documented exit seeking behaviors, received adequate supervision to prevent elopement which placed the resident in immediate jeopardy. The deficient practice was cited as past non-compliance when the facility terminated staff O from employment on 05/25/18. The facility immediately re-in-serviced all staff on the 1:1 Directive which explains that a resident who needs 1:1 supervision was to never be left alone. The facility would review this occurrence in the monthly QA meeting and include this training as part of the new hire packet. The aadministrator, DON and Human Resources Director provided in-service training to all staff on 5-25-18 focusing on the 1:1 Directive. Staff who were away for the Holiday weekend were not allowed to work until they had been in-serviced.

The facility reported a census of 66 residents and with 4 residents sampled for elopement (when a cognitively impaired resident left the facility grounds unattended and without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent an elopement, after staff identified the resident at risk for elopement. Resident #1 exited the facility without staff knowledge on 8/13/17, between 9:00 PM and 10:00 P.M. and remained missing until 8/14/17 at 8:00 A.M. (7 hours later) when a psychiatric facility staff found the resident approximately 5 miles from the facility. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The August 2017 physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The admission 5 day Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with intact cognition, poor safety awareness, delusions (a false belief despite evidence to contradict) and hallucinations (someone sees, hears, smells, tastes or feels things that don't exist outside their mind). The resident received anti-depressant medications (medication to relieve feelings of sadness), anti-psychotic medications (used to treat mental health illness), and did not wander during the assessment period. He/she was independent with his/her activities of daily living (ADLs) and walked without the use of assistive devices. The admission Care Area Assessment (CAA) dated 2/17/17 for cognition recorded the resident had [DIAGNOSES REDACTED]. He/she has short/long term memory problems, delusions, and yelled out or talked to himself/herself. The CAA recorded he/she received a daily hypnotic medication (a psychoactive medication used to induce sleep) for insomnia (difficulty sleeping), psychotropic and anti-depressant medications. The electronic medical record (EMR) lacked documentation of an admission elopement assessment. The 5/3/17 elopement risk evaluation recorded a score of 7.0 which placed the resident at risk for elopement from the facility The 7/19/17 elopement risk evaluation recorded the resident had an increased risk for elopement with a score of 9.0. The nurses' notes dated 7/20/17 at 12:09 A.M. documented the resident paced all night and experienced increased pacing since his/her Visitaril (an antihistamine medication - sometimes used as a sleep aid) was discontinued. The care plan dated 7/27/17 lacked interventions to prevent an elopement. Review of the nurse's note dated 8/13/17 at 9:50 P.M. recorded staff did not observe the resident in his/her room, but the resident did not sign out of the facility. Staff last observed the resident at 9:00 P.M. The front door alarmed at 9:08 P.M. as one of the residents with a wander guard bracelet (a device that alerts staff when an elopement risk resident neared an exit) sat by the door; a staff member responded and did not see anyone. Staff notified the nursing director and administrator. Review of the nurse's note dated 8/13/2017 at 10:40 P.M. recorded the staff notified the local police department the resident walked away from the facility without staff knowledge. The nurses' note documented there was a concern regarding the resident's ability to make safe choices and he/she needed medications. The staff gave the officer a photograph of the resident. Review of the nurse's note dated 8/13/2017 at 11:00 P.M. recorded licensed nurse J notified licensed nurse H (oncoming nurse) staff could not locate the resident. The note documented nurse H stated at 10:00 P.M. when he/she came to work, he/she thought he/she saw the resident a few blocks from the facility, but was unsure. Review of the nurse's note dated 8/14/2017 at 1:00 A.M. recorded staff members searched the outside perimeters of the facility, near areas such as closed gas stations, and the bus station, but were unable to locate the resident. According to the facility's investigation, witness reports documented staff last saw the resident at approximately 9:00 P.M. on 8/3/17. The investigation recorded it was unclear how the resident exited the facility. The resident told the social worker and administrator that he/she was on the smoker's patio, when he/she became scared after seeing blue and red smoke come from the vents. He/she reported jumping two fences, because he/she needed to get out of there. The report recorded staff notified the police, a search was conducted, and on 8/14/17 at 8:25 A.M., a local outpatient psychiatric facility called and stated the resident walked into their offices. Direct care staff O's notarized witness statement documented around 9:00 P.M. on 8/13/17 he/she saw the resident in the east hallway. The resident walked down the hallway and stood by the nurse's station, when staff H heard the door alarm sound. Direct care staff O ran down the hall looked out the door and did not see anyone. He/she had to escort another resident (#2), identified as an elopement risk, away from the door. Direct care staff O stated he/she concluded resident #2 set the door alarm off. About an hour, later night shift nurse R came and told him/her and nurse N that he/she saw the resident #1 by the highway. Licensed nurse R's notarized witness statement dated 8/13/17 at 9:55 A.M. documented as he/she drove to work, he/she observed a person walk in the opposite direction. He/she was unsure who the person was, but the gait looked like resident #1. Staff R arrived at the facility and asked staff if the resident there, because he/she may have seen him/her. Upon further inquiry, staff realized it was the resident. Nurse S asked nurse R and another staff to go and look for the resident. It was about 10:05 P.M. Licensed nurse N's notarized witness statement documented the night shift nurse stated he/she saw the resident outside of the facility. Staff searched his/her room and he/she was not there. The door alarmed at 10:08 P.M., but the resident was not near the door. Nurse N directed two staff to go and look for the resident. Nurse N notified administration and the police department and he/she stayed at the facility to call the local hospitals. According to Google maps, the resident walked approximately 4.2 miles The area traveled showed the resident walked in the inner city, with busy streets, different motor vehicle speed limits of 25 to 45 miles per hour (MPH), across traffic, curbs, sidewalks, businesses, residential areas, and up and down slopes. According to wunderground.com, on 8/3/17 at 10:53 P.M. the temperature was 73.8 degrees Fahrenheit (F) with winds from the southeast (SE) at 9 mph, and scattered clouds. On 8/4/17 at 3:01 A.M. the temperature was 68.1 degrees F, with winds of 5 mph, and at 7:53 A.M. it was 70.0 degrees F with south winds at 4.6 mph and overcast skies. On 8/16/17 at 8:48 A.M. the resident layed in bed, clothed, and listened to music. On 8/16/17 at 1:30 P.M. the resident stated he/she was outside on the smoking patio and thought he/she saw blue and red smoke come from the roof vents, became scared, and jumped the fence to get away. The resident remembered walking down 6th street to a discount store, spent some time outside of the store, and then walked to the psychiatric facility. He/she stated there were not many cars that night, and he/she slept outside. The resident further stated he/she was scared that night and was glad they found him/her. On 8/16/17 at 9:27 A.M., direct care staff O stated this was the resident's first attempt to elope. On 8/16/17 at 9:30 A.M. administrator A stated initially staff thought the resident exited through the front door, and followed a visitor out. Now, after talking with the resident, it was believed he/she was on the smoking patio, had a bad dream, saw red smoke, became fearful, and jumped the fence. Staff A stated this made sense, because staff last observed the resident on the smoking patio and the resident had a history of [REDACTED]. On 8/16/17 at 2:24 P.M. licensed nursing staff R verified his/her statement. The facility's undated Elopement Prevention policy documented the purpose was to implement an organized method of providing a safe environment for residents who were at risk for wandering and directed staff to assess the resident, monitor the resident and check the functions of all doors with the Resident Monitoring System a minimum of once daily. The facility failed to ensure this resident received adequate supervision and appropriate interventions to prevent an elopement after staff identified the resident as an elopement risk when he/she exited the facility on 8/13/17 without staff knowledge. This deficient practice placed resident #1 in immediate jeopardy. The deficiency was cited as past non-compliance on 8/15/17 when the facility implememted the following: New smoking and elopement assessments were done on the resident. It was determined that the resident should wear a Wanderguard bracelet. When resident now smokes, his/her cigarettes he/she will do so with staff supervision. All exterior exit door codes were changed on 8/13/17, except the smoking patio exit door and staff was inserviced on 8/14/17about the new codes and not providing residents, families or vendors with the codes. Elopement policy and procedure were updated to include doing a head count when a door alarm has sounded. This policy and procedure change was inservice on 8/14/17. Staff members that did not come to the inservice due to vacation (2) or inability to come to the facility (1) did not work until they werte inserviced on the policy and procedure change. The administrator or designee will be responsible for auditing compliance for door code polity adherence. The DON or designee will be responsible for monitoring for Wanderguard placement checks are being conducted.

The facility reported a census of 45 residents. The sample included 3 residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent an elopement (when a cognitively impaired resident leaves the facility grounds unattended and without staff knowledge) after staff identified the resident was at risk for elopement. Resident #1 exited the facility without staff knowledge on 6/18/17, walked approximately 0.2 miles (335 feet), and was found by a police officer approximately 100 yards away from the facility. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The June 2017 physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The admission 5 day Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with intact cognition and poor safety awareness. The resident received anti-depressant medications (medication to relieve feelings of sadness) and did not wander during the assessment period. He/she was independent with his/her activities of daily living (ADLs) and walked with a walker. The elopement risk assessment dated [DATE] documented the resident had a score of 11, which indicated a moderate risk for elopement. The care plan dated 6/1/17 documented the resident had periods of confusion and wanted to go home. The care plan directed staff to provide one on one care if the resident displayed exit seeking behaviors, attempt to redirect him/her, notify the nurse of any exit seeking behaviors, ensure the placement of his/her wander guard (a bracelet worn to signal a device that alarmed when a resident neared an exit) and to check its function every shift. The nurse's note on 5/31/17 at 5:56 P.M. documented the resident sat in the director of nursing's office and stated he/she wanted to go home. The nurse's note dated 6/18/17 at 2:45 P.M. recorded at approximately 2:05 P.M., staff reported observing the resident walk down the side walk outside of the facility without his/her walker. Staff immediately went outside and searched for the resident. Staff found the resident's shoes and his/her walker in the field to the west of the building. Staff continued to search for the resident. This writer drove around for approximately 10 minutes and attempted to locate the resident. This writer returned to facility and immediately called 911. A police officer came out to the facility to take the report, and informed staff an unknown person found the resident at approximately 2:45 P.M. near a cross street not far from the building. Staff notified the administrator, the assistant director of nursing, and the physician. Staff received orders to transport the resident to the emergency room for an evaluation and treatment. According to the facility's investigation, witness reports documented staff noticed the resident missing around 2:00 P.M. on 6/18/17. Staff found the resident's shoes and walker in a field behind the facility on 6/18/17 at 2:29 P.M. When staff could not locate the resident at this time, they called the police. When police arrived at the facility, they informed licensed nursing staff H the resident had been found on 6/18/17 at 2:45 P.M., and at 3:10 P.M., the resident was assessed at the hospital emergency room . This investigation lacked documentation of when (what time) the resident exited the facility, through what door the resident exited the facility, how long he/she was gone, where he/she was found and what activity specifically he/she was doing when located. According to direct care staff's O signed and notarized witness statement, he/she last saw the resident on 6/18/17 at approximately 1:15 P.M. This placed the resident outside of the facility for 94 minutes or 1.34 hours. (This conflicts with the information in the facility's investigation that the resident was outside of the facility for 45 minutes.) According to Google maps, the resident walked 335 feet from the facility, approximately 1 block. Review of the area the resident traveled revealed an automotive shop on the southeast corner, paved roads traveled at 25 MPH, and included nearby hazards of uneven surfaces, wooded areas, rocks and weed growth. According to wunderground.com, the temperature on 6/18/17 between 1:15 P.M. and 2:09 P.M. was 81 degrees with light winds and clear sky. On 6/21/17 from 10:00 A.M. to 2:30 P.M. the facility had eight exit/entry doors to the building; four of these doors had a wanderguard alert system and 4 did not. Of the 4 wanderguard alarm systems, two did not function correctly (did not lock down and/or alarm when tested ). On 6/21/17 at 3:00 P.M. the resident sat outside with other residents with staff present. On 6/21/17 at 2:30 P.M. maintenance staff M confirmed the two wander guard alarms did not function as expected, and was unsure why. He/she stated the facility recently obtained new wander guard alarms, and was in the process of installing them on all of the doors. On 6/21/17 at 5:00 P.M., licensed nursing staff H stated he/she worked on 6/18/17. He/she stated at approximately 2:09 P.M. on 6/18/17, he/she received a phone call from direct care staff O, who just finished his/her shift, that the resident was on the northwest corner of the two cross streets in front of the facility (approximately 100 yards from the facility's entrance). Staff H and direct care staffs P and Q left the facility to search for the resident. Staffs P and Q continued to search while Staff H returned to the facility to his/her vehicle to expand the search. When Staff H was unable to find the resident, he/she said he/she returned to the facility, and called the police at 2:29 P.M. The police arrived to the facility at 2:35 P.M., and stated they had received a report from a passerby who saw the resident. Staff H further stated he/she notified the resident's physician, and received orders to have the resident evaluated at the hospital. On 6/22/17 at 9:36 A.M., direct care staff R stated on 6/18/17 at 2:09 P.M., he/she just finished his/her shift. On the way home from work, he/she observed the resident on the northwest corner of two cross streets near the facility. Staff R stated he/she called licensed nursing staff H and informed him/her of the resident's location. Staff R further stated at that time, he/she was unable to remain with the resident due to other obligations. Staff R stated the resident did not appear to be in any distress, so he/she felt the resident was safe to leave there. The facility's undated Elopement Prevention policy documented the purpose was to implement an organized method of providing a safe environment for residents who were at risk for wandering, and directed staff to assess the resident, monitor the resident and check the functions of all doors with the Resident Monitoring System a minimum of once daily. The facility failed to ensure this resident received adequate supervision and appropriate interventions to prevent an elopement after staff identified the resident as an elopement risk when he/she exited the facility on 6/18/17 without staff knowledge. This deficient practice placed resident #1 in immediate jeopardy. This deficient practice was determined to be past non-compliance when the facility implemented the following on 6/19/17: Staff installed personal alarms on the doors that were not part of the wander guard system and checked them every shift; staff moved the resident to the secure unit; the facility further educated staff about appropriate interventions for exit-seeking behaviors, the wander guard system, monitoring the current plan of correction and responding to alarms; wander guard checks every shift by charge nurses, and door alarms and wander guard system checks daily.

