Every finding on record at Mcpherson Operator, LLC

Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for the residents who resided in the facility and received meals from the facility's kitchen. Findings included:- On 07/13/26 at 11:30 AM, during a follow-up tour of the dietary department/kitchen, observations revealed:The steam table where prepared food was stored leaked water onto the floor, which was not contained beneath the steam table.The steam table had a black, round power cord that hung above the food being served, which had grey fuzzy material on it.The metal shelving next to the steam table, which stored steam table pans and various other dishes, had a sticky material/grease like feel.The water piping, which was below the dishwasher and three-compartment sink, had black, brown buildup of debris.Dietary Staff (DS) DD prepared and served beverages for the residents, by handling the drinking surface of cups and glasses without washing hands between residents or wearing gloves.DS DD wore a hairnet that did not cover/contain hair while in and out of the kitchen while food and drinks were prepared and served.DS CC lacked the use of gloves while obtaining and preparing two peanut butter sandwiches.During plating food, DS CC handled the plates with his thumb touching the surface on which the food was placed.The fluorescent lights throughout the kitchen and dining room had bug debris in them. On 07/13/26 at 12:30 PM, Consultant GG verified concerns with cleanliness and serving concerns and reported the facility had plans to do some upkeep, cleaning, remodeling, and safe serving. The facility's Sanitation policy, dated 10/2025, documented all kitchen areas and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. The facility's Preventing Foodborne Illness, dated 10/2025, documented food service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Hairnets and/or chef caps and/or beard restraints must be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Contact between food and bare (ungloved) hands is prohibited.

Based on observation and interview, the facility failed to maintain a homelike environment free of unsafe flooring. Findings included:- Observations from 07/12/26 through 07/14/206 revealed concerns with the following flooring:rooms [ROOM NUMBER] had black tape holding down the wood-like laminate flooring in various places throughout the rooms.Rooms 12, 26, 35, and 36 had missing wood-like laminate planks in various places throughout the rooms.The therapy room and activity rooms had black tape holding down wood-like laminate planks throughout the entire rooms. On 07/14/26 at 01:00 PM, Administrative Staff A reported that the facility had a contractor coming to the facility on [DATE] to evaluate the flooring for replacement, and the flooring had been a concern. Administrative Staff A stated it was monitored through the Quality Assurance (QA) meetings for several months. The facility's Floor policy, dated 12/2009, documented that the floors shall be maintained in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 6 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication without an appropriate indication of use or a physician documented rationale, including risks versus benefits and review of nonpharmacological interventions that were attempted and failed. Findings included:- R6's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation, chronic pulmonary edema (accumulation of extravascular fluid in the lung tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R6 had intact cognition with inattention and disorganized thinking, which fluctuated. R6 had not exhibited behaviors. R6 required substantial/maximal support for functional abilities and was dependent on mobility. R6 received a scheduled pain medication regimen and had a condition or chronic disease that may have resulted in a life expectancy of less than six months. The MDS further documented that R6 received an antipsychotic, antidepressant, anticoagulant, diuretic (medication used to promote excretion of fluids), and anticonvulsant. R6 received the antipsychotic on a routine basis, had no gradual dose reduction (GDR) attempt, or physician-documented contraindication. R6's Care Plan initiated on 01/15/2026 documented that R6 utilized psychotropic medications; Seroquel (antipsychotic) and Depakote (anticonvulsant) related to behavior management of dementia with agitation and major depressive disorder. The plan directed staff to administer medications as ordered, consult with pharmacy and physician to consider dosage reduction when clinically appropriate, and the ongoing need for the use. The plan also directed staff to monitor and record the occurrence of target behavior, side effects, and adverse effects of psychotropic medications. The Progress Note dated 02/18/2026 at 04:58 PM documented that R6 had been verbally aggressive with staff, cursing and yelling at them. Staff attempted to assist him with care, and he continued to curse the staff. When the staff left the room, R6 began banging on the wall. The Physician Order date 02/20/2026 directed staff to administer Seroquel 25 milligrams (mgs) at bedtime for a mood disorder and discontinue Abilify (an antipsychotic). The Progress Note dated 03/09/2026 documented that R6 appeared to be tolerating medication well and occasionally yelled out after meals if not taken back to his room. The staff reported that R6 had been cooperative during care. The Progress Note dated 03/26/2026 at 10:25 AM documented that while staff was assisting R6 with lying down after breakfast, R6 made inappropriate sexual comments. The staff informed R6 that he was inappropriate, ensured R6 had a call light, and left the room. The Physician Order dated 04/02/2026 directed staff to administer Seroquel 25 mg twice a day for increased agitation. The Progress Note dated 04/16/2026 at 01:27 AM documented that R6 was being monitored due to increased behaviors including verbally abusive to staff. R6 had received as-needed anti-anxiety medications earlier in the night and had not had any more behaviors so far of the shift. The Physician Order dated 04/30/2026 directed staff to administer Seroquel 25 mg in the morning and Seroquel 50 mg in the evening. R6's EMR lacked documentation related to the nonpharmacological interventions that were attempted prior to initiation of Seroquel. The record further lacked evidence of a physician documented rationale which included the risks versus benefits for use of the Seroquel. On 07/13/2026 at 09:30 AM, R6 finished breakfast in the dining room. Certified Medication Aide (CMA) S administered R6's medications. CMA S reported that R6 was cooperative for her, but he could be resistive to care provided by the Certified Nurse Aides (CNA), during which he became verbally and physically abusive. On 07/14/2026 at 10:28 AM, CNA N reported R6 had a few behaviors related to hollering out. CNA N stated she tried to figure out what R6 may need, and R6 could usually verbalize needs. CNA N stated that if R6 had behaviors, she would document them in the EMR and notify the nurse. CNA N was unsure what interventions were for R6's behaviors but would check the Care Plan for specifics. On 07/14/2026 at 11:21 AM, Licensed Nurse (LN) G reported that R6's behaviors consisted of calling out when he wanted to lie down. LN G reported that the CNA's could usually figure out what he needed, and R6 was easily redirected. LN G stated the nurses would document in the progress notes about behaviors and interventions used to treat the resident. On 07/14/2026 at 02:08 PM, Administrative Nurse D reported that R6 had been taking Seroquel due to behaviors. Administrative Nurse D reported the nursing staff would document behaviors and interventions in the progress notes. Administrative Nurse D was unaware of the indications for the use of antipsychotics. The facility's Use of Psychotropic Drugs policy, dated 04/2025, documented residents will only receive psychotropic or other approved medications that have an effect on brain activity when necessary to treat specific conditions for which they are indicated and are effective, and will not be used for discipline or convenience of the staff. Adequate indications for use refer to the identified, documented clinical rationale for administering a medication, which is based upon an assessment of the resident's condition and therapeutic goals, after any other treatments have been clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with the manufacturer's recommendation and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals.

Based on observation, interview, and record review, the facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) for one resident, Resident (R) 46, upon the resident's discharge from the facility. Findings included:- R46's Electronic Medical Record (EMR) documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow) of the lower leg, acquired absence of the left leg below the knee (surgical removal of the body part), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two.The admission Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R46 had intact cognition. R46 required supervision with toileting hygiene, lower body dressing, and setup assistance with eating, upper body dressing, personal hygiene, and mobility. R46 had lower functional impairment on both sides, had a surgical wound, and had a fall with injury.R46's 03/30/2026 Care Plan documented the following interventions for R46:03/26/2026- R46's goal was to be discharged to home upon completion of skilled services and would like home health services. The care plan documented by the facility would make arrangements with required community resources to support independence post discharge.03/30/2026- obtain blood work and blood cultures as ordered, follow facility protocols for treatments of wounds, and administer medications as ordered. The Nurse's Note, dated 04/28/2026, documented R46 stated he was going to go stay with his family member until he went to his upcoming appointment. Staff explained that they required a physician's order to leave the facility. R46 stated he would pack up his stuff and just leave. The staff explained that if he left against medical advice (AMA), the facility would not be able to send any medication with him and that the insurance might not pay for his state, but R46 did not care. R46 signed AMA paperwork, packed his belongings, and sat outside until his family arrived.R46's EMR lacked a complete recapitulation of his stay in the facility.On 07/14/2026 at 01:50 PM, Administrative Nurse D stated R46 had left AMA during the evening shift. Usually, social service and nursing complete the discharge paperwork. Administrative Nurse D verified a completed recapitulation was not done for R46.The facility's Discharge Summary and Plan policy, dated 03/2026, documented the discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The recapitulation would include, but not limited to: diagnoses, course of illness, treatment or therapy, pertinent lab, audiology, and consultation results, reconciliation of all pre-discharge medications with the resident's post-discharge medications, for prescribed and over the counter, and a final summary paragraph that may be released to any provider with the consent of the resident or representative.

Based on observation, interview, and record review, the facility failed to ensure staff used alternative communication methods for one resident, Resident (8), who had difficulty speaking. Finding included:- R8's Electronic Medical Record (EMR) documented diagnoses of left submandibular gland mass ( a lump or swelling in the salivary gland located just below the jawbone, tongue mass (an unusual lump or growth on the tongue), dysphasia (difficulty swallowing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinsons disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, and severe protein calorie malnutrition (a life threatening condition caused by a prolonged deficit in both protein and energy intake).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had intact cognition. R8 required partial staff assistance with showers, lower body dressing, putting on his shoes, mobility, and transfers. The MDS documented that he had adequate hearing, unclear speech, usually made himself understood, and moved or spoke slowly for 12 to 14 days during the lookback period. The MDS further documented R8 felt bad about himself for two to six days and felt depressed for two to six days of the lookback period.R8's 05/04/2026 Care Plan included the following interventions:02/04/2026- allow R8 time to speak. Ensure the television was turned down, low noise to be able to hear him, anticipate and meet his needs, encourage him to continue stating thoughts even if he was having difficulty, focus on a word or phrase that made sense, or respond to the feelings R8 was trying to express. The care plan further directed staff to monitor for physical, nonverbal indicators of discomfort or distress, wait 30 seconds before providing R8 with words, document R8's ability to express and comprehend language, memory, reasoning ability, problem-solving, and ability to attend. The CP directed staff to monitor the changes in his ability to communicate and the contributing factors for communication problems and validate R8's message by repeating it aloud.On 07/12/2026 at 08:55 AM, R8 sat in his recliner. R8 was unshaven, he had on a t-shirt that had several large areas of dried sputum (a mixture of saliva and mucus that is coughed up from the lower respiratory tract), no socks or shoes, and his hair was uncombed. The pressure-reducing cushion in his chair also had dried sputum and debris on it, and his gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) was unsecured and lying freely on his lap. R8's tongue protruded (extended or bulged outward) from his mouth, and he had drool coming out of his mouth that hung down to his shirt. His speech was unclear and soft in tone. As he started to speak, he began to cough, and he had a large amount of thick yellow sputum that he coughed into a tissue. He tried to throw it away in the trash can that sat beside the recliner, but he missed, and it went onto the floor. He had a pad of paper and a pen beside his bed that had a lot of writing on it, which looked unclear. On 07/13/2026 at 08:00 AM, R8 sat in his recliner. When asked how he was doing, he leaned over to his pad of paper and started to write. His writing was shaky, misspelled, and parts of the words were illegible, but eventually communicated that he had had a bad night. He had a towel on his lap and a washcloth on the bedside table. R8 attempted to talk, but his speech was unclear. On 07/13/2026 at 10:30 AM, Licensed Nurse (LN) G gowned and gloved and went into R8's room to administer his 10:00 AM enteral feeding (tube feeding of liquid nutrition directly into the gastrointestinal tract). R8 sat in his recliner with his head resting on the bedside table next to his recliner. LN G attempted to ask him questions about his pain and if he was feeling ok, but his speech was unclear. R8 attempted to write on the pad of paper, but LN G was unable to decipher what was on the paper. She continued to ask the same questions and asked if he wanted his 10:00 AM feeding. R8 continued to try to speak, and LN G would ask him different questions, but he did not give answers that we could understand. LN G asked him again if he wanted his feeding, and he shook his head yes. R8 was still leaning to the left, and LN G asked him to sit up better; he complied. LN G finished his feeding and put the g-tube under his shirt.On 07/13/2026 at 10:45 AM, LN G stated she had tried to give R8 a paper with words so he could tell her what he needed, but she was unsure where it was. She stated that at times it was very difficult to understand what he was saying because the mass in his mouth had gotten larger over the last two weeks. LN G stated that sometimes it was like playing charades to understand what he wants or needs.On 07/13/2026 at 02:50 PM, CNA M stated that sometimes R8 would write down words, shake his head yes or no, but sometimes staff did not really know what he wanted.On 07/14/2026 at 10:50 AM, Certified Medication Aide R stated R8 wrote small, so it was sometimes hard to know what he wanted, but could shake his head yes or no.On 07/14/2026 at 10:20 AM, Social Services X stated R8 would type in his phone to tell her what he needed, but she had to guess what he said, and she would continue to try to decipher the words. Social Services X further stated that she would have to find someone to help her understand what he needed.On 07/14/2026 at 01:45 PM, Administrative Nurse D stated that the mass in R8's tongue has increased in size over the last couple of weeks and that he can say yes or no answers but was very soft spoken. She further stated she had not thought about providing him with any alternative communication methods to help with communication.The facility's Quality of Life-Activities of Daily Living policy, dated 03/2026, documented that the community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Residents are provided with appropriate care and services, including communication.

Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL) for one resident, Resident (R) 8, who required assistance from staff with dressing, grooming, and shaving. Findings included:- R8's Electronic Medical Record (EMR) documented diagnoses of left submandibular gland mass (a lump or swelling in the salivary gland located just below the jawbone, tongue mass (an unusual lump or growth on the tongue), dysphasia (difficulty swallowing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinsons disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, and severe protein calorie malnutrition (a life threatening condition caused by a prolonged deficit in both protein and energy intake).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had intact cognition. R8 required partial staff assistance with showers, lower body dressing, putting on his shoes, mobility, and transfers. The MDS documented R46 required supervision with upper body dressing, personal hygiene, and ambulation. The MDS further documented R8 felt bad about himself for two to six days and felt depressed for two to six days of the lookback period.R8's 05/04/2026 Care Plan included the following interventions:02/05/2026- provide one person assistance with bathing, personal hygiene. Allow R46 sufficient time for dressing and undressing. He required oral care frequently due to dry mouth. The plan directed staff to report any decline in function.On 07/12/2026 at 08:55 AM, R8 sat in his recliner. R8 was unshaven, he had on a t-shirt that had several large areas of dried sputum (a mixture of saliva and mucus that is coughed up from the lower respiratory tract), no socks or shoes, and his hair was uncombed. The pressure-reducing cushion in his chair also had dried sputum and debris on it, and his gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) was unsecured and lying freely on his lap. R8's tongue protruded (extended or bulged outward) from his mouth, and he had drool coming out of his mouth that hung down to his shirt. His speech was unclear and soft in tone. As I started to talk to him, he began to cough, and he had a large amount of thick yellow sputum that he coughed into a tissue. He tried to throw it away in the trash can that sat beside the recliner, but he missed, and it went onto the floor.On 07/13/2026 at 08:00 AM, R8 sat in his recliner. He had a towel on his lap and a washcloth on the bedside table.On 07/12/2026 at 12:40 PM, R8 sat in his recliner with no socks or shoes on. His bare feet were on the floor. He leaned over with his chest on his knees and remained there.On 07/13/2026 at 10:40 AM, after his enteral feeding, Licensed Nurse (LN) G said R8 was never shaved by staff. Observation revealed R8 put his hand to his face and LN G asked him if he would like to be shaved, R46 shook his head up and down to indicate yes. LN G stated she would send someone down to sort it all out.On 07/13/2026 at 11:45 AM, R8 walked with his walker from the bathroom. He had drool hanging from his mouth. He was not wearing any socks or shoes and was still unshaven.On 07/14/2026 at 07:30 AM, R8 was in his recliner, feet elevated. He leaned to the left with his head lying on the bedside table.On 07/14/2026 at 08:25 AM, R8 sat in his recliner. His bed pillow was on the floor; he had a soiled washcloth draped over one arm of the walker. He leaned over and took his phone out of the trash can.On 07/13/2026 at 02:50 PM, Certified Nurse Aide (CNA) M stated R8 was a one person assist with transfers and ambulation, and he was not to be up alone in his room. She stated staff got him up for the day early in the morning, changed his clothes if needed, and repositioned him every two hours and as needed.On 07/14/2026 at 01:45 PM, Administrative Nurse D stated R8 was usually up around 06:00 AM; staff got him dressed, made sure he was clean, and had what he needed. Administrative Nurse D further stated staff should make sure R8 had clean clothes and make sure his hair was combed.The facility's Quality of Life-Activities of Daily Living policy, dated 03/2026, documented that the community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure one resident, Resident (R) 8, was invited or provided with individualized person-centered activities. Findings included:- R8's Electronic Medical Record (EMR) documented diagnoses of left submandibular gland mass ( a lump or swelling in the salivary gland located just below the jawbone, tongue mass (an unusual lump or growth on the tongue), dysphasia (difficulty swallowing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinsons disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, and severe protein calorie malnutrition (a life threatening condition caused by a prolonged deficit in both protein and energy intake).The Admission/5 Day Medicare Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired cognition. R8 was dependent upon staff assistance for toileting hygiene, lower body dressing, putting on shoes, mobility, and transfers. R8 was depressed seven to eleven days of the lookback period, had inattention, disorganized thinking, and his level of consciousness fluctuated. The MDS further documented R8 felt listening to music, keeping up with news, going outside, doing things in groups, and religious services were somewhat important.The Quarterly MDS, dated 05/05/2026, documented R8 had intact cognition. R8 required partial staff assistance with showers, lower body dressing, putting on his shoes, mobility, and transfers. The MDS documented R8 felt bad about himself for two to six days and felt depressed for two to six days of the lookback period.R8's 05/04/2026 Care Plan included the following interventions:02/05/2026- R8 was dependent upon staff for activities, cognitive stimulation, and social interaction. All staff are to converse with him while providing care, encourage ongoing family involvement, and invite the family to attend special events, activities, and meals. Introduce R8 to residents with similar backgrounds and interests, and encourage/facilitate interaction. Inviting R8 to schedule activities, he needed 1:1 bedside/in-room visits and activities if unable to attend out of room events. R8 required assistance /escorted to activity functions and would require assistance from staff during the activity. The care plan further directs staff to modify his daily schedule to accommodate his activity participation and provide a program of activities that were of interest and empowered him by encouraging/allowing choice, self-expression, and responsibility. Provide him with an activity calendar and notify him of any changes. If he chooses not to participate, turn on the television or music.The Recreation/Activity admission Assessment, dated 02/09/2026, documented R8 enjoyed music, news, doing things in groups of people, religious services, and going outside,The EMR for R8 lacked documentation he was invited to or participated in activities.On 07/14/2026 at 07:30 AM, R8 was in his recliner with his feet elevated. He leaned to the left with his head lying on the bedside table; he had his television on.On 07/13/2026 at 02:50 PM, Certified Nurse Aide M stated R8 did not attend activities, he watches television in his room or family would visit.On 07/14/2026 at 10:00 AM, Activity Z stated that R8 went to some activities but did not participate by observing. Activity Z stated most of the activities involved food and since R8 cannot eat, he does not like to go to the activity. She further stated that she does not document when resident's go to the activities unless they are doing outside of the facility, so she was unable to provide dates and activities that he attended. Activity Z further stated she did give him some magazines, and she will take him his mail but does not have any type of in-room activity for him.On 07/14/2027 at 10:45 AM, Licensed Nurse (LN) G stated, R8 did not attend activities, he stays in his room most of the time except when he had physical therapy.On 07/14/2026 at 01:45 PM, Administrative Nurse D stated that staff takes him outside for short periods of time during breakfast meal and that they were planning on implementing a new program for activities.The facility's Activities and Social Events policy, dated 10/2025, documented resident had the right to choose the types of activities and social events in which they wished to participate in. Activities, social events, and schedules are developed in conjunction with the residents' interests, assessment, and plan of care. The staff would evaluate a resident's physical and mental capacity to participate in various levels of activities. They would note in the medical record any restrictions or needs that might be relevant to participation.

Based on observation, interview, and record review, the facility failed to implement effective person-centered interventions and review the interventions for effectiveness after repeated falls in order to prevent falls for one resident, Resident (R)8, who had multiple falls. Findings included:- R8's Electronic Medical Record (EMR) documented diagnoses of left submandibular gland mass ( a lump or swelling in the salivary gland located just below the jawbone, tongue mass (an unusual lump or growth on the tongue), dysphasia (difficulty swallowing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinsons disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, and severe protein calorie malnutrition (a life threatening condition caused by a prolonged deficit in both protein and energy intake).The Admission/5 Day Medicare Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired cognition. R8 was dependent upon staff assistance for lower body dressing, putting on shoes, mobility, transfers, and dependent upon staff for toileting. R8 had no functional impairment, no falls, was continent of bladder and bowel and did not ambulate.The Quarterly MDS, dated 05/05/2026, documented R8 had intact cognition. R8 required partial staff assistance with showers, lower body dressing, putting on his shoes, mobility, transfers, toileting, and supervision with ambulation. The MDS documented R8 had no functional limitations, was occasionally incontinent of bladder, and had two or more falls with injury.The Fall Risk Assessments, dated 01/30/2026 and 04/30/2026, documented R8 was a high risk for falls. R8's 05/04/2026 Care Plan included the following interventions:03/12/2026-Anticipate and meet his needs, be sure his call light is ready and encourage him to use it when needing assistance, educate him and his family about safety reminders, follow facility fall protocol, offer toileting, encourage him to lay down in bed in the afternoon, and physical therapy to evaluate and treat. The care plan directed staff to review root cause of past falls, educate the resident, and ensure that he wore appropriate footwear when transferring or in a wheelchair.03/13/2026-orange tape placed around the call light as a reminder to use the call light for assistance.04/29/2026-Provide verbal education to R8 to ask staff to assist with moving furniture.05/05/2026- Verbal education on call light use and toileting assistance was provided.07/07/2026-Signage placed in room to remind R8 to use his call light for assistance.The Fall Investigation, dated 02/02/2026 at 06:30 PM, documented staff found R8 on the floor during walking rounds. He stated he was trying to get changed. The investigation documented the root cause was that he had two mattresses on his bed, and they took off the regular mattress and left on the air mattress.The Fall Investigation, dated 03/11/26 at 04:22 PM, documented R8 was in the bathroom seated on his wheelchair pedals. R8 was unable to say what he was doing. The investigation documented that R8 sustained a skin tear (a traumatic wound that occurs when the outer layer of skin separates from the underlying tissue) to his left forearm that measured two centimeters (cm) x 1.5 cm. R8 had decreased safety awareness and gait imbalance. Staff assisted R8 to the bathroom and back to his bed. Orange tape was placed around the call light, and he was educated to call for assistance.The Fall Investigation, dated 03/12/2026 at 0245 PM, documented R8 was found lying on the floor in his bathroom between the toilet and his wheelchair. He was unable to tell staff what he was doing. The brakes were locked on his wheelchair, and he did not have on non-skid socks. R8 had gait imbalance, decreased safety awareness, and strength. He was assisted into bed, and education was provided for staff with the need to encourage or offer to lie down in the afternoon.The Fall Investigation, dated 04/29/2026 at 08:39 AM, documented R8 was on his left side with his head propped up by his arm. He was in the middle of the room between the recliner and television stand. R8 sustained a skinny tear to his left elbow. R8 stated that he tried to move a dining chair to a different spot in his room, lost his balance and fell. Three staff assisted R8 up and into his chair. Education was provided to R8 to call for assistance to move furniture.The Fall Investigation, dated 05/05/2026 at 06:21 PM, documented R8 was on the floor but got himself back up before the nurse could assess him. R8 did not sustain any injury and stated he tried to get himself to the bathroom, slipped and fell. R8 had decreased safety awareness and strength, and gait imbalance. Staff reeducated R8 to use his call light and wait for assistance.The Fall Investigation, dated 06/22/2026 at 03:07 AM, documented staff found R8 on all fours on the floor, he had an abrasion (scrape) to the middle of his forehead and a skin tear to his left elbow. R8 was unable to state what he was doing. Staff assisted the resident back into his recliner and educated him to use his call light. The Nurse's Note dated 07/07/2026 at 08:58 PM, documented R8 was lying on his left side in front of his recliner. His call light was in reach but not turned on. Staff placed signage in his room to remind him to use the call light. On 07/12/2026 at 02:15 PM, R8 walked out of the bathroom with the use of his walker. His gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) was unsecured and hung down between his legs when he walked.On 07/13/2026 at 11:45 AM, R8 walked over to his dresser with the use of his walker. His G-tube was unsecured and hung down between his legs.On 7/13/2026 at 10:30 AM, Licensed Nurse (LN) G stated he has had falls, she put a sign on the wall so that he could be reminded to use his call light when he got up alone. LN G stated R8 was getting physical therapy to help with strength and balance.On 07/13/2026 at 02:50 PM, Certified Nurse Aide (CNA) M stated R8 was a one person assist and has not gotten up on his own. He has had some falls and was reminded to call for assistance. CNA M stated R8 was impulsive and will get up when he wants to.On 07/14/2026 at 01:45 PM, Administrative Nurse D stated R8 was very weak when he came to the facility, he was very underweight, and he was now receiving therapy. Staff put a sign on his wall reminding him to use the call light for assistance. The facility's Falls and Fall Risk, managing policy, dated 06/2025, documented the interdisciplinary team would attempt to identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remained relevant.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent complications of enteral tube feeding for one resident, Resident (R)8 when staff failed to properly anchor and secure his gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) on four separate occasions. Findings included:- R8's Electronic Medical Record (EMR) documented diagnoses of left submandibular gland mass ( a lump or swelling in the salivary gland located just below the jawbone, tongue mass (an unusual lump or growth on the tongue), dysphasia (difficulty swallowing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinsons disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, and severe protein calorie malnutrition (a life threatening condition caused by a prolonged deficit in both protein and energy intake).The Admission/5 Day Medicare Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired cognition. R8 was dependent upon staff assistance for lower body dressing, putting on shoes, mobility, transfers, and dependent upon staff for toileting. The MDS further documented that R8 received 51% or more of his calories via g-tube and did not eat.The Quarterly MDS, dated 05/05/2026, documented R8 had intact cognition. R8 required partial staff assistance with showers, lower body dressing, putting on his shoes, mobility, transfers, toileting, and supervision with ambulation. The MDS further documented R8 received 51% or more of his calories via g-tube and did not eat.R8's 05/04/2026 Care Plan included the following interventions:02/04/2026- Administer medication as ordered, monitor for effectiveness and adverse effects, check residual prior to feeding or administer medications. If there were more than 100 milliliters (ml) of stomach content, withhold the feeding or medications and notify the physician. Discuss with R8 any concerns about tube feedings, the advantages, disadvantages and potential complications. Elevate the head of the bed at least 30-45 degrees (semi or high Fowler's position) if tolerated by the residents physical or medical condition during and for one hour after feeding or medication. R8 was to have nothing by mouth (NPO), obtain and monitor diagnostic work as ordered.The Physician's Order, dated 05/15/2026, directed staff to provide R8 with Two Cal HN (a concentrated, high-calorie and high-protein medical nutritional supplement), five times per day, via g-tube, total volume of 325 ml with each feeding.The Physician's Order, dated 05/15/2026, directed staff to flush the g-tube five times a day with water, 30 ml before and after each feeding, 30ml before and after each medication administration, and 5 to 10ml between each medication. On 07/12/2026 at 08:55 AM, R8 sat in his recliner. His G-tube was unsecured and lying freely on his lap. On 07/12/2026 at 02:15 PM, R8 walked out of the bathroom with the use of his walker. His G-tube was unsecured and hung down between his legs when he walked. On 07/13/2026 at 10:30 AM, Licensed Nurse (LN) G gowned and gloved and went into R8's room to administer his 10:00 AM enteral feeding (tube feeding of liquid nutrition directly into the gastrointestinal tract). LN G 8 asked him again if he wanted his feeding, and he shook his head yes. R8 was still leaning to the left, and LN G asked him to sit up better; he complied. LN G checked for residual, flushed his g-tube with 30 ml of water, she then provided him with 325 ml of his Two Cal, then flushed his g-tube again with 30 ml of water, without any concerns. After she was finished with his feeding she put the G-tube under R8's shirt but did not secure it.On 07/13/2026 at 11:45 AM, R8 walked over to his dresser with the use of his walker. His G-tube was unsecured and hung down between his legs.On 07/14/2026 at 10:45 AM, LN G verified that she does not secure the G-tube; she just puts it under his shirt.On 07/14/2026 at 01:45 PM, Administrative Nurse D stated, R8 had come to the facility with a binder but he did not like it, so the family took it home. She stated that they had not tried anything different to see if he could tolerate having the tube secured.The facility's Enteral Nutrition policy, dated 02/2026, documented residents who can eat enough alone or with assistance would not be fed by enteral methods unless the residents clinical condition demonstrated that the enteral feeding was clinically indicated and consented to by the resident and representative. Central supply or Food Service Manager would be responsible for ordering all tube feeding supplies.

Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the Director of Nursing and the Medical Director for Resident (R) 6's use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) without an appropriate indication or a physician documented rationale including risks versus benefits and a record of nonpharmacological attempts that were unsuccessful. Findings included: - R6's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation, chronic pulmonary edema (accumulation of extravascular fluid in the lung tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R6 had intact cognition with inattention and disorganized thinking, which fluctuated. R6 had not exhibited behaviors. R6 required substantial/maximal support for functional abilities and was dependent on mobility. R6 received a scheduled pain medication regimen and had a condition or chronic disease that may have resulted in a life expectancy of less than six months. The MDS further documented that R6 received an antipsychotic, antidepressant, anticoagulant, diuretic (medication used to promote excretion of fluids), and anticonvulsant. R6 received the antipsychotic on a routine basis, had no gradual dose reduction (GDR) attempt, or physician-documented contraindication. R6's Care Plan initiated on 01/15/2026 documented that R6 utilized psychotropic medications; Seroquel (antipsychotic) and Depakote (anticonvulsant) related to behavior management of dementia with agitation and major depressive disorder. The plan directed staff to administer medications as ordered, consult with pharmacy and physician to consider dosage reduction when clinically appropriate, and the ongoing need for the use. The plan also directed staff to monitor and record the occurrence of target behavior, side effects, and adverse effects of psychotropic medications. The Physician Order date 02/20/2026 directed staff to administer Seroquel 25 milligrams (mgs) at bedtime for a mood disorder and discontinue Abilify (an antipsychotic). The Physician Order dated 04/02/2026 directed staff to administer Seroquel 25 mg twice a day for increased agitation. The Physician Order dated 04/30/2026 directed staff to administer Seroquel 25 mg in the morning and Seroquel 50 mg in the evening. R6's EMR lacked documentation related to the nonpharmacological interventions that were attempted prior to initiation of Seroquel. The record further lacked evidence of a physician documented rationale which included the risks versus benefits for use of the Seroquel. The Pharmacist Medication Regimen Review dated 01/08/2026, 02/06/2026, 03/06/2026, 04/07/2026, 05/20/2026, 06/09/2026 and 07/09/2026, lacked mention of the appropriate indication of use for antipsychotic medication for R6. On 07/14/2026 at 10:28 AM, CNA N reported R6 had a few behaviors related to hollering out. CNA N stated she tried to figure out what R6 may need, and R6 could usually verbalize needs. CNA N stated that if R6 had behaviors, she would document them in the EMR and notify the nurse. CNA N was unsure what interventions were for R6's behaviors but would check the Care Plan for specifics. On 07/14/2026 at 11:21 AM, Licensed Nurse (LN) G reported that R6's behaviors consisted of calling out when he wanted to lie down. LN G reported that the CNA's could usually figure out what he needed, and R6 was easily redirected. LN G stated the nurses would document in the progress notes about behaviors and interventions used to treat the resident. On 07/14/2026 at 02:08 PM, Administrative Nurse D reported that R6 had been taking Seroquel due to behaviors. Administrative Nurse D reported the nursing staff would document behaviors and interventions in the progress notes. Administrative Nurse D was unaware of the indications for the use of antipsychotics. The facility's Medication Regimen Reviews, dated -3/2026, documented that the CP shall review the medication regimen per state and federal guidelines. The foci of the CP drug regimen review shall include, at a minimum, psychotropic drugs. A review of new orders for this class of drug to include the documentation of a specific condition as diagnosed and documented in the clinical record. The need for gradual dose reductions, behavioral interventions, unless clinically contraindicated, and review of the resident's psychotropic medications as needed for a documented diagnosis-specific condition.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff left an unlocked shower door open on Country Hall and Resident (R) 12 entered, fell , and sustained a fractured wrist. This placed the residents at risk for preventable accidents or injuries. Findings included: - R12's Electronic Medical Record (EMR) recorded diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and muscle weakness. R12's Quarterly Minimum Data Set (MDS), dated [DATE], recorded a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R12 required partial to moderate staff assistance with most Activities of Daily Living (ADL) and with tub to shower transfer. The Fall Care Area Assessment (CAA), dated 0716/24, was triggered but lacked a reason for the triggered area. R12's ADL Care Plan, dated 01/08/25, directed staff to provide one staff to assist with bathing and required supervision to one staff assistance with personal hygiene tasks, including brushing hair, oral care, and perineal cleansing. The care plan documented R12 frequently did not wait for assistance and would self-transfer and would frequently refuse staff assistance with ADLs. The care plan documented R12 would remove her oxygen at times and/or ambulate out of the room with her oxygen on, and staff would have to assist her to reapply her oxygen to avoid respiratory complications. R12's Fall Care Plan, dated 02/08/25, documented that the resident was at risk for falls, staff would place non-slip strips on the floor in front of the recliner, wear skid socks or shoes when ambulating, and staff to check on the resident frequently. The Fall Care Plan directed staff to place a non-slip pad on the wheelchair or chair and to use the call light when she needed assistance. The Fall Risk Evaluation, dated 12/09/24, documented a score of 14.0 (a score of 10.0 or greater indicated a high risk for falls). On 04/21/25 at 08:15 AM, observation revealed the shower room door on Country Hall was locked. The Nurses Note, dated 02/08/25 at 10:34 PM, recorded R12 was at the nurse's station around 07:45 PM and asked when her shower days were. The nurse aide stated on Tuesdays and Thursdays with hospice. The resident stated hospice was not here, and she wanted a shower. The nurse told the resident the staff were busy at the time, but they would get someone to assist her when things were less busy. R 12 went back to her room. The nurse was passing medications to other residents at the nurses' station. At approximately 10:00 PM, the nurse walked down the hall to take medications to another resident when someone was calling out from the shower room. The nurse entered the shower room and observed R12 sitting on her buttocks, naked on the floor, with her legs crossed. Observation revealed the resident's wheelchair was sitting in the doorway with her oxygen tank on her walker in her room across the hall from the shower house. The resident had a pull-up and her pajamas sitting on the counter, and her dirty clothes were folded on the counter in the shower room. The nurse reached for the resident's arm to obtain her blood pressure, and the resident requested her right arm be used. She held up her left arm and stated, This wrist is broken. Observation revealed the left wrist was swollen and deformed on the radial side (side closest to the wrist). The resident denied hitting her head, no other injuries were noted at that time, and her vital signs were obtained. The nurse asked the resident how she got into the shower room, and R12 stated, I just opened the door. The resident apologized and stated it was a bad idea. The Director of Nursing was notified of the fall at 10:06 PM, and the resident was sent to the hospital by Emergency Medical Services at 10:35 PM. The resident was transported to the hospital out of town due to the fractured wrist. R12's Facility Report Investigation undated, documented on 02/08/25 at 10:00 PM, License Nurse (LN) H was passing medications down Country Hall and heard someone yelling from the shower house. LN H opened the door and observed R12 naked on the floor in the shower, sitting on her buttocks, with her legs crossed. LN H stated the water was on, the shower chair positioned behind the resident LN H observed the wheelchair just inside the shower room door, and the resident's walker with the oxygen tank was still in the resident's room. The investigation documented the resident was alert and oriented, and R12 reported the shower room door was not closed, and she went into the shower house independently and slipped, falling on her left wrist. The resident reported to the nurse that her wrist was broken. The resident reported pain of a 10 out of 10 to the left wrist but denied any other pain or injury and denied hitting her head. Emergency Medical Services were contacted at 10:06 PM for transport to the emergency room . The resident returned to the facility on [DATE] and was diagnosed with a left radial and ulnar fracture. The facility had a staff in-service to educate on keeping all doors closed with keypads or locks shut, including the shower house, public restrooms. Laundry room, kitchen, ect. to prevent injury. The facility installed self-closures on all shower house doors. The investigation revealed the resident was interviewed for preference for showers days/times, and the information was updated on the care plan, nurse aide tasks, and the shower schedule. On 04/21/25 at 04:00 PM, observation revealed R12 sat in the recliner in her room, with oxygen on per nasal cannula, and watching TV. On 04/22/25 at 09:15 AM, Administrative Nurse D verified R12 entered the open shower house unattended and had the fall that resulted in a fractured left wrist. Administrative Nurse D stated the keypad on the door was locked; however, the door was not pulled shut, so the resident was able to enter the shower house. Administrative Nurse D verified the facility had an in-service and educated staff to keep all doors with keypads or locks shut, and the maintenance staff had installed self-closures on all the shower house doors. On 04/23/25 at 01:30 PM, Administrative Staff A verified R12 fell in the shower house that resulted in a fractured wrist. Administrative Staff A verified that they did an investigation and determined the door was not completely closed, and the resident was able to enter on her own. Administrative Staff A verified that they did an investigation but did not report to the state due to the resident was able to state what happened. The facility's Accidents policy, dated October 2024, documented the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The facility-oriented and resident-oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusted interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. The facility completed the following corrective actions prior to the surveyors entering the facility. The facility submitted education regarding shower room doors: assuring the shower room doors were closed and locked at all times for resident safety, the facility added a self-locking number pad lock to the shower doors, added self-closure to shower door, added self-closure springs to door hinges as added security and back up, and the facility purchased and attached self-closures to utilize in place of the hinge springs for added protection and back up and was completed by 03/20/25. This deficient practice was deemed to be Past Non-Compliance (PNC) as all corrections were completed prior to the surveyors entering the building. The scope and severity of the deficient practice remained at a G.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to measure and record food temperatures for food items at mealtime and the daily refrigerator and freezer temperatures for the evening shift. The facility further failed to record the chemical Parts Per Million (PPM) of the sanitizing solution (Chemical PPM- 50-400) on the Sanitizer Bucket Log three times a day. This placed the residents at risk for food borne illnesses. Findings included: - On 04/21/25 at 07:45 AM, during the initial kitchen tour, the daily temperature logs for the refrigerator and freezer for April 2025, lacked documentation of the temperatures were taken during the following days on the evening shift: 04/10/25, 04/11/25, 04/12/25, 04/13/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, and 04/20/25 On 04/21/25 at 07:50 AM, Dietary Staff BB verified the lack of documentation and stated the temperatures of the refrigerator and freezer were supposed to be taken daily in the morning and in the evening. On 04/22/25 at 11:30 AM, during the full kitchen tour, the daily temperature logs for the refrigerator and freezer that previously lacked daily temperatures on the initial tour were filled in with identical temperatures for each day. Dietary Staff CC verified that a dietary staff member had filled in the log and was unsure if the numbers on the log were the accurate temperatures for the refrigerator and freezer. On 04/22/25 at 12:10 PM, Dietary Staff BB obtained the temperatures of the noon meal (taco meat and refried beans) and documented the temperatures in the weekly Temperature Log. Upon record review, the logs for April 2025, the log lacked documentation of daily food temperatures for the following days and mealtimes: 04/01/25- dinner 04/02/25-dinner 04/03/25-dinner 04/04/25-breakfast, lunch, and dinner 04/05/25-dinner 04/06/25-dinner 04/07/25-dinner 04/10/25-dinner 04/11/25-dinner 04/12/25-dinner 04/13/25-dinner 04/14/25-dinner 04/15/25-dinner 04/16/25-dinner 04/17/25-dinner 04/18/25-breakfast and lunch 04/20/25-dinner On 04/22/25 at 12:15 PM, Dietary Staff CC verified the lack of documentation and stated the meal temperatures were to be taken for every meal served. On 04/22/25 at 12:25 PM, Dietary Staff BB plated the noon meal. On two separate occasions, Dietary Staff BB found plates with dried food particles on them and set them both on the meal preparation table. On 04/22/25 at 12:30 PM, Dietary Staff CC stated they were aware of resident complaints of dirty dishes and stated they adjusted the spot treatment solution and were using a type of brillo pad (a scouring pad used for cleaning dishes, made from steel wool) to clean the cups. Dietary Staff CC stated staff were to record the PPM three times a day to make sure they have the right solution when cleaning the kitchen areas. Upon review of the facility's daily Sanitizer Bucket Log for April 2025 the log lacked documentation of the chemical PPM for the sanitizing solution for the following: Morning: 15 times out of 22 opportunities Afternoon:15 out of 21 opportunities Evening: 20 out of 21 opportunities The facility's Food Preparation and Service policy, dated 10/24, documented, residents are provided with meals that were prepared by methods that conserve value, flavor, and appearance. Residents were provided with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Thermometers would be placed in hot and cold storage areas and checked for accuracy by accepted public health standards. The temperature of foods held in steam tables would be monitored by food service staff. The facility's Sanitation policy, dated 10/24, documented that equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Between uses, cloths and towels used to wipe kitchen surfaces would be soaked in containers filled with approved sanitizing solution. Sanitizing solution would be changed at least once per shift or if the solution becomes cloudy or visibly dirty.

The facility identified a census of 42 residents. Based on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment. Findings included: - On 04/22/25 at 03:40 PM review of staffing for background checks was completed for facility Staff. Upon request and review, the facility was unable to provide evidence a criminal background check was completed for Certified Medication Aide (CMA) R, who had worked at the facility since his hire date of 08/29/24. On 04/22/25 at 04:30 PM, Administrative Staff A stated the business manager would obtain criminal background/record checks on all employees prior to the employee working at the facility. Administrative Staff A verified facility staff could not find a criminal record check for CMA R, and the business office manager who was at the facility started in August 2024. Administrative Staff A verified CMA R would be placed on suspension and not work in the building until they obtained a criminal background check. The facility's Abuse Prevention Program, Screening of Employees dated October 2024 documented the community will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, entered into the State nurse aide registry or against the professional license they hold with the state licensure body. The facility administration and employees were committed to protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from the agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any there individual. Background checks were completed per state guidelines on each employee. The community would not knowingly employ an individual who: Has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property, or; Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse. Neglect, exploitation, mistreatment of residents, or misappropriation of resident property. Pre-employment screening would consist, at a minimum: Employment history, Information from former employers as available, and Documentation of status and any disciplinary actions from license or registration boards or registries. The facility would report to the state nurse aide registry or licensing authorities any knowledge of actions by a court of law if found during a background check or ongoing employment. Regardless of the source of the check, the facility would maintain the document that the screening occurred.

The facility had a census of 42 residents. The sample included 12 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility staff failed to immediately report to the nurse in charge an incident between Resident (R) 12 and R17. This placed R17 at risk for ongoing abuse and/or mistreatment and a lack of adequate supervision. Findings included: - R17's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and muscle weakness. R17's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R17 had moderately impaired cognitive function. The MDS recorded R17 required extensive assistance with transfers, activities of daily living (ADL), and propelled in a wheelchair. The MDS documented the resident received Hospice services. The MDS documented the resident had no behaviors and received antidepressants (a class of medications used to treat mood disorders), antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), and opioids (a class of controlled drugs used to treat pain). R17's Activities of Daily Living (ADL) Care Plan, dated 03/24/25, recorded R17 required extensive staff assistance with most ADL care. R17's Care Plan documented the resident had bilateral lower extremity contractures, and staff would monitor for skin breakdown and increased immobility. R17's Smoking Care Plan, dated 03/24/25, recorded R17 had the potential for injuries related to smoking. R17's plan of care documented the resident had been placed in Group 2 for supervised smoking breaks, and staff assisted the resident with smoking, including lighting and extinguishing the cigarettes, and the resident would wear a smoking apron. R17's Behaviors Care Plan, dated 03/24/25, recorded R17 had behaviors related to dementia, anxiety, and the disease progression. R17's plan of care recorded the resident had behaviors related to smoking and had attempted to get cigarettes out of the smoking box, had been more anxious and fixated on supervised smoke breaks, and would yell out for a cigarette as soon as the residents went outside for the smoke break. R17's plan of care directed staff to intervene as necessary, protect the rights and safety of others, and be removed from the situation and taken to an alternate location as needed. The Nurses Notes dated 03/14/25 at 11:00 PM (late entry) documented Certified Medication Aide (CMA) R reported to the charge nurse that R12 had made contact with her open hand to R17's left shoulder just prior to a smoke break. CMA R reported R12 was wheeling onto Presidential hallway with her wheelchair, and she tried to maneuver around R17 when R12 made contact with an open hand to R17's left shoulder in an attempt to get R17 to move out of the way. R17 recounted the event to nursing staff, stating R12 was behind her in the wheelchair, and R12 tried to get around her, and R17 stated, I guess I did not move fast enough. CMA R immediately separated the residents. The charge nurse performed a skin assessment, and no redness or signs of injury were noted at the time of the incident. R17's Facility Report Investigation dated 03/20/25, documented on 03/14/25 at 08:00 PM, CMA R witnessed the incident between R12 and R17 and did not report the incident to the charge nurse until approximately 09:45 PM on 03/14/25. The charge nurse made contact with the administrative staff and the Director of Nursing. The charge nurse completed a skin assessment following the incident and noted no redness, discoloration, or pain, or any other signs of injury in the area where the contact was made. The nurse asked R17 what happened, and the resident stated, I guess I did not move quickly enough. R12 was put on 1:1, the primary care physician saw R12 the following day, and psychiatric staff saw R12 the following Monday. The intervention was to put the two residents on different smoke breaks to eliminate the potential for further encounters. CMA R completed a witness statement regarding the encounter. On 04/22/25 at 09:30 AM, R17 sat in a wheelchair, dressed in street clothes, on the patio outside the Presidential hallway exit door. The resident was smoking a cigarette with 4 other residents and a staff member present. On 04/22/25 at 08:45 AM, Administrative Nurse D stated that on 03/14/25 at 08:00 PM, R17 was hit on the shoulder by R12, and CMA R stated the residents were friends, so he thought it was no big deal and failed to report it until 09:45 PM. Administrative Nurse D verified it was the facility policy to have staff report and incident of this nature immediately, and the facility would investigate and determine what further action was needed to be done. On 04/22/25 at 08:50 AM, Administrative Staff A stated CMA R failed to report the incident to the nurse in charge immediately, and he should have. Administrative Staff A verified that they investigated, gathered CMA R's witness statement, and reported to the State agency. Administrative Staff A verified that R12 was put on 1:1 after the incident was reported at 09:45 PM, and R12 was seen the following day by the primary care physician and psychiatric the following Monday. The facility's Abuse, Neglect, and Exploitation policy, dated August 2024, recorded it was the responsibility of the employees, facility consultants, Attending Physicians, family member, visitors etc. to promptly report any incident or suspected incident of neglect, exploitation, or resident abuse, including injuries of unknow source, and theft or misappropriation of resident's property to facility management as outlined below. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. The policy documented when an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management, regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy: 1. A licensed nurse or physician shall immediately examine the resident. 2. Findings of the examination must be recorded in the resident's medical record. c. 3. The person performing the examination must document the examination findings in the resident's record and obtain a written, signed, and dated statement from the person reporting the incident. 4. A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. Reporting to the state is per state guidelines. 5. Upon receiving information concerning a report of abuse, staff shall be assigned to monitor the resident's reactions to statements regarding the incident and his/her involvement in the investigation 6. All phases of the investigation would be kept confidential in accordance with the facility's policies governing the confidentiality of medical records. 7.Administrative policies governing the notification of the resident's representative (sponsor) and Attending Physician are located in our facility's resident rights policies and procedures. Inquiries concerning abuse reporting and investigations should be referred to the Administrator or Abuse Coordinator.

