Every finding on record at Meadowbrook Rehabilitation Hospital

The facility identified a census of 109 residents. The sample included 22 residents, with two reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent avoidable accidents when direct care staff used the incorrect sling size while attempting to transfer Resident (R) 112, a quadriplegic (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord) resident with a history of traumatic brain injury. On 08/04/25 at 08:00 PM, Certified Nurse Aide (CNA) N and CNA O attempted to transfer R112 from her wheelchair to her bed, used the wrong sling size, the mechanical lift tipped over, and R112 fell to the floor from the lift's highest position. The facility's failure to ensure staff used the correct sling size while transferring R112 with the full mechanical lift placed R112 in immediate jeopardy to their health and safety and at risk for injury. Findings Included:- The Electronic Medical Record (EMR) included R112 had the following diagnoses: quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle weakness, and traumatic brain injury (TBI-an injury to the brain caused by external forces). The 05/11/25 Quarterly Minimum Data Set (MDS) indicated R112 had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS indicated she had bilateral impairment of her upper and lower extremities, was dependent on staff for transfers, used a wheelchair for mobility, and had no falls.The 09/09/25 Cognitive Loss/Dementia Care Area Assessment (CAA) indicated R112 was at risk for acute mental status changes. The CAA instructed staff to use short and simple sentences and allow adequate time for her to understand others and to communicate her needs. The 09/04/24 Care Plan indicated R112 required a Hoyer lift with two staff present for transfer to her bed and chair. The plan instructed staff to use a medium-sized sling for Hoyer transfer (09/04/24). The plan instructed staff to use the Hoyer sling (09/04/24). Review of the 08/04/25 Facility Investigation #1822 revealed the Hoyer lift fell over, and R112 fell to the floor during the transfer. The note revealed staff assessed R112 with no injuries and sent the resident to an acute medical facility for further assessment. The investigation concluded staff used the wrong size sling to transfer R112 with the mechanical lift. The 08/04/25 Witness Statement by Certified Nurse Aide (CNA) N revealed on 08/04/25 at approximately 08:00 PM she assisted CNA O. CNA N noted she prepared R112 for a mechanical lift transfer by removing the wheelchair's headrest and positioning her next to the mechanical lift. CNA N noted R112's sling was attached to the mechanical lift, and staff raised R112 in the air with the lift. CNA N indicated the lift sling became stuck on R112's wheelchair as she was lifted. The statement revealed staff stopped and fixed her sling positioning. CNA N noted the staff lifted R112 as high as the mechanical lift would go, but R112 did not clear the armrest of her chair. CNA N noted staff attempted to lower the back of her wheelchair but could not get R112 to clear the chair's armrest upon transfer. CNA N stated she attempted to pull the wheelchair out as CNA O attempted to lift R112 up in the sling. The statement revealed the mechanical lift began to tilt as staff attempted to reposition R112, while the lift was in the highest position. The statement indicated both the resident and the mechanical lift fell over to the ground. The 08/04/25 Witness Statement by CNA O revealed on 08/04/25 she assisted CNA N with transferring residents. CNA O noted when they raised R112 all the way up in the mechanical lift, they realized the sling was too big. CNA O documented they could not get R112 over the wheelchair's armrest and attempted to maneuver her (R112) around the chair. CNA O's statement revealed R112 fell to the floor when the mechanical lift tilted and fell over. An observation on 09/15/25 at 10:01 AM, revealed the facility had three mechanical lifts. The supply area revealed several small, medium, and large transfer slings for the Hoyer lifts.During an interview on 09/15/25 at 10:15 AM, CNA P stated each care plan should indicate the size of sling required for each resident. CNA P stated using the wrong size sling could hurt the resident or cause them to fall. CNA P stated the facility held annual training related to transfers and accident prevention.During an interview on 09/15/25 at 10:30 AM, Licensed Nurse (LN) H stated the facility had multiple sling sizes and she expected staff to verify which sling each resident required by looking at their care plan. LN H stated staff were trained to verify the sizes. LN H stated staff should never attempt to reposition or maneuver a resident while lifted in the air.During an interview on 09/15/25 at 02:30 PM, Administrative Nurse E stated she expected staff to verify the sling size required for transfers and use the mechanical lifts per facility training. Administrative Nurse E stated the care plans contained the appropriate sling size for transfers for each resident. She stated the facility trained all staff upon hire and annually regarding mechanical lift use.On 09/15/25 at 02:30 PM, Administrative Staff A stated the facility completed verbal education to the two staff members involved, replaced and provided extra slings, updated affected residents, and placed cheat sheets in the sling closets that contained the mechanical lift sling measurements, immediately after the incident on 08/04/25. Administrative Staff A stated the facility started a facility-wide re-education for all care staff on 09/15/25 related to mechanical lift transfers.The facility's Incidents and Accidents policy 07/01/25 indicated the facility was expected to ensure the appropriate interventions are implemented to prevent potential accidents and injuries. The policy indicated the facility ensured all residents were screened for potential risks. The policy indicated staff were to use the appropriate techniques and equipment designated by the facility to minimize the risks related to falls and accidents. On 09/15/25 at 02:30 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure R112 remained free from accidents in immediate jeopardy. The facility provided an acceptable plan for the removal of the immediacy on 09/16/25 at 08:30 AM, which included the following: The facility provided verbal education with CNA N and CNA O on 08/04/25. The facility's slings were replaced to ensure proper sizes on 08/04/25. The facility provided documentation of mechanical lift observations completed by their administrative team from 08/05/25 to 09/17/25. All affected residents who required mechanical lift transfers were reviewed, and care plans were updated as needed on 08/05/25. The administrative nursing team would audit three mechanical lift transfers weekly, starting on 09/15/25. Facility-wide re-education was started on 09/15/25 related to safe mechanical lift transfers. The surveyor verified the implementation of the IJ removal plan while on-site on 09/16/25 at 09:00 AM. The deficient practice remained at a D scope and severity, upon removal of the IJ immediacy.

The facility identified a census of 109 residents. The sample included 22 residents, with three medication rooms. Based on observation, record review, and interviews, the facility failed to secure medication carts containing residents' insulin (a hormone that lowers the level of glucose in the blood) pens and needles, residents' scheduled medications, and over-the-counter medication. Findings included:- On 09/14/25 at 09:05 AM, at the facility walk-through, four medication carts sitting in the commons area room were unlocked and unsecured. The medication cart contained insulin pens, needles, residents scheduled medications, and over-the-counter medications. The Certified Medication Aides (CMA) and the Licensed Nurse (LN) secured the carts. LN J locked all the medication carts. On 09/14/25 at 09:15 AM, a medication cart in the 800 hallway was unlocked and unsecured. The medication cart contained scheduled medications and over-the-counter medications. The CMA secured the cart. LN J locked the cart. On 09/16/25 at 11:30 AM, Licensed Nurse (LN) G stated the medication carts should never be left unattended. She stated insulin pens and needles should be locked in the cart when staff are not within eyesight of the medication cart. On 09/16/25 at 11:45 AM, Administrative Nurse D stated medication carts should be locked and never left unattended. She stated the facility expected that medication carts be locked, and the keys be with the nurse or CMA. The facility's Medication Storage policy dated 04/09/25 documented it was the policy of this facility to ensure all medications housed on our premises would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

The facility identified a census of 109 residents, six residents on a puree textured diet. One resident received a double portion of their pureed diet, so the facility prepared seven pureed servings. Based on observation, record review, and interviews, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals. Findings included:- On 09/15/25 at 11:25 AM, Dietary Staff CC placed cooked country fried steak and stated she had added one cup of beef broth into the food processor and then started the machine. Dietary Staff CC then added several spoons of thickener powder into the food processor. Dietary Staff CC checked the consistency of the country-fried steaks. Dietary Staff CC then placed the country-fried steak into a metal container. Dietary Staff CC cleaned the food processor bowl and then placed corn into the food processor, then stated she had added one cup of chicken broth into the food processor with the corn. Dietary Staff CC added several spoons full of thickener powder to the food processor with the corn. Dietary Staff CC placed the pureed corn into a metal pan. Dietary Staff CC cleaned the food processor bowl. Dietary Staff CC placed the cake into the food processor and stated she had added about a cup of milk to the food processor with the cake. Dietary Staff CC started the food processor, then checked the consistency of the cake, and she added more milk to the food processor. Dietary Staff CC then placed the pureed cake into a metal pan. Dietary Staff CC never had reviewed a recipe during the process. The facility provided the recipe for the pureed altered diet, which lacked the indication of the servings and the fluid measurement to be added to maintain the nutritional value for each serving of food. On 09/16/25 at 12:10 PM, Dietary Staff BB stated that Dietary Staff CC should reference the recipes. Dietary Staff BB stated the recipe should have the servings identified with the measurement needed to maintain the nutritional value. The facility's Therapeutic Diet Orders policy dated 03/26/25 documented the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

The facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician-ordered laboratory tests were obtained as ordered for Resident (R) 15 and R9. The facility also failed to consistently take and record blood pressures and pulse for R5's beta blocker (a medication to slow down your heart rate and reduce the force of your heart's contraction). Findings included:- R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), epilepsy (brain disorder characterized by repeated seizures), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 08/27/25 documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R15 had received an anticonvulsant (a medication that prevents or treats seizures and convulsions) medication, antidepressant (a class of medications used to treat mood disorders) medication, antiplatelet (medication that helps prevent blood clots from occurring) medication, antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and a diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. R15's Psychotropic Drug Use Care Area Assessment (CAA) dated 08/27/25 documented he was at risk of adverse effects related to the medication he had received. R15's Care Plan, dated 06/27/22, documented the nursing staff would obtain lab work as ordered by the physician. The plan of care was documented the physician, and the CP would review the medications monthly. R15's EMR under the Orders tab revealed the following physician orders: Complete Blood Count (CBC- laboratory test) with differential laboratory test every three months, dated 06/16/22. complete metabolic panel (CMP- laboratory blood test) every three months, dated 06/16/22. Vitamin B12 level (laboratory test) yearly, dated 06/16/22.Vitamin D level (laboratory test) yearly, dated 06/16/22. Valproic Acid level (laboratory test to monitor for medication levels) quarterly, dated 12/15/22. Keppra level (laboratory test to monitor for medication levels) quarterly, dated 07/06/23. Continue Vitamin B12, Hemoglobin A1C, T4, TSH, and Vitamin D every 12 months, dated 10/24/24. Keppra, CBC, CMP, and Valproic acid every three months, dated 10/24/24. Review of R15's EMR under the Misc tab under Laboratory lacked test results, and the facility was unable to provide evidence of results for the following laboratory tests CBC and CMP, from May 2025 and August 2025. R15's EMR also lacked the Keppra levels and Valproic acid level lab test from April 2025 and July 2025. R15's EMR also lacked results from yearly lab work. On 09/15/2025 at 03:36 PM, R15 propelled his wheelchair in the common area. R15's oxygen tank was attached to the back of his wheelchair. On 09/15/25 at 11:26 AM, Licensed Nurse (LN) G stated she entered the order into the laboratory portal as ordered by the physician. LNG stated if the order was for an extended period, that could also be entered into the portal. On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected the nurse who obtained the lab order to enter the order into the laboratory provider portal to be drawn as it was ordered. Administrative Nurse D stated the lab order could be entered into the lab providers portal to be an ongoing order if that was what the physician had ordered. Administrative Nurse D stated the physician can review the lab in the provider's portal, and then the medical records person would download the results into the resident's EMR. Administrative Nurse D stated the medical records would help ensure the lab test were obtained as ordered. The facility's Laboratory Services and Reporting policy dated 12/11/24 documented the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), paranoid schizophrenia (characterized by persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and conspiracy), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated 04/08/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R9 had received antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R9 had received antidepressant medication, antianxiety medication, and antipsychotic medication during the observation period. R9's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/09/25 documented she was at risk for adverse side effects related to the medication she had received. R9's Care Plan, dated 06/27/22, documented the nursing staff would obtain the laboratory tests as ordered by the physician. The plan of care dated 04/18/24 documented her medications would be reviewed monthly by the physician and the pharmacist. R9's EMR under the Orders tab revealed the following physician orders: Continue Vitamin B12 level (laboratory test to monitor medication level), Hemoglobin A1C (laboratory test to monitor blood sugar level), LIPID panel (laboratory test to monitor medication level), T4 (laboratory test to monitor medication level), TSH (laboratory test to monitor medication level), and Vitamin D (laboratory test to monitor medication level) yearly, dated 10/24/24.Complete Blood Count (CBC- laboratory blood test), complete metabolic panel (CMP- laboratory blood test), and Haldol (antipsychotic) level (laboratory test to monitor cat levels) every three months, dated 10/24/24. Review of R9's EMR under the Misc tab under Laboratory lacked test results, and the facility was unable to provide evidence of results for the following laboratory tests: Vitamin B12, T4, TSH, and Vitamin D level from yearly lab work in April 2025. R9's EMR also lacked evidence of results for a CBC and CMP from March 2025. On 09/16/25 at 09:25 AM, R9 laid on her bed covered with her quilt. On 09/15/25 at 11:26 AM, Licensed Nurse (LN) G stated she entered the order into the laboratory portal as ordered by the physician. LN G stated if the order was for an extended period, that could also be entered into the portal. On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected the nurse who obtained the lab order to enter the order into the laboratory provider portal to be drawn as it was ordered. Administrative Nurse D stated the lab order could be entered into the lab providers' portal to be an ongoing order if that was what the physician had ordered. Administrative Nurse D stated the physician can review the lab in the provider's portal, and then the medical records person would download the results into the resident's EMR. Administrative Nurse D stated that medical records would help ensure the lab tests were obtained as ordered. The facility's Laboratory Services and Reporting policy dated 12/11/24 documented the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. - R5's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), hypertension (HTN- high blood pressure), obesity (excessive body fat), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), venous insufficiency (poor circulation), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R5 needed partial to moderate assistance with toileting, and setup or clean-up for eating, oral hygiene, bathing, and dressing. The MDS documented R5 had heart failure and hypertension. R5s Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/21/24 would be addressed in R5's care plan. The CAA documented staff were to assist with activities of daily living (ADL), as needed, and anticipate care. The CAA documented therapy services would be used as needed to help increase functional mobility, and staff were to encourage R5 to participate in ADL care as much as able to promote independence. R5's Care Plan dated 10/17/24 documented R5 had hypertension related to lifestyle choices. R5's plan of care documented staff were to avoid taking the blood pressure reading after physical activity or emotional distress, and staff were to educate R5 about the importance of maintaining a normal weight for my height, the value of regular exercise, limiting salt intake, the adverse effects of tobacco and alcohol use, the importance of medication and diet compliance. R5 plan of care documented nursing was to give anti-hypertensive (medications to lower blood pressure) medications as ordered and monitor for side effects such as hypotension (low blood pressure), increased heart rate, and effectiveness. The care plan for R5 documented nursing staff would monitor for edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R5's EMR under Orders revealed the following physicians' orders: Coreg (beta blocker) oral tablet 6.25 milligrams (mg) (Carvedilol), give 6.25 mg by mouth two times a day for HTN, hold for systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60. R5's EMR under the Treatment Administration Record (TAR) recorded the following dates, which lacked evidence the blood pressure was obtained: 09/01/25, 09/04/25, 09/07/25, 09/10/25, 09/12/25, 09/13/25, and 09/14/25. On 09/14/25 at 09:47 AM, R5 sat on the side of his bed, drinking from a brown cup. On 09/16/25 at 11:30 AM, Licensed Nurse (LN) G stated that the certified medication aides (CMA), or the nurses, should always obtain vitals if a medication has perimeters. On 09/16/24 at 11:45 AM, Administrative Nurse D stated she was unsure why the blood pressure and pulse were not obtained before a resident received a beta blocker. She stated quality checks were done by the assistant director of nursing to ensure medications that should have perimeters have the perimeters put in place. The facility's Documentation in the Medical Record policy dated 01/30/24 documented that each resident's medical record would contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members would document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation would be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation may be performed manually or as per the facility's specific electronic medical record software program.

The facility identified a census of 109 residents. The sample included 22 residents. Based on interviews and record reviews, the facility's direct care staff failed to verify and utilize the appropriate Hoyer lift sling while transferring Resident (R) 112, resulting in a non-injury fall from the Hoyer lift. Findings included:- The Medical Diagnosis section within R112's Electronic Medical Records (EMR) included diagnoses of Quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle weakness, and traumatic brain injury (TBI- an injury to the brain caused by external forces). R112's Quarterly Minimum Data Set (MDS) completed 05/11/25 indicated a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairments. The MDS indicated she was dependent on staff for transfers, bathing, dressing, personal hygiene, bed mobility, and oral hygiene. The MDS indicated she used a wheelchair and had no falls. The MDS noted she had bilateral impairments of her upper and lower extremities. R112's Cognitive Impairment Care Area Assessment (CAA) completed 09/09/25 indicated she was at risk for acute mental status changes and nutritional impairments related to her cognitive impairments. The CAA instructed staff to use short and simple sentences and allow adequate time for her to understand and to communicate her needs. R112's Falls or Functional Abilities CAA was not triggered. R112's Care Plan initiated 09/04/24 indicated she required assistance from two staff for bathing, bed mobility, dressing, personal hygiene, and footwear (09/04/24). The plan indicated she required a Hoyer lift with two staff present for transfers to her bed and chair (09/04/24). The plan instructed staff to use a medium-sized sling for Hoyer transfer (09/04/24). The plan instructed staff to use the Hoyer sling (09/04/24). The plan noted she used a specialized wheelchair for mobility (11/18/24). A review of Facility Investigation #1822 completed on 08/04/25 revealed that the on-duty nurse was notified by direct care staff that the Hoyer lift tilted during an attempted transfer of R112. The note revealed that the lift and R112 fell to the floor during transfer from her wheelchair to her bed. The note revealed that other staff were called to assist with removing the Hoyer and her wheelchair. The note revealed R112 was assessed with no injuries. The note revealed R112 was sent to an acute medical facility for further assessment. The investigation's root-cause analysis revealed that staff used the wrong size sling to transfer R112 with the Hoyer lift. A Witness Statement completed by Certified Nurse's Aide (CNA) N on 08/04/25 revealed on 08/04/25 at about 08:00 PM that she assisted CNA O with getting residents prepared for bed. CNA N noted she prepared R112's for a Hoyer Lift transfer by removing her wheelchair's headrest and positioning her next to the Hoyer lift. CNA N noted R112's sling was then hooked up to the Hoyer lift. The statement revealed that the staff raised R112 in the air with the lift. CNA N indicated the lift sling became stuck on R112's wheelchair as she was lifted in the Hoyer Lift. The statement revealed that the staff stopped and fixed her sling positioning. CNA N noted R112 was lifted as high as the Hoyer lift would go, but R112 did not clear the armrest of her chair. CNA N noted staff attempted to lower the back of the wheelchair, but could not get R112 to clear the Chair's armrest upon transfer. CNA N stated she attempted to pull the wheelchair out as CNA O attempted to lift R112 up in the sling. The Statement revealed that the Hoyer lift began to tilt as staff attempted to reposition R112 while the lift was in the highest position. The statement indicated that both the resident and Hoyer fell over to the ground. A review of a Witness Statement completed on 08/04/25 by CNA O noted on 08/04/25 that she assisted CNA N with transferring the residents to their beds. CNA O stated that when they raised R112 all the way up in the Hoyer lift, they realized the sling was too big. The statement revealed they could not get R112 over the wheelchair's armrest and attempted to maneuver her around the chair. The statement revealed R112 fell to the floor when the Hoyer lift tilted and fell over. On 09/15/25, CNA N and CNA O were not available for an interview. On 09/15/25 at 10:15 AM, CNA P stated that each care plan should indicate the size of sling required for each resident. She stated that using the wrong size could hurt the resident or cause them to fall. She stated the facility held annual training related to transferring and accident prevention. She stated that all staff were given training on Hoyer lifts and proper transfer techniques. On 09/15/25 at 10:30 AM, Licensed Nurse (LN) H stated the facility had multiple sling sizes and staff were expected to verify which sling each resident required by looking at their care plan. She stated that staff have been trained to verify the sizes and know the specific sling loops in use. She stated that if staff had questions related to issues with transfers, they were expected to stop the transfer and get help. She stated staff should never attempt to reposition or maneuver a resident while lifted in the air. On 09/15/25 at 02:30 PM, Administrative Nurse E stated that staff were expected to verify the size required for transfers and use the lifts as they have been trained to do. She stated that the care plans contained the appropriate sling size for transfers for each resident. She stated all staff were trained to use the Hoyer lifts upon hire and annually. Administrative Nurse E stated. On 09/15/25 at 02:30 PM, Administrative Staff A stated the facility started a facility-wide re-education plan for all care staff on 09/15/25 related to safe Hoyer lift transfers. The facility's Competent Staff policy dated 02/2025 indicated the facility was to ensure staff had sufficient competencies and skill sets to provide nursing services to ensure resident safety.