The facility reported a census of 64 residents. The sample included 7 residents reviewed for abuse. Based on observation, interview, and record review the facility failed to protect the residents in the facility when Resident #50 repeatedly abused 7 residents (#46, #4, #22, #36, #26, #5, and #51). Resident #50 hit Resident #46 in the face two times on 12/23/16, slapped Resident #4 in the face on 12/26/17, hit Resident #22 in the head on 12/27/16, slapped Resident #36 on the hand on 1/2/17, punched Resident #26 in the face knocking him/her out of the chair and causing bruising on 3/6/17, hit Resident #5 in the face causing a laceration and bruising on 3/21/17, and hit Resident #51 multiple times in the face on 4/19/17. This deficient practice placed all the residents of the facility in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#50 included [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 11/21/16, documented a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderate cognitive loss. The resident had hallucinations (sensing things while awake that appear to be real, but the mind created), but had no behaviors towards others. The resident required extensive assistance with bed mobility, transfers, toileting and bathing. The resident received an antipsychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions) 7 of 7 days, and an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication for 7 of 7 days of the assessment period. The quarterly MDS, dated [DATE], documented a BIMS score of 11, which indicated moderate cognitive loss. The resident had hallucinations and physical behavior symptoms directed towards others. He/she required limited assistance for bed mobility and transfers, and did not walk. The resident had no limitations on upper or lower extremities, and used a wheelchair for mobility. He/she received antipsychotic and antidepressant for medication for 2 of 7 days, and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication for 3 of 7 days of the assessment period. The (CAA) Care Area Assessment, dated 11/21/16, for behavior did not trigger. The CAA for cognitive loss /dementia documented the resident had a memory deficit and a [DIAGNOSES REDACTED]. The care plan, dated 11/23/16, directed staff to monitor the resident closely around other residents that are yelling and screaming, as he/she becomes agitated and will try to walk and hit them. On 12/27/16 staff obtained a medication review and an evaluation at an acute psychiatric hospital. Staff encouraged the resident to sit at a table alone or only with his/her sibling (also a resident) due to increased delusions, and allegations of hitting another resident in the face. On 12/28/16, the physician ordered an increase in the [MEDICATION NAME] (an antipsychotic medication) dose. On 12/31/16 the resident returned from the acute psychiatric facility with orders to increase [MEDICATION NAME] and Trazadone (an antidepressant medication used to treat depression and anxiety disorders). Staff discontinued 1:1 supervision (a staff with him/her at all times) on 12/31/16 after staff noted him/her to be calm and quiet for 3 shifts. On 1/2/17, after slapping another resident's hands, staff resumed 1:1 supervision. On 1/4/17, the facility transferred the resident again to an acute psychiatric facility for evaluation and treatment. On 3/6/17 staff maintained the resident on 1:1 supervision while awaiting further evaluation. The staff ensured the resident maintained arm's length from other residents at all times. If the resident had delusions and became agitated, staff was to allow him/her space. If the resident made inappropriate sexual comments, the staff re-educated him/her that the behavior was not appropriate. On 3/11/17, the physician again transferred the resident to an acute psychiatric facility for assaultive behavioral issues. On 3/20/17, the resident returned from the acute psychiatric facility, and staff placed him/her on 1:1 supervision while up, and staff allowed the resident to be in dining room without 1:1 supervision. On 3/21/17, staff changed the 1:1 supervision to include all areas of the facility. On 3/21/17 at 11:45 AM staff obtained a physician order [REDACTED]. On 3/22/17, the resident returned from the hospital and staff continued 1:1 supervision while awake. On 3/31/17, after the resident had delusions and became agitated, staff offered alternatives, like TV, activity of choice, and 1:1 as needed. (Staff had already placed this same intervention on 3/6/17). On 4/19/17, after another incident, the resident ate meals in his/her unit only and staff continued to seek appropriate placement for the resident. The nurse' notes dated 12/23/16 at 2:37 PM stated staff notified the charge nurse that Resident #50 punched Resident #46 twice in the face. The intervention implemented at that time was to have only the sibling of Resident #50 to sit at the table with him/her. The nurse's notes dated 12/27/16 at 12:07 AM documented the aides found this resident sitting on the floor in the dining room. The Certified Nurse's aide present in the dining room stated he/she did not see an incident but thought the resident had stood up to punch another resident and lost his/her balance. The nurse's notes dated 12/27/16 at 4:48 PM documented Resident #50 struck Resident #22 in the back of the head. The nurse's notes dated 1/2/17 at 9:52 AM documented that staff notified the charge nurse that Resident #50 struck Resident #36. He/she caused no injury. One-on-one supervision was restarted after this incident. The nurse's notes dated 3/6/17 documented the resident struck another (same gender) peer in the day room, and staff maintained 1:1 supervision. The nurse's notes dated 3/21/17 at 9:37 AM documented the resident stood up and punched Resident #5. Staff immediately intervened and removed the resident from the dining room. When this writer questioned the resident as to what happened, he/she stated resident #5 was staring, so he/she got up and hit him/her. The resident then asked this writer if he/she could hit him/her again. This writer redirected the resident and informed him/her this behavior was inappropriate. The resident sat at the nurse's station with 1:1 staff supervision. The nurse's note dated 4/19/17 at 10:34 AM documented the resident just struck Resident #51 in the dining room. Staff returned the resident to his/her unit by his/her 1:1 aide. The facility called law enforcement and the victim filed a report with the officer. Law enforcement issued a citation and contacted the department's crisis intervention team (CIT). CIT met with Resident #50 and the decision was made to transport the resident by ambulance to the emergency department at an acute hospital for assessment and possible admission to a higher level of care. The nurse's note dated 4/19/17 at 11:25 AM documented the resident ate breakfast in the dining room. Staff L was assigned as the resident's 1:1. The resident asked Staff L for more jelly. Staff L left the dining room to go to the kitchen for more jelly when Resident #51 entered the dining room. Resident #51 approached Resident #50's table spoke to Resident #50, and Resident #50 stood up and punched Resident #51 in the face 3 times with a closed fist. Staff took Resident #50 back to his/her room. Following this incident, staff sent Resident #50 the emergency department for an evaluation. On 4/19/17 at 3:30 PM, Direct Care Staff G stated he/she assisted another resident in the dining room with breakfast at the time of the incident. Staff G stated he/she observed Resident #51 come in to the dining room and sit at the same table as Resident #50. Staff G further stated staff were expected to keep Resident #50 at a table by himself/herself, because he/she hit other residents while in the dining room. Staff G further stated he/she observed Resident #50 stand up from his/her wheelchair, take a few steps toward Resident #51, and strike him/her with a closed fist 3 or 4 times in the face. Staff G stated staff provided Resident #50 with 1:1 supervision due to his/her behavior. Direct Care Staff L was assigned to provide 1:1 with the resident. After the incident, Staff G stated he/she took the resident's arm and asked him/her to sit down. The resident sat back down and ate breakfast as if nothing had happened. On 4/19/17 at 4:14 PM Direct Care Staff L stated he/she usually worked on the other hall, but today he/she was assigned 1:1 with the resident. He/she brought the resident into the dining room this morning and sat him/her at a table by himself/herself for breakfast. Staff L asked the resident if he/she needed anything, and he/she asked for additional jelly. Staff L stated he/she left the resident unsupervised and went to the kitchen to get the jelly. He/she heard a commotion while in the kitchen, returned to the dining room, and was informed Resident #50 hit Resident #51. On 4/19/17 at 4:10 PM, observation revealed the resident sat in a wheelchair by the nurse's station, supervised by Licensed Nursing Staff S. Resident #50 sat calmly and quietly in a wheelchair. On 4/19/17 at 4:20 PM, Resident #50 stated he/she wanted to go to his/her room, Staff S took the resident to his/her room and was replaced by Direct Care Staff H who finished pushing the resident to his/her room, the last room on left side of the hall. Staff H placed the resident's belongings in the room and then pushed the resident back to the TV room and stayed with the resident. On 4/19/17 at 4:56 PM, observation revealed Direct Care Staff L came into the television room, spoke with Staff H, and Staff H left the room. Staff L remained in the room with the resident. On 4/19/17 at 4:57 PM, observation revealed Staff L walked to the doorway and nodded her head to Resident #50 to follow him/her into the hallway which he/she did. This writer saw the resident was alone in the hallway. There were no other residents in the hallway. Staff L stepped into an open door across the hall. Resident #50 rolled his wheelchair to the exit door near the nurses' station on the west wing. He/She reached the door and pulled the handle, setting off the alarm. At that time there were other staff trying to access the unit but his/her wheelchair blocked the door. The staff entering told Resident #50 that he/she had to remain in the unit. Staff L then reappeared and rushed to the door. Staff H also came to the door and returned the resident to his/her room. Staff left the resident unattended in the hall for approximately 45 seconds. On 4/19/17 at 5:10 PM interview with staff H about the incident at 4:57 PM revealed staff provided the resident with 1:1 supervision. Staff H stated he/she cleaned some food off of the floor, and asked Staff L to stay with the resident, so he/she could wash his/her hands. Staff H further stated staff L said he/she would stay with the resident. On 4/19/17 Resident #22 and Resident #5 were interviewed. Both residents denied feeling unsafe in the facility. Resident #22 stated specifically he/she was not afraid of Resident #50. On 4/20/17 at 12:15 PM, Resident #51 stated he/she does not feel safe at the facility, as long as Resident #50 resided at the facility. He/she stated his/her nose was still sore from being punched in the face by Resident #50 on 4/19/17. The facility's policy, Unmanageable Residents, updated 2010, documented if a resident became abusive, the Nurse/supervisor must provide safety for all the residents of the facility. The facility failed to protect all residents in the facility when Resident # 50 repeatedly abused 7 Residents (#46, #4, #22, #36, #26, #5, and #51). Resident #50 hit Resident #46 in the face two times on 12/23/16, slapped Resident #4 in the face on 12/26/17, hit Resident #22 in the head on 12/27/16, slapped hit Resident #36 on the hand on 1/2/17, punched hit Resident #26 in the face knocking him/her out of the chair and causing bruising on 3/6/17, hit Resident # 5 in the face causing a laceration and bruising on 3/21/17, and hit Resident #51 multiple times in the face on 4/19/17. This deficient practice placed all facility residents in immediate jeopardy. The immediate jeopardy was abated on 4/20/17 at 7:15 PM when the facility implemented the following: Staff continued to seek a more appropriate facility for the resident; staff ensured the resident did not eat in the dining room, but in his/her room; staff cleared the hallway to provide easy access to the shower room; staff allowed the resident to go to the day room, outside, and participate in one on one activities; while the resident sat in the day room or outside, the resident would be alone with one on one supervision; education for all staff about one on one supervision, to not let any resident get within arm reach of the resident, and not to leave the resident until another staff was within arm reach of the resident; staff provided continuous one on one supervision; interdisciplinary team reviewed each incident within 2 hours of occurrence to verify the incident is investigated and interventions put into place; the quality improvement committee will review incidents at the monthly meeting. The deficiency remained scope and severity of an F.

The facility reported a census of 64 residents. The sample included 7 residents reviewed for abuse. Based on observation, interview, and record review the facility failed to provide an environment free of physical abuse for 7 Residents (#46, #4, #22, #36, #26, #5, and #51) when Resident #50 hit Resident #46 in the face two times on 12/23/16, slapped Resident #4 in the face on 12/26/17, hit Resident #22 in the head on 12/27/16, slapped Resident #36 on the hand on 1/2/17, punched Resident #26 in the face knocking him/her out of the chair and causing bruising on 3/6/17, hit Resident #5 in the face causing a laceration and bruising on 3/21/17, and hit Resident #51 multiple times in the face on 4/19/17. This deficient practice placed these seven residents in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#50 included [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 11/21/16, documented a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderate cognitive loss. The resident had hallucinations (sensing things while awake that appear to be real, but the mind created), but had no behaviors towards others. The resident required extensive assistance with bed mobility, transfers, toileting and bathing. The resident received an antipsychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions) 7 of 7 days, and an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication for 7 of 7 days of the assessment period. The quarterly MDS, dated [DATE], documented a BIMS score of 11, which indicated moderate cognitive loss. The resident had hallucinations and physical behavior symptoms directed towards others. He/she required limited assistance for bed mobility and transfers, and did not walk. The resident had no limitations on upper or lower extremities, and used a wheelchair for mobility. He/she received antipsychotic and antidepressant for medication for 2 of 7 days, and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication for 3 of 7 days of the assessment period. The (CAA) Care Area Assessment, dated 11/21/16, for behavior did not trigger. The CAA for cognitive loss/dementia documented the resident had a memory deficit and a [DIAGNOSES REDACTED]. The care plan, dated 11/23/16, directed staff to monitor the resident closely around other residents that are yelling and screaming, as he/she becomes agitated and will try to walk and hit them. On 12/27/16 staff obtained a medication review and an evaluation at an acute psychiatric hospital. Staff encouraged the resident to sit at a table alone or only with his/her sibling (also a resident) due to increased delusions, and allegations of hitting another resident in the face. On 12/28/16, the physician ordered an increase in the [MEDICATION NAME] (an antipsychotic medication) dose. On 12/31/16, the resident returned from the acute psychiatric facility with orders to increase [MEDICATION NAME] and Trazadone (an antidepressant medication used to treat depression and anxiety disorders). Staff discontinued 1:1 supervision (a staff with him/her at all times) on 12/31/16, after staff noted him/her to be calm and quiet for 3 shifts. On 1/2/17, after slapping another resident's hands, staff resumed 1:1 supervision. On 1/4/17 the facility transferred the resident again to an acute psychiatric facility for psych evaluation and treatment. On 3/6/17, staff maintained the resident on 1:1 supervision while awaiting further evaluation. The staff ensured the resident maintained arm's length from other residents at all times. If the resident had delusions and became agitated, staff was to allow him/her space. If the resident made inappropriate sexual comments, the staff re-educated him/her that the behavior was not appropriate. On 3/11/17, the physician again transferred the resident to an acute psychiatric facility for assaultive behavioral issues. On 3/20/17, the resident returned from the acute psychiatric facility, and staff placed him/her on 1:1 supervision while up, and staff allowed the resident to be in dining room without 1:1 supervision. On 3/21/17, staff changed the 1:1 supervision to include all areas of the facility. On 3/21/17 at 11:45 AM, staff obtained a physician order [REDACTED]. On 3/22/17, the resident returned from the hospital and staff continued 1:1 supervision while awake. On 3/31/17, after the resident had delusions and became agitated, staff offered alternatives, like TV, activity of choice, and 1:1 as needed. (Staff had already placed this same intervention on 3/6/17). On 4/19/17, after another incident, the resident ate meals in his/her unit only and staff continued to seek appropriate placement for the resident. The nurse's notes dated 12/23/16 at 2:37 PM, stated staff notified the charge nurse that Resident #50 punched Resident #46, twice, in the face. The intervention implemented at that time was to have only the sibling of Resident #50 to sit at the table with him/her. The nurse's notes dated 12/27/16 at 12:07 AM, documented the aides found this resident sitting on the floor in the dining room. The certified nurse aide present in the dining room stated he/she did not see an incident, but thought the resident had stood up to punch another resident and lost his/her balance. The nurse's notes dated 12/27/16 at 4:48 PM, documented Resident #50 struck Resident #22 in the back of the head. The nurse's notes dated 1/2/17 at 9:52 AM, documented that staff notified the charge nurse that resident #50 struck Resident #36. He/she caused no injury. One-on-one supervision was restarted after this incident. The nurse's notes dated 3/6/17 documented the resident struck another (same gender) peer in the day room, staff maintained 1:1 supervision. The nurse's notes dated 3/21/17 at 9:37 AM documented the resident stood up and punched Resident #5. Staff immediately intervened and removed the resident from the dining room. When this writer questioned the resident as to what happened, he/she stated Resident #5 was staring, so he/she got up and hit him/her. The resident then asked this writer if he/she could hit him/her again. This writer redirected the resident and informed him/her this behavior was inappropriate. The resident sat at the nurse's station with 1:1 staff supervision. The nurse's note dated 4/19/17 at 10:34 AM documented the resident just struck Resident #51 in the dining room. Staff returned the resident to his/her unit by his/her 1:1 aide. The facility called law enforcement and the victim filed a report with the officer. Law enforcement issued a citation and contacted the department's crisis intervention team (CIT). CIT met with resident #50 and the decision was made to transport the resident by ambulance to the emergency department at an acute hospital for assessment and possible admission to a higher level of care. The nurse's note dated 4/19/17 at 11:25 AM documented the resident ate breakfast in the dining room. Staff L was assigned as the resident's 1:1. The resident asked Staff L for more jelly. Staff L left the dining room to go to the kitchen for more jelly when Resident #51 entered the dining room. Resident #51 approached Resident # 50's table spoke to Resident # 50, and Resident #50 stood up and punched Resident #51 in the face 3 times with a closed fist. Staff took Resident #50 back to his/her room. Following this incident, staff sent Resident #50 the emergency department for an evaluation. On 4/19/17 at 3:30 PM, direct care staff G stated he/she assisted another resident in the dining room with breakfast at the time of the incident. Staff G stated he/she observed Resident #51 come in to the dining room and sit at the same table as Resident #50. Staff G further stated staff were expected to keep Resident #50 at a table by himself/herself, because he/she hit other residents while in the dining room. Staff G further stated he/she observed Resident #50 stand up from his/her wheelchair, take a few steps toward Resident #51, and strike him/her with a closed fist 3 or 4 times in the face. Staff G stated staff provided Resident #50 with 1:1 supervision due to his/her behavior. Direct care staff L was assigned to provide 1:1 with the resident. After the incident, staff G stated he/she took the resident's arm and asked him/her to sit down. The resident sat back down and ate breakfast as if nothing had happened. On 4/19/17 at 4:14 PM, Direct Care Staff L stated he/she usually worked on the other hall, but today he/she was assigned 1:1 with the resident. He/she brought the resident into the dining room this morning and sat him/her at a table by himself/herself for breakfast. Staff L asked the resident if he/she needed anything, and he/she asked for additional jelly. Staff L stated he/she left the resident unsupervised and went to the kitchen to get the jelly. He/she heard a commotion while in the kitchen, returned to the dining room, and was informed Resident #50 hit Resident #51. On 4/19/17 at 4:10 PM, observation revealed the resident sat in a wheelchair by the nurse's station, supervised by licensed nursing staff S. Resident #50 sat calmly and quietly in a wheelchair. On 4/19/17 at 4:20 PM Resident #50 stated he/she wanted to go to his/her room, Staff S took the resident to his/her room and was replaced by direct care staff H who finished pushing the resident to his/her room, the last room on left side of the hall. Staff H placed the resident's belongings in the room and then pushed the resident back to the TV room and stayed with the resident. On 4/19/17 at 4:56 PM, Direct Care Staff L came into the television room, spoke with Staff H, and Staff H left the room. Staff L remained in the room with the resident. On 4/19/17 at 4:57 PM, observation revealed Staff L walked to the doorway and nodded his/her head to resident #50 to follow him/her into the hallway which he/she did. This writer saw the resident was alone in the hallway. There were no other residents in the hallway. Staff L stepped into an open door across the hall. Resident #50 rolled his/her wheelchair to the exit door near the nurses' station on the west wing. He/she reached the door and pulled the handle, setting off the alarm. At that time there were other staff trying to access the unit, but his/her wheelchair blocked the door. The staff entering told Resident #50 that he/she had to remain in the unit. Staff L then reappeared and rushed to the door. Staff H also came to the door and returned the resident to his/her room. Staff left the resident unattended in the hall for approximately 45 seconds. On 4/19/17 at 5:10 PM interview with Staff H about the incident at 4:57 PM revealed staff provided the resident with 1:1 supervision. Staff H stated he/she cleaned some food off of the floor, and asked Staff L to stay with the resident, so he/she could wash his/her hands. Staff H further stated staff L said he/she would stay with the resident. On 4/19/17 Resident #22 and Resident # 5 were interviewed. Both residents denied feeling unsafe in the facility. Resident #22 stated specifically he/she was not afraid of Resident #50. On 4/20/17 at 12:15 PM, Resident #51 stated he/she does not feel safe at the facility, as long as Resident #50 resided at the facility. He/she stated his/her nose was still sore from being punched in the face by Resident #50 on 4/19/17. The facility's policy, Unmanageable Residents, updated 2010, documented if a resident became abusive, the Nurse/supervisor must provide safety for all the residents of the facility. The facility failed to provide an environment free of physical abuse for 7 residents (#46, #4, #22, #36, #26, #5, and #51) when Resident #50 hit Resident #46 in the face two times on 12/23/16, slapped Resident #4 in the face on 12/26/17, hit Resident #22 in the head on 12/27/16, slapped hit Resident #36 on the hand on 1/2/17, punched hit Resident #26 in the face knocking him/her out of the chair and causing bruising on 3/6/17, hit Resident #5 in the face causing a laceration and bruising on 3/21/17, and hit Resident #51 multiple times in the face on 4/19/17. This deficient practice placed these seven residents in immediate jeopardy. The immediate jeopardy was abated on 4/20/17 at 7:15 PM when the facility implemented the following: Staff continued to seek a more appropriate facility for the resident; staff ensured the resident did not eat in the dining room, but in his/her room; staff cleared the hallway to provide easy access to the shower room; staff allowed the resident to go to the day room, outside, and participate in one on one activities; while the resident sat in the day room or outside, the resident would be alone with one on one supervision; education for all staff about one on one supervision, to not let any resident get within arm reach of the resident, and not to leave the resident until another staff was within arm reach of the resident; staff provided continuous one on one supervision; interdisciplinary team reviewed each incident within 2 hours of occurrence to verify the incident is investigated and interventions put into place; the quality improvement committee will review incidents at the monthly meeting. The deficiency remained at a scope and severity of an H.

