Every finding on record at Logan County Senior Living Inc

Based on observation, interviews, and record review, the facility failed to provide the required supervision to prevent Resident (R) 1, a cognitively impaired resident at risk of elopement and a high risk for falls, from exiting the facility without staff knowledge or supervision. The facility also failed to ensure staff performed the required 15-30 minute safety checks; therefore, staff did not identify the resident was out of the facility for one hour and 15 minutes. On 06/06/2026 at 10:00 AM, R1 exited the facility via the North door, which was left ajar by a staff member. At 11:15 AM, Certified Nurse Aide (CNA) M alerted staff that R1 was missing. Staff located R1 lying face down in the grass of the facility at 11:45 AM, one hour and 45 minutes after the resident eloped. The weather at the time was 77-81 degrees Fahrenheit (F) with wind speeds up to 16 miles per hour (mph). The facility was in a residential area with posted speed limits of up to 30 mph on the surrounding streets. The facility's failure to provide adequate supervision and the necessary safety checks placed R1 in immediate jeopardy. Findings Included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), severe dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, and unsteadiness on feet. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) interview could not be completed. The MDS documented R1 had short and long-term memory deficits and had severely impaired cognition. The MDS documented R1 was dependent on staff for most of her activities of daily living (ADLs) except bed mobility and ambulation, which were supervision/touching assist. The MDS documented R1 had behavioral symptoms not directed towards others during the look-back period and wandered the facility, which intruded on the privacy of others and put R1 at risk. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/26/2026, documented R1 had a decline in eating, oral hygiene, toilet hygiene, bathing, dressing, and personal hygiene. The CAA documented R1 had potential for unmet needs, was unaware of her surroundings, and had poor safety awareness related to her diagnosis of severe dementia. The Functional Abilities CAA, dated 05/26/2026, documented R1 frequently wandered into other residents' rooms, handling and picking up objects that did not belong to her, and tried to open doors. She displayed pacing, exit seeking, and repetitive movements during the look-back period. The CAA documented R1 wore a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) due to being a high risk for elopement. The Fall CAA, dated 05/26/2026, documented R1 had the potential for falls with injury related to her diagnosis of Alzheimer's disease, balance problems, muscle weakness, and pacing/wandering. Staff were to minimize R1's risk for falls. R1's Care Plan, documented R1 was a high risk for falls and needed a safe environment. An intervention dated 06/04/2026 directed staff to perform 15-minute safety checks on R1 due to a fall. R1's Care Plan documented R1 had behaviors of wandering, packing, attempting to follow staff leaving the facility, or entering other residents' rooms and taking items and becoming aggressive with staff when they attempted to redirect her. An intervention dated 09/10/2024 documented R1 had a WanderGuard on her left ankle. An intervention dated 03/18/2026 documented R1 was a high risk for elopement and directed staff to distract R1 with pleasant diversions, structured activities, food, conversation, television, or a book. An intervention dated 05/20/2026 documented the resident was on 30-minute safety checks. R1's Wandering Risk Score, dated 05/26/2026, documented R1 had a risk score of 20.0, which indicated a high risk for wandering. R1's Fall Risk Score dated 06/04/2026, documented R1 had a risk score of 17.0, which indicated R1 was at high risk for falls. The Fall Progress Note dated 06/06/2026, documented R1 had a fall outside the facility at 11:45 AM on the north side of the facility. Staff found R1 lying in the grass, and R1 did not recall the events which led to the fall. The fall was unwitnessed, neurological checks were initiated, and R1 could move all of her extremities. Staff assisted R1 into a wheelchair and took her to the dining room. The factors which contributed to the fall were identified as an unfamiliar area and uneven surfaces. CNA N's notarized Witness Statement, dated 06/06/2026, documented at about 09:55 AM, CNA N witnessed R1 in the beauty shop resting with her eyes closed in the beauty chair. CNA N documented she took a break. At 11:15 AM, CNA M came to CNA N's assigned hall and asked for assistance locating R1. All staff looked for R1 in all the rooms, closets, storage rooms, and pantry. When CNA N walked to the dining room, another resident in the dining room stated R1 went out the north dining room door. CNA N stated she grabbed the key to the dining room door and immediately unlocked it. CNA N found R1 lying face down in the grass just outside the building. CNA N stated she called for help at 11:45 AM. CNA M's notarized Witness Statement, dated 06/06/2026, documented CNA M last saw R1 at approximately 09:55 AM. CNA M stated she then went down the other hall to assist with toileting another resident. CNA M headed back down her hall and assisted two other residents to get up and ready for lunch. CNA M stated she assisted another resident with toileting and ambulation then she walked back down the hall looking for R1 to get her to lunch. CNA M stated she looked in several rooms, the bathroom, and other areas, and then asked the other CNAs and nurse for assistance in finding R1. Licensed Nurse (LN) G's notarized Witness Statement, dated 06/06/2026, documented LN G witnessed R1 entered the nurse's station at 09:55 AM, then R1 wandered into the dining room. At 11:15 AM, CNA M notified LN G she could not find R1. Staff immediately began searching the facility. LN G stated she checked each room, bathrooms, and locked doors. Staff were unable to locate R1. LN G stated, I never heard the WanderGuard alarm go off, and the only door without one is the dining room and kitchen. CNA N opened the dining room door and found R1 lying face down in the grass on the north side of the building at 11:45 AM. The facility's incident report, dated 06/15/2026, documented at approximately 11:30 AM on 06/06/2026, staff noted R1 was not present in the dining room for the noon meal. Staff checked R1's room and common areas without locating her. LN G initiated a facility search and subsequently located R1 lying face down in the grass outside the facility, approximately six to eight feet from the exit door. R1 was assessed immediately upon discovery, and no apparent injuries were identified. R1 was unable to communicate effectively due to her severe cognitive impairment. Neurological checks were initiated and were normal per R1's baseline. The weather conditions at the time R1 was located were approximately 77 degrees (Fahrenheit) in the area with partial sun. R1 wore a black short-sleeved shirt, purple pants, and gripper socks. Skin assessment monitoring was initiated due to the environmental exposure. Assessments continued to not indicate any injury or skin concerns. The investigation revealed R1 exited through the unalarmed north side dining room door that had not been fully latched after a staff member accessed the supply shed. R1 was outside for an unknown period at the time of discovery. LN G was directed to review surveillance footage and complete protocol documentation. Camera review later determined that R1 exited the facility at approximately 10:00 AM, which indicated R1 had been outside and unsupervised for approximately ninety minutes. At the time of the resident's exit, one CNA and two dietary staff members were on break. On 06/16/2026 at 10:00 AM, observation revealed the north door was locked, and an exit alarm was located on the left side of the door. LN G unlocked the north door, and the door alarm sounded. Outside the door, there was a concrete sidewalk leading to the storage area. The concrete was raised two inches off the ground. To the west of the exit was an air conditioning unit, and to the west of the sidewalk, three feet from the wall of the facility, into the grass area were rocks. To the east of the exit was a grassy area with a big tree that shaded the northeast side of the building. Beyond the tree is the sidewalk and then a four-inch curb before the street. LN G pointed to the area where R1 was found, approximately eight feet off the sidewalk in the grass. The facility was in a residential area with streets surrounding with posted speeds of up to 30 mph. On 06/16/2026 at 10:30 AM, observation revealed R1 lay in bed with her eyes closed and the lights off. On 06/16/2026 at 10:30 AM, LN G stated R1 was a known wanderer and an exit seeker. LN G stated CNA M did not know R1 was missing until 11:15 AM when CNA M came to other staff and asked for help finding R1. LN G stated R1 was on hospice, and since the fall outside, R1's health status had declined. LN G stated CNA M did not perform the 15-minute safety checks per her assignment. On 06/16/2026 at 01:30 PM, Administrative Nurse D stated CNA M had failed to perform the 15-minute safety checks to ensure R1's safety on 06/06/2026. Administrative Nurse D stated CNA M admitted she had not informed other staff she was not going to be able to complete the safety checks for R1, so other staff could take over the checks. The facility's Wandering and Elopements Policy, revised March 2019, documented the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. On 06/16/2026 at 02:00 PM, Administrative Nurse D was provided the Immediate Jeopardy [IJ] Template and was notified of the facility's failure to provide adequate supervision for R1, and placed R1 in IJ. The facility completed all corrective actions by 06/06/2026, prior to the onsite survey.The corrective actions included: Education with staff to ensure that all doors were latched and locked when leaving an area. Education to ensure all staff performed safety checks as assigned, Elopement education, and immediate verbal education to the CNA M of the importance of safety checks. The north dining room door was evaluated for mechanical issues, and an alarm was placed on the door to alert staff when the door opens. Due to the corrective actions being completed prior to the onsite survey, the deficient practice was deemed past noncompliance and remained at the scope and severity of J (isolated, immediate jeopardy).

Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 was free from verbal abuse. Findings included:R2's Electronic Medical Record (EMR) documented she had diagnoses of dementia, traumatic brain injury (TBI-an injury to the brain caused by external forces), major depressive disorder, arthritis, and atrial fibrillation (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS), dated 05/15/2026, documented R2 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R2 had functional impairment in both her bilateral upper and lower extremities and she was dependent on staff for transfer, bed mobility, dressing, and mobility in a wheelchair. The MDS documented R2 had verbal behaviors directed towards others one to three days during the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/05/2026, documented R2 had the potential for unmet needs, difficulty focusing on tasks and conversations, and mood/behavioral changes related to severe dementia. The Functional Abilities CAA, dated 05/05/2026, documented R2 had the potential for further mobility decline, contractures, falls, and skin breakdown due to arthritis in her bilateral upper shoulders and bilateral lower extremities. The Behavioral Symptoms CAA, dated 05/05/2026, documented R2 had behaviors which could affect her care outcomes and the environment related to R2 refusing care and screaming at others. R2's Care Plan, initiated 04/09/2022, documented R2 had the potential for behavioral problems (being verbally aggressive, confusion, threatening others). The care plan directed staff to provide opportunities for positive interactions, positive attention, and to anticipate and meet R2's needs. The care plan directed staff to explain all procedures to R2 before starting and allow R2 a few minutes to adjust to changes. The care plan documented R2 had limited physical mobility in her upper and lower extremities due to extensive arthritis and directed staff to use a full body lift for transfers. The Behavior Note, dated 04/14/2026, documented R2 yelled out at staff and cussed at staff about taking a bath late. Licensed Nurse (LN) H's notarized Witness Statement documented LN G heard R2 yell at CNA P to Quit. LN H stepped into R2's room and observed CNA P getting R2 ready to transfer to the bath chair to take a bath. R2 calmed down when LN H stepped into the room. LN H left the room. R2 then started yelling again. LN H stepped back into the room, and R2 stopped yelling and stated her arm hurt. CNA P stated she had not touched R2's arm. CNA P followed LN H out of R2's room. LN G stated she told CNA P to get CNA O to help her transfer R2 into the bath chair. CNA O and CNA P took R2 to the bathhouse at 10:00 PM LN H noted she could hear R2 yelling in the bathhouse. LN G stepped into the bathhouse to see what was going on. R2 yelled at CNA P to quit and get out of the bathhouse. CNA O finished the bath while CNA P stepped outside for a breather. At 10:50 PM, CNA O notified LN H that CNA P had yelled at R2 and called R2 a [expletive]. LN H contacted Administrative Nurse D and was instructed to send CNA P home. CNA P had no more contact with any other residents in the building. CNA O's Notarized Witness Statement, dated 04/14/26, documented CNA O went to assist CNA P with transferring R2 from her bed to the shower chair. R2 yelled at CNA P, No, leave me alone. I don't want a bath. It is too late for a bath. I will do it tomorrow. CNA P told R2 she only got two baths a week, so she was going to take a bath. CNA O stated she asked R2 if anything was wrong, and R2 said her arm hurt. CNA O stated she and CNA P got R2 up to the shower chair, and R2 yelled all the way to the bathhouse. CNA O stated about five minutes later, CNA P called on the radio and stated she wanted someone in the bathhouse with her, as R2 was screaming and saying Ouch. CNA O went into the bathhouse, and R2 refused to raise her arms for CNA P to clean her underarms. CNA O noted she asked R2 if she could raise her arms so she could be washed. R2 stated, I will as soon as she leaves. CNA P looked at R2 and said, Oh, I'm the [expletive] problem? I will leave. She can deal with you, and threw the washcloth and left. CNA O stated she finished R2's bath. CNA O dried, lotioned, and dressed R2. CNA P came back into the bathhouse to assist with getting the lift sling under R2. CNA P bent down to pull the sling between R2's legs. R2 grabbed CNA P's hair. CNA O got R2 to let go of CNA P's hair. CNA O noted as they lifted R2 in the air with the lift, R2 stated CNA P should have given herself a bath because her private parts probably stink. CNA P laughed and said, What's your smell like? Poo nanny? Nope, you are not going to get any dick in here. R2 then told CNA P to get the [expletive] out of her room and started screaming for her mom. CNA P told R2, Your mom is not coming. She is dead, and you are in a nursing home. R2 told CNA P she hoped she would come down here and deal with you. CNA P replied, I hope she does and takes you with her. I am tired of your [expletive]. R2 told CNA P to just leave her alone and get out. CNA P called R2 [expletive]. On 06/16/2026, at 09:45 AM, observation revealed a CNA assisting R2 back to her room after breakfast. R2 visited calmly with the CNA and was joking with her. On 6/16/2026 at 09:50 AM, R2 had no memory of the situation which happened with CNA P. On 06/16/2026 at 11:00 AM, CNA O stated she did not know what to do when CNA P began to act as she had, so she just stayed in the room to make sure R2 was safe, and then afterwards went and told LN H what had happened. On 06/16/2026 at 01:30 PM, Administrative Nurse D stated when the incident was reported to her by LN H, it was reported CNA P had called R2 a [expletive]. Administrative Nurse D stated after digging into what happened that night and finding out what CNA P had said to R2, she was appalled. She could not believe anyone would talk to a resident in that manner. Administrative Nurse D stated she had been proud of LN H for stepping in and telling CNA P to take a break and getting CNA O to take over for her. Administrative Nurse D stated she did not understand why CNA P came back in to continue to assist R2; it was almost like CNA P was looking for a fight.

