Every finding on record at Medicalodges Arkansas City

The facility identified a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from resident-to-resident sexual abuse when Resident (R) 1, who had a history of inappropriate sexual behaviors, exposed his genitals to R9, a cognitively impaired resident. This deficient practice resulted in the residents being at risk for impaired psychosocial well-being including fear and embarrassment, and risk for ongoing sexual abuse. Findings included: - R1's Electronic Medical Record (EMR) revealed the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's 12/06/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R1 had no symptoms of depression or behaviors. The MDS noted R1 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medications. R1's 12/06/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R1 took antipsychotic medications to manage his schizophrenia and delusional disorder and an antidepressant to manage his depression. R1's Care Plan intervention dated 12/28/16 directed staff to speak calmly to him during a behavior. He had childlike behaviors and lacked impulse control. The plan directed staff to attempt to redirect though it may be difficult. The plan directed staff that if R1 becomes disruptive, allow personal space; and use positive reinforcement. R1's Care Plan dated 12/07/24 documented R1 took antipsychotic medications for delusional disorder and schizophrenia. He took Zyprexa (an antipsychotic medication), Clozaril (an antipsychotic medication), valproic acid (a mood stabilizing medication), and Paxil (a medication to treat depression that lowers libido). R1 occasionally displayed the following behaviors: obsessive with needs, rude and demanding of staff, hoarding, and food obsession; he made statements of feeling sad. R1's Care Plan dated 12/07/24 documented R1 had obsessive behaviors with his needs; he was rude and demanding of staff. The plan noted he made statements of feeling sad, had sexually inappropriate behaviors, and had hallucinations (sensing things while awake that appear to be real, but the mind created) and paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) that are monitored by staff. R1's Care Plan dated 06/24/25 documented R1's Paxil was increased related to increased sexual behavior. R1's Physician's Orders documented a 09/12/19 order for one tablet of Estrace (a hormone), one milligram (mg), by mouth one time a day for delusional disorder. R1's Physician's Orders documented a 09/26/23 order for one tablet of Zyprexa, five mg, by mouth at bedtime related to delusional disorder. R1's Physician's Orders documented a 02/12/24 order for two capsules of valproic acid 250 mg, by mouth one time a day, for mood disorder. R1's Physician's Orders documented a 04/23/24 order for one Clozaril 100 mg tablet by mouth one time a day and two tablets at bedtime for schizophrenia and anxiety. R1's Physician's Orders documented on 06/25/25 the psychiatric provider ordered one Paxil 20 mg by mouth one time a day for increased sexual behaviors related to anxiety. R1's EMR behavior monitoring tasks documented R1 was sexually inappropriate one time in the last 30 days and refused care one time in the last 30 days. No other behaviors were documented. R1's Progress Notes dated 06/21/25 at 04:31 PM documented R9 (a female resident with severe cognitive impairment) reported to Administrative Staff B that R1 inappropriately touched her leg and exposed himself to her. The facility called the police who came to the facility and interviewed both residents. The officer stated he would write a report. The note documented R1 would be one-on-one with staff. Staff notified Administrative Staff A and R1's Durable Power of Attorney (DPOA). R1's Behavior Note dated 06/22/25 at 04:13 AM documented R1 was one-on-one for inappropriate behaviors. He had behaviors of taking items from his room and giving them to the nurse. R1 reported he did not want the items, or he thought they were not his. R1's Behavior Note dated 06/22/25 at 03:13 PM documented he was one-on-one for inappropriate behaviors. The note documented R1 had no behaviors. R1's EMR lacked evidence indicating one-on-one documentation for the night shift on 06/22/25. R1's Nurse's Note dated 06/23/25 at 10:01 AM documented staff called R1's physician to notify her of R1's change in behavior. The staff received an order for a urine analysis (UA). The order directed if the UA was negative, to refer to R1's mental health provider for possible medication adjustments. R1's Nurse's Note dated 06/23/25 at 10:25 AM documented staff obtained the UA and sent it to the lab. R1's Behavior Note dated 06/23/25 at 06:37 PM documented he was one-on-one for inappropriate behaviors; no behaviors were noted. R1's Nurse's Note dated 06/24/25 at 12:53 AM documented the UA did not show infection. The note recorded staff received a new order from Consultant II to increase R1's Paxil from 10 mg to 20mg once a day. R1's RISK Progress Note dated 06/24/25 at 05:05 PM documented R1's behavior was due to his mental status. R1's Behavior Note dated 06/24/25 at 07:15 PM documented R1 had impatient behaviors and was redirected. A review of the incident packet provided by the facility during the survey revealed the facility identified 46 facility staff but only 20 staff signed off on the education provided on 06/23/25 on abuse, neglect, and exploitation prevention. On 06/24/25 at 03:24 PM, observation revealed R1 wandered the halls without staff present. On 06/25/25 at 11:32 AM, observation revealed R1 wandered the halls without staff present. On 06/25/25 at 01:11 PM, R1 sat in a chair next to another female in the dining area, Administrative Nurse D walked by and did not say anything. During an interview on 06/25/25 at 10:44 AM, R9 stated she was in the family room when R1 walked in the room, touched her leg then pulled down his pants and exposed himself. R9 stated she was shocked and felt sad. R1 said, Goodbye and walked away. She stated that no staff came in. She said this was the first time R1 was ever inappropriate with her, and she reported it to Administrative Staff B. R9 said the police came and talked to her about it. R9 stated she was a little bit scared now when she sees him, and she sometimes sees him in the dining room. He does not sit beside her, but he says, Hi. R9 stated she felt like the staff would keep her safe and said R1 was pretty friendly' with other staff and residents. R9 said she wished she could have stopped R1, but it just happened so fast. R9 started crying. During an interview with 06/25/25 at 12:26 PM, Administrative Staff B stated she walked into the family room when R9 asked to talk to her. R9 told Administrative Staff B that R1 came into the family room and said hi, he touched her knee and then exposed himself. R1 then left the room. Administrative Staff B stated she brought R9 to the dining room where she felt safe, then told Licensed Nurse (LN) G and Administrative Staff A. During an interview on 06/25/25 at 01:15 PM Certified Medication Aide (CMA) T said R1 was not supposed to be near other female residents and said R1 should be one-on-one with staff. CMA T went to the staff that was one-on-one with another resident and instructed her that she was to be with R1, also. During an interview with 06/25/25 at 02:23 PM, LN G said she called Administrative Staff A who directed her to make a police report. The police officer interviewed the residents involved and said he was going to write a report and left. LN G said staff kept the residents separated and initiated one-on-one status. LN G said it was her first day back, and she was unsure if staff continued one-on-one for R1. LN G said staff still separated the residents if they saw them together. LN G said R1 had not gone near R9 since the incident. During an interview with 06/25/25 at 02:28 PM, Administrative Nurse D stated when Administrative Staff A was notified, they immediately separated R1 and R9 and then called the police. Administrative Nurse D stated R1 and R9 had been separated since the incident and staff did one on one for R1 until labs were completed and R1's medications were changed. Administrative Nurse D said she did not know about R1's history until after the incident. Administrative Staff A and the Nurse Consultant discussed the situation and one on one was the immediate intervention. Administrative Nurse D said that Administrative Staff A and the Nurse Consultant discussed the situation, and determined the one-on-one would be discontinued and the medication change was made. During an interview on 06/25/25 at 02:41 PM, Administrative Staff A reported that Administrative Staff B called her and notified her of the incident. They notified the Nurse Consultant and requested a urinalysis due to this and other behavior changes. Administrative Staff A said she and the Nurse Consultant interviewed R9 who stated she felt safe now. Administrative Staff A confirmed R1 was one-on-one through the weekend. R1 saw a psychologist on Monday, and she will see him again in mid-July. During an interview on 06/30/25 at 08:50 AM, Administrative Staff D said that all the staff that work with the residents should have received and signed the education. During an interview on 06/30/25 at 11:46 AM, Consultant Staff JJ stated all staff should have had the education. During an interview on 07/01/25 at 02:39 PM, Consultant Staff II, a psychiatric nurse practitioner stated the nurse called her on 06/24/25 at 10:00 AM to report the situation. Consultant Staff II reports this is the first time she was aware of any behaviors of that kind, and she had only been working with R1 a few months, so she really did not know him that well. Consultant Staff II will follow up with R1 on 07/12/25, to evaluate the progress he has made and discuss behaviors at that time. Consultant Staff II said it would be beneficial for R1 to remain away from female residents until they know how he will react to the medication change. The facility policy Abuse, Neglect, and Exploitation, dated 09/2017 explained that the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy indicated that sexual abuse included, but wasn't limited to, sexual harassment, sexual coercion, or sexual assault. It further indicated that mental abuse included, but was not limited to, verbal, and non-verbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment, or threats of punishment or deprivation. The policy further explained that all residents would be assessed and/or monitored for unmet needs and/or behaviors that might lead to conflict, neglect, aggression, and any other behaviors that might lead to abuse or mistreatment from or toward other residents and/or staff. The policy also indicated that resident care plans would include problems observed and/or a history of previous problems such as signs of self-injurious behavior, wandering into other resident rooms, communication disorders, etc., which might result in aggressive behavior, agitation, and/or conflict. Based on the negative psychosocial impact including verbalizations of sadness and fear and as evidenced by tearfulness, this deficient practice is cited at a G to represent the actual psychosocial harm for R9.

The facility reported a census of 40 residents, one main kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food-borne bacteria. This placed the residents at risk for foodborne illness. Findings included: - During an initial tour of the kitchen on 06/24/25 at 03:39 PM, the following areas of concern were noted: 1. The stationary can opener had a sticky, thick substance covering the entire can opener. 2. Two machines utilized to puree food had dried food and liquids. 3. The inside and outside of the microwave oven had dried on foods and liquids. 4. Four cutting boards had deep grooves making them unsanitizable. 5. The front of the white cabinet doors and upper cabinet doors throughout the kitchen had dried on food and liquids. The handles to the cabinets contained a build-up of a sticky substance. 6. The inside of the cabinets which contained plastic pitchers, equipment parts, and other kitchen supplies rested directly on the bottom of the cabinets which contained a sticky, unknown substance. 7. A three-tiered metal cart holding eating utensils, syrup, measuring cups, and clean dishes had food debris on all three layers. 8. Eight plastic containers that contained cooking utensils, scoops, spatulas, and other utensils had a sticky substance on the lids. 9. Two black, plastic three-tiered carts used to transport cups of fluid to the residents in the dining room had food debris on all three layers. 10. Four plastic containers containing dry cereal had lids covered in dust. 11. A five-gallon container of sherbet ice cream was uncovered and undated in the reach-in freezer. 12. An empty gallon container of vanilla ice cream in the reach-in freezer was undated. 13. One of the two-door reach-in freezers had dried food and liquid on the front of the doors. 14. One of the two-door reach-in freezers had three boxes of food with a heavy build-up of ice. The kitchenette in the south dining room had the following concerns: 1. The hand-washing sink was visibly dirty with a brown substance and small pieces of trash. 2. The microwave had dried food and liquid on the inside and outside. 3. The trash can had dried food and liquid covering the front. 4. The freezer contained three open containers of ice cream which were unlabeled and undated. 5. The bottom shelf of the freezer had food debris and hair. 6. The two-door cabinet had dried on food and liquids. On 06/26/25 at 01:58 PM, Dietary staff BB confirmed the areas of concern and stated they would be added to the cleaning schedule. The facility policy for Date Marking, dated 2011, included: All foods stored for more than 24 hours will be properly labeled. The Cleaning Rotation for the kitchen, dated 2011, documented that can openers, blenders, and food processors shall be cleaned following each use. The hand-washing sink, microwave oven, and food carts shall be cleaned each day. Trash barrels, drawers, and cupboards shall be cleaned weekly. Refrigerators, freezers, and storage bins shall be cleaned monthly.

The facility reported a census of 40 residents. The sample included 14 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement adequate and acceptable infection control practices related to laundry services. This deficient practice placed the residents at risk for infections. Findings included: - During an observation on 06/24/25 at 02:56 PM, residents' clean clothes were carried by a hanger down the hall, uncovered, and placed in a resident's room by laundry staff. During an observation on 06/25/25 at 10:13 AM, staff carried resident clothes on a hanger down the hallway, uncovered. During an observation on 06/30/25 at 12:05 PM, observed in the soiled laundry storage there was a barrel with soiled laundry in and no cover, and there was soiled laundry sitting in the open on a covered transport bin. During an observation on 06/30/25 at 12:10 PM, the washing room, next to a washer, had a parked housekeeping cart, also observed were dirty mop buckets sitting on the drainage grate behind the washers. During an observation on 06/30/25 at 01:10 PM, the clean laundry folding counter at one end had a dryer sheet box, a dumbbell weight, a stuffed dog, and two large totes. Observed on the other end of the clean laundry folding counter was a binder, a laptop and speakers, and a refrigerator. On 06/30/25 at 12:10 PM, Maintenance V stated that the housekeeping staff stored their cleaning carts in the washing room. On 06/30/25 at 01:10 PM, Maintenance V stated that the refrigerator on the clean laundry folding counter was for the staff ' s personal use and personal food items. On 06/30/25 at 12:12 PM, Housekeeping W stated that the resident's clothes were transported by the transport carts and that they should be closed completely when transporting them down the hall and when the resident's clothes were taken into the resident ' s room. On 06/30/25 at 12:40 PM, Administrative Staff A stated that it was not acceptable to have items other than clean laundry on the clean laundry folding counters. Administrative Staff A further stated that dirty mop buckets should not have been left or stored between or behind the washers. On 06/30/25 at 12:57 PM, Housekeeping U stated that the only items that should have been on the clean laundry counter were clean laundry; it was not appropriate for other items to be stored there. Housekeeping U further stated that dirty mop buckets should not have been stored or left between the washers. On 06/30/25 01:48 PM, Housekeeping U reported that the facility did not have a policy related to clean laundry storage and delivery. The facility policy titled Infection Management Process, dated 12/2019 indicated that laundry services were performed off the resident living units and laundry services included cleaning of clothing using proper product and water temperature mix. It further indicated that soiled resident linen and clothing would be transported in an enclosed container to the laundry to avoid contamination to the resident living areas and to the employees.