The facility identified a census of 68 residents. The sample included 1 resident reviewed for abuse. Based on observation, record review, and interview, the facility failed to provide an environment free from physical abuse from direct care staff S for 1 resident (#1). Findings included: - The electronic record for resident #1 included [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented the resident suffered from short term and long term memory problems, and had moderately impaired decision making skills. The Quarterly MDS dated [DATE] documented the resident experienced short term and long term memory problems, and had moderately impaired decision making skills. The Care Area assessment dated [DATE] for cognition documented the resident suffered from short term and long term memory problems, disorganized thinking, and trouble concentrating. The care plan dated 8/4/16 documented staff were to cue the resident with all tasks. Review of the nurse's note dated 10/23/16 at 5:57 AM documented the resident had a bruise on the right side of his/her face, which measured 29 centimeters (cm) by 19 cm. Review of licensed nursing staff H's witness statement, undated, documented direct care staff S stated the resident laid on the call light cord, which produced the mark on the right side of the resident's face. On 10/26/16 at 8:35 AM, the resident sat in a wheelchair in the hall. There was a large bruise to the right side of his/her face, which measured approximately 30 cm by 20 cm. On 10/26/16 at 10:50 AM, administrative staff A stated direct care staff S said the resident laid on the call light cord. Staff A further stated he/she did not believe staff S, and staff S was subsequently terminated. On 10/26/16 at 10:56 AM, the resident's roommate stated when direct care staff S provided care to the resident on 10/24/16, he/she heard a loud slap. On 10/26/16 at 1:26 PM, direct care staff O stated when he/she arrived at the facility the morning of 10/24/16, he/she noticed an area on the right side of the resident's face, which resembled a handprint. On 10/26/16 at 2:36 PM, direct care staff T stated when he/she left the faciity on [DATE], he/she noticed a handprint shaped mark on the right side of the resident's face. On 10/26/16 at 4:40 PM, licensed nursing staff H stated when he/she first saw the resident, there was a large red area on the right side of his/her face. On 10/26/16 at 3:23 PM, administrative nursing staff D stated licensed nursing staff H notified him/her of a large bruise on the right side of the resident's face. On 10/26/16 at 5:35 PM, administrative nursing staff E stated when he/she arrived at the facility on 10/24/16, licensed nursing staff H asked if he/she would look at the resident's face. Staff E stated the mark on the resident's face appeared worse than what a call light cord would cause. He/she then notified administrative nursing staff D. The facility's policy Abuse Prevention Program, dated 2/19/15, documented all residents of the facility would be free of physical abuse. The facility failed to provide an environment free of physical abuse from direct care staff S for this cognitively impaired resident.

The facility identified a census of 72 residents 46 of which were identified as cognitively impaired and independently mobile. Based on observation, record review, and interview the facility failed to ensure a safe environment for the residents as evidenced by accessible water over 140 degrees Fahrenheit. The facility water temperature in the unsecured laundry room was 173 degrees Fahrenheit. This placed the residents in immediate jeopardy. The facility also failed to develop timely interventions to prevent falls for 1 (#55) of 3 residents sampled for falls. Findings included: - During the initial tour of the facility on 8/27/15 at approximately 9:30 A.M., observation revealed the laundry room located on the main hallway of the facility enclosed by a door that lacked a locking mechanism. The sink inside the room had water that reached 173 degrees Fahrenheit. A second thermometer indicated the water reached 165.7 degrees Fahrenheit. Interview on 8/27/15 at 2:00 P.M. with housekeeping staff X revealed an unsampled resident with severely impaired cognition frequently entered the laundry room independently. Staff X reported the resident would enter the laundry room and rummage through the clean laundry, which was on the side of the room which contained the sink. Staff X reported the laundry room was staffed from 6:30 A.M. until approximately 3:00 P.M. However, when the laundry staff was on break or delivering laundry items to residents the room was not attended. After approximately 3:00 P.M. and until 6:30 A.M. (a duration of 15 1/2 hours) there was no laundry staff onsite. He/she also reported that he/she felt like the door being unlocked was a concern and had voiced it to administration in the past. Interview on 8/27/15 at 2:36 P.M. resident #55 revealed he/she knew where the laundry room was located and had never seen residents go in there. He/she admitted that he/she went in to the laundry room alone on occasion. This deficient practice placed the indepdently mobile residents in immediate jeopardy. The facility abated the immediate jeopardy was abated on 8/28/15 at 3:00 P.M when they held an inservice to educate staff on the importance of the laundry room door to be locked at all times when the room was unattended by staff. The scope and severity remains at a E. - Resident #55's electronic medical record identified the resident had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident had moderately impaired cognition, had no behaviors, required limited staff assistance with bed mobility, transfers, dressing, locomotion on/off the unit, and required extensive staff assistance with dressing and personal hygiene. The MDS recorded the resident was not steady when moving from seated to a standing position, walking, turning around, moving on/off the toilet, and surface to surface transfer. The resident utilized a walker and a wheelchair and had not fallen since admission or the prior assessment. The resident's Cognitive Loss/ Dementia Care Area Assessment (CAA) dated 4/13/15 documented the resident had a [DIAGNOSES REDACTED]. loss impacted his/her Activities of Daily Living (ADLs). The resident's ADL CAA dated 4/13/15 included the resident had decline and required more help with transfers, mobility and toileting. The resident's risk factors included dementia, communication, pain, Parkinson's disease, incontinence, balance problems with transfers and the use of anti-depression medications which could impair his/her ADL function. The resident required one person to help with hygiene, toileting, transfers and showers and the resident could walk with his/her walker for short distances. The resident's Fall CAA dated 4/13/15 documented the resident was at risk for falls due to his/her dementia, Parkinson's disease, incontinence, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), CVA (Cerebrovascular accident (stroke) - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and cardiac issues. The resident also had balance problems which caused him/her to fall. The resident's care plan reviewed 7/9/15 included the resident was at risk for falling related to Parkinson's disease, poor cognitive skills and did not ask for staff assistance with transfers. The resident had an unsteady gait and poor balance. The care plan included an entry dated 1/21/14 staff provided non-skid socks to the resident to prevent slipping and ensured the resident's environment was free of clutter. An entry dated 4/29/14 included staff placed landing strips beside the resident's bed when the resident was in bed. An entry dated 5/3/14 documented staff ensured the resident's bed was in low position when the resident was in bed, and placed a perimeter mattress on the resident's bed to define boundaries. An entry dated 5/18/14 included staff placed a positioning wedge to help the resident turn from side to side. On 8/20/15 staff added a roll back device to the resident's wheelchair. An entry dated 8/1/15 included physical therapy/occupational therapy evaluated the residents for transfers. A nurses' note (NN) dated 9/07/2014 and timed 9:40 PM documented at approximately 3:45 P.M. the resident laid on the floor outside of his/her bathroom in front of his/her wheelchair. The resident stated he/she had just came from the bathroom and slipped and hit his/her head on the floor. The resident was not wearing any shoes. Staff applied ice to the back of the resident's head. A nurse's note (NN) dated 09/10/2014 and timed 10:10 P.M. documented the resident laid on his/her back in his/her bathroom. The resident stated he/she was going to the bathroom and staff educated the resident on the importance of using his/her call light to ask for staff assistance. No interventions noted. A NN dated 10/14/2014 and timed 3:06 P.M. documented the resident's roommate summoned staff, the resident lost his/her balance while trying to reach for something and attempted to use the straight back chair in his/her room to catch himself/herself and knocked it over so the back of chair was on floor & the resident scooted over to bed to get onto the mat to try to get up. No interventions noted. A NN dated 10/25/2014 and timed 4:08 P.M. documented the resident sat on the floor in his/her room. No interventions noted. A NN dated 11/10/2014 and timed 11:48 A.M. documented the resident sat on the floor in his/her room. No interventions noted. A NN dated 11/10/2014 and timed 2:45 P.M. documented the resident sat on the floor in his/her room, the resident leaned against his/her night stand and the knob imprint from the night stand was on the resident's right temple. Interventions included a urine analysis and for the following shift to follow up. A NN dated 1/12/2015 and timed 10:45 A.M. and recorded as a late Entry for 1/12/15 timed 2:22 P.M. the resident was on the floor in front of his/her wheelchair just outside of his/her bathroom. The resident laid flat on his/her stomach with his/her legs crossed. The resident was able to uncross his/her legs and roll onto his/her back. No interventions noted. A NN dated 1/23/2015 and timed 2:30 P.M. documented the resident sat on the floor in his/her room in front of his/her wheelchair. Candy was on the floor under him/her and he/she stated he/she ate candy and dropped the wrappers and the candy and had bent over to push up when his/her wheelchair rolled away. No interventions noted. A NN dated 8/02/2015 and timed 1:06 A.M. documented the resident sat on the floor in his/her room. The resident sustained [REDACTED]. Interventions included staff educated the resident to use the call light and placed a fall mat. A NN dated 8/20/2015 and timed 1:36 P.M. included the resident fell from his/her wheelchair and struck his/her head on the bathroom door frame. The resident had a small abrasion above his/her left eyebrow. The resident complained of right shoulder/clavicle pain and the facility transferred the resident to a local emergency for an evaluation. Interventions included staff placed anti-lock brakes (device to prevent the wheelchair frame chassis from collapsing) on the resident's wheelchair. On 9/2/15 at 7:15 A.M. the resident laid in bed. Observation revealed the resident's bed in a low position and no fall mat or wedge in place. On 9/1/15 at 2:14 P.M. observation revealed an anti-roll back device (device to keep a wheelchair from rolling backwards) on the resident's wheelchair but did not reveal an anti-lock brake on the resident's wheelchair. On 9/1/15 at 2:00 P.M. nursing administrative staff D stated at one point the resident had an anti-roll back device on his/her wheelchair, the facility discontinued the device and after the resident's fall on 8/20/15 the facility replaced the anti-roll back device on the resident's wheelchair. He/she confirmed the incident log included the facility placed anti-lock brakes on the resident's wheelchair after the resident fell on [DATE]. On 9/1/15 at 2:14 P.M. direct care staff H stated the resident's wheelchair had anti-roll backs but not anti-lock brakes. On 9/2/15 at 1:13 P.M. direct care staff I stated the resident did not ambulate and required extensive staff assistance with activities of daily living tasks. On 9/2/15 at 3:30 P.M. direct care staff J stated the resident was at risk for falls, staff checked on the resident every 30 minutes and the resident utilized a fall mat. On 9/2/15 at 4:48 P.M. licensed nurse G stated the resident was at risk for falls, utilized a fall mat and staff assisted the resident to the bathroom as often as possible. The facility's undated Fall Policy and Procedure include investigations should include interventions in place at the time of the fall. The facility failed to implement timely and effective interventions for this cognitively impaired resident with a history of falls.

The facility had a census of 68 residents. Based upon observation, record review and interview the facility failed to provide adequate supervision and timely interventions to prevent accidents for 5 (#20, #33, #63, #83, #3 ) of 5 residents sampled for accidents and failed to ensure the environment was free of accident hazards for 5 of 6 days onsite of the survey. Findings included: - Resident #33's Significant Change Minimum Data Set (MDS) 3.0 dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, limited staff assistance with transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene and the activity of walking in room/corridor did not occur. The resident was not steady but was able to stabilize with staff assistance when moved from seated to standing, walking, turning around, moving on/off the toilet and surface to surface transfers, the resident utilized a walker and wheelchair and had sustained one non-injury fall. The resident's Fall Care Area Assessment (CAA) dated [DATE] documented the resident was at risk for falls due to a mental decline, had an unsteady gait, pain in his/her left knee and received psychotropic medication (medications used to treat mental disorders). The CAA included the resident had cognition deficits, was incontinent of urine and bowel, had poor balance and behaviors. Staff monitored the resident for falls, the resident had a perimeter mattress (a type of mattress with wedges) to help set boundaries, staff needed to observe the resident closely in the dining room due to standing up and falling when he/she leaned over chairs. The resident used a wheelchair and walker and was at risk for fractures due to a [DIAGNOSES REDACTED]. The resident's care plan updated [DATE] included the resident was at risk for falls related to psychotropic medications, a history of falls, at times was unsteady on his/her feet, and had balance problems. The resident did not always ask for help, the resident was at risk for spontaneous fracture related to a [DIAGNOSES REDACTED]. On [DATE] staff monitored the resident for appropriate footwear and encouraged the resident to slow down when he/she walked too fast or to sit down and rest awhile when he/she appeared tired. On [DATE] staff ensured the resident's call light and frequently used items were in reach at all times. On [DATE] staff educated the resident to reach back and locate his/her bed before he/she sat. On [DATE] the physician changed the resident's medication and ordered laboratory and radiology tests were ordered to rule out an acute illness. On [DATE] staff placed a perimeter mattress on the resident's bed. On [DATE] staff educated the resident to ask for staff assistance when getting out of the wheelchair. On [DATE] staff reviewed the resident's care plan and determined no updates were required. A nurse's note dated [DATE] and timed 9:30 A.M. included the resident slipped off the shower chair and hit his/her head on the wall and no injuries were observed. No interventions noted. A nurse's note dated [DATE] and timed 3:15 P.M. included the resident fell in his/her bathroom. No interventions noted. A nurse's note dated [DATE] and timed 2:30 P.M. included the resident came around the corner by the nurse's desk and fell over a box that was left in the hallway. No interventions noted. A nurse's note dated [DATE] and timed 10:45 P.M. documented the resident fell at approximately 10:30 P.M. and received a small lump on the back of his/her head, close to the top of his/her head. No interventions noted. A nurse's note dated [DATE] and timed 6:20 A.M. documented staff found the resident on the floor by the side of his/her bed. The resident stated he/she slipped off the bed onto the mat. No interventions noted. A nurse's note dated [DATE] and timed 3 P.M. to 11P.M. shift documented the resident was very unsteady and needed staff assistance going to the dining room. No interventions noted. A nurse's note dated [DATE] and timed 1:45 P.M. documented staff observed the resident on the floor, the resident's right side was beside the straight back chair and the resident stated he/she fell . Interventions included staff educated the resident to make sure his/her chair touched his/her legs prior to sitting down. A nurse's note dated [DATE] and timed 6:00 P.M. documented the resident fell in the dining room. Interventions included a referral for therapy to screen the resident for falls when he/she attempted to sit in a chair. A nurse's note dated [DATE] and timed 4:05 P.M. documented the resident tripped over another resident's walker while ambulating down the hallway. Interventions included staff encouraged the resident to look behind him/her before backing up to prevent tripping over objects which could be behind him/her. A nurse's note dated [DATE] and timed 6:15 P.M. documented the resident stumbled, direct care staff grabbed onto the resident and staff lowered the resident to the floor. Interventions included staff asked the resident's physician for laboratory testing and discussed the possibility of increasing the resident's fluid restriction. A nurse's note dated [DATE] and timed 11:30 A.M. documented staff observed the resident trying to sit on the side of his/her bed, but the resident slid and sat on the floor. Interventions included staff educated the resident to reach back and feel for his/her bed before he/she sat on the bed. A nurse's note dated [DATE] and timed 10:22 P.M. documented the resident sat on the floor beside his/her bed. The resident stated he/she sat on the side of his/her bed and slipped to the floor. A nurse's note dated [DATE] timed 3:40 A.M. documented the resident laid on his/her left side on the floor next to his/her bed and the resident stated he/she fell out of bed. Staff placed the resident in bed and observed the resident's bed was too short and narrow for the resident. Staff placed the call light within reach and encouraged the resident to use it. According to the resident's care plan the facility placed a perimeter on the resident's bed on [DATE]. A nurse's note dated [DATE] and timed 10:33 A.M. documented the facility informed the resident's physician the resident fell 3 times within the past 3 days and the resident's increase use of the wheelchair. The resident complained of knee pain and staff requested a different pain medication, and questioned the possibility of obtaining x-rays of the resident's knees. A nurse's note dated [DATE] and timed 1:39 P.M. documented the resident's physician gave orders for bilateral knee injections if the resident agreed. The physician gave an order to discontinue the Tylenol and to start the resident on Narco ,[DATE] milligrams four times a day as needed for pain, a complete blood count (CBC- a laboratory test that provided information about the kinds and numbers of cells in the blood), comprehensive metabolic panel (CMP-group of blood tests that provided an overall picture of the body's chemical and physical balance) and a thyroid stimulating hormone test (TSH-test to detect the function of the thyroid gland). Staff notified the resident of the new physician's orders [REDACTED]. The note included the resident transferred with assist one staff, ambulated with his/her walker and used his/her wheelchair when tired. A nurse's note dated [DATE] and timed 4:53 P.M. documented staff reported the resident almost fell again. The nurse informed staff the resident needed constant supervision as the resident continued trying to get up without staff assistance. A late entry nurse's note dated [DATE] timed 12:25 A.M. documented on [DATE] at 8:30 P.M. the resident sat on the floor next to his/her bed. The resident stated he/she attempted to get in his/her wheelchair and slid to the floor. Staff reminded the moderately cognitively impaired resident to use the call light for all of his/her needs and the resident voiced understanding of the call light system. A late entry nurse's note dated [DATE] at 2:59 P.M. documented on [DATE] staff visited with the resident regarding his/her refusal of therapy. The resident stated he/she did not participate due to his/her knee pain and staff and resident discussed different pain management options including giving the resident pain medication 30 minutes prior to the start of therapy and the resident agreed. The nurse and the resident discussed trying a perimeter mattress to help alert the resident to the edge of the bed and the resident agreed. A nurse's note dated [DATE] and timed 2:55 P.M. documented staff spoke with the day nurse regarding giving the resident a pain medication 30 minutes prior to therapy (5 days after the conversation with the resident). A nurse's note dated [DATE] and timed 10:03 A.M. documented the resident laid on his/her back on the floor. The resident got out of his/her wheelchair and ambulated to the door of the unit on his/her own. The resident sustained [REDACTED]. The area surrounding the abrasion was very red and tender to the touch. The resident complained of lower back and bilateral shoulder pain. A nurse's note dated [DATE] and timed 10:28 A.M. documented staff contacted the resident's physician of the above incident and obtained a physician's orders [REDACTED]. Interventions included staff educated the resident to ask for assistance with ambulation. A nurse's note dated [DATE] and timed 6:28 P.M. documented the resident sat on his/her buttock in front of a dining room chair. Interventions included for staff to assist the resident to meals. A nurse's note dated [DATE] and timed 11:47 A.M. documented the resident laid on his/her left side in the dining room beside a tipped over chair. Staff stated the resident leaned over the chair and fell over. Interventions included a psychologist recommended mental health services. A nurse's note dated [DATE] and timed 5:27 P.M. documented staff observed the resident placed himself/herself on the floor in the dining room. The resident continued to stand up and ambulate without staff assistance. Interventions included staff continued with the resident's current care plan and monitored the resident closely. A nurse's note dated [DATE] and timed 11:35 P.M. documented at approximately 6:30 P.M. staff summoned the nurse to the day room on the unit. The resident laid on his/her back holding his/her head up off the floor. The resident stated he/she lost his/her balance and fell . A nurse's note dated [DATE] and timed 8:38 A.M. documented when staff assisted the resident that A.M. with dressing and transferring staff observed the resident's right thigh was swollen and the resident did not want to bear complete weight to his/her right leg when standing to transfer, only partially lifted his/her right leg and the resident complained of pain. Staff telephoned the resident's physician and obtained a physician's orders [REDACTED]. A nurse's note dated [DATE] and timed 10:40 A.M. documented staff received the report from the mobile x-ray and the report included the resident had an acute intertrochanteric (a line located on the anterior side of the proximal end of the thigh bone) right hip fracture. The resident's right upper thigh was very edematous (swollen), cool to the touch with external rotation. The resident had facial grimacing and complained of right leg pain. A nurse's note dated [DATE] and timed 10:46 A.M. documented staff contacted the resident's physician with the findings of the x-ray report. A nurse's note dated [DATE] and timed 11:00 A.M. documented the resident's physician gave an order to send the resident to a local hospital. A nurse's note dated [DATE] and timed 11:25 A.M. documented the facility transferred the resident to a local hospital. A nurse's note dated [DATE] and timed 2:25 P.M. documented the local hospital informed the facility the resident admitted to the hospital due to his/her right hip fracture. On [DATE] at 11:10 A.M. observation revealed 3 residents on the unit and no staff on the unit. Further observation revealed nursing staff T on the patio outside supervising the remainder of the residents during a smoke break. During interview with direct care staff T at that time he/she stated direct staff Q (the other nursing staff previously on the unit) had to go to the bathroom. At 11:15 A.M. direct care staff T was still outside with residents, 3 residents remained unsupervised on the unit and direct care staff Q entered the unit. Observation revealed direct care staff Q had a bag of chips in his/her hand and the surveyor asked the staff if he/she was coming back from his/her break and direct care staff Q stated yes. On [DATE] at 12:35 P.M. the resident propelled his/her wheelchair toward the dining room. Direct care staff CC told the resident he/she was sliding out of the wheelchair. Direct care staff CC assisted the resident from the wheelchair, slid the wheelchair cushion to the back of the wheelchair and assisted the resident back into the wheelchair. Direct care staff CC stated the resident's wheelchair cushion moved and the cushion probably needed Dycem (non-slip material) under it to prevent it from moving. On [DATE] at 7:05 A.M. direct care staff T entered the resident's room to assist the resident with morning care. Observation revealed the resident's feet in direct contact with the foot board. Observation revealed the resident had a scar on his/her mid back that measured approximately 6 inches by .05 inches. Direct care staff T stated the scar was a result of a fall. At that time the resident stated he/she was 6 foot 3 inches tall. Direct care staff T stated approximately 2 months ago the resident received a new bed and the perimeter mattress. Direct care staff T stated prior to that time the bed the resident slept in was smaller and shorter than the one he/she currently used. After performing A.M., care direct care staff T ambulated the resident via a gait belt to his/her wheelchair. Observation revealed a wheelchair cushion in place and no Dycem under the cushion. On [DATE] at 1:47 P.M. observation revealed no staff on the unit. Further observation revealed 3 residents still remained on the unit. Further observation revealed direct care staff T on the patio supervising the other residents smoke break. Direct care staff T stated direct care staff XX (the other staff previously on the unit) was off the unit because he/she was taking an online CPR (cardiopulmonary resuscitation) class. On [DATE] at 7:00 A.M. the resident laid in bed. Observation revealed the resident's feet were in direct contact with the footboard. On [DATE] at 7:23 A.M. licensed nurse H stated the resident was in the hospital due to a hip fracture. Licensed nurse H stated prior to the resident's hospitalization , staff checked on the resident every 30 minutes. Licensed nurse H stated staff monitored residents for 72 hours after a fall and staff updated the resident's care plan after each fall. On [DATE] at 2:09 PM licensed nursing staff I stated the resident was at risk for falls prior to the hip fracture on [DATE]. Licensed nursing staff I stated prior to the resident's hip fracture staff checked on the resident every 30 minutes and placed a perimeter mattress on his/her bed. The resident leaned when he/she sat in a chair and staff asked the resident to sit up and the resident did not always ask for staff assistance even though staff asked him/her to. Licensed nursing staff I stated he/she did not observe the resident intentionally placing himself/herself on the floor. Licensed nurse I stated on [DATE] a dietary staff summoned him/her to the unit because the resident was on the floor. He/she assessed the resident and did not observe any injures, shortening or rotation of the resident's extremities. Licensed nurse I stated no nursing staff were present on the unit when the resident fell . On [DATE] at 3:18 P.M. administrative nursing staff D stated on [DATE] dietary staff observed the resident on the floor, 1 nursing staff was outside smoking and another nursing staff was somewhere on the unit at the time of the resident's fall. Administrative nursing staff D stated prior to the resident's hip fracture the facility obtained a new wheelchair for the resident, placed a perimeter mattress on the resident's bed in March of 2014, the resident had received knee injections bilaterally, the facility obtained a physician's orders [REDACTED]. On [DATE] at 3:30 P.M. dietary staff II stated on [DATE] at approximately 6:30 P.M. he/she went to the unit to tell nursing staff the residents could go to the dining room for the dinner meal. Dietary staff II stated when he/she entered the unit he/she observed the resident on the floor in the day room. Dietary staff II stated there were no nursing staff on the unit. Dietary staff II stated 1 nursing staff was outside smoking and he/she was told another staff was in the bathroom but he/she did not see any nursing staff on the unit. The facility failed to ensure the resident received adequate staff supervision to prevent falls and also failed to place timely effective interventions for this resident with a history of multiple falls that fell and sustained a hip fracture on [DATE]. - Resident #20's annual Minimum Data Set (MDS) 3.0 dated [DATE] identified the resident scored 15 (cognition intact) on the Brief Interview for Mental Status, was independent with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, toilet use, eating, personal hygiene and dressing. The MDS identified the resident was steady at all times when moved from seated to standing position, during surface to surface transfers and walking and turning around. The MDS recorded the resident had no functional limitation in his/her upper and lower extremities, utilized a walker, had 2 or more non-injury falls and 1 non-major injury fall since the last assessment. The resident's quarterly Minimum Data Set (MDS) 3.0 dated [DATE] identified the resident scored 14 (cognition intact) on the Brief Interview for Mental Status, had no behaviors, required staff supervision for bed mobility, walking in the room/corridor, locomotion on/off the unit, eating, toilet use and personal hygiene and was independent with transfers and dressing. The MDS identified the resident was unsteady but was able to stabilize without staff assistance when moved form seated to standing position, during surface to surface transfers, walking and turning around. The MDS recorded the resident had functional limitation on one side of upper and lower extremity and had 2 or more non-injury falls since the last assessment. The above represented the resident's functional ability declined. The resident's Fall Care Area Assessment (CAA) dated [DATE] documented the resident was at an increased risk for falls related to his/her fall history, visual deficit, psychotropic medication usage, impulsivity and non-compliance with safety reminders. The resident had several falls since his/her MDS, the resident frequently forgot safety reminders, frequently forgot to use his/her walker and left it in other rooms and ambulated without the device. Staff frequently reminded the resident to use the walker at all times. Staff monitored the resident for safety and ambulatory changes. The resident's care plan last reviewed [DATE] included the following fall interventions in place since [DATE]: The resident had a history of [REDACTED]. Staff encouraged the resident when standing in the line for smoke break to watch who was ahead of him/her and not bump into others. The resident had an unsteady gait, ambulated independently in the hallways and used a wheelchair at times. Staff ensured the resident's call light and frequently used items were in reach at all times and provided proper, well-maintained footwear. Staff ensured the resident's environment was free of clutter, staff reminded the resident to have the back of the chair against the wall when he/she sat on the back patio chairs so he/she did not trip over the legs of the chair. Staff reminded the resident to use his/her walker, and the need to slow down when ambulating. Staff reminded the resident if there were spills or other residents items, such as oxygen tubing on the floor to notify staff and not perform the task himself/herself. A nurse's note dated [DATE] and timed 11:00 A.M. documented the resident fell in his/her room and the resident stated he/she lost his/her balance. A nurse's note dated [DATE] timed 8:30 P.M. documented the resident was in the day room, walked without his/her walker, stated he/she lost his/her balance and fell . A nurse's note dated [DATE] timed 9:30 A.M. documented the resident walked on the sidewalk off the patio when the front end of his/her walker was caught in a corner of the sidewalk and the person walking behind the resident was unable to stop in time which caused the resident to fall to his/her hands and knees. A nurse's note dated [DATE] and timed 8:00 A.M. documented late entry for [DATE]. The nurse spoke with the resident after his/her fall on [DATE] regarding watching out for change in terrain when ambulating and staff encouraged the resident to try to stay toward the back of the smoke line so he/she did not get "ran over" by his/her peers. A nurse's note dated [DATE] timed 3:00 P.M. documented the resident fell after a push from another resident and the resident's head was bleeding. The note included the resident had a laceration present on the upper back of his/her left head that measured approximately 1.25 inches long with a width of 0.25 inches. The skin covering the wound was intact and the bleeding stopped after staff cleaned the wound. The resident's care plan included an entry the resident fell on [DATE] while trying to clean up a spill in the hallway. Interventions included staff encouraged the resident to notify staff of spills and to not attempt to clean up the spills due to his/her unsteady gait and staff would respond to spills in a timely manner to prevent falls. A nurse's note dated [DATE] and timed 3 P.M. to 11 P.M. shift documented the resident ambulated independently with his/her walker, had a steady gait and needed frequent reminders to use his/her walker. An undated facility's investigation report documented that on or around [DATE] the resident attempted to place a sheet over a wet area on the floor in the day room, the resident's foot slipped and the resident fell forward and hit the right side of his/her head. A nurse's note dated [DATE] and timed 3:55 P.M. documented the resident tripped over another resident's oxygen tubing, fell on his/her right elbow, was able to get himself/herself up and the resident had a small bruise to his/her right elbow. Interventions included when the resident observed his/her roommate's oxygen tubing on the floor, the resident should walk around the tubing and notify nursing staff. A nurse's note dated [DATE] and timed 5:59 P.M. documented the resident was in the dining room, walked across the room to get a salt shaker for another resident, slipped to the floor and got up before anyone could get to him/her. Interventions included staff reminded the resident to use his/her walker. A nurse's note dated [DATE] and timed 2:12 P.M. documented the resident was in the day room and stated he/she just lost his/her balance and fell forward. The resident caught himself/herself with his/her hands and eased to the ground. The note included the resident did have his/her walker with him/her but was not walking with it at the time he/she fell . Staff continued to remind the resident to use his/her walker at all times. A nurse's note dated [DATE] and timed 4:08 P.M. documented the oncoming nurse was notified another resident pushed this resident down and the resident "busted" open the back of his/her head. The resident's physician gave an order to transfer the resident to a local emergency room . A nurse's note dated [DATE] and timed 7:17 P.M. documented the resident returned to the facility with physician orders [REDACTED]. The note included the resident had 6 staples on the lower back of his/her head approximately 1 inch in length. Review of the resident's clinical record lacked evidence the facility spoke to the resident regarding therapy or restorative nursing services. On [DATE] at 3:15 P.M. observation revealed the resident in the day room sweeping up spilled popcorn. Further observation revealed staff in the day room and did not assist the resident with cleaning up the spill. On [DATE] at 3:33 P.M. the resident reported a resident pushed him/her down and he/she required staples to the back of his/her head. The resident showed the surveyor where the staples were placed. Observation revealed the staples no longer in place but one could detect where the staples were. On [DATE] at 7:45 A.M. the resident ambulated in the day room without his/her walker. Observation revealed the resident's legs turned inward when he/she ambulated. On [DATE] at approximately 7:30 A.M. the resident used the exercise bike in the day room for approximately 5 minutes. On [DATE] at 7:20 A.M. licensed nurse H stated the resident did not fall since his/her date of employment 10 days ago. During interview with the resident on [DATE] at 10:15 A.M. the resident stated he/she stumbled and fell at times. The resident stated the facility did not ask him/her about therapy or restorative nursing services. The resident asked what was restorative nursing services, the surveyor explained, and the resident stated he/she would like that. On [DATE] at 10:30 A.M. administrative nursing staff D stated the resident was at risk for falls and ambulated independently with a walker. Administrative nursing staff D stated staff reminded the resident to use his/her walker and to notify staff of spills. Administrative nursing staff D stated the coding on the resident's MDS regarding the functional limitation was inaccurate and the resident did not have a functional limitation in his/her extremities. Administrative nursing staff D stated the resident's legs turned inward when he/she ambulated due to the rigidity caused by the Huntington's Chorea. Administrative nursing staff D stated direct care staff performed restorative nursing services but did not document the services received. On [DATE] at 11:30 A.M. direct care staff T stated the resident was at risk for falls but did not frequently fall. Direct care staff T stated staff reminded the resident to use his/her walker. On [DATE] at 2:15 P.M. direct care staff I stated the resident was at risk for falls and ambulated with a walker. The facility failed to implement timely and effective interventions for this resident with a history of falls to prevent falls. - The significant change Minimum (MDS) data set [DATE] for resident #63 revealed the resident had short/long term memory problems and had moderately impaired cognitive skills for daily decision making. The resident required limited assistance of one person for bed mobility, transfer, locomotion on/off unit, dressing, toilet use, and personal hygiene, required supervision of one person with walking in her/his room and eating. The resident was not steady and only able to stabilize with staff assistance with moving from seated to standing position, walking, turning around, moving on/off toilet, and surface to surface transfers, had no impairments to the upper/lower extremities and used a wheelchair (w/c) for mobility. The Care Area Assessment for falls dated [DATE] revealed the resident was at risk for falls due to her/his [DIAGNOSES REDACTED]., shuffling gait, muscle rigidity and weakness), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and cardiac (heart) issues. The resident also had balance problems which could cause her/him to fall and did not have a fall since last assessment. The revised care plan dated [DATE] for history of falls after a return from the hospital on [DATE] with left hip fracture revealed nursing staff would offer to assist the resident to get up in the afternoon, had landing strips beside her/his bed, and staff rearranged the resident's room. The resident was sent to the emergency roiagnom on [DATE] for evaluation, nursing staff assessed the resident for new risk factors upon return and updated the care plan as needed, nursing staff would supervise the resident when she/he was outside on the back patio working in the garden, keep the resident's call light within reach at all times, keep personal and frequently used items within the resident's reach, non-skid socks provided and used to prevent slipping, provide a clutter free environment, and provide proper and well maintained footwear. The nurse's notes (NN) dated [DATE] at 12:15 P.M. revealed nursing staff was called to the resident's room and upon arrival the resident was on the floor in between her/his bed and television (TV). The resident was found sitting on her/his bottom and holding her/himself upright by holding onto the foot board of her/his bed. Prior to the fall the resident was seen by nursing staff in her/his bed resting with her/his eyes closed. The resident was unable to state what she/he was doing prior to the fall. Staff observed the resident was to have her/his back towards a clothing basket and several plastic storage bins were scattered all over the floor. The resident had a 2 centimeter (cm) hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) noted on the right side of her/his face near his/her right upper lip, a 1.5 cm laceration to the corner of her/his right eye, a 1 cm abrasion over her/his right eyebrow and a 1 cm laceration to her/his right eyelid. All areas were cleansed and dried thoroughly and steri strips were applied to the laceration on her/his right eye lid and the corner of her/his right eye. The abrasion to her/his right hand, above her/his right eyebrow and 2 cm hematoma between her/his right hand and in back were left open to air without any active drainage noted. The resident had a scant amount of red drainage noted from her/his right eyelid laceration and the corner of her/his right eye prior to the steri strip application. It was noted the resident did not have on any foot wear at this time. The resident was able to tolerate range of motion (ROM) to all extremities without pain or discomfort. The resident was assisted off the floor with the assistance of 2 nursing staff and the call light was place within the resident's reach. The resident's family and phy

The facility identified a census of 68 residents. The sample was 27 residents. Based on observation, interview, and record review, the facility failed to follow ordered and care planned interventions to prevent the development of pressure ulcers and treat existing pressure ulcers for 1 resident (#51) and failed to document, assess, and put interventions in place for newly recognized pressure ulcers for 1 resident (#39) of the 6 residents reviewed for pressure ulcers. Findings included: - The signed physician's orders [REDACTED].#51 dated 4/11/14 revealed [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 (MDS) with an Assessment Reference Date (ARD) of 8/22/13 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated he/she was moderately impaired cognitively. He/she did not reject care, required extensive assistance of 2 or more staff for bed mobility, transfer, and toilet use, did not walk, required extensive assistance of 1 for dressing and personal hygiene, was independent with set up for eating, required total dependence with 2 or more staff members for bathing, used a wheelchair and limb prosthesis, had an indwelling catheter and was occasionally incontinent of bowel. He/she had one stage 2 pressure ulcer. The Care Area Assessment (CAA) for Activity of Daily Living (ADL) function from the 8/22/13 MDS revealed he/she had a left [MEDICAL CONDITION] that minimized his/her ability to stand and walk. He/she frequently used his/her prosthetic leg, was noncompliant with care related to ADL, which included bathing, turning, and oral hygiene because he/she needed to smoke, had a [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 4/28/14 revealed the resident had a BIMS of 3 indicating he/she was severely impaired cognitively. He/she rejected care 4 to 6 days, required total dependence of 2 or more staff for transfer and bathing, extensive assistance of two or more people for bed mobility, toilet use, and dressing, extensive assistance of 1 for locomotion and personal hygiene, supervision of 1 for eating, and did not walk. He/she had no impairment with range of motion in the upper extremities, had impairment on one side of the lower extremities, and used a wheelchair. He/she had an indwelling catheter and was always incontinent of bowel. He/she weighed 188 pounds, received a mechanically altered, therapeutic diet, had one stage 3 pressure ulcer and one unstageable pressure ulcer. The most advanced pressure ulcer measured 5.4 centimeters (cm) bu (x) 3.5 cm with eschar (dead tissue). The nutritional status care plan dated 12/5/13 last updated 4/17/14 revealed the resident had a possibility for weight loss or eating issues due to not having teeth or dentures. On 12/5/13 interventions to monitor the resident to ensure he/she was able to swallow and chew appropriately and to monitor his/her weight were in place. Staff added wounds and a change in diet on 4/14/14, as well as recent pneumonia (inflammation of the lungs), dysphagia (swallowing difficulty), recent weight loss due to an increase in [MEDICATION NAME] (a medication to increase urine production), and a recent hospital stay. On 4/14/14 staff added an intervention for speech therapy for swallowing and cognition, and supplements as ordered. On 4/17/14 staff added interventions of a chopped, mechanical soft diet with nectar thickened liquids. Staff monitored for choking. The care plan for ADLs dated 12/5/13 (with no revision date) revealed the resident was incontinent of bowel. The resident required extensive assist with bed mobility and to toilet; and wore briefs. The care plan for pressure ulcers dated 12/5/13 revealed the resident was at risk for pressure ulcers related to a history of pressure ulcers, immobility, diabetes mellitus and dementia. Interventions included to administer the resident's treatments as ordered, document side effects and effectiveness, report any signs of skin breakdown, turn and reposition every two hours, and use a pressure reducing cushion when the resident was in the chair. Review of the care plan revealed the following updated interventions: 1/6/14 staff identified blisters on the resident's right foot and staff were to complete a treatment to the right foot and leg as ordered. 2/2/14 use of boots to relieve pressure on the heels and use a cushion for pressure reduction when the resident was in the chair. 2/25/14 assess and record the condition of the skin surrounding the pressure ulcer, assess the pressure ulcer for location, stage, size, presence or absence of granulation tissue (tissue with a rich blood supply) weekly, observe and report signs of [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] (local or generalized infection of the bone and bone marrow) [MEDICAL CONDITION], and to provide incontinent care after each incontinent episode. Staff identified a macerated (softening caused by constant wetness) area to the coccyx (small triangular bone at the base of the spine), and right calf abrasions. 2/28/14 EZ boot (a plastic splint with a soft fleece liner that supported the foot, correctly positions the lower extremity and eliminated pressure) on the right foot. 3/3/14 Infection of the right lower leg at the lateral (pertained to the side, away from the middle) ankle. Staff were to provide antibiotics as ordered. Staff were to evaluate, record and report the effectiveness and any adverse side effects, assess the location, size presence or absence of granulation tissue, dress the wound as ordered, observe and report signs of localized infection,[MEDICAL CONDITION] (blood infection), and record the amount, type and odor, color and consistency of drainage from the wound. 4/4/14 The resident had three areas on the right lower foot, one of which he/she returned from the hospital with on 4/4/14; staff changed his /her wheelchair to minimize pressure on the feet with elevated foot rests while in the wheelchair. 4/29/14 staff added an intervention for a protein supplement to help wound healing and a new wound treatment. The admission bladder evaluation dated 8/13/13 revealed the resident did not have open areas. The 8/13/13 Braden Assessment (an assessment used to determine the risk of development of pressure ulcers) revealed a score of 16 indicating the resident was at risk for pressure ulcers. The 8/15/13 Nutrition Risk Assessment revealed the resident was 71 inches tall, weighed 198 pounds, needed 2250 calories, 72 grams of protein, 2250 milliliters (ml) of fluid, and scored 7 which indicated the resident was a moderate nutritional risk. The resident did not have any skin conditions. The 2/5/14 Braden Assessment score 14 which indicated moderate risk for pressure ulcers. The 3/13/14 Braden Assessment score was 12 which indicated high risk for pressure ulcers. A 2/26/14 [MEDICATION NAME] (blood test used to determine nutritional status) result revealed a value of 13 milligrams per deciliter (mg/dl) which was low. The normal range was 19.5 to 35.8 mg/dl. A phone order on 3/17/14 revealed an order for [REDACTED]. twice a day. The clinical record revealed weights as follows: 8/2013-198 pounds (lb), 9/2013-193 lb, 10/2013-194.2 lb, 11/2013-193.2 lb, 12/2013-190.8 lb, 1/2014-187.8 lb, 2/3/14-195 lb, 3/5/14-199 lb, 3/13/14-200.8 lb, 4/4/14-198.8 lb, 4/15/14-185.4 lb, 4/22/14-188.2 lb, and 4/28/14-185.8 lb. Wound sheets revealed: On 3/9/14 a stage 3 ulcer to the right lateral foot measured 6 cm x 5 cm x 0.6 cm with an onset date of 2/19/14. On 3/21/14 a stage 3 ulcer to the right lateral foot measured 4 cm x 2.5 cm x 0.6 cm. On 3/27/14 a stage 3 ulcer to the right lateral foot measured 2.4 cm x 2.0 cm x 0.5 cm with an onset date of 2/14 and an unstagable right heel ulcer measured 9 cm x 7 cm with an onset date of 3/28/14. On 4/4/14 a stage 3 ulcer to the right lateral foot measuring 2.4 cm x 2 cm x 0.7 cm and an unstageable right heel ulcer measured 7 cm x 9 cm. The resident's 4/11/14 POS revealed orders to paint the right heel with [MEDICATION NAME] (a topical anti-infective) twice a day, apply silver alginate dressing (an antimicrobial, highly absorbant wound dressing) to right lateral foot daily, and to off load heels. On 4/18/14 a stage 3 ulcer to the right lateral foot measured 3.4 cm x 3 cm x 0.4 cm and an unstageable right lateral foot measured 2 cm x 2 cm with an onset date of 4/14/14. On 4/26/14 a stage 3 ulcer to the right lateral foot measured 5.4 cm x 3.5 cm x 0.5 cm and an unstageable right heel ulcer measured 7 cm x 6 cm. On 5/2/14 a stage 3 ulcer to the right lateral foot measured 5.4 cm x 3.6 cm x 0.5 cm and an unstageable right heel ulcer measured 7 cm x 6 cm. Nurse's notes revealed: On 2/19/14 at 10:55 A.M. staff noted a pressure ulcer on the right outer foot lateral aspect measuring 2.5 cm x 2 cm x 0.3 cm. On 2/24/14 at 3:02 P.M. the right lateral foot wound measured 1.5 cm in length by 2 cm in width and was 1/3 slough (dead tissue, usually cream or yellow in color) filled. On 2/27/14 at 4:07 P.M. the right foot lateral ulcer had purulent (producing or containing pus) drainage and a foul odor. On 2/28/14 at 3:49 P.M. the right lateral foot wound area appeared to have increased moist, green, foul smelling drainage. The area measured 3 cm in length by 4 cm in width by 0.4 cm in depth. The wound bed was jagged and the area that had slough was now black. On 3/4/14 at 3:23 P.M. the area on the right lateral foot remained necrotic (pertaining to the death of tissue in response to disease or injury) with little drainage. On 3/5/14 at 12:56 P.M. the wound on the right lateral foot was 2 cm x 3 cm and grayish in color. On 3/6/14 at 2:20 P.M. the right lateral foot wound measured 4 cm in length and 3 cm in width and had a foul odor. On 3/9/14 at 10:08 A.M. the wound on the resident's right lateral foot increased from stage 3 to a stage 4, had eschar, and foul yellow drainage noted with redness and inflamed tissue around the wound bed. Measurements were 6 cm in length by 5 cm in width with 0.6 cm in depth. On 3/10/14 at 7:06 P.M. the resident admitted to the hospital for a wound infection. A dietary note on 3/13/14 at 6:22 P.M. recommended prostat twice a day for wound healing. On 3/13/14 at 9:15 P.M. the resident returned to the facility at 5:00 P.M. On 3/15/14 at 12:48 P.M. on 3/14/14, an open area to the right lateral foot measured 2.5 cm in length x 2.0 cm in diameter. Depth was approximately 0.5 cm. An area to the wound bed was pink and clean and without slough and the edges were well approximated. No odor was present. On 3/21/14 at 7:59 A.M. the resident's wound was measured on 3/20/14 and his lateral left foot was a healing stage three, measured 4 cm by 2.5 cm with 0.6 cm depth, and had no slough, drainage, or odor noted. On 3/28/14 at 10:25 A.M. the resident had a new area on the right heel that measured 9 cm x 7 cm, and was an intact, purple discolored area. On 4/7/14 at 4:08 P.M. the wound on the lateral right foot measured 2.4 x 2.0 cm with a depth of 0.7 cm., had 30 percent (%) visible slough present in the wound bed, no eschar, no odor, and a small amount of yellow drainage. On 4/7/14 at 4:12 P.M. the area on the right heel was very dark in color with firm underlying tissue. The area was not open and measured 7 cm x 8 cm with no depth. On 4/15/14 at 5:11 A.M. the resident had an area of black eschar to the right heel measuring 7 cm in length x 5 cm in width and an open area to the right lateral foot measuring 2.5 cm in length x 2.0 cm in width. The wound bed was pink and had granulation tissue. No odor was present. On 4/18/14 at 7:16 A.M. the open area on the lateral right foot measured 3.4 cm x 3 cm and was a stage 2. The wound bed was covered with a thin layer of yellow slough with no signs of infection noted. Another area proximal (closest to the center of the body) to the first area, was 2 x 2 cm in size and covered with thick dark brown slough. No signs of infection were present at either site. The right heel was covered with dark calloused skin that measured 8 cm x 6 cm. A dietary note on 4/18/14 at 1:52 P.M. revealed the resident returned from the hospital with an order for [REDACTED]. Review of the nurse's notes on 4/20/14 at 1:21 P.M. staff encouraged the resident to lay down between meals but he/she refused. On 4/25/14 at 9:17 A.M. the wounds on the right lateral foot declined since the last assessment. The 2 areas merged into one and measured 5.4 cm x 3.5 cm and was a stage 3. The wound bed was pale pink with slough around the edges and covering about 30% of the wound bed. The surrounding tissue was dark and non-blanchable. The wound had no odor or signs of infection. The right heel measured 7 cm x 6 cm and was black calloused tissue. Black eschar was loosely adherent and started to slough off in places. The tissue under the eschar was pink and healthy. A dietary note on 4/25/14 at 12:55 P.M. revealed the resident's wound was not healing with the current plan and recommended prostat once daily for extra protein and healing. A phone order on 4/28/14 revealed an order for [REDACTED]. Recorded on 5/5/14 at 9:33 A.M. the wound on the right heel measured 7 cm x 6 cm with black eschar and healthy pink tissue underneath. The eschar was loosely adhered in areas and was sloughing off. The right lateral foot measured 5.4 cm x 3.6 cm. The surrounding tissue remained dark. Staff encouraged the resident to lay down and float heels although he/she was non compliant with this a lot of the time. The clinical record lacked evidence the facility provided education regarding potential outcomes for refusing position changes. Observation on 5/6/14 at 8:43 A.M. revealed 2 staff entered the resident's room to get him/her out of bed. The resident laid in bed on his/her back on a pressure reducing mattress with an EZ boot on the right foot and the right foot elevated on a pillow. He/she was transferred into a wheelchair with a pressure reducing cushion and a padded foot rest. During continued observation at 9:04 A.M. while eating breakfast, the resident did not receive a magic cup as ordered and as signed on the medication administration record (MAR) by staff as given. At 9:20 A.M. the resident went outside to smoke. At 9:37 A.M. he/she was brought back inside and placed at a table in the dining room and given a cup of coffee. At 10:00 A.M. the resident remained at the table in the dining room and drank coffee. At 10:20 A.M. the medication aid came to the dining room and gave the resident his/her pills. This medication administration did not include a magic cup or prostat as ordered and signed on the MAR. At 10:35 A.M. the resident went back outside and remained in the same position in the wheelchair. At 11:00 A.M. the resident remained outside. At 11:15 A.M. a skin check was requested. Staff brought he resident was inside at 11:24 A.M. He/she was down and staff removed the brief. The resident had a reddened buttocks with numerous open, undressed areas on both sides and also on the gluteal folds. Numerous areas of red drainage were on the brief. The staff did not reposition this dependent resident for 2 hours and 41 minutes. Observation on 5/6/14 at 12:39 P.M. in the dining room revealed the resident ate 100% of a magic cup and a bowl of jello and drank 4 ounces (oz) of orange juice and 8 oz of milk. He/she did not eat the lunch of a sloppy joe and pea salad. Staff offered him/her a substitute and he/she declined. Observation on 5/7/14 at 8:35 A.M. revealed the resident received breakfast and did not receive a magic cup as ordered and as signed on the MAR. Observation on 5/7/14 at 10:05 A.M. during the dressing change to the pressure ulcers revealed a right heel wound that measured 6 cm in length x 7 cm in width with no eschar or drainage. Right lateral foot wound measured 4.6 cm in width x 2.9 cm in length with an estimated depth of 0.4 to 0.5 cm. Interview on 5/6/14 at 11:40 A.M. with direct care staff OO revealed staff should reposition the resident every 2 hours especially since he/she had open areas and the resident received a magic cup with meals. The kitchen was responsible for giving the resident the magic cups. Interview on 5/7/14 at 11:00 A.M. with direct care staff S revealed magic cups came from the kitchen with meals, were printed on the meal ticket and were the responsibility of the kitchen and the staff member who passed the meal tray to ensure the resident received it. The medication aid asked the staff member who picked up the meal tray how much of the magic cup the resident ate and charted it in the MAR. Interview on 5/7/14 at 12:38 P.M. with direct care staff OO revealed he/she told the medication aid inaccurate information because the resident did not have a magic cup this morning. He/she did not give the medication aid the percent of the magic cup for 5/6/14. Interview on 5/7/14 at 12:40 P.M. with direct care staff S revealed he/she could amend the charting for this morning on the magic cup intake since he/she received incorrect information and acknowledged it was not a good practice to chart based on information received from another person. Interview on 5/7/14 at 10:23 A.M. with administrative nursing staff E revealed the resident had an EZ boot on the right foot, a pressure relieving cushion in the wheelchair, an EZ boot kick stand and padded foot rest on the wheelchair, pillows in bed to elevate the feet, a pressure reducing mattress, received prostat and vitamin C once a day, and received a magic cup three times a day. The dietary staff gave the medication aide the magic cup and the medication aid documented the percent consumed in the MAR. He/she expected staff to reposition the resident every 2 hours although he/she was not always cooperative, and expected staff to document noncompliance. He/she revealed the right heel ulcer a stage a 2 and was previously unstageable. The right lateral foot wound was a stage 3. Interview on 5/7/14 at 12:44 P.M. licensed nursing staff K revealed medication aids charted magic cup intakes. When licensed nursing staff K passed medications he/she asked the staff how much of the magic cup the resident consumed if he/she could not look him/herself. Licensed nursing staff K acknowledged it was not good practice to chart based on what someone else told him/her. He/she expected staff to turn the resident every 2 hours and expected him/her to receive all supplements as ordered. Interview on 5/7/14 at 12:51 P.M. with dietary aid FF revealed magic cups were printed on the meal tickets and this resident got a magic cup at all meals. Interview on 5/7/14 at 2:40 P.M. with administrative nursing staff D revealed the resident's right lateral foot wound developed on 2/19/14. He/she came back from the hospital with a second one on 4/14/14 and the 2 eventually grew together. The facility did not have 1 consistent person who staged and measured wounds, if one was found in the evening or on a weekend there were a couple of floor nurses who could measure wounds but was usually done by the director of nursing or the assistant director of nursing. The resident's heel wound developed in the facility on 3/28/14. an order for [REDACTED]. It was the medication aide's responsibility to give the resident magic cups, the kitchen provided the magic cups but ultimately it was the medication aides responsibility, medication aides initialed when they gave the magic cups on the MAR and wrote a percent eaten. He/she believed it was acceptable to get that information from other staff and not observe the percent eaten themselves, it was his/her expectation that if medication aides charted something as given they actually gave it. It was also his/her expectation staff repositioned the resident but if it was longer than 2 hours because he/she wanted to go smoke that was okay because the resident got agitated and refused care, the resident did refuse care at times, and repositioning and refusals of care were care planned. Interview on 5/7/14 at 3:19 P.M. licensed nursing staff I revealed the medication aid was responsible for making sure the resident received magic cups and charted on the MAR. He/she expected the medication aid to visualize for themselves the percent taken before they charted. Interview of 5/15/14 at 2:54 P.M. with consultant staff MM revealed he/she expected the resident to receive nutritional supplements as ordered and expected the facility staff to reposition the resident frequently, at least every 2 hours, to promote wound healing. A policy for pressure ulcers, requested of the facility, was not received. The facility failed to prevent the development of multiple avoidable pressure ulcers and failed to provide interventions as planned to promote healing of the existing pressure ulcers for this dependent resident. - The electronic physician's orders [REDACTED].#39 dated 3/18/14 to 4/30/14 revealed the [DIAGNOSES REDACTED]. by periods in which respiration was absent). The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. He/she required extensive assistance of one person for bed mobility and toileting. The resident required extensive assistance of two persons for transfers. He/she required a wheelchair for ambulation and had no skin issues noted. The Admission MDS dated [DATE] revealed the resident scored an 8 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately cognitively impaired. He/she required extensive assistance of one person for bed mobility, transfers and toileting. He/she required a wheelchair for ambulation and had no skin issues noted. The Care Area assessment dated [DATE] for pressure ulcers revealed the resident was at risk for developing pressure ulcers due to impaired mobility and cognitive impairment. He/she had a pressure relieving mattress and pressure relieving wheelchair cushion. The care plan dated 12/3/13 revealed the resident was at risk for pressure ulcers due to immobility, incontinency of bowels, and dementia. The care plan directed staff to turn and reposition the resident every 2 hours and staff to report any signs of skin breakdown. Nurse's note dated 5/7/14 at 11:33 P.M. revealed the resident's skin was warm, dry and intact, with an old dry scar tissue in the right gluteal fold. Observation on 5/6/14 at 8:25 A.M. the resident sat in dining room in wheelchair with a pressure relieving cushion in place. Observation on 5/6/14 at 9:45 A.M.,10:32 A.M.,11:12 A.M. and 12:02 P.M. the resident sat in the doorway of his/her room in wheelchair with pressure relieving cushion in place. Observation on 5/6/14 at 2:00 P.M. the resident watched television while laying in bed. Observation on 5/7/14 at 1:19 P.M. direct care staff O and direct care staff P used a stand up lift to transfer the resident from his/her wheelchair to the resident's bed. The staff performed pericare and surveyor observed 2 scabbed areas each approximately 2 centimeter (cm) by (x) 2 cm in size located on the resident's right buttocks near the sacrum, one area was approximately 1 cm above the second area. Staff applied moisture barrier cream to this area. Observation on 5/8/14 at 8:30 A.M. the resident had one open area approximately 2 cm x 2 cm on the right buttocks near the sacrum approximately 1 cm above a scabbed area of approximately 2 cm x 2 cm located on the right buttocks near the sacrum. Observation on 5/12/14 at 12:42 P.M. the resident's top open area merged with the bottom scabbed area, was now an open area of approximately 5 cm long by 2 cm in width. Interview on 5/7/14 at 1:53 P.M. with licensed nursing staff L stated the licensed nursing staff did weekly skin checks on the residents, and direct care staff reported skin changes, the nurses would follow up on these changes, and put a treatment in place. Licensed nursing staff L was unaware of any skin issues until he/she was informed by this surveyor the resident had two scabbed areas on his/her buttocks. The record lacked evidence the nursing staff assessed this resident's skin condition until it was documented in a nursing progress note dated 5/7/14 at 11:33 P.M. Interview on 5/7/14 at 2:03 P.M. direct care staff O stated any changes in skin condition would be reported to the nurse, and acknowledged the scabbed area on the buttocks would be reported to the nurse. Interview on 5/7/14 at 2:54 P.M. direct care staff V stated any changes in skin condition would be reported to the nurse. Interview on 5/7/14 at 3:00 P.M. administrative nursing staff D stated he/she expected the direct care staff to inform the nurse of changes in skin condition and the nurse would assess this, implement a proper treatment and report to the resident's physician. Interview on 5/8/14 at 7:17 A.M. licensed nursing staff H stated direct care staff would report any change in skin condition even redness, and he/she would assess the resident. He/she was unaware of any changes in skin condition for this resident until informed by this surveyor the resident had two scabbed areas on his/her buttocks. Interview on 5/12/14 at 12:42 P.M. direct care staff O stated the resident's buttocks scabbed areas merged and opened up and were worse. The facility failed to provide a policy and procedure on monitoring for skin irregularities. The facility failed to accurately and timely assess and treat this resident who was a cognitively impaired and dependent resident with pressure ulcers.