The facility had a census of 109 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 15, R12, R80, R13, and R54's protected health information (PHI) private on a medication cart parked in the main dining room. Findings included:- On 09/14/25 at 9:00 AM, an observation revealed a medication cart parked in the 800 hallway with a laptop computer open on the cart. There was no Licensed Nurse (LN) or Certified Medication Aide (CMA) around the cart. Nursing staff left the computer screen unlocked and open with R15's PHI on the screen, visible to all who passed by the medication cart. The information visualized included R15's medication, date of birth , allergy information, and code status. LN J locked the screen. On 09/14/25 at 09:05 AM, an observation revealed four medication carts parked in the commons room with a laptop computer opened on the medication cart. LN and CMA walked away from the medication carts and were in the dining room. The nursing staff, LN and CMA, left the computer screen unlocked and open, and the PHI of R12, R80, R13, and R54 were visible on the screen to all who passed by the medication cart. The information visualized included R12, R80, R13, and R54's medications, date of birth , allergy information, and code status. LN J locked all screens.On 09/16/25 at 11:30 AM, LN H stated the medication cart should be locked and the computer screen should be closed.On 09/16/25 at 11:45 PM, Administrative Nurse D stated she expected the nursing staff to close the computer screen before walking away from the medication cart. Administrative Nurse D stated the resident's PHI should never be left on the computer screen. The facility's HIPAA Sanctions policy dated 05/12/25 documented that it was the policy of this facility to apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of our residents' personally identifiable health information. The facility, as a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), would implement policies and procedures to prevent, detect, contain, and correct any HIPAA violations. All employees were expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. All employees would be educated on relevant policies and procedures for which they were expected to comply, including this sanctions policy.

The facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory tests to monitor antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) for Resident (R) 9 were completed. The facility also failed to ensure the physician had documented a rationale with the risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorders characterized by a gross impairment in reality testing) medication with no gradual dose reduction for R7.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), paranoid schizophrenia (characterized by persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and conspiracy), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated 04/08/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R9 had received antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R9 had received antidepressant medication, antianxiety medication, and antipsychotic medication during the observation period. R9's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/09/25 documented she was at risk for adverse side effects related to the medication she had received. R9's Care Plan dated 06/27/22 documented the nursing staff would obtain the laboratory tests as ordered by the physician. The plan of care dated 04/18/24 documented her medications would be reviewed monthly by the physician and the pharmacist.R9's EMR under the Orders tab revealed the following physician orders: Complete Blood Count (CBC- laboratory blood test), complete metabolic panel (CMP- laboratory blood test), and Haldol (antipsychotic) level (laboratory test to monitor cat levels) every three months, dated 10/24/24. Haldol injection solution (haloperidol lactate) inject 150 milligrams (mg) intramuscularly one time a day every 28 days related to schizophrenia, dated 09/03/25. Review of R9's EMR under the Misc tab under Laboratory lacked test results, and the facility was unable to provide evidence of results for the following laboratory tests: Haldol level in March 2025 and June 2025. On 09/16/25 at 09:25 AM, R9 laid on her bed, covered with her quilt. On 09/15/25 at 11:26 AM, Licensed Nurse (LN) G stated she entered the order into the laboratory portal as ordered by the physician. LN G stated if the order was for an extended period, that could also be entered into the portal. On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected the nurse who obtained the lab order to enter the order into the laboratory provider portal to be drawn as it was ordered. Administrative Nurse D stated the lab order could be entered into the lab providers portal to be an ongoing order if that was what the physician had ordered. Administrative Nurse D stated the physician could review the lab in the provider's portal, and then the medical records person would download the results into the resident's EMR. The facility's Use of Psychotropic Medications policy, dated 02/05/25, documented it was the intent of this policy to ensure that residents only received psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications would only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Residents who used psychotropic drugs would receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. - R7's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (HTN- high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), paranoid schizophrenia (characterized by persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and conspiracy), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated 07/14/25 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R7 received antiplatelet (medication that helps prevent blood clots from occurring) medication, antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, anticonvulsant (a medication that prevents or treats seizures and convulsions) medication, hypoglycemic (a class of medication used to lower blood sugar) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The MDS documented a gradual dose reduction had not been attempted. The MDS lacked a date of a gradual dose reduction had been attempted in the past. The MDS documented there was no physician documentation that a gradual dose reduction was clinically contraindicated. R7's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/28/25 documented she was at risk for adverse effects related to the medication she had received. R7's Care Plan dated 06/27/22 documented the physician and pharmacist would review her medication monthly. The plan of care documented the facility would discontinue or reduce her medications to keep them at the lowest dose possible. R7's EMR under the Orders tab revealed the following physician orders: buspirone hci (antianxiety) tablet 15 milligrams (mg), give one tablet by mouth three times a day for anxiety, dated 06/15/22. Olanzapine (antipsychotic) tablet 15 mg, give half of a tablet (7.5 mg) by mouth in the afternoon for schizophrenia, dated 02/17/25. Risperdal (antipsychotic) tablet 3 mg (risperidone), give one tablet by mouth two times a day related to schizophrenia, dated 08/04/25.trazodone hci (antidepressant) oral tablet 50 mg, give 1 tablet by mouth at bedtime for depression with targeted symptom of insomnia, dated 08/04/25.Xanax (antianxiety) oral tablet 1 mg (alprazolam), give one tablet by mouth three times a day for anxiety, dated 08/12/25. The facility was unable to provide physician documentation that a gradual dose reduction was clinically contraindicated. On 09/15/25 at 01:53 PM, R7 laid on her bed, she offered no concerns at that time. On 09/16/25 at 11:45 AM, Administrative Nurse D stated that medical records would help ensure the lab tests were obtained as ordered. Administrative Nurse D stated the nurse practitioner reviewed the resident's psychotropic medications. The facility's Use of Psychotropic Medications policy, dated 02/05/25, documented it was the intent of this policy to ensure that residents only received psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications would only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Residents who used psychotropic drugs would receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs.

The facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations had been reviewed and addressed by the physician within 30 days for Residents (R) 15 and R9. The facility also failed to ensure the CP had identified and reported the physician-ordered laboratory tests had not been followed for R15 and R9. Findings included:- R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), epilepsy (brain disorder characterized by repeated seizures), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 08/27/25 documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R15 had received an anticonvulsant (a medication that prevents or treats seizures and convulsions) medication, antidepressant (a class of medications used to treat mood disorders) medication, antiplatelet (medication that helps prevent blood clots from occurring) medication, antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and a diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. R15's Psychotropic Drug Use Care Area Assessment (CAA) dated 08/27/25 documented he was at risk of adverse effects related to the medication he had received. R15's Care Plan, dated 06/27/22, documented the nursing staff would obtain lab work as ordered by the physician. The plan of care documented the physician, and the CP would review the medications monthly. R15's EMR under the Orders tab revealed the following physician orders: Complete Blood Count (CBC- laboratory test) with differential laboratory test every three months, dated 06/16/22.complete metabolic panel (CMP- laboratory blood test) every three months, dated 06/16/22. Vitamin B12 level (laboratory test) yearly, dated 06/16/22.Vitamin D level (laboratory test) yearly, dated 06/16/22. Valproic Acid level (laboratory test to monitor for medication levels) quarterly, dated 12/15/22.Keppra level (laboratory test to monitor for medication levels) quarterly, dated 07/06/23.Continue Vitamin B12, Hemoglobin A1C, T4, TSH, and Vitamin D every 12 months, dated 10/24/24. Keppra, CBC, CMP, and Valproic acid every three months, dated 10/24/24. Review of the Monthly Medication Review (MMR) from September 2024 to August 2025 lacked documentation or recommendations for the lack of physician-ordered laboratory test. Review of R15's EMR under the Misc tab lacked MMRs from October 2024 and December 2024. The facility was able to provide the MMR's on 09/16/25, which were reviewed by the physician and dated 09/16/25. Review of R15's EMR under the Misc tab under Laboratory lacked test results, and the facility was unable to provide evidence of results for the following laboratory tests, CBC and CMP, from May 2025 and August 2025. R15's EMR also lacked the Keppra levels and Valproic acid level lab test from April 2025 and July 2025. R15's EMR also lacked results from yearly lab work. On 09/15/25 at 03:36 PM, R15 propelled his wheelchair in the common area. R15's oxygen tank was attached to the back of his wheelchair. On 09/15/25 at 11:26 AM, Licensed Nurse (LN) G stated she did not work with the pharmacy MMRs. LN G stated the administrative nurses took care of the MMRs. On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected the CP to identify and report any irregularities monthly during the monthly reviews. Administrative Nurse D stated R15's laboratory tests should have been discontinued in February 2025 when he was admitted to hospice services. The facility's Pharmacy Services policy dated 04/09/25 documented it is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), paranoid schizophrenia (characterized by persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and conspiracy), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated 04/08/25 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R9 had received antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medication that calms and relaxes people) medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R9 had received antidepressant medication, antianxiety medication, and antipsychotic medication during the observation period. R9's Psychotropic Drug Use Care Area Assessment (CAA), dated 04/09/25, documented she was at risk for adverse side effects related to the medication she had received. R9's Care Plan, dated 06/27/22, documented the nursing staff would obtain the laboratory tests as ordered by the physician. The plan of care dated 04/18/24 documented her medications would be reviewed monthly by the physician and the pharmacist.R9's EMR under the Orders tab revealed the following physician orders: Continue Vitamin B12 level (laboratory test to monitor medication level), Hemoglobin A1C (laboratory test to monitor blood sugar level), LIPID panel (laboratory test to monitor medication level), T4 (laboratory test to monitor medication level), TSH (laboratory test to monitor medication level), and Vitamin D (laboratory test to monitor medication level) yearly, dated 10/24/24.Complete Blood Count (CBC- laboratory blood test), complete metabolic panel (CMP- laboratory blood test), and Haldol (antipsychotic) level (laboratory test to monitor cat levels) every three months, dated 10/24/24. Review of the Monthly Medication Review (MMR) from September 2024 to August 2025 lacked documentation or recommendations for the lack of physician-ordered laboratory tests. Review of R9's EMR under the Misc tab lacked MMRs from December 2024 and April 2025. The facility was able to provide the MMRs on 09/16/25, which were reviewed by the physician and dated 09/16/25. Review of R9's EMR under the Misc tab under Laboratory lacked test results, and the facility was unable to provide evidence of results for the following laboratory tests: Vitamin B12, T4, TSH, and Vitamin D level from yearly lab work in April 2025. R9's EMR also lacked evidence of results from the Haldol level in March 2025 and June 2025. R9's EMR also lacked evidence of results for a CBC and CMP from March 2025. On 09/16/25 at 09:25 AM, R9 laid on her bed covered with her quilt. On 09/15/25 at 11:26 AM, Licensed Nurse (LN) G stated she did not work with the pharmacy MMRs. LN G stated the administrative nurses took care of the MMRs. On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected the CP to identify and report any irregularities monthly during the monthly reviews. Administrative Nurse D stated the medical records would ensure the MMRs were reviewed by the physician, and the administrative nurses would enter the physician's orders into the resident's EMR. The facility's Pharmacy Services policy dated 04/09/25 documented it is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.

The facility identified a census of 109 residents. The sample included 22 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 16 received services and treatment for his right-hand contracture (abnormal permanent fixation of a joint or muscle) to prevent an avoidable reduction of range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included:- R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, contracture of right hand, hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS) dated 03/14/25 documented a staff interview, which indicated moderately impaired cognition. The MDS documented R16 had limited ROM in his upper and lower extremities on one side of his body. The MDS documented R16 required substantial to maximum assistance with oral hygiene, bathing, toileting, and application of footwear. The MDS documented R16 was at risk for the development of pressure-related injuries. The MDS documented the facility placed pressure-reducing devices on R16's bed and in the wheelchair. The Quarterly MDS dated [DATE] documented a staff interview, which documented moderately impaired cognition. The MDS documented R16 had limited ROM in his upper and lower extremities on one side of his body. The MDS documented R16 required substantial to maximum assistance with oral hygiene, bathing, toileting, lower extremity dressing, and application of footwear. The MDS documented R16 was at risk for the development of pressure-related injuries. The MDS documented the facility placed pressure-reducing devices on R16's bed and in the wheelchair. R16's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 03/17/25 documented he required staff assistance with activities of daily living. R16's Care Plan dated 04/04/25 documented he was to wear a hand brace during the morning, and it would be removed at bedtime as tolerated. R16's EMR under the Orders tab revealed the following physician orders: Apply the right-hand splint in the morning and remove it at bedtime every day, dated 04/03/25. On 09/16/25 at 07:58 AM, R16 propelled his wheelchair from his room to the dining room. R16 lacked a cushion in his wheelchair. R16's right hand was tightly closed and lacked his right-hand splint. R16's right foot slid along the floor under the wheelchair as he propelled himself with his left hand. On 09/16/25 at 11:10 AM, Certified Nurse Aide (CNA) M stated the direct care staff could place a brace or hand splint on a resident. CNA M stated she would ask the nurse if there were any questions or problems with the brace or splint. On 09/16/25 at 11:26 AM, Licensed nurse (LN) G stated the nurse was the person responsible for ensuring the splint or brace was on the resident. LN G stated the order for the brace or splint was listed on the Treatment Administration Record (TAR). On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected the charge nurse to ensure the resident was wearing their brace or splint. Administrative Nurse D stated the nurse would have to sign that the brace or splint was applied as ordered.The facility's Restorative Nursing Programs policy dated 10/14/24 documented it was the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Residents who were identified during the comprehensive assessment process would receive services from restorative aides when they are assessed for restorative nursing services. These services may include Splint or brace assistance.

The facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to monitor the low-air-loss (a special type of medical mattress that uses microscopic holes to provide a constant, slow airflow) mattress for Resident (R) 54 and further failed to provide a pressure-reducing device for R16's wheelchair. Findings Included - R54's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), age related cognitive (relates to the processes of the mind, such as thinking, learning, remembering, and understanding) decline, hypertension (HTN- elevated blood pressure), lack of coordination, muscle weakness, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R54 was dependent on staff for all activities of daily living (ADL). The MDS was at risk for pressure injury and had a pressure-reducing cushion in her chair and a pressure-reducing mattress on her bed. R54's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 04/24/25 documented pressure ulcers would be addressed in R54's care plan. The CAA documented nursing staff would assist with repositioning per protocol and as needed to help maintain skin integrity. Licensed Nurse (LN) staff were to monitor skin integrity every week. The CAA documented incontinence creams were to be used as needed to help maintain skin integrity. The CAA documented pressure redistributing surface in place to R54's bed and to her wheelchair to help maintain skin integrity. R54's Care Plan dated 02/06/23 documented R54 was at risk for skin Integrity related to incontinence and impaired mobility. R54's plan of care dated 08/08/23 documented staff were to do daily visual skin checks during routine cares and bathing and report abnormal findings to the nurse. R54's plan of care dated 05/27/25 documented that the staff were to check the low air loss mattress and pump function every shift to ensure settings were correct, and staff were to compare R54's weight to the settings on the pump to check for accuracy. R54's EMR under the Orders tab documented the following physician's order: Check the low air loss mattress and pump function to ensure proper working order and check to ensure correct settings in place per label on pump (setting based on weight/or per manufacturer guidelines) every shift, dated 01/27/25. R54's Weekly Skin Assessment dated 09/11/25 documented previously identified areas, various healing bruises to the bilateral upper extremities. The resident was encouraged to wear long sleeves/Geri sleeves (a type of protective sleeve). R54's EMR under the Weight and Vitals tab documented R54's weighed 128.6 pounds (lbs.) on 09/01/25. R54's low air loss mattress 6000 ProAir set at 50-pound increments, was set at 240 lbs. R54's Braden Scale for Prediction Pressure Sore Risk dated 07/23/25 documented a score of 13, indicating a moderate risk for pressure ulcers. On 09/14/25 at 09:42 AM, R54 laid in her bed, in her room. On 09/15/25 at 10:50 AM, R54 laid in her bed, in her room. On 09/16/25 at 02:17 PM, Certified Nurse's Aide (CNA) M stated all staff checked the low air loss mattresses to ensure the mattress was in working order, plugged in, and set at the correct weight. She stated normally there would be a piece of tape with the correct settings on the monitor of the mattress. On 09/16/25 at 02:31 PM, Licensed Nurse (LN) G stated it was on the nursing Treatment Administration Record (TAR) to monitor the settings of all low air loss mattresses. She stated the nurses documented the mattress was set at the correct settings. On 09/16/25 at 04:31 PM, Administrative Nurse D stated there was a quality team that checked mattresses every day. She stated it was also on the nursing TAR to ensure the low-air-loss mattresses were set at the correct settings. Administrative Nurse D stated the machines were set by weight. The facility's Pressure Injury Prevention Management policy, dated 12/03/24, documented the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriately needed. - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, contracture (abnormal permanent fixation of a joint or muscle) of right hand, hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS) dated 03/14/25 documented a staff interview, which documented moderately impaired cognition. The MDS documented R16 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) on his upper and lower extremities on one side of his body. The MDS documented R16 required substantial to maximum assistance with oral hygiene, bathing, toileting, and application of footwear. The MDS documented R16 was at risk for development of pressure-related injuries. The MDS documented the facility placed pressure-reducing devices on R16's bed and in the wheelchair. The Quarterly MDS dated [DATE] documented a staff interview, which documented moderately impaired cognition. The MDS documented R16 had limited ROM in his upper and lower extremities on one side of his body. The MDS documented R16 required substantial to maximum assistance with oral hygiene, bathing, toileting, lower extremity dressing, and application of footwear. The MDS documented R16 was at risk for development of pressure related injuries. The MDS documented the facility placed pressure-reducing devices on R16's bed and in the wheelchair. R16's Pressure Ulcer Care Area Assessment (CAA) dated 03/17/25 documented he was at risk for skin breakdown. R16's Care Plan, dated 09/13/24 documented pressure redistribution devices placed on the bed and wheelchair. On 09/14/25 at 10:12 AM, R16 laid asleep on his bed. R16's wheelchair was next to the bed and lacked a cushion on the chair. No wheelchair cushion was noted in R16's room. On 09/15/25 at 07:24 AM, R16 laid on the bed with the head of his bed elevated. R16's wheelchair sat next to his bed and lacked a cushion in the wheelchair. On 09/16/25 at 07:58 AM, R16 propelled his wheelchair from his room to the dining room. R16 lacked a cushion in his wheelchair. R16's right hand was tightly closed and lacked his right-hand splint. R16's right foot slid along the floor under the wheelchair as he propelled himself with his left hand. On 09/16/25 at 11:10 AM, Certified Nurse Aide (CNA) M stated the direct care staff are responsible to ensure there was a cushion in a resident's wheelchair if it had been on the resident's plan of care. On 09/16/25 at 11:26 AM, Licensed nurse (LN) G stated the nurse was the person who was responsible to ensure the cushion was in the resident's wheelchair if it was on their plan of care. LN G stated she felt the residents who used a wheelchair for transportation should have a cushion in the wheelchair to prevent skin breakdown. On 09/16/25 at 11:45 AM, Administrative Nurse D stated she expected everyone who worked with the residents to ensure the equipment they were care planned to be available and in place. Administrative Nurse D stated she expected any resident who triggered to be at risk of skin breakdown to have their pressure-reducing devices in place. The facility's Pressure Injury Prevention Management policy dated 12/03/24 documented this facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate.

The facility identified a census of 109 residents. The sample included 22 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to consistently follow a physician's order for daily weight monitoring for fluid overload and further failed to ensure Resident (R) 2's fluid restriction was monitored per the physicians' orders. Findings included:- R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of fluid overload (a condition where the body has too much fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), difficulty in walking, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), venous insufficiency (poor circulation), hypertension (HTN- high blood pressure), and acquired absence of left leg below knee. R2's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R2 was dependent on staff for toileting and needed set up or clean up assistance from staff for eating, and substantial to maximal staff assistance with bathing and dressing. The MDS documented R2 had renal insufficiency (a condition where the kidneys are unable to function properly, leading to a decrease in their ability to filter waste products from the blood and maintain fluid balance), heart failure, and hypertension. R2's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 03/30/25 documented R2's functional mobility would be addressed in R2's care plan. The CAA documented staff were to assist with activities of daily living (ADL) care as needed and anticipate care. The CAA for R2 documented therapy services would be used as needed to help increase functional mobility, and staff were to encourage R2 to participate in ADL care as much as able to promote independence.R2's Care Plan revised on 05/18/25 documented R2 had potential for dehydration/potential fluid deficit related to physician-ordered fluid restriction and history of infections. R2's care plan documented R2 required dialysis (a procedure where impurities or wastes are removed from the blood). R2's plan of care documented that nursing staff would administer medications as ordered, obtain daily weights, and call the physician if R2 gained more than three pounds in one day or five pounds in a week. R2's plan of care documented staff were to monitor and document intake and output as per facility policy. R2's EMR under the Orders tab revealed the following physician orders:Daily weights, call the physician if the patient gains more than three pounds in one day or five pounds in a week, dated 06/09/25. Fluid restriction: 1500 milliliters (ml) per day. Meals: 240 ml breakfast; 240 ml lunch; 240 ml dinner (total 720 ml). Nursing 180 ml night shift medication passes: 150 ml per medication pass for morning, noon, evening, and overnight medication pass every shift for fluid restriction related to fluid overload, dated 06/29/25.R2's EMR under the weights and Vitals tab documented weights were obtained every Monday, Wednesday, and Friday only. R2's EMR lacked weights for Tuesday, Thursday, Saturday, and Sunday.R2's EMR under the Treatment Administration Record (TAR) documented a signature by nursing for fluid restriction. R2's EMR lacked documentation of meals consumed daily. On 09/14/25 at 12:12 PM, R2 laid in her bed asleep.On 09/15/25 at 03:00 PM, R2 laid in her bed with her eyes shut.On 09/16/25 at 11:10 AM, Certified Nurse's Aide (CNA) M stated that nursing would make a list of anyone who needed to be weighed. She stated the aides obtained the weights and returned the list to the nurse. She stated she looks at the resident's care plan and communicates with her nurse to see if there were any changes with any of the residents. On 09/16/25 at 11:27 AM, Licensed Nurse (LN) G stated the nurses gave the CNA staff a list of residents needed weighted for the day. LN G stated the nurse should follow up to ensure the weights were done and call the physician if needed. LN G stated if a resident was on fluid restriction, the staff would give the resident what fluids the resident asked for, and the nurse would educate the resident on how much fluid the resident could consume for the day.On 09/16/25 at 11:45 PM, Administrative Nurse D stated nursing was to ensure weights were obtained. Administrative Nurse D said nurses would then report to the physician or follow the orders as prescribed. Administrative Nurse D stated that the fluid restrictions were hard to obtain accurate intake, and she stated R2 was not compliant with her fluid restriction. The facility's Fluid Restrictions policy dated 03/26/25 documented it was the policy of this facility to ensure that fluid restrictions would be followed in accordance with the physician's orders. Fluid restrictions were basically the restriction of fluid intake. This may be due to underlying medical conditions that may cause fluid buildup, such as congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), or end-stage renal disease (ESRD- a terminal disease of the kidneys). In addition to electrolyte imbalance disorders such as hyponatremia (insufficient sodium in the blood), fluid restriction amounts can vary according to the resident's condition and the physician's judgment.The facility's Weight Monitoring policy dated 10/30/24 documented based on the resident's comprehensive assessment, the facility would ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident's preferences indicated otherwise.