The facility reported a census of 40 residents. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for one of the five Certified Nurse Aides (CNA) reviewed, CNA M, placing the affected residents at risk for decreased quality of care. Findings included: A review of five employee personnel files, employed by the facility for greater than one year, revealed the following: CNA M's personnel file revealed she was hired on 12/13/23. Her file lacked an annual performance review. On 06/26/25 at 09:45 AM, Administrative Staff A stated the facility had not completed an annual evaluation for CNA M. The facility policy for Performance Reviews, undated, included: Full and part-time employees shall receive a formal, written evaluation on an annual basis.

The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment in two of the three resident halls including the shower room on Hall A and Hall B as well as one supply storage room on Hall A which placed the residents at risk of unsanitary living conditions. Findings included: - During an environmental tour on 06/30/25 at 08:49 with Hskp/Maintenance U, the following concerns were noted: Hall A The shower room window had a build-up of dust, debris, and dead bugs. A four-tiered metal cart used to hold clean towels, wash clothes and toiletries had multiple areas of rust. The toilet seat was discolored and had several gouged areas on the seating surface. A storage room had two boxes resting directly on the floor. One unopened box contained urinary catheter (a flexible tube inserted into the bladder to drain urine) supplies. One opened box contained various wound supplies including assorted dressings, tape, and measuring devices. Hall B The shower room window had a build-up of dust, debris, and dead bugs. A four-tiered metal cart used to hold clean towels, wash clothes and toiletries had multiple areas of rust. The shower corner had missing caulk around approximately 50 percent (%) of the area. The hand-washing sink had rust around the faucet and drain. The paper towel dispenser contained multiple areas of rust. On 06/30/25 at 08:49 Hskp/Maintenance U confirmed the areas of concern listed above needed to be addressed. The facility policy for Housekeeping, Laundry and Maintenance, undated, included: Staff shall ensure sinks and paper towel dispensers are kept clean. Boxes shall be kept off the floor at all times.

The facility identified a census of 40 residents. The sample included 14 residents with three residents sampled for nutrition Based on observation, interview, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for Resident (R) 3 when the facility failed to implement interventions and recommendations including providing fortified foods to prevent further loss. This deficient practice placed the resident at risk for continued weight loss. Findings: - R3's Electronic Medical Record (EMR) revealed the following diagnoses: unspecified psychosis (any major mental disorder characterized by a gross impairment in reality perception), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) R3's 07/26/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of five, indicating severely impaired cognition. The MDS recorded R3's weight was 193 pounds, and she had no known weight loss. R3 consumed a regular textured diet with no eating or swallowing concerns. The 07/26/24 Nutritional Status Care Area Assessment (CAA) documented R3's weight as 193 pounds, and her height as five foot two inches. R3's risk factors included weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. R3's 04/25/25 Quarterly MDS documented a BIMS score of four, indicating severely impaired cognition. The MDS recorded R3's weight was 173 pounds, and she had no known weight loss. R3 consumed a regular textured diet with no eating or swallowing concerns. R3's Care Plan dated 05/29/24 documented she likes cranberry juice and black coffee at breakfast and any juice at lunch and supper. The plan directed staff to provide a regular diet and encourage low sugar and low sodium. Updated on 09/05/24, the plan documented R3 needed set up and or physical help for meals. On 06/25/25 R3's Care Plan was updated to include a mug with a handle, lid, and straw. The plan noted R3 gets tired and may not be able to hold her cup for long. The plan directed staff to provide R3 with built-up utensils at every meal as they are easier for her to grab and hold. R3's Care Plan lacked documentation that R3 was on a fortified diet and had an order for health shakes. R3's Physician's Orders noted a sugar-free supplement one time a day for a nutritional supplement, ordered on 02/21/25. R3's Physician's Orders documented an order for a fortified foods diet, regular texture, and regular consistency fluids dated 06/10/25. R3's Progress Note from the Registered Dietician (RD) dated 05/05/25 at 12:56 PM documented R3 currently weighed 164 pounds and continued to lose weight due to inadequate oral intake related to pneumonia (an infection in the lungs). R3 took a few bites at lunch and fell asleep. The Certified Medication Aide (CMA) reported R3 had been declining the sugar-free supplements. The RD noted the resident needed about 1700 calories per day to maintain current weight and 1950 calories per day for a half-pound weight gain per week. The RD recommends the addition of a fortified diet to the current diet order due to weight loss. The RD recommended staff notify the physician of the significant weight loss. R3's Weight Progress Note dated 05/23/25 at 04:27 PM documented R3 had a significant weight loss of 10 percent (%). R3 was on a regular diet with health shakes. R3's Progress Note from the RD dated 06/09/25 at 01:26 PM documented R3 weighed 163 pounds, which was a 10% weight loss since 01/08/25. The RD noted the weight loss was due to a decrease in oral intake and refusing meals. The RD recommended continuing with the sugar-free supplement and adding a fortified diet. R3's Weight Progress Note dated 06/10/25 at 12:59 PM documented R3 received a fortified diet and a sugar-free house supplement that she refused half of the time. The Weight Progress Note dated 06/10/25 documented staff notified the physician regarding R3's weight loss. On 06/26/25 at 11:28 AM Certified Nurse Aide (CNA) S sat beside R3. R3 had a clothing protector on and had a cup with a lid, a handle, and a straw. Staff did not offer her a drink and she did not take a drink. At 11:45 AM, R3 remained at the table, staff had not offered her a drink. At 11:48 AM, R3's food arrived. It was a wrap with french fries. CNA S gently touched R3 and asked her if she wanted to take a bite. CNA S placed some French fries on the fork and offered her a bite. R3 did not want the bite. CNA S waited for a minute then pushed the food to the middle of the table and left to go assist another resident. On 06/26/25 at 11:55 AM, CNA P reported that sometimes R3 just won't eat. CNA P said she would try something else when she was done assisting another resident. Later she reported that she tried dessert, and R3 spit it out. CNA P also reported that she did not use built-up silverware as was in R3's plan of care. CNA P said R3 was dependent on staff assistance. CNA P said she was unsure if R3's meal had a fortified food item On 06/26/25 at 12:01 PM, CNA S reported she had been working at the facility for almost a year and R3 required staff assistance for meals since CNA S started. CNA S said R3 had not used built-up silverware and verified that R3 did not have any fortified foods for lunch. On 06/26/25 at 12:22 PM, Dietary Staff CC reported R3 was on a regular diet. Dietary Staff CC said in order to make fortified foods, they add items like extra butter or cheese to add extra calories and fat to foods. Dietary Staff CC confirmed R3 did not get any fortified items and stated R3 was not on a fortified diet. On 06/26/25 at 12:29 PM, CMA T stated that R3 does not drink her shake at all. CMA T reviewed the charting for June 2025 and verified 14 out of the 25 days were marked as shake refused. On 06/26/25 at 03:20 PM, CNA R reported that when R3 does not want to eat, she will scream if staff persists, R3 will slap items away. On 06/30/25 at 08:50 AM, Administrative Nurse D stated that R3 spits out food if she does not want to eat. Administrative Nurse D said the facility fortifies foods by adding cheese to eggs and items to increase calories and fat in food. Administrative Nurse D said if a resident's diet order changes, the nurse should communicate it to dietary staff with a dietary communication slip and the dietary manager also has access to the EMR. Administrative Nurse D said R3's diet order for fortified foods should have been communicated. The facility policy Weight Assessment and Intervention, dated 2011, included: that a 10% weight loss is undesirable and severe. The care plan would be reviewed by the interdisciplinary team and updated. Interventions will be individualized and based on careful consideration of choice, nutrition needs, function, and environmental factors.

The facility reported a census of 40 residents. The sample included three residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff reported an incident of verbal abuse immediately to the Administrator as required when Certified Nurse Aide (CNA) M began taunting Resident (R)1 and making fun of R1's eyebrows and wrinkles. This deficient practice placed R1 at risk for impaired psychosocial wellbeing and ongoing abuse.Findings Include:- R1's Electronic Medical Record (EMR) revealed the following diagnoses: encephalopathy (broad term for any brain disease that alters brain function or structure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), hypothyroidism (condition characterized by decreased activity of the thyroid gland), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively leading to a buildup of waste and extra fluid).R1's 04/04/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero indicating severely cognitive impairment. The MDS recorded R1 had physical behaviors towards others occurring one to three days during the look back period; verbal behaviors towards others occurred one to three days during the look back period; and other behaviors such as hitting occurred one to three days during the look back period.R1's 03/04/25 Cognitive Loss Care Area Assessment (CAA) triggered secondary to orientation, memory and recall deficits noted during the BIMS interview. Contributing factors included long and short-term memory loss., self-care deficits, falls and injuries, incontinence, decreased socialization, skin breakdown, weight loss and fluid imbalance.R1's Care Plan dated 04/04/25 directed staff to monitor behaviors such as resistance to cares, grabbing, and pushing staff away. The plan directed staff If R1 appeared restless, anxious or wandered, assess R1 for pain, thirst or hunger.R1's Care Plan dated 04/04/25 indicated R1 experiences mood, behavior and psychosocial problems. The plan directed staff to monitor for aggressive and attention seeking behavioral expressions. The plan instructed staff to intervene as necessary to protect the rights and safety of others. Staff were directed to speak in a calm manner, divert attention from the situation, and take to an alternative location as needed.R1's Risk Progress Notes dated 08/05/25 at 11:56 AM documented a root cause that indicated a staff member did not follow policy and procedure regarding appropriate interactions with a resident. The note listed interventions which included a state report, law enforcement and family notification, suspension of the staff member, nursing assessment, an all-staff in-service on the abuse neglect and exploitation policy; R1's Care Plan was updated.R1's Administrator Note dated 08/06/25 at 12:30 PM documented Administrative Staff A was able to contact R1's durable power of attorney (DPOA) that day after several attempts over the past couple of days to notify her of an abuse allegation involving R1.The facility's investigation documented that during the evening shift on 07/31/25, R1 got up after being put to bed at 06:20 PM and wheeled herself to the dining room. R1 began calling the staff explicit names and CNA M and her coworker started to laugh because it was so random. R1 then started throwing hands and elbows to the two staff that tried to help her so CNA M went to try and help lay R1 down. CNA M started to antagonize R1 with statements that her eyebrows were bushy, and her skin was wrinkled. A report was made with the local law enforcement with a case number of A25-10288.CNA O's Witness Statement dated 08/04/25 documented between 08:30 PM to 9:00 PM on 07/31/25 there was three CNA staff in the is dining room when CNA M tried to take R1 to her room. CNA O noted R1 turned around and elbowed CNA M because she was not ready to go back to her room. CNA M continued to keep her hand on the handle of the wheelchair and mocked R1 making comments about her eyebrows and her wrinkled skin. CNA P's Witness Statement dated 08/04/25 documented R1 got up out of bed and came into the dining room R1 was interested in what the staff members were doing with their eyelashes; R1 then made an inappropriate statement to the staff. The staff started laughing and tried to take R1 back to bed. R1 did not want to go back to bed, and she started to stand up at the nurses' station. CNA P was able to get her to sit down so she would not fall but R1 did swing at that staff member. CNA M was making fun of R1's eyebrows then proceeded to clock out and go home.On 08/12/25 at 09:50 AM R1 sat in the commons area in her wheelchair having a conversation with another staff member.During an interview on 08/12/25 at 08:25 AM, R1 revealed that she has not had any staff members were mean to her. R1 said it was great there, everyone was nice to her.During an interview on 08/12/25 at 12:05 PM CNA N said she observed CNA M on the evening shift on 07/31/25 being rude to R1 and making fun of her. CNA N also said she did not know what to do during the situation when it happened. She said she notified Administrative Staff A in the morning on the next day. CNA N confirmed she received training on abuse, neglect and exploitation as well as reporting.During an interview on 08/12/25 at 12:11 PM, CNA O revealed that CNA M started making comments about R1's eyebrows and the wrinkles on her face on 07/31/25. CNA O said she did tell CNA M to leave R1 alone, and attempted to contact Administrative Staff A but could not find the number. CNA O stated her shift ended at 10:00 PM so she was not aware of what happened after that time. CNA O stated she contacted Administrative Staff A the next day and attended the in-service on abuse, neglect, exploitation and reporting.During an interview on 08/12/25 at 01:28 PM, CNA P said the incident with CNA M and R1 happened in the dining room and started with R1 calling the two other staff members an explicit name. CNA M said something back to the R1. CNA P said CNA M did finish her shift that night and she did not know if the director of nursing or the administrator had been notified. CNA P verified she attended an in-service on abuse. neglect and exploitation plus reporting after the incident.During an interview on 08/12/25 at 02:30 PM, Administrative Staff A revealed she had heard about the incident on 08/01/25. She said she suspended CNA M and started her investigation. Administrative Staff A said she did not think the acting director of nursing knew about the verbal abuse.During an interview on 08/12/25 at 03:17 PM, Administrative Staff D revealed he could not recall being notified of the incident. He stated a CNA from night shift told him about the resident being aggressive and nothing about CNA M being rude to R1.The facility's policy Abuse, Neglect, and Exploitation revised on 10/2022 explained all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are to be reported immediately to the Administrator and/or their designated representative, the appropriate state agency and when applicable, law enforcement not later than two hours after the allegation is made if the allegation involves abuse OR results in serious bodily injury or not later than 24 hours if the allegation does not involve abuse AND does not result in serious bodily injury.On 08/04/25 the facility completed corrective actions which included re-education for all staff on prevention of abuse, neglect and exploitation (ANE), reporting all allegations of ANE immediately to the Administrator, and the residents' right to be free from ANE. CNA M was terminated from the facility. Facility staff monitored R1 for any negative psychosocial impact, and there was none noted or reported.All corrective actions were completed prior to the onsite survey therefore the noncompliance was deemed past noncompliance at a scope and severity of D to reflect the potential for more than minimal risk to the resident but no actual harm.