The facility identified a census of 72 residents. The sampled included 5 residents. Based on observation, interview, and record review, the facility failed to adequately monitor blood glucose and administer insulin as ordered to 1 of 3 diabetic residents sampled (#2). Findings included: - According to the clinical face sheet, the facility admitted /readmitted resident #2 on 2/21/08. Review of the physician's order [REDACTED]. Review of the admission Minimum Data Set 3.0 Assessment, dated 7/19/13, recorded the resident with a BIMS (brief interview for mental status) of 15 (cognitively intact). The resident experienced periods of disorganized thinking and had [MEDICAL CONDITION] The comprehensive care plan dated 7/31/13 recorded the resident at risk for complications related to diabetes and directed staff: - receive insulin per doctor order - have blood glucose level (the blood sugar concentration or blood glucose level was the amount of glucose (sugar) present in the blood) checked using accucheck as ordered -Observe for signs and symptoms of [MEDICAL CONDITION] (a greater than normal amount of glucose in the blood), if observed, alert charge nurse for notification of physician as needed. Nurse to recheck blood glucose PRN (as needed) and report to physician as needed -nurse to notify physician if blood level of less than 60 for possible adjustment of insulin dose. Offer resident orange juice and protein snack to restore BS (blood sugar) level prior to contacting the physician. According to the Lexi-Comp Drug Information Handbook for Nursing, 12th Edition, page 1536, a normal range for fasting blood glucose, was 60-110 milligrams per deciliter (mg/dl). Review of the physician standing orders for blood glucose dated 9/17/12, directed: Blood Glucose if below 60, nursing would: Give orange juice with a pack of sugar (if resident able to swallow) Give liquid [MEDICATION NAME] (an injectable medication used to raise very low blood sugar) (if not able to swallow) Recheck glucose in 10 minutes If not responding to the above, administer injectable [MEDICATION NAME] Recheck Recheck BS in one hour Call the physician after these measures for further instruction Call the physician with blood sugars greater than 400 (signed and dated by physician on 9/17/12 or 13 (illegible). Physician orders [REDACTED]. Review of the treatment administration record (TAR), dated October 2013, recorded on 10/1/13 at 8:00 AM, the resident had a low blood sugar of 42, and documented staff administered 24 units of [MEDICATION NAME] insulin. The clinical record lacked evidence the facility notified the physician of the low blood sugar or administered the orange juice with sugar, liquid [MEDICATION NAME], or Glucerna as planned. The clinical record lacked evidence of when the staff rechecked the resident ' s blood sugar after administering the insulin. The TAR on 10/2/13 at 8:00 A.M. recorded a blood sugar of 79 and recorded the resident received [MEDICATION NAME]24 units at breakfast. On 10/2/13 at noon, staff recorded a blood sugar of 84 and recorded the [MEDICATION NAME]16 units was not given at lunch. The clinical record lacked evidence the facility notified the physician of holding the noon insulin dose. Nursing notes on 10/2/13 recorded: At 1:00 P.M. staff yelled, the resident was unresponsive and transferred the resident in his/her wheelchair from the dining room to the resident ' s room. At 1:05 P.M., staff obtained a glucometer check of the resident ' s blood sugar that recorded 27. The staff administered " sips of orange juice with a throat massage to swallow the liquid. " At 1:10 P.M., a [MEDICATION NAME] injection given. At 1:12 P.M., a glucometer check revealed the resident ' s blood sugar was 42 and oxygen saturation of 83 percent. (An oxygen saturation in the blood below 90 percent was considered critical.) Staff placed the resident on supplemental oxygen at 2 liters per nasal cannula that increased the saturation to 85 percent, with the resident still unresponsive and clammy. At 1:20 P.M., a glucometer check revealed a blood sugar of 70. At 1:25 P.M., the resident opened his/her eyes and asked what happened. Nursing notes, on 10/3/13, recorded: At 4:15 A.M., a glucometer check revealed a blood sugar of 38. Staff administered Glucerna to the resident. The facility did not follow their standing orders to recheck the blood glucose in 10 minutes and did not give the orange juice with sugar. At 5:30 A.M., a glucometer check revealed a blood sugar of 48. The resident requested and staff provided another Glucerna. The facility did not follow their standing orders to recheck the blood glucose in 10 minutes and did not give the orange juice with sugar. At 6:15 A.M., a glucometer check revealed a blood sugar of 52. Staff documented the resident was drowsy and lethargic and administered a [MEDICATION NAME] injection. The facility did not follow their standing orders for the timing of the blood sugar recheck and administered [MEDICATION NAME] injectable without orders. At 6:35 A.M., a glucometer check revealed a blood sugar of 121 and resident alert and talking. The 10/13 TAR revealed the staff held the 8:00 A.M. insulin dose without a physician's order [REDACTED]. At 9:15 A.M., the resident with a temperature of 100 degrees, oxygen saturation of 60% with 2 liters of supplemental oxygen by nasal cannula, expiratory wheezes (a [MEDICATION NAME] sound produced when airflow from the lungs was narrowed), and bilateral hand tremors (unintentional shaking movements). The clinical record lacked evidence of a glucometer check at this time. At 9:30 A.M., the facility transferred the resident to an acute care hospital emergency room . At 9:40 A.M., the staff placed a call to the resident ' s physician. At 9:45 A.M., the physician returned the call to the facility and gave staff the order to send to the resident to the hospital. The clinical physician notes recorded from 10/3/13 through 10/14/13 revealed the resident was hospitalized with acute [MEDICAL CONDITION] (a sudden onset of the lungs not able to get enough oxygen into the blood), [MEDICAL CONDITION] (inadequate supply of oxygen), bacterial pneumonia (a type of pneumonia caused by bacteria), dysphagia (difficulty in swallowing) with PEG (percutaneous endoscopic gastrostomy) tube placement (insertion of a tube into the gastrointestinal tract when a resident cannot ingest, chew or swallow food) and was intubated (was the placement of a flexible plastic tube into the windpipe to maintain an open airway) emergently in the emergency room . The nursing notes revealed the resident readmitted to the facility on [DATE] at 3:15 P.M. with a PEG tube. The TAR revealed an order dated 10/15/13 for 2-Cal HN (a nutritionally complete, high-calorie enteral formula), 1 can (8 ounces or 237 cubic centimeters) at 7:00 A.M., 10:00 A.M., 1:00 P.M., 5:00 P.M., and 8:00 P.M., though the peg tube. The clinical record lacked evidence the facility monitored this diabetic resident ' s blood sugars from readmission on 10/14/13 at 3:15 P.M. to 10/15/13 at 8:00 A.M. The TAR for 10/15/13 revealed the resident ' s blood sugar at 8:00 A.M. was 140 or 190 (illegible). The sliding scale revealed the staff to administer 2 or 4 units respectively. The TAR or nurses notes lacked evidence the resident received the sliding scale insulin as ordered. The TAR for 10/15/13 revealed the resident ' s blood sugar at noon was 289 and the resident was to receive 6 units of sliding scale insulin. The TAR or nurses notes lacked evidence the resident received the sliding scale insulin as ordered at noon on 10/15/13. The TAR for 10/16/13 at 8:00 A.M. revealed a blood sugar of 330 and the TAR lacked evidence the resident received the 8 units of insulin as ordered. The TAR for 10/16/13 at bedtime revealed the resident ' s blood sugar was 462. The facility notified the physician and he/she ordered staff to administer 12 units of insulin and start [MEDICAL CONDITION] protocol, which consisted of notifying the physician if the blood sugar was over 400. The TAR lacked evidence the facility rechecked the blood sugar after they administered the 12 units of insulin at bedtime on 10/16/13. The physician orders [REDACTED].M. revealed orders for 2-Cal HN at 95 milliliters per hour, continuously from 7:00 P.M. to 7:00 A.M. The TAR for 10/17/13 at 7:00 A.M., lacked evidence the staff assessed the resident ' s blood sugar as ordered. The TAR for 10/17/13 at 12:00 noon revealed a blood sugar of 427. The clinical record lacked evidence the facility followed the [MEDICAL CONDITION] protocol and notified the physician. The TAR revealed a blood sugar of 60 on 10/18/13 at 8:00 P.M. The clinical record lacked evidence the facility administered the liquid [MEDICATION NAME] or rechecked the blood sugar in 10 minutes per their protocol. The TAR revealed on 10/19/13 at 7:30 A.M. the resident ' s blood sugar was 599. The clinical record lacked evidence the facility notified the physician per their standing orders or rechecked the blood sugar. The TAR revealed on 10/19/13 at 4:30 P.M. the resident ' s blood sugar was 42 and the clinical record lacked evidence the facility notified the physician or started their [DIAGNOSES REDACTED] protocol. The TAR revealed on 10/20/13 at 7:30 A.M. the resident ' s blood sugar was 503. The clinical record lacked evidence the facility notified the physician. The TAR on 10/20/13 at 11:30 A.M. revealed the facility did not assess the resident ' s blood sugar. At 4:30 P.M., the resident ' s blood sugar was 40. The clinical record lacked evidence the facility notified the physician or initiated their standing orders. The TAR on 10/20/13 at 8:00 P.M. revealed the resident ' s blood sugar was 280 and the facility did not administer the 6 units of insulin per the sliding scale order. The TAR on 10/21/13 at 7:30 A.M. revealed the resident ' s blood sugar was 586 and the facility did not administer the standing orders of [MEDICATION NAME] 15 units. The clinical record lacked evidence the facility notified the physician per their standing orders. The TAR on 10/21/13 at 11:30 A.M. revealed the resident ' s blood sugar was 574. Further review revealed the staff did not administer the 12 units of insulin per the sliding scale and did not notify the physician. At 4:30 P.M., the resident ' s blood sugar was 548 and the clinical record lacked evidence the staff notified the physician. At bedtime, the blood sugar was 423 and the record lacked evidence the staff notified the physician. The TAR on 10/22/13 at 7:00 A.M. revealed the resident ' s blood sugar was " hi. " The clinical record lacked evidence the staff notified the physician or assessed the resident until 10:45 A.M. (3 hours and 45 minutes later). Review of the EvenCareG2 (glucometer) manufacture information, documented a reading of " hi " indicated a blood glucose reading above 600. The nursing notes dated 10/22/13 at 10:45 A.M. revealed the resident was lethargic, bowel sounds hypoactive, lung sounds diminished, disoriented and had a large amount of whitish emesis this A.M. Nursing notes dated 10/22/13 at 10:50 A.M. revealed the facility received orders from physician V to send the resident to the emergency room for evaluation. Nursing notes dated 10/22/13 at 11:40 A.M. revealed the facility notified the family the resident was transferred to the hospital. The nursing notes dated 10/22/13, timed 4:00 P.M. revealed the nurse spoke with the hospital and the resident was admitted to the ICU (intensive care unit) for hypokalemia (low level of potassium in the blood), hypercalcemia (greater than normal amounts of calcium in the blood) and ARI (acute [MEDICAL CONDITION], the kidneys fail to adequately filter waste products from the blood. The resident ' s blood sugar on admission was 720. On 10/30/13 at 10:20 A.M. administrative nursing staff D reported on Sunday afternoon, 10/27/13, the hospital discharge planner called and reported the resident would return to the facility that day and according to a swallow study, he/she no longer required the tube feeding. The clinical record lacked documentation when the resident returned until 10/28/13 at 5:30 A.M. The TAR on 10/27/13, for the evening accucheck, revealed a blood sugar of 180. The sliding scale insulin order revealed the staff would administer 2 units of insulin. The staff documented administration of 4 units. The TAR on 10/28/13, for the noon accucheck, revealed a blood sugar of 270 and the staff would administer 6 units of sliding scale insulin. The TAR lacked evidence the staff administered the insulin as ordered. The TAR on 10/30/13, for the evening accucheck, revealed a blood sugar of 383. The staff administered 8 units of insulin instead of the 10 units of insulin per the sliding scale orders. On 10/29/13 at 8:00 A.M. the resident reported he/she just got back yesterday from the hospital. Observation during personal cares on 10/29/13 at 8:05 A.M., revealed the resident with a PEG tube, and required assistance of direct care staff O and P to transfer from the bed to a wheelchair. On 10/29/13 at 5:00 P.M., the resident sat in his/her wheelchair in the treatment room to receive his/her evening insulin as ordered. An interview on 10/29/13 at 8:50 A.M., licensed nursing staff H reported the med aides performed the accuchecks and the licensed nurses administered the insulin and documented on the TAR. On 10/29/13 at 11:10 A.M. direct care staff Q revealed, when a resident ' s blood sugar was less than 60 or over 400, and he/she would tell the nurse so they could call the physician for orders. On 10/29/13 at 11:39 A.M. licensed nursing staff H reported the facility ' s diabetic parameters were 60 to 400 for blood sugars. If the resident ' s blood sugar was less than 60 and the resident was still responding, staff gave Glucerna, and called the physician. If the resident was not very responsive, staff gave [MEDICATION NAME] per standing orders, and then rechecked the blood sugar every 15 minutes until stable. When stable, staff called the physician or if the resident did not respond, staff called the physician. On 10/30/13 at 4:00 P.M. administrative nursing staff E reported the resident ' s blood sugars were always erratic. 10/31/13 at 7:30 A.M. licensed nursing staff I reported the TAR had parameters to follow for resident blood sugars. 10/31/13 at 3:00 P.M. administrative nursing staff D confirmed the facility ' s old policy for blood glucose monitoring was inadequate. 10/31/13 at 3:30 P.M. dietary consultant staff EE reported the resident returned to the facility from the hospital with enteral feeding recommendations of 2-Cal HN. Dietary consultant staff EE revealed this was not a diabetic enteral formula. Interview on 11/6/13 at 2:05 P.M. with physician consultant V reported he/she was new to caring for this resident but aware the resident was a diabetic and received sliding scale insulin for his/her blood sugars. Consultant V said he/she expected staff to follow the standing orders and notify him/her if the blood sugars were outside the parameters. The facility failed to accurately and consistently monitor this diabetic resident ' s blood sugars, administer insulin as physician ordered, and notify the physician with blood sugars outside of the documented parameters. The facility failed to follow the resident ' s plan of care and standing facility orders/protocol for diabetic management. The facility ' s policy further failed to indicate the amount of [MEDICATION NAME] for staff to administer for [DIAGNOSES REDACTED].

