Every finding on record at Life Care Center of Andover

Based on observation, interview, and record review the facility failed to ensure a safe environment free from accidents for Resident (R)1. On 03/28/26, Certified Nurse Aide (CNA) N and CNA M attempted to transfer R1 from his electric scooter to his bed using a full-body mechanical lift. R1's scooter became tangled with the lift, so CNA N turned her back to R1 to move the scooter. During this time, without the hands-on assistance of CNA N, CNA M moved the lift, and R1, who was approximately four feet in the air, began to sway. One of the sling loops came unhooked and R1 fell to the floor. As a result, R1 sustained head injuries, including a concussion (damage to the brain caused by violent jarring or shaking, such as a blow), a frontal skull fracture (a break in the bone forming the forehead), and subarachnoid hemorrhage (bleeding in the space just outside the brain). This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Annual Minimum Data Set (MDS) dated 03/31/26 documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had impairment on both sides of his lower extremities, he used a wheelchair, and was completely dependent on staff for toileting, showering, dressing, and transfers. The Functional Ability Care Area Assessment (CAA), dated 03/25/26, documented R1 had risks for falls, continued decline in activity of daily living (ADLs), skin breakdown, and pain. The CAA documented R1's plan of care would include a decrease in fall risk. The Fall CAA, dated 03/25/26, documented R1's Care Plan would reflect his current physical function related to ADL, strength and endurance, mobility, decrease in fall risk, and minimize injuries related to falls. R1's Care Plan, initiated 04/13/23, documented R1 required a mechanical Hoyer (total body mechanical lift) with two staff members for assistance during transfer, using the small red sling. The plan directed staff to assist R1 with his ADLs, keep R1's call light within reach, and complete a fall risk assessment. The Fall Risk Assessment, dated 03/28/26, documented R1 had a fall risk score of 16, which indicated R1 was a high fall risk. The Nurse's Note, dated 03/28/26, documented at 12:40 AM, staff summoned Licensed Nurse (LN) G to R1's room. Upon LN G's arrival at R1's room, R1 laid in a supine position between the Hoyer lift's legs with his head facing the door. CNA M and CNA N were present in the room and reported they attempted to transfer R1 from his electric wheelchair to bed. When CNA M and CNA N pushed the Hoyer lift forward towards the bed, the lift got stuck on the carpet. R1 swung side to side, and one strap of the sling came loose, which prompted the fall. R1 sustained a visible laceration (cut) to the left side of his head, R1 voiced neck pain, and staff assessed R1 and noted confusion. At 12:50 AM, the on-call provider ordered staff to transport R1 to the emergency room by the emergency medical personnel. At 12:57 AM, Emergency Medical Services (EMS) arrived at the facility and transferred R1 to the hospital. The emergency room Report, dated 03/28/26, documented R1, who had a history of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), was dropped from a mechanical lift and sustained a concussion, an abrasion, a frontal skull fracture, and a subarachnoid hemorrhage. R1 would be admitted to the Intensive Care Unit (ICU) for observation, a repeat computed tomography (CT scan- a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) to be completed later that day, and neurosurgery (a medical field focused on the surgical and nonsurgical treatment of disorders affecting the nervous system) to consult. R1 would be placed on Keppra (seizure medication) for seizure (violent involuntary series of contractions of a group of muscles) prophylaxis (preventative in nature). The Facility Incident Report, dated 04/03/26, documented CNA M and CNA N assisted with a transfer via a mechanical lift on 03/28/26 when R1 slipped out of the sling onto the floor. Staff reported they attempted to transfer R1 from the electric wheelchair to the bed. Based on the investigation, it was found that the leg of the lift became entangled in the electric wheelchair. It was believed that the loops of the lift sling became dislodged, which caused R1 to fall forward. It was reported that the cause of the sling loop coming dislodged was caused by R1 swinging in the sling side to side. Upon further investigation, this scenario was implausible. It is believed, based on the return demonstration, that the loop of the lift sling was not loaded properly. When the lift went into forward motion, this caused the loop of the sling to become dislodged. CNA M's unnotarized Witness Statement, dated 03/28/26, documented at around midnight on 03/28/26, CNA N and CNA M went to transfer R1 from the chair to the bed. CNA M and CNA N got R1 secured on the Hoyer, made sure all four straps were in place, and also crisscrossed at the crotch area. CNA M went to lift R1 into the air and after CNA M got R1 lifted high enough into the air, CNA N went to remove R1's electric wheelchair. When CNA N attempted to move the chair out of the way, CNA M noted the chair got stuck on the leg of the Hoyer. CNA M moved the Hoyer back just a little bit so the chair would maneuver out of the way. The Hoyer seemed to get stuck on the carpet, and the motion caused R1 to swing, which caused the straps that were crisscrossed to come loose from the Hoyer. R1 fell headfirst to the floor. CNA N's unnotarized Witness Statement, dated 03/28/26, documented around 12:40 AM, CNA N and CNA M were putting R1 in bed. CNA N and CNA M got him on the Hoyer lift. CNA N tried to get the electric chair out of the way, and it got stuck. CNA N moved the electric chair back and heard a big bang on the floor. CNA N looked, and there was R1 beside her on the floor. CNA N stated she did not know how R1 ended up on the floor. On 05/14/26 at 10:30 AM, observation revealed R1 lay in bed with the television on. R1's arms were contracted to his chest due to cerebral palsy. R1's eyes wandered around the room as if he could not keep his eyes focused on one point of origin. On 05/14/26 at 10:30 AM, R1 stated he had a lot of pain due to the fall. R1 stated he could not remember much of what happened after he fell. He remembered one of the CNAs saying, Something's not right before the transfer. R1 stated he remained scared to be transferred with a Hoyer lift now and said he wanted three to four staff to be in the room for every transfer. R1 stated he feels a sense of falling every time they get him up in the lift. R1 stated that at the end of the month, he was moving to another facility because the CNAs had let him fall. On 05/14/26 at 11:00 AM, CNA N stated R1's electric scooter got stuck, so she turned her back on R1 and CNA M to try to get the scooter to move out of the way. CNA M jerked the Hoyer lift away from the scooter, and CNA N heard a big bang on the floor and looked and saw R1 on the floor. CNA N stated she thought she had checked the straps on the lift sling, but she could not be sure. On 05/14/26 at 11:30 AM, CNA M stated she and CNA N got R1 up into the lift sling with the Hoyer lift to move him from his electric scooter to his bed. CNA M stated R1's electric scooter got tangled up in the Hoyer lift legs, and she pulled the Hoyer lift away from the scooter. R1 started to sway in the sling and then fell forward headfirst. CNA N ran and got the nurse. CNA M stated she had raised R1 approximately four feet in the air, and that was the height he fell from. CNA M stated they had used the sling that was in the room, which staff had used previously, and were not sure if it was the right sling or not. CNA M stated she was pretty sure she had checked the sling loops to make sure they were secured. On 05/14/26 at 10:00 AM, Administrative Nurse D stated the CNAs did not follow the facility protocol when they transferred R1. Administrative Nurse D stated both CNAs had been educated on the correct protocol for mechanical lift transfers prior to the accident. Administrative Nurse D stated the CNAs had been terminated for not following the facility's transfer policy. The facility's Limited Lift Program (Safe Patient Handling) Policy, revised 02/20/24, documented that the facility will assess residents for the need for assistance with transfer activities, mobility, or repositioning using a validated mobility assessment by nursing or therapy. Associates will be responsible for utilizing mechanical lifting devices, transferring devices, and proper body mechanics to lift, transfer, and/or pivot non-ambulatory patients as indicated. The facility must ensure the resident environments remain as free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents. On 05/14/26 at 01:04 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was notified that the facility's failure to ensure R1 remained free from accidents placed R1 in IJ. The facility completed corrective actions by 04/01/26, prior to the onsite survey, which included: termination of CNA M and CNA N for improper lift protocol, staff education on the use of mechanical lifts, mechanical lift competency check-off for all CNAs, including return demonstration, and inspection of all lifts and slings for safety. The above corrective actions were verified as completed by the onsite surveyor, therefore the deficient practice was deemed past noncompliance and remained at the scope and severity of J (isolated, immediate jeopardy).

The facility reported a census of 97 residents. The sample included eight residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from staff-to-resident abuse. On 09/17/25, R1, a severely cognitively impaired resident with a history of behaviors and traumatic brain injury (TBI-an injury to the brain caused by external forces), demonstrated escalating combative and aggressive behaviors. At approximately 08:30 PM, Licensed Nurse (LN) G intervened in R1's behavioral event, and as a result, R1 grabbed LN G's genitals and called LN G obscene names. LN G yelled at R1, grabbed his arm, and stated he would beat the resident up, then lock the resident in his room. LN G reported he employed a restraint technique that involved grabbing R1 around the neck to prevent further aggressive behaviors. Certified Nurse Aide (CNA) M witnessed this staff to resident abuse but did not report the event to administrative staff until the following day, 09/18/25, when she came in for her evening (02:00-10:00 PM) shift. The facility's failure to prevent LN G from ongoing and unrestricted access to Rl and all residents on the locked memory care unit after LN G abused Rl placed Rl and all residents on the locked unit in immediate jeopardy. (See F600)Findings Included:- R1's Electronic Medical Record (EMR) revealed diagnoses of traumatic brain injury, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R1's 02/05/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R1's MDS documented that he had minimal depression and disorganized thinking or was incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) continually. The MDS documented R1 had behaviors during the lookback period, including yelling, cussing, and hitting staff. The MDS documented R1 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antianxiety (a class of medications that calm and relax people) medications.R1's 02/07/25 Behavioral Symptoms Care Area Assessment (CAA) triggered due to physical and verbal abusive behavior towards staff and other residents. R1 was resistant to care, wandered, yelled out, and cursed. The CAA noted risk factors included injuring oneself or others, decreased socialization, social isolation, and increased anxiety. R1's would be care planned for interventions to monitor behavior patterns, decrease agitation, and monitor the effectiveness of psychotropic (alters mood or thoughts) medications and any adverse effects of medications.R1's 08/08/25 Quarterly MDS documented a BIMS score of five, which indicated severely impaired cognition. The MDS recorded R1 had no depression, and R1 had verbal behavioral symptoms directed towards others, including threatening others, screaming at others, and cursing at others. The MDS recorded R1 rejected care during the lookback period. The MDS documented R1 received antipsychotic and anticonvulsant (a class of medication that controls or prevents seizures by stabilizing abnormal electrical activity in the brain) medications.R1's Care Plan dated 02//25/25 instructed staff when R1 became agitated, staff should intervene before the agitation escalated; staff should guide R1 away from the source of/ distress and engage calmly in conversation. If R1's response is aggressive, staff are to walk calmly away and approach later. R1's Care Plan documented staff instructed R1 would use profanity frequently with the staff and directed staff to reapproach and encourage the use of appropriate language.R1's EMR recorded an order for Physician Order Behavior Monitoring documented staff monitored the resident for behaviors including agitation, aggressive, refusal of cares, combativeness, accusatory behaviors, gets hyper-stimulated easily and use of profanity at others Intervention Codes: (1) redirect, (2) 1 on 1, (3) refer to nurse notes, (4) activity, (5) return to room, (6) toilet, (7) give food, (8) give fluids, (9) change position, (10) adjust room temperature, (11) back-rub, and (12) others chart to prog notes. Date ordered 05/06/25.R1's Progress Note on 09/17/25 at 09:20 PM documented that at 08:00 PM, R1 lunged toward LN G and R1 attempted to punch the painting in the hallway. CNA M assisted R1 to his room and remained with R1 as a one-on-one for the remainder of the shift. At 08:30 PM, R1 exited his room and spat on the staff. LN G assisted R1 to his room and offered R1 several things, one of which was not coffee since the supply was not refilled. R1 threw the snacks offered back at the staff. R1 broke the outside door handle to his room and shut his room door, which caused R1 to be locked inside his room for about one hour until it was fixed. Staff advised R1 that to be able to come out of his room, he would need to wear a diaper or shorts to have his genitals covered.R1's Progress Note on 09/18/25 at 04:45 AM documented R1 stated that he wanted out of the building and started to throw chairs against the doors of residents and the entrance and exit of the building. LN G asked R1 why he was doing this, and R1 stated that he wanted to leave, and no one would let him out. R1 wrecked the furniture in the dayroom. LN G requested R1 to refrain from trying to wake everyone up and to quit damaging the chairs. LN G advised R1 that there would be coffee coming with his breakfast, and that it was not too long away. R1 continued to throw wheelchairs. CNA M's Witness Statement dated 09/17/25 documented R1 started to have extreme behaviors, which included running around the unit, cursing, and throwing cups. CNA M noted that she tried to keep R1 away from LN G and the other residents, but R1 grabbed LN G's genitals and LN G then grabbed R1 by his arm, pushed him away, and stated that if he could, he would lock R1 in a room and beat the living [expletive] out of R1. LN G's Witness Statement dated 09/17/25 documented on that date, R1 was yelling obscenities and slapping a picture frame with his hand, so LN G yelled at R1 to stop. R1 continued to slap the picture and make noise, so LN G walked over to the area, and R1 stopped. LN G noted that when he returned to the medication cart, R1 started hitting the picture with a closed fist, so LN G ran over to stop the resident. R1 began calling LN G obscenities, and LN G documented that he told R1 to stop and noted I grabbed him around the neck, without applying any pressure to his trachea, using a MAST [sic] maneuver that I learned as a last resort to keep him from doing this.The facility's 09/18/25 Investigation 2621768 documented after the incident, LN G asked CNA M to take R1 to his room and stay with him until the completion of her shift. The investigation noted CNA M did not notify anyone of this incident at the completion of her shift. The investigation documented the incident was reported to Administrative Nurse F on 09/18/25 when CNA M worked her afternoon shift (02:00 PM to 10:00 PM). The investigation noted LN G gave a statement which also included that he told (facility) management in an interview that this actions towards R1 were a scare tactic and said he did not mean to harm the resident in any way. LN G confirmed that he visited with R1 throughout the night that night and asked R1 if they could quit doing those actions in the hall and come to a truce and R1 agreed. The facility placed LN G on suspension on 09/18/25 and terminated his employment on 09/26/25.During an observation on 10/06/25 at 10:15 AM, R1 was in the dining room with his breakfast tray in front of him. A female resident sat at the same table to R1's left side. R1 hit his cup of coffee with his left hand backwards, and the coffee went on that female resident and to the floor. Staff intervened immediately.During an interview on 10/06/25 at 10:40 AM, Administrative Nurse D stated she expected staff to report any type of abuse alleged or witnessed immediately to the administrative staff.During an interview on 10/06/25 at 02:40 PM, Administrative Staff A reported that LN G did not have formal dementia training since being hired on 12/30/24. Additionally, Administrative Staff A reported the facility would use Hand in Hand (a training series for nursing homes, on person-centered care of persons with dementia and prevention of abuse) but said LN G did attend a monthly staff meeting via Zoom on 09/10/25 that reviewed working with dementia and behaviors- behavioral management and documentation, along with several other topics. Administrative Staff A verified LN G completed his whole shift the evening on 09/17/25 through 09/18/25 including continuing to provide care to R1.The facility's policy Abuse-Protection of Residents dated 05/06/25 documented the following methods to ensure the protection of residents during an investigation may include but are not limited to; Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Immediate notification of the alleged victim's practitioner and the family or responsible party; Removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents.On 10/06/25 at 03:50 PM, Administrative Staff A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that the facility failed to prevent LN G from ongoing and unrestricted access to residents on the locked memory care unit after LN G abused Rl placed the residents on the locked unit in immediate jeopardy. The facility completed corrective actions on 09/19/25, which included the following:1. The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher. All residents with an assessed BIMS score of 12 or higher were interviewed to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews. No findings were noted.2. The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review on 09/18/25.3. The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated on 09/18/25.4. The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation of 09/18/25. Nursing Staff employees would have education provided prior to their next scheduled shift.5. The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT) on 09/19/25, including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manger, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.6. The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.7. The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.On 10/06/25 at 02:00 PM, the surveyor verified implementation of the above corrective actions. The scope and severity remained at a K.

The facility reported a census of 97 residents. The sample included eight residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from staff-to-resident abuse. On 09/17/25, R1, a severely cognitively impaired resident with a history of behaviors and traumatic brain injury (TBI-an injury to the brain caused by external forces), demonstrated escalating combative and aggressive behaviors. At approximately 08:30 PM, Licensed Nurse (LN) G intervened in R1's behavioral event, and as a result, R1 grabbed LN G's genitals and called LN G obscene names. LN G yelled at R1, grabbed his arm, and stated he would beat the resident up, then lock the resident in his room. LN G reported he employed a restraint technique that involved grabbing R1 around the neck to prevent further aggressive behaviors. Certified Nurse Aide (CNA) M witnessed this staff to resident abuse but did not report the event to administrative staff until the following day, 09/18/25, when she came in for her evening (02:00-10:00 PM) shift. The facility's failure to ensure residents remained free from physical and verbal abuse placed R1 in immediate jeopardy. Findings Included:- R1's Electronic Medical Record (EMR) revealed diagnoses of traumatic brain injury, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R1's 02/05/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R1's MDS documented he had minimal depression and disorganized thinking or was incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), continually. The MDS documented R1 had behaviors during the lookback period, including yelling, cussing, and hitting staff. The MDS documented R1 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antianxiety (a class of medications that calm and relax people) medications.R1's 02/07/25 Behavioral Symptoms Care Area Assessment (CAA) triggered due to physical and verbal abusive behavior towards staff and other residents. R1 was resistant to care, wandered, yelled out, and cursed. The CAA noted risk factors, which included injuring oneself or others, decreased socialization, social isolation, and increased anxiety. R1's would be care planned for interventions to monitor behavior patterns, decrease agitation, and monitor the effectiveness of psychotropic (alters mood or thoughts) medications and any adverse effects of medications.R1's 08/08/25 Quarterly MDS documented a BIMS score of five, which indicated severely impaired cognition. R1 had no depression, and had verbal behavioral symptoms directed towards others, including threatening others, screaming at others, and cursing at others. R1 rejected care during the lookback period. The MDS documented R1 received antipsychotic and anticonvulsant (a class of medication that controls or prevents seizures by stabilizing abnormal electrical activity in the brain) medications.R1's Care Plan dated 02//25/25 instructed staff when R1 became agitated, staff should intervene before the agitation escalated; staff should guide R1 away from the source of/ distress and engage calmly in conversation. If R1's response was aggressive, staff were to walk calmly away and approach later. R1's Care Plan documented staff were instructed to know R1 would use profanity frequently with the staff and directed staff to reapproach and encourage the use of appropriate language.R1's EMR recorded an order for Physician Order Behavior Monitoring documented staff monitored the resident for behaviors including agitation, aggressive, refusal of cares, combativeness, accusatory behaviors, gets hyper-stimulated easily and use of profanity at others Intervention Codes: (1) redirect, (2) 1 on 1, (3) refer to nurse notes, (4) activity, (5) return to room, (6) toilet, (7) give food, (8) give fluids, (9) change position, (10) adjust room temperature, (11) back-rub, and (12) others chart to prog notes. Date ordered 05/06/25.R1's Progress Note on 09/17/25 at 09:20 PM documented at 08:00 PM, R1 lunged toward LN G and R1 attempted to punch the painting in the hallway. CNA M assisted R1 to his room and remained with R1 as a one-on-one for the remainder of the shift. At 08:30 PM, R1 exited his room and spat on the staff. LN G assisted R1 to his room, offered R1 several things, and R1 threw the snacks offered back at the staff. R1 broke the outside door handle to his room and shut his room door, which caused R1 to be locked inside his room for about one hour until it was fixed. Staff advised R1 that to be able to come out of his room, he would need to wear a brief or shorts to have his genitals covered.R1's Progress Note on 09/18/25 at 04:45 AM documented R1 stated he wanted out of the building and started to throw chairs against the doors of resident rooms and the entrance and exit of the building. LN G asked R1 why he was doing this, and R1 stated that he wanted to leave, and no one would let him out. R1 wrecked the furniture in the dayroom. LN G requested R1 to refrain from trying to wake everyone up and to quit damaging the chairs. LN G advised R1 that there would be coffee coming with his breakfast, and that it was not too long away. R1 continued to throw wheelchairs. CNA M's Witness Statement dated 09/17/25 documented R1 started to have extreme behaviors, which included running around the unit, cursing, and throwing cups. CNA M noted that she tried to keep R1 away from LN G and the other residents, but R1 grabbed LN G's genitals and LN G then grabbed R1 by his arm, pushed him away, and stated that if he could, he would lock R1 in a room and beat the living [expletive] out of R1. LN G's Witness Statement dated 09/17/25 documented on that date, R1 yelled obscenities and slapped a picture frame with his hand, so LN G yelled at R1 to stop. R1 continued to slap the picture and make noise, so LN G walked over to the area, and R1 stopped. LN G noted when he returned to the medication cart, R1 started hitting a picture with a closed fist, so LN G ran over to stop the resident. R1 began calling LN G obscenities, and LN G documented that he told R1 to stop and noted I grabbed him around the neck, without applying any pressure to his trachea, using a MAST [sic] maneuver that I learned as a last resort to keep him from doing this.The facility's 09/18/25 Investigation 2621768 documented after the incident, LN G asked CNA M to take R1 to his room and stay with him until the completion of her shift. The investigation noted CNA M did not notify anyone of this incident at the completion of her shift. The investigation documented the incident was reported to Administrative Nurse F on 09/18/25 when CNA M worked her afternoon shift (02:00 PM to 10:00 PM). The facility placed LN G on suspension on 09/18/25 and terminated his employment on 09/26/25.During an observation on 10/06/25 at 10:15 AM, R1 sat in the dining room with his breakfast tray in front of him. A female resident sat at the same table to R1's left side. R1 hit his cup of coffee with his left hand backwards, and the coffee went on that female resident and on to the floor. Staff intervened immediately.During an interview on 10/06/25 at 09:05 AM, LN H reported he received Abuse Neglect and Exploitation (ANE) training the previous week. LN H reported staff had to redirect and reapproach R1 quite often due to his behaviors.During an interview on 10/06/25 at 09:08 AM, Certified Medication Aide (CMA) R reported she had just completed ANE training the previous week. CMA R reported R1 required a lot of redirection due to his behavior.During an interview on 10/06/25 at 10:40 AM, Administrative Nurse D stated she expected staff to report any type of abuse alleged or witnessed immediately to the administrative staff.During an interview on 10/06/25 at 02:40 PM, Administrative Staff A reported LN G did not have formal dementia training since being hired on 12/30/24. Additionally, Administrative Staff A reported the facility would use Hand in Hand (a training series for nursing homes, on person-centered care of persons with dementia and prevention of abuse) but said LN G did attend a monthly staff meeting via Zoom on 09/10/25 that reviewed working with dementia and behaviors- behavioral management and documentation, along with several other topics.The facility's policy Abuse Prevention dated 05/06/25 documented that the residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Identify, correct, and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, including trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residents' needs, care needs and behavioral symptoms, if any.On 10/06/25 at 03:50 PM, Administrative Staff A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that the facility failed to ensure residents remained free from staff-to-resident abuse, placing R1 in IJ.The facility completed corrective actions on 09/19/25, which included the following:1. The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher. All residents with an assessed BIMS score of 12 or higher were interviewed to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews. No findings were noted.2. The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review on 09/18/25.3. The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated on 09/18/25.4. The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation of 09/18/25. Nursing Staff employees would have education provided prior to their next scheduled shift.5. The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT) on 09/19/25, including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manger, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.6. The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.7. The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.On 10/06/25 at 02:00 PM, the surveyor verified implementation of the above corrective actions to address the staff-to-resident abuse. The scope and severity remained at a J.

The facility reported a census of 97 residents. The sample included eight residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from staff-to-resident abuse. On 09/17/25, R1, a severely cognitively impaired resident with a history of behaviors and traumatic brain injury (TBI-an injury to the brain caused by external forces), demonstrated escalating combative and aggressive behaviors. At approximately 08:30 PM, Licensed Nurse (LN) G intervened in R1's behavioral event, and as a result, R1 grabbed LN G's genitals and called LN G obscene names. LN G yelled at R1, grabbed his arm, and stated he would beat the resident up, then lock the resident in his room. LN G reported he employed a restraint technique that involved grabbing R1 around the neck to prevent further aggressive behaviors. Certified Nurse Aide (CNA) M witnessed this staff to resident abuse but did not report the event to administrative staff until the following day, 09/18/25, when she came in for her evening (02:00-10:00 PM) shift. The facility failure to report abuse immediately to the administrator placed Rl in immediate jeopardy. (See F600)Findings Included:- R1's Electronic Medical Record (EMR) a Progress Note on 09/17/25 at 09:20 PM documented at 08:00 PM, R1 lunged toward LN G and R1 attempted to punch the painting in the hallway. CNA M assisted R1 to his room and remained with R1 as a one-on-one for the remainder of the shift. At 08:30 PM, R1 exited his room and spat on the staff. LN G assisted R1 to his room, offered R1 several things, and R1 threw the snacks offered back at the staff. R1 broke the outside door handle to his room and shut his room door, which caused R1 to be locked inside his room for about one hour until it was fixed. Staff advised R1 that to be able to come out of his room, he would need to wear a brief or shorts to have his genitals covered.R1's Progress Note on 09/18/25 at 04:45 AM documented R1 stated he wanted out of the building and started to throw chairs against the doors of resident rooms and the entrance and exit of the building. LN G asked R1 why he was doing this, and R1 stated that he wanted to leave, and no one would let him out. R1 wrecked the furniture in the dayroom. LN G requested R1 to refrain from trying to wake everyone up and to quit damaging the chairs. LN G advised R1 that there would be coffee coming with his breakfast, and that it was not too long away. R1 continued to throw wheelchairs. CNA M's Witness Statement dated 09/17/25 documented R1 started to have extreme behaviors, which included running around the unit, cursing, and throwing cups. CNA M noted that she tried to keep R1 away from LN G and the other residents, but R1 grabbed LN G's genitals and LN G then grabbed R1 by his arm, pushed him away, and stated that if he could, he would lock R1 in a room and beat the living [expletive] out of R1. LN G's Witness Statement dated 09/17/25 documented on that date, R1 yelled obscenities and slapped a picture frame with his hand, so LN G yelled at R1 to stop. R1 continued to slap the picture and make noise, so LN G walked over to the area, and R1 stopped. LN G noted when he returned to the medication cart, R1 started hitting a picture with a closed fist, so LN G ran over to stop the resident. R1 began calling LN G obscenities, and LN G documented that he told R1 to stop and noted I grabbed him around the neck, without applying any pressure to his trachea, using a MAST [sic] maneuver that I learned as a last resort to keep him from doing this.The facility's 09/18/25 Investigation 2621768 documented after the incident, LN G asked CNA M to take R1 to his room and stay with him until the completion of her shift. The investigation noted CNA M did not notify anyone of this incident at the completion of her shift. The investigation documented the incident was reported to Administrative Nurse F on 09/18/25 when CNA M worked her afternoon shift (02:00 PM to 10:00 PM). The facility placed LN G on suspension on 09/18/25 and terminated his employment on 09/26/25.During an observation on 10/06/25 at 10:15 AM, R1 sat in the dining room with his breakfast tray in front of him. A female resident sat at the same table to R1's left side. R1 hit his cup of coffee with his left hand backwards, and the coffee went on that female resident and on to the floor. Staff intervened immediately.During an interview on 10/06/25 at 10:40 AM, Administrative Nurse D stated she expected staff to report any type of abuse alleged or witnessed immediately to the administrative staff.The facility's policy Abuse Prevention dated 05/06/25 documented all alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g., bruising and skin tears) will be immediately reported to theadministrator and/or director of nursing. All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All residents, families, resident representatives, and visitors are encouraged to immediately report incidents of suspected resident abuse and/or neglect to facility administration. When an incident of resident abuse is suspected, the incident must be reported to thesupervisor regardless of the time lapse since the incident occurred. The supervisor notifies the director of nursing and the executive director of the alleged incident.On 10/06/25 at 03:50 PM, Administrative Staff A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that the facility failed to ensure staff reported occurrences of abuse immediately to the Administrator placing R1 in IJ.The facility completed corrective actions on 09/19/25, which included the following:1. The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher. All residents with an assessed BIMS score of 12 or higher were interviewed to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews. No findings were noted.2. The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review on 09/18/25.3. The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated on 09/18/25.4. The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation of 09/18/25. Nursing Staff employees would have education provided prior to their next scheduled shift.5. The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT) on 09/19/25, including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manger, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.6. The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.7. The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.On 10/06/25 at 02:00 PM, the surveyor verified implementation of the above corrective actions. The scope and severity remained at a J.

The facility reported a census of 93 residents. The sample included three residents. Based on interview and record review the facility failed to assess for pain and take action to manage severe pain for Resident (R)1. Additionally, the facility failed to communicate R1's pain between her nurses, doctors, and other healthcare providers. As a result of the deficient practice, R1 had severe pain with ineffective pain relief for six days. This deficient practice also placed R1 at risk for discomfort and further decline in her overall well-being. Findings included: - R1's Electronic Health Record (EHR) included diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and chronic pain. R1's 11/02/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R1 was dependent on staff for all activities of daily living (ADL). The MDS documented R1 had impairment of both the upper and lower extremities on one side. The MDS documented R1 received routine medications and did not receive as needed pain medications or non-medicated pain interventions during the observation period. The MDS noted R1 did not report pain during the interview. The MDS documented R1 received opioid (a class of controlled drugs used to treat pain) medication during the observation period. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/08/24 documented R1 triggered due to orientation, memory, and recall deficits noted during the BIMS interview. The CAA noted R1's risk factors included self-care deficits, falls, and injuries. The CAA noted the care plan would reflect the resident's current cognitive status, ADL status, encourage active participation in facility functions, maintain communication, decrease fall and pressure ulcer risk, and maintain R1's dietary intake and hydration status. The Pain CAA did not trigger on the MDS. R1's 05/05/25 Quarterly MDS documented a BIMS score of zero, which indicated severely impaired cognition. The MDS documented R1 as dependent on staff for all activities of daily living (ADL). The MDS documented R1 had impairment of both the upper and lower extremities on one side. The MDS documented R1 received routine medications and as-needed pain medications: R1 did not receive non-medicated pain interventions during the observation period. The MDS documented R1 received opioid medication. R1's Care Plan dated 05/23/23 directed staff to evaluate the effectiveness of R1's pain interventions and administer pain medications as ordered. The plan dated 10/10/23 directed staff to provide non-pharmacological pain interventions including diversional activities, massage, quiet environment, and repositioning. The plan, dated 11/15/23, directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The plan directed staff to notify the physician if the interventions were unsuccessful or if R1's complaint was a significant change from the resident's past experience of pain. The plan directed staff to observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, and/or withdrawal or resistance to care. The plan directed staff to report to the nurse a loss of appetite, refusal to eat, and weight loss. R1's Physician Orders documented the following orders: Acetaminophen (over-the-counter pain medication) oral tablet 325 milligrams (mg), give two tablets by mouth at bedtime for back pain, dated 12/14/23. Acetaminophen oral tablet 325 mg, give two tablets by mouth every six hours as needed for pain, dated 12/14/23. Hydrocodone-acetaminophen (opioid medication use to treat severe pain) oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for pain, date ordered 01/15/24. Hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth two times a day for arthritis pain, date ordered 01/15/24. R1's Progress Note dated 04/30/25 at 12:47 PM documented R1 cried out in pain in the dining room. The note documented staff noted R1's left arm was behind her in a wheelchair and R1 hollered out loudly in pain when her arm was touched. The note documented R1 had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) on her left elbow. Staff notified R1's physician and received an order for an X-ray of R1's left humerus (upper arm bone) and left elbow immediately. The Progress Note dated 04/30/25 at 04:10 PM, documented the X-ray results were negative. The X-ray Reports dated 04/30/25 documented no fractures (broken bone) of the left elbow or left humerus. The Provider Progress Note dated 05/01/25 at 10:25 AM documented R1 hurt her left elbow after being repositioned in the wheelchair. The noted documented the X-rays showed no acute displaced fractures. The note recorded R1 had acetaminophen 325 mg two tablets by mouth every six hours for pain and R1 had left-side weakness and received supportive care. The Progress Note dated 05/05/25 at 03:05 PM documented R1 had a shower, and no new concerns were noted. The Progress Note dated 05/21/25 at 02:09 PM documented R1 received a shower that day and recorded R1 had yellow bruises on her chest area and the nurse was aware. The Orders Administration Note dated 05/23/25 at 04:14 PM, documented R1 exhibited uncontrolled crying and poor oral intake. The note lacked mention of any actions taken or follow-up assessment for ongoing pain. The Orders Administration Note dated 05/24/25 at 09:39 AM, documented R1 exhibited uncontrolled crying and poor oral intake. The note lacked mention of any actions taken or follow-up assessment for ongoing pain. The Orders Administration Note dated 05/25/25 at 11:33 AM, documented R1 received acetaminophen 325 mg, two tablets by mouth as needed for pain. The Orders Administration Note dated 05/25/25 at 12:29 PM, documented the as needed acetaminophen was ineffective. R1's record lacked evidence of further actions or pain management interventions implemented in response to the ineffective medication. The Orders Administration Note dated 05/26/25 at 08:08 AM, documented R1's scheduled (two times daily) hydrocodone-acetaminophen tablet 5-325 mg ran out. The pharmacy was unable to provide a code to remove the medication from the emergency kit due to the need for a new signed prescription from the physician. The note documented staff placed the request for a new prescription in the MD Book to notify the physician. The Orders Administration Note dated 05/26/25 at 06:24 PM, documented staff notified the provider via phone regarding R1's need for a new hydrocodone prescription. The note documented the facility received the medication and R1 would receive a scheduled dose that night. The Orders Administration Note dated 05/28/25 at 03:39 PM, documented R1 exhibited uncontrolled crying and poor oral intake. The note lacked mention of any actions taken or follow-up assessment for ongoing pain. The Order Note dated 05/29/25 at 10:0 AM, documented the provider was in the facility to see R1 and provided new orders. The note documented the orders discontinued the current acetaminophen order and started acetaminophen 325 mg two tablets by mouth twice a day scheduled, and as needed, every six hours for pain. R1's May 2025 Medication Administration Record (MAR) revealed the facility administered as needed acetaminophen 325 mg tablet two by mouth every six hours on 05/05/25 and was effective. The facility also administered as needed acetaminophen on 05/25/25 and noted it was ineffective. R1 received hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for pain, one time on 05/28/25, which staff documented as effective. The Progress Note dated 05/29/25 at 06:01 PM, documented the X-ray results showed an acute mildly displaced fracture of the surgical neck of the proximal (nearer to a point of reference or attachment) left humerus, new to the prior X-ray results. The Progress Note dated 05/29/25 documented R1's pain would be managed by as needed narcotics. The staff notified the provider of R1's excruciating pain on Friday (05/23/25) and staff monitored R1 and administered medications. The note documented staff received a new order that day to obtain X-rays of R1's left humerus and to send her to the hospital. R1's Hospital Report dated 05/29/25 at 10:47 PM, documented R1 had an acute comminuted (a fracture where the bone breaks into three or more pieces due to a sudden, traumatic injury) fracture of the left humerus neck. The Progress Note dated 05/30/25 at 09:22 AM, documented R1 returned from the hospital. R1 did not require surgery but R1 was to wear a sling on her left arm and follow up with an orthopedic physician (bone doctor) the following week. R1's May 2025 Treatment Administration Record (TAR) documented an order for a pain level every shift, day and night, using a 0-10 pain scale (zero indicating no pain and 10 the worst pain imaginable). Both day and night pain levels for 05/01/25 through 05/28/25 documented the resident had no pain. The night pain level for 05/28/25 and day pain level for 05/30//25 noted the resident was hospitalized . The night pain level for 05/30/25 noted the resident had no pain. The day pain level for 05/31/25 noted R1's pain was four and the night pain level for the same day recorded R1 had no pain. During an interview on 06/03/25 at 11:00 AM, Certified Medication Aide (CMA) R reported as needed medications would be given under the direction of a Licensed Nurse (LN). CMA R reported if a resident's pain medication was not effective the resident would be assessed by the LN and the LN would direct staff what needed to be provided to the resident. CMA R reported if the resident had another as needed medication that could be administered, the LN would give the direction to administer the medication. CMA R reported she could not say if R1 had pain issues as CMA R had not worked in R1's hallway. During an interview on 06/03/25 at 11:29 AM, Certified Nurse Aide (CNA) M reported R1 discharged that morning. CNA M reported R1 was very stiff to move, the left was R1's weak side, and she would stiffen up during showers and transfers. CNA M reported R1 would hold her left arm on her stomach during movements. CMA M reported R1 had pain, but once she received her medications, she was okay. CMA M reported she noticed R1 had an increase in pain in the past couple of weeks before the fracture was noted. CNA M reported R1 screamed out in pain quite loudly on her shower day, and CNA M reported that to the nurse. CNA M reported she always let a nurse know if a resident was in pain. During an interview on 06/03/25 at 12:25 PM, CNA N reported she was in the dining room when R1 hollered out in pain because R1's left arm was behind her. CNA N reported she gently moved R1's arm from behind the resident that day. During an interview on 06/03/25 at 05:00 PM, LN G reported she verbally told the provider on 05/23/25 about R1's excruciating pain when the provider was in the facility. LN G reported she forgot to document that in the EHR because she was quite busy. LN G reported she noticed R1 was not eating well and the resident did cry so that is why she documented the behavior notes for the dates 05/23/25, 05/24/25, and 05/28/25. LN G said she could not recall if she had finished the progress notes as she reported she was busy and sometimes she forgot. LN G reported R1's hydrocodone was discontinued and why she did not give the resident any as needed hydrocodone after she gave the ineffective acetaminophen on 05/25/25. LN G verified the acetaminophen was ineffective and said she must have forgotten to follow up on any documentation. LN G reported R1 received routine pain medication the morning of 05/23/25 therefore she felt it was too soon to give R1 more pain medication at 12:30 PM. LN G reported other nurses knew R1 had increased pain since 05/23/25 and said it would be documented in the Team Health Book at the nurse's station, since the provider was in the facility almost daily. During an interview on 06/03/25 at 11:38 AM, Administrative Nurse E reported R1 had pain when staff transferred her with the mechanical lift but once she was transferred, she was fine. Administrative Nurse E said R1's body would stiffen because she had contractures (abnormal fixation of muscles or joints). Administrative Nurse E reported she noted around the beginning of May, R1 complained of left arm pain and had some swelling. Administrative Nurse E said an X-ray was negative. Administrative Nurse E reported she was not R1's direct care nurse so she did not know if R1 had any other discomfort. Administrative Nurse E reported if a pain medication was not effective, the nurse would notify the provider with a phone call. During an interview on 06/03/25 at 04:09 PM, Administrative Nurse D was not sure if the fracture was related to the incident on 04/30/25 for R1 as she had an open investigation for the fracture. Administrative Nurse D reported she expected the nurse to call the physician if a pain intervention was ineffective, or if the resident was experiencing increased pain, the nurse should call the provider and document that in the EHR. Administrative Nurse D reviewed R1's documentation in EHR for the three behavior notes that LN G documented uncontrolled crying and poor oral intake and reported she expected the nurses to complete a progress note on what interventions were completed and if they were effective or ineffective and document what was done for the resident. Administrative Nurse D said she expected the nurses to complete that documentation. During an interview on 06/03/25 at 05:15 PM Administrative Nurse D sat at the nursing station in the 200 hallway and reviewed the Team Health Book. Administrative Nurse D verified the book lacked any documentation about R1's increased pain in the month of May until 05/26/25 which was regarding the prescription that was needed for R1's hydrocodone refill. Administrative Nurse D reported the provider was generally in the facility every day and would look at the book. She further stated the provider was currently on vacation so she could not contact him until next week but went on to say that when the provider assessed R1 on 05/29/25, he changed the medication orders for pain and ordered the X-ray. Administrative Nurse D reported that R1's pain not being addressed the week prior to the fracture was a concern. The facility's Pain Assessment and Management dated 04/22/25 documented the facility must ensure pain management to each resident who requires such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

The facility identified a census of 96 residents. The sample included 20 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed Certified Nurse Aide (CNA) O was employed with the facility for more than 12 months: CNA O hired on 06/13/23. CNA O had no yearly performance evaluation upon request. On 03/27/25 at 08:55 AM, Administrative Staff A stated the department directors were responsible to complete their staff yearly performance reviews. Administrative Staff A stated human resource department helps the department directors to track their yearly performance reviews and yearly required in-services. Administrative Staff A stated the facility was unable to locate the yearly performance review for CNA O's yearly performance review. The facility did not provide a policy related to yearly performance reviews for staff.