The facility reported a census of 40 residents; the sample included 14. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for Resident (R)1, regarding antidepressants (medications used to treat symptoms of depression, a mood disorder that can cause persistent sadness, loss of interest in activities, and difficulties with daily functioning) medication. This placed the resident at risk for impaired care due to unidentified care needs. Findings included: - R1's Electronic Medical Record (EMR) included the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue). R1's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received an antipsychotic and antidepressant (medications used to treat symptoms of mood disorders that can cause persistent sadness, loss of interest in activities, and difficulties with daily functioning) medications during the assessment period. The Psychotropic Drugs Care Area Assessment (CAA), dated 12/06/24, documented the resident took psychotropic medications to manage his diagnoses of Schizophrenia and delusional disorder. R1's Quarterly MDS, dated 06/06/25, documented the resident had a BIMS score of 13, indicating intact cognition. He received antipsychotic medications during the assessment period. The MDS inaccurately documented the resident did not receive antidepressant medications during the observation period. R1's Care Plan revised 03/25/25 instructed staff the resident occasionally displayed behaviors and staff were to be firm but gentle when redirecting with the resident. R1's EMR revealed the following physician's order: Paxil (an antidepressant medication), 10 milligrams (mg), by mouth (PO), every day (QD), for a diagnosis of anxiety, ordered 04/30/25. On 06/30/25 at 02:11 PM, the resident ambulated in the hall and the commons area. On 06/30/25 at 07:55 AM, Administrative Nurse D confirmed the Quarterly MDS, dated 06/06/25, was inaccurate as the resident received anti-depressant medication during the assessment period. The facility reported they utilized the Resident Assessment Instrument (RAI) for accurate completion of the MDS and did not provide a policy.

The facility reported a census of 40 residents; the sample included 14 residents. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for Resident (R)23, regarding Black Box Warnings (BBW), placing the resident at risk for inadequate care due to uncommunicated care needs. Findings included: - R23's Electronic Medical Record (EMR) included psychotic disorder with delusions (significant impairment in an individual's perception of reality, leading to the presence of false beliefs that are not based in reality) and high-risk behaviors (actions that significantly increase the likelihood of experiencing negative consequences). R23's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The resident did not receive any high-risk medication during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/21/25, did not trigger. R23's Quarterly MDS, dated 04/18/25, documented the resident had a BIMS score of three, indicating severe cognitive impairment. He received antipsychotic (medications used to manage psychosis, including symptoms like delusions, hallucinations, and disordered thoughts) and antidepressant (medications used to treat symptoms of depression, a mood disorder that can cause persistent sadness, loss of interest in activities, and difficulties with daily functioning) medications during the assessment period. R23's Care Plan revised 04/21/25, lacked staff instruction regarding Black Box Warnings (BBW) for medications the resident received. R23's EMR revealed the following physician's orders: Sertraline (an antidepressant medication), 100 milligrams (mg), by mouth (PO), every day (QD), for a diagnosis of psychotic disorder with delusions, ordered 05/22/25. Zyprexa (an antipsychotic medication), 5 mg, PO, QD, for a diagnosis of high-risk behaviors, ordered, 05/22/25. A review of R23's Medication Administration Mar (MAR) for May 2025, revealed the resident received the medications, as ordered. On 06/30/25 at 07:55 AM, Administrative Nurse D stated he expected expectation all BBW medications to be included in the care plan. The facility policy for Electronic Care Plans revised 12/2020, included: Medications will be addressed in each resident's care plan.

The facility identified a census of 40 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to revise Resident (R) 3's Care Plan with the interventions to prevent further weight loss. This deficient practice placed the resident at risk for continued weight loss due to uncommunicated care needs. Findings: - R3's Electronic Medical Record (EMR) revealed the following diagnoses: unspecified psychosis (any major mental disorder characterized by a gross impairment in reality perception), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) R3's 07/26/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of five, indicating severely impaired cognition. The MDS recorded R3's weight was 193 pounds, and she had no known weight loss. R3 consumed a regular textured diet with no eating or swallowing concerns. The 07/26/24 Nutritional Status Care Area Assessment (CAA) documented R3's weight as 193 pounds, and her height as five foot two inches. R3's risk factors included weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. R3's 04/25/25 Quarterly MDS documented a BIMS score of four, indicating severely impaired cognition. The MDS recorded R3's weight was 173 pounds, and she had no known weight loss. R3 consumed a regular textured diet with no eating or swallowing concerns. R3's Care Plan dated 05/29/24 documented she likes cranberry juice and black coffee at breakfast and any juice at lunch and supper. The plan directed staff to provide a regular diet and encourage low sugar and low sodium. Updated on 09/05/24, the plan documented R3 needed set up and or physical help for meals. On 06/25/25 R3's Care Plan was updated to include a mug with a handle, lid, and straw. The plan noted R3 gets tired and may not be able to hold her cup for long. The plan directed staff to provide R3 with built-up utensils at every meal as they are easier for her to grab and hold. R3's Care Plan lacked documentation that R3 was on a fortified diet and had an order for health shakes. R3's Physician's Orders noted a sugar-free supplement one time a day for a nutritional supplement, ordered on 02/21/25. R3's Physician's Orders documented an order for a fortified foods diet, regular texture, and regular consistency fluids dated 06/10/25. R3's Progress Note from the Registered Dietician (RD) dated 05/05/25 at 12:56 PM documented R3 currently weighed 164 pounds and continued to lose weight due to inadequate oral intake related to pneumonia (an infection in the lungs). R3 took a few bites at lunch and fell asleep. The Certified Medication Aide (CMA) reported R3 had been declining the sugar-free supplements. The RD noted the resident needed about 1700 calories per day to maintain current weight and 1950 calories per day for a half-pound weight gain per week. The RD recommends the addition of a fortified diet to the current diet order due to weight loss. The RD recommended staff notify the physician of the significant weight loss. On 06/26/25 at 11:28 AM Certified Nurse Aide (CNA) S sat beside R3. R3 had a clothing protector on and had a cup with a lid a handle, and a straw. Staff did not offer her a drink and she did not take a drink. At 11:45 AM, R3 remained at the table, staff had not offered her a drink. At 11:48 AM, R3's food arrived. It was a wrap with french fries. CNA S gently touched R3 and asked her if she wanted to take a bite. CNA S placed some French fries on the fork and offered her a bite. R3 did not want the bite. CNA S waited for a minute then pushed the food to the middle of the table and left to go assist another resident. They did not provide built-up utensils as directed in the care plan. On 06/30/25 at 08:50 AM, Administrative Nurse D stated that he or the MDS Nurse completed the care plans and was responsible for updating them. Administrative Nurse D said fortified foods should have been updated on the care plan. Administrative Nurse D stated he was unsure about the built-up utensils but had not seen the resident use them. The facility policy Electronic Care Plan, dated 12/2020, documented the resident's person-centered plan of care as an active working document that reflects the care needs and resident's voice.

- R30's Electronic Medical Record (EMR) revealed a diagnosis of cardiovascular accident (CVA-also known as a stroke, a medical emergency where blood flow to a part of the brain is interrupted, leading to brain cell damage). R30's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. He required set-up assistance for mobility in his manual wheelchair. He had impairment on one side of his upper and lower extremities. The Functional Abilities Care Area Assessment (CAA), dated 01/24/25, documented the resident had left upper and lower extremity weakness and decreased safety awareness. Staff were to expect further activity of living (ADL) decline. R30's Quarterly MDS, dated 04/25/25, documented the resident had a BIMS score of 12, indicating moderately impaired cognition. He had upper and lower extremity weakness on one side and was independent with mobility in his manual wheelchair. R30's Care Plan, revised 4/21/25, instructed staff the resident would propel himself in his wheelchair by placing one foot on top of the other, but he would frequently request staff assistance in propelling him in his wheelchair. A review of the resident's EMR from 05/28/25 through 06/25/25 revealed the resident was occasionally dependent on staff assistance with mobility in his wheelchair. On 06/26/25 at 09:20 AM, Certified Medication Aide (CMA) T propelled R30 in his wheelchair from the front commons area to the beauty shop to administer medication. R30's left foot was not on the foot pedal of his wheelchair and became caught underneath the seat of the wheelchair when CMA T began to propel the wheelchair. R30 had facial grimacing and audible moans and exclamations of pain. Upon assessment, the resident had no injury. On 06/26/25 at 09:20 PM, R30 stated his left foot had not been on the foot pedal when CMA T began to propel his wheelchair. He said his foot became caught underneath the wheelchair which caused him pain in his foot and ankle. The resident stated the pain went away once staff placed his foot back onto the foot pedal. On 06/26/25 at 09:20 AM, CMA T stated the resident's left foot did not always stay on the foot pedal of his wheelchair. CMA T said the resident would often propel himself in the wheelchair and staff would propel him at times, as well. On 06/30/25 at 09:43 AM, Administrative Nurse D stated it was the expectation for staff to utilize foot pedals while propelling residents in their wheelchairs. The facility did not provide a policy for utilizing foot pedals while propelling residents in their wheelchairs. - R24's Electronic Medical Record (EMR) revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R24's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. He had impairment on one side of his lower extremity and was dependent on staff for mobility in his wheelchair. The Functional Abilities Care Area Assessment (CAA), dated 11/01/24, documented the resident required staff assistance with all activities of daily living (ADLs). R24's Quarterly MDS, dated 05/02/25, documented the resident had a BIMS score of three, indicating severe cognitive impairment. He had impairment on one side of his lower extremity and was independent with wheelchair mobility. R24's Care Plan, revised 04/29/25, instructed staff the resident was able to propel himself in his wheelchair but required staff assistance at times. On 06/24/25 at 03:50 PM, Certified Nurse Aide (CNA) N propelled the resident in his wheelchair to the dining room. R24's shoed feet skimmed the floor underneath the wheelchair during transport. The wheelchair lacked foot pedals. On 06/24/25 at 03:50 PM, CNA N stated the resident's wheelchair did not have foot pedals because he would propel himself at times. On 06/26/25 at 03:20 PM, CNA R stated staff should utilize foot pedals when propelling residents in their wheelchairs. On 06/30/25 at 09:43 AM, Administrative Nurse D stated it was the expectation for staff to utilize foot pedals while propelling residents in their wheelchairs. The facility did not provide a policy for utilizing foot pedals while propelling residents in their wheelchairs. The facility reported a census of 40 residents; the sample included 14 residents including seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to implement appropriate interventions following falls for Residents (R)9 and the facility failed to utilize foot pedals for R30 and R24, placing the residents at risk for injuries and further accidents. Findings included: - R9's Electronic Medical Records (EMR) documented R9 had diagnoses that included intellectual disability (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), generalized muscle weakness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R9's 02/14/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of seven, indicating R9 had severe cognitive impairment. The MDS documented R9 had no falls. The 02/14/25 Falls Care Area Assessment (CAA) documented R9 had impaired gait and mobility. She was dependent for all cares except eating; she did not walk with or without assistance. She had no falls. The 02/14/25 Cognitive Loss/Dementia CAA documented R9 had orientation, memory, and recall deficits, as well as short-term and long-term memory loss. R9's Quarterly MDS documented R9 had a BIMS score of four, indicating severe cognitive impairment. The MDS documented R9 had a noninjury fall. R9's Care Plan documented on 08/30/23 that R9 was at risk for falls related to weakness, frequent falls at home, and knee pain. The plan recorded interventions that instructed R9 was supposed to wear non-slip footwear; initiated on 02/13/23. R9's bed should be in the lowest position and the floor mat was to be in place to decrease the chance of injury as she occasionally tried to get out of bed on her own; initiated 06/20/24. R9's Care Plan documented on 03/13/25, R9 had a non-injury fall. Her bed was in the lowest position and the floor mat was in place. The plan noted staff reminded R9 to use her call light before trying to get up alone. R9's Fall Note dated 03/14/25 at 11:11 AM, documented R9 sat on the floor with her legs stretched out in front of her. She had regular socks on both feet. R9 was able to tell staff that she was getting up and going to call help. R9's Progress Note dated 04/07/25 at 04:20 PM documented a root cause analysis for R9's fall was completed. The note documented R9 tried to move herself to a sitting position in her bed and fell to her mat on the floor. R9's bed was in the low position and a grab rail was in place. R9 had been working with restorative and made very good progress. R9 felt she would be able to transfer herself to a sitting position, but was unable to and did not use call light for assistance. R9 was educated to use the call light so that staff could assist her if needed. Observation on 06/24/25 at 04:51 PM, R9 sat in a high-back wheelchair and rocked forward and back in her wheelchair. On 06/26/25 at 03:20 PM, Certified Nurse Aide (CNA) R said when a resident fell, the nurse assessed the resident, assessed the situation to find out what caused the fall, and then put an appropriate intervention in place. CNA R stated Administrative Nurse D updated the care plans. CNA R said R9 attempted to get up on her own. CNA R stated staff lowered R9's bed, but she still tried to get up every once in a while. On 06/30/25 at 08:28 AM, Licensed Nurse (LN) G was unsure whose responsibility it was to come up with the interventions to prevent falls. LN G said Administrative Nurse D updated the care plan with the new interventions. LN G stated it was not an appropriate intervention just to remind R9 to use her call light and not attempt to get up alone because R9 would not remember. On 06/30/25 at 08:50 AM, Administrative Nurse D stated sometimes the nurse comes up with an intervention after a fall and then staff discuss it in the morning meeting making sure the root cause analysis was completed, and the intervention was appropriate. Administrative Nurse D verified that reminders or education were not an appropriate intervention for residents with a low BIMS. The facility's policy Falls Management dated 12-2022, documented the facility strives to minimize the risk tor resident falls and to reduce injuries associated with resident falls. The plan of care is to be reviewed and revised with each fall occurrence and new interventions implemented.

The facility identified a census of 40 residents. The sample included 14 residents with one resident reviewed for urinary tract infections (UTI). Based on observation, record review, and interviews, the facility failed to provide adequate care and services to prevent UTI to the extent possible for Resident (R) 1 when failed to provide incontinence care monitor identify, and report signs and symptoms of ongoing UTI. This placed the resident at risk for ongoing UTI and related complications. Findings included: - R2's Electronic Health Record (EHR) revealed diagnoses of chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body), unspecified urinary incontinence (involuntary leakage of urine), and irritable bowel syndrome with diarrhea (IBS- abnormally increased motility of the small and large intestines). R2 ' s Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment documented R2 was always incontinent of urine, and she utilized a wheelchair and walker for locomotion. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/13/24 documented R2 required substantial to maximum assistance for toileting hygiene. The Urinary Incontinence and Indwelling Catheter CAA dated 09/13/24 documented R2 required assistance for toileting and was always incontinent. R2's Quarterly MDS, dated 06/13/25 documented a BIMS score of 12, which indicated moderate cognitive impairment. Per the staff interview, R2 had memory problems with severely impaired cognition. The assessment documented R2 utilized a wheelchair for locomotion, was dependent on staff for toileting needs, and required substantial assistance for bathing activities of daily living (ADL). R2's Discharge with Return Anticipated Minimum Data Set (MDS), dated [DATE] did not document a Brief Interview for Mental Status (BIMS) score. The assessment documented R2 utilized a wheelchair for locomotion was dependent on staff for toileting needs and required substantial assistance for bathing activities of daily living (ADL). R2's Care Plan noted on 06/09/18, that R2 was at risk for recurrent urinary tract infections (UTIs) due to her history of UTIs. The plan recorded interventions for staff to monitor for signs and symptoms of dehydration such as lethargy, increased weakness, and decreased urine output. The plan also recorded interventions that directed staff to report continued signs and symptoms of infection to the charge nurse and that staff would encourage fluids as tolerated with each meal and each time care is provided. The plan recorded that intervention that staff would provide proper peri care with each incontinence episode to help prevent infection. An Infection Note documented on 06/12/25 at 01:14 PM that R2 had completed antibiotic therapy for her UTI on 06/11/25 and that R2 reported that she still felt as though the UTI was still present, but she was unable to specify the symptoms. It was documented that the physician was aware. A Nursing Note documented on 06/12/25 at 01:16 PM that R2 was seen by a provider that day and concerns were voiced about the UTI still being present. No orders were given, and staff were advised to continue to monitor R2. An Infection Note documented on 6/12/2025 at 10:06 PM that R2 remained on antibiotic follow-up for UTI and had no adverse reactions. The note documented that R2 denied pain but did express concerns of burning and stinging at times upon urination. An Infection Note was documented on 06/13/25 at 03:46 PM that R2 continued antibiotic follow-up for a recent UTI and she showed no s/s of adverse reactions. A Nursing: Progress Note documented on 06/20/25 at 07:09 AM that the nurse went into the resident's room at 06:45 AM and R2 was sitting in her wheelchair unable to respond to questions but she would track with her eyes. R2 then started to have yellowish/green emesis. The nurse notified the provider and received an order to send R2 out to the hospital via Emergency Medical Services (EMS) for further evaluation. A Nursing: Progress Note documented on 06/24/25 at 07:44 AM, as a late entry for 06/19/25 at 09:34 AM, noted that staff certified nurse aides (CNA) reported to the nurse that R2 had increased confusion and refused to go to bed, which was unusual for R2. The progress note recorded that R2 notified the staff that she had burning upon urination. This nurse assessed R2 and noted that she would answer appropriately at times but then would talk about something else. The progress note also recorded that R2 was monitored frequently due to confusion and would also take off her nasal cannula. A Nursing: Progress Note documented on 06/24/25 at 07:50 AM, as a late entry for 06/20/25 at 05:00 AM, recorded R2 was assisted to bed during the night but ended up getting back up into her wheelchair without assistance. R2 showed no signs of distress, no complaints of nausea or vomiting were noted, and no unresponsive episodes were noted. The staff spoke with the day nurse and made her aware of R2 ' s behavior and both agreed that she possibly had another UTI and the provider would be notified. R2's EHR documented an order for methenamine hippurate (urinary tract antiseptic) two times a day as a UTI prophylactic (preventative in nature). The medication was started on 01/06/25. Observation on 06/26/25 at 09:21 AM R2 was in bed with her eyes closed. Observation on 06/26/25 at 11:05 AM, R2 continued to remain in bed with eyes closed. On 06/24/25 at 03:31 PM, R2 and her representative reported that R2 had been sent to the hospital for a UTI the morning of 06/20/25 and returned to the facility on [DATE]. R2 and her representative also reported that R2 was left in her wheelchair all night on 06/19/25. On 06/25/25 at 03:15 PM, Licensed Nurse (LN) G stated that to help prevent a UTI she would try to toilet the resident every two hours and encourage fluids. LN G also stated that she would ensure the resident was properly cleaned and dried with each toileting. LN G further stated that she would have then monitored for urinary frequency and urgency for UTI early signs, and difficulty urinating, and would have asked if there was a burning sensation, and monitored for confusion or increased confusion. On 06/25/25 at 03:22 PM, Certified Nurse Aide (CNA) N stated that for UTI prevention she checked residents and toileted them every two hours, and when they requested. CNA N also stated that she would report to the nurse if the resident developed any mood swings, behavior changes, or urine color changes, and if the resident reported if it hurt to urinate. On 06/25/25 at 03:32 PM, CNA O stated that for UTI prevention she would do frequent, every two-hour, toileting and checks or changes and proper peri-care for the residents. CNA O would monitor for any unusual behaviors outside of their norm, monitor urine odor, and ask the resident if they had any pain or changes in urinating. On 06/25/25 at 03:36 PM, Administrative Nurse D stated that UTI prevention and monitoring expectations were to push and encourage fluids, staff were to provide proper peri-care (the cleaning of the genital and anal areas), staff were to monitor for change in mentation, behavior changes, pain and/or difficulty in urination and report immediately to the nurse. Administrative Nurse D further stated that staff were supposed to do two-hour rounds on the residents and that included toileting checks, and staff were to chart in EHR the bowel/bladder elimination if the residents were incontinent or toileted. On 6/26/25 at 9:21 AM, CNA P reported that R2 requested to go back to bed to rest after breakfast that morning. On 06/26/25 at10:37 AM, Consultant GG stated that it's expected for staff to toilet residents as soon as possible for prevention of UTI, toileting in general varies from resident to resident, those that continuously leak urine or are less aware need more frequent toileting. Consultant GG further stated that staff should monitor for changes in behavior, mentation, and urinary signs such as pain or burning and he expected to be notified by the next morning. Consultant GG also stated that R2 was not typically prone to urosepsis and had been treated for a UTI within the last month. On 06/26/25 at 11:05, Certified Medication Aide (CMA) T stated that R2 reported that she felt weak that day. On 06/26/25 at 11:06 AM, LN G stated she had not been notified of any changes in R2, she had assisted her back into bed at about 09:00 AM and noticed that she was but had not notified anyone yet. The facility policy Nursing Services: Incontinence Management Protocol-Procedure, not dated, indicated that a urinary incontinence assessment will be completed for residents who are identified by the MDS as a2.3.4 for bladder incontinence. The policy further indicated that the nursing staff would monitor and evaluate the resident's responses to preventative efforts and treatment interventions and revise the approaches as appropriate with the interdisciplinary team. The facility policy Incontinence Management Policy, dated 12/2017 indicated that the facility's purpose was to restore or maintain the resident's current bowel and bladder function unless clinically indicated. The policy further indicated that the residents were to be assessed to identify their history and pattern of bowel and bladder function. The policy also indicated that the plan of care would address individualized focus, goals, and interventions directed toward managing the resident's bowel and bladder incontinence.

The facility reported a census of 40. There were 14 residents included in the sample. Based on interview, observation, and record review the facility failed to implement effective behavioral interventions for Resident (R) 37 ' s behaviors. This deficient practice placed the resident at risk for mental anguish, social isolation, and impaired quality of life. Findings include: - A review of R37 ' s Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), severe intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), unspecified mood [affective] disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), insomnia (inability to sleep), and impulsiveness (sudden, forceful, irresistible urges to do something). R37 ' s admission Minimal Data Set (MDS), dated 09/01/24 documented R37 ' s behaviors impacted others related to him significantly intruding on the privacy or activity of others and significantly interfering with the other resident's participation in activities or social interactions. The assessment also indicated that R37 would wander frequently and that his wandering would intrude upon other ' s privacy. The Communication Care Area Assessment (CAA), dated 09/01/24 documented that R37 had an impaired ability to make himself understood through verbal and non-verbal expression and had an impaired ability to understand others through verbal content. The Behavioral Symptoms CAA, dated 09/01/024 documented that R37 wandered. R37's Quarterly MDS, dated 05/30/25 documented a Brief Interview for Mental Status score of three, indicating severe cognitive impairment. The assessment documented that R37 wandered for one to three days during the observation period. R37's Care Plan noted on 05/12/25, R37 required staff assistance with activities of daily living (ADL) due to intellectual disability and the interventions included that staff would provide 1:1 monitoring with visual contact at the doorway when in R37 ' s room and within appropriate distance during meals and any activity outside of his room as to provide intervention/redirection immediately when behaviors indicated (ie touching others). R37's Care Plan noted on 05/12/25, that R37 had mood/behavior and psychosocial problems, and could be manipulative, passive/aggressive, and attention-seeking at times. The interventions included 1:1 monitoring, and staff were to redirect R37 to more appropriate behavior. Staff were to report any aggressive behaviors to his family and physician. Staff were to also assist R37 in developing more appropriate methods of coping and interacting with staff and encourage R37 to express feelings appropriately. A Nursing: Progress Note documented on 04/10/25 at 07:49 AM documented that the nurse was notified by the Certified Nurse Aide (CNA) that a female resident was touched by R37 on the chest and he tried to kiss her. The note documented that the CNA had seen R37 walking toward the female resident and told R37 to stop several times, but he did not stop or respond to requests to stop. The note recorded the CNA then observed the male resident trying to touch the female resident ' s breast. The progress note further documented that the residents were separated by staff and R37 went to his room. A Behavior Note, documented on 05/30/25 at 12:11 PM that R37 continued to be on 1:1 with staff and he frequently moved between his bedroom and the dining area and was not easily redirected and ignored staff when they tried to assist him. A Behavior Note, documented on 06/20/25 at 04:22 PM R37 had outbursts of foul language and extremely loud noises and was difficult to redirect at times but calmed after taking his evening medications. A Behavior Note, documented on 06/21/25 at 03:10 PM R37 remained 1:1 with loud outbursts of foul language and attempted touching multiple staff that shift. A Behavior Note, documented on 06/26/25 at 02:28 PM R37 remained 1:1 with some behaviors that shift that included very loud noises, did not listen to staff and R37 attempted to and did touch staff but was eventually redirected. Observed on 06/24/25 at 10:00 AM R37 walked up and grabbed and hugged the female state surveyor upon entry into the facility; staff were present but did not intervene or redirect R37. Observed on 06/26/25 at 12:15 PM R37 continuously grabbed and pushed down on the female CNA Q's left arm and kept holding onto her left arm. CNA Q did not stop R37 ' s behavior or redirect him. On 06/24/25 at 03:06 PM, Consultant HH stated that R37 was 1:1 due to sexual inappropriateness towards females and that he would grab and hug female staff. On 06/25/25 at 11:53 AM, Administrative Staff A stated that 1:1 was a decision that was made with the interdisciplinary team based on the resident's behaviors and needs. Administrative Staff A reported that R37 was 1:1 based on his behaviors of inappropriate touching and that he was very touchy and grabbing/hugging; he was not allowed to touch any person without permission from that person. On 06/25/25 at 12:07 PM, Administrative Nurse D stated that 1:1 was determined by the behavior of the resident and if other interventions had failed. Administrative Nurse D reported that R37 was 1:1 because he would inappropriately pinch people. On 06/26/25 at 12:15 PM, CNA Q stated that R37 wasn't really bothering her so she did not ask him to stop his behavior that occurred in the dining room. She said it was better than causing a scene or escalating his behaviors. The facility did not provide a policy for behavioral management.

The facility reported a census of 40 residents. The sample included 14 residents. Based on interviews, record reviews, and observation, the facility failed to ensure a safe environment in all areas of the facility including the laundry area. Findings included: - During an observation on 06/30/25 at 12:05 PM the dryer-maintenance access room had large pieces of paint coming off around and above the dryers. During an observation on 06/30/25 at 01:10 PM there were multiple fluorescent light fixture covers that were broken and hanging. One light cover was above the clean laundry hanging counter and the other plastic cover was above the clean laundry delivery carts. Multiple light fixtures have broken plastic covers. Another observation made at this time revealed paint flaking off the ceiling above the clean laundry delivery carts. On 06/30/25 at 12:05 PM, Maintenance V stated the paint flaking in the dryer-maintenance access room was not much of an issue because the dryer elements and the electrical components were enclosed. On 06/30/25 at 12:40 PM, Administrative Staff A reported that it was not acceptable to have peeling paint anywhere, especially above the clean linen or where it can fall on the dryers. Administrative Staff A also stated that new light covers had been ordered for the broken fixtures in the clean linen room and the old ones had to be left in place to cover the bulbs until the new ones would arrive. On 06/30/25 at 12:57 PM, Housekeeping U stated that there should not have been flaking paint anywhere, especially over the laundry or over the dryers. Housekeeping U further stated that the light fixture covers should have been removed and/or replaced somehow, it was unacceptable to leave broken and hanging fixtures above the clean laundry areas. The facility policy titled Housekeeping, Laundry and Maintenance indicated that housekeeping, laundry, and maintenance must provide their services to the facility on a 24-hour basis, either as scheduled or on an on-call basis. The policy stated that the departments must maintain the interior and exterior of the facility and furnishings in a clean, orderly, and attractive manner. The policy further indicated that the facility will be kept free of offensive odors, safety hazards, and accumulations of dust, dirt, and unacceptable levels of bacterial and viral organisms using standard procedures and work methods.

The facility reported a census of 41 residents, including 11 female residents with moderate to severe cognitive impairment. The sample included 13 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to report allegations of resident-to-resident abuse to the Licensed Nursing Home Administrator (LNHA), State Agency (SA) and/or Law Enforcement (LE) as appropriate when Resident (R) 1 repeatedly touched cognitively impaired female residents, R2 and R3, and displayed sexual behaviors such as masturbating in the presence of other residents. On 01/25/25 R1 grabbed R3's breast. The facility placed R1 on one-to-one with staff and sent the resident to an acute behavioral facility, but did not implement interventions to prevent further resident-to-resident abuse when R1 returned on 02/22/25 other than a medication for sexual aggression. The facility failed to notify LE. On 03/01/25 staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25 R1 grabbed R2's breast and staff directed R1 to his room but did not notify LE. On 03/10/25 the facility placed R1 on visual one-to-one when R1 was outside his room. On 03/19/25 R1 attempted to touch a female resident's leg but was redirected by staff back to his room with no further interventions noted. On 03/20/25 the facility documented R1 was on one-to-one when out of his room and there had been no inappropriate incidents. On 03/27/25 staff observed R1 stroking his penis next to an unidentified male resident but did not implement any interventions related to this incident or report the incident as alleged abuse to the SA. On 03/30/25 staff observed R1 stroking R3's leg. The facility noted that R1 gravitated to R3 as R3 resembled R1's spouse and the facility-initiated arms-length one-to-one. The facility's failure to report allegations of resident-to-resident abuse to the LNHA, SA, and LE as appropriate placed R2, R3 and all cognitively impaired female residents in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) included the diagnoses of altered mental status, psychotic disorder (a mental disorder characterized by gross impairment in reality perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), high-risk sexual behavior, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R1 displayed no behaviors to indicate psychosis. The assessment documented R1 utilized a walker and/or wheelchair for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/21/25 documented R1 had dementia (a progressive mental disorder characterized by failing memory, and confusion) with short-term and long-term memory loss. The Psychosocial Well-Being CAA dated 01/21/25 documented R1 lacked interest in interacting with or participating in activities. R1's Care Plan, reviewed 04/08/25, documented on 01/19/25, the resident had a cognitive loss that affected memory. Interventions dated 01/19/25 directed staff to help R1 establish a regular daily schedule with tasks divided into several steps. The plan directed staff to be patient with R1, remind R1 who they were, and explain care prior to initiation; staff would provide one instruction at a time in a calm tone. An update dated 01/27/25 noted R1 was placed on one-to-one monitoring for redirecting of behaviors, initiated on 01/25/25, created on 01/27/25, and revised on 03/10/25. The plan noted that R1 would be evaluated by geriatric psychiatry for behaviors of touching another person without their approval, which was initiated on 01/25/25, created on 01/27/25, and revised on 04/02/25. R1's Care Plan reviewed 04/08/25 documented on 01/27/25, R1 was at risk for sexually inappropriate behaviors related to maladaptive (unhealthy or ineffective ways of coping with something difficult or stressful) mood and behavior. The care plan included an intervention dated 01/27/25 that directed staff to administer medications as ordered to manage R1's behavior, created on 01/28/25. Interventions created on 01/2825 effective for 01/27/25 included staff observing R1's mood and behaviors, staff obtaining a psychiatric evaluation as ordered, staff redirecting inappropriate behavior with alternative activities, and staff reporting changes in behavior to the nurse and physician being informed as indicated. The plan documented staff would ensure R1 was on one-on-one observation at an arm's length when not in his room, created on 01/28/25 and revised on 04/02/25 The Progress Notes section of R1's EHR documented the following notes: On 01/25/25 at 11:14 AM, staff observed R1 walked up to R3, a cognitively impaired resident, and touched her breast. Staff redirected R1 to his room. On 02/03/25 at 01:59 PM, staff documented a root cause analysis of the incident on 01/25/25 and documented, according to R1's responsible person, R1 had a history of sexual aggression and grabbed R3's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room; R1 was started on medication for sexual aggression. On 03/01/25, Licensed Nurse (LN) I documented staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25, LN I documented R1 grabbed R2's (a cognitively impaired resident) breast, and staff directed R1 to his room. LN I documented the notification of Administrative Staff A and Administrative Nurse B of the incident. On 03/06/25 at 11:56 AM, Administrative Nurse B documented LN I reported R1 had grabbed R2's breast in the dining area. On 03/10/25 at 01:03 PM, staff documented a root cause analysis of the incident on 03/05/25 and documented according to R1's responsible person, R1 had a history of sexual aggression and R1 grabbed R2's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room. On 03/19/25 at 05:51 AM, staff documented R1 was up and down during the night and wandered from his room to the common area and back; redirection attempts were unsuccessful. Additionally, staff documented an unknown Certified Nurse Aide (CNA) stopped R1 from reaching for an unidentified female resident's leg. The CNA told R1 to stop and R1 walked back to his room before physical contact was made. Staff documented the notification of Administrative Staff A and Administrative Nurse B. On 03/20/25 at 03:16 PM, Social Services Designee (SSD) M documented R1 was observed throughout the week related to a previous incident (undated) and R1 remained on one-on-one observation when outside of his room. SSD M documented R1 had no inappropriate incidents. On 03/27/25 at 02:15 AM, staff documented R1 was observed stroking his penis while seated next to another male resident at 02:05 AM. Staff documented there was no physical contact observed between the two residents, and Administrative Staff A and Administrative Nurse B were notified. On 03/30/25 at 06:20 AM, LN F documented R1 stroked R3's left lower leg. Staff moved R3 and R1 returned to his room. On 03/30/25 at 07:51 AM, staff documented R1 looked up the dresses on wooden Easter decorations in the dining room and stated, Let me get that [expletive]. On 03/30/25 at 06:02 PM, staff documented R1 continued to try and look up the dresses on the Easter decorations. On 04/03/25 at 02:17 PM, SSD M documented a referral for R1 to be transferred to a different facility was sent. On 04/02/25 at 10:44 AM, LN F documented on 03/30/25 R1 was observed slowly rubbing R3's lower left leg. The note documented LN F placed herself between R1 and R3 and remained there until R1 returned to his room. LN F assessed R3 and determined her to be free of injury. The note recorded R1 continued to be on one-on-one observation. LN F documented she notified Administrative Staff A and Administrative Nurse B. On 04/08/25 at 02:14 PM, staff documented a root cause analysis, and the facility noted that R1 gravitated to R3 as R3 resembled R1's spouse; the facility-initiated arms-length one-on-one monitoring for R1 and continued to try to get the resident transferred to an all-male facility. A review of the facility's investigation and witness statements for the 01/25/25 incident revealed no additional information. The investigation report lacked documentation that Law Enforcement (LE) was notified. The facility lacked an investigation report for the incident on 03/01/25. A review of the facility's investigation and witness statements for the 03/05/25 incident revealed no additional information. The investigation report lacked documentation that LE was notified. The facility lacked an investigation report for the incident on 03/27/25. A review of the facility's investigation for the 03/30/25 incident revealed no additional information. The investigation report lacked witness statements and lacked documentation that LE was notified. On 04/08/25 at 01:40 PM, R1 was unable to be interviewed due to the resident's cognitive impairment. During an interview on 04/08/25 at 04:40 PM, LN F stated on 03/30/25 R1 was observed rubbing the lower left leg of R3. LN F stated she placed herself between R1 and R3 until R1 went back to his room. During an interview on 04/09/25 at 03:20 PM, Administrative Staff A stated the facility did not notify LE of any of the documented incidents from 01/25/25 to 04/09/25. During an interview on 04/09/25 at 03:42 PM, CNA H stated she was unaware of the details of the events and stated R3 looks like R1's wife. CNA H stated R1 was confused and continued to attempt to touch R3 and rub her leg. CNA H stated if staff observed R1 with this type of behavior, staff had to stand between R1 and the female residents and report the incidents to the nurse on duty. During an interview on 04/09/25 at 03:46 PM, CNA J stated if R1 reached for a female resident staff would protect the female resident and attempt to redirect R1 with a different activity and report the incident to the nurse or a member of management. During an interview on 04/09/25 at 04:15 PM, LN K stated she was aware of the incidents with R1 and inappropriate contact and stated if staff observed R1 attempt inappropriate contact, R1 should be removed as quickly as possible to ensure the safety of the other residents. LN K stated she would report the incident to management immediately and then follow management's discretion as to whether to call law enforcement. During an interview on 04/09/25 at 04:25 PM, Administrative Nurse C stated the facility's expectation in the event of unwanted or inappropriate sexual contact staff should separate the residents to ensure resident safety and perform any required assessments and document everything in the EHR. Staff would then notify management who would immediately develop and implement an intervention to prevent the incident from happening again. This included notifying and educating all the staff and obtaining signatures. Administrative Nurse C stated after the incident on 01/25/25, R1 was placed under visual one-on-one monitoring until R1 was sent to a behavioral health unit (BHU). Administrative Nurse C stated she was unaware if the management team was aware of the incident on 03/01/25, and after the incident on 03/05/25 R1 was placed on one-on-one monitoring when he was out of his room. Administrative Nurse C stated when the incident occurred on 03/30/25 R1 was placed on one-on-one monitoring where staff must stay within an arms-reach of R1 when out of his room with a staff member placed outside the door to his room. Administrative Nurse C stated the management team was actively trying to find alternate placement for R1 at a more appropriate facility. Administrative Nurse C stated LE should be contacted for any unwanted physical or sexual contact and confirmed that LE was not contacted for any incidents that involved R1 between 01/25/25 and 04/09/25. During an interview on 04/09/25 at 04:54 PM Administrative Staff A revealed that after the incident on 01/25/25, R1 was placed under one-on-one visual monitoring until he was transferred to the behavioral health unit. Administrative Staff A said when R1 returned to the facility, he was self-isolating and would only come out of his room for meals and after the incident on 03/05/25, R1 was placed on one-on-one visual monitoring when he was outside of his room. Administrative Staff A stated after the incident on 03/30/25, R1 was placed on one-on-one monitoring within arm-length reach of staff except when he was in his room, then staff would be outside his room. Administrative Staff A stated the facility continued to try to find alternative placement at an all-male dementia unit. Administrative Staff A in the event of unwanted physical or sexual contact between residents, she expected staff to immediately separate the residents, assess the residents involved, and then notify management. Administrative Staff A stated staff followed the appropriate procedure for all the events reviewed involving R1. Administrative Staff A stated the event on 03/01/25 was not fully investigated or called to LE because the contact was not believed to be sexual in nature. Administrative Staff A confirmed the Progress Note dated 03/19/25 and stated she was unaware of the information and stated it would be considered a near-miss. Administrative Staff A stated the event documented on 03/27/25 was not investigated or reported because the other male resident in the area was unaware of R1's actions, R1's genitals were not exposed and R1 was not aggressive. Administrative Staff A stated LE should only be notified if another resident is harmed or if the resident's family wants LE involved. Administrative Staff A confirmed if someone touched anyone's breast without consent, LE should be notified and further confirmed R2 and R3 were incapable of providing consent and the touching from R1 was sexual in nature so it should have been reported to LE. The facility's Abuse, Neglect and Exploitation policy dated 10/2022 documented residents have the right to be free from verbal, sexual, physical, and mental abuse. The facility would keep residents free from abuse and take swift and immediate action to investigate allegations of abuse. The policy documented every employee had the responsibility to report allegations of abuse and the Administrator or Director of Nursing (DON) would investigate allegations and report the results to the proper authorities. All reports or suspicions of abuse would result in an investigation and all reasonable suspicions of a crime would be reported as required. On 04/10/25 at 11:35 AM, Administrative Staff L and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and informed that the facility's failure to report allegations of resident-to-resident abuse to the LNHA, SA, and/or LE as appropriate placed R2, R3 and all cognitively impaired female residents in immediate jeopardy The facility submitted an acceptable plan for removal of the immediate jeopardy on 04/10/25 at 02:56 PM which included the following: The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured. The facility notified Law Enforcement on 04/10/25. LN I received disciplinary action for failure to report the incident on 03/10/25. LN F received disciplinary action for failure to report the incident on 03/30/25 until 04/02/25. The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being. The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals. The facility immediately educated all staff on 04/10/25 regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations. The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation. The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone on 04/10/25. Implementation of the corrective measures to remove the immediacy was verified on-site on 04/10/25 at 03:35 PM. The deficient practice remained at a scope and severity level of E (patterned, potential harm).

The facility reported a census of 41 residents and 11 female residents with moderate to severe cognitive impairment. The sample included 13 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to immediately implement protective measures to prevent further potential abuse, after an allegation of resident-to-resident abuse and further failed to conduct thorough investigations when Resident (R) 1 repeatedly touched cognitively impaired female residents, R2 and R3, and displayed sexual behaviors such as masturbating in the presence of other residents. On 01/25/25 R1 grabbed R3's breast. The facility placed R1 on one to one with staff and sent the resident to the acute behavioral facility but did not implement interventions to prevent further resident to resident abuse when R1 returned on 02/22/25 other than a medication for sexual aggression. On 03/01/25 staff observed R1 rubbing the leg of an unidentified female resident. The facility did not implement interventions in response to this incident or investigate the incident. On 03/05/25 R1 grabbed R2's breast and staff directed R1 to his room but did not implement interventions to prevent further sexual contact. On 03/10/25 the facility placed R1 on visual one to one when R1 was outside his room. On 03/19/25 R1 attempted to touch a female resident's leg but was redirected by staff back to his room with no further interventions noted. On 03/20/25 the facility documented R1 was on one to one when out of his room and there had been no inappropriate incidents. On 03/27/25 staff observed R1 stroking his penis next to an unidentified male resident but did not implement any interventions related to this incident or investigate the incident. On 03/30/25 staff observed R1 stroking R3's leg. The facility noted that R1 gravitated to R3 as R3 resembled R1's spouse and the facility-initiated arms -length one to one. The facility's failure to immediately implement protective measures to prevent further potential abuse, after an allegation of resident-to-resident abuse, and to conduct thorough investigations placed R2, R3 and all cognitively impaired female residents in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) included the diagnoses of altered mental status, psychotic disorder (a mental disorder characterized by gross impairment perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), high-risk sexual behavior and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of three, which indicated severely impaired cognition. R1 displayed no behaviors to indicate psychosis. The assessment documented R1 utilized a walker and/or wheelchair for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/21/25 documented R1 had dementia (a progressive mental disorder characterized by failing memory, and confusion) with short-term and long-term memory loss. The Psychosocial Well-Being CAA dated 01/21/25 documented R1 lacked interest in interacting with or participating in activities. R1's Care Plan, reviewed 04/08/25, documented on 01/19/25, the resident had a cognitive loss that affected memory. Interventions dated 01/19/25 directed staff to help R1 establish a regular daily schedule with tasks divided into several steps. The plan directed staff to be patient with R1, remind R1 who they were, and explain care prior to initiation; staff would provide one instruction at a time in a calm tone. An update dated 01/27/25 noted R1 was placed on one-to-one monitoring for redirecting of behaviors, initiated on 01/25/25, created on 01/27/25, and revised on 03/10/25. The plan noted that R1 would be evaluated by geriatric psychiatry for behaviors of touching another person without their approval, which was initiated on 01/25/25, created on 01/27/25, and revised on 04/02/25. R1's Care Plan reviewed 04/08/25 documented on 01/27/25, R1 was at risk for sexually inappropriate behaviors related to maladaptive (unhealthy or ineffective ways of coping with something difficult or stressful) mood and behavior. The care plan included an intervention dated 01/27/25 that directed staff to administer medications as ordered to manage R1's behavior, created on 01/28/25. Interventions created on 01/2825 effective for 01/27/25 included staff observing R1's mood and behaviors, staff obtaining a psychiatric evaluation as ordered, staff redirecting inappropriate behavior with alternative activities, and staff reporting changes in behavior to the nurse and physician being informed as indicated. The plan documented staff would ensure R1 was on one-on-one observation at an arm's length when not in his room, created on 01/28/25 and revised on 04/02/25 The Progress Notes section of R1's EHR documented the following notes: On 01/25/25 at 11:14 AM, staff observed R1 walked up to R3, a cognitively impaired resident, and touched her breast. Staff redirected R1 to his room. On 02/03/25 at 01:59 PM, staff documented a root cause analysis of the incident on 01/25/25 and documented, according to R1's responsible person, R1 had a history of sexual aggression and grabbed R3's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room; R1 was started on medication for sexual aggression. On 03/01/25, Licensed Nurse (LN) I documented staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25, LN I documented R1 grabbed R2's (a cognitively impaired resident) breast, and staff directed R1 to his room. Additionally, Administrative Staff A and Administrative Nurse B were notified of the incident. On 03/06/25 at 11:56 AM, Administrative Nurse B documented LN I reported R1 had grabbed R2's breast in the dining area. On 03/10/25 at 01:03 PM, staff documented a root cause analysis of the incident on 03/05/25 and documented according to R1's responsible person, R1 had a history of sexual aggression and R1 grabbed R2's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room. On 03/19/25 at 05:51 AM, staff documented R1 was up and down during the night and wandered from his room to the common area and back; redirection attempts were unsuccessful. Additionally, staff documented an unknown Certified Nurse Aide (CNA) stopped R1 from reaching for an unidentified female resident's leg. The CNA told R1 to stop and R1 walked back to his room before physical contact was made. Staff documented Administrative Staff A and Administrative Nurse B were notified. On 03/20/25 at 03:16 PM, Social Services Designee (SSD) M documented R1 was observed throughout the week related to a previous incident (undated) and R1 remained on one-on-one observation when outside of his room. SSD M documented R1 had no inappropriate incidents. On 03/27/25 at 02:15 AM, staff documented R1 was observed stroking his penis while seated next to another male resident at 02:05 AM. Staff documented there was no physical contact observed between the two residents, and Administrative Staff A and Administrative Nurse B were notified. On 03/30/25 at 06:20 AM, LN F documented R1 stroked R3's left lower leg. Staff moved R3 and R1 returned to his room. On 03/30/25 at 07:51 AM, staff documented R1 looked up the dresses on wooden Easter decorations in the dining room and stated, Let me get that [expletive]. On 03/30/25 at 06:02 PM, staff documented R1 continued to try and look up the dresses on the Easter decorations. On 04/03/25 at 02:17 PM, SSD M documented a referral for R1 to be transferred to a different facility was sent. On 04/02/25 at 10:44 AM, LN F documented on 03/30/25 R1 was observed slowly rubbing R3's lower left leg. The note documented LN F placed herself between R1 and R3 and remained there until R1 returned to his room. LN F assessed R3 and determined her to be free of injury. The note recorded R1 continued to be on one-on-one observation. LN F documented she notified Administrative Staff A and Administrative Nurse B. On 04/08/25 at 02:14 PM, staff documented a root cause analysis, and the facility noted that R1 gravitated to R3 as R3 resembled R1's spouse; the facility-initiated arms-length one-on-one monitoring for R1 and continued to try to get the resident transferred to an all-male facility. A review of the facility's investigation and witness statements for the 01/25/25 incident revealed no additional information. The investigation report lacked documentation that Law Enforcement (LE) was notified. The facility lacked an investigation report for the incident on 03/01/25. A review of the facility's investigation and witness statements for the 03/05/25 incident revealed no additional information. The investigation report lacked documentation that LE was notified. The facility lacked an investigation report for the incident on 03/27/25. A review of the facility's investigation for the 03/30/25 incident revealed no additional information. The investigation report lacked witness statements and lacked documentation that LE was notified. On 04/08/25 at 01:40 PM, R1 was unable to be interviewed due to the resident's cognitive impairment. During an interview on 04/08/25 at 04:40 PM, LN F stated on 03/30/25 R1 was observed rubbing the lower left leg of R3. LN F stated she placed herself between R1 and R3 until R1 went back to his room. During an interview on 04/09/25 at 03:20 PM, Administrative Staff A stated the facility did not notify LE of any of the documented incidents from 01/25/25 to 04/09/25. During an interview on 04/09/25 at 03:42 PM, CNA H stated she was unaware of the details of the events and stated R3 looks like R1's wife. CNA H stated R1 was confused and continued to attempt to touch R3 and rub her leg. CNA H stated if staff observed R1 with this type of behavior, staff had to stand between R1 and the female residents and report the incidents to the nurse on duty. During an interview on 04/09/25 at 03:46 PM, CNA J stated if R1 reached for a female resident staff would protect the female resident and attempt to redirect R1 with a different activity and report the incident to the nurse or a member of management. During an interview on 04/09/25 at 04:15 PM, LN K stated she was aware of the incidents with R1 and inappropriate contact and stated if staff observed R1 attempt inappropriate contact, R1 should be removed as quickly as possible to ensure the safety of the other residents. LN K stated she would report the incident to management immediately and then follow management's discretion as to whether to call law enforcement. During an interview on 04/09/25 at 04:25 PM, Administrative Nurse C stated the facility's expectation in the event of unwanted or inappropriate sexual contact staff should separate the residents to ensure resident safety and perform any required assessments and document everything in the EHR. Staff would then notify management who would immediately develop and implement an intervention to prevent the incident from happening again. This included notifying and educating all the staff and obtaining signatures. Administrative Nurse C stated after the incident on 01/25/25, R1 was placed under visual one-on-one monitoring until R1 was sent to a behavioral health unit (BHU). Administrative Nurse C stated she was unaware if the management team was aware of the incident on 03/01/25, and after the incident on 03/05/25 R1 was placed on one-on-one monitoring when he was out of his room. Administrative Nurse C stated when the incident occurred on 03/30/25 R1 was placed on one-on-one monitoring where staff must stay within an arms-reach of R1 when out of his room with a staff member placed outside the door to his room. Administrative Nurse C stated the management team was actively trying to find alternate placement for R1 at a more appropriate facility. Administrative Nurse C stated LE should be contacted for any unwanted physical or sexual contact and confirmed that LE was not contacted for any incidents that involved R1 between 01/25/25 and 04/09/25. During an interview on 04/09/25 at 04:54 PM Administrative Staff A revealed that after the incident on 01/25/25, R1 was placed under one-on-one visual monitoring until he was transferred to the behavioral health unit. Administrative Staff A said when R1 returned to the facility, he was self-isolating and would only come out of his room for meals and after the incident on 03/05/25, R1 was placed on one-on-one visual monitoring when he was outside of his room. Administrative Staff A stated after the incident on 03/30/25, R1 was placed on one-on-one monitoring within arm-length reach of staff except when he was in his room, then staff would be outside his room. Administrative Staff A stated the facility continued to try to find alternative placement at an all-male dementia unit. Administrative Staff A in the event of unwanted physical or sexual contact between residents, she expected staff to immediately separate the residents, assess the residents involved, and then notify management. Administrative Staff A stated staff followed the appropriate procedure for all the events reviewed involving R1. Administrative Staff A stated the event on 03/01/25 was not fully investigated or called to LE because the contact was not believed to be sexual in nature. Administrative Staff A confirmed the Progress Note dated 03/19/25 and stated she was unaware of the information and stated it would be considered a near-miss. Administrative Staff A stated the event documented on 03/27/25 was not investigated or reported because the other male resident in the area was unaware of R1's actions, R1's genitals were not exposed and R1 was not aggressive. Administrative Staff A stated LE should only be notified if another resident is harmed or if the resident's family wants LE involved. Administrative Staff A confirmed if someone touched anyone's breast without consent, LE should be notified and further confirmed R2 and R3 were incapable of providing consent and the touching from R1 was sexual in nature so it should have been reported to LE. The facility's Abuse, Neglect and Exploitation policy dated 10/2022 documented residents have the right to be free from verbal, sexual, physical, and mental abuse. The facility would keep residents free from abuse and take swift and immediate action to investigate allegations of abuse. The policy documented every employee had the responsibility to report allegations of abuse and the Administrator or Director of Nursing (DON) would investigate allegations and report the results to the proper authorities. All reports or suspicions of abuse would result in an investigation and all reasonable suspicions of a crime would be reported as required. On 04/10/25 at 11:35 AM, Administrative Staff L and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and informed of the facility's failure to immediately implement protective measures to prevent further potential abuse, after multiple allegations and/or incidents of resident-to-resident abuse, and to conduct thorough investigations, placed R2, R3, and all cognitively impaired female residents in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 04/10/25 at 02:56 PM which included the following: The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured. The facility notified Law Enforcement on 04/10/25. LN I received disciplinary action for failure to report the incident on 03/10/25. LN F received disciplinary action for failure to report the incident on 03/30/25 until 04/02/25. The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being. The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals. The facility immediately educated all staff on 04/10/25 regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations. The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation. The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone on 04/10/25. Implementation of the corrective measures to remove the immediacy was verified on-site on 04/10/25 at 03:35 PM. The deficient practice remained at a scope and severity level of E (patterned, potential harm).

The facility reported a census of 41 residents with 13 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from resident-to-resident abuse when on 01/25/25 Resident (R)1 grabbed R3's breast, and the facility failed to place any interventions to protect R3 and other residents from R1's unwanted sexual advances and touching. The facility placed R1 on a one-to-one with staff and sent the resident to a geriatric psychiatric (geri-psych) facility but did not implement interventions to prevent further resident-to-resident abuse when R1 returned on 02/22/25 other than medication for sexual aggression. On 03/01/25 staff observed R1 rubbing the leg of an unidentified female resident. The facility did not implement interventions in response to this incident. On 03/05/25 R1 grabbed R2's breast and staff directed R1 to his room but did not implement interventions to prevent further sexual contact. On 03/10/25 the facility placed R1 on visual one-to-one when R1 was outside his room though on 03/19/25, R1 again attempted to touch a female resident's leg but was redirected by staff back to his room with no further interventions noted. On 03/20/25 the facility documented R1 was on one-to-one when out of his room and there had been no inappropriate incidents. On 03/27/25 staff observed R1 stroking his penis next to an unidentified male resident but did not implement any interventions related to this incident. On 03/30/25 staff observed R1 stroking R3's leg. The facility noted that R1 gravitated to R3 as R3 resembled R1's spouse and the facility-initiated arms-length one-to-one. The facility's failure to ensure cognitively impaired residents remained free from sexual and/or physical resident-to-resident abuse placed R2, R3, and all cognitively impaired female residents unable to consent in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) included the diagnoses of altered mental status, psychotic disorder (a mental disorder characterized by gross impairment in reality perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), high-risk sexual behavior, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R1 displayed no behaviors to indicate psychosis. The assessment documented R1 utilized a walker and/or wheelchair for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/21/25 documented R1 had dementia (a progressive mental disorder characterized by failing memory, and confusion) with short-term and long-term memory loss. The Psychosocial Well-Being CAA dated 01/21/25 documented R1 lacked interest in interacting with or participating in activities. R1's Care Plan, reviewed 04/08/25, documented on 01/19/25, the resident had a cognitive loss that affected memory. Interventions dated 01/19/25 directed staff to help R1 establish a regular daily schedule with tasks divided into several steps. The plan directed staff to be patient with R1, remind R1 who they were, and explain care prior to initiation; staff would provide one instruction at a time in a calm tone. An update dated 01/27/25 noted R1 was placed on one-to-one monitoring for redirecting of behaviors, initiated on 01/25/25, created on 01/27/25, and revised on 03/10/25. The plan noted that R1 would be evaluated by geriatric psychiatry for behaviors of touching another person without their approval, which was initiated on 01/25/25, created on 01/27/25, and revised on 04/02/25. R1's Care Plan reviewed 04/08/25 documented on 01/27/25, R1 was at risk for sexually inappropriate behaviors related to maladaptive (unhealthy or ineffective ways of coping with something difficult or stressful) mood and behavior. The care plan included an intervention dated 01/27/25 that directed staff to administer medications as ordered to manage R1's behavior, created on 01/28/25. Interventions created on 01/2825 effective for 01/27/25 included staff observing R1's mood and behaviors, staff obtaining a psychiatric evaluation as ordered, staff redirecting inappropriate behavior with alternative activities, and staff reporting changes in behavior to the nurse and physician being informed as indicated. The plan documented that staff would ensure R1 was on one-on-one observation at an arm's length when not in his room, created on 01/28/25 and revised on 04/02/25 The Progress Notes section of R1's EHR documented the following notes: On 01/25/25 at 11:14 AM, staff observed R1 walked up to R3, a cognitively impaired resident, and touched her breast. Staff redirected R1 to his room. On 02/03/25 at 01:59 PM, staff documented a root cause analysis of the incident on 01/25/25 and documented that, according to R1's responsible person, R1 had a history of sexual aggression and grabbed R3's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room; R1 was started on medication for sexual aggression. On 03/01/25, Licensed Nurse (LN) I documented staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25, LN I documented R1 grabbed R2's (a cognitively impaired resident) breast, and staff directed R1 to his room. LN I documented the notification of Administrative Staff A and Administrative Nurse B of the incident. On 03/06/25 at 11:56 AM, Administrative Nurse B documented that LN I reported R1 had grabbed R2's breast in the dining area. On 03/10/25 at 01:03 PM, staff documented a root cause analysis of the incident on 03/05/25 and documented that according to R1's responsible person, R1 had a history of sexual aggression and R1 grabbed R2's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room. On 03/19/25 at 05:51 AM, staff documented R1 was up and down during the night and wandered from his room to the common area and back; redirection attempts were unsuccessful. Additionally, staff documented an unknown Certified Nurse Aide (CNA) stopped R1 from reaching for an unidentified female resident's leg. The CNA told R1 to stop and R1 walked back to his room before physical contact was made. Staff documented that Administrative Staff A and Administrative Nurse B were notified. On 03/20/25 at 03:16 PM, Social Services Designee (SSD) M documented R1 was observed throughout the week related to a previous incident (undated) and R1 remained on one-on-one observation when outside of his room. SSD M documented R1 had no inappropriate incidents. On 03/27/25 at 02:15 AM, staff documented R1 was observed stroking his penis while seated next to another male resident at 02:05 AM. Staff documented there was no physical contact observed between the two residents, and Administrative Staff A and Administrative Nurse B were notified. On 03/30/25 at 06:20 AM, LN F documented R1 stroked R3's left lower leg. Staff moved R3 and R1 returned to his room. On 03/30/25 at 07:51 AM, staff documented R1 looked up the dresses on wooden the Easter decorations in the dining room and stated, Let me get that [expletive]. On 03/30/25 at 06:02 PM, staff documented R1 continued to try and look up the dresses on the Easter decorations. On 04/03/25 at 02:17 PM, SSD M documented the facility sent a referral for R1 to be transferred to a different facility. On 04/02/25 at 10:44 AM, LN F documented that on 03/30/25 R1 was observed slowly rubbing R3's lower left leg. The note documented LN F placed herself between R1 and R3 and remained there until R1 returned to his room. LN F assessed R3 and determined her to be free of injury. The note recorded R1 continued to be on one-on-one observation. LN F documented she notified Administrative Staff A and Administrative Nurse B. On 04/08/25 at 02:14 PM, staff documented a root cause analysis, and the facility noted that R1 gravitated to R3 as R3 resembled R1's spouse; the facility-initiated arms-length one-on-one monitoring for R1 and continued to try to get the resident transferred to an all-male facility. A review of the facility's investigation and witness statements for the 01/25/25 incident revealed no additional information. The investigation report lacked documentation that the facility notified Law Enforcement (LE). The facility lacked an investigation report for the incident on 03/01/25. A review of the facility's investigation and witness statements for the 03/05/25 incident revealed no additional information. The investigation report lacked documentation that the facility notified. The facility lacked an investigation report for the incident on 03/27/25. A review of the facility's investigation for the 03/30/25 incident revealed no additional information. The investigation report lacked witness statements and lacked documentation that the facility notified LE. On 04/08/25 at 01:40 PM, R1 was unable to be interviewed due to the resident's cognitive impairment. During an interview on 04/08/25 at 04:40 PM, LN F stated on 03/30/25 R1 was observed rubbing the lower left leg of R3. LN F stated she placed herself between R1 and R3 until R1 went back to his room. During an interview on 04/09/25 at 03:20 PM, Administrative Staff A stated the facility did not notify LE of any of the documented incidents from 01/25/25 to 04/09/25. During an interview on 04/09/25 at 03:42 PM, CNA H stated she was unaware of the details of the events and stated R3 looks like R1's wife. CNA H stated R1 was confused and continued to attempt to touch R3 and rub her leg. CNA H stated if staff observed R1 with this type of behavior, staff had to stand between R1 and the female residents and report the incidents to the nurse on duty. During an interview on 04/09/25 at 03:46 PM, CNA J stated if R1 reached for a female resident staff would protect the female resident and attempt to redirect R1 with a different activity and report the incident to the nurse or a member of management. During an interview on 04/09/25 at 04:15 PM, LN K stated she was aware of the incidents with R1 and inappropriate contact and stated if staff observed R1 attempt inappropriate contact, R1 should be removed as quickly as possible to ensure the safety of the other residents. LN K stated she would report the incident to management immediately and then follow management's discretion as to whether to call law enforcement. During an interview on 04/09/25 at 04:25 PM, Administrative Nurse C stated the facility's expectation in the event of unwanted or inappropriate sexual contact staff should separate the residents to ensure resident safety and perform any required assessments and document everything in the EHR. Staff would then notify management who would immediately develop and implement an intervention to prevent the incident from happening again. This included notifying and educating all the staff and obtaining signatures. Administrative Nurse C stated after the incident on 01/25/25, R1 was placed under visual one-on-one monitoring until R1 was sent to a behavioral health unit (BHU). Administrative Nurse C stated she was unaware if the management team was aware of the incident on 03/01/25, and after the incident on 03/05/25 R1 was placed on one-on-one monitoring when he was out of his room. Administrative Nurse C stated when the incident occurred on 03/30/25 R1 was placed on one-on-one monitoring where staff must stay within an arms-reach of R1 when out of his room with a staff member placed outside the door to his room. Administrative Nurse C stated the management team was actively trying to find alternate placement for R1 at a more appropriate facility. Administrative Nurse C stated LE should be contacted for any unwanted physical or sexual contact and confirmed that LE was not contacted for any incidents that involved R1 between 01/25/25 and 04/09/25. During an interview on 04/09/25 at 04:54 PM Administrative Staff A revealed that after the incident on 01/25/25, R1 was placed under one-on-one visual monitoring until he was transferred to the behavioral health unit. Administrative Staff A said when R1 returned to the facility, he was self-isolating and would only come out of his room for meals and after the incident on 03/05/25, R1 was placed on one-on-one visual monitoring when he was outside of his room. Administrative Staff A stated after the incident on 03/30/25, R1 was placed on one-on-one monitoring within arm-length reach of staff except when he was in his room, then staff would be outside his room. Administrative Staff A stated the facility continued to try to find alternative placement at an all-male dementia unit. Administrative Staff A in the event of unwanted physical or sexual contact between residents, she expected staff to immediately separate the residents, assess the residents involved, and then notify management. Administrative Staff A stated staff followed the appropriate procedure for all the events reviewed involving R1. Administrative Staff A stated the event on 03/01/25 was not fully investigated or called to LE because the contact was not believed to be sexual in nature. Administrative Staff A confirmed the Progress Note dated 03/19/25 and stated she was unaware of the information and stated it would be considered a near-miss. Administrative Staff A stated the event documented on 03/27/25 was not investigated or reported because the other male resident in the area was unaware of R1's actions, R1's genitals were not exposed and R1 was not aggressive. Administrative Staff A stated LE should only be notified if another resident is harmed or if the resident's family wants LE involved. Administrative Staff A confirmed if someone touched anyone's breast without consent, LE should be notified and further confirmed R2 and R3 were incapable of providing consent and the touching from R1 was sexual in nature so it should have been reported to LE. The facility's Abuse, Neglect and Exploitation policy dated 10/2022 documented that residents have the right to be free from verbal, sexual, physical, and mental abuse. The facility would keep residents free from abuse and take swift and immediate action to investigate allegations of abuse. The policy documented every employee had the responsibility to report allegations of abuse and the Administrator or Director of Nursing (DON) would investigate allegations and report the results to the proper authorities. All reports or suspicions of abuse would result in an investigation and all reasonable suspicions of a crime would be reported as required. On 04/10/25 at 11:35 AM, Administrative Staff L and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and informed that the facility's failure to ensure cognitively impaired residents remained free from sexual and/or physical resident-to-resident abuse placed R2, R3, and all cognitively impaired female residents unable to consent in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 04/10/25 at 02:56 PM which included the following: The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured. The facility notified Law Enforcement on 04/10/25. LN I received disciplinary action for failure to report the incident on 03/10/25. LN F received disciplinary action for failure to report the incident on 03/30/25 until 04/02/25. The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being. The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals. The facility immediately educated all staff on 04/10/25 regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations. The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation. The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone on 04/10/25. Implementation of the corrective measures to remove the immediacy was verified on-site on 04/10/25 at 03:35 PM. The deficient practice remained at a scope and severity level of a G (isolated actual harm) to represent the psychosocial impact of the abuse for R2 and R3 using the reasonable person concept, due to the residents' inability to self-identify and/or verbally express their feelings.

The facility reported a census of 38 residents with six residents selected for review, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure staff used a gait belt while assisting Resident (R)1 in the shower room on 07/22/24. R1 was no longer to bear weight and required staff to assist him to the floor. R1's leg was underneath him, which resulted in a left ankle fracture (broken bone). Findings included: - The Medical Diagnosis tab for R1 included diagnoses of muscle weakness, other abnormalities of gait and mobility, hemiplegia (paralysis of one side of the body) affecting the left nondominant side, cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), and nondisplaced oblique fracture (bone broken at an angle) of the shaft of the left fibula (one of the two bones of the lower leg). The Admission Minimum Data Set (MDS) dated [DATE], assessed R 1 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 had impairment to his range of motion of his upper and lower extremities on one side, used a wheelchair for mobility, and was dependent on staff for moving from sitting to standing. The Falls Care Area assessment dated [DATE], revealed R1 was at risk for falls related to left-sided weakness and physical performance limitation affecting his balance, gait, strength, and muscle endurance. R1 required assistance with transfers. The Quarterly MDS dated [DATE], assessed R1 with a BIMS score of 10, indicating moderate cognitive impairment, he had no changes to his range of motion limitations, continued to use a wheelchair for mobility, and he required substantial/maximal assistance from staff to move from sitting to standing. The Care Plan dated 05/06/24, revealed R1 required assistance of one to two staff for transfers and occasionally required two staff to provide assistance when he was tired and had been up in the chair for extended periods. R1 was at risk to fall and required appropriate shoes and non-slip footwear. The Fall Risk assessment dated [DATE], revealed R1 was at moderate risk for falls and was not able to independently come to a standing position. The Progress Notes dated 07/22/24 at 05:28 PM, revealed while a Certified Nurse Aide (CNA) (lacked name) attempted to pull R1' s pants up in the shower room, the CNA lowered R1 to the floor. Licensed Nurse (LN) G assessed R1 for injuries and no obvious injury noted, however, R1 complained of pain at a level 9 out of 10 to his left ankle. LN G assessed R1 to have typical range of motion to all four extremities. The staff used a total body mechanical lift to transfer residents to pick R1 off the floor and placed him in a wheelchair. LN G contacted the physician who ordered an x-ray to R1's left ankle. R1 had to be transported (lacked by who) to the hospital for the x-ray to be obtained. The facility Witness Statement for R1 on 07/22/24 by CNA M, revealed she had given R1 a shower and he stated yes when asked if he felt stable enough to stand so she could pull his pants up. CNA M then had R1 grab onto the grab rail with his good hand. CNA M held R1's pants with one hand and used her other hand to support him and when she was halfway done pulling up his pants, R1 fell dead weight and she lowered R1 to the ground as slow as possible. When CNA M lowered R1 to the floor, his ankle twisted, and he complained of ankle pain after staff lowered him to the floor. CNA M stated R1 had a gripper sock on and was on traction slips at the time of the fall. The facility Witness Statement for R1 on 07/22/24, by LN G, revealed R1 stated when he went down (when staff lowered him to the floor) his left foot went under him and twisted. The Imaging Results dated 07/22/24 revealed R1 had a left fibular [NAME] C fracture (a break in the fibula above the joint where the two leg bones connect). The facility investigation for the incident on 07/22/24 revealed CNA M did not utilize a gait belt when assisting R1. The Progress Note dated 07/23/24 revealed R1's physician rounded and gave new orders for him to be non-weight bearing to his left leg and the moon boot to be on when out of bed, likely six to eight weeks. On 09/25/24 at 10:03 AM, Administrative Nurse D stated gait belts are not included on the care plan as it was facility policy when providing more than supervision for transfers, a gait belt should always be used. On 09/25/24 at 10:48 AM, Administrative Staff A stated the facility did not have a policy for gait belt use, but it was the facility's standard practice. On 09/25/24 at 12:27 PM, CNA M stated R1 did not have use of his left foot or ankle due to a stroke and before transferring him on 07/22/24, she made sure R1 had his feet planted. CNA M stated while standing R1 he went dead weight (did not bear any weight) and she slowly lowered R1 to the floor. CNA M stated R1 had a gripper sock on his left foot and a shoe on his right foot, which was what he had in place when he she took him to the shower room. CNA M stated she was not using a gait belt when assisting R1. Observation on 09/25/24 at 12:59 PM, revealed R1 sitting up in his wheelchair in his room with a boot in place to his left foot (over 9 weeks since the fall). On 09/25/24 at 01:00 PM, R1 stated his foot was in the boot because he broke it. He stated he had a hold of the bar in the shower room when standing and he went to take a step back and whoop down he went. R1 stated the girl helping him (did not know her name) was not using a gait belt. R1 stated he had a black gait belt but reported he did not know why she did not use the gait belt. On 09/25/24 at 01:15 PM, CNA N stated the staff were to use a gait belt on everyone and R1 had a stroke so R1 definitely should have one in use. On 09/25/24 at 01:32 PM, LN G stated when CNA M assisted R1 in the shower room on 07/22/24, she should have used a gait belt and he had told her she should have had one. On 09/25/24 at 02:15 PM, Administrative Staff A stated she expected CNA M to use a gait belt when standing R1 up. The facility failed to ensure staff utilized a gait belt when assisting R1, who required staff to assist in lowering him to the floor, which caused a fracture to his left ankle when his leg was underneath him. On 07/25/24, the onsite surveyor verified correction of the deficient practice when the facility completed these actions: 1. LN G provided on the spot education to CNA M for use of gait belt with transfers. 2. The facility trained all nursing staff on 07/28/24 and 07/29/24 for gait belt and mechanical lift training. 3. The facility provided disciplinary action to CNA M on 07/31/24 for lack of gait belt use when transferring residents. All corrections were completed prior to the onsite survey, therefore the deficient practice was deemed past non-compliance and remained at a scope and severity of a G.

The facility census totaled 29 residents on 3 halls with a commons area where residents gathered for meals and activities. The two medication carts were also parked/stored in the commons area. Based on observation, interview, and record review, the facility failed to secure and provide appropriate storage of medications in the medication cart when both medication carts used by the facility remained unlocked when not in direct line of vision of the nurse and medication aide that passed medications from the two carts. Findings included: - On 10/09/23 at 08:35 AM, Licensed Nurse (LN) G removed an insulin pen from the medication cart. He then walked down the hall and around a corner, not in view of the medication cart. The medication cart was not locked. Interview on 10/09/23 at 08:40 AM, LN G reported he was unaware that he had left the medication cart unlocked. He acknowledged the medication cart should be locked whenever he left the cart. An inspection of the medication cart revealed the cart contained all resident insulins, breathing treatments, and narcotics in a locked box in the cart. The cart also contained treatment supplies used for the residents. Interview on 10/10/23 at 09:39 AM, Administrative Nurse E reported all medication carts were to be locked when unattended. Administrative Nurse E reported there was no policy for the medication carts, as this would be a standard of practice. The facility lacked a policy for medication carts. The facility failed to secure and provide appropriate storage of medications in the two medication carts when both medication carts used by the facility remained unlocked when not in direct line of vision of the nurse and medication aide that passed medications from the two carts. - On 10/10/23 at 09:38 AM, a medication cart was in the hallway near the commons area. The cart was unlocked with no staff in view of the cart. Certified Medication Aide (CMA) S exited a resident room and acknowledged the cart was left unsecured. On 10/10/23 at 09:38 AM, CMA S stated that medication carts should be locked when left unattended. Interview on 10/10/23 at 09:39 AM, Administrative Nurse E reported all medication carts were to be locked when unattended. Administrative Nurse E reported there was no policy for the medication carts, as this would be a standard of practice. The facility lacked a policy for medication carts. The facility failed to secure and provide appropriate storage of medications in the two medication carts when both medication carts used by the facility remained unlocked when not in direct line of vision of the nurse and medication aide that passed medications from the two carts.

The facility reported a census of 29 residents. The facility identified one central kitchen with one dining area. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility. Findings included: - Initial tour of the kitchen on 10/04/23 at 12:50 PM with Dietary Staff BB, revealed the following areas of concerns: 1. In the kitchen food preparation area, four of the four cutting boards inspected contained non-cleanable surfaces as evidenced by deep gouges in the material with retained unknown black/brown residue. 2. In the kitchen food service area, two stacks of plates were stored right-side up on the top of the steam table and contained unknown debris on the eating surfaces. 3. In the kitchen food service area, two stacks of plates were stored right-side up in a plate holder, lacked a cover and contained unknown debris on the eating surfaces. 4. In the kitchen food preparation area, the sink identified by Dietary Staff BB for food preparation lacked a two-inch air gap on the discharge line between the sink and municipal sewer connection. 5. In the upright freezer, two packages of sliced bologna luncheon meat had a manufacturer's expiration date of 07/31/23. 6. In the upright freezer, a large container of orange sherbet lacked a sealed lid and was open to air. 7. In the upright freezer, a box of cobbler crusts was unsealed and open to air. 8. In the walk-in refrigerator, a zipper-style plastic bag of diced bell peppers had an expiration date of 09/24/23. 9. In the walk-in refrigerator, a large container of coleslaw dressing had an expiration date of 09/02/23. 10. In the walk-in refrigerator, a large container of pickle relish had an expiration date of 09/13/23. 11. In the walk-in refrigerator, a large container of honey mustard dressing was unsealed and open to air. 12. In the walk-in refrigerator, a tray of leftover brownies was unsealed and open to air. 13. In the kitchen area, Dietary Staff CC observed walking in the kitchen without hair-restraint device in place. 14. The outside trash storage dumpster lacked appropriate covering. On 10/04/23 at 01:20 PM, Dietary Staff BB stated that all staff present in the kitchen should be always wearing a hair-restraint device. The facility failed to provide a policy for food storage and labeling as requested on 10/04/23 and 10/10/23. The facility failed to provide a policy for hair-restraint use in the kitchen areas as requested on 10/04/23 and 10/10/23. The facility failed to provide sanitary food preparation and storage of food. This deficient practice had the potential to cause the spread of food borne illness to the residents of the facility.

The facility reported a census of 34 residents with three sampled and reviewed for skin and wound management. Based on record review and interview, the facility failed to prevent neglect through the failure to ensure licensed nursing staff assessed a wound on Resident (R)1's right lateral foot weekly, from 12/21/22 to 02/16/23, failed to initiate a treatment for a wound identified on 12/26/23 until 01/27/23 (31 days later), failed to complete treatments as ordered, failed to notify the primary care physician when the wound deteriorated, and failed to notify the primary care physician in a timely manner with critical radiology results. The facility's lack of action led to the deterioration of the wound on R1's foot, which developed osteomyelitis and required hospitalization and possible amputation below the knee pending. This deficient practice placed this resident in immediate jeopardy and those in the facility which had wounds present. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, open wound of foot, long term use of insulin, and aphasia (condition with disordered or absent language function). The Minimum Data Set (MDS) tab for R1 revealed he entered the facility on 12/16/22. The Admission MDS dated [DATE] revealed R1 had absence of speech, could rarely make himself understood, rarely understood others, and had severely impaired decision making. The MDS lacked an assessment of his cognition. R1 required two or more staff to assist him with bed mobility, transfers, and dressing. He had range of motion impairment to the right side of his upper and lower extremity and used a wheelchair for mobility. He was at risk for developing pressure ulcers (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), has no ulcers or other wounds present, had a pressure relieving device for his chair and bed, was not on a turning and repositioning program, and had applications of ointments/medications other than to his feet. The Pressure Ulcer/Injury Care Area assessment dated [DATE] for R1 revealed he had no skin conditions but was at risk due to needing extensive to total assistance with mobility and repositioning. He had right side paralysis, severe cognitive and physical deficits, no current skin concerns, and had a pressure reducing mattress on the bed and chair. The Quarterly MDS dated [DATE] assessed R1 with a short and long-term memory problem, continued to have absence of speech and could rarely make himself understood and could rarely understand others. There was no change in his assistance needed for bed mobility, transfers, and dressing. R1 continued to have limited range of motion to one side of his upper and lower extremities and used a wheelchair for mobility. R1 continued to be at risk for pressure ulcers/injuries and had one stage three pressure ulcer (full thickness loss of skin usually over a bony prominence, a result of pressure, or pressure in combination with shear and/or friction) that was not present on admission. R1 had an infection of the foot, other open lesions on the foot, and did not have any diabetic ulcers. He continued to have a pressure reducing device for bed and chair and was not on a turning/repositioning program. R1 was on a nutrition/hydration program to manage skin problems, received pressure ulcer/injury care, received applications of ointments/medications other than to feet, and applications of dressings to feet (with or without topical medications). The Care Plan initiated 12/16/22 revealed R1 required staff extensive to total assistance with activities of daily living (ADLs) related to his physical limitations and right-side paralysis. R1 was at risk for skin breakdown due to incontinence and needing extensive to total assistance for positioning. The staff were to assist to alter his weight/body position, provide appropriate pressure relieving devices to the bed and wheelchair, monitor and report any changes while providing cares or assisting with bathing such as bruising or skin tears, and to provide skin assessments per protocol and as indicated. The staff were to contact R1's physician as needed if there were changes in his skin condition. Additions to the care plan included on 02/12/23 R1 had an open area to his right outer foot, on 02/14/23 to encourage and assist to consume all the offered flood/fluids to assist in maintaining adequate nutrition/hydration and to see the treatment administration record (TAR) for current skin concerns, orders, and treatments. Additionally, on 03/09/23, R1 was to receive Clindamycin (antibiotic which can be prescribed to treat skin infections), 150 milligrams (mg), four times a day, daily, for foot wound. The Clinical Health Review dated 12/16/22 for R1 revealed a Braden Pressure Ulcer Risk score of 10, indicating high risk for pressure ulcer development. The assessment identified a skin tear to his right hand and MASD (moisture associated skin damage - superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration). The Skin/Wound Condition assessment dated [DATE] for R1 revealed no new skin issues and lacked presence of the issues included in the Clinical Health Review on 12/16/22. The assessment tab lacked further Skin/Wound Condition Assessment completion by the licensed staff until 02/16/23. The facility failed to conduct a weekly skin inspection between 12/21/22 until 02/16/23, eight weeks total without a licensed nurse skin assessment. The Nurse's Note dated 12/26/22 for R1 revealed after his shower was given and staff noted two open areas on his right foot. The wound to the right great toe measured 0.8 centimeters (cm) by 0.5 cm and the right outer foot measured 1.9 cm by 0.9 cm. The areas were cleansed, and a staff applied a dry sterile dressing to each. The TAR and the Licensed Medication Administration Record (MAR) dated December 2022 for R1 lacked treatment orders for the right foot, for five days following the identification of the open areas. The TAR dated January 2023 for R1 revealed an order dated 01/27/23 to cleanse the open area to the right outer foot with normal saline, pat dry, apply calcium alginate (a highly moisture absorbent product/dressing), and cover with bordered gauze daily for the open area. R1 went 26 days in January 2023, for a total of 31 days without treatment to the right outer foot from 12/27/22 until 01/27/23. The TAR dated February 2023 for R1 included the order dated 01/27/23 for the treatment to the right foot and discontinued on 02/14/23. The TAR lacked signature on 02/06/23, 02/07/23, and 02/11/23 to verify the licensed nursing staff completed the physician ordered treatment. On 02/15/23, a new order instructed the staff to cleanse the open area to the right outer foot with normal saline, pat dry, apply Medihoney (gel used to wound to aid in wound healing and removal of necrotic [dead] tissue), and cover with border gauze daily for the open area. The Orders tab included an order dated 02/16/23 for R1 for a weekly skin assessment to be done on Thursday at AM Pass time. The Skin/Wound Condition assessment dated [DATE] for R1 revealed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown tissue]) and/or eschar (dead tissue that may be tan, brown, or black and appear scab like) to the wound bed of a pressure ulcer to the left (rather than right) lateral foot. The assessment included preventive measures of floating heels, heel/elbow protectors, and repositioning. The assessment lacked measurements of the area, notification to the physician, and notification to the resident or responsible party. The Physician Order tab located in the paper chart, revealed R1's primary care physician signed an order, dated 02/14/23 for wound treatment to the right outer foot. The Orders tab located in the electronic medical record (EMR) revealed a physician order for R1 dated 02/22/23 for Wound Care Plus (contracted wound care company) to evaluate and treat. The Wound Care Center Progress Note dated 02/22/23 for R1 revealed the wound to the right foot identified as a Wagner Grade 3 Diabetic Ulcer (an ulcer with bone involvement) and measured 2.5 cm by 2 cm by 0.1 cm with 76-100 percent (%) slough present to the wound bed. This assessment revealed an increase in size in the wound when measured by the facility on 12/26/23. Consultant Wound Care Staff HH performed a skin/subcutaneous tissue level excisional/surgical debridement (removal of dead tissue from the wound). The wound had signs and symptoms of infection, and she obtained a tissue culture for submission to microbiology. The Skin/Wound Condition assessment dated [DATE] revealed an open area to the right foot, treatment ordered by the wound center in place, and notification to the resident or responsible party and physician on 02/28/23. The Progress Note dated 03/01/23 by Consultant Wound Care Staff HH revealed R1's wound measured 3.0 cm by 3 cm by 0.1 cm and continued to have 76-100 % slough present in the wound bed. The note lacked results of the culture obtained from the wound on 02/22/23. The Skin/Wound Condition assessment dated [DATE] for R1 revealed he had a Stage three pressure ulcