Every finding on record at Locust Grove Village

Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week.Findings included:- The facility's August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, and March 2026 nursing schedule lacked evidence of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 08/04/2025, 08/10/2025, 09/27/2025, 10/04/2025, 10/11/2025, 10/18/2025, 10/19/2025, 10/25/2025, 10/26/2025, 11/08/2025, 11/29/2025, 12/19/2025, 12/28/2025, 01/01/2026, 01/03/2026, 01/24/2026, and 03/08/2026. The facility was unable to provide verifiable, auditable evidence of RN coverage.On 07/23/2026 at 10:29 AM, Administrative Nurse D stated the facility did not have a nurse for the days that showed no Registered Nurse (RN) coverage on the Payroll Based Journal (PBJ). Administrative Nurse D stated there was not an RN in the facility on those dates but stated that she was always on call.On 07/22/2026 at 08:39AM Administrative Staff A stated he expected the facility to have an RN in the building for eight hours a day. He stated the facility had talked about applying for a nursing waiver. Administrative Staff A stated the facility used contract nursing when they could.The facility's Nursing Staff policy dated 03/15/2015 documented the facility would have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. Staffing levels would assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Staff levels at the facility would consider the number, acuity, and diagnoses of the resident population.

Based on interviews and record review, the facility failed to provide the services of a full-time certified dietary manager for the 36 residents who resided in the facility and received their meals from the kitchen.Findings included:- On 07/20/2026 at 07:50 AM, Dietary Staff CC stated the facility did not have a Certified Dietary Manager (CDM). She stated she was the kitchen supervisor, and the person taking over the CDM was on vacation. Dietary Staff CC stated Dietary Staff BB had just started taking her classes for the CDM.On 07/22/2026 at 08:00 AM, Administrative Staff A stated he was aware the facility did not have a CDM. He stated the facility did have a person who was taking the class. Administrative Nurse A stated the Registered Dietician comes to the facility once a month.The facility's Dietary Manager policy dated 2018 documented that the day-to-day functions of the dietary department are under the supervision of a qualified dietary manager.

Based on observation, record review and interviews, the facility failed to follow sanitary dietary standards related to food storage and service.Findings included:- During the initial tour on 07/20/2026 at 07:40 AM, observation revealed the following:In the walk-in refrigerator, 17 individual pieces of cake and individual slices of pie sat on a stainless-steel cart, wrapped and undated. A steam table pan of beef tips was covered with aluminum foil, unlabeled and undated. A large steam table pan of rice was covered with aluminum foil, unlabeled and undated. A platter of ham slices was placed on the second shelf in the walk-in cooler, unlabeled and undated. A fourth of a jug of apple juice and half a jug of orange juice were on the top shelf of the walk-in refrigerator, unlabeled and undated. In the nutrition area outside the kitchen, three frosted cinnamon rolls were in a snack cart, unlabeled and undated.Outside the dining room area, a white refrigerator contained two buns, a bucket of ice cream, and an open drink that was unlabeled and undated.On 07/21/2026 at 11:00AM the food temperature log revealed no temperatures recorded for 07/04/2026,07/05/2026, 07/09/2026, 07//10/2026, 07/12/2026, 07/16/2026, 07/172026, and 07/19/2026 supper meal.On 07/20/2026, Dietary Staff CC stated the cakes and pies were going to be thrown away. She stated she was unaware that food put in the cooler for the same day needed to be dated and labeled. Dietary Staff CC stated the beef tips and the rice were for supper. She stated the facility had high school kids working in the evening, and food was cooked in the morning for the supper meal. She stated the ham was supposed to be labeled and dated and placed in the freezer, and she was unaware that opened juice jugs needed to have a date. She stated the employee refrigerator used to be cleaned and ensured that no foods were undated or unlabeled; she was unsure if that was still the kitchen staffs duty.On 07/21/2026, Dietary Staff DD stated she was aware the evening shift was not recording temperatures of foods and that there had been complaints the supper meal foods were cold. She stated it was the expectation of the facility to take temperatures before each meal was served.On 07/22/2026 at 08:00AM Administrative Staff A stated he was aware the facility did not have a CDM. He stated the facility did have a person who was taking the class. Administrative Nurse A stated the Registered Dietician comes to the facility once a month.The facility's Food Storage policy dated 06/2014 documented that food storage areas would be maintained in a clean, safe, and sanitary manner.

Based on observation, record review, and interviews, the facility failed to store medications and biologicals within professional standards of practice when the facility failed to date check vials of of intramuscular (IM-injected directly into a muscle) lorazepam (a class of medications that calm and relax people), high dose influenza (highly contagious viral infection) vaccine, and influenza vaccine, that were past the date to be used.Findings included:- On [DATE] at 01:50 PM, the medication room refrigerator contained four vials of IM lorazepam, 20 vials of high-dose influenza, and 40 vials of influenza vaccine. The vials were dated 06/2026 and were outside the recommended date to be used.On [DATE] at 1:52 PM, Licensed Nurse (LN) G stated the pharmacist comes once a month and destroys medication and removes all outdated medication. She stated nurses were to periodically check for outdated medication also.On [DATE] at 09:06 AM, Administrative Nurse D stated the pharmacy consultant was at the facility every quarter to destroy medication. She stated she did know the influenza vaccines were outdated and was waiting on a return label to send the vaccine back to get credit. Administrative Nurse D stated she was unaware the lorazepam had expired. She stated it was the overnight shift duty to check the refrigerator for expired medication when taking the temperature of the refrigerator.The facility was unable to provide a policy related to medication storage as requested on [DATE].

Based on interviews, observation, and record review the facility failed to ensure the as needed (PRN) Benadryl being used for its psychotropic (alters mood or thought) properties had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 6's PRN Benadryl.Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder).The Significant Change Minimum Data Set (MDS) dated 06/16/2026 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R6 received diuretic (a medication to promote the formation and excretion of urine) medication during the observation.R6's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/2026, documented he had advanced dementia and periods of confusion.R6's Care Plan documented the following interventions:06/17/2026 - Staff would administer as needed medication for insomnia. R6 does not sleep well at night. Staff would, as much as possible, minimize daytime sleeping by inviting and encouraging participation in group or individual activities.06/19/2026 - Staff would provide non-medication approaches to help R6 rest, such as a back rub, quiet atmosphere, consistent schedule, and offer hot chocolate.R6's EMR under the Orders tab revealed the following physician orders:Benadryl (diphenhydramine hcl) (antihistamine) 25 milligram (mg) give one capsule by mouth every four hours as needed for insomnia dated 06/17/2026. The medication order lacked a stop date.On 07/21/2026 at 12:46 PM, R6 pushed himself from the dining room to the common area. R6 locked the brakes on his wheelchair prior to transferring himself into another chair in the common area. Staff refilled R6's insulated cup with water and placed it next to him on the table.On 07/22/2026 at 10:15 AM, Licensed Nurse (LN) H stated R6's Benadryl order should have an automatic stop date after 14 days if used for insomnia. On 07/22/2026 at 10:35 AM, Administrative Nurse D stated R6's Benadryl should have a 14-day stop date if used for insomnia. Administrative Nurse D stated the pharmacist should have caught that during their monthly pharmacy reviews.The facility's undated Psychotropic Medications policy documented the facility residents would not be given any psychotropic medications that are not adequately clinically indicated and necessary to treat a specific condition. Psychotropic medications would be used as clinically indicated and not for convenience. Proper processes would be followed to ensure the medication used was appropriate and not considered a chemical restraint.

Based on interviews, observation, and record review the facility failed to ensure Resident (R) 6 had a current physician order with an appropriate indication for the ongoing use of an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) which included the size of catheter needed.Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder).The Significant Change Minimum Data Set (MDS) dated 06/16/2026 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R6 had an indwelling Foley catheter during the observation period.R6's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/19/2026 documented he had a Foley catheter in place before admission to hospice for urinary retention.R6's Care Plan documented the following interventions:11/25/2025 - Staff would provide catheter care every shift.11/25/2025- Staff would hand him his shirt and have him put it on. Because of catheter tubing, he required maximum assistance with his pants, and then he was able to assist with pulling his pants on. Staff would help him get his socks and shoes on and off.12/08/2025 - Staff would irrigate his catheter as needed.03/25/2026 - Staff would utilize enhanced barrier precautions related to his catheter.06/17/2026 - Staff would ensure his catheter tubing did not cause pressure to his skin. Staff would continue to utilize his foley catheter (a tube inserted into the bladder to drain urine into a collection bag) and provide catheter care along with peri care every shift and as needed.07/14/2026 - Staff would change his catheter as needed related to obstructed flow ifirrigation was not successful. 18French(Fr)/10 18Fr/10 cubic centimeter (cc).R6's EMR under the Orders tab revealed the following physician orders:Catheter care every shift, twice a day dated 10/31/2025.May irrigate Foley catheter as needed dated 12/07/2025.The EMR lacked a physician order with appropriate indication and size for insertion.On 07/21/2026 at 12:46 PM, R6 pushed himself from the dining room to the common area. R6 locked the brakes on his wheelchair prior to transferring himself into another chair in the common area. Staff refilled R6's insulated cup with water and placed it next to him on the table.On 07/22/2026 at 10:15 AM, Licensed Nurse (LN) H stated the orders for R6's catheter should be under his physician orders in the EMR. LN H was unable to locate R6's catheter orders in his EMR. LN H was not sure what the indication for R6's catheter was or what type and size of catheter was ordered for him.On 07/22/2026 at 10:35 AM, Administrative Nurse D stated the orders for R6's catheter were under the physician orders. Upon review of his orders, she was unable to locate the orders under the physician orders. She stated the orders might be located on the hospice care plan that was scanned into his EMR under the History and Physical tab. She was unable to locate the physician order. She stated R6's catheter was never to be changed again, and he had the catheter for comfort measures.The facility was unable to provide policy-related catheter orders as requested on 07/22/2026.

Based on interviews, observation, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident(R)6's as needed psychotropic (alters mood or thought) medication. Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder).The Significant Change Minimum Data Set (MDS) dated 06/16/2026 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R6 received diuretic (a medication to promote the formation and excretion of urine) medication during the observation.R6's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/19/2026 documented he had advanced dementia and periods of confusion. R6 had difficulty sleeping at night.R6's Care Plan, documented the following interventions:06/17/2026 - Staff would administer as needed medication for insomnia. Staff would, as much as possible, minimize daytime sleeping by inviting and encouraging participation in group or individual activities.06/19/2026 - Staff would provide non-medication approaches to help R6 rest, such as a back rub, quiet atmosphere, consistent schedule, and offer hot chocolate.R6's EMR under the Orders tab revealed the following physician orders:Benadryl (diphenhydramine hcl) (antihistamine) 25 milligram (mg) give one capsule by mouth every four hours as needed for insomnia dated 06/17/2026. The medication order lacked a stop date.Review of the Monthly Medication Review (MMR) from October 2025 to July 2026 provided by the facility lacked documentation of a recommendation for an automatic stop date for R6's Benadryl, which was being used for insomnia.On 07/21/2026 at 12:46 PM, R6 pushed himself from the dining room to the common area. R6 locked the brakes on his wheelchair prior to transferring himself into another chair in the common area. Staff refilled R6's insulated cup with water and placed it next to him on the table.On 07/22/2026 at 10:15 AM, Licensed Nurse (LN) H stated she did not address the monthly pharmacy reviews that would be LN G or Administrative Nurse D.On 07/22/2026 at 10:35 AM, Administrative Nurse D stated R6's Benadryl should have a 14-day stop date if used for insomnia. Administrative Nurse D stated she expected the pharmacist would have caught that during their monthly pharmacy reviews.The facility's Medication Regime Reviews policy dated 11/2016 documented the consultant licensed pharmacist would review the drug regimen of each resident at admission, and at least monthly thereafter. The drug review would include a review of the residents' health record.

Based on interviews, observation, and record review, the facility failed to ensure collaboration with the hospice provider for Resident (R) 6.Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder).The Significant Change Minimum Data Set (MDS) dated 06/16/2026 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R6 received hospice services during the observation period.R6's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/2026, documented he had advanced dementia and periods of confusion.R6's Care Plan, documented the following interventions:06/12/2026 - Staff would report skin breakdown. Staff would follow hospice orders as needed for wound care. Staff would use protective sacral (large triangular bone/area between the two hip bones) dressing and protective paste to inner buttocks as needed. Staff would administer lorazepam (antianxiety) as needed for anxiety. Staff would assist with position changes as needed depending on his strength and condition. R6 would use positioning devices and pillows if he became too weak to maintain his own position. Staff would continue his restorative program, as he can tolerate, to maintain joint range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) to prevent contractures. Staff would ensure he had access to fluids in and out of his room.Staff would ensure he received oral care each shift. Staff would use softer mouth swabs if a toothbrush became too uncomfortable. Staff would respect his wishes if he refused meals. Staff would initiate hospice standing orders as needed depending on his condition. No labs, x-ray, or provider appointments except his physician. Staff would obtain monthly weights.06/17/2026 - Staff would administer medication at night as ordered for insomnia. Staff would, as much as possible, minimize daytime sleeping by inviting and encouraging participation in group or individual activities. Staff would administer oxygen as needed. Staff would provide medications as needed for excess secretions and/or anxiety related to air hunger. Staff would provide a regular diet as tolerated and request food or fluid consistency changes as needed for swallowing or chewing problems. Staff would continue to utilize his foley catheter (a tube inserted into the bladder to drain urine into a collection bag) and provide catheter care along with peri care every shift and as needed. Staff would change the catheter as needed. Staff would observe for verbal and nonverbal signs of pain and administer pain medications as ordered. Staff would provide non-medication approaches to manage pain: heat, ice, massage, relaxation, prayer, or meditation. Staff would promote optimal bowel function and record bowel frequency. Staff would provide bowel management as needed. Staff would provide emotional support and understanding to R6 and my family. Staff would acknowledge, validate,and empathize during emotional expressions.06/19/2026 - Staff would continue to administer medications for atrial fibrillation and HTN.06/23/2026 - Staff would administer medications as ordered.07/14/2026 - Staff would keep family informed of any condition changes.Hold pills if unable to safely swallow. Edited: 06/17/2026The care plan lacked other services provided by hospice and the hospice provider.R6's EMR under the Orders tab revealed the following physician orders:06/10/20/26 Admit to hospice services.On 07/21/2026 at 12:46 PM, R6 pushed himself from the dining room to the common area. R6 locked the brakes on his wheelchair prior to transferring himself into another chair in the common area. Staff refilled R6's insulated cup with water and placed it next to him on the table.On 07/22/2026 at 10:05 AM, Certified Nurse Aide (CNA) M stated all staff had access to the resident's care plans. CNA M stated she had a care plan sheet that contained the residents care plan information. CNA M stated she was unable to tell if R6 was on hospice services. CNA M stated the nurse would let the staff know if a resident was on hospice.On 07/22/2026 at 10:15 AM, Licensed Nurse (LN) H stated she thought the hospice staff would come weekly. LN H said she was not aware that hospice provided any written communication at the time of their visits to R6. LN H was unable to find any written documentation from R6's hospice provider.On 07/22/2026 at 10:35 AM, Administrative Nurse D stated the facility staff would know which hospice provided services to R6 because the facility only contracted with one hospice. Administrative Nurse D stated that hospice did not provide extra bathing services, but did receive a weekly visit from a nurse and social service staff.The facility's Hospice Program policy dated 01/2018 documented that the facility contracts for hospice services for residents who wish to participate in such programs.

Based on record reviews, and interviews, the facility failed to offer and provide or obtain a signed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)11, R4 and R25.Findings included:- Review of R11's clinical record revealed R11 received the PCV-13 on 03/07/2019, and the PPV23 on 01/20/2021. R11's medical record lacked a declination for the PCV20, or evidence that the PCV20 was offered and administered.R4's clinical record lacked a declination for the PCV20, or evidence the PCV20 vaccine was offered and administered.R25's clinical record lacked a declination for PCV20, or evidence the PCV20 vaccine was offered and administered.On 07/21/2026 at 02:10 PM, Administrative Nurse D stated immunizations were tracked by the Minimum Data Set (MDS) coordinator. She stated she does not get a signed declination for the PCV20. Administrative Nurse D stated she placed a note in the quarterly MDS progress note that the resident had declined the PCV20. She stated R11 had not received his vaccine due to his wife not wanting him to leave the facility. Administrative Nurse D stated the residents had to leave the facility to receive the vaccines.The facility's Pneumococcal Vaccine policy dated 11/2023 documented that receipt of the vaccinations was essential to the health and well-being of the facility's residents. The facility would have an established immunization program against pneumococcal disease. All residents would be offered the pneumococcal vaccine to aid in preventing infections and pneumonia.

The facility identified a census of 34 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to prevent an episode of staff-to-resident physical abuse. On 06/28/25 at approximately 06:40 PM, Certified Nurse Aide (CNA) M took cognitively impaired Resident (R)1 to the bathroom. CNA M called for assistance, and CNA N came to R1's room. CNA M told CNA N that R1 bit her, so CNA N took over care. CNA N noticed R1 was dabbing her face with toilet paper, and the toilet paper had blood on it. CNA N asked R1 what happened, and R1 said, Honey, can you believe it? Her fist hit my jaw. CNA N observed a purple bruise on R1's right jaw and blood in the resident's mouth. CNA N informed LN G and CNA M of R1's statement. CNA M denied hitting R1. Following the incident, R1 became scared and paranoid to be in her room, afraid she was there, and did not want anyone to touch her. The facility's failure to prevent the staff-to-resident physical abuse placed R1 in immediate jeopardy.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and pain.R1's Annual Minimum Data Set, dated 06/20/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS documented R1 required supervision with eating, oral hygiene, toilet transfer, and ambulation. The MDS documented R1 was dependent on staff for bathing and required moderate to extensive assistance with toileting, dressing, personal hygiene, and sitting to lying. The MDS documented R1 had no physical behaviors directed towards others during the lookback period; R1 had verbal behaviors one to three days during the lookback period.The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/20/25, documented R1 had severe cognitive impairment due to dementia with behaviors. R1's behaviors included verbal behavior towards others and wandering. R1's communication ability was impacted by cognitive impairment and hearing problems. R1 required staff assistance with activities of daily living.The Behavioral Symptoms CAA, dated 06/20/25, documented R1 had wandering and verbal behaviors directed towards others one day during the lookback period. R1's behaviors did not interfere with other residents or place R1 at risk. R1's behaviors were easily redirectable by giving foods and fluids.The Psychosocial Well-Being CAA, dated 06/20/25, documented R1 had insomnia, mood swings, restlessness, agitation, and anxiety. R1's anxiety was due to her dementia and limited ability to comprehend and cope. The CAA noted observation of R1's non-verbal communication was important, as R1 conveyed her moods by facial expressions and body language. R1 liked to be around others, talk, and hold hands with staff and other residents.R1's Care Plan directed staff R1 needed guidance, cues, and assistance with activities of daily living, and to allow R1 to do what she could (01/06/25). The care plan directed staff if R1 seemed anxious to help R1 to an area with less noise and activity (03/28/25).R1's Care Plan documented interventions that directed staff R1 had dementia, and to allow her to make choices and decisions as much as R1 was able; R1 liked to spend time in the living areas visiting and talking to other residents and staff (06/20/25). The Care Plan lacked interventions related to behaviors prior to the incident on 06/28/25.The Weekly Skin Assessment on 06/16/25, documented R1's skin was warm and dry, with no skin issues noted.The Progress Note, dated 06/28/25 at 07:30 PM, documented R1 stated she had to go to the bathroom, and staff attempted to take her. R1 became agitated and started swinging and hitting at the staff. After the incident, R1 had a small bruise to her chin and scratches to her cheek. Staff applied an ice pack to the resident's chin. The note recorded staff notified Administrative Nurse D and planned to notify R1's physician.The Progress Note, dated 06/28/25 at 09:13 PM, documented staff notified R1's responsible party of the incident, and LN G explained R1 was combative during toileting and R1 had a bruise on her chin. R1's responsible party was understanding and stated the resident could get that way sometimes.The Progress Note, dated 06/28/25 at 11:36 PM, documented the bruising on R1's chin was purple in color and more prominent. R1 was agitated and wanted out of bed. Staff assisted R1 to the toilet, then to her wheelchair, and gave her fluids. R1 left the ice pack on her chin for about twenty minutes.Licensed Nurse (LN) G's Notarized Witness Statement, dated 06/28/25, documented at approximately 06:45 PM, CNA M approached LN G and reported R1 bit her neck. LN G noted CNA M's neck was red on the left side, but there were no bite marks. LN G documented CNA N said CNA M hit R1. CNA N then showed LN G pictures of R1. CNA M stated her hands were down and she did not hit R1. LN G noted she asked CNA M to leave. After CNA M left, LN G went to R1's room. R1 was in her wheelchair. LN G documented the right side of R1's chin was red with a bruise forming, and R1's right cheek had some scratches. There was also an abrasion on R1's right cheek. LN G noted the left lower side of R1's teeth and gumline had blood visible. LN G applied a cool cloth to R1's chin, then notified Administrative Nurse D of the event. LN G took pictures of R1 and sent them to Administrative Nurse D.CNA N's Notarized Witness Statement, dated 06/28/25, documented CNA N heard on the radio R1 was biting, hitting, and shaking. CNA N went to R1's room and, as she turned into the bathroom, CNA M flung herself against the bathroom wall. CNA N asked what was going on, and CNA M stated she was trying to get R1 into her pajamas when R1 bit her neck. CNA N told CNA M to show her neck to LN G and tell her what happened, so LN G could document the behavior. CNA N knelt in front of R1, who was dabbing her face with toilet paper. CNA N noticed the toilet paper had blood on it and asked R1 what happened. R1 responded, Honey, can you believe it? Her fist hit my jaw. CNA N stated she could see a purple bruise and blood in R1's mouth. CNA N then told CNA O that R1 reported CNA M hit her. CNA N took a picture of R1's face and walked to the nurse's station, where CNA M was talking to LN G. CNA N told CNA M and LN G they needed to talk privately. CNA N showed CNA M and LN G the picture and reported that R1 said CNA M hit her. CNA M stated she did not hit R1; her hands never touched R1. CNA N asked CNA M how R1 got the marks on her face and bleeding. LN G told CNA M she had to go home while this (incident) was investigated. LN G and CNA N went to R1's room. LN G assessed R1's face. R1 reached out and cupped CNA N's face and stated, Honey, I don't know why that kid did that to me. R1 stated, She hit my face and then bit me like this, as R1 leaned forward to demonstrate what happened. CNA N asked R1, So she hit you and bit you? R1 stated, Yes, honey, she did. I told her, no, stop that, and she wouldn't, so I hit her. I didn't want to hit her, but I had to, honey. CNA N then stated later she took R1 to her room, and R1 was scared, looking around the room and asking if CNA M was there. CNA N reassured R1 that CNA M went home. CNA N documented she stayed with R1, as R1 acted paranoid.The Progress Note, dated 06/29/25 at 11:36 PM, documented R1 had a dark purple bruise on her chin and down her neck. R1's lower lip and right lower cheek area were edematous (swollen). R1 did not complain of pain to the area but touched the area to her chin at times.The Weekly Skin Assessment, dated 06/30/25, documented a bruise to R1's right elbow. R1 had bruising and swelling to her lip, chin, right cheek, and upper neck.The Facility Incident Report, dated 06/30/25, documented on 06/28/25 at approximately 06:40 PM R1 approached the nurse workstation and requested to use the bathroom. CNA M wheeled R1 to her room. Once in the bathroom, CNA M reported R1 became combative and bit her on the left neck region. CNA M called for assistance, and CNA N responded and relieved CNA M to report the incident to LN G. R1 dabbed her face with toilet paper, and when it was removed, there was blood on it. R1 reported, Honey, can you believe it? Her fist hit my jaw. Staff observed a purple bruise on R1`s chin, and blood on her mouth. CNA N requested assistance from CNA O and reported R1's claims to LN G. LN G received reports from CNA M and CNA N. CNA M was dismissed from the shift pending further investigation. The staff completed a thorough examination of R1. The right side of R1's chin had a red area, with a bruise forming, and she had blood in her gumline. R1's right cheek had scratches on it and a little abrasion. The staff notified Administrative Staff A, Administrative Nurse D, R1's primary care physician, and R1's responsible party. The facility report documented upon review of all statements and descriptions of the incident, the facility could not conclude without a doubt that abuse, neglect, and exploitation took place.CNA M's Notarized Witness Statement, dated 07/01/25, documented CNA M sat at the nurse's desk when R1 came to the desk in her wheelchair and asked for help to use the bathroom. In the bathroom, R1 took hold of the rails, stood up, and stated, Hurry up and pull my pants down. CNA M stated she asked R1 to turn, and said she would help with that as soon as she got the wheelchair out of the bathroom. CNA M got R1's slacks down, but not her underwear, and R1 sat down. CNA M asked R1 to please stand back up so CNA M could pull her underpants down, and R1 cursed and said she was about to urinate right then. CNA M told R1 she would help her to stand back up so she could pull R1's underwear down. CNA M put her arms underneath R1's arms and lifted R1 with R1's head on her left side. CNA M documented R1 bit her on the neck as CNA M pulled R1's pants down. CNA M called LN G and told LN G that R1 was biting and kicking. As CNA M waited for a response, CNA M told R1 she was going to change her shirt into pajamas and took R1's shirt off. CNA N came to R1's bathroom, and CNA M showed CNA N her neck. CNA N told CNA M to show LN G her neck and tell LN G what happened. A few minutes later, CNA N came to the desk and asked LN G and CNA M to talk in private. CNA N showed them a picture of a bruise on R1's chin area, stated it was unacceptable, and reported R1 said, That girl hit me with her fist. CNA M noted she asked CNA N how she could hit R1 in the face when her hands were busy pulling down R1's slacks and underwear. CNA M noted that LN G told her to go home pending the investigation, so CNA M returned the radio, clocked out, gathered her stuff, and left.CNA P's Notarized Witness Statement, dated 08/14/25, documented CNA P came into work the night shift on 06/28/25. R1 was in the living room. CNA P obtained report about what had happened. CNA P documented R1 was worked up and visibly upset. Later that night, CNA P took R1 to her room to lie her down, and when R1 entered the room, R1 repeatedly said she was scared to be in her room and asked if she was there. CNA P asked R1 who she was talking about, and R1 said she was afraid of the lady who hit her. CNA P documented R1 was really upset and scared about staying in her room, so CNA P brought R1 back to the living room. Later that night, CNA P was eventually able to convince R1 that CNA M was not there, and R1 agreed to lay down for the night. CNA P documented R1's face had a cut that looked like a (finger) nail had dug in, R1's face had started to bruise, and her lip was swollen.LN H's Notarized Witness Statement, dated 08/14/25, documented the day after the incident, R1 did not want anyone to touch her. R1 sat at the nurse's desk and stated she could not believe the woman hit her. LN H documented R1's mouth still had blood in it and her lip was puffy and purple. R1 was guarded about anyone touching her or doing care, which was abnormal behavior.CMA R's Notarized Witness Statement, dated 08/14/25, documented CMA R came into work the day after the incident at 05:40 AM. R1 was already awake and in her wheelchair. CMA R stated she immediately saw a large bruise on the right side of R1's face and a swollen lower lip. CMA R asked LN G what happened to R1, and LN G stated a staff member hit R1 the night before. CMA R started to talk with R1, and R1 stated, I can't believe she did that to me. She hit me, sweetheart. Why would anyone want to hurt me?On 08/14/25 at 10:00 AM, observation revealed R1 sat in her wheelchair in front of the nurse's desk with a lap blanket over her lap. R1's head was forward, and she leaned her chin on her hand. When addressed, R1 looked up, smiled, and said, Boo.On 08/14/25 at 10:15 AM, CMA R stated she came in the morning after the incident, and there was no doubt in her mind R1 had been punched. CMA R stated the whole right side of R1's jaw was black and purple, and she had a fat lip, and there was still blood on her lip. CMA R stated R1 had never had behavioral issues directed towards others and stated if R1 had bitten CNA M, she had to have been provoked. CMA R stated R1 was still talking about the incident the next morning and stated, That girl hit me, and She's not here, is she?On 08/14/25 at 10:30 AM, LN H stated she was the nurse on the next morning after the incident happened, and it appeared R1 had been hit with a fist. R1 had significant black/purple bruises to the right side of her face, and her jaw and lower lip were swollen. LN H stated R1 came up to her in her wheelchair and asked her if she was going to hit R1 too. LN H stated that it broke her heart when R1 asked her that.On 08/14/25 at 12:00 PM, CNA P stated she had come into work on the night shift after the incident, and R1's chin was dark purple, and her lip was swollen. CNA P stated R1 was guarded with anyone touching her, and when staff approached R1, she put up her arm to protect herself, like she was scared she was going to be hit again. CNA P stated she had no doubt R1 had been hit in the face.On 08/14/25 at 01:00 PM, Administrative Nurse D stated the facility could not prove that CNA M hit R1 because there was a handrail on the right side of the toilet, and if R1 had reached up and bit CNA M, then came back down and hit her face on the handrail, which would explain her injuries. Administrative Nurse D stated they did not have to fire CNA M because CNA M already put in her two weeks' notice, and she just did not come back to work. Administrative Nurse D stated she interviewed the staff who worked after the incident, but they had not told her anything about suspecting CNA M hit R1. Administrative Nurse D confirmed R1's Care Plan did not had anything about R1 being physically aggressive towards others until after the incident.The facility's Freedom from Abuse, Neglect, and Exploitation Policy, dated August 2022, documented it is the policy of the facility that each resident will be free from abuse. Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment by a court of law. Residents have the right to be free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to meet the resident's medical symptoms. The policy included all seven required components.On 08/14/25 at 01:45 PM, Administrative Nurse D received a copy of the Immediate Jeopardy [IJ] Template and was notified that the facility's failure to ensure R1 remained free from abuse placed R1 in immediate jeopardy.The facility submitted an acceptable immediate jeopardy removal plan on 8/14/25 at 04:35 PM which included the following:Social Services would follow up immediately with R1 regarding her psychosocial wellness and continue to offer R1 support regarding the incident.The facility staff would be re-educated on Abuse, Neglect, and Exploitation, completed on 08/14/25. Administrative Nurse D interviewed all alert and oriented residents to establish residents' safety, and the residents felt free from staff abuse and neglect on 08/14/25.The facility held a Quality Assurance and Performance Improvement (QAPI) meeting immediately concerning the incident.The facility notified R1's primary care provider and R1's responsible party on 06/28/25.The facility notified Law Enforcement on 07/09/25 and the medical director on 08/14/25.The corrective actions to remove the immediacy were verified onsite on 08/14/25 at 06:00 PM. The scope and severity remained at a G (isolated, actual harm).

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, interview, and record review the facility failed to employ a full time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 36 residents of the facility at risk for inadequate nutrition. Findings included: - On 09/10/24 at 12:00 PM, observation revealed Dietary Staff (DS) BB in the facility kitchen assisting with the noon meal service. On 09/10/24 at 12:45 PM, Dietary Staff (DS) BB stated the prior Registered Dietician (RD) had assisted her with training related to the CDM certification. She stated she had completed the courses and was scheduled to take the test in November 2024. The facility's Dietary Manager policy stated the dietary manager was a certified dietary manager licensed by this state in accordance with the American Dietetic Association rules, regulations and guidelines. The policy stated the dietary manager was responsible for the day-to-day functions of the dietary department. The policy stated during the completion of the CDM course, the RD would provide on-site visits weekly. The facility failed to employ a full time CDM to supervise the preparation of meals and sanitation in the facility's kitchen, placing the 36 residents of the facility at risk for inadequate nutrition.

The facility had a census of 36 residents. Based on observation, interview, and record review the facility failed to store biologicals as required when staff failed to discard or destroy expired medications and vaccines. This deficient practice placed residents of the facility at risk of receiving ineffective medications. Findings included: - On 09/09/24 at 09:33 AM, observation revealed Certified Medication Aide (CMA) M obtained medication to administer to residents from the Shade medication cart. The cart contained one bottle of multivitamins with minerals which had no expiration date. On 09/09/24 at 09:40 AM, Licensed Nurse (LN) G opened the medication storage room, and observation in the medication refrigerator revealed three bisacodyl (laxative) suppositories that expired 07/2024; three bisacodyl suppositories that expired 05/2024; three boxes of Fluzone quadrivalent vaccines (flu shot), expired 06/2024 and two boxes of Fluzone high dose vaccines, expired 06/2024. LNG verified the expiration dates. On 09/09/24 at 11:00 AM, Administrative Nurse D verified staff were to remove from stock or dispose of expired medications. The facility's Storage of Medications policy, dated 04/2014, stated drug containers that had missing, incomplete, or incorrect labels should be returned to the pharmacy for proper labeling. The policy stated the facility should not use discontinued or outdated drugs or biologicals and all such drugs would be returned to the dispensing pharmacy or destroyed. The facility failed to discard or destroy expired medications and vaccines, placing residents of the facility at risk of receiving ineffective medications.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, interview, and record review the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to measure and provide the proper amounts of food for the four residents with a pureed diet. This placed the four residents at risk for impaired nutrition. Findings included: - On 09/10/24 at 11:20 AM, observation revealed Dietary Staff (DS) CC prepared the pureed foods for four residents. DS CC placed several ladles of meatloaf into the mixer without measuring the amount. DS CC then added approximately one-half cup of juice from the pan of vegetables before pureeing the mixture. She did not measure the pureed meatloaf when placing it in a cup for each resident. DS CC then pureed two cups of scalloped potatoes with one-half cup of vegetable juice and did not measure the servings when placed in resident cups. DS CC pureed one cup of squash with a fourth cup of vegetable juice and did not measure the serving size for each resident. On 09/10/24 at 11:20 AM, DS CC stated she did not have recipes for the pureed foods and stated she just eyeballed the amounts instead of measuring. On 09/10/24 at 12:45 PM, Dietary Staff (DS) BB stated should follow recipes for pureed foods and measure portions when serving pureed. She stated the Registered Dietician taught them to measure food before the pureed process. The facility's Standardized Recipes policies, dated 11/2023, stated a file of tested , standardized recipes, adjusted to appropriate yield, was used in the preparation of foods. The recipe file was maintained in the kitchen and was available to cooks throughout their tour of duty. Recipes are periodically reviewed for revisions and updating. The facility's Recommendations for Preparing Pureed Foods directed staff to place one serving of food per serving in the food processor and puree the food item until it is as smooth as possible. If it is too thin add food thickener a little at a time until consistency is reached. When serving pureed food, the quantities may be more or less than the original volume you started with so you may not need to give them all of it. The suggested liquids to use when pureeing foods directed staff to use a broth for meats and vegetable juice milk, or a broth for other foods. The facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance while preparing the pureed diet. This placed the affected residents at risk for impaired nutrition.

The facility had a census of 36 residents. The sample included 13 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to ensure a bed rail that met safety requirements and addressed risks for entrapment for Resident (R)4. This placed her at risk for accident or injury due to unidentified risks associated with side rail use. Findings included: - R4's Electronic Medical Record (EMR) recorded diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), and right knee pain. R4's Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS documented R4 required the assistance of one staff with bed mobility and transfers. The MDS lacked documentation the resident had side rails. R4's EMR recorded a Side Rail Assessment completed on 07/10/24 upon admission. The assessment documented the resident does not transfer independently and the rails were not a high risk for entrapment. The rails and hoops were considered for safety and security, and the resident would need to use the side rail due to her weakness and balance deficit; the rail would help the resident turn side to side, move up and down in bed, pull herself from a laying to sitting position, supporting herself, transferring more safely, exiting the bed more safely, and improving balance. The assessment documented the rails/hoops were recommended due to a family request. Further evaluation was required by physical therapy or occupational therapy to recommend the type of side rail and usage. The assessment did not document the rail's openings or address the space between the side rail/hoop and the mattress. R4's EMR lacked evidence that therapy evaluated the type of rail and its usage. The Logbook Documentation provided by the facility revealed the facility's maintenance staff checked the bed and rails on 08/07/24 for cleaning and care, sanitizing methods, environmental conditions for storage and transport as well as a Maintenance Check. The document recorded the Maintenance Check which included inspecting connectors on rails and tightening as necessary; removal of burs or rough edges to prevent injury; verification of the function of the spring knob assembly if applicable and ensuring the latch was free of dirt and/or foreign material that could impair function; ensuring the side rails engaged and locked as specified; tightening, adjusting, or replacing any parts such as end caps, knobs, bolts, screws etc. that were loose or showed signs of wear, or were missing. The check did not address the rail opening, or the area between the rail and mattress. On 09/10/24 at 04:00 PM, observation revealed a one-fourth side rail on the left side of R4's bed with an opening approximately 16.5 inches by 32 inches. Continued observation and examination revealed the side rail was able to slip out of the bed and move. The resident had her own personal full-size mattress and used a remote control to elevate the head of the bed and change the bed position at the foot of the mattress. On 09/11/2024 at 10:00 AM, Administrative Nurse E verified the bed rails on R4's bed had too large of an opening, and the rail was not able to be affixed to the bed securely for stability and was able to be moved easily. Administrative Nurse A verified the facility lacked any further assessment for the use of the side rail. The Bed Safety policy, dated 2014, documented the facility strives to provide a safe sleeping environment for the resident. The resident's sleeping environment would be assessed by the interdisciplinary team, to consider the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. To try to prevent deaths/injuries from the beds and related equipment (including frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: Inspection by the maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. Review that gaps within the bed system are within the dimensions established by the Federal Drug Administration (FDA) The review shall consider situations that could be caused by the resident's weight, movement, or bed position. Ensure that the bed rails are properly installed using the manufacturer's instructions or other pertinent safety guidance to ensure proper fit. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment such as altered mental status, or restlessness. Maintenance will document this review in the TELS program. The facility's education and training activities would include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. If side rails were used, there would be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. The staff would obtain consent for the use of the side rails from the resident or the resident's legal guardian. Before using the side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with the side rails. The facility failed to adequately assess R4's actual rail in use to ensure safe openings and failed to assess for safe use of a side rail prior to placing it on R4's bed. This placed her at risk for accident or injury due to unidentified risks associated with side rail use.

The facility had a census of 36 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a 14-day stop date or specified duration, for Resident (R)10's as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic drug medications. Findings include: - R10's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R10's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded he required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation R10 received an antianxiety medication during the observation period. R10's Care Plan, dated 07/25/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan documented the resident received lorazepam (antianxiety medication) for anxiety and restlessness. R10's Physician's Order, dated 07/25/24, directed the staff to administer lorazepam 0.5 milligrams (mg) to 3 mg, three times a day (morning, afternoon, and at bedtime) PRN. The order lacked a stop date. R10's EHR lacked evidence of a specified duration which included a physician's rationale for the extended use of the PRN lorazepam. The Consultant Pharmacist's monthly review for R10 completed on 08/19/24 lacked evidence the CP identified the PRN lorazepam with no stop date. On 09/10/24 at 07:45 AM, R10 sat in a wheelchair at the dining room table. Certified Medication Aide (CMA) R administered the resident's medication. On 09/11/24 at 11:00 AM, Administrative Nurse D verified the resident received lorazepam PRN, with a physician order date of 07/25/24, and no stop date. Administrative Nurse D verified the Consultant Pharmacist had sent monthly reviews to the facility and lacked a recommendation for the 14-day stop date or rationale for continued use of the medication. The facility's Pharmacy Services- Role of the Consulting Pharmacist policy, dated March 2023 documented the facility would contract the services of the Consulting Pharmacist. The Consulting Pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including identifying pertinent resources and references about medications and their proper use and monitoring in the population. The Consultant Pharmacist would review the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, pertinent resident-specific documentation irregularities, and pertinent resident-specific documentation in the medical record, as indicated. The facility failed to ensure the CP identified and reported the lack of a 14-day stop date for the use of PRN lorazepam for R10. This placed the resident at risk for unnecessary psychotropic medication.

The facility had a census of 36 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)10's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R10's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R10's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R10 had severely impaired cognition. The MDS recorded he required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation R10 received an antianxiety medication during the observation period. R10's Care Plan, dated 07/25/24, recorded R10 required extensive assistance with most activities of daily living (ADL) care. R10's Care Plan documented the resident received lorazepam (antianxiety medication) for anxiety and restlessness. R10's Physician's Order, dated 07/25/24, directed the staff to administer lorazepam 0.5 milligrams (mg) to 3 mg, three times a day (morning, afternoon, and at bedtime) PRN. The order lacked a stop date. R10's EMR lacked evidence of a specified duration which included a physician's rationale for the extended use of the PRN lorazepam. On 09/10/24 at 07:45 AM, R10 sat in a wheelchair at the dining room table. Certified Medication Aide (CMA) R administered the resident's medication. On 09/11/24 at 11:00 PM, Administrative Nurse D verified the resident received lorazepam PRN, with a physician order date of 7/25/24. Administrative Nurse D verified the order did not have a 14-day stop date or a reason for the continued use with the appropriate rationale. The facility did not provide a policy related to PRN psychotropic medications. The facility failed to ensure R10 was free of unnecessary psychotropic drugs when they failed to obtain a stop date for the use of PRN lorazepam. This placed R10 at risk for adverse side effects from the continued use of psychotropic medications.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to discard expired medications in the emergency drug treatment kit/box located in the medication room. This placed residents at risk for ineffective medications. Findings included: - On 01/29/23 at 08:40 AM, observation during the initial tour revealed the emergency medication kit/box, had an expiration date, 12/22 written on the top of the kit/box. On 01/31/23 at 09:50 AM, Administrative Nurse D verified the emergency treatment kit had numerous expired medications. Administrative Nurse D verified the pharmacist had not been on site to identify the expired medications, however the nurses should identify the expired kit during use and said she would contact the local pharmacy to get replacement medications. The facility's Emergency Drug Kit policy, dated 4/2021, documented a supply of drugs typically used in emergencies shall be maintained at each nurse's station. An emergency drug kit contains the drugs and biologicals that are essential to providing emergency treatment. A kit is available at the nurse's station and is stored in the medication room. An inventory listing is maintained of the content of the kit. The pharmacist shall inspect the emergency medical kit monthly and record the findings on the record maintained with each kit. Medications and supplies used from the emergency kit must be replaced upon the next routine drug order. Indicated on the drug order form that the supply is needed to replenish the kit. Drugs removed from the emergency kit must be entered on the emergency medication administration log. The lock tag for the kit must be recorded when removed- who opened, and the reason the kit was opened, and date. The facility failed to ensure expired medications were remoevd and replaced, placing the residents at risk for use of an ineffective medication.

The facility had a census of 31 residents. The sample included 12 residents with five reviewed for falls. Based on observation, interview and record review the facility failed to provide adequate supervision for Resident (R) 29 who fell when she was left unattended in the shower room and R35 who fell while unsupervised in an unlocked treatment room. This deficient practice placed R29 and R35 at risk for injuries from falls. Findings included: - R29's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six. The MDS documented R29 required supervision for eating, extensive assistance of two staff for transfers, bed mobility, toileting, dressing, and did not walk. R29 used a wheelchair and balance unsteady and required human assistance to stabilize during transfers. The MDS documented R29 had two or more non-injury falls since the prior MDS, received antianxiety medication seven days, and a bed alarm was used daily. The Fall Care Plan, dated 11/10/22, directed staff to use a silent alarm to monitor attempts to self-transfer from bed to recliner without assistance and not to leave R29 in her wheelchair when alone in her room. The paln directed staff to try to keep R29 in the commons area when she was not sleeping or with someone in her room, place a fall mat beside her bed, gripper socks, and low bed. The plan directed to use a gait belt and walker, assist with walking to or from the bathroom. The 01/15/23 update directed staff to not leave R29 unattended in the shower room. The Fall Risk Assessments, dated 10/24/22, 12/18/22, and 01/16/23 all indicated R29 a high fall risk. The Fall Note, dated 01/15/23 at 10:37 AM, documented staff took R29 to the bathroom in the shower room and then left to get or check something. Staff returned to the shower room and found R29 by the shower room door, where she had slid down to the floor because she needed to get somebody. No injuries were noted. On 01/30/23 at 12:56 PM, observation revealed R29 in a recliner in the living room, feet elevated, glasses on, and looking around. Further observation at 01:30 PM, Certified Medication Aide (CMA) S woke R29 and asked if she could take her to her room. CMA S transferred R29 to her wheelchair, asked her if she needed to go to the bathroom, and assisted R29 to toilet. CMA S then assisted R29 to bed, placed the call light in reach, bed low, and a pressure alarm was on. On 01/26/23 at 01:22 PM, CMA S stated when staff see R29 trying to get out of bed, staff toilet her and assist her to her wheelchair and have her sit in the living room. On 01/31/23 at 01:45 PM, Administrative Nurse D verified staff should not have left R29 alone and unsupervised in the shower room. The facility's Fall Prevention policy, dated 05/2015, stated various strategies would be implemented to minimize fall risk. A fall risk assessment would be completed at admission, quarterly, with any significant change and after a fall if the resident not previously identified at risk. Based on the resident assessment and their individual needs, interventions would be implemented to minimize the risk of falls and documented on the care plan. The facility failed to provide adequate supervision when staff left R29 alone in the shower room and she fell . This deficient practice placed R29 at risk for injury from falls. - R35's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease with early onset (a specific brain disease marked by symptoms of dementia that gradually get worse over time), psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Annual Minimum Data Set (MDS), dated [DATE], documented short, long term memory problems with severely impaired decision making. The MDS documented R35 had hallucinations (seeing or hearing things that are not here), delusions (belief in something that is clearly not real), and wandered daily. The MDS documented R35 required supervision for walking in the corridor, extensive assistance of one staff for walking in her room, hygiene, and extensive assistance of two staff for transfers, dressing, eating and toileting. R35's balance was unsteady and required assistance to regain balance. R35 had one minor injury fall since the prior MDS and received antipsychotic (medications used to treat major mental disorders) and antianxiety medications seven days of the lookback period. The Care Area Assessment (CAA), dated 04/15/22, documented R35 had a history of falls and her balance varied from steady to unsteady. The CAA documented R35's vision was impaired, and her cognition was severely impaired due to Alzheimer's disease. The Fall Care Plan, dated 04/15/22, directed staff to ensure R35 had gripper socks on, gripper strips in front of her bed, a fall mat in place, bed alarm, pressure alarm in the recliner, low bed, and staff were to leave the shower room doors closed when not in use. The care plan did not address the 01/05/22 fall in the treatment room until 01/25/22 with the statement the care plan was reviewed and remained appropriate. The Fall Note, dated 01/05/22 at 06:00 AM, documented at 06:00 AM, R35 went into the treatment room and staff heard help me, help me and found R35 sitting on the floor on her buttocks with her head toward the door, and her feet toward the sink in the treatment room. The nurse noted a bruise on her left side forehead. Staff assisted R35 up and obtained R35's vital signs. The physician and family were notified. The Social Services Note, dated 1/18/22, stated R35 continued to wander the halls. 01/26/23 at 12:00 PM, Social Services X stated R35 had poor cognition, bad eyesight and did not want to wear her glasses. R35 would run into things, walked with head down often, and fell occasionally. Social Services X stated staff could not restrain R35, staff constantly looked for her and watched the cameras for her. R35 was very mobile and quick. On 01/26/23 at 02:03 PM, Administrative Nurse D stated at that time of the fall, 01/05/22, the treatment room was enclosed, and staff had to go through the nutrition room which was left open. Administrative Nurse D stated staff had not closed the treatment room door and R35 went in and she tripped over the weight scale. Administrative Nurse D stated she educated staff and placed signage to ensure the door to the treatment room locked and had maintenance staff change the door lock to a keypad. Administrative Nurse D stated the nurse on duty did not write a witness statement. On 01/31/23 at 08:52 AM, Licensed Nurse (LN) G verified the treatment room had a key lock at the time of the fall and staff were to close and lock the door. She verified R35 had fiddled with the doorknob of the treatment room at times. On 01/31/23 at 01:45 PM, Administrative Nurse D verified staff should have ensured the treatment room door was closed and locked when leaving the area. The facility's Fall Prevention policy, dated 05/2015, stated various strategies would be implemented to minimize fall risk. A fall risk assessment would be completed at admission, quarterly, with any significant change and after a fall if the resident not previously identified at risk. Based on the resident assessment and their individual needs, interventions would be implemented to minimize the risk of falls and documented on the care plan. The facility failed to provide adequate supervision for R35, who was unsupervised when she entered an unlocked treatment room and fell , placing R35 at risk for injury.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, facility medical director, and physician, the lack of a 14 day stop date for Resident (R)11 and R13's as needed (PRN) psychotropic (a medication that affects mood and/or thought) or rationale for continued use. This placed the residents at risk for inappropriate use of a psychotropic medication with side effects. Findings included: - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental, uncertainty and irrational fear), and depression (mood disorder characterized by persistent sadness). R11's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R11 required supervision with transfer, dressing, toilet use, , and required limited assistance of one staff for locomotion on and off the unit and hygiene. The MDS documented R11 received an antidepressant medication for all seven of the look back days. The Psychotic Drug Use Care Area Assessment (CAA), dated 03/18/22, documented R11 received Wellbutrin (antidepressant) daily for major depressive disorder and as needed Ativan (psychotropic antianxiety medication) for anxiety. The Mood Care Plan, dated 12/02/22 recorded the resident displayed signs and symptoms of depression, such as feeling down, depressed and bad about herself, and tired. The resident had chronic pain that affected her mood and at times was verbally aggressive towards staff. Staff administered Ativan as needed for her persistent anxiety after non-pharmacological interventions have been attempted. The Physician's Order, dated 10/24/22, directed the staff to administer Ativan 0.5 milligrams (mg), administer one half tablet or 0.25 mg twice a day as needed for anxiety. The order lacked a stop date. Review of the Medication Administration Record in the EMR revealed the resident last received the Ativan 0.25mg on 01/24/23 for anxiety from a bloody nose, with documented relief from the anxiety. Review of the Medication Regimen Reviews lacked evidence the Consultant Pharmacist identified the need for the as needed Ativan 14 day stop date. On 01/25/23 at 04:20 PM, observation revealed the resident sat in a recliner in her room with a bedside table in front of her and the activity director painting her fingernails. Certified Medication Aide (CMA) R administered the resident's morning medications to her. On 01/31/23 at 09:40 AM, Administrative Nurse D verified the resident received Ativan, with a physician order date of 10/14/22. Administrative Nurse D verified the facility failed to obtain the 14 days stop date or reason for continued use with the appropriate rational. Administrative Nurse D verified the Consultant Pharmacist failed to recommend a 14 day stop date for use of the residents as needed Ativan. The Antipsychotic Medication Use policy dated October 2017 recorded antipsychotic medication therapy shall be used as appropriate with the proper assessment, diagnosis and physician or mental health expert oversight. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The PCP would identify, evaluate and document, with input from other disciplinary and consultants as needed, symptoms that may warrant the use of antipsychotic medications. All residents with an order for antipsychotic medications would be assessed for ongoing use. The assessment would include proper diagnosis, AIMS testing, behavior monitoring, gradual dose reduction and care plan use. A monthly drug regimen review would be completed on all residents by the consulting pharmacist, and appropriate recommendations for dose reduction are made to the physician. The facility's Pharmacy Services- Role of the Consulting Pharmacist policy, dated February 2018 documented the facility would contract the services of the Consulting Pharmacist. The Consulting Pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including identify pertinent resources and references about medications and their proper use and monitoring in the population. Help the facility evaluate and optimize their medication administration and documentation process. Identifying pertinent resources and references about medications and their proper use and monitoring in the population. Regular review of the emergency medication supply and provide facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. The facility's Consultant Pharmacist failed to recommend to the facility Director of Nursing (DON), medical director, and physician the need for a 14 day stop date or rationale for continued use of PRN Ativan. This placed the resident at risk for inappropriate use of an as needed psychotropic medication with side effects. 26768 - R13's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. The MDS documented R13 demonstrated physical, verbal and other behaviors which placed resident and others at risk physically, interfered with her care, and disrupted the environment. R13 required extensive staff assistance for eating, hygiene, dressing, toilet use, bed mobility, transfers and received antipsychotic (medication used to treat psychosis) and antianxiety medication seven days of the lookback period. The Psychotropic Medication Care Area Assessment (CAA), dated 11/25/22, documented R13 had various mental health disorders and received psychotropic medications for these conditions. The assessment stated R13 had behaviors at times, such as crying, throwing food, aggression during cares. The Medication Care Plan, dated 12/01/22, directed staff to talk to R13 when she was sad or anxious. If R13 was wandering and agitated, offer a drink or snack, like Cola and chocolate. The care plan directed staff to apply Ativan (antianxiety drug) cream as needed for anxiety. Utilize PRN Ativan if non-medication approaches are ineffective to relieve anxiety. May use oral or topical. Monitor adverse effects: speech pattern changes, loss of strength, over-sedation, gait changes, irritability, increased sweating, dizziness. The Physician Order, dated 10/02/19, directed staff to administer Ativan 0.5 milligrams (mg), three times daily (TID), as needed (PRN) for anxiety. The order lacked a stop date. The Physician Order, dated 10/13/21, directed staff to administer Ativan cream, 1 mg, topically, PRN every six hours, for anxiety. The order lacked a stop date. The Medication Administration Record (MAR) documented the PRN Ativan was administered almost daily, sometimes three times daily for behaviors of anxious, crawling on floor, crying, hitting at staff, or combative. The Consultant Pharmacist Review, dated 06/13/2022, documented a risk versus benefit documentation was due for the PRN use of Ativan. The physician response documented her current status warrants need to continue medications and monitoring to continue. The documentation lacked a request for a stop date for the use of the PRN Ativan. The Consultant Pharmacist Reviews, 07/18/22 through 01/24/23 documented no suggestions at this time. On 01/26/23 at 09:01 AM, observation revealed Certified Medication Aide (CMA) T administered medications to R13 in her room. CMA T crushed the pills, including Ativan, and mixed with chocolate pudding. R13 accepted medication easily without problems. On 01/26/23 at 07:56 AM, CMA T stated R13 can become upset with staff or anybody at times, due to multiple personalities and severe dementia. On 01/31/23 at 01:45 PM, Administrative Nurse D verified the lack of a stop date for the PRN Ativan and stated the Consultant Pharmacist had not notified her of the need for one. The Antipsychotic Medication Use policy dated October 2017 recorded antipsychotic medication therapy shall be used as appropriate with the proper assessment, diagnosis and physician or mental health expert oversight. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.The PCP would identify, evaluate and document, with input from other disciplinary and consultants as needed, symptoms that may warrant the use of antipsychotic medications. All residents with an order for antipsychotic medications would be assessed for ongoing use. The assessment would include proper diagnosis, AIMS testing, behavior monitoring, gradual dose reduction and care plan use. A monthly drug regimen review would be completed on all residents by the consulting pharmacist, and appropriate recommendations for dose reduction are made to the physician. The facility's Consultant Pharmacist failed to recommend to the facility Director of Nursing (DON), medical director, and physician the need for a 14 day stop date or rationale for continued use of PRN Ativan. This placed the resident at risk for inappropriate use of an as needed psychotropic medication with side effects.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to ensure a 14- day stop date for Resident (R)11 and R13 who received as needed (PRN) psychotropic (medication that affects mood and/or thoughts) that lacked a 14 day stop date or rationale for continued use. This placed the affected residents at risk for unintended affects related to psychotropic drug medications. Findings included: - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental, uncertainty and irrational fear), and depression (mood disorder characterized by persistent sadness). R11's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of fourteen, indicating intact cognition. R11 required supervision with transfer, dressing, toilet use, , and required limited assistance of one staff for locomotion on and off the unit and hygiene. The MDS documented R11 received an antidepressant medication for all seven of the look back days. The Psychotic Drug Use Care Area Assessment (CAA), dated 03/18/22, documented R11 received Wellbutrin (antidepressant) daily for major depressive disorder and as needed Ativan (psychotropic antianxiety medication) for anxiety. The Mood Care Plan, dated 12/02/22 recorded the resident displayed signs and symptoms of depression, such as feeling down, depressed and bad about herself, and tired. The resident had chronic pain that affected her mood and at times was verbally aggressive towards staff. Staff administered Ativan as needed for her persistent anxiety after non-pharmacological interventions have been attempted. The Physician's Order, dated 10/24/22, directed the staff to administer Ativan 0.5 milligrams (mg), administer one half tablet or 0.25 mg twice a day as needed for anxiety. The order lacked a stop date. Review of the Medication Administration Record in the EMR revealed the resident last received the Ativan 0.25mg on 01/24/23 for anxiety from a bloody nose, with documented relief from the anxiety. On 01/25/23 at 04:20 PM, observation revealed the resident in a recliner in her room with a bedside table in front of her and the activity director painting her fingernails and Certified Medication Aide (CMA) R administered the resident's morning medications to her. On 01/31/23 at 09:40 AM, Administrative Nurse D verified the resident received Ativan, with a physician order date of 10/14/22. Administrative Nurse D verified the facility failed to obtain the 14 days stop date or reason for continued use with the appropriate rational. The Antipsychotic Medication Use policy dated October 2017 recorded antipsychotic medication therapy shall be used as appropriate with the proper assessment, diagnosis and physician or mental health expert oversight. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.The PCP would identify, evaluate and document, with input from other disciplinary and consultants as needed, symptoms that may warrant the use of antipsychotic medications. All residents with an order for antipsychotic medications would be assessed for ongoing use. The assessment would include proper diagnosis, AIMS testing, behavior monitoring, gradual dose reduction and care plan use. A monthly drug regimen review would be completed on all residents by the consulting pharmacist, and appropriate recommendations for dose reduction are made to the physician. The facility failed to ensure R11 was free of the use of unnecessary psychotropic drugs when they failed to obtain a stop date for the use of PRN Ativan, placing R11 at risk for adverse effects from the continued use of those medications. 26768 - R13's Electronic Medical Record (EMR) documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. The MDS documented R13 demonstrated physical, verbal and other behaviors which placed resident and others at risk physically, interfered with her care, and disrupted the environment. R13 required extensive staff assistance for eating, hygiene, dressing, toilet use, bed mobility, transfers and received antipsychotic (medication used to treat major mental disorders), and antianxiety medication seven days of the lookback period. The Psychotropic Medication Care Area Assessment (CAA), dated 11/25/22, documented R13 had various mental health disorders and received psychotropic medications for these conditions. The assessment stated R13 had behaviors at times, such as crying, throwing food, aggression during cares. The Medication Care Plan, dated 12/01/22, directed staff to talk to R13 when she was sad or anxious. If R13 was wandering and agitated, offer a drink or snack, like cola and chocolate. The care plan directed staff to apply Ativan (antianxiety drug) cream as needed for anxiety. Utilize PRN Ativan if non-medication approaches were ineffective to relieve anxiety. May use oral or topical. Monitor adverse effects: speech pattern changes, loss of strength, over-sedation, gait changes, irritability, increased sweating, dizziness. The Physician Order, dated 10/02/19, directed staff to administer Ativan 0.5 milligrams (mg), three times daily (TID), as needed (PRN) for anxiety. The order lacked a stop date. The Physician Order, dated 10/13/21, directed staff to administer Ativan cream, 1 mg, topically, PRN every six hours, for anxiety. The order lacked a stop date. The Medication Administration Record (MAR) documented the PRN Ativan was administered almost daily, sometimes three times daily, for behaviors of anxious, crawling on floor, crying, hitting at staff, or combative. The Consultant Pharmacist Review, dated 06/13/2022, documented a risk versus benefit documentation was due for the PRN use of Ativan. The physician response documented her current status warrants need to continue medications and monitoring to continue. The documentation lacked a request for a stop date for the use of the PRN Ativan. On 01/26/23 at 09:01 AM, observation revealed Certified Medication Aide (CMA) T administered medications to R13 in her room. CMA T crushed the pills, including Ativan, and mixed with chocolate pudding. R13 accepted medication easily without problems. On 01/26/23 at 07:56 AM, CMA T stated R13 can become upset with staff or anybody at times, due to multiple personalities and severe dementia. On 01/31/23 at 01:45 PM, Administrative Nurse D verified the lack of a stop date for the PRN Ativan and stated the Consultant Pharmacist had not notified her of the need for one. The Antipsychotic Medication Use policy dated October 2017 recorded antipsychotic medication therapy shall be used as appropriate with the proper assessment, diagnosis and physician or mental health expert oversight. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The PCP would identify, evaluate and document, with input from other disciplinary and consultants as needed, symptoms that may warrant the use of antipsychotic medications. All residents with an order for antipsychotic medications would be assessed for ongoing use. The assessment would include proper diagnosis, AIMS testing, behavior monitoring, gradual dose reduction and care plan use. A monthly drug regimen review would be completed on all residents by the consulting pharmacist, and appropriate recommendations for dose reduction are made to the physician. The facility failed to ensure R13's drug regimen was free of unnecessary psychotropic drugs when they failed to obtain a stop date for the use of PRN Ativan beyond the 14-day requirement, placing R13 at risk for unnecessary side effects from the continued use.

The facility identified a census of 41 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to have a thorough system in place for training the facility's drivers of the transportation van on the correct safety measures for securing the facility's 10 residents who travel in wheelchairs. Resident #1's wheelchair became unsecured on 2 separate occasions while riding in the facility van, and during the last incident he/she experienced a life-threatening situation, which resulted in death. This deficient practice placed any resident transported in a wheelchair in the facility van in immediate jeopardy. Findings include: - Resident #1's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated [DATE], documented the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15, and no behaviors. The assessment documented the resident independent with locomotion off the unit, required supervision with locomotion on the unit, eating, toilet use, hygiene, bed mobility, walking, required limited staff assistance with transfers, and extensive staff assistance of 1 staff with dressing. The resident used no mobility devices, reported occasional mild pain, and had 2 or more non-injury falls. The significant change MDS, dated [DATE], documented the same except the resident required extensive assistance with locomotion, used a wheelchair, experienced one minor injury fall, and had frequent, severe pain. The [DATE] (CAA) Care Area Assessment summary for (ADL) activities of daily living documented the resident experienced a decline in function, received extensive staff assistance with ADLs. Pain was limited his/her mobility at times and caused him/her to need a wheelchair or physical assistance with bed mobility, transfers, and walking. The summary documented the resident at risk for falls due to incontinence, unsteady balance, medications, medical conditions, and a history of falls. Interventions included transport in wheelchair to appointments. The [DATE] care plan for ADLs recorded the resident walked without use of a walker, but if he/she was in pain or feeling weak and unsteady he/she used a wheelchair with staff to propel. The care plan directed staff to assist with transportation to scheduled appointments. Intervention added on [DATE], would use transport wheel chair to go to all appointments, Intervention added on [DATE] directed staff to ensure the seat belt was tight when staff buckled him/her in the van. The [DATE] acknowledgement sheet documented Nurse Aide G reviewed the facility's safety policy and an updated policy on safe handling and movement of residents. In addition, Nurse Aide G watched the taped in-service. No further information regarding the in-service was documented. The [DATE] at 5:23 PM, nurse's note documented facility staff transported the resident to an out of town physician appointment and on the return trip the van driver stated while driving, a car pulled out in front of the van and he/she had to put on the brakes. The note documented the resident fell out of his/her wheelchair, staff immediately pulled the van over and the resident independently got back into the wheelchair. The resident landed on his/her right side, stated he/she wasn't hurt and upon return to the facility a nurse immediately assessed him/her. The resident stated he/she was having some pain to his/her right shoulder, but nursing found no bruising and the resident could move his/her arm within normal limits, without signs of pain. Staff asked the resident if he/she wanted an X-ray done and he/she refused. At 5:30 PM the resident stated he/she still had a little pain to his/her shoulder, could move it without difficulty, but would like to follow up with the doctor. Staff notified the resident's responsible party and physician of the fall. The [DATE] at 7:20 AM, nurse's note documented the resident had pain to his/her right shoulder after being thrown forward in the facility van. The facility's fall investigation documented x-ray results the next day showed no injury to the resident's right shoulder. The investigation documented the van was assessed for malfunction in the straps, retrained the driver on [DATE] in person and on the Relias computer module (an education system presented on the computer) before returning to service as van transport. The facility's van maintenance inspection documentation showed an inspection monthly, by the facility's maintenance person, on [DATE], [DATE], [DATE] and [DATE]. The [DATE] van inspection documented pass for the doors, lift, seatbelts, triangles, and tie-downs. The facility's appointment book/transportation schedule lacked documentation of the transportation of the resident on [DATE]. The [DATE] fall risk assessment score 18= high risk- interventions: non-slip socks if no shoes (no slippers), restorative program, and directed staff to transport the resident in a wheelchair to his/her appointments. The [DATE] at 9:20 AM, nurse's note documented the resident left for a physician appointment, regarding back pain, in a wheelchair with staff. The [DATE] at 1:43 PM, nurse's note documented a phone call from the physician reporting the resident would be admitted to the hospital for [MEDICAL CONDITION] Urinary Tract Infection and very low sodium. The note documented staff notified the family and received verbal consent for a bed hold. The [DATE] at 9:34 PM, nurse's note documented the hospital discharged the resident and Nurse Aide G picked the resident up in the facility van at 3:05 PM, for transport back to the facility. An off-duty staff member contacted the facility to report he/she observed the facility van at approximately 4:05 PM, with police present. The note documented the administrator contacted law enforcement and learned there was an incident in the van and resident was deceased . The note documented the facility's van driver, Nurse Aide G, was transported to the hospital for medical attention. On [DATE] at 7:55 AM, observation of the facility van revealed the seat belt apparatus not frayed, bolts secure, no obvious concerns noted. Maintenance Staff U demonstrated using the van chair lift and seat belts. On [DATE] at 11:05 AM, observation revealed Nurse Aide O demonstrated how to load a resident for transport. Maintenance Staff U played the part of a resident. Nurse Aide O loaded the resident in the wheelchair, placed the straps in the back on the X cross-brace under the wheelchair. Then he/she placed the short front straps on the front vertical bar of the wheelchair leg. All straps had a ratchet system which allowed the user to release the ratchet with a lever until the straps were in place, then the ratchet system tightened and could only become looser if the lever was released. The ratchet system also had a tightening knob for further security. After securing the resident and wheelchair with a seatbelt, Nurse Aide O attempted to move the wheelchair around to see if the system held. The resident attempted to bounce the wheelchair, and tried to lean back to see if the front straps held. The wheelchair was secure. On [DATE] at 8:00 AM, Maintenance Staff U stated the facility had not used the facility van recently due to an accident. Maintenance Staff U stated he/she performed a monthly van inspection and occasionally took it to a supplier of handicap accessible vans and he/she stated the company checked everything when the facility brought the van in. Maintenance Staff U stated staff reported problems by phone or entered the maintenance concern on the computer. Maintenance Staff U stated the van had no safety concerns or other issues, and he/she only drove the van when it was empty. Maintenance Staff U reported he/she last inspected the van [DATE]. On [DATE] at 8:15 AM, Administrative Staff A verified he/she had not reported the incident to the state agency due to the police investigation determined no abuse or neglect occurred. Administrative Staff A would not comment on whether the incident with grievous harm should have been reported to the state agency. Administrative Staff A stated he/she was gathering the reports for the facility investigation. Administrative Staff A reported the staff person who was driving the van during the incident, was ill and seeing a physician. On [DATE] at 11:37 AM, Nurse Aide O stated he/she last drove the bus 2 weeks ago, when he/she took a resident to an appointment. Nurse Aide O stated the railroad tracks were rough in general and rougher with the facility van. Nurse Aide O stated he/she drove slowly over them, usually in the left side lane. Nurse Aide O stated he/she rode in a seat in the bus, not a wheelchair, and the bumps were bearable and he/she did not bounce out of the seat. Nurse Aide O stated he/she never heard of the safety hooks or straps coming undone or residents pushing the ratchet lever to release the straps, and was unaware of any incidents involving the resident. Nurse Aide O stated the facility trained him/her on transportation shortly after employment, and a month or 2 ago had a training in-service including strapping residents' wheelchairs into the van. On [DATE] at 11:52 AM, Nurse Aide P stated he/she drove the bus a week ago. Nurse Aide P stated he/she received training from another van driver a week or 2 prior to driving the van out of town 2 months ago. Nurse Aide P stated he/she was trained to lock the wheelchair, cross the back belts, hook the front straps to the wheelchair frame, closer to the wheel, and secure the seatbelt across the resident and through the frame. Nurse Aide P stated there had been no equipment malfunctions during his/her resident transports. Nurse Aide P stated the ratchet system could not be made to stay open, it retracted when the red button was released. He/she stated residents had not messed around with the belts or straps. On [DATE] at 12:09 PM, Social Services Staff X stated he/she drove the van and it could be a bouncy ride. He/she typically drove on far-right side, slow, over the railroad tracks, approximately 10 (mph) miles per hour. Social Services Staff X stated some residents complained to drivers about the bumps. Social Services Staff X stated he/she was trained to drive the van approximately 1 ½ to 2 years ago by the last van driver. Social Services Staff X stated he/she placed a resident in a wheelchair on the van facing front, locked the wheelchair brakes, secured the 4 ratchet hooks on the bottom bars of the wheelchair, ensured the ratchet system was tight, placed the seat belt on the resident and through the frame of the wheelchair. Social Services Staff X stated he/she had no issues with straps/belts coming off or failing and no residents hit the ratchet button. On [DATE] at 12:33 PM, Nurse Aide N stated he/she trained van drivers, including Nurse Aide M, whom he/she trained about 2 years ago. Nurse Aide M stated he/she was unsure if he/she watched a video during his/her training, and did not know where to locate the video. Nurse Aide M stated he/she provided trainees with a document of training certificate, but did not keep a copy for the facility. Nurse Aide M stated he/she physically demonstrated how to place a resident on the lift, raise, secure the resident with wheelchair brakes, belts, and ratcheting straps. Nurse Aide M stated he/she hooked the straps on the x-frame bars under the wheelchair, nowhere else, and placed the seat belt above the wheelchair arms. Nurse Aide M stated he/she was trained by the prior maintenance staff who used a video for training. Nurse Aide M stated he/she had no issues with straps coming loose or with residents releasing the ratchet, and was unaware of any failures of the security system. On [DATE] at 12:55 PM, Nurse Aide Q stated he/she was trained to drive the facility van 6 months ago by maintenance staff, and they used no video or book. Nurse Aide Q stated the trainer demonstrated how to secure the resident in a wheelchair, but did not request a return demonstration. Nurse Aide Q stated he/she placed a resident in a wheelchair in the correct place in the back of the van, locked the wheelchair brakes, secured the back belts, then the front strap hooks, then the seatbelt. Nurse Aide Q stated he/she attached the back hooks to the bottom center brace area of the wheelchair, and attached the front hooks to a frame bar, not wheels or the wheel knob. Nurse Aide Q stated he/she did not cross the back straps, and placed the seat belt under the wheelchair arm rest and around the resident. Nurse Aide Q stated the red ratchet button in front released the strap, and if you take your hand off the red button, the strap will stop there and stay tight until you hit the red button. Nurse Aide Q stated staff can manually tighten the strap ratchet with the silver knobs on the ratchet box. Nurse Aide Q stated the strap system worked properly, never malfunctioned, no hooks had slipped off, and the seatbelts worked fine when he/she had driven the van. Nurse Aide Q stated he/she drove slowly over the railroad tracks because they were rough and made the van bounce. On [DATE] at 1:12 PM, Nurse Aide R stated he/she was trained in (MONTH) (YEAR) by another van driver who demonstrated the lift, how to lock the wheelchair brakes and emergency brake. The trainer further demonstrated to take the resident off the lift and place in the back of the bus, attach the back straps to the horizontal frame bar, behind the X, without crossing the straps. He/she attached the front strap hooks on the frame bar and used the manual ratchet knob ensure they were tight. Nurse Aide R stated staff pushed down the red lever to release the ratchet for the straps, and must hold the lever down or the strap will stop coming out. Nurse Aide R stated he/she used the manual ratchet knob after he/she placed the hooks, placed the seatbelt under the armrest, around the resident, and ensured the seat belt was secure. Nurse Aide R stated training involved one-time demonstration and return demonstration. Nurse Aide R stated he/she had never heard of a resident touching the lever, straps, or belts, and he/she had not had the wheelchair safety system fail or malfunction. On [DATE] at 1:30 PM, Nurse Aide S stated he/she was hired as a van driver, but had not driven the van for a few years. Nurse Aide S stated he/she was trained by demonstration and returned demonstration, without a video or other information. On [DATE] at 1:45 PM, Detective GG verified all staff had not reported the same system of securing the residents in wheelchairs in the van. On [DATE] at 3:05 PM, Nurse Aide M stated, on [DATE], he/she checked the resident first, after seeing the wheelchair wheels in the air. Nurse Aide M stated he/she could not release the seat belts and he/she called 911. Nurse Aide M stated the resident's face had started to turn purple and he/she was unable to breathe. Nurse Aide M stated when a policeman arrived, they attempted to lift the resident without success. Nurse Aide M stated (EMS) Emergency Medical Service and Firemen arrived, he/she gave them the resident's paperwork, and they were able to free the resident. Nurse Aide M stated he/she was unable to observe after that as the EMS made him/her get off the bus due to his/her anxiety attack. Nurse Aide M stated the EMS declared the resident dead, but he/she did not know what happened next as the EMS transported him/her to the hospital for anxiety. Nurse Aide M stated his/her van driver training involved buckling the wheelchairs in, how to run the lift, the parking brake, and driving the van. Nurse Aide M stated the trainer demonstrated how to perform the safety procedures and he/she returned the demonstration one time. Nurse Aide M stated he/she also rode with another driver and buckled the resident in. Nurse Aide M stated the procedure was to place the resident in the correct spot and lock the wheelchair wheels, crisscross the straps in the back and hook them on the crossbars underneath the seat. He/she stated the resident used a regular wheelchair. Nurse Aide M stated after securing the back straps, he/she hooked the ratchet straps on the vertical bar the front of the wheelchair below the horizontal cross bar, and the ratchets tightened automatically. Nurse Aide M stated he/she did not tighten the strap with the silver knob. Nurse Aide M stated he/she placed the seat belt around the resident, over the wheelchair arms, as the resident was too large to place the belt under the wheelchair arm rest. Nurse Aide M stated he/she asked the resident if he/she was okay, went outside the bus to move the lift into the van, and then drove to the hearing aid store, picked up an item, and started to drive back to the facility. On [DATE] at 5:00 PM, Administrator A verified the facility lacked records of how and when the van drivers were trained. On [DATE] at 828 AM, Administrator A verified facility staff train other employees to transport residents, the facility had no specific trainer, and another van driver trained the new drivers. Administrator A reported the facility used drawings and video to train staff. Upon request the administrator did not provide documentation or video used for training. Administrator A verified he/she expected all staff to be trained the same, but verified the facility did not perform a skills check routinely to ensure all transportation staff were trained correctly in the safety measures. On [DATE] at 9:12 AM, Nurse Aide T stated he/she drove the van and was trained 4 years ago by observing a demonstration of securing the resident and then he/she returned the demonstration. Nurse Aide T stated the trainer used a paper showing a wheelchair and which bars to hook the straps to. Nurse Aide T stated the former maintenance staff also trained him/her by demonstrating for several staff how to hook the wheelchairs in. Nurse Aide T stated he/she was just trained those 2 times. Nurse Aide T stated he/she places the resident in the wheelchair on one side in the back of the bus, locks the wheelchair brakes, hooks the back straps on the back horizontal bars of the frame, not crossed. Nurse Aide T stated he/she straps the front hooks to the horizontal bar where it meets the vertical bar of the frame, tightens the straps using the silver knob on the ratchet system, and straps the seat belt under the wheelchair arms and across the resident. He/she stated the seat belt hooks into the same place the back hooks are attached to the floor. The facility provided Vehicle Usage Policy, dated [DATE], recorded to provide safe transportation of facility residents, guidelines were followed related to the training of staff, maintenance and up-keep of the van. All personnel who were eligible to drive the facility van will be trained in the proper use of the vehicle. This included the use of the lift, the seat belt system, and the vehicle operation. All resident were to be seated if transporting on the van lift. All resident wheelchair brakes were to be locked on the van lift. All wheelchairs shall be secured with floor brakes as well as the seatbelt harness system. Residents in the seating area should be secured in seatbelts. They should not stand while on the bus. Please report any maintenance concerns to the director of maintenance for follow-up service repair on the van. The facility Freedom from Abuse, Neglect and Exploitation (ANE) Policy, dated [DATE], defined neglect as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or mental illness. All accidents/incidents with the potential to meet the definitions of abuse, neglect or misappropriation of resident property were investigated by the administrator. All allegations of ANE were reported immediately to the state agency (within 24 hours). All incident reports should be submitted immediately to the administrator, and no later than 24 hours after the occurrence. Investigation reports shall be completed and submitted to the state agency within 5 working days of the initial report, if warranted by the investigation. Every employee was responsible for reporting of suspected ANE. Instances of ANE were reported immediately to the administrator. If the administrator was unavailable, reports are made to the next person in charge. Reports were made in person, in writing, or by telephone. The facility failed to provide thorough, consistent training, regarding securing the wheelchaired residents, for the staff who transported those residents in the facility van. This deficient practice placed any facility resident transported in a wheelchair in immediate jeopardy. The facility abated the Immediate Jeopardy on [DATE] at 5:20 PM when the facility re-trained 6 designated transportation van drivers with review of the vehicle usage policy, performed a driver competency performance audit of securing a person, and provided a video and diagrams for securement. The facility removed the van involved in the incident from service until a professional assessment is completed. The facility further suspended transportation of residents in facility vehicles until [DATE]. The deficient practice remained at a scope and severity of G.

The facility had a census of 41 residents. The sample included 12 residents of which 1 resident was reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to develop and implement timely and effective interventions to prevent the development of pressure ulcers for 1 of 1 sampled resident for pressure ulcers. Resident #2 developed a facility acquired deep tissue injury (a pressure related injury to subcutaneous tissues under intact skin). Findings included: - Resident #2's [DIAGNOSES REDACTED]., not enough insulin made or the body cannot respond to the insulin). The admission (MDS) Minimum Data Set assessment, dated 10/10/16, recorded a (BIMS) Brief Interview for Mental Status score of 7, which indicated severe cognitive impairment and required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and extensive assistance of 1 staff for personal hygiene. The assessment recorded the resident at risk for developing a pressure ulcer (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure combination with shear and/or friction), had 1 unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) deep tissue injury, which was present on admission. The assessment documented pressure ulcer care, pressure reducing device for his/her bed/chair, turning/repositioning program, nutrition or hydration interventions, with applications of non-surgical dressing other than to feet and applications of dressing to his/her feet for pressure ulcer interventions. The quarterly MDS, dated [DATE], was unchanged except, recorded a BIMS score of 12, which indicated moderate cognitive impairment, and required limited assistance of 1 staff for bed mobility, transfers, toileting, and personal hygiene. The MDS indicated the resident had 2 unstageable pressure ulcers, present on admission, with largest pressure ulcer measuring 3.5 (cm) centimeters x 3.5 cm and 0.1 cm depth. The MDS indicated the same preventive measures in place to prevent further pressure ulcer development. The (CAA) Care Area Assessment for pressure ulcers dated 10/12/16, indicated the resident had functional limitation to his/her left lower leg due to a left [MEDICAL CONDITION] and on admission had a Suspected Deep Tissue Injury to his/her left heel which measured 4 cm x 3 cm, purple in color. The admission nursing assessment indicated the resident had a pressure reducing mattress, received nutritional interventions, and staff repositioned him/her. The 10/3/16 Braden scale for predicting pressure ulcers score was 19-not at risk. The 10/16/16 Braden scale for predicting pressure ulcers score was 17-at risk. The 10/3/16 admission care plan informed staff the resident was at risk for pressure ulcer development due to impaired sensory perception and interventions in place were an air mattress on his/her bed, elevate the resident's heels and use heel protectors. The care plan further indicated the resident had a suspected deep tissue injury to his/her left heel and directed nursing to apply skin prep (used to help protect skin from moisture), twice a day. The care plan informed staff the resident had an immobilizer to his/her left leg. The care plan did not specify interventions regarding the immobilizer or skin inspections. The 10/13/16 care plan update indicated staff were to keep the resident's head of bed no higher than 30 degrees and encourage and/or assist the resident with repositioning. The care plan did not specify the frequency of repositioning. The 10/3/16 hospital discharge summary lacked information regarding the resident's skin or use of immobilizer. The nursing note dated 10/3/16, (day of admission to the facility) recorded the resident had a suspected deep tissue injury to the resident's left heel measuring 4 cm x 3 cm, purple in color and heel protector on, with 1+ [MEDICAL CONDITION] (swelling barely detectable impression when finger is pressed into skin) to his/her left leg. The 10/5/16 at 12:54 PM, nurse's note recorded the immobilizer on the resident's left leg was on at night and off during the day, since admission, and lacked documentation regarding removing the immobilizer and doing a skin check. The 3:41 PM, nurse's note recorded the nurse removed the resident's immobilizer from his/her left leg and noted redness with pain to the left back of the resident's calf and the heel was purple/black. The note further recorded the nurse applied a Vaseline gauze dressing to the area on the back of the resident's left calf. Further review of the resident's medical record revealed [REDACTED]. Review of the medical record revealed, on 10/6/16 the resident went to the doctor's office. The physician ordered staff to apply an ace bandage to the resident's left lower leg from his/her foot to below his/her left knee, which was to be on during the day and off at night. The physician also ordered [MEDICATION NAME] (protein supplement for wound healing), twice a day, and a protein shake/drink in the afternoon. The 10/6/16 dietitian admit note indicated the resident received a regular diet and admission weight was 162.8 pounds. The note indicated the resident had recent hip surgery, had a surgical incision to his/her hip and also pressure ulcers to his/her left heel and back of the left calf. The note indicated the resident was able to eat on his/her own and often ate in his/her room. The dietician recommended [MEDICATION NAME], twice a day, for wound healing. The 10/10/16 physician's order instructed staff to do weekly nursing assessments, measure active wounds and document in the progress notes. The 10/22/16 weekly wound evaluation flow sheet indicated the resident had a 3 cm x 2 cm with 0.1 cm in depth open area with minimal serous (thin, watery) exudate (drainage) with 50% slough (dead tissue, usually cream or yellow in color) and necrotic (pertaining to the death of tissue in response to disease or injury) tissue. (15 days after first noticing redness on the back of the resident's left calf) Further review of the resident's medical record indicated this entry was the first measurement of the resident's open area on the back of the resident's left calf since the redness was discovered on 10/5/16. Review of the medical record revealed, the 10/20/16 doctor office appointment stated the resident's family member reported the resident had been elevating his/her heel, but now has developed soreness to the back of his/her calf where staff have been elevating the leg. The back of the calf revealed a 2 cm well defined area, where he/she had skin breakdown with mild drainage. The 10/29/16 at 11:00 AM, nurse's note indicated the resident had slight [MEDICAL CONDITION] in his/her left foot and the left calf wound area was open and had a small amount of eschar (dead tissue). The 11/1/16 at 12:45 PM, nurse's note recorded the resident returned from a doctor's appointment with an order for [REDACTED]. The 11/8/16 at 10:07 AM, nurse's note recorded the resident admitted to the facility with suspected deep tissue injury to left back of calf (even though nursing documentation stated redness to the back of the left calf was not present until 10/5/16) and the wound now measured 3.2 cm with slough, moderate drainage, red wound bed and a foul smell noted. The note recorded the nurse cleansed the wound with wound cleaner, and applied ExelGinate Silver (contains antimicrobial silver and is indicated for moderate to heavily draining wounds), covered with foam and wrapped with gauze. The note further recorded staff faxed the resident's physician regarding the skin issue and the treatment provided. The physician replied at 11:58 AM, (same day) he/she agreed with the treatment provided. The 11/16/16 hospital skin wound care consult documented the resident had arterial insufficiency (condition that slows or stops the flow of blood through your arteries) to the left lower leg as well as [MEDICAL CONDITION] (term used to describe a problem with the nerves) with significant loss of protective sensation. The resident's family member reported the resident had been wearing a boot while in the facility, to protect his/her eschar covered ulcer to the left posterior heel, which the boot appeared to have facilitated the development of the eschar covered left calf wound. The left calf pressure injury caused by the medical device, measured 2.5 x 3 cm and had no exudate, with eschar, [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (redness or inflammation of the skin) and peri wound with [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. The 11/29/16 orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) physician notes stated quarter size eschar present on the back of the mid lower leg with no [DIAGNOSES REDACTED] or drainage present. The resident is doing well following hip surgery but had developed pressure wounds on the back of his/her lower left leg with eschar present and wounds were dry. The physician's order directed staff to perform daily dressing changes to the area, to wash the wounds with [MEDICATION NAME] (an antiseptic used to disinfect the skin), nursing to apply abdominal (absorbant) pads, and to replace the protective boot which was in place. The note further indicated if the wound did not heal or became infected this could lead to referral to a wound care clinic, surgical debridement (removal of nonliving tissue) or even amputation of the resident's lower leg. The 12/23/16 at 1:31 PM, nurse's note indicated a new order for a wound care clinic consult. review of the resident's medical record revealed [REDACTED]. The 12/28/16 wound clinic first visit recorded the resident had a history of [REDACTED]. The left lower calf wound measured 1.6 cm x 2.6 cm and 0.3 cm in depth with necrotic/eschar slough, which was debrided. On 1/19/17 at 3:14 PM, observation revealed Nurse K and Administrative Nurse B performed the resident's dressing change to his/her left back of calf. Nurse K removed the old dressing from the resident's left back of calf, which had a small amount serosanguinous (containing or relating to both blood and the liquid part of blood (serum) drainage), and measured the wound at 2.5 cm x 2.5 cm and <0.2 cm depth. Administrative Nurse B described the left calf having 40% slough and 50% pink wound bed. Nurse K cleansed the wound with wound cleanser sprayed on 4 x 4 and wiped gently over the wound bed and surrounding tissue. Nurse K applied a 2 x 2 silver alginate (an antimicrobial, highly absorbent wound dressing) folded to fit into the wound bed on the resident's left calf, covered with [MEDICATION NAME] dressing and wrapped the left calf with gauze and secured with paper tape on top of the gauze. Further observation revealed the resident had obvious [MEDICAL CONDITION] in the lower left leg and top of the left foot. On 1/19/17 at 2:50 PM, Nurse Aide L stated he/she knew the resident had pressure ulcers but did not do anything for the ulcers and would report any skin discoloration, skin tears, bruises, or any open areas. Nurse Aide L stated the resident turns himself/herself, was continent of bowel/bladder, had a foot cradle (devices that attach to the bed and keep sheets and blankets from touching and rubbing the resident's legs or feet) on the foot of the resident's bed and wore a heel protector on his/her left foot. On 1/19/17 at 3:30 PM, Nurse K stated the resident had 2 pressure ulcers which were present on admission and since the resident had been going to the wound clinic the dressing orders were changing every week. Nurse K stated the pressure ulcers were getting smaller and healing faster since having the PAD (peripheral artery disease (also called [MEDICAL CONDITION]) is a common circulatory problem in which narrowed arteries reduce blood flow to the resident's limbs) surgery in November. Nurse K stated the wound clinic did not want the resident to wear ace bandages or Ted hose and the [MEDICAL CONDITION] on top of the resident's foot and lower leg was new. Nurse K stated the resident does turn himself/herself every 2 hours, with staff checking to remind him/her to turn if he/she hadn't already turned himself/herself. On 1/23/17 at 11:20 AM, Administrative Nurse B verified the resident had the unstageable pressure ulcer on his/her left heel on admission, but the unstageable pressure ulcer on the back of his/her left calf was first noticed on 10/5/16, with redness at the site, and the resident was wearing an immobilizer at that time. Administrative Nurse B stated the staff would not have taken the immobilizer off daily, as it was ordered to be on at all times, but staff removed the immobilizer for bathing. Administrative Nurse B verified the nurse applied a Vaseline gauze dressing on 10/5/16, when noticing the redness on the back of the left calf and did not know where the nurse got that order, as it was not the facility's standing order for pressure ulcers until the pressure ulcer was at a Stage II. The redness on the resident's posterior calf was a Stage I. Administrative Nurse B verified the nurse who applied the Vaseline gauze dressing no longer worked at the facility and also verified lack of documentation of the resident's back left calf from 10/5/16 - 10/22/16 and lack of documentation from 12/11/16-12/28/16 prior to going to the wound clinic. At 5:35 PM, Administrative Nurse B stated the (PT) Physical Therapy consult the physician ordered on [DATE] for the non open pressure ulcer, included PT already working with the resident and the therapy department do not treat pressure ulcers at the facility. Administrative Nurse B stated therapy had discontinued the immobilizer on 10/6/16, when the physician ordered the ace wrap to the left lower leg below the knee and including the resident's foot. On 1/24/17 at 9:15 AM, Physician's Clinical Nurse C stated the physician had dictated on the 10/6/16 office visit the resident had redness to his/her lower left calf and ordered a PT consult for non open pressure ulcer, ace wrap to the resident's left lower leg from foot to below knee with instructions to have nursing apply on in AM and remove in PM. Physician's Clinical Nurse C stated the physician would expect the nurse who was applying the ace wrap to observe the resident's skin prior to re-wrapping the resident's left leg and to report any skin discoloration or open areas. Physician's Clinical Nurse C stated the physician had dictated, on 11/2/16, the resident's pressure ulcers on the resident's left lower leg and left heel were improving with granulating tissue in wound beds. Physician Clinical Nurse C stated the facility had notified the physician's office on 11/8/16, regarding the resident having a pressure ulcer measuring 3.2 cm with moderate slough and foul smell from the back of left calf which nursing had covered with a foam dressing and the physician okayed the dressing order. The 5/14 facility's pressure ulcer treatment and prevention policy indicated all residents would be assessed for risk of developing pressure ulcers and interventions initiated to prevent impaired skin integrity. The policy also indicated residents that are admitted with or develop pressure ulcers shall receive appropriate monitoring and treatments to promote healing. The policy stated residents would be assessed for risk of developing pressure ulcers on admission/readmission, then weekly for 4 weeks, quarterly and upon identification of a significant change in condition. Upon identification of risk factors, determine which factors could be removed, modified, or stabilized. Preventative interventions should be initiated immediately and included in the plan of care. treatment of [REDACTED]. Implement treatment using Wound Care Formulary (unless specific physician order designates other treatment). Document the rationale or justification for failure to implement appropriate interventions to address risk factors. The Wound Care Formulary deep tissue wound Stage 1- indicated no treatment. The facility failed to develop and implement interventions to prevent the development of a pressure ulcer for this cognitively impaired resident. The facility failed to remove an immobilizer and assess the skin on the back of left calf after Resident #2 admitted to the facility, with a nurse applying a dressing, without a physician's order, to the back of the resident's left calf and lack of documentation from 10/5/16 when the redness was first noted until 10/22/16 when the pressure ulcer measured 3 cm x 2 cm and had slough with necrotic tissue (15 days later) which placed the resident at increased risk for further pressure ulcer development.

