Every finding on record at Meade District Hosp Ltcu Dba Lone Tree Retirement

The facility reported a census of 33 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.Findings included:- Observation of the kitchen and food storage areas on 08/19/25 at 07:40 AM revealed the following areas of concern:Dry storage concerns:Four cases of soda cans and a 50-pound bag of sealed flour were stored on the floor.One unsealed bag of marshmallows.One bag of unsealed russet instant mashed potatoes.A large container of pinto beans that was not sealed with the lid all the way.Several bottles of spices with no date opened and no expiration date.Walk-In Cooler concerns:Several containers of caffeine and sunshine drink with straws in them, with initials TP and no date. Two bags of fresh broccoli unsealed,One bag of sliced onions unsealed.One box of Pizza [NAME] pizza, no date, no name.One unsealed bag of shredded cheese,One bowl of mixed fruit labeled Joyce, no date.Walk-in freezer concerns:One bag of unsealed biscuits, an unsealed waffle, and a bag of unsealed ground beef.A plastic storage container on the top shelf, no date, no label, looks like ice and noodles.Two free-standing refrigerators in the kitchen had one bag of unsealed roast beef and an open gallon of milk with no date when opened.During the second observation on 08/20/25 at 10:20 AM, revealed several cooking pans with black colored debris on the bottom of them; one frying pan was dented, and four cutting boards had several scratches noted over the surfaces. During an interview on 08/20/25 at 07:55 AM, Certified Dietary Manager (CDM) BB reported that some of the items in the fridge and freezer were staff food items and that they have stored those items in the fridge for over 30 years, and no one had ever had a concern with staff items in the fridge. CDM BB reported that the flour and soda pop should not have been placed on the floor and verified that it was delivered on 08/13/25. CDM BB said staff were expected to keep items off the floor. Additionally, CDM BB stated staff were expected to label all food items in the kitchen when opened, and all items should be properly sealed.During an interview on 08/20/25 at 10:30 AM, CDM BB reported she would have the pans and cutting boards replaced.During an interview on 08/20/25 at 01:00 PM, Administrative Staff A stated she expected all food items to be stored, sealed, labeled, and dated properly. Additionally, Administrative Staff A said she expected kitchen equipment to be in good working order.The facility's policy Food Receiving and Storage dated 10/2017 documented personal staff items and food storage.Employees may store their personal items in employee refrigerators or designated storage areas that follow sanitation and appropriate storage. Employee personal staff items may be stored in designated areas, including food storage areas, provided they are properly covered, clearly labeled with the staff member's name, and maintained in a sanitary manner.The facility's policy Dietary Food Storage dated 01/10/25 documented food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items taken out of original packaging will be labeled and stored in air-tight containers. The label must include the received by date and/or open date.The facility's policy Food Handling & Preparation dated 01/10/25 documented to maintain clean, organized kitchens and equipment.

The facility reported a census of 33 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.Findings included:- During a tour of the kitchen on 08/19/25 at 07:40 AM, observation revealed three garbage cans with no lids on them. During an observation on 08/20/25 at 10:20 AM, the same three garbage cans were found with no lids in the kitchen. Certified Dietary Manager (CDM) BB reported that the garbage cans did have lids and pulled a lid out from behind a garbage can and placed it on the can next to the steamer counter. CDM BB reported that the garbage cans should be covered. During an observation on 08/20/25 at 11:25 AM, the garbage can that was approximately three feet away from the stove had no lid. Dietary Staff CC had just finished cooking hamburgers and reported that the garbage cans in the kitchen rarely had a lid placed on them. During an interview on 08/20/25 at 01:00 PM, Administrative Staff A reported she expected all the garbage cans to always have the proper lids on them in the kitchen. The facility's policy Waste Disposal, revised on 10/10/24, states that all garbage will be disposed of daily and as needed throughout the day. Trash will be deposited into a sealed container outside the premises.The facility did not provide a policy on waste management.

The facility reported a census of 33 residents. Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP). This failure has the potential to affect all 33 residents.Findings included:- During an interview on 08/19/25 at 07:50 AM, Administrative Staff A revealed she was the facility IP, and Administrative Nurse D assisted with the task. Administrative Staff A provided a certificate for completion of Nursing Home Infection Prevention Training Course dated 01/22/25.During an interview on 08/21/25 at 01:06 PM, Administrative Staff A reported she had a bachelor's degree in Aging Sociology but no health-related degrees. She confirmed she was the IP of the facility while Administrative Nurse D was taking the IP class to receive her certification. During an interview on 08/21/25 at 01:10 PM, Consultant Staff GG stated he thought any staff member could be the IP of the facility.The facility's Infection Control Policy dated 01/10/2025, documented the IP was responsible for overseeing the infection control program, including but not limited to surveillance of infections, tracking and trending infections in the facility, and having primary training in nursing, medical technology, microbiology, epidemiology, or another related field.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for five residents: Resident (R) 7, and R4 related to personal alarms; R5 related to pressure ulcers and medications; R2 related to dental; and R25 related to nutrition. This deficient practice placed the affected residents at risk for impaired care due to unidentified care needs. Findings included:During an observation and interview on 08/19/25 at 01:23 PM, R7 reported she has had some falls and hit her head, which she needed staples sometime this past year. Observation revealed a bed and chair alarm in her room.R7's Care Plan in the Electronic Health Record (EHR) directed staff to provide a silent alarm on R7's bed and chair dated 09/11/24. R7's EHR recorded a Quarterly MDS, dated [DATE], and an Annual MDS, dated [DATE], which both lacked documentation of R7's bed and chair alarm in Section P.During an observation and interview on 08/19/25 at 01:39 PM, R4 sat in a recliner with her representative present. R4's representative pointed out the silent alarm under R4 and stated the alarm was utilized while R4 was in bed or in the recliner. R4's EHR recorded a Care Plan that noted staff provided a silent alarm on the bed and chair dated 04/20/25. R4's EHR recorded a Significant Change MDS, dated [DATE], which lacked documentation of R4's bed alarm in Section P.During an interview on 08/20/25 at 05:25 PM, Certified Nurse Aide (CNA) T reported that R4 and R7 had a silent alarm on their bed and chair, and have had them for quite some time.During an interview on 08/21/25 at 12:00 PM, Administrative Nurse E confirmed both R4 and R7's comprehensive and quarterly assessments were coded incorrectly for alarms.R5's Electronic Health Record (EHR) recorded a Physician Order for Remeron (an antidepressant used to treat mood disorders) 30 milligram (mg) tablet dated 11/24/21.R5's Quarterly MDS, dated [DATE], lacked documentation of R5's antidepressant in Section N.R5's EHR recorded a Skin/Wound Note dated 12/30/24, which documented a wound to the coccyx had healed.R5's EHR recorded a Skin/Wound Note dated 01/06/25, 01/13/25, 01/20/25, 01/27/25, documented no skin issues noted.A Progress Note dated 02/01/25 at 02:36 PM documented the resident transferred to the hospital.The admission Skin Note dated 02/04/25 at 03:08 PM, documented a Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) on the coccyx (area over the tailbone); the wound was healed prior to leaving the facility but present on readmission. R5's Quarterly MDS, dated [DATE], incorrectly recorded the resident had one facility-acquired Stage 3 (full-thickness pressure injury extending through the skin into the tissue below).During an observation on 08/21/25 at 8:50 AM, R5 had a dressing noted on her coccyx during care.During an interview on 08/21/25 at 12:55 PM, Administrative Nurse D confirmed that R5's pressure ulcer was healed in December of 2024, and when R5 was readmitted from the hospital in February 2025, the wound was open.During an interview on 08/21/25 at 01:20 PM, Administrative Nurse E confirmed R5's quarterly assessment dated [DATE] was coded incorrectly for antidepressant and facility-acquired pressure ulcer.- R2's Electronic Health record (EHR) recorded a Progress Note 03/04/25 at 11:10 AM, which documented R2's upper dentures and lower dentures were broken.R2's EHR recorded an admission Assessment dated 03/04/25 at 12:33 PM, which documented R2 had upper dentures.R2's Care Plan, revised 03/10/25, documented the resident had upper dentures and directed staff to provide a toothbrush and soak the dental device at night. The plan instructed staff to report changes, problems with gums, dental devices, or signs of pain such as grimacing while eating. The plan noted R2's lower dentures were lost prior to admission.R2's EHR recorded an admission MDS, dated 03/10/25, which lacked documentation in Section L of R2's edentulous (no natural teeth) status.During an interview on 08/19/25 at 9:16 AM, R2 reported she had been without a lower denture for six months; she reported she lost them at dinner at a restaurant.During an interview on 08/21/25 at 01:20 PM, Administrative Nurse E confirmed the admission assessment was coded incorrectly for R2's dental status.R25's Electronic Health record (EHR) recorded a Physician Order for a regular portion-regular diet with soft texture; ground meat or cut up in small pieces; always serve with gravy or sauces, dated 12/25/24.R25's Care Plan, revised 12/25/24, instructed staff to offer the resident a regular diet with regular portions, soft texture (meat cut up in small pieces or ground meat texture with gravy or sauce).R25's Annual MDS, dated [DATE], and Quarterly MDS, dated 08/05/25, lacked documentation in Section K of R25's mechanically altered diet (require change in texture of food or liquids).During an observation on 08/19/25 at 01:54 PM, R25 sat in his recliner, drooling from his mouth. R25 wiped off his face and gurgled when he talked.During an interview on 08/21/25 at 01:20 PM, Administrative Nurse E confirmed R2's comprehensive and quarterly assessments were coded incorrectly for his mechanically altered diet.The facility did not provide a policy on accurate MDS.

The facility reported a census of 33 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 5 with a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure injury. The facility further failed to ensure adequate hand hygiene during personal care for R5 and R32 when staff failed to complete adequate hand hygiene. The facility failed to deliver food in a sanitary manner for several residents in the dining room. These deficient practices had the potential to spread infections to the residents in the facility.Findings included:- Observation on 08/20/25 at 05:49 PM, Certified Medication Aide (CMA) R delivered food to the resident's tables with thumbs touching the eating surface of the plate.Observation on 08/20/25 at 05:49 PM, Certified Nurse Aide (CNA) P delivered food to residents with thumbs touching the eating surface of the plates.Observation on 08/20/25 at 05:55 PM, CNA O delivered food to residents with thumbs touching the eating surface of the plates.Observation on 08/20/25 at 06:09 PM, CNA Q delivered plates of food to the residents with thumbs touching the eating surface of the plates.Observation on 08/21/25 at 08:50 AM, CNA S and CNA M provided peri-care care to R5. R5 had EBP signage and personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) located outside her room. Neither CNA donned a gown, but only wore gloves. CNA S removed her glove from her right hand in between the dirty and clean actions during peri-care provided and applied a new glove to her right hand without performing hand hygiene. CNA S and CNA M completed peri-care to R5, then removed their gloves. Both CNA applied a clean pair of gloves without performing hand hygiene first and proceeded to assist R32, R5's roommate, with peri-care. CNA S and CNA M transferred R32 back to her recliner from the shared bathroom. CNA S and CNA M then removed their gloves but did not perform hand hygiene. They exited the room. CNA M pushed the mechanical lift out of the room and down the hall. CNA M stopped at R1's room as the resident asked the CNA M to do a couple of things in her room. CNA M entered R1's room without performing hand hygiene, adjusted the thermometer, and moved some items in the room; then CNA M came out of the room and, without performing hand hygiene, continued to push the mechanical lift down the hall to the storage room. CNA M pushed the lift into the room and then performed hand hygiene. The mechanical lift was not cleaned off after use and before being placed in the common storage area.During an interview on 08/20/25 at 06:00 PM, Consultant Staff GG said he expected staff to keep their hands clear of the eating surface of plates since that was an infection control concern. He stated staff were provided education.During an interview on 08/21/25 at 09:10 AM, CNA S and CNA M reported they should have worn a gown when providing care to R5, and reported they normally washed their hands after care was provided. CNA M reported she normally wiped down the mechanical lift after each use.During an interview on 08/21/25 at 10:18 AM, Licensed Nurse (LN) G reported the staff should perform hand hygiene after removing gloves and between resident care provided. LN G said the mechanical lift should be sanitized after use, and confirmed the staff were required to wear gowns and gloves with EBP residents during the hands-on care.During an interview on 08/21/25 at 01:06 PM, Administrative Nurse D stated she expected staff to wear the required PPE for residents who have EBP. She stated she expected staff to complete hand hygiene when gloves were removed and between resident care. She said she expected staff to sanitize the shared equipment between residents.The facility's policy Infection Control dated 01/10/25, documented staff perform hand hygiene before and after direct contact with a resident and immediately after removing gloves.The facility's policy Enhanced Barrier Precautions dated 11/12/24, documented EBP were implemented as one intervention this facility uses to reduce transmission of resistant organisms that employs targeted PPE use during high contact resident care activities. The facility's policy Food Handling & Preparation dated 01/10/25, documented ensuring safe, nutritious, and palatable food service in compliance with federal and state requirements. Use tongs, scoops, or utensils-not bare hands-to prepare and serve food.

The facility reported a census of 33 residents. The sample included 12 residents with two reviewed for dignity. Based on observation, interview and record review, the facility failed to treat residents in a dignified manner when Resident (R)4 received care without privacy. This deficient practice placed the resident at risk for decreased psychosocial well-being and embarrassment. Findings included:- R4's Electronic Health Record (EHR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (a progressive mental disorder characterized by failing memory and confusion). R4's 07/17/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment documented R4 was dependent on staff for transfers. The 07/17/25 Cognitive Loss / Dementia Care Area Assessment (CAA) documented R4 had impaired cognitive function. The 07/17/25 ADL Functional / Rehabilitation Potential CAA documented R4 had a self-care performance deficit related to impaired balance, impaired coordination related to progression of Alzheimer's disease, and other medical conditions. Observation on 08/19/25 at 01:07 PM revealed Certified Nurse Aide (CNA) M went into R4's room with a mechanical lift and left the door to the hallway open, and the privacy curtain remained in the open position. CNA M pressed the call light for additional assistance, and while waiting for help, connected R4 to the mechanical lift. The procedure was fully visible from the hallway. At 08/19/25 at 01:09 PM, CNA N walked by R4's room, then went in and closed the door. During an interview on 08/19/25 at 01:20 PM, CNA M revealed the door and/or privacy curtain should have been closed to provide privacy and dignity for R4 when the resident was being connected to the mechanical lift. During an interview on 08/21/25 at 11:25 AM, Licensed Nurse (LN) G revealed when mechanical lifts are in use, or when connecting to a resident or resident's sling, the doors and privacy curtains should be closed to provide privacy and dignity for the residents. During an interview on 08/21/25 at 11:40 AM, Administrative Nurse D revealed doors should be closed and curtains drawn during every stage of mechanical lift use to provide privacy and dignity for the residents. The facility's Resident Rights policy, dated 01/10/25, documented all residents have the right to a dignified existence. The facility must protect and promote each resident's dignity and respect in all aspects of care and daily life. The policy documented residents would receive care in a manner that enhances and maintains their dignity and respect.

The facility had a census of 33 residents. The sample included 12 residents with one resident reviewed for discharge. Based on observation, interview, and record review, the facility failed to provide a written discharge summary or recapitulation of the stay for Resident (R) 37. This placed the resident at risk for impaired rights related to continuity of care. Findings included:- R37's Electronic Health Record (EHR) documented diagnoses that included chronic pain and hypothyroidism (a condition characterized by decreased activity of the thyroid gland).R37's Nursing Home Discharge Minimum Data Set (MDS), dated [DATE], documented R37's discharge from the facility to the community on 06/19/25.R37's EHR noted Physician Orders, which documented an order to discharge to independent apartments on Thursday, 06/19/25, dated 06/17/25.The EHR Progress Notes documented:On 06/11/25 at 11:09 AM, fax communication with the physician who requested orders to discharge the resident to home.On 06/12/25 at 10:25 AM, fax communication received from the physician with written orders to discharge the resident to home on or about 06/19/25 with medications and treatments.On 06/17/25 at 10:33 AM, the physician performed a routine 60-day visit with R37 and documented an order to discharge to independent apartments on 06/19/25.On 06/19/25 at 10:44 AM, staff documented R37's family was at the facility moving R37's belongings to an independent apartment due to R37 being discharged the same day.On 06/19/25 at 12:27 PM, staff documented a discharge meeting was held for R37. Administrative Nurse D reviewed the medication list with R37, and R37 had made arrangements for follow-up appointments with her primary healthcare provider as well as transportation arrangements with family in the community.On 06/19/25 at 01:26 PM, staff documented R37 was at the nurses' station at 01:00 PM and told staff she was leaving. Staff documented R37 was supplied with her medications.On 06/19/25 at 01:31 PM, staff documented fax communication with the physician to inform them R37 was discharged to home at 01:00 PM.R37's EHR lacked evidence that the facility provided a written discharge summary or recapitulation of the stay to R37 or R37's family.On 08/20/25, the facility provided a printed copy of R37's Planned Discharge - Interdisciplinary evaluation that documented a discharge date , brief reason for admission, treatment provided, treatment progression, and reason for discharge. The evaluation did not contain the condition at the time of admission, destination of discharge, to whom the resident was released, disposition of medications and/or personal possessions, instructions for after care/continuity of care, or summary of the stay.During an interview on 08/20/25 at 01:31 PM, Administrative Nurse D revealed the discharge summary and recapitulation should be in the EHR under the Evaluations tab. Administrative Nurse D confirmed that R37's EHR Evaluations tab lacked a recapitulation of the stay, and a brief recapitulation was documented on a Planned Discharge - Interdisciplinary evaluation.During an interview on 08/20/25 at 01:36 PM, Administrative Staff A stated the recapitulation should be in each resident's medical record.During an interview on 08/20/25 at 04:30 PM, R37 stated during the actual discharge process on 06/19/25, she was provided with a reconciliation of her medications and was not provided with a written discharge summary or recapitulation of the stay. R37 stated the facility did not assist her with coordinating transportation in the community or follow-up appointments with her primary care provider because she had already made those arrangements independently.The facility's Resident Rights policy, dated 01/10/25, did not address the discharge process.The facility's Admission, Transfer, and Discharge Policy policy, dated 01/10/25, documented the facility would comply with regulations to protect residents' rights during discharge. At least 30 days advanced written notice would be provided, except in case of emergency situations, and would include reason, effective date, location, contact information for LTCO (Long Term Care Ombudsman) and SA (State Agency), and appeal rights. The policy did not document providing a written discharge summary, recapitulation of stay, or reconciliation of medications to the resident or residents' representatives.