The facility identified a census of 109 residents. The sample included 22 residents. Based on observation, record review, and interviews, the facility failed to identify the significant change in Resident (R) 54's condition and complete a comprehensive Significant Change Minimum Data Set (MDS) with the discontinuance of hospice services. Findings included: - R54's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), age related cognitive (relates to the processes of the mind, such as thinking, learning, remembering, and understanding) decline, hypertension (HTN- elevated blood pressure), lack of coordination, muscle weakness, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought).The Quarterly MDS dated 11/23/23, documented R54 received hospice services.The Quarterly MDS dated 02/23/24, documented R54 received hospice services.The Annual MDS dated 05/23/24, documented R54 did not receive hospice services.The Quarterly MDS dated 08/23/24, documented R54 did not receive hospice services. The Quarterly MDS dated 02/23/25, documented R54 received hospice services.The Annual MDS dated 04/25/25, documented R54 received hospice services. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R54 was dependent on staff for all activities of daily living (ADL). The MDS documented R54 received hospice services. R54's Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA) dated 04/24/25 documented R54's cognition would be addressed in R54's care plan with her goals. The CAA documented staff would monitor for signs and symptoms of acute mental status changes and treat the underlying condition. The CAA documented staff would communicate using short and simple sentences to allow adequate time for R54 to understand others and for her to communicate her needs. The CAA documented staff were to approach R54 in a calm and non-threatening manner to help R54 to feel calm and unhurried, and her BIMS was to be completed quarterly and as needed to help monitor for trends in cognition. R54's Care Plan dated 11/02/24 documented R54's Hospice Services were discontinued, and R54 received palliative care, starting 11/02/24, with a diagnosis of senile degeneration of the brain (a progressive decline in cognitive function that occurs with aging). The plan of care for R54 documented symptoms would be managed with current interventions through the next review date, as evidenced by no signs and symptoms of air hunger (unable to get air), pain, agitation, and restlessness. The plan of care for R54 documented staff would assess for pain, restlessness, agitation, constipation, and other symptoms of discomfort, give medication as ordered, and evaluate effectiveness. Bereavement service provided by the palliative team as needed to help with grief and loss; provide R54 and my family support, including caregivers and other residents, before and after death.A review of R54's clinical record lacked evidence the facility completed a Significant Change MDS to address the resident's discontinuance of hospice services. On 09/14/25 at 09:42 AM, R54 laid in her bed, in her room.On 09/15/25 at 10:50 AM, R54 laid in her bed, in her room.On 09/16/25 at 11:45 AM, Administrative Nurse D stated she was unaware that a Significant Change MDS needed to be done, going off hospice services or going on palliative care services. The facility's Maintaining Minimum Data Set Assessments dated 09/18/24, documented the facility would maintain all resident assessments completed within the previous 15 months in the resident's active clinical record. The form of storage may be electronic or hard copy. The facility would maintain all MDS records for 15 months after the completion date, including: Comprehensive Assessment Records, Quarterly Assessment Records, CAA Summary, Entry, Reentry, and Death Tracking Records, Discharge Assessment Records - planned and unplanned Correction Request Forms (including signed attestation), and payment assessments.

The facility identified a census of 109 residents. The sample included 22 residents, with four sample residents reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17, R87, and their representatives were provided bed hold and a written notification of transfer, as soon as practicable, upon their transfer to the hospital. The facility failed to ensure R76, and his/her representative was provided a bed hold, as soon as practicable, upon transfer from the facility. Findings included: - R17's Electronic Medical Record (EMR) included diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), venous insufficiency (poor circulation), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), heart failure, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), morbid obesity (excessive body fat) with alveolar hypoventilation (condition where the lungs do not adequately exchange carbon dioxide and oxygen), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and encephalopathy (a broad term for any brain disease that alters brain function or structure). R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R17 had intact cognition, required partial/moderate assistance with toileting hygiene, bathing, lower body dressing, rolling side to side in bed, and sitting to lying in bed. R17's MDS documented that R17 received a scheduled pain medication regimen, had pain that interfered with therapy activities, sleeping, and day-to-day activities. The MDS further documented that R17 experienced shortness of breath or trouble breathing when lying flat and used oxygen and a non-invasive mechanical ventilator (a method of delivering pressurized breathing support through a mask). R17's Discharge MDS, dated [DATE], recorded a Discharge Return Anticipated of unplanned short-term general hospital discharge status. On 07/24/25, R17's MDS recorded an entry into the facility. The Progress Note dated 07/20/25 at 02:48 PM documented R17's oxygen levels had been running lower than usual, with complaints of having a hard time catching her breath. Respiratory Therapy checked the carbon monoxide level, and the physician was notified of R17's condition. The Progress Note further documented that the physician ordered R17 to be sent to the emergency department. The Director of Nursing, along with the R17 family member, was notified of the transfer to the emergency department. The Progress Note dated 07/24/25 at 06:26 PM documented R17 returned to the facility from the hospital. On 09/15/25 at 09:09 AM, R17 ate breakfast in her bed, wearing oxygen via nasal canula. R17 reported the swelling in her legs had improved. R17 reported painful joints, but this was not new pain to her related to the joints wearing out due to her age. On 09/15/25 at 01:41 PM, Licensed Nurse (LN) I and LN H reported that the nurse filled out the Bed Hold Assessment in the resident's EMR when a resident was sent to the hospital. LN I and LN H stated that the nursing staff did not obtain a written form or have the resident or resident representative sign a Bed Hold. On 09/16/25 at 08:31 AM, Social Service X stated that recently the facility owner corporation had given direction that a written bed hold was to be obtained from the resident or resident representative at the time of discharge, if possible, but due to the nature of emergencies, the bed hold could be given the next day. On 09/16/25 at 08:00 AM, Administrative Nurse E reported she was not aware of the facility's policy for who was responsible for the Bed Hold procedure, due to being new to the role of Administrative Nurse at this facility. The facility's Bed Hold Notice policy, dated 02/05/25, documented that it was the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance and at the time of a transfer for hospitalization or therapeutic leave. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident's representative within 24 hours. The facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility would keep a signed and dated copy of the bed-hold notice information given to the resident and or resident representative in the resident's file and/or medical record. - R87's Electronic Medical Record (EMR) documented diagnoses of transient cerebral ischemic attack (TIA- mini-stroke- is a temporary blockage of blood flow to the brain that causes stroke-like symptoms but resolves on its own, typically within minutes to hours and before permanent damage occurs), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a chronic condition where the heart can't pump enough blood and oxygen to meet the body's needs), and pulmonary embolism (condition where a blood clot travels from another part of the body, usually the legs, and blocks one or more arteries in the lungs). R87's admission Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R87 had a functional limitation in range of motion of both upper and lower extremities on both sides. R87 was dependent on staff for all his activities of daily living (ADL) cares. R87 used a wheelchair to assist with mobility. R87's overall goal was to remain in the facility. R87 had active discharge planning occurring for the resident to return to the community. R87's Discharge MDS dated 07/15/25 documented an unplanned discharge to an acute hospital with a return anticipated. R87's Entry MDS dated 07/18/25 documented a re-entry to the facility from an acute hospital. Upon R87's transfer to the hospital on [DATE], the facility failed to provide R87 and or his representative with the bed hold policy and a written notification of transfer as required. R87's Functional Abilities Care Area Assessment (CAA) dated 03/27/25 documented that staff were to assist with ADL cares as needed, anticipating cares, so that care needs were effectively met. Therapy services were to be used as needed to help increase functional mobility. Staff to encourage R87 to participate in ADL cares as much as able and promote independence. R87's Care Plan, initiated on 03/08/25, revised on 07/18/25, directed staff that R87's discharge plan was to go home with home health services and family. The Care Plan directed staff to review R87's discharge plan quarterly in the care plan meetings. The Care Plan directed staff that therapy was to assist with R87's goal of going home. On 09/15/25 at 10:15 AM, R87 laid in his bed watching TV. On 09/16/25 at 08:15 AM, Administrative Nurse E stated there had been a lack of understanding on who was responsible for ensuring the bed hold was completed. Administrative Nurse E stated nursing thought it was social services' responsibility, and social services thought it was a nursing responsibility. On 09/16/25 at 08:22 AM, Social Services X stated she had thought that the bed hold was a nursing responsibility to complete, so the bed holds were not being completed as required. Social Services X stated she was unsure about the written notification upon transfer. On 09/16/25 at 08:31 AM, Administrative Staff B stated the bed hold had not been provided as required, but would be from here on out. Administrative Staff B stated she had been misinformed on what was required for the bed hold. Administrative Staff B stated the facility had not been providing the written notification of transfers to residents and their representatives, either, but would begin doing so as of today. The facility's Bed Hold Notice policy dated 02/05/25 documented it was the policy of the facility to provide written information to the resident and or the resident representative regarding bed hold practices, both well in advance and at the time of a transfer for hospitalizations or therapeutic leave. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies: The duration of the State bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility; The reserve bed payment policy in the state plan policy, if any. The facility policies regarding bed-hold periods include allowing a resident to return to the next available bed. Conditions upon which the resident would return to the facility: The resident required the services which the facility provides; The resident was eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility would keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. The facility would provide this written information to all facility residents, regardless of their payment source. The facility lacked a policy regarding written notification upon transfers. - R76's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), non-pressure chronic ulcer of left foot, major depressive disorder (major mood disorder that causes persistent feelings of sadness), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), heart failure, acquired absence of right leg below the knee, fracture (broken bone) of left femur (broken bone), sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R76's Quarterly/Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R76 had intact cognition, required substantial to maximal assistance with toileting hygiene, and sitting to lying and lying to sitting. The MDS documented R76 needed partial to moderate assistance with lower-body dressing. The MDS documented R76 had pain occasionally, which affected sleep, day-to-day activities, and interfered with therapy activities. The MDS further documented that R76 had one unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R76's Discharge MDS dated [DATE] recorded a Discharge Return Anticipated of unplanned short-term general hospital status. On 06/11/25, R76's MDS recorded an entry into the facility. On 09/15/25 at 02:22 PM, R76 lay in bed, listening to music on his phone. R76 talked about his return to the facility from the hospitalization, reporting he was doing well. On 09/15/25 at 01:41 PM, Licensed Nurse (LN) I and LN H reported that the nurse filled out the Bed Hold Assessment in the resident's EMR when a resident was sent to the hospital. LN I and LN H stated that the nursing staff did not obtain a written form or have the resident or resident representative sign a Bed Hold. On 09/16/25 at 08:31 AM, Social Service X stated that recently, the facility owner corporation had given direction that a written bed hold was to be obtained from the resident or resident representative at the time of discharge, if possible, but due to the nature of emergencies, the bed hold could be given the next day. On 09/16/25 at 08:00 AM, Administrative Nurse E reported she was not aware of the facility's policy for who was responsible for the Bed Hold procedure, due to being new to the role of Administrative Nurse at this facility. The facility's Bed Hold Notice policy, dated 02/05/25, documented that it was the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance and at the time of a transfer for hospitalization or therapeutic leave. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident's representative within 24 hours. The facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility would keep a signed and dated copy of the bed-hold notice information given to the resident and or resident representative in the resident's file and/or medical record.

The facility had a census of 109 residents. The sample included 22 residents. Based on record review and interviews, the facility failed to submit complete and accurate staff information through Payroll-Based Journal (PBJ) as required.Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2024 Quarter (Q) 4 and FY 2025 Q1, Q2, Q3 indicated excessively low weekend staffing.A review of the facility's weekend and licensed nurse hours revealed appropriate weekend and licensed nurse coverage.On 09/16/25 at 11:32 AM, Administrative Staff A reported she was responsible for the PBJ submissions. Administrative Staff A reported the use of a software program to verify hours before submission and had made some changes related to removing ancillary staff from the total hours. Administrative Staff A stated the weekend staffing patterns for licensed nurses remained the same.The facility's Payroll Based Journal policy, dated 02/25/25, documented the facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

The facility identified a census of 102 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1, a cognitively impaired resident, remained free from staff-to-resident abuse. On 10/31/24, Certified Nurse Aide (CNA) M and CNA N got R1 ready for a shower. R1 started yelling and swatted at CNA M. CNA M swatted at R1 in return. After CNA M and CNA N got R1 up with the Hoyer lift (full body mechanical lift) and into the shower chair. R1 yelled loudly, and CNA M put her hand on R1's mouth and told R1 to hush. This deficient practice resulted in impaired psychosocial well-being for R1 and placed R1 at risk for continued abuse. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebrovascular disease (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, cognitive communication deficit, speech and language deficits following cerebrovascular disease, and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated R1 was unable to complete the interview. R1 had no behaviors. R1 had impairment on one side of both upper and lower extremities. R1 was dependent on staff for transfers. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of five which indicated severe cognitive impairment. R1 had no behaviors. R1 had impairment on one side of both upper and lower extremities. R1 was dependent on staff for transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/26/24, documented R1 had impaired cognition. The Functional Abilities/Rehabilitation Potential CAA dated 03/26/24, documented R1 required assistance with activities of daily living (ADL). R1's Care Plan dated 07/06/22, documented R1 had impaired cognitive function or impaired thought processes related to short-term memory loss and directed staff to approach R1 in a gentle, friendly, and unhurried manner. R1's Care Plan dated 02/06/23, documented R1 required moderate to extensive dependence on staff for ADLs and directed two staff to transfer R1 with a Hoyer lift using a medium or large lift sling. R1's Care Plan dated 07/27/23, documented R1 resisted care related to anxiety and directed staff to allow her to make decisions about her treatment regime, encouraged R1 to participate as much as possible during care activities, give R1 a clear explanation of all care activities as they occurred with each contact, and praised R1 for appropriate behaviors. The facility's Investigation dated 11/07/24, documented on 10/31/24 at around 04:35 PM, Administrative Nurse D notified Administrative Staff A that CNA N witnessed CNA M put her hand over R1's mouth to keep her from screaming and that CNA M swatted at R1's hand and told her to be quiet. CNA O also witnessed CNA M tell R2 she could not have any more soda and R2 was being annoying. The facility suspended CNA M immediately pending an investigation. Administrative Nurse E assessed R1 without any findings of redness or bruising. The facility notified R1's representative, R1's provider, and law enforcement. The facility investigation substantiated that CNA M was abusive to R1 and R2 and terminated her on 11/07/24 . In CNA N's Witness Statement dated 10/31/24, CNA N stated she and CNA M were getting R1 up for a shower on 10/31/24 and R1 started yelling and screaming. She stated CNA M yelled at R1 and said she was not doing that [expletive] and told R1 to quit her [expletive] too. CNA N stated as she and CNA M got R1 into the wheelchair, R1 started hitting CNA M in the head. CNA N stated CNA M swatted at R1 and told her to be quiet. CNA M also put her hand over R1's mouth as well and taunted R1, making R1 more upset. CNA N stated she felt uncomfortable being in the room with CNA M and she felt bad for R1 as she did not deserve to be treated that way. In CNA M's Witness Statement dated 10/31/24, CNA M stated that on 10/31/24, she did not swat at R1, but she moved R1's hand into the sling so it would not get hurt. CNA M stated she did not put her hand on R1's mouth or touch her in any way that would have hurt R1. In Administrative Nurse E's Witness Statement dated 10/31/24, Administrative Nurse E stated after staff informed her of the incident between CNA M and R1, she went to R1's room to perform a skin assessment. She stated R1 had no obvious skin issues, however, R1 kept using her left arm and motioned towards Administrative Nurse E's arm then R1 grabbed Administrative Nurse E's forearm tightly then let go. Administrative Nurse E stated R1 stated no, then took her hand and covered her mouth with it. Administrative Nurse E asked R1 if CNA M covered her mouth and R1 yelled yes as she nodded her head up and down. Administrative Nurse E informed R1 that the facility took care of the situation and R1 thanked her. On 11/12/24 at 01:09 PM, R1 sat in her wheelchair in her bedroom and watched television. She did not remember staff putting their hands on her mouth on 10/31/24. On 11/12/24 at 12:44 PM, CNA N revealed that on 10/31/24, she and CNA M were getting R1 up for a shower between 10:00 AM and 11:00 AM and R1 started yelling. She said she could tell CNA M was getting agitated as R1 was refusing the shower. CNA N said that while they got R1 up, R1 started yelling more and swatting at CNA M. She stated that CNA M swatted back at R1 and taunted her instead of walking away. CNA N said once they had R1 up with the lift and into the shower chair, R1 yelled very loudly, and CNA M put her gloved hand over R1's mouth and told her to hush. She said CNA M said she was not dealing with that [expletive] and told R1 she did not have to deal with R1's [expletive]. CNA N stated she took R1 out of the room and showered her. She said after R1's shower, she took a 15-minute break because she needed a breather and needed to figure out how to handle the situation. CNA N stated she came back in and went to help CNA O with R2. CNA N stated after CNA M told R2 she could not have any more soda, she and CNA O reported to Administrative Nurse D what happened with CNA M and R2 and what happened earlier with CNA M and R1. On 11/12/24 at 12:57 PM, CNA M said she helped CNA N get R1 up for a shower and R1 became agitated and screamed a lot. She said she helped move R1 into her bed after her shower and she moved R1's arm over into the sling and tried to calm her down. CNA M said R1 became agitated before the shower and had become aggressive and hit CNA M a couple of times. CNA M stated she did not put her hand over R1's mouth and never hit her. On 11/12/24 at 01:27 PM, Administrative Nurse E said she had CNA M in her office for being rude to another resident when there was a knock at the door and Administrative Nurse D stepped out. She said that CNA N told Administrative Nurse D what happened with R1, and Administrative Nurse D told Administrative Nurse E they had a bigger issue and Administrative Nurse E went into the hallway. She stated she told CNA M to stay in the office then she and Administrative Nurse D went into Administrative Staff A's office to report what happened with CNA M. Administrative Nurse E said she talked to R1, who was unable to make out sentences, but when asked if she was okay, R1 grabbed Administrative Nurse E's arm and made a smacking motion then made a motion over her mouth. Administrative Nurse E stated she asked R1 if CNA M put her hand over R1's mouth and she stated yes. She stated she had not been notified that CNA M had swatted at R1's arm so when she came out of her room, she asked CNA N if CNA M had smacked R1. Administrative Nurse E said CNA N stated that CNA M swatted at R1's hand because R1 smacked CNA M. Administrative Nurse E stated CNA M talked to the police, filled out a witness statement, clocked out, and left the faciity on suspension. On 11/12/24 at 01:36 PM, Administrative Nurse D stated somebody had written up a grievance about CNA M so she talked to CNA M on 10/31/24 about customer service. She stated while CNA M was in the office, CNA N knocked on the door so Administrative Nurse D stepped out into the hallway. Administrative Nurse D stated CNA N reported that CNA M put her hand over R1's mouth and swatted at the resident. She stated she told CNA M to stay in the office then she reported the incident to Administrative Staff A. Administrative Nurse D stated she had CNA M fill out a witness statement then CNA M talked to law enforcement and the facility suspended her pending an investigation. Administrative Nurse D stated Administrative Nurse E talked to R1 and R1 motioned that her mouth was covered and she was smacked. She stated CNA M denied touching R1. She stated if staff got frustrated during care, she expected staff to make sure the resident was safe and then reapproach them later or find someone else who could help them. On 11/12/24 at 03:10 PM, Administrative Staff A stated that on 10/31/24, she was in an interview with law enforcement when Administrative Nurse D and Administrative Nurse E knocked on her door to report that CNA M put her hand on R1's face and slapped her arm. She stated she immediately called CNA M into the office with law enforcement, and CNA M gave her a statement and then wrote a witness statement. Administrative Staff A stated she informed CNA M of her suspension pending the active investigation. During the investigation, Administrative Nurse E assessed R1 and R1 gestured slapping her arm and covering her mouth. Administrative Staff A stated she terminated CNA M after that. She stated she expected staff to report abuse concerns immediately after an incident. Administrative Staff A stated if staff became frustrated during care, she expected them to step out and take a break or let someone else take care of their load until the frustration passed. The facility's Abuse, Neglect, and Exploitation policy, dated 2024, directed the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. The facility failed to prevent staff-to-resident abuse for R1 on 10/31/24. This deficient practice resulted in impaired psychosocial well-being for R1 and placed R1 at risk for continued abuse. The facility put the following corrections into place before the onsite visit: The facility suspended CNA M immediately on 10/31/24. Administrative Nurse E assessed R1 with no injuries found on 10/31/24. The facility notified R1's representative, R1's provider, and law enforcement on 10/31/24. The facility obtained witness statements on 10/31/24. The facility conducted abuse, neglect, and exploitation training on 10/31/24. The facility interviewed residents with high BIMS on 11/01/24 regarding abuse. Social Services followed up with R1 on 11/06/24. The facility updated R1's care plan on 11/07/24. The facility terminated CNA M on 11/07/24. Because the facility implemented and completed the corrections before the onsite survey, this deficient practice was cited as past noncompliance. The scope and severity remain a G based on the reasonable person concept due to the circumstances of R1's cognitive impairment and inability to fully express her feelings.