The facility had a census of 34 residents. The sample included 3 residents reviewed for elopement risk. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 sampled residents. Resident #1 displayed exit seeking behaviors evidenced by 11 attempts to leave the facility in one day. The same day, the cognitively impaired resident left the facility, without the staff's knowledge, and an off duty staff person found him/her 3 blocks away from the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 8/26/16, indicated the resident had short/long term memory problems, moderately impaired decision making skill, inattention, disorganized thinking, wandering, and displayed physical, verbal and other behaviors. The assessment indicated the resident independent with walking, transfers, required supervision with locomotion, and limited assistance with toileting. The assessment indicated the resident received antianxiety medications during the look back period. The 5/30/16 (CAA) Care Area Assessment for cognitive loss/dementia stated the resident had a [DIAGNOSES REDACTED]. The 8/1/16 care plan indicated staff identified the resident as an elopement risk and initiated a Wanderguard (a device, worn by the resident, which triggered an alarm if the resident attempted to open a door) for the resident on 5/23/16. The 6/1/16 update directed staff to provide exercise, music, personalization of his/her room, recreational activities to prevent the resident from eloping, and utilize exit alarms. The 8/1/16 update directed staff to monitor the resident's behaviors every shift, notify the physician of increased behaviors, and notify the nurse if the resident became agitated. The 9/8/16 update (after the resident eloped) directed staff to assist with finding the resident a quiet area to rest, when agitated, place a new Wanderguard, and directed staff to check the Wanderguard, twice daily, for effectiveness. The care plan indicated the resident was to see the mental health (APRN) Advanced Practice Registered Nurse on 9/12/16. The care plan stated the resident liked to take walks when it is not too hot, and if exit seeking a walk may calm him/her. Review of the nurse's progress notes revealed the following: 9/6/16 at 5:48 AM, the resident was restless, walking up and down the halls after supper. 9/6/16 at 2:26 PM, the resident was exit seeking most of the day, going into other resident's rooms. 9/7/16 at 1:36 AM, the resident was very anxious/restless after supper. 9/7/16 at 11:37 AM, the resident was pacing the halls, very frustrated, and staff were unable to redirect him/her. 9/7/16 at 4:15 PM, recorded at 3:35 PM, the resident walked in the south hall with his/her hand on the handrail. The resident appeared agitated, pacing up and down the hall, and then appeared to lower him/herself to the floor using the handrail, as witnessed by staff. The resident quickly got up and continued walking. He/she did not hit his/her head and had no signs of injury. The resident continued to pace and became agitated when staff redirected him/her. Staff continued to monitor the resident closely and re-approach him/her when indicated. The resident went out of the east hall door several times, and staff provided redirection, but it was not always effective. 9/8/16 at 3:30 AM, the resident was exit seeking part of the evening but calmed down after staff administered a (PRN), as needed, Ativan (antianxiety medication) and a warm moist pack to his/her knee. The resident ambulated throughout the facility and outside. 9/8/15 at 9:51 AM, the resident exhibited extreme, aggressive behavior, going out every exit and trying to walk to the street. The note recorded it took 3 staff to coax him/her back into the facility. The note further documented the resident went out of the facility 11 times during the morning, was going into other resident's rooms, and when approached to redirect, he/she shook his/her hands/fists in the staff's face. The resident threw his/her Wanderguard (necklace) off and started disrobing (taking off his/her clothes). 9/8/16 at 11:31 AM, staff received a physician order [REDACTED]. 2) Seroquel (antipsychotic), 25 mg, daily at bedtime. 9/8/16 at 8:36 PM, the resident was exit seeking throughout the morning, and exited the facility at least 11 times with staff. Staff attempted to redirect the resident several times to his/her room or to a quiet area. The resident continued to get agitated and exit seek more. At 9:45 AM, the resident took his/her Wanderguard off his/her neck, threw it on to the floor, and staff put the Wanderguard back on. At 9:55 AM, a staff member brought the resident baseball cards to look at for a distraction from exit seeking and walked with the resident to the assisted living main entrance sitting area. The resident sat down and looked at the baseball cards. At 10:15 AM, a staff member walked into the facility with the resident and stated the resident had walked 2 blocks away. Staff checked the resident's Wanderguard and it did not work. Interventions included: Staff provided 1:1 contact until staff applied a new Wanderguard. Staff evaluated the facility's call/ door system, and noted the assisted living entrance had been opened several times from 10:00 AM to 10:15 AM, related to church services being held, but had not alarmed when the resident went out. Education was given to staff on duty, at the time of incident, to ensure that they are checking door alarms adequately. On 9/12/16 at 12:30 PM, observation revealed the resident independently ambulated, with no assistive device, a steady gait, and a Wanderguard bracelet on his/her left wrist. On 9/12/16 at 3:07 PM, observation of the front door exit for the assisted living revealed a keypad alarm system, but no Wanderguard alarm system. The alarm sounded when pushing on the door and after 15 seconds, the door opened, and a louder alarm sounded. Staff responded immediately and Administration Staff B verified the exit did not have a Wanderguard alarm on it. On 9/12/16 at 12:44 PM, Nurse Aide E stated the resident wore the Wanderguard on his/her wrist and stated the resident had thrown the Wanderguard at times. On 9/12/16 at 1:10 PM, Nurse Aide C verified on 9/8/16, approximately 10:10 AM, he/she was driving, a few blocks away from the facility, when he/she saw Resident #1 walking down the sidewalk with a glass of water. Nurse Aide C stated the resident was 3 blocks from the nursing home. Nurse Aide C stated he/she stopped and asked the resident what he/she was doing, the resident told him/her he/she did not know, Nurse Aide C offered the resident a ride, which he/she accepted, and took him/her back to the facility at the entrance by the assisted living, Nurse Aide C stated when they entered the facility, the resident's Wanderguard did not alarm. On 9/12/16 at 4:41 PM, Nurse Aide D verified, on 9/8/16, Resident #1's Wanderguard alarm was not functioning and did not alarm when he/she went from the nursing home through the doors to the assisted living side of the facility and sat by the front door. Nurse Aide D stated he/she went to notify staff of the broken Wanderguard, and did not know the resident left the facility until an off duty staff member brought him/her back to the facility. Nurse Aide D stated another staff member had been with them and gave the resident an envelope with baseball cards and was unsure if the other staff person was with the resident when he/she left the area. Nurse Aide D verified the resident was left unsupervised in the assisted living side of the facility and a staff person should have stayed with the resident. On 9/12/16 at 3:45 PM, Administrative Staff F stated he/she had observed the resident to be agitated/restless that morning. Administrative Staff F stated he/she was working in the activity room preparing for a church service when he/she observed the resident walk past with a nurse aide following him/her. Administrative Staff F verified the Wanderguard alarm did not alarm and told the nurse aide to keep a close eye on the resident since the Wanderguard was not working. Administrative Staff F stated he/she gave the resident an envelope of baseball cards to occupy him/her and guided him/her to a chair by the assisted living exit door. Administrative Staff F stated he/she went back to work in the activity room and was unsure if the aide stayed with the resident when he/she left the area. On 9/12/16 at 4:55 PM, Administrative Nurse A verified the cognitively impaired resident, was at risk for elopement, and staff should not have left the resident unattended, without the Wanderguard working, on the assisted living side of the facility. He/she verified, at the time of the elopement, visitors were going in and out of the same exit the resident used to elope. On 9/13/16 at 11:56 AM, Medication Aide I stated his/her (MAR) Medication Administration Record included a check of the resident's Wanderguard twice daily, started 9/8/16, in the afternoon, after the resident eloped. Medication Aide I stated prior to 9/8/16, staff did not check placement or function of the Wanderguard. He/she stated the resident went to the exits often enough that staff were aware his/her Wanderguard was functioning. On 9/12/16 at 5:10 PM, Maintenance Staff G stated he/she checked the exit door alarms weekly and all passed on 9/2/16. Maintenance Staff G verified he/she did not have a system to check the Wanderguard alarms routinely. Maintenance Staff G stated he/she checked the Wanderguard bracelets when they were first placed and set up. He/she stated the system sends a page when the battery was low, but it does not notify staff when the Wanderguard was broken. On 9/13/16 at 10:10 AM, Nurse H (nurse on duty the day of the elopement) stated staff did not inform him/her of the actual elopement until later, after an off duty staff member returned the resident to the facility. Nurse H stated the resident was restless, attempted to exit 11 times already that morning, became angry, and raised his/her fists at staff. Nurse H stated the director of nursing informed him/her of the elopement. Nurse H stated the nurses do not document checking the Wanderguard, and stated he/she had always checked for Wanderguard placement but had not documented it. He/She verified nurses were responsible to ensure placement and function of Wanderguards. The facility's 5/2014 Elopement Precaution policy stated the definition of an elopement: an unwitnessed (not seen or alerted by door monitor alarm) exit from the facility grounds by a resident who had impaired decision making ability and was oblivious to their own safety needs. The resident's care plan will be modified to indicate the resident at risk for elopement and if a resident repeatedly attempted to exit the facility, a monitoring schedule will be implemented to ensure resident safety. If a resident was discovered missing, a search shall begin immediately. Staff will be educated about elopement precautions at hire and at least annually. Doors exiting the facility will be alarmed at all times. The executive director and/or director of nursing will be notified by the charge nurse for approval before a door alarm was disabled. Once each shift, the charge nurse will ensure that residents assessed to be at risk were located, the door alarm system functioning properly, and document on the door alarm check sheet. Wanderguard bracelets were reviewed daily by maintenance with the call light response report. The Wanderguard alert system on the doors will be tested weekly by environmental staff and recorded. If a door alarm sounds, one staff person will silence the alarm, another staff will visually check inside and outside the area or exit which triggered, to determine the reason for the alarm. If staff cannot visually identify a reason for the alarm, they must go to the area checking for persons leaving the building. If the reason for the alarm cannot be immediately identified, staff will check residents at risk for elopement. The control panel must be reset after the alarm reason has been determined. The facility failed to provide adequate supervision for cognitively impaired Resident #1, who had displayed 11 attempts to exit the building unattended, earlier in the day, when staff left the resident unattended, with a known non-functioning Wanderguard, on the assisted living side of the facility, during a time when visitors were coming to the facility for a public activity. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 9/14/16 at 4:40 PM, after completion of training of all staff regarding elopement prevention and review of the facility's elopement policy. Staff provided 1:1 supervision until a new Wanderguard was placed, closed and coded the assisted living doors and the door alarm company coded the staff pagers to alert when the assisted living doors opened without staff. The facility changed the elopement policy to instruct staff to monitor and document the functioning of the Wanderguards of the 5 residents of the facility who wore Wanderguards, and changed the Medication Administration Record to include that documentation. This deficient practice remained at a scope and severity of D.