The facility reported a census of 65 residents. The sample included 3 residents. Based on observation, record review, and interview the facility failed to provide supervision for 1 (#3) resident to prevent the resident from leaving the facility unsupervised. This failure placed the resident in immediate jeopardy (IJ). The facility failed to monitor the wanderguard (an electronic device to notify the staff when a resident attempted to leave the facility) for placement and function for 3 (#1, #2, #3) residents, and failed to complete an Elopement Risk Assessment for 3 (#1, #2, and #3) residents sampled for at risk for elopement. The facility identified 42 residents as cognitively impaired and independently mobile and considered by the facility at risk for elopement. Findings included: - The signed physician's orders [REDACTED].#3 revealed a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) 3.0 dated 5/15/13 revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment) with no presence of wandering. The resident was independent for bed mobility, transfer, walking in room/corridor, and locomotion on/off the unit, and was steady at all times with balance during transition and walking. The resident did not use a mobility device. The Care Area Assessment (CAA) dated 5/22/13 for Cognitive Loss and Dementia revealed the resident had a BIMS score of 5, had short/long term memory problems and impaired decision making skills for daily living. The resident enjoyed going outdoors and was an elopement risk as she/he would follow people out of the entry/exit doors. The care plan for at risk for elopement dated 5/28/13 and revised on 5/29/13 noted the resident was at risk due to impaired safety awareness and history of attempts to leave the facility unattended, revealed the resident wore a wanderguard on her/his left ankle and nursing staff would check for proper functioning and placement per facility policy. The resident enjoyed the outdoors and nursing staff would direct the resident to the enclosed area off the dining room when she/he required fresh air. The nursing staff would direct the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books and she/he preferred to read the newspaper, watch television, and listening to music. The nursing staff would identify the pattern of wandering and monitor the resident's location every 30 minutes during waking hours and report/document wandering behaviors and attempt diversional interventions in the nurses' notes. Staff would provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs and pictures. The Fall Risk assessment dated [DATE] revealed a score of 16 where a score of 10 or higher indicated the resident was at risk for falls. The Fall Risk Assessment also indicated the resident displayed wandering, periods of restlessness, and periods of altered perception or awareness of surrounds. Record review on 7/2/13 at 8:55 A.M. lacked an admission elopement assessment. The Risk of Elopement/Wandering Review form dated 5/27/13 revealed an incomplete assessment and failed to identify the resident was at risk for elopement. There was no elopement assessment done prior to 5/27/13. The May 2013 Wanderguard Check List revealed the facility admitted the resident on 5/9/13 and placed a wanderguard on the resident on 5/10/13. Record review on 7/2/13 at 9:00 A.M. revealed a lack of documentation nursing staff monitored the resident's wanderguard for placement and function from 6/1/13 to 7/1/13. The certified nursing aide (CNA) Worksheets (identified the resident ' s care needs) dated 5/11/13 to (-) 5/26/13 lacked information the resident wore a wanderguard and required 30 minute location checks. The CNA Worksheet also lacked documentation nursing staff checked the resident's location on 5/19/13 from 11:00 A.M. - 6:30 A.M., on 5/25/13 from 10:30 A.M. - 6:30 A.M., and 5/26/13 from 10:00 - 10:30 A.M., 1:00 P.M. - 2:30 P.M. The Facility ' s self-reported Investigation Report dated 5/28/13 at 10:50 A.M. revealed on 5/26/13 the resident was last seen between 1:00 P.M. and 1:40 P.M., at approximately 3:00 P.M. the resident received a telephone call and as nursing staff went in search for the resident, she/he could not be found. A search was initiated and at approximately 4:07 P.M. maintenance staff X found the resident on name of street approximately 0.9 miles or 11 blocks from the facility. The Nursing Notes (NN) dated 5/26/13 at 4:45 P.M. revealed nursing staff assessed the resident and had a 3 centimeter (cm) by ( x) 1.5 cm purple bruise on the right upper arm with 1 cm x 1 cm diameter skin tear. The resident did not complain of pain and nursing staff implemented 15 minute checks on the resident for 72 hours. Record review 7/2/13 at 12:00 P.M. revealed the NNs dated 5/26/13 lacked documentation the resident left the facility. According to Weather Underground the heat temperature index on 5/26/13 at 2:53 P.M. was 82.3 degrees Fahrenheit, at 3:53 P.M. 83.8 degrees, and was mostly sunny with maximum wind speed 21 mph gusting to 29 mph. The NN dated 5/29/13 at 2:45 P.M. revealed the resident walked out the door of the facility, smokers were in the vicinity, and the resident was redirected to the patio. Observation on 7/1/13 at 2:43 P.M. revealed the resident ambulated out the facility's main entrance/exit door without a mobility device, activity staff member accompanied and the wanderguard door alarm sounded. Interview on 7/1/13 at 3:37 P.M. with direct care staff O stated the resident wore a wanderguard on her/his ankle and she/he was not sure who checked the function of the wanderguards. Interview on 7/1/13 at 4:40 P.M. with licensed nursing staff H stated the resident wore a wanderguard on her/his ankle and she/he was not sure who checked the wanderguard for placement/function. She/he was not aware of the elopement assessments. Interview on 7/2/13 at 7:51 A.M. with maintenance staff X stated she/he in May 2013 received a telephone call from the facility and was informed the resident was missing. She/he assisted in the search and found the resident on name of street approximately 0.9 miles or 11 blocks from the facility. The resident appeared tired and did not have any signs or symptoms of injury. The resident was returned to the facility. She/he was not sure how the resident got out of the facility as the door alarms were all in working order. The resident was known to wander and would ask staff how to get out. She/he was not sure how long the resident was missing. Interview on 7/2/13 at 8:05 A.M. with administrative staff B stated the office secretary checked the function of the residents' wanderguards on the weekdays and nursing staff checked the wanderguards on weekends. The nursing staff checked the wanderguards Monday through Sunday starting at the end of May 2013 as the office secretary was no longer employed at the facility. Interview on 7/2/13 at 9:05 A.M. with administrative nursing staff D and licensed nursing staff I said up until the end of May 2013 the office secretary checked the functional status of resident wanderguards on the weekday and they were checked by nursing staff on the weekends. Now the nursing staff checked resident wanderguards Monday to Sunday. Interview on 7/2/13 at 9:10 A.M. with administrative nursing staff D stated she/he could not find the last three months of wanderguard checks for the east side hallway. She/he assumed nursing staff did not check the resident's wanderguard during those past three months for placement and function. The CNA preformed 30 minute resident checks on all residents in the facility. Interview on 7/2/13 at 12:11 A.M. with administrative nursing staff D stated the charge nurse checked the wanderguards and completed elopement assessments and she/he was not sure why the resident's Elopement Assessment was not completed. She/he said residents who were mobile and confused received wanderguards and nursing staff should complete elopement assessments within 24 hours of admission, and check wanderguards every (Q) shift. The undated policy and procedure titled Resident Monitoring Procedure revealed nursing staff were responsible for implementation and maintenance of resident monitoring devices. Staff would complete a Risk to Wander assessment on all residents at the time of move-in, annually, and with any significant change. If a resident was determined to be at risk to wander and/or if a new resident was independently mobile, whether by walking or in a wheelchair, there would be a resident monitoring device placed on the resident's ankle or wrist. The undated policy and procedure titled Elopement Policy revealed the following steps staff would implement for any resident whose assessment, upon move-in, or at any time during her/his length of stay indicated impaired decision making and/or impaired cognition, ability to be mobile by ambulating or by use of a wheelchair or other assistive device, and a history of wandering or elopement: staff would alert the care plan team and plan appropriately for the resident being at risk for elopement and for use of a Resident Monitoring System, staff would note the use of a Resident Monitoring System on the Medication Administration Record, Team Sheet, and Care Plan, and staff would complete a 30 minute location checks for all residents using a Resident Monitoring System. Interview on 7/2/14 at 11:58 A.M. with administrative staff A was notified of IJ status by surveyor staff II for failure to provide supervision to prevent the resident from leaving the facility unsupervised, failure to monitor a facility exit door with a wanderguard alarm, failure to complete an elopement assessments for the residents at risk of elopement, failure to monitor the placement and function of residents with wanderguards, and failure to provide registered nurse (RN) coverage identified on the incident date of 5/26/13 The facility failed to assess and provide supervision and prevent this cognitively impaired independently mobile resident from leaving the facility. The facility abated the immediate jeopardy on 7/3/13 at 4:00 P.M. when: 1. The facility changed the door codes and only staff were told the code. 2. The wanderguard system will alarm when a resident with a wanderguard approaches the door. 3. Staff training regarding elopements, electronic door monitoring, wanderguard system, abuse, neglect, exploitation prevention, 30 minute checks of the residents and documentation of the checks, release of responsibility (signing in and out residents) completed on 7/3/13 at 4:00 P.M. 4. Quality Assurance (QA) will review all state reportable incidents and incidents with potential for resident harm at the following QA meeting. 5. The day shift charge nurse will check wanderguard replacement and function daily and document on the Treatment Administration Record. This deficient practice remained at a scope and severity of an E. - The signed physician's orders [REDACTED].#2 revealed [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) 3.0 dated 5/22/13 revealed a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) with no presence of wandering. The resident was independent with no setup or physical help from staff for bed mobility, transfers, walking in room/corridor, and locomotion on/off the unit. The resident was steady at all times during transitions and walking and a mobility device was not used. The Care Area Assessment (CAA) dated 6/4/13 for Activities of Daily Living (ADLs) function revealed the resident ambulated ad lib with a steady gait. The care plan dated 6/11/13 for potential for falls revealed the resident wore a wanderguard per elopement risk protocol. The Risk of Elopement/Wandering Review form dated 3/8/13 revealed an incomplete assessment and failed to identify the resident was at risk for elopement. The Nursing Notes (NN) dated 5/20/13 at 9:20 P.M. revealed the resident ambulated all over the facility and her/his gait was worse with the more tea the resident drank. NN dated 5/21/13 untimed revealed the resident ambulated all over the facility and her/his gait was unsteady when the resident drank too many liquids. Record review on 7/1/13 at 3:45 P.M. revealed a lack of documentation of the resident's wanderguard placement and functional monitoring from 6/1/13 to 7/1/13. The certified nursing aide (CNA) Worksheets dated 5/9/13 to (-) 5/26/13 revealed the resident required location checks every 30 minutes and wore a wanderguard. The CNA Worksheet lacked documentation nursing staff checked the resident's location on 5/19/13 from 11:00 A.M. to 6:30 AM, on 5/25/13 from 10:30 A.M. to 6:30 A.M., and 5/26/13 from 10:00 to 10:30 A.M., 1:00 P.M. to 2:30 P.M. Observation on 7/2/13 at 2:13 P.M. revealed the resident ambulated independently without a mobility device in the dining room and wore a wanderguard on the left ankle. Interview on 7/1/13 at 4:35 P.M. with direct care staff P stated the resident wore a wanderguard bracelet and she/he was not sure who and how often staff checked the wanderguards. Interview on 7/1/13 at 4:40 P.M. with licensed nursing staff H stated the resident wore a wanderguard on her/his ankle and was not sure who check the wanderguard for placement/function. She/he was not aware of the elopement assessments. Interview on 7/2/13 at 8:05 A.M. with administrative staff B stated the office secretary checked the function of the residents' wanderguards on the weekdays and nursing staff checked the wanderguards on weekends. The nursing staff checked the wanderguards Monday through Sunday starting at the end of May 2013 as the office secretary was no longer employed at the facility. Interview on 7/2/13 at 9:05 A.M. with administrative nursing staff D and licensed nursing staff I stated that until the end of May 2013 the office secretary checked the functional status of residents' wanderguards on the weekdays and nursing staff checked them on the weekends. Since the end of May the nursing staff now checked residents' wanderguards Monday to Sunday. Interview on 7/2/13 at 9:10 A.M. with administrative nursing staff D stated she/he could not find the last three months of wanderguard checks for the east side hallway. She/he assumed nursing staff did not check the resident's wanderguard during those past three months for placement and function. The CNA preformed 30 minute resident checks on all residents in the facility. Interview on 7/2/13 at 12:11 A.M. with administrative nursing staff D stated the charge nurse checked the wanderguards and completed elopement assessments and she/he was not sure why the resident's Elopement Assessment was not completed. She/he said residents who were mobile and confused received wanderguards and nursing staff should complete elopement assessments within 24 hours of admission, and check wanderguards every (Q) shift. The undated policy and procedure titled Resident Monitoring Procedure revealed nursing staff were responsible for implementation and maintenance of resident monitoring devices. Staff would complete a Risk to Wander assessment on all residents at the time of move-in, annually, and with any significant change. If a resident was determined to be at risk to wander and/or if a new resident was independently mobile, whether by walking or in a wheelchair, there would be a resident monitoring device placed on the resident's ankle or wrist. The undated policy and procedure titled Elopement Policy revealed the following steps staff would implement for any resident whose assessment, upon move-in, or at any time during her/his length of stay indicated impaired decision making and/or impaired cognition, ability to be mobile by ambulating or by use of a wheelchair or other assistive device, and a history of wandering or elopement: staff would alert the care plan team and plan appropriately for the resident being at risk for elopement and for use of a Resident Monitoring System, staff would note the use of a Resident Monitoring System on the Medication Administration Record, Team Sheet, and Care Plan, and staff would complete a 30 minute location checks for all residents using a Resident Monitoring System. The facility failed to assess the resident ' s elopement risk status and failed to monitor the function of the wanderguard for this cognitively impaired independently mobile resident who was at risk for elopement. - Resident #1's physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 5/8/13 documented the resident with a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. She/he had no wandering behavior during look back period. The resident required limited assistance for transfers and ambulation in the room and the corridor. The activities of daily living Care Area assessment dated [DATE] documented the resident received restorative nursing and rode a stationary bike in the therapy room and participated in the walk to dine program. He/She could propel the wheelchair down the hallways independently. The resident needed limited assistance with transfers and bed mobility. The care plan dated 9/11/12 and reviewed 5/28/13 for elopement risk documented the resident wore a wanderguard (a bracelet for an exit alarm device). The care plan directed staff to check on the resident every 30 minutes, offer activities when he/she was restless, and check the wander guard for proper function per policy. The Risk of Elopement/Wandering Review assessment dated [DATE] revealed staff documented the resident had intermittent confusion, Schizophrenia (a major mental disorder) and ambulated independently. The assessment did not indicate if the resident was an elopement risk and the form was incomplete. Review of the April 2013, May 2013, and June 2013 Medication Administration (MAR) and Treatment Administration records (TAR) revealed staff did not document if the resident had a wanderguard or if staff checked the wanderguard function. Review of the clinical record on 7/1/13 lacked individual wander guard function and placement checks for April, May and June 2013. Review of the 30 minute checks for June 2013 revealed staff failed to document 30 minute checks on 6/1/13 and on 6/2/13 staff did not check the resident from 7:00 A.M. to 8:00 A.M. Staff did not document 30 minute checks from 11:00 A.M. to 2:30 P.M. On 6/5/13 staff did not document 30 minute checks from 12:30 A.M. to 6:30 A.M. The 6/6/13 30 minute checks lacked documented checks from 3:00 P.M. to 10:00 P.M. On 6/7/13 staff did not document 30 minute checks from 3:00 P.M. to 9:30 P.M. On 6/9/13, 6/10/13, 6/17/13, 6/18/13, 6/19/13, 6/20/13, and 6/27/13 staff did not document 30 minute checks. Observation on 7/1/13 at 4:13 P.M. revealed the resident sat in the wheelchair in front of the nursing station. The resident had a wanderguard on her/his left ankle. Interview on 7/1/13 at 4:13 P.M. the resident reported he/she had a bracelet on his/her left ankle. He/She reported staff did not check the wanderguard on his/her leg and that was ok because it did not hurt. He/She said staff gave him/her the bracelet because he/she tried to "escape" from the facility. Interview on 7/1/13 at 4:26 P.M. direct care staff O stated she/he had no knowledge the resident was at risk for wandering because the resident did not seek to exit and did not know the resident wore a wanderguard. If a resident did have a wanderguard she/he checked to make sure the bracelet was not digging into the residents ' skin. If the residents ' wanderguard was missing, then she/he would notify the nurse. Interview on 7/1/13 at 4:37 P.M. with licensed nursing staff H stated if a resident sought to seek an exit, she/he redirected them and offered food, drinks, and activities and take the resident outside on the locked patio. She/he was not aware of elopement risk assessments. She/he would chart the resident's wandering in the nurse's notes. She/he did not check the resident's wanderguard for functioning or for placement because she/he felt it was not warranted. The resident did not exhibit exit seeking behavior. If the resident tried to leave, then she/he would check to see if the wanderguard was on and chart in the nurse's notes. Interview on 7/2/13 at 8:05 A.M. with administrative staff B stated the office secretary checked the function of the residents' wanderguards on the weekdays and nursing staff checked the wanderguards on weekends. The nursing staff checked the wanderguards Monday through Sunday starting at the end of May 2013 as the office secretary was no longer employed at the facility. Interview on 7/2/13 at 9:05 A.M. with administrative nursing staff D and licensed nursing staff I stated that until the end of May 2013 the office secretary checked the functional status of residents' wanderguards on the weekdays and nursing staff checked them on the weekends. Since the end of May the nursing staff now checked residents' wanderguards Monday to Sunday. Interview on 7/2/13 at 9:10 A.M. with administrative nursing staff D stated she/he could not find the last three months of wanderguard checks for the east side hallway. She/he assumed nursing staff did not check the resident's wanderguard during those past three months for placement and function. The CNA preformed 30 minute resident checks on all residents in the facility. Interview on 7/2/13 at 12:11 A.M. with administrative nursing staff D stated the charge nurse checked the wanderguards and completed elopement assessments and she/he was not sure why the resident's Elopement Assessment was not completed. She/he said residents who were mobile and confused received wanderguards and nursing staff should complete elopement assessments within 24 hours of admission, and check wanderguards every (Q) shift. The undated policy and procedure titled Resident Monitoring Procedure revealed nursing staff were responsible for implementation and maintenance of resident monitoring devices. Staff would complete a Risk to Wander assessment on all residents at the time of move-in, annually, and with any significant change. If a resident was determined to be at risk to wander and/or if a new resident was independently mobile, whether by walking or in a wheelchair, there would be a resident monitoring device placed on the resident's ankle or wrist. The undated policy and procedure titled Elopement Policy revealed the following steps staff would implement for any resident whose assessment, upon move-in, or at any time during her/his length of stay indicated impaired decision making and/or impaired cognition, ability to be mobile by ambulating or by use of a wheelchair or other assistive device, and a history of wandering or elopement: staff would alert the care plan team and plan appropriately for the resident being at risk for elopement and for use of a Resident Monitoring System, staff would note the use of a Resident Monitoring System on the Medication Administration Record, Team Sheet, and Care Plan, and staff would complete a 30 minute location checks for all residents using a Resident Monitoring System. The facility failed to assess and monitor the wanderguard for this independently mobile resident at risk for elopement.