The facility identified a census of 96 residents with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to storage, preparation, and meal service. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns. Findings Included: - On 03/24/25 at 07:10 AM, an inspection of the facility's kitchen was completed with the following concerns identified: An inspection of the dry food storage area revealed 4 large plastic bins of Fruits Loops, Raisin Bran, Frosted Flakes, and Frosted Mini Wheat. The bins lacked dates opened for the cereal. An inspection of the food serving area revealed a mobile counter for plate storage. The plates were stored upward with no barrier to prevent contamination of the eating surfaces. On 03/24/25 at 07:30 AM, an inspection of the main dining room revealed trash and food debris under the ice machine and condiment counter. On 03/24/25 at 07:40 AM, an inspection of the 500 hall dining room revealed a bottle of drain cleaner in a cabinet underneath the sink. The product contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 03/27/25 at 08:01 AM Dietary Staff BB stated all food items were expected to be labeled and dated once stored in the kitchen. She stated plates and cooking utensils were to be stored downward to prevent contamination. She stated the kitchen recently started cleaning the dining areas due to confusion that facility staff were expected to clean it before. The facility's Food Safety policy revised 09/2022 indicated all facility staff were expected to follow safe and sanitary practices related to food storage, preparation, and service. The policy noted food will be handled and stored in a manner to prevent contamination. The policy noted the kitchen was to be maintained in a functioning and sanitary manner.

The facility identified a census of 96 residents. The sample included 20 residents, with four residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing to dependent Resident (R) 18, R15, R43, and R55 per their preferred preferences. Findings included: - R18's Electronic Medical Record (EMR) documented diagnoses of pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the buttock, Guillan-Barre syndrome (a disorder in which the body's immune system attacks the nerves), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). R18's Admission Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R18 had functional limitation in range of motion with impairment on one side of her upper extremity. R18 used a walker and a wheelchair to assist with mobility. R18 was dependent on staff for toileting, bathing, dressing, and putting on footwear. R18 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) to assist with bladder continence. R18 was frequently incontinent of bowel. R18 was a risk for pressure ulcer development. R18 required supplemental oxygen. R18's Functional Abilities Care Area Assessment (CAA) dated 08/26/24 documented her risk factors include further ADL decline, falls, incontinence, skin breakdown, and pain. The care plan would reflect her current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk. R18's Care Plan revised 01/13/25 directed staff to check her nail length and trim and clean them on bath days as necessary. Staff were directed that R18 was totally dependent on two staff to provide a bath or shower and as necessary. R18's care plan lacked staff direction on her preferred bath or shower days. R18's Documentation Survey Report v2 for December 2024 documented an ADL bathing task on Tuesday and Sunday days as needed. R18 received a bed bath on 12/03/24. R18 refused a bath on 12/17/24. On 12/06/24 at 01:59 PM a Health Status Note late entry note, documented R18 had a bed bath on 12/06/24, with nail care done, and linens changed. On 12/12/24 at 08:55 PM a Health Status Note in the EMR documented R18 had a bed bath on 12/10/24, with nail care done, and linens changed. R18's EMR lacked a Health Status Note documenting a bath was offered to or refused by R18 between 12/12/24 and 12/19/24. On 12/20/24 at 09:25 AM a Health Status Note in the EMR documented R18 had a bed bath on 12/20/24, with nail care done, and linens changed. On 12/24/24 at 09:16 AM a Health Status Note in the EMR documented R18 refused a shower on 12/24/24. R18 stated she just had one. On 12/31/24 at 04:41 PM a Health Status Note documented a late entry that R18 had a bed bath 12/31/24. R18's EMR lacked a Health Status Note documentation of a bath offered or refused by R18 between 12/25/24 and 12/30/24. R18's January 2025 Documentation Survey Report v2 in the EMR documented an ADL bathing task on Tuesday and Sunday days as needed. R18 received a bed bath on 01/31/25. On 01/14/25 at 09:18 AM a Health Status Note documented R18 had a bed bath 01/14/25. R18's EMR Progress Notes tab lacked documentation that she received, was offered, or refused any bathing other than on 01/14/25 and 01/31/25 for the month of January 2025. R18's February 2025 Documentation Survey Report v2 in the EMR documented an ADL bathing task on Tuesday and Sunday days as needed. R18 received a bed bath on 02/04/25. The report had an entry on 02/16/25 marked not applicable activity did not occur. On 02/04/25 at 10:49 AM a Health Status Note documented a late entry note that R18 had a bed bath on 02/04/25. R18's hair was washed, and the linens were changed. On 02/11/25 at 04:11 AM a Health Status Note documented a late entry that R18 refused a shower on 02/11/25. R18's EMR Progress Notes tab lacked documentation that she received, was offered, or refused any bathing between 02/05/25 and 02/10/25. R18's EMR Progress Notes tab lacked documentation that she received, was offered, or refused any bathing between 02/12/25 and 02/24/25. On 02/25/2025 at 09:31 AM a Health Status Note documented a note that R18 had a bed bath 02/25/25. R18's hair was washed, nail care was done, and linens changed. R18's March 2025 Documentation Survey Report v2 in the EMR documented an ADL bathing task on Tuesday and Sunday days. The report documented R18 received a bed bath on 03/11/25, 03/16/25, 03/18/25, and 03/23/25. The report documented not applicable, activity did not occur, on 03/02/25, 03/09/25, and 03/25/25. R18's EMR Progress Notes tab lacked documentation that she received, was offered, or refused any bathing between 02/26/25 and 03/03/25. (Eight days) On 03/04/25 at 09:53 AM a Health Status Note documented a late entry note that R18 had a bed bath on 03/04/25. Nail care was done, and the linens changed. No new skin concerns noted. On 03/11/25 at 02:19 AM a Health Status Note documented a late entry note R18 had a bed bath 03/11/25. Her hair was washed, nail care was done, and the linens changed. No new skin concerns was noted. On 03/18/25 at 08:55 AM a Health Status Note documented a late entry note that R18 had a bed bath on 03/18/25. On 03/27/25 at 09:15 AM, R18 stated she did get bed baths or shower at least once a week but sometimes it was longer in between them. R18 stated she knew that the facility was short of staff, and they would not always get hers done as she required more help bathing than some of the other residents. On 03/27/25 at 10:33 AM, Certified Nurse Aide (CNA) P stated the nurse's station had a bathing schedule list that had who was to get bathed each day on it. CNA P stated most of the time the bathing was able to be completed daily but some days when the unit was short of staff a resident might have to wait until the next day. CNA P stated typically a resident would be offered bath by the aide twice then the aide would tell the nurse if the resident had refused. On 03/27/25 at 10:40 AM, Licensed Nurse (LN) J stated there was a list at the nurse's station that had the days each resident was scheduled for bathing or a shower, which was typically twice a week per the resident's preference. LN J said the aides would offer the resident a bath twice and then the nurse would be told. LN J said after the aide told the nurse that a resident had refused the nurse would offer one more time and if the resident still refused then the nurse should document a note of the refusal. The facility's Activities of Daily Living (ADL) policy last reviewed 09/10/24 documented the resident would receive assistance as needed to complete ADLs. Any change in their ability to perform ADLs would be reported to the nurse. Quality of care is a fundamental principle that applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility would ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. A resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to ensure staff provided consistent bathing to dependent R18 per her preferred bathing preferences. This deficient practice placed these residents at risk for skin breakdown and possible injury/infection. 45668 - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of type two diabetes (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder), morbid obesity (severely overweight), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R15's Quarterly Minimum Data Set (MDS) completed 03/07/25 noted a Brief Interview for Mental Status (BIMS) score of eleven indicating mild cognitive impairment. The MDS noted she had physically aggressive behaviors towards others. The MDS noted she was dependent on staff assistance for bed mobility, toileting, bathing, transfers, personal hygiene, and dressing. The MDS noted she was frequently incontinent of bowel and bladder. The MDS noted she was not on a toileting program. The MDS noted she was at risk for skin breakdown and pressure ulcers but had no unhealed wounds. The MDS noted she had pressure-reducing devices and a repositioning program in place. R15's Behavioral Care Area Assessment (CAA) completed 11/01/24 indicated she was at risk for physical aggression, decreased socialization, isolation, and anxiety. The plan indicated her care plan was to reflect interventions to decrease her behaviors and agitation. R15's Functional Abilities CAA completed 11/01/24 indicated she was at risk for a decline in her activities of daily living (ADL) related to her medical diagnoses. The plan indicated her care plan was to reflect interventions to maintain her current level of functioning. R15's Care Plan initiated on 03/04/20 indicated she was at risk for ADL deficit due to her medical diagnoses and behaviors. The plan noted she was dependent on two staff for assistance with bathing, transfers, bed mobility, toileting, personal hygiene, and dressing (12/03/23). The plan noted she was resistant to care and wished to set her own schedule (12/03/23). The plan instructed staff to allow her to make her own decisions and encourage participation (12/03/23). The plan instructed staff to give clear explanations during each interaction, leave and return five to ten minutes after refusals, and praise appropriate behaviors (12/03/23). A review of R15's EMR under Documentation Survey Report from 01/01/25 through 03/27/25 (86 days reviewed) revealed she received bathing opportunities on occasions (01/09, 01/20, 02/10, and 03/03). The review revealed bathing was marked rejected on two occasions (1/30 and 3/3). The review revealed bathing was not given under Not Applicable circumstances on 19 occasions (1/2, 1/6, 1/13, 1/16, 1/23, 1/27, /1/30, 2/3, 2/6, 2/13, 2/17, 2/20, 2/24, 2/27, 3/6, 3/10, 3/13, 3/17, 3/17, 3/20, and 3/24). R15's EMR under Progress Notes revealed an Interdisciplinary Team (IDT) note completed on 03/13/25. The note revealed she had continued refusal of care and medications due to her medical diagnosis. The note revealed was not receiving behavioral health services. The note indicated the team will continue to monitor her changes and worsening mental health. On 03/24/25 at 10:03 AM, R15 lay in her bed on her right side next to her side rail. She stated she had not had a bath in almost a month and staff would not provide them when it was convenient for her. R15's hair was matted and greasy. Her nails were dirty. R15 stated she would often refuse care when she was upset or didn't like the staff taking care of her. On 03/27/25 at 09:52 AM, Certified Nurse's Aide (CNA) N stated R15 had ongoing behaviors. She stated it was hard to get her to take baths and provide care due to her behaviors and rejection of care. She stated staff often would ask multiple times if she wanted care or baths and she would still refuse. On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated R15 would often refuse ADL care and medications. She stated nursing would often offer the medications but R15 would refuse care. She stated R15 could be physically aggressive towards staff but most of the time she just refuses. On 03/27/25 at 11:34 AM, Administrative Nurse D stated staff were expected to provide consistent care for R15 and report refusals to the nurse. She stated that R15 should be educated on the importance of medication and care. She stated staff should make multiple attempts to provide these things to her. She stated staff could also call the resident representative for assistance with refusals. The facility's Activities of Daily Living (ADL) policy last reviewed 09/2024 indicated all residents would be provided ADL assistance and consistent bathing opportunities for all residents. The policy noted residents will be assessed for their specific care needs and provided interventions. The facility failed to provide consistent bathing opportunities for R15. This deficient practice placed R15 at risk for impaired psycho-social well-being and skin breakdown. 49634 - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertensive heart disease ( a condition where hypertension (high blood pressure) damages the heart muscles over time), heart failure (a condition of low heart output), diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), respiratory failure (a condition where the lungs struggle to exchange oxygen and carbon dioxide effectively, leading to low oxygen levels in the blood (hypoxemia) and or high carbon dioxide levels (hypercapnia), obesity (excessive body fat), bed confinement status, and palliative treatment (treatment designed to relieve or reduce the intensity of uncomfortable symptoms). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R43 was dependent on staff for toileting, dressing and bathing. The MDS documented R43 required set up and clean up for eating. The Quarter MDS dated [DATE] documented a BIMS of 15 which indicated intact cognition. The MDS documented R43 was dependent on staff for toileting, dressing and bathing. The MDS documented R43 required set up and clean up for eating. R43's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/10/25 documented the risk factors for R43 included decline in activities of daily living (ADL), falls, incontinence, skin breakdown, and pain. R43's care plan will reflect current ADL status and functional ability, maintain continence status, decrease pain, decrease fall, and pressure ulcer risk. R43's Care Plan dated 07/17/24 documented R43 has an ADL self-care performance deficit related to obesity, and R43 would maintain current level of function. R43's plan documented staff would check fingernail length, clean, and trim nails on bath day. R43's plan documented two staff were required to give R43 a bath. R43's EMR under Task documented R43 preferred bathing on Wednesday and Saturday in the evening. R43's Lookback Report from the Tasks lacked evidence of bathing from 01/01/25 through 03/25/25. The EMR lacked evidence of refusals. On 03/26/25 at 08:44 AM, R43 laid on his bed looking at iPad. R43's hair appeared greasy. On 03/27/25 at 08:15 AM, R43 laid on his bed looking at his iPad. R43 had a green hospital gown on with a food stain on the front of his gown. R43's hair appeared greasy. On 03/27/25 at 10:40 AM, Licensed Nurse (LN) H stated a hospice aide gave R43 his bath. She stated, he received two bed baths a week. On 03/27/25 at 10:52 AM, Certified Nursing Aide (CNA) N stated R43 has refused bathing from the facility aides. She stated the hospice aide comes twice a week to give R43 a bed bath. On 03/72/25 at 11:36 AM, Administrated Nurse D stated the hospice bath aide gives R43 a bed bath, she stated the facility aide should be offering R43 bed baths on his scheduled days also. The facility's Activities of Daily Living (ADLs) policy last reviewed 09/10/24 documented the resident would receive assistance as needed to complete ADLs. Any change in their ability to perform ADLs would be reported to the nurse. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility would ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. A resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide consistent bathing for R43 who required assistance with bathing. This deficient practice placed R43 at risk for complications related to poor hygiene and impaired dignity. 41037 - R55's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance with personal care, muscle weakness, and pneumonitis due to inhalation of food and vomit (an inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R55 had bilateral upper and lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R55 was dependent on staff assistance for his activities of daily living (ADL). The MDS documented R55 was independent with mobility in a motorized wheelchair. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The MDS documented R55 had a pressure reducing device on his bed and in his wheelchair. The MDS lacked documentation R55 was provided a restorative nursing program during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R55 had bilateral upper and lower limitation in ROM. The MDS documented R55 was dependent on staff assistance for his ADLs. The MDS documented R55 was dependent on staff assistance for wheelchair mobility. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers. The MDS documented R55 had a pressure reducing device on his bed and in his wheelchair. The MDS lacked documentation R55 was provided a restorative nursing program during the observation period. R55's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/15/24 documented risk factors included self-care deficits, falls, decreased socialization, bowel and bladder incontinence, skin breakdown, weight loss, and fluid imbalance. The facility would care plan his current ADL status. R55's Care Plan dated 09/24/23 documented he required assistance of two staff members for his bathing activity. Review of R55's EMR under the Reports tab and Bathing task was reviewed for the following dates 01/01/25 to 03/24/25 (82 days). The EMR documented five Showers (SW) on 01/03/25, 01/14/25, 01/17/25, 02/06/25, and 03/13/25. The EMR documented one Not Applicable (NA) on 01/25/25. The EMR documented two Bed Bath (BB) on 01/28/25 and 02/10/25. The EMR documented 11 Activity Did Not Occur (8) on 01/08/25, 01/21/25, 02/03/25, 02/13/25, 02/17/25, 02/20/25, 02/24/25, 03/03/25, 03/06/25, 03/17/25, and 03/20/25. R55's clinical record lacked evidence he was offered or refused care during the 82-days reviewed. On 03/24/25 at 09:44 AM, R55 laid flat on his bed with his enteral feeding (within or via the small intestine). R55's enteral formula container and water bag was undated and unlabeled. R55's hair looked oily and had a body odor noted. R55's bilateral hands were clenched tightly closed without any type of contracture prevention device. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated R55 received his bathing on dayshift. CNA N stated he never refused his bath/shower. CNA N stated the only reason he would not be taken to the shower would be if there was a problem with his gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated R55 never refused his bath/shower. LN I stated R55 had infection around his G-tube currently that the physicians were treating, so he would need his bath to keep that area clean. On 03/27/25 at 11:36 AM, Administrative Nurse D stated R55 should receive two baths weekly. Administrative Nurse D stated if a resident refused his bath, the CNAs would report that to the charge nurse, then the charge nurse would try to find out why the resident had refused. Administrative Nurse D stated the staff attempt to provide the resident's preference for bathing. The facility's Activities of Daily Living (ADL) policy last reviewed 09/10/24 documented the resident would receive assistance as needed to complete ADLs. Any change in their ability to perform ADLs would be reported to the nurse. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility would ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. A resident who was unable to carry out ADLs received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide consistent bathing for R55 who was dependent on staff for bathing. This deficient practice had the risk for poor hygiene, skin breakdown, decreased self-esteem, and dignity.

The facility identified a census of 96 residents. The sample included 20 residents, with four residents reviewed for tube feeding. Based on observation, record review, and interviews, the facility failed to ensure safe enteral nutritional feedings for Residents (R)71, R245, R9, and R55. This deficient practice placed the residents at risk for malnutrition and complications related to their enteral feedings (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). Findings Included: - The Medical Diagnosis section within R71's Electronic Medical Records (EMR) included diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), dysphagia (difficulty swallowing), cerebrovascular disease (abnormal blood flow to the brain), and a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). R71's Quarterly Minimum Data Set (MDS) completed 01/20/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she was dependent on staff assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS noted she had one-sided upper and lower extremity impairment. The MDS noted she received enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). The MDS indicated not weight loss. R71's Feeding Tube Care Area Assessment (CAA) completed 10/11/24 indicated she received enteral nutrition with a gastrostomy tube. The CAA noted care plan interventions were implemented to maintain his nutritional status. The CAA noted he was at risk for complications related to his enteral feedings including aspiration (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) and fluid imbalance. R71's Care Plan initiated on 11/17/23 indicated she was dependent on staff assistance for bed mobility, transfers, toileting, bathing, dressing, and personal hygiene. The plan noted she received enteral feedings via a feeding tube (tube for introducing high-calorie fluids into the stomach). The plan instructed staff to elevate the head of her bed at 45 degrees for thirty minutes after feedings. The plan instructed staff to check tube placement and residual volume (amount of fluid in the stomach) per the facility's protocol. R71's EMR under Orders revealed an order (dated 10/02/24) for staff to inspect and verify the positioning of her PEG tube each shift. The order instructed staff to provide enteral access site care each shift and as needed. The order instructed staff to check for residual fluids at the beginning of each shift and record the amount. The order instructed staff to maintain the head of her bed at 30 degrees or greater each shift. R71's EMR under Orders revealed an order (dated 10/02/24) for staff to administer Osmolite 1.5 (nutritional supplement used for tube feedings) at 65 milliliters per hour (ml/hour) for 24 hours via enteral feeding pump for a total of 1430ml. The Order instructed staff to also flush with 150ml of purified water every four hours. On 03/24/25 at 10:04 AM, R71 slept in her bed. R71 positioning was almost flat with her low air-loss mattress (adjustable air mattress system used to prevent pressure on the body) pump set to firm. R71's enteral pump was running at 65 ml/hr. R71 had an unlabeled/undated bag of Osmolite 1.5 supplement. On 03/24/25 at 02:32 PM, R71 slept flat in her bed as her continuous supplement pump ran at 65 ml/hr. The supplement bag was still unlabeled/undated. On 03/25/25 at 09:21 AM, R71's body positioning was adjusted, and her supplement bag was labeled/dated. On 03/27/25 at 09:52 AM, Certified Nurse's Aide (CNA) N stated residents were not to lay flat in bed when tube feeding was administered due to the risk of aspiration and choking. She stated staff were to make sure residents on tube feeding were in an elevated position while in bed. On 03/27/25 at 10:32 AM, Licensed Nurse I stated staff were expected to date and label the enteral feeding bags when they were administered and hung in the resident's rooms. She stated staff needed to know the date and time the administration was started to ensure consistent nutrition was being given. She stated the head of the resident's bed was elevated at least 45 degrees to prevent aspiration or acid reflux during feeding. On 03/27/25 at 11:32 AM, Administrative Nurse D stated staff were expected to elevate the enterally feed residents to at least 45 degrees while administering enteral nutrition. She stated the bags should always be labeled with the date and time to ensure consistent feedings. The facility did not provide a policy related to enteral nutrition as requested on 03/27/25. - The Medical Diagnosis section within R245's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder), end-stage renal failure (kidney failure), and a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). R245's Admission Minimum Data Set (MDS) completed 01/13/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she was dependent on staff assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS noted she had bilateral upper extremity impairment. The MDS noted she received enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). The MDS noted she admitted with a stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS noted she had pressure reducing devices for her bed and wheelchair. The MDs noted she received hospice services (end of life comfort care). R245's Feeding Tube Care Area Assessment (CAA) completed 02/12/25 indicated she received enteral nutrition with a gastrostomy tube. The CAA noted care planned interventions were implemented to maintain his nutritional status. The CAA noted he was at risk for complications related to his enteral feedings including aspiration and fluid imbalance. R245's Falls Care Area Assessment (CAA) completed 02/12/25 indicated she was at-risk for a deficit of her activities of daily living (ADL) related to her medical diagnoses. The CAA noted her care plan addressed her ADL decline. R245's Care Plan initiated 01/09/25 indicated she was dependent on staff assistance for bed mobility, transfers, toileting, bathing, dressing, and personal hygiene. The plan noted she received enteral feedings via a feeding tube (tube for introducing high-calorie fluids into the stomach). The plan instructed staff to elevate the head of her bed at 45 degrees for thirty minutes after feedings. The plan instructed staff to check tube placement and residual volume (amount of fluid in the stomach) per the facility's protocol. R245's EMR under Orders revealed an order (dated 01/08/25) for staff to inspect and verify the positioning of her percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach) each shift. The order instructed staff to provide enteral access site care each shift and as needed. The order instructed staff to check for residual fluids at the beginning of each shift and record the amount. The order instructed staff to maintain the head of her bed at 30 degrees or greater each shift. R245's EMR under Orders revealed an order (dated 01/08/25) for staff to administer TwoCal HN (nutritional supplement used for tube feedings) at 50 milliliters per hour (ml/hour) continuously via enteral pump. The Order instructed staff to also flush with 170 ml of purified water every four hours. On 03/24/25 at 09:21 AM, R245 slept flat in her bed. R245's bed was in the low position. Her Low-air-loss (adjustable air mattress system used to alleviate pressure areas of the body) mattress pump was set to 400lbs (maximum weight). R245's enteral feeding pump was set to 55 ml/hr and an unlabeled/undated bag of unknown supplement was being administered. The bag was 1/3 full of supplement. On 03/24/25 at 12:12 PM, R245 slept in bed. Enteral pump still set to 55 ml/hr. Enteral supplement bags still not labeled or dated. Unknown type of supplement in bag. On 03/25/25 at 07:43 AM, R245 slept flat in bed and the enteral feeding bag was not labeled or dated. There was an unknown supplement in feeding bag and the enteral pump was running at 55 ml/hr. The enteral bag was almost empty. On 03/25/25 at 09:18 AM, R245's positioning adjusted with head elevated. The enteral pump was set to 55 ml/hr and the enteral feedings bag was now labeled and dated. On 03/27/25 at 09:52 AM, Certified Nurse's Aide (CNA) N stated residents were not to lay flat in bed when tube feeding was administered due to the risk for aspiration and choking. She stated staff were to make sure residents on tube feeding were in an elevated position while in bed. On 03/27/25 at 10:32 AM, Licensed Nurse I stated staff were expected to date and label the enteral feeding bags when they were administered and hung in the resident's rooms. She stated staff need to know the date and time the administration was started to ensure consistent nutrition was being given. She stated the head of the resident's beds were elevated at least to 45 degrees to prevent aspiration or acid reflux during feeing. On 03/27/25 at 11:32 AM, Administrative Nurse D stated staff were expected to elevate the enterally feed resident's to at least 45 degrees while administering enteral nutrition. She stated the bags should always be labeled with the date and time to ensure consistent feedings. The facility failed to provide a policy related to enteral nutrition at requested on 03/27/25. - The Medical Diagnosis section within R9's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), type to diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dysphagia (difficulty swallowing), and pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R9's Admission Minimum Data Set (MDS) completed 01/20/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted he was dependent on staff assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS noted he had one-sided upper and lower extremity impairment. The MDS noted he received enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). R9's Feeding Tube Care Area Assessment (CAA) completed 01/23/24 indicated she received enteral nutrition with a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). The CAA noted care planned interventions were implemented to maintain his nutritional status. The CAA noted he was at risk for complications related to his enteral feedings including aspiration and fluid imbalance. R9's Care Plan initiated 03/12/25 indicated he was at risk for skin breakdown, pressure injuries, urinary tract infections (UTIs), and wound infections. The plan noted he had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). The plan lacked information related to his enteral feedings or management of his percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). The plan instructed staff to elevate the head of her bed at 45 degrees for thirty minutes after feedings. The plan instructed staff to check tube placement and residual volume (amount of fluid in the stomach) per the facility's protocol. R9's EMR under Orders revealed an order (dated 01/31/25) for staff to inspect and verify the positioning of her PEG-tube each shift. The order instructed staff to provide enteral access site care each shift and as needed. The order instructed staff to check for residual fluids at the beginning of each shift and record the amount. The order instructed staff to maintain the head of her bed at 30 degrees or greater each shift. R9's EMR under Orders revealed an order (dated 01/31/25) for staff to administer Jevity 1.5 (nutritional supplement used for tube feedings) at 70 milliliters per hour (ml/hour) for 24 hours via enteral feeding pump for a total of 1430 ml. The Order instructed staff to also flush with 200 ml of purified water every four hours. On 03/24/25 at 07:45 AM, R9 lay flat in his bed. R9's enteral feeding pump ran at 70 ml/hr. A clear unlabeled/undated bag of unknown supplement was administered to him through the feeding pump. On 03/27/25 at 09:52 AM, Certified Nurse's Aide (CNA) N stated residents were not to lay flat in bed when tube feeding was administered due to the risk for aspiration and choking. She stated staff were to make sure residents on tube feeding were in an elevated position while in bed. On 03/27/25 at 10:32 AM, Licensed Nurse I stated staff were expected to date and label the enteral feeding bags when they were administered and hung in the resident's rooms. She stated staff need to know the date and time the administration was started to ensure consistent nutrition was being given. She stated the head of the resident's beds were elevated at least to 45 degrees to prevent aspiration or acid reflux during feeing. On 03/27/25 at 11:32 AM, Administrative Nurse D stated staff were expected to elevate the enterally feed resident's to at least 45 degrees while administering enteral nutrition. She stated the bags should always be labeled with the date and time to ensure consistent feedings. The facility failed to provide a policy related to enteral nutrition at requested on 03/27/25. - The Medical Diagnosis section within R55's Electronic Medical Records (EMR) included diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance with personal care, muscle weakness, and pneumonitis due to inhalation of food and vomit (inflammation of the lungs). R55's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS indicated he had bilateral upper and lower limitations in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The MDS documented that R55 was dependent on staff assistance for his activities of daily living (ADL). The MDS documented that R55 was independent with mobility in a motorized wheelchair. The MDS noted he received enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). R55's Feeding Tube Care Area Assessment (CAA) completed 08/15/24 indicated she received enteral nutrition with a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). The CAA noted that planned interventions were implemented to maintain his nutritional status. The CAA noted he was at risk for complications related to his enteral feedings including aspiration (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) and fluid imbalance. R55's Care Plan initiated on 07/25/23 indicated he was at risk for a decline in his activities of daily living (ADL). The plan noted he was dependent on staff for assistance with bathing, toileting, personal hygiene, dressing, transfers, and bed mobility. The plan noted he required enteral nutrition via a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). The plan instructed staff to elevate the head of her bed at 45 degrees for thirty minutes after feedings. The plan instructed staff to check tube placement and residual volume (amount of fluid in the stomach) per the facility's protocol. R55's EMR under Orders revealed an order (dated 09/02/24) for staff to inspect and verify the positioning of her PEG tube each shift. The order instructed staff to provide enteral access site care each shift and as needed. The order instructed staff to check for residual fluids at the beginning of each shift and record the amount. The order instructed staff to maintain the head of her bed at 30 degrees or greater each shift. R55's EMR under Orders revealed an order (dated 09/02/24) for staff to administer Jevity 1.5 (nutritional supplement used for tube feedings) at 75 milliliters per hour (ml/hour) continuously via an enteral pump. The Order instructed staff to also flush with 250 ml of water every four hours. On 03/24/25 at 07:56 AM, R55 lay in his bed. The head of his bed was slightly elevated but below 30 degrees. R55's enteral pump ran at 75 ml/hr. His clear enteral bag was unlabeled and undated with an unknown supplement inside. On 03/25/25 at 07:50 AM, R55 lay in his bed. The head of his bed again was slightly elevated but not below 34 degrees. His enteral nutrition pump ran at 75 ml/hr. His enteral supplement bag was again not dated or labeled. On 03/27/25 at 09:52 AM, Certified Nurse's Aide (CNA) N stated residents were not to lay flat in bed when tube feeding was administered due to the risk of aspiration and choking. She stated staff were to make sure residents on tube feeding were in an elevated position while in bed. On 03/27/25 at 10:32 AM, Licensed Nurse I stated staff were expected to date and label the enteral feeding bags when they were administered and hung in the resident's rooms. She stated staff needed to know the date and time the administration was started to ensure consistent nutrition was being given. She stated the head of the resident's bed was elevated at least 45 degrees to prevent aspiration or acid reflux during feeding. On 03/27/25 at 11:32 AM, Administrative Nurse D stated staff were expected to elevate the enterally feed residents to at least 45 degrees while administering enteral nutrition. She stated the bags should always be labeled with the date and time to ensure consistent feedings. The facility failed to provide a policy related to enteral nutrition as requested on 03/27/25.

The facility identified a census of 96 residents. The facility identified 32 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and three residents on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record review, observations, and interviews, the facility failed to cover all linen, and store pillows in a sanitary manner. The facility further failed to ensure R69's urine bag was not dragging on the floor. The facility failed to ensure staff performed hand hygiene during wound dressing changes and urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) care. This deficient practice placed residents at risk for infections. Findings included: - On 03/24/25 at 08:28 AM, the following concerns were identified during the initial tour: in the shower room on hall 500 a linen cart was uncovered, and a pillow laid on top of the cabinets uncovered. The whirlpool had a Do Not Use sign which contained a stack of bedspreads in the middle of the shower room. On 03/24/25 at 08:32 AM, on hall 300 a linen cart was covered, and a pillow laid on top of the linen cart uncovered. On 03/24/25 at 12:06 PM, R69's urinary catheter bag drug on the floor, underneath his wheelchair during lunch time. On 03/25/25 at 08:25 AM, R43 laid on his bed looking at his iPad. R43's CPAP laid in his windowsill; the CPAP was not stored in a sanitary manner. On 03/25/25 at 09:58 AM, during wound care for R18 Administrative Nurse E, Administrative Nurse F, and Licensed Nurse (LN) K entered R18's room but failed to do hand hygiene or wash their hands before entering R18's room. Administrative Nurse F had her hands full of wound supplies from her wound cart. Administrative Nurse F placed a barrier on the counter in R18's room and placed the wound supplies on top of the barrier. Administrative Nurse F, Administrative Nurse E, and LN K donned gowns. LN K sanitized her hands prior to donning gloves. LN K placed a barrier on the bed under R18. LN K then obtained a package that had a wound wipe, she opened the wipe and wiped one of R18's wounds and threw the wipe in the trash can beside the bed. LN K failed to doff the dirty gloves before she opened and cleaned R18's second wound. Administrative Nurse E told LN K after she cleansed the next wound, she needed to change her gloves and do hand hygiene. LN K doffed her gloves and performed hand hygiene before donning clean gloves. On 03/26/25 at 08:20 AM, LN J did not perform hand hygiene between glove changes during R9's catheter care. On 03/26/25 at 09:12 AM, LN J did not perform hand hygiene between glove changes during R55's feeding tube (tube for introducing high-calorie fluids into the stomach), while changing the dressing. On 03/27/25 09:03 AM, LN I administered medication via feeding tube to R55. LN I gowned and gloved, gave apple juice, water, and two medications. LN I placed a cover over R55's abdomen, prior to giving medication. LN I adjusted R55's pillow, his gown covering his brief, and then adjusted R55's brief, LN I did not do hand hygiene or change gloves. LN I then started 30 milliliters (ml) of water flush and a prefilled vial of medication. LN I did not do hand hygiene or glove changes during administration of medication or water flush. The Infection Prevention policy revised on 12/21/21 documented the goals of the infection program was to reduce the risk of acquisition and transmission of health care associated infects. Monitor for any occurrences of infection and implement appropriate control measures. Identify and correct problems relating to infection prevent and control practices. The facility failed to cover all linen, and store pillows a sanitary manner, the facility failed to ensure R10's urine collection bag was below the level of his bladder and failed to ensure R69's urine bag was not dragging on the floor. The facility further failed to ensure R43's CPAP was stored in a sanitary manner, and R4's nasal cannula was also stored in a sanitary manner, and further failed to constantly do hand hygiene during wound dressing changes and urinary catheter care. This defiant practice placed the residents at risk for infections.

The facility identified a census of 96 residents. The sample included 20 residents. Based on observation, record review and interviews, the facility failed to ensure adequate bariatric equipment was available to provide the necessary care and promote the resident's highest practicable level of function and quality of life for Resident (R) 43. The facility also failed to ensure R81 had foot pedals in use on the wheelchair and a call light available within reach. These deficient practices placed the residents at risk for impaired quality of life and health complications related to unmet needs. Findings Included: - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertensive heart disease (a condition where high blood pressure damages the heart muscles over time), heart failure (a condition of low heart output), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), obesity (excessive body fat), bed confinement status, and palliative treatment (treatment designed to relieve or reduce the intensity of uncomfortable symptoms). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R43 was dependent on staff for toileting, dressing, personal hygiene, and bathing. The MDS recorded R43 was dependent on staff for wheelchair mobility and did not ambulate. The MDS recorded R43 had no functional impairment of the upper or lower extremities. The MDS documented R43 required set up and clean up for eating. R43's MDS documented it was very important to R45 to choose between a tub bath, shower, bed bath or sponge bath. The MDS recorded doing things with groups of people and going outside was very important to R43. The MDS noted R43 weighed 712 pounds. The Quarterly MDS dated [DATE] documented a BIMS score of 15. The MDS documented R43 was dependent on staff for most activities of daily (ADL) except personal hygiene and eating for which he required set up assistance. The MDS recorded that lying to sitting activity, transfers (to chairs, toilet, and showers) and walking were not attempted due to medical conditions or safety concerns. The MDS recorded the resident did not use a wheelchair or scooter. The MDS recorded R43 weighed 712 pounds. R43's ADL Function/Rehabilitation Potential Care Area Assessment (CAA) dated 07/08/24 documented R43's risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. The CAA documented the care plan would reflect R43's current ADL status and functional ability and R43 would maintain continence status, have decreased pain, and decreased fall and pressure ulcer risk. R43's Activities CAA dated 07/08/24 documented R43's risk factors included decreased socialization, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R43's care plan would be initiated to improve symptoms through one-on-one activity and would encourage participation in group activities. R43's Care Plan documented R43 had an ADL self-care performance deficit related to morbid obesity dated 07/17/24. The plan documented R43 was dependent on the assistance of two staff for bathing, repositioning in bed, and toilet use (dated 07/18/24). The plan directed staff that R43 required the assistance of two staff and a mechanical lift for transfers (07/18/24). R43's Care Plan documented the resident was dependent on staff to meet his emotional, intellectual, physical, and social needs due to the resident's immobility (07/18/24). The plan documented staff would invite R43 to scheduled activities and the facility would plan a program of activities that was of interest to the resident, and which empowered the resident by encouraging and allowing choices and self-expression. The plan was revised on 10/18/24 to note that if R43 chose not to participate in organized activities, he preferred to watch TV and play games on his tablet. R43's EMR under the Orders tab documented the following physician's order: Weights monthly starting on the first of each month dated 10/01/24. R43's EMR under the Weights and Vitals tab documented R43 weighed 711.7 pounds on 07/03/24. R43's medical record lacked any other recorded weights from 07/04/24 through 03/26/25. The record lacked evidence of refusals. R43's EMR under Tasks documented bathing was scheduled for Wednesday and Saturday in the evening. R43's Lookback Report from the Tasks lacked evidence of bathing from 01/01/25 through 03/25/25. There was no evidence of refusals. R43's EMR under Lookback Report under Transfers from 01/01/25 through 03/26/25 documented activity (transfers) did not occur. There was no evidence of refusals. On 03/25/25 at 08:25 AM, R43 laid on his bed looking at his iPad. On 03/27/25 at 10:40 AM, Licensed Nurse (LN) H stated R43's hospice service provided his bathing, and he always received a bed bath. LN H stated the facility was unable to obtain weights for R43 because the facility did not have a mechanical lift with scale that could accommodate R43's weight. LN H stated if staff needed to get R43 out of bed and out of his room or the facility, staff would have to use some sort of gurney (a wheeled stretcher for transporting patients) but the facility did not have one readily available. On 03/27/25 at 10:52 AM, Certified Nursing Aide (CNA) N stated hospice gives R43 a bed bath twice a week. She stated R43 usually refused to have facility staff give him a bath. CNA N stated when the facility must move R43, they used a gurney, and pulled him through the doorway. CNA N stated the facility's mechanical lift would not lift R43. On 03/72/25 at 11:36 AM, Administrated Nurse D stated the hospice bath aide gives R43 his bed bath and the facility staff offer twice a week. Administrative Nurse D stated the facility did not have a lift to get R43 out of bed. She stated the facility had to move R43 when the 100-hall flooded, and staff had to call Emergency Medical Response (EMR) to get the resident moved. She stated EMR slid R43 on a slide board on to the gurney and pulled him through the door. Administrative Nurse D confirmed the facility lacked the ability to obtain a weight on R43. The facility failed to provide an accommodation of needs policy. The facility failed to ensure adequate adaptive equipment including a suitable mechanical lift, and wheelchair was available to provide R43 the necessary care and promote the resident's highest practicable level of function and quality of life. This placed the resident at risk for decreased quality of life and health complications due to unmet needs. - R81's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses dementia (a progressive mental disorder characterized by failing memory and confusion), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), hyperlipidemia (condition of elevated blood lipid levels), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), insomnia (inability to sleep), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), unsteady on feet, lack of coordination, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and palliative treatment (treatment designed to relieve or reduce the intensity of uncomfortable symptoms). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R81 required set up and clean up for eating and oral hygiene, partial to moderate assistance from staff for toileting, and substantial to maximum assistance with bathing. The MDS documented R81 used a wheelchair. R81's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 03/07/25 documented R81's risk factors include further activities of daily living (ADL) decline, falls, incontinence, skin breakdown, and pain. Care plan would reflect current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk. R81's Falls CAA dated 03/07/25 documented R81 risk factors included falls and other major and minor injuries related to falls. R81's Care Plan revised 09/24/2024 documented R81 was at risk for falls related to poor safety awareness. The plan documented on 01/23/25 R81 had an unwitnessed fall. The plan documented on 02/10/25 R 81 had an unwitnessed fall, the provider followed up with labs and imaging. On 03/25/25 at 07:42 AM, R81's call light was clipped to the wall in the middle of her room. On 03/25/25 at 08:50 AM, Certified Nurse's Aide (CNA) M pushed R81 without foot pedals into the dining room. On 03/25/25 at 07:42 AM, R81's call light was clipped to the wall in the middle of her room. On 03/25/25 at 12:10 PM, CNA M pushed R81 without foot pedals out of the large dining room. On 03/26/25 at 07:42 AM, R81's call light was clipped to the wall in the middle of her room. On 03/27/25 at 09:47 AM, CNA M stated call lights should always be within the residents reach when the residents were in their rooms. She stated all the residents have foot pedals and should be used if the resident was being pushed. On 03/27/25 at 10:02 AM, Licensed Nurse (LN) G stated call lights should be placed near the resident, or with in reach. LN G stated residents should not be pushed without pedals. She stated residents that do not have foot pedals are able to propel themselves. On 03/27/25 at 11:36 AM, Administrative Nurse D stated residents call light should be within reach, if the resident was in their room. She stated all wheelchairs have foot pedals and should be used if the staff are pushing the wheelchair. The facility failed to provide a policy that obtained to foot pedals and call light use. The facility failed to ensure R81s call light was within his reach, and further failed to ensure R81 had foot pedals on her wheelchair, if staff were pushing her. This deficient practice left R81 vulnerable to unmet care needs due to the inability to call for staff assistance and possible injury from falls.

The facility identified a census of 96 residents. The sample included 20 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure that written notification of transfer provided to Resident (R) 8 included the required information. The facility failed to ensure staff provided the written notification of transfer as soon as practicable to the resident's representative. This deficient practice placed R8 at risk for uninformed care choices. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), paranoid schizophrenia (subtype of schizophrenia characterized by persistent delusions of persecution, distrust, and hallucinations), and respiratory failure (inadequate gas exchange by the respiratory system causing a decreased level of oxygen in the blood). R8's Discharge MDS dated 07/22/24 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. R39's Entry MDS dated 07/27/24 documented a re-entry to the facility from an unlisted facility. A Notice of Resident Transfer/Discharge to Alternate Healthcare Setting form was not provided to R8 or her representative for her discharge from 07/22/24 to 07/27/24. R8's Annual MDS dated 07/30/24 documented a Brief Interview for Mental Status (BIMS) score of zero which indicated a severely impaired cognition. R8 had functional limitation in range of motion (ROM) of both upper and lower extremities. R8 used a wheelchair for mobility. R8 was dependent on staff for all functional abilities. R8 was always incontinent of bladder and frequently incontinent of bowel. R8's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/02/24 documented her risk factors include self-care deficits, falls and injuries, incontinence, decreased socialization, skin breakdown, weight loss, and fluid imbalance. The care plan would reflect R8's current cognitive status, activities of daily living (ADL) status, continence status, mobility, encourage active participation in facility functions, maintain communication, decrease falls, and skin breakdown risk, and maintain dietary intake and hydration status. R8's Discharge MDS dated 08/01/24 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. R8's Entry MDS dated 08/13/24 documented a re-entry to the facility from an unlisted facility. A Notice of Resident Transfer/Discharge to Alternate Healthcare Setting form dated 08/01/24 lacked the reason for her transfer or discharge. The notice was not mailed and provided to R8's representative as required. R8's Discharge MDS dated 09/07/24 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. R8's Entry MDS dated 09/08/24 documented a re-entry to the facility from an unlisted facility. A Notice of Resident Transfer/Discharge to Alternate Healthcare Setting form dated 09/06/24 lacked the reason for her transfer or discharge. The notice was not mailed and provided to R8's representative as required. R8's Discharge MDS dated 03/01/25 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. R39's Entry MDS dated 03/05/25 documented a re-entry to the facility from an unlisted facility. A Notice of Resident Transfer/Discharge to Alternate Healthcare Setting form dated 03/01/25 lacked the reason for her transfer or discharge. The notice was not mailed and provided to R8's representative as required. R8's Care Plan revised on 08/05/24 directed staff that she would be a long-term stay. On 03/26/25 at 07:31 AM, R8 reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline). R8 had a splint on bilateral hands and wrists. On 03/27/25 at 10:40 AM, Licensed Nurse (LN) H stated the nurses would complete the notice of transfer form and a copy would be sent with the resident to where they were being transferred to. LN H stated a copy was given to the social worker and the resident's representative would be notified by phone of the transfer. On 03/27/25 at 11:37 AM, Administrative Nurse D stated when a resident was transferred out of the facility the transfer form was completed by the nurse, a copy was made for the resident to take with them, then a copy was given to social services so they could do the bed hold policy. Administrative Nurse D stated as far as she knew the notice of transfer was not mailed to the resident's representative but would be notified by phone of the transfer. The Notice if Transfers and Discharges policy revised 10/29/24 documented the written notice must include the reason for the transfer or discharge; the effective date of transfer or discharge; the location to which the resident was transferred or discharged ; a statement of the resident's appeal rights; the name, address and telephone number of the office of the state long-term care ombudsman; for nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; and for nursing facilities with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. When a resident was temporarily transferred on an emergency basis to and acute care facility, notice of transfer may be provided to the resident and the representative as soon as practicable before the transfer. The policy lack clarification that the for was to be provided in written form. The facility failed to ensure that written notification of transfer provided to R8 included the reason for the transfer. The facility failed to ensure staff provided the written notification of transfer as soon as practicable to the resident's representative. This deficient practice placed R8 at risk for uninformed care choices.

The facility identified a census of 96 residents. The sample included 20 residents. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 24 which included individualized, person-centered interventions for her trauma-based care. The facility also failed to develop a comprehensive care plan for R9 which included individualized person-centered intervention for his activities. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R24 had no behaviors during the observation period. The MDS documented R24 had an active diagnosis of PTSD. The Quarterly MDS dated [DATE] documented a BIMS score of five which indicated severely impaired cognition. The MDS documented R24 had no behaviors during the observation period. The MDS documented R24 had an active diagnosis of PTSD. R24's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/14/24 documented her risk factors included self-care deficits, falls with possible injuries, incontinence, decreased socialization, skin breakdown, weight loss, and fluid imbalance. R24's Care Plan dated 09/23/21 documented staff would analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The plan of care lacked individualized triggered-specific interventions that identified ways to decrease exposure to triggers which could re-traumatize her. On 03/25/25 at 07:17 AM, R24 sat in her wheelchair next to the bed with the lights off in the room. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated she was not aware R24 had a diagnosis of PTSD. CNA N stated R24 would often yell out. CNA N stated she would expect to find the information of R24's PTSD which included what might possibly re-traumatize her. CNA N stated she would also expect to find the interventions that would help address R24's trauma. On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated R24's diagnose of PTSD could explain why R24 yelled out frequently. LN I stated she would expect the care plan to have information on what had happened to cause the PTSD and what interventions that were in place to prevent re-traumatization. On 03/27/25 at 11:00 AM, Social Services Staff X and Social Services Staff Y stated R24's last Trauma Informed Care assessment was completed on 02/26/20. Social Services Staff X and Social Services Staff Y stated the trauma-based assessment would only be assessed at the time of admission and only if Administrative Nurse D would request a reassessment. Social Services Staff X and Social Services Staff Y stated the MDS coordinator would be responsible to develop R24's care plan. Social Services Staff X and Social Services Staff Y stated R24 would not require any increased monitoring due to her diagnosis of PTSD. On 03/27/25 at 11:36 AM, Administrative Nurse D stated she would expect to find R24's PTSD addressed on her care plan. Administrative Nurse D stated she was not sure the frequency R24 should be assessed for her trauma-based care. Administrative Nurse D stated that would be handled by the social service department. The facility's Comprehensive Care Plans and Revisions policy last revised 09/11/24 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. The facility failed to develop a comprehensive care plan for R24 which included individualized person-centered interventions for her PTSD. This deficient practice placed R24 at risk for impaired care due to uncommunicated care needs and re-traumatization. - The Medical Diagnosis section within R9's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), type to diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dysphagia (difficulty swallowing), and pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R9's Admission Minimum Data Set (MDS) completed 01/20/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted he was dependent on staff assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS noted he had one-sided upper and lower extremity impairment. The MDS noted he received enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). R9's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/23/25 documented his risk factors included self-care deficit, falls with injuries bowel incontinence, decreased socialization, skin breakdown, weight loss and fluid imbalance. R9's Care Plan dated 03/19/25 documented he was on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). The plan of care lacked person centered activities for R9. Review of R9's EMR under Reports for Activity Participation lacked documentation of any activity participation. The facility was unable to provide any activity documentation upon request. On 03/24/25 at 07:45 AM, R9 lay flat in his bed. R9's enteral feeding pump ran at 70 milliliters/hour (ml/hr.). R9's roommates TV was on, the curtain that divided the room was pulled to block the TV from R9's vision. No music or TV was on in the room on R9's side of the room. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated R9 enjoyed having his TV or radio on when he was in bed. CNA N stated everyone had access to the residents' care plan and the Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated R9 enjoyed listening to music when he was in bed. LN I stated his activities of choice should be on his care plan. LN I stated everyone had access to the residents' care plan and the Kardex. On 03/27/25 at 11:36 AM, Administrative Nurse D stated R9 enjoyed music. Administrative Nurse D stated his person-centered activities should be care planned. The facility's Comprehensive Care Plans and Revisions policy last revised 09/11/24 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. The facility failed to identify and create a person-centered comprehensive care plan that included meaningful activities for R9. This deficient practice placed R9 at risk for a decline in physical, mental, and psychosocial well-being and independence.

The facility reported a census of 96 residents. The sample included 20. Based on observations, interviews, and record review, the facility failed to revise Residents (R)73s care plan to reflect her visitation requirements and R85's fall intervnetions. These deficient practices placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of aphasia (difficulty speaking), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R73's Quarterly Minimum Data Set (MDS) completed 01/03/25 noted a Brief Interview for Mental Status (BIMS) score of ten indicating mild cognitive impairment. The MDS noted she was dependent on staff assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS noted she was at risk for falls, pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). R73's Cognitive Loss Care Area Assessment (CAA) completed 09/17/24 indicated she had cognitive loss related to her orientation, memory, and recall deficits. The CAA noted she was at risk for falls, skin breakdown, weight loss, and a decline of her activities of daily living (ADL). The plan noted her care plan addressed her risks. R73's Care Plan initiated 10/09/23 indicated she had a self-care performance deficit related to her medical diagnoses. The plan noted she required substantial staff assistance for transfers, bathing, personal hygiene, dressing, and toileting. The plan instructed staff to provide a safe care environment due to her risk of falling. The plan instructed staff to ensure her call light remained within reach, keep room clear from clutter, and assist her with ADLs (10/14/23). The plan noted she had difficulty with communication. The plan instructed staff to allow adequate time for conversation, allow her to express her thoughts, and anticipate her needs (10/17/23). R73's EMR under Special Instructions indicated R73's family representative was only allowed to visit her in a common area. A Facility Reported Investigation completed 02/09/25 indicated staff overheard R73's family representative yelling and witnessed the representative's arm around R73's neck in an aggressive manner. The report indicated staff immediately separated the representative and removed them from the building. The report indicated local law enforcement was notified of the incident. On 03/25/25 at 11:01 AM, R73 sat in her wheelchair in her room. She stated her mom was not allowed to return to the facility per R73's wishes. She stated if she had to talk with her representative, she wanted staff to be present or in a supervised area. On 03/027/25 at 09:52 AM, Licensed Nurse (LN) I stated the care plan should reflect relevant information related to the resident's care. She stated R73'S representative can only visit in the common area due to safety concerns. He stated the care plan should reflect that information. On 03/027/25 at 11:34 PM, Administrative Nurse D stated 73's family representative was not allowed back at the facility per R73's request. She stated she was not sure if R73's care plan reflected the incident or contained information about the representative. The facility's Comprehensive Care Plans and Revisions policy last revised 09/11/24 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. The facility failed to revise R73's care plan to reflect visitation requirements. This deficient practice placed R73 at risk for impaired quality of life and safety concerns. 41037 - R85's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of lack of coordination, fracture right hip (broken bone), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, aphasia (condition with disordered or absent language function), and communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R85 was independent with bed mobility. The MDS documented R85 required supervision to touch assistance with personal hygiene and dressing. The MDS documented R85 had no limitations with upper and lower extremity range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R85 had one non-injury fall since admission or previous MDS assessment. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R85 had limited ROM to lower extremity on one side. The MDS documented R85 was dependent on staff assistance for eating, oral hygiene, personal hygiene, her bathing, toileting activity, and transfers. The MDS documented R85 had orthopedic surgery. R85's Falls Care Area Assessment (CAA) dated 12/04/24 documented her risk factors included falls with major and minor injuries related to past falls. R85's Care Plan dated 12/02/24 documented a medication review would be completed by the physician. The plan of care dated 12/18/24 documented for a no apparent acute injury staff would determine and address causative factors of the fall. The plan of care dated 12/08/24 documented R85 had a witnessed fall on 12/17/24 and staff would offer her to take rest breaks when wandering on the unit. The plan of care dated 01/09/25 staff would increase observation for 72 hours post fall. The plan of care dated 01/10/25 documented R85 had a fall in the dining room and staff would encourage her to wear non-skid footwear. The plan of care dated 01/14/25 documented R85 had an injury of unknown origin, and the therapy department would evaluate her ambulation needs and any assistive devices needed. The plan care dated 03/20/25 documented R85 had an unwitnessed fall so staff would provide purposeful rounding for 72 hours and place a floor mat on the left side of her bed. The plan of care dated 03/26/25 directed staff to offer R85 cares during rounding. The care plan lacked new long-term interventions to prevent future falls. R85's EMR under the Progress Notes tab the following Health Status Note dated 12/02/24 at 01:48 PM documented R85 was found on the floor in another resident's room. No injuries noted. On 12/02/24 at 12:03 PM an Admission Note documented a visit dictated by the physician. No medication changes were documented. On 12/05/24 at 11:48 AM an Encounter Note dictated by the physician which documented that R85's Depakote (mood stabilizer) medication was discontinued per family's request. On 12/18/24 at 01:00 AM an Event Note that documented R85 had a witnessed fall while she was wandering in the hallway. On 12/18/24 at 08:57 AM a Health Status Note documented R85 continued fall follow-up monitoring. RF85 had a skin tear documented on her right elbow. On 01/09/25 at 06:30 PM an Event Note documented R85 was found on the floor in her room. No injuries noted. On 01/10/25 at 03:50 PM an Alert Note documented R85 was found on the floor in the dining room. R85 was found lying on her right side. On 01/14/25 at 07:07 PM an Event Note documented R85 complained of right hip pain during staff provided incontinence care. The physician was notified, and an X-ray was obtained, and the results showed a displaced intertrochanteric fracture of her right femur. R85 was admitted to the hospital with a right hip fracture. On 03/20/25 at 09:28 AM a Health Status Note documented R85 was found on the floor mat next to her bed. On 03/25/25 at 04:59 PM an Event Note documented R85 was found sitting on the floor on the floor mat next to her bed. On 03/26/25 at 07:27 AM, R85 laid asleep on her bed in the lowest position with the floor mat next to the bed on the right side of the bed. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated R85 was on the secured unit until her right hip fracture. CNA N stated R85 was a high fall risk and was to have her bed in the lowest position and a fall mat next to her bed. CNA N stated everyone had access to the care plan and the Kardex (nursing tool that gives a brief overview of the care needs of each resident). CNA N stated she would review R85's care plan to find all the fall interventions that were in place to prevent falls. On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated everyone had access to the residents' care plan and the Kardex. LN I stated R85's fall interventions should be on her care plan. LN I stated R85 should have her call light within reach, fall mat on the floor next to her bed and the bed in the lowest position. On 03/27/25 at 11:36 AM, Administrative Nurse D stated R85 had the right hip fracture from the possible fall on 01/10/25. Administrative Nurse D stated R85 had not had any pain from 01/10/25 to 01/14/25 when staff had reported the pain while they provided care. Administrative Nurse D stated they had found the right hip fracture after the x-ray. Administrative Nurse D stated after the 72-hour observation interventions was completed, she stated there was no new interventions placed on R85's care plan to prevent future falls. The facility's Comprehensive Care Plans and Revisions policy last revised 09/11/24 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. The facility failed to revise R85's plan of care to include the new fall preventive measures to prevent future falls for a resident who was a high fall risk. This deficient practice placed R85 at risk of falls and possible future injuries.

The facility identified a census of 96 residents. The sample included 20 residents, with four residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 55 was provided a touch pad call light. This deficient practice placed R55 at risk of unmet care needs and inability to call for assistance if needed. Findings included: - R55's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance with personal care, muscle weakness, and pneumonitis due to inhalation of food and vomit (an inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R55 had bilateral upper and lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R55 was dependent on staff assistance for his activities of daily living (ADL). The MDS documented R55 was independent with mobility in a motorized wheelchair. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and had a pressure reducing device on his bed and in his wheelchair. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R55 had bilateral upper and lower limitation in ROM. The MDS documented R55 was dependent on staff assistance for his ADLs and dependent on staff assistance for wheelchair mobility. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers and had a pressure reducing device on his bed and in his wheelchair. R55's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/15/24 documented risk factors included self-care deficits, falls, decreased socialization, bowel and bladder incontinence, skin breakdown, weight loss, and fluid imbalance. The facility would care plan his current ADL status. R55's Care Plan dated 11/07/23 documented staff would provide him with a mechanical pad call light in order to request staff assistance. On 03/25/25 at 08:16 AM, R55 laid on his bed, head of the bed was slightly elevated. R55's bed was elevated three feet of the floor with bed rails up in place bilaterally. R55's push button call light was attached to the right bed rail and hung off the bed out of his reach. R55's bilateral hands were clenched tightly closed with no palm grippers in place. R55's low air mattress was unplugged from the wall and was not working. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated R55 could not operate a push button call light. CNA N stated she was not sure who would assess the residents for the appropriate equipment. On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated R55 could not operate the push button call light. On 03/27/25 at 11:36 AM, Administrative Nurse D stated R55 was not able to operate the push button call light. Administrative Nurse D stated he probably would do better if he had a touch pad call light. The facility's Activities of Daily Living (ADLs) policy last reviewed 09/10/24 documented a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility failed to ensure R55 had a touch pad call light. This deficient practice placed R55 at risk of uncommunicated needs and ability to call for assistance.

The facility identified a census of 96 residents. The sample included 20 residents, with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure staff set the appropriate weight for Resident (R) 245's low air-loss mattresses (specialized air mattress used to reduce pressure on the body) and failed to ensure R55's low air-loss mattress was plugged in and functioning. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R245's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder), end-stage renal failure (kidney failure), and a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). R245's Admission Minimum Data Set (MDS) completed 01/13/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she was dependent on staff assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS noted she had bilateral upper extremity impairment. The MDS noted she admitted with a stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS noted she had pressure-reducing devices for her bed and wheelchair. The MDs noted she received hospice services (end-of-life comfort care). The MDS noted she weighed 228 pounds (lbs.). R245's Pressure Ulcer Care Area Assessment (CAA) completed 01/14/25 indicated she was at risk for further pressure ulcers related to her urinary incontinence, impaired mobility, and history of pressure ulcers. The CAA noted she required frequent repositioning and a special mattress. R245's Care Plan initiated on 01/09/25 indicated she was dependent on staff assistance for bed mobility, transfers, toileting, bathing, dressing, and personal hygiene. The plan noted she was at risk for impaired skin integrity and pressure ulcers. The plan instructed staff to provide preventative skin care, turning/repositioning, weekly skin checks, and provide a pressure redistribution mattress. A review of the low air-loss mattress manufacturer's operation (Meridian Medical) manual indicated the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range selected. R245's EMR under Vitals revealed she weighed 228.1 pounds (lbs.) on 03/21/25. On 03/24/25 at 09:20 AM, R245 slept in her bed. R245's bed was set to a low height with her call light next to her bed within reach. R245's low air-loss mattress was set to 400 lbs. (maximum setting). The mattress pump had fixed weight settings of 80 lbs, 110 lbs, 140 lbs, 170 lbs, 200 lbs, 230 lbs, 260 lbs, 290 lbs, 320 lbs, 350 lbs, and 400 lbs. On 03/24/25 at 12:35 PM, R245 rested in her bed. Her low air-loss mattress pump was set at 400 lbs. On 03/25/25 at 08:01 AM, R245's low air-loss mattress pump was changed to a firmness pump. On 03/27/25 at 09:52 AM, Certified Nurse's Aide (CNA) N stated staff just checked to make sure the pump was turned on and the bed was inflated. She stated some of the mattresses were calculated by the resident's weight. On 03/27/25 at 10:32 AM, Licensed Nurse I stated staff were expected to ensure the low air-loss mattress was functioning and turned on. She stated the beds were set by the resident's current weight. On 03/27/25 at 11:32 AM, Administrative Nurse D stated most of the mattresses in the facility were set by comfort settings but some of them went by what the resident weighed to ensure the correct pressure was being applied. The facility's Skin Integrity and Pressure Ulcer- Prevention and Management policy revised 08/2021 indicated the facility implements individualized interventions based on each resident's comprehensive assessment and risk. The policy noted the facility will implement interventions that prevent pressure-related injures to include repositioning, comprehensive skin assessments, safe lifting devices, and pressure redistribution surfaces. 41037 - R55's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance with personal care, muscle weakness, and pneumonitis due to inhalation of food and vomit (an inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R55 had bilateral upper and lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R55 was dependent on staff assistance for his activities of daily living (ADL). The MDS documented R55 was independent with mobility in a motorized wheelchair. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The MDS documented R55 had a pressure reducing device on his bed and in his wheelchair. The MDS lacked documentation R55 was provided a restorative nursing program during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R55 had bilateral upper and lower limitation in ROM. The MDS documented R55 was dependent on staff assistance for his ADLs. The MDS documented R55 was dependent on staff assistance for wheelchair mobility. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers. The MDS documented R55 had a pressure reducing device on his bed and in his wheelchair. The MDS lacked documentation R55 was provided a restorative nursing program during the observation period. R55's Pressure Ulcer Care Area Assessment (CAA) dated 08/15/24 documented he was at risk of development of pressure ulcers due to his fluid deficit, his current ADL status, and his functional ability. R55's Care Plan dated 08/07/23 documented a pressure reducing mattress was placed on his bed. The plan of care dated 11/09/23 documented a low air loss mattress was placed R55's bed. Review of R55's clinical record lacked documentation of monitoring his low air loss mattress function. On 03/25/25 at 08:16 AM, R55 laid on his bed, head of the bed was slightly elevated. R55's bed was elevated three feet of the floor and the low air mattress was unplugged from the wall and not functioning. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated staff just checked to make sure the pump was turned on and the bed was inflated. She stated some of the mattresses were calculated by the resident's weight. On 03/27/25 at 10:32 AM, Licensed Nurse I stated staff were expected to ensure the low air-loss mattress was functioning and turned on. She stated the beds were set by the resident's current weight. On 03/27/25 at 11:32 AM, Administrative Nurse D stated most of the mattresses in the facility were set by comfort settings but some of them went by what the resident weight to ensure the correct pressure was being applied. The facility's Skin Integrity and Pressure Ulcer- Prevention and Management policy revised 08/2021 indicated the facility implements individualized interventions based on each resident's comprehensive assessment and risk. The policy noted the facility will implement interventions that prevent pressure-related injures to include repositioning, comprehensive skin assessments, safe lifting devices, and pressure redistribution surfaces.

The facility identified a census of 96 residents. The sample included 20 residents with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)55 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R55 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R55's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance with personal care, muscle weakness, and pneumonitis due to inhalation of food and vomit (an inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R55 had bilateral upper and lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R55 was dependent on staff assistance for his activities of daily living (ADL). The MDS documented R55 was independent with mobility in a motorized wheelchair. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The MDS documented R55 had a pressure reducing device on his bed and in his wheelchair. The MDS lacked documentation R55 was provided a restorative nursing program during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R55 had bilateral upper and lower limitation in ROM. The MDS documented R55 was dependent on staff assistance for his ADLs. The MDS documented R55 was dependent on staff assistance for wheelchair mobility. The MDS documented R55 had a feeding tube. The MDS documented R55 was at risk for development of pressure ulcers. The MDS documented R55 had a pressure reducing device on his bed and in his wheelchair. The MDS lacked documentation R55 was provided a restorative nursing program during the observation period. R55's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/15/24 documented risk factors included self-care deficits, falls, decreased socialization, bowel and bladder incontinence, skin breakdown, weight loss, and fluid imbalance. The facility would care plan his current ADL status. R55's Care Plan dated 11/14/24 documented staff would apply palm grips on bilateral hands. The plan of care documented R55 was to wear the palm grips four to six hours a day seven days a week. The plan of care documented the staff would monitor his skin integrity, pain, and circulation. The plan of care documented nursing staff would provide a passive ROM program to R85's upper extremities, with stretching, flexion, and extension of his digits, wrists, and shoulders. The plan of care documented nursing staff would provide the restorative program up to 15 minutes per day and up to seven days a week. Review of R55's clinical record under the Medication Administration Record (MAR), under the Treatment Administration Record (TAR), and under the Reports tab for the Documentation Survey Report form 01/01/25 to 03/25/25 (84 days) lacked documentation of a nursing restorative program and application of his palm grippers. On 03/24/25 at 09:44 AM, R55 laid flat on his bed with his enteral feeding (within or via the small intestine). R55's enteral formula container and clear bag was undated and unlabeled. R55's hair looked oily and had a body odor noted. R55's bilateral hands were clenched tightly closed without any type of contracture prevention device. On 03/25/25 at 08:16 AM, R55 laid on his bed, head of the bed was slightly elevated. R55's bed was elevated three feet of the floor with siderails up in place bilaterally. R55's push button call light was attached to the right siderail and hung off the bed out of his reach. R55's bilateral hands were clenched tightly closed with no palm grippers in place. On 03/26/25 at 07:35 AM, R55 laid on his bed with elevated three feet off the floor. Bilateral side rails up and locked in place R55's hand was tightly clenched closed with no palm grippers in place. On 03/26/25 at 09:12 AM, Administrative Nurse D stated she did not believe R55 had any type of contracture preventive devices. She would have to review his chart. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated if R55 was to wear palm grippers usually the therapy department would apply them and remove them. CNA N stated if nursing staff would be responsible to apply his palm grippers therapy would educate the staff about the application and removal of palm grippers. CNA N stated if a resident a restorative program of splint application that would be documented on the POC under the Tasks tab. On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated therapy would usually apply the hand grippers and monitor the amount of time to be worn and removed. LN I stated if nursing was responsible for the application of the On 03/27/25 at 11:36 AM, Administrative Nurse D stated she had found R55's palm grippers and was going to have the therapy department reevaluate his contractures. The facility's Restorative Nursing policy last revised 09/20/24 documented to promote the resident 's optimum function, a restorative program would be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities. Restorative programs may be initiated by nursing and /or therapy.