The facility had a census of 35 residents. The sample included 11 residents. Based on observation, interview, and record review the facility failed to monitor and follow the plan of care for fall prevention for 1 of 3 residents reviewed for accidents. Resident #5 had a history of [REDACTED]. Findings included: - Resdient #5's annual (MDS) Minimum Data Set assessment, dated 9/25/15, indicated the resident had severe cognitive impairment with short and long term memory problems, moderately impaired cognitive skills for decision making, and displayed behaviors of inattention, disorganized thinking, altered level of consciousness, and psychomotor retardation (slowing-down of thought and a reduction of physical movements in an individual). The assessment also revealed the resident displayed physical and verbal behaviors towards others, rejection of care, and wandering. The MDS further indicated the resident required extensive assistance from 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, an unsteady balance, nly able to stabilize with staff assistance. The MDS indicated the resident required no assistive devices, was always incontinent of bowel and bladder, had 2 non injury falls, 1 injury fall, and received antipsychotic (medication used to control psychosis), antianxiety (medication used to relieve anxiety), antibiotic, anticoagulant (medication used to thin the blood), and diuretic (medication used to remove excess water through the kidneys) medications. The 9/25/15 fall (CAA) Care Area Assessment indicated the resident ambulated with an unsteady gait, and he/she transferred with assistance of 1-2 staff without devices. The quarterly MDS assessment, dated 12/25/15, indicated the same as above except, he/she had severely impaired cognitive skills for decision making, hallucinations (sensing things while awake that appear to be real, but the mind created) and displayed delusional behaviors (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS further indicated the resident frequently incontinent of bowel, had 2 non injury falls, and 1 fall with injury. The 10/1/15 care plan instructed staff to monitor the resident closely after his/her family leaves, ensure he/she is wearing eyeglasses, encourage him/her to not stand without assistance, provide proper well-maintained footwear, and a personal alarm, and to keep his/her call light within reach. The 10/26/15 care plan update instructed staff to observe the resident frequently and place him/her in a supervised area when out of bed. The 12/16/15 care plan update instructed staff to observe the resident frequently and place him/her in a supervised area when out of bed. The 1/22/16 care plan update instructed staff to assist the resident out of his/her room in his/her broda chair, to be close to other residents and staff when possible. The 2/7/16 care plan update instructed staff not to leave the resident in his/her recliner unattended. The 12/24/15 at 8:21 PM, nurse's note indicated the resident fell out of his/her recliner, in his/her room, onto the floor. The note further indicated 3 staff assisted the resident to the toilet, he/she did not void, was combative, and staff were unable to get a blood pressure. The note indicated staff observed the resident shake his/her fist at staff, grind his/her teeth, and talked as there was someone talking with his/her. The note further indicated staff assisted the resident to bed, and placed an alarm, the bed in low position. The 12/25/15 at 7:15 PM, nurse's notes indicated the resident did not follow commands, combative, anxious, and argumentative. The note further indicated the resident bit staff on the forearm, hit staff, had an unsteady gait, and required assistance from 2 staff. The 12/25/15 at 10:57 AM, nurse's note indicated the resident remained anxious and combative, sat on the couch by the nurse's station, and was unsteady when he/she sat up. The note further indicated the resident received 1 to 1 care by the staff. The 12/25/15 at 1:47 PM, nurse's note indicated staff found the resident lying on the floor in his/her room, close to his/her recliner. The note indicated the resident had no apparent injuries, was combative, restless, anxious, and was physically abusive to staff. The note further indicated the resident attempted to stand on his/her own and staff provided 1 to 1 supervision. The 12/25/15 fax to the physician indicated staff found the resident on the floor in his/her room at 7:15 AM and at 8:10 PM on 12/24/15. The fax informed the physician the resident was combative, unsteady, and rejected care. The physician responded on 12/28/15 he/she noted the incident. The 2/7/16 at 2:37 PM, nurse's note indicated staff found the resident lying on his/her stomach, on the floor, near the recliner in his/her room. The note further indicated the resident had an approximate 1 (cm) centimenter by 1 cm laceration to his/her left eyebrow, and staff cleansed it and applied a pressure dressing. The 2/7/16 at 2:42 PM, nurse's note indicated staff sent the resident to the emergency room for evaluation and treatment. The 2/7/16 fax to the physician informed the physician staff found the resident on the floor in his/her room, near his/her recliner, and he/she sustained a left eyebrow laceration. The fax further informed the physician the resident's family wanted him/her to be treated in the emergency room . The physician responded he/she had seen the resident in the emergency room . The 2/7/16 emergency room discharge instructions directed staff to apply ice packs to the affected area for 20 minutes 4 times a day, beginning 24 hours after the injury. The instructions further instructed staff to remove the sutures on 2/14/16, and to apply triple antibiotic ointment twice daily for 7 days. On 3/30/16 at 1:23 PM, observation revealed staff propelled the resident to his/her room in a broda chair. Further observation revealed staff used a sit to stand lift, assisted the resident to stand from his/her broda chair, and transfered the resident to the toilet. Continued observation revealed staff toileted the resident, then assisted him/her with personal cleansing, and transferred him/her with the sit to stand to his/her bed. Observation revealed staff removed his/her shoes, assisted him/her to lie down, covered him/her with a blanket, and placed his/her call light within reach of the resident. Further observation revealed staff attached a personal alarm, lowered the bed, and placed a mat on the floor beside the bed. On 3/30/16 at 1:23 PM, Nurse Aide A stated the resident stood up from the recliner once, so now staff do not put him/her in the recliner unless his/her family is here visiting with the resident. On 4/4/16 at 10:01 AM, Nurse Aide B verified staff give report prior to each shift including any changes with a resident, and the aides also have access to the care plans. Nurse Aide B stated staff place the resident in his/her recliner if he/she is calm, so staff do not seat him/her in the recliner often. Nurse Aide C stated the resident had climbed out of his/her recliner after being placed by agency staff, who do not realize he/she stands up out of the recliner independently. On 4/4/16 at 10:52 AM, Nurse C verified the resident's care plan instructed staff not to leave the resident unattended in his/her recliner, and staff should not have placed the resident in his/her recliner unattended. On 4/4/16 at 2:22 PM, Medication Aide D verified he/she was informed not to place the resident in his/her recliner, and when new staff come in to work in the building, staff are to inform them. On 4/4/16 at 2:49 PM, Medication Aide F stated on 12/24/15, the resident slid out of his/her recliner. Medication Aide F further verified the recliner is leather, and dycem (a pad used to prevent sliding) only works to a point, and a person can still slide out. On 4/5/16 at 3:08 PM, Nurse E stated he/she recalled the resident was not agitated prior to him/her being placed in his/her recliner on 2/7/16 by staff. Nurse E further verified the resident was care planned not to be left unattended in his/her room. Nurse E recalled the aide being new, and he/she had not instructed the new aide not to place the resident in the recliner. On 4/6/16 at 8:25 AM, Administrative Nurse G verified the resident's care plan instructed staff to leave the resident in a supervised area when out of bed. At 11:35 AM, Administrative Nurse G stated when the resident was in his/her recliner in his/her room, it was considered a supervised area because staff walk down the hall and observe the resident. The facility's 5/2015 Fall Prevention policy informed staff interventions are implemented to minimize the resident's risk of falls based on the resident assessment and individual needs. The policy directed staff to provide communication to all direct care staff and document daily. The facility failed to implement Resident #5's plan of care, to not leave Resident #5 unattended in his/her room, and he/she fell a second time from the recliner and sustained a laceration which required sutures.