The facility had a census of 70 residents. The sample included 3 residents. Based upon observation, record review, and interviews the facility failed to provide supervision and effective interventions to prevent falls for 1 (#20) resident and failed to ensure 1 door was monitored to alert staff when residents entered and exited the facility. Findings included: - Resident #20's annual Minimum Data Set (MDS) 3.0 dated 7/3/13 identified the resident scored 12 (moderately impaired cognition) on the Brief Interview for Mental Status, did not exhibit behaviors, was independent with bed mobility, transfers, walking in the room/corridor, locomotion on the unit, required staff supervision with locomotion off the unit, dressing, eating, toilet use, and personal hygiene. The MDS coded the resident was steady at all times when moved from seated to standing position, walking, turning around, moving on/off the toilet, and surface to surface transfers. The MDS recorded the resident did not utilize mobility devices, was continent of bladder and bowel and had not fallen since the prior assessment/admission/reentry. The resident's Activities of Daily Living Care Area Assessment (CAA) Worksheet dated 7/17/13 included the resident ambulated independently. The resident's Urinary Incontinence CAA Worksheet dated 7/17/13 included the resident was at risk for falls and the facility would proceed to care plan the resident at risk for falls. The resident's care plan dated 4/23/13 revealed the facility implemented a fall care plan for the resident on 8/5/11. The care plan included the resident was at risk for falls related to medications, and [DIAGNOSES REDACTED]. A nurse's note dated 7/22/13 and timed 6:30 P.M. documented the resident was on the floor in the dining room bent over like he/she was attempting to rise from the floor and no injuries noted on the floor. The updated care plan listed the interventions included staff would keep the resident under direct supervision at all times. A nurse's note dated 7/23/13 and timed 8:25 A.M. included the facility transferred the resident to a local hospital regarding the resident's inability to ambulate. A nurse's note dated 7/25/13 and timed 2:30 P.M. documented the resident returned to the facility with [DIAGNOSES REDACTED]. A nurse's note dated 8/7/13 and timed 4:50 P.M. documented staff observed the resident on the floor, the resident laid on his/her right side, the resident had a skin tear on his/her right elbow approximately 0.7 centimeters (cm) by 0.7 cm, and an abrasion on his/her shoulder that measured approximately .1 cm in circumference. Interventions included staff ensured the resident wore proper footwear. A nurse's note dated 8/9/13 and timed 7:00 P.M. documented the resident continued to refuse to stand, and the resident used his/her legs to propel himself/herself in the wheelchair. A nurse's note dated 8/10/13 and timed 12:00 P.M. documented the resident complained of right hip and upper thigh pain, staff observed swelling in the resident's hip area and the resident yelled he/she was hurting. A nurse's note dated 8/10/13 and timed 1:00 P.M. documented staff obtained a physician's orders [REDACTED]. A nurse's note dated 8/10/13 and timed 7:00 P.M. documented the resident was admitted to a local hospital. A nurse's note dated 8/15/13 and timed 3:10 P.M. documented the resident returned to the facility with a [DIAGNOSES REDACTED]. A radiology report dated 8/10/13 documented the resident's right leg had a subcapital femoral neck fracture with varus angulation and lateral displacement of the distal fragment by greater than three-quarter bone (broken hip bone). A nurse's note dated 8/19/13 and timed 5:15 A.M. documented staff reported to a licensed nurse he/she needed help getting the resident off the floor, when staff went back to assist the resident, the resident was already in the wheelchair, and staff would perform neurological checks since the fall was unwitnessed. Interventions included staff placed a floor mat beside the resident's bed when the resident was in bed and staff maintained the resident's bed in the lowest position. Review of the facility's investigation documented on 7/22/13 and 8/7/13 the resident fell and on 8/10/13 the facility transferred the resident to a local hospital, and the resident had a displaced right femoral head fracture (broken hip bone). The investigation documented the resident's care plan included staff performed 30 minute checks and the resident was under direct supervision by staff at all times. On 9/3/13 at approximately 8:45 A.M. the resident sat in his/her wheelchair on the unit where he/she resided. On 9/3/13 at approximately 9:15 A.M. the resident sat in his/her wheelchair in the dining room. On 9/13/13 at 12:00 P.M. the resident exited his/her room and self propelled the wheelchair down the hall. Observation revealed a staff member in the hallway but did not provide 1 on 1 supervision for the resident. On 9/3/13 at 2:30 P.M. observation revealed the resident laid in bed, the bed in the lowest position and no fall mat on the floor. Observation also revealed no staff in the resident's room. On 9/3/13 at 2:35 P.M. direct care staff H entered the resident's room to perform the 30 minute check. Direct care staff H confirmed the fall mat was not on the floor beside the resident's bed. Observation revealed the fall mat in a curled position and located at the foot of the resident's bed. Direct care staff H removed the floor mat from the foot of the resident's bed and placed the fall mat beside the resident's bed. Direct care staff H stated the resident required staff assistance/supervision when getting in and out of bed. Direct care staff H stated another staff assisted the resident to bed and should have placed the fall mat on the floor beside the resident's bed. On 9/3/13 at approximately 2:15 P.M. licensed nurse D stated prior to the resident's hip fracture the resident ambulated independently and did not utilize a wheelchair. Licensed nurse D stated direct supervision meant staff provided 1 on 1 staff supervision (1 staff with the resident at all times). Licensed nurse D stated the resident did not received 1 on 1 staff supervision. On 9/3/13 at approximately 2:22 P.M. direct care staff I stated the resident required staff supervision when he/she ambulated, and the resident did not receive 1 on 1 staff supervision. On 9/3/13 at 2:31 P.M. direct care staff H stated direct supervision meant staff assisted the resident as needed and the resident did not receive 1 on 1 staff supervision. On 9/3/13 at approximately 2:40 P.M. licensed nurse E stated the resident required staff supervision with transfers including back and forth to bed, and staff placed a fall mat by the resident's bed when the resident was in bed. Licensed nurse E stated staff checked on the resident every 30 minutes and the resident did not receive 1 on 1 staff supervision. On 9/3/13 at 2:57 P.M. administrative nursing staff B confirmed the resident fell and sustained a hip fracture. Administrative nursing staff B stated the facility implemented the fall mat after the resident fell on [DATE] and staff should place the fall mat beside the resident's bed when the resident was in bed. Administrative nursing staff B stated the resident required staff assistance when transferring. Administrative nursing staff B stated direct supervision at all times meant staff provided 1 on 1 staff supervision at all times. Administrative nursing staff confirmed the resident's care plan included the facility provided direct supervision at all times and he/she confirmed the resident did not receive 1 on 1 staff supervision. The facility failed to provide direct supervision at all times as care planned and also failed to consistently place the fall mat beside the resident's bed when the resident was in bed for this cognitively impaired resident who fell and sustained a hip fracture. - On 9/3/13 during the initial tour of the facility from approximately 8:45 A.M. to 9:00 A.M. observation revealed the dining room had 2 exit doors. Further observation revealed a resident in a wheelchair half in and half out of the door asking for staff assistance to re-enter the building (through the right side of the door). Observation also revealed another resident in a wheelchair exited the right side of door and no alarm alerted staff the resident exited the building. Observation revealed the unarmed door led to a a patio and a courtyard. Observation revealed several residents sat on the patio and smoked and no staff were present. Observation revealed the left side of the door was locked, and a sign on the door that read for emergency, push until alarm sounded and the door could be opened in 15 seconds. Observation also revealed a key pad by the exit door. Observation revealed individuals entered and exited the exit door without a code. On 9/3/13 administrative staff C at approximately 9:45 A.M. confirmed the exit door was unarmed. Administrative staff C stated staff did not always accompany residents outside. Administrative staff C confirmed since the right side of the door was not alarmed, staff would not know when residents entered and/or exited the facility. Review of the facility's electronic monitoring system for Exit Doors dated 8/2013 included the electronic monitoring devices for exit door would not disabled unless approved by the facility administrator or designee. While the electronic monitoring system was disabled there would be staff present to monitor the door. The facility failed to ensure all exit doors were monitored.

The facility reported a census of 66 residents. The sample included 3 residents. Based on observation, record review, and staff interview the facility failed to adequately secure a resident in a whirlpool seat for 1 (#1) resident in the sample that fell and sustained multiple fractures. Findings included: - The physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) of 3/28/12 revealed a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired cognition); required extensive assistance in bathing by one person; was not steady, only able to stabilize with human assistance for moving from seated to standing position and surface to surface transfer; had impairment to the upper extremities; and no falls since admission or prior assessment. The Care Area Assessment (CAA) dated 7/21/11 for activity of daily living (ADL) functional/rehabilitation potential revealed the resident had left hand limitations and a right arm amputee; had a [DIAGNOSES REDACTED]. The CAA dated 7/21/11 for falls revealed a fall risk assessment of 16; had [DIAGNOSES REDACTED]. The revised care plan dated 1/17/12 for limited use of the left hand and right arm amputee with lower extremity weakness revealed the resident self propelled in a wheelchair; required the assistance of two staff with a gait belt for transfers; staff would assist the resident with baths at least two times a week; the resident did not like to be bathed, disliked the safety/gait belts, and would curse the staff; if necessary, one male and one female staff member would help with the bath; staff would wash the resident's skin gently due to the resident ' s complaints of her/his skin hurting when washed; and staff would provide a quiet, calm, gentle re-assurance, and reminder to the resident for safety reasons for use of the belts. The revised care plan dated 1/17/12 for falls revealed the resident required two staff members with all transfers; staff would make sure the resident's shoes had non-skid surface on the bottom of her/his shoes; staff would ensure the resident was safely positioned in her/his wheelchair; and staff would use a gait belt for all transfers. The Fall Risk assessment dated [DATE] revealed a score of 18 which 9 plus and up placed the resident at a high risk for falls. The Nursing Notes dated 4/7/12 at 10:45 A.M. revealed a certified nursing aide (CNA) called the nurse into the shower room and the resident was on the floor; the resident had a laceration to the forehead and nose, bruising to the right stump, and scrapes to each knee bilaterally; the left leg was at a 90 degree angle, had mottling from the left knee to the left hip area; dorsal, posterior, and popliteal pulses were palpable; was alert and oriented; staff used 4 by 4s for the blood on the resident's forehead; the CNA reported the resident had leaned forward and began to slip and she/he finished up with the resident; and the CNA tried to stop and hold the resident but the belt loosened and the resident slipped out of the chair on to the floor. At 11:30 A.M. revealed orders were received to transfer the resident to emergency room (ER) by ambulance. At 5:45 P.M. staff received a report from the ambulance staff, the resident had a fractured left hip and sutures to the forehead; the resident's lungs sounds were clear, had palpable dorsal and pedal pulses, was alert and oriented times three, and had dried reddish drainage to the facial area; had tolerated water well, refused supper, and no emesis was noted; and neurological checks revealed pupils were reactive at 2-3 millimeters (mm). At 6:00 P.M. hospice was in to evaluate the resident. The ER Summary dated 4/7/12 revealed [DIAGNOSES REDACTED]. The x-ray dated 4/7/12 for a left hip anterial/posterial (AP) and lateral revealed a transcervical fracture of the left hip. The femoral shaft fragment was subluxed superiorly by several centimeters. The femoral head remained within the acetabulum. The final x-ray impression was a transcervical fracture of the left hip. The computerized tomography (CT) maxillo-facial without contrast dated 4/7/12 revealed an old nasal fracture and a new acute fracture line at the far posterior aspect of the nasal bone which was not displaced. Staff interview on 5/1/12 at 3:11 P.M. with Direct Care Staff Q stated she/he worked nights and the CNA who regularly gave the resident her/his bath was not there and she/he gave the bath to the resident; was taught to use the abdominal strap when using the whirlpool chair and after the inservice two weeks ago know to use the center and abdominal strap with the whirlpool chair. The undated policy and procedure, at the time of the fall, titled Whirlpool Baths revealed staff would position the resident in the whirlpool chair and fasten the seat belt. The revised policy and procedure dated 4/9/12, revised after the incident occurred, titled Securing Resident with Seat Belts during Whirlpool Bathing revealed to assure all residents receiving a whirlpool bath were safe and/or remain safe by preventing falls or injuries while in the whirlpool staff would transfer resident into the whirlpools chair using proper transfer technique; run the seat belt around the resident, through the center strap, and around the resident to the d-ring connector. The plan documented the in-service training for all staff occurred 4/9/12 through 4/12/12. Observation on 5/1/12 at 10:00 A.M. of resident #2 revealed Direct Care Staff O dried and dressed the resident while she/he sat on the whirlpool bath seat which was elevated in the air about tub rim level; the waist strap was in place, and the center strap hung down under the front of the seat and was not in use. Staff interview on 5/1/12 at 10:10 A.M. with Direct Care Staff O stated the center strap was used for those resident who slouched or slide forward but all residents could use it; not all residents want to use the center strap because they want to be able to clean their bottoms; the west hall residents do not use the center strap because they can sit up without problems; she/he worked at the facility for [AGE] years and did not have any resident fall out of the whirlpool chair; and received education/training on the whirlpool but unsure of the date. Resident #2 interviewed on 5/1/12 at 1:36 P.M. stated she/he never used the center strap and was unaware there was a center strap; had only used the strap that went around her/his waist. Staff interview on 5/1/12 at 1:49 P.M. with Licensed Nursing Staff H stated the certified nursing aides (CNA's) were to use the abdominal and center straps when residents were placed in a whirlpool tub. The CNA staff would now receive training on the tub as new hires and then yearly with competency testing. Staff interview on 5/1/12 at 1:54 P.M. with Licensed Nursing Staff K stated sometimes the abdominal strap was used if a resident was stable and could sit and did not have problems with leaning; if a resident leaned or had problems with sliding forward the center strap would also be used; the policy and procedure stated the same as to when the center strap was used; and staff recently received training on the whirlpool tub and received training when they were hired. The resident was known to be feisty and very aggressive with what and how things were to be done; to her/his knowledge the resident had complained of the chair strap being too tight and wanted it loosened; and the CNA involved knew how to use the whirlpool bath. Staff interview on 5/1/12 at 2:55 P.M. with Administrative Nursing Staff D stated staff should place the abdominal and center strap on the resident for safety when using the whirlpool. Staff interview on 5/1/12 at 3:00 P.M. with Administrative staff A stated the policy and procedure for whirlpool tub use was updated and a staff inservice was performed on how to use the whirlpool tub and the proper way to strap residents in for safe transfer in and out of the whirlpool tub. Staff interview on 5/1/12 at 3:18 P.M. with Direct Care Staff R stated residents who used the whirlpool tub, the abdominal and center straps were used and if the resident was to lean forward the chest strap was used; and staff recently were inserviced on how to use the whirlpool. Staff interview on 5/1/12 at 3:40 P.M. with Direct Care Staff P stated every resident who received a whirlpool bath would be secured in the bath chair by using the abdominal and center straps. Staff interview on 5/1/12 at 4:30 P.M. with Licensed Care Staff I stated nursing staff were to use both the abdominal and center strap at all times when a resident used the whirlpool bath; and was not sure how often staff were inserviced on the whirlpool tub but there was an inservice recently. Staff interview on 5/1/12 at 4:40 P.M. with Licensed Care Staff J stated staff were to use the center and abdominal straps when placing a resident in and out of the whirlpool tub; and an inservice was held recently on the use of the whirlpool bath. The facility failed to secure the resident on the whirlpool chair and this dependent resident fell and received multiple fractures. The facility failed to follow their revised policy for the use of the whirlpool chair.