The facility reported a census of 33 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the Payroll-Based Journaling (PBJ) as required. Findings included:- Review of the PBJ Staffing Data Report for Fiscal Year (FY) 2024 Quarter (Q) 3 (April 1 - June 30) and FY 2024 Q4 (July 1 - September 30) revealed the facility did not have Licensed Nursing Coverage 24 hours a day on the following dates: 04/13/24, 04/28/24, 05/04/24, 05/05/24, 05/10/24, 05/11/24, 05/12/24, 05/25/24, 07/03/24, 07/07/24, 08/18/24, 09/22/24. Review of the facility's nursing schedule and payroll data for the above dates revealed the facility had 24-hour nursing coverage. During an interview on 08/20/25 at 04:00 PM, Consultant HH provided the nursing schedule and payroll data that revealed the time-keeping system had automatically removed a 30-minute lunch period for the above dates, even though the nurses remained in the building. The facility did not provide a policy related to PBJ reporting.

The facility reported a census of 32 residents, with three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)2, who the facility identified as an elopement risk. On 05/25/24 R2 displayed an increase in his wandering/exit seeking behavior which included statements he was going to leave, and he attempted to push open the front. On 05/26/24 R2 pushed on the doors leading to the apartments, displayed agitation, and thought the facility was a jail. On 05/27/24 at 10:38 AM, R2 attempted to exit the front entrance without success. On 05/27/24 at 10:40 AM, visitors entered the building and held the door open for R2 and he exited the front entrance without staff knowledge. R2 remained outside, unsupervised by staff until 10:43 AM, when Certified Nurse Aide (CNA) LL noticed R2 sitting outside unattended. The failure to provide adequate supervision and effective intervention to address the exit seeking behaviors, placed R2 in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with agitation, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, and altered mental status. The Admission Minimum Data Set, dated dated dated [DATE] assessed R2 with a Brief Interview of Mental Status score of three, indicating severe cognitive impairment. R2 wandered one to three days of the assessment period, did not require the use of mobility devices, and was independent with walking and transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/30/24 revealed R2 was at risk for impaired cognitive function or thought process related to anxiety, forgetfulness, and confusion. The Behavioral Symptoms CAA dated 04/30/24 revealed R2 was at risk for physical and verbal unusual behaviors directed towards others, related to complications from loss of independence and anxiety. The CAA lacked information about R2's wandering. The Care Plan dated 05/06/24 for R2 included a goal of R2 not having any episodes of wandering or elopement through the next review period. The care plan revealed R2 may have wandered one to three days and the staff were to perform a Wandering Risk scale quarterly and as needed. The staff were to keep the medical provider informed of changes in behavior, and to watch for and report to the nurse of any signs and symptoms of wandering. The care plan lacked additional interventions related to wandering/exit seeking until 05/27/24 when the facility added new interventions to include a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) to his right ankle and if R2 verbalized thought of wanting to leave the facility, the staff were to stay with him and have someone notify the nurse. Additionally, on 05/27/24, the facility posted signage at the front door for visitors to not let residents out of the facility. The Wandering Risk Scale dated 05/18/24, scored R2 at a nine, which indicated R2 was at risk to wander. The Census tab for R2 revealed a room change to a different hallway on 05/22/24. The Progress Note dated 05/19/24 at 08:04 PM, revealed R2 wandered down the hall and walked into two other resident rooms. The Progress Note dated 05/23/24 at 03:59 AM, revealed R2 had been wandering the hallway he resided on throughout the night, had gone in another resident room, and hollered out where is everyone at? The Progress Note dated 05/23/24 at 06:29 AM, revealed R2 had walked up and down his hallway and another hallway in the facility all day yesterday after R2 was moved into another room. The Progress Note dated 05/24/24, revealed R2 walked up and down the halls most of the shift. R2 went on a facility bus ride and at supper time asked if staff had seen his brother. R2 did not sit in chairs for very long before he got right back up and started walking again. The Progress Note dated 05/25/24 at 02:20 AM, revealed R2 had recent medication changes and continued to have difficulty sleeping. R2 was wandering around the hallways at night and noted R2 wandered to the front door, at times. The Progress Note dated 05/25/24 at 05:41 PM, revealed R2 constantly stated he was going to leave. The Progress Note dated 05/25/24 at 06:00 PM, revealed R2 went to the front door and attempted to push it open. The Progress Note dated 05/26/24 at 04:50 PM, revealed R2 went up front and to the double doors leading to the apartments and was pushing on the doors. R2 thought the facility (staff) was keeping him from his house. The Progress Note dated 05/26/24 at 05:08 PM, revealed R2 thought the facility was a jail and displayed agitation. The Progress Note dated 05/26/24 at 05:52 PM, revealed Licensed Nurse (LN) G received a phone call from R2's family. LN G informed family R2 had been restless and wanting to go to the farm and the house, more agitated and trying to open doors, and the facility (staff) possibly would put a Wander Guard on him. The Progress Note dated 05/26/24 at 06:58 PM, revealed R2 had confusion to place, time, and situation, ambulated independently with a front wheeled walker, and had six episodes of wandering in the last week. The Progress Note dated 05/27/24 at 10:54 AM, revealed LN H notified Administrative Nurse D regarding R2 seated on the outdoor bench at the entrance of the building. The Progress Note dated 05/27/24 at 11:12 AM, revealed R2 sat at the front door in a chair after elopement, upset and stated, this is jail and they are all liars! and refused to move. R2 had a Wander Guard placed to his right ankle. Administrative Nurse D reviewed the facility camera which revealed at 10:38 AM, R2 walked to the front door and attempted to enter a door code, then turned towards a chair. At 10:40 AM, visitors opened the front door and left it open for R2 to exit. R2 then turned and sat on the bench outside the front doors, and when a truck was outside, he became upset and wanted to leave in the truck. On 06/12/24 at 12:02 PM, observation of facility video footage from 05/27/24 revealed at 10:39 AM, R2 was at the front entrance and could not get out. He sat down in a chair at 10:40 AM until three visitors came in the front doors and held the door open for him. R2 then went outside and sat on a bench next to the front doors. At 10:43 AM, two staff exited the front of the building to bring R2 back inside. On 06/12/24 at 12:09 PM, observation revealed R2 sat in the dining room eating his lunch with his walker beside him. R2 then exited the dining room with the walker. Right before he made it to his room CNA O approached his side and offered the restroom, which R2 declined. R2 sat in his recliner and had a Wander Guard in place to his right ankle. On 06/12/24 at 12:52 PM, CNA LL stated on 05/27/24 she was propelling a resident down [specified hall] and happened to glance to the left and observed R2 outside on the bench by the front doors, through a resident room window. CNA LL then got on the walkie talkie and asked if anyone was out with R2 or had let him out and received a response back no. CNA LL stated then we all started to head to the front door. CNA LL did not know if his family was there with him or if R2 was just sitting there. CNA LL stated when staff tried to get him in, he became agitated, but were able to get him in and then applied a Wander Guard. On 06/12/24 at 02:10 PM, CNA M stated R2 wandered on the evening shift and R2 wandered more since he moved to another room. CNA M stated before the room change, he would come out of his room and go back in and now he goes to all areas of the facility and other resident rooms. CNA M stated before R2 eloped, he would try to open the doors on the halls, resident room doors and say he wanted to go to another city and CNA M saw him try to push doors open. CNA M stated she made the charge nurse aware when R2 did that. On 06/12/24 at 03:05 PM, CNA N stated she was off duty two days prior to the elopement and worked the day R2 eloped. CNA N stated when she received report the morning before R2 eloped, she was told R2 had been wandering a little bit. CNA N stated she was shocked when she heard he had been wandering around and wanted to leave because he was not like that before. On 06/12/24 at 03:19 PM, CNA O stated around the time R2's medicine changed he seemed to be worse, before he would walk around, she did not think out of confusion, he just liked to walk around. On 06/12/24 at 03:46 PM LN G stated she recalled when he attempted to open the double doors, she informed staff to keep an eye on him like they would with someone with a Wander Guard, or until a decision could be made about application of a Wander Guard. LN G recalled she discussed a Wander Guard bracelet but could not recall if that was before of after R2 eloped. LN G stated R2 seemed to have increased behaviors after going on an outing to a cemetery such as pushing on doors and telling people he was going to the farm. On 06/12/24 at 04:15 PM, Administrative Nurse D stated when a resident would display exit seeking behaviors, staff should redirect or attempt interventions. If interventions did not work, usually staff would then apply a Wander Guard. Administrative Nurse D stated the weekend before the elopement (which occurred on Monday) CNA P contacted her regarding R2 and had told them to try different interventions such as taking him to the common area to monitor him and to call the family, as he had not had exit seeking behaviors prior to that weekend and had gone on a bus ride on Friday (05/24/24). Administrative Nurse D stated she did not recall talking to a nurse that weekend. Administrative Nurse D stated he was not exit seeking, just wandered into other rooms and was not talking about the leaving until the bus ride on that Friday when she wrote the note about his wandering on 05/26/24. Administrative Nurse D stated she was not aware R2 had pushed on the doors and would have expected the staff to notify her of that behavior. The facility's policy Wandering/Wander Guard updated 04/24/24, revealed residents with exit seeking behaviors or high risk for elopement as determined by nursing would have a Wander Guard placed. The facility failed to implement additional interventions when cognitively impaired R2, identified as an elopement risk, displayed exit seeking behaviors and then eloped from the facility when incoming visitors held the door open for him on 05/27/24, without staff knowledge. On 06/13/24 at 10:42 AM, Administrative Staff A was provided the Immediate Jeopardy Template and notified of the facility's failure to provide adequate supervision when R2, who had been displaying exit seeking behaviors several days before, eloped from the facility on 05/27/24 at 10:40 AM. The immediate jeopardy was determined to first exist on 05/27/24 at 10:40 AM, when R2 exited the facility without staff knowledge. The surveyor verified the facility identified and implemented corrective actions completed on 05/29/24 at 02:30 PM when the facility completed the following: 1. On 05/27/24, electronic communication message sent out via electronic medical record communication board. 2. On 05/27/24 at 12:35 PM, the staff placed a Wander Guard to R2's right ankle and posted signage at the front door stating Please do not let anyone out the doors. Check with charge nurse at Nurse's Station. 3. On 05/27/24, R2's care plan updated to include the Wander Guard, Wander Risk Assessment completed, and the Medical Director notified. 4. On 05/27/24 at 02:30 PM a meeting was held with CNA's, CMA's and Licensed Nurses to educate on Elopement and Behaviors. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 27 residents with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility. Findings included: - On 08/28/23 at 10:32 AM during the initial tour of the kitchen, revealed the facility's dish washer was not in working order. Dietary staff were washing all the dishes with the three-sink method. Dietary staff CC was in the dish room washing the dishes. He reported the dish machine was broke down and replacement parts were on back order. Until then, the dishes were being washed manually and sanitized. The dishes were sanitized with chlorine after washing. Dietary staff CC was not sure how to test the level of chlorine being used to sanitize the dishes. Dietary supervisor BB instructed/supervised dietary staff CC while he used testing strips to check the chlorine level. The sanitizing sink water tested at a concentration of 100 PPM and air dried. During the initial tour on 08/28/23 at 10:32 AM, the following areas of concern were noted: The reach-in refrigerator had the following concerns: 1. Two open bags of cheese lacked an opened date. 2. A bowl of salad lacked a date. 3. One-half green pepper lacked a date. 4. A peeled cucumber lacked a date. 5. A large bag of salad mix lacked an opened date. The walk-in refrigerator had the following concern: 1. A box with three bags of rotten strawberries. 2. Two bags of rotted bananas. 3. A large bag of broccoli that was discolored and mushy in texture. The dry storage area had the following concerns: 1. A large bag of tortilla chips open to the air and lacked an opened date. 2. A partial box of noodles with the box open to air and lacked an opened date, 3. An open bag of flour tortillas open and lacked an opened date. Dietary Staff BB verified the above concerns at the time of the tour. On 08/30/23 at 10:50 AM, a follow-up tour of the kitchen staff hand washed the residents' tableware/dishes in a three-sink method. There was no log visible for checking the sanitization of the chlorine used to sanitize the dishes. Dietary staff BB stated there was no log and the facility did not have a schedule to test the chlorine. On 08/30/23 at 12:00 PM, dietary staff CC reported he did not know he should test the chlorine levels. Review of the facility's policy for Food Receiving and Storage dated 07/14, revealed dry food to be labeled and dated with use by date and rotated using a first in-first out system. All foods stored in the refrigerator or freezer would be covered, labeled, and dated. The facility's policy for Sanitization dated 10/08, revealed manual washing and sanitizing would employ a three-step process for washing, rinsing, and sanitizing: Scrape food particles and wash using hot water and detergent; rinse with hot water to remove soap residue; and sanitize with hot water of chemical sanitizing solution of chlorine 50 PPM for 10 seconds. The facility failed to store foods safely and ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility.

The facility census totaled 27 residents with all residents receiving meals from the one main kitchen. Based on observation and interview the facility failed to maintain mechanical, electrical, and patient care equipment in good working condition by the failure to have a functioning dish machine since 08/08/23. This failure has made it necessary to manually wash all dishes used in the kitchen and for residents with questionable sanitization. This had the potential to affect all residents residing in the facility. Findings included: - On 08/28/23 at 10:32 AM during the initial tour of the kitchen, revealed the facility's dish washer was not in working order. Dietary staff were washing all the dishes with the three-sink method. Dietary staff CC was in the dish room washing the dishes. He reported the dish machine was broke down and replacement parts were on back order. Until then, the dishes were being washed manually and sanitized. The dishes were sanitized with chlorine after washing. Dietary staff CC was not sure how to test the level of chlorine being used to sanitize the dishes. Dietary supervisor BB instructed/supervised dietary staff CC while he used testing strips to check the chlorine level. The sanitizing sink water tested at a concentration of 100 PPM and air dried. On 08/30/23 at 10:50 AM, a follow-up tour of the kitchen staff hand washed the residents' tableware/dishes in a three-sink method. There was no log visible for checking the sanitization of the chlorine used to sanitize the dishes. Dietary staff BB stated there was no log and the facility did not have a schedule to test the chlorine. Interview on 08/30/23 at 10:50 AM dietary staff BB stated she had no idea how long the dishwasher would be down. She reported being told by Administrative Staff A the part had been ordered and was on back order with no delivery date available. On 08/30/23 at 1:30 PM Administrative staff A reported she did not know how long it was going to take to get the part or if there was a plan to do anything else with the dish machine. She reported she would contact the hospital maintenance department who had ordered the part to get a copy of the invoice when the part was ordered and get an update on what was happening with that. She would send a copy of the invoice and plan to surveyor that day. On 08/30/23 at 1:30 PM a request was made for a policy for maintaining equipment. On 08/31/23 at 12:00 PM, Administrative staff A revealed no invoice had been received as stated and no policy was received. The facility failed to maintain mechanical, electrical, and patient care equipment in good working condition by the failure to have a functioning dish machine since 08/08/23.

The facility has a census of 27 with 12 residents included in the sample, two reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice regarding the use of nebulizer (a device that delivers medication as a mist to the lungs) for Resident (R) 26, and R27. Findings included: - The ''Physician Orders'' dated 07/04/23 for Resident (R)26 revealed the diagnosis included chronic obstructive pulmonary disease (COPD - a progressive irreversible condition characterized diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status BIMS score of 15, that indicated intact cognition. The MDS further revealed R26 had shortness of breath and received oxygen therapy. The Care Plan dated 04/18/23, revealed R26 had shortness of breath and would require pulmonary rehabilitation at the local hospital. The resident had shortness of breath with ambulation, sitting in a wheelchair, and while lying flat in bed. Staff offer R26 breathing treatments. R26's shortness of breath could increase anxiety. Staff should monitor the resident for decreased air movement or wheezing as needed. Review of the Physician Orders dated 07/04/23, revealed the following: Budesonide inhalation suspension 0.5 mg (milligrams), 1 application, inhale orally, two times a day for COPD. Albuterol sulfate, inhalation nebulization solution (2.5 mg/3 milliliter (ml), one vial, inhale orally, three times a day, and every 4 hours as needed, for COPD. Change the nebulizer and oxygen tubing on the 15th of each month. Clean the nebulizer after each use and soak in vinegar water through the night, and up to three times a day for breathing treatment use. On 08/28/23 at 09:42 AM, observation revealed both the nebulizer machine and the nebulizer tubing/medication chamber laid directly on the resident's bed. R26 reported the nurse had just brought her the nebulizer treatment. The nurse would bring the treatment in, set it up in the machine, and just leave the nebulizer treatment for when she wanted to take the treatment. On 08/28/23 at 10:45 AM, (one hour and 3 minutes later), observation revealed R26 was out of her room, however, the nebulizer machine and nebulizer tubing/ medication chamber remained on her bed. The medication chamber contained moisture and fluid droplets. On 08/29/23 at 09:35 AM, the nebulizer machine, tubing and medication chamber laid directly on the bed. The medication chamber contained clear fluid. On 08/29/23 at 01:45 PM, Interview with Certified Nurse Aide (CNA) M reported R26's nebulizer machine remained on her bed around 11:45 AM. On 08/30/23 at 09:46 AM, Interview with Licensed Nurse (LN) G reported staff should rinse out nebulizers after each use. Staff had been instructed to cleanse the nebulizer chamber/mouth pieces with vinegar water after each breathing treatment. On 08/30/23 at 01:20 PM, interview with Administrative Nurse D revealed she expected the nursing staff to rinse the resident's nebulizer after each treatment. Night shift should soak the nebulizers in vinegar water. On 08/31/23 at 11:25 AM, interview with Administrative Nurse D revealed the nursing staff does not monitor the residents with nebulizer treatments for effectiveness, as staff do not obtain a oxygen saturation or check breath sounds before or after the nebulizer treatment. The undated facility's policy for Nebulizer Treatment, revealed when all the medication gone from the medicine cup, remove the mask or mouthpiece and turn the machine off. Staff should wash their hands, then wash the (nebulizer) mask or mouthpiece and nebulizer part with warm water, rinse with a strong stream of warm water for 30 seconds. Shake off the excess water, air dry, place the pieces in a basket at the sink in between use. The policy did not document monitoring for the effectiveness of the nebulizer treatment. The facility failed to provide respiratory care consistent with professional standards of care for R 26 regarding the use and cleaning of the nebulizer. - R27's Physician Orders dated 07/04/23, revealed the following diagnosis of atrial fibrillation (rapid irregular heartbeat). Review of the Physician Orders dated 08/22/23, revealed an order for albuterol sulfate inhalation, nebulizer, two times a day, for shortness of air for 10 days. Albuterol sulfate inhalation nebulization solution 0.63/mg (milligrams) 3 milliliters (ml), 1 vial, inhale orally two times a day, for shortness of air for 10 days. Observation on 08/28/23 at 01:29 PM, revealed R27's nebulizer attached to the nebulizer machine on the resident's bedside table. The fluid from the nebulizer medication chamber leaked out and there was a puddle of the liquid medication directly underneath the medication chamber. Observation on 08/29/23 at 10:05 AM, The resident was not in the bedroom, however the nebulizer attached to machine contained droplets of clear fluid in the nebulizer. On 08/30/23 at 09:46 AM, Interview with Licensed Nurse (LN) G reported staff should rinse out nebulizers after each use. Staff had been instructed to cleanse the nebulizer chamber/mouth pieces with vinegar water after each breathing treatment. On 08/30/23 at 01:20 PM, interview with Administrative Nurse D revealed she expected the nursing staff to rinse the resident's nebulizer after each treatment. Night shift should soak the nebulizers in vinegar water. On 08/31/23 at 11:25 AM, interview with Administrative Nurse D revealed the nursing staff does not monitor the residents with nebulizer treatments for effectiveness, as staff do not obtain a oxygen saturation or check breath sounds before or after the nebulizer treatment. The undated facility's policy for Nebulizer Treatment, revealed when all the medication gone from the medicine cup, remove the mask or mouthpiece and turn the machine off. Staff should wash their hands, then wash the (nebulizer) mask or mouthpiece and nebulizer part with warm water, rinse with a strong stream of warm water for 30 seconds. Shake off the excess water, air dry, place the pieces in a basket at the sink in between use. The policy did not document monitoring for the effectiveness of the nebulizer treatment. The facility failed to provide respiratory care consistent with professional standards of care for R 27 regarding the use and cleaning of the nebulizer.