45668 The facility reported a census of 96 residents with 20 residents sampled. Based on observation, interview, and record review the facility failed to provide timely incontinenct care to Resident (R) 81, to prevent an incontinence episode during the lunchtime meal in the dining room, which left a puddle of urine on the floor by the resident. This failure placed the resident at risk for potetial negative psychosocial well-being, due to embarassment and frustration. The facility staff also failed to ensure they educated R10 regarding keeping the urinary catheter bag below the level fo the bladder, in order to prevent the potential infection control issue, which could lead to urinary tract infections. Findings included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), obstructive uropathy (blockage in the urinary tract), benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and history of falls. R10's Quarterly Minimum Data Set (MDS) completed 12/26/24 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted he used a wheelchair for mobility. The MDS noted he required substantial to maximal assistance with dressing, bed mobility, bathing, transfer, personal hygiene, and toileting. The MDS noted he had an indwelling urinary catheter (Foley Catheter - tube placed in the bladder to drain urine into a collection bag). R10's Urinary Incontinence Care Area Assessment (CAA) completed 04/24/24 indicated he was at risk for urinary tract infections (UTI) and discomfort related to his medical diagnoses. The CAA noted staff would monitor for abnormalities related to his Foley catheter. R10's Care Plan initiated on 09/04/19 indicated he required supervision to touch assistance from staff for bed mobility, transfers, dressing, personal hygiene, toileting, and bathing. The plan noted he had an indwelling urinary catheter due to obstructive uropathy. The plan instructed staff to provide catheter care each shift and ensure the catheter tubing and urine collection bag remained below the level of the bladder. The plan instructed staff to monitor the tubing for kinks. On 03/24/25 at 09:30 AM, R10 lay in his bed asleep. R10's catheter collection bag was placed on the side of his bed. The urine collection bag was above the level of his bladder and urine pooled in the tubing of his urinary catheter. On 03/24/25 at 02:15 PM, R10 sat in his wheelchair in the front hallway. R10's urine collection bag was hung off his armrest on the left side of his wheelchair. Bright yellow urine pooled in the catheter tubing. On 03/25/24 at 07:13 AM, R10 sat in his wheelchair in the front hallway. His urinary catheter collection bag hung off the left side handrail of his wheelchair. R10 sat in the lobby with his catheter bag above his bladder level. The bag hung off his armrest until he returned to his bed to rest after breakfast. On 03/27/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R10 catheter tubing and urine collection bags must be hung below the level of the bladder to prevent infections. On 03/27/25 at 10:30 AM, Licensed Nurse (LN) I stated catheter bags need to remain below the level of the resident's bladder to prevent backflow of old urine into the bladder. On 03/27/25 at 11:32 AM, Administrative Nurse D stated staff were expected to ensure each catheter was positioned below the resident's bladder. She stated that R10 liked to place his catheter bag on his wheelchair armrest, but it still was an infection risk. The facility's Indwelling Urinary Catheter Management policy issued 06/2023 indicated the facility was to ensure standards of practice were followed to ensure safe and sanitary urinary catheter care. The policy indicated staff were to ensure unobstructed urine flow within the catheter by inspecting the tubing for kinks, frequent emptying, and maintaining the catheter collection bag below the level of the resident's bladder. 49634 - R81's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), hyperlipidemia (condition of elevated blood lipid levels), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), insomnia (inability to sleep), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), unsteady on feet, lack of coordination, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and palliative treatment (treatment designed to relieve or reduce the intensity of uncomfortable symptoms). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R81 required set up and clean up for eating and oral hygiene, partial to moderate assistance from staff for toileting, and substantial to maximum assistance with bathing. The MDS documented R81 did not have a bladder program and was frequently incontinent. R81's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 03/07/25 documented R81's risk factors included skin breakdown, falls, and recurrent UTI's. The CAA documented the care plan would reflect current toileting skills. R81's Care Plan dated 09/21/24 documented R81 had urinary incontinence and would have no skin breakdown related to urinary incontinence, staff would provide peri care as needed. On 03/24/25 at 12:12 PM, R81 sat in the large dining room, R81 was incontinent of bladder. R81's bladder incontinence left a puddle of urine on the floor, in the area where other residents were eating lunch. On 03/27/25 at 09:46 AM, Certified Nurse Aide (CNA) M stated residents should be asked if they need toileted more often. CNA M stated most of the residents are toileted before meals, or before they were laid down. On 03/27/25 at 10:02 AM, Licensed Nurse (LN) G stated all nursing staff were responsible to ensure residents were toileted as needed. She stated nursing should anticipate the resident's needs. On 03/27/25 at 11:36 AM, Administrative Nurse D stated staff should anticipate the resident's needs, and ask residents more often. She stated staff know the residents well and can anticipate their needs. The facility's Bowel and Bladder Program policy dated 09/24/24 documented the facility would ensure that a resident who was continence of bladder on admission receives care, including assistance, and service to maintain continence unless their clinical condition was or becomes such that continence was not possible to maintain. The facility would ensure that a resident who was admitted with incontinence of bladder, receives appropriate treatment and service to prevent urinary tract infections and to restore as much normal bladder function as possible.

The facility identified a census of 96 residents. The sample included 20 residents, with three sample residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 4 had her physician-ordered supplemental oxygen on as ordered. The facility failed to ensure R4's nasal cannula (NC - a thin hollow tube that assists in providing supplemental oxygen) was appropriately stored when not used. The facility failed to ensure R43'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) mask was stored appropirately when not in use. This deficient practice placed R4 and R43 at risk of respiratory complications and possible infection. Findings included: - R4's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (a condition where the lungs are unable to adequately perform their primary function of gas exchange), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and dementia (a progressive mental disorder characterized by failing memory and confusion). R4's Annual Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) scored of nine which indicated moderately impaired cognition. R4 required partial assistance from staff for the activities of daily living (ADL). R4 required oxygen therapy (the administration of oxygen at concentrations greater than that in ambient air). R4's Functional Abilities Care Area Assessment (CAA) dated 06/18/24 documented she was at risk for functional decline due to COPD, impaired mobility, CHF, and multiple co-morbidities. Staff would continue to monitor R4 and provide assistance daily. R4's Care Plan last revised on 01/24/25 directed staff that she was on oxygen therapy related to COPD. Staff were directed that R4 was to be administered oxygen at three liters via NC. Staff were directed to observe for signs and symptoms of respiratory distress and report it to the physician. R4's Order Summary documented a physician's order dated 12/11/19 for oxygen at three liters per minute per NC for COPD. R4's Order Summary documented a physician's order dated 06/19/19 to clean oxygen concentrator (a machine that provides supplemental oxygen) filter with soap and water weekly every Sunday. R4's Order Summary documented a physician's order dated 08/07/24 to check oxygen saturation (percentage of oxygen in the blood) every shift. R4's Order Summary documented a physician's order dated 03/19/25 to change oxygen tubing every Sunday on night shift. On 03/25/25 at 07:39 AM, R4 laid on her bed resting. R4's oxygen concentrator was on in her room and the oxygen NC was laid on her bedside table and was not bagged. On 03/26/25 at 08:02 AM, R4 ambulated down the hallway, with the assistance of a walker. R4 did not have her supplemental oxygen on. On 03/27/25 at 10:15 AM, R4 sat on the side of her bed watching tv. R4's oxygen concentrator was on, but she did not have the NC in her nose. The NC laid on her bed, unbagged. On 03/27/25 at 10:30 AM, Certified Nurse Aide (CNA) P stated R4 was aware that she was to always have her supplemental oxygen on, but she would put on and take off her NC when she wanted. CNA P stated R4's NC should be stored in a bag when it was not in use. CNA P stated when R4 took her NC off she would not place it in the provided bag. On 03/27/25 at 10:40 AM, Licensed Nurse (LN) H stated she was aware that R4 was supposed to have her oxygen on all the time, but she put it on and took the NC off when she wanted to. LN H stated R4 did not have a portable oxygen tank to take with her when she walked with her walker. LN H stated R4 was reminded frequently to use her supplemental oxygen and to put the NC in the provided bag when she did not have it on, but R4 was very forgetful. On 03/27/25 at 11:37 AM, Administrative Nurse D stated R4 was non-compliant a lot with her supplemental oxygen. Administrative Nurse D stated R4's care plan should reflect that she refused to have her supplemental oxygen on. Administrative Nurse D stated R4's NC should be stored in the provided bag when not being used and that R4 would not always remember to place the NC in the bag. The facility's Oxygen Administration (Safety, Storage, Maintenance) policy revised on 10/11/24 documented to assure that oxygen was administered and stored safely within the healthcare centers or in an outside storage area. An oxygen order should be written for specific liter flow required. Oxygen supplies should be changed weekly and when visibly soiled. The equipment should be labeled with the resident's name and dated when setup or changed out. Oxygen and respiratory supplies should be stored in a bag labeled with the resident's name when not in use. The facility failed to ensure R4 had her physician-ordered supplemental oxygen on as ordered. The facility failed to ensure R4's NC was appropriately stored when not used. This deficient practice placed R4 at risk of respiratory complications and possible infection. 49634 The facility identified a census of 96 residents. The sample included 20 residents, with three sample residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure R43'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) mask was stored appropriately when not in use. This deficient practice placed R4 and R43 at risk of respiratory complications and possible infection. Findings included: - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertensive heart disease (a condition where hypertension (high blood pressure) damages the heart muscles over time), heart failure (a condition of low heart output), diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), respiratory failure (a condition where the lungs struggle to exchange oxygen and carbon dioxide effectively, leading to low oxygen levels in the blood (hypoxemia) and or high carbon dioxide levels (hypercapnia)), obesity (excessive body fat), bed confinement status, and palliative treatment (treatment designed to relieve or reduce the intensity of uncomfortable symptoms). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R43 was dependent on staff for toileting, dressing, and bathing. The MDS documented R43 required set up and clean up for eating. The MDS documented R43 was on hospice. The Quarter MDS dated [DATE] documented a BIMS of 15 which indicated intact cognition. The MDS documented R43 was dependent on staff for toileting, dressing, and bathing. The MDS documented R43 required set up and clean up for eating. The MDS documented R43 was on hospice. The MDS documented R43 used a noninvasive mechanical ventilator (a medical procedure that uses a machine to assist or take over the work of breathing). R43's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 01/10/25 documented R43's risk factors include further activities of daily living (ADL) decline, falls, incontinence, skin breakdown, and pain. The MDS documented R43's care plan would reflect current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk. R43's Care Plan date 07/17/24 documented R43 had altered respiratory status and difficulty breathing related to sleep apnea (a disorder of sleep characterized by periods without respirations), staff were to observe for changes in orientation, increased restlessness, anxiety, and air hunger. The plan documented staff were to position R43 with proper body alignment for optimal breathing pattern. R43's EMR under the Orders tab revealed the following physician orders: CPAP, fill humidifier with sterile or distilled water every shift dated 07/01/24. CPAP Clean reservoir with warm soapy water, rinse; set out to dry everyday shift, seven days dated 07/02/24. Clean CPAP mask with warm soapy water, rinse, and air dry as needed dated 07/02/24. CPAP on while sleeping/napping and off while awake every shift dated 07/02/24. On 03/25/25 at 08:25 AM, R43 laid on his bed looking at his iPad. R43's CPAP laid in his windowsill; the CPAP was not stored in a sanitary manner. On 03/27/25 at 10:02 AM Licensed Nurse (LN)H stated all respiratory equipment should be placed in an appropriate bag labeled with the resident's name when the resident was not using the equipment. She stated R43 would not have been able to place the mask in the windowsill. On 03/27/25 at 10:52 AM, Certified Nurse's Aide (CNA) N stated R43 was able to take off his mask but was not able to place his mask in the windowsill. She stated the mask should be in a bag when not in use. On 03/27/25 at 11:36 AM, Administrative Nurse D stated all respiratory equipment should be stored in a sanitary manner when not in use. The facility did not provide a policy pertaining to the storage of respiratory equipment when not in use.

The facility identified a census of 96 residents. The sample included 20 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 24's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of PTSD, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R24 had no behaviors during the observation period. The MDS documented R24 had an active diagnosis of PTSD. The Quarterly MDS dated [DATE] documented a BIMS score of five which indicated severely impaired cognition. The MDS documented R24 had no behaviors during the observation period. The MDS documented R24 had an active diagnosis of PTSD. R24's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/14/24 documented her risk factors included self-care deficits, falls with possible injuries, incontinence, decreased socialization, skin breakdown, weight loss, and fluid imbalance. R24's Care Plan dated 09/23/21 documented staff would analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The plan of care lacked individualized triggered-specific interventions that identified ways to decrease exposure to triggers which could re-traumatize her. On 03/25/25 at 07:17 AM, R24 sat in her wheelchair next to the bed with the lights off in the room. On 03/27/25 at 09:52 AM, Certified Nurse Aide (CNA) N stated she was not aware R24 had a diagnosis of PTSD. CNA N stated R24 would often yell out. CNA N stated she would expect to find the information of R24's PTSD which included what might possibly re-traumatize her. CNA N stated she would also expect to find the interventions that would help address R24's trauma. On 03/27/25 at 10:37 AM, Licensed Nurse (LN) I stated R24's diagnose of PTSD could explain why that R24 yelled out frequently. LN I stated she would expect what had happened to cause the PTSD and what interventions that were in place to prevent re-traumatization on the care plan. On 03/27/25 at 11:00 AM, Social Services Staff X and Social Services Staff Y stated R24's last Trauma Informed Care assessment was completed on 02/26/20. Social Services Staff X and Social Services Staff Y stated the trauma-based assessment would only be assessed at the time of admission and only if Administrative Nurse D would request a reassessment. Social Services Staff X and Social Services Staff Y stated the MDS coordinator would be responsible to develop R24's care plan. Social Services Staff X and Social Services Staff Y stated R24 would not require any increased monitoring due to her diagnosis of PTSD. On 03/27/25 at 11:36 AM, Administrative Nurse D stated she would expect to find R24's PTSD addressed on her care plan. Administrative Nurse D stated she was not sure the frequency R24 should be assessed for her trauma-based care. Administrative Nurse D stated that would be handled by the social service department. The facility's Trauma-Informed Care policy last reviewed 09/06/24 documented based on the comprehensive assessment of a resident, this facility must ensure that residents who are diagnosed mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being. The facility must ensure that residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Trigger-specific interventions would identify ways to decrease the resident 's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. The facility would monitor the effects of their approaches to ensure they are implemented as intended and are having the desired effect to achieve the measurable objectives and the resident's goals for care. For residents with a history of trauma in particular, the facility should evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. Remember to involve the resident and/or his or her family or representative in this evaluation to ensure clear and open discussion and better understand if interventions must be modified.

The facility identified a census of 90 residents. The sample included three residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to ensure an environment free from preventable accidents for Resident (R) 1. On 04/30/24, Certified Nurse Aide (CNA) M was providing incontinence (lack of voluntary control over urination or defecation) care for R1 when she noticed R1 was close to the edge of the bed. She moved her hand to wipe R1's buttocks and R1 rolled off the bed onto the floor. R1 was sent to the Emergency Department (ED) for evaluation and treatment where he received 13 staples for a laceration to his scalp because of the fall. The deficient practice also placed the resident at risk for increased pain and a further decline in mobility. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (cerebrovascular accident [CVA]- the 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), quadriplegia (paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), lack of coordination, and generalized muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had short-term and long-term memory problems and his cognitive skills for daily decision-making were severely impaired. R1 had impairment on both sides of the upper and lower extremities. R1 was dependent on staff for activities of daily living (ADLs). R1 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel movements. R1 had no falls since the last assessment. The Quarterly MDS dated [DATE], documented R1 had short-term and long-term memory problems, and his cognitive skills for daily decision-making were severely impaired. R1 had impairment on both sides of the upper and lower extremities. R1 was dependent on staff for ADLs. R1 had an indwelling catheter and was always incontinent of bowel movements. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/14/24, documented R1 had cognitive-communication deficits related to memory problems and risk factors included self-care deficits, falls, and incontinence. The Urinary Incontinence and Indwelling Catheter CAA dated 03/14/24, documented R1 had a foley catheter (indwelling catheter) which placed him at risk for infection and injury if it dislodged. R1's Care Plan dated 01/08/19, documented R1 had an ADL self-care performance deficit related to CVA with deficits, bilateral upper and lower extremity contractures (abnormal permanent fixation of a joint), and quadriplegia. The plan documented an intervention, revised 09/21/22, that directed R1 was totally dependent on one to two staff for repositioning and turning in bed on rounds and as necessary. The plan documented an intervention, revised on 04/21/23, that R1 was dependent on one staff for incontinence care. R1's EMR revealed an Event Note on 04/30/24 at 11:04 PM. The note documented the nurse was notified that R1 was on the floor. Upon entering R1's room, R1 was lying on the floor, facing the window with his head bleeding. CNA M stated she assisted R1 when he rolled over, and he fell when she reached for wipes from the other side. R1 had an open area on the upper head that was bleeding and the nurse applied pressure to the wound to stop the bleeding. Staff helped R1 off the floor and called Emergency Medical Services (EMS) to transfer R1 to the ER for further evaluation. R1's EMR revealed Discharge Instructions, dated 05/01/24, for his ED visit on 04/30/24. The instructions documented R1 had a scalp laceration and was to return to the ED in 10 days for staple removal. The facility's investigation, dated 05/07/24, documented on 04/30/24 at approximately 09:30 PM, CNA M went to R1's room to provide perineal (the region of the body between the anus and the genital organs) care. CNA M stated she attempted to clean bowel movement off R1 when she noticed he was close to the edge of the bed. She stated when she moved her hand to wipe R1's buttocks, he rolled off the side of the bed onto the floor. CNA M immediately notified Licensed Nurse (LN) G. LN G reported when he entered R1's room, R1 was lying on the floor with his head bleeding. LN G performed first aid and applied gauze to the laceration on the top of R1's scalp. LN G obtained orders from the on-call physician to send R1 to the ED for further evaluation. R1 returned to the facility after receiving 13 staples to the midline of his scalp. In an undated Witness Statement, CNA M stated on 04/30/24 around 09:15 PM, she assisted R1 by changing him. She stated she was told by another CNA that R1 was a one-person assist, so she went to change him. CNA M stated she was holding onto R1 while trying to clean bowel movement off him and noticed he was close to the edge. She stated she moved her hand to wipe R1 and he rolled off the side of the bed. CNA M stated she told LN G what happened, and he assisted with R1. On 06/25/24 at 01:30 PM, R1 lay in bed, positioned on his right side with his eyes closed. On 06/25/24 at 01:49 PM, LN H stated after R1 fell out of bed on 04/30/24, there was an investigation and education was completed. She stated he now required two staff with bed mobility and incontinence care. LN H said R1 was stiff and contracted and he was difficult to move so it was better to have two staff. On 06/25/24 at 02:08 PM, Administrative Nurse D stated after R1 fell out of bed, staff were educated to make sure the resident was closer to the staff before turning the resident. She stated R1 required one to two staff with bed mobility but was changed to two staff with bed mobility after the fall. On 06/25/24 at 02:58 PM, CNA N stated if a resident was heavy or on the edge of their bed, there should be two staff. She stated she had access to the care plan which had bed mobility requirements. CNA N stated two staff provided bed mobility with R1. She stated if she rolled a resident over and noticed they were on the edge of the bed, she laid them back down and got assistance. On 06/25/24 at 03:04 PM, LN I stated the care directive on the tablets and the care plan directed staff on resident assistance in bed. She stated if the resident was on the edge of the bed when rolled over, the staff brought the resident back to the middle of the bed and got assistance to prevent them from rolling off the bed. On 06/25/24 at 03:07 PM, Administrative Nurse D stated the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) directed the level of assistance with bed mobility and positioning. She stated she expected staff to pull the resident over to them to give them plenty of room to turn the resident. Administrative Nurse D stated she expected staff to know their own and the resident's limits, follow the Kardex, and ask for help for residents the staff did not know. On 07/01/24 at 11:51 AM, CNA M stated on 04/30/24, she asked one of the CNAs if R1 required one-person or two-person assistance and she was told he required one-person assistance. She stated R1 was in the middle of the bed facing the wall and she had her hand on him, but she could not reach his call light. CNA M stated she tried to reach for a wipe and R1 rolled off the bed. She stated she noticed he was close to the edge of the bed when she started incontinence care. She stated he did not move because he was contracted, and she did not know how to explain what happened. The facility's Fall Management policy, revised 04/07/22, directed an avoidable accident occurred when the facility failed to implement interventions including adequate supervision consistent with the resident's needs, goals, care plan, and current professional standards in practice to eliminate the risk of an accident. The facility's Activities of Daily Living policy, revised 02/12/24, directed for bed mobility, staff utilized appropriate safety measures and any necessary equipment to maintain resident safety. The facility failed to prevent a fall with injury for R1. The deficient practice also placed the resident at risk for increased pain and a further decline in mobility. The facility put the following corrections into place by 05/11/24: R1 went to the ER for evaluation and treatment on 04/30/24. R1's Care Plan was updated to include two staff for repositioning and turning in bed on 05/05/24. Staff received education on safe transfers/fall prevention from 05/01/24 to 05/11/24. Due to the corrective actions completed prior to the onsite survey, the deficient practice was cited as past noncompliance, with the scope and severity of G.

The facility reported a census of 94 residents, with three residents sampled for accidents with a mechanical lift. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from accident hazards on 02/20/24 when Certified Nurse Aide (CNA) E used a mechanical lift by himself, while transferring R1. As a result, R1 fell from the full body mechanical lift and fractured her pelvis. This failure placed R1 in immediate jeopardy and placed 30 residents, who required a full body mechanical lift for transfers, at risk for injury. Findings Included: - R1's diagnoses from the Electronic Health Record (EHR) included osteomyelitis (local or generalized infection of the bone and bone marrow), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 12/14/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R1 had range of motion impairments on both sides of her lower extremities. The 12/14/23 Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R1 required substantial to total assistance of staff for all ADLs and mobility. The resident had MS and functional quadriplegia (paralysis of all four extremities and sometimes he trunk and internal organs), which placed R1 at further risk for falls. The 12/09/23 Care Plan revealed an 05/25/23 intervention that R1 required the use of a mechanical lift with two staff assistance for transfers. The 12/08/23 Fall Risk assessment documented R1 was a fall risk. The Progress Note dated 02/20/24 at 05:08 PM documented R1 fell during a mechanical lift transfer with CNA E. CNA E indicated R1 slid out of the sling and hit her head on the bed frame, and then he assisted her to the floor. R1 stated she had pain in her neck and the back of her head. On 02/20/24 at 12:00 AM, the Progress Note documented R1 recently had a fall and was sent to a local hospital. X-rays revealed a left pubic rami fracture (type of pelvic fracture) which was non-operable. When R1 returned to the facility, R1 had increased pain and an analgesic prescribed for the pain. On 02/20/24, a Witness Statement by CNA E, revealed at approximately 04:30 PM, R1 was about to be transferred from her electric wheelchair to her bed with the mechanical lift and CNA E lifted R1 from the electric wheelchair, and she began to slide from the sling. R1 held onto CNA E's left hand and CNA E lowered R1 to the floor. CNA E then notified the charge nurse. On 02/20/24, a Witness Statement by CNA F, revealed Licensed Nurse (LN) D asked CNA F and CNA G to answer a call light that had been on for a while. They went down to the room, opened the door and R1 was on the floor with no sling around her, and CNA E stood over R1. The lift was behind CNA E and the only sling in the room was crumpled in a ball on her bed. They immediately informed the charge nurse. On 02/20/24, a Witness Statement by CNA G, revealed CNA G was at the nurse station when LN D asked her to go and answer the call light because the resident in the room (roommate) called and she could not understand what she was saying. CNA G went with CNA F and opened the door and saw R1 lying on the floor with CNA E standing over her. The mechanical lift was behind the door and the sling was on her bed. CNA G went back to the nurse station and informed the nurse that R1 was on the floor. On 02/20/24, a Witness Statement by LN D, documented she was at the nurse station when a unit manager alerted her that R1's roommate had called saying R1 fell out of the sling during a transfer to bed. Two CNAs went to the room and came back to report R1 fell . LN D ran down to the room and saw R1 on her back, on the floor, with her head under the bed frame. CNA E reported he attempted to transfer R1 by himself. R1 stated she hit her head and her left leg/thigh hurt. LN D and CNA E placed the mechanical lift sling under R1 and transferred R1 back into bed. Orders obtained (later) and R1 transferred to a local hospital at 06:38 PM. On 02/20/24, a Witness Statement by LN C, documented she answered a phone call from a resident stating she needed help in the room. LN C sent two CNAs to the room to see what she needed. The two quickly returned and stated that R1 was on the floor. When LN C and LN D got to R1's room, they saw CNA E in the room with the mechanical lift above R1, who was on the floor on her back. R1's head was under the bed. CNA E stated he tried to transfer R1 by himself and had to lower her to the floor. R1 stated she hit her head and her leg hurt. After completion of a head-to-toe assessment and neurological assessment, LN C, LN D, and CNA E used a mechanical lift to put R1 back into bed. On 02/29/24 at 12:20 PM, R1 sat in her bed. R1 stated she had her call light on to get staff assistance to the commode. R1 reported staff administer medications for the pain. Two unidentified CNAs entered the room to transfer R1 with a full body mechanical lift. On 02/29/24 at 11:39 AM, Administrative Nurse B stated she expected all nursing staff to know the appropriate and safe protocol with a mechanical lift. Administrative Nurse B stated she always expected two staff present with the use of a mechanical lift. On 02/29/24 at 12:30 PM, LN C revealed at the time of the fall she had received a call from R1's roommate and could not really understand all she was saying, so she sent two CNAs down to her room to find out what she needed. They came back and told her that R1 was on the floor. She stated CNA E transferred R1 by himself. LN C said there should always be at least two staff when transferring a resident with a mechanical lift. The facility's policy for Limited Lift Program (Safe Patient Handling) revised 08/09/23, documented the facility would provide education, upon hire and annually, to associates on the proper use of lifts in accordance with the manufacturer guidelines. The education would include the need to have two associates present during the transfer. The facility failed to ensure Resident (R)1 remained free from accident hazards when CNA E used a mechanical without two staff present, on 02/20/24, and R1 fell from the full body mechanical lift and fractured her pelvis. On 02/29/24 at 02:00 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) Template and notified the failure to ensure R1, who required a mechanical lift, remained free from accident hazards when one staff attempted to transfer a resident that required a mechanical lift without another staff member. The facility identified and implemented the following corrective actions completed 02/22/24 at 04:15 PM. 1. Inspection of the full body mechanical lift sheet for tears or frays, completed on 02/21/24 at 03:00 PM. 2. Hoyer (full body mechanical lift) education initiated on 2/21/24. Those not present received phone education, with the last education on 02/22/24 at 04:15 PM. 3. CNA E suspended on 02/21/24 at approximately 10:00 AM and terminated at approximately 03:00 PM per phone call. 4. Quality Assurance Performance Improvement (QAPI) meeting held on 02/21/24 at approximately 12:00 PM. 5. Education of nursing and therapy related to safe Hoyer transfers held on 02/21/24. 6. Audits of resident that required mechanical lift to verify the transfer status, correct sling size, how staff could access the information, completed on 02/21/24 at 05:00 PM. Due to the actions identified and implemented prior to the onsite visit, the deficient practice was deemed past noncompliance at a J scope and severity.

The facility reported a census of 88 residents, with three residents sampled for accidents. Based on observations, record review, and interview, the facility failed to follow Resident (R) 1's care planned, which required total dependence of two staff for toilet use. R1 slid out of his bed when Certified Nurse Aide (CNA) M failed to follow the resident's care plan and have an additional staff member present to assist with toileting. The resident slid out of his bed during cares and sustained a fracture to his right knee. Findings included: - R1's signed Physician Order Sheet, dated 07/31/23, documented the facility admitted the resident on 08/07/23. The resident's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) left dominant side contracture (shortening) of muscle, left foot, ankle & right contracture, unsteadiness on feet, fracture (broken bone) of lower end of right femur (thigh bone) subsequent encounter for closed fracture with routine healing. The 05/08/23 Significant Change of Condition ((MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. He required total dependence of two staff for toileting, bed mobility, and transfers. The resident did not ambulate. The resident was not steady, and only able to stabilize with staff assistance. He had impairment to upper and lower extremities, used a mechanical lift for transfers, and wheelchair for mobility device. The 05/08/23 Fall Care Area Assessment (CAA), documented the resident as at risk for fall related to injury secondary to impaired balance and hemiplegia and hemiparesis following a cerebral vascular accident. The Activities of Daily Living Care Plan dated 09/15/21 documented the resident required two staff assistance with the use of a mechanical lift. The Fall Risk Evaluation dated 05/05/23 revealed a score of 12, which indicated a high risk for falls. The Nursing Notes revealed on 08/04/23 at 11:06 AM Certified Nurse Aide (CNA) M notified Licensed Nurse (LN) G on 08/04/23 at 10:50 AM that R1 slid off of the bed when he repositioned himself to change his brief. CNA M asked CNA N to assist her with the mechanical lift to transfer the resident from the floor to the resident's bed. LN M completed a head-to-toe assessment on the resident. The resident complained of right knee pain. The resident's health care provider was notified to obtain an x-ray of the resident's right knee. The Mobile X-Ray results, dated 08/04/23, documented the resident had a displaced fracture of the distal femoral metaphysis of the right knee. Review of the facility Investigation, dated 08/11/23, revealed on 08/04/23 at approximately 10:50 AM, CNA M reported that R1 turned on his call light and asked to have his brief changed, due to an incontinence episode. While CNA M changed the resident, he grabbed the bed rail to assist CNA M to position him on his right side. The resident's feet slid off of the bed and his body followed him onto the floor. The resident reported to LN G when she entered the room, as the resident still laid on the floor, that he slid off of the bed to the floor while CNA M provided perineal care. The resident denied hitting his head. LN G observed R1's right extremity was warm to touch, slightly pink, and had limited range of motion. The facility health care provider was notified. The results of the right knee x-ray revealed a fracture to distal femoral metaphysis. Orthopedic surgery was consulted for further evaluation and management and the surgeon's progress note noted the resident had osteopenia (bones are weaker than normal but not so far gone that they break easily). The resident had surgical repair of the fracture on 08/05/23. On 09/07/23 at 11:45 AM, Certified Nurse Aide M and Certified Nurse Aide O transferred R1 with a full body mechanical lift with no concerns. On 09/07/23 at 11:35 AM, R1 reported CNA M was changing his brief and he held onto the grab bar to turn onto his right side. The resident reported that his feet began to slide off of the bed and his body continued to slide until he fell on to the floor. The nursed assessed R1 and an x-ray was done, revealing a fracture to his right knee. He reported he was transferred to the Emergency Department (ED) and then to surgery on his right knee. On 09/11/23 at 09:01 AM LN G reported CNA M did not notify her that R1 had fallen out of bed until he was transferred back into bed. The nurse reported that she observed the resident's right knee was red in color so she notified the health care provided and a mobile x-ray was obtained. The x-ray results identified a fracture R1's right knee. The resident was transferred to the ED for further evaluation and was also admitted to the hospital for surgical repair to his right knee. On 09/11/23 at 02:15 PM, CNA M reported that she did not follow the residents care plan for toilet use. The resident required total dependence of two staff for toileting. The staff member reported that she should have waited for a second staff member before toileting the resident. On 09/11/23 02:00 PM CNA O reported the resident's care plan identified the resident as two-person total dependence for toilet use. On 09/12/23 at 07:57 AM CNA N reported that CNA M called her to assist R1 off of the floor. On 09/12/23 at 04:00 PM Administrative Nurse D reported that CNA M did not follow the dependent resident's care plan for toilet use. The resident required total dependence of two-staff for toilet use. The facilities policy for, Fall Management, dated 09/29/22, documented for staff to assess the resident's risk of an accident and implement measures to reduce the hazards and risks. The facility failed to follow Resident (R)1's care planned intervention of total dependence on two-staff for toilet use. R1 slid out of his bed when CNA M failed to follow the resident's care plan and the resident slid out of his bed and sustained a fracture to his right knee.

The facility reported a census of 82 residents. Based on observation, interview, and record review, the facility failed to provide a safe environment for Resident (R) 1 when the resident left the facility without staff supervision. R1 left the facility, located in a heavily trafficked [NAME] area, without staff knowledge, accepted a ride from an unknown bystander, and was found 8.6 miles from the facility and returned to the facility by police officers. The weather outside at that time the resident left the facility was below freezing at approximately three degrees Fahrenheit, with winds up to 21 miles per hour (MPH). This failure placed the resident in immediate jeopardy. Findings Included: - R1's diagnoses from the Electronic Health Record (EHR) included alcohol abuse, disorientation, abnormal gait (manner or style of walking) and mobility, muscle weakness, and dementia (progressive mental disorder characterized by failing memory, confusion). The 11/18/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) score of nine, indicating moderately impaired cognition. R1 had physical behaviors directed toward others and wandering on one to three days of the seven-day look back period of the assessment. R1 required limited to extensive assistance of one staff with all activities of daily living (ADL). R1 was unsteady, but able to stabilize without staff assistance and used a walker. R1 did not have any range of motion impairments and did not use a wander/elopement alarm (a device/bracelet that sets off an alarm when a resident wearing one attempts to leave the facility without staff supervision). The 11/18/22 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R1 had a history of severe dementia related to a history of alcohol abuse. The 11/18/22 Behavioral Symptoms CAA documented R1 had wandering and exit seeking behaviors. The 11/14/22 Care Plan documented R1 was at risk for elopement and had displayed exit-seeking behaviors. Staff were to encourage R1 to participate in activities of interest or diversional activities as tolerated. Staff were to give medications, which included a nicotine patch, as ordered. Staff were to provide safe wandering (in the locked unit). On 12/23/22, staff added R1 had a wander/elopement alarm in place, staff were to complete an elopement risk evaluation, R1 had an actual elopement, R1 was to have one on one supervision, and R1 had been added to the elopement book, after the elopement. The 12/23/22 Elopement Risk assessment documented R1 as an elopement risk. The 11/10/22 Physician Orders documented an order to admit R1 to the dementia locked unit of the facility. As of 12/07/22 the physician placed an order for Seroquel 25 milligrams (mg) twice daily. As of 12/23/22 staff were to place a wander/elopement alarm on R1 and check placement and functionality each shift. The Progress Note dated 12/18/22 at 11:08 PM, documented R1 watched the doors as he sat in a chair in the hallway most of the evening. R1 walked from one door to the other door often. The Progress Note dated 12/22/22 at 11:22 AM documented R1 reviewed in RISK (a facility meeting of management staff to go over issues in the facility) meeting and continued to display intermittent behaviors and required frequent redirection. The Progress Note dated 12/23/22 at 02:51 PM, documented Certified Nurse Aide (CNA) M reported she gave R1 coffee in his room around 10:20 AM and then went into another resident's room to provide care. Around 11:00 AM, CNA M reported she looked out of the window in the common room that was open and did not see anyone, she then searched rooms down the hall. As she went to report R1 missing to Administrative Nurse F, the nurse immediately initiated a head count of all residents in the facility and an outdoor perimeter search. After approximately 10 minutes of searching outside, staff notified law enforcement of the missing resident. The medical director and R1's daughter were notified of the elopement and the search continued. At 12:05 PM, R1's daughter called the facility and reported law enforcement located R1. At 11:18 AM, law enforcement located R1 at a convenience store 8.9 miles from the facility, with an unknown male member of the community who gave R1 a ride. Law enforcement picked R1 up at the convenience store at 11:18 AM, one hour after facility staff last saw R1, and returned him to the facility at 12:35 PM. The resident wore a white puffer coat and purple gloves, that the facility did not know where the coat and gloves came from. R1 ambulated into the facility and to his room. Staff completed a nursing assessment, with no new skin issues noted, and vital signs were within baseline. Staff notified the Medical Director and received an order to send R1 to a hospital for evaluation. R1 returned to the facility. According to Weatherunderground.com, the temperature between 09:53 AM and 12:53 PM was between three to 10 degrees Fahrenheit with an 18 to 21 mile per hour wind from the west, northwest. The Witness Statement for the incident on 12/23/22 for R1 by CNA M documented R1 was last seen by CNA M around 10:20 AM when she handed R1 a cup of coffee. She then went to assist another resident with cares, when she exited, she saw a housekeeper who had come down the hall from the TV room and she asked her if she saw R1 in the TV room. CNA M then went and looked in the TV room and saw an open window and looked out it but did not see anyone. Together her and the housekeeper looked in the rooms as they walked back down the hall and when R1 was not found, she notified the Administrative Nurse F. The Witness Statement for the incident on 12/23/22 for R1 by Housekeeping Staff U documented she was going to lunch about 11:00 AM and noted the TV room was cold. CNA M then asked her if she saw R1 in that room and she stated she had not, but the room was cold. CNA M asked her to assist with looking for R1. On 12/27/22 at 01:50 PM, R1 laid in his bed in his room covered with blankets. On 12/27/22 at 01:50 PM, R1 stated he remembered walking out in the cold for a bit, he did not remember why he left, if he had fallen, or how he got back. R1 stated he was not afraid of anyone, that he can remember, and that he did not remember where he was going. He did remember a lady giving him a white coat. On 12/27/22 at 02:00 PM the window in the TV room, opposite the window R1 eloped out of, opened with little effort over the tamper resistant screw in the windowsill. Administrative Staff A was brought in to look at the window and confirmed it had been secured, along with all of the windows on the unit, and was unsure how it opened. On 12/27/22 at 03:30 PM, Administrative Nurse E stated that they documented R1's location every 15 minutes, and she confirmed he was not on 15-minute checks prior to the elopement. She stated there were usually two staff on the unit and confirmed on 12/23/22 there was only one staff present. On 12/28/22 at 07:44 AM, Administrative Nurse D stated at the time of the elopement she received a call at approximately 11:08 AM to 11:10 AM informing her the resident was missing. During the call she instructed staff to call law enforcement due to the cold weather. When she arrived at the facility law enforcement was in the building and she went through the timeline with an officer to get specific times. At 10:20 AM, CNA M gave R1 coffee in his room, she then went to provide care for another resident in their room and closed the door. Around 11:00 AM she came out of that room and saw a housekeeper walking down the hall and asked her if R1 was in the TV room. Housekeeping Staff U stated R1 was not in the TV room, but she felt a cold wind in the TV room. CNA M went to the TV room and looked out the open window and saw no one outside. CNA M completed room checks as she came back down the hall. At 11:15 AM, the facility notified law enforcement and at 12:05 PM, law enforcement called the facility and notified them they had R1 in custody. At 12:35 PM, law enforcement returned R1 to the facility. R1 wore a white puffer coat and purple gloves that did not come from the facility. R1 wore two pair of sweatpants, a t-shirt under a sweatshirt, and nonskid socks with house shoes. The officer informed Administrative Nurse D that at 10:51 AM, a concerned citizen called in a hitchhiker and the citizen drove the resident to the convenience store. Law enforcement took custody of R1 at 11:18 AM. The bystander that gave R1 a ride to the convenience store waited with R1 until officers arrived and confirmed he had not given the coat and gloves to R1. Administrative Nurse F followed the footprints in the snow and directed the search for R1. Administrative Nurse D reported that she and a law enforcement officer concluded that R1 was picked up and transported approximately 122 blocks to the location the bystander had given R1 a ride to the convenience store and where law enforcement took custody of R1. Upon his return to the facility, staff placed R1 on one-on-one supervision. On 12/28/22 at 08:26 AM, Administrative Nurse F confirmed she looked at the footprints below the window and they were directly under the window facing out. There were only about four sets that went northeast and then stopped abruptly at the concrete. She then dispatched two staff to search for R1. On 12/28/22 at 08:52 AM, CNA M reported she had only worked on the secured unit a few times and that day was probably the third or fourth time. She reported she always worked alone when she worked on the unit. CNA M stated if she required assistance on the unit, she would need to go to the dining room and call out for someone to come assist her. She stated the nurse and housekeeping did come back to the unit to help at times. CNA M reported on 12/23/22, she gave R1 a cup of coffee in his room, she then went into another resident's room to assist them with incontinence care. About 20-25 minutes later, she came out of that room and R1 was not in his room. CNA M stated she saw housekeeping staff in the hallway coming towards her from the common room and asked her if she saw R1 in the common room, housekeeping staff answered, no but it is cold in there. CNA M then went to the common room and noted the window open and wind coming in the room. CNA M then looked out the window and saw no one. CNA M went and told Administrative Nurse F that she could not find R1. Administrative Nurse F then instructed staff to look for R1. When R1 returned, CNA M reported that he did not appear to be in distress, his face was not red, he was not cold. CNA M stated that R1 usually walked up and down the halls, she stated she believed he was looking for his wife. CNA M reported that she believed there should always be two staff in the unit as there were other residents who liked to fight a bit. On 12/28/22 at 09:00 AM, Maintenance Staff V stated he was told to put screws in all of the windowsills of the locked unit and completed this. He stated he was further instructed to place a different type of screws instead, and he replaced the existing screws with tamperproof screws. Maintenance Staff V stated the tamperproof screws were placed to allow the windows to only open a small amount and upon testing them they did not pass the screws. Maintenance Staff V confirmed he only placed the screws on the windows on the secured unit. On 12/28/22 at 09:20 AM, R1 laid on his bed in his room covered with a blanket. Certified Medication Aide (CMA) R pulled up the blinds and multiple screws observed screwed into the windowsill. CMA R demonstrated the window would only open a few inches. On 12/28/22 at 10:26 AM, Physician GG confirmed she received a call from the facility regarding the elopement at the time of elopement and then upon return of R1 to the facility, at which time she gave an order to send R1 to the emergency room for evaluation and treatment. She stated that it was not due to any injury, real or suspected, but just to be safe. She stated she believed he had sustained no injury, per the emergency room report. The facility's revised 08/30/22 Missing Residents/Actual Elopement Event policy, outlined steps for staff to follow in the event of a resident becoming unaccounted for including who to notify and when (including law enforcement and other appropriate agencies). The facility's 11/23/22 Area of Focus: Elopement policy, defined elopement as when a resident leaves the premises without authorization. The policy further directed staff to perform wandering and/or elopement assessments on admission/readmission and to revise care plans as indicated. The facility failed to provide a safe and secure environment for R1 who had impaired cognition and exit seeking behaviors, when he exited the facility, unsupervised, out of a window in the common TV room, and law enforcement located him 8.6 miles away and returned R1 to the facility. On 12/28/22 at 02:23 PM, Administrative Staff A was informed of the immediate jeopardy status and provided the Immediate Jeopardy Template for failure to provide a safe environment and adequate supervision to prevent elopement for R1, who was independently mobile and cognitively impaired. This deficiency was cited as immediate jeopardy, past non-compliance as the facility completed the following, as of 12/23/22 at 05:30 PM: 1. R1's placed on one-to-one supervision upon return to the facility. 2. All residents at risk for elopement, with a BIMS of 12 or below, audited for accuracy on 12/23/22. 3. The elopement book assessed for accuracy on 12/23/22. 4. Secured unit window check completed on 12/23/22 to ensure proper securement. 5. On 12/23/22, maintenance completed work on R1's room and all other windows to secure them from opening more than a few inches on 12/23/22. 6. An elopement drill was conducted on 12/23/22. 7. A QAPI (Quality Assurance and Performance Improvement) meeting was held on 12/23/22. 8. All staff educated on elopement policy and resident incident prior to working new shift. Education initiated immediately on 12/23/22 following the incident and completed on 12/23/22 at 05:30 PM.

The facility reported a census of 78 residents and identified 16 insulin dependent residents. The six residents sampled included three residents reviewed for medications. Based on observation, interview, and record review, the facility failed to ensure one of the three sampled residents, Resident (R) 1, was free of significant medication errors, when an agency licensed nurse administered [MEDICATION NAME] (insulin type), 45 units, and [MEDICATION NAME] (insulin type), 37 units, to R1, a non-diabetic resident. R1 admitted to the hospital and then into ICU (intensive care unit) where he received treatment with IV (intravenous) glucose and staff closely monitored his blood sugar levels. R1 remained in the hospital for two days related to this significant medication error. Findings included: - Resident (R) 1's Electronic Medical Record (EMR), revealed an admission date of [DATE]. R1 was a non-English speaking resident, with [DIAGNOSES REDACTED]. The resident lacked a [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident was unable to score on the Basic Interview for Mental Status (BIMS), due to his inability to speak English. He did not receive any injections in the look back period. The resident's care plan, dated 05/13/19, did not include interventions for a diabetic person. Review of the resident's current list of physician's orders [REDACTED]. The facility self-investigation of the medication error documented, on 08/31/19 at approximately 08:45 AM, after breakfast, agency Licensed Nurse (LN) C went into the dining room and administered [MEDICATION NAME], 45 units, and [MEDICATION NAME], 37 units, to R1. Prior to the insulin injection, LN C asked R1 his name and he answered Ya and she injected him with the two types of insulin. Agency LN C, then turned around and saw R2 (another resident of the same nationality) and realized she had given the insulin to the wrong resident. The nurse had previously viewed the resident's picture on the Medication Administration Record, [REDACTED]. LN C realized the mistake and immediately notified the nurse supervisor and checked R1's blood sugar, which was 208 milligrams/deciliter (mg/dl) The staff placed a call to the physician who gave orders to send R1 to the ER (emergency room ) via EMS (emergency medical service). At 09:10 AM, the EMS arrived and R1's blood sugar was tested by facility staff with EMS present, at 134 prior to transport to the hospital. The hospital called the facility and reported the resident admitted to the ICU (intensive care unit) for IV (intravenous) glucose treatment and blood sugar monitoring. The Hospital Discharge Summary, dated 09/02/19, documented the hospital staff treated the resident with continuous IV [MEDICATION NAME] (A form of sugar, five percent in water is used to treat low blood sugar, insulin shock, or dehydration), and close monitoring of the blood sugar until the [DIAGNOSES REDACTED] (low blood sugar) resolved. The resident discharged back to the facility on [DATE]. Review of the resident's hospital laboratory blood glucose testing results revealed R1's lowest blood sugar reading was 83. (Normal blood sugar levels two hours after eating, is less than 140.) Various observations, on 09/10/19 and on 09/12/19, revealed the resident often moved about the facility self-propelling a wheelchair, smiling and nodding at staff members and other residents. The resident fed himself in the dining room with other residents. He often said Ya in response to asked questions. On 09/10/19 at 10:30 AM, Administrative Nurse B verified that agency LN C had previously worked in the facility, but on a different hall. The facility policy for Identification of Residents Prior to Administering Medications and Providing Treatments or Procedures, dated 11/27/18, included, .and if the resident was unable to tell you his or her full name, then validate the resident's identity with a second associate who is familiar with the resident and compare the resident's name to the MAR/TAR. The facility failed to ensure the non-English speaking, non-diabetic resident remained free of significant medication errors, when agency LN C failed to follow the facility policy for identification of residents and administered two types of insulin to the wrong resident. The resident spent two days in the hospital ICU with IVs and close monitoring of blood sugar levels.

The facility reported a census of 73 residents. The sample included 3 residents, selected for review for unsafe wandering. Based on observation, interview, and record review, the facility failed to ensure that one resident (#1), with known exit-seeking behaviors and confusion; received adequate supervision to prevent the resident from exiting through the southwest hall door, triggering an alarm, to which only 1 staff responded, but deactivated and failed to thoroughly search the outside area. The resident ambulated without staff supervision for an unknown amount of time over a flat grassy area, and onto a residential street, when he/she randomly found by two facility staff, who happened to be on break. This deficient practice placed the resident in Immediate Jeopardy. Findings included: - Resident #1's annual MDS (minimum data set) assessment, dated [DATE], assessed the resident with a BIMS (brief interview for mental status) of 10, indicating the resident experienced moderately impaired cognition. The resident was free of wandering, and ambulated independently. The resident was free of impairment of range of motion in his/her upper and lower extremities, and had steady balance at all times. The resident used a walker for mobility. The resident's quarterly MDS, dated [DATE], assessed the resident with wandering behaviors 1 to 3 days of the 7-day look-back period. The resident's elopement care plan, dated [DATE], documented the resident was at risk for elopement, and required a wander-guard (a small electronic device, worn on the ankle or wrist, that will trigger a door alarm when approached). Staff were to encourage the resident to participate in activities to divert from exit seeking behavior. Staff required to complete an elopement risk assessment, and add the resident to the facility's elopement book. The resident's elopement risk assessment, dated [DATE], assessed the resident at risk for elopement. The resident would exit-seek, looking for his/her car. Review of a nursing note, dated [DATE] at 5:05 PM, documented that the alert, but confused, resident approached the facility nursing station, and stated that he/she wanted to go home, and live with his/her parents (deceased ). Nursing staff instructed the resident to speak with his/her doctor about it. The resident wore his/her wander-guard. Review of a nursing note, dated [DATE] at 12:04 PM, documented that the resident approached staff about leaving the facility, and that staff told the resident that he/she must speak with the facility's social worker about moving out. The resident wore his/her wander-guard. Review of a nursing note, dated [DATE] at 11:21 PM, documented that at 7:20 PM, a door alarm sounded on the southwest hall. At an undisclosed time, staff assisted the resident was assisted back to the nursing station, and a skin assessment was done. The note failed to document that the resident left the building, without staff knowledge, but was found by two off-duty staff, who were on break and unaware the resident eloped from the building. On [DATE] at 10:45 AM, the resident's spouse and adult child explained that they were not happy with the care provided by the facility, because the resident left the building, unsupervised, on an evening shift and was found wandering around in the street, near a residential area. They were upset, because the resident experienced confusion, and could get hurt if he/she wandered into unfamiliar areas. The facility didn't notify the family until the next day, that the resident left the building. On [DATE] at 11:05 AM, direct care staff D recalled that he/she brought lunch to a coworker (staff E) around the beginning of May. Staff D parked outside the southwest hall, in a parking lot, when staff E, turned and saw the resident ambulating down a residential street, off facility property. The resident wore a button-up shirt, pants, and black dress shoes. Staff D and [NAME] approached the resident and asked what he/she was doing outside, and the resident stated that he/she was trying to find his/her car. Staff D reported that the resident appeared tired, and had cold hands. Staff D and [NAME] escorted the resident to the employee entrance on the southeast hall, and walked with him/her back to the nursing station. Staff D notified licensed nursing staff G and C that the resident was found ambulating on the residential street, and recalled that none of the staff present were aware that the resident was missing. Staff D recalled that the staff present at the nursing station, including staff G and C, were going about routine business, and were unaware the resident was missing. Staff C notified administrative staff A and administrative nursing staff B of the resident eloping from the building, after staff D and [NAME] returned with him/her from outside. Staff D wrote a notarized witness statement corroborating his/her interview. On [DATE] at 2:15 PM, staff [NAME] recalled that he/she was at lunch with a coworker, parked in a parking lot outside the southwest hall, when he/she saw the resident ambulating in a residential street, near the curb. The resident appeared to be more confused than normal, and looked tired. Staff [NAME] reported that he/she and staff D approached the resident, and found the resident had cold hands, as if he/she had been outside for a while. The resident stated that he/she was looking for his/her car, because he/she needed to go to work. Staff D and [NAME] escorted the resident to the employee entrance on the southeast hall, and walked with him/her to the nursing station. Staff [NAME] recalled that they notified staff G and C that they found the resident outside, and none of the staff present, including staff G and C, were aware that the resident was missing. Staff C notified staff A and B, of the resident eloping from the building. Staff [NAME] wrote a notarized witness statement corroborating his/her interview. On [DATE] at 3:16 PM, staff C explained that if a door alarm went off, staff were to go to the area, go outside, and sweep the area. Staff C recalled that the resident frequently displayed exit-seeking behaviors, which included looking for his/her vehicle, and looking for his/her parents. The resident would wander throughout the building, and would push against doors. Staff C recalled that one day, an alarm went off on the southwest hall, and that staff G checked the alarm, and reset it. Staff D and [NAME] returned with the resident. Staff C recalled that staff G intended to start a resident count when staff D and [NAME] returned with the resident. Staff C could not recall if he/she notified any administrative nursing staff, but possibly notified staff A and B. Staff C wrote a notarized witness statement corroborating his/her interview. Staff C could not recall filling out an incident report. Staff G, on duty at the time of the elopement, was unavailable to be reached for interview. Staff G's unnotarized witness statement, provided by the facility, documented that he/she responded to the alarm on the southwest hall at 7:20 PM. Staff G went outside, and found no residents, but failed to thoroughly search the vicinity, and returned to the nursing station at 7:22 PM. Staff G documented that one staff person brought back the missing resident, however, other notarized witness forms from staff C, D, and [NAME] documented that 2 staff returned with the resident. On [DATE] at 4:00 PM, staff A and B stated that the resident did not elope from the building, because staff G checked the alarm and looked outside the door, and was found by staff D and E, who happened to be on break. Staff A and B stated that staff G initiated a resident count, and looked outside the building, when he/she looked outside the door. Staff A and B provided a copy of the facility's investigation of the incident. Review of the facility's investigation, unsigned, dated [DATE], documented that at 7:20 PM, staff G overheard a door alarm sound on the southwest hall. Staff G went to the door, stepped outside, did not see anyone, and deactivated the alarm. Staff G failed to thoroughly search the area for any residents, instead, staff G returned to the nursing station to initiate a resident head count. The investigation (dated [DATE]) documented that the resident's family was notified that evening, however, previous interviews with the resident's spouse and adult child revealed that facility staff failed to notify the family until [DATE]. The investigation failed to explain how the resident could exit the building, walk several hundred feet, be intercepted and redirected by staff D and E, and then walk with those staff from outside the building to the nursing station, in a span of 2 minutes. Review of the facility policy, revised ,[DATE], for Elopement, defined an elopement as a resident leaving facility grounds without staff knowledge, and that staff would immediately and thoroughly search the facility grounds. The facility failed to ensure a secure and safe environment for this cognitively impaired resident assessed as an elopement risk, when the resident left the building, through a secured door which alarmed. Facility staff responded to deactivate the alarm, looked outside, but failed to thoroughly search the immediate vicinity, and returned to the nursing station to initiate a resident head count. The resident was then found by two off-duty staff, who happened to be in the wandering path of the resident. This deficient practice placed the resident in immediate jeopardy. The facility removed the immediate jeopardy on [DATE] at 6:35 PM when facility staff completed the following: 1.) On [DATE] at 7:22 PM, facility staff completed a count of all residents. 2.) On [DATE] beginning at 7:25 PM, the resident received one-on-one supervision for the remainder of the shift. 3.) On [DATE] at 7:45 PM, facility staff checked all door and wanderguard alarms and found them to be functional. 4.) On [DATE] at 7:55 PM, facility staff checked all wanderguard bracelets for correct functionality. 5.) On [DATE] at 8:15 PM, facility staff reviewed the elopement book to ensure that all residents at risk for elopement had information present in the book. 6.) On [DATE], resident #1 began receiving treatment at a behavioral health unit. On [DATE], the resident's family notified the facility that the resident would not be returning to the facility. 7.) On [DATE] at 5:07 PM, facility staff reviewed the removal plan with the Quality Assurance committee, including the Medical Director. 8.) On [DATE] at 5:30 PM, facility staff checked all door and wanderguard alarms and found them to be functional. 9.) On [DATE] at 5:40 PM, facility staff reviewed the elopement book to ensure that all residents at risk for elopement had information present in the book. 10.) On [DATE] at 5:42 PM, facility staff reviewed all residents identified as an elopement risk, reviewed the care plan for each resident, and reviewed elopement assessments for each resident. 11.) On [DATE] at 5:45 PM, facility staff checked all wanderguard bracelets for correct functionality. 12.) On [DATE] at 6:35 PM, all staff in the facility received education regarding the revised elopement process, which included: A.) Staff responding to a door and wanderguard alarm immediately including making a full ground search if unable to identify who entered or exited the door. B.) Staff must request another staff to initiate a head count of all residents at risk for elopement at the time of responding to the alarm. C.) All other employees would be educated prior to working their next scheduled shift. The immediate jeopardy abated to a D level deficiency.

The facility reported a census of 101 residents of which 7 were identified as elopement risks. Three of these residents were included in the sample. Based on observation, record review and interview, the facility failed to provide adequate supervision and/or assistive devices to prevent 1 of the 3 residents reviewed, when facility staff failed to respond to an exit door alarm when resident (#1), exited the facility without staff knowledge at approximately 9:45 pm at night, walked down the sidewalk, across the parking lot to the assisted living facility next door, and with the outside temperatures measuring 26 degrees Fahrenheit. This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of resident #1's physician order [REDACTED]. The admission MDS (minimum data set), dated 1/28/19, assessed the resident with a BIMS (brief interview for mental status) score of 9, indicating moderate cognitive impairment, with no behaviors or wandering. He/she required supervision with transfers and ambulation. The CAA (care area assessment), dated 2/12/19, for cognitive loss, assessed the resident as alert with confusion due to dementia and he/she used a walker and/or wheelchair for mobility. The care plan, dated 1/28/19, documented the resident at risk for elopement, with interventions to complete an elopement risk assessment, encourage the resident to participate in activities to divert from exit seeking behaviors, and personal safety alarm device: Wanderguard (bracelet that sets off an alarm when residents wearing and attempts to exit the building without an escort.) The facility updated the plan of care on 3/1/19 to include: advised the staff that the resident had impaired cognitive thought processes and to keep the resident's routine consistent to prevent confusion. He/she was an elopement risk and wore a personal safety alarm device. The staff should encourage the resident to participate in activities to divert from exit seeking behavior. The admission elopement risk assessment, dated 1/28/19, assessed the resident as an elopement risk and he/she would wear a personal safety alarm device. The quarterly elopement risk assessment, dated 3/1/19, re-assessed the resident as an elopement risk with a history of wandering and elopement. Review of the facility's incident report, dated 3/3/19, documented on 2/28/19, the resident exited out of the facility without staff knowledge and went to the assisted living facility next door. Review of the facility's video footage, dated 2/28/19, with Administrative Staff A, revealed at approximately 9:25 pm, the resident was walking down 500 hall with his/her rolling walker and wearing a long sleeved shirt, nightgown and shoes. He/she stopped and talked to pharmacy consultant staff G by the nurse's desk until approximately 9:35 pm. The resident headed down 500 hall towards 300/500 hall exit door. Licensed staff E saw the resident walking down the hallway. At 9:43 pm, the resident was looking out the 300/500 hall exit door and pushed on the door handle, setting off the wanderguard alarm. He/she wiped off the window and pushed on the door handle again. The green light on top of the door indicated the door was open. The wanderguard and door alarm were sounding as he/she walked out the door and down the sidewalk. Licensed staff E was at the nurse's desk and looked down the hallway at approximately 9:45 pm. At approximately 9:49 pm, licensed staff E was walking with an unsampled resident down the 500 hallway with the alarm still sounding. Direct care staff B came to the 500 hall looking for resident#1 at approximately 9:55 pm. to administer medication, at which time, staff knew the resident was missing. At approximately 10:00 pm, after notification from staff C the resident was at the assisted living center, facility staff went to get the resident. The resident arrived back with assistance from facility staff at approximately 10:08 pm. Licensed staff E shut off the alarm at approximately 10:11 pm. Observation, on 3/6/19 at 11:51 am, revealed the resident sleeping in his/her recliner. A personal safety device was present on the resident's right wrist. Observation, on 3/06/2019 at 4:52 pm, revealed the resident on his/her walker, seated in the dining room with peers watching a movie. On 3/06/2019 at 4:25 pm, Administrative Nursing Staff A stated he/she received lots of phone calls from the staff the evening the resident eloped. He/she received a call stating the resident was next door at the assisted living facility and the staff were going over to get him/her. The assisted living staff came over and said the resident was at their facility. The staff brought the resident back to the building and nursing staff assessed him/her and no injury was found. The family was notified. The resident did not have any complaints and stated that he/she was instructed by God to just go, so he/she was following directions. The staff stayed with the resident and someone constantly had eyes on him/her. The facility started an investigation and talked to all the staff that were there that night about what happened and why. The facility staff started elopement drills with education every shift for 3 days after the elopement. Staff checked and made sure all the residents were in the facility. The staff checked all residents with wanderguard bracelets to make sure they were in place on the residents and working. The maintenance staff checked all the doors to make sure they were locked. We have signs up to alert visitors to watch for residents trying to leave with them. All residents were re-evaluated for risk of elopement and updated the assessments accordingly. Licensed nursing staff D (from the assisted living facility), interviewed on 03/7/19 at 9:09 am, verified the information in his/her statement and stated he/she had nothing further to add. The witness statement, dated 2/28/19, written by licensed nursing staff D, documented at approximately 9:30 pm, he/she heard a knock on the back door of the assisted Living facility. Staff C was at the nurse's station and reported someone was standing at the door with a walker. Staff C asked the person's name, but he/she could not tell him/her. Staff D called the facility, on the facility phone, but nobody answered. Staff C went to the nursing facility to let them know one of their residents was in the assisted living facility. Staff from the nursing facility then came and assisted the resident back to the facility. Direct care staff C (from the assisted living facility), interviewed on 03/7/19 at 9:27 am, verified the information in his/her statement and stated he/she had nothing further to add. The witness statement, dated 2/28/19, written by direct care staff C, documented at approximately 9:30 pm, he/she heard a knock at the (back) door by the nurse's station. Staff C let the resident in and tried to find out his/her name. Staff C assisted the resident to a chair while staff D called the nursing facility. Unable to contact anyone there by phone, staff C went to talk to the staff to verify the identity of the resident. Staff C remained at the nursing facility until nursing facility staff verified and coordinated the resident's return to the nursing facility. Direct care staff B, interviewed on 03/7/19 at 11:43 am, verified the information in his/her statement and stated he/she had nothing further to add. The witness statement, dated 2/28/19, written by direct care staff B, documented at approximately 9:45 pm, he/she went to the resident's room to administer his/her medications, and found that the resident was not in his/her room. Staff B went to look for the resident and met direct care staff C from the assisted living facility next door. Staff C stated that a resident from this facility walked over to their facility and was with staff at the nurse's desk at the assisted living facility. On 3/7/19 at 2:10 pm, Licensed Nursing Staff E reported that he/she heard the alarm go off sometime after 9:00 pm, but he/she was too busy to respond. He/she assumed the CNA (certified nurse aide) staff would take care of the alarm. Licensed nursing staff F, interviewed on 03/7/19 at 3:40 pm, verified the information in his/her statement and stated he/she had nothing further to add. The witness statement, dated 2/28/19, written by licensed nursing staff F, documented staff had alerted him/her that a resident had exited the building and was at the assisted living facility next door. Staff F documented that several certified nurse aides went to assist the resident back to the facility. When the resident returned, he/she was wearing a nightgown, long sleeve shirt, shoes and a jacket. Staff F performed a head to toe assessment and took the resident's vital signs. The resident was unable to explain what happened. The facility Elopement Policy, dated 2/2009, evidenced residents are assessed at the time of admission for the potential of elopement, a specific plan and interventions are developed and implemented from the time of admission for those residents at risk for wandering or elopement. A specific system is developed to notify staff that exit doors have been opened. The facility staff failed to respond in a timely manner to a sounding door alarm. The confused resident, assessed and care planned for elopement risk, exited the facility, walked down the sidewalk, across the parking lot to the assisted living facility next door, at approximately 9:45 pm in the dark, with the weather temperature measuring 26 degrees. This deficient practice placed the resident in immediate jeopardy. The deficient practice was identified as past non-compliance and corrected on 3/1/19 at 10:45 pm when they completed the facility completed the following: 1). A head count of all residents in house and all accounted for 2/28/19. 2). 15 minute checks initiated on the resident 2/28/19. 3). Exterior doors checked for functionality and all doors were in operable working order 2/28/19. 4). All wanderguard alarms were checked an in operable working order 2/28/19 at 11:00 PM. 5). All residents were reevaluated for risk of elopement and elopement assessment updated accordingly 3/1/19. 6). Elopement books updated accordingly with residents information/photo 3/1/19. 7). Care plans updated for residents at risk for elopement 3/1/19. 8). Q (every)-shift monitoring in place to ensure functionality of wanderguard bracelets 3/1/19. 9). Quality Assurance (QA) meeting on 03/1/19 at 9:00 am. Medical director informed of incident on 2/28/19 and discussion held with him/her on 3/1/19 at 11:00 am following the QA meeting. 9). Elopement drills conducted beginning on 3/1/19 at 4:58 pm and will continue through all shifts 10). Staff education on Facility Elopement Policy and immediate response to door alarms, to search the immediate area, then deactivate the alarm and conduct head count. The majority of staff in the facility inserviced as of 3/1/19 at 10:45 pm. The remaining staff on vacation leave will be inserviced as they return to work.

The facility reported a census of 86 residents. The 31 residents sampled included 4 residents reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide planned interventions for prevention of pressure ulcers for 2 of the 4 residents reviewed including resident (#59) for failure to ensure staff applied and maintained the multipodus boots to the resident's feet/heels to provide pressure relief and prevent the development of an unstageable pressure ulcer to the right heel and resident (#49) at risk for development of pressure ulcers with failure to provide timely repositioning. Findings included: - The Physician order [REDACTED].#59, documented [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) after re-admission from a hospitalization , dated 8-02-17, documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. The resident required extensive assistance of 2 staff for bed mobility and transfers. Locomotion on the unit required extensive assistance of 1 staff. The resident was at risk for pressure ulcers with unhealed pressure ulcers present including 1 unstageable pressure ulcer due to suspected deep tissue injury (SDTI), on the left heel. Treatments included: Pressure reducing device for chair and bed, pressure ulcer care, application of nonsurgical dressings, with or without topical medications, other than to feet, and applications of ointments/medications other than to feet. The MDS lacked identification of the use of a turn and reposition program for the resident. The Care Area Assessment (CAA) for pressure ulcers, dated 8-02-17, lacked documentation of an analysis of findings. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 6, indicating severely impaired cognition. The resident required extensive assistance of 1 for bed mobility, transfers and personal hygiene. The resident had 1 unstageable pressure ulcer with slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue). Dimensions of the unhealed stage III (Full thickness tissue loss without exposed bone, tissue or muscle), or stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) pressure ulcer measured, 2.0 X 3.0 X 0.1 cm (centimeters) with the most severe tissue type being slough, on the left heel. There was no worsening of the pressure ulcer and no unhealed pressure ulcers. Treatments included: Pressure reducing device for chair and bed; nutrition/hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressings, with or without topical medications, other than to feet, applications of ointments/medications other than to feet and application of dressings to feet with or without topical medications. The MDS lacked identification of the use of a turn and reposition program for the resident. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 5, which indicated severe cognitive impairment. The resident required extensive assistance of 1 for bed mobility, transfers and personal hygiene. The resident had an unstageable pressure ulcer with slough and/or eschar, measuring 1.3 X 1.4 X 0.1 cm. The most severe tissue type was slough. There was no worsening in pressure ulcers and no current pressure ulcers were at a lesser stage than on the prior assessment, one healed pressure ulcer, the left heel. The resident had a pressure reducing device for his/her bed and chair, had a turning and repositioning program and had nutritional/hydration interventions in place to manage skin problems. The care plan for pressure ulcers, dated 1-10-18, instructed staff to assist with positioning every 2 hours and PRN (as needed). 11/28/17, The resident was to have multipodus boots (floats the heel to prevent pressure) on his/her bilateral feet at all times. The resident was to have Prosource (a nutritional supplement) 30 ml (milliliters) every day for wound healing, ordered 12-11-17. Prior to the development of the right heel pressure ulcer, the plan of care included: staff were to assist the resident to reposition his/her weight every two hours to relieve pressure, have a cushion in his/her wheelchair and a pressure reduction mattress to the bed. Staff were to encourage the resident to elevate his/her legs after meals. The resident's heels were to be floated on pillows while he/she was in bed. Review of the weekly pressure ulcer documentation lacked documentation of a stage III pressure ulcer, documented in the 10-27-17 MDS. Review of the resident's re-admission documentation from the hospital in July, (YEAR), revealed the resident had a SDTI (Suspected Deep Tissue Injury) to the left heel which measured, 3.0 X 4.0 cm (centimeters). The wound was 100% dark purple, with no drainage or odor present. The resident returned from the hospital with a multipodus boot in place to the left heel. The wound became an unstageable pressure ulcer on 8-17-17, with 100% black eschar. Review of the weekly pressure ulcer documentation on the resident's right heel, included: On 11-28-17, a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough), measuring 2.5 X 2.5 X 0.1 cm., noted on the right heel. The pressure ulcer had a red wound bed with no drainage or odor. The facility notified the physician of the pressure ulcer and a treatment to cleanse the area with normal saline (NS), pat dry, and apply a foam dressing and change every day and PRN. On this date, nursing requested a multipodus boot from therapy for the resident's right foot and received the boot on 12-05-17 (7 days later). On 12-04-17, the stage II pressure ulcer improved and measured, 2.0 X 2.0 X 0.1 cm. On 12-11-17, the stage II pressure ulcer had no change. A new order to clean the right heel with NS, pat dry, and apply [MEDICATION NAME] (a medication for wounds). Staff were to cover the area with a foam dressing and change every other day (QOD) and PRN. On 12-18-17, the stage II pressure ulcer deteriorated to an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer, measuring 2.0 X 1.8 X 0.1 cm. The pressure ulcer had slough on the wound bed with no drainage or odor. The facility received a new treatment order to cleanse the right heel with NS, pat dry, and apply calcium alginate (a drug used externally in the treatment of [REDACTED]. Staff were to change the dressing QOD and PRN. On 12-26-17, the unstageable pressure ulcer improved and measured, 2.0 X 1.5 X 0.1 cm. On 1-01-18, the unstageable pressure ulcer had no change and measured, 2.0 X 2.0 X 0.1 cm. On 1-08-18, the unstageable pressure ulcer improved and measured, 1.0 X 1.0 X 0.1 cm. On 1-15-18, the unstageable pressure ulcer improved (although the measurements show the area increased in size) and measured, 1.5 X 1.5 X 0.1 cm. On 1-22-18, the unstageable pressure ulcer improved and measured, 1.3 X 1.4 X 0.1 cm. On 1-29-18, the unstageable pressure ulcer had no change and measured, 1.3 X 1.4 X 0.1 cm. Nursing requested new multipodus boots for the resident from the therapy department. On 2-05-18, the unstageable pressure ulcer improved and measured, 1.0 X 1.5 X 0.1 cm. On 2-12-18, the unstageable pressure ulcer improved and measured, 0.8 X 1.0 X 0.1 cm. On 2-19-18, the unstageable pressure ulcer had no change and measured, 1.0 X 1.5 X 0.1 cm. On 2-27-18, the unstageable pressure ulcer improved and measured, 1.0 X 1.0 cm. On 3-05-18, the unstageable pressure ulcer resolved. On 3-01-18 at 5:21 a.m., observation revealed the resident resting in bed with his/her eyes closed. The resident did not have on the multipodus boots at that time and his/her heels rested directly on the foam mattress of the bed. On 3-01-18 at 10:59 a.m., observation revealed the resident propelled his/herself around the commons area in his/her wheelchair utilizing his/her feet and hands. The multipodus boot to the resident's right foot became unfastened and the resident's right heel came into direct contact with the floor each time the resident moved his/her foot to propel themselves. On 3-01-18 at 3:03 p.m., observation revealed licensed nursing staff F, changed the dressings to the resident's right heel. The wound to the resident's right heel contained brownish/black eschar, at that time. On 3-04-18 at 5:13 p.m., observation revealed the resident with bilateral multipodus boots on. The resident's right heel rested directly on the floor due to the multipodus boot having come unfastened. On 3-05-18 at 7:41 a.m., observation revealed the resident sitting in his/her wheelchair. The resident's right heel rested directly on the floor due to the multipodus boot having come unfastened. On 3-01-18 at 5:37 a.m., direct care staff C stated, the staff remove the resident's boots quite often because the right boot comes unhooked all of the time. On 3-01-18 at 11:05 a.m., central supply staff H stated, the resident's right heel rested directly on the floor due to the multipodus boot having come unfastened. On 3-01-18 at 5:38 a.m., licensed nursing staff B stated, the resident was to have the multipodus boots on at all times due to having a pressure ulcer on his/her heel. On 3-01-18 at 3:03 p.m., licensed nursing staff F stated, the wound nurse does weekly measurements of all wounds. On 3-05-18 at 8:28 a.m., licensed nursing staff I stated, a wound would be considered to deteriorate if the wound changed in staging, but not in size. Staff I was aware of the Velcro of the resident's multipodus boot not working properly and the resident's heel resting directly on the floor. On 3-05-18 at 3:43 p.m., administrative nursing staff A stated, the resident acquired a pressure ulcer to his/her right heel at the facility and it should not have become an unstageable pressure ulcer. It was the expectation of staff A for the staff to apply the multipodus boot properly and not allow the resident's right heel to come into direct contact with the floor. On 3-06-18 at 11:47 a.m., physician staff G stated, the SDTI to the resident's left heel was present on re-admit from the hospital in (MONTH) and turned into an unstageable pressure ulcer at the facility within a couple of weeks. The facility was aware of the resident's risk of his/her heels breaking down due to the issue with the left heel. The facility should have been more alert at preventing the breakdown to the resident's right heel. Staff G stated he/she felt the unstageable pressure ulcer to the resident's right heel was preventable. The facility policy for Wound Care, undated, included: It was the responsibility of this facility to provide the residents with a quality wound care program to prevent and manage wounds and pressure ulcers. Skin care programs are developed with an interdisciplinary approach. The facility failed to ensure the proper application of multipodus boots on a consistent basis. The cognitively impaired resident developed an avoidable unstageable pressure ulcer on the right heel. - The signed physician order [REDACTED].# 49 recorded [DIAGNOSES REDACTED].(abnormal condition that may affect the flow of oxygen to the heart), Dysphasia (swallowing difficulty), Depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness), Chronic Pain, and Spinal Stinosis ([MEDICAL CONDITION] condition of the spine that could cause weakness and loss of use of extremities. The admission MDS (Minimum Data Set), dated 1-18-18 identified staff were unable to complete the resident's BIMS (brief interview for mental status), as the resident was rarely or never understood as cognitive skills were severely impaired and he/she has an altered level of consciousness. The resident needed one person physical assistance for bed mobility and identified the resident at risk for pressure ulcers with a pressure reducing device used in the chair and was at risk for a pressure ulcer. He/she was always incontinent of bladder. The MDS lacked identification of the use of a turn and reposition program for the resident. The CAA (care area assessment), for pressure ulcer, dated 1-18-18, assessed the resident at risk for developing a pressure ulcer due to having a [DIAGNOSES REDACTED]. Staff were to monitor the blood sugars are per the physician's orders [REDACTED]. The plan of care, dated 1-18-18, for risk of developing pressure ulcers instructed the staff to assist as needed to reposition/shift weight to relieve pressure and to avoid long periods of skin to skin contact. Minimize injury due to shear and friction through proper positioning, transfers and turning schedules. The Braden scale (assessment for predicting pressure sore risk) dated 2-18-18, scored a 9. (9 and under is very high risk for skin breakdown). On 2-19-18 at 11:00 am, documented in a progress note the current interventions in place include; air mattress, wheel chair cushion, float heels while in bed, and reposition every 2 hours and as needed. Observations, intermittently, every 15 minutes on 3-1-18 from 9:47 am until 12:22 pm, revealed the resident lying on his/her left side on an air mattress with floating heels. At 12:22 pm, staff entered the resident's room and repositioned the resident on his/her back. Staff failed to reposition this resident from 9:47 am to 12:22 pm for approximately two hours and thirty minutes. On 3-5-18 at 3:47 pm, direct care staff Y revealed that this resident needed to be turned and repositioned every 2 hours, adding that there are times that staff are so busy it may be up to 3 hours before we turn him/her. On 3-1-18 at 9:47 am, licensed staff BB, confirmed the resident needed to have a change of position every 2 hours to prevent skin breakdown. On 3-5-18 at 4:28 pm, administrative staff A, stated that the expectation for this resident was that he/she be turned every 2 hours. The policy for pressure ulcer/injury prevention, dated 11/2017, instructed staff to reposition residents at least every 2-4 hours as consistent with the overall patient goal and medical condition. The facility failed to reposition this cognitively impaired dependent resident every 2 hours, to prevent the development of pressure ulcers.

The facility reported a census of 86 residents with 31 selected for review, including 2 residents selected for accidents. Based on observation, interview and record review, the facility failed to implement fall interventions for these 2 residents (#46 and 231) as assessed and planned and resident #46 sustained a fractured ankle. Findings included: - Review of resident #46's physician order [REDACTED]. The quarterly MDS (minimum data set), dated 1-10-18, assessed the resident with severely impaired cognitive status, fluctuating altered level of consciousness, required extensive assistance of 2 person for bed mobility, toilet use, extensive assist of 1-2 staff with transfers, and limited assistance of 1 person when walking in room, with balance not steady, but able to stabilize with staff assistance. This MDS assessed the resident had no impairment of the upper or lower extremities, was mobile with a walker or wheelchair. The resident was frequently incontinent of bowel and bladder, and had no falls since prior assessment. The significant change MDS (minimum data set), dated 10-26-17, assessed the resident with a BIMS (brief interview for mental status) score of 11 (8-12 indicated moderate impairment), extensive assistance of 2 persons for bed mobility, transfer and toileting, walk in room with limited assistance of 1 person and balance not steady but able to stabilize with staff assistance. This MDS recorded the resident sustained [REDACTED]. The CAA (care area assessment) dated, 10-26-17, for activities of daily living, assessed the resident's need for extensive staff assistance with most daily care needs related to weakness and received skilled therapy (physical and occupational) services for weakness and falls. The CAA, dated 10-26-17, for falls assessed the resident had increased falls due to unsteady gait, weakness, and use of high risk medications, required assistance with transfers and mobility, and received skilled physical and occupational services. The care plan, revised 11-10-17, advised staff of the resident's alteration in mobility and safety due to history of falls, poor safety awareness, decreased cognition, weakness and shortness of air with activity. Interventions directed staff to keep the walker out of the resident's reach, remind the resident to call for assistance before ambulating, place a mat on the floor at bedside (dated 9-13-17 but discontinued on 11-14-17, as the resident was able to ambulate with assistance per nurses' note dated 11-16-17 at 12:55 pm. The resident was mobile to the bathroom occasionally with the four-wheel walker or wheelchair. The resident utilized a 1/4 enabler rail for positioning needs and bed mobility. Staff removed the personal comforter which caused the resident to slide from the bed, remind resident to sit all the way back in wheelchair, and to ensure the bed was in a low position. An intervention, dated 12-10-17, for a non-injury fall and confusion due to urinary tract infection with current treatment, directed staff to move the bed against the wall to prevent a fall on the side of the bed without a fall mat. An undated entry, advised a therapy screen requested to assist with changes in cognition and ADL (activities of daily living) related to acute condition. An update, on 3-2-18, advised staff of a non-injury fall and included an intervention of a low bed position and frequent visual checks while in bed. The plan lacked the intervention to use a gait belt (a device used to transfer residents from one position to another) as was a facility policy and procedure, and lacked additional interventions to address the resident's falls on 12-30-17 which resulted in an ankle fracture and a fall on 3-2-18. The rehabilitation services multidisciplinary screening tool, dated 11-10-17, revealed the resident demonstrated ability for toileting, and required assistance of 1 staff with a gait belt for toilet transfer. The rehabilitation services multidisciplinary screening tool, dated 11-14-17, assessed the resident required care giver assistance with a gait belt for transfers. The rehabilitation services multidisciplinary screening tool, dated 12-12-17, documented the nursing staff report of intermittent confusion, with recent [DIAGNOSES REDACTED]. A nurse note, dated 12-30-17, documented staff ambulated the resident to the bathroom, and the resident fell backward landing on his/her bottom (without a gait belt per interview on 3-5-18 at 2:30 pm). A nurse note, dated 3-2-18 at 5:00 am, documented the resident attempted to transfer him/herself from the bed and staff found the resident on the floor mat beside the bed. Review of the radiology reports, dated 1-2-18, revealed an area of lucency (lightness) on the right malleolus(ankle bone), with concern of a non-displaced fracture and soft tissue swelling. An x ray report, dated 1-17-18, documented a trimalleolar (ankle) fracture. A CT (computerized Axial Tomography), dated 1-25-18, documented an acute [MEDICAL CONDITION] (ankle). Observation, on 3-5-17 at 7:30 am, revealed the resident laid in bed with the bed positioned 2 foot away from the room wall. The bed was at a knee height, and no staff in the room. Direct care staff LL and U, entered the resident's room at 7:38 am. Staff LL confirmed the resident's bed was not in a low position because they were going to transfer the resident to his/her wheelchair. Staff LL demonstrated the low bed position (approximately 16 inches lower). Staff LL and U then raised the bed up, and positioned the resident in the sling for the sit to stand lift and transferred the resident from his/her bed to his/her wheelchair. Staff U stated the resident transferred using the sit to stand lift. Interview, on 3-5-18 at 2:30 pm, with direct care staff T, stated the resident had a fall in late (MONTH) (YEAR). Staff T stated the resident could ambulate with a walker with a fairly steady gait. Staff T stated he/she was in the resident's room with direct care staff NN. Staff NN did not place a gait belt on the resident and walked behind the resident as he/she ambulated to the bathroom with his/her four-wheeled walker. Staff T stated she heard the resident/staff and saw the resident fall onto his/her bottom and Staff T fell backward as the resident fell upon him/her. Staff T stated residents should have a gait belt on to assist with ambulation and safety. Interview, on 3-6-18 at 7:15 am, with consulting staff M, revealed the resident received physical/occupational therapy prior to the fall for strengthening, and therapy staff deemed the resident safe for ambulation with staff assistance and a gait belt. Staff M stated if a resident was weak or confused, staff should follow the resident with a wheelchair in case of a fall. Interview, on 3-6-18 at 8:30 am, with administrative nursing staff J, revealed he/she did not know why the resident's bed was not against the wall (as noted 3-5-18 at 7:30 am) as indicated on the care plan. Staff J stated several residents had room changes and perhaps staff were unaware of the intervention. Interview, on 3-6-18 at 10:30 am, with administrative nursing staff A, revealed the resident sustained [REDACTED]. Interview, on 3-6-18 at 11:45 am, with physician G, confirmed the facility should have measures in place to prevent falls as much as possible. Interventions to use a gait belt, and follow a resident with a wheelchair when unsteady would be expected to prevent injury. The facility policy for incident management, dated 2/2007, advised staff to identify residents at risk for incidents and implement procedures to reduce incident risk and minimize the potential for occurrence. The facility policy for gait belts for transfer, undated, advised staff to use a gait belt to safely transfer or ambulate the resident. The facility failed to provide supervision and assistive devices to prevent falls for this resident when staff failed to use the gait belt during ambulation. The resident fell and sustained an ankle fracture. - Resident #231's physician orders, dated 2/14/18, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The 5 day MDS (minimum data set), dated 2/21/18, revealed the resident with short/long term memory issues, and severely impaired daily decision making. The resident required extensive staff assistance for bed mobility, transfers, and locomotion. The resident did not walk in his/her room. The resident's balance was not steady, and mobility per wheelchair. The resident with functional limitation in range of motion to upper and lower extremity on one side. The resident with history of falls, and with a non-injury fall. The MDS lacked identification of the use of bed rails for the resident. The admission MDS, dated [DATE], revealed the resident with short and long term memory issues, and with severely impaired daily decision making. The resident with inattention, disorganized thinking and altered level of consciousness, behavior of this type continuously present, and does not fluctuate. The resident with a mood score of 27 out of 30, indicating severe mood and/or depression. The resident with delusions of : physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others; and behavior of this type occurred daily. The resident at a significant risk for physical illness and/or injury, which interferes with the resident's care. The resident's behaviors put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupted care or living environment. The resident required extensive staff assistance for bed mobility, transfers, and locomotion. and the resident did not walk in his/her room. The resident's balance was not steady, and mobility per wheelchair. The resident with functional limitation in range of motion to upper and lower extremity on one side. The resident with history of falls, and with a major injury fall. The MDS lacked identification of the use of bed rails for the resident. The CAA (care area assessment), dated 2/25/18, for [MEDICAL CONDITION], documented the resident with a history of mental illness, and [MEDICAL CONDITION]. The resident with a current pelvic fracture and he/she does not qualify for surgical intervention. The CAA (care area assessment), dated 2/25/18, for cognition, ADL's (activities of daily living), and falls the following analysis of findings: The resident with a history of dementia and mental illness. The resident was verbally aggressive, and had difficulty making needs known. The baseline care plan and initial discharge plan reviewed on 2/21/18: The resident at risk for falls, due to new environment, position in chair/wheelchair. --Assistive devices to be within reach. --The bed to be in the low position. --The staff to assist the resident with transfers and toileting. The baseline care plan lacked instruction to staff regarding the use of the 1/8 bed rail for transfer and turning purposes. The care plan, updated on 3/6/18, to include an additional intervention of pillows for positioning. Safety related to medications with the interventions as follow: --The care plan updated on 2/28/18, to educate the family on bed location (low) and do not leave the resident sitting upright alone. The care plan lacked an intervention for a fall which occurred on 2/22/18. The evaluation for use of bed rails, dated 2/14/18,documented the resident with a medical [DIAGNOSES REDACTED]. The facility identified all reasons that contribute to the resident's need to use bed rails as follows: left side weakness, cognitive requested rails, history of rolling out of bed. The bed rails would assist the resident in turning side to side, moving up and down in bed, pulling himself/herself from laying to sitting position, improving balance, supporting himself/herself entering/exiting the bed more safely, transferring more safely, avoid rolling out of bed, and providing a sense of security. The resident without restraints. The resident with [MEDICAL CONDITION], a decline in cognitive status or fluctuations in consciousness related to a stroke. The resident without uncontrolled or involuntary body movement, and left sided weakness. The use of bed rails does not create an accident hazard or a barrier for the resident. The bed rails do not act as a physical restraint. The use of bed rails would not have a negative psychosocial outcome for the resident. The use of bed rails are recommended, at that time, due resident request (resident is cognitively confused) and conditions identified. A 1/8 partial bed rail placed to the left and right side of the resident's bed. Staff failed to place the use of the bed rails on the plan of care. The fall risk assessment, dated 2/14/18, documented the resident with a fall risk score of 16. A score of 10 or higher indicated the resident was at risk for falls. On 3/5/18, the resident scored a 20. The progress note, dated 2/22/18 at 7:16 AM, documented the resident was found laying on the floor on his/her right side beside the bed. The resident stated he/she was looking for his/her spouse. The bed was in the low position, a floor mat was in place beside the bed, the call light was in reach, and the resident without injury noted. The staff notified the physician who ordered the staff to keep monitoring the resident. The progress note dated 2/22/18 at 6:19 PM, documented the resident on a fall follow-up for a fall that occurred this AM. The resident without complaint of pain or discomfort. Staff lowered the bed to floor and the call light was within reach. The resident educated about the importance of the use of the call light, but the resident does not mentally comprehend. The staff alerted about frequent checks on the resident and not leaving the door closed. Staff failed to place these interventions on the plan of care. The progress note, dated 2/25/18 at 2:37 AM, documented the resident complained of pain to the right hip, a 9 out of 10 on a scale of 0-10. The physician notified and an order obtained for [MEDICATION NAME] (a opiod pain medication) 5 mg(milligrams/325 mg, 4 times a day PRN (as needed) for pain, and for a X-ray of the right hip. The progress note, dated 2/25/18 at 1:14 PM, documented the results of the X-ray was a comminuted (a fracture in which the bone was broken into several pieces) right inferior pubic ramus fracture (pelvis fracture). Staff notified the physician who ordered limited weight bearing on the right leg and PRN pain medication. The progress note, dated 2/27/18 at 11:22 PM, the resident being assisted to eat by the spouse in bed with the head of the bed elevated, the bed in the low position, about a foot off the floor. The spouse came to speak with a nurse at the doorway of the room when the resident rolled to his/her right side, and slid to the ground with his/her right arm tangled in the 1/8 bed rail. The spouse rushed to the resident and pulled roughly on his/her right arm and shoulder, lifting the resident off the ground by his/her right arm and swinging the resident onto the bed. The resident screamed it hurt and to stop hurting him/her. Staff asked the spouse not to move the resident any further, reminding the spouse that the resident had a pelvic fracture. Staff notified the physician who ordered X-rays to be taken of the right shoulder and right hip. The spouse educated that the resident was to be in a low bed, can not be left in a upright position in his/her bed alone, and also to let the staff reposition the resident. The progress note, dated 3/5/18 at 10:03 AM, documented at 10:30 PM, the nurse heard a resident yelling, so he/she started walking down the hall to see which resident it was. The nurse opened the door to the resident's room and found the resident lying on the floor mat. When the staff asked what had happened, the resident stated help him/her get up he/she was falling off the bed. The resident's call light was within reach and his/her bed was in the low setting. On 3/5/18 at 7:55 AM, the resident lying in bed with his/her eyes closed. The bed was in the lowest position, the fall mat was beside the bed, and pillows were on both sides of the resident, on the bed. On 3/5/18 at 8:45 AM, direct care staff L and GG in the residents room and repositioned the resident in the high back wheelchair. Direct care staff L propelled the resident to the dining room. On 3/5/18 at 11:46 AM, the resident calling out loudly for help to get out of bed. Licensed nursing staff CC went into the resident's room and told the resident he/she could not get up yet because staff CC needed to get help. The resident lying in bed, the bed in the lowest position, a fall mat beside the bed, pillows in place on both sides of the resident. At 12:15 PM, administrative staff W and direct care staff L went into the resident's room, provided peri care, and a clean incontinent brief put in place. The resident kept stating he/she wanted to be up on his/her feet/dogs. Staff placed a lift sheet under the resident, the resident placed his/her arms across his/her chest as directed and transferred by lift to the wheelchair. The resident was unavailable for afternoon observations. On 3/5/18 at 8:55 AM, direct care staff L stated he/she noticed when the resident first arrived that the resident would swing his/her legs off of the bed and his/her legs would dangle off the side of the bed, so staff L would put the bed in the lowest position. The fall mat came later because other staff observed the resident would swing his/her legs off the bed. Staff L was not aware of any fall the resident had this weekend or of an intervention put in place for the fall. Furthermore, he/she stated he/she had begun putting pillows around the resident because of the resident moving around in the bed. On 3/5/18 at 3:21 PM, direct care staff Y stated the resident always had a fall mat and a low bed. The use of pillows started after the resident fell . The resident could swing his/her legs over the side of the bed. Staff Y unaware of the resident with a fall this weekend, or of an intervention. The care plan would inform staff as to how to take care of the resident. On 3/5/18 at 11:17 AM, licensed nursing staff CC stated the resident fell 2 weeks ago and then again this weekend. The intervention was to put pillows on both sides of the resident so he/she could not roll off the bed, the other fall interventions included the bed in the lowest position and a fall mat. Staff failed to place the intervention of using the pillows beside the resident on the plan of care, until 03/06/18. On 3/6/18 10:59 am, administrative nurse staff A stated the resident was able to reposition himself/herself and used the bed rails to reposition. When the resident fell on the 2/27/18, the resident's spouse was with him/her. In that case when the resident slid from the bed, the resident may have been attempting to get out of bed. Staff A stated he/she did not believe the side rail was a causative factor, nor that the side rail should be padded to prevent the resident from getting his/her arm caught. The CNA's (certified nursing assistant) complete rounds with the on and off going staff, a intervention should be placed on the care directives for the CNA's, and staff should check the directives to provide the care for the residents. There is also a communication book at the desk that all nursing staff should be checking for any new information on the residents and staff were to sign off they checked the book. Furthermore, the charge nurse should inform the CNA's of any changes of the residents during the shift. Staff A stated there are interventions in place for the resident's 3 falls on the care plan. The facility policy for incident management, dated 2/2007, documented the facility identifies residents at risk for incidents and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence. Each resident receives adequate assistance and oversight. The facility failed to develop in a timely manner and provide adequate supervision and assistive devices to prevent accidents for this resident identified as a fall risk.

The facility reported a census of 65 residents with 3 reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure 1 resident (#1) of 3 residents admitted with pressure ulcers, received care and services to prevent the recurrence and/or worsening of pressure ulcers present upon admission. The resident experienced the recurrence of 4 stage II (2) pressure ulcers and the recurrence of 1 stage III (3) pressure ulcer, and the development of 2 stage II pressure ulcers related to the facility's failure to assess, identify, and monitor the residents, skin condition, failure to maintain pressure relieving devices and proper positioning and elevation of the resident's extremities, and failure to ensure physician ordered treatments were available for staff administration. Findings included: - Resident #1's physician order [REDACTED]. The admission Minimum Data Set, dated dated [DATE] included a Brief Interview for Mental Status score of 10/15, indicating moderately impaired cognition, with altered levels of consciousness, concerns with sleep and feeling tired, and lacked identification of rejection of care. The assessment identified the resident needed extensive assistance of staff for ADL's (activities of daily living) except eating, which required limited assistance. The resident was to receive a therapeutic and mechanically altered diet, and identified no weight loss. The assessment identified the resident had 4 stage 2 pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and 1 stage 3 pressure ulcer present on admission. Additionally, per the assessment, 2 unstageable wounds were present on admission. Interventions included pressure relieving devices for the chair and the bed, pressure ulcer care, and application of dressings to the feet. The Pressure Ulcer Care Area Assessment, dated 5/18/17, documented the resident had pressure ulcers to the feet and sacrum, caused by impaired mobility. Staff identified the resident was at risk for new or worsening of pressure ulcers. The Care Area Assessment for ADLs, dated 5/18/17, included the resident required extensive assistance with ADLs and transfers due to weakness. The Nutritional Care Area Assessment, dated 5/18/17, included the resident was at risk for nutritional decline due to forgetfulness, impaired mobility, anxiety, depression and the requirement of mechanically soft meats. A Braden Skin Risk assessment, dated 5/5/17 and 5/14/17 scored the resident at 18, and on 5/19 and 5/26/17 the resident scored 17. The assessment identified scores of 15-18 indicated the resident at high risk for pressure ulcer development. Review of the residents initial care plan, upon admission and dated 5/5/17, recorded the following interventions: Provide a regular NAS (no added salt) diet with weekly weights. An actual break in skin integrity with pressure relieving mattress and seat cushion. Elevate heels off the bed surface floating heels. Reposition every 2 hours in the bed and chair. Skin treatment, as ordered. Therapy consult. Weekly skin checks. Review of the comprehensive care plan, also dated 5/5/17 included: Assess podus (therapeutic, pressure relieving) boots, shoes, straps, heel protectors, 02 tubing, glasses, casts, catheter tubing, and etcetera for pressure. Resident required extensive assistance of 1 staff with transfers, dressing, toileting, bathing and propelling of the wheelchair. Assistance with set-up for meals. Sits and sleeps in the recliner daily and every night, by choice. Observe and report to the medical doctor for signs and symptoms of malnutrition, significant weight loss, chewing and/or swallowing problems. Provide diet, as ordered, including a therapeutic diet and mechanically altered diet Complete Braden Scale Risk Assessment quarterly and PRN (as needed). Complete weekly skin checks. Discuss non-compliance issue with resident/responsible party. Educate resident/responsible party about treatment/prevention. Minimize pressure over boney prominences. Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, and/or discoloration noted during bathing or daily care. Observe for pain and medicate PRN per MD orders Consult dietitian PRN. Provide pressure relieving or reduction device, air mattress and chair cushion Report changes in skin status (signs/symptoms of infection, non-healing, new areas) to MD. Wound care as ordered by MD. Air mattress added 5/9/17. Refuses to sleep in bed, prefers to sleep in recliner, added 5/10/17. Review of the resident's clinical record wound documentation identified the resident admitted on [DATE] with the following pressure ulcers along with follow-up documentation of the measurements: Right 3rd toe: 5/5/17 -- stage II measured 1.0 cm (centimeter) by 1.0 by < (less than) 0.1 cm. 5/10/17 -- stage II; unchanged 5/15/17 - healed times 1 week 5/22/17 - healed times 2 weeks Lacked further wound measurements. Right 2nd toe: 5/5/17 -- 1 cm by 1 cm by < 0.1 cm. 5/10/17 -- 1 cm by 1 cm by < 0.1 cm. 5/15/17 -- Healed times 1 week. 5/22/17 -- healed times 2 weeks. Lacked further wound measurements. Right great toe: 5/5/17 -- Stage III, 1 cm by 1 by < 0.5 cm. 5/10/17 - Stage III, 1 by 1 by < 0.5 cm, with yellow slough. 5/15/17 -- Healed times 1 week. 5/22/17 Healed times 2 weeks. Lacked further wound measurements. Left heel: 5/5/17 -- stage II, 1 cm by 1 cm by 0 cm. 5/10/17 -- stage II, 1 cm by 1 cm by < 0.1 cm. 5/15/17 -- healed times 1 week. 5/22/17 -- healed times 2 weeks. Lacked further wound measurements. Left Heel: 5/5/17 - unstageable, 1.8 cm by 1.5 cm by 0 cm. 5/10/17 - unstageable, 1.6 cm by 1.5 cm by < 0.1 cm, black in color. 5/15/17 -- Healed times 1 week. 5/22/17 -- Healed times 2 weeks. Lacked further wound measurements. Right Heel: 5/5/17 - unstageable, 1.0 cm by 1.2 cm by < 0.1 cm. 5/10/17 - unstageable, 1 cm by 1 cm by < 0.1 cm, brown in color. 5/15/17 -- healed times 1 week. 5/22/17 -- Healed on wound rounds. 6/14/17 -- stage 2, 4.5 cm by 5.5 cm by < 0.1 cm, noted observed by doctor on rounds. Weekly Skin Integrity Data Collection reports included: 5/21/17 -- noted redness to right toes, and open areas to bilateral heels and right great toe. 5/28/17 -- noted open areas to bilateral heels. 6/2/17 -- noted open areas to bilateral heels, right great toe and right 3rd and 4th toes. 6/9/17 -- noted bilateral heels and right great and 3rd and 4th toes (was not identified as open). 6/16/17 -- noted open areas to bilateral heels and redness to right toes. Information on the weekly skin integrity data collection noted to proceed to the appropriate skin condition record, if open areas are noted. physician's orders [REDACTED]. 5/5/17 - Multipodus (a brace-like boot which floats the heel) boots in place while in bed daily. (May 2017 TAR (treatment administration record) documented completed). Discontinued 6/3/17 (new physician order [REDACTED]. 5/5/17 -- Clean left medial ankle with wound cleaner, apply skin prep, let air dry, and cover with foam dressing, every 3 days. (Per June 2017 TAR, last completed on 6/19/17) 5/5/17 -- Clean bilateral posterior ankles with wound cleanser, paint right posterior ankle with [MEDICATION NAME] and apply a foam dressing. Apply skin prep to the left posterior ankle and apply foam dressing every 3 days. (Per June 2017 TAR, last treatment was on 6/19/17) 5/5/17 - Critic-aid (moisture barrier ointment to prevent and treat skin irritation) to buttocks, topically TID (three times daily). 5/5/17 -- Clean right great toe abrasion with wound cleanser, paint with [MEDICATION NAME] and cover with Bandaide, daily. 6/3/17 -- Float heels, when in bed. 6/14/17 -- Right heel: apply skin prep to heel, cover with foam, and apply calcium alginate (a medicated dressing) to 2nd and 3rd toes to dry out, wrap all in Kerlix, every other day and PRN. 6/14/17 -- Heel cup to right heel, wrapped with Kerlix, No AFO (adaptive foot orthotic) until healed, daily and PRN. 6/14/17 -- Right toes: clean with wound cleaner; apply Santyl to the tip of the great toe, apply calcium alginate, cut to size of great toe, wrapped with Kerlix, daily and PRN. 6/19/17 -- Clean right foot with wound cleanser, pat dry; apply skin prep to great toe, 3 and 4 toes, cover with gauze, daily and PRN. 6/19/17 -- Right heel: clean with wound cleaner, pat dry; apply calcium alginate with bordered gauze daily and PRN, making sure to clean in between toes. Review of the physical therapy notes, dated 5/11/17 to 6/21/17 identified the resident declined in progression of the gait training provided, when the pressure ulcers to feet increased in severity, causing the resident increased pain and difficulty with ambulation. Review of nursing notes from 5/29/17 to 6/15/17 identified the nursing staff continued to provide treatment to the resident's bilateral heels, however, the documentation in nursing notes failed to identify the status of the wounds, including measurements to ensure the continuous monitoring and appropriate treatment for [REDACTED]. On 6/15/17 at 6:43 AM, documentation noted a new order for treatment to the right heel. The physician during rounds noted a blister, red in color, to the resident's heel and determined that friction from the resident's AFO caused the blister. Observation of the resident on 6/20/17 at 11:39 AM, identified the resident seated in a wheelchair in his/her room. The resident's non-skid socks lay on the floor nearby, with the resident's bare feet resting directly on the floor. A dressing over the toes on the right foot and a loose Kerlix bandage on the left leg ankle were present. At 12:10 PM on 6/20/17 the resident remained seated in wheelchair in his/her room, with bare feet on the floor. An overbed table with the resident's lunch on it was in front of the resident, who ate independently. On 6/20/17 at 12:33 PM, consultant staff A, assisted the resident with cueing and swallowing techniques at the meal. The resident requested assistance for toileting and direct care staff C, provided assistance for transfer into and onto the toilet, providing limited to extensive assistance for the transfer, with the resident utilizing the grab bars in the toilet to assist with the transfer. The staff had applied the resident's non-skid socks for the transfer. After toileting and hand washing the staff returned the resident to the bedroom, to complete his/her meal with consultant staff A. At that time, staff C reported the resident does not wear shoes or braces at that time, as one or the other caused the blister on his/her foot. Intermittent observations at 12:45, 1:00, 1:15, 1:30, 1:45, and 2:00 PM identified the resident remained in the wheelchair. The wheelchair contained a thick pressure relieving cushion in the seat of the chair. On 6/20/17 at 2:18 PM, licensed nursing staff B set up the treatment tray for wound care for the resident. The staff gathered a disposable tray with several dressings, a roll of gauze, 4x4s and ointment, placing the tray on the overbed table. The staff entered the resident's room, inquired about the resident's pain, with the resident requesting additional pain medication. The staff administered [MEDICATION NAME], 50 mg (milligrams, per order). Staff B completed the set-up, removed the resident's sock and completed the treatment to the right foot. The staff verified the physician made rounds sometime last week and found the blister on the resident's right heel. Additionally, at that time the physician wrote new treatment orders for the toes and the heel. Observation of the resident's right foot identified the great toe with black eschar across the top and tip of the toe, the 2nd and 3rd toes appeared scabbed over, each ranging approximately in size from 0.5 cm to 1.5 cm in diameter across the tops and the ends of the resident's toes. The resident's right heel exhibited an area approximately 5-6 cm in diameter, with the top layer of skin peeled back and still attached at one edge of the blister. The left foot, exhibited the 3rd and 4th toes with scabbed areas, approximately 0.5 to 1.0 cm in diameter across the ends and tops of the toes (first time observed/documented). The left heel exhibited a fluid filled blister, approximately 1.0 to 1.5 cm in diameter. Continued intermittent observations from 2:18 PM to 4:44 PM (at 2:30, 2:45, 3:00, 3:15, 3:30, 3:45, 4:00, 4:15, and 4:30 PM) identified the resident remained in the wheelchair, feet on the floor, with non-skid socks in place. At 4:44 PM on 6/20/17 the resident remained in the wheelchair with his/her feet on the floor. The resident reported he/she did not sit in the recliner any longer, as it had become too difficult for him/her to get out of, and it is just easier to sit in the wheelchair. The resident was noted at times to minimally shift his/her weight in the chair; however, no significant distribution of weight occurred. At 4:50 PM on 6/20/17 licensed nursing staff B returned to the resident's room to take the resident to the dining room for the supper meal. Staff B placed non-padded foot pedals on the chair, placed the resident's feet on the foot pedals then propelled the resident to the dining room. The staff did not offer toileting and the resident did not request toileting at that time. Intermittent observations at 5:00, 5:15, 5:30, and 6:00 PM identified the resident remained at the dining table in the wheelchair. At 6:15 PM the resident self-propelled the wheelchair out of the dining room. The resident remained, following the dressing change, from 2:30 pm until at least 6:15 PM, with his/her feet resting on the floor or wheelchair pedals, without a significant relief of pressure to these affected areas and without elevation of the affected extremities. On 6/21/17 at 5:05 AM, observation identified the resident laid in the bed, with the head of the bed elevated at approximately 20 to 30 degrees. The resident lay flat on his/her back and the resident's feet rested directly onto the surface of the low air loss mattress. At 6:41 AM on 6/21/17 the resident rang the call light for assistance. Upon entering the room with direct care staff C, the resident sat on the edge of the bed, with the head of the bed raised to a high position, and the resident's feet rested directly on the floor. The resident's feet had non-skid socks in place. Staff C assisted the resident to stand and transfer to the wheelchair for transport into the bathroom. Observation at 7:50 AM on 6/21/17 identified the resident ate breakfast in his/her room. At 9:10 AM the resident used a recumbent bike machine in therapy. The therapist was heard instructing the resident in the need to elevate his/her legs throughout the day for [MEDICAL CONDITION] control as well as pressure relief. The resident acknowledged the instructions, but told the staff the recliner was too difficult to get out of; the therapy staff acknowledged that the resident had an option of resting in the bed, or staff could help him/her out of the recliner. The resident was next observed seated in the wheelchair in his/her room, with the overbed table in front of the resident. At 1:35 PM on 6/21/17, a requested skin check of the resident with nursing staff identified the resident's buttocks with 2 stage II open areas; one approximately 0.5 cm by 0.25 circular area on the left buttock and an area approximately 0.5 cm, in length, in the crease of the buttocks. The resident's buttocks area appeared to have multiple healed areas. Licensed nursing staff D, applied a [MEDICATION NAME] ointment to the resident's buttocks area, reporting that the ordered Criticaid ointment was currently not available. After completion of the toileting and skin check, direct care staff E inquired of the resident whether he/she wanted to sit in the recliner or in the bed. The resident chose to lay down in the bed, with the staff's assistance, however, upon laying the resident onto the pressure relieving mattress, the staff failed to offer the resident a side lying position for off-loading pressure to the buttocks, and furthermore, failed to provide off-loading of the heels. Staff had made the resident comfortable and left the room and returned in just a few minutes with licensed nursing staff E who instructed the staff member in the use of an off-loading wedge for use under the resident's feet. Intermittent observations at 2:15, 3:00 and 3:45 PM, of the resident, during the afternoon, identified the resident slept most of the afternoon in the bed. On 6/20/17 at 11:39 AM, the resident reported the blisters occurred as a result of the AFO rubbing a place on his/her heels, and indicated he/she was not walking or wearing shoes at this time. The resident stated the physician found the areas on his/her feet, not the nursing staff, and was not sure how long the blister was on his/her left heel before anyone identified it. On 6/20/17 at 11:15 AM, direct care staff C reported the resident required limited assistance with transfers and had some trouble with his/her feet and was not wearing shoes, braces or walking at this time. Continues to stand for transfers and toileting, but no walking. Direct care staff F, on 6/20/17 at 6:17 PM, reported the resident needed toileting assistance for clothing management, and was able to complete own cares for personal hygiene after set up at the sink. The staff reported the resident wore only non-skid socks at bedtime and staff were to float the resident's heels due to the blistering on the resident's heel. On 6/21/17 at 11:58 AM, direct care staff C reported the resident does not like to get out of the wheelchair during the daytime and preferred to stay in the wheelchair after assisted up in the morning until bedtime. Staff reported the resident's bottom was beginning to get a little irritated, because he/she doesn't reposition and only gets out of the wheelchair when he/she needs to toilet. Direct care staff E reported, on 6/21/17 at 12:15 PM, he/she assisted the resident with toileting only one time this morning, otherwise he/she provided no other assistance to the resident. On 6/21/17 at 12:55 PM, administrative nursing staff H verified the lack of wound measurement, monitoring and implementation of appropriate interventions to prevent the worsening of the resident's wounds to his/her feet. Staff H additionally voiced concern that staff failed to reposition and provide pressure relief, as per the care plan. On 6/23/17 at 11:49 AM, consultant staff J, reported the physician inspected the residents heels on the morning of 6/14/17. The staff reported the staff removed a dressing from the heel of the right foot, and the physician reported the wound on the right heel was worse than when previously observed, and changed the orders for the treatment. The facility policy, dated 2/25/15, directed staff to minimize injury due to shear and friction through proper positioning, transfers, and turning schedules; reposition at least every 2-4 hours as consistent with overall patient goal and medical condition; utilize positioning devices to keep bony prominences from direct contract and heel protection/suspension should be implemented while the patient was in bed. The Skin Rounds Process Guide, dated 12/26/15, directed to determine a team member to record measurements, assessments, and plans, during rounds. The facility failed to consistently assess, identify, and monitor this resident's skin condition. Furthermore, the facility failed to ensure pressure relieving devices in place and elevation of extremities to prevent recurrence or development of pressure ulcers. In addition, the facility failed to ensure the physician ordered treatment of [REDACTED]. The resident developed recurring pressure ulcers of 6/20/17 - 1 stage III and 5 stage II, and 2 stage II new pressure ulcers.

The facility reported a census of 74 residents. The 32 residents selected for review included 4 reviewed for accidents. Based on observation, interview and record review, the facility failed to fully assess the fall risk and failed to develop and implement timely and effective interventions to provide adequate supervision and/or assistive devices to prevent repeated accidents for these 4 selected residents including; resident #35 who experienced a fall which resulted in bilateral femur fractures (A fracture of the thighbone that occurs just above the knee joint.) and a tibial fracture (The shinbone or tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle.); resident #45 who experienced a fall which resulted in a head laceration and required sutures; resident #46 who experienced an improper transfer with a mechanical lift, fell and sustained a head laceration with sutures, nose fracture, and an ankle fracture; and resident #32 who experienced a fall during improper resident care in a safe manner, and sustained a head laceration with staples. The facility identified 14 confused and self-mobile residents. The facility furthermore, failed to ensure a safe environment for these 14 residents with accessible hazardous chemicals in an unlocked media room. Findings included: - Review of resident # 35's physician order [REDACTED]. The annual MDS (minimum data set), dated 1-18-16, assessed the resident with a BIMS(brief interview for mental status) score of 09, indicating moderate cognitive impairment. The resident was dependent on 2 staff for bed mobility and transfers, had limitation in range of motion in his/her lower extremity on one side, and a fall in the last 2-6 months. The resident was always incontinent of bowel/bladder and not on a toileting plan. The resident ' s balance of surface to surface transfers were unsteady and he/she required staff assistance to stabilize. The quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 12, indicating moderate cognitive impairment, required extensive assistance of 2 staff for bed mobility, dependent on 2 staff for transfers/toileting needs, and limitation in range of motion in his/her lower extremity on one side. The resident ' s balance and incontinence remained without change, without a toileting plan. The CAA (Care area assessment), for falls, dated 1-18-16, assessed the resident at risk for falls, due to inability to ambulate and incontinence, utilized the Hoyer lift for transfers, and able to make needs known to staff. The care plan, dated 4-15-16, revealed the resident was at risk for fall related injury related to impaired mobility secondary to morbid obesity, required a Hoyer lift for all transfers, and used the quarter bed rail to assist with bed mobility and incontinence care. The care plan, dated 7-1-16, identified the resident was currently bedbound with bilateral lower extremity fractures. Staff were advised to use the Hoyer lift with 2 staff members, no pillow in the wheelchair due to the resident sliding, he/she used the quarter rail to assist with bed mobility and incontinence care and able to hold onto the rail while staff provided cares. The plan of care lacked interventions after the resident ' s attempt to get out of bed to self-toilet on 5/27/16. Review of the fall risk evaluation, dated 4-4-16, revealed a score of 16 (scores greater than 10 indicated at risk for falls) indicated the resident was at risk for falls. The fall risk evaluation score, dated 6-22-16, revealed a score of 20. The fall risk evaluation score, dated 7-1-16, revealed a score of 14 and suggested staff keep the bed in the lowest position and to place the call light within the resident ' s reach. The medical record lacked an assessment of the resident's ability to use the electric bed control. A nurses' note, dated 5-27-16 at 11:47 am, revealed direct care staff notified the charge nurse of the resident's increased confusion and attempt to get out of bed, with the resident communicating to the staff that he/she wanted to get up. Staff obtained an order from the physician for a urinalysis and educated the resident to not get up without assistance and the resident verbalized understanding. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The medical record lacked any further follow-up upon completion of the antibiotic, to ensure no further UTI was present. Review of nurses' notes, dated 6-22-16, revealed at approximately 4:30 am, a direct care staff member found the resident on the floor, by the bedside, with his/her lower extremity malpositioned and the resident reporting pain. The nurse called for emergency transport to the hospital. Review of an acute care surgeon's note, dated 6-22-16, revealed the hospital trauma team evaluated the resident, and determined the resident sustained [REDACTED].) and a left tibial shaft fracture (The shinbone or tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle.) and proceeded with surgical repair. Review of the safety note, dated 6-26-16, and signed by administrative nursing staff B, revealed the resident reported to staff he/she attempted to get out of bed to take him/herself to the bathroom without using his/her call light. This note revealed direct care staff provided pericare to the resident at 2:30 am, left the bed in a low position, and gave the resident the call light and bed control. This same direct care staff heard the resident call for help at 4:30 am, and found both the bed and the head of the bed elevated. The safety committee determined the resident used the bed control to raise up the bed, elevated his/her head, used the bedside mobility rail to turn, and slid out of bed. The note indicated the resident did not use his/her call light for assistance. The safety committee determined the need for a therapy screen, a urinalysis and floor mats by the bed, upon the resident's return to the facility. Observation, on 8-17-16 at 7:30 am, revealed the resident's bed in a high position (31 inches from the floor to the top of the pressure relieving mattress), with the head of the bed raised at approximately a 45 degree angle, and no floor mats beside the bed. The resident was alert to name and stated he/she had a fall from the bed trying to get to the bathroom and did not turn on the call light. The resident could not find his/her call light at this time. The call light was tied to the bed ' s quarter rail, but the end slipped down the rail onto the floor. The electric bed ' s controls attached to the lower portion of the quarter rail could not be reached by the resident when he/she attempted. Observation, on 8-17-16 at 8:30 am, revealed direct care staff RR assisted the resident to elevate his/her head of the bed with the electric controls, positioned on the bed rail. Interview, on 8-17-16 at 8:30 am, with direct care staff RR revealed the resident could use his/her call light, but since his/her fall out of the bed, was more confused and could be difficult to understand. Staff RR stated staff elevated the resident's bed so the resident could see the TV. Observation, on 8-17-16 at 5:00 pm, revealed both the resident's bed and his/her head of the bed elevated. At this time, Nursing staff L, confirmed the resident's bed height was high and lacked either of the planned bilateral floor mats. Staff L stated the resident used the call light, and he/she thought the resident could use the electric bed controls to raise and lower the bed height and elevate the head of the bed. Staff L stated the resident's bed should be in a low position, and floor mats should be in place along each side the bed. Interview, on 8-17-16 at 7:30 pm, with licensed nursing staff O, revealed he/she had not known the resident to attempt to get out of bed on his/her own and reported the resident was incontinent of bowel and bladder. Interview, on 8-18-16 at 11:40 am, with consulting surgeon staff W, revealed the resident did not have pathological fractures but sustained a traumatic injury, from the resident ' s fall on 6-22-16. Interview on 8-18-16 at 1:20 pm, with direct care staff T, reported he/she did not know the resident had an attempt to get out of bed (5-27-16) prior to the fall on 6-22-16. The resident required 2 staff to provide care in bed and could roll in bed if staff assisted the resident to use the positioning rail. The resident's bed was in an elevated position when he/she found the resident. Staff T stated he/she and a charge nurse worked from 10 pm to 6 am. Staff T stated he/she would ask the charge nurse or a direct care staff from another hall for assistance with residents that required 2 staff assistance. At the time of the resident's fall, staff T stated the charge nurse was not on the unit, and he/she ran to another unit to find assistance. Interview, on 8-18-16 at 1:50 pm, with licensed nursing staff M revealed he/she did not know the resident made a prior attempt to get out of bed unassisted (5-27-16). Staff M worked from 6 pm to 6 am, and was on a break when a direct care staff found the resident on the floor. The resident usually was alert, but did have some confusion and it surprised Staff M that the resident would attempt to move him/herself out of the bed. Staff M thought the bed was in a low position at the time that staff found the resident on the floor. Interview, on 8-22-16 at 9:35 am, with administrative staff C, revealed the facility lacked an assessment of the resident's ability to use the electric bed control. Interview, on 8-22-16 at 3:15 pm, with administrative nursing staff B, confirmed he/she investigated the resident's fall, and did not report it to the state agency as the resident was alert (BIMS 12) and told staff he/she attempted to take themselves to the bathroom and fell from the bed. Staff B stated he/she did not know if the interventions of repeat urinalysis, fall mats and bed in low position were on the care plan upon return to the facility as indicated in the safety committee note, dated 6-26-16. The undated, facility policy for falls advised the staff to review and revise the care plan to reflect current fall risk and resident specific interventions designed to reduce recurrence. Action plans developed by the PIC (Performance Improvement Committee) are communicated to the staff. The facility failed to determine the root cause and provide adequate supervision and/or assistive devices to prevent this resident from experiencing an injury fall after the resident attempted to get out of bed without assistance on 5-27-16. On 6-22-16, 26 days after the first attempt to get out of bed unassisted, the resident once again attempted to get out of bed without staff assistance, fell and sustained a bilateral femur fractures and a tibial fracture, which required emergency care and surgical intervention. - Review of resident #45's physician order [REDACTED]. The admission MDS (minimal data set), dated 6-27-16, assessed the resident with a BIMS (brief interview for mental status) score of 7, indicating severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. This MDS assessed the resident with no impairment in the upper or lower extremities, incontinent of bowel and bladder and sustained a fall prior to admission. The CAA (care area assessment), for ADLs (activities of daily living) dated 7-5-16, assessed the resident required extensive assistance of 1-2 staff for bed mobility, toileting and transfer. Staff advised the resident sustained [REDACTED]. The care plan, dated 6-20-16, advised staff the resident required extensive assistance with most daily care needs related to impaired mobility and a healing right hip fracture, severe cognitive loss and experienced occasional episodes of bowel and bladder incontinence. The care plan advised the staff to offer scheduled toileting. The care plan advised staff the resident was at risk for falls due to poor safety awareness, and poor cognitive ability. The care plan advised staff the resident ' s wheelchair had auto locking brakes and he/she was on the falling leaf program. An update to the care plan, on 7-24-16, advised staff to keep the resident in close observation, continue to instruct the resident with the use of the call light, and to keep the bed in a low position. The fall risk assessments, dated 6-20-16, 7-8-16 and 7-24-16, assessed the resident with a score of 17, with greater than 10 indicating at risk for falls. Interventions included placing the call light within reach, close observation and re-instruction on the use of the call light. A nurses' note, dated 7-24-16 at 1:30 pm, revealed direct care staff found the resident on his/her knees on the floor of his/her room wiping up blood pooling on the floor. The resident sustained [REDACTED]. Review of the fall follow-up form, for the incident dated 7-24-16 at 1:30 pm, revealed staff found the resident on the floor with a laceration to his/her scalp. The resident informed staff he/she was trying to transfer from his/her wheelchair to the bed. Observation, on 8-17-16 at 10:00 am, revealed the resident positioned in a low bed in his/her room. The wheelchair was close to the bed. The resident ' s water pitcher was on the bedside table, not within reach. The resident reported at this time, he/she could locate the call light. The resident stated he/she did not require staff assistance with dressing, toileting or transferring from the wheelchair into the bed and would get up to obtain a drink of water from the bedside table. Interview, on 8-17-16 at 10:00 am, with direct care staff R, revealed staff did not assist the resident with toileting, transferring or dressing, and stated the resident was independent with activities of daily living. The resident could transfer him/herself on and off the toilet, was self-mobile in his/her wheelchair and could transfer him/herself from the wheelchair into bed. Interview, on 8-18-16 at 9:45 am, with consulting staff U, revealed therapy staff felt the resident was not safe for self-transfer or ambulation. The resident had poor safety awareness with cognitive impairment, and was not patient enough to wait for staff assistance. Therapy would be picking him/her back up as staff felt the resident had a decline in ability. Interview, on 8-18-16 at 11:00 am, with licensed nursing staff I, revealed he/she was filling in. Staff I stated he/she thought the resident did not require assistance with ambulation, and could use the call light. Staff I stated he/she was not sure how the resident fell in his/her room, but the resident did have adjustment difficulties when first admitted to the facility. Interview on 8-22-16 at 8:00 am, with licensed nursing staff M, revealed the resident often transferred him/herself, and was not safe to ambulate by him/herself. Staff M stated staff should check the resident frequently. Observation, on 8-22-16 at 10:10 am, revealed the resident toileted him/herself in his/her bathroom unassisted, and wheeled him/herself out of the bathroom. Interview, on 8-22-16 at 4:10 pm, with administrative staff B, revealed the resident did not call staff for assistance and got up out of his/her wheelchair by him/herself and fell . Staff B explained the facility failure to determine the root cause analysis of the resident's fall. The facility policy for the Falling Leaf/ falling star policy, undated, advised staff to update the care plan with resident specific interventions. The policy advised staff that residents may have limitation in safety awareness and have a greater potential to fall and require more diligent supervision. The facility failed to ensure staff awareness of the resident's needs for assistance with transfers and toileting to prevent falls. This confused resident fell and sustained a laceration to the back of the head which required staples in the hospital. - Resident #46's annual MDS (minimum data set), dated 3-3-16, assessed the resident with a BIMS (brief interview for mental status) score of 8 indicating moderate cognitive impairment, total dependence of 2 staff for transfer, and impairment of bilateral upper and lower extremities. The resident had no prior falls documented. The CAA (care area assessment), for activities of daily living, dated 3-17-16, assessed the resident as dependent on staff for daily care needs and mobility with contractures in all extremities and quadriplegia ( paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). The care plan, reviewed 6-23-16, advised staff the resident had a self-care deficit due to impaired mobility, quadriplegia and required 1-2 person assist bed mobility and transfers. This care plan advised 2 staff to utilize the mechanical lift with all transfers, lock brakes on bed and chair before transferring. An addition to the care plan, dated 6-24-16, advised staff of the resident's fractured left ankle and staff to support the resident's ankle during bathing, turning and pericare. A nurses' note, dated 6-23-16 at 5:33 pm, revealed at approximately 8:20 am, staff notified him/her the resident was on the floor. This licensed staff observed the resident lying face first on the floor, in a pool of blood with a laceration on the resident's face and called emergency service. This licensed staff documented one direct care staff attempted to transfer this resident with a mechanical lift without the required second staff. Review of a progress note, dated 6-23-16, by medical staff X, revealed the resident fell out of the Hoyer lift onto the right forehead, and transferred to a hospital for head trauma evaluation. A nurses' note, dated 6-23-16 at 5:53 pm, revealed the resident returned to the facility at 12:30 pm, with an undetermined (due to dried blood) number of stitches noted to his/her forehead in the Y shaped laceration. The nurses' note revealed the hospital reported the resident sustained [REDACTED]. A nurses' note, dated 6-24-16 at 1:30 pm, revealed the resident stated he/she had pain in the ankles, feet and hips and licensed staff obtained an order for [REDACTED]. The mobile x ray report, dated 6-24-16, revealed a fracture of the resident's left ankle. A nurses' note, dated 6-24-16 at 7:36 pm, documented the resident transferred to a hospital for treatment of [REDACTED]. A fall safety note, dated 6-24-16, documented the witnessed fall from the lift indicated the resident leaned forward during the transfer from the bed to chair and fell from the lift. Observation, on 8-17-16 at 9:45 am, revealed direct care staff RR and WW transferred the resident, with a Hoyer (mechanical) lift, from a sitting position in his/her wheelchair into his/her bed. Interview, on 8-17-16 at 9:45 am, with direct care staff RR revealed the resident transferred with the Hoyer lift which required 2 staff in attendance. Interview, on 8-17-16 at 5:10 pm, with licensed nursing staff L, charge nurse on the resident's hall on 6-23-16, reported the direct care staff member transferred the resident with the Hoyer lift improperly with only the one staff member in attendance. Staff L stated transfers with the Hoyer lift always required 2 staff. Interview, on 8-17-16 at 5:30 pm with direct care staff YY, revealed he/she worked the resident's hallway and assisted direct care staff ZZ in dressing the resident in his/her bed on 6-23-16 at approximately 8:00 am. Staff YY further explained he/she left the room to turn in the hall tray meal tickets to the dining room as 2 direct care staff (including him/her) and the charge nurse were working on the hall. Staff ZZ then came to the dining room to get assistance after the resident's incident. Staff YY stated staff ZZ transferred the resident from his/her bed by him/herself and did not cross the mechanical lift sling's leg straps properly, which allowed the resident to fall from the mechanical lift. Interview, on 8-18-16 at 8:54 am, with medical consultant V, revealed the resident's injuries, on 6-23-16, resulted from improper transfer with the mechanical lift. Interview, on 8-22-16 at 4:10 pm, with administrative nursing staff B, revealed the investigation determined direct care staff (ZZ) improperly transferred the resident with the Hoyer lift, which resulted in the resident's facial laceration with sutures, nasal fracture, and left ankle fracture. The facility policy for mechanical lift use, dated 11-97, advised 2 staff perform transfer with the mechanical lift. The facility failed to ensure direct care staff safely transferred this dependent resident with the Hoyer lift which lead to a fall and resulted in a facial laceration with sutures, nasal fracture and ankle fracture. - Review of resident #32's physician order [REDACTED]. The quarterly MDS (minimum data set), dated 3-15-16, assessed the resident with a BIMS (brief interview for mental status) score of 13, indicating intact cognitive status, and required extensive assistance of 2 staff for bed mobility/transfers. This MDS assessed the resident with impairment in range of motion ability in the bilateral upper and lower extremities. The significant change MDS (minimum data set), dated 5-26-16, assessed the resident without cognitive change, a decline to totally dependent on 2 staff for bed mobility/transfers, and without change in range of motion abilities. The CAA (care area assessment) for activities of daily living, dated 6-6-16, assessed the resident's [DIAGNOSES REDACTED]. The CAA for falls, dated 6-6-16, assessed the resident at risk for fall related injuries, related to total staff dependence of staff for transfers and positioning. The care plan, dated 5-19-16, advised staff of the resident's risk for falls due to inability to bear weight on the lower extremities and total dependence on 1-2 staff for transfers. It also advised staff of the resident's impaired mobility weakness, pain and cervical spine stenosis (narrowing or constricting) and inability to move his/her limbs. The care plan dated 6-8-16 advised staff to place the bed against the wall, place bolsters on the bed, and keep the bed in a low position. An update recorded on 8-17-16, revealed on 6-8-16 a bariatric bed (larger, holds more weight) with an air mattress was instituted and advised 2 staff for transfers and repositioning. The fall risk assessments, dated 9-24-15, 12-16-15, and 3-8-16 assessed the resident at risk for falls and advised the use of a low bed. The investigation safety note, dated 6-7-16, revealed a direct care staff turned and repositioned the resident in bed while providing care, and the resident fell out of the bed. This investigation failed to document the root cause of the resident's fall, failed to document the height of the bed, condition and type of the mattress, and reason one direct care staff provided care to a resident that required 2 direct care staff. This investigation advised to place the bed in a low positron, place the call light within reach, apply bolsters on both sides of the bed, and ensure 2 direct care staff to provide care to the resident when in bed. Observation, on 8-22-16 at 10:00 am, revealed the resident positioned in a bariatric bed. The bed height was a height of 31 inches. The bed was not positioned against a wall. Interview, on 8-22-16 at 7:40 am, with licensed nursing staff M, revealed the resident should have 2 staff present when repositioning in bed or transferring. The resident fell out of bed when 1 CNA (certified nursing assistant) was providing care to the resident. Interview, on 8-22-16 at 9:00 am, with direct care staff SS states he/she assisted another direct care staff with transferring the resident into bed, then left the room. Staff SS stated he/she got called away from assisting with the resident, as there were 2 direct care staff working on this hall and the charge nurse. Staff SS stated he/she thought the resident required one staff to provide pericare. Interview, on 8-22-16 at 2:45 pm, with medical consultant X, revealed the resident required 2 staff in attendance for safety as the resident was quadriplegic (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). Interview, on 8-22-16 at 3:30 pm, with administrative nursing staff B, revealed he/she investigated the fall, and found that 2 direct care staff transferred the resident into bed with the Hoyer lift, but then one direct care staff turned the resident in bed, and the resident fell out of the bed to the floor. Staff B stated the resident did have bolsters on his/her bed, which later staff replaced in a bariatric bed. The resident sustained [REDACTED]. The facility policy for investigation of a resident fall, undated, advised staff to investigate falls to determine the causal factors surrounding events and possible trends. The facility failed to reposition this dependent resident in a safe manner, which resulted in a fall from his/her bed. The resident sustained [REDACTED]. - Observation on 8/15/16 at 9:56 AM revealed an unlocked Media Room . Upon turning the knob, the door opened freely. Observation of the room revealed 3 cleaning supplies sitting on a shelf approximately 4 foot high in open view with miscellaneous hazard labels in place. The following chemicals were observed in the unlocked maintenance room: Crystal Red Stain Plus: Identified as a danger that caused serious eye damage by the manufacturer. Crystal Odor Protectant: Identified as a danger that caused serious damage to the eye by the manufacturer. Hoover Clean Plus: Identified as a hazard to eyes, skin and the gastrointestinal system if ingested by the manufacturer. During an interview on 8/15/16 at 9:56 AM with therapy staff FF revealed the door to the media room should be locked at all times. During an interview with housekeeping staff GG on 8/22/16 at 1:32 PM revealed he/she knew there were chemicals stored in the media room and he/she expected the media room to be locked at all times. On 8/24/16 at 3:58 PM Administrative staff A reported the facility did not have a chemical storage policy. The facility failed to maintain a safe environment for 14 cognitively impaired and independently mobile residents related to unlocked chemicals.

The facility reported a census of 74 residents with 32 residents sampled. The sample included 3 residents reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to ensure 2 of the 3 sampled residents (#64 & #101) who entered the facility without pressure ulcers, did not develop pressure ulcers. In addition the facility failed to provide the necessary treatment and services for 2 of the 3 sampled residents (#64 and #124) to promote healing of the facility acquired pressure ulcers. Findings included: - Resident #64's signed physician orders, dated 8/14/16, documented the resident with the [DIAGNOSES REDACTED]. The 5-day MDS (minimum data set), dated 6/17/16, revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The resident required extensive staff assistance of 2 for bed mobility, transfers, and toileting; extensive staff assistance of 1 for locomotion; and limited staff assistance of 1 for ambulation. The resident was without impairment in functional range of motion, and for mobility used a walker and a wheelchair. The resident weighed 175 pounds. The resident had a stage 1 or greater pressure ulcer or a scar over a bony prominence. The resident was at risk for pressure ulcers, and had 1 unstageable, unhealed pressure ulcer which had eschar (dead tissue). The pressure ulcer measured approximately 3.0 cm (centimeters) by 2.3 cm. The resident had a pressure reducing device for the chair and bed, and received pressure ulcer care. However, this resident who required 2 staff for bed mobility lacked a turning and repositioning program. The significant change MDS, dated [DATE], revealed the following changes from the prior assessment: The resident weighed 169 pounds, and received a therapeutic diet. The pressure ulcer measured 2.9 cm by 2.7 cm without measurable depth. The resident received application of ointments and medications other than to feet, and application of dressings to the feet. The resident had a pressure reducing device for the chair and bed, and received pressure ulcer care. However, this resident who required 2 staff for bed mobility lacked a turning and repositioning program. The CAA (care area assessment), dated 7/26/16, for pressure ulcers, documented the resident continued to have a pressure ulcer to the right outer foot, and had frequent urinary incontinence. The interim care plan, dated 6/2/16, documented the resident was at risk for breakdown in skin integrity and instructed staff to: - Schedule time out of bed as tolerated, and to complete weekly skin checks. The resident required staff assistance of 1 for ADL's (activities of daily living). Updates to this interim care plan, dated 6/16/16, identified the following: - Staff were to elevate the resident's heels off the bed surface and to float the heels, with no pressure on the heels. - The head of the bed was to be elevated less than 30 degrees. - Schedule time out of bed for the resident as tolerated. - Bi-weekly skin checks by the nurse. - Skin prep (a liquid film forming dressing) to the right foot 4 times a day. - Keep the resident's feet from passing onto the foot board at the end of the bed. Staff updated the care plan again, on 6/21/16, to include; staff were to remove the resident's foot board. The resident required staff assistance of 2 for ADL's. The comprehensive care plan, dated 6/21/16, advised staff the resident had an unstageable pressure ulcer to the right outer foot and identified the following: - The resident was able to assist with frequent repositioning, and utilized 1/4 side rails. - Assist and remind the resident to reposition himself/herself frequently for pressure relief. - Consult and/or make a referral for screen as needed. - Float the resident's heels when in bed. - Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during bathing or daily care. - Wound care as ordered by the physician. - Two staff assistance with transfers and ambulation. - The resident required extensive assist of 1-2 staff with bed mobility, and transfers. - Used a wheelchair for mobility with limited staff assistance. The resident was able to ambulate with a front wheeled walker, but only with staff assistance. The Braden Scale Assessments for Predicting Pressure Sore Risk, dated 6/2/16 and 6/10/16, had a high risk score of 21. A score of 15-18 indicated a mild risk for pressure ulcers. The H&P (history and physical) from the hospital, dated 5/13/16, lacked documentation of a skin issue for the resident. The initial data collection tool/nursing service assessment, dated 6/2/16, documented the resident had redness on his/her bottom, an abrasion over the right ankle, and a treatment in place. The weekly skin integrity data collection assessments, dated 6/2/16 and 6/6/16, documented the resident's skin was intact. The initial Data Collection Tool/Nursing Service, dated 6/10/16, documented the resident's skin was intact with redness to the groin folds. The resident was able to position himself/herself in bed. The weekly skin integrity data collection assessments, dated 6/13/16 and 6/16/16, documented the residents skin was intact. The electronic nurses notes dated, 6/16/16, documented a wound to the bottom of the resident's right foot, on the lateral (outer) side. The wound measured 3 by 2.3 cm (centimeters), and had 100% black eschar with slight redness around the edges of the wound bed. The physician ordered skin prep (a skin toughener), applied 4 times a day until healed, to off load the heels at all times, and ensure that the residents feet were not pressed against the foot board at the end of the bed. The signed physician telephone order, dated 6/16/16, documented skin prep applied to the bottom of the resident's right foot, lateral side, 4 times a day until healed. The order directed the staff to float the resident's heels at all times, and to make sure his/her feet did not press against foot board of the bed. The Pressure Ulcer risk assessment tool, dated 6/17/16, documented the resident with a risk factor for pressure ulcers and had decreased or impaired bed and chair mobility; and urinary or bowel incontinence. The admission H & P, dated 6/19/16, documented the resident was at a long term care facility. Several days ago he/she developed an ulceration of his/her right lateral foot. The family became concerned about the area and requested further evaluation. The resident was brought to the emergency department last night. The physician documented the resident had an ulceration with eschar to his/her right lateral base of 5th metatarsal (the smallest toe). There was concern for possible infection of the wound. The physician was unable to stage the wound to the bottom of the resident's right foot, due to eschar (a thick black wound covering). The physician ordered to treat the wound with Zpysn ( a [MEDICATION NAME] type antibiotic) and [MEDICATION NAME] (an antibiotic), and to consult with a podiatrist (foot physician). The discharge orders, 6/21/16, documented the resident was to follow-up with the podiatrist who saw the resident in the hospital. A Data Collection Tool/Nursing Service assessment, dated 6/21/16, documented the resident with a pressure ulcer to the right lateral foot, approximately 3 by 3 cm, and without change in ambulation or mobility. The Pressure Ulcer Risk Assessment tool, dated 6/21/16, documented the resident's risk factors were a history of pressure ulcers to the right foot. The weekly skin integrity data collection assessments, dated 6/23/16 and 6/27/16, documented the resident's right foot treatment dressing was place. The Pressure Ulcer Risk Assessment Tool, dated 6/27/16, documented the resident's risk factors were a history of pressure ulcers, and decreased mobility or impairment in the bed and chair. The Pressure Ulcer Risk Assessments, dated 7/2/16 and 7/11/16, remained unchanged from the previous assessments. The electronic wound noted dated 6/29/16, documented the resident with a pressure ulcer to his/her right lateral foot, and measured approximately 2.8 cm by 2.5 cm, and had 100% of eschar covering the wound. The weekly skin integrity data collection assessment, dated 6/30/16, documented the resident's treatment was in place to the right foot. The electronic wound note, dated 7/5/16 documented the right outer foot wound measured, 3 by 2.8 cm, and the wound was no longer soft, but contained a hard black eschar covering. The physician's orders [REDACTED]. The wound shows no signs of symptoms of infection. The intervention in place to prevent further skin breakdown were to float the resident's heels in the bed. The weekly skin integrity data collection assessments, dated 7/7/16 and 7/11/16, documented the resident with a treatment in place to the right foot. The wound note, dated 7/12/16, documented the wound to right outer foot measured 3 cm by 2.5 cm, had 100% eschar coverage of the wound bed. The wound without drainage, or odor, and continue with current treatment. The wound without signs or symptoms of infection. The intervention in place to prevent further skin breakdown remained the same. The weekly skin integrity data collection assessments, 7/14/16 and 7/18/16, documented the resident with the dressing to the right foot intact. The electronic wound note, dated 7/19/16, documented the wound to the right outer foot measured 3 by 2.5 cm, the wound bed had 100% eschar, and without odor or drainage from the wound. The intervention in place to prevent further breakdown remained the same. The electronic wound note, dated 7/26/16, documented the resident's wound to the right foot measured 2.9 cm by 2.7 cm, the wound bed covered with 100% of eschar, and without odor or drainage. Continue with the current treatment order. The intervention in place to prevent further breakdown remained the same. The weekly skin assessment integrity data collection assessment dated [DATE], documented the resident's right foot ulcer treatment was in place. The electronic wound note, dated 8/3/16, documented the resident with an unstageable wound to the right foot which measured 2.8 by 2.9 cm by 0 cm depth. The wound bed had 100% of eschar coverage, and the wound was without drainage or odor. The wound has not changed from the previous assessment. The intervention in place to prevent further breakdown remained the same. The weekly skin integrity data collection assessments, dated 8/4/16 and 8/8/16, documented the resident had a right foot wound dressing in place. The electronic wound note, dated 8/9/16, documented the resident with a unstageable wound to the right foot which measured 2.5 by 2.5 cm by 0 cm depth. The wound bed had 100% eschar coverage. The wound had improved from the last week. The intervention in place to prevent further breakdown remained the same. The 8/11/16, weekly skin integrity data Collection assessment remained unchanged from the previous assessment dated [DATE]. The physician ordered on [DATE], directed staff to change the right foot wound dressing two times daily. Soak the [MEDICATION NAME] (a non-stick dressing) with [MEDICATION NAME], apply the [MEDICATION NAME] to the wound and cover with an adhesive border gauze twice a day. Furthermore the physician ordered [MEDICATION NAME], (an antibiotic medication, wound infection) 500 mg (milligrams), 1 by mouth daily for 5 days. The electronic wound note, dated 8/14/16, documented the resident with an unstageable pressure ulcer to the right lateral foot, which measured 3.0 cm by 2.5 cm, by <0.1 cm depth. The wound had 75% eschar coverage, with 25% of yellow slough (dead tissue, usually cream or yellow in color). The wound remained without drainage or odor. The wound had not changed from last week's assessment. The H & P (Physician's notes from a hospitalization stay), dated 8/17/16, documented the resident arrived at 1:08 PM, by a private vehicle. The resident had a right foot ulcer, which started approximately 2 months ago and was still present. The resident denied any complaints, except the nursing home was concerned that the wound was not healing. The resident was not seen for a follow-up appointment with the podiatrist as recommended by his/her previous physician's discharge instruction. The resident had not been seen or evaluated by a wound care team. For the course of care: the physician spoke with the resident's nurse at the facility and advised that the resident needed to be followed-up by the podiatrist as mentioned in his/her previous discharge instructions, and to be evaluated on a routine basis by a wound care team. The TAR (treatment administration record) for June 2016, documented on 6/10/16, per nursing, the resident was to have a skin assessment, twice a week, on Mondays and Thursdays. Then a written in order, dated 6/21/16, documented the same, for staff to complete the resident's skin assessments twice a week. However, the medical record lacked documentation for the 23rd, 27th, and 30th. The TAR for June 2016, included orders instructing staff to apply skin prep to the bottom, of the lateral side of the resident's right foot, 4 times a day, starting 6/16/16. However, staff failed to apply or document completion of this treatment, on 5 occasions, from 6/16/16 through 6/30/16. On 8/18/16 at 8:28 AM, observation revealed the resident did not have his/her feet elevated. Licensed nursing Staff BB removed the dressing on the residents right lateral foot. The wound measured approximately 2 by 2 cm, with a black eschar covering the wound, which appeared loose on one end, revealing yellow slough. The nurse discarded the dressing, and washed his/her hands. Staff BB put on gloves, placed a 2 cm by 4 cm [MEDICATION NAME] soaked [MEDICATION NAME] on the residents foot, and covered with a bordered gauze dressing. Staff BB removed his/her gloves, washed her hands and put on a pair of non-skid socks on the resident. At 8:45 AM, 9:00 AM, 9:15 AM, 9:30 AM, 9:45 AM, 10:00 AM, the resident remained without a change in position. On 8/18/16 at 9:30 AM, the resident stated he/she acquired the pressure ulcer from the foot board on the bed at the time and stated that when lying in bed, the bottom of his/her right foot would rub against the foot board, and he/she had to go to the hospital for it. On 8/18/16 at 2:02: PM, direct care staff JJ stated when he/she assisted the resident, he/she required staff assistance. The resident slid down in the bed toward the foot board a lot, and his/her feet would touch the foot board. The resident had an area to the bottom of the right foot. The resident had been using a heel riser, which would keep his/her heels off the bed. The resident now would kick the heel riser off the bed. On 8/18/16 at 2:32 PM, direct care staff LL stated the resident had an area to his/her right foot. The resident had been using the heel riser, but previously the resident did not have it under him/her. On 8/18/16 at 10:10 AM, licensed nursing staff BB stated the resident's pressure ulcer was facility acquired. The resident had been rubbing his/her foot on the foot board of his/her bed. The resident was suppose to have the cushion to float his/her heels in place, but he/she had been refusing, and when he/she asked, the resident did not want it. On 8/18/16 at 12:28 PM, licensed nursing administrative staff D stated the wound was facility acquired. Consulting medical staff X assessed the resident's right foot and thought it might be getting worse because of the slough under the wound bed, and wanted the resident seen by a doctor. On 8/18/16, at 1:00 PM, licensed nursing staff BB stated the resident did not have an order for [REDACTED]. On 8/18/16 at 3:00 PM, licensed nursing staff BB stated he/she called the facility podiatrist and the podiatrist office recommended for follow-up visits, and both stated the resident had not been seen. On 8/22/16 at 2:15 PM, consulting medical staff X stated the resident had a slow healing wound ulcer, on the bottom of his/her right foot. The resident obtained the pressure ulcer from resting his/her foot on the foot board, and caused a good sized wound with eschar, per report. Staff X had not heard the resident was to have a follow-up appointment with the podiatrist; however he/she had been treating the pressure ulcer since. The resident was high risk for skin breakdown due to he/she was frail and had diabetes. The resident's pressure ulcer could have possibly been avoided if the staff had monitored the resident's skin more frequently. On 8/22/16 at 2:56 PM, licensed administrative staff B stated he/she wondered if the staff missed the pressure area on admission. When a resident admitted the staff were to complete a full assessment on admission, which included skin. Now either he/she would do the assessment or administrative nursing staff B. The resident had skin assessments two times a week. The wound nurse assessed the wound 1 time a week and then the nurse did it one time a week. The aides were also to do a skin assessment with a bath or shower. When staff B was told of the pressure ulcer, the foot board on the bed was taken off, the resident's heels were to be elevated, and a turning and repositioning program implemented. If the staff would have observed the area on the residents foot sooner, the pressure ulcer might have been avoided. The facility policy for pressure ulcer prevention, revised on 2/25/15, documented a comprehensive skin assessment on admission and re-admission to the center, which may possibly indicate an unavoidable stage 3 or 4 with slough, drainage or even eschar within a few days. A skin assessment should be performed weekly by a licensed nurse. Measures to protect the resident against the adverse effect of external mechanical forces, such as pressure, friction, and shear were implemented in the plan of care. Heel protection/suspension should be implemented while the resident was in bed. The facility failed to provide the necessary treatments and services to prevent the development and promote the healing of pressure ulcers as the facility failed to monitor and provide the resident with assessments, treatments, and follow-up with the podiatrist as ordered. - The facility admitted resident #101 on 3/21/16 and then readmitted the resident after hospitalization on [DATE], per the EMR (electronic medical record), with [DIAGNOSES REDACTED]. The May, 2016 POS included orders for: Float heel on pillow/heel boots every shift and PRN (as needed), ordered 4/4/16. Prevalon Boot (pressure relieving device) to the resident's right foot every shift, ordered 4/6/16. Skin prep (toughens the skin) to the resident's right heel topically, tid (three times daily), ordered 4/6/16. Air mattress to bed, ordered 4/6/16. Coccyx: clean with normal saline, pat dry, apply [MEDICATION NAME] (dressing) daily, AKA (above knee amputation), keep clean/dry, and change every 3 days, ordered 4/17/16. A review of the Braden Skin Risk Assessments identified the staff scored the resident at risk for skin breakdown, with a score of 12 on the 4/4/16 and 5/7/16 assessments. The 4/4/16 initial data collection, lacked identification of skin wounds, upon assessment, with readmission to the facility. The 4/6/16 Medication Administration Record [REDACTED] Skin prep (a skin toughener), three times daily, to the right heel for redness, order dated 4/6/16. Duoderm (dressing for pressure ulcer), to the coccyx, every 3 days, and as needed, ordered on [DATE]. Cleanse the coccyx site with normal saline, pat dry, and apply [MEDICATION NAME] (a bordered dressing) daily, ordered on [DATE]. The resident's temporary care plan, dated 4/4/16 instructed staff to provide: 1.) Extensive assistance with bed mobility, transfers, dressing, toileting, and bathing. 2.) Resident at risk for pressure ulcers. 3.) Prevalon boot to the right heel, at all times. 4.) Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration, noted during bathing or daily care. 5.) Foot cradle to the bed at all times, to keep pressure from bedding off of the resident's lower extremities. 6.) Remind and assist, as needed, with frequent repositioning. Review of the weekly wound evaluations, from 4/5/16 to 5/17/16, identified the staff documented the resident with redness to the coccyx. However, the evaluations lacked any sizing or description of the wound, to ensure monitoring of the healing process. Review of the weekly wound evaluations, from 4/5/16 to 5/17/16, revealed the lack of documentation on 4/5/16, 4/11/16, 4/16/16, 4/19/16, 4/23/16, 4/30/16, 5/10/16, and 5/14/16 of the resident's right heel wound. Furthermore, the assessments identifying the heel redness failed to identify the sizing or description of the heel, to ensure adequate monitoring of the healing process. Nurses notes, on 4/6/16 at 5:43 PM, documented redness noted to the resident's right heel and buttocks, with the physician notified. The physician ordered an air mattress to the bed, a Prevalon boot (pressure relieving boot) to the resident's right foot, and skin prep (skin toughener), three times daily to the right heel. The staff updated the TAR (treatment administration record). The resident refused to turn side to side due to pain and difficulty with breathing when lying on his/her side. Nurses notes, on 4/6/16 at 9:45 PM, documented the physician changed orders, as above, for the resident's right heel breakdown and sacral shearing. Nurses notes, on 4/11/16 at 3:05 PM, documented the staff received a new order for an air mattress. Nurses notes, on 4/16/16, documented the staff received a new physician's orders [REDACTED]. Nurses notes, on 4/16/16 at 5:23 PM, documented the resident's coccyx contained a reddened area, which blanched, but remained red after turning a bit off of the resident's side. Staff applied Duoderm to the site and discussed the need for turning frequently and providing good skin care, with the resident voicing understanding. On 4/17/16 at 5:46 PM, staff documented a new physician's orders [REDACTED]. Further review of the resident's nurses notes, through 5/19/16, identified the continued documentation of treatments. However, the staff never described the wound in size or stage to ensure adequate monitoring of the healing process. Review of the weekly wound evaluations, from 4/5/16 to 5/17/16, revealed the lack of evaluations on 4/5/16, 4/11/16, 4/16/16, 4/19/16, 4/23/16, 4/30/16, 5/10/16, and 5/14/16 of the right heel. Furthermore, the assessments identified the resident's right heel redness but failed to identify the size or description of the heel area, to ensure adequate monitoring of the healing process. Administrative nursing staff D reported on 8/22/16 at 5:25 PM, the resident's air mattress should have been added to the resident's care plan. Furthermore, staff D indicated the staff wound assessments should include measurements and descriptions of the resident's wounds. Administrative nursing staff B verified on 8/24/16 at 1:15 PM, the facility failed to implement the physician ordered air mattress on 4/6/16, however, did place the air mattress to the resident's bed on 4/11/16 (5 days later). Additionally, staff B reported the resident's wounds would have required staging, had the wounds not have been blanchable after the staff turned the resident for a specific period of time. The staff could not say with certainty, due to the lack of documentation, the condition of the wounds, regarding blanchable, sizing, staging, and description. The facility policy for Pressure Ulcer Prevention, dated 2/25/15, included ulcers that are present, or which develop after admission, are treated according to medical orders. Weekly, wound assessments are performed and recorded on the Pressure Ulcer Status Record, in the patient's medical record. The facility failed to implement timely physician orders [REDACTED]. - Review of the clinical record revealed resident #124 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The care plan, dated 8/13/2016, advised the staff to provide the following care: 1.) The resident is unable to complete ADLs (Activities of Daily Living) related to amputation and impaired mobility. The resident requires an assist of 1 staff to complete ADLs. 2.) The resident has a break in skin integrity related to a Braden score of 16, Incontinence, Pressure Ulcer and Surgical Wound. Reposition every 2 hours. Lift/pull sheet on the bed. Wound vac to sacrum. Weekly skin check. Observation, on 8/18/2016 at 1:59 pm, revealed the Resident resting on the right side. A pressure reducing mattress was on the bed. The wound dressing to sacral area was intact. The [DEVICE] was on continuous suction and the tubing connected to the vacuum rested directly on the floor. Interview, on 8/22/2016 at 11:56 am, with Direct Care Staff Q, stated that if he/she noted the wound vac tubing on the floor, he/she would clean it with alcohol swabs and attach it to the bed so the tubing was not touching the floor. Interview, on 8/22/2016 at 2:13 pm, with Licensed Nursing Staff BB, stated that the nurses are responsible for changing the dressing and the wound vac. The wound vac tubing should not be on the floor. Interview, on 8/22/2016 at 4:59 pm, with Administrative Nursing Staff B, stated that if he/she walked into a resident's room and found the tubing on the floor, he/she would contact the CNAs (certified nurses aide) and/or nurse to let them know and to give staff education. The facility failed to provide the necessary services and treatment to prevent the increased risk of further skin breakdown from infection for this resident with a pressure ulcer and a wound vac.