The facility had a census of 25 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistance organism which employ targeted gown and glove use during high contact care) were used for two residents with urinary catheters (a tube inserted into the bladder to drain the urine into a collection bag), Resident (R)3 and R6 Findings included: - The Electronic Medical Record (EMR) for R3 documented a diagnosis of neuromuscular dysfunctions of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying).The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. R3 was dependent upon staff assistance for toileting hygiene, transfers, and mobility. The MDS documented R3 had a urinary catheter.The Quarterly MDS, dated 11/18/25, documented R3 had had a BIMS of 7. R3 was dependent upon staff assistance for toileting hygiene and transfers. The MDS further documented R3 had a urinary catheter.The Care Plan, dated 11/14/25, initiated on 12/11/24, documented R3 was at risk of multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) transmission through direct contact related to the indwelling medical device. The care plan directed staff to utilize gloves and gowns before performing any high contact care activities. This would include bathing, transferring residents from one position to another, while providing hygiene, changing briefs or assisting with toileting. The care plan further directed staff to use gowns and gloves when caring for an indwelling medical device, like a urinary catheter, and wound care. The care plan further directed staff to communication tools to explain the necessity and procedures of EBP effectively.On 02/10/26 at 08:55 AM, observation revealed a small red paper by R3's door that stated she was on EBP precautions and directed staff when to wear gowns and gloves. Certified Nurse Aide (CNA) M and CNA O donned clean gloves but did not put on a gown. CNA removed R3's incontinence brief and used foam cleanser to perform incontinence care. CNA O took R3's catheter bag and hooked it onto her pocket of her shirt while R3 rolled onto her right side so that CNA M could finish personal cares. The total mechanical lift sling was placed under R3, and they attached it to the lift to transfer her into her wheelchair. When questioned, CNA M stated she did not realize she needed to wear a gown unless she was emptying the catheter bag.On 02/10/26 at 09:49 AM, Administrative Nurse D stated they should have worn a gown while providing care and she had recently provided reeducation to staff regarding EBP.The facility's Enhanced Barrier Precautions policy, dated 12/24, directed staff to wear gloves and gown during high contact resident care activities. The policy further documented, staff are trained prior to caring for residents on EBP's and signs are placed on the door or wall outside the resident's room which communicate the type of precautions and personal protective equipment (PPE-gowns, face shields and/or eyeglasses/goggles, and gloves).- The Electronic Medical Record (EMR) for R6 documented a diagnosis of neuromuscular dysfunctions of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying.The admission Minimum Data Set (MDS), dated [DATE], documented R6 had a BIMS (Brief Interview for Mental Status Score of 11, which indicated moderately impaired decision-making skills. R6 was dependent upon staff assistance for toileting hygiene, showers, lower body dressing, transfers, and mobility. The MDS further documented R6 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag).The Quarterly MDS, dated 01/27/26, documented R6 had a BIMS score of 11, which indicated moderately impaired decision-making skills. R6 was dependent upon staff assistance for dressing, showers, toileting, and hygiene. The MDS further documented R6 had a urinary catheter and a urinary tract infection (UTI-an infection in any part of the urinary system).The Care Plan, dated 02/04/26, initiated on 07/29/25, documented R6 was at risk of multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) transmission through direct contact related to the urinary catheter. The care plan directed staff to utilize gloves and gowns before performing any high contact care activities. This would include bathing, transferring residents from one position to another, while providing hygiene, changing briefs or assisting with toileting. The care plan further directed staff to use gowns and gloves when caring for an indwelling medical device, like a urinary catheter, and wound care. The care plan further directed staff to communication tools to explain the necessity and procedures of EBP effectively. Change gowns and gloves before caring for another resident to prevent cross contamination. The care plan directed staff to ensure signage explaining EBP's is clear and visible throughout the facility. Implement enhanced cleaning protocols for rooms and equipment of residents requiring EBPs and informing residents and families about EBPs through welcome packets, meetings and educational materials. The care plan directed staff to monitor as needed and documentation of residents' conditions, focusing on infection signs and PPE effectiveness.On 02/10/26 at 08:45 AM, observation revealed R6's door did not have signage stating he was on EBP but had a three-drawer storage cart with gowns and gloves. Certified Nurse Aide (CNA) N, CNA P, and Licensed Nurse (LN) G went into R6's room and donned clean gloves but did not put gowns on. CNA P removed R6's attend, performed catheter care, had him roll to the left and used foam cleanser to provide personal cares. CNA P changed her gloves and applied ointment to his buttocks. CNA P placed a clean attend incontinence brief on him. LN G removed a small dressing from his left below the knee amputation, changed gloves, then went to get a small dressing. When questioned, she stated she did not put a gown on because she did not work with his catheter, she was just changing the small bandage to a scabbed area to the amputation site.On 02/10/26 at 09:49 AM, Administrative Nurse D stated the CNAs, and the Nurse should have worn a gown since they were providing high contact care. Administrative Nurse D further stated, she had recently provided education to staff about EBP and that she would talk to them again.On 02/10/26 at 11:42 AM, CNA N and CNA P went into R6's room, put gloves on but did not put on a gown. R6 stated, he was ready to get up and wanted in his electric wheelchair. CNA N stated, she was confused about when she should wear EBP and wanted clarification. This surveyor directed her to talk to the Director of Nursing, who is also the Infection Preventionist about any concerns they have and when they should wear PPE. Further observation revealed CNA P took the catheter bag from the side of the bed and laid it on his bed so that they could transfer him. CNA N had R6 roll to his left side and placed the full mechanical lift sling under him, and attached the sling to the lift, and transferred him into his electric chair.On 02/10/26 at 11:55 AM, Administrative Nurse D asked if they had been providing catheter care and this surveyor reminded her that the care plan directed staff to wear PPE while transferring the resident from his bed to the chair. Administrative Nurse D stated, staff should have worn gowns as well as gloves.The facility's Enhanced Barrier Precautions policy, dated 12/24, directed staff to wear gloves and gown during high contact resident care activities. The policy further documented, staff are trained prior to caring for residents on EBP's and signs are placed on the door or wall outside the resident's room which communicate the type of precautions and personal protective equipment (PPE-gowns, face shields and/or eyeglasses/goggles, and gloves).

The facility had a census of 25 residents. The sample included 12 residents, with five reviewed for hospitalization. Based on interview, and record review, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) for four residents, (R) 1, R6, R7, R12, and R13, and failed to provide two residents, R6 and R12, with written information regarding the facility's bed hold policy when they were transferred to the hospital.Findings included- The Nurse's Note, dated 11/01/25 at 03:21 AM, documented R1 admitted to the hospital for possible pulmonary embolism (occurs when a clump of material, most often a blood clot, gets stuck in an artery in the lungs, and blocks the flow of blood). R1's clinical record lacked evidence of the ombudsman notification for the 11/01/26 hospital transfer. The Nurse's Note dated 12/10/25 at 01:54 AM, documented R6 admitted to the hospital for pneumonia. R6's clinical record lacked evidence that the family received the bed hold notification or that the Ombudsman was notified of the hospital transfer. The Nurse's Note, dated 09/11/25 at 05:11 PM, documented R7 admitted to the hospital for pulmonary edema. The Nurse's Note, dated 01/03/26 at 09:58 PM, documented R7 admitted to the hospital for acute pulmonary edema. R7's clinical record lacked evidence of the ombudsman notification for R7's 09/11/25 and 01/03/26 hospital transfer. R12's Nurse's Note dated 12/19/25 at 09:02 AM documented R12 had chills, was not feeling well, lung sounds were diminished and had slurred speech. Staff received an order to send R12 to the emergency room and R12 left the facility with staff in the facility van. The Nurse's Notes dated 12/19/25 at 01:30 PM, documented R12 admitted to the hospital acute care with diagnosis of bilateral pneumonia (type of bacterial infection) and low blood pressure. R12's clinical record lacked a bed hold policy and a resident or resident representative signature. R12's clinical record lacked documentation staff notified the Long-Term Care Ombudsman (LTCO) of R12's discharge from the facility to the hospital. R13's Nurse's Note date 09/19/25 at 11:35 PM documented R13 had severe abdominal pain on her right side, elevated blood pressure and rectal bleeding. An order was received to send R13 to the emergency room, R13 left the facility with staff and transported in the facility van. The Nurse's Notes dated 09/20/25 at 04:30 AM, documented R13 admitted to the hospital acute care with diagnosis of urinary tract infection (UTI-an infection in any part of the urinary system,) colitis (inflammation of the large intestine, characterized by severe diarrhea and ulceration of the large intestine) and elevated lactate (substance produced in the body when oxygen levels ae low or during intense physical activity) levels. R13's clinical record lacked documentation staff notified the Long-Term Care Ombudsman (LTCO) of R13's discharge from the facility to the hospital. On 02/10/26 at 11:11 AM, Social Service X stated she had not notified the ombudsman of the hospital transfers. On 02/11/26 at 11:35 AM, Administrative Staff A stated the ombudsman should be notified when a resident was discharged from the facility and was unaware that it had not been done. The facility's Transfer or Discharge Noise, policy, dated March 2025, documented residents (or residents' representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language they understand. A copy of the notice must be sent to the Office of the State-Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

The facility had a census of 25 residents. The sample included 12 residents, with five residents reviewed for immunizations, Resident (R) 2, R15, R16, and R27, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer and/or obtain an informed declination or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). Findings Included: - Review of the clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20 for the following residents. Review of R2's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R2 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R15's EMR revealed the resident admitted to the facility on [DATE]. R15 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R16's EMR revealed the resident admitted to the facility on [DATE]. R16 had not been offered or received a pneumococcal PVC20 vaccine since admission. Review of R27's EMR revealed the resident admitted to the facility on [DATE]. R27 had not been offered or received a pneumococcal PCV20vaccine since admission. On 02/11/26 at 09:30AM, Administrative Nurse D stated residents were offered pneumonia vaccines on admission and as indicated. Administrative Nurse D said the resident or resident representative would sign a consent or declination for receiving the vaccine. Administrative Nurse D verified that every resident in the building was not reviewed to determine if they were eligible to receive the PVC20 vaccine. Administrative Nurse D verified they did not have a definitive system in place to determine who was eligible, if they were eligible, if they had been offered or declined the vaccinations, and verified this was something they had recently been working on. The facility's Pneumococcal Vaccine policy, dated 10/2019, documented all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, all residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessment of pneumococcal vaccination status would be conducted within five working days of the resident's admission if not conducted prior to admission. Before receiving the pneumococcal vaccine, the resident or legal representative would receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Information would be provided in the current vaccine information statement (VIN). Provision of the education would be documented in the resident's medical record. Pneumococcal vaccines would be administered to residents per the facility's physician-approved pneumococcal vaccination protocol. Residents/Representatives have the right to refuse vaccinations. If refused, appropriate entries would be documented in each resident's medical record indicating the date of the refusal or the pneumococcal vaccination. For residents who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination would be documented in the resident's medical record. Administration of the pneumococcal vaccines or vaccinations would be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