The facility identified a census of 102 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure staff immediately reported staff-to-resident abuse for R1 on 10/31/24. This deficient practice placed R1 at risk for further abuse. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebrovascular disease (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, cognitive communication deficit, speech and language deficits following cerebrovascular disease and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated R1 was unable to complete the interview. R1 had no behaviors. R1 had impairment on one side of both upper and lower extremities. R1 was dependent on staff for transfers. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of five which indicated severe cognitive impairment. R1 had no behaviors. R1 had impairment on one side both upper and lower extremities. R1 was dependent on staff for transfers. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 03/26/24, documented R1 had impaired cognition. The Functional Abilities CAA dated 03/26/24, documented R1 required assistance with activities of daily living (ADLs). R1's Care Plan dated 07/06/22, documented R1 had impaired cognitive function or impaired thought processes related to short-term memory loss and directed staff to approach R1 in a gentle, friendly, and unhurried manner. R1's Care Plan dated 02/06/23, documented R1 required moderate to extensive dependence on staff for ADLs and directed two staff transfer R1 with a Hoyer lift using a medium or large lift sling. R1's Care Plan dated 07/27/23, documented R1 resisted care related to anxiety and directed staff to allow her to make decisions about her treatment regime, encouraged R1 to participate as much as possible during care activities, gave R1 a clear explanation of all care activities as they occurred with each contact, and praised R1 for appropriate behaviors. The facility's Investigation, dated 11/07/24, documented on 10/31/24 at around 04:35 PM, Administrative Nurse D notified Administrative Staff A that CNA N witnessed CNA M put her hand over R1's mouth to keep her from screaming and that CNA M swatted at R1's hand and told her to be quiet. CNA O also witnessed CNA M tell R2 she could not have any more soda and R2 was being annoying. The facility suspended CNA M immediately pending an investigation. Administrative Nurse E assessed R1 without any findings of redness or bruising. The facility notified R1's representative, R1's provider, and law enforcement. The facility investigation substantiated that CNA M was abusive to R1 and R2 and terminated her on 11/07/24. In CNA N's Witness Statement dated 10/31/24, CNA N stated she and CNA M were getting R1 up for a shower on 10/31/24 and R1 started yelling and screaming. She stated CNA M yelled at R1 and said she was not doing that [expletive] and told R1 to quit her [expletive] too. CNA N stated as she and CNA M got R1 into the wheelchair, R1 started hitting CNA M in the head. CNA N stated CNA M swatted at R1 and told her to be quiet. CNA M also put her hand over R1's mouth as well and taunted R1, making R1 more upset. CNA N stated she felt uncomfortable being in the room with CNA M and she felt bad for R1 as she did not deserve to be treated that way. On 11/12/24 at 01:09 PM, R1 sat in her wheelchair in her bedroom and watched television. She did not remember staff putting their hands on her mouth on 10/31/24. On 11/12/24 at 12:44 PM, CNA N revealed that on 10/31/24, she and CNA M were getting R1 up for a shower between 10:00 AM and 11:00 AM and R1 started yelling. She said she could tell CNA M was getting agitated as R1 was refusing the shower. CNA N said that while they got R1 up, R1 started yelling more and swatting at CNA M. She stated that CNA M swatted back at R1 and taunted her instead of walking away. CNA N said once they had R1 up with the lift and into the shower chair, R1 yelled very loudly, and CNA M put her gloved hand over R1's mouth and told her to hush. She said CNA M said she was not dealing with that [expletive] and told R1 she did not have to deal with R1's [expletive]. CNA N stated she took R1 out of the room and showered her. She said after R1's shower, she took a 15-minute break because she needed a breather and needed to figure out how to handle the situation. CNA N stated she came back in and went to help CNA O with R2. CNA N stated after CNA M told R2 she could not have any more soda, she and CNA O reported to Administrative Nurse D what happened with CNA M and R2 and what happened earlier with CNA M and R1. On 11/12/24 at 02:45 PM, Certified Medication Aide (CMA) R stated if she witnessed abuse, she stopped the abuse, removed the abuser from the room, and notified the nurse immediately. She stated she reported any abuse concerns immediately and used the abuse calling chain which included calling the numbers on the chain until she spoke with someone personally. On 11/12/24 at 02:56 PM, Licensed Nurse (LN) G stated if she witnessed abuse, she separated the abuser from the victim and reported it immediately. She stated the facility had an abuse calling tree that included Administrative Staff A, Administrative Nurse D, Administrative Nurse E, and social services. LN G stated she reported any concerns of abuse immediately, she did not take a break then report her concerns. On 11/12/24 at 02:30 PM, Administrative Nurse D stated she assumed CNA N reported the incident between CNA M and R1 immediately. She stated she did not know CNA N took a break before reporting the incident. On 11/12/24 at 03:10 PM, Administrative Staff A stated that she expected staff to report abuse concerns immediately after an incident. On 11/14/24 at 01:34 PM, CNA N stated she remembered that 10/31/24 was half a shift so she did not come in until noon. She stated she was confused regarding the time of the event on 10/31/24. She stated on 10/31/24, she started work at 12:00 PM, and about 30 minutes to an hour later, she helped CNA M get R1 up for a shower. CNA N stated that R1 had bowel movement all over her and CNA M decided she needed a shower. She stated R1 screamed and swatted at CNA M then CNA M swatted back at R1 and taunted R1. CNA N stated once they lifted R1 up in the Hoyer lift to put her in the shower chair, R1 yelled loudly, and CNA M used her gloved hand to cover her mouth once they put her in the shower chair. She stated she took R1 out of the room and gave her a shower. CNA N stated when she was done with the shower, CNA M helped her lay R1 down in bed. She stated she needed a breather for her mental health after the incident and went outside. CNA M stated when she came back in, CNA O needed help getting R2 up so she did that and then she reported what she had witnessed earlier to Administrative Nurse D. She stated she thought she had 24 hours to report abuse which she did and did not know she needed to report abuse immediately. The facility's Abuse, Neglect, and Exploitation policy, dated 2024, directed the facility provided protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. The policy directed staff to report all alleged violations to the administrator immediately but not later than two hours after the allegation is made if the events that caused the allegation involved abuse or resulted in serious bodily harm. The facility failed to ensure staff reported staff-to-resident abuse for R1 immediately. This deficient practice placed R1 at risk for further abuse.

The facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview and record review, the facility failed to ensure its certified nurse aides (CNA) received 12 hours in-services annually as required. This deficient practice placed the 100 residents of the facility at risk for inadequate care. Findings included: - The facility provided a list of CNAs who had worked at the facility for more than one year and the in-service records for those staff The facility lacked evidence that any of the aides had the required 12 hours of in-services for 2023. On 01/24/24 at 11:10 AM, Administrative Nurse D verified the facility had not provided the required 12 hours of in-services annually for their CNA staff. The facility's Required Training, Certification and Continuing Education of Nurse Aides policy, dated 01/09/24, stated it was the policy of the facility to comply with State and Federal regulation and requirements pertaining to training, certification, and continuing education of its nurse aides. The policy stated the facility would provide at least 12 hours of in-service training annually, based on the employment date and documentation of in-services would be maintained in the employee's personnel file. Minimum training would include dementia management; abuse, neglect, and exploitation prevention; resident rights; infection prevention and control; safety and emergency procedures; behavioral health; and identification of changes in condition. The facility failed to ensure CNA staff received 12 hours in-services annually as required. This deficient practice placed the 100 residents of the facility at risk for inadequate care.

The facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to promote and provide dignity for Resident (R) 28, who had an uncovered urinary catheter (insertion of a catheter into the bladder to drain the urine) bag. The facility further failed to promote dignity and respect during dining for the 15 residents seated in the dining room when staff discussed their personal issues and looked at their cell phones when assisting residents in eating the meal. These deficient practices placed the residents at risk for an undignified experience and impaired quality of life. Findings included: - On 01/22/24 at 05:10 PM, observation revealed R28 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. Further observation revealed an uncovered urinary catheter bag hung on the side of R28's chair with clear yellow urine. On 01/23/24 at 11:50 PM, observation revealed R28 sat in a Broda chair at the dining table. An uncovered urinary catheter bag hung on the side of the chair. On 01/24/24 at 08:10 AM, observation revealed R28 sat in the hallway outside of his room in a Broda chair. Further observation revealed an uncovered urinary catheter bag hung on the side of his chair. On 01/23/24 at 12:30 PM, observation revealed four direct care staff sat at an assisted dining table with residents. The staff discussed personal issues and looked at one of the staff member's cell phones. The staff discussed what was on the cell phone, while at the same time giving residents bites of food. The residents were not included in the conversation. There were 15 residents in the dining room during this occurrence. On 01/25/24 at 09:00 AM, Administrative Nurse D verified R28's urinary catheter bag should be covered. Administrative Nurse D also verified direct care staff should not discuss personal issues and not be on their cell phones when assisting residents with their meals. The facility's Promoting/Maintaining Resident Dignity policy, dated 01/09/24, stated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life. The facility failed to promote and maintain dignity for R28 by not covering his urinary catheter. The facility further failed to promote and provide dignity for residents during dining. These deficient practices placed the residents at risk for an undignified experience and impaired quality of life.

The facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to provide activities of daily living (ADL)care and assistance to Resident (R) 28, R38, R18, and R61. This deficient practice placed the residents at risk for poor hygiene and impaired dignity. Findings included: - R28's Electronic Medical Record (EMR) documented R28 had diagnoses of urinary retention (lack of ability to urinate and empty the bladder), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four indicating severely impaired cognition. The MDS further documented R28 required moderate staff assistance with dressing, grooming, and personal hygiene. R28's Care Plan dated 01/03/24 directed the staff to provide R28 assistance with dressing, grooming, and changing his clothes as needed. The plan directed staff to shave R28 three times a week. On 01/22/24 at 05:10 PM, observation revealed R28 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline). Further observation revealed the resident was unshaven. His hands and nails were visibly soiled with a dark brown and yellow substance. He wore a gray shirt with large, dried spots of yellow on the front. On 01/23/24 at 10:10 AM, observation revealed R28 sat in a Broda chair in front of the TV in the dining room. Further observation revealed the resident remained unshaven. His hands and nails continued to be visibly soiled with a dark brown and yellow substance. He still wore a gray shirt with large, dried spots of yellow on the front. He had a green and yellow substance on his face, around his mouth. On 01/24/24 at 01:30 PM, observation revealed R28 sat in a Broda chair in front of the TV in the dining room. Further observation revealed the resident remained unshaven, with visibly soiled hands and nails. R28 continued to wear a soiled gray shirt and had a green and yellow substance on his face around his mouth. On 01/24/24 at 03:00 PM, Certified Nurse Aide (CNA) N stated staff were to assist the resident with shaving, changing his clothes, and cleaning his hands and mouth. On 01/25/24 at 09:00 AM, Administrative Nurse D verified R28 required staff assistance with dressing, grooming, and personal hygiene. Administrative Nurse D stated she expected direct care staff to provide the required assistance for R28. The facility's policy for Activities of Daily Living, dated 01/09/24, states a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal care. The facility failed to provide ADL assistance for R28, placing him at risk for poor hygiene and impaired dignity. 32358 - R38's Electronic Medical Record (EMR) documented R38 had diagnoses of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder(major mood disorder which causes persistent feelings of sadness), muscle weakness, extrapyramidal (movement disorders as a result of taking certain medications), and movement disorder( refers to a group of nervous system (neurological) conditions that cause you to have abnormal voluntary( controllable muscular actions ) or involuntary ( abnormal and uncontrollable muscular actions that occur without conscious effort or intention) movements, or slow, reduced movements). R38's Annual Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated severe cognitive impairment. The MDS documented R38 required supervision with bathing. The MDS documented it was very important to R38 to choose between a tub bath, shower, bed bath, or sponge bath. The Care Area Assessment (CAA), dated 11/14/23, documented the resident had impaired cognition and required assistance with activities of daily living (ADLs). The CAA instructed staff to assist R38 with ADLs and encourage R38 to participate in ADL care as much as able to to promote independence. R38's Care Plan revised 01/03/24, documented R38 required one staff assistance with showering. The care plan documented R38 would often refuse bathing and refuse staff assistance to clean, comb her hair, or have it cut. The care plan instructed staff to continue to offer bathing/showers and remind R38 of the importance of hygiene and offer her washcloths and soapy water for sponge bathing if she continued to refuse a bath/shower. The Body Audit Communication Form for Shower/Bathing documented during the last four months R38 received a shower on 10/12/23. The Shower Sheets revealed R38 received a shower on the following dates: September 2023 - 11,21,23 October 2023 - 10.17.30 November 2023 -13 December 2023 - 18, January 2024 - 23 On 01/23/24 at 07:27 AM, observation revealed R38 independently ambulated from her room to the dining room with a black short-sleeve shirt over a long-sleeved white shirt with red airplanes and navy slacks. R38 had matted hair all over her head. On 01/24/24 at 07:35 AM, observation revealed R38 sat on a love seat, in the living area, by the dining room. She wore the same clothes she wore the prior day and had matted hair all over her head. On 01/25/24 at 07:45 AM, observation revealed R38 sat in the love seat in the living room area by the dining room with the same clothes she wore the prior day and had matted hair all over her head. Observation revealed R38 scratched her head with her fingers and could not get her fingers through the matted part of her hair. On 01/24/24 at 2:00 PM, Certified Medication Aide (CMA) R stated R38 recently had an episode of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and, had to be hospitalized . CMA R stated R38 refused bathing because the resident thought there was lysergic acid diethylamide (LSD- a mind-altering drug) on the shower floor. CMA R stated R38 would not let staff touch her hair since she came back from the hospital, but R38 tried to untangle her hair but instead pulled it out. CMA R stated R38 had a lot more hair before the hospital visit. On 01/24/24 at 02:15 PM, Licensed Nurse (LN) K stated R38 had not received a shower for a long time because she refused as she believed there were drugs on the floor. LN K stated when R38 did agree at times to give herself a sponge bath in a sink in her room, staff put soap and water in a basin and R38 washed herself. LN K stated R38 did not wash her hair. LN K stated night shift staff were supposed to lay out clean clothes for R38 to wear the next day, but R38 often refused to wear them and would throw them on the floor. LN K stated R38 often wore the same clothes to bed that she had worn all day. On 01/24/24 at11:45 AM, Administrative Nurse F verified the above documentation regarding R38's bathing record and stated R38 was a hard one to get to take a shower and wash her hair because the resident thought the shower floor had LSD on it, so often refused to take one. Administrative Nurse F stated staff offered to let her go to the beautician to get her hair washed and cut but she refused as the resident was afraid if she did, she would not have any hair left. Administrative Nurse F stated R38 had a basin and washcloths in her bathroom so she could take a sponge bath herself. The facility's Bathing a Resident Policy, revised 02/09/24, documented It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The facility failed to provide bathing regularly for R38. This placed the resident at risk for poor personal hygiene. 32360 - The Electronic Medical Record (EMR) for R18 had diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), a history of urinary tract infections (an infection in any part of the urinary system), and mixed incontinence (involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing, or coughing). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition, and was dependent upon staff for toileting, transfers, and bed mobility. R18 required substantial to maximum assistance with mobility and personal hygiene. The MDS further documented R18 had no upper or lower impairment and no falls. R18 had moisture-associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucous) and a turning and repositioning program. The Quarterly MDS, dated [DATE], documented R18 had severely impaired cognition, inattention, and disorganized thinking. R18 was dependent upon staff for toileting and transfers and required substantial to maximum assistance with mobility and personal hygiene. The MDS further documented R18 had two or more non-injury falls. R18 had upper and lower impairment on one side and had no skin issues. R18's Bowel and Bladder Assessment, dated 12/28/23, documented R18 was unable to participate in bowel and bladder training, was incontinent daily, and was sometimes aware of toileting needs. R18's Care Plan, dated 01/03/24, initiated on 04/24/20, documented R18 was incontinent and directed staff to offer toileting upon rising, before and after meals, at bedtime, and as needed. The update, dated 05/13/20, directed staff to observe R18's skin daily while providing activities of daily living assistance, report any changes to the nursing staff, and use a commercial moisture barrier on the skin as indicated. The update, dated 10/15/20, directed staff to provide good peri-care after incontinent episodes and use barrier cream as needed. On 01/24/24 at 07:30 AM, observation revealed R18 sat in the dining room in her wheelchair. On 01/24/24 at 07:45 AM, the surveyor requested to observe a transfer, repositioning, and care for R18. Certified Nurse Aide (CNA) N stated R18 would not be repositioned until after lunchtime. On 01/24/24 at 01:45 PM, observation revealed CNA M and CNA N attached the sling to the full lift and transferred R18 into bed. Further observation revealed CNA N removed R18's shoes and pants, loosened her incontinence brief, and assisted her to her right side. R18's buttocks were red and excoriated (raw and irritated). CNA N stated the redness was from staff not applying barrier cream on R18 when staff changed her brief. CNA N further stated that R18 should be repositioned every two hours but had been up since 06:00 AM, as staff were busy, and staff had not had time to check and change R18 or reposition her. CNA N provided peri-care, applied barrier cream, put on a clean incontinence brief, placed pillows on either side of R18, and covered her up. On 01/24/24 at 02:15 PM, Licensed Nurse (LN) H stated that R18 should be repositioned every two hours. When LN H learned R18 had not been repositioned, checked, and changed, for eight hours, she stated she was not surprised as her staff were very busy and had not even had lunch yet. On 01/25/24 at 09:30 AM, Administrative Nurse D stated R18 should have been repositioned checked, and changed every two hours. Administrative Nurse D stated R18 should not have sat in her wheelchair for eight hours. The facility's Activities of Daily Living (ADLs) policy, dated 01/09/24, documented the facility would ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable which would include toileting, bathing, dressing, grooming, eating, transfers, ambulation, and communication abilities. The facility would provide a maintenance and restorative program to assist the resident to achieve and maintain the highest practicable outcome based on the comprehensive assessment. The facility failed to provide assistive care for R18 for eight hours which caused her buttocks to be red and excoriated. This placed the resident at risk for further skin breakdown. - The Electronic Medical Record (EMR) for R61 documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), weakness, and other lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R61 had severely impaired cognition and was dependent upon two staff for eating, bed mobility, transfers, toileting, and dressing. R61 had upper and lower functional impairment on one side and did not ambulate. The Significant Change 5-Day Medicare MDS, dated [DATE], documented R61 had severely impaired cognition and was dependent on staff for eating, toileting, mobility, dressing, and personal hygiene. R61 had upper and lower functional impairment on one side and required extensive assistance from one staff for eating. R61's Care Plan, dated 12/12/23, initiated on 12/31/20, documented R61 had left-sided weakness and directed staff to use a full body lift for transfers. R61 was non-ambulatory and dependent upon one staff to push her wheelchair. The update, dated 07/19/23, documented R61 was allowed to have a mechanical soft diet if she was one-on-one with staff or a trained family member. The update, dated 07/24/23, documented R61 was able to eat a mechanical soft diet as long as she was one-on-one with therapy, or a trained family member and she would also receive nutrition via gastronomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). On 01/23/24 at 09:18 AM, observation revealed R61 laid in bed. Her untouched breakfast tray sat on her bedside table. R61 stated she had not had her breakfast yet and said she needed assistance. Further observation revealed at 10:44 AM, the breakfast tray was still on her bedside table, untouched, and staff stated R61's representative would be in to assist R61 with lunch. On 01/24/24 at 08:48 AM, observation revealed R61 laid in bed. Her breakfast tray sat on her bedside table. Further observation revealed at 10:40 AM, R61's representative came to assist her. R61 stated she did not want to eat a reheated breakfast, so her representative used the microwave to cook the resident prepackaged oatmeal and assisted in feeding R61 the oatmeal and a banana the representative brought in. On 01/24/24 at 09:33 AM, Licensed Nurse (LN) H stated R61's representative was usually there to assist with the breakfast meal and liked to assist R61 with her meals, so staff usually did not assist R61. On 01/25/24 at 09:30 AM, Administrative Nurse E stated R61's representative usually assisted R61 with breakfast, but staff should offer to assist her representatives were not there. The facility's Activities of Daily Living (ADLs) policy, dated 01/09/24, documented the facility would ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable which would include toileting, bathing, dressing, grooming, eating, transfers, ambulation, and communication abilities. The facility would provide a maintenance and restorative program to assist the resident to achieve and maintain the highest practicable outcome based on the comprehensive assessment. The facility failed to provide assistive cares and services for eating for R61. This placed her at risk for weight loss and unmet ADL needs.

The facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to complete competency assessments for staff to ensure staff possessed the skills and abilities necessary to provide care to facility residents. This placed the residents who used mechanical lifts at risk for impaired care and decreased quality of life. Findings included: - The facility lacked documentation of any skills competency checks for any Licensed Nurse (LN) staff or Certified Nurse Aides (CNA) for 2023. On [DATE] at 07:48 AM, Resident (R) 70, an alert and oriented resident, stated a CNA used a sit-to-stand lift to transfer him. R70 stated while he was in the lift, the battery died . The CNA was unaware of the emergency release button to let R70 safely sit back down, so the CNA left R70 standing up, in the lift and left the room. R70 stated he yelled for help as he was starting to fall. A review of R76's medical record revealed on [DATE], staff were transferring R76 and bumped her head with the Hoyer (full body mechanical lift)) lift during the transfer. Staff sent R76 to the emergency room for evaluation and no injury was found. Staff involved were to be given re-education on proper mechanical lift usage before returning to work. On [DATE] at 02:03 PM, Certified Medication Aide (CMA) R stated the facility had not had a skills competency check in the past year. She stated if an incident happened with a resident the staff involved would be verbally in-serviced. On [DATE] at 11:10 AM, Administrative Nurse D verified the lack of a competency evaluation program in the past year. The facility's Competency Evaluation policy, dated [DATE], stated the facility would evaluate each employee to ensure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Evaluation of staff competency would be accomplished through the facility's training program. Initial competency was evaluated during the orientation process. Subsequent and or annual competency was evaluated at a frequency determined by the facility assessment, evaluation of the training program, and or job performance evaluations. Checklists would be used to document training and competency evaluations and maintained in the employee's personnel file. The facility failed to complete competency assessments for staff to ensure staff possessed the skills and abilities necessary to provide care to facility residents. This placed the residents who used mechanical lifts at risk for impaired care and decreased quality of life.

The facility identified a census of 87 residents. The facility identified 16 residents at risk for 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) in the South building. The sample included four residents with three sampled for accidents. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. Resident (R) 1 was severely cognitively impaired and a high risk for elopement due to her dementia (progressive mental disorder characterized by failing memory, confusion). On 02/17/23 at 08:21 PM, Certified Medication Aide (CMA) R attempted to administer R1's medications, but R1 was agitated and refused. At 08:28 PM, R1 climbed out her bedroom window and walked, in the dark, approximately one mile to the local drug store. The temperature outside was 37 degrees Fahrenheit (F). At 08:59 PM, local law enforcement (LE) received a call from the local drug store that R1 was at the drug store, confused, and did not know where she came from or where she lived. LE went to the drug store at 09:09 PM, and eventually brought R1 to the facility's North building where facility staff informed LE, R1 was not on the resident roster. Another LE officer alerted the officer with R1, that R1 was a resident from the South building. The officer brought R1 to the facility's South building where staff confirmed R1 had exited via a window. Upon return at approximately 09:52 PM, R1 was agitated. The facility failure placed R1 in immediate jeopardy. Findings included: - R1 admitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbances and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 was independent with no help for bed mobility; independent with setup help only for transfers, walking, and toileting; and supervision with setup help only for locomotion and dressing. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of three which indicated severe cognitive impairment. R1 required supervision with setup help for all Activities of Daily Living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/28/22, documented R1 had cognitive impairment. The Elopement Care Plan dated 09/16/22, documented R1 was at risk for elopement related to cognitive status, mobility status, and assessment indicating at risk or high-risk potential for wandering/elopement. The Care Plan directed the staff were educated on elopement potential, triggers, and preventative measures and staff kept R1's routine consistent to alleviate confusion. The Care Plan dated 02/10/23, documented R1 was an elopement risk/wanderer related to dementia and a desire to live elsewhere. Staff distracted R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The Assessments tab of R1's EMR documented a Wandering/Elopement Risk Scale on 01/04/23 documented a score of 12, which indicated high risk for wandering. The facility's Investigation dated 02/22/23, documented on 02/17/23 R1 left the building by climbing out of her window at 08:28 PM. R1 reported to the police that she jumped out of the window because the staff would not let her go through the front door. Earlier that evening, R1 took a shower and was fully dressed in warm clothes, a jacket, and shoes. R1 was still wearing her warm clothes including a jacket when the police [NAME] her back to the facility at 09:52 PM. At 08:21 PM, CMA R attempted to give R1's her medications, but R1 was agitated and refused. Staff last saw R1 at 08:21 PM, eight minutes prior to her exiting out of the window. R1 walked to the local drug store. Video footage at the local drug store showed R1 walked on the sidewalk, crossed the parking lot and entered the store at 08:48 PM, 20 minutes after she exited the facility. R1 asked the cashier at the drug store to call the police because she was lost. Upon return to the facility, R1 was agitated but after she had time to calm down, she allowed an assessment. R1 was negative for injury, interviewed, and immediately placed on one-to-one supervision. R1's baseline was disorientation to facility name, year, and full situation with periods of lucid mentation. On 02/18/23, R1's window screen was found hidden under her bed. She reported to staff she did not go out the door because staff would have stopped her. R1 did not recall the event very well. In an undated Witness Statement, Certified Nurse Aide (CNA) N stated she showered R1 at about 04:30 PM. After dinner around 07:00 PM, several nurses were in and out of R1's room trying to give her medications. CNA N stated R1 was threatening nurses, cussing them out, and telling them to get out of her room. She stated she last saw R1 around 08:00 PM. In a Witness Statement on 02/22/23, CNA M stated she saw R1 cursing at the nurse telling her she did not live there and that she was being held hostage. After several attempts from the CMA, she still refused medications, went to her room, and slammed the door. In a Witness Statement on 02/22/23, CMA S stated she last saw R1 sometime before 08:30 PM when she last attempted to give R1 her night medications. She stated R1 was not in a good mood and that was the second time she had attempted to give R1 her medications. CMA R stated she told the nurse who told CMA R to chart on R1's behaviors. In a Witness Statement on 02/22/23, Licensed Nurse (LN) G stated she was finishing up her charting around 09:45 PM when CNA O reported the police were at the door. The police came in with R1, reported she was picked up at the drug store, and brought to the facility. She stated staff did not know R1 was not in the building. The staff informed the charge nurse, LN I, and took R1 to her room where her left window was open without a screen in place. According to the Kansas State University Historical Weather website, the temperature in the area of the facility on 02/17/23 at 08:00 PM was 37.3 degrees Fahrenheit (F), the temperature at 09:00 PM was 36.0 degrees F, and the temperature at 10:00 PM was 35.3 degrees F. The Narrative Report provided by LE, documented on 02/17/23 at 08:59 PM, LE was dispatched to the drug store for an older female who was not sure how she ended up at the store. Upon arrival at 08:59 PM, LE contacted R1 near the front of the store and she explained that she walked from a medical facility to the store, but she could not recall where her family lived, her phone number, or any information to help locate her home. LE contacted a facility in the area and they stated R1 was not a resident there. LE then transported R1 to the facility's North building where they provided LE with a resident roster which did not show R1 as a resident. LE received a call from another LE officer who informed the LE office with R1 that she was a resident at the South building. LE transported R1 to the South building of the facility where staff told LE R1 left her room through a window. On 02/28/23 at 11:50 AM, the surveyor observed the area outside of R1's left window. The area directly in front of the window had a rock garden with a bush to the side of the window. The parking lot was located straight ahead and had uneven terrain with potholes and loose gravel. On 02/28/23 at 03:35 PM, the surveyor observed the South building of the facility was located one block from the highway. The posted speed limit was 45 miles per hour (mph) until the highway turned into the city's Main Street where it was 35 mph. The drug store was located 0.9 miles from the South building and R1 had to cross the highway/street to get to the drug store. On 02/28/23 at 11:37 AM, Administrative Nurse D stated administration looked at the facility's cameras and saw what time R1 left the building. She stated the times reported in the Investigation were the correct times. On 02/28/23 at 12:38 PM, Administrative Staff A stated she received a call from Administrative Nurse D stating a resident was brought back to the facility by police. She stated R1 climbed out of the window and staff did go to her room and saw the window was open. R1 was placed on one-to-one supervision at that time and maintenance came in to secure her window the next morning. Administrative Staff A stated she verified with the drug store whose camera showed R1 crossed their parking lot and entered the drug store at 08:48 PM. She stated R1 asked the drug store to call the police because she was lost. The last time staff saw R1 was around 08:21 PM and the cameras showed she exited the window at 08:28 PM. On 02/28/23 at 01:52 PM, Administrative Staff A stated it may have crossed the facility's mind at one point that a resident could open a window, but since it was not a normal way to elope, they did not really think about it. On 02/28/23 at 02:25 PM, CNA O stated if a resident was an elopement risk and actively exit seeking, the resident was closely monitored. He stated if they were agitated, staff redirected them. CNA O stated if a resident was missing, the staff completed a full head count, checked outside, and the nurse gave any further instructions. On 02/28/23 at 02:46 PM, LN H stated if a resident was exit seeking, the provider was notified, and staff monitored the resident closely with one-to-one supervision. She stated if a resident eloped, staff searched all over the building outside and inside, did a full head count to figure out who was missing, and notified administration, family, provider, and the police. On 02/28/23 at 02:50 PM, Administrative Nurse D stated if a resident was actively exit seeking, staff were expected to report that to administration so they could establish if there was a potential for elopement. She stated the resident was placed on one-to-one and if it was a change in condition, the provider was notified for possible orders. Administrative Nurse D stated if a resident eloped, a head count was conducted, staff looked outside, and the administrator and herself was notified. On 03/01/23 at 11:11 AM, CNA M stated she last saw R1 around 08:30 PM when CMA R attempted to give her medication. She stated R1 would not take her medication and R1 stated the facility was holding her hostage. CNA M stated R1 went into her room and slammed her door. CNA M thought she went to bed. She stated it was close to 10:00 PM when the police were at the door, saying R1 went out of the window. R1 wore jeans, a sweatshirt, and shoes. She stated when R1 was agitated like that, she left her alone and she normally came back out and asked if she had taken her medication. On 03/02/23 at 10:56 AM, CMA S stated she last saw R1 a little before 08:30 PM in her room when she tried to give R1 her night medications. R1 had refused her medications twice and she left to give her time to cooldown. She stated she asked CMA R to try to give R1 her medications. She could not recall what R1 was wearing the last time she saw her. The facility's Elopements and Wandering Residents policy, revised 2/20/23, directed residents were assessed for elopement and unsafe wandering upon admission and throughout their stay. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards were added to the resident's care plan and communicated to appropriate staff. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. R1 exited the facility via a window and walked on rough terrain to the local drug store located almost a mile away and on the other side of a busy street when the temperature was 37 degrees F outside. The facility failure placed R1 in immediate jeopardy. The facility submitted a plan for removal of the immediate jeopardy to the state agency, which included the following: 1. R1 was immediately placed on one-to-one supervision upon return to the facility and remained on one-to-one until her transfer to a facility with a memory care unit on 02/18/23 2. On 02/20/23, the facility ordered supplies that allowed the facility to properly adjust windows. The supplies were received on 02/27/23 and the facility windows were secured for North and South buildings as of 02/28/23. 3. The facility provided education to the South building staff on 02/20/23 and provided education to the North building staff from 02/20/23 to 02/23/23. 4. The South building completed an elopement drill on 02/23/23, and the North building on 02/28/23. After removal of the immediate jeopardy, the deficient practice remained a D scope and severity.

The facility reported a census of 88 residents with 33 residents at the North campus. The sample included one resident reviewed for elopement (when a cognitively impaired resident exits the facility without staff knowledge or supervision). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R)1, who was cognitively impaired, at high risk for elopement, and at risk for falls due to an unsteady gait. On 01/01/23 at approximately 03:00 PM, R1 sat in the dining room with other residents. At 03:30 PM staff responded to the dining room door alarm. Staff observed R1's empty wheelchair next to the dining room door. Another resident in the area told staff R1 exited the facility through the dining room door. Licensed Nurse (LN) H and LN I, the 200-hall nurse, went in opposite directions around the facility to look for R1. They met at the midpoint, but had not located R1. LN I went back inside the facility to call the alert for the missing person while LN H circled the facility again. After circling the facility, a second time, LN H located R1 on the sidewalk in front of the facility approximately 15 minutes to 30 minutes after staff identified R1 was missing. R1 stated he had walked to the park. LN H escorted R1 back into the facility. The facility staff failed to provide adequate supervision and allowed R1 to wander outside of the facility without staff knowledge or supervision. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, abnormalities of gait and mobility, weakness, and attention and concentration deficit. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R1 required supervision with set up help only for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. R1 walked in his room and the corridor and locomotion on and off the unit independently with set up help only. The MDS recorded R1 had no behaviors. The Discharge Assessment-Return Not Anticipated MDS dated [DATE] recorded R1 had a BIMS of seven, which indicated severe cognitive impairment. The Cognition Care Area Assessment (CAA) dated 12/08/22 documented staff were to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition. The Falls CAA dated 12/08/22 documented staff to anticipate and meet R1's care needs so that R1 did not attempt to unsafely perform activities of daily living (ADL) cares without staff assistance. The Morse Fall Scale for R1 dated 12/05/22 documented R1 was at high risk for falling. R1 had a history of falls and exhibited a weak gait. R1 was forgetful of his own safety limits The Wandering/Elopement Risk Scale dated 12/05/22 documented a score of 14, which indicated a high risk for elopement. The Elopement Care Plan initiated on 12/05/22 directed staff to engage R1 in active conversation as a form of redirection. Education for healthcare decision makers and staff of elopement potential, triggers and preventative measures. The Admission Summary dated 12/05/22 at 06:04 PM documented R1 stated several times he wanted to go to his apartment to turn the heater on. Staff attempted to orient R1 to the call light and were not successful as R1 was perseverating on returning to his apartment. The Behavior Note dated 12/06/22 at 10:03 AM documented R1 was confused and did not remember that he was supposed to stay in his room due to quarantine because R1 had the flu. The note recorded R1 was found in the dining room approximately 10 minutes before the note entry without a mask on. A Skilled Note dated 12/6/22 at 12:29 PM documented R1 has exceptions noted with his mood. R1 was anxious and had wandering behavior. An Administration Note dated 12/10/22 at 04:42 PM documented R1 declined his Coreg (medication used to treat heart failure or high blood pressure) that evening stating I don't want it, I don't need it and I don't want to be here anymore. The note recorded R1 was shaking his finger aggressively at the nurse and staff were unable to calm R1 at that time. A PMR Follow Up dated 12/14/22 at 07:07 AM documented R1 wheeled himself down the hall in his wheelchair. R1 was confused, at his baseline, and said he wanted his coat so he could leave. The note recorded staff tried to redirect the resident but R1 insistent on getting his coat to leave. A Skilled Note dated 12/20/22 at 12:16 PM documented R1 was agitated and/or irritable, R1 had delusions (belief that is clearly false and that indicates an abnormality in the affected person's content of thought) and R1 had wandering behavior. A Skilled Note dated 12/21/22 at 01:27 PM documented R1 had a fluctuating mood, R1 was agitated and/or irritable, had delusions and wandering behavior. An Incident Note dated 01/01/23 at 04:44 PM documented LN H was notified by LN I that R1 walked out through the dining room doors, and the alarm was going off. LN H immediately went to the dining room. The alarm was still going off. R2 confirmed to LN H that R1 walked out the door. R1's wheelchair was in front of the door. LN H and LN I both went outside to look for R1. Both nurses met after circling the building. LN I went back inside to do room checks. LN H called the Director of Nursing (DON) and the Assistant Administrator. LN H then called LN J, and a code gold (missing person code) was initiated. LN H circled the building a second time. R1 was located on the sidewalk in front of building. R1 stated he went for walk to the park. R1 was brought back into building. R1 denied any pain. A Witness Statement, dated 01/01/23, from LN H documented LN I notified LN H, at approximately 03:30 PM on 01/01/23, that a resident had walked out the dining room door. LN I stated the alarm was going off. LN H went to dining room to find R1's wheelchair in front of door. Both LN H and LN I went out to look for R1. LN I went left and LN H went right. After the first round LN H and LN I met up in the middle. LN I went back inside to do a head count. While searching, LN H also notified the DON, the assistant administrator, and LN J. A code gold was also activated. LN H found R1 on the sidewalk in front of the building after she went around a second time. R1 had on shoes, jeans, shirt, and a coat. R1 stated he went to the park. LN H walked R1 back into facility. R1 denied pain and no injuries were found on assessment. Administration was notified, family was notified, physician was notified, and R1 was placed on 15-minute checks. A Witness Statement, dated 01/01/23, from LN I documented CNA M said R2, in the dining room, told LN I that R1 left the building from the dining room. LN I walked with CNA M and found R1's wheelchair empty, sitting in front of the door. The door alarm was going off, but it wasn't very loud, and LN I could not get it to cancel. LN H had the master code to cancel the alarm. LN H and LN I went outside to look for R1, LN I and LN H split directions and LN H found the resident on the sidewalk. LN H walked the resident back inside. R1 was in a good mood and very confused. R1 did not have a wanderguard on. The Facility Investigation dated 01/05/23 recorded on 01/01/23 LM H saw R1 in the dining room around 03:00 PM. At around 03:30 PM the dinging room door was alarming. LN H noted R1's empty wheelchair by the dining room door. The investigation recorded R1 left the facility at 03:30 PM and was brought back to the building at 03:45 PM by LN H. Administrative nurse D interviewed R1, and R1 stated he knew he went for a walk and went to see if an old barbeque placed that used to be in town was still there, and when it was not, he came back to the facility. The investigation noted R1 had memory impairment, but usually with objects or appointments. He was able to find his room. The investigation recorded the resident had a BIMS of eleven (moderate cognitive impairment) but was not confused and wondering. A Witness Statement, dated 01/18/23, by LN G, on duty at the time of the elopement, documented sometime in the afternoon after lunch time LN G came out of an unidentified resident's room into the hallway and saw a bunch of [unidentified] staff at the nurse's station; an [unidentified] Certified Nurse's Aide (CNA) approached LN G and said, someone eloped. Another [unidentified] staff member said R1 got out of the dining room door; when LN G asked about the alarm that would have gone off, CNA M told LN G she cleared the alarm and had not actually gone to look at the door. LN G immediately called LN H, and LN H stated R1 was located and coming back towards the building with her. During the phone call, a code gold was called over the intercom and then code gold cleared called almost immediately after. LN G went to the dining room and saw R1's wheelchair parked in front of the door that faces the street on the east side of the building. Shortly after, LN G observed LN H, LN J and R1 walking up the stairs to the main entrance to the rehab door. A Witness Statement, dated 01/18/23, documented on LN J worked as a house supervisor on the hospital side on 01/01/23. LN J received a call at reception from LN H. LN H stated R1 had eloped, and LN H was outside. As LN H was on the phone with LN J, LN H spotted the resident. LN J asked if LN H still needed LN J's assistance. LN H stated LN H might need help bringing the resident in. LN J went outside, LN H was with R1. R1 walked willingly inside. LN J walked with LN H and R1 inside the building According to Wunderground.com, the weather at the time of the elopement was 61 degrees Fahrenheit (F.). Observation on 01/17/23 at 04:40 PM revealed the facility was in an [NAME] area along a heavily trafficked road with four lanes of traffic. The posted speed along that stretch of the road was 35 miles per hour. R1's exact route was unknown although per observation, the resident would have had to walk across a side street to go to the park area. From the doorway that the resident exited, a sidewalk went down and around the building where there were parking lots. The area had many houses between the facility and the park. The front of the facility, where the resident was found, was on the four-lane highway. In an interview on 01/17/23 at 04:14 PM Administrative Nurse D stated R1 had not eloped. In an interview on 01/18/23 at 11:54 AM LN I reported that staff had looked for the R1 a good 20 to 30 minutes. LN I stated that when R1 was brought back into the building, R1 was very confused. LN I said at shift change R1 also wandered into another residents room on the wrong hallway. On 01/18/23 at 03:50 PM Administrative Nurse D stated R1 had no behaviors or wandering or exit seeking. Administrative Nurse D further stated the elopement assessment done upon R1's admission, which recorded R1 as an elopement risk, was done in error and contained inaccurate assessment information. Administrative Nurse D said R1 was alert and oriented. Administrative Nurse D revealed that she was unaware of the assessment findings of R1's Elopement/Wandering Risk Scale (dated 12/05/22) until 01/17/23. On 01/18/23 at 04:00 PM Administrative Staff A stated that R1 was able to tell staff where he was going and he came back willingly. Administrative Staff A further stated R1 was not an elopement risk. On 01/18/23 at 04:12 PM Administrative Nurse D stated R1 was alert and oriented and just chose to go out by himself. Administrative Nurse D said the resident was city. The facility Elopement and Wandering Residents policy implemented 02/01/20 documented the facility ensured that residents who exhibited wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy further documented that alarms are not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner. The facility failed to provide adequate supervision to prevent an elopement for R1, who was cognitively impaired, at high risk for elopement, and at risk for falls due to an unsteady gait. R1 wandered outside of the facility without staff knowledge or supervision. This deficient practice placed R1 in Immediate Jeopardy. After the elopement, the facility placed R1 on 1:1 until 01/02/23. All residents were accounted for, R1 was assessed. The facility provided education and in-service to staff regarding elopement which was completed by 01/04/23. The facility conducted an elopement drill on 01/04/23. The corrective actions were completed prior to the onsite survey so the deficient practice was cited at past noncompliance.

The facility identified a census of 34 residents. The sample included three residents reviewed for neglect. The facility failed to ensure staff responded promptly to Resident (R)1's request for bathing assistance. R1, who prepared to attend his brother's funeral, asked staff for bathing assistance so he would not feel ashamed or embarrass his mother because of his unkempt appearance. Staff were aware of R1's request as well as the reason for the request, but made no effort to expedite the bathing assistance nor offered any reassurance that they intended to provide the assistance, only saying they would try' if they had time. This staff indifference resulted in mental anguish and unnecessary distress for R1. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab documented diagnoses of traumatic subdural hemorrhage (a collection on blood in the space between the outer layer and the middle layer covering the brain), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), muscle weakness, and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of one staff member for transfers, bed mobility, and dressing. R1 required extensive assistance of two staff members with toilet use, and limited assistance of one staff member for personal hygiene. R1 required physical help in part of bathing from one staff member. R1 had no behaviors exhibited during the look back period and was documented to be improved on behavior status, care rejection, or wandering compared to the prior assessment. The MDS documented it was somewhat important for R1 to choose between a tub bath, shower, bed bath or sponge bath. The ADL Care Area Assessment (CAA) dated 03/03/22 documented R1 needed staff to assist with activities of daily living (ADL) cares as needed, anticipating cares, so that care needs were effectively met. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. R1 required extensive assistance of one staff member for transfers, bed mobility, dressing, and toilet use. R1 required limited assistance of one staff member for personal hygiene. R1 required physical help in part of bathing of one staff member. R1 had no behaviors exhibited during the look back period. The ADL Self Care Performance Deficit Care Plan initiated on 03/09/21 revised on 11/16/22 directed staff that R1 would often refuse bathing or shower, but to continue to offer bathing/showers and remind R1 the importance of hygiene. Staff were further directed that R1 could request a bath/shower at any time and staff were to do their best to accommodate R1. Staff were directed that R1 could wash his upper half of his body but required assistance with his bottom half. R1 preferred showers. The Behavior Care Plan initiated 03/22/21 directed staff to encourage R1 to express his feelings appropriately. On 04/20/21 directed staff to monitor behavior episodes and attempt to determine underlying cause. It further directed staff to consider location, time of day, persons involved, and situations. The Tendency to Exhibit Behaviors Care Plan initiated on 03/15/21 directed staff to assist with the development of appropriate methods of coping and interacting to alleviate behaviors. The Care Plan lacked any interventions to address R1's psychosocial wellbeing or the loss of family members. In a phone interview on 12/27/22 at 09:26 AM, R1 stated he was yelling and begging for staff to assist him, but staff were not responding to his requests. He stated he still had not received a bath and his brother's funeral was that day at 05:00 PM. R1 said he stunk of urine and his hair was gross. He said he was going to shave his head so he would not be an embarrassment to his mother at the funeral. R1 further reported on the previous day he used his call light to call for help at 07:30 AM, but staff did not respond until 08:50 AM. He stated he was forced to lay in a soiled brief for 1.5 hours waiting for staff assistance. R1 said he had not received a shower since 12/06/22. He did report he had declined to take a shower on 12/9 and 12/13. R1 stated he felt very upset and was desperate for someone to help make sure he received a shower to go to the funeral. On 12/27/22 at 11:50 AM R1 was up in his electric wheelchair. He was dressed, his hair appeared to be a half inch in length. R1 had a towel in his lap and the electric hair clipper sat on his nightstand. He had an unkept beard that appeared to be a quarter of an inch to a half inch in length. R1 slouched in his wheelchair and appeared defeated in his mannerisms. R1 stated that he needed to get ready for his brother's funeral but was not sure he would be ready in time. R1 stated he did not want to upset his mother with not being ready or not looking presentable. R1 further stated that he was trimming his fingernails and was cutting his hair and beard so that he looked presentable for the funeral. R1 stated that he just shaved his head because his hair was so dirty it was itchy, and that was the easiest way to help stop the itching. R1 stated his hair was dirty and itchy because he was not getting regular showers. R1 stated he was very frustrated and irritated about not receiving assistance for his grooming and bathing. R1 revealed that his showers were in the evening and on night shift. R1 stated that if he refused a shower, it was primarily because of the time of day or because he was out of the facility. He said if he missed his scheduled shower time, another shower was not offered to him. R1 further revealed that he had stopped asking for a shower on days that were not his shower days because nursing staff told R1 that it was not his shower day or would not tell him anything and walk away from him. R1 stated that this made him angry and was very frustrating. On 12/27/22 at 12:06 PM R1 sat in his electric wheelchair leaning over the right side, with a towel tied around his neck like a clothing protector. He faced the nightstand with the clippers in his hand. R1 had both sides of his head shaved as short as the electric clippers would go without a guard on it. R1 stated that he was getting there with getting his hair cut. R1 stated he had been very worried that he would not be able to get his long hair trimmed up and he worried he would look shaggy. On 12/27/22 at 12:22 PM Licensed Nurse (LN) G stated that R1 had a funeral to go to that day, but R1 would not leave until 05:00 PM. LN G revealed that a staff member told her R1 wanted a shower that day, but LN G stated staff did not know for sure what time staff would fit R1 in, to get a shower. LN G further stated that it was not typical for R1 to shave his head. On 12/27/22 at 01:26 PM Certified Nurse Aide (CNA) M stated that she had never been assigned to provide R1 a shower in the past. CNA M revealed she was aware that R1 had a funeral that day and wanted a shower. She further stated she would do her best to work him into the shower schedule that day but was not sure when it would happen. CNA M confirmed she had not provided R1 with a plan, or time, regarding his shower. On 12/27/22 at 01:28 PM R1 moved his electric wheelchair out of his room and into the hallway. R1 asked if he had any long hairs left (after shaving his head). Observation revealed there were long hairs on the back and right side of his neck. R1 was informed of the observation, and he stated that he would get it taken care of. R1 shaved his entire beard and mustache off. R1 revealed that he was covered with hair now and just needed to get to the shower, but staff had not given him a shower or a proposed time to receive one yet. On 12/27/22 at 01:46 PM Administrative Nurse D stated R1 had many behaviors and would frequently refuse cares. Administrative Nurse D stated she was not aware that R1 had a funeral to go to that day and was unaware if staff planned to give him a shower that day. On 12/27/22 at 02:23 PM R1 went to the shower room with CNA M. At 02:24 PM CNA M exited the shower room alone and went to the nurse's station. CNA M reentered the shower room at 02:25 PM. CNA M left the shower room alone at 02:34 PM, returned to the shower room with supplies at 02:35 PM, and then exited the shower room alone at 02:39 PM. R1 remained in the shower room alone at that time. CNA M nor any other nursing staff re-entered the shower room until the call light went off at 03:03 PM. CNA N then entered the shower room and R1 exited the shower room fully clothed in his manual wheelchair at 03:24 PM. On 12/27/22 at 03:55 PM R1 stated he felt good getting the shower and said that if the state agency had not intervened, R1 did not believe the shower would have happened timely for him to go to his brother's funeral. R1 became tearful, and further stated that due to the intervention that day, he was able to get ready for the funeral. He went on to say he hoped it would change things for him in the facility. On 12/27/22 at 04:24 PM R1 was in his bed getting his shoes on. R1 stated he needed to go outside to get a little bit of a break from everything because he was overwhelmed from everything that was going on. R1 held his head down and did not make eye contact while he stated he was very thankful for the help to get to this point, and said he was not used to receiving much assistance. On 12/27/22 at 04:36 PM Social Services X stated she had told the nursing staff R1 needed a shower before he left. Social Services X revealed that R1 was upset and yelling for assistance prior to 11:45 AM. The Activities of Daily Living (ADLs) Policy dated 08/01/19 documented the facility would ensure a resident's abilities in ADL's would not deteriorate unless deterioration was unavoidable. Residents that were unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The Freedom from Abuse, Neglect, and Exploitation Policy and Procedure revised 11/06/2017 documented the resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility failed to ensure R1 was free from neglect when staff did not respond R1's request for bathing assistance. R1, who prepared to attend his brother's funeral, asked staff for bathing assistance so he would not feel ashamed or embarrass his mother because of his unkempt appearance. Staff were aware of R1's request as well as the reason for the request but made no effort to expedite the bathing assistance nor offered any reassurance that they intended to provide the assistance, only saying they would try' if they had time. This staff indifference resulted in mental anguish and unnecessary distress for R1.

The facility identified a census of 57 residents. The sample included four residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to acknowledge and implement a plan of care to address Resident (R) 1's personal history of trauma, increased depression, as well an actual suicide attempt. On [DATE] staff identified R1 in his room with a trash bag over his head in an effort to suffocate himself. R1 stated he wanted to die due to his decreased mobility and increased need for assistance. R1 was sent to the hospital for psychiatric treatment and returned to the facility on [DATE]. Upon return, the facility failed to initiate a plan of care, which addressed R1's recent actual suicide attempt or the causative factors. On [DATE] staff conducted a multidisciplinary care plan meeting where they reviewed R1's traumatic history and history of suicide in R1's immediate family. On [DATE] at 08:20 AM staff found R1, again, with a plastic bag over his head, tied at the neck. The facility's failure to acknowledge the recent suicide attempt, the history of familial suicide, and the increased depression resulted in a second actual suicide attempt. This deficient practice placed R1 in Immediate Jeopardy Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of acquired absence of left leg below knew, Asperger's (a neurodevelopment disability that affects the ability to effectively interact and communicate with people), difficulty in walking, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder), muscle weakness, history of falling, and mixed receptive-expressive language disorder (neurodevelopmental condition in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe). The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 indicated no concerns during his mood interview, and no behaviors. R1 was independent with no setup needed from staff for activities of daily living (ADL), except R1 required supervision with walking in the corridor. R1 took antidepressants (class of medication used to treat depression) seven out of seven days through the look back period. The ADL Care Area Assessment (CAA) dated [DATE] documented the care plan would make sure that staff were aware of R1's current ADL needs and preferences. The Psychotropic CAA dated [DATE] documented psychotropic (affects mood and thought) drugs would be addressed in R1's care plan to be monitored for all side effects and potential therapeutic benefits of medications. R1's Care Plan dated /revised on [DATE] directed staff to know R1 had a self-care deficit and required limited staff assistance with his care needs. It directed staff to encourage R1 to discuss his feeling about self-care deficit as needed. R1's plan of care recorded on [DATE] directed R1 was independent for meeting his emotional, intellectual, physical, and social needs through meaningful activities program both self-directed and in groups. It directed staff R1 enjoyed self-initiated activities such as watching televisions in his room and playing with his tablet on the internet. R1's Care Plan dated [DATE] and revised on [DATE] directed staff R1 required assistance with ADL related to increased risk for falls. It directed staff to recognize early signs of anxiety, treat or change environment (decrease stimulations, remove from loud setting). R1's Care Plan lacked any interventions to address suicidal ideation and actual suicide attempts, prior to [DATE]. The care plan further lacked resident-centered interventions related to R1's history of personal trauma related to suicide and abuse. The Social Services Note dated [DATE] at 02:40 PM documented R1's family reported that R1 had a counselor every couple of weeks at his previous facility. R1's family further reported that R1 started talking of suicide after he lost his leg. The Skilled Note dated [DATE] 04:08 PM documented R1 had behaviors. R1 was anxious, agitated, with fluctuating mood. The Skilled Note dated [DATE] at 07:48 AM documented R1 was anxious and agitated. The Skilled Note dated [DATE] at 04:51 AM documented R1 had exceptions noted with mood and was noted with behaviors, was anxious, and agitated. The Skilled Note dated [DATE] at 03:56 PM documented R1 had exceptions noted with mood and noted behaviors. R1 was anxious, agitated and/or irritable. The Incident Note dated [DATE] at 06:25 PM documented R1 fell in his room and reported his body was failing him. The Social Service Note dated [DATE] at 11:57 AM documented R1's family member was worried about R1 being able to see the psychologist. The note further documented R1 was put on the weekly list. The Skilled Note dated [DATE] at 01:20 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, have agitation and/or irritable. The Skilled Note dated [DATE] at 10:08 PM documented R1 was agitated and/or irritable. The Skilled Note dated [DATE] at 10:08 AM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and tearful. The Skilled Note dated [DATE] at 10:08 AM documented R1 had exceptions noted with behaviors, displayed disruptive behaviors, was resistant of cares and had delusions. The Skilled Note dated [DATE] at 12:21 PM documented R1 had exceptions noted with behaviors, displayed disruptive behaviors, was resistant to cares and had delusions. The Skilled Note dated [DATE] at 01:14 PM documented R1 had exceptions noted with mood and with behaviors. R1 was noted to be anxious, agitated, and/or irritable. The Skilled Note dated [DATE] at 08:25 AM documented R1 had exceptions noted with mood, and with behaviors. R1 was noted to be anxious, agitated, and/or irritable. The Skilled Note dated [DATE] at 12:18 PM documented R1 had exceptions noted with mood. The Skilled Note dated [DATE] at 10:18 AM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Skilled Note dated [DATE] at 11:47 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Skilled Note dated [DATE] at 10:18 AM documented R1had exceptions noted with mood. R1 was anxious. The Psychological Diagnostic Interview dated [DATE] documented R1's mother made statements about wanting to die, and being anxious, agitated, and depressed. R1 had a past psychiatric history. R1 reported that his father was abusive to his mother and siblings, and that R1's mother completed suicide. R1 reported worsened anxiety and depression after the most recent hospital stay. R1 had perseverative and obsessive thoughts and repeated his statements often, including wanting to die. Nursing staff indicated that the statements had increased more recently. R1 indicated this was related to not wanting to be in the state that R1 was currently in and R1's current functioning. Treatment goals were discussed with nursing staff about R1's suicidal ideation, psychosis, anxiety and depression. It was suggested R1 eat in a less populated area for meals, as increased social interactions seemed to be a trigger for R1's anxiety. The Skilled Note dated [DATE] at 02:12 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Administration Note dated [DATE] at 02:48 PM documented R1 complained of his body not working and discussed with psychiatrist about issues. The Skilled Note dated [DATE] at 02:12 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Skilled Note dated [DATE] at 01:12 PM documented R1 had exceptions noted with mood and behaviors. R1 was agitated and/or irritable. The Behavior Note dated [DATE] at 07:53 AM documented R1 was approached by staff and immediately started screaming R1 could not take the anxiety any longer, R1's body was failing him and R1 just wanted to be put out of misery. R1 continued stating the facility just needed to ship R1 to an insane asylum. Staff informed R1 the doctor would be contacted. The Behavior Note dated [DATE] at 08:52 AM documented R1 frequently exhibited behaviors stating he had demons inside of his body and that his body was failing him. The note further documented that attempts at redirections were usually unsuccessful. The Behavior Note dated [DATE] at 08:59 documented R1 requested an exorcism. The Nurses Note dated [DATE] at 07:36 PM documented R1 was started on an antipsychotic medication (class of medications used to treat severe mood and mental disorders). Staff attempted to notify the practitioner to request an order for 14 day as needed Ativan (medication used to treat anxiety) due to R1's increased anxiety. The call went to voicemail. The Nurses Note dated [DATE] at 08:28 PM documented the Psychiatric Nurse Practitioner ordered Hydroxyzine (medication used to treat anxiety) 10 milligrams three times a day. The Skilled Note dated [DATE] at 02:14 PM documented R1 had exceptions noted with mood and behaviors. R1 had anxiety, agitation, and/or irritable. The Skilled Note dated [DATE] at 02:14 PM documented R1 had exceptions noted with mood and behaviors. R1 had anxiety, agitation, and/or irritable. The Skilled Note dated [DATE] at 12:12 PM documented R1 had exceptions noted with mood. R1 had anxiety and agitation. The Skilled Note dated [DATE] at 11:25 AM documented R1 had exceptions noted with mood and behaviors. R1 had noted anxiety, agitation, and/or irritable. The Skilled Note dated [DATE] at 11:25 PM documented R1 had exceptions noted with mood and behaviors. R1 had anxiety, agitation, and/or irritable. The Psychotherapy Progress Note dated [DATE] documented a treatment plan goal that staff would report a 50 percent reduction in R1's statements related to wanting to die. The Nurses Note dated [DATE] at 06:10 AM documented R1 made the discouraged statement that he was never going to get better. The Behavior Note dated [DATE] at 10:16 PM documented R1 was attention seeking during that shift. R1 asked repetitively if he should use his walker or wheelchair for mode of ambulation. R1 sat in the hallway versus sitting in the recliner in R1's room, which was his usual behavior. The IDT Weekly Note dated [DATE] at 10:12 AM documented R1 had an increase in behaviors displaying more signs and symptoms of depression. The Incident Note dated [DATE] at 05:39 AM documented R1 had taken a trash bag and placed it over his head and was attempting to suffocate himself. An unidentified nursing staff ripped the bag so R1 could breathe. When staff asked R1 what was going on, R1 reported he had no reason to live anymore. R1 further reported that his lack of being able to do ADL and being a vegetable was the reason R1 wanted to die. R1 was brought to the nurse's station, and Administrative Nurse E was notified. The eInteract SBAR Summary on [DATE] at 05:40 AM documented R1 was sent out for a psychiatric evaluation and was admitted for inpatient psychiatric stay. The Nurses Note dated [DATE] at 07:55 AM documented R1 was placed on one on one, and the mental health nurse practitioner ordered to send R1 out for a psychiatric evaluation due to R1 having a plan and following through with a suicidal attempt. R1's family was notified and stated going out was good as R1 had become more depressed and that antidepressants were not working. The Social Services Note dated [DATE] at 02:19 PM documented R1's family reported R1's mother had committed suicide. The Admission/Readmission/Quarterly Assessment Note dated [DATE] at 12:45 PM documented R1 readmitted to the facility from the hospital after a psychiatric stay. R1 was orientated to call light, bed controls, and telephone location and use. The Multidisciplinary Care Conference dated [DATE] at 11:12 AM documented R1's vision was adequate with glasses, hearing was limited, and he had an appointment later that month to follow up. R1 could communicate his needs and wants. R1 had occasional incontinence due to urgency. R1 used a wheelchair for mobility since his return from the hospital and worked with therapy to improve mobility. R1 required limited assistance needed for ADL. He ate well. R1 would peripherally observe activities and enjoyed food related to activities. R1 had no changes in cognition and he stated he did not have as much anxiety. He remained a full code (wanted resuscitative measures if pulse and/or respirations ceased). R1's mother committed suicide, his father was abusive and died of heart attack at [AGE] years old. R1 started therapy services that week with emphasis on ambulation, transfers, balance, safety, ADLs, cognition, and eating/swallowing. R1's care plan was reviewed and updated. The Behavior Note dated [DATE] at 08:22 AM documented R1 was found in his room with a plastic bag tied over his head. R1 was kept under one-on-one supervision. R1 stated he was not choosing to feel that way and wanted to find out why he did feel that way. The Behavior Note dated [DATE] at 08:50 AM documented R1 reported he was depressed and lost his will to fight. The Transfer to Hospital Summary note dated [DATE] at 09:34 AM documented the Psychiatric Nurse Practitioner was contacted and ordered R1 to be sent out for treatment. R1 was transferred to the hospital. The Admission/Readmission/Quarterly Assessment Note dated [DATE] at 04:20 PM documented R1 arrived at the facility via wheelchair. R1 was oriented to the call light, place, person, and situation. The Behavior Note dated [DATE] at 08:33 AM documented staff administered hydroxyzine as ordered related to restlessness, wandering away from the table, and refusing to eat after receiving insulin (hormone given to control blood sugar levels). R1 received education to eat related to hisreceived insulin. R1 stated his body was already dead, to call the hospital, and that R1 was going to put a bag over his head. The staff notified the Psychiatric Nurse Practitioner who ordered hydroxyzine 20 milligrams three times a day for R1. The staff placed R1 on one-on-one as soon as he made the statement. The notarized Witness Statement by Certified Medication Aide (CMA) R dated [DATE] documented CMA R had pulled her medication cart right beside R1's room. A second unidentified staff member came to the medication cart to ask for something but stopped right outside of R1's room and motioned to CMA R that R1 had a bag over his head. CMA R pushed the unidentified staff member aside and went to R1 and removed the bag from R1's head. At that time, CMA R took R1 to the social worker office and notified Social Services X of what had happened. On [DATE] at 09:10 AM Administrative Nurse E stated that R1 should have had something in his care plan about his suicidal ideation. Administrative Nurse E verified there was nothing on the care plan to alert staff about concerns with R1's suicidal ideation. She further verified that direct care staff working with R1 would not have known what to do with no directives on the Kardex (tool used to summarize care needed for each resident) for the nursing staff, especially agency staff. On [DATE] at 10:31 AM Administrative Nurse D stated she expected R1's care plan to be updated to reflect his suicidal ideation. Administrative Nurse D further stated that when R1's family member reported R1 was suicidal, Administrative Nurse D expected that to have been added to the care plan immediately and added to the Kardex so that the staff were aware of the concerns for R1. On [DATE] at 10:25 AM Consultant GG reported it would make sense to have interventions in place to prevent future attempts at suicide for R1. The Behavior Management and Monitoring Plan policy implemented [DATE] documented residents who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving appropriate services and interventions to meet their needs. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions. Behaviors should be identified and approaches for modification or redirection should be included in the comprehensive plan of care. Target Behaviors, that are individualized to each resident, will be monitored each shift by Licensed Nursing as indicated. The facility failed to acknowledge and implement a plan of care to address R1's personal history of trauma, increased depression as well an actual suicide attempt. The facility's failure to acknowledge the recent suicide attempt, the history of familial suicide and the increased depression resulted in a second actual suicide attempt. This deficient practice placed R1 in Immediate Jeopardy. On [DATE] the facility initiated the following actions to remove the immediacy: 1. R1's care plan was revised by Director of Nursing to include his suicidal history and individualized interventions. 2. Current residents with a past history of suicidal ideation were identified through active diagnosis and interview. Individualized care plans were implemented by Director of Nursing. 3. Education was provided to active staff on facility suicide prevention policy and education added to new-hire and agency training. 4. An individualized behavior monitoring task has been added to the TAR for residents with an active diagnosis of suicidal ideation. 5. Ad Hoc QAPI meeting was held. After the corrective actions were completed and the immediacy removed, the deficient practice remained at a scope and severity of D.

The facility identified a census of 57 residents. The sample included five residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to safely secure freestanding armoires, in use as resident closets, to prevent accidents and/or injury. On 08/10/22, Resident (R) 2, who required assistance with transfers, attempted to use the handles of the armoire in his room to stand up, which resulted the armoire tipping over onto the resident. The armoire pinned R2 into his wheelchair and required four staff members to lift the armoire off and pull R2's wheelchair back and out of the way. As a result, R2 received a laceration on his chin that would not stop bleeding and required emergent treatment at the hospital, which included sutures to his chin and inside of his mouth. Findings included: - R2's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, extrapyramidal (movement disorders as a result of taking certain medications) and movement disorders, hemiplegia (paralysis of one side of the body), and arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement). The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R2 required limited assistance of one staff member with transfers, dressing, toilet use, and personal hygiene; supervision and set up help with eating. R1 required supervision with no setup or help with locomotion on and off the unit, and bed mobility. The Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 06/16/22 documented R2 required assistance with all ADLs. R2 was able to communicate his wants and needs. The Falls CAA dated 06/16/22 documented R2 was supervised by staff while up in wheelchair for safety. The ADL Care Plan revised 06/29/22 directed staff to supervise R2 while up in wheelchair for safety. The Falls Care Plan revised on 07/06/22 documented R2 needed a safe environment. The eInteract Transfer Form: Transfer to Hospital assessment dated [DATE] documented R2 needed to transfer related to an open area on his chin and noted the cut on the chin continued to bleed. The Infection Control Worksheet assessment documented R2 was sent to the emergency room due to an incident that cause a laceration to the jaw. R2 received stitches and was placed on prophylactic antibiotic related to stitches being placed. The Nurses Note dated 08/10/22 at 06:37 PM documented R2 arrived back from the emergency room sometime after 03:00 PM. R2 had five stitches and dissolvable stiches inside of his mouth. R2 had a new order from the emergency room for an antibiotic, and staff were to remove the stitches in seven to ten days. The Discharge Instructions dated 08/10/22 documented R2 had internal mouth stitches as well as external chin stitches. Orders directed staff to rinse R2's mouth out with water after eating. The internal stitches would take several weeks to dissolve. The instructions directed R2's external stitches were not to get wet on 08/10/22, but ok to get wet on 08/11/22 when bathing; it directed to avoid soaking the stitches. Order directed staff to clean external stitches daily with warm soapy water, apply bacitracin (antibiotic ointment) and keep clean/covered. R2 was to return for external suture removal in five days. The discharge diagnoses noted was chin laceration (cut), facial injury, and laceration of internal mouth. The Weekly Skin Check dated 08/11/22 at 01:30 PM documented bruising to R2's chin and swelling to the chin and lower right cheek. The resident had stitches to the right side of his chin. R2's EMR lacked description or explanation of any event that caused the laceration to R2's chin. The notarized Witness Statement dated 12/07/22 signed by Certified Medication Aide (CMA) R documented staff heard R2 screaming from his room. When CMA R went to check on R2, CMA R saw the armoire on top of R2. R2 will still in his wheelchair with the armoire on top of him, laying across his chin. R2 was bleeding and it took a total of four staff members to free R2 from under the armoire. Once R2 was out from under the armoire, Licensed Nurse (LN) G took over his care. R2 went out to the hospital because LN G could not get the bleeding to stop. The notarized Witness Statement dated 12/07/22 signed by Administrative Nurse E documented LN G brought R2 to the conference room window and reported that R2 had pulled his armoire onto himself and cut his chin. R2 also appeared to have an open area on the bottom inside of his mouth as well. Administrative Nurse E applied pressure while LN G called and obtained an order to send R2 to the hospital, and prepared paperwork to go out with R2. The notarized Witness Statement dated 12/07/22 signed by Administrative Staff A documented staff reported R2 pulled the armoire down on himself when R2 attempted to pull himself up from his wheelchair. R2 had a cut on his chin and upon assessment, R2 was sent out to the hospital; he came back to the facility with stitches. On 12/07/22 at 02:15 PM the armoire in R2's room could be pulled away from the wall with nothing in place to secure the top half of the armoire to the wall. The armoire was approximately five and a half feet tall, by two feet deep by three feet wide. The armoire had two doors that opened outward from the middle of the armoire to the top, with two full width drawers on the bottom third of the armoire. Observation of several more rooms revealed none of the armoires were anchored or attached to the wall to prevent tipping. On 12/07/22 at 02:05 PM CMA R stated that none of the armoires were attached to the walls before or since the accident. CMA R further stated she thought that Maintenance U was supposed to secure the armoires to the wall, but CMA R did not think it had happened yet. On 12/07/22 at 02:35 PM Administrative Nurse D stated she could not locate a risk investigation or any notes within R2's EMR that indicated what happened to R2 that required sutures to his chin. On 12/07/22 at 03:30 PM Administrative Nurse E stated that she thought Maintenance U was told to attach all of the armoires to prevent tipping right after R2 pulled the armoire over on himself. On 12/08/22 at 02:13 PM Maintenance U stated he talked about the need to secure the armoires because it was a problem, but that was all that was done. Maintenance U further stated that there was supposed to be a meeting to discuss a solution but that meeting never happened. He further stated that he is the only maintenance man for the entire building and there was a lot to do. The undated Accidents and Supervision policy documented the residents' environment was to remain as free of accident hazards as possible; and each received adequate supervision and assistive devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; monitoring for effectiveness and modifying interventions when necessary. The facility failed to ensure the armoires, used for a closet inside the resident's room, were anchored securely to prevent tipping. This deficient practice resulted in a cognitively impaired resident, who attempted to use the armoires to pull himself to a standing position, tipping the armoires onto himself and sustained lacerations which required emergent treatment and sutures.

The facility ' s census totaled 33 residents with 4 sampled. Based on observation, interview, and record review, the facility failed to provide effective interventions to prevent elopement of 1 of 1 residents sampled (#1) at risk for elopement with cognitive deficits and previous elopement attempts. This failure placed the resident in immediate jeopardy. Resident #1 was found walking alone approximately 0.8 miles from the facility at 7:30 P.M. crossed the highway with a speed limit of 45 mile per hour (MPH). Findings included: - Resident # 1 ' s physician's order [REDACTED]. The admission Minimum Data Set assessment dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 12 (moderately impaired cognition), did not have inattention, did not have disorganized thinking, no altered level of consciousness, no psychomotor retardation, no acute change in mental status, no hallucinations, and no delusions. He/she had wandering behavior 1-3 days which placed the resident at significant risk of getting to a potentially dangerous place, required set up from staff with transfers, walking, was steady at all times moving, and did not have extremity impairment. Review of the cognitive loss/dementia Care Area Assessment (CAA) dated 8/2/15 noted the resident scored 12 out of 15 in the BIMS indicating that his/her orientation and recall were moderately impaired, the resident was at risk for cognitive deficits related to Traumatic Brain Injury (TBI) with increased risk related to personality changes. He/she was alert and oriented to person and place, had noted behaviors and moments of poor recall. The resident was able to make his/her own decision, however, does have a guardian to assist with decision making and/or current plan of care. Review of the Activities of Daily Living (ADL) CAA dated 8/2/15 noted the resident required supervision and minimum to moderate assistance with ADL's. He/she had poor coordination at times, with an unsteady gait. He/she ambulated independently thorough out the facility with supervision as needed. Review of the Falls Care Area Assessment (CAA) dated 8/2/15 noted the resident was at risk for falls related to current medication regimen, [DIAGNOSES REDACTED]. He/she had a [DIAGNOSES REDACTED]. He/she had one on one (1:1) observation from staff related to impulsivity and elopement, an had a wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). Review of the behavior Care Area Assessment (CAA's) dated 8/2/15 noted the resident wandered/eloped from this facility twice since admission. He/she was on 1:1 observation related to wandering/elopement incident on 7/23/15 with wander guard remaining intact and fully functioning. On 8/4/15 at 3:50 P.M. administrative staff B stated the resident admitted to the hospital on [DATE] and attempted to elope on the following dates: 9/22/14 attempted to follow staff through the 400 hall door; 10/9/14 made multiple attempts to follow staff, refused to come back; 1/27/15 the resident was playing basketball and did not want to come back into the building, on 6/10/15 the resident participated in a group gardening activity outside and walked away from the group. Staff had to redirect the resident to get him/her back in the building. Review of the initial plan of care dated 7/20/15 noted the resident was at risk for elopement, had a wanderguard in place, eloped 7/23/15 at 7:15 P.M., and staff now provided 1:1 observation. The resident ' s care plan dated 8/4/15 noted staff provided 1:1 observation at all times. Staff escorted the resident when they left the building, staff would notify the physician of any elopements or attempted elopement, placed a wanderguard on the resident, staff encouraged the resident to let the wanderguard to remain intact, monitor the effectiveness of the wanderguard, place photo identification in the resident ' s medical record in the event of an elopement, and staff encouraged the resident to remain in the facility during the duration of his/her stay. The staff were to ensure a safe environment for the resident. The Elopement wandering risk (MDS) data set [DATE] revealed the resident was ambulatory by self, oriented to person, place, had impulsive behaviors, was a new admission, had history of elopement 2 or more times, was at risk for elopement, consider secure unit placement. It was not marked for a wanderguard. The physician order [REDACTED].M. included a new order for 15 minutes checks due to the patient ' s statement of elopement, place wanderguard. Review of the treatment administration record (TAR) for July and August 2015 noted the staff checked the resident ' s wanderguard placement and functioning every shift starting on the night shift on July 24th through August 4, 2015. It lacked documentation of staff checking the placement and functioning on July 20th, 21st, 22nd, and 23rd. On 8/5/15 at 8:49 A.M. administrative nursing staff E stated the resident admitted with a wanderguard and staff checked placement and function of the wanderguard every shift since admission. He/she acknowledged the resident ' s July 2015 TAR lacked documentation, and stated the staff did not check the wanderguard. The nurse ' s note dated 7/22/15 at 3:21 P.M. the resident had to be redirected several times today. The resident had outbursts in regards to snacks and meals. He/she did not remember eating and became angry with staff, called them names and raised his/her voice. The resident requested to be moved to a different room, and staff moved him/her into a different room. The nurse ' s note dated 7/24/15 at 2:36 A.M. noted that on 7/23/15 on the 6:00 P.M. to 6:00 A.M. shift the resident had impulse control issues. He/she followed certain staff members around the unit as they worked. The staff encouraged the resident to leave staff members alone. At approximately 7:00 P.M. the wander guard door alarm sounded, and the resident was not located on the unit. Staff member located client outside, he/she was brought back to facility per vehicle and escorted inside at 7:35 P.M. At 8:00 P.M. this nurse was informed that the resident wouldn ' t be spending time on the 300 hall till more staff was available to monitor him/her . At 8:20 P.M. the resident was standing at the front desk, he/she did not have a staff member with him/her. At 8:25 the resident went out the front door, staff followed him/her outside to front parking lot. At 8:30 the resident was back inside the building. He/she demonstrated to staff how he/she got the door opened. Record review revealed the resident eloped on 7/23/15 around 7:00 P.M. It was unknown the exact route the resident took from the facility to where staff found him/her. The most direct route on the streets from the facility revealed it was approximately 0.8 miles from the facility. The resident was seen last at approximately 7:00 P.M. at the nurses desk. The wanderguard alarmed when he/she went out of the building, and staff went looking for the resident. Licensed staff H found the, got the resident to get in the car and returned the resident to the facility. According to wunderground.com on 7/23/15 at 6:53 P.M. the temperature was 87.1 degrees with clear skies. The exact route the resident traveled was unknown. There were 13 steps out to the front of the building, the driveway of the facility was approximately 200 feet to the highway. The facility ' s driveway opened to a 4 lane highway on a curve with moderate traffic, the speed limit was 45 miles per hour (mph). Staff found the resident 0.8 miles from the facility, on a street that had a 35 mph speed limit. The notarized witness statement of licensed staff I dated 8/5/15 documented on 7/23/15 a little before 7:00 P.M. he/she observed resident #1 standing by the lobby desk. He/she completed giving medications for a patient. He/she then heard the front door alarm sounding. He/she did not know it was the wanderguard sounding also. A staff member came out of the bathroom and turned off the wanderguard alarm, the front door alarm had already been disarmed. They then realized resident #1 might be missing and started looking for him/her. Staff performed the inside search first. At about 7:15 P.M. staff started looking outside for the resident. As other staff searched outside for the resident, he/she returned to his/her other residents. When licensed staff H returned the resident to the facility about 7:35 P.M. he/she demonstrated the use of the green button. The house supervisor instructed him/her to have the resident go to the 300 hall until the facility had more staff. Resident #1 returned to the unit a little after 8:00 P.M. unescorted by staff, stopped by the front lobby desk. At 8:20 P.M. the front door alarm went off again. He/she ran to the front door, along with 2 other staff members. Resident #1 was walking down the ramp towards the parking lot. The 2 other staff members went past licensed staff I while he/she held the door open. When the staff brought the resident back into the building they placed him/her on the 300 hall until the safety officer made it into the facility to sit with the resident. On 8/3/15 at 3:08 P.M. the resident was in the lobby talking to staff. The resident was not exit-seeking. He/she walked at a fast pace, with a steady gait, to his/her room. On 8/3/15 at 4:15 P.M. the resident was in a staff member ' s office, and the 1:1 aide was in the hall outside of the door. On 8/3/15 at 5:01 P.M. the resident sat at the dining room table by him/herself, and did not display elopement behaviors. The staff observed the resident. On 8/4/15 at 10:45 A.M. the resident watched television in the common room with the Certified Nurse Aide (CNA) in the room. On 8/4/15 at 11:30 A.M. the resident walked past the front doors and did not attempt to elope. On 8/5/15 at 8:58 A.M. direct care staff redirected the resident from wanting to go into the social workers office, the resident was agitated but easily redirected to watch television. On 8/3/15 at 3:10 P.M. the resident stated he/she left the facility by reaching over the half door and pushed the green button behind the nurses ' desk. He/she said he/she went for a walk, walked on the sidewalk in the neighborhood. A staff member picked him/her up after walking around the neighborhood. He/she could not remember the exact path he/she went. He/she had a wanderguard on his/her right ankle, which he/she stated was on when he/she went for the walk. He/she thought he/she was gone around 30 minutes. When he/she was back in the building, he/she pushed the button again and went outside a second time. The staff were right behind him/her and he/she made it to the parking lot. A staff member asked him/her how he/she got out so he/she told the staff member, then went back inside and showed the staff how he/she pushed to button to open the front door. The staff told the resident he/she could not push the button anymore, and a staff member has been with him/her all the time since that day. He/she had not tried to leave since then. On 8/4/15 at 11:11 A.M. contract staff GG stated he/she would go out of the door to check for residents if the alarm sounded. There was only one resident who was an elopement risk and that resident had on a wanderguard. On 8/3/15 at 4:32 P.M. direct care staff P said the resident was an elopement risk. The staff made sure a staff member was close to the resident at all times with 1:1 aides. The staff did not give out the door access code to anyone. When direct care staff P would hear the door alarm, he/she would go to check the exit doors to see if there was resident is outside, and then ask other staff if they saw anyone. On 8/5/15 at 1:41 P.M. direct care staff said when the red light goes off it is the wanderguard alarm. The staff go outside, see if anyone is in the parking lot, into the parking lot, go to the edge of the building looking for a resident. There was only one resident right now and that was an elopement risk. On 8/4/15 at 10:21 A.M. licensed staff H stated the evening resident #1 eloped he/she licensed staff I was at the medication cart near the nurses ' station when the alarm was sounding, he/she was the resident ' s nurse for that shift. Licensed staff H finished patient cares in a room, when he/she came out of the room, he/she heard the alarm, saw the red light, and went outside looking for resident #1 around both sides of the building. He/she then went into the 500 hall of the hospital to ask if they had found the resident. He/she got in his/her car, went right out of the facility driveway, down several blocks, then went left on a back street. He/she called into the facility to see if staff found the resident, and was told no one found the resident yet. He/she told them to call the Dr. Gold code (the facility ' s elopement code name) and call the director of nursing (DON). He/she continued to drive and found the resident on the side of the street. The resident told licensed staff H that he/she just need to walk . The resident got in the car and they returned to the facility. From the time licensed staff H saw the light going off to when he/she found the resident was about 15 minutes. He/she did not know how long the alarm was going off before he/she heard it. Licensed staff H stated the resident was spontaneous in his/her actions, was easily redirected, for the most part he/she had good safety awareness but at times he/she could get spontaneous. Later that evening the resident demonstrated the green button at the nurse ' s desk to open the doors. After staff returned the resident to the building, they placed him/her on the 300 hall so he/she could use the computer. At approximately 8:30 P.M. he/she heard the door alarm sounding again. He/she went outside, and the resident was out there with other staff. The resident was being resistive and a third staff member talked the resident to return to the facility. They called the security officer in to sit with the resident. On 8/5/15 at 4:07 P.M. licensed staff I stated he/she worked the night on 7/23/15 and was resident #1 ' s nurse. At a little before 7:00 P.M. licensed staff I was in the 100 hall way standing at the medication cart, observed resident #1 standing near the lobby/nurses desk. Licensed staff I turned his/her attention back to the medication cart for medication for the next resident. The door alarm went off and he/she went to investigate. He/she did not know the wanderguard was alarming at that time. A coworker came out of the bathroom, noticed the wanderguard alarm was alarming, punched in the code to stop the alarm, then they started looking for the resident. First we stopped the alarm because you can ' t talk over the alarm. He/she stated he/she did not look out the door when it was alarming. There were visitors coming in and out during that time frame, it is just a busy time of night. It was less than 5 minutes from the time he/she heard the alarm to the time he/she started looking for the resident. They searched in the building first looking for the resident, it wasn ' t an organized search but staff checked all areas. The resident had a wanderguard bracelet on his/her ankle and when he/she would go through the door it would alarm. Licensed staff I said he/she looked in the building first in case the resident opened the door and came back in the building. The resident had been opening the door by pushing the green button previously. Licensed staff I had not seen him/her push the button. Licensed staff H got in his/her car driving to look for the resident. Licensed staff I returned to his/her duties for other residents. He/she did not know the code name to announce an elopement. When staff returned the resident to the facility, licensed staff H started the resident on a staff 1:1. The house supervisor told them to put the resident on the 300 Hall because that is where he/she came from until more staffing could get here. Somewhere between 8:00 P.M. and 8:20 P.M. the resident was in the front lobby without any staff. He/she was preparing medication and when he/she finished with the person he/she was working with, the door alarm was going off again. He/she went through the door and saw the resident in the parking lot without staff. He/she yelled at the resident to stop, when 2 staff went through the door past him/her to get to the resident. They brought the resident back into the building he/she demonstrated how he/she used the green button at the nurses station to open the front door. The staff kept resident #1 on the 300 hall until the security officer arrived to sit with the resident. On 8/5/15 1:12 P.M. administrative nursing staff D stated resident #1 admitted with a wanderguard due to being an elopement risk. The staff found the resident away from the facility unsupervised on 7/23/15. When staff returned the resident they placed the resident on the 300 hall so he/she could be watched, he/she knew that area, and the computer was available for residents to use. There was no button he/she could push to get out of the building. At 8:20 P.M. the resident showed up standing at front desk, he/she did not have a staff member with him/her. A at 8:25 P.M. the resident went out the front door. Staff followed him/her to front parking lot. At 8:30 P.M. the staff brought the resident back inside, he/she was demonstrating to staff how he/she opened the door by using the green button behind the nurses desk. At 8:55 P.M. the staff sent the resident back on the 300 hall until the safety officer arrived to help monitor the resident. On 8/5/15 at 12:34 P.M. contract staff HH stated the resident was an elopement risk when he/she came to the facility. Staff response time should be 30 seconds to see why the door alarm was going off. There was a green button at the nurses ' desk that when pushed would open the front door. In theory the wanderguard should let staff know as soon as the alarm went off the resident went through the door. The resident was capable of getting 0.8 miles away from the facility in 15 minutes, he/she walked fast. The resident is very impulsive, had short term memory issues but he/she can remember what he/she wanted to, was always moving, and never sat down. We have performed IQ test on the resident and the resident is at a 5th grade level, which was his/her base line since childhood. He/she would not be surprised the resident figured out how to open the door with in day or two. Staff should monitor the function of the wanderguard. On 8/5/15 at 5:20 P.M. administrative staff A stated the facility did not have a policy for the wanderguard. The facility ' s undated Resident Elopement Policy noted staff identified the residents ' at risk for elopement and interventions were put into place to prevent elopement. The facility ' s policy for missing patients, revised 10/11/12 noted when a patient was missing a Dr. Gold would be announced on the public announcement system by the nursing supervisor and over the phone intercom system. Staff member checked their immediate areas for the resident, and a systematic search of the building and the grounds would be directed by the nursing supervisor. The local police department would be notified if the resident was not found. The facility failed to provide adequate supervision to prevent a resident from leaving the facility twice without staff knowledge and they did not respond timely to the resident leaving the facility. The resident was able to walk 0.8 miles across a 4 lane highway with a speed limit of 45 MPH. The immediate jeopardy was abated on 8/7/15 to a D after the facility preformed elopement risk assessments on all residents residing in the building, in-serviced all staff on the revised elopement policy, created an elopement book with the residents at risk for elopement picture in it and placed the books at the nurses ' desk and the front lobby, completed elopement drills and disarmed the green button that opened the doors, and installed a key pad entrance at the exit doors.

The facility identified a census of 30 residents. The sample included 18 residents. Based on record review and interview, the facility failed to maintain nutritional status for 2 residents with significant weight loss. (#56, #35) Findings included: - Resident #35 admitted to the facility on [DATE], and discharged on [DATE]. The resident's admission Minimum Data Set (MDS) 3.0 dated 2/9/12 recorded the Brief Interview for Mental Status (BIMS) score was 14, which indicated intact cognition. The MDS recorded the resident required staff supervision for eating and extensive staff assistance for bed mobility, transfers, locomotion on the unit, dressing and toilet use and did not walk. His/her weight was 94 pounds (#) on 1/31/12, and he/she did not have tooth problems. The Nutritional assessment dated [DATE] recorded the resident was on a cardiac diet, had protein calorie [MEDICAL CONDITION] and consumed 25-50 percent (%) of meals. The Registered Dietician (RD) note dated 2/2/12 recorded the resident's [MEDICATION NAME] and [MEDICATION NAME] laboratory values indicated protein depletion, the resident's oral intake fluctuated, and recommended to change the resident's diet to No-Added-Salt (NAS) and give 2 cal (a high protein, high calorie nutritional supplement), 90 cubic centimeters (cc.) 3 times per day during medication pass. The February and March 2012 Medication Administration Records (MARs) and Treatment Administration Records (TARs) lacked evidence that staff carried out the 2/2/12 RD's recommendation for the 2 cal nutritional supplement. The resident's weight record dated 2/5/12 documented the resident's weight at 92#. The nutrition Care Area Assessment (CAA) dated 2/9/12 recorded the resident was on a cardiac diet, his/her appetite was fair, consumed 25-100% of most meals, had full dentures, had no difficulty with chewing and received Prostat (a high protein, high calorie nutritional supplement), 30 cc. 3 times per day. The resident's weight record dated 2/18/12 documented the resident's weight at 91# (a 1# weight loss since the RD recommended the supplement). The resident's weight record dated 3/5/12 documented the resident's weight at 89# (a 3# weight loss since the RD recommended the supplement). The resident's weight record dated 3/20/12 documented the resident's weight at 87# (a 5# weight loss since the RD recommended the supplement). The resident's weight record dated 3/20/12 revealed the resident lost 7# (7.4%) since his/her admission weight on 1/31/12. The RD note dated 3/22/12 recorded the resident's oral intake decreased and the resident's weight was 87#, down 7#, received 2 cal 90 cc., and recommended to increase the 2 cal to 120 cc. 3 times per day during medication pass. The RD note and weight record reflected the resident had a 5.4% weight loss since 2/2/12 when the RD recommended the nutritional supplement that the facility failed to provide for 7 weeks. During an interview on 6/19/12 at 4:54 P.M., dietary staff C stated the facility's process for RD recommendations was the RD gave the written recommendation to administrative nursing staff A, and nursing staff A passed the recommendation to the staff nurse to call the doctor, get an order and implement the order. Dietary staff C further stated he/she gave weight loss information to administrative nursing staff A as soon as he/she received the weights. Dietary staff C acknowledged the resident had a significant weight loss. During an interview on 6/19/12 at approximately 5:10 P.M., administrative nursing staff A stated the RD reviewed resident's weight losses and staff discussed weight loss at meetings on Fridays. The RD reviewed and made recommendations in writing, and gave the recommendations to administrative nursing staff A. Administrative nursing staff A delegated licensed staff to call the doctor, get and order, implement the order and update the resident's care plan or he/she did the process him/herself. Staff A stated the RD recommended the 2 cal supplement on 2/2/12, but did not know what happened to the order and acknowledged staff did not give the resident the supplement in February or March until the order increased on 3/22/12, 7 weeks later. Administrative nursing staff A acknowledged the resident had significant weight loss. During an interview on 6/20/12 at 2:42 P.M., administrative dietary staff D stated the resident was low weight and had poor oral intakes. Dietary staff D stated he/she talked talk with administrative nursing staff A about weight loss, and puts a written copy in administrative nursing staff A's mailbox and also went over his/her recommendations with the facility dietary staff C. He/she and facility dietary staff C tried to follow through with the recommendations to make sure they were followed by speaking with facility licensed nurses and looked at the TAR to make sure the resident took the supplement, but that was not done in this case. If there was an ongoing weight loss issue, dietary staff C notified dietary staff D again. Staff D stated he/she missed that staff did not place the recommendation on the TAR and acknowledged the resident did have significant weight loss. The facility lacked a RD dietary recommendation policy. The facility failed to implement nutritional interventions for this resident with significant weight loss. - Resident #56 admitted to the facility on [DATE] and discharged on [DATE]. The resident's admission Minimum Data Set (MDS) 3.0 dated 2/23/12 recorded the Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. The MDS recorded the resident required staff supervision for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. His/her weight was 146 pounds (#), and he/she did not have swallowing problems, chewing problems or tooth problems. The nutrition Care Area Assessment (CAA) dated 2/23/12 recorded the resident was on a No-Added-Salt (NAS) diet, his/her appetite was fair and he/she consumed 25-50 percent (%) of his/her meals. The nutrition care plan dated 3/2/12 directed staff to report to the physician any signs or symptoms of [MEDICAL CONDITION] and weight loss, monitor the resident's weight and record it, obtain and monitor lab work as ordered. report results to physician and follow up as indicated, Registered Dietician (RD) to evaluate and make diet change recommendations as needed, evaluate any resident weight loss, administer medications and monitor for side effects and effectiveness, provide the resident with a NAS diet as ordered, encourage diet compliance and assess the resident's food preferences. The Nutritional assessment dated [DATE] recorded the resident's Body Mass Index (BMI) indicated the resident was overweight, and staff should monitor the resident's intake, labs and weights. The dietary note dated 3/2/12 recorded the resident's oral intake was average to low, meal intakes averaged 50-75% and intakes on several meals were 25% and the resident refused some meals. The dietary note lacked documentation of the resident's current weight. The dietary note dated 3/6/12 recorded the resident's meal intake averaged 25-75%, the resident's weight on 3/5/12 was 132#, down 14# in 17 days and staff would refer to the RD for follow up. The note reflected the resident had a 9.6% weight loss in 17 days. The RD note dated 3/8/12 recommended 2 Cal HN (a high protein, high calorie nutritional supplement) 90 cubic centimeters (cc) 3 times per day during medication pass to prevent further weight loss. The March 2012 physician's orders [REDACTED]. During an interview on 6/19/12 at 4:54 P.M., dietary staff C stated the facility's process for RD recommendations was the RD gave the written recommendation to administrative nursing staff A, and nursing staff A passed the recommendation to the staff nurse to call the doctor, get an order and implement the order. Dietary staff C further stated he/she gave weight loss information to administrative nursing staff A as soon as he/she received the weights. Dietary staff C acknowledged the resident had a significant weight loss. During an interview on 6/19/12 at approximately 5:10 P.M., administrative nursing staff A stated the RD reviewed resident's weight losses and staff discussed weight loss at meetings on Fridays. The RD reviewed and made recommendations in writing, and gave the recommendations to administrative nursing staff A. Administrative nursing staff A delegated licensed staff to call the doctor, get and order, implement the order and update the resident's care plan or he/she did the process him/herself. Administrative nursing staff A stated he/she could not find the order for the nutritional supplement in the resident's chart, and thought the RD recommendation was missed because staff A was out of town on that particular Friday and did not receive it. Administrative nursing staff A acknowledged the resident had a significant weight loss. During an interview on 6/20/12 at 2:42 P.M., administrative dietary staff D stated he/she talked talk with administrative nursing staff A about weight loss, and put a written copy in administrative nursing staff A's mailbox and also went over his/her recommendations with the facility dietary staff C. He/she and facility dietary staff C tried to follow through with the recommendations to make sure they were followed by speaking with facility licensed nurses and looked at the TAR to make sure the resident took the supplement, but that was not done in this case. If there was an ongoing weight loss issue, dietary staff C notified dietary staff D again. Staff D stated he/she missed that staff did not place the recommendation on the TAR and acknowledged the resident did have significant weight loss. The facility lacked a RD dietary recommendation policy. The facility failed to implement nutritional interventions for this resident with significant weight loss.

The facility documented a census of 31 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to provide the necessary treatment and services to prevent pressure ulcers, prevent infection, to promote the healing of pressure ulcers and to prevent new sores from developing for 1 of 2 sampled residents (#9). Findings included: - Resident #9 ' s Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE], documented the resident with a Brief Interview for Mental Status score of 12, which indicated the resident with moderately impaired decision-making skills. The MDS further documented the resident required extensive assistance of 2 staff for bed mobility, dressing, and personal hygiene and required total assist with 2 people for transfers and toilet use. The MDS also documented the resident with an indwelling catheter, frequently incontinent of bowel, and at risk for pressure ulcers with no pressure ulcers at that time. The Resident Assessment Protocols (RAPS) dated 3/10/2010 related to skin breakdown, documented the resident as incontinent of bowel and non-ambulatory. The resident required extensive assist with transfers and bed mobility, and nursing staff was to assess and monitor for skin breakdown. The 3/21/11 care plan documented the resident with a potential for impaired skin integrity related to immobility. The nursing interventions included to monitor the resident ' s skin every shift, provide am/pm cares, provide adequate fluids/nutrition, consult dietician, Nylex (air mattress on the resident ' s bed), turn the resident every 2 hours, treatments per physicians orders, reposition in wheelchair every 2 hours, cushion in w/c, moisture barrier cream, monitor for signs and symptoms of infection and a weekly skin assessment. A review of the resident ' s chart revealed a physician telephone order dated 3/13/11 for the treatment of [REDACTED]. The pressure ulcer risk assessment dated [DATE] documented a total score of 17 (a score of 7 or higher indicated the resident was at risk for a pressure ulcer and indicated for staff to complete a care plan). The facility ' s skin condition sheet dated 3/22/11, after the resident ' s return from the hospital on 3-20-11, documented the resident with a facility acquired Stage 2 pressure ulcer on the medial (near the middle) coccyx measuring 0.5 centimeters (cm) by 0.7 cm. The skin condition sheet further documented the resident with a hospital acquired Stage 2 pressure ulcer on the right buttock measuring 0.3 cm by 0.2 cm. The skin condition sheet revealed that nursing would continue to use wound gel as the treatment for [REDACTED]. Observation on 3/23/2011 at 10:05 A.M., revealed direct care staff A and direct care staff B providing incontinent care to resident #9 with no dressing to pressure ulcers. Staff repositioned the resident to his/her right side and noted the resident to be incontinent of bowel. Direct care staff A used a wet wipe to cleanse rectal area from the front to the back (over the pressure ulcer at the top of the coccyx). Direct care staff A used an additional 3 wet wipes and continued to cleanse the rectal area upward over the pressure ulcer. Direct care staff A used another wet wipe to cleanse the left buttocks. Staff then turned the resident to his/her left side and observed another pressure ulcer on the resident ' s right buttocks. Staff then applied an incontinent brief and placed the lift sheet under the resident. Staff dressed the resident and assisted him/her into a wheelchair that had a cushion in the seat. The resident continued to sit up in his/her wheelchair until 1:30 P.M. when staff assisted the resident back to bed, a total of 3 hours and 25 minutes, without repositioning the resident. The pressure ulcers remained uncovered during the 3 hours and 25 minutes. Direct care staff A revealed that the resident has had no dressing covering the wounds since he/she obtained the wounds. Direct care staff A revealed that the licensed staff applies a cream over the wounds. Observation on 3/24/11 at 10:00 A.M. revealed licensed nursing staff A and licensed nursing staff B measured the un-covered pressure ulcers. Observation revealed 4 stage 2 pressure ulcers which included 4 areas as follows: 1) Mid coccyx 0.3 cm by 1 cm 2) Right proximal buttocks 1 cm by 1 cm 3) Right buttocks 2 cm by 1.8 cm 4) Right distal buttocks 3.5 cm by 0.5 cm. Licensed nursing staff B removed his/her gloves, washed his/her hands and applied new gloves. Licensed nursing staff B cleansed the open wounds with a wound cleaner and then removed his/her gloves, washed his/her hands and applied new pair of gloves. Licensed nursing staff B applied wound gel to a gauze pad and applied the gel to the open areas. Licensed nursing staff B stated that the pressure ulcers were not all there when he/she checked the resident on 3/22/11. Licensed nursing staff A revealed that the resident had all 4 pressure ulcers before he/she went to the hospital (returned from the hospital on [DATE]). Licensed nursing B stated that the resident returned from the hospital with only 2 pressure ulcers. Staff assisted the resident into the wheelchair per lift at 10:00 A.M. and remained up in the wheelchair at 2:15 P.M. visiting with spouse and another family member, a total of 4 hours and 15 minutes without repositioning the resident. The pressure ulcers remained uncovered. The revised April 2007 facility policy " Pressure Ulcers/Skin Breakdown- Clinical Protocol " instructed the nursing staff to: 1) Protect; 2) Manage drainage; 3) Promote moist wound healing; 4) Treatment: a. Cleanse with normal saline or other skin cleanser in accordance with physician orders [REDACTED]. b. Apply barrier cream, hydrogel or hydrogel sheet (cut to fit); c. Cover with non-adhesive light gauze or transparent dressing; d. Alternate dressing (use of thin [MEDICATION NAME]); and e. Change per physician order [REDACTED]. The revised April 2007 facility policy " Repositioning " documented that for residents with a Stage I or above pressure ulcer that every 2 hour turning is inadequate. Residents who are in a chair should be on a every 1 hour repositioning program. On 3/23/2011 at 11:46 A.M., licensed nursing staff A revealed that the resident had the open area before he/she went to the hospital and the open area was still there when he/she returned on 3/20/11. Licensed nursing staff B stated that he/she assessed the wounds weekly, did the measurements and provided suggestions for the treatments for wounds. The facility usually tried the wound gel first and it just depends on where the pressure ulcer area as to whether nursing would apply a dressing or not. The nursing staff should reposition the resident every 2 hours to relieve the pressure. On 3/23/11 at 3:15 P.M., administrative staff A revealed that if a resident had an open area that the wound should have a covering over the opened area. The dietary documentation dated 3/24/2011 revealed that the resident readmitted from the hospital with multiple wounds with a pressure ulcer to right buttocks. The dietary documentation also revealed that nutritional support was in place. The facility failed to provide necessary treatment and services to promote healing by not repositioning the resident every 2 hours or less, by not covering the pressure ulcers with a dressing, by allowing incontinent bowel to get into the pressure ulcers and causing the resident to developed 2 new Stage 2 pressure ulcers.

The facility had a census of 34 residents. The sample included 6 residents. Based upon observation, record review and staff interview the facility failed to promote the healing of pressure ulcers and prevent the development of additional pressure ulcers for 1 (#120) of 2 residents sampled for pressure ulcers. Findings included: - Review of resident # 120's Physician order [REDACTED]. During the entrance meeting on 6/1/11 at 12:00 P.M. Administrative Staff A reported the resident readmitted to the facility with a pressure ulcer. The resident's quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date of 2/25/11 identified the resident scored 15 (a score of 15 indicated the resident cognitively intact) on the Brief Interview for Mental Status and did not exhibit any behaviors. The MDS 3.0 recorded the resident required extensive staff assistance with bed mobility, transferring, dressing and toilet use, did not walk in the room or corridor, independent with eating and locomotion on and off the unit. The assessment identified the resident at risk for the development of pressure ulcers, utilized a pressure relieving device for the bed and wheelchair and not on a repositioning/turning program. The resident's Pressure Ulcer Care Area Assessment (CAAs) dated 1/20/11 documented the resident spent most of his/her day in the bed and/or wheelchair, at risk for the development of pressure ulcers due to a [DIAGNOSES REDACTED]. The CAAs documented the resident scored a 17 ( a score of 17 indicated at risk for the development of pressure ulcers) on the Braden Scale For Predicting Pressure Sore Risk, received [MEDICATION NAME] for [MEDICAL CONDITION], had a history of [REDACTED]. The resident's care plan dated 5/27/11 documented the resident had actual impaired skin integrity related to the open area on the resident's coccyx and that staff monitored the resident's skin every shift and as needed, turned the resident every 2 hours, repositioned the resident every 2 hours when the resident sat in the wheelchair, and applied moisture barrier cream as needed. An entry to the care plan dated 5/30/11 documented the facility applied zinc oxide to the resident's buttock and perineal area twice a day and as needed. An entry to the resident's care plan dated 6/1/11 read to discontinue the zinc oxide treatment and to start the treatment of [REDACTED]. The resident's Admission (MDS) data set [DATE] (date the resident readmitted to the facility) and timed 4:00 P.M. documented the resident had 2+ [MEDICAL CONDITION], continent of bowel, urethral catheter in place, had an open area on his/her coccyx and received a regular non concentrated sweet , decreased potassium diet . The pressure ulcer risk assessment performed at that time identified the resident scored a 14 (according to the legend a sore of 7 or higher indicated the resident at risk for pressure ulcer development and a care plan was indicated). The Admission Data Set did not identity the stage or description of the open area on the resident's coccyx nor did it include the resident's weight. An Interagency Discharge Form Nursing Personal assessment dated [DATE] and timed 1:40 P.M. documented the resident had a Stage II pressure ulcer (diagram pointed to the resident's coccyx) and the hospital used an Allevyn Border dressing. A nurse's note dated 5/27/11 and timed 4:30 P.M. documented the resident readmitted to the facility with 2-3 generalized [MEDICAL CONDITIONS] wraps on his/her bilateral lower extremities, open area reported on the resident's coccyx and staff unable to assess the area due to the resident did not want to go to bed at that time. A nurse's note dated 5/28/11 and timed 9:00 P.M. documented that after dinner the resident went from the wheelchair to bed on his/her back and staff unable to access his/her coccyx or scrotum and that staff had to move him/her once in bed. The resident skin assessment dated [DATE] and timed 11:00 P.M. documented staff removed the dressing from the resident's buttocks, no skin issues there, staff observed an open area on the resident's inner right leg next to the perineal area that measured approximately 2 centimeters by 2 centimeters, top layer of skin gone, staff noted a small amount of bright red blood, some dry bowel movement (BM) cleansed away and staff applied barrier cream. The resident's Skin Conditions (Observation) Sheet dated 5/31/11 and timed 3:30 P.M. documented the resident had a Stage 2 pressure ulcer on the right gluteal fold that measured .60 cm by 1.00 cm with scant serosanguineous drainage and the facility continued with the zinc oxide treatment. The clinical record lacked evidence the facility had measured the Stage II pressure ulcer to the resident's right gluteal fold until 5/29/11 (2 days after the resident readmitted to the facility). A laboratory report dated 4/16/11 recorded the resident's [MEDICATION NAME]'s level at 3.2 grams/deciliter (normal reference range 3.5-5.7 g/dL). A nutritional progress note (completed by a Registered Dietician) dated 6/1/11 and timed 8:10 AM read the nutritional note completed secondary to the resident's readmission to the facility, the resident readmitted under Hospice care, had 2-3+ [MEDICAL CONDITION] in his/her right upper had and his/her bilateral lower extremities with 4+ [MEDICAL CONDITION] BLE, no new weight since readmission, numerous venous stasis ulcer at multiple sites noted, no new comprehensive or basic metabolic panel. The note did not address the resident's pressure ulcer. During interview with dietary staff A on 6/2/11 at 1:45 P.M. the staff reported the Registered Dietician could not perform a comprehensive assessment of the resident's nutritional status on 6/1/11 because the dietician did not know the resident's readmission weight and provided the facility's nutritional protocol to address wound healing. The nutritional protocol included that residents with a Stage II received a multivitamin with minerals every day, 30 kilocalorie's per kilograms, and 1/2 grams of protein per kilogram. The resident's June 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During interview with licensed nurse B on 6/2/11 at 2:00 P.M. the staff confirmed the resident did not receive a multivitamin with minerals every day. The facility's policy and procedure for prevention of decubitus ulcer revised 3/29/11 included that upon admission the nurse would assess the resident for risk of skin breakdown, if the resident triggered out as high risk, staff would turn and reposition the resident every two hours, complete a pressure treatment record upon admission and obtain an order for [REDACTED]. Review of the residents re-positioning flow sheet for May 28th through May 31st did not support the facility repositioned the resident every 2 hours as care planned. For example, from 6:00 A.M. to 6:00 P.M. on 5/28/11 the facility repositioned the resident once, twice on 5/29/11 and once on 5/30/11. During interview with direct care staff H on 6/2/11 at 2:20 P.M. the staff reported the resident not on a repositioning/turning program. During interview with licensed nurse D on 6/2/111 at 2:30 P.M. the staff confirmed the resident not on a repositioning/turning program as care planned. On 6/1/11 at 1:25 P.M. observation revealed the resident sat on the edge of his/her bed. At that time the resident reported that he/she had an open area on his/her "backside" and he/she thought the open area developed in the hospital. The resident's spouse stated the staff did not reposition the resident every 2 hours. On 6/1/11 at 2:00 P.M. observation revealed direct care staff A and direct care staff D and 2 Hospice staff in the resident's room. The observation revealed the resident incontinent of bowel and direct care staff A performed incontinent care. Prior to completing the incontinent care, observation revealed the resident required assistance of 4 to transfer him/her from the edge off the bed to the center of the bed. Observation at this time revealed the resident had a Stage II pressure ulcer on his/her right gluteal fold that measured approximately .5 centimeters by .5 centimeters on his/her right buttock and an open area in the center of his scrotum. Further observation revealed no dressing on the pressure ulcer. After the resident was in bed Licensed nurse C reported the facility had just obtained a physician's orders [REDACTED]. During interview with licensed nurse E on 6/1/11 at 2:30 P.M. the staff reported that when he/she observed the resident on 5/31/11 the resident did not have any open areas, the area on the resident's buttock scabbed over and the facility felt the zinc oxide appropriate and after learning the resident had a Stage II pressure ulcer the facility obtained a physician's orders [REDACTED]. During interview with licensed nurse E on 6/2/11 at 11:30 P.M. the nurse reported that he/she had entered the measurements on the skin condition report on 5/31/11 and he/she confirmed the documentation read the resident had a Stage 2 on his/her right gluteal fold with scant serosanguineous drainage. According to the 2009 International Guideline Prevention of Pressure Ulcers: Quick Reference Guide: "Wound dressings are a central component of pressure ulcer care. The selection of the dressing should be based on the tissue in the ulcer bed, the condition of the skin around the ulcer bed, and the goals of the person with the ulcer. Generally maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing or closure...use [MEDICATION NAME] dressing for clean Category/Stage II pressure ulcers in body areas where they will not roll or melt... The facility failed to reposition the resident every 2 hours as needed, failed to measure and assess the pressure ulcer in a timely manner, failed to use a dressing to promote healing and failed to thoroughly assess the resident's nutritional status.