The facility had a census of 42 residents. The sample included 12 residents, with two reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide one resident, Resident (R) 27, with written information regarding the facility's bed hold policy when R27 was transferred to the hospital. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - The Electronic Medical Record (EMR) for R27 documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow), chronic kidney disease (moderate decline in kidney function) stage 3, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), hypertension (high blood pressure), lymphedema (swelling caused by accumulation of lymph fluid in the body), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R27 had moderately impaired cognition. R27 was dependent upon staff for toileting hygiene, lower body dressing, mobility, and transfers. The MDS documented R27 was at risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), had one unhealed pressure ulcer, and had a pressure relieving device for her bed and chair. The Medicare 5-Day MDS, dated 04/01/25, documented R27 had moderately impaired cognition. R27 was dependent upon staff for mobility, toileting hygiene, lower body dressing, transfers, and R27 did not ambulate. The MDS further documented R27 was at risk for pressure ulcers, had one unhealed pressure ulcer, had a pressure-relieving device for her bed and chair, and had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). R27's Care Plan, dated 02/17/25, initiated on 03/16/23, directed staff to encourage frequent position changes to reduce potential pressure, encourage good nutrition and hydration, educate on the causes of skin breakdown, and R27 had a pressure-reducing cushion in her wheelchair. The update, dated 09/17/24, directed staff to administer treatments as ordered and monitor for effectiveness. The care plan further documented R27 had an air mattress (a specialized mattress designed to prevent and treat pressure ulers by providing constant, low level air loss through tiny hols in the mattress) help offload pressure and prevent further skin breakdown, and she had a history of refusing to use the mattress to prevent skin breakdown. R27's Progress Notes dated 03/20/25 at 10:31 AM, documented R27's skin as warm to the touch and grey. R27 had an episode of yellow emesis (vomit) upon swallowing one pill. R27 was repositioned in bed when she leaned to one side and was unable to hold her position. R27 had intermittent confusion, and the physician was notified. Staff were advised to call the ambulance for further evaluation at the hospital, and they were subsequently admitted . R27's clinical record lacked evidence that a copy of the bed hold policy was provided to the resident or representative when he was transferred to the hospital. On 04/22/25 at 09:10 AM, observation revealed R27 watching television in bed. On 04/22/25 at 02:30 PM, Social Service X stated she had not provided R27 or her representative the written bed hold notice when he went to the hospital. On 04/23/25 at 09:30 AM, Licensed Nurse G stated that the bed hold policy should be given to the resident or the representative before discharge to the hospital. On 04/23/25 at 10:00 AM, Administrative Nurse D stated they should have had a bed hold notice provided to R27 and her responsible party. Upon request, a policy for bed hold notification was not provided by the facility.

The facility had a census of 42 residents. The sample included 12 residents, with one reviewed for hospice (a type of health care that focused 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 coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 17. This placed the residents at risk for inadequate end-of-life care. Findings included: - R17's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and muscle weakness. R17's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R17 had moderately impaired cognition. The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented R17 received hospice services. R17's Activities of Daily living (ADL) Care Plan, dated 03/24/25, recorded R17 required extensive staff assistance with most ADL care. R17's plan of care documented the resident had bilateral lower extremity contractures and staff would monitor for skin breakdown and increased. immobility. R17's Hospice Care Plan, dated 03/24/25, documented the resident received hospice services due to the end-of-life process. R17's care plan documented staff would administer medication for comfort and keep the resident as comfortable as possible. The care plan lacked instructions on the services provided by hospice, including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. Review of R17's clinical record revealed the resident was admitted to hospice care on 01/14/24 with a diagnosis of sarcopenia (a condition characterized by the gradual loss of muscle mass and function, primarily occurring with age). The facility had a plan of care provided by hospice in the electronic health record. On 04/22/25 at 11:15 AM, R17 was dressed in street clothes in a recliner in her room. R17 was eating some candy and visiting with her husband. On 04/22/25 at 04:30 PM, Administrative Nurse D verified that the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The facility's Hospice Program policy, dated October 2024, documented the community may contract for hospice services for residents who wish to participate in such programs, including services that would be provided and the coordination of services. The facility would obtain a physician's order for Hospice services to include diagnosis, including physician orders for the prognosis and the basis for prognosis that matched the hospice information on the certification of terminal illness. The policy documented the facility would clarify the residents' advance directives and preferences for end-of-life planning. Identify in writing the services that Hospice would be providing and address in the resident's person-centered care plan. The policy documented hospice would along with the Hospice provider, discuss, plan and obtain orders for preferences in pain management, symptom control, treatment of acute illnesses, and choices regarding hospitalization . Although the Hospice provider retains the primary responsibility for the provision of the hospice care and services, including but not limited to, the community must coordinate the care and ensure the resident receives all necessary care and services.

The facility had a census of 39 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to prepare and serve food in a sanitary condition for the 39 resident's who resided in the facility placing them at risk for food borne illness. Findings included: - On 08/01/23 at 08:15 AM, observation revealed the following: The large silver freezer, pulled out approximately 12 inches from the wall with multiple dead bugs, leaves, and dirt on the floor. The wall beside the large silver refrigerator had dried red liquid splattered from the floor up to the ceiling. Two dirty rags were on the floor next to a cart that had dirty rags. The inside of the door of the microwave had dried food debris. The small toaster had dried food debris on the sides of the toaster. On 08/01/23 at 12:00 PM, observation revealed three plates with the noon meal of two soft tacos, Spanish rice, and lettuce on a cart. Further observation revealed flies around the plates landing on the food as the plates were uncovered as the dietary staff prepared three other plates of food. On 08/01/23 at 12:05 PM, Dietary BB stated she did not know where the flies had come from, but the kitchen had bug traps that were cleaned monthly by the exterminator. On 08/01/23 at 12:25 PM, Dietary CC stated there was a daily cleaning schedule for the AM and PM cook that gave them their tasks. Dietary CC verified the dirty wall, and stated, something must have exploded, and staff could not get the whole wall clean without getting a step ladder the clean the ceiling. Dietary CC verified the bugs and debris from behind the freezer and stated the pest control company had just replaced the bulbs in the bug traps and that the pest control came to the facility monthly. The facility's AM Cook Duties form, dated 07/31/23, stated the following would be completed and signed daily: Clean all equipment after use, including toasters. Sweep and mop floors The AM Dining Aide Duties form, dated 07/31/23, included the following: Ensure the wall around the dishwasher was free of food splatter/debris. Sweep and mop the floor in your area. The facility's Sanitation F812 policy, dated 10/2022, stated the food service area should be maintained in a clean and sanitary manner. All kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. Kitchen and dining room surfaces not in contact with food would be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. Utensils, counters, shelves, and equipment shall be kept clean. The facility failed to prepare and serve food in a sanitary condition for all residents who resided in the facility and received meals from the facility kitchen, placing them at risk for food borne illness.

The facility had a census of 39 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training and possessed the required certification in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 8/03/23 at 02:30 PM, Administrative Nurse D stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse D stated she had not completed the training modules and had not taken the test for certification. The facility ' s Infection Preventionist policy, dated October 2022 documented the InfectionControl Preventionist is responsible for assessing, implementing, developing, monitoring the infection prevention and control program, coordinating and implementation with updating the established infection control policies and practices. The facility would designate a qualified individual on-site, who is responsible for implementing programs and activities to prevent and control infections. The Infection Control Preventionist is recommended to have a background in nursing, medical technology, microbiology, epidemiology or other related fields, and educated in Infection Control and knowledge of natural guidelines. The facility failed to ensure the person designated as the Infection Preventionist possessed the required certification, placing the residents at risk for lack of identification and treatment of infections.

The facility had a census of 39 residents. Based on observation, interview, and record review the facility failed to ensure effective pest control in the facility kitchen. This deficient practice placed the residents of the facility at risk for decreased health and wellness. Findings included: - On 08/01/23 at 11:50 AM, observation during the noon meal service revealed a lot of flies in the kitchen landing on plates of residents' food and the food service utensils. Dietary Staff (DS) BB plated food slowly (first time doing this task) and the flies were getting on the food. On 08/01/23 at 12:00 PM, observation revealed, three plates with the noon meal of two soft tacos, Spanish rice, and lettuce on a cart with flies around the plates, landing on the food as the plates were uncovered while the dietary staff prepared three other plates of food. On 08/01/23 at 12:05 PM, Dietary BB stated she did not know where the flies had come from, but the kitchen had bug traps that were cleaned monthly by the exterminator. On 08/01/23 at 12:25 PM, Dietary CC stated the pest control company had just replaced the bulbs in the bug traps and they came to the facility monthly. On 08/01/23 at 12:25 PM, Maintenance Staff U stated the pest control company came monthly and had recently checked all the fly and rodent traps. He stated they were also responsible to clean out the bug traps, they facility was not allowed to. The facility's Pest Control policy, dated 02/2020, stated the facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents. The facility failed to ensure effective pest control in the facility kitchen, placing the residents of the facility at risk for decreased health and wellness.

The facility had a census of 39 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to notify the physician of Resident (R) 24's out of parameter blood pressures. This deficient practice placed R24 at risk for abnormally low blood pressures without physician awareness. Findings included: - R24's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure) and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R24 required supervision for eating, toileting, bed mobility, transfers, and total staff assistance with dressing. The MDS documented R24 received diuretic (help rid the body of salt (sodium) and water, commonly used to treat high blood pressure) medications. The Medication Care Plan, dated 06/15/23, documented R24 took medications with black box warnings including atenolol (blood pressure drug) and Lasix (diuretic). The care plan directed staff to administer medications per physician order, monitor for side effects and effectiveness. The Physician Order, dated 06/19/2023, directed staff to administer atenolol, 25 milligrams (mg), twice daily, for hypertension. The order stated to hold the medication if the systolic blood pressure (SBP-the pressure caused by the heart contracting and pushing out the blood) was less than 110 millimeters of mercury (mmHg) and or the diastolic blood pressure (DBP-the pressure in the arteries when the heart rests between beats) was less than 60 mmHg and notify the physician. The July 2023 Medication Administration Record (MAR) documented R24's SBP was less than 110 mmHg on 15 days. The documentation indicated the atenolol was not held per physician orders and the recrod lacked evidence the physician was notified. On 08/01/23 at 12:20 PM, observation revealed R24 sat in a wheelchair in his room. On 08/02/23 at 11:34 AM, observation revealed Licensed Nurse (LN) G administered medications to R24, who took the pills whole with water. On 08/03/23 at 01:44 PM, LN H stated staff send the physician a fax with abnormal blood pressures and should document that in a progress note. On 08/03/23 at 03:04 PM, Administrative Nurse D stated staff should follow the order for administration of atenolol and notify the physician as ordered. Administrative Nurse D verified the lack of documentation of holding atenolol as ordered and notification of the physician. Upon request the facility did not provide a policy for physician notification of change. The facility failed to notify the physician of the out of parameter blood pressures, placing R24 at risk for abnormally low blood pressures without physician awareness.

The facility had a census of 42 residents. The sample included 6 residents, which 3 were reviewed for elopement. Based on observation, record review, and interview the facility failed to provide adequate supervision to prevent 1 of 3 residents from leaving the building, without staff supervision, and was found approximately 2 blocks away from the facility. This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 6/20/18, documented the resident had a (BIMS) Brief Interview for Mental Status score of 7, which indicated severely impaired cognition. The MDS documented the resident had hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and no wandering behavior during the 7 day look back period. The MDS documented the resident required staff supervision with bed mobility, transfer, locomotion on and off unit, eating, dressing, personal hygiene, and independent with toilet use. The MDS indicated the resident's balance not steady, but able to stabilize without staff assistance, had no upper or lower extremity impairment and used a walker for mobility. The 6/20/18 (ADLs) Activities of Daily Living (CAA) Care Area Assessment documented the resident ambulated with four wheeled walker with staff supervision. The 7/27/18 revised care plan documented the resident a risk for elopement due to history of attempts to leave the facility unattended. The care plan instructed staff to provide 1:1 at all times, (initiated on 7/27/18) and to check the resident's Wanderguard (bracelet that sets off an alarm when residents wearing on attempt to exit the building without an escort) bracelet every shift. (initiated on 7/27/18) The 6/23/18 at 12:17 PM nurse's note documented the resident tried to go outside through the front entrance door, was confused, uncooperative and stated he/she worked for Trump now and needed to get out of the facility. The note documented the activity director escorted the resident back to his/her room. The 7/2/18 at 2:06 PM social service note documented the social service worker was notified, by nursing staff, the resident had went out the door, when someone else was entering the facility. The note documented social service staff went outside with nursing staff, greeted the resident, and asked him/her how he/she was feeling. The note documented the resident did not reply, so social service staff stated lets go have a cigarette and talk, the resident took the social service's hand and went back into the facility. The note documented social service staff went outside with the resident and attempted to talk with the resident, however the resident stated Can't she just smoke his/her cigarette, did not want to talk right now and continued to smoke. The note documented the resident was shaking and gait appeared unsteady. The 7/17/18 wandering and elopement evaluation form documented the resident was a readmission, alert and oriented x 4, had BIMS score 13-15, which indicated cognitively intact, had no wandering/exit seeking patterns, and did not have a Wanderguard bracelet. The 7/27/18 at 7:04 PM nurse's note, documented the resident was unsupervised outside smoking during the smoke break, stood on his/her walker and tried to climb over the fence and get out, and another resident outside saw him/her and stopped him/her. The 7/27/18 incident report documented the resident left the building at approximately 8:05 PM on 7/27/18. The report documented the resident was observed by a resident walking past his/her window and reported to staff, and staff immediately proceeded to follow the resident toward the direction given by reporting resident. The report documented the resident was located across the street ambulating with his/her 4 wheeled walker and was immediately brought back to the facility. The report revealed the resident wore a Wanderguard bracelet, the nurse assessed the resident, no signs of injuries or distress were noted. The report documented an investigation started immediately to determine how the resident exited the building, staff reported no audible alarm at the time of the exit but did upon return of the resident back to the facility. The report documented the resident stated he/she knew the people that were leaving the building so he/she followed them to their car, where they were waiting for him/her, but they left and he/she followed them. The 8/1/18 at 2:47 PM notarized statement from Nurse Aide M documented he/she was coming out of a resident's room when Medication Aide N stopped him/her in the hallway around 8:00-8:30 PM on 7/27/18, to inform him/her another resident had reported the resident had escaped from the facility and walked by his/her window outside. The statement documented staff proceeded to look for the resident in hope to bring him/her back safely. The 8/1/18 at 3:20 PM notarized statement from Medication Aide O documented on 7/27/18 at about 7:30 PM or 8:00 PM, he/she was in a resident's room and heard the nurse calling his/her name STAT and he/she stepped out of the room and the nurse told him/her to get his/her car and go get the resident because he/she was walking down the street and another aide was watching the resident from the parking lot. The statement documented Medication Aide O found the resident a block past main street sitting on his/her walker seat, asked the resident to please get in his/her car, and the resident said he/she really wanted a cigarette, but got into his/her car. The statement documented Medication Aide O brought the resident back to the facility without any problems, and he/she did not hear the alarm go off at the front entrance door when the resident left, but when he/she brought the resident back, did hear it go off. The 8/1/18 at 10:30 PM notarized statement from Nurse Aide N documented on 7/27/18 at 7:45 PM he/she had just came in to work and the resident was sitting on his/her walker, the resident asked him/her if he/she could go smoke and Nurse Aide N told the resident after he/she clocked in and answered some of the call lights. The statement documented Nurse Aide N came back from answering lights, the nurse told him/her the resident was outside to go check. Nurse Aide went out and saw the resident walking, told the nurse to get his/her car keys so he/she could go get the resident, because he/she would not be able to get to the resident on foot, so the nurse went and got Medication Aide O and they went and got the resident in Medication Aide O's car. On 8/2/18 at 9:31 AM, observation revealed the resident ambulated with his/her walker towards the nurse's station with staff beside him/her. Further observation revealed staff went with the resident outside for a smoke break, the resident came back in with staff by his/her side and followed the resident to his/her room, and the resident shut the door behind him/her. On 8/2/18 at 11:35 AM, Administrative Staff A stated staff did follow policy, once they found out the resident was outside the facility. The facility's revised (MONTH) (YEAR) Elopement policy documented for residents requiring increased monitoring of wandering, the licensed nurse would initiate elopement/Wandering supervision for a specific period of time identified in the care plan or physician orders. Examples of resident behavior requiring such actions were attempted elopement, moderate or high risk scoring on a assessment and/or wandering not conductive to the safety of the resident or other residents in the community. The facility failed to ensure Resident #1 received adequate supervision, he/she left the building unattended by staff, and was found unsupervised 2 blocks away from the facility, which placed the resident in immediate jeopardy. The deficient practice was identified as past non-compliance with the facility immediately implemented the following on 7/27/18: 1:1 staff supervision. Placed an alarm on the resident door to alert staff when the resident leaves his/her room. Face to face education to all staff on elopement policy, checking door alarms, residents at risk for elopement; location of elopement book as no staff allowed to work without this education. Checked all Wanderguard alarms and regular door alarms.

The facility identified a census of 33 residents. The sample included 18 residents of which 3 were reviewed for accidents. Based on observation, interview and record review, the facility failed to thoroughly assess for causative factors for a fall, and implement appropriate interventions to prevent additional falls, for 1 of 3 sampled residents. Resident #37 fell on [DATE] and sustained a fracture (broken bone) of the right wrist/arm. Findings included: - The physician's orders [REDACTED].#37 had lung cancer (abnormal cell growth with the potential to invade or spread to other parts of the body), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), seizures (violent involuntary series of contractions of a group of muscles), heart failure, hypotension (low blood pressure), urine retention (inability to empty the bladder completely), and a history of falls. The significant change (MDS) Minimum Data Set assessment, dated 9/25/17, documented Resident #37 had a (BIMS) Brief Interview for Mental Status score of 11, indicating moderately impaired cognition, required limited assistance of 1 staff for (ADLs) Activities of Daily Living, and had range of motion impairment on 1 side. The MDS further documented the resident's balance was unsteady, required staff assistance to rebalance, used a wheelchair and walker for mobility, experienced a fall without injury, received an antidepressant medication, used supplemental oxygen, and received hospice care since the previous assessment. The 10/16/17 Falls (CAA) Care Area Assessment documented the resident had a tendency to forget he/she should not be up on his/her own without assistance, resulting in multiple falls, experienced chronic pain, and he/she used a morphine pump (equipment that administers small doses of the narcotic medication directly into the blood stream) for pain control. The 9/28/17 care plan directed staff to ensure the resident had adequate rest periods, assist him/her to the bathroom, observe the resident's ability to perform ADLs, and report any improvement or decline. The care plan further directed staff to ensure the resident wore appropriate footwear (5/4/17, reviewed 10/3/17) when he/she walked or moved around in the wheelchair, wore nonskid socks during the night (10/13/17), place the call light within the resident's reach (10/10/17), and encourage the resident to use the call light for assistance as needed. The care plan documented staff moved the resident to a room closer to the nurse's station (10/16/17), placed a scoop mattress (mattress with a scoop shaped foam side, which defines the edge of the mattress) on the bed (8/18/17), and directed staff to review information on past falls to determine the cause of falls. The 8/2/17 Fall Risk Assessment documented a score of 10, a high risk for falls. The 8/18/17 at 8:38 AM, nurse's note documented staff found the resident sitting in the doorway of his/her room on the floor. The resident reported he/she fell out of bed, scooted to his/her recliner looking for the call light, and scooted to the door looking for help. The 10/3/17 at 9:30 PM nurse's note documented staff found the resident on the floor by the doorway to his/her room. The resident reported he/she fell by the chair after going to the bathroom. The note documented the resident broke his/her glasses, had a skin tear above and below the left eye, and a small scrape on the right arm. Staff notified the physician and responsible party of the resident's fall. The 10/4/17 at 12:58 PM, nurse's note documented the resident remained on fall follow up throughout the shift, with bruising and scabbed areas to the resident's left eye, and neurological assessments (an evaluation of a person's nervous system) within normal limits. The 10/13/17 at 3:00 PM, nurse's note documented, at approximately 2:00 AM, staff found the resident on the floor in the doorway of his/her room. The note documented staff observed the resident leaning into the hallway to obtain the staff's attention and did not use the call light. The note further documented the resident stated he/she did not use the walker, lost his/her shoes, slipped, and fell as he/she returned from the bathroom. The note documented the resident stated he/she used his/her right arm/wrist to catch/break the fall, and scooted him/herself on the floor, to the doorway, to obtain the staff's attention. The note documented the resident rated the pain to his/her right wrist as a 10 on a scale of 1 to 10, (1 as no pain and a 10 as the worst pain) and staff notified the hospice nurse, who informed the staff he/she would come to the facility in the morning to check the resident's status. The staff placed non-skid socks on the resident's feet, sent a fax to the physician, and notified the resident's responsible party and the director of nursing. The 10/13/17 at 1:29 PM, nurse's note documented the result of the resident's x-ray, of the right wrist/arm, reported the resident had an impacted fracture of the distal radius (the end of the shorter forearm bone was bent backward and driven into another bone and caused a break in the bone) from a fall at 2:00 AM and staff notified the physician by fax of the result and left a message. The note documented the resident had an ace wrap on the right wrist/arm, with the arm elevated on a pillow as the resident rested in a recliner. The note further documented the result of the investigation revealed the resident's slippers slid on the floor going to the bathroom, an intervention was added to the care plan to place the slippers out of the resident's reach, provide non-skid socks to the resident, and staff moved the resident to a room closer to the nurse's station. On 10/23/17 at 12:45 PM, observation revealed the resident stood up from his/her chair in the dining room, with a wheeled walker the resident began to walk across the dining room, stopped and asked the staff to provide assistance, because he/she was tired. On 10/24/17 at 9:15 AM, Nurse Aide H stated the resident had good movement with walking, staff provided 1 person assistance, with use of a wheeled walker and a gait belt. Nurse Aide H further stated staff assisted the resident to the bathroom, the care plan had not directed the frequency to help him/her, although Nurse Aide H stated he/she tried to check on the resident every few hours to see if he/she needed to urinate, since the resident fell and hurt his/her arm. On 10/24/17 at 9:57 AM, Nurse Aide S stated the resident used the call light to let staff know when he/she needed to use the bathroom. Nurse Aide S stated staff provided assistance of 1, with use of a gait belt, and a wheeled walker to help the resident walk in his/her room and the hallways, and described the resident as forgetful, so staff provided the resident with cues and reminders to use the call light for assistance. Nurse Aide S was unsure if the care plan stated a frequency to assist the resident to the bathroom. On 10/24/17 at 11:10 AM, Nurse C stated the resident had 2 falls because the resident had gotten up without asking for assistance from staff and fell . Nurse C stated the resident had some cognitive impairment, although the resident's cognition had improved from the time of admission. Nurse C stated one staff should assist the resident to the bathroom with use of a gait belt and wheeled walker. Nurse C stated the nurse was responsible for the initial investigation after a fall, assessment of the resident, and notification of emergency medical services, physician, family, and risk management. Nurse C further stated the nurse was responsible to update the care plan if a new intervention was needed. On 10/24/17 at 5:10 PM, Administrative Nurse B verified the resident had 2 falls in (MONTH) (YEAR) and stated he/she typed an intervention into an electronic notation following the 10/3/17 fall. Administrative Nurse B verified the intervention which directed staff to assist the resident to his/her room, toilet, and place him/her in a chair or bed, before and after meals, at bedtime, and upon the resident's request was entered into the computer, but was not transferred to the resident's medical record, care plan, the nurse aide's ADL sheet, or any location for staff to access. Administrative Nurse B verified a care plan change after the first fall may have prevented the second fall with injury. On 10/30/17 at 1:22 PM, Physician R stated the resident had confusion and multiple co-morbidities (the presence of two or more diseases or conditions in a resident) which made him/her a risk for falls, he/she did not provide an expectation for fall prevention, and voiced he/she was not aware of the interventions provided by the nursing home to prevent falls. The facility's 8/2014, Managing Falls and Fall Risk policy and procedure directed staff to attempt to identify appropriate 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. If falling recurs despite initial interventions, staff would re-evaluate the situation, implement additional or different interventions, or indicate the current approach remains relevant. The facility failed to provide, cognitively impaired Resident #37 with adequate supervision to prevent falls when staff failed to thoroughly assess for causative factors for 10/3/17 fall and implement appropriate interventions to prevent additional falls that resulted in a fractured wrist.

The facility had a census of 33 residents. The sample included 18 residents of which 3 were reviewed for nutrition. Based on observation, record review, and interview the facility failed to implement timely and effective interventions to prevent significant weight loss for 2 of 3 sampled residents. Resident #51, had a 17 (lbs) pound, significant weight loss in 28 days and Resident #13, had an 14% significant weight loss in 90 days. Findings included: - Resident #51's medical record revealed the following [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 8/24/2017, recorded the resident scored 9, on the (BIMS) Brief Interview for Mental Status, which indicated the resident had moderate cognitive impairment. The MDS recorded the resident required extensive assistance of 2 staff with bed mobility, transfers, extensive assistance of one staff for locomotion on and off the unit, dressing, toilet use, personal hygiene, and supervision with set up help only for eating. The MDS further documented the resident weighed 115 lbs and received a therapeutic diet. The MDS documented no or unknown weight loss or gain. The nutritional (CAA) Care Area Assessment, dated 8/29/2017, documented staff encouraged the resident to eat, offered him/her a variety of foods, observed and assessed his/her weight, as ordered, and reported concerns to the primary care physician. The CAA lacked documentation of the resident's weight. The care plan, dated 9/28/2017, documented the resident had a [DIAGNOSES REDACTED]. The care plan documented the resident required a dietary consult for nutritional regimen, ongoing monitoring, and the facility would monitor, report, document, to the physician, any signs of [DIAGNOSES REDACTED], (sweating, tremors, increased heart rate, nervousness, slurred speech, lack of coordination, or a staggering gait). The medical record revealed a physician diet order, dated 8/17/2017, for carbohydrate controlled liberal diabetic diet (a diet in which carbohydrate intake is either limited or set at a particular value), and regular texture. The physician telephone order, dated 8/22/2017, directed staff to provide regular ice cream, twice a day, and kitchen staff would provide with each meal for the resident. The 8/22/2017 Nutrition Assessment completed by the (DM) Dietary Manager recorded the resident's weight was 115 lbs, height 67 inches, and he/she received a regular diet. The assessment further recorded that the resident had a poor appetite, and ate less than 50% intake of his/her meals. Review of the medical records revealed no ongoing correspondence of the resident's continued weight loss. The medical records lacked a (RD) Registered Dietician admission dietary assessment. The (RD) progress note, dated 8/24/2017, provided by the RD via e-mail, recorded the resident had a weight loss since admission, and directed staff to continue with ice cream twice a day at meals. The RD suggested to review likes and dislikes with the resident or family, weigh the resident weekly, and documented he/she would reassess the resident on his/her next visit to the facility. The medical record lacked the presence of the RD progress note. The 9/08/2017 nutrition weight change warning note, documented the resident's weight was 104 lbs (a 9 lbs weight loss since 8/22/2017). The note documented the resident received a Carbohydrate Controlled-Liberal Diabetic diet, with regular texture. The note further documented the resident refused to eat most of his/her meals and refused any sort of alternatives. The RD and the DM would continue to monitor. The note lacked additional interventions to address the resident's weight loss. The 9/15/2017 nutrition weight change warning note, documented the resident's weight was 102 lbs. The note documented the resident received a regular diet, and a magic cup (a frozen dessert supplement that provides 260 calories and 9 grams of protein) or ice cream with his/her meals. The note documented the resident consumed 5-20% of his/her meals and refused alternatives. The RD and the DM would continue to monitor. The weight record revealed the following: 8/18/17- 119 lbs 8/22/17- 115 lbs 9/07/17-104 lbs (16 days between the last date the resident was weighed, and not weekly as ordered) 9/15/17- 102 lbs (17 lbs weight loss, 14% in 28 days) The (MONTH) 18-31, (YEAR) meal percentage log/food intake record revealed the resident ate up to 10% of his/her meals and refused numerous meals. Continued review revealed the resident ate ice cream 3 of the 39 meals. The (MONTH) 1-16, (YEAR) meal percentage log/food intake record revealed the resident ate up to 25% of his/her meals and refused numerous meals. The log lacked any documentation the resident consumed any supplements. The medical record lacked documentation of the residents likes/dislikes, and if staff honored his/her preferences. The medical record revealed the facility admitted the resident on 8/17/2017, and discharged from the facility on 9/16/2017. The physician visit note, dated 8/21/2017, recorded the resident was at his/her ideal body weight, and was disoriented as to time and place. The physician notes indicated a friend requested to take the resident home to live with him/her and the physician declined the request, and documented he/she did not anticipate the resident recovering enough to live independently without a lot of interventions. The physician visit note, dated 9/05/2017, documented the resident stated he/she had an appetite but was not presently hungry, and recorded the resident was markedly paranoid. On 10/24/2017 at 11:30 AM, Administrative Nurse B stated the resident lost 17 lbs in 28 days and verified the lack of a Registered Dietician assessment. Administrative Nurse B stated the facility had a weekly meeting to discuss residents at risk for weight loss, and they obtained a physician order [REDACTED]. preferences and add the choice to his/her diet, next add shakes and protein supplements. Administrative Nurse B stated after those steps are taken they approve the staff to call the physician for additional interventions/medications to help prevent further weight loss. On 10/24/2017 at 3:00 PM, Nurse Aide F stated the nurse aides and nurses encouraged the resident to eat in the dining room and he/she refused. Staff would deliver a room tray and he/she would eat some of the food, if staff stayed in the room during his/her meal. If the resident did not eat his/her meal, staff would provide the resident a magic cup, or chocolate shake that was provided to the resident in addition to his/her meal. On 10/25/2017 at 2:20 PM, Dietary Manager D stated after admission to the facility, the resident lost 17 lbs in 28 days and verified the lack of a Registered Dietician assessment. Dietary Manager D verified the lack of additional interventions other than the physician order [REDACTED]. On 10/25/2017 at 3:20 PM, Registered Dietician E verified he/she had not completed an admission nutritional assessment on Resident #51, however he/she did e-mail a recommendation to the facility on [DATE] acknowledging the resident had a weight loss since admission, directed staff to continue with the ice cream shakes, review the residents likes and dislikes, weigh weekly, and he/she would assess him/her on the next visit. Registered Dietician E verified the resident was not in the facility on his/her monthly return visit in September. Registered Dietician E stated he/she was at the facility once a month to complete assessments, would review the newly admitted residents since his/her last visit, and any annual or significant change reviews. Registered Dietician E verified the facility staff were to alert him/her to an urgent assessment need through e-mail and he/she had the ability to remote on to the computerized program to complete an updated assessment or add suggestions per information on the computerized system. On 10/26/2017 at 2:30 PM, Physician M verified the facility admitted the resident for further medical care and rehabilitation, after he/she presented to the emergency room with [MEDICAL CONDITION] and weakness. Physician M verified the facility did not alert him/her to concerns with residents in a timely fashion. Physician M verified the resident did not want to live at the facility and wanted to return to his/her home, however he/she was not capable of taking care of him/herself. Physician M indicated his/her usual treatment for [REDACTED]. The facility's Weight Assessment and Interventions policy, dated 9/2012, recorded the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain for their residents. 1) Each resident is weighed upon admission, the next day, weekly x 2, and unless indicated otherwise, monthly thereafter. 2) Weights will be recorded per facility protocol. 3/ Any weight change of 5% or more since the last weight, the resident would be weighed the next day for confirmation. If the weight change is verified, nursing were to notify the Registered Dietician per facility protocol. 4) The threshold for significant unplanned and undesired weight change will be based on the following criteria (where percentages of body weight loss= (usual weight -actual weight)/(usual weight x 100): 1 month -5% weight change is significant, greater than 5% is severe. 3 months -7.5% weight change is significant; greater than 7.5% is severe. 6 months -10 % weight change is significant; greater than 10% is severe. The interdisciplinary team will identify conditions and medications that may be causing anorexia, weight gain, or increasing the risk of weight loss. The facility failed to implement timely and effective interventions to prevent weight loss for Resident #51, who lost 17 pounds, (14% in one month), resulting in significant weight loss, placing the resident at risk for increased health concerns. - The physician's orders [REDACTED].#13 had [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 7/5/17, revealed Resident #13 had moderately impaired cognition and required total assistance of 2 staff for bed mobility, transfers, and toileting. The MDS further documented the resident required total assistance of 1 staff for locomotion and limited assistance of 1 staff for eating. The MDS documented the resident complained of difficulty or pain with swallowing, had no natural teeth, and weighed 196 (lbs) pounds, with no weight loss or gain. The 30-day Medicare MDS assessment, dated 9/13/17, documented a 5% or more weight loss, with a weight of 168 lbs (a 14% weight loss). The 7/11/17 nutrition (CAA) Care Area Assessment documented the resident received a regular diet, had a good appetite, and staff encouraged him/her to eat snacks between meals. The CAA further documented the staff monitored the resident for side effects of medications, [MEDICAL CONDITION] (swelling), and symptoms of elevated blood pressure. The 6/28/17 care plan directed staff to provide a regular diet, with regular consistency, soft texture, a 4 (oz.) ounce house supplement shake with meals to prevent weight loss, and to obtain a monthly weight. The resident's recorded weights were: 8/23/17 190 lbs (return from hospital) 9/07/17 168 lbs (a 22 # weight loss) 9/15/17 166 lbs (a 2 # weight loss) - (12% weight loss in 46 days) 9/21/17 167 lbs (a 1 # weight gain) The 6/29/17 physician order [REDACTED]. The 7/4/17 at 10:22 AM, nurse's note documented the resident denied nausea and vomiting, but asked for a Tums (medicine that treats heartburn). The note indicated the resident received [MEDICATION NAME] (medicine used to treat symptoms caused by excess stomach acid) every morning for GERD. The 7/5/17 at 4:00 PM, RD assessment documented the resident's weight as 196 lbs, and he/she received a regular mechanical soft (foods that can be made easier to chew or swallow and does not restrict fat, fiber, spices, or seasonings) diet, with 2200 calories, and 80 grams of protein daily. The assessment further documented the resident consumed 50-75% of meals, was wheelchair bound, alert and oriented, and had an abrasion to the right buttocks. The assessment documented the resident's calorie needs as 2215 to 2659 calories, 88 grams of protein, and 2658 (ml) milliliter of fluids daily The 7/6/17, telephone order documented nursing staff notified the physician the resident complained of heartburn. The telephone order documented the resident had an order of [MEDICATION NAME], 20 mg, by mouth, every day and made no medication changes. On 7/14/17 the physician changed the order for [MEDICATION NAME] to 40 mg, by mouth, every day for GERD. On 7/28/17 the physician directed staff to provide a 4 oz. house supplement shake with each meal for weight loss. The 7/28/17 endoscopy (a nonsurgical procedure used to examine a person's digestive tract) revealed the resident had a hiatal hernia (protrusion of the stomach through an abnormal opening in the muscle wall of the cavity that surrounds it). Review of the (MONTH) meal intake and snack record documented the resident's meal and snack consumption fluctuated up and down from 25% to 50% for the 3 meals, and a few meals the resident ate approximately 75%. The 8/15/17 discharge with return anticipated, MDS documented the resident weight as 196 lbs, when he/she was transferred to the hospital for a carotid endarterectomy (a procedure to remove material on the inside of an artery (blood vessels that carry blood away from the heart)). The resident returned to the facility on [DATE]. The 8/23/17 five day Medicare MDS documented the resident weight as 190 lbs. The 8/23/17 at 11:23 PM, nurse's note documented the resident's appetite increased after his/her endarterectomy, and was alert and oriented with no signs of confusion. The 8/24/17 at 1:16 PM, nurse's note documented the resident's weight at 190 lbs, meal intake was poor, and he/she complained of difficulty eating because of the hiatal hernia. Staff offered the resident a strawberry shake with milk upon the resident's request. The note documented staff would monitor the resident's weight weekly, and the RD would review the resident's status on the next visit. The 8/24/17 RD note directed staff to monitor weights weekly, obtain the resident's height, and enter the value into the medical record. The RD further directed staff to continue to offer strawberry shakes and other liquid supplements when the resident complained of the hernia, and did not want to eat due to heartburn or stomach upset. The 8/28/17 at 1:39 PM, progress note documented the physician addressed the resident's complaint of heartburn, stomach upset, but did not state if staff notified the physician of the resident's weight loss. The 8/28/17 physician's orders [REDACTED]. Review of the (MONTH) Meal Intake Log documented the resident consumed 50% to 75% of breakfast, with a decreased consumption for the remaining 2 meals from 25% to 50%. The resident's consumed milk shake intake was not recorded in a percentage for the entire month, the record lacked entries on approximately 1/3 of the shakes provided. The 9/15/17 at 9:50 AM, progress note documented the medical record triggered a Weight Change Warning, of an 11.5% weight loss in 1 month, but lacked evidence staff notified the physician. The 9/19/17 at 11:48 AM, nurse's note documented the resident was alert and oriented, able to make his/her needs known, and complained of nausea. The staff administered [MEDICATION NAME] and as needed [MEDICATION NAME] (narcotic pain medication) every 4 hours throughout the shift. The 9/22/17 at 11:51 AM, medical record revealed a weight loss warning and documented the resident's weight at 167 lbs. The warning documented the RD and dietary manager would continue to follow the resident's status, although the warning did not specify the RD was notified and the date. The nurse's note associated with the warning, documented the resident refused most meals due to pain from the hernia. The note documented the resident stated the food looked and smelled appetizing, it just hurt him/her to eat anything. The note further documented staff offered health shakes to the resident with his/her meals for nutrition. Review of the (MONTH) Meal Intake Log documented the resident meal consumption fluctuated up and down from 25% to 50% for the 3 meals, and a few meals the resident ate approximately 75%. The milk shake intake consumed was not recorded in a percentage from (MONTH) 1 through the 5th, the record revealed the resident had not consumed the shakes for 20 out of 66 opportunities. The 9/23/17 at 9:45 AM, the nurse's note documented the resident discharged from the facility, with personal belongings, follow-up appointment information, and home health care orders explained to the family representative. On 10/23/17 at 4:00 PM, Dietary Staff D stated the resident complained frequently of an upset stomach caused by the hiatal hernia, and had a decreased appetite. Dietary Staff D stated the RD completed annual assessments on the residents, if there were concerns with a particular resident, such as weight loss, he/she made a list and provided the information to the RD to review on the next visit. On 10/24/17 at 9:51 AM, Nurse Aide H stated the resident had a poor appetite and never ate an entire meal. Nurse Aide H stated the resident received a milk shake at mealtime, and occasionally accepted a snack in between meals. On 10/24/17 at 11:50 AM, Nurse C stated the resident received physical therapy following a hip repair, had a very large hiatal hernia, complained of heartburn, and an upset stomach frequently. Nurse C further stated the nurses provided medications for the heartburn and stated the resident had significant weight loss due to the hiatal hernia. The facility's 9/2012, Weight Assessment and Intervention policy indicated the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain for our residents. Each resident is weighed upon admission, the next day, weekly x 2, and unless indicated otherwise, monthly thereafter. Weights will be recorded per community protocol. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight change is verified, nursing will notify the Registered Dietician per facility protocol. The threshold for significant unplanned and undesired weight change will be based on the following criteria (where percentages of body weight loss = (usual weight - actual weight)/(usual weight x 100)): 1 month - 5% weight change is significant, greater than 5% is severe. 3 months - 7.5% weight change is significant, greater than 7.5% is severe. 6 months - 10% weight change is significant, greater than 10% is severe. The interdisciplinary team will identify conditions and medications that may be causing anorexia, weight gain or increasing the risk of weight loss. Review of the facility's 9/2012, Weight Assessment and Intervention policy and procedure documented the resident would be reweighed the next day for a weight change of 5% or more, the record lacked evidence the resident was reweighed the next day. The facility failed to reassess and provide additional and timely interventions for Resident #13, who continued to have significant weight loss.

The facility had a census of 35 residents. The sample included 3 residents. The facility identified 27 residents who were full code (when an individual has cardiac or respiratory arrest, the facility is ethically and legally obligated to perform life-saving measures). Based on record review and interview, the facility failed to initiate (CPR) cardiopulmonary resuscitation (emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.), for 1 of 3 sampled residents. Resident #1 was found unresponsive, without a pulse or respirations, and ultimately died . Staff were unaware of the resident's code status.This deficient practice placed Resident #1 in immediate jeopardy. This deficient practice of not having a system to identify resident's code status affected all residents in the facility. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 9 which indicated moderately impaired cognition. The assessment revealed the resident required total assistance of 2 staff for bed mobility, transfers, toileting, bathing, and limited assist of 1 staff for locomotion on and off the unit, eating, and personal hygiene. The [DATE] initial plan of care lacked evidence of the resident's code status. The [DATE] signed code status form indicated the resident was a full code and wished to receive full resuscitation. The [DATE] at 7:34 AM, nurse's note recorded a nurse aide alerted the nurse and found the resident lying in bed with his/her head tilted to the left, neck collar in place, with dried blood in the nose and mouth. The note stated the nurse checked for breath sounds for 1 minute, the resident did not have a pulse, and he/she was cold to the touch. The nurse looked for the resident's code status, and was unable to locate it. The dayshift nurse arrived for duty and did the CPR protocol, determining he/she was a full code. Staff obtained the crash cart, lowered the resident to the floor and initiated CPR. The dayshift nurse called (EMS) Emergency Medical Services and continued CPR until EMS arrived. The [DATE] at 9:02 AM, nurse's note recorded, when dayshift Licensed Nurse B arrived, Licensed Nurse C was on the phone and directed the nurse to the resident's room. The resident laid on his/her back, head slightly tilted to the left toward the wall, his/her color was waxy yellow, dried blood in his/her mouth, nose and a few splatters of blood was on the wall. No breathing or pulse noted. When the night shift nurse was asked how long since staff found the resident, and the nurse responded, about 5 minutes and he/she was unsure of his/her code status. The dayshift nurse was able to determine the resident was a full code and initated CPR, and EMS took over when they arrived. The [DATE] EMS report documented staff did a welfare check prior to EMS arrival. The resident was pulseless and apneic (absence of breathing), and initiated CPR. The resident had dried blood in his/her mouth and face, jaw was set, does not open to assess, rigor mortis (the stiffening of the joints and muscles of a body after death) in both upper and lower extremities, cold to the touch, without breath sounds and the resident's pupils were fixed and dilated with a film over the eyes. The EMT (a specially trained medical technician certified to provide basic emergency services (as cardiopulmonary resuscitation) before and during transportation to a hospital) called the emergency room doctor who advised to stop CPR. On [DATE] at 12:53 PM, per notarized statement, Licensed Nurse B stated at approximately 5:30 AM on [DATE], he/she was walking toward the front door and Nurse Aide D waved him/her over and told Licensed Nurse B that Resident #1 was dead. Licensed Nurse B stated the resident's color was waxy and yellow, had dried blood to the nose and mouth, splatters of blood on the wall and he/she was not breathing. Licensed Nurse B asked how long since he/she had been found and what was his/her code status. He/she was told it had been 5 minutes since staff found the resident and staff stated they did not know the code status and could not find it. Both Licensed Nurse B and Licensed Nurse C went to the crash cart and did not find his/her name on the list, and no code status in the computer but did find the resident's name in the advanced directive book which stated the resident was a full code. Licensed Nurse B directed the nurse aides to place the resident on the floor while he/she called EMS and Licensed Nurse C started chest compressions. (Licensed Nurse C did not have a current CPR certification) On [DATE] at 4:00 PM, per notarized statement, Licensed Nurse C stated at approximately 5:15 - 5:20 AM, Nurse Aide D told him/her to come to the resident's room quickly. Licensed Nurse C went in the room and the resident was in bed, with dried blood, in his/her mouth and nose, he/she felt for a pulse for a minute, went and got his/her stethoscope and did not find a pulse and the resident did not have any respirations. He/she looked on the resident's name plate, and did not see a red heart (indicates full code status). When Licensed Nurse B came in for dayshift he/she went to the resident's room and agreed the resident was deceased , Licensed Nurse B went to the crash cart and looked on the computer and did not find the resident's code status. Licensed Nurse B looked in the advanced directive book and saw the resident was a full code. Licensed Nurse C took the crash cart to the resident's room. Staff placed the resident on the ground and staff initated CPR. Licensed Nurse B called EMS, then took over chest compressions while Licensed Nurse C used the ambu bag (an artificial-respiration device consisting of a bag that staff squeezed by hand) on the resident. Licensed Nurse C stated he/she did not know there was a code status book at the nurse's station. On [DATE] at 4:50 AM, per notarized statement, Nurse Aide D stated he/she went to the resident's room at 5:00 AM and the resident's color was white, blood on his/her nose, and the wall, and the resident's arm was cold. Nurse Aide D stated he/she went to get the nurse. On [DATE]/16 at 3:19 PM, Administrative Nurse A stated whoever finds a resident without pulse or respiration needed to notify the nurse, and what the next step was depended upon the resident's code status. Administrative Nurse A stated, all resident code status's are located on the resident's door by the red heart (indicating full code), in the computer, on a list at the crash cart and in an advanced directive book at the nurse's station. On [DATE] at 3:36 PM, Administrative Staff E stated Licensed Nurse C's CPR certification expired in August of 2016, but he/she had been recertified as of [DATE]. The [DATE] facility's Cardiopulmonary Resuscitation and Basic Life Support Policy stated, the purpose of the procedure was to provide guidelines for the initiation of CPR in victims of sudden [MEDICAL CONDITION]. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who would direct resuscitative efforts, including non-licensed personnel. If an individual, resident, staff, or visitor was found unresponsive and not breathing normally, a licensed staff person who was certified in CPR/BLS shall initiate CPR unless it is known that a DO NOT RESUSCITATE (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual or there was obvious signs of irreversible death (e.g. rigor mortis). The facility failed to identify and facilitate Resident #1's right to formulate an advanced directive and follow the facility policy, when Resident #1 was found unresponsive, without a pulse and respirations, the facility had no clear indication of his/her code status, and failed to immediately initiate CPR, which placed the 27 residents, who reside in the facility with full code status, at risk for death. This deficient practice placed Resident #1, in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 4:15 PM when the facility completed staff education on code status information, compentencies over cardiac assessment, skin assessment, breath and heart sounds, follow-up monitoring for code status, and ensured CPR certified staff were on all shifts. This deficient practice remains at the scope and severity of a G.

The facility had a census of 40 residents. The sample included 7 residents. Based on observation, record review and interview, the facility failed to ensure a resident assessed as an elopement risk, had adequate supervision to prevent the resident from leaving the facility without staff's knowledge for 1 of 3 residents reviewed for elopement. The resident was gone from the facility for approximately 1 hour and 20 minutes and was found at a gas station 4 blocks away from the facility. This failure placed the resident in immediate jeopardy. (#1) Findings included: - Resident #1's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 7/16/15, indicated the resident had a (BIMS) Brief Interview for Mental Status Score of 0 which revealed severely impaired cognition. The assessment revealed the resident was independent with ambulation and required set-up assistance for transfers. The assessment further revealed the resident had hallucinations, (an experience involving the apparent perception of something not present), delusions (belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument) and wandered daily. The 11/8/14 (CAA) Care Area Assessment for accidents stated the resident was confused most of the time, and walked around the facility visiting with staff and other residents. The CAA further stated the resident had a wanderguard bracelet (a tracking device designed to prevent persons at risk from leaving a facility) and the staff check the wanderguard on him/her daily. The 8/1/15 care plan stated the resident was an elopement risk, wears a wanderguard bracelet and directed the staff to check the bracelet placement and function every shift. The care plan further directed the staff to monitor the resident's behavior of yelling, kicking at staff, wandering, and to log each behavior on the behavior log on the (MAR) Medication Administration Record. The 5/3/15 wandering risk assessment indicated the resident was a high risk for wandering. The 5/1/15 physician's orders [REDACTED]. The 5/30/15 at 10:17 PM, nurse's note stated the resident had been pacing the hallways and had been trying to get out of various doors in the facility. The note revealed at 3:50 PM, the resident pulled the fire alarm in the dining room and staff redirected the resident to the TV room located in the dining room area. The note further stated the resident went down another hallway and attempted to pull another fire alarm when another resident stopped Resident #1. The 6/1/15 physician's orders [REDACTED]. The 7/1/15 at 9:27 AM, nurse's note stated the consulting mental health physician increased the resident's Seroquel, (an antipsychotic medication) to, 50 mg, 1 by mouth, twice a day and to continue to administer 25 mg at bedtime. The note further directed the facility to increase the resident's (IM) Intramuscular Ativan, to 0.50 ml to equal 1 mg every 4 hours as needed for increased anxiety. The 7/6/15 at 2:48 AM, nurse's noted stated the resident continued to wander around the building, up and down the hallways and in and out of other resident rooms. The 7/17/15 at 10:23 PM, nurse's note stated the facility received a call from the city dispatch stating the resident was at a local gas station down the street. The note further stated the gas station had called 911 and (EMS) Emergency Medical Service to assess the resident. The resident returned to the facility with EMS with no injury. The note stated the resident was alert and staff placed a wanderguard bracelet on the resident because he/she had removed the bracelet prior to leaving the facility. The note further stated the staff would monitor the resident's location every 15 minutes during the night. On 7/17/15 at 9:00 PM, the temperature outside was 89.1 degrees F with a heat index of 92.9 degrees F and at 9:52 PM, the temperature outside 87.1 degrees F with a heat index 89.9 degrees F. The resident was dressed in long pants and a long sleeved sweater. On 8/11/15 at 1:30 PM, during tour of the facility, a sign on the front door directed visitors to ask staff to let them out of the facility and to not let residents follow them outside without staff present. On 8/11/15 at 3:30 PM, observation revealed the resident ambulated up and down the halls of the facility, pushed on the doors, then went to the front door causing the wanderguard alarm to sound. Further observation revealed the staff redirected the resident away from the front door. On 8/12/15 at 9:10 AM and 9:30 AM, observation revealed 2 residents went to the front door, put in the door code, opened the door and went outside. On 8/11/15 at 9:43 AM, Administrative Nurse A stated he/she had been the nurse working the night the resident left the facility and had checked the placement of the wanderguard at the beginning of the shift. Administrative Nurse A stated there were 2 nurse aides and 2 nurses working that evening and all of them were assisting residents and were not monitoring the resident. Administrative Nurse A stated the resident had a history of [REDACTED]. Administrative Nurse A stated the resident had cut off his/her wanderguard and left the facility. Administrative Staff A verified the staff were not aware that the resident had left the facility until they received a call from 911 dispatch that the resident was down at a local gas station.(approximately 1 hour and 23 minutes after the resident was last seen by the staff) Administrative Nurse A stated EMS brought the resident back to the facility, staff assessed the resident and found no injury. Administrative Nurse A stated the facility's intervention after the resident left the facility unsupervised was to change the front door code, provided a teachable moment sheet that directed the staff to monitor the resident's location every 15 minutes and document findings on a special form. (review revealed the form was signed by 11 staff members). The facility provided a second teachable moment which directed the staff not to give the door code to anyone who was not a staff member (8 staff signed the form). On 8/11/15 at 10:15 PM, Licensed Nurse C stated the resident had still been in the facility at 9:00 PM on July 17, and at that time he/she saw the resident come out of another resident's room. Licensed Nurse C stated he/she did not check the resident to see if the resident still had on the wanderguard or if the resident had anything to cut off the wanderguard when leaving the other resident's room. Licensed Nurse C stated staff assessed the resident after he/she returned and determined he/she had no any injuries. Licensed Nurse C stated the resident was tired and wanted to go to bed when he/she returned. On 8/12/15 at 1:56 PM, Nurse Aide B stated the resident wanders all over the facility and goes in and out of other resident's room. Nurse Aide B stated the resident had left the faciity on a previous occasion after the resident pulled the fire alarm. Nurse Aide B stated the resident had went out the dining room door and Nurse Aide B was told by a nurse to go find the resident. Nurse Aide B stated the resident was outside by the dumpster. (observation revealed the dumpster approximately 30 feet from the dining room door) Nurse Aide B stated the only training he/she received after the resident recently left the building unsupervised, was to be informed staff had changed the door code on the front door and instructed staff not to give the door code to anyone other than a staff member. Nurse Aide B verified there are residents of the facility that did know the code and go outside on their own. On 8/12/15 at 9:09 AM, Administrative Staff D verified staff are not to give the door code to any visitors or residents in the facility. On 8/25/15 at 4:50 PM, Physician K stated the resident was an elopement risk and the staff should monitor the resident more closely so he/she was unable to find ways to cut off his/her wanderguard. Physician K further stated the staff should monitor the resident so he/she was unable to leave the facility unsupervised. The September 2012 Facility's Elopement Policy directed the staff to evaluate, investigate and report all cases of missing residents. The policy stated each resident evaluated for elopement and wandering will have interventions initiated, reviewed and modified. The facility failed to ensure adequate supervision for Resident #1 who left the facility without the staff's knowledge and was gone 1 hour and 20 minutes before staff received a call from local EMS the resident was found at a local gas station. The facility abated the Immediate Jeopardy, on 8/12/15, when the facility provided an inservice on the elopement policy and procedure to all staff and placed the resident on 1:1 supervision. The Director of Nursing planned to audit all resident to evaluate for safety in regards to elopement risk. The facility planned to have a new monitoring system installed which featured a door control that activates an additional door lock in the event a resident with a wanderguard entered the field being monitored at the door. The new alarm system included a strap on the bracelet designed to stop a resident from removing it. The deficient practice remains at a scope and severity of a D.

The facility had a census of 40 residents. The sample included 7 residents of which 3 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to implement effective interventions to prevent the development of a pressure ulcer for 1 of 3 sampled residents who developed a stage 2 pressure ulcer which became infected and required hospitalization for treatment. (#4). Findings included: - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 7/13/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 5 which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff members for transfers, bed mobility, and toileting. The assessment further revealed the resident was at risk for skin breakdown, had a stage 2 pressure ulcer (partial thickness skin loss of epidermis and dermis), on a turning and repositioning program, and had pressure reducing devices for the bed and chair. The 7/13/15 (CAA) Care Area Assessment for pressure ulcers stated the resident had developed a stage 2 pressure ulcer to his/her buttocks. The CAA stated the staff treated the pressure ulcer with skin prep, duoderm (a skin dressing that promotes healing of wounds), and encouraged the resident to reposition him/herself when in his/her chair. The CAA stated the staff encouraged the resident to lay in bed, because most of the nights. because he/she wanted to sleep in his/her recliner. The 1/15/15 Braden scale assessment revealed the resident was not at risk for skin breakdown. The 6/22/15 care plan stated the resident required the assistance of 1 person for bed mobility. (the care plan lacked direction for staff to provide preventative measures to decrease the risk of pressure ulcer development for the at risk resident). The 7/3/15 updated care plan directed the staff to reposition the resident every 2-3 hours, provide a pressure relieving device to bed and chair, and elevate the resident's heels with pillows under the lower legs when he/she was in bed. The 7/3/15 at 10:21 PM, nurse's note stated the resident had an area on his/her gluteal crease (to the right of the groove of the left buttocks).The note further stated the physician directed the staff to apply [MEDICATION NAME] cream and report back to the physician on 7/6/15. The 7/7/15 at 11:10 PM, nurse's note stated the resident had an open area to his/her left buttocks. The staff notified the physician who directed the staff to apply skin prep to the surrounding skin, place a duoderm dressing on the wound and change the dressing every 3 days. The note further stated the staff assessed the wound as a stage 2 pressure ulcer. The 7/7/15 weekly skin assessment indicated the resident had an open area to his/her left buttocks and the wound measured 1.5 (cm) centimeters x 1.0 cm. The 7/7/15 (RD) Registered Dietician assessment recommended a multivitamin with minerals daily and [MEDICATION NAME] (a supplement to promote wound healing) two times daily for the resident to promote healing. The 7/17/15 physician's orders [REDACTED]. (10 days after the RD's recommendation) review of the resident's medical record revealed [REDACTED]. status) was 3.6. (normal is 3.4 - 8.5) The 7/12/15 at 9:38 AM, nurse's note stated the facility faxed the physician about the resident's wound and although the wound had not healed, the physician discontinued the treatment. The 7/16/15 weekly skin assessment indicated the resident had an open area to his/her right buttocks which measured 2.5 cm x 1.5 cm. (review of the medical record revealed the resident's wound was on the left buttocks and not the right) The 7/26/15 at 10:14 PM, nurse's note stated the staff applied duoderm to the resident's buttocks as ordered. (review of the medical record lacked documentation of any measurements of the pressure ulcer) The 7/28/15 at 10:35 AM, nurse's note stated the resident had a large baseball sized abscess (a swollen area within body tissue, containing an accumulation of pus) noted to his/her left buttocks, with bright red skin and warm to the touch. The note further stated the staff notified the physician. The 7/28/15 at 8:53 PM, nurse's note stated the physician admitted the resident to a local hospital with the [DIAGNOSES REDACTED]. The 7/28/15 History and Physical from the local hospital noted the resident was admitted due to a small decubitus sore on his/her right buttocks (although the pressure ulcer was on the resident's left buttocks). The History and Physical further stated the resident would be assessed for [DIAGNOSES REDACTED] (a type of necrotizing infection or gangrene usually affecting the perineum) or [MEDICAL CONDITION] (a bacterial infection involving the inner layers of the skin) and would be monitored through the night. On 7/29/15 hospital operative report stated the resident had left buttock [MEDICAL CONDITION] which had progressed to an abscess that would be drained. The report stated the resident was given a sedative and an incision was made to the abscess. The report further stated the wound was irrigated with saline and then dressed with saline-soaked gauze, 4 x 4's and an abd pad placed over the wound. The 8/3/15 at 10:01 PM, nurse's note stated the facility readmitted the resident with a [DIAGNOSES REDACTED]. The note further stated the resident was on contact precautions (procedures that reduce the risk of spread of infections through direct or indirect contact). The facility readmitted the resident to the facility on [DATE] with readmission orders [REDACTED] [MEDICATION NAME], (an antibiotic) 875 (mg) milligrams, by mouth, every 12 hours. [MEDICATION NAME], (an antibiotic) 450 mg, by mouth, every 8 hours. [MEDICATION NAME], (an antibiotic) 750 mg, by mouth, daily in the am. The 8/3/15 physician's orders [REDACTED]. strips for sterile drainage of open and/or infected wounds) into the wound and cover with 4 x 4 gauze or abd(abdominal) pad, and secure with tape. The 8/5/15 at 11:11 AM, nursing assessment of the resident's left buttock wound indicated the area surrounding the abscess was slightly red with no abnormal drainage noted. The note further stated the resident tolerated the wound treatment without complaint of pain. On 8/13/15 at 3:01 PM, observation revealed Licensed Nurse E and Nurse Aide B put on protective gowns, gloves, and masks and entered the resident's room. Licensed Nurse E had the resident roll onto his/her left side, pulled out the packing strip from the left buttock wound, flushed the wound, repacked the wound and covered it with a 4 x 4 dressing and tape. Further observation revealed the area surrounding the wound was slightly reddened and without drainage, and the center of the wound was approximately 1.0 cm around and .75 cm in depth. (review of the medical record lacked documentation of the stage of the pressure ulcer) The 8/19/15 documentation from the physician stated the occurrence of the abscess could be related to the pressure ulcer since the abscess was in the vicinity of the pressure ulcer and directed the staff to continue to monitor the resident's skin closely and to encourage extensive amounts of time in bed on he/she side so the issue does not occur again. On 8/12/15 at 1:25 PM, Administrative Nurse G verified the care plan lacked interventions to prevent the resident from developing a pressure ulcer prior to 7/3/15 when the resident developed the pressure ulcer. On 8/13/15 at 9:30 AM, Nurse Aide H stated the resident never slept in his/her bed, only in a recliner. Nurse Aide H verified he/she was not sure whether the resident had a pressure relieving device prior to his/her skin breakdown. On 8/13/15 at 1:28 PM, Licensed Nurse F stated the resident's wound started as a split and then an abscess formed under the left buttock pressure ulcer and the physician admitted him/her to the hospital. On 8/13/15 at 3:01 PM, Licensed Nurse E verified the charting for the location was incorrect and the pressure ulcer was on the left buttocks and not on the right. On 8/17/15 at 2:30 PM, Administrative Nurse A verified staff should have implemented preventative measures for the at risk resident prior to him/her developing a pressure ulcer. The 5/13 Facility's Pressure Ulcer Risk Assessment Guidelines directed the staff to review the resident's care plan to assess for any special needs of the resident, assess the resident's skin weekly, and care plan with interventions individualized for the resident and their particular risk factors. The facility failed to implement effective interventions to prevent the development of a pressure ulcer for Resident #4, who was at risk for skin breakdown and developed a pressure ulcer which became infected and required hospitalization .

The facility had a census of 42 residents. The sample included 8 residents. Based on observation, interview and record review the facility failed to decrease the risk for infection and provide appropriate urinary care for 3 of 3 residents reviewed for catheter care. (#2, #7, #8) Findings included: - Resident #2's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/12/13, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview of Mental Status score of 4 and no behaviors. The MDS further indicated the resident required extensive assistance from 1 staff for bed mobility, transfers, walk in room and corridor, dressing, toilet use and personal hygiene and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The MDS further indicated the resident had a urinary tract infection in the last 30 days. The 8/23/13 care plan instructed the staff to administer an antibiotic per physician's order [REDACTED]. The (CAAs) Care Area Assessment, dated 4/11/13, indicated the resident had the urinary catheter placement for [MEDICAL CONDITION] (a lack of ability to urinate), and felt he/she still had to urinate, and would try to get up, causing him/her to fall, numerous times. The 5/31/13 physician's orders [REDACTED]. The 8/15/13 at 10:39 AM, nurse's notes indicated the resident's urine had a pudding like consistency in the urinary catheter at times, and the facility notified the physician of the thick consistency and problems with flushing the catheter. The 8/15/13 at 3:33 PM, nurse's notes indicated the facility received a physician's orders [REDACTED]. intake. The 8/15/13 at 7:29 PM, nurse's notes indicated the resident's family called the facility to notify them the resident ' s urologist had told the family, earlier in the year, the only treatment they could provide the resident is the use of a silver tipped catheter. (A silver tipped catheter helps reduce the frequency of urinary tract infections in those who require chronic catheterizations) The 8/15/13 primary care physician's orders [REDACTED]. The 8/15/13 at 10:33 PM, nurse's note indicated the staff had not changed the resident's urinary catheter due to the unavailability of a silver tipped catheter. The 8/16/13 at 9:54 AM, nurse's note indicated the resident's family declined the resident to see the urologist again. Review of the medical record revealed the staff assessed the resident as cognitively impaired and no behaviors exhibited in the most recent MDS. (Increased behaviors can indicate possible urinary tract infections) Further review of the nurse's notes revealed the following: On 8/17/13 at 7:00 PM, the resident grabbed another resident's fruit off the table and threw it on the floor. On 8/19/13 at 1:22 PM, the resident attempted to take another resident's walker and would not let it go. On 8/20/13 at 2:54 PM, the resident had been tearful and the staff obtained and sent a urinalysis to the laboratory with a large amount of yellow mucous and dark amber urine noted. On 8/21/13 at 2:29 AM, the resident had thrown silverware, plates and cups on the floor in the main dining room. On 8/22/13 at 12:35 PM, the resident had a positive urinalysis that indicated the resident had an urinary tract infection. The 8/23/13 physician's orders [REDACTED]. [MEDICATION NAME] (an antibiotic) 100 (mg) milligrams, twice daily, for 7 days, for a urinary tract infection. Cipro (an antibiotic) 250 mg, twice daily, for 7 days, for a urinary tract infection. The 8/23/13 at 7:28 PM nurse's notes indicated the resident had a poor appetite, kept spitting out his/her medications, and the staff finally administered the resident's medications successfully. Review of the vital sign electronic medical record revealed the resident had the following temperature: 8/27/13 99.6 8/28/13 99.4 9/3/13 99.6 9/4/13 101.6 The 8/29/13 at 3:05 AM, nurse's note indicated the resident continued on an antibiotic for a urinary tract infection and remained without fever, although the urine was dark yellow. (Although low grade temperatures had been recorded in the electronic medical record) The 8/30/13 at 4:49 AM, nurse's notes indicated the resident remained free of fever and had dark urine. The 8/30/13 at 10:03 PM, nurse's notes indicated the resident finished the antibiotic for the urinary tract infection. The 9/1/13 at 3:49 PM, nurse's notes indicated the resident on follow up for treatment of [REDACTED]. The medical record lacked any further documentation in regards to the appearance of the resident ' s urine. The 9/4/13 at 12:35 PM, nurse's note indicated the staff noted the resident was weak and required assistance with his/her meal. The note indicated the staff attempted to get the resident up for his/her noon meal and the resident unable to bear weight or follow directions. The resident had lethargy (sluggishness, lifelessness), weakness, a temperature of 101.6, and the facility received an order from the resident's primary care physician to transport the resident to the emergency department. The 9/4/13 hospital (H&P) History and Physical indicated the resident had been seen in the emergency department for a high fever, [MEDICAL CONDITION](rapid heartbeat), and altered mental status (a state of awareness that is different from the normal awareness of a person). The H&P indicated the resident's urinary catheter bag had thick, pus-like, heavy urine, which required replacement of the catheter, and once replaced about 400 ml (milliliters) to 600 ml thick orange odorous urine returned. The H&P indicated the hospital admitted the resident with the [DIAGNOSES REDACTED]. The 9/7/13 hospital discharge summary indicated the resident stable enough to be discharged , had his/her catheter replaced before discharge, and to remain on oral antibiotics over the next 10 days. The discharge summary indicated the hospital treatment included intravenous (by veins) fluids, antibiotics, and the urine culture showed Proteus mirabilis (a bacteria). The 9/16/13 at 12:08 AM, nurse ' s note indicated the staff replaced the urinary catheter using a silver tipped catheter. On 9/26/13 at 6:59 AM, observation revealed the resident seated in his/her wheelchair in the facility ' s common area. Observation revealed the resident ' s pant leg on his/her right leg damp, and the catheter drainage bag not visible. On 9/26/13 at 8:39 AM, observation revealed 2 staff propelled the resident to his/her room due to his/her pants were wet. The staff identified the port to his/her urinary catheter had been left open and the damp area on his/her clothes from urine leaking from the catheter. On 9/26/13 at 10:05 AM, observation revealed Nurse Aide D and Nurse Aide B prepared to assist the resident to his/her bed. The staff washed their hands, applied gloves, and assisted the resident to transfer from his/her wheelchair to the bed. Observation revealed Nurse Aide B removed the resident ' s pants and brief, and provided perineal care for a small bowel movement. Observation revealed with the same soiled gloves, Nurse Aide B cleaned the resident ' s bottom and front then used a personal wipe to and cleanse the catheter tubing from insertion of the catheter to the drainage bag. On 9/25/13 at 3:00 PM, Nurse C verified the staff had not changed the resident ' s catheter since 7/15/13, prior to the resident ' s admission to the hospital on [DATE] [MEDICAL CONDITION]. Nurse C further verified the facility had not notified the physician of the catheter not being replaced. On 9/26/13 at 10:17 AM, Nurse Aide D verified Nurse Aide B did not change his/her gloves after cleaning the resident ' s bottom and perineal area. Nurse Aide B further stated he/she did not know he/she should change his/her gloves. Nurse Aide D verified he/she not aware of the need to change gloves after performing perineal care. On 9/26/13 at 11:01 AM, Nurse C verified the staff should change his/her gloves before providing the resident catheter care and further verified the port being left open, created an infection control concern. On 9/26/13 at 3:52 PM, Physician Nurse E verified the physician had ordered the facility to change the resident ' s catheter on 8/15/13 and the facility had notified the physician on 8/16/13 the facility did not have a silver tipped catheter and would replace it on 8/20/13. Physician Office Nurse E verified the facility had received an order for [REDACTED]. The facility failed to provide Resident #2 with adequate urinary catheter care. - The 9/10/2013 physician order [REDACTED]. The significant change in status (MDS) Minimum Data Set 3.0 assessment, dated 9/13/2013, indicated the resident had long term memory problems and independent decision making. The MDS indicated the resident required total assistance from staff for all (ADLs) Activities of Daily Living. The MDS indicated the resident had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and frequent bowel incontinence. The 9/4/2013 at 1:00 PM nurse ' s notes revealed the resident was readmitted to the facility with an indwelling urinary catheter. The 9/17/2013 at 8:13 PM nurse ' s notes revealed the nurse received an order clarification to remove the indwelling catheter, wait 12 hours, and use a straight catheter (a tube-shaped medical device that is used to remove urine from a person ' s bladder for temporary use and is removed immediately after urine is taken from the bladder) for draining residual urine from the resident ' s bladder and report the finding, in the morning, to the physician. The 9/17/2013 at 3:19 PM, nurse ' s notes indicated the nurse removed the resident ' s indwelling urinary catheter. The 9/17/2013 at 3:43 PM, nurse's notes indicated the physician order [REDACTED]. (French), 30(ml) milliliter, indwelling urinary catheter and change the catheter on the 15th of each month. The 9/18/2013 at 4:52 AM, nurse ' s notes indicated the nurse had inserted the indwelling urinary catheter in the resident. The 9/11/2013 care plan instructed the staff to provide catheter care every shift and as needed The 9/18/2013 at 4:52 AM, nurse ' s notes indicated the staff inserted an indwelling urinary catheter with residual of 100 (ml) milliliters of urine. On 9/25/2013 at 8:40 AM, observation revealed Nurse Aide A applied gloves, obtained a container from the resident ' s bathroom, unclamped the urine drainage bag spigot, and without cleaning the spigot, emptied clear yellow urine from the urine collection bag. Observation revealed Nurse Aide A clamped the spigot closed, and without cleansing the spigot, attached it to the indwelling urinary catheter bag. Nurse Aide A, placed the indwelling catheter bag in a cloth bag and hung the bag at the foot of the resident ' s bed. Nurse Aide A disposed of his/her soiled gloves, applied new gloves, used pre-moistened, warmed disposable cloths to provide perianal care, and without removing the soiled gloves, Nurse Aide A, used a clean moistened cloth, and cleansed the catheter tubing from the insertion site to the indwelling urinary catheter bag. On 9/26/2013 at 11:15 AM, Administrative Nurse C verified the staff should change gloves in between providing perianal care and cleansing a resident ' s indwelling urinary catheter and should clean the spigot on the drainage bag with a disinfectant sponge or alcohol wipe before and after emptying. The facility ' s undated Catheters/Urinary/Catheter Care policy instructed the staff to cleanse the spigot on the drainage bag with a disinfectant sponge before and after emptying. The facility failed to provide proper indwelling urinary catheter care for Resident #7. - Resident #8 ' s quarterly (MDS) Minimum Data Set 3.0 assessment, dated 6/26/2013, indicated the resident had short and long term memory problems, severely impaired cognitive skills for daily decision making, and required total assistance of staff for all (ADL) s Activities of Daily Living. The MDS indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. The 9/10/2013 care plan instructed the staff to provide catheter care every shift and as needed. The 8/8/2013 urine analysis (examination of urine) revealed the resident had a [MEDICAL CONDITION] urinary tract infection (an infection in any part of your urinary system your kidneys, ureters, bladder and urethra). The Nursing Home/skilled admission orders [REDACTED] On 9/25/2013 at 1:40 PM, observation revealed, the resident, seated in a wheelchair in the commons area with his/her indwelling urinary catheter tubing touching the carpeted floor underneath the resident ' s wheel chair. On 9/25/2013 at 3:38 PM, observation revealed the resident seated in a wheelchair in the commons area with his/her Foley catheter tubing touching the carpeted floor underneath the resident ' s wheel chair. On 9/25/2013 at 10:48 AM, Nurse Aide B washed his/her hands, applied gloves, attached the resident ' s indwelling urinary catheter urine collection bag to the side of the resident ' s wheel chair, used a urinal from the resident ' s bathroom, unclamped the spigot, emptied red tinged colored urine into the urinal, clamped the spigot, and without cleaning, inserted the spigot back into the catheter urine collection bag. On 9/26/2013 at 11:15 AM, Administrative Nurse C verified the resident ' s indwelling urinary catheter tubing should not be touching the floor. Administrative Nurse C verified the staff should clean the spigot on the drainage bag with a disinfectant sponge or alcohol wipe before and after emptying. The facility's undated Catheters/Urinary/Catheter Care policy instructed the staff to cleanse the spigot on the drainage bag with a disinfectant sponge before and after emptying. The facility failed to provide proper catheter care and implement approaches to manage an indwelling urinary catheter for Resident #8.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview and record review the facility failed to assess and monitor a resident and obtain timely medical care and physician input for additional interventions for Resident #1 who had a marked decline including yellowish green drainage of his/her legs after the antibiotic had been stopped for over 7 days for 1 of 5 residents reviewed for provision of care and services (#5) and failed to assess a resident's condition after a change. (#1) Findings included: - Resident #5's admission (MDS) Minimum Data Set 3.0 assessment, dated 6/27/13, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 9, and required assistance from 2 staff for bed mobility, transfers, dressing and toileting. The MDS also indicated the resident had almost constant level 7 (severe) pain, and open [MEDICAL CONDITION] other than ulcers, rashes, cuts with application of non surgical dressings, ointments, and medications. The 6/27/13 (CAAs) Care Area Assessment indicated the resident had [MEDICAL CONDITION] (skin infection caused by bacteria that is characterized by heat, redness and swelling) of both lower extremities and was treated with antibiotics. The CAAs further indicated the resident was at risk for further breakdown of his/her lower legs if not protected from injury. The 6/28/13 care plan instructed the staff to assess the resident's lower extremities for skin temperature, pulses, [MEDICAL CONDITION], circulation and motion sensation. The care plan further instructed the staff to report signs of [MEDICAL CONDITION] which included: localized pain, redness, swelling, tenderness, drainage, fever, chills, malaise (vague uneasy feeling of body weakness, distress or discomfort), [MEDICAL CONDITION](rapid heartbeat greater than 100 beats per minute) and [MEDICAL CONDITION] (low blood pressure). The 6/20/13 hospital physician's progress note indicated the resident's legs are less warm and painful and will convert the resident to an oral antibiotic and transfer him/her to a skilled nursing facility. The 6/21/13 hospital skin discharge report indicated the resident has a scabbed area to the back of his/her left calf. The 6/21/13 physician orders [REDACTED]. Administer [MEDICATION NAME] (an antibiotic), 875/125 (mg) milligrams, twice daily, to the resident. Apply [MEDICATION NAME] (sulfa antibiotic) cream to the weeping areas on the resident ' s bilateral lower extremities and to cover with gauze and tape. The facility's weekly skin assessments indicated the resident had bilateral lower extremity [MEDICAL CONDITION] on the following: 6/21/13, 6/28/13, 7/5/13, 7/12/13, 7/19/13, 7/25/13, 8/2/13, 8/9/13 and 8/16/13 The 7/1/13 physician's progress note indicated the resident continued to have painful swollen [DIAGNOSES REDACTED] (redness or inflammation of the skin) to his/her lower legs. The 8/9/13 at 12:53 PM, nurse's notes indicated the resident had [MEDICAL CONDITION] in both lower extremities and the right leg was extremely red hot and swollen with green-yellow drainage. The 8/9/13 physician order [REDACTED]. The 8/11/13 at 3:02 AM, nurse's notes indicated the resident had continued to be [MEDICAL CONDITION] (swollen) and redness to his/her bilateral lower extremities. The 8/11/13 at 10:25 AM, nurse's note indicated the resident continued to be on an antibiotic for [MEDICAL CONDITION] and his/her left leg had improved some and his/her right leg continued to be very red with "much" yellow drainage. The 8/13/13 at 2:21 AM, nurse's note indicated the resident ' s bilateral lower extremity remained [MEDICAL CONDITION] and his/her right lower extremity was more red and warm to touch then his/her left lower extremity. The 8/15/13 at 10:28 AM, nurse's note indicated the resident continued to have red weepy legs and the pain in his/her legs was severe. The 8/15/13 at 9:15 PM, nurse's note indicated the resident had a moderate amount of drainage from the right lower extremity. The 8/19/13 at 9:44 PM, nurse's note indicated the resident had a large amount of yellow drainage to the dressings when changed. Review of the resident's (MAR) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurse's notes indicated the facility's staff continued to chart the resident was on an antibiotic from 8/21/13 to 8/27/13, when the resident ' s oral antibiotic was stopped on 8/20/13. The 8/22/13 at 11:02 AM, nurse's note indicated the resident continued to have slight redness, swelling and crusty patches to his/her bilateral lower extremities. The 8/23/13 weekly skin assessment indicated the resident continued with white moist looking patches to his/her bilateral lower extremities. The 8/23/13 at 3:35 AM, nurse's note indicated the resident ' s bilateral lower extremities remained very swollen. The 8/23/13 at 11:33 AM, nurse's note indicated the resident's legs remained slightly red and very swollen with "much" crusty drainage and the primary care physician would be notified. The 8/25/13 at 11:22 AM, nurse's note indicated the resident's legs were a little more red and swollen with white crusty material from the drainage. The nurse ' s note further indicated a fax would be sent to the primary care physician. (This was a Sunday and 5 days after the antibiotic was stopped per physician's orders [REDACTED]. The 8/25/13 at 9:35 PM, nurse's note indicated the residents bilateral legs are still very weepy , reddened and painful and the area looked "much worse" then the other day. The documentation revealed no mention of notifying the physician since the previous note. The 8/26/13 at 9:00 PM, nurse's note indicated the staff had faxed and called the physician several times to get something done for the increase of drainage and [MEDICAL CONDITION] to the resident's legs. The note indicated the family had decided to try and change physicians, due to no response for new treatment for [REDACTED]. The 8/27/13 at 9:22 AM, nurse's note indicated the facility staff had faxed the resident's information to another physician requesting he/she take over the resident ' s care. (7 days after the antibiotic was stopped and staff documented a progressive marked decline of the physical status of the resident's legs) The 8/27/13 at 11:44 AM, nurse's notes indicated the infected area to the right leg measured 25 (cm) centimeters by 40 cm and the left leg measured 23.5 cm by 42 cm. The 8/27/13 at 2:37 PM, nurse's note indicated the resident was transferred to the emergency room to have his/her legs evaluated. The 8/27/13 physician's orders [REDACTED]. On 8/27/13 at 10:34 AM, observation revealed the resident seated in his/her recliner with his/her legs elevated with Nurse F beside him/her to do a dressing change. The resident ' s legs appeared to be a dark red and purple color and had oozing yellow and green drainage covering his/her right calf. Nurse F sprayed the right leg with wound cleanser and wiped the area with a clean gauze pad. The area measured 25 cm by 40 cm. A thin layer of [MEDICATION NAME] cream is applied to the area and covered with gauze that had been placed directly on the resident ' s bedside table with no barrier to prevent further infection. Nurse F cleaned the left leg with wound cleanser and wiped it with a clean gauze pad. The area measured 23.5 cm by 42 cm. Nurse F applied a thin layer of Sivadene cream and wrapped with gauze. At that time Nurse F verified the assessment of the resident's legs. On 8/27/13 at 12:30 PM, Nurse A verified the resident goes back and forth with the [MEDICAL CONDITION] getting worse and better and that a culture had not been performed. Nurse A further stated the facility staff had a hard time contacting the primary care physician. Nurse A further verified if the resident ' s physician is unable to be contacted the concern should be taken to the medical director. On 8/27/13 at 2:00 PM, Nurse A verified the staff had sent the resident to the emergency room for evaluation of his/her legs. Nurse A further verified the staff had charted the resident was on an antibiotic when he/she was not. Nurse A stated he/she expected the staff to notify the resident's physician when they noted a change of the resident ' s condition. On 8/27/13 at 2:35 PM, Physician's Office Staff G verified the physician took over care of the resident on 7/1/13 and the facility had contacted the office 4 times on 7/8/13, 7/31/13, 8/9/13 and 8/16/13 in regards to pain and antibiotic medication changes. Physician ' s Office Staff G further verified the resident had an appointment last week with the physician and it had been rescheduled by the facility. On 8/27/13 at 2:56 PM, Nurse A verified the fax the staff had documented, on 8/25/13 in the nurse's note that was actually sent to physician, was a print out of a nurse ' s note with no communication to the physician, no fax number for the physician's office, making it uncertain if the physician received the communication by the facility. Nurse A further verified the resident ' s appointment was rescheduled per the resident and the family request. On 8/28/13 at 9:25 AM, Nurse F verified when he/she contacted the medical director, on 8/27/13, in regards to assume care of the resident, he/she had not communicated the marked decline in the resident's condition. On 8/29/13 at 4:11 PM, Physician J verified he/she would expect the facility to notify his/her with a change in the resident's condition such as color and drainage. Physician J further verified if the facility had not received contact returned from a fax he/she would prefer a phone call. The facility failed to obtain timely medical care after assessing and documenting a marked decline in Resident #5's lower extremities which had yellowish green drainage after he/she had not received an antibiotic from 8/20/13 to 8/27/13. - Review of Resident #1's medical record indicated the resident was admited 7/23/13 and discharged [DATE]. The 7/23/13 at 4:26 PM, admission nurse's note indicated the resident had been admitted to the facility from the hospital after an electrolyte imbalance. The admission assessment indicated the resident had chronic pain associated with the [DIAGNOSES REDACTED]. The admission note further indicated the resident to be alert and oriented and he/she had a porta catheter (implantable venous access) to the upper right chest. The admission note indicated he/she was a smoker, gets emotional, and was able to ambulate independently throughout the facility. The admission note indicated the resident was continent of bowel and bladder, had no open area, but had bruising from lab draws and intravenous catheters. The 7/23/13 care plan instructed the staff to report any abnormal observations to the physician immediately of the resident, inregards to [MEDICAL CONDITION]. The 7/23/13 hospital discharge summary included dictation from the physician that stated: the resident was stable with a sodium level of 130 and the 120's was acceptable for the resident. Normal sodium levels range from 135-145. The 7/23/13 physicians order instructed the staff to administer to the resident: Sodium Chloride (an electrolyte), 1 gram, three times daily, for electrolyte disorder. Review of the July 2013 (MAR) Medication Administration Record, [REDACTED]. (8 days) The 7/29/13 at 9:23 AM, nurse's note indicated the facility notified the physician the resident had wheezing in his/her lungs, suppressed appetite and a brown tinged drainage from his/her nose. The 7/29/13 at 5:53 PM, nurse's note indicated the resident had returned from a visit with his/her physician. The 7/30/13 at 4:53 PM, nurse's note indicated the physician called with a new order to start the resident on an antibiotic for an elevated white blood cell count. The 7/30/13 laboratory value for his/her sodium level was at 130. review of the resident's medical record revealed [REDACTED]. (2 days) The 7/31/13 at 4:12 AM, nurse's note indicated the resident was found not breathing, staff initiated cardiopulmonary resuscitation, and he/she was transferred to the hospital by ambulance. Review of the MAR indicated [REDACTED]. On 8/28/13 at 9:52 AM, Nurse A verified the staff had not administered the physician ordered medication or documented a nursing assessment of the resident. The facility failed to adequately assess and administer a physician ordered treatment to Resident #1.

2 The facility had a census of 42 residents. The sample included 8 residents. Based on observation, interview and record review the facility failed to decrease the risk for infection and provide appropriate urinary care for 3 of 3 residents reviewed for catheter care. (#2, #7, #8) Findings included: - Resident #2's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/12/13, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview of Mental Status score of 4 and no behaviors. The MDS further indicated the resident required extensive assistance from 1 staff for bed mobility, transfers, walk in room and corridor, dressing, toilet use and personal hygiene and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The MDS further indicated the resident had a urinary tract infection in the last 30 days. The 8/23/13 care plan instructed the staff to administer an antibiotic per physician's order [REDACTED]. The (CAAs) Care Area Assessment, dated 4/11/13, indicated the resident had the urinary catheter placement for [MEDICAL CONDITION] (a lack of ability to urinate), and felt he/she still had to urinate, and would try to get up, causing him/her to fall, numerous times. The 5/31/13 physician's orders [REDACTED]. The 8/15/13 at 10:39 AM, nurse's notes indicated the resident's urine had a pudding like consistency in the urinary catheter at times, and the facility notified the physician of the thick consistency and problems with flushing the catheter. The 8/15/13 at 3:33 PM, nurse's notes indicated the facility received a physician's orders [REDACTED]. intake. The 8/15/13 at 7:29 PM, nurse's notes indicated the resident's family called the facility to notify them the resident ' s urologist had told the family, earlier in the year, the only treatment they could provide the resident is the use of a silver tipped catheter. (A silver tipped catheter helps reduce the frequency of urinary tract infections in those who require chronic catheterizations) The 8/15/13 primary care physician's orders [REDACTED]. The 8/15/13 at 10:33 PM, nurse's note indicated the staff had not changed the resident's urinary catheter due to the unavailability of a silver tipped catheter. The 8/16/13 at 9:54 AM, nurse's note indicated the resident's family declined the resident to see the urologist again. Review of the medical record revealed the staff assessed the resident as cognitively impaired and no behaviors exhibited in the most recent MDS. (Increased behaviors can indicate possible urinary tract infections) Further review of the nurse's notes revealed the following: On 8/17/13 at 7:00 PM, the resident grabbed another resident's fruit off the table and threw it on the floor. On 8/19/13 at 1:22 PM, the resident attempted to take another resident's walker and would not let it go. On 8/20/13 at 2:54 PM, the resident had been tearful and the staff obtained and sent a urinalysis to the laboratory with a large amount of yellow mucous and dark amber urine noted. On 8/21/13 at 2:29 AM, the resident had thrown silverware, plates and cups on the floor in the main dining room. On 8/22/13 at 12:35 PM, the resident had a positive urinalysis that indicated the resident had an urinary tract infection. The 8/23/13 physician's orders [REDACTED]. [MEDICATION NAME] (an antibiotic) 100 (mg) milligrams, twice daily, for 7 days, for a urinary tract infection. Cipro (an antibiotic) 250 mg, twice daily, for 7 days, for a urinary tract infection. The 8/23/13 at 7:28 PM nurse's notes indicated the resident had a poor appetite, kept spitting out his/her medications, and the staff finally administered the resident's medications successfully. Review of the vital sign electronic medical record revealed the resident had the following temperature: 8/27/13 99.6 8/28/13 99.4 9/3/13 99.6 9/4/13 101.6 The 8/29/13 at 3:05 AM, nurse's note indicated the resident continued on an antibiotic for a urinary tract infection and remained without fever, although the urine was dark yellow. (Although low grade temperatures had been recorded in the electronic medical record) The 8/30/13 at 4:49 AM, nurse's notes indicated the resident remained free of fever and had dark urine. The 8/30/13 at 10:03 PM, nurse's notes indicated the resident finished the antibiotic for the urinary tract infection. The 9/1/13 at 3:49 PM, nurse's notes indicated the resident on follow up for treatment of [REDACTED]. The medical record lacked any further documentation in regards to the appearance of the resident ' s urine. The 9/4/13 at 12:35 PM, nurse's note indicated the staff noted the resident was weak and required assistance with his/her meal. The note indicated the staff attempted to get the resident up for his/her noon meal and the resident unable to bear weight or follow directions. The resident had lethargy (sluggishness, lifelessness), weakness, a temperature of 101.6, and the facility received an order from the resident's primary care physician to transport the resident to the emergency department. The 9/4/13 hospital (H&P) History and Physical indicated the resident had been seen in the emergency department for a high fever, [MEDICAL CONDITION](rapid heartbeat), and altered mental status (a state of awareness that is different from the normal awareness of a person). The H&P indicated the resident's urinary catheter bag had thick, pus-like, heavy urine, which required replacement of the catheter, and once replaced about 400 ml (milliliters) to 600 ml thick orange odorous urine returned. The H&P indicated the hospital admitted the resident with the [DIAGNOSES REDACTED]. The 9/7/13 hospital discharge summary indicated the resident stable enough to be discharged , had his/her catheter replaced before discharge, and to remain on oral antibiotics over the next 10 days. The discharge summary indicated the hospital treatment included intravenous (by veins) fluids, antibiotics, and the urine culture showed Proteus mirabilis (a bacteria). The 9/16/13 at 12:08 AM, nurse ' s note indicated the staff replaced the urinary catheter using a silver tipped catheter. On 9/26/13 at 6:59 AM, observation revealed the resident seated in his/her wheelchair in the facility ' s common area. Observation revealed the resident ' s pant leg on his/her right leg damp, and the catheter drainage bag not visible. On 9/26/13 at 8:39 AM, observation revealed 2 staff propelled the resident to his/her room due to his/her pants were wet. The staff identified the port to his/her urinary catheter had been left open and the damp area on his/her clothes from urine leaking from the catheter. On 9/26/13 at 10:05 AM, observation revealed Nurse Aide D and Nurse Aide B prepared to assist the resident to his/her bed. The staff washed their hands, applied gloves, and assisted the resident to transfer from his/her wheelchair to the bed. Observation revealed Nurse Aide B removed the resident ' s pants and brief, and provided perineal care for a small bowel movement. Observation revealed with the same soiled gloves, Nurse Aide B cleaned the resident ' s bottom and front then used a personal wipe to and cleanse the catheter tubing from insertion of the catheter to the drainage bag. On 9/25/13 at 3:00 PM, Nurse C verified the staff had not changed the resident ' s catheter since 7/15/13, prior to the resident ' s admission to the hospital on [DATE] [MEDICAL CONDITION]. Nurse C further verified the facility had not notified the physician of the catheter not being replaced. On 9/26/13 at 10:17 AM, Nurse Aide D verified Nurse Aide B did not change his/her gloves after cleaning the resident ' s bottom and perineal area. Nurse Aide B further stated he/she did not know he/she should change his/her gloves. Nurse Aide D verified he/she not aware of the need to change gloves after performing perineal care. On 9/26/13 at 11:01 AM, Nurse C verified the staff should change his/her gloves before providing the resident catheter care and further verified the port being left open, created an infection control concern. On 9/26/13 at 3:52 PM, Physician Nurse E verified the physician had ordered the facility to change the resident ' s catheter on 8/15/13 and the facility had notified the physician on 8/16/13 the facility did not have a silver tipped catheter and would replace it on 8/20/13. Physician Office Nurse E verified the facility had received an order for [REDACTED]. The facility failed to provide Resident #2 with adequate urinary catheter care. - The 9/10/2013 physician order [REDACTED].#7 had a [DIAGNOSES REDACTED]. The significant change in status (MDS) Minimum Data Set 3.0 assessment, dated 9/13/2013, indicated the resident had long term memory problems and independent decision making. The MDS indicated the resident required total assistance from staff for all (ADLs) Activities of Daily Living. The MDS indicated the resident had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and frequent bowel incontinence. The 9/4/2013 at 1:00 PM nurse ' s notes revealed the resident was readmitted to the facility with an indwelling urinary catheter. The 9/17/2013 at 8:13 PM nurse ' s notes revealed the nurse received an order clarification to remove the indwelling catheter, wait 12 hours, and use a straight catheter (a tube-shaped medical device that is used to remove urine from a person ' s bladder for temporary use and is removed immediately after urine is taken from the bladder) for draining residual urine from the resident ' s bladder and report the finding, in the morning, to the physician. The 9/17/2013 at 3:19 PM, nurse ' s notes indicated the nurse removed the resident ' s indwelling urinary catheter. The 9/17/2013 at 3:43 PM, nurse's notes indicated the physician order [REDACTED]. (French), 30(ml) milliliter, indwelling urinary catheter and change the catheter on the 15th of each month. The 9/18/2013 at 4:52 AM, nurse ' s notes indicated the nurse had inserted the indwelling urinary catheter in the resident. The 9/11/2013 care plan instructed the staff to provide catheter care every shift and as needed The 9/18/2013 at 4:52 AM, nurse ' s notes indicated the staff inserted an indwelling urinary catheter with residual of 100 (ml) milliliters of urine. On 9/25/2013 at 8:40 AM, observation revealed Nurse Aide A applied gloves, obtained a container from the resident ' s bathroom, unclamped the urine drainage bag spigot, and without cleaning the spigot, emptied clear yellow urine from the urine collection bag. Observation revealed Nurse Aide A clamped the spigot closed, and without cleansing the spigot, attached it to the indwelling urinary catheter bag. Nurse Aide A, placed the indwelling catheter bag in a cloth bag and hung the bag at the foot of the resident ' s bed. Nurse Aide A disposed of his/her soiled gloves, applied new gloves, used pre-moistened, warmed disposable cloths to provide perianal care, and without removing the soiled gloves, Nurse Aide A, used a clean moistened cloth, and cleansed the catheter tubing from the insertion site to the indwelling urinary catheter bag. On 9/26/2013 at 11:15 AM, Administrative Nurse C verified the staff should change gloves in between providing perianal care and cleansing a resident ' s indwelling urinary catheter and should clean the spigot on the drainage bag with a disinfectant sponge or alcohol wipe before and after emptying. The facility ' s undated Catheters/Urinary/Catheter Care policy instructed the staff to cleanse the spigot on the drainage bag with a disinfectant sponge before and after emptying. The facility failed to provide proper indwelling urinary catheter care for Resident #7. - Resident #8 ' s quarterly (MDS) Minimum Data Set 3.0 assessment, dated 6/26/2013, indicated the resident had short and long term memory problems, severely impaired cognitive skills for daily decision making, and required total assistance of staff for all (ADL) s Activities of Daily Living. The MDS indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. The 9/10/2013 care plan instructed the staff to provide catheter care every shift and as needed. The 8/8/2013 urine analysis (examination of urine) revealed the resident had a [MEDICAL CONDITION] urinary tract infection (an infection in any part of your urinary system your kidneys, ureters, bladder and urethra). The Nursing Home/skilled admission orders [REDACTED] On 9/25/2013 at 1:40 PM, observation revealed, the resident, seated in a wheelchair in the commons area with his/her indwelling urinary catheter tubing touching the carpeted floor underneath the resident ' s wheel chair. On 9/25/2013 at 3:38 PM, observation revealed the resident seated in a wheelchair in the commons area with his/her Foley catheter tubing touching the carpeted floor underneath the resident ' s wheel chair. On 9/25/2013 at 10:48 AM, Nurse Aide B washed his/her hands, applied gloves, attached the resident ' s indwelling urinary catheter urine collection bag to the side of the resident ' s wheel chair, used a urinal from the resident ' s bathroom, unclamped the spigot, emptied red tinged colored urine into the urinal, clamped the spigot, and without cleaning, inserted the spigot back into the catheter urine collection bag. On 9/26/2013 at 11:15 AM, Administrative Nurse C verified the resident ' s indwelling urinary catheter tubing should not be touching the floor. Administrative Nurse C verified the staff should clean the spigot on the drainage bag with a disinfectant sponge or alcohol wipe before and after emptying. The facility's undated Catheters/Urinary/Catheter Care policy instructed the staff to cleanse the spigot on the drainage bag with a disinfectant sponge before and after emptying. The facility failed to provide proper catheter care and implement approaches to manage an indwelling urinary catheter for Resident #8.

The facility had a census of 41 residents. The sample included 5 residents. Based on observation, record review and interview the facility failed to secure an exit door and resident courtyard area, adequately assess a significant change in mental status and provide necessary supervision for Resident #1, who eloped 2 times within 14 hours and was found on busy highways both times. This failure placed the resident in jeopardy. Findings included: - Review of the physician orders, dated 06/04/13, revealed the resident had the following Diagnoses: [REDACTED]. 1) Psychosis - any major disorder characterized by a gross impairment in reality testing 2) Schizophrenia with Hallucinations - psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought, perception and emotional reaction 3) Anxiety Disorder - a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear 4) Depression - abnormal emotional state chacterized by exaggerated feeling of sadness, worthlessness and emptiness Review of the 05/09/13 Elopement/Wandering Assessment and Intervention Tool revealed the resident was an elopement risk due to a [DIAGNOSES REDACTED]. The assessment also indicated the resident eloped from the facility on 03/30/13, 04/07/13 and 05/09/13. Resident #1's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 05/14/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact) with inattention, delusions and wandering behaviors. The MDS also indicated the resident was independent with walking, used no assistive devices and the resident received antipsychotic and antidepressant medications 7 days a week. The 05/18/13 care plan indicated the resident was an elopement risk related to his/her "inappropriate/unsafe decision making." The care plan directed the staff to record and monitor behaviors, observe for signs of distress and frequently verify the resident's presence in facility. The care plan indicated the resident had eloped on 06/29/13 and directed the staff to observe the resident every 15 minutes. The June 2013 (MAR) Medication Administration Record indicated the resident received the following scheduled, physician's orders [REDACTED]. 1) 02/04/13 - Benztropine Mesylate (anticholinergic) 0.5 (mg) milligrams, every day for psychosis 2) 02/28/13 - Lithium (antimanic) 450 mg, 2 times a day, for psychosis 3) 04/03/13 - Depakote (anticonvulsant) 500 mg, 2 times a day for psychosis 4) 04/19/13 - Lamictal (anticonvulsant) 150 mg, every day for psychosis 5) 05/28/13 - Lexapro (antidepressant) 10 mg, every day for depression 6) 06/18/13 - Paliperidone (antipsychotic) 156 mg, every 28 days, for psychosis On 06/27/13, a storm damaged down a section of fence surrounding the facility's courtyard (per facility's unusual occurrence investigation). The 06/29/13 at 10:12 PM, nurse's note indicated the staff last noted the resident in the facility at 7:30 PM. The nurse's note indicated, at 8:30 PM, an off duty employee reported the resident running on a highway (two lane with no shoulders, just prior to darkness) north of the facility. The nurse's note indicated the staff returned the resident to the facility at 9:00 PM and the resident was in a frantic state with wild movements and hallucinations of ghosts trying to kill him/her with a gun and meat hook. The nurse's note indicated the staff notified the physician and received an order to administer Haldol (antipsychotic) 5 mg to the resident. Review of facility's 15 Minute Surveillance flow sheet revealed the staff initiated 15 minute observations of the resident on 06/29/13 at 11:00 PM. The 06/30/13 at 10:35 AM, nurse's note indicated the staff could not locate the resident in the facility or on the grounds at 9:40 AM. The 06/30/13 at 5:17 PM, nurse's note indicated a neighboring town's law enforcement agency (approximately 30 miles west on Highway 56) had notified the facility the resident was in their custody (approximately 8 hours after the resident eloped from the facility). The 06/30/13 Emergency Physician Record indicated the resident had eloped from the facility and was gone approximately 10 hours. The record indicated the resident was paranoid and hallucinating and had a history of [REDACTED]. The record also indicated the resident had a significant change in mental status the previous night and would receive a psychiatric evaluation the next day. The record further indicated the hospital agreed to discharge the resident to the facility, if the facility provided supervision of the resident, 100% of the time. The 06/30/13 at 9:11 PM, nurse's note indicated the staff transported the resident from the hospital emergency room to the facility (resident assessed for injuries, dehydration and mental status). The nurse's note indicated the staff initiated one to one surveillance and scheduled a psychiatric evaluation the next day. The 07/01/13 Mental Health Screening Form indicated the resident was a potential danger to him/her self and had psychotic symptoms such as delusions, hallucinations, eloping and suicidal ideations. The screening form indicated the resident made statements concerning self harm and harming several peers at the facility. The screening form indicated the resident had a history of [REDACTED]. The screening form indicated the resident was admitted from a psychiatric hospital to the facility. The screening form recommended involuntary admission to a state hospital in accordance with the following criteria: The resident is likely, in the reasonably forseeable future, to cause substantial physical injury or physical abuse to self or others or substantial damage to another's property, as evidenced by behavior causing, attempting or threatening such injury, abuse or damage. The 07/01/13 State Hospital Admission form indicated the resident had paranoid ideations, auditory and visual hallucinations and suicidal threats/serious attempts to harm self. The admission form indicated a recommendation was made to involuntaryily admit the resident to the state hospital. The 07/01/13 at 7:19 PM, nurse's note indicated 2 staff transported the resident to the state hospital. On 07/02/13 at 7:30 AM. observation revealed Highway 56, west of the town where the facility was located was heavily traveled (numerous semi - tankers and cattle trucks) related to the multiple natural gas terminals and oil refineries near the town and feedlots in western Kansas. Observation also revealed a busy railroad ran parallel to Highway 56 (also due to the natural gas terminals and oil refineries). On 07/02/13 at 8:47 AM, Nurse A stated the resident knew the exit code for the patio door and went in and out of the facility unsupervised. Nurse A stated the staff did not supervise the resident in the courtyard and the resident had several elopements from the courtyard. Nurse A further stated the facility had not repaired the damaged fence (laying on the ground) prior to the resident's 2 elopements. On 07/02/13 at 10:24 AM, Nurse C stated the resident knew the exit code to the patio door (several residents, who go out to the courtyard to smoke, know the code and might have told the resident) and the resident regularly went out to the courtyard unsupervised. Nurse C stated the resident had a history of [REDACTED]. Nurse C stated the resident had a significant mental status change, during and after the 06/29/13 elopement, and was very agitated and paranoid, when he/she returned to the facility. Nurse C stated the resident was very agitated, pacing and flailing his/her arms and refused to go to his/her room, related to the resident's hallucinations of ghosts/spirits in the room. Nurse C stated the staff had difficulty redirecting the resident's fears and behaviors and the staff notified the physician, requesting an antipsychotic medication order to calm/sedate the resident. On 07/02/13 at 10:55 AM, Nurse Aide D stated the resident knew the exit code for the patio door and staff had not usually supervised the resident in the courtyard. Nurse Aide D stated the resident had a history of [REDACTED]. Nurse Aide D stated the resident was unsupervised in the courtyard, on the morning of 06/30/13, and eloped through the broken fence. On 07/02/13 at 1:31 PM, Nurse Aide E stated he/she observed the resident seated unsupervised in the courtyard on the morning of 06/30/13 (section of courtyard fence still laying on the ground) and a few minutes later, the staff was alerted the resident had eloped again. Review of the 07/02/13 witness statement of an alert and oriented resident, who was with the resident in the courtyard on the morning of 06/30/13, revealed the witness stated "I was sitting outside in the smoking area and the resident was sitting there also. The resident was sitting in a chair crying. The next thing I know, the resident got up and walked off. I didn't try to stop him/her as I did not want to make him/her mad." On 07/02/13 at 1:44 PM, Nurse C stated the staff was providing 15 minute observations of the resident, on the morning of 06/30/13, and allowed the resident to go outside in the courtyard unsupervised. Nurse C stated the courtyard fence had not been repaired and the resident eloped from the courtyard a second time. On 07/08/13 1:54 PM, Medical Consultant F stated he/she assessed the resident's mental status and the resident's paranoia, auditory and visual hallucinations and suicidal ideations would greatly interfere with the resident's safety and ability to care for his/her self. Medical Consultant F stated he/she recommended one to one constant supervision while at the facility and an involuntary admission to the state hospital related to the resident's risk for harm to self and/or others. The facility's undated Wandering Resident Policy directed the staff to place identified residents (at high risk for elopement) in rooms for increased supervision, as needed. The policy also directed the staff to immediately revise the care plan with interventions and measurable outcomes to protect the resident. The facility failed to secure an outside exit door (multiple residents knew the exit code) and repair the wind damaged courtyard fence, which allowed the courtyard to be unsecured for 3 days. The facility failed to adequately assess the resident's significant change in mental status and behaviors, during and after the first elopement. The next morning, the facility failed to provide adequate supervision to protect the resident and the resident eloped a second time from the unsecured courtyard. The resident traveled/hitchhiked on a potentially dangerous highway to a town 30 miles away. The facility abated the Immediate Jeopardy, on 07/03/13 at 2:00 PM, when it inserviced all staff to place a resident on one to one monitoring/supervision until the cause of the elopement was identified and corrected and the staff, confirmed understanding the process with their signatures. The damaged courtyard fence was repaired to secure the courtyard on 06/30/13 at 2:30 PM. The resident, who eloped 2 times, was evaluated and transferred to a state hospital on [DATE]. The facility assessed all the residents to ensure no other resident was at risk for elopement and provided the documentation to the state agency. The deficient practice remains at a scope and severity of a D.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide necessary services to 3 of 12 sampled residents, and 5 unsampled residents residing in the facility. (#17, #45, and #12) The findings included: - Resident #17's medical record revealed [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set 3.0, dated 3/23/11, (ARD) Assessment Reference Date, indicated the resident had dementia, short and long term memory problems and severely impaired decision making skills. The MDS further indicated the resident required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Review of the 3/17/11 care plan directed the staff to "provide assistance as needed to complete activities of daily living and hygiene needs" and to "keep skin clean and dry". On 3/30/11 at 12:00 PM, observation revealed the resident in their wheelchair at the entrance to main dining room/TV area leaning severely to the left and forward. The resident's left mid-upper arm supported their weight against the wheelchair's padded arm, and his/her arms crossed and lying in their lap. Further observation revealed the resident's left arm from pressure point (mid-upper arm) to left hand was a discolored dusky gray, nail beds were blue-purple, and their left hand with mild [MEDICAL CONDITION]. On 3/30/11 at 1:30 PM further observation revealed the resident continued to sit in the same place and same position as described in the 12:00 PM observation. The resident occasionally attempted to raise his/her head up with minimal movement of either arm observed. (1 1/2 hours) On 3/31/11 at 2:45 PM, continued observation revealed Staff G and Staff C (CMA) Certified Medication Aide, took the resident to their room via a wheelchair with one staff holding the resident's feet off of floor and the other staff propelled the wheelchair. Further observation revealed the staff left the resident seated in the same position in his/her wheelchair. On 3/30/11 at 3:20 PM, observation revealed the resident to lean over the left arm of the wheelchair with their cheek resting on the metal arm of the wheelchair and his/her left fingers very nearly touching the floor. On 3/30/11 at 3:25 PM, Nurse M and Nurse J entered the resident's room and transferred the resident from the wheelchair to the recliner. The staff did not toilet or provide personal hygiene care for the dependent resident was not toileted and no personal hygiene given to the resident. ( 3 hours and 25 minutes without repositioning the dependent resident) Further observations at 3:45 PM, 4:00 PM, 4:25 PM and 5:30 PM revealed the resident continued to sit in their recliner. On 3/31/11 at 9:00 AM, the staff pushed the resident in their wheelchair from the dining area to the adjoining TV area. Observation revealed the resident leaned forward and to the left with their arms crossed in their lap while seated in their wheelchair. On 3/31/11 at 10:30 AM, observation revealed C.N.A.- B and C.N.A. - H stood the resident, removed the urine-soaked incontinent brief without performing personal hygiene, and replaced incontinent brief. On 3/31/11 at 11:45 AM, C.N.A.- B and C.N.A. - H transferred the resident to their wheelchair without toileting or performing personal cares at this time. During continued observation of Resident #17, 5 unsampled residents were observed for care provision. All remained in the TV area without staff approaching them to provide personal cares. On 3/30/11 at 3:30 PM Nurse P verified that residents should be repositioned and toileted every 2-3 hours and with the present staffing schedule it was impossible. The facility failed to provide resident #17 and 5 unsampled residents the necessary assistance with toileting and personal hygiene. - Resident #45's medical record revealed [DIAGNOSES REDACTED]. On 3/30/11 from 7:56 AM to 11:00 AM (approximately 3 hours) observation revealed the resident seated in their wheel chair at the dining room table eating breakfast. Observation revealed staff propelled the wheelchair from the dining room table to the lobby area after the resident finished eating. Continued observation revealed the resident remained in the same spot in the lobby area and staff had not offered the resident the opportunity to toilet or reposition until 11:00 AM at which time they were removed from the area to take a shower. On 3/30/11 from 2:00 PM to 5:05 PM (approximately 3 hours) observation revealed the resident remained in the same position, in their recliner, in their room without staff offering the resident the opportunity to toilet or reposition. On 4/4/11 at 10:20 AM, observation revealed Aide I provided assistance to the resident in their room. Observation revealed Aide I applied a gait belt around the resident's waist, assisted the resident to a standing position and the resident ambulated with assistance of a walker into the bathroom. Observation revealed the resident required Aide I to give instructions for each step, turning around, sitting, standing, holding onto the grab bar in the bathroom and washing the resident's hands. Aide I provided personal care to the resident and assistance with ambulation back to their wheelchair. Interview with Aide I revealed the resident required assistance from 1 staff for ambulation, dressing, hygiene and toileting. The quarterly (MDS), Minimum Data Set 3.0, with an (ARD) assessment reference date of 1/13/11, indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision of 1 staff with ambulation and the resident independent with dressing, eating, toileting and hygiene. The 1/13/11 care plan indicated the resident required a wheelchair for mobility and directed the staff to provide one staff assist with wheelchair mobility. Continued review of the care plan revealed no direction to staff for the resident's needed assistance with their activities of daily living in regards to their present status. Review of the undated care plan summary, located at the nurse's station to guide nursing staff in the resident's care, indicated the resident required no staff assistance with ambulation. On 4/4/11 at 2:15 PM, Nurse M verified the resident had a change in their ability to perform activities of daily living since their last assessment 1/13/11. On 4/4/11 at 2:30 PM, Nurse N verified the resident's ability in self care with activities of daily living had declined with dressing, toileting and hygiene. The facility failed to provide dependent Resident #45 with the care and services required to meet their needs. - Resident #12's medical record revealed [DIAGNOSES REDACTED]. The significant change (MDS) Minimum Data Set 3.0 assessment, dated 3/23/11, (ARD) Assessment Reference Date, indicated the resident had short term and long term memory loss with severely impaired cognitive skill and mental status change. The MDS also indicated the resident required extensive assistance with bed mobility, transfers, dressing and toileting. The MDS further indicted the resident had a Stage II pressure ulcer. The 3/24/2011 Care Plan indicated the resident was bedfast all of the time, directed the staff to assist the resident with (ADL'S) Activities of Daily Living, to turn/reposition every two hours, and to maintain functional alignment. The care plan indicated the resident incontinent of bowel, wears briefs, and used barrier cream after each incontinent episode. Continued review revealed a goal that the resident would not exhibit complications of prolonged immobility and skin breakdown. On 3/31/2011 at 7:45 AM, observation revealed the resident lying on their back on their bed. Continued observation at 10:45 AM found the resident still in the same positioned on their back. (3 hours) The 3/30/2011 wound care nurse's notes revealed the following documentation: The resident's coccyx wound has eschar in the center of the wound bed that is brown and the wound has a moderate amount of serosanguinous exudate. The wound care nurse ordered the use of the skin prep, Santyl (ointment that continuously removes dead tissue from wounds), calcium alginate and foam, and change daily. Further instructions indicated to make sure the Santyl is 2 mm thick, the depth of a nickle, in order to last 24 hours. On 3/31/2011 at 10:54 AM, Nurse D and Aide C turned the resident to remove the urine soaked incontinent brief. Upon removal of the incontinent brief, the resident's buttocks/coccyx were found to be reddened. Nurse D removed a soiled pressure ulcer dressing which exposed a 2 inch by 2 inch moist soggy area. Nurse D washed the pink- moist open area with Sterile saline and soap, applied a gauze dressing with [MEDICATION NAME] (antibiotic ointment) and tape to seal the dressing. On 4/04/2011 at 2:30 PM, Nurse M repositioned the resident on their right side to change the dressing on the resident's coccyx. Observation revealed the residents incontinent briefs was soiled with a large amount of brownish amber liquid. Nurse M verified the resident's indwelling catheter had been leaking since 4/03/2011. Continues observation revealed the resident did not have a catheter leg strap in place to secure the catheter. Observation of the residents coccyx area revealed and pink-moist open area with large reddened area around the wound. On 4/04/2011 at 2:30 PM, Nurse M revealed the resident had a foley catheter to keep the resident dry and allow the pressure ulcer on their coccyx to heal. On 4/03/2011 the physician examined the resident at the nursing home and changed the pressure ulcer treatment to a Collagen Alginate patch daily. On 4/04/2011 at 1:30 PM, Nurse M verified the new physician ordered dressing was not available at the facility and the staff had to obtain corporate approval prior to ordering the new dressing. Nurse M indicated the earliest they would be able to get the dressing from the Wichita pharmacy would be 4/04/2011 at 10:00 PM.( approximately 34 hours after the physician ordered the new dressing) The facility failed to provide dependent Resident #12 with the care and service required to meet their needs

The facility had a census of 45 residents. The sample included 9 residents. Based on record review and interview the facility failed to provide the necessary services to maintain good personal hygiene for 1 of 9 sampled residents. The facility transferred Resident #1 to the emergency room due to a very red and excoriated scrotum with bloody drainage which was diagnosed as a scrotal yeast infection and returned to the facility with a physician's orders [REDACTED]. Review of the medical record revealed no documentation the facility implemented the physician's orders [REDACTED]. The resident returned to the facility with a physician's orders [REDACTED]. Findings included: - Resident #1's medical record revealed [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set 3.0 assessment, dated 04/01/11, indicated the resident's (BIMS) Brief Interview for Mental Status score was 7, which indicated severe impairment. The MDS also indicated the resident required total assist with bed mobility, transfers, toilet use and personal hygiene. The MDS further indicated the resident frequently incontinent of bowel. The 03/09/11 care plan directed the staff to provide total assistance for all the resident's (ADLs) activities of daily living except eating. The care plan indicated the resident a risk for skin issues and directed the staff to keep the resident's skin clean and dry. The care plan indicated the resident had an indwelling catheter since returning from the hospital on [DATE]. The 04/28/11 Clinical Admission Observation form (when the resident returned from the hospital) indicated the resident had a 3.6 (cm) centimeter by 3.0 cm Stage II pressure ulcer on the left heel that was present when the facility had discharged the resident to the hospital. The observation form also indicated the resident at risk for pressure ulcers due to decreased activity, immobility, poor skin integrity, incontinence and predisposing diseases. The observation further indicated the resident had no other skin issues. The 04/30/11 at 12:33 PM, nurse's note indicated the resident had a very large, loose bowel movement that was all over the resident's front and back. The nurse's note also indicated a moderate amount of blood noted in the resident's incontinent brief and running down the resident's legs. The nurse's note indicated the bleeding from the resident's scrotum and no open areas noted. The nurse's notes further indicated the resident's admission assessment, dated 04/28/11 (2 days ago), indicated the resident's scrotal area red but no bleeding noted. The nurse's note indicated the facility sent the resident to the emergency room due to the scrotum bleeding. The 04/30/11 at 1:15 PM, emergency room nurse's note indicated the resident's scrotum very red and excoriated with bloody drainage. The 04/30/11 emergency room Record indicated the physician diagnosed the resident with scrotal yeast infection. The 04/30/11 physician's orders [REDACTED]. The physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. The 05/01/11 at 1:10 PM, nurse's note indicated the resident's scrotal area very excoriated with some bleeding noted. The 05/02/11 at 3:17 AM, nurse's note indicated minimal bleeding noted from the resident's scrotal area. The 05/03/11 Shower Body Check Program form indicated the resident's scrotal area red and swollen with no drainage noted. The 05/05/11 Shower Body Check Program form indicated the resident's scrotal area red and swollen with greenish drainage noted. The significant change (MDS) Minimum Data Set 3.0 assessment, dated 05/05/11, indicated the resident had short and long term memory problems with severely impaired decision making skills. The MDS also indicated the resident required total assistance with bed mobility, transfers, toilet use and personal hygiene. The MDS further indicated the resident received no scheduled or as needed pain medications and had daily vocalizations, facial expressions and protective body movements and/or postures that indicated pain. The 05/07/11 at 11:07 AM, nurse's note indicated the resident's penis extremely swollen with copious amounts of green drainage. The nurse's note indicated the facility sent the resident to the emergency room . The note indicated the resident returned with a physician's orders [REDACTED]. The 05/09/11 at 4:00 PM, nurse's note indicated the resident was admitted to the hospital related to the resident's declining condition and the physician's concerns regarding the resident's heels. The 05/09/11 at 4:10 PM, hospital nurse's note indicated the nurse unable to move the resident's bilateral lower extremities. The note also indicated the gauze wrap on the resident's bilateral lower extremities very wet due to drainage from the resident's scrotal area and heels. The 05/09/11 hospital's Patient Data Base form indicated the resident's bilateral lower extremities very tight to spread apart to provide appropriate cleaning and/or hygiene. The form further indicated the resident's penis and scrotum swollen and excoriated. The 05/09/11 History & Physical indicated the resident's groin area may be developing [MEDICAL CONDITION] related to yeast infection and/or urinary tract infection. The History & Physical also indicated the progression of the scrotal area infection related to nursing home care. On 05/12/11 at 9:44 AM, an interview with a medical professional, indicated the resident's bilateral heels had not recieved the necessary cares and protection to prevent the development and/or worsening of the resident's pressure ulcers. The complainant also indicated the development of yeast infection and [MEDICAL CONDITION] on the resident's excoriated scrotal area were related to the poor personal hygiene cares provided by the facility staff. On 5/17/11 at 2:10 PM, Nurse C verified the facility should have implemented the physician's orders [REDACTED]. The facility failed to provide the necessary services to maintain good personal hygiene for Resident #1.

The facility had a census of 42 residents, the sample included 12 residents of which 3 had pressure sores. Based on observation, record review and interview, the facility failed to provide necessary treatment and services in accordance with the comprehensive plan of care to prevent the development of pressure ulcers for 1 of the 12 sampled residents and 1 resident for repositioning. (#12, #17) Findings included: - Resident #12's medical record revealed [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set 3.0 assessment, (ARD) Assessment Reference Date, 3/1/11, indicated the resident had a pressure ulcer since 12/21/10. The significant change (MDS) Minimum Data Set 3.0 assessment, (ARD) Assessment Reference Date, dated 3/23/11, indicated the resident had short term and long term memory loss with severely impaired cognitive skills and mental status change. The MDS also indicated the resident required extensive assistance with bed mobility, transfers, dressing and toileting. The MDS further indicated the resident had a Stage II pressure ulcer. The 3/24/2011 Care Plan indicated the resident was bedfast all of the time, directed the staff to assist the resident with (ADL'S) Activities of daily Living , to turn/reposition every two hours, and maintain functional alignment. The resident was incontinent of bowel, wore briefs, and used barrier cream after each incontinent episode. Continued review revealed the resident will not exhibit complications of prolonged immobility, and skin breakdown. On 3/31/2011 at 7:45 AM, observation revealed the resident laid on their back on their bed. Continued observation at 10:45 AM found the resident still in the same positioned on their back. (3 hours) The 3/30/2011 wound care nurse's notes revealed the following documentation: The resident's coccyx wound has eschar in the center of the wound bed that is brown and the wound has a moderate amount of serosanguinous exudate. The wound care nurse ordered the use of the skin prep, Santyl (ointment that continuously removes dead tissue from wounds), calcium alginate and foam (a dressing), and to change daily. Further instructions indicated to make sure the Santyl is 2 (mm) millimeter thick, the depth of a nickle, in order to last 24 hours. On 3/31/2011 at 10:54 AM, Nurse D and Aide C turned the resident to remove the urine soaked incontinent brief. Upon removal of the incontinent brief, the resident's buttocks/coccyx were found to be reddened. Nurse D removed a soiled pressure ulcer dressing which exposed a 2 inch by 2 inch moist soggy area. Nurse D washed the pink-moistened open area with Sterile saline and soap, applied a gauze dressing with [MEDICATION NAME] (antibiotic ointment) and tape to seal the dressing. (Nurse D failed to follow the wound nurse's orders for treatment of [REDACTED]. On 4/3/11 (no time noted) the physician examined the resident at the nursing home and changed the pressure ulcer treatment to a Collagen Alginae patch daily. On 4/04/2011 at 2:30 PM, Nurse M repositioned the resident on their right side to change the dressing on the resident's coccyx. Observation revealed the resident's incontinent brief was soiled with a large amount of brownish amber liquid. Nurse M verified the resident's indwelling catheter had been leaking since 4/03/2011. Continued observation revealed the resident did not have a catheter leg strap in place to secure the catheter. Observation of the resident's coccyx area revealed a 2" x 1" pink-moistened, open area with the area around the wound observed to be large and reddened. On 4/04/2011 at 1:30 PM, Nurse M verified the new physician ordered dressing was not available at the facility and staff had to obtain corporate approval prior to ordering the new dressing. Nurse M indicated the earliest they would be able to get the dressing from the pharmacy would be 4/04/2011 at 10:00 PM (approximately 34 hours after the physician ordered the new dressing). On 4/4/11 at 2:30 PM, Nurse M indicated the resident had a foley catheter to keep the resident dry and allow the pressure ulcer on their coccyx to heal. The facility failed to provide necessary treatment and services in accordance with the comprehensive plan of care to treat the resident. - This deficient practice also affected Resident #17, who was not provided the necessary assessments and services to maintain appropriate wheelchair positioning.

The facility had a census of 45 residents. The sample included 9 residents, of which 3 were reported with facility acquired pressure ulcers. Based on observation, record review and interview the facility failed to provide the necessary treatments and services to prevent the development and/or worsening of pressure ulcers for 2 of 3 sampled residents. Resident # 1, who had a Stage II pressure ulcer on their left heel, developed an avoidable Stage II facility acquired pressure ulcer on their right heel 9 days after the facility failed to implement a physician order [REDACTED]. Findings included: - Resident #1's medical record revealed [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set 3.0 assessment, dated 04/01/11, indicated the resident's (BIMS) Brief Interview for Mental Status score was 7, which indicated severe impairment. The MDS also indicated the resident required total assist with bed mobility, transfers, toilet use and personal hygiene. The MDS further indicated the resident had a Stage II pressure ulcer (facility acquired left heel pressure ulcer on 03/07/11). The 04/28/11 care plan directed the staff to provide total assistance for all the resident's (ADLs) activities of daily living except eating. The care plan directed the staff to float the resident's heels while in bed and place booties on the resident's feet while in the wheel chair. Continued review of the care plan revealed no documentation to direct the staff to reposition the resident or place their heel protectors on the resident's feet when in bed. The 4/28/11 Clinical Admission Observation form (when the resident returned from the hospital) indicated the resident had a 3.6 (cm) centimeter by 3.0 cm Stage II pressure ulcer on their left heel that was present when the facility discharged the resident to the hospital. The Clinical Admission Assessment form also indicated the resident at risk for pressure ulcers due to decreased activity, immobility, poor skin integrity and predisposing diseases. The observation further indicated the resident had no other skin issues. The 4/28/11 readmission physician orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. The 05/03/11 and 05/05/11 Shower Body Check Program forms indicated the resident's left heel had an open area and the resident's right heel had no skin problems. The significant change (MDS) Minimum Data Set 3.0 assessment, dated 05/05/11, indicated the resident had short and long term memory problems with severely impaired decision making skills. The MDS also indicated the resident required total assistance with bed mobility, transfers, toilet use and personal hygiene. The MDS further indicated the resident received no scheduled or as needed pain medications and had daily vocalizations, facial expressions and protective body movements and/or postures that indicated pain. The 05/07/11 at 11:14 AM, nurse's note indicated the transportation aide informed the nurse the resident had an open area on the right heel. The nurse's note indicated the nurse assessed a "6 cm round blister with some drainage" on the resident's right heel (9 days after the resident was readmitted to the facility and the facility failed to implement the physical therapy consult for protective covering for the resident's heels. The 05/07/11 Pressure Ulcer Description Form indicated the resident had "6 cm broken blister on the right heel, Stage II with clear exudate (drainage)". The form also indicated the resident had a bootie on the right foot when staff noted the blister. The form further indicated the nurse notified the (DON) Director of Nursing the resident may require protective boots even though the physician had ordered a Physical Therapy consult for protective heel coverings 9 days earlier. The 05/08/11 at 11:43 AM, nurse's note indicated the resident's left heel had bloody drainage. The note also indicated the resident's right heel blister had deflated and had a small amount of clear drainage. The 05/09/11 at 4:00 PM, nurse's note indicated the resident admitted to the hospital related to the physician's concerns regarding the resident's heels. The 05/09/11 at 4:10 PM, hospital nurse's note indicated the nurse unable to move the resident's bilateral lower extremities. The note also indicated the gauze wrap on the resident's bilateral lower extremities very wet due to drainage from the resident's heels. The note further indicated the physician present to debride the resident's bilateral heels. The 05/09/11 History & Physical indicated the facility had not addressed the resident's heel protection as ordered by the physician on 4/28/11 and the resident developed a large denuded (stripped or laying bare) skin area on the right heel. The History & Physical indicated the physician had debrided (removal of devitalized tissue) the resident's bilateral heel ulcers and applied a sterile dressing. The 05/12/11 Physical Therapy Plan of Treatment assessment indicated a 6 cm by 2 cm Stage III pressure ulcer with moderate serous drainage on the resident's left heel. The assessment indicated a 5 cm by 2 cm Stage II pressure ulcer with beefy granulation and minimum drainage on the resident's right heel. On 05/12/11 at 9:44 AM, an interview with a medical professional, indicated the resident's bilateral heels had not received the necessary cares and protection to prevent the development and/or worsening of the resident's pressure ulcers. The complainant also indicated the development of yeast infection and [MEDICAL CONDITION] on the resident's excoriated scrotal area were related to the poor personal hygiene cares provided by the facility staff. On 5/17/11 at 2:10 PM, Nurse C verified the facility had not provided a PT consult to address the resident's heel protection as ordered by the physician on 04/28/11. Nurse C verified the resident's care plan should be updated to direct the staff to provide appropriate and consistent pressure ulcer interventions. Nurse C indicated the facility had no policies or procedures in place to address the care and/or prevention of pressure ulcers. The facility failed to provide the necessary treatments and services to prevent the development and worsening of bilateral heel pressure ulcers for Resident #1. - Resident # 2's medical record included physician's orders [REDACTED]. The 4/7/2011 quarterly Braden Scale ( A skin risk assessment) indicated that the resident was at risk for developing a pressure ulcer and the facility had implemented the use of a pressure reducing mattress for the resident. On 5/16/2011 at 10:30 AM, observation revealed the resident seated in a recliner in their room with bilateral extremities elevated. Continued observation revealed the resident's recliner had no pressure relieving cushion in place. The quarterly (MDS) Minimum Data Set 3.0 assessment, (ARD) Assessment Referance Date, 4/14/2011, indicated the resident had short and long term memory problems and severly impaired decision making skills. The MDS also indicated the resident required moderate staff assistance with all (ADLs) Activities of Daily Living, was incontinent of and bowel and bladder, resident was at risk for pressure ulcers and there were no skin issues. The 02/16/11 laboratory results revealed the resident had a total protein level of 6.3 ( normal range 6.4-8.5). The 04/04/11 (RD) Registered Dietician assessment indicated the resident's weight was stable and the resident received a mechanical soft diet with sugar free shakes three times a day between meals. The dietician's assessment indicated the diet was adequate to meet the estimated needs at this time. The facility was to continue current plan of care. The 04/14/11 care plan directed the staff to report signs of skin breakdown, and to apply the nursing order moisture barrier cream after each incontinent episode. The updated care plan dated 5/5/2011 indicated that barrier cream was to be applied to the open area on the resident's left buttock. The facility shower body check program, dated 4/18/2011, revealed the resident had reddened areas on their left buttock. Further review of the facility shower body check program, dated 4/25/2011, revealed the resident had several blistered areas on the left buttock and the left buttock was reddened. The nurses notes, dated 4/28/2011, at 2:42 AM indicated the resident had an open area to the left buttock that measured 0.4 cm (centimeters) long by 0.4cm wide with no drainage from the area, the open area was a stage 2 pressure ulcer. The facility notified the physician via facsimile. The nurses notes also stated the facility would use barrier cream on the open area to the resident's left buttock with each incontinent brief change. On 5/16/2011 at 11:15 AM, observation revealed the resident was laying on their right side on their bed while Nurse D measured the open area on the resident ' s left buttock. The open area on the resident's left buttock measured 0.5 cm long by 0.3 cm wide. On 5/16/11 at 11:15 AM, Nurse D verified the resident's left buttock was a stage 2 pressure ulcer and the area had increased in size since the last measurement on 5/5/2011. Nurse D indicated that pressure ulcers are to be measured weekly at the facility and it had been 12 days since the last time the pressure ulcer had been measured. Nurse D also verified that more aggressive measures should be taken for the resident to prevent pressure ulcers, and the resident should have a pressure reducing cushion in their chair. On 5/16/2011 at 2:40 PM, observation revealed the resident laying supine on his/her bed. Further observation at 5:20 PM, revealed the resident remained in a supine position on his/her bed ( 2 hours and 40 minutes). On 5/17/2011 at 11:50 AM, Nurse E verified the physician had not been notified regarding the increase in size of the pressure ulcer. On 5/17/2011 at 1:00 PM, Nurse C verified the facility did not have a protocol for pressure ulcer prevention or a protocol for resident's who had developed a pressure ulcer. The facility failed to provide necessary treatment and services to prevent the development of any increase in size of pressure ulcers for the resident who was at risk for developing pressure ulcers.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional status, such as body weight and protein levels, for 1 of 12 sampled residents. Resident #27 had a severe weight loss of 18.1 (%) in the last 6 months. Findings included: - Resident #27's medical record revealed [DIAGNOSES REDACTED]. On 03/30/11 at 6:32 PM, observation revealed the resident seated in a wheelchair at the dining room table. Continued observation revealed the resident unable to eat independently due to severe bilateral hand tremors causing the food to spill from the resident's spoon. Further observation revealed the resident yelled several times for staff assistance. Continued observation revealed the resident attempted to drink independently but the resident's hand tremors caused some of the drink to spill. Continued observation revealed the staff placed a flexible straw in the resident's drink which allowed the resident to drink independently. Resident Weights: 10/19/10 - 151.8 pounds 11/01/10 - 152.3 pounds 11/18/10 - 147.7 pounds Review of the medical record revealed no documentation the staff obtained the resident's weight in December 2010. 01/12/11 - 142.8 pounds (readmission weight after the resident was hospitalized for [REDACTED]. This fluid may be blood, plasma, or electrolyte solution. May result from hemorrhage, burns, GI loss, or fluid shifts) ) 01/18/11 - 127.3 pounds 02/02/11 - 127.4 pounds 03/01/11 - 121.0 pounds 03/29/11 - 124.3 pounds Resident with 27.5 pound (18.11 percent) severe weight loss in the last 6 months. The 02/14/11 (RD) Registered Dietician progress note indicated the resident had a 13 percent weight loss the past 3 months. The progress note also indicated the RD recommended the staff administer 2 ounces of Med Pass 2.0 (protein and calorie supplement) to the resident three times a day. review of the resident's medical record revealed [REDACTED]. The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 02/23/11, (ARD) Assessment Reference Date, indicated the resident had severely impaired decision making skills and behaviors that included verbal and physical abuse and resistance to cares. The MDS also indicated the resident required total assistance with all (ADLs) activities of daily living including eating. The MDS further indicated the resident weighed 125 pounds and had a significant weight loss in the last 6 months. The 02/17/11 care plan directed the staff to assist the resident as needed at meals and record and monitor the resident's meal intake. The care plan also directed the staff to provide diabetic snacks for the resident and to weigh the resident monthly. Continued review of the care plan revealed no documentation of the resident's severe weight loss or interventions to prevent further weight loss. Review of the resident's Dietary Intake Record revealed the following findings: January 2011 Dietary Intake Record - 75 meals with no intake documentation and no documentation of any dietary supplement intake February 2011 Dietary Intake Record - 42 meals with no intake documentation and no documentation of any dietary supplement intake March 2011 Dietary Intake Record - 32 meals with 0 percent and/or no intake documentation and no documentation of any dietary supplement intake review of the resident's medical record revealed [REDACTED]. The 03/31/11 RD progress note indicated the resident weighed 124 pounds and received a mechanical soft diet. The progress note also indicated the RD recommended the staff administer 4 ounces of Med Pass 2.0 supplement to the resident four times a day to prevent further weight loss. The progress note further indicated the Med Pass 2.0 supplement provided an extra 40 grams of protein and 960 calories per day necessary to meet the resident's estimated needs. On 04/04/11, review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 04/04/11 at 11:29 AM, Nurse M verified the resident had a severe weight loss and should have received the RD's recommended dietary supplements to prevent further weight loss. Nurse M also verified the dietary staff should accurately record and monitor the resident's meal and supplement intake. The facility failed to provide the necessary dietary interventions to maintain acceptable parameters of nutritional status and prevent a severe weight loss for Resident #27.

The facility had a census 41 residents. Based on observation, record review and interview, the facility failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans. Findings included: - On 03/30/11 at 12:00 PM, observation revealed a resident seated in a wheelchair near the entrance to the dining room. Continued observation revealed the resident's upper torso leaned to the left over the wheelchair arm and the resident's head hung down, chin resting on their upper chest. Continued observation revealed the resident remained in this position without staff intervention until 2:45 PM (2 hours and 45 minutes). At 2:45 PM, continued observation revealed 2 staff members propelled the resident's wheelchair to the resident's room and left the resident sitting in the wheelchair. Continued observation revealed the resident slumped forward with their left cheek resting on the wheelchair arm and the resident's left arm and hand dangling almost to the floor. At 3:25 PM, continued observation revealed the staff transferred the resident from the wheelchair to the recliner in the resident's room and the resident was not toileted or checked for incontinence. Continued observation until 5:30 PM, revealed the resident remained seated in the recliner and the resident had not been toileted or checked for incontinence. On 03/30/11 at 3:12 PM, observation revealed an aide responded to the call light in room [ROOM NUMBER] which was initiated at 2:40 PM. (It took the staff 32 minutes before this resident's call light was answered). On 3/30/11 at 4:35 PM, observation revealed an aide responded to the call light in Resident #17 room which was initiated at 4:11 PM (it took the staff 24 minutes to answer this resident's call light). Continued observation and a check of the evening staffing scheduled revealed that 1 nurse and 2 Aides were scheduled to provide the direct care for the 41 residents currently residing at the facility. On 03/30/11 at 5:00 PM, observation revealed 2 aides were scheduled to provide all the residents in the facility with transportation (residents using wheel chairs and walkers, few of which actually were ambulatory without the assistance of the direct care staff), transfers, positioning and assistance with dining needs. Continued observation revealed 5 residents remained seated in their wheelchairs in the living room since 2:00 PM ( 3 hours) . Continued observation revealed the staff did not reposition or toilet these 5 residents before the facility direct care staff transported these 5 residents to the dining room for supper. On 03/30/11 at 6:00 PM, observation revealed 4 administrative staff assisted the residents with the evening meal and delivered room trays. On 04/04/11 at 5:45 PM, Administrative Staff E verified the administrative staff did not usually assist the residents during the evening meal. On 03/31/11 at 9:00 AM, observation revealed the direct care staff propelled 8 residents seated in wheelchairs from the dining room to the living room area. Continued observation revealed the 8 residents did not attempt to reposition themselves or propel their wheelchairs. At 10:06 AM, continued observation revealed the direct care staff began removing the 8 residents from the living room and the following observations were noted: 1) At 10:15 AM , observation revealed the direct care staff propelled a resident to the resident's room and then transferred the resident to a recliner. Continued observation revealed the direct care staff had not toileted or checked this resident for incontinence. 2) At 10:30 AM, observation revealed the direct care staff propelled another resident to the resident's room and then transferred the resident to a recliner. Continued observation revealed the direct care staff had not toileted or checked this resident for incontinence. At 10:40 AM, Aide A stated " there's not enough staff to help the residents and we're getting cut again." 3) At 10:45 AM, observation revealed 2 direct care staff propelled the resident to the resident's room, assisted the resident to stand and changed the resident's urine soaked sweatpants and incontinent brief. Continued observation revealed the direct care staff did not provide any other incontinent cares and the direct care staff then transferred the resident back to the wheelchair. 4) At 10:55 AM, observation revealed the nurse propelled a resident to the resident's room, turned the call light on and directed the direct care staff to toilet the resident. Continued observation revealed the direct care staff entered the room and informed the resident, "I need to get help to transfer you", the direct care staff then turned the call light off and left the resident's room. At 11:30 AM (35 minutes later) the surveyor requested the direct care staff to assist the resident with toileting, as the direct care staff had never returned to the resident's room after the 10:55 AM observation. 5) At 10:50 AM , observation revealed the nurse propelled the resident to the resident's room and directed the staff to reposition the resident due to the resident's feet dangling to the floor. Continued observation revealed the staff repositioned the resident and placed the resident's feet on the wheelchair foot pedals. Continued observation revealed the staff had not toileted or checked the resident for incontinence and propelled the resident back to the living room area. On 03/31/11 at 6:32 PM, observation revealed the resident, seated in a wheelchair, at the dining room table. Continued observation revealed the resident unable to eat independently due to severe bilateral hand tremors causing the food to spill from the resident's eating utensils. Continued observation revealed the resident yelled for staff assistance. - On 03/30/11 6:11PM, resident #27 was seated in their wheelchair at the dining table, separate from the other residents, and no other residents seated at table. The resident yells for nursing assistance multiple times (12 times in approximately 20 minutes) (coffee, sugar, repostioning,assist to stand up) the resident is polite and told the staff thank you. The resident was served their meal at 6:32 PM. The resident had severe hand tremors, and was unable to feed themself their soup, yelled for assist with feeding, and tells the staff the food will be all over the place without their assistance.The resident has no more yelling after the staff provides assistance. The resident has polite conversation during the rest of the meal. On 03/31/11 at 6:35 PM, observation revealed the staff delivered a room tray to a resident's room and placed the room tray on the resident's bedside table. At 7:00 PM ( 25 minutes later), continued observation revealed the staff entered the room and started to assist the resident with their resident's room tray. The surveyor requested the staff to check the food temperatures of the resident's food tray and noted the following results: 1) pureed corn - 85 degrees 2) pureed potato soup - 85 degrees 3) vanilla yogurt - 80 degrees 4) vanilla healthshake - 70 degrees 5) 2 calorie shake - 74 degrees The surveyor requested the staff deliver a new food tray to the resident. The resident was a member of the Stage II sample and documentation indicated the resident required extensive assist with all (ADLs) activities of daily living including eating. On 03/31/11 at 7:05 PM, Staff G indicated the staff had been very busy assisting residents with their meals in the dining room and could not return in a timely manner to assist the dependent resident with their room tray. Review of the resident council meeting minutes for January (01/03/11), February (02/02/11), and March (03/04/11) revealed documentation of the residents' concerns regarding staffing, call light response and ADL assistance. The 02/02/11 council meeting minutes indicated the residents' had concerns with only one CNA scheduled from 2:00 PM to 6:00 PM to provide cares and assistance to all the residents. On 4/4/11 at 5:00 PM, during a confidential interview with a resident council member, they reported the residents' concerns about timely assistance not provided by the staff during the 2:00 PM to 10:00 PM shift. The council member indicated the residents at the council meeting complained of waiting 30 to 45 minutes for staff to answer the residents' call lights. The council member indicated the residents also had concerns about residents being left in the dining room after meals. The council member indicated these concerns had been reported at each resident council meeting the past few months and no changes had been noted. On 04/05/11 at 4:45 PM, Social Service Staff L indicated the residents' concerns had been reported to the appropriate departments for them to address. Staff L indicated the facility had received several grievances reported by residents and/or family, during care plan meetings, concerning lack of staff and timely cares or assistance not provided to the residents. On 04/04/11 at 3:12 PM, Administrative Staff E indicated the facility had no system in place to document and/or monitor call light response time. Administrative Staff E indicated the nursing staff supervised and monitored the call light responses. Confidential interviews conducted with residents and/or family, during the survey process, indicated the facility did not have enough staff to provide timely call light responses. On 04/04/11 at 5:45 PM, Administrative Staff E verified the facility had been in the process of reducing the direct care staff hours on the schedule for the past several months. Administrative Staff E verified the most recent staff reductions had been initiated on 04/01/11. The facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.