The facility reported a census of 27 with 12 residents included in the sample. Based on observation, interview and record review the facility failed to provide a sanitary environment by the failure to clean the nebulizer equipment between uses for Resident (R)26, R27 and on R16 failed to provide proper hand hygiene during incontinent care. Findings included: - The ''Physician Orders'' dated 07/04/23 for Resident (R)26 revealed the diagnosis included chronic obstructive pulmonary disease (COPD - a progressive irreversible condition characterized diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status BIMS score of 15, that indicated intact cognition. The MDS further revealed R26 had shortness of breath and received oxygen therapy. The Care Plan dated 04/18/23, revealed R26 had shortness of breath and would require pulmonary rehabilitation at the local hospital. The resident had shortness of breath with ambulation, sitting in a wheelchair, and while lying flat in bed. Staff offer R26 breathing treatments. R26's shortness of breath could increase anxiety. Staff should monitor the resident for decreased air movement or wheezing as needed. Review of the Physician Orders dated 07/04/23, revealed the following: Budesonide inhalation suspension 0.5 mg (milligrams), 1 application, inhale orally, two times a day for COPD. Albuterol sulfate, inhalation nebulization solution (2.5 mg/3 milliliter (ml), one vial, inhale orally, three times a day, and every 4 hours as needed, for COPD. Change the nebulizer and oxygen tubing on the 15th of each month. Clean the nebulizer after each use and soak in vinegar water through the night, and up to three times a day for breathing treatment use. On 08/28/23 at 09:42 AM, observation revealed both the nebulizer machine and the nebulizer tubing/medication chamber laid directly on the resident's bed. R26 reported the nurse had just brought her the nebulizer treatment. The nurse would bring the treatment in, set it up in the machine, and just leave the nebulizer treatment for when she wanted to take the treatment. On 08/28/23 at 10:45 AM, (one hour and 3 minutes later), observation revealed R26 was out of her room, however, the nebulizer machine and nebulizer tubing/ medication chamber remained on her bed. The medication chamber contained moisture and fluid droplets. On 08/29/23 at 09:35 AM, the nebulizer machine, tubing and medication chamber laid directly on the bed. The medication chamber contained clear fluid. On 08/30/23 at 09:46 AM, Interview with Licensed Nurse (LN) G reported staff should rinse out nebulizers after each use. Staff had been instructed to cleanse the nebulizer chamber/mouth pieces with vinegar water after each breathing treatment. On 08/30/23 at 01:20 PM, interview with Administrative Nurse D revealed she expected the nursing staff to rinse the resident's nebulizer after each treatment. Night shift should soak the nebulizers in vinegar water. The undated facility's policy for Respiratory Therapy Prevention of Infection related to medication nebulizer/ continuous aerosol revealed: Staff would obtain equipment, wash hands, after completion of therapy. 1. Remove the nebulizer container. 2. Rinse the container with fresh tap water. 3. Dry on a clean paper towel or gauze sponge. 4. Wipe the mouthpiece with damp paper towel or gauze sponge. 5. Store the circuit in plastic bag, marked with date and resident's name between uses. The facility failed to provide respiratory care consistent with professional standards of care for R 26 regarding the cleaning of the nebulizer. - R27's Physician Orders dated 07/04/23, revealed the following diagnosis of atrial fibrillation (rapid irregular heartbeat). Review of the Physician Orders dated 08/22/23, revealed an order for albuterol sulfate inhalation, nebulizer, two times a day, for shortness of air for 10 days. Albuterol sulfate inhalation nebulization solution 0.63/mg (milligrams) 3 milliliters (ml), 1 vial, inhale orally two times a day, for shortness of air for 10 days. Observation on 08/28/23 at 01:29 PM, revealed R27's nebulizer attached to the nebulizer machine on the resident's bedside table. The fluid from the nebulizer medication chamber leaked out and there was a puddle of the liquid medication directly underneath the medication chamber. Observation on 08/29/23 at 10:05 AM, The resident was not in the bedroom, however the nebulizer attached to machine contained droplets of clear fluid in the nebulizer. On 08/30/23 at 09:46 AM, Interview with Licensed Nurse (LN) G reported staff should rinse out nebulizers after each use. Staff had been instructed to cleanse the nebulizer chamber/mouth pieces with vinegar water after each breathing treatment. On 08/30/23 at 01:20 PM, interview with Administrative Nurse D revealed she expected the nursing staff to rinse the resident's nebulizer after each treatment. Night shift should soak the nebulizers in vinegar water. The undated facility's policy for Respiratory Therapy Prevention of Infection related to medication nebulizer/ continuous aerosol revealed: Staff would obtain equipment, wash hands, after completion of therapy. 1. Remove the nebulizer container. 2. Rinse the container with fresh tap water. 3. Dry on a clean paper towel or gauze sponge. 4. Wipe the mouthpiece with damp paper towel or gauze sponge. 5. Store the circuit in plastic bag, marked with date and resident's name between uses. The facility failed to provide respiratory care consistent with professional standards of care for R 27 regarding the cleaning of the nebulizer. 31078 - Observation on 08/28/23 at 12:50 PM, revealed staff assisted R16 from the dining room to her room. Certified Nursing Assistant (CNA)N and CNA O assisted the resident to the toilet. The resident stood in the bathroom with CNA O holding onto R16's gait belt and CNA N, while wearing gloves, pulled the residents pants down and removed R16's wet brief. The resident was then assisted to sit on the toilet and a clean brief placed on the resident. The resident voided in the toilet then CNA N stood the resident and provided perineal (peri) care with wet wipes. CNA N failed to remove her soiled gloves and failed to provide hand hygiene when CNA N pulled the resident's clean brief and clean pants up into place. CNA N failed to wash her hands after removal of the soiled gloves. Interview on 08/28/23 at 01:00 PM, CNA N reported she understood the need to change gloves between dirty and clean techniques. The facility's policy for Perineal Care dated 03/21, revealed the staff were to provide privacy for the resident, wash hands and don gloves. They were to remove the soiled brief and place in a closable plastic bag and remove their gloves and wash their hands, then don on clean gloves. Staff were to wash and dry the peri-rectal area and remove gloves. Staff were to wash hands or use alcohol-based hand rub and don clean gloves to put clean brief on the resident. Remove gloves and perform hand hygiene. The facility failed to provide a clean, sanitary environment for R16 by the failure to perform hand hygiene and change gloves between dirty and clean surfaces, to ensure no possible infections for this resident.

The facility reported a census of 27 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all nursing personnel by the required deadline. Finding included: - The PBJ reported provided by the Centers for Medicare & Medicaid services (CMS) for Fiscal Year (FY) 2022 Quarter three documented the facility failed to have staff Licensed Nursing Coverage 24 hour/day on 04/09/22, 04/16/22, 06/05/22, and 06/19/22. The PBJ reported provided by the CMS for FY 2022 Quarter four documented the facility had a one-star staffing rating. The facility failed to have staff Registered Nurse hours on 07/02/22, 07/16/22, 08/27/22, and 09/10/22. The facility failed to have staff Licensed Nurse Coverage 24 hours/day on 07/02/22, 07/04/22, 07/09/22, 07/10/22, 07/16/22, 07/17/22 07/23/22, 07/30/22, 07/31/23, 08/06/22, 08/13/22, 08/14/22, 08/20/22, 08/27/22, 08/28/22, 09/03/22, 09/04/22, 09/10/22, 09/11/22, 09/17/22, 09/24/22, and 09/25/22. The PBJ reported provided by the Centers for Medicare & Medicaid services (CMS) for Fiscal Year (FY) 2022- 2023 Quarter one documented the facility failed to have staff Licensed Nursing Coverage 24 hours/day on 10/01/22, 10/02/22, 10/08/22, 10/09/22, 10/15/22, 10/16/22, 10/22/22, 10/23/22, 10/29/22, 10/30/22, 11/05/22,11/06/22, 11/12/22, 11/13/22, 11/19/22, 11/24/22,, 11/26/22, 11/27/22, 12/03/22, 12/04/22, 12/08/22, 12/10/22, 12/11/22, 12/16/22, 12/17/22, 12/18/22, 12/19/22, 12/23/22, 12/24/22, 12/25/22, 12/26/22, 12/27/22, and 12/31/22. The PBJ reported provided by the Centers for Medicare & Medicaid services (CMS) for Fiscal Year (FY) 2023 Quarter two documented the facility failed to have staff Licensed Nursing Coverage 24 hours/day on 01/0,1/23, 01/07/23, 01/08/23, 01/13/23, 01/20/23, 01/21/23, 01/22/23, 01/25/23, 01/28/23, 02/04/23, 02/11/23, 03/11/23, 03/12/23, and 03/26/23. Upon review of printed staffing day sheets provided by the facility, the dates above it was revealed that the facility had proof of RN hours and LN hours. On 08/30/23 at 09:04 AM with Administrative Nurse D revealed the payroll clocking system the facility used, would kick the nurses out of the system. The facility changed to a different payroll system, and the hours are reviewed they are submitted. The facility failed to provide a policy regarding Reporting Direct-Care Staffing Information (Payroll-Based Journal) as requested on 08/30/23. The facility failed to submit complete and accurate staffing information to the federal regulatory agency through PBJ) failed to submit/ provide Licensed Nursing Coverage 24 hours/day and RN staffing hour data for all nursing personnel by the required deadline.

The facility reported a census of 33 residents, with 12 in the sample, and four reviewed for oxygen/respiratory care. Based on observation, interview, and record review the facility failed to change oxygen tubing and nebulizer tubing routinely and failed to ensure the nebulizer and oxygen tubing were stored sanitarily for Resident (R)9, R28, R17, and R25. Findings included: - The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R17 required extensive assistance of two staff for most activities of daily living (ADL) and with no shortness of breath noted. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment, and no changes noted in ADL function. The health conditions indicated shortness of breath with sitting, exertion, or laying down and noted R17's use of oxygen. The Care Plan dated 12/04/20 revealed R17 receive nebulizer treatments and instructed staff to clean the nebulizer after each use. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident used oxygen at two liters, per nasal cannula, while napping. Observation on 11/09/21 at 10:33 AM revealed R17's bubbler and oxygen tubing did not have a date to indicate when it was last changed. The oxygen tubing was wrapped up and laying over the top of the bubbler. Observation on 11/10/21 at 09:46 AM revealed the handheld nebulizer laying on bedside table/night stand. The nebulizer was not rinsed after the 07:00 AM treatment, and the nebulizer did not have a date to indicate when it was last changed. Observation on 11/10/21 at 12:55 PM revealed the handheld nebulizer remained at the bedside, still attached to the tubing. Observation on 11/15/21 at 10:31 AM revealed R17 laid in bed, and did not use the oxygen and the oxygen tubing hung off of the concentrator, with no storage bag observed. Further observation revealed the nebulizer was still attached to the tubing, indicating the staff did not rinse the nebulizer after the 07:00 AM treatment. Interview with Certified Medication Aide (CMA) I on 11/15/21 at 01:50 PM revealed the nurse cleaned the nebulizer equipment and the medication aides did not give the residents those treatments. Interview with Licensed Nurse (LN) C on 11/16/21 at 09:20 AM revealed the nurses administer the breathing treatments. LN C stated she did not rinse the nebulizer after each use. Interview on 11/16/21 at 08:59 AM, Administrative Nurse B expected the staff on the night shift to soak the nebulizers in vinegar and water over night. Administrative Nurse B said the staff do not rinse the nebulizer in between treatment and stated the tubing was changed on the first and fifteenth of every month. Administrative Nurse B verified there was no documentation in the resident's chart to indicate when it was changed and expected the staff to use the form to document tubing changes and nebulizer cleaning. The policy on Administering Medication through a Small Volume (Handheld) Nebulizer dated 2001 revealed the purpose of the procedure was to safely and aseptically administer aerosolized particles of medication into the resident's airway. When treatment was complete, turn off nebulizer, and disconnect T-piece, mouthpiece and mediation cup. The policy then indicated to rinse and disinfect the nebulizer equipment according to facility protocol. The facility failed to ensure the sanitary storage and routine changing of oxygen tubing, and the cleaning and proper storage of the nebulizer after use, for R17. - The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicated moderate impaired cognition. R25 required extensive assistance of two staff for all activities of daily living. The Care Plan dated 12/04/20 revealed R25 received nebulizer treatments and instructed staff to clean the nebulizer after each use. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/09/21 at 01:07 PM revealed R25's handheld nebulizer laying on bedside table with no date on tubing when last changed and nebulizer not rinsed after treatment time. Observation on 11/10/21 at 01:00 PM R 25's handheld nebulizer laying on bedside table/night stand the nebulizer was not rinsed after treatment at 07:00 AM no date on tubing for nebulizer when last changed. Observation on 11/15/21 at 10:00 PM handheld nebulizer remained at bedside still attached to tubing. Interview with Certified Medication Aide (CMA) I on 11/15/21 at 1:50 PM revealed the nurse cleaned the nebulizer equipment and the medication aides do not give the residents those treatments. Interview with Licensed Nurse (LN) C on 11/16/21 at 09:20 AM revealed the nurses administer the breathing treatments. LN C stated she did not rinse the nebulizer after each use. Interview on 11/16/21 at 08:59 AM, Administrative Nurse B expected the staff on the night shift to soak the nebulizers in vinegar and water over night. Administrative Nurse B said the staff do not rinse the nebulizer in between treatment and stated the tubing was changed on the first and fifteenth of every month. Administrative Nurse B verified there was no documentation in the resident's chart to indicate when it was changed and expected the staff to use the form to document tubing changes and nebulizer cleaning. The policy on Administering Medication through a Small Volume (Handheld) Nebulizer dated 2001 revealed the purpose of the procedure was to safely and aseptically administer aerosolized particles of medication into the resident's airway. When treatment was complete, turn off nebulizer, and disconnect T-piece, mouthpiece and mediation cup. The policy then indicated to rinse and disinfect the nebulizer equipment according to facility protocol. The facility failed to ensure the sanitary storage and routine changing of oxygen tubing, and cleaning and proper storage of the nebulizer after use, for R25. - Review of R28's pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 01/26/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment and the resident received O2. The 10/19/21 Quarterly MDS revealed R28 received O2. The 07/16/21 Comprehensive Care Plan revealed R28 suffered from shortness of breath, staff assessed her oxygen saturation as needed and offered oxygen via nasal cannula or mask as ordered. The Care Plan lacked information about the care of the tubing/cannula and how often changed. The 09/28/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders lacked information about how often to change O2 tubing. Observation on 11/09/21 at 09:41 AM revealed R28's O2 tubing rolled up on the concentrator with the undated cannula hanging and no storage bag noted. Observation on 11/10/21 at 01:28 PM revealed R28s O2 concentrator was next to her bed, the undated tubing was not in a storage bag on the concentrator. Observation on 11/15/21 at 11:24 AM revealed R28s O2 tubing with nasal cannula laid over the back of the concentrator, no in a containment bag, and remained undated. Interview on 11/10/21 at 01:33 PM with Certified Nurse Aide (CNA) G revealed R28 used the O2 at night. She acknowledged there was no storage bag on the concentrator and the tubing was wound around the machine and then stated that was how it always was. Interview on 11/15/21 at 08:40 AM with Licensed Nurse (LN) C revealed R28 received O2 and did not know when the O2 tubing and bottle were last changed. Interview on 11/15/21 at 04:45 PM with Administrative Nurse B revealed she expected the nurses to update the care plans with new orders and clarify orders if not clear. The 10/2010 Oxygen Administration policy/procedure revealed the purpose it to provide guidelines for safe oxygen administration. [Staff must] verify that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [Staff should] record the date and time the procedure was performed in the resident's medical record. The facility failed to ensure O2 tubing and supply change orders were in place for R28 and failed to ensure the sanitary storage of the resident's O2 tubing when not in use. - Review of R9's pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/17/21 Quarterly Minimum Data Set (MDS) revealed R9 received oxygen. The 08/17/21 Annual MDS revealed the resident received O2. The 08/06/21 Comprehensive Care Plan revealed R9 used O2. The staff followed the cleaning instructions from the O2 supplier but lacked information on the frequency of O2 supplies. The 03/25/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/10/21 at 08:53 AM revealed R9 lying on her back with the head of the bed slightly elevated. She had her nasal cannula in place running at 2 liters (L) per minute and O2 tubing and bottle lack a date when it was last changed. Interview on 11/15/21 at 08:40 AM with Licensed Nurse (LN) C revealed R28 received O2 and did not know when the O2 tubing and bottle were last changed. Interview on 11/15/21 at 04:45 PM with Administrative Nurse B revealed she expected the nurses to update the care plans with new orders and clarify orders if not clear. The 10/2010 Oxygen Administration policy/procedure revealed the purpose was to provide guidelines for safe oxygen administration. [Staff must] verify that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [Staff should] record the date and time the procedure was performed in the resident's medical record. The facility failed to ensure O2 tubing and supply change orders were in place for R9 and failed to ensure the sanitary storage of the resident's O2 tubing when not in use.

The facility reported a census of 33, with 12 residents in the sample. Based on observation, interview, and record review the facility failed to ensure Resident (R) 6 was treated with dignity when they did not provide a privacy bag for an indwelling catheter bag. Findings included: - The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R6 required extensive assistance of two staff for most activities of daily living. The Care Plan dated 01/29/21 revealed R6 had an indwelling foley catheter due to [CONDITION(S)] and staff would change the indwelling foley catheter and drainage bag as ordered. Observation on 11/15/21 at 10:00 AM revealed the residents indwelling catheter bag hanging on the side of the bed with no privacy bag and the catheter bag visible from doorway. On 11/15/21 at 02:00 PM interview with Certified Nurse Aide (CNA) E revealed the facility policy was to place catheter bags in a privacy bag on the resident's bed and wheelchair. On 11/16/21 at 09:24 AM interview with Licensed Nurse (LN) C revealed the resident's catheter bag needed to be below the bladder and was not aware it needed to be in a privacy bag. On 11/16/21 at 09:10 AM interview with Administrative Nurse B revealed the indwelling catheter bag should always be in a privacy bag The facility provide a policy Quality of Life- Dignity revealed each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality by keeping the resident urinary catheter bags covered. The facility failed to ensure R6 was treated with dignity when a privacy bag was not provided for indwelling catheter bag.

The facility census totaled 33 residents, with 12 included in the sample. Based on interview and record review the facility failed to provide Resident (R) 26 or the resident representative with a bed-hold policy upon transfer to a hospital. Findings included: - The signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the Quarterly MDS dated [DATE] revealed no significant changes from MDS dated [DATE]. Review of the Care Plan dated 10/12/21 revealed the resident last transferred to the hospital on 10/25/21 and returned 10/28/21. The Health Status Note dated 10/25/21 at 05:10 PM revealed R26 went to the hospital for further evaluation. The Health Status Note dated 10/25/21 at 07:05 PM revealed this nurse informed Administrative Nurse B the resident transferred to the hospital. Review of the Electronic Medical Record for R26 lacked record of a bed hold policy being sent with the resident on 10/25/21 and/or follow up with the resident's representative. On 11/16/21 at 01:15 PM Licensed Nurse C reported she did not know anything about sending a bed hold with a resident when they went to the hospital. On 11/16/21 at 01:30 PM Administrative Staff A verified no bed hold policy was sent with the resident to the hospital. Review of the facility's policy Bed-Holds and Returns dated 03/17 revealed prior to transfers and therapeutic leaves, residents or resident representatives would be informed in writing of the bed-hold and return policy. The facility failed to provide R26 or the resident's representative with a bed-hold policy upon transfer to a hospital.

The facility census totaled 33 residents, with 12 included in the sample. Based on observation, interview, and record review the facility failed to revise care plans for Resident (R) 9 and R28 in include care of the oxygen both residents were receiving. Findings included: - Review of R9's pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/17/21 Quarterly Minimum Data Set (MDS) revealed R9 received oxygen. The 08/17/21 Annual MDS revealed the resident received O2. The 08/06/21 Comprehensive Care Plan revealed R9 used O2, the staff followed the cleaning instructions from the O2 supplier but lacked information on the frequency of O2 supplies. The 03/25/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/10/21 at 08:53 AM revealed R9 lying on her back with the head of the bed slightly elevated. She had her nasal cannula in place running at 2 liters (L) per minute and O2 tubing and bottle lack a date to indicate when it was last changed. Interview on 11/15/21 at 08:40 AM with Licensed Nurse (LN) C revealed R9 received O2 on an as needed basis during the day and continuous at night. She stated she had not updated or reviewed care plans for the resident. Interview on 11/15/21 at 04:45 PM with Administrative Nurse B revealed she expected the nurses to update the care plans with new orders and clarify orders if not clear. The 10/2010 Oxygen Administration policy/procedure lacked instructions on the care of the O2 supplies. The facility failed to revise care plans for R9 to include the oxygen the resident was received. - Review of R28's pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 01/26/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment and received O2 (oxygen). The 10/19/21 Quarterly MDS revealed R28 received O2. The 07/16/21 Comprehensive Care Plan revealed R28 suffered from shortness of breath, staff assessed her oxygen saturation as needed, and offered oxygen via nasal cannula or mask as ordered. The Care Plan lacked information about the care of the tubing/cannula and how often changed. The 09/28/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders lacked information about how often O2 tubing changed. Observation on 11/09/21 at 09:41 AM revealed R28's O2 tubing rolled up on the concentrator with the undated cannula hanging with no storage bag noted. Observation on 11/10/21 at 01:28 PM revealed R28's O2 concentrator was next to her bed, the undated tubing was not in a storage bag on the concentrator. Observation on 11/15/21 at 11:24 AM revealed R28's O2 tubing with nasal cannula laid over the back of the concentrator, not in a storage bag, still not dated. Interview on 11/10/21 at 01:33 PM with Certified Nurse Aide (CNA) G revealed R28 used the O2 at night. She acknowledged there was no storage bag on the concentrator and the tubing was wound around the machine and then stated that was how it always was. Interview on 11/15/21 at 08:40 AM with Licensed Nurse (LN) C revealed R9 received O2 on an as needed basis during the day and continuous at night. She stated she had not updated or reviewed care plans for the resident. Interview on 11/15/21 at 04:45 PM with Administrative Nurse B revealed she expected the nurses to update the care plans with new orders and clarify orders, if not clear. The 10/2010 Care Plans policy revealed it is to describe services that are furnished to attain or maintain the resident's highest level of health and being. The facility failed to revise care plans for R28 to include the care of the oxygen and tubing.

The facility census totaled 33 residents. Based on observation, interview, and record review the facility failed to thoroughly investigate resident falls for Resident (R) 6, R7, R8, and R10 to determine the root cause of the fall(s) to tailor interventions to specific resident needs, which included adequate supervision, toileting, and assistive devices to prevent avoidable accidents. R6 experienced a right shoulder fracture, R7 experienced a left femur fracture requiring a total hip replacement and R8 experienced a right femur fracture that required hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint). Findings included: - Review of R6's pertinent [DIAGNOSES REDACTED]. Review of the 04/07/20 Annual Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of two, indicating severely impaired cognition. The resident had fluctuating inattention and disorganized thinking. The resident required the use of a wheelchair with extensive two-person assistance for transfers and extensive one-person assistance for locomotion on unit due to unsteady gait with a wander alarm used daily during the seven-day review period. R6 experienced no falls since last MDS. Review of the 06/30/20 Quarterly MDS revealed a BIMS of three, indicating severely impaired cognition. The resident had fluctuating inattention and disorganized thinking. R6 wandered four to six days, but less than daily in the seven-day review period. The resident required the use of a wheelchair with extensive two-person assistance for transfers and extensive one-person assistance for locomotion on unit due to unsteady gait with wander and bed alarm used daily during the seven-day review period. R6 experienced two or more minor injury falls since the last MDS. Review of the 04/07/20 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed R6 with severely impaired cognition along with difficulty with orientation and recall, but aware of person and family. At times she repeated Where do I go or What should I be doing and needed cues from staff about what to do next. The CAA noted her forgetfulness contributed to her confusion. She did not remember her past injuries, such as her cervical(neck/spine) fracture (broken bone). Review of the 04/07/20 Falls CAA revealed R6 fell last on 01/26/20 and indicated R6 was at high risk for falls due to impaired balance, inability to bear weight, weakness, kyphotic posture (a spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back), and poor safety awareness. R6 could not remember how to use a call light. The facility utilized a Wander Guard (a device that sets off an alarm when residents are wearing one attempt to exit the building without an escort) since R6 was at a high risk of wandering. She needed assistance with all Activities of Daily Living (ADL) and required a total lift. R6 experienced a C1 (cervical-neck) fracture that remained a concern in her history, and the family was made aware of the risks related to R6 not wearing a cervical collar, especially with the resident's history of falling, such as R6's neck could break, and could result in paralysis or death. Review of 06/24/20 and 09/24/20 Nursing Morse Fall Scale assessments revealed R6 as a high risk for falls. Review of the Safety and Falls Care Plan (revised on 10/02/20) revealed R6 as a high risk for falls. The staff offered to assist R6 into bed or a recliner when she indicated sleepiness to the staff by closing her eyes. R6 last fell on [DATE], and the staff offered to reposition when restless, but not in a recliner for repositioning. On 09/07/20, an x-ray revealed R6 suffered a right acromial (outer end of the scapula, extending over the shoulder joint and forming the highest point of the shoulder, to which the collarbone is attached) fracture to her right shoulder from the fall on 09/01/20. Revision on 09/09/20 indicated R6 required better staff monitoring for residents at high risk for falls when staff placed a resident in an area with no alarms. Revision 09/18/20 indicated staff repositioned her frequently when she was in her wheelchair or assist her to bed to rest, but not a recliner if restless. R6 could not bear weight and used the total lift for transfers with extensive assistance support of two staff due to her kyphotic posture and her slightly limited upper extremity range of motion. Review of revision 10/02/20 My Communication and Memory Care Plan revealed R6 experienced severely impaired cognitive function with poor short-term memory and long-term memory. R6 needed reminders, cues, and assistance from staff in organizing her daily routine and safety decisions due to disorganized thinking and inattention. Review of the 10/02/20 Behavior Care Plan (revised 10/02/20) revealed R6 stayed busy and wandered more during the evenings. Review of the 08/03/20 at 10:42 AM Weekly Summary Note revealed R6 as alert but disoriented and often unable to make her needs known. Two staff assisted R6 with transfers and one staff with ADLs. She used a high back wheelchair for locomotion and wandered throughout the halls. Review of 08/11/20 at 10:09 PM Weekly Summary Note revealed R6 was alert but disoriented to time/place with episodes of confusion at times. R6 experienced gait and mobility problems and was unable to transfer/pivot self, and required two staff assistance with sit-to-stand during transfers. Review of 09/01/20 at 03:04 PM Nursing Fall Scene Investigation revealed R6 experienced an unwitnessed fall in the common area. R6 seated in a recliner and then found by CNA N on the floor on her right side with legs bent at the knee and drawn up. Staff noted a skin tear to the lower right forearm, but R6 denied pain/other injuries. Staff documented R6 had been alone and unattended before the fall. They also documented she was alert and confused with her shoes on her feet. Vital signs not completed by LN D. The monitoring video revealed CNA N left the resident seated on the edge of the recliner, alone, while CNA N walked away to get the nurse. The investigation revealed a contributing factor to her fall as the amount of assistance needed and noted R6 needed more staff monitoring in the common area. The initial root cause noted as CNA N did not stay with the resident and did not use her walkie talkie to alert a nurse. The intervention noted as better monitoring for high fall risk resident in the area with no alarms, and the care plan updated. The facility reported this a near-miss and not a fall. CNA N reported to LN D she assisted the resident to the floor and that R6 did not fall. Several days later, the resident complained of right shoulder pain and limited range of motion (ROM) with a fracture noted. Review of the undated fall scene investigation statement from CNA N revealed R6 placed in a recliner and scooted out of the recliner. She was seated in her wheelchair asleep before staff transferred her to the recliner. Review of 09/02/20 at 11:44 AM Health Status Note Late Entry revealed two staff assisted R6 to the recliner in the common areas for repositioning. Licensed Nurse (LN) D was in the nurse's station and heard CNA N call for assistance because CNA N found the resident seated on the floor. When LN D asked CNA N what happened, she stated that she assisted R6 to the floor. LN D suspected nothing different than what CNA N told her, so two staff assisted the resident off the floor and to her wheelchair. R6 did not complain of any pain at that time and LN D noted a skin tear to R6's right hand. Review of 09/02/20 at 01:05 PM Health Status Note revealed R6 complained of left shoulder pain. Staff applied a warm pack to the area and gave the resident scheduled Tylenol. Review of 09/07/20 at 10:00 AM Health Status Note revealed R6 exhibited limited mobility and complained of pain to her right shoulder with bruises noted to be yellowish-green and purplish-blue in color. The staff notified R6's physician, and orders obtained to send the resident to the emergency room at 09:30 AM, via facility transport. Review of 09/07/20 x-ray (electromagnetic [MEDICAL CONDITION] that differentially penetrates structures within the body and creates images of these structures on photographic film or a fluorescent screen) rt shoulder two to four views revealed an acute (new) fracture that involved the lateral (away from the middle of the body) margin of the acromion (outer end of the scapula, extending over the shoulder joint and forming the highest point of the shoulder, to which the collarbone is attached). Review of 09/07/20 at 12:20 PM Order or Exam Note revealed R6 arrived back from the emergency room with a sling applied to her right arm. An x-ray of R6's right shoulder revealed a [DIAGNOSES REDACTED]. Review of 09/29/20 at 07:25 PM Care Plan Note Late Entry revealed resident exhibited bilateral shoulder pain rated four out of 10 with exercises. Staff transferred R6 with a full lift since the right shoulder fracture in the beginning of September, and she exhibited limited ROM to bilateral (both) shoulders with moderate strength. She exhibited kyphosis secondary to spinal cord injury after a motor vehicle accident with injury in her history. R6's fall goal indicated no other major injuries related to a fall through the next review date by staff assisting with transfers. Observation of resident on 10/12/20 at 09:59 AM to 10:54 AM revealed R6 used her feet to self-propel in her wheelchair with ease in the common area. R6 stated she needed to sleep and then once to her room, she then self-propelled out of her room and back to the common area. Interview with CNA B on 10/13/20 at 09:01 AM revealed R6 fell and sustained a fracture not long ago. Interventions before she fell included staff checked on her very often, she used a fall mat, and a low bed. R6 wanted to move around a lot and she asked to go out too. CNA B said the staff did not usually place her in the recliners because she did not tend to stay seated and tried to climb out. Interventions after her fall included a thick mat by her low bed, staff sat her in her wheelchair to self-propel around halls, or staff placed her at the common area table with a locked wheelchair, an activity, and easily visible. Her confusion made conversation hard, but she responded to staff with a head shake to indicate yes or no. Interview with CNA C on 10/13/20 at 02:23 PM revealed the fall R6 experienced when she broke her shoulder happened because the staff placed her in the recliner to reposition her. She sat there for 30 minutes, but she did not sit still. CNA N watched R6 as she attempted to get out of the chair and said she assisted the resident to the floor. CNA C stated whether staff assisted a resident to the floor, or if a resident fell from a surface, a fall was a fall. We know now R6 fell from the chair to the floor and fractured her right shoulder because the administrative staff watched the video. Staff interventions for falls for R6 included laying the resident in bed to stretch out. Her fall from the recliner, the one and only time staff placed her in a recliner, resulted in her fracture. CNA N stated the staff completed visual checks when they walked down the halls because of the resident's pronounced confusion. Interview with CNA C on 10/14/20 at 04:13 PM revealed he and CNA P found a large bruise on R6's right shoulder on 09/02/20 when they dressed her in her nightgown, and the resident reported pain with movement. CNA C reported these findings to LN F. Interview with CNA P on 10/14/20 at 04:36 PM revealed when she assisted R6 to get ready for bed on 09/02/20, and she found a substantial greenish colored bruise on R6's right shoulder. CNA P reported this to LN F. Interview with LN D on 10/13/20 at 01:33 PM revealed R6 sat in the recliner in the common area for repositioning on 09/02/20. CNA N assisted LN D with R6's transfer to the recliner and staff tasked CNA N with keeping watch of her. The next thing LN D knew, CNA N called for help, and when LN D asked if the resident fell , the CNA responded that she had not fallen, but sat on the edge of the chair and eased from the edge of the chair to the floor. LN D did not consider the scenario to be a fall and did not complete vital signs. She indicated she questioned R6 about pain with none reported, but noted a skin tear to her right forearm, which she cleansed and covered. LN D indicated she did not fill out a fall report or report the fall to administration. On 09/07/20, CNA E called from the bath house and asked LN D to assess R6's right shoulder, to which she noted the bruising green in color, and black and blue in axillary (armpit) area. LN D sent R6 to the emergency room (ER). She indicated she did not contact the Director of Nursing (DON). The hospital reported R6 fractured her right shoulder, and the next day Administrative Nurse A worked, LN D reported to her the findings, and indicated she should watch the video of the fall from 09/01/20 to see what happened. CNA N's story did not match with what she reported to LN D, and she indicated she should have filled out a fall report. CNA N should have checked on R6 frequently and considered frequently to be at least visual checks every 10-15 minutes. LN D indicated the inconsistent information reported by CNA N the day she fell led to the delay in appropriate care for R6. Interview with Administrative Nurse A on 10/08/20 at 09:27 AM revealed she watched the video of R6's fall and saw CNA N failed to go to the resident and then call for help with her walkie talkie. Administrative Nurse A stated CNA N left the resident unattended on the recliner's edge and went to get the nurse, which resulted in R6's fall and right shoulder fracture. CNA N no longer works in the facility. The interdisciplinary facility team met once a week to address falls/issues, and the root cause of falls decided by the nurse reviewed and changed as appropriate. Administrative Nurse A indicated falls noted in the facility were more prevalent during the evening hours. Interview with Administrative Nurse A on 10/14/20 at 12:30 PM revealed the intervention from LN D indicated better monitoring needed for residents at risk for falling when placed in an area with no alarms. She indicated the proper intervention for this fall would have been positioning her in bed or repositioned in her chair with better monitoring but disagreed more frequent checks were indicated. She also indicated that whether a resident slid to the floor or fell from the chair, both scenarios were considered a fall. LN D did not fill out a fall scene investigation until 09/07/20 when R6 went to the ER and found to have a right shoulder fracture. Administrative Nurse A indicated she knew the resident had been at the recliner's edge, but not on the floor. LN D did not call Administrative Nurse A when R6 went to the ER, but stated she expected facility staff to notify her anytime a resident left the facility for the ER. Interview with Administrative Nurse A on 10/14/20 at 04:35 PM revealed the charting on 09/02/20 at 09:00 AM was struck out and recharted at 09:00 PM by LN F. Staff did not report the finding to Administrative Nurse A. After investigating the fall, she noticed the documented bruising regarding R6 and educated LN's and CNA's that this information needed to be reported. She advised the CNAs that if the LN on duty did not address their concerns regarding resident care, they were to report directly to her. Review of revised March 2018 Falls- Clinical Protocol policy revealed falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. For an individual who has fallen, the staff will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. The staff will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the staff will re-evaluate the situation and reconsider possible reasons for the resident's falling and also consider current interventions. Review of revised March 2018 Falls and Fall Risk, Managing policy revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of revised March 2018 Assessing Falls and Their Causes policy revealed evaluate chains of events or circumstances preceding a recent fall including whether there is a pattern of falls for this resident. The facility failed to adequately supervise R6 which resulted in a fall with fracture and then failed to thoroughly investigate the fall in a timely manner even after finding major bruising to right shoulder and pain the day after the fall the CNA's reported to the nurse. There were six days between the resident's fall and her evaluation at the hospital revealing the fracture. - Review of R8's pertinent [DIAGNOSES REDACTED]. Review of the 02/11/20 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of three, indicating severely impaired cognition. The resident had fluctuating inattention and disorganized thinking. R8 wandered four to six days, but less than daily during the seven-day review period. The resident required a walker with extensive assistance one-person for transfers, extensive two-person assistance for toilet use (frequently incontinent of bowel and bladder) and walking in corridor/locomotion required supervision one-person assistance. No falls noted since last MDS. Review of the 08/11/20 Quarterly MDS revealed a BIMS score of three, indicating severely impaired cognition with fluctuating inattention and disorganized thinking. R8 wandered daily during the seven-day review period. The resident required a walker with extensive assistance of one-person for transfers, personal hygiene, toilet use (frequently incontinent of bowel and bladder), walking in the corridor required supervision, and locomotion on unit required supervision with one-person assistance. R8 experienced one non-injury fall since the last MDS. Review of the 02/11/20 Cognitive Loss/Dementia CAA revealed R8 admitted to the facility on [DATE], alert to person, but unable to cognitively process place, and repeatedly said I do not know with chronic fluctuating inattention and disorganized thinking. Review of the 02/11/20 Falls CAA revealed her fall risk score indicated a high risk for falls and she frequently walked in the hallways with her walker. Review of 08/07/20, 09/25/20, and 10/06/20 Nursing Morse Fall Scale revealed R8 was at high risk for falls. Review of the revised 08/12/20 Care Plan revealed R8 needed a Wander Guard and a front wheeled walker. Revision on 05/12/20 indicated R8 needed cues and reminders to use her front wheeled walker for locomotion and transfers. R8 forgot to request assistance when getting out of bed and the staff predicted her needs. For transfers, she required extensive assistance with support of one staff with her walker, and for locomotion on and off unit R8 required staff supervision with setup and cues to use her walker. Review of the revision on the 08/12/20 Safety and Falls Care Plan revealed R8 high risk for falls. Staff kept R8's call light within reach and encouraged her to use the call light for assistance if weak or experienced pain. Staff needed to answer all requests for assistance promptly. Review of the revised 08/12/20 Bowel and Bladder Care Plan revealed a revision on 02/28/20, revealed staff offered assistance to the bathroom every two hours while awake: 11:00 AM, 01:00 PM, 03:00 PM, 05:00 PM, 07:00 PM, 09:00 PM, 11:00 PM, 01:00 AM, 03:00 AM, 05:00 AM, and 07:00 AM. Staff assisted R8 with evening activities of daily living and restroom use during the night. She enjoyed being seated in the common's area. Review of the 08/07/20 at 05:43 AM Care Plan Note revealed R8 required the assistance of one staff with ADLs, used a walker for ambulation, wandered aimlessly in the home, up and down hallways, and often forgot to take her walker. Review of 09/03/20 at 03:00 AM Behavior Note revealed R8 walked in the hallway alone with her blanket comforter, stated I do not know when staff questioned her. Staff assisted R8 into a recliner chair, offered an ice cream bar, and staff closely observed R8 for her safety. Review of 09/11/20 at 10:16 AM Weekly Summary Note revealed R8 required staff assistance of one with ADLs, used a walker for locomotion with forgetfulness, and staff reminded her to use a walker as she always walked around the facility. Staff toileted R8 every two hours and as needed due to incontinence. Review of 09/25/20 at 01:00 AM Incident Note revealed R8 screamed for help in the common area near the common table and staff found the resident lying on the floor in supine (on back) position. Review of 09/25/20 at 01:00 AM Nursing Fall Scene Investigation revealed R8 had an unwitnessed fall in the common area due to R8 ambulated alone and unattended near the common area table, lost her balance, and did not use her walker, resulting in a skin tear to her right elbow and a fracture to the shaft of the right femur, and required surgical repair. The root cause indicated as footwear, but staff last toileted the resident on 09/24/20 at 09:17 PM (approximately 4 hours later with a toileting schedule, which required staff to toilet the resident every two hours). A review of staffing on 09/25/20 for the night shift revealed CNA I and LN F worked on shift for all 34 residents. Review of 09/25/20 at 01:40 AM statement from CNA S revealed R8 was in bed sleeping at 10:00 PM, up at 10:30 PM/11:00 PM and walked without the walker (from 09:17 PM to 01:00 AM staff did not toilet the resident). A review of 09/25/20 x-ray revealed a sub capital right femoral neck fracture with varus (fracture line extends through the junction of the head and neck of femur). Review of the revision of 09/25/20 Care Plan revealed R8's last fall on 09/25/20 indicated staff offered toileting while still awake and staff offered to assist her to bed at approximately 12:00 AM to 01:00 AM. Observation of resident on 10/12/20 at 01:40 PM to 03:09 PM revealed the resident slept in her recliner in her room, with her walker in front of her, and side table next to the resident with items in reach. R8 dressed appropriately, groomed, with shoes in place. She made no attempts to ambulate or get up during observation. At 01:50 PM, CNA T and CNA G in R8's room to assist the resident to bed due to exhibited sleepiness, but R8 stated no, grimacing when she moved her pelvis in the chair. CNA G notified LN H about the resident's pain. At 02:05 PM, CMA U entered the room to give Tylenol 1000 milligrams for pain. At 02:25 PM, Administrative Nurse A and CMA U came in R8's room to pull the resident up in recliner, and R8 stated that she wanted to cry because of pain. Staff checked her brief and it was dry. At 02:54 PM, the resident sat in her personal recliner, covered with a blanket. She exhibited no grimacing, eyes closed with relaxed facial expression, and no signs or symptoms of discomfort at this time. At 03:09 PM, LN D stopped in R8 room and assessed the effectiveness of the earlier pain medication administration and the resident indicated she experienced less pain at this time. Interview with CNA B on 10/13/20 at 09:27 AM revealed fall interventions included staff checked her often because R8 attempted to get up from her bed and walked without her walker. After her fall with fracture, the staff completed many visual checks, but she did not know of any other interventions for this resident. Since she fell , she does not walk or try to get up as much as she did before her fall. She required two-person assistance for toileting every two hours and brief checks/changes and walked with two-person assistance. Interview with CNA I on 10/13/20 at 04:03 PM revealed staff took R8 to the bathroom every time she attempted to get up and around, and that was the only time she would assist R8 to the bathroom because and she did not push her call light for assistance. R8's confusion caused safety concerns and required one staff to assist with toileting and transferring. CNA I primarily worked on the night shift, and R8 attempted often ambulated without assistance, but went to bed around midnight or one o'clock. CNA I indicated no other fall interventions. During an interview with CNA O on 10/14/20 at 01:32 PM revealed she had not received any type of communication as to which residents experienced incontinence of bladder and needed briefs changed or toileting plans. During an interview with CNA P on 10/14/20 at 04:36 PM, the CNA reported concerns with the amount of staff available to provide care and services to the residents. CNA P reported being short-handed all the time, and sometimes there were just three staff members to provide care for all the residents. CNA P stated staffing was absolutely part of the reason for the residents falling and sustaining serious injuries. CNA P said, if the LN were doing assessments, the other LN passed medications, and the CNA was busy with other residents, then there was no one to monitor the other residents or answer call lights timely. Interview with LN M on 10/11/20 at 10:20 PM revealed the staff do have some difficulty getting everything done for the residents as the evening shift only had three staff members. Interview with Administrative Nurse A on 10/08/20 at 09:27 AM revealed R8 fell at the common area table because she got up and walked unassisted and walked around the table without her walker. The facility met once a week to address falls/issues, and the root cause decided by the nurse evaluated for appropriateness. Falls occurred more during the evening and nights. The fall investigations do not include whether the resident experienced incontinence when they fell , the investigations should include this information. They believed that only having three staff members was not enough personnel for the total number of residents and that some of the falls were related to a lack of staff. Review of revised March 2018 Falls- Clinical Protocol policy revealed falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. For an individual who has fallen, the staff will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. The staff will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the staff will re-evaluate the situation and reconsider possible reasons for the resident's falling and also consider current interventions. Review of revised March 2018 Falls and Fall Risk, Managing policy revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of revised March 2018 Assessing Falls and Their Causes policy revealed evaluate chains of events or circumstances preceding a recent fall including whether there is a pattern of falls for this resident. The facility failed to supervise R8, a wandering, cognitively impaired resident, that required assistance every two-hour toileting and transfers/ambulation for safety to prevent avoidable accidents which resulted in a fractured right femur. - Review of R7's pertinent [DIAGNOSES REDACTED]. of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery). Review of the 06/02/20 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of five, indicating severely impaired cognition. The resident had fluctuating inattention and disorganized thinking. The resident required a walker/wheelchair for ambulation due to unsteadiness with extensive two-person assistance for transfers and toilet use (frequently incontinent of bladder and occasionally incontinent bowel during a seven-day review period), and extensive one-person assistance for locomotion on unit. R7 experienced one non-injury fall since last MDS. Review of the 09/01/20 Quarterly MDS revealed a staff assessment for mental status indicated long/short-term memory problems and severely impaired decision-making skills with fluctuating inattention and disorganized thinking. He wandered one to three days of the seven-day review period. The resident required a wheelchair for ambulation due to unsteadiness with extensive two-person assistance for transfers and toilet use (frequently incontinent of bladder and always incontinent bowel during the seven-day review period), extensive one-person assistance for locomotion on unit. R7 experienced one non-injury fall and one minor injury fall since the last MDS. A review of the 06/02/20 Cognitive Loss/Dementia CAA revealed R7 experienced severely impaired cognition with poor temporal orientation/recall with chronic fluctuating inattention and disorganized thinking. Review of the 06/02/20 ADL CAA revealed R7's used a walker for transfers and ambulation. Review of the 06/02/20 Falls CAA revealed R7 had a history of [REDACTED]. He used a high-low bed with a concave mattress and a walker. Review of 08/27/20 Nursing Morse Fall Scale revealed moderate risk, and fall scales d(TRUNCATED)

The facility census totaled 35 residents. The facility identified an average of 15 residents attended coffee hour. Based on observation, interview, and record review, the facility failed to store food under safe/sanitary conditions by the failure to label brownies stored in the activity room refrigerator for use during coffee hour. This had the potential to affect all residents who attended coffee hour. Findings included: - Observation on 8/8/17 at 8:51 AM revealed in the bottom two drawers of the activity room refrigerator, were more than 6 individually bagged and unlabeled brownies. Interview with activity staff G on 8/8/17 at 8:51 AM revealed the items were brownies the residents made for the local fair and he/she had served to the other residents during coffee hour. He/she confirmed the brownies were undated and stated he/she needed to dispose of them. Interview with dietary staff H on 8/9/17 at 12:38 PM revealed all of the facility staff were responsible to date food when opened and dispose of the food upon the expiration date. Review of the policy entitled Kansas, downloaded 1/2011, revealed the facility would cover, label, and date food items opened and not in original container. The facility failed to ensure all food items used for activities were labeled with the food name and date of expiration.

The facility reported a census of 42 residents with 6 sampled for abuse. Based on observation, interview and record review the facility failed to protect all residents from abuse following an incident of witnessed staff-to-resident abuse on 4/1/17 for resident #1. The 2 alleged perpetrators (direct care G and direct care H) continued to provide care for all residents in the facility between 4/1/17 and 4/11/17. The facility also failed to protect the residents after staff reported to the nurse an allegation of mistreatment towards residents (#5 and #6) by direct care staff H on 4/9/17 and the alleged perpetrator continued to work until 4/11/17. On 4/9/17 a nurse suspected the same alleged perpetrator (direct care staff H) pulled resident #4's hair and the nurse failed to report to administration and allowed the alleged perpetrator to continue to provide care to all residents until 4/11/17. This failure placed all residents in the facility in immediate jeopardy. The facility also failed to report to the State agency a resident-to-resident altercation between resident #2 striking resident #7 which occurred on 1/3/17. Findings included: - Review of resident #1's annual minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9, indicating moderate cognitive impairment. The resident required extensive assistance of 2 staff for activities of daily living (ADLs) and rejected care on 1-3 days of the 7 day observation period. The quarterly MDS dated [DATE] indicated the resident had moderately impaired cognition with a BIMS score of 8. He/she displayed physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing or abusing others sexually) on 1-3 days of the 7 day observation period. He/she displayed verbal behavioral symptoms toward others (threatening, screaming or cursing at others) on 4-6 days and rejected care on 1-3 days of the 7 day observation period. He/she required extensive assistance with all ADLs. Review of the care area assessments (CAA) dated 4/21/16 revealed: The cognition CAA directed staff the resident needed cues for recall to decrease potential confusion. The resident knew the location of his/her room, that he/she lived in a nursing home and the names of staff. The ADL CAA indicated the resident required assistance with all ADLs. He/she had trouble with balance and could only stabilize with assistance from staff. He/she might agree to use a front wheeled walker during transfers and his/her primary mode of locomotion was the wheelchair which he/she propelled independently. The behavioral CAA indicated the resident's daily mood fluctuated. When he/she was in a bad mood he/she was less likely to bear weight, walk and required more staff assistance or the sit-to-stand mechanical lift with transfers. He/she might decline to allow staff to assist him/her with brushing his/her teeth or other cares. When upset he/she may curse, become demanding or rude to the staff. However, during the observation period the resident did not have any behaviors. The care plan dated 1/26/17 indicated the resident required extensive assistance of 2 staff for bed mobility, transfers, walking in the corridor, dressing and toilet use. The facility made a report on 4/11/17 to the State agency regarding an allegation of staff to resident abuse. The facility reported direct care staff D witnessed direct care staff G and direct care staff H forcing resident #1 to take medications. Staff D said staff G held the resident's hands and pinched his/her nose. When the resident opened his/her mouth staff H (also trained for medication administration) shoved the spoon full of medications into the resident's mouth. Staff H allegedly popped the resident in the mouth, held his/her over the resident's mouth and demanded he/she swallow. When staff H removed his/her hand the resident screamed you are killing me, you hurt me so bad. The facility indicated the incident occurred on 4/1/17. Review of the nurse's notes between 4/1/17 and 4/12/17 revealed no notes about the alleged incident of abuse which occurred on 4/1/17. Observation on 4/12/17 at 1:05 PM revealed the resident lay in bed while direct care staff A and direct care staff B provided incontinent care. The resident yelled, shouted, and slapped at the staff. Staff B talked reassuringly to the resident. Staff A attempted to explain to the resident that he/she needed to clean the resident's bottom. Observation on 4/13/17 at 2:31 PM revealed direct care staff C and direct care staff A propelled the resident in his/her wheelchair to his/her room. Staff C explained to the resident his/her shirt was wet. He/she agreed to let staff change the shirt but when staff A started to remove the shirt he/she became agitated and said, No, do not do that, staff stopped and tried explaining again. The resident then named direct care staff L could change the shirt and staff A left the room to locate staff L. Meanwhile staff B stayed with the resident and talked calmly and he/she allowed staff to change his/her shirt. Interview on 4/12/17 at 10:48 AM with direct care staff E (also trained to administer medications) revealed he/she heard from direct care staff C on 4/10/17 at about 4:00 PM of the alleged abuse which occurred on 4/1/17. He/she did not know where the nurse was at that time so he/she continued to pass medications and then left at the end of his/her shift without telling the nurse about the conversation. The next morning 4/11/17 at 6:15 AM he/she was still thinking about what he/she had heard and talked with direct care staff J about it. Direct care staff J went to the nurse about it. Interview on 4/12/17 at 11:06 AM with direct care staff H (trained to administer medications and an alleged perpetrator) reported he/she worked on all 3 units and passed medications on all units. Interview on 4/12/17 at 12:33 PM with direct care staff G (trained to administer medications and an alleged perpetrator) revealed he/she said he/she usually worked the 100 and 300 hall but did assist on the 200 hall when needed. Interview on 4/12/17 at 2:40 PM with direct care staff D revealed he/she worked on Saturday 4/1/17. On 4/1/17 at about 7:30 PM he/she heard resident #1 yelling. Staff D walked towards the resident's room. The door was open and no privacy curtained pulled. He/she observed direct care staff G on the left side of the resident with his/her left arm over the top of the resident's chest as his/her right hand held the resident's nose closed (nostrils pinched together). Once the resident opened his/her mouth to breathe direct care staff H (trained to administer medication) shoved a spoonful of crushed medication mixed with applesauce or pudding into the resident's mouth. The resident tried to spit the medication back out and staff H popped the resident in the mouth, held his/her hand over the resident's mouth and said rudely, Swallow it. When staff H removed his/her hand the resident screamed, You are killing me! You hurt me so bad. Staff D said he/she could hear staff H's hand smack the resident's lips. Staff D reported there was no visible blood on the resident's mouth or signs of injury from the encounter and the resident would not allow staff D to see inside his/her mouth or provide oral care. Staff D said he/she did not report the incident to any other staff members that evening out of fear of retaliation from staff G and Staff H. Staff D said he/she finally talked about the incident on 4/10/17 when he/she talked with direct care staff C about staff H being rough and verbally abusive to residents on the previous evening of 4/9/17 (a separate incident than previously mentioned). During the conversation staff D told staff C of the incident which occurred on 4/1/17. Staff D did not know when or how administrative nurse K learned of the incident but he/she assumed direct care staff E overheard and told administrative nurse K. Interview on 4/12/17 at 10:00 AM with administrative nurse K revealed he/she received a report of staff-to-resident abuse from direct care staff J on 4/11/17 at approximately 10:00 AM. Nurse K interviewed direct care staff E and then notified the administrator of the allegation. He/she notified human resources of the need to suspend the 2 alleged perpetrators (direct care staff G and direct care staff H) pending the outcome of the investigation. He/she had an expectation for staff to report all allegation of abuse immediately to their supervisor, the director of nursing or administrator. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility would prevent further potential abuse while investigation was in progress. The facility should protect the resident from harm during the investigation by reassignment or suspension. The facility's undated policy titled Reporting Abuse to Facility Management directed any individual observing an incident of resident abuse or suspecting resident abuse to immediately report such incident to the Administrator, Director of Nursing Services or Charge Nurse. Upon receiving a report of physical or sexual abuse, a licensed nurse or physician would immediately examine the resident. The facility failed to protect all residents from abuse and ensure staff reported witnessed abuse immediately following an incident of witnessed staff-to-resident abuse on 4/1/17. The 2 alleged perpetrators continued to provide care for all residents in the facility between 4/1/17 and 4/11/17. This failure placed all residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who has the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated direct care staff G and direct care staff H on 4/13/17. This deficient practice remained at the scope and severity of an F. - Review of resident #4's admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 4 indicating severe cognitive impairment. He/she wandered on 4-6 days of the observation period and required extensive assistance from 1 staff for activities of daily living except eating which only required limited assistance. The cognition care area assessment (CAA) dated 1/22/17 identified the resident as alert to his/her surroundings and person. His/her answers may not be consistent and he/she was confused at times. He/she had moderately impaired daily decision making skills. The activities of daily living (ADL) CAA did not trigger for a further assessment. The care plan dated 1/22/17 directed staff to provide extensive to dependent assistance for all ADLs. Review of the nurse's notes between 4/1/17 and 4/18/17 revealed on 4/9/17 at 10:15 PM the resident argued with another resident in the commons area. Staff took resident #4 to the south hall dining/snack room. The resident began screaming (shrieking scream) and stated, That person (interview with nurse F as below identified the person as direct care staff H) pulled my hair! and Why don't you just kill me or let me go so I can kill myself? Staff assisted the resident to bed and placed the resident on 15 minute checks for suicidal ideation. The note lacked any evidence of a nurse assessment for injury following the report. The note indicated that at 10:15 PM staff administered [MEDICATION NAME] (a pain reliever) for pain and restlessness. Subsequent notes through 4/18/17 lacked any further documentation regarding the incident. Interview with licensed nurse F on 4/13/17 at 4:15 PM revealed on 4/9/17 at about 9:30-10:00 PM he/she walked from 200 hall and heard resident #4 shrieking and as he/she came around to 300 hall he/she saw direct care staff H coming from the south dining room. Nurse F continued to the dining room where the resident sat in his/her wheelchair. The resident said, Get me out of here. Take me home. He/she (nurse F reported as staff H) pulled my hair. Nurse F said he/she checked the resident's scalp and found no redness or loose hair. Nurse F said he/she did not call the director of nursing or administrator about the incident because of the resident's cognition level and no evidence of an injury. He/she did leave a note for the director of nursing to call him/her on (4/10/17). Interview on 4/13/17 at 3:18 PM with administrative nurse K revealed he/she had no knowledge of the incident and confirmed the nurse's notes reflected an allegation of abuse. He/she had not received any reports of abuse or mistreatment. He/she had a note from licensed nurse F to talk with licensed nurse F about direct care staff H but nurse H was on vacation at the time. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility would prevent further potential abuse while investigation was in progress. The facility should protect the resident from harm during the investigation by reassignment or suspension. The facility's undated policy titled Reporting Abuse to Facility Management directed any individual observing an incident of resident abuse or suspecting resident abuse to immediately report such incident to the Administrator, Director of Nursing Services or Charge Nurse. Upon receiving a report of physical or sexual abuse, a licensed nurse or physician would immediately examine the resident. The facility failed to protect all residents from abuse and mental anguish and failed to ensure staff immediately reported an allegation of staff-to-resident mistreatment/abuse on 4/9/17. This failure allowed the alleged perpetrator to continue to provide care for all residents in the facility between 4/1/17 and 4/11/17, at which time the alleged perpetrators were suspended. This failure placed all residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who has the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated direct care staff H on 4/13/17. This deficient practice remained at the scope and severity of an F. - The admission minimum data set (MDS) for resident #5 dated 12/12/16 included a brief interview for mental status (BIMS) score of 3 indicating severely impaired cognition. He/she displayed no behaviors. He/she required extensive assistance of 2 staff for all activities of daily living (ADLs) except eating which required limited assistance. The cognition care area assessment (CAA) dated 12/19/16 identified the resident with severely impaired cognitive function. He/she had poor short term memory and poor recall which caused confusion. The ADL CAA did not trigger for a further assessment. The quarterly MDS dated [DATE] revealed no change in cognition with physical and verbal behaviors towards others on 1-3 days of the 7 day observation period. He/she also wandered on 1-3 days of the observation period. He/she required limited assistance of 1 staff for transfers, walking, toilet use and personal hygiene. He required limited assistance of 2 staff with dressing. Review of the nurse's notes between 4/1/17 and 4/18/17 revealed a weekly summary note dated 4/3/17 at 7:05 AM: Resident was alert and orient to self and family with periods of confusion toward situations and need for help with ambulation and transfers. He/she had behaviors over the past week of abusive language, biting, grabbing, kicking, pinching/scratching, pushing, yelling and wandering 1 time. On 4/5/17 at 12:24 PM an unidentified direct care staff reported to the nurse he/she provided care for the resident and the resident grabbed the staff's finger and attempted to force the finger backwards. The resident scowled at all staff and repeatedly declined care and pushed staff away. Subsequent notes reflected no further behaviors until 4/9/17 at approximately 8:00 PM staff assisted the resident to the bathroom. During care the resident bit direct care staff H which required staff H to seek first aid for the bite which broke the surface of his/her skin and left a purple bite mark approximate size of 2.5-3 centimeters. Staff tried to provide incontinent care. The note lacked any information about the manner in which staff provided the care. During an interview below direct care staff C alleged direct care staff H verbally and physically abused a resident during routine cares on 4/9/17. Direct care staff C said the resident bit the staff H because of the treatment. Review of the nurses' notes revealed no information regarding an episode of verbal or physical abuse on 4/9/17. Interview on 4/12/17 at 3:07 PM with direct care staff C revealed he/she worked on Sunday 4/9/17 with direct care staff H. Staff C said during resident cares staff H used a loud, short and curt voice when caring for resident #5. Staff H held the resident standing while staff C provided incontinent care. Resident #5 then bit staff H on the left forearm. Staff C said when the care was completed staff H then sort of pushed/shoved the resident into his/her wheelchair. Staff C demonstrated how staff H holding the resident by his/her clothing pushed/shoved and let go so the resident landed roughly in the chair. Staff C said he/she felt staff H abused the resident at the time and reported to the nurse. Interview with licensed nurse F on 4/13/17 at 4:15 PM revealed he/she had 2 direct care staff (staff C and staff M) report on 4/9/17 evening shift that direct care staff H talked abrasively, rude and with a bad attitude towards residents and coworkers. He/she allegedly threw items in a resident's room. When nurse F went to staff H to find out what went on he/she saw staff H in the commons areas pitching magazines into a bin but did not talk with him/her about the allegation. He/she reported he/she left a note for the administrative nurse K about staff H's behavior. Interview on 4/13/17 at 3:18 PM with administrative nurse K revealed he/she received a text message from direct care staff C late on Sunday 4/9/17 about the need to talk regarding staff H. He/she did not interpret the text as an allegation of abuse. He/she did receive a note from nurse F upon arrival to work on 4/10/17. Nurse F was on vacation and could not be reached at that time. At the time of this conversation nurse K did not know the allegation included verbal abuse and physical shove into the wheelchair and he/she planned to investigate the incident. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility would prevent further potential abuse while investigation was in progress. The facility should protect the resident from harm during the investigation by reassignment or suspension. The facility's undated policy titled Reporting Abuse to Facility Management directed any individual observing an incident of resident abuse or suspecting resident abuse to immediately report such incident to the Administrator, Director of Nursing Services or Charge Nurse. Upon receiving a report of physical or sexual abuse, a licensed nurse or physician would immediately examine the resident. The facility failed to protect residents after an incident involving verbal and physical abuse towards resident #5 on 4/9/17. This failure placed all residents in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who had the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated direct care staff H on 4/13/17. This deficient practice remained at the scope and severity of an F. - The annual minimum data set (MDS) for resident #6 dated 9/12/16 included a brief interview for mental status (BIMS) score of 12 indicating moderate cognitive impairment. He/she displayed physical and verbal behaviors towards others and rejected cares on 1-3 days of the 7 day observation period. He/she required extensive assistance of 2 staff for all activities of daily living (ADLs) except eating which required supervision. The cognition care area assessment (CAA) dated 9/16/16 revealed moderately impaired cognitive status. His/her long-term memory was more accurate than his/her short-term memory. He/she might have episodes of [MEDICAL CONDITION] such as: fluctuating inattention & disorganized thinking with unpredictable switching from subject-to-subject. He/she was easily redirected back on topic and may have difficulty focusing on what is being said. The activities of daily living (ADL) CAA indicated he/she depended on staff assistance for ADLs. He/she required extensive assistance with bed mobility, transfers, and locomotion on the unit, dressing, toilet use, and personal hygiene. The quarterly MDS dated [DATE] included a BIMS score of 15 indicating cognition intact. He she had no behaviors and required the same ADL assistance as the annual MDS dated [DATE]. During an interview below direct care staff C alleged direct care staff H verbally and physically abused resident #6 during routine cares on 4/9/17. Review of the nurse's notes between 4/1/17 and 4/18/17 revealed on entry on 4/5/17 at 8:40 AM which indicated the resident propelled independently via a wheelchair at times but staff usually propelled him/her. He/she was alert, but often confused. He/she had no behavior symptoms over the past week. The notes go from 4/7/17 about sliding scale insulin to 4/10/17 about pain medication administered as needed. There were no notes about any incidents on 4/9/17. Interview on 4/12/17 at 3:07 PM with direct care staff C revealed he/she worked on Sunday 4/9/17 with direct care staff H. Late in the evening of 4/9/17 when staff C asked staff H to help with resident #6's care staff H entered the resident's room, took the last 2 pair of gloves and threw the glove box on the floor, kicked the pads which were on the floor and had a scary attitude. While changing the resident's garments staff H pushed hard on the resident's hip and he/she called out, Do not do that. It hurts me. Staff H said to the resident in a rude, loud manner I have to clean you up. Staff C said he/she felt staff H abused the resident at the time and reported to the nurse. Interview with licensed nurse F on 4/13/17 at 4:15 PM revealed he/she had 2 direct care staff (staff C and staff M) report on 4/9/17 evening shift that direct care staff H talked abrasively, rude and with a bad attitude towards residents and coworkers. He/she allegedly threw items in a resident's room. When nurse F went to staff H to find out what was going on he/she saw staff H in the commons areas pitching magazines into a bin. He/she reported he/she left a note for the administrative nurse K about staff H's behavior. Staff F said he/she was on vacation with poor cell phone reception and had not spoken to administrative nurse K yet. Interview on 4/13/17 at 3:18 PM with administrative nurse K revealed he/she received a text message from direct care staff C late on Sunday 4/9/17 about the need to talk regarding staff H. He/she did not interpret the text as an allegation of abuse. He/she did receive a note from nurse F upon arrival to work on 4/10/17. Nurse F was on vacation and could not be reached at that time. At the time of this conversation nurse K did not know the allegation included verbal abuse and physical shove of the right hip to the point it caused the resident pain and he/she planned to investigate. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility prevents further potential abuse while investigation is in progress. The facility should protect the resident from harm during the investigation by reassignment or suspension. The facility's undated policy titled Reporting Abuse to Facility Management directed any individual observing an incident of resident abuse or suspecting resident abuse to immediately report such incident to the Administrator, Director of Nursing Services or Charge Nurse. Upon receiving a report of physical or sexual abuse, a licensed nurse or physician would immediately examine the resident. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who has the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated direct care staff H on 4/13/17. This deficient practice remained at the scope and severity of an F. - The quarterly minimum data set ((MDS) dated [DATE] for resident #2 included a brief interview for mental status (BIMS) score of 5 indicating severe impairment. He/she displayed behaviors of wandering and rejected care 1-3 days of the 7 day observation period. He/she required extensive assistance of 2 staff for activities of daily living (ADLs). The annual minimum data set ((MDS) dated [DATE] revealed the same cognition and ADL ability as the 10/31/16 MDS. He/she displayed behaviors of verbalization towards others on 1-3 days of the 7 day observation period, rejected care and wandered on 4-6 days of the observation period. The cognition care area assessment (CAA) dated 2/9/17 identified the resident with severe cognitive impairment, fluctuating inattention and disorganized thinking. He/she was alert to his/her surroundings but had impaired memory recall. The ADL CAA dated 2/9/17 indicated he/she had impaired balance with functional limitations that interfered with his/her ADL abilities. He/she could propel independently in a regular wheelchair but required staff assistance to get to a specific destination. The behavioral CAA dated 2/9/17 identified the resident rejected medication or care and yelled at times. His/her actions did not put the resident or the staff at risk and his/her actions did not intrude on the privacy of others or disrupt the living environment. During the day he/she could propel independently in a wheelchair wandering and might pick up another resident's items or looking for spouse. The functional rehabilitation potential care plan with onset date of 5/1/16 directed staff to provide extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use. He/she needed 1 person assist for locomotion on /off the unit and personal hygiene. The behavior and well-being care plan with an onset date of 5/3/16 included directions to staff to monitor for signs/symptoms of depression such as: hopelessness, anxiety, sadness, [MEDICAL CONDITION], negative statements or tearfulness, hallucinations or delusion. He/she might demonstrate the following towards others: hit, kick, push, grab, spit and yell or curse (not recently). If he/she became anxious or angry or aggressive or easily annoyed make sure he/she was safe, leave him/her alone, and then staff or another staff member could re-approach as needed. Slowly approach the resident from the front. Review of a nurse's note dated 1/3/17 at 6:43 PM revealed before dinner the nurse heard loud voices coming from the dining room. Upon entering the dining room the nurse found resident #2 holding four sets of rolled silverware and hitting a resident (#7) with one of the sets of silverware. This nurse immediately moved resident #2 away from resident #7 removed the silverware he/she held and took the resident down 300 hall (an area of less stimulation). The resident got angry about this, yelling at the nurse this was his/her house and they needed to leave. The nurse spoke with staff on 300 hall to advise them of the situation and ask them to keep the resident on the 300 hall for dinner. The facility identified a resident-to-resident altercation on 1/3/17 and provided a single page incident summary as the investigation. There were no witness statements from staff or other residents. The findings of the investigation essentially repeated the nurse's note. The conclusion portion did not identify what caused this event but included the resident was hard of hearing and did not hear resident #6 tell him/her to stop hitting. Actions included removal of the resident from the main dining room to 300 hall dining room to eat lunch. On 4/13/17 at 12:02 PM observation revealed the resident sat at the table in main dining room. He/she was pleasant when talking with the staff who were present (direct care staff M and direct care staff N). There were other residents at the table but resident #2 did not interact with them. Interview on 4/18/17 at 1:51 PM with direct care staff O revealed the resident slept late, will usually ate in the main dining room and he/she had not displayed behaviors recently. Interview on 4/18/17 at 2:26 PM direct care staff P revealed when the resident needed to use the bathroom or go to bed he/she might use any toilet or bed he/she saw instead of his/her own. Staff P reported the resident could resist cares in the morning and he/she would take a swing at staff or raise his/her voice. Staff P did not work at the facility at the time of the January incident but stated the resident would get agitated in the dining room at times and he/she brought the resident back to the 300 hall where it was quieter. Interview 4/18/17 at 1:13 PM administrative nurse Q revealed he/she did not report the incident to the State agency because he/she understood the resident hit the table, the other resident's plate and he/she did not know resident #2 hit resident #6. He/she reviewed the nurse's notes at this time and confirmed it reflected the resident hit resident #6. Regarding the investigation portion of the incident report he/she confirmed the investigation lacked evidence of a thorough investigation and merely repeated the information from the nurse's note. The facility's policy titled Respect and Dignity dated 2016 directed employees residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The policy included a component of investgation which read: investigation: determining occurrence, injury, responsibility (Incident report and Risk Management). The component did not include the procedure for the investigation.

The facility reported a census of 42 residents with 6 sampled for abuse. Based on observation, interview and record review the facility failed to provide an environment free from abuse when direct care staff G and direct care staff H abused resident #1 on 4/1/17 by restraining, pinching nose closed until the resident open his/her mouth and shoved a spoon full of meds into his/her mouth. Direct care staff H abused 3 of 6 additional residents on 3 separate incidents (#4, #5 and #6) in regards to hair pulling, loud, angry and curt voice and pushing hard against resident #6's hip to the point of pain. This failure placed these residents in immediate jeopardy. Findings included: - Review of resident #1's annual minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9, indicating moderate cognitive impairment. The resident required extensive assistance of 2 staff for activities of daily living (ADLs) and rejected care on 1-3 days of the 7 day observation period. The quarterly MDS dated [DATE] indicated the resident had moderately impaired cognition with a BIMS score of 8. He/she displayed physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing or abusing others sexually) on 1-3 days of the 7 day observation period. He/she displayed verbal behavioral symptoms toward others (threatening, screaming or cursing at others) on 4-6 days and rejected care on 1-3 days of the 7 day observation period. He/she required extensive assistance with all ADLs. Review of the care area assessments (CAA) dated 4/21/16 revealed: The cognition CAA directed staff the resident needed cues for recall to decrease potential confusion. The resident knew the location of his/her room, that he/she lived in a nursing home and the names of staff. The ADL CAA indicated the resident required assistance with all ADLs. He/she had trouble with balance and could only stabilize with assistance from staff. He/she might agree to use a front wheeled walker during transfers and his/her primary mode of locomotion was the wheelchair which he/she propelled independently. The behavioral CAA indicated the resident's daily mood fluctuated. When he/she was in a bad mood he/she was less likely to bear weight, walk and required more staff assistance or the sit-to-stand mechanical lift with transfers. He/she might decline to allow staff to assist him/her with brushing his/her teeth or other cares. When upset he/she may curse, become demanding or rude to the staff. However, during the observation period the resident did not have any behaviors. The care plan dated 1/26/17 indicated the resident required extensive assistance of 2 staff for bed mobility, transfers, walking in the corridor, dressing and toilet use. Review of the facility's investigation signed 4/18/17 revealed on 4/11/17 at 10:00 AM administrative Nurse K received notification of an allegation of staff to resident abuse which occurred on 4/1/17 (nurse K stated he/she determined the date after he/she reviewed the schedule). The investigation reflected an allegation of abuse by direct care staff G and direct care staff H. One held the resident's hands and pinched the resident's nose. When the resident opened his/her mouth the other direct care staff (also trained to administer medications) shoved a spoon full of medications into the resident's mouth. The resident tried to spit the medications out and direct care staff H popped the resident in the mouth and held his/her mouth closed until he/she swallowed the pills. When the staff removed his/her hand the resident screamed, You are killing me, and you hurt me so bad. The investigation conclusion revealed the facility staff determined there was a credible witness statement to support the termination of direct care staff G and direct care staff H both involved in the incident of staff to resident abuse regarding holding, pinching the nose, forcing medication into the mouth and popping the resident in the mouth and forcing the resident to swallow the medication. Review of the nurses' notes between 4/1/17 and 4/12/17 revealed no notes about the alleged incident of abuse which occurred on 4/1/17 and no head-to-toe assessment of the resident after staff reported the incident to administration on 4/11/17. The notes reflected the resident had confusion and behaviors for example: on 4/1/17 at 3:49 PM the resident repeatedly came to the nurse's station, demanding that this nurse take him/her to the place I belong and would direct this nurse to take him/her to the dining room. Once the resident was there he/she would then find someone else to bring him/her back to the nurse's station and this repeated. Observation on 4/12/17 at 1:05 PM revealed the resident lay in bed while direct care staff A and direct care staff B provided incontinent care. The resident yelled, shouted, and slapped at the staff. Staff B talked reassuringly to the resident. Staff A attempted to explain to the resident that he/she needed to clean the resident's bottom. Observation on 4/13/17 at 2:31 PM revealed direct care staff C and direct care staff A propelled the resident in his/her wheelchair to his/her room. Staff C explained to the resident his/her shirt was wet. He/she agreed to let staff change the shirt but when staff A started to remove the shirt he/she became agitated and said, No, do not do that, staff stopped and tried explaining again. The resident then named direct care staff L could change the shirt and staff A left the room to locate staff L. Meanwhile staff B stayed with the resident and talked calmly and he/she allowed staff B to change his/her shirt. An attempt to interview the resident on 4/12/17 at 1:15 PM revealed he/she could not give specific details of date and time or reliable history of events. Interview on 4/12/17 at 11:06 AM with direct care staff H (trained to administer medications and an alleged perpetrator) revealed he/she did not know of any incidents which would be considered abuse. He/she worked on all 3 of the units and passed medications on all units. He/she could name specific residents who had a history of [REDACTED].#1. He/she said he/she had no knowledge of medications being forced upon the resident. When asked if he/she had popped the resident in the mouth while giving medications he/she denied the allegation of popping the resident in the mouth while attempting to get him/her to take medications. Interview on 4/12/17 at 12:33 PM with direct care staff G (trained to administer medications and an alleged perpetrator) revealed he/she did not recall any instances of dealing with resistive residents recently. He/she had not seen anybody forcing medication to a resident or held the nose for the resident to swallow. He/she said if a coworker asked him/her to do that he/she would tell them that's not right and let the charge nurse know. He/she said he/she usually worked the 100 and 300 hall but did assist on the 200 hall when needed. Interview on 4/12/17 at 2:40 PM with direct care staff D revealed he/she worked on Saturday 4/1/17. On 4/1/17 at about 7:30 PM he/she heard the resident yelling. Staff D walked towards the resident's room. The door was open and no privacy curtained pulled. He/she observed direct care staff G on the left side of the resident with his/her left arm over the top of the resident's chest as his/her right hand held the resident's nose closed (nostrils pinched together). Once the resident opened his/her mouth to breathe direct care staff H (trained to administer medication) shoved a spoonful of crushed medication mixed with applesauce or pudding into the resident's mouth. The resident tried to spit the medication back out and staff H popped the resident in the mouth, held his/her hand over the resident's mouth and said rudely, Swallow it. When staff H removed his/her hand the resident screamed, You are killing me! You hurt me so bad. Staff D said he/she could hear staff H's hand smack the resident's lips. Staff D reported there was no visible blood on the resident's mouth or signs of injury from the encounter and the resident would not allow staff D to see inside his/her mouth or provide oral care. Staff D said he/she did not report the incident to any other staff members that evening out of fear of retaliation from staff G and staff H. Interview on 4/12/17 at 10:00 AM with administrative nurse K revealed he/she received a report of staff-to-resident abuse from direct care staff J on 4/11/17 at approximately 10:00 AM. Nurse K interviewed direct care staff E and then notified the administrator of the allegation. He/she notified human resources of the need to suspend the 2 alleged perpetrators (direct care staff G and direct care staff H) pending the outcome of the investigation. On 4/13/17 at 3:18 PM nurse K reported he/she believed the abuse occurred. The facility's policy titled Respect and Dignity dated 2016 directed employees residents have the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility failed to provide an environment free from abuse when staff G and staff H abused resident #1 on 4/1/17. This failure placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents' rights, signs of abuse, reporting and ways to report, who has the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated staff G and staff H on 4/13/17. This deficiency remained at the scope and severity of an H - Review of resident #4's admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. He/she wandered on 4-6 days of the observation period and required extensive assistance from 1 staff for activities of daily living (ADLs) except eating which only required limited assistance. The cognition care area assessment (CAA) dated 1/22/17 identified the resident as alert to his/her surroundings and person. His/her answers might not be consistent and he/she was confused at times. He/she had moderately impaired daily decision making skills. The ADL CAA did not trigger for a further assessment. The care plan dated 1/22/17 directed staff to provide extensive to dependent assistance for all ADLs. The cognition care plan directed staff the resident's hearing was adequate without the use of hearing aids and he/she can hear during normal conversation. His/her speech was clear and easy to understand. He/she is limited to making concrete request and responds to simple direct communication. The behavior care plan directed staff if the resident became anxious, angry, aggressive or easily annoyed make sure he/she was safe, leave him/her alone and then re-approach as needed or use another staff member. Staff should slowly approach the resident from the front, using soothing conversation and the presence of a second staff member would make him/her more comfortable. On 4/5/17 at 8:44 AM the resident was mobile via a wheelchair, which he/she could propel independently. He/she needed staff to propel the wheelchair when he/she went to a specific destination. He/she was alert and frequently confused. He/she had 4 episodes of wandering, 1 of pinching/scratching, 1 of yelling/screaming, and 1 of grabbing over the past week. On 4/9/17 at 10:15 PM the resident argued with another resident in the commons area. Staff took the resident to the south hall dining/snack room. The resident began screaming (shrieking scream) and stated, That person (during interview with nurse F he/she identified the direct care staff H was who the resident last had contact with) pulled my hair! and Why don't you just kill me or let me go so I can kill myself? Staff assisted the resident to bed and placed the resident on 15 minute checks for suicidal ideation. The note lacked any evidence of a nurse assessment for injury following the report. The note indicated that at 10:15 PM staff administered [MEDICATION NAME] (a pain reliever) for pain and restlessness. Subsequent notes through 4/18/17 lacked any further documentation regarding the incident. Interview with licensed nurse F on 4/13/17 at 4:15 PM revealed on 4/9/17 at about 9:30-10:00 PM he/she walked from 200 hall and heard resident #4 shrieking and as he/she came around to 300 hall he/she saw direct care staff H coming from the south dining room. Nurse F continued to the dining room where the resident sat in his/her wheelchair. The resident said, Get me out of here. Take me home. He/she (nurse F reported as direct care staff H) pulled my hair. Nurse F said he/she checked the resident's scalp and found no redness or loose hair. Interview on 4/13/17 at 3:18 PM with administrative nurse K revealed he/she had no knowledge of the incident and confirmed the nurses' notes reflected an abusive occurrence may have happened. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility failed to provide the resident with an environment free from abuse when staff H abused resident #4 on 4/9/17. This failure placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who had the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility also terminated staff H on 4/13/17. This deficiency remains at the scope and severity of an H. - The admission minimum data set (MDS) for resident #5 dated 12/12/16 included a brief interview for mental status (BIMS) score of 3 indicating severely impaired cognition. He/she displayed no behaviors. He/she required extensive assistance of 2 staff for all activities of daily living (ADLs) except eating which required limited assistance. The cognition care area assessment (CAA) dated 12/19/16 identified the resident with severely impaired cognitive function. He/she had poor short term memory and poor recall which caused confusion. The ADL CAA did not trigger for a further assessment. The quarterly MDS dated [DATE] revealed no change in cognition with physical and verbal behaviors towards others on 1-3 days of the 7 day observation period. He/she also wandered on 1-3 days of the observation period. He/she required limited assistance of 1 staff for transfers, walking, toilet use and personal hygiene. He required limited assistance of 2 staff with dressing. Review of the nurse's notes between 4/1/17 and 4/18/17 revealed a weekly summary note dated 4/3/17 at 7:05 AM: Resident was alert and orient to self and family with periods of confusion toward situations and need for help with ambulation and transfers. He/she had behaviors over the past week of abusive language, biting, grabbing, kicking, pinching/scratching, pushing, yelling and wandering 1 time. On 4/5/17 at 12:24 PM an unidentified direct care staff reported to the nurse he/she provided care for the resident and the resident grabbed the staff's finger and attempted to force the finger backwards. The resident scowled at all staff and repeatedly declined care and pushed staff away. Subsequent notes reflected no further behaviors until 4/9/17 at approximately 8:00 PM staff assisted the resident to the bathroom. During care the resident bit direct care staff H which required staff H to seek first aid for the bite which broke the surface of his/her skin and left a purple bite mark approximate size of 2.5-3 centimeters. Staff tried to provide incontinent care. The note lacked any information about the manner in which staff provided the care. During an interview below direct care staff C alleged direct care staff H verbally and physically abused a resident during routine cares on 4/9/17. Direct care staff C said the resident bit the staff H because of the treatment. Review of the nurses' notes revealed no information regarding an episode of verbal or physical abuse on 4/9/17. The facility reported administrative nurse K received notification of the incident on 4/10/17 and were in the process of investigation. Interview on 4/12/17 at 3:07 PM with direct care staff C revealed he/she worked on Sunday 4/9/17 with direct care staff H. Staff C said during resident cares staff H used a loud, short and curt voice when caring for resident #5. Staff H held the resident standing while staff C provided incontinent care. Resident #5 then bit staff H on the left forearm. Staff C reported when the care was complete staff H then pushed/shoved the resident into his/her wheelchair. Staff C demonstrated how staff H holding the resident by his/her clothing pushed/shoved and let go so resident the landed roughly in the chair. Staff C said he/she felt staff H abused the resident at the time and reported to the nurse. Interview with licensed nurse F on 4/13/17 at 4:15 PM revealed he/she had 2 direct care staff (staff C and staff M) report on 4/9/17 evening shift that direct care staff H talked abrasively, rude and with a bad attitude towards residents and coworkers. He/she allegedly threw items in a resident's room. When nurse F went to staff H to find out what went on he/she saw staff H in the commons areas pitching magazines into a bin but did not talk with him/her about the allegation. Nurse F reported he/she left a note for the administrative nurse K. Interview on 4/13/17 at 3:18 PM with administrative nurse K revealed he/she received a text message from direct care staff C late on 4/9/17 about the need to talk regarding staff H. He/she did not interpret the text as an allegation of abuse. He/she did receive a note from nurse F upon arrival to work on 4/10/17. Nurse F was on vacation and could not be reached at that time. At the time of this conversation nurse K did not know the allegation included verbal abuse and a physical shove into the wheelchair and he/she planned to investigate. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility failed to provide an environment free from abuse when staff H abused resident #5 on 4/9/17. This failure placed this resident in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who has the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated staff H on 4/13/17. This deficiency remains at the scope and severity of an H. - The annual minimum data set (MDS) for resident #6 dated 9/12/16 included a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. He/she displayed physical and verbal behaviors towards others and rejected cares on 1-3 days of the 7 day observation period. He/she required extensive assistance of 2 staff for all activities of daily living (ADLs) except eating which required supervision. The cognition care area assessment (CAA) dated 9/16/16 revealed moderately impaired cognitive status. His/her long-term memory was more accurate than his/her short-term memory. He/she might have episodes of [MEDICAL CONDITION] such as: fluctuating inattention & disorganized thinking with unpredictable switching from subject-to-subject. He/she was easily redirected back on topic and may have difficulty focusing on what is being said. The ADL CAA indicated he/she depended on staff assistance for ADLs. He/she required extensive assistance with bed mobility, transfers, and locomotion on the unit, dressing, toilet use, and personal Hygiene. The quarterly MDS dated [DATE] included a BIMS score of 15, indicating cognition intact. He she had no behaviors and required the same ADL assistance as the annual MDS dated [DATE]. During an interview below direct care staff C alleged direct care staff H verbally and physically abused resident #6 during routine cares on 4/9/17. Review of the nurse's notes between 4/1/17 and 4/18/17 revealed on entry on 4/5/17 at 8:40 AM which indicated the resident propelled independently via a wheelchair at times but staff usually propelled him/her. He/she was alert, but often confused. He/she had no behavior symptoms over the past week. The notes go from 4/7/17 about sliding scale insulin to 4/10/17 about pain medication administered as needed. There were no notes about any incidents on 4/9/17. The facility reported administrative nurse K received notification of the incident on 4/10/17 and were in the process of investigation. Interview on 4/12/17 at 3:07 PM with direct care staff C revealed he/she worked on Sunday 4/9/17 with direct care staff H. Late in the evening of 4/9/17 when staff C asked staff H to help with resident #6's care staff H entered the resident's room, took the last 2 pair of gloves and threw the glove box on the floor, kicked the pads which were on the floor and had a scary attitude. While changing the resident's garments staff H pushed hard on the resident's hip and he/she called out, Do not do that. It hurts me. Staff H said to the resident in a rude, loud manner, I have to clean you up. Staff C said he/she felt staff H abused the resident at the time and reported to the nurse. Interview with licensed nurse F on 4/13/17 at 4:15 PM revealed he/she had 2 direct care staff (staff C and staff M) report on 4/9/17 evening shift that direct care staff H talked abrasively, rude and with a bad attitude towards residents and coworkers. He/she allegedly threw items in a resident's room. When nurse F went to staff H to find out what was going on he/she saw staff H in the commons areas pitching magazines into a bin but did not talk with him/her about the allegation. He/she reported he/she left a note for the administrative nurse K. Interview on 4/13/17 at 3:18 PM with administrative nurse K revealed he/she received a text message from direct care staff C late on Sunday 4/9/17 about the need to talk regarding staff H. He/she did not interpret the text as an allegation of abuse. He/she did receive a note from licensed nurse F upon arrival to work on 4/10/17. Nurse F was on vacation and could not be reached at that time. At the time of this conversation nurse K did not know the allegation included verbal abuse and a physical shove of the right hip to the point it caused the resident pain. The surveyor notified nurse K of this allegation and nurse K said he/she would complete an investigation. The facility's policy titled Respect and Dignity dated 2016 directed employees that residents had the right to be free from verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The facility failed to provide an environment free from abuse when staff H abused resident #6 on 4/9/17. This failure placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 4/17/17 at 2:15 PM by implementation of the following measures: the facility provided education of all staff members on the topic of Abuse, Neglect and Exploitation (ANE) which included definitions, residents rights, signs of abuse, reporting and ways to report, who has the responsibility to report (anyone). The facility planned to train staff of these policies and procedures upon new hire orientation, monthly in-service will include a portion on ANE policy and procedures and with the online education classes on ANE. The facility terminated staff H on 4/13/17. This deficiency remains at the scope and severity of an H.