The facility reported a census of 74 residents. The 32 residents sampled, included 4 reviewed for urinary catheters/urinary incontinence. Based on observation, record review, and interview, the facility failed to ensure 2 of the 4 sampled residents (#124 and #72), received appropriate care and services to prevent the risk of urinary infections and to promote urinary continence. furthermore, resident #72 was occasionally incontinent of urine and declined to frequently incontinent of urine, without an individualized toileting plan too maintain as much normal bladder function as possible. Findings included: - Resident 72's significant change MDS (minimum data set), dated 1/6/16, revealed the resident had a BIMS (brief interview for mental status) score of 5, indicating severely impaired cognition. The resident rejected care which occurred 1-3 out of the 7 day assessment period. The resident required supervision for bed mobility, transfers, and toileting and was independent with ambulation. The resident had a trial toileting program with an outcome of decreased wetness. The resident was occasionally incontinent of urine and received a diuretic (medication to excrete excess fluids from the body) medication. The quarterly MDS, dated [DATE], revealed the resident had the following changes from the 1/6/16 MDS: The resident had disorganized thinking which fluctuated. The resident required staff supervision and set-up assistance for bed mobility, transfers, and toileting. The resident had a trial toileting program, and was not on a toileting program. The resident was frequently incontinent of urine and received and received a diuretic medication. The quarterly MDS, dated [DATE] , revealed the following changes from the previous MDS assessment: The resident required supervision of 1 staff for bed mobility, transfers, and toilet use. A trial toileting program had not been attempted with frequent incontinence of urine, and he/she was not on a toileting program currently. The CAA (care area assessment), dated 1/18/16, for urinary incontinence, identified the resident had occasional urinary incontinence. The resident had worn soiled clothing and would not allow staff to assist with peri-care or changing of the soiled clothing. The resident was not currently on a toileting program. The resident would toilet him/herself, and the staff prompted the resident to toilet. The care plan reviewed on 4/5/15, documented the resident experienced occasional urinary incontinence, The resident required staff assistance with toileting for safety and was on a scheduled voiding program. The staff were to explain to the resident the toileting program. Adjust the toileting schedule PRN (as needed) if the elimination pattern changed. Provide limited staff assistance with toileting related transfers. The resident was able to assist using a transfer rail, assist as needed with peri-care, and pulling up the resident's clothing. The resident's routine toileting schedule was as follows: upon rising, before and after meals, at bedtime and if awake during the night and PRN. An addition dated, 4/13/16, identified the resident declined in urinary continence, with frequent urinary incontinence and toileted him/herself without asking for assistance. The staff were to report any decline in incontinence. The plan of care lacked an individualized toileting plan for this resident with increased urinary incontinence. The facility was unable to find and provide a completed 3 day voiding diary for this resident with increased urinary incontinence, when requested. The 4/20/15, assessment for bowel and bladder training assessment, documented the resident had severe mental impairment; was usually mentally aware of toileting needs; and the resident was continent of urine most of the day. The resident had a total score of 7. A score of 7-14, indicated the resident was a candidate for toileting, timed or scheduled voiding. The evaluation documented no need to proceed to the urinary incontinence assessment. The resident without change in urinary status, and staff to continue with the current toileting program. Furthermore the staff were to complete the urinary incontinence assessment on admission, and quarterly, if the score changed from the last quarter, the staff were to complete a urinary incontinence assessment. If the resident was without a change in the assessment score, document below why staff were not proceeding to urinary incontinence assessment. The 7/8/15, assessment for bowel and bladder training, documented the resident had a score of 9, which indicated the resident was a candidate for toileting, timed or scheduled voiding. The evaluation documented, proceeding to urinary incontinence assessment. The resident should continue with the current toileting program (scheduled). The 10/5/15, assessment for bowel and bladder training, documented the resident had a score of 8, which indicated the resident was a candidate for toileting, timed or scheduled voiding. The evaluation was not completed. The 1/7/16, assessment for bowel and bladder training, documented the resident had a score of 8, which indicated the resident was a candidate for toileting timed or scheduled voiding. The evaluation documented, staff were not to proceed to complete the urinary incontinence assessment, the resident had occasional urinary incontinence, and toileted himself/herself. The assessment for bowel and bladder training, dated 4/7/16, documented the resident had severe mental impairment, required assistance with mobility, usually was mentally aware of toileting needs, and continent of urine most of the day. The resident's score indicated the resident was a candidate for toileting, timed, or scheduled voiding. It documented the resident toileted him/herself, and refused assist most often. The assessment for bowel and bladder training, dated 7/5/16, remained unchanged from above. Continue with prompted toileting, resident toileted himself/herself, and the resident refused assist on most occasions. On 8/17/16 at 7:51 AM, the resident sat at the dining room table, and had a strong urine odor, eating breakfast. At 8:00 AM, 8:15 AM, 8:30 AM, 8:45 AM, 9:00 AM, and 9:15 AM, the resident remained without change. At 9:20 AM, the resident finished his/her juice and ambulated with a walker by himself/herself to the common shower/bathroom. On 8/17/16 at 9:28 AM, direct care staff UU assisted the resident with undressing, and the resident sat on a shower chair. Staff UU stated the resident was independent with toileting and the staff just checked on him/her. On 8/17/16 at 10:30 AM, the resident sat in a chair in his/her room with a robe on over his/her regular clothing. The resident's room continued with a strong urine odor. On 8/17/16 at 1:56 PM, the resident sat in his/her room eating lunch, and reported he/she was just fine. The resident further stated he/she had gone to the bathroom, and does all the time by him/herself. The residents room continued to have a strong urine odor. Unable to tell if the resident had a urine odor because the entire room had an odor. The resident's clothing appeared clean. At 2:15 PM, 2:30 PM, 2:45 PM, and 3:00 PM the resident remained without a change. On 8/17/16 at 2:03 PM, direct care staff Z stated the care plans were on the staff tablets (electronic documentation), and the CNA's (certified nursing assistant) document the ADLs (activities of daily living) on the tablet. The staff were instructed to cue the resident to change his/her clothes. The CNA's were to go through the resident's clothing to make sure all soiled clothing was not left in the resident's room during showers. The resident toileted himself/herself, and wore pull-up briefs. The resident did not allow staff to assist him/her with toileting most of the time. On 8/17/16 at 2:32 PM, direct care staff UU stated the CNA's usually documented the resident was incontinent of bladder. On 8/17/16 at 3:04 PM, direct care staff SS and CC stated the resident would refuse baths, was incontinent of urine, and would hide his/her soiled clothes. Furthermore, the resident would not allow peri-care. On 8/17/16 at 7:11 PM, licensed nursing staff VV stated the resident occasionally had urinary incontinence. The staff were to provide peri care, which most of the time was done, if the resident did not refuse. The CNA's asked the resident at night if he/she wanted to use the bathroom. On 8/18/16 at 12:49 PM, administrative licensed nursing staff E stated the facility staff were unable to find a 3 day voiding diary for the resident. The voiding diary was to be done on admission and readmission, however was unsure if staff completed the diary with a change of condition in the resident. On 8/18/16 at 3:37 PM, administrative nursing staff E stated if the resident had a change in incontinence, the staff would refer the resident to therapy. On 8/18/16 at 3:50 PM, administrative licensed nursing staff D stated staff only do a three day voiding diary on admission, then staff do the bladder assessment quarterly. If there was a decline, nursing would refer the resident to the therapy department, which would do a 3 day voiding diary. The therapy department would have the CNA's complete the diary. On 8/22/16 at 12:02 PM, licensed nursing administrative staff D reviewed the resident's urinary incontinence assessment for 7/8/15, and stated the facility does not have the 3 day voiding diary. Staff D also checked for a referral to therapy, and the resident lacked a referral. Staff D stated he/she felt staff should of completed a urinary incontinent assessment. On 8/22/16 at 2:56 PM, administrative licensed nursing staff C stated staff completed the bowel and bladder assessments quarterly, and a 3 day voiding diary on admission. If the resident had a change from continent to any type of incontinence, this would be a change. Staff C stated the staff would do an assessment, review the resident's diagnoses, and look for a history of UTI (urinary tract infection). However the staff would not complete another 3 day voiding diary. If the resident had a change in their urinary status, staff would submit a therapy screen. On 8/22/16 at 3:00 PM, administrative nursing staff B stated staff toileted the resident upon awakening, before and after meals, and at bedtime; and was not a scheduled toileting program or an individualized toileting program. The facility failed to provide an individualized toileting plan to maintain as much normal bladder function as possible for the resident. This resident went from being occasionally incontinent to a declined status of frequently incontinent of urine. - Review of the clinical record revealed resident #124 admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. The care plan, dated 8/13/16, advised the staff to provide the following care: 1.) The resident is unable to complete ADLs (Activities of Daily Living) relating to amputation and impaired mobility. The resident requires an assist of 1 staff to complete ADLs. 2.) The resident has incontinence of bladder related to [MEDICATION NAME] (tube directly through the abdomen, into the bladder wall, to drain the urine). The resident requires catheter and ostomy care. Observation, on 8/18/2016 at 9:42 am, revealed the resident rested on his/her right side in bed. The tubing connected to the resident's [MEDICATION NAME] extended down from the bed, to a urinary collection bag, which staff placed inside of a plastic tub. However, the tubing rested directly on the floor between the bed and the plastic tub. On 8/22/2016 at 11:56 am, Direct Care Staff Q, stated the urine collection bag was supposed to be below the resident and the urine tubing should not be on the floor. Interview, on 8/22/2016 at 2:13 pm, with Licensed Nursing Staff BB, revealed that usually the staff connected the catheter tubing to the bed and not on the floor. The resident asked that staff put the bag in a basin. He/she said it was backing up. Staff BB was sure there was a way to keep the tubing off of the floor. Interview, on 8/22/2016 at 4:59 pm, with Administrative Nursing Staff B, stated that if he/she walked into a room and found the [MEDICATION NAME] tubing on the floor, he/she would contact the CNAs (certified nurses aide) and/or nurse to let them know and would give the staff education. The facility failed to provide the necessary services to prevent the risk of infection, for this resident with a [MEDICATION NAME].

The facility had a census of 66 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to provide the planned interventions to prevent reported falls for 1 (#1) of 3 residents sampled for falls. The resident experienced a fall with head laceration, which required the resident to receive 3 staples in the emergency room to close. Findings included: - The POS (physician order [REDACTED].#1, dated and signed on 01/08/2016, documented the following [DIAGNOSES REDACTED]. The Significant Change MDS (minimum data set), dated 12/09/2016, documented a BIMS (brief interview for mental status) score of 02, indicating severely impaired cognition, physical and verbal behaviors on 4 to 6 days and rejection of cares. The resident needed extensive assistance with bed mobility, transfers, locomotion, dressing, and personal hygiene, and total dependence with toilet use. The resident had no falls since admission or the prior assessment. The Cognitive loss/dementia CAA(care area assessment), dated 12/23/2015, documented the resident had a [DIAGNOSES REDACTED]. The resident received hospice services for end stage of Alzheimer's disease with severe cognitive loss. The resident was dependent on staff for daily decision making needs. The Fall CAA, dated 12/23/2015, documented the resident was a high risk for fall, had history of falls, had impaired mobility, severe cognitive loss, no safety awareness, and used psychotropic medications. The resident was dependent on the staff for transfers and mobility with interventions in place. The care plan, dated 06/08/2015, documented the resident was at risk for falls, and directed staff to provide environmental adaptations, keep the bed in the low position, have the call light within reach, provide adequate glare free lighting, maintain area free of clutter, and to lock the brakes on the wheelchair before transfers. The resident was to wear gripper socks when not wearing shoes and required extensive assist of 1 to 2 staff with transfers and locomotion. Updates on the care plan on the following dates included: On 08/14/2015, the resident was not to be left in the wheelchair in the resident's room unattended. On 08/28/2015, the resident's door and privacy curtain were to remain open when the resident was in bed for visual checks, on the falling star program, have a medication review, and a concave mattress. On 12/19/2015, resident had a fall today, staff witnessed the resident throw him/herself out of wheelchair, and staff were to monitor the resident in the commons area. On 12/25/2015, observe for spontaneous behaviors that increase risk for falls, and to keep the resident in visual range to observe activity. On 12/27/2015, observe the resident frequently, keep the resident in visual field/range for observation, do not leave the resident in areas that are isolated, frequent checks on the resident with positive support and redirection. On 12/28/2015, use of a non skid mat in the wheelchair to prevent sliding out of the wheelchair. Undated new interventions documented a fall mat at the bedside and a check and change toileting at scheduled times. The fall investigation for an unwitnessed non-injury fall on 08/14/2015, documented the resident was sitting in wheelchair in alone in his/her room. The new intervention listed was to have the resident screen by therapy, education to the staff and resident not to be left alone in room while up to wheelchair. The fall investigation lack a root cause analysis of the fall. The fall investigation for an unwitnessed fall on 08/28/2015, documented the resident was last seen laying in bed and was found on the floor. The new intervention listed to place resident on the falling star program, request concave mattress from hospice and medication review. The fall investigation listed the cause of fall as anxiety. The fall investigation for the injury fall on December 27, 2015, documented the resident was found on the floor by his/her bed and wheelchair. The resident had a laceration on the back of her head. The resident had been taken to his/her room after breakfast and left alone in the wheelchair. The Fall Risk Assessments dated 12/19/2015, 12/25/2015, 12/27/2015 and 12/28/2015, all revealed a score of 22, indicating the resident at high risk for falls. The nursing note, dated 12/26/2015, at 9:45 AM, evidenced staff found the resident on the floor by the bed and the wheelchair. The resident had a laceration to the back of his/her head. Staff received new orders to send the resident to the hospital for evaluation and treatment. A telephone order, dated 12/27/2015, directed facility staff to remove the staples from the head laceration in 7 days. Observation, on 02/22/2016 at 1:16 PM, revealed the resident laying crossways on the bed. A fall mat and concave mattress were in place, and the call light was in reach. The resident appeared to be sleeping. Observation, on 02/22/2016 at 4:24 PM, revealed the resident was laying in the bed with a fall mat and a scoop mattress in place and the call light was in reach. On 02/22//2016 at 1:19 PM, Direct care staff E advised the resident was a one person assist, but since the resident resisted cares and became combative, staff did 2 person assist depending on his/her mood. On 02/22/2016 at 4:24 PM, Direct care staff F reported the resident was a one person assist unless was resistive to cares then use two people. The staff always use a gait belt for transfers and any time the resident was in the bed we have the mat on the floor, bed in lowest position, and a scoop mattress. On 02/22/2016 at 2:39 PM, Direct care staff G advised, he/she was working on the day the resident fell and hit his/her head, but could not say what happened exactly, but around 9:30 or 9:45 AM, after breakfast, the resident had finished breakfast and asked if Staff G could take him/her to their room. The resident was in the wheelchair and Staff G pushed the resident to their room. Staff G advised he/she checked the resident for incontinence and placed him/her back into the wheelchair in front of the TV. Staff G advised the facility had care plans that direct staff on what the residents needs are, but this resident was not on the hall where staff G normally worked. He/she thought, however, the resident's care plan did say not to leave him/her in the room alone. Staff G stated not knowing why he/she left the resident alone and thought he/she just forgot, because normally the resident stays out front by the nurses' area, so staff could keep watch on him/her. On 02/23/2016 at 8:58 AM, Administrative nursing staff B, advised the resident had behaviors and several falls in December. On the fall where the received the laceration, he/she was accidentally put in the room and left alone . Staff G was in the dining room helping and the resident asked to be taken to his/her room, which Staff G did. Staff checked the resident, made sure he/she was dry, gave the resident the call light and turned on the TV. The CNAs (certified nursing assistants) had care directives on the tablets which would tell him/her not to leave the resident alone in the room. The facility policy, entitled Incident Management, revised 11/08, documented the facility identifies residents at risk for incidents and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence. Develop an organized method to define, monitor, and reduce risks associated with incidents and falls that can compromise a resident's lifestyle and quality of life. Identify residents who are at risk for incidents and implement care plan procedures designed to reduce the risks of incidents. The facility failed to provide interventions as planned for this cognitively impaired resident when the staff left the resident unattended in the wheelchair in the resident's room. The resident experienced a fall from the wheelchair which resulted in a laceration to the head requiring three staples.

The facility reported a census of 99 residents with 16 selected for review. Based on observation, record review and interview, the facility failed to provide physician prescribed hydration for one resident( #64) with [MEDICAL CONDITION]. Findings include: - Record review revealed resident #64 admitted to the facility 1-14-11 having been in acute care. [DIAGNOSES REDACTED]. The resident [DIAGNOSES REDACTED]. The resident required hospitalization on [DATE] for hypercoagulation. The resident readmitted to the facility 5-10-11. The resident admitted to acute care on 5-30-11 with rectal bleeding and returned the facility 06-07-11 with a sodium of 154, BUN(blood urea nitrogen norm 4-20) of 98, creatinin of 2.38 (norm .64-1.2) and a (GFR)glomerular filtration rate of 26 (norm >60.) The admitting MDS (minimum data set), dated 1-20-11 assessed the resident with a BIMS(brief interview of mental status) score of 15 with no mood or behavior indicators. The resident assessed as extensive assist with bed mobility, transfers, toileting , personal hygiene and bathing. The resident assessed as having no impairments in upper and lower extremities. The resident assess as having adequate hearing and vision with clear speech and able to make self understood and understands others. The MDS indicated the resident received greater than 51 percent of calories and greater than 501milliliters of fluid from enteral tube feedings. The quarterly MDS, dated [DATE], revealed the resident with a BIMS score of 13 and having mood/ behavior assessed as feeling tired. This MDS assessed the resident as having minimal difficulty with hearing, using corrective lenses, and having clear speech with understanding of others and making self understood. The resident assessed as having a swallowing disorder with cough/choking during meals or when swallowing. The physician order [REDACTED]. Additionally the physician orders [REDACTED]. Review of the MAR(medication administration record) dated 6-10-11 revealed "free water 300 cc per PEG tube every 6 hours". The times indicated for staff to administer the water as 10:00 am and 1400(2pm). The Glucerna 1.2 administration transcribed on the MAR dated 6-10-11 revealed " Glucerna 1.2 cal/ml liquid 355 ml per PEG tube four times daily (total of 8 cans per day) Administration times documented at 6 am, 11:00 am, 4:00pm and 7:00pm. This MAR revealed an entry "flush PEG with 5 milliliters before and after meds and after [MEDICATION NAME]". Medications ordered through the PEG tube totaled 4 per day given at 7:00 am, and 1 given at 8:00 pm. The Daily Care Guide issued to the certified nursing staff advised the staff to provide assistance of 2 for transfers, bathing, dressing, and toileting. Eating indicated as "tube feeder". Interventions included "NPO(nothing by mouth), tube feedings. may have pleasure feedings.'" This care guide printed on 6-21-11. Observation, on 6-15-11 at 2:00 pm, revealed the resident revealed the resident laying in bed, clothed in a T-shirt and adult incontinent brief. The resident's torso and legs exposed through the open door way as the resident had kicked the top sheet off. The resident attempted to respond to greeting and revealed a thick, red tongue with dry fissures on the surface of the tongue. The oral cavity contained thick sticky saliva. The resident's skin on their legs noted to be dry and flaking. Observation on 6-16-11 at 7:30 am, revealed the resident laying in bed clothed in a T-shirt and an adult incontinent brief. The resident's torso and legs exposed. The resident's tongue remains thick, red in color with dry fissures and sticky saliva. The resident responded to questions by opening their eyes and attempting verbalization. Interview, on 6-16-11 at 7:45 am, with licensed staff N revealed the resident received tube feedings for nutritional needs. Staff N stated the resident could have pleasure food. Interview, on 6-16-11 at 8:00 am, with licensed staff R, revealed the resident allowed pleasure foods with the tube feeding as the main source of nutrition. Staff R accompanied this surveyor to the resident's room and stated the resident could have ice chips and ice cream. Staff R did not respond to the surveyor's observation of dry tongue and mucous membranes. On 6-16-11, mid to late morning, staff R stated that the physician ordered a BUN and lab work. Observation, on 6-20-11 at 9:10 am, revealed the resident with stubble on cheeks and chin, alone in their room attempting to spoon ice cream into their mouth with a plastic spoon. With the ice cream frozen the plastic spoon was not sufficient as a scoop. The resident then raised the container of ice cream to their mouth in another attempt to eat it. Observation also revealed a liter bag of IV(intravenous) fluid infusing in the resident's right hand. Interview, on 6-20-11 at 9:10 am, with licensed staff N, revealed the resident admitted to acute care due to [MEDICAL CONDITION] on 6-17-11 and returned to the facility on [DATE] with and order for IV fluids which was infusing. Staff N confirmed the resident assessed as having swallowing problems.Licensed staff AA stated the resident assessed by speech therapy as an aspiration risk. Staff N stated the resident was not a choking risk. Staff AA and staff N stated the resident's physician ordered pleasure foods as the resident requested. Staff AA stated the resident needed a metal spoon to scoop the ice cream which needed to thaw out before eating. Observation, on 6-20-11 at 9:20 am, revealed the resident, alone in their room, attempting to spoon the ice cream into their mouth, the ice cream dropped off the spoon and onto the resident's shirt. The resident then reached for the cup of ice ships sitting on the over bed table and brought the cup to their mouth in an attempt to obtain them. Interview, on 6-20-11 at 10:30 am, with therapy staff V, revealed the resident assessed as a silent aspiration risk with ability to chew but at risk for aspiration on any consistency and could aspirated on saliva. Further more staff V provided education to family and resident regarding the potential for aspiration and the resident continued to desire pleasure foods. Observation on 6-20-11 at 12:58 pm, revealed the resident laying on their back in bed. Observation, on 6-20-11 at 4:00pm, revealed the resident sitting in their wheelchair in the hallway, attempting to propel self. The resident sat clothed in the same T shirt with the chocolate ice cream stain, an adult incontinent brief, with a crochet shawl tucked around the their lap, and socks on their feet. Interview, on 6-20-11 at 4:00 pm, with certified staff DD, revealed the resident attempting to propel themselves out of their room. Staff DD stated they had not worked on this hall in a long time and that the resident changed since they last saw them. Staff DD confirmed the observation that the resident need a shave. Staff DD stated the resident status as NPO (nothing by mouth). Certified staff P stated they thought the resident could have pleasure foods, but was not sure. Staff DD and P looked at their Daily Care Guides and stated they could not say for sure if the resident was NPO or could have pleasure foods but would ask the charge nurse. Observation , on 6-20-11 at 5:30 pm, revealed the resident sitting in their wheelchair at a dining room table in the main dining room with the same stained T shirt. The resident fed themselves one serving of ice cream and a cup of ice chips without difficulty. Observation, on 6-21-11 at 7:30 am, revealed the resident laying in bed with a hospital gown on, with legs uncovered and lying sideways in their bed. The resident replied appropriately to simple questions. the resident stated they ate ice cream for dinner last evening. Observation, on 6-21-11 at 9:05 am, revealed the resident sitting up in bed, eyes closed, a spoon in the resident's hand and the cup of ice spilled on the bedside table. Observation revealed multiple pieces of ice chips laying on the resident's upper shoulder and neck, saturating the neck edge of the T shirt. Observation, on 6-21-11 at 12:03 pm, revealed the resident laying in bed uncovered with their right leg over the edge of the bed and their head leaning against the side rail. Observation revealed the resident's tongue red in color with dry fissures, and stubble on the residents cheeks and chin. Licensed staff N stated they had not given the resident anything by mouth since the ice chips at 8:24 am. Interview, on 6-21-11 at 1:30 pm, with licensed staff N, revealed the resident ate 2 servings of ice cream and a cup of ice chips. Interview, on 6-21-11 at 5:00pm, with certified staff II, revealed they thought the resident was NPO with pleasure foods allowed that the family brought in. Observation, on 6-22-11 at 7:00 am, revealed the resident sitting at the dining room table in the main dining room with licensed staff R drinking ice tea. Staff R stated the resident requested oatmeal in addition to the ice tea. Interview, on 6-21-11 at 6:10 pm, with administrative staff B, revealed the physician's orders [REDACTED]. The MAR indicated on 6-15-11 300 milliliters administered at 10am. Staff B revealed they had notified the physician when the error was discovered but would not reveal the date of the discovery, stating the lab order was obtained 6-16-11. Staff B stated investigation of the error was not documented. Record review revealed a phone order from the physician dated 6-17-11 instructing staff to "discontinue current flush orders and start free water flush 300 milliliter every 3 hours and recheck the BMP(basic metabolic profile) on 6-19-11, may continue to have pleasure food on request." Another phone order from the physician dated 6-17-11 revealed ..."transport to hospital elevated BUN, Creat, unable to start IV for [MEDICATION NAME] 1.5 with 20 milliequivalents of potassium at 75 milliliters per hour". The resident admitted to acute care 06-17-11 with [DIAGNOSES REDACTED]. The review of lab drawn on 6-17-11 revealed a sodium of 157, BUN of 98, creatinine of 2.38 and a GFR of 26. The facility failed to provide this resident, with compromised renal function and hydration status, the physician ordered fluid for hydration, further compromising the metabolic functioning of the resident, resulting in acute care evaluation and administration of intravenous fluids.

The facility reported a census of 120 residents, 6 considered as elopement risks. Based on observation, record review and interviews, the facility failed to provide adequate supervision and assistive devices to prevent 1 (#01) of 3 sampled residents from leaving the facility in the early morning hours without staff knowledge, which placed this resident in immediate jeopardy. Findings included: - The facility readmitted resident #01 on 11/1/09. [DIAGNOSES REDACTED]. The 9/22/10, minimum data set assessment identified the resident with short term, long term and moderately impaired decision making skills. The behaviors documented included wandering with risk of getting to dangerous places. The 9/22/10 plan of care identified the potential for elopement, with a history of falls. "Tends to wander, check wanderguard 1 x /wk and prn (as needed)". On Sunday, 10/31/10 at 4:50 A.M., licensed nurse A, while driving a car in the east entrance noted something in the dark, on the ground, near the street. The nurse ran into the facility and summoned assistance. Licensed nurse A and licensed nurse B went out by the sidewalk (approximately 150 feet) in front of the building and found resident #01 on hands and knees. Licensed nurse B documented, "...went outside and found resident in driveway kneeling on (his/her) knee shivering ..." The 2 nurses walked the resident back into the facility. The resident wore a light colored sweat suit and a wanderguard that failed to sound as they entered the unlocked front door. It remains unclear after interview, on 11/17/10 and 11/18/10 at various times, with 2 licensed nurses A and B and 1 certified nurse aide C, what, if anything, the resident wore on his/her feet at the time of this incident. The physical assessment, completed immediately following the return to the facility, by nursing staff B, the resident's body temperature measured 95.9 degrees Fahrenheit, (normal temperature of the body, taken orally is 98.6 F), pulse 58, respirations 18, blood pressure 184/84 and oxygen saturation at 96 % on room air. According to nurse B's documentation in the medical record, the staff toileted the resident and assisted him/her to bed at 4:15 A.M. At 5:10 A.M., all doors in the facility remained unlocked. No alarms went off when opened according to licensed supervisor nurse A. At 5:20 A.M., the supervisor checked the exit doors again and found them locked but without alarms that activated when opened. On 11/17/10 during interviews at various times, administrative staff E reported the resident moved out of the facility to a locked special care unit on 11/16/10. The resident's routine in the facility included, ambulating with a front wheeled walker throughout the facility, sleeping during the day and with wandering behaviors at night. The resident wore a wanderguard on the ankle according to the facility elopement procedures. Staff E reported the investigation revealed the resident left the building probably through the front door, left the front wheeled walker inside and the wanderguard alarm on the ankle failed to sound. Interviews with night staff, which included 3 nurses and 5 nurse aides failed to identify who turned the key to the door locks off, according to the administrative staff. On 11/17/10 at 9:10 A.M., maintenance personal D reported someone had turned the key off and disabled all the door locks and alarms, on the early morning of 10/31/10. Maintenance D reported the facility had 2 key controls for the door locks and alarms that are set to automatically lock from 9:00 P.M. to 5:55 A.M. One key is located at the hall 5 nurses station and the other is located on the wall in the front lobby off hall 2. Staff D stated, "Someone probably turned off the key to go outside and smoke." On 11/17/10 at 11:50 A.M., licensed nurse A reported the front door unlocked when he/she entered on 10/31/10 at 4:50 A.M. He/she reported resident #01, "Was cold," when discovered outside and the resident stated, "Help me." Nurse A reported that represented a change for this resident because he/she was a do it myself person. He/she reported the residents (body) temperature as, "95 something I believe." On 11/17/10 at 2:10 P.M., ancillary staff F reported he/she checked the wanderguards weekly and this wanderguard last checked on Friday, 10/29/10, 2 days prior to the elopement. The wanderguard worked and displayed an expiration date of 10/10/2011. Following the elopement and return to the facility, nurse staff B completed a new elopement assessment, dated 10/31/10, that included, "Wanders during the night, able to ambulate independently, poor safety awareness d/t (due to) dementia. Reasons documented included, "Cognitive impairment with poor decision making shills, [DIAGNOSES REDACTED]." On 11/17/10 at 5:30 A.M., the resident sat in a soft chair, with a front wheeled walker in front of the chair and watched TV with other resident's in a locked special care unit. Observation, at this time and medical record failed to document any signs of injury to the resident. The facility failed to ensure the doors locked and the door alarm system worked as planned on 10/31/10. Furthermore, the facility failed to have a system to ensure the wanderguard bracelet system working on at least a daily basis. The wandering [AGE] year old resident ambulated outside the facility approximately 150 feet near a busy street in the early AM. A computer weather check revealed the temperature at 4:54 A.M., at 45 degrees F. with wind speed at 5.8 miles per hour. The resident appeared cold, shivering, exhibited a body core temperature of 95.9 Degrees F. and asked staff for help, which placed this resident in immediate jeopardy. The facility abated the immediate jeopardy, on 10/31/10 at 6:00 A.M., by initiating the following: 1). Maintenance Director ensured all doors working correctly. 2). All 6 wanderguards were checked for functioning and all functioned properly. 3). Immediate education to staff regarding the lock/unlock system was initiated. 4). The over-ride lock and key on hall 5 and at the front entrance were covered with plexi-glass that can only be accessed by breaking the cover. This was completed by plant supervisor on 11/1/10. 5). Only hall 5 door will be accessible from the outside between 8:00 P.M. and 6:00 A.M. via a coded keypad. All other doors will remain locked per policy. This policy will be reviewed monthly x 2, annually and with orientation of new staff. The scope and severity remained at a level of a D.