The facility identified a census of 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to prevent staff from physically forcing Resident (R) 1 to take her medications when she refused to take her medications. On 12/15/24 at approximately 07:20 AM, Licensed Nurse (LN) G attempted to administer medications to R1. R1 swatted LN G's hand away indicating R1 did not want to take the medications. LN G pushed R1's hands away into her lap, removed R1's coffee cup asR1 attempted to grab it and replaced it with a cup of water. LN G then held R1's shoulders and attempted to spoon the medications into R1's mouth. R1 spit out the medications and LN G placed the medications that were spit out back on the spoon and attempted to administer the medications again. LN G grabbed the back of R1's head, pushed her head forward, lifted the water cup up to R1's mouth, and poured water into R1's mouth. R1 attempted to spit the medications back out. Certified Nurse's Aide (CNA) M intervened, sat beside R1, and encouraged R1 to take her medications. R1 accepted direction from CNA M and swallowed her medications. Based on the reasonable person concept, this deficient practice resulted in feelings of fear for R1 and placed R1 at risk for further psychosocial harm, intimidation, and neglect. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and need for assistance with personal care. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R1 required supervision or touch assistance for oral hygiene, toileting hygiene, dressing, and personal hygiene The MDS documented R1 was independent with ambulation, bed mobility, and transfers. The MDS documented R1 had a mood severity score of 15, which indicated moderately severe depression. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/10/24, documented R1 previously lived with her son, had a BIMS score of 6, which indicated severely impaired cognition, and only sometimes understood others. The Functional Abilities CAA, dated 09/10/24, documented R1 was unsteady on her feet, was incontinent of urine, and required some assistance with her activities of daily living (ADL). R1's Care Plan documented R1 had a communication problem with the potential for unmet needs due to miscommunication and confusion. The care plan directed staff to anticipate and meet R1's needs, allow R1 adequate time to respond, not rush R1, and use simple, brief, consistent cues, and words (09/18/24). The care plan documented R1 had the potential for sadness, a sense of hopelessness, and directed staff to allow R1 time to answer questions, verbalize feelings and fears, and encourage participation from R1, who depended on others to make her own decisions (09/18/24). CNA N's Notarized Witness Statement, dated 12/19/24, documented CNA N was in the dining room assisting another resident. LN G was trying to get R1 to take her pills. CNA M stood beside R1. R1 did not want to take her pills. LN G got the pills in R1's mouth and put her hand behind her head and poured water in her mouth so R1 would take her pills. CNA M told LN G she would sit with R1 and make sure R1 got her pills down. LN G walked away. CNA M and CNA N looked at each other and CNA N reported the incident to Administrative Nurse D at 7:38 AM over the phone. Administrative Nurse D's Notarized Witness Statement, dated 12/19/24, documented LN G told Administrative Nurse D R1 usually takes her meds for me. I was just trying to get her to take them. Administrative Nurse D documented LN G stated this after LN G was told she was suspended pending investigation due to a report from other employees who were in the dining room area and witnessed LN G grab R1's neck when LN G tried to administer medications to R1; even after R1 swatted the meds away. CNA M's Notarized Witness Statement, dated 12/20/24, documented CNA M entered the dining room and witnessed LN G trying to force pills into R1's mouth. LN G tipped R1's head back and tried to pour water into R1's mouth. CNA M stated she sat down next to R1 and offered to help. Once R1 swallowed her pills, CNA M and LN G walked away. CNA M and CNA N talked about the incident and CNA N stated she would call and report the incident to Administrative Nurse D. The Facility Incident Report, dated 12/20/24, documented on 12/15/24 at 07:38 AM, Administrative Nurse D received a phone call from CNA N who stated she was in the dining room and LN G was giving medications. LN G went to R1 to give her meds and LN G put her hand on the back of R1's head and tipped her head back to get her to take them around 07:24 AM. Administrative Nurse D notified Administrative Staff A. Administrative Staff A and Administrative Nurse D came to the facility and reviewed the camera footage. Upon review, R1 sat in a dining room chair at the dining room table eating her breakfast meal. LN G approached R1 to administer R1's medications. R1 swatted or pushed R1's hands away which indicated R1 did not want to take the medications. LN G responded by pushing R1's hands down to her lap and removed the coffee cup R1 attempted to grab and replaced it with a cup of water. LN G then used her left arm to hold R1's shoulder and placed the medications into R1's mouth with a spoon. R1 attempted to spit the medications out. LN G took the medications R1 spit out, placed them back on the spoon, and administered them again. LN G grabbed the back of R1's head, pushed her head forward, lifted the water cup to R1's mouth, and poured water into R1's mouth. R1 again attempted to spit out the medications. CNA M approached and sat next to R1 and encouraged R1 to take a drink of water. R1 complied, drank the water, and swallowed her medications. LN G stepped back, monitored R1 for signs of swallowing, and observed LN G resume eating. LN G was placed on immediate suspension pending investigation. LN G's behavior demonstrated frustration and a failure to respect R1's verbal and physical refusal to take medications. LN G violated appropriate care protocols and failed to adhere to resident rights by using physical force to administer medications. On 02/17/25 at 10:00 AM, R1 laid in bed watching television. R1 was unable to have a conversation or answer questions. On 02/17/25 at 11:30 AM, R1 wandered into the activity room and said, I need to go to bed. R1 pulled out a chair, sat down, And was unable to make conversation. R1 stated again, I need to go to bed, got up from the table, and left the room. On 02/17/25 at 10:15 AM, CNA N stated R1 did not want to take her medications so LN G forced them into R1's mouth and poured water into R1's mouth. CNA N stated it was unusual for R1 to react like that, as she normally did not react to much of anything. On 02/17/25 at 12:00 PM, Administrative Nurse D stated she expected facility staff not to force residents to do anything they did not want to. She expected the facility staff to honor resident wishes and resident rights. Administrative Nurse D stated all education was completed with all current staff at the facility by 12/22/24. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Policy, revised April 2021, documented residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical and chemical restraint not required to treat the resident's symptoms. The facility-wide commitment and resource allocation to support the following objectives: Protect the residents from abuse, neglect, exploitation and misappropriation of resident property, develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents, theft, exploitation or misappropriation of resident property, ensure adequate staffing and oversight/support to prevent burnout, stressful work situations, and high turnover rates, conduct employee background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of resident property by a court of law, had a finding entered into the state registry concerning abuse, neglect, exploitation or mistreatment of residents, establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems, provide staff orientation and training programs that include topics such as abuse prevention, identification and reporting, stress management, and handling verbally or physically aggressive resident behavior, implement measure to address factors that may lead to abusive situations, identify all possible incidents of abuse and neglect, investigate and report any allegation within timeframes required by federal requirements, protect residents from any further harm during the investigation, establish and implement QAPI review for analysis of reports, allegations or findings of abuse, neglect, and mistreatment of residents, and involve the resident council in monitoring and evaluating the facility's abuse prevention program. The facility failed to prevent staff from physically forcing R1 to take her medications. Based on the reasonable person concept, this deficient practice resulted in feelings of fear for R1 and placed R1 at risk for further psychosocial harm, intimidation, and neglect. The facility completed corrective actions to correct the deficit practice, which were completed by 12/22/24. The actions included: immediate steps were taken to ensure R1's safety following the incident; LN G was immediately suspended pending investigation; all notifications were completed to Administrative Staff A, Administrative Nurse D, R1's responsible party, R1's primary care provider, the Ombudsman, and KDADS; Police were notified and a case was opened; a thorough investigation was conducted including staff interviews, resident assessments and a review of incident details; all staff were re-educated on the Abuse, Neglect, and Exploitation policy and procedures emphasizing the importance of immediate reporting and adherence to abuse prevention protocols; staff educations and retraining on abuse prevention, proper redirection techniques and resident rights to reinforce care standards and ensure compliance; twice daily skin assessments were implemented for R1 to monitor for potential injuries with no concerns noted throughout the monitoring period; and a report was made to the KSBN regarding the investigation and findings involving LN G. Since all corrective actions were completed before the onsite survey, the deficient practice was deemed past noncompliance and remained at G to represent the psychosocial harm to R1.

The facility had a census of 27 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on following days: 01/03/23, 01/13/23, 01/14/23, 01/16/23, 01/19/23, 01/26/23, 01/27/23, 01/29/23. 02/02/23, 02/06/23, 02/12/23, 02/14/23, 02/16/23, 02/23/23, 02/25/23, 02/26/23, 03/12/23, 03/26/23. The PBJ report for FY 2023 Quarter 3 indicated no licensed nurse coverage on 04/09/23, 04/21/23, 05/04/23, 05/06/23, 05/20/23, 05/21/23, 05/29/23, 06/10/23 and 06/11/23. The PBJ report for FY 2023 Quarter 4 indicated no licensed nurse coverage on 08/13/23, 08/20/23, 08/26/23, 08/27/23, 08/28/23, 09/02/23, 09/03/23, 09/17/23, 09/22/23, 09/23/23, 09/24/23, and 09/30/23. Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 04/02/24 at 11:30 AM, Administrative Staff A verified the facility submitted accurate nursing hour data for the PBJ, however the corporate staff that would input the data failed to document the correct hours, and the corporation has a new employee that is currently submitting the data. She verified the nurse clock in hours and nurse coverage on all the days. The facility's Staffing, Sufficient and Competent policy, dated August 2022 documented the facility provides enough nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with residents' care plans and the facility assessment. License nurses and certified assistants are available 24 hours a day, 7 days a week to provide competent resident care and services . A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (&) days a week. RN's may be scheduled more than 8 hours depending on the acuity of needs of the residents. Licensed nurses are required to supervise nurse's aide and nursing assistants and are scheduled in such a way that permits adequate time to do so. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 27 residents. The sample included 13 residents. Based on record review and interview, the facility failed to provide Resident (R)5, R19, and R79 or their representative, the accurate Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions about their skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. A review of the ABN provided to R5 revealed that R5 received form CMS-R-131 instead of CMS Form 10055. The resident's skilled services ended on 03/02/24. A review of the ABN provided to R19 revealed that R19 received form CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 12/14/23. A review of the ABN provided to R79 revealed that R79 received form CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 02/02/24. On 04/02/24 at 01:45 PM, Social Services X verified she provided R5, R19, and R79, and/or their representative, the CMS-R-131 form, and failed to provide the 10055 forms. On 04/02/24 at 01:55 PM, Administrative Staff A verified the facility provided the CMS-R-131 form to R5, R19, and R79, and/or their representative, and verified the facility was previously owned by the local hospital and was bought out by a new corporation. Administrative Staff A said the facility had only been Medicare certified for a few years and had been using that form but also said the facility would switch to the correct form. The Advanced Beneficiary and Medicare Non-Coverage Notices policy, dated September 2022, documented that residents were informed in advance when changes would occur to their bills. The facility issues the Skilled Nursing Facility Advance Beneficiary Notices (CMS form 10055). The facility failed to provide R5, R19, and R79 or their representatives, the correct 10055 form which included an estimated cost of continued services when discharged from skilled care. This placed the residents at risk of uninformed decisions about their services and the continuation of their skilled services.

The facility had a census of 27 residents. The sample included 13, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R)22, who had dementia and behaviors. This placed the resident at risk for abuse and decreased quality of life. Finding included: - R22's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbance, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), and pain. The Admission Minimum Data Set (MDS), dated [DATE], documented R22 had moderately impaired cognition. R22 required set-up assistance with toileting, eating, dressing, and personal hygiene, and was independent with mobility and transfers. The assessment further documented R22 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and had no behaviors. The Quarterly MDS, dated [DATE], documented R22 had severely impaired cognition. R22 required set-up assistance with personal hygiene and was independent with toileting, transfers, and mobility. The assessment further documented R22 received antipsychotic medications and had no behaviors. R22's Care Plan, dated 03/07/24 and initiated on 11/16/23, directed staff to administer medications as ordered, and communicate R22's capabilities with the resident, family, and caregivers. The plan directed staff to cue, reorient, and supervise as needed, and document any changes in R22's cognitive function. The plan lacked an individualized dementia treatment plan or guidance for staff when R22 had behaviors. The Physician's Order, dated 11/16/23, directed staff to administer Risperdal (an antipsychotic medication), 0.5 milligrams (mg) by mouth daily for the diagnosis of psychosis (any major mental disorder characterized by gross impairment in perception). This medication was discontinued on 02/14/24. The Physician's Order, dated 11/22/23, directed staff to monitor for behaviors. The Physician's Order, dated 01/18/24, directed staff to contact t Service to evaluate and treat for psychiatric and psychological needs. The Physician's Order, dated 02/17/24, directed staff to decrease the Risperdal medication to 0.25 mg daily for seven days and then discontinue. The Physician's Order, dated 02/17/24, directed staff to administer Zoloft (an antidepressant medication), 25 mg for seven days then increase to 50 mg for the diagnosis of depression. The Physician's Order, dated 02/24/24, directed staff to administer Depakote (an anticonvulsant also used to treat mood disorders), 125 mg twice per day for the diagnosis of depression with psychotic symptoms. The Nurse's Note, dated 12/29/23 at 08:57 AM, documented R22 smacked a Certified Nurse Aide's (CNA) buttocks and made an inappropriate remark about the size of her buttocks. The Nurse's Note, dated 12/30/23 at 12:00 PM, documented R22 was verbally aggressive with another resident after a resident made a remark about R22's wife. The kitchen staff thought the verbal altercation might come to blows. The Nurse's Note, dated 03/03/34 at 06:22 PM, documented R22 slapped a CNA on the buttocks after she served his drinks and turned away. The note further documented the CNA asked R22 not to do that again and he asked her if she wanted a kiss as a reward for the drinks; the staff stated No and walked away. On 04/002/24 at 08:00 AM, observation revealed R22 at the dining table waiting for breakfast. R22 did not exhibit any behaviors. On 04/04/24 at 08:40 AM, Certified Medication Aide (CMA) R stated R22 yelled shut up at another resident who was loud but also said R22 had no other behaviors towards her. CNA R further stated if R22 had any behaviors toward her, she would tell him that it was not appropriate and tell the charge nurse. On 04/04/24 at 09:00 AM, Licensed Nurse (LN) G stated R22 had sexually inappropriate behaviors towards staff and recently started to see a physician through web-based mental health provider; he still had behaviors. On 94/04/24 at 1:00 PM, Administrative Nurse D verified R22's Care Plan did not have person centered interventions for R22's dementia behaviors and stated staff redirected R22 when he was inappropriate. The facility's Care Plans, Comprehensive Person-Centered policy, dated 03/22, documented a comprehensive, person-centered care plan would be developed to include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The interdisciplinary team review and update the care plan if there was a significant change in the condition of the resident, when the desired outcome was met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly in conjunction with the required quarterly MDS assessment. The facility failed to revise the care plan with person centered interventions for R22 who had dementia and behaviors. This placed R22 at risk for decreased quality of life due to uncommunicated care needs.

The facility had a census of 27 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to staff followed acceptable standard of practice related to wound care for Resident (R) 79, who had an infected wound. This placed the resident at risk for delayed healing and other complications. Findings included: - The Electronic Medical Record (EMR) for R79 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis is made or the body cannot respond to the insulin), Charcot arthropathy (a rare complication of diabetes-related neuropathy (nerve damage)), Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), neuropathy, chronic kidney disease, stage three (mild to moderate damage to the kidneys and they are less able to filter waste and fluid out of your blood), and vascular insufficiency (improper function of the vein valves in the leg). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R79 had intact cognition. R79 required set-up assistance for eating, personal hygiene, and mobility. R79 was dependent on staff for toileting and transfers. R79 did not ambulate. The assessment further documented R79 had a diabetic ulcer (a serious complication caused by a combination of poor circulation, susceptibility to infection, and nerve damage from high blood sugar levels), cellulitis (skin infection caused by bacteria), and had dressings to his feet. R79's Care Plan, dated 02/01/24, initiated on 08/17/23, directed staff to float R79's heels on a pillow while lying in bed and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. The update, dated 03/13/24, documented R79 had a diabetic ulcer and directed staff to ensure appropriate protective devices were applied to affected areas. The plan documented R79 had a wound vacuum (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) in place on the wound on his right heel after the area was surgically debrided (process of removing dead tissue from wounds) and directed to monitor blood sugar levels, monitor and document the size of the wound, monitor for infection, and keep skin clean and dry. The Physician's Order, dated 03/11/24, directed staff to change R79's right heel wound vacuum every Monday, Wednesday, and Friday. Cleanse the area with normal saline, pat dry, apply foam, secure with film, then cut a slit in the film cover with suctioning attachment; ensure a proper seal, and cover with another layer of film. The Physician's Order, dated 03/27/24, directed staff to send R79 to the hospital daily for ceftriaxone sodium (an antibiotic), 2 grams (gm), intravenous (IV-administered directly into the bloodstream via a vein), until 04/08/24, for right heel wound. The Physician's Order, dated 03/27/24, directed staff to send R79 to the hospital daily for Daptomycin (an antibiotic), 500 milligrams (mg), IV daily, until 04/08/24, for right heel wound. On 04/02/24 at 08:15 AM, observation revealed Administrative Nurse D moved several personal items off R79's bedside table and set the scissors and wound vacuum supplies on it but did not sanitize the table first. Further observation revealed Administrative Nurse D washed her hands, donned a clean gown and gloves, removed the tubing from the wound vacuum, and removed the old dressing and foam from the wound. Wearing the same gloves, Administrative Nurse D cleansed the wound with wound cleanser, did not change her gloves, and then placed the bottle directly on R79's bed with the nozzle on the bed. Continued observation revealed Administrative Nurse D removed her gloves, washed her hands, donned clean gloves, and cut the foam for the wound vacuum without sanitizing the scissors. She placed the foam into the wound, covered it with film, attached the wound vacuum tubing, and turned on the wound vacuum. Administrative Nurse D removed her gloves and immediately took the wound cleanser and scissors and laid them both inside R79's dresser drawer. Administrative Nurse D then washed her hands and sanitized the bedside table. On 04/02/24 at 08:30 AM, Administrative Nurse D verified she did not sanitize the bedside table before setting the clean supplies on it. Administrative Nurse D stated she should not have laid the wound cleanser on the resident's bed and acknowledged the potential for cross-contamination. The facility's Wound Care policy, dated 10/10, directed staff to assemble the equipment and supplies as needed, wipe nozzles, bottle tops, with alcohol before opening. Use a disposable cloth to establish clean field on resident's overbed table and place all items to be used during the procedure on the clean field and arrange the supplies so they can be easily reached. Place a disposable cloth next to the resident to serve as a barrier to protect the bed linen and other body sites. When finished with the dressing, remove the disposable cloth net to the resident and discard into the designated container, saturate the bedside table with alcohol, wipe reusable supplies with alcohol as indicated, such as outsides of containers that were touched by unclean hands, scissor blades and return them to the resident's drawer in the treatment cart. The facility failed to staff followed acceptable standard of practice related to wound care for R79, who had an infected wound. This placed the resident at risk for delayed healing and other complications.

The facility had a census of 27 residents. The sample included 13 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure the environment was free of accident hazards for two sampled residents, Resident (R) 9, and R18, when the facility failed to assess the residents to safely use an electric wheelchair or to safely smoke. This placed the residents at risk for preventable accidents and injury. Findings included: - The Electronic Medical Record (EMR) documented R9 had diagnoses of diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 a Brief Interview for Mental Status score (BIMs) of 11, which indicated moderately impaired cognition. R9 required set-up assistance with toileting, dressing, and personal hygiene, and was independent with mobility and transfers. The assessment documented that R9 used a wheelchair for mobility. R9 had no impairments of the upper or lower extremities. R9's Care Plan, dated 01/25/24 and initiated on 01/15/24, documented that R9 used a wheelchair for locomotion throughout the facility. R9 was able to independently propel himself and had an electric wheelchair. The plan directed R9 must have a footrest to place his feet on. The update, dated 03/11/24, documented R9 was unsafe at times with his electric wheelchair and directed staff to use the manual wheelchair due to R9's confusion or unsafe actions. R9's EMR lacked documentation the facility assessed R9's ability to safely operate the electric wheelchair before R9's use of the chair in the facility. The Physician's Order, dated 03/11/24, directed staff to monitor R9 for unsafe electric wheelchair use. The Physician's Order, dated 03/12/24, directed staff to have Physical Therapy (PT) evaluate and treat for physical deconditioning and unsafe transportation in an electric wheelchair. The Nurse's Note, dated 02/05/24 at 10:00 AM, documented R9 ran over R22's feet with his electric wheelchair. R22 got mad and there was a fight between the two residents. A family member alerted staff and asked for assistance to separate the two residents. The Nurse's Note, dated 02/07/24 at 01:45 PM, documented R9 came down the hallway in his electric wheelchair and did not slow down until another resident was right in front of him. R9 yelled for the resident to get out of his way. The Nurse's Note, dated 02/10/24 at 03:15 PM, documented R9 was confused, leaning in his electric wheelchair, and running into furniture. R9 did not remember how to turn it off. The note further documented R9's confusion occurred daily and R9 could not be redirected. The Nurse's Note, dated 02/11/24 at 05:12 PM, documented R9 continued to increase in confusion and needed more assistance from staff drove up and down the halls in his electric wheelchair, bumped into doorways, the snack cart, and almost ran over a visitor. The Nurse's Note, dated 02/29/24 at 04:05 PM, documented R9 was confused and could not figure out how to use his electric wheelchair or his electric recliner. The Nurse's Note, dated 03/11/24 at 09:50 AM, documented R9 was upset and yelled at the nurse that he wanted his electric wheelchair back; R9 said was told it was broken and that maintenance would work on it but when he talked to maintenance, they were unaware what was going on with it. The note documented the nurse told R9 that he had been confused and had not controlled the electric wheelchair very well; he ran into walls, got his foot caught, and ran into lifts. R9 was upset and asked why they told him it required work on it instead of being told he had been confused and the nurse stated they felt the white lie was better than making the resident upset. R9 stated he would give them one week and if he did not get the wheelchair back, he would call his lawyer and press charges. Staff reminded R9 that he was able to move around the facility in his manual wheelchair but R9 stated that he could not get around as fast in the manual wheelchair. On 04/03/24 at 03:14 PM, observation revealed R9 sat in a manual wheelchair in the hallway most of the day and was friendly with staff. On 04/03/24 at 08:50 AM, Certified Medication Aide (CMA) R stated R9 had advanced cancer which caused him to become confused and he would run into mechanical lifts, and courtesy carts, and he ran over another resident's feet. CMA R further stated R9 drove down the hall so fast that he turned into another resident's room, who was in the dying process, and almost ran over a family member. On 04/03/24 at 09:00 AM, Licensed Nurse (LN) G stated R9 was rude to the CNA staff and had been confused. LN G said R9 tried to use his television remote to work the electric wheelchair so it was taken away. On 04/03/24 at 01:00 PM, Administrative Nurse D stated the facility had not completed a safety assessment for R9 when he got his electric wheelchair and because of his increased confusion, he was getting physical therapy. The facility's Assistive Devices and Equipment policy, dated 01/20, documented the facility maintained and supervised the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents, these may include mobility devices (wheelchairs, walkers, and canes), and recommendations for the use of the devices and equipment are based on the comprehensive assessment and documented in the resident medical record. The resident, family, and visitors are trained as indicated on the safe use of equipment and devices. The residents are assessed for lower extremity strength, range of motion, balance, and cognitive abilities when determining the safest use of devices and equipment. The facility failed to ensure the environment was free of accident hazards for R9, who was unsafe on his electric scooter. This placed the resident at risk for injury. - R18's Electronic Medical Record (EMR) documented diagnoses of nicotine dependence (when you need nicotine, the chemical in tobacco that makes it hard to quit), diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), edema (swelling resulting from an excessive accumulation of fluid in the body tissue), and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had intact cognition and was independent with toileting, dressing, personal hygiene, mobility, and transfers. The assessment revealed R18 did not have any functional impairment. R18's Care Plan, dated 04/01/24, initiated on 04/20/23, documented R18 required supervision while she smoked, and her smoking supplies were stored in the medication cart. R18's EMR lacked evidence the facility assessed R18 for safe smoking practices. The Nurse's Note, dated 01/10/24 at 09:38 PM, documented R18 was upset and accused staff of not wanting to take her out to smoke, called the nurse a derogatory name, went to her room, and slammed the door. The Nurse' Note, dated 02/08/24 at 09:23 PM, documented that at 06:15 PM, R18 yelled at staff to go out and smoke because she could not wait until 07:00 PM for a cigarette. Staff explained to R18 that the scheduled time to smoke was 07:00 PM and R18 yelled that it only took five seconds to get her a cigarette and take her out. R18 went back to her room and slammed the door. The Nurse's Note, dated 03/26/24 at 03:09 AM, documented that during the evening shift, R18 wanted to go outside for a cigarette and became angry when staff would not take her out due to the rain, snow, and wind. On 04/04/24 at 09:00 AM, observation revealed R18 outside with a staff member, smoking a cigarette. On 04/03/24 at 09:48 AM, Certified Nurse Aide (CNA) M stated R18 was taken outside to smoke five times a day, at 07:00 AM, 09:00 AM, 01:00 PM, 08:00 PM, and 10:00 PM. CNA M said R18 would often get mad at staff if they could not take her outside due to the weather. CNA M stated if it was colder than 32 degrees, staff would not take R18 outside. On 04/03/24 at 01:45 PM, Administrative Nurse D verified a smoking assessment for R18 was not completed. Administrative Nurse D said R18 would get angry if the staff did not take her outside when she wanted to go smoke. The facility's Smoking Policy, dated 10/23, documented the facility has established and maintained safe resident smoking practices. Before and upon admission, the resident was informed of the facility's smoking policy, which is located outside of the building, and smoking was not allowed inside the facility under any circumstances. The resident's smoking status was evaluated upon admission of the current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. The resident's ability to smoke safely was reevaluated quarterly, upon a significant change, and as determined by the staff. The facility failed to evaluate R18 for safe smoking practices. This placed R18 at risk for preventable accidents and related injury.

The facility had a census of 27 residents. The sample included 13 residents with nine reviewed for mood and behavior. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)2. This placed her at risk for impaired quality of life due to untreated and ongoing mental health concerns. Findings - R2's Electronic Health Record (EHR) revealed diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R2's Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the resident had a mood score of 16 which indicates moderate to severe depression. The MDS further indicated the resident had thoughts of being better off dead or of hurting herself. R2's Care Plan, dated 03/04/24 documented the resident had depression and was at risk for lack of hope for the future, changes in mood, sadness, and impaired concentration due to depression and schizophrenia disorder bipolar type. The care plan documented that staff would administer R2's medication as ordered and monitor and document for side effects and effectiveness. The facility would arrange for a psychiatric consult with follow-up as needed. The care plan directed staff to monitor and report any risk for self-harm, suicidal plan, past attempts at suicide, risky actions, intentional self-harm or attempts for self-harm, refusing to eat or drink, refusing medications and therapies, a sense of hopelessness or helplessness, impaired judgment, or safety awareness. The care plan directed staff to remove the resident to a calm safe environment and allow her to vent her feelings when conflict arises. The Social Services Notes, dated 02/23/24 at 09:40 AM, documented the resident stated she was feeling down and hopeless and she felt this way every day. The social service note documented the resident stated she was currently on medication for depression. R2's clinical record revealed lacked evidence or documentation from social service staff regarding resident statements or her behaviors. R2's clinical record lacked psychotherapy notes or evidence of mental health services. On 04/01/24 at 04:00 PM, observation revealed R2 sat in her recliner, watching TV, dressed in a nightgown. Her hair was scraggly and uncombed. On 04/03/24 at 12:50 PM, Administrative Staff A verified the documentation on the Admission MDS indicating the resident felt she would be better off dead or hurting herself. Administrative Staff A verified the section of the MDS was completed by the Social Service Designee (SSD) and she nor the Director of Nursing were informed that R2 had said that or felt that way. Administrative Staff A verified the SSD should convey the information to the charge nurse and the charge nurse would assess the resident and notify the physician; the staff would alert the Administrator and the DON and further action would be taken to provide care for the resident and keep her safe until further treatment as needed. The facility's, Suicide Threats policy, dated December 2007, documented resident suicide threats shall be taken seriously and addressed appropriately. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor or Charge Nurse. The Charge Nurse would immediately assess the situation and shall notify the Charge Nurse and/or Director of Nursing of such threats. A staff member shall stay with the resident until the Nurse Supervisor arrives to evaluate the resident. After assessing the resident in more detail, the Nurse Supervisor shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update the care plan accordingly, until a physician has determined that a risk of suicide does not appear to be present. Staff shall determine details of the situation objectively in the resident's medical record. The facility failed to assess, monitor, and provide mental health services for R2 after R2 verbalized she would be better off dead or had thoughts of self-harm. This deficient practice placed her at risk for impaired quality of life due to untreated and ongoing mental health concerns.

The facility had a census of 27 residents. The sample included 13, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R)22, who had dementia and behaviors. This placed the resident at risk for abuse and decreased quality of life. Finding included: - R22's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbance, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), and pain. The Admission Minimum Data Set (MDS), dated [DATE], documented R22 had moderately impaired cognition. R22 required set-up assistance with toileting, eating, dressing, and personal hygiene, and was independent with mobility and transfers. The assessment further documented R22 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and had no behaviors. The Quarterly MDS, dated [DATE], documented R22 had severely impaired cognition. R22 required set-up assistance with personal hygiene and was independent with toileting, transfers, and mobility. The assessment further documented R22 received antipsychotic medications and had no behaviors. R22's Care Plan, dated 03/07/24 and initiated on 11/16/23, directed staff to administer medications as ordered, and communicate R22's capabilities with the resident, family, and caregivers. The plan directed staff to cue, reorient, and supervise as needed, and document any changes in R22's cognitive function. The plan lacked an individualized dementia treatment plan or guidance for staff when R22 had behaviors. The Physician's Order, dated 11/16/23, directed staff to administer Risperdal (an antipsychotic medication), 0.5 milligrams (mg) by mouth daily for the diagnosis of psychosis (any major mental disorder characterized by gross impairment in perception). This medication was discontinued on 02/14/24. The Physician's Order, dated 11/22/23, directed staff to monitor for behaviors. The Physician's Order, dated 01/18/24, directed staff to contact t Service to evaluate and treat for psychiatric and psychological needs. The Physician's Order, dated 02/17/24, directed staff to decrease the Risperdal medication to 0.25 mg daily for seven days and then discontinue. The Physician's Order, dated 02/17/24, directed staff to administer Zoloft (an antidepressant medication), 25 mg for seven days then increase to 50 mg for the diagnosis of depression. The Physician's Order, dated 02/24/24, directed staff to administer Depakote (an anticonvulsant also used to treat mood disorders), 125 mg twice per day for the diagnosis of depression with psychotic symptoms. The Nurse's Note, dated 12/29/23 at 08:57 AM, documented R22 smacked a Certified Nurse Aide's (CNA) buttocks and made an inappropriate remark about the size of her buttocks. The Nurse's Note, dated 12/30/23 at 12:00 PM, documented R22 was verbally aggressive with another resident after a resident made a remark about R22's wife. The kitchen staff thought the verbal altercation might come to blows. The Nurse's Note, dated 03/03/34 at 06:22 PM, documented R22 slapped a CNA on the buttocks after she served his drinks and turned away. The note further documented the CNA asked R22 not to do that again and he asked her if she wanted a kiss as a reward for the drinks; the staff stated No and walked away. On 04/002/24 at 08:00 AM, observation revealed R22 at the dining table waiting for breakfast. R22 did not exhibit any behaviors. On 04/04/24 at 08:40 AM, Certified Medication Aide (CMA) R stated R22 yelled shut up at another resident who was loud but also said R22 had no other behaviors towards her. CNA R further stated if R22 had any behaviors toward her, she would tell him that it was not appropriate and tell the charge nurse. On 04/04/24 at 09:00 AM, Licensed Nurse (LN) G stated R22 had sexually inappropriate behaviors towards staff and recently started to see a physician through web-based mental health provider; he still had behaviors. On 94/04/24 at 1:00 PM, Administrative Nurse D verified that R22's Care Plan did not have person-centered interventions for R22's dementia behaviors and stated staff redirected R22 when he was inappropriate. The facility's Dementia policy, dated 11/18, documented the individual confirmed with dementia, the interdisciplinary team would identify a resident-centered care plan to maximize remaining function and quality of life, and the nursing assistance team would receive initial training in the care of residents with dementia and related behaviors. In-services would be conducted at least annually thereafter. The policy further documented the physician would order appropriate interventions to address significant behavioral and psychiatric symptoms based on pertinent clinical guidelines and consistent with regulatory requirements. The facility failed to develop and implement individualized interventions and/or a dementia treatment plan for R22 who had dementia and behaviors. This deficient practice placed the resident at risk for abuse and decreased quality of life.

The facility had a census of 27 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of out-of-parameter blood sugars for one resident, Resident (R) 18. This placed the resident at risk for unnecessary medication side effects and other related complications. Findings included: - The Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), edema (swelling resulting from an excessive accumulation of fluid in the body tissue), and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had intact cognition and was independent with toileting, dressing, personal hygiene, mobility, and transfers. The assessment revealed R18 received hypoglycemic (low blood sugar) medication. R18's Care Plan, dated 04/01/24, initiated on 04/20/23 directed staff to avoid exposure to extreme heat or cold, check the body for breaks in the skin, and treat promptly as ordered by the physician. The plan directed staff to administer diabetes medication as ordered by the physician and document for side effects and effectiveness. The Physician's Order, dated 12/30/22, directed staff to obtain R18's blood sugar daily at bedtime. The order was discontinued on 03/26/24. The Physician's Order, dated 06/27/23, directed staff to notify the physician if R18's blood sugar was less than 70 milliliters (ml) per deciliter (dL) or greater than 170 milliliters dL. The Physician's Order, dated 03/26/24, directed staff to obtain R18's blood sugar every Monday and Thursday for the diagnosis of diabetes mellitus type two. R18's Treatment Administrative Record, dated February 2024, documented the following days R18's blood sugar was out of parameters and the physician was not notified. 02/03/24-178 mm/dL 02/07/24-176 mm/dL 02/17/24-235 mm/dL 02/20/24-219 mm/dL 02/29/24-180 mm/dL R18's Treatment Administrative Record, dated March 2024, documented the following days R18's blood sugar was out of parameters and the physician was not notified. 03/09/24-202 mm/dL 03/12/24-181 mm/dL 03/18/24-202 mm/dL 03/19/24-214 mm/dL 03/22/24-179 mm/dL On 04/01/24 at 04:00 PM, observation revealed R18 ambulated with her walker into the dining room. On 04/03/24 at 01:45 PM, Administrative Nurse D verified the physician was not notified of the out-of-parameter blood sugars. On 04/04/24 at 09:00 AM Licensed Nurse (LN) G stated she would notify the doctor if the resident's blood sugar was over 400 mm/dL and verified the Treatment Administration Record did not indicate what the blood sugar parameters were for R18. The facility's Diabetes Clinical Protocol, dated 11/20, documented as part of the initial assessment, the physician would help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose intolerance, the physician would order desired parameters for monitoring and reporting information related to blood sugar management. The facility failed to notify the physician when R18's blood sugar was out of the physician-ordered parameters. This placed the resident at risk for unnecessary medication side effects and other related complications.

The facility had a census of 27 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to date Resident (R)11's insulin (a hormone that allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the resident at risk for ineffective medications. Findings included: - On [DATE] at 10:30 AM, observation revealed R11's Levemir (long-acting insulin) flex pen lacked an open date. On [DATE] at 10:35 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the insulin pen when expired. On [DATE] at 04:00 PM, Administrative Nurse E verified the nurses should label and date the flex pens with the resident's name and discard expired and/or outdated pens. According to www.Medlineplus.gov, Levemir pens can be used within 42 days, but after that time they must be discarded. The facility's Insulin Administration policy, dated [DATE], documented the facility would provide safe administration of insulin to residents with diabetes. The type of insulin, dosage requirements, strength, method of administration, and blood sugar parameters must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. The nurse would check the expiration date The facility failed to dispose of an outdated insulin flex pen for R11 placing the resident at risk for ineffective medication.

The facility had a census of 27 residents. The sample included 13 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)3. This placed R3 at risk for inappropriate end-of-life care. Findings included: - R3's Electronic Health Record (EHR) revealed diagnoses of heart failure (a condition with low heart output and the body becomes congested with fluid), abnormal weight loss, stage 3 kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R3's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS failed to document the resident received hospice services. R3's Care Plan, dated 03/07/24, recorded R3 required extensive assistance with most activities of daily living (ADL) care. R3's Care Plan documented there was a holistic (treating someone as mind and body, instead of treating only the part of the body that is the sickest) approach to resident care by collaboration between hospice and nursing facility staff. A review of R3's Care Plans revealed the resident was admitted to hospice care on 03/07/24 but lacked evidence of coordination of care between hospice and the facility. The facility had not received the hospice care plan from hospice, so the hospice care plan was not available to review in the EHR. The review revealed there was no communication book or external document. On 04/01/24 at 04:00 PM, observation revealed R3 sat in a recliner in her room hollering. Staff went into the resident's room and assisted her in standing with two staff using a gait belt. Staff assisted her to the commode in her room, assisted with toileting activity, and then assisted her back to the room following peri care. On 04/02/24 at 04:05 PM, Administrative Staff A stated she expected the facility to have a hospice care plan for R3 to be able to coordinate care with hospice services. Administrative Staff A verified the facility lacked a hospice care plan for R3 since her admission to hospice 03/07/24. The Hospice Program policy, dated July 2017, documented the hospice contractor who contracts with the facility must have a written agreement outlining in detail the responsibilities of the facility and the hospice agency and are held responsible for meeting the same professional standards and timelines of services as any contracted individual or agency associated with the facility. The responsibility of hospice is to manage the resident's care as it relates to the terminal illness and related conditions. The facility would coordinate care provided to the resident by the facility staff and the hospice staff. Coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility (including the responsible provider and discipline assigned to specific tasks) to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The coordinating care plan shall be revised and updated as necessary to reflect the resident's status including, but not limited to diagnosis, problem list, symptom management, bowel and bladder care, nutrition and hydration, oral health, skin integrity, spiritual, activity and psychosocial needs, and mobility and positioning. The facility failed to coordinate care between the facility and the hospice provider for R3, who received hospice services. This deficient practice placed her at risk for inappropriate end-of-life care.

The facility had a census of 27 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures for Resident (R) 79 before, during, and after wound care. This placed the resident at risk for continued wound infection, cross contamination, and other infectious disease. Findings included: - On 04/02/24 at 08:15 AM, observation revealed Administrative Nurse D moved several personal items off R79's bedside table and set the scissors and wound vacuum supplies on it but did not sanitize the table first. Further observation revealed Administrative Nurse D washed her hands, donned a clean gown and gloves, removed the tubing from the wound vacuum, and removed the old dressing and foam from the wound. Wearing the same gloves, Administrative Nurse D cleansed the wound with wound cleanser, did not change her gloves, and then placed the bottle directly on R79's bed with the nozzle on the bed. Continued observation revealed Administrative Nurse D removed her gloves, washed her hands, donned clean gloves, and cut the foam for the wound vacuum without sanitizing the scissors. She placed the foam into the wound, covered it with film, attached the wound vacuum tubing, and turned on the wound vacuum. Administrative Nurse D removed her gloves and immediately took the wound cleanser and scissors and laid them both inside R79's dresser drawer. Administrative Nurse D then washed her hands and sanitized the bedside table. On 04/02/24 at 08:30 AM, Administrative Nurse D verified she did not sanitize the bedside table before setting the clean supplies on it. Administrative Nurse D stated she should not have laid the wound cleanser on the resident's bed and acknowledged the potential for cross-contamination. The facility's Wound Care policy, dated 10/10, directed staff to assemble the equipment and supplies as needed, and wipe nozzles, and bottle tops, with alcohol before opening. Use a disposable cloth to establish a clean field on the resident's overbed table and place all items to be used during the procedure on the clean field and arrange the supplies so they can be easily reached. Place a disposable cloth next to the resident to serve as a barrier to protect the bed linen and other body sites. When finished with the dressing, remove the disposable cloth net from the resident and discard it into the designated container, saturate the bedside table with alcohol, and wipe reusable supplies with alcohol as indicated, such as the outsides of containers that were touched by unclean hands, scissor blades and return them to the resident's drawer in the treatment cart. The facility failed to ensure adequate infection control measures during wound care for R79, who had an infection in a wound. This placed the resident at risk for continued wound infection, cross contamination, and other infectious disease.

The facility had a census of 27 residents. The sample included 13 residents. Based on record review and interview the facility failed to ensure the residents received their mail on Saturdays. Findings included: - On 04/02/24 at 10:30 AM during the resident council meeting, the residents verbalized there was no mail delivery on Saturdays. On 04/02/24 at 11:15 AM, Activity Staff Z verified the administration staff would get the mail during the week from a mailbox outside the facility and the key to the mailbox was located in the nurse's station. On 04/02/24 at 11:20 AM, Administrative Staff A verified the Administration staff would get the mail during the week from the mailbox in front of the facility, then the Social Service staff would deliver the mail to the residents. Administrative Staff A verified the key to the mailbox was kept in the nurse's station. Administration Staff A verified she was not sure if the weekend staff knew they were to get the mail and deliver it to the residents on Saturdays, but she would inform them. The facility's Mail and Electronic Communication policy, dated May 2017 documented that residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, emails, and other electronic forms of communication confidentially. Mail will be delivered to the resident unopened. Mail and packages will be delivered to the resident within 24 hours of delivery on the premises or to the facility's post office box (including Saturday deliveries.) The facility failed to ensure the residents received their mail on Saturdays.

The facility identified a census of 24 residents with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to prevent a fall out of a wheelchair when staff failed to place foot pedals on the wheelchair before assisting Resident (R) 1 outside in her wheelchair. On 12/15/23 at approximately 06:20 PM, Licensed Nurse (LN) G propelled R1 down the sloped sidewalk, without foot pedals on the wheelchair, and R1 planted her feet on the sidewalk and leaned forward, causing her to fall face first on the sidewalk. The fall resulted in a forehead hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) and laceration (cut) which required sutures to close, abrasions, and a cervical (neck/spine) fracture (broken bone) of R1's first vertebrae (the first bone at the top of the spine). The deficient practice also placed R1 at risk for increased pain and impaired mobility. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had the diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), unsteadiness on feet, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. The MDS further documented R1 required substantial assistance from staff for toileting, bathing, dressing, bed mobility, and transfers. The MDS documented R1 used a manual wheelchair and was able to self-propel herself independently in the wheelchair in corridors or similar spaces and able to make turns in the wheelchair. The MDS documented R1 reported occasional pain during the observation period and rated her pain at a four on a 0-10 pain scale (scale used to rate pain with zero representing no pain and 10 representing the worst pain imaginable). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/19/23, documented R1 had moderate cognitive impairment. R1 had one day of exhibiting yelling, screaming, physical behaviors (pinching/scratching/spitting), used abusive language, and rejected care. R1 called 911 several times and had combative behaviors. The CAA documented R1 was at risk for activities of daily living (ADL) declines due to her cognitive impairment. The Fall CAA, dated 07/19/23, documented R1 had functional limitations to her bilateral upper extremities and bilateral lower extremities. The CAA documented R1 was non-ambulatory, her balance was not steady, and she was only able to stabilize with staff assistance with the use of a wheelchair for mobility and a sit-to-stand lift (mechanical lift to aid with standing) for transfers. R1's Care Plan directed staff R1 used a wheelchair when she was not in her recliner or in bed, could independently self-propel, and preferred to self-propel herself backwards. R1's Care Plan documented R1 was a high risk for falls. The care plan lacked any direction to staff about use of foot pedals on R1's wheelchair when propelled by staff. The Health Status Note, dated 12/15/23, documented R1 was very confused that day, was crying, and was adamant that her children were young and at home alone and she wanted to leave. R1's behaviors started at 03:00 PM. R1 stated, If you will just take me to the parking lot to see if my car is there. If it's not then I will stop asking and stop crying. LN G took R1 out of the front door in her wheelchair. LN G pushed R1 down the sidewalk to the area where the sidewalk began to slope. R1 looked around then put her feet down, stood up and fell forward, hitting her head on the side. R1 laid on the sidewalk on her left side. LN G obtained assistance from other staff and emergency medical services (EMS) was called at 06:17 PM. R1's neurological checks were within normal limits, R1's vision was good, her pupils measured three millimeters (mm). R1 denied pain everywhere except her head and complained she was cold. EMS arrived at 06:26 PM. EMS staff assessed R1 and assisted her to roll on to her right side and then onto her back. EMS transferred R1 to the stretcher and transported her to the local hospital at 06:40 PM. The emergency room Paperwork, dated 12/15/23, documented R1 presented to the emergency room after being pushed in a wheelchair that hit a crack on the sidewalk and caused R1 to fall forward out of the wheelchair and strike her head. R1 reported neck pain and right knee pain. R1 had a large hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on her forehead with a small laceration (cut). R1 had abrasions to her upper nose and distal forehead. A soft cervical collar was on R1's neck upon arrival to the emergency room and emergency room staff then applied a Miami J (a cervical collar that provides comfortable immobilization of the neck after injury). The x-ray report documented R1 had a non-displaced fracture through the lamina (the roof of the spinal canal that provides support and protection for the backside of the spinal cord) of the first cervical vertebrae. The radiologist called the doctor to report the finding at 07:36 PM. The decision was made to transfer R1 to a higher level of care by emergency flight. The Admission Paperwork, dated 12/16/23, documented R1 was admitted to the hospital after a ground level fall and was found to have an acute C1 fracture. R1's history was limited due to dementia. R1 reported pain to her neck and face and a headache. R1 presented with in a c-collar, mild tenderness, left periorbital (around the eye) hematoma, and a three-centimeter (cm) laceration to the left forehead with surrounding hematoma. Plan was for non-operative management of the fracture, maintain c-collar, and pain control. The Discharge Paperwork, dated 12/19/23, documented R1 required an Aspen collar. The paperwork documented orders for activity as tolerated, upright cervical x-ray when/if able, Keppra (anti-seizure medication) twice a day for seven days, physical and occupational therapy, pain control as needed, and follow up with primary care physician in one to two weeks. The Facility Incident Report, dated 12/21/23, documented on 12/15/23 LN G took R1 outside due to R1's delusions of needing to leave the facility and look for her family. LN G took R1 outside and while R1 looked, she leaned forward, planted her feet on the ground, and it appeared R1 tried to stand up from her wheelchair. LN G could not get R1 to sit back or lean back in her wheelchair. R1 then fell to the ground and had a laceration to her head from the fall. LN G stated she could not stop the fall. LN G called Administrative Nurse D and informed her the hospital told LN G she was under investigation, and they would be turning LN G in, as R1 stated LN G had gone over a crack in the sidewalk and dumped her out of the wheelchair. Administrative Nurse D called the hospital to ask about the report and investigation. The emergency room nurse informed Administrative Nurse D R1 had a fracture to her neck as well as a laceration and the hospital transferred R1 to another facility and said they would be turning the incident in to the state. Administrative Staff A and Administrative Nurse D called the staff at the facility to see if they saw anything and no one saw what happened. Staff also reported they had no concerns regarding LN G. Administrative Staff A and Administrative Nurse D went to the facility to evaluate the scene of the fall. There were no rough cracks in the cement in front of the facility or to the decline area where R1 fell . LN H, the night shift nurse, came and showed Administrative Staff D and Administrative Nurse D where the wheelchair was observed post fall, and where R1 landed. R1 had just passed the pillar at the front of the building and went over the initial crack in the cement passed the pillar; the crack was very smooth and would not have caused any kind of fall from a wheelchair/seated position. The facility implemented corrective actions in response to the incident which included staff kept R1's c-collar in place for healing; removed sutures to R1's forehead laceration on the appropriate date; re-directed R1 when she was confused, delusional, or hallucinating; staff offered R1 activities or tasks that helped her during times of confusion, delusions or hallucinations; a medication review with medication adjustment was performed to assist with delusional disorder and hallucination diagnosis; staff re-directed R1 before going outside and staff received education on behaviors and targeted behavior charting. LN G's Witness Statement, dated 12/21/23, documented LN G noted R1 had increased confusion and was upset and cried. R1 propelled herself in the halls, crying, and wanted to talk to her husband; R1 said her children were home alone and she needed to leave. R1 stated, Please help me out to my car. R1 refused to eat but did take her medications. The statement recorded LN G planned to leave at 06:10 PM but R1 requested LN G take her to the parking lot to look for her blue and white car, and R1 said if LN G would do that then R1 would stop crying and quit asking to leave. LN G attempted to take R1 out of the south door to the parking lot, but R1 stated she wanted to go out the front. LN G took R1 out the front and R1 looked around, then put her feet on the ground, leaned forward, and was face down on the sidewalk. R1 laid more on her left side and her glasses laid above her head. R1 complained her head hurt and she was cold. LN G had staff paged for assistance. Upon assessment, R1 could move all of her extremities, complained only pain in her head but due to her size, emergency services were called. LN H's Witness Statement, dated 12/21/23, documented LN G stated she was going to take R1 outside so R1 could see that her car was not at the facility in hopes to reorient R1. Shortly after exiting the building through the front door pushing R1 in her wheelchair, LN G alerted staff R1 fell out of her wheelchair headfirst, and LN G needed help. LN H and other staff walked outside with LN G. R1 laid on the concrete in front of the building in a prone position slightly turned to her left with blood forming under her forehead. On 12/28/23 at 10:00 AM, observation revealed R1 sat in her recliner with a c-collar in place attempted to eat breakfast. R1 had multiple areas of bruising in different stages of healing on her forehead, under her eyes, and down into her cheeks. There was a large hematoma in the middle of her forehead. R1 had a cup of coffee with a straw and appeared to have difficulty as she tried to get the straw over the c-collar to her mouth. On 12/28/23 at 10:00 AM, R1 stated she tried to eat breakfast, but the collar was in her way. R1 said that she fell when she was leaving work. She went on to say she was in a wheelchair and the girl pushing the wheelchair down the ramp went too fast, and lost control of the wheelchair. R1 said that's when she fell face first on the sidewalk. R1 stated she was in pain all the time. On 12/28/23 at 10:30 PM, LN G stated she finished giving nursing report. LN G said R1 was waiting for her outside of the office and begged her to take R1 outside to see if the car was there. LN G told R1 she would take her outside to look for her car if she would stop crying and exit seeking and R1 stated if she saw that her car was not here, she would believe. LN G stated she did not expect to be outside long because it was cold outside. LN G stated she did not put foot pedals on R1's wheelchair and stated she did not even think about putting R1's foot pedals on her wheelchair. She said she wheeled R1's wheelchair out of the door and then as they were going down the sloped sidewalk, R1 planted her feet on the sidewalk then leaned forward to her left, looking down the street, and fell face first onto the sidewalk. On 12/28/23 at 11:00 AM, Administrative Nurse D stated nothing could have prevented the fall from happening. R1's delusions were very real to her and R1 was not very redirectable once she got a thought in her mind. Administrative Nurse D stated even if foot pedals were on R1's chair, R1 would have put her feet down behind the foot pedals and still planted her feet as Administrative Nurse D saw R1 do that before. The undated Managing Falls and Fall Risk Policy, documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to prevent a fall out of a wheelchair by not placing foot pedals on the wheelchair before assisting R1 outside in her wheelchair. The deficient practice resulted in facial abrasions, hematoma, laceration requiring sutures, increased pain, and neck fracture for R1.

The facility identified a census of 23 residents with three residents reviewed for accidents. Based on record review, observation, and interview, the facility failed to follow Resident (R) 1's care plan, which directed two staff to assist the resident for transfers with a sit to stand lift, which resulted in a very large skin tear to R1's posterior left calf which measured 4.5 centimeters (cm) by 3 cm. On 10/30/23 between 05:00 PM and 05:30 PM, Certified Nurse Aide (CNA) M transferred R1 from the toilet using the sit to stand lift by herself and R1 sustained a skin tear to her left posterior leg. CNA M did not notice R1 was bleeding from the skin tear until after she transferred R1 back to the wheelchair using the sit to stand lift by herself. This deficient practice placed R1 at risk for skin tears, pain, and delayed healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of two, which indicated severely impaired cognitive status. The MDS documented R1 had functional limitation of range of motion to her bilateral upper extremities and bilateral lower extremities. The MDS further documented R1 required substantial/maximum assistance with all of her Activities of Daily Living (ADLs). The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 11/08/23, documented R1 had frequent urinary incontinence and limited range of motion to her bilateral upper and lower extremities. The CAA documented R1 required substantial assistance for toileting, bathing, dressing, bed mobility, and transfers and was non-ambulatory. R1was at risk for pressure injury. The CAA documented the goal was for R1 to maintain her skin integrity and avoid skin breakdown or pressure injury development. R1's Care Plan revised 04/04/23, directed staff to use a sit to stand lift for all transfers and use two staff for toileting and perianal care. The care plan documented R1 would have intact skin free of redness, blisters or discoloration through the review date and caregivers would be educated as the causes of skin breakdown including transfer/positioning requirement, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. The Skin/Wound Note, dated 10/18/23, documented a CNA was transferring R1 with the sit to stand lift from the bathroom to her wheelchair and bumped the back side of her left leg on something during the transfer creating a skin tear approximately the size of a nickel. Serous (thin, clear) fluid immediately started running out of the skin tear changing over to pale colored blood. The nurse was unable to secure R1's skin once it was put in place due to the amount of fluid coming out of the wound. The nurse placed a Covaderm (nonstick gauze) over the open area after cleaning it and applying pressure, but fluid soaked the Covaderm in a short period of time, so the nurse wrapped Kling (gauze wrap) around the area of the skin tear. Fluid had already started to soak through the wrap while being secured with tape. The Health Status Note, dated 10/30/23, documented a skin tear and blood blister noted to the back of R1's left calf. Staff cleaned the area with normal saline and collagen powder (protein powder to promote healing), applied Telfa and covered it with Kerlex (stretchy gauze wrap). The skin tear measured 4.5 cm by 3 cm without approximated edges. The blood blister measured 5 cm by 4.5 cm and the total are measured 7.5 cm by 4.5 cm. R1 denied any pain or discomfort to area. R1's primary care physician was notified by fax at 10:29 PM. Skin tear protocol was initiated per standing orders. The Wound Data Collection Tool, dated 10/30/23, documented a full thickness skin loss of the left posterior calf, which measured 4.5 cm by 3 cm. The wound bed had 100% granulation (new tissue formed during wound healing) tissue. The area also presented with a partially intact blister, which measured 4.5 cm by 5 cm and heavy serosanguineous (semi-thick blood-tinged drainage) drainage noted. Collagen powder, Telfa, and Kerlex applied. The Skin/Wound Note, dated 11/08/23, documented the dressing to the back of R1's left calf had a moderate amount of drainage noted. Staff changed the , cleansed the area cleansed with normal saline and a Telfa pad and applied Kerlex. The skin tear measured 2.5 cm by 2.5 cm. The blister measured 4.5 cm by 4.5 cm and was no longer fluid filled. The skin over the blister remained intact. The Wound Collection Data Tool, dated 11/21/23, documented the skin tear measured 3.5 cm by 3.5 cm. The wound bed had 100 % granulation tissue present. Minimum serosanguineous drainage noted. Covaderm dressing placed after cleansing with normal saline. The Wound Collection Data Tool, dated 11/28/23, documented the skin tear measured 3 cm by 2.5 cm. The wound bed had 100 % granulation tissue present. Minimum serosanguineous drainage was noted and staff placed a bordered gauze on the area. The Facility Incident Report, dated 11/03/23, documented on 10/30/23 at 09:22 PM Licensed Nurse (LN) G reported to Administrative Nurse D that R1 had sustained a significant skin tear to her left posterior calf, and it occurred when CNA M transferred R1 before supper. Administrative Nurse D called Administrative Staff A and notified her of R1's skin tear and the deviation from R1's care plan. Administrative Nurse D called CNA M and asked CNA M what happened before supper and what had happened with the skin tear. CNA M stated R1 had an old skin tear on the back of her left calf and when CNA M went to adjust R1's feet on the sit to stand lift, CNA M grabbed R1's leg and it reopened the skin tear up. Administrative Nurse D asked CNA M if there were two staff in the room and CNA M stated no, she did not have two people for the transfer with the mechanical sit to stand lift, as everyone else was busy handling something else. CNA M stated she reported the skin tear to LN H and told her it needed a dressing. LN H was busy and when the night nurse, LN G, arrived she was able to get a dressing on the area. LN G went into R1's room at 09:30 PM and had to change the dressing again due to it was seeping fluid and blood. LN G measured the area and the skin tear measured 4.5 cm by 3 cm and there was a partially intact blister that had a significant amount of fluid in it, seeping as well. The blister measured 7.5 cm by 4.5 cm. R1's skin tear was unable to be approximated (the edges were together) and was left open after cleaning. Staff faxed R1's primary care physician about the skin tear and blood blister and used the standing order for dressing changes and weekly measurements. R1's chart noted on 10/18/23 R1 sustained a skin tear to the back of her calf when a transfer was performed, and it was the size of a nickel and was able to be approximated. CNA M's Witness Statement, dated 11/01/23, documented CNA M worked with R1 on 10/30/23 on the 06:00 AM to 06:00 PM shift. CNA M gave R1 a bath that morning and took off the gauze and pad from her left leg to wash it. R1's wound was okay until about 05:00 to 05:30 PM when CNA M took R1 to the bathroom. CNA M had to move R1's legs back in order to pull up R1's pants. CNA M stated she did not know that she had broken open the wound until after CNA M placed R1 in her wheelchair and saw the blood. CNA M stated her hand moved a little in order for it to break open when CNA M moved R1's leg back in the bathroom. CNA M stated she took R1 out to the dining room and told LN H about the skin tear and LN H said ok. CNA M went to help other residents and to take the laundry to the soiled linen closet and the trash out to the dumpster. On 11/29/23 at 10:00 AM, observation revealed R1 sat in her recliner watching television. She had a dressing to her left calf. On 11/29/23 at 10:30 AM, CNA M stated she did not know if she caused the skin tear to R1's left calf when she moved her leg on the sit to stand lift or if it happened when she was moving the sit to stand lift to place R1 in her wheelchair. CNA M stated she did not see the skin tear until R1 was in her wheelchair and then she saw the blood. CNA M stated she used the sit to stand lift to transfer R1 by herself without a second staff in the room. On 11/29/23 at 11:30 AM, Administrative Staff A stated CNA M did not follow R1's Care Plan when she transferred R1 without a second staff member present, but there was nothing to say that transferring R1 with only one staff caused the skin tear to occur. On 11/29/23 at 11:30 AM, Administrative Nurse D stated she reeducated all of the staff about always having two staff when operating any mechanical lift, and skin tear protocol including charting and dressing changes. Administrative Nurse D stated all education and training was completed on 10/31/23. Administrative Nurse D stated staff were told to keep R1's legs elevated to prevent swelling. The facility's Using a Mechanical Lifting Machine Policy, revised July 2017, documented the purposed of this procedure is to establish general principles of safe lifting using a mechanical lifting device. At least two nursing assistants are needed to safely move a resident with a mechanical lift. Be mindful of the resident's position, balance and skin. The facility failed to follow R 1's Care Plan for requiring two staff assist for transfers with a sit to stand lift. Subsequently, R1 acquired a significant skin tear to her posterior left calf. This deficient practice also placed R1 at risk for skin tears, pain, and delayed healing. On 10/31/23 the facility completed all corrective actions related to the deficient practice therefore the citation was deemed past noncompliance at a G scope and severity.

The facility identified a census of 25 residents with three residents reviewed for quality of care. Based on record review, observation, and interview, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to ensure Resident (R)1 received the antibiotic treatment as ordered by the infectious disease physician. On [DATE] R1 readmitted to the facility after an acute hospital stay related to empyema (collection of pus in the pleural cavity related to bacterial pneumonia). Upon readmission, facility staff noted R1's three antibiotic medications did not have a stop date noted. R1's admission paperwork noted multiple times the resident was to continue antibiotics for four weeks, but facility staff did not review the admission paperwork and health information sent by the hospital and failed to contact the ordering physician for clarification. Facility staff called the resident's primary care physician, relayed inaccurate and/or incomplete information, and received orders to continue the antibiotics for seven days and then discontinue. R1's antibiotic treatment stopped on [DATE]. On [DATE] the resident was noted to be pale with his eyes rolled back, he had abnormal vital signs with a blood pressure of ,d+[DATE] mmHg (millimeters of Mercury), pulse of 124 BPM (beats per minute), and oxygen saturation of ,d+[DATE]% on room air. Staff notified the physician and received orders to send R1 to the hospital. R1 was sent to a higher level of care. R1 was admitted to the intensive care unit with respiratory failure due to empyema. R1 expired on [DATE]. The facility's failure to ensure staff provided nursing care and treatment consistent with standards of practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS further documented R1 required supervision of one staff for bed mobility, transfers, ambulation, locomotion, eating, and personal hygiene. The MDS documented R1 used oxygen as a resident in the facility. The Oxygen Therapy Care Plan, dated [DATE], directed staff to monitor R1 for signs and symptoms of respiratory distress, report to the doctor as needed, and to titrate oxygen settings to keep oxygen saturation above 90 percent (%). The Impaired Cognitive Function Care Plan, dated [DATE], directed staff to monitor/document/report as needed any changes in cognitive function. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R1 had a BIMS score of four and had documented physical, verbal, and other behaviors that included wandering and rejection of care during the look back period. The Health Status Note, dated [DATE], documented at 08:43 PM staff called the facility nurse to the bath house to assess R1. When the nurse entered R1 was slouched in the bath chair with drool running down the right side of his face and a slight facial droop. R1 was not responding to questions. R1's vital signs were assessed and measured at the following: blood pressure (BP) ,d+[DATE] mm/Hg, pulse 88 beats per minute and respirations 13 breaths per minute. Staff notified R1's representative and she wanted R1 to be seen in the emergency room . Staff notified R1's primary care physician and they ordered to send R1 to the emergency room . At 08:52 PM, R1's vital signs were BP ,d+[DATE] mm/Hg, oxygen saturation 77% on six liters of oxygen, pulse bouncing between 110 to 135 beats per minute, and respirations 24 per minute. At 09:04 PM emergency medical system in the building and transported R1 to the hospital. The Health Status Note, dated [DATE] at 03:05 AM, documented the local hospital was transferring R1 to a higher level of care and was waiting for a plane. The Health and Physical Document (H & P), dated [DATE], documented R1 had septic shock (a life-threatening condition caused by a severe localized or system-wide infection) suspected due to right-side empyema. R1's right sided weakness was due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead) rather than acute ischemia (decreased supply of oxygenated blood to a body part). The H & P documented R1 was critically ill with accompanied acute impairment of one or more vital organ systems. The hospital Infectious Disease Consult Note, dated [DATE], documented R1 had an infectious process due to due to a right sided empyema and hydropneumothorax (abnormal presence of air and fluid in the pleural space) with a pleural (pertaining to the pleura the thin covering that protects the lungs) drainage catheter (a flexible tube inserted through a narrow opening into a body cavity) in place that was actually a biliary (relating to the bile duct) drain that had migrated to R1's lung. On [DATE] the biliary tube was removed and replaced with an actual chest tube in radiology and the pleural fluid that returned was turbid (cloudy, opaque or thick with suspended matter) and had 30,000 white cells (blood cells that protect against illness and disease) of which 100% were neutrophils (a part of the white blood cell that is an innate part of the immune system). The gram stain (a method used to classify bacterial species) had many neutrophils and a rare gram-positive coccus (type of bacteria). Pleural fluid growth showed moderate growth of Raoultella (type of bacteria), moderate growth of Citrobacter (type of bacteria), and moderate growth of MRSA (methicillin resistant staphylococcus aureus - type of bacteria). R1 had been on vancomycin (antibiotic) and ceftriaxone (antibiotic). R1 also had a urine culture that had greater than 100,000 colonies of white cells of E. coli (type of bacteria). The infectious disease doctor recommended four weeks of antibiotic treatment with cefdinir, Flagyl, and linezolid. The Hospital Progress Note, scanned into R1's EMR under the Misc tab, dated [DATE], documented R1 was seen that morning with his son at his bedside. R1 complained of intermittent right abdominal pain, otherwise no complaints. R1 appeared to be resting comfortably. The report documented R1 was receiving cefdinir 300 milligrams (mg) by mouth twice a day, flagyl 500 mg by mouth every twelve hours, and linezolid 600 mg by mouth twice a day. Recommendations were to continue cefdinir, flagyl and linezolid for four weeks and if R1 did not tolerate them, then they would need to consider intravenous (IV - given through a vein) antibiotics. The Hospitalist Progress Note, under the Misc. tab dated [DATE], documented R1 was somewhat grumpy and wanting to leave the hospital. R1 denied chest pain or shortness of breath. R1's chest tube had been removed and R1 was afebrile. R1 transitioned to oral antibiotics. Tentative plans were for R1 to go to swing bed near his hometown. Antibiotics would be continued(cefdinir, flagyl, and linezolid) for four weeks. The Health Status Note, under Progress Notes tab dated [DATE], documented Administrative Nurse D received a nurse to nurse report regarding R1. The discharging facility nurse reported R1 was admitted for suspected stroke with negative CT (computed tomography) scan and MRI (magnetic resonance imaging). R1 actually had an infection, a urinary tract infection, and this was suspected to be the cause of R1's stroke like symptoms. R1's chest tube and biliary drain was also infected and tested positive for MRSA. R1 had the drain removed and a dressing was in place. The Admission Summary Note, dated [DATE], documented R1 was readmitted to the facility at 05:04 PM. R1 returned to the facility via personal vehicle with his son driving. R1 was weak with transfer, but able to stand pivot with one person assist. R1 was alert and oriented to person only. R1's lung sounds were clear throughout all lobes. R1's bowel sounds were active to all quadrants. R1 had no complaints of pain or discomfort. The Discharge Instructions, under the Misc. tab dated [DATE], documented R1 was being discharged to the facility for skilled care with orders for physical therapy, occupational therapy, and speech therapy to see R1. The instructions documented R1 would be on a cardiac diet with no activity restrictions. The discharge instructions ordered the facility to obtain a comprehensive metabolic panel (CMP-lab text) and complete blood count (CBC-lab test) every Monday for three weeks and fax to the discharging physician. The medication orders in the discharge instructions documented R1 would be on cefdinir 300 mg twice a day, Flagyl 500 mg twice a day, and linezolid 600 mg twice a day for infection treatment and prevention. The medication orders did not have a stop date. Administrative Nurse D wrote in beside the orders Times 7 days per primary care physician. The discharge instructions documented R1 was to follow up with the discharging physician and cardiology in two to three weeks and was to follow up with his primary care physician in one to two weeks. R1's EMR documented R1 was given the antibiotics cefdinir, Flagyl, and linezolid twice a day for seven days with the last date administered on [DATE]. The Antibiotic Monitoring Note, dated [DATE], documented R1 was taking cefdinir, Flagyl, and linezolid related to the diagnosis of MRSA in right rib wound. The Antibiotic Monitoring Note, dated [DATE], documented R1 completed his antibiotics that day. A late entry Laboratory Note, dated [DATE], but entered on [DATE], documented a voicemail was left with R1's responsible party stating that lab results were sent to the discharging physician's office and R1's antibiotics were finished. The Health Status Note, dated 08.08.23, documented R1 was pale with his eyes rolling back. His BP was ,d+[DATE] mm/Hg, oxygen saturation was ,d+[DATE]% on room air, and pulse was 124 bpm. R1's primary care physician was notified of R1's status at 08:19 PM and he gave orders to send R1 to the emergency room . The Health Status Note, dated [DATE], documented R1 was transferred to a higher level of care. The Health Status Note, dated [DATE], documented R1's responsible party called to the facility asking questions about R1's antibiotic treatment from his previous hospital admission. The responsible party told the facility the family was under the impression that R1's antibiotics were to be given for four weeks after his discharge from the hospital and the nurse last night stated the antibiotics were only scheduled for seven days. Administrative Nurse D stated that there was no end date for the antibiotics upon R1's return to the facility so she consulted R1's primary care physician on how long R1 was to take the antibiotics and he made the order for seven days. The Hospital Heath and Physical, dated [DATE], documented R1 was transferred to a higher level of care related to acute respiratory failure. After CT results were obtained, it was noted R1 had an empyema to his right lung and recommendations were for a chest tube to be placed and IV fluid resuscitation. The Hospital Consultation Report, dated [DATE], documented R1 was admitted to the hospital with septic shock from empyema and cardiogenic shock (when the heart cannot pump enough blood and oxygen to the brain and other vital organs) from sepsis. The Hospital Progress Note, dated [DATE], documented R1 had septic shock due to empyema, which was improving. The empyema (MRSA, Raoultella and Citrobacter) was due to a mal-positioned cholecystostomy tube (tube to drain fluid from the gall bladder). The empyema was recently evaluated by infectious disease at another hospital and R1 was placed on a four-week regimen of antibiotics. R1 was only administered seven days of antibiotics at the long-term care facility. Once R1 was more stable, will plan on transitioning R1 back to oral antibiotics. The Hospital Discharge Summary, dated [DATE], documented R1 expired on [DATE] at 11:20 AM. On [DATE] at 10:00 AM, Administrative Nurse D stated she had not called the hospital and clarified the antibiotics duration because R1 got to the facility after 05:00 PM and she was the charge nurse that day. Administrative Nurse D stated the discharging physician was not going to follow R1 after his discharge. Administrative Nurse D stated all she was told in the nurse to nurse report was that R1 had MRSA in his biliary tube site and his nares. Administrative Nurse D stated that is what she reported to R1's primary care physician when she called him for an end date on the antibiotics. Administrative Nurse D stated R1's primary care physician stated R1 had probably been on antibiotics while at the hospital so stated to go ahead and continue the antibiotics for seven more days. Administrative Nurse D stated she never read through the other discharge documents the discharging facility had sent until after the family notified the facility R1 was supposed to have been on antibiotics for four weeks. Administrative Nurse D stated she then read the progress notes from the discharging hospital stating antibiotics were to continue for four weeks. On [DATE] at 01:20 PM, Administrative Staff A stated Administrative Nurse D had done nothing that any other nurse would not have done. Administrative Nurse A stated getting a new admission especially late in the day is overwhelming and that she probably would have done the exact same thing as Administrative Nurse D. The facility Admission Criteria Policy, revised [DATE], documented the objectives of our admission policy are to provide uniform criteria for admitting residents to the facility, admit residents who can be cared for adequately by the facility, address concerns residents and family have during the admission process, assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. Prior to or prior to admission the resident's attending physician provides the facility with information needed for the immediate care of the resident including at least: type of diet, medication orders, including as necessary, a medical condition or problem associated with each medication and routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment. The facility failed to ensure staff provided nursing care and treatment consistent with standards of practice which placed R1 in Immediate Jeopardy. On [DATE] the facility completed the following corrective actions to address the immediacy for R1: On [DATE] the medical director, nurse consultant, and regional manager were consulted. On [DATE] a report was made with state agency. On [DATE] an admission/readmission checklist was made to include a second nurse check of medication list. A nurse-to-nurse report template was created. On [DATE], added if order clarification is needed and discharge provider is unavailable a temporary order will be obtained from the primary care provider while awaiting clarification from discharge provider. Admission/Readmission Audit, including review of hospital discharge paperwork will be completed within 72 hours of admission/readmission by DON and designee. On [DATE] all nurses were educated on a second nurse check of orders from any new admission or readmission. Administrative staff were educated on the admission audit. On [DATE] all nurses were educated on the additions made to the admission/readmission checklist. After the immediacy was removed the deficient practice remained at a scope and severity of G to represent the actual harm to R1.

The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from verbal and mental abuse and mistreatment. On 08/06/23 at approximately 02:00 AM, Certified Nurse Aide (CNA) M heard Licensed Nurse (LN) G holler at Resident (R)1 shut the [expletive] up or I swear I will kill you. CNA M asked CNA N who she should report the incident to, and CNA N told CNA M to talk to Administrative Nurse D next time CNA M saw her. Five days later, CNA M reported the incident to LN H. Upon receiving the allegation, the facility started an investigation which revealed another resident, R2, reported LN G had yelled and cussed at him. The investigation further revealed other staff heard LN G cussing in the hallways and telling residents to be quiet, then shutting the residents' doors so LN G would not have to hear them yelling, though the staff had not reported this to the facility administrator when it occurred. The facility failed to ensure R1 and R2 were free from staff abuse and mistreatment. This placed R1 and R2 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of insomnia (inability to sleep), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and age-related debility. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R1 required limited to extensive assistance with all activities of daily living (ADL) except for eating which was supervision/set-up help. The MDS documented R1 exhibited verbal behaviors directed towards others one to three days during the look back period. The MDS documented R1 had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming/disruptive sounds) one to three days during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/15/23, documented R1 had severe cognitive impairment and required cues for recall. The Behavioral Symptom CAA, dated 05/15/23, documented R1 had behaviors of yelling/screaming and crying. The Behavioral Care Plan, dated 05/22/23, documented R1 had occasional episodes of yelling/screaming and directed staff to analyze key times, places, circumstances, triggers, and what de-escalated R1's behavior and document. The care plan directed staff to assess and anticipate R1's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. The Impaired Cognitive Function Care Plan, dated 05/09/23, directed staff to cue, reorient, and supervise R1 as needed. The care plan directed staff to monitor/document/report as needed any changes in cognitive function specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The Nurse's Note, dated 06/22/23, documented R1 was in bed and yelling about wanting to get up. R1 stated, I wish I could just go to sleep but I can't. The Mood/Behavior Note, dated 08/06/23 at 01:00 AM, documented R1 yelled help me and please and woke up other residents. R1 exhibited this behavior from 08/05/23 at 07:00 PM to 08/06/23 at 01:00 AM. R1 was in her room, in her recliner watching television. When staff asked R1 what she needed or why she was hollering R1 stated, I don't know or I'm not hollering. Staff told R1 that she was disturbing other residents and R1 stated, No I'm not. Interventions that were tried: food, beverages, pain medication, repositioning, different setting, different staff approaching, and talking to R1. None of the interventions were effective. The Facility Incident Report, dated 08/14/23, documented on 08/10/23 at 07:48 PM Administrative Staff A called Administrative Nurse D to inform her a report was made to the night shift nurse LN H, by CNA M, that LN G yelled at R1 during the night on 08/06/23 at approximately 02:00 AM. CNA M reported she went to the nurses station to ask CNA N to help her with repositioning another resident. While CNA M and CNA N were in the nurse's station, CNA M stated she heard R1 yelling out and LN G went to R1's room and told R1 to Shut the [expletive] up or I swear I am going to kill you. CNA M stated she asked CNA N what she should do since she didn't know who to call or where the information was so turn it in. CNA M stated she did not feel the interaction was appropriate. CNA M stated CNA N told her she should talk to Administrative Nurse D when she saw her next. Administrative Nurse D went to the facility to interview CNA M and educated CNA M on proper Abuse, Neglect, and Exploitation procedure and to call Administrative Nurse D any time with concerns. CNA M then filled out a witness statement. Administrative Nurse D called CNA N to ask what had occurred. CNA N stated she did not remember the statement that was made or the incident that was reported because the night was very busy, and the residents were restless, and she was running around helping a lot of people. Administrative Nurse D called LN G and spoke to her about the incident that occurred. LN G stated she never said anything like that. LN G stated she went to R1's room and told her to use her call light if she needed help because she knew how to use a call light. LN G stated R1 was sitting in her recliner and when LN G left the room, R1 used her call light, and CNA N went into her room to assist her. LN G was placed on suspension while the investigation was pending. LN G had worked one shift after the incident, the night shift of 08/06/23 06:00 PM to 06:00 AM. On 08/11/23 at 09:30 AM, Administrative Nurse D interviewed R1 about the incident that was reported. R1 stated, Yes the nurse yelled at me at supper and then again during the night. Administrative Nurse D asked R1 if she remembered what the nurse said and R1 stated, No I just remember her yelling at me and it making me feel worse. I don't know what I did wrong. Administrative Nurse D assured R1 she did not do anything wrong. When Administrative Nurse D interviewed R1, R1's arms and hands were shaking and Administrative Nurse D assured R1 the facility would protect her and do the right thing, and R1 thanked Administrative Nurse D. On 08/11/23, LN G came to the facility to speak with Administrative Nurse D and to fill out a Witness Statement. LN G told Administrative Nurse D she had a hard time when the residents were restless and when R1 yelled out a lot, LN G had to step away, but she had not yelled or said anything inappropriate to the residents. Administrative Nurse D spoke to three cognitively intact residents. Two of the residents had no problems with LN G. R2 stated LN G had yelled and cussed at him before and he did not like her. R2 denied LN G had been physically mean to him. Administrative Nurse D spoke to CNA N about LN G. CNA N stated LN G got overwhelmed when the residents were crazy and LN G would make comments about wanting to kill herself, but CNA N stated she had never heard LN G be mean to someone when CNA N had been in the room, but LN G would make comments about hating it at the facility and wanting to kill herself. Administrative Nurse D interviewed CMA R, who had recently switched to day shift from night shift. CMA R stated LN G was a very loud person with a horrible potty mouth. CMA R stated she had heard LN G yelling in the halls and cussing about residents. CMA R did not know if the residents heard or understood LN G. CMA R stated LN G would get frustrated and voice her feelings very loud in the hall and there were several nights when a resident was yelling out all night and LN G would go into their room and tell them to be quiet and shut their door so she could not hear them. CMA R stated she would go and open the resident's doors up and check on them or talk to them. CMA R stated there were times she would tell LN G a resident was anxious, and LN G would say she wasn't going to give the resident anything because she did not want them to make them sleep too much and LN G did not want to chemically restrain the residents. CMA R stated LN G did not want to do anything when she was at the facility and would complain all of her shift. On 08/14/23 the facility terminated the employment of LN G. On 08/15/23 at 10:00 AM, observation revealed R1 seated at the dining room table in the commons area coloring in a picture book. On 08/15/23 at 10:00 AM, R1 stated the nurse had yelled at her and growled at her and she was scared, but she was not scared anymore. On 08/15/23 at 11:30 AM, CNA M stated she had heard LN G yell at R1 stating Shut the [expletive] up or I am going to kill you! CNA M stated she did not know what to do about the situation but knew what LN G said was horribly inappropriate and something needed to be done. On 08/15/23 at 12:50 PM, Administrative Nurse D stated the results of the investigation she conducted showed LN G did not have a lot of patience, could be loud and inappropriate in the halls, and LN G did not need to be working with the elderly. Administrative Nurse D stated she expected staff to know the reporting procedure for any alleged abuse and neglect allegations, so the facility could provide safety for the residents. On 08/15/23 at 03:30 PM, Administrative Staff A expressed regret the facility hired LN G and said she expected all staff to know and adhere to the abuse and neglect policy of the facility. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated September 2022, documented all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to the local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation of resident property must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or results in bodily harm or within 24 hours of an allegation that does not involve abuse or result in bodily harm. The facility failed to ensure R1 and R2 were free from staff abuse and mistreatment. This placed R1 and R2 in immediate jeopardy. On 08/15/23, the onsite surveyor verified the following corrective actions to remove the immediacy for R1 and R2: On 08/10/23 the facility immediately educated CNA M, CNA N, LN H on the process of how to report abuse, neglect, and exploitation. The facility immediately suspended LN G pending the investigation. On 08/10/23 the facility submitted the incident to the State Agency. On 08/11/23 Administrative Nurse D filed a police report. On 08/15/23 Administrative Nurse D reported LN G to Kansas State Board of Nursing Licensing Department. On 08/15/23 the facility emailed all agency staff schedulers the abuse, neglect, and exploitation (ANE) information and what the facility expected of their staff upon entering the facility. On 08/15/23 Administrative Nurse D and Administrative Staff A educated all staff either in person or via phone call about the facility expectations regarding ANE. The facility also gave written warnings to the staff who heard LN G act inappropriately during her shift and failed to report to Administrative Nurse D or Administrative Staff A. On 08/15/23 the facility hung posters in staff areas regarding the proper way to report any suspicion of ANE, provided all residents the same information for self-reporting, and called resident representatives regarding the provided information as well. After the immediacy was removed, the deficient practice remained at the scope and severity of G to represent the isolated, actual harm to R1 as evidence by R1's verbalizations of fear.

The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview the facility failed to ensure staff identified a situation of verbal and mental abuse and mistreatment as an allegation of abuse and failed to immediately report to the facility administrator (LNHA). On 08/06/23 at approximately 02:00 AM, Certified Nurse Aide (CNA) M heard Licensed Nurse (LN) G holler at Resident (R)1 shut the [expletive] up or I swear I will kill you. CNA M asked CNA N who she should report the incident to, and CNA N told CNA M to talk to Administrative Nurse D next time CNA M saw her. Five days later, CNA M reported the incident to LN H. Upon receiving the allegation, the facility started an investigation which revealed another resident, R2, reported LN G had yelled and cussed at him. The investigation further revealed other staff heard LN G cussing in the hallways and telling residents to be quiet, then shutting the residents' doors so LN G would not have to hear them yelling, though the staff had not reported this to the facility administrator when it occurred. The facility failed to ensure staff identified a situation of verbal and mental abuse and mistreatment as an allegation of abuse and failed to immediately report to the LNHA. This placed R1 and R2 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of insomnia (inability to sleep), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and age-related debility. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R1 required limited to extensive assistance with all activities of daily living (ADL) except for eating which was supervision/set-up help. The MDS documented R1 exhibited verbal behaviors directed towards others one to three days during the look back period. The MDS documented R1 had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming/disruptive sounds) one to three days during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/15/23, documented R1 had severe cognitive impairment and required cues for recall. The Behavioral Symptom CAA, dated 05/15/23, documented R1 had behaviors of yelling/screaming and crying. The Behavioral Care Plan, dated 05/22/23, documented R1 had occasional episodes of yelling/screaming and directed staff to analyze key times, places, circumstances, triggers, and what de-escalated R1's behavior and document. The care plan directed staff to assess and anticipate R1's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. The Impaired Cognitive Function Care Plan, dated 05/09/23, directed staff to cue, reorient, and supervise R1 as needed. The care plan directed staff to monitor/document/report as needed any changes in cognitive function specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The Nurse's Note, dated 06/22/23, documented R1 was in bed and yelling about wanting to get up. R1 stated, I wish I could just go to sleep but I can't. The Mood/Behavior Note, dated 08/06/23 at 01:00 AM, documented R1 yelled help me and please and woke up other residents. R1 exhibited this behavior from 08/05/23 at 07:00 PM to 08/06/23 at 01:00 AM. R1 was in her room, in her recliner watching television. When staff asked R1 what she needed or why she was hollering R1 stated, I don't know or I'm not hollering. Staff told R1 that she was disturbing other residents and R1 stated, No I'm not. Interventions that were tried: food, beverages, pain medication, repositioning, different setting, different staff approaching, and talking to R1. None of the interventions were effective. The Facility Incident Report, dated 08/14/23, documented on 08/10/23 at 07:48 PM Administrative Staff A called Administrative Nurse D to inform her a report was made to the night shift nurse LN H, by CNA M, that LN G yelled at R1 during the night on 08/06/23 at approximately 02:00 AM. CNA M reported she went to the nurses station to ask CNA N to help her with repositioning another resident. While CNA M and CNA N were in the nurse's station, CNA M stated she heard R1 yelling out and LN G went to R1's room and told R1 to Shut the [expletive] up or I swear I am going to kill you. CNA M stated she asked CNA N what she should do since she didn't know who to call or where the information was so turn it in. CNA M stated she did not feel the interaction was appropriate. CNA M stated CNA N told her she should talk to Administrative Nurse D when she saw her next. Administrative Nurse D went to the facility to interview CNA M and educated CNA M on proper Abuse, Neglect, and Exploitation procedure and to call Administrative Nurse D any time with concerns. CNA M then filled out a witness statement. Administrative Nurse D called CNA N to ask what had occurred. CNA N stated she did not remember the statement that was made or the incident that was reported because the night was very busy, and the residents were restless, and she was running around helping a lot of people. Administrative Nurse D called LN G and spoke to her about the incident that occurred. LN G stated she never said anything like that. LN G stated she went to R1's room and told her to use her call light if she needed help because she knew how to use a call light. LN G stated R1 was sitting in her recliner and when LN G left the room, R1 used her call light, and CNA N went into her room to assist her. LN G was placed on suspension while the investigation was pending. LN G had worked one shift after the incident, the night shift of 08/06/23 06:00 PM to 06:00 AM. On 08/11/23 at 09:30 AM, Administrative Nurse D interviewed R1 about the incident that was reported. R1 stated, Yes the nurse yelled at me at supper and then again during the night. Administrative Nurse D asked R1 if she remembered what the nurse said and R1 stated, No I just remember her yelling at me and it making me feel worse. I don't know what I did wrong. Administrative Nurse D assured R1 she did not do anything wrong. When Administrative Nurse D interviewed R1, R1's arms and hands were shaking and Administrative Nurse D assured R1 the facility would protect her and do the right thing, and R1 thanked Administrative Nurse D. On 08/11/23, LN G came to the facility to speak with Administrative Nurse D and to fill out a Witness Statement. LN G told Administrative Nurse D she had a hard time when the residents were restless and when R1 yelled out a lot, LN G had to step away, but she had not yelled or said anything inappropriate to the residents. Administrative Nurse D spoke to three cognitively intact residents. Two of the residents had no problems with LN G. R2 stated LN G had yelled and cussed at him before and he did not like her. R2 denied LN G had been physically mean to him. Administrative Nurse D spoke to CNA N about LN G. CNA N stated LN G got overwhelmed when the residents were crazy and LN G would make comments about wanting to kill herself, but CNA N stated she had never heard LN G be mean to someone when CNA N had been in the room, but LN G would make comments about hating it at the facility and wanting to kill herself. Administrative Nurse D interviewed CMA R, who had recently switched to day shift from night shift. CMA R stated LN G was a very loud person with a horrible potty mouth. CMA R stated she had heard LN G yelling in the halls and cussing about residents. CMA R did not know if the residents heard or understood LN G. CMA R stated LN G would get frustrated and voice her feelings very loud in the hall and there were several nights when a resident was yelling out all night and LN G would go into their room and tell them to be quiet and shut their door so she could not hear them. CMA R stated she would go and open the resident's doors up and check on them or talk to them. CMA R stated there were times she would tell LN G a resident was anxious, and LN G would say she wasn't going to give the resident anything because she did not want them to make them sleep too much and LN G did not want to chemically restrain the residents. CMA R stated LN G did not want to do anything when she was at the facility and would complain all of her shift. On 08/14/23 the facility terminated the employment of LN G. On 08/15/23 at 10:00 AM, observation revealed R1 seated at the dining room table in the commons area coloring in a picture book. On 08/15/23 at 10:00 AM, R1 stated the nurse had yelled at her and growled at her and she was scared, but she was not scared anymore. On 08/15/23 at 11:30 AM, CNA M stated she had heard LN G yell at R1 stating Shut the [expletive] up or I am going to kill you! CNA M stated she did not know what to do about the situation but knew what LN G said was horribly inappropriate and something needed to be done. On 08/15/23 at 12:50 PM, Administrative Nurse D stated the results of the investigation she conducted showed LN G did not have a lot of patience, could be loud and inappropriate in the halls, and LN G did not need to be working with the elderly. Administrative Nurse D stated she expected staff to know the reporting procedure for any alleged abuse and neglect allegations, so the facility could provide safety for the residents. On 08/15/23 at 03:30 PM, Administrative Staff A expressed regret the facility hired LN G and said she expected all staff to know and adhere to the abuse and neglect policy of the facility. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated September 2022, documented all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to the local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation of resident property must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or results in bodily harm or within 24 hours of an allegation that does not involve abuse or result in bodily harm. The facility failed to ensure staff identified a situation of verbal and mental abuse and mistreatment as an allegation of abuse and failed to immediately report to the LNHA. This placed R1 and R2 in immediate jeopardy. On 08/15/23, the onsite surveyor verified the following corrective actions to remove the immediacy for R1 and R2: On 08/10/23 the facility immediately educated CNA M, CNA N, LN H on the process of how to report abuse, neglect, and exploitation. The facility immediately suspended LN G pending the investigation. On 08/10/23 the facility submitted the incident to the State Agency. On 08/11/23 Administrative Nurse D filed a police report. On 08/15/23 Administrative Nurse D reported LN G to Kansas State Board of Nursing Licensing Department. On 08/15/23 the facility emailed all agency staff schedulers the abuse, neglect, and exploitation (ANE) information and what the facility expected of their staff upon entering the facility. On 08/15/23 Administrative Nurse D and Administrative Staff A educated all staff either in person or via phone call about the facility expectations regarding ANE. The facility also gave written warnings to the staff who heard LN G act inappropriately during her shift and failed to report to Administrative Nurse D or Administrative Staff A. On 08/15/23 the facility hung posters in staff areas regarding the proper way to report any suspicion of ANE, provided all residents the same information for self-reporting, and called resident representatives regarding the provided information as well. After the immediacy was removed, the deficient practice remained at the scope and severity of D