The facility had a census of 43 residents with 14 sampled for review and 3 reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure 1 or 3 residents sampled for accidents/falls received adequate supervision (failure to implement appropriate fall prevention strategies and determine causal factors for the resident ' s falls) in order to prevent accidents. Resident #29 sustained a fall on 6/18/14 that resulted in a fractured hip. (#29) The facility also failed to ensure hazardous chemicals remained inaccessible to 15 cognitively impaired independently mobile residents. Findings included: - Resident # 29 ' s physician order [REDACTED]. Resident #29 ' s Quarterly MDS (Minimum data set) dated 12/26/13 revealed a BIMS (Brief interview for Mental Status) score of 8 which indicated moderate cognitive impairment. The resident was independent with set up only for his/her transfers. The resident required supervision with one person assist for locomotion on the unit. The resident required extensive assist with one person for toilet use. The assessment also indicated the resident had no falls since the prior assessment. The resident received antianxiety medication over the 7 day look back period. The MDS revealed the resident had frequent urinary incontinence, but had at least one episode of continent voiding. Resident # 29 ' s Significant Change MDS dated [DATE] revealed a BIMS score of 7 that indicated severe cognitive impairment. The resident required extensive assist with two persons for transfers, toilet use, personal hygiene, and dressing. The MDS also stated the resident had a fracture, one fall with non-injury, and one fall with a major injury. The MDS revealed the resident had frequent urinary incontinence, but had at least one episode of continent voiding. Resident #29 ' s Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS (Brief interview for Mental Status) score of 7 which indicated severe cognitive impairment. The resident required extensive assistance with two persons for transfers, dressing, personal hygiene, dressing, eating, and toilet use. The assessment indicated the resident had a fall with a hip fracture and 2 or more non-injury falls. The resident received antianxiety medication over the 7 day look back period. The MDS revealed the resident had frequent urinary incontinence, but had at least one episode of continent voiding. The ADL (activities of daily living) CAA dated 3/27/14 revealed the resident had a fractured right hip and was unable to complete his/her ADLs. The resident was unable to bear weight without pain and had limited range of motion to his/her lower extremities with poor balance and coordination. Resident #29 ' s 3/27/14 fall CAA stated the resident fell when he/she went to the bathroom without his/her walker and fractured his/her right hip. The resident was unable to bear weight for any length of time and became unbalanced when he/she tried. The Resident ' s urinary incontinence CAA dated 3/27/14 revealed the resident was incontinent since his/her admission. The resident was now dependent on staff for transfers and toileting. The resident had improved from frequently incontinent to occasionally incontinent. The CAA stated that staff continued to toilet and care for the resident. The Morse Fall Scale (above 45 indicated a high risk for falls) dated 9/6/13 indicated while the resident was independent with ADLs and using a front wheel walker for ambulation revealed a score of 70 indicating. After the resident fell , the resident ' s score increased to 80 on 3/19/14. The resident had a score of 65 after the fall on 5/11/14 and a score of 55 on 6/5/14. Review of the resident ' s care plan dated 1/7/14, with a initiated date of 5/2/13 revealed the resident was a high risk for falls and interventions were to have the resident use a front wheeled walker for ambulation dated 1/7/14 as he/she was independent and he/she may forget to use the walker. The care plan also directed the staff to remind the resident of the importance of using the resident ' s walker. Resident #29 was on the " Falling Star " program dated 5/2/13 a program used by staff to identify residents at risk for falls. The care plan revealed the resident also had a high-low bed initiated on 5/2/13 and revised on 1/7/14. Resident #29 ' s bed was to be in the lowest position when in bed and had the bed alarm in place also initiated on 5/2/13 and revised on 1/7/14. The care plan revised on 4/9/14 revealed the resident had limited physical mobility related to arthritis and a fracture of the right hip on 3/18/14. The resident had a rocking recliner wheel chair for assist of mobility, along with a mat on the floor by the bed when the resident was lying down. The care plan lacked any revisions or reassessment to resident #29 ' s fall care plan after the falls dated 3/27/14, 3/31/14, 5/4/14, 5/11/14, 5/24/14 6/5/14 or 6/28/14. Review of the Fall Investigation dated 3/18/14 revealed the resident sat against the wall by the door. The resident was coming from the bathroom, slipped, fell and landed on his/her bottom. The resident ambulated with his/her walker. The intervention on the Fall Investigation was to continue frequent checks, to keep the resident ' s walker within reach, and to continue pain medication to keep the resident comfortable. The resident had a fracture to the right hip. The care plan lacked the evidence of revision with the recommendations listed on the fall investigation or reassessment and identification of causal factors. Review of the clinical record lacked evidence of an incontinence assessment or implementation of an individualized toileting plan for resident #29. Review of the Fall Investigation dated 3/27/14 revealed the resident was on the floor beside the common area table. Another resident witnessed the incident and stated resident #29 slid out of the wheel chair. The interventions on the Fall Investigation stated to check the resident frequently for 24 hours. The nursing care plan lacked evidence of a revision with the recommendations listed on the fall investigation. The Fall Investigation dated 3/31/14 revealed the resident was on the floor in front of the recliner in the lobby. The resident was sitting in the recliner and was trying to get up. The interventions on the Fall Investigation directed to increase the resident ' s exercise and for staff to interact with the resident more. The nursing care plan lacked evidence of a revision with the recommendations listed on the fall investigation dated 3/31/14. Review of the Fall Investigation dated 5/4/14 revealed the resident sat in the wheel chair after Church services and the resident was found on the floor and landed on his/her buttocks. The resident continued to be restless. The intervention listed on the Fall Investigation directed staff not leave the resident unattended in the dining room. The care plan lacked evidence of revision with the recommendations to keep the resident in full view of the staff while in the dining area. Review of the nursing care plan lacked evidence of implementation of the intervention to keep the resident in full view of the staff, an intervention previously suggested on 5/4/14 Review of the Fall Investigation dated 5/11/14 revealed the resident pulled him/herself out of the wheel chair and fell on the floor. The resident was at Church services in the dining area near the back of the room. The resident complained of pain to the right leg in which the pain was chronic since the fall on 3/18/14 with a fracture. The interventions on the Fall Investigation stated the resident should be positioned in full view of the staff. Review of the Fall Investigation dated 5/24/14 revealed the resident was found sitting on the floor in the common area. The resident had confusion and denied any pain to the right hip. The suggested fall interventions included not leaving the resident unattended and for staff to push the resident up to the table in the commons area. After review of the care plan, the facility failed to revise the care plan with fall prevention interventions previously suggested on 5/4/14 and 5/11/14 to not leave the resident unattended. Review of the Fall Investigation dated 6/5/14 revealed the resident was found on the floor lying on left side in front of the recliner in the sitting area. Resident # 29 was confused and was talking about a fire. The fall investigation suggested for staff to stay with the resident, especially if he/she was restless. Review of the care plan lacked evidence of implementation of this intervention that was previously suggested on 3 prior fall investigations. A Fall Committee meeting dated 6/11/14 revealed the resident tried to climb out of the recliner. The resident continued to be restless in his/her room. The meeting notes stated staff toileted the resident and positioned the resident in a recliner in a common area. The Fall Committee Interventions included keeping the resident in an activity when he/she was restless, offer to take the resident to the toilet when he/she wakes and was restless, and to offer fluids and/or to stand as he/she could tolerate. The facility failed to implement these interventions onto the care plan. Review of the Fall Investigation dated 6/28/14, revealed the resident was found on the floor in his/her room after the bed alarm sounded. The resident was wincing, had tenderness with skin tears to his/her left and right elbows. Recommended interventions directed staff to check the resident frequently and answer the bed alarms promptly. The facility continued to repeat the same interventions and failed to include the interventions on the care plan that were stated on the fall investigation. Review of the clinical record lacked evidence of an incontinence assessment or implementation of an individualized toileting plan for resident #29. A nursing note dated 6/28/14 revealed staff called the charge nurse to the resident ' s room, stating his/her bed alarm sounded and he/she was found on the floor when staff arrived. The resident was found lying on the floor with torso and head off the floor resting on his/her elbows. Resident reported he/she was in pain. The resident moved his/her arms and went to move left leg the resident winced and sucked in his/her breath and stated it hurt. The resident sustained [REDACTED]. The resident was alert and spoke clearly. The resident ' s pajama bottoms were down around the ankles as well as the brief being half was down to the knees. The note did not indicate if the resident was incontinent. A nursing note dated 6/30/14 revealed the resident was sent to the hospital for x-rays via an ambulance. Upon returning to the facility, the resident ' s [DIAGNOSES REDACTED]. Fall Committee meeting on 7/2/14 revealed the resident was found on the floor with his/her pajamas and brief down around his/her ankles. The suggested interventions from the fall committee included frequent visual checks on the resident and for the staff to respond promptly to the bed alarm. The report also indicated the facility moved the resident to a room closer to the nurses ' station. After each review of the fall investigations, the Fall Committee reports, and the nurses' notes, the facility failed to implement fall prevention strategies suggested and failed to review interventions for appropriateness in order to prevent future falls. An observation on 7/23/14 at 2:00 pm revealed the resident was lying in bed sleeping. The resident ' s breathing was shallow and unlabored. The resident had a fall mat in place; the bed was in the lowest position, and call light in reach. An observation on 7/24/14 at 9:08 am revealed the resident received a bed bath by hospice staff T. The resident was unresponsive to verbal stimuli during the bath; breathing was shallow, using accessory muscles to breath. The resident ' s bed was in the lowest position, fall mat was put back in front of the bed after the bath, and the call light was in reach. On 7/25/14 at 11:10 am with direct care staff H revealed the resident was on the falling star program and was a risk for falls. Staff reported the resident seemed to fall more in the evening time. Staff H revealed the resident required two plus pivot assist for all transfers before he/she fell this last time. Staff reported the resident used to ambulate on his/her own with a walker before the fall that broke his/her hip. An interview on 7/25/14 at 1:45 pm with direct care staff I revealed the resident used to walk with a walker prior to his/her falls. Staff reported the resident had confusion and required a bed alarm, bed in the lowest position, and staff added a blue fall mat after the fall with the broken hip. Staff reported when the resident was out in the common area he/she used a rocker wheel chair and a pull away alarm that attached to his/her clothing. On 7/25/14 at 11:52 am an interview with licensed nursing staff E revealed when the resident tried to climb out of bed, the nursing staff brought him/her out with the nurse for interaction or do one on one activity. Staff E reported the resident was to have the bed in the lowest position, alarm on, and fall mat in place. Nursing staff E reported the falls seemed to be more in the evening time. The resident would often become combative or restless. Staff would check on the resident every two hours and after meals. Staff E revealed the fall on 6/28/14 happened at night around 11:55 pm staff found the resident on the floor after the bed alarm went off with no other details about the fall on the fall report. Nursing Staff E reported he/she did not know if the bed was in the lowest position, if the call light was in reach, or if the fall mat was in place at the time of the fall. Licensed nursing staff E revealed the resident sustained [REDACTED]. An interview on 7/25/14 at 2:55 pm with administrative nurse B revealed interventions recommended on the Fall Investigations or recommendations from the Fall Committee should be revised on the nursing care plan at the time the incident happened. Administrative nurse B confirmed the interventions recommended on the investigations or by the fall committee were not added to the care plan for resident #29. Attempts to contact resident #29 ' s attending physician on 7/29/14 at 12:00 pm and 4:00 pm proved unsuccessful when no return call received from the physician after leaving a message. Review of the Fall Investigation Policy dated 7/31/12 revealed the resident ' s environment should be evaluated for conditions that may aggravate falling. With each fall the care plan should be updated and reviewed, including documentation of implemented interventions. The facility failed to evaluate each of resident #29 ' s falls for causative factors and develop an individualized plan of care including a toileting plan, with appropriate fall prevention strategies to prevent future falls. Resident #29 sustained repeated falls on dated 3/27/14, 3/31/14, 5/4/14, 5/11/14, 5/24/14, 6/5/14 or 6/28/14. On 6/28/14, resident #29 fell and fractured his/her left hip. - Observation on 7/22/14 at 8:30 a.m. revealed a bottle of glade and rubbing alcohol on the sink in the central supply room. There was also Dakin's solution, hydrogen peroxide, Alcare, and Alpicare on table in central supply room. There was a bottle glade white board cleaner in the closet, and sani cloth plus wipes and antiseptic hand gel on shelf above desk in the room. Interview on 7/22/14 at 10:11 a.m. with maintenance staff P revealed the room was locked at the end of the day but not during the day because the staff that used the office would come and go throughout the day. Observation on 7/22/14 at 10:15 a.m. revealed alcohol preps located in the special care unit kitchen drawer. Direct care staff N confirmed they were in an area accessible to residents and removed them. Observation on 7/22/14 at 10:17 a.m. revealed an unlocked soiled utility room on the 200 hall with sani-wipes on the counter. Observation on 7/22/14 at 10:18 a.m. revealed comet disinfecting bathroom cleaner in a cabinet under the sink and sani wipes on the counter in the open area just outside of the medication room. Interview on 7/22/14 at 10:20 a.m. with administrative nursing staff B revealed the sani wipes should not be in areas accessible to residents. Staff B removed the sani wipes and locked the cabinet. Observation on 7/22/14 at 8:58 AM revealed janitor closet in the 200 hall that could be opened with a push, even though the knob was locked. There was hdqC2- mop cleaner, Spar cling, restroom disinfectant, and Vane-sol- mop cleaner in the closet. Interview on 7/22/14 at 8:59 AM with administrative nursing staff B revealed he/she thought the door was locked and he/she turned the knob to check the door. Staff B then pushed on the door and it opened. He/she verified that the chemicals in the closet would be accessible to residents and pulled the door shut all the way at that time. Interview on 7/25/14 at 10:20 AM with maintenance staff P revealed he/she did not do much with the dining room in the memory care unit, and if alcohol wipes were in the drawer it would be the nurses responsibility to remove them. Observation of the central supply room on 7/25/14 at 10:25 AM with maintenance staff P revealed the door was propped wide open. Staff P reported that the maintenance staff that used the room was in and out all day and the room would get locked at night. Staff P reported there were other office workers around to visualize the area. Observation of the office directly across the hall, at that time, was locked and no one was in the office. Direct visualization from the other nearby offices was not possible. Staff P reported resident's rarely made it down there, but staff P did confirm that if a resident was confused and wandered down that hall then he/she could potentially get into the office unsupervised. Interview on 7/25/14 at 10:28 AM with maintenance staff P revealed the cabinet by the medication room was now locked. He/she reported that there was a lock but the key had disappeared so it was unlocked when the surveyors entered the facility. Now there was a key and the cupboard could be locked. The soiled utility room in the 200 hall was locked at this time and staff P reported it should always be locked. The janitor closet in 200 hallway was locked and staff P reported that he/she removed some of the old insulation in the door that was causing it to stick and making it so that you had to pull the door shut tight. Staff P reported areas should remain free from chemicals that could be potentially harmful for residents. Observation on 7/25/14 at 10:50 AM revealed resident #5 in his/her wheel chair unattended, propelled himself/herself all the way down the hall adjacent to the hall where the open central supply room was located. The resident was confused and did not know his/her name when asked. The resident did not turn down the hall towards the offices at that time, but could have, without staff noticing. There were no staff members in the hall observing the resident at that time Review of the facility's undated policy Storage of Housekeeping Supplies revealed doors must be kept locked at all times where any chemicals are stored. The facility failed to maintain an environment free of harmful chemicals for the residents. This had the potential to affect 15 residents who were independently mobile with cognitive impairment.

The facility had a census of 47 residents, with 13 selected for sample. Two sampled residents experienced pain. Based on observation, interview and record review, the facility failed to provide two of two sampled residents with the necessary care and services (pain assessment and treatment) to maintain the residents' highest practicable physical well-being. (Residents #2, 36). Resident #2 experienced multiple daily episodes of significant pain which caused the resident to moan and cry out. Direct care staff failed to communicate with licensed nursing staff about the pain, and the pain went untreated. Findings included: - Resident #2's clinical record included an 8/30/10 Significant Change MDS (Minimum Data Set) which identified the resident with long and short term memory problems, unclear speech, the need for staff assistance with all ADLs (activities of daily living), range of motion limitations of the arm and hand, daily/moderate pain, falls within the past 30 days as well as a fracture within the past 180 days. RAP (resident assessment protocol) notes dated 8/24/10 for "Falls" included, "....Is a high fall risk.....Had a fall on 8/13/10 that resulted in a fractured right arm..." The 8/24/10 Care Plan noted resident #2's, "increased pain since fall and fractured arm," and directed staff to administer pain medication as ordered. The care plan did not include specific interventions related to pain assessment/treatment. The care plan also directed staff to, "report to charge nurse if notice increased facial expressions...." Current physician orders [REDACTED]. o An 11/20/09 order for [MEDICATION NAME] 650 mg. (milligrams) three times daily for arthritis o An 8/14/10 order for [MEDICATION NAME] 5/500 mg . every four to six hours as needed for arm pain o An 8/31/10 order for [MEDICATION NAME] 0.2 to 0.25 ml (milliliters) as needed every one to two hours for pain During an observation on 9/20/10 at 5:00 p.m., resident #2 sat in a wheelchair at the dining room table. The resident wore a short cast/splint on the right wrist area. The resident repeatedly moaned and attempted to readjust his/her position in the wheelchair. Direct Care Staff R assisted other residents with their meals, and frequently asked resident #2 such questions as, "Are you ok (resident name)?", or "Do you have pain (resident name)?". Resident #2 did not respond to the questions but continued to moan throughout the meal. The resident did not resist care or exhibit undesired behaviors during this time period, yet he/she moaned each time an attempt was made to reposition him/herself in the wheelchair. Direct Care Staff did not communicate with a licensed nurse about resident #2's moaning and obvious discomfort. The clinical record did not include evidence a licensed nurse assessed resident #1's moaning and symptoms of pain during or after the evening meal on 9/20/10. According to September MARs (medication administration records), staff did not administer prn (as needed) pain medication on 9/20/10 even though the resident experienced significant pain as described previously. During an observation on 9/21/10 at 3:30 p.m., resident #2 lay on his/her back in bed. Direct Care Staff S and T prepared to get the resident out of bed. Staff S asked the resident if he/she wanted to get up, to which the resident replied, "yes." When Staff S and T moved resident #2 from a lying to a sitting position, the resident cried out loudly, with facial grimacing noted. When staff attempted to put resident #2's casted right arm through the sleeve of a sweater, the resident moaned loudly and attempted to pull away, as if in pain. According to Staff S, resident #2 fell a few weeks ago and broke his/her arm. Then, a short time later, the resident hurt his/her back during another fall. Since that time, the resident frequently "screams" or cries out during transfers. According to Staff S, "I think it's (his/her) back that hurts so bad when we move (him/her}. After staff assisted the resident to the wheelchair, he/she continued to exhibit evidence of pain as evidenced by moaning and extreme facial grimacing. Neither Direct Care Staff S or T communicated with a licensed nurse about resident #2's pain. The clinical record did not include evidence of assessment by a licensed nurse of the moaning, grimacing, crying out in the late afternoon or early evening hours of 9/21/10. According to September MARs, staff administered prn [MEDICATION NAME] in the early morning hours of 9/21/10, but did not administer additional pain medication in the late afternoon or evening hours even though the resident experienced significant pain as described previously. During an additional observation on 9/22/10 at 9:30 a.m., Direct Care Staff U and T prepared to get resident #2 out of bed. When staff approached the resident about getting up and explained breakfast was waiting, resident #2 was agreeable to getting up. When staff raised the resident from a lying to a sitting position on the bed, the resident cried out and moaned loudly. According to Staff U, resident #2, "always does that when we get (him/her) up." When asked if he/she had pain, resident #2 responded, "Oh my, yes." The resident did not respond to questions about location/intensity of the pain. Neither Direct Care Staff U or T communicated with a licensed nurse about resident #2's pain. According to September MARs (medication administration records), staff did not administer prn (as needed) pain medication on 9/22/10 even though the resident experienced significant pain as described previously. During an interview on 9/23/10 at 8:45 a.m., Administrative Nurse B confirmed resident #2 fell and fractured his/her wrist in August 2010. According to Nurse B, the resident fell again in late August and complained of back pain after that fall. Although X-rays revealed no evidence of back injury, Nurse B confirmed resident #2's back pain started after the late August fall. Nurse B also reported direct care staff should report evidence of pain to the charge nurse. In summary, the facility failed to provide resident #2 with the necessary care and services (assessment/treatment of [REDACTED]. Direct Care staff observed the resident crying out, moaning and grimacing with position changes, and failed to communicate those observations to licensed nurses, therefore the resident's symptoms of pain remain unassessed/untreated. - This deficient practice of facility failure to provide the necessary assessment and treatment to manage pain also affected resident #36. Non-licensed staff administered prn (as needed) pain medication nightly without benefit of assessment by a licensed nurse, and without notifying the physician of the resident's need for prn medication nightly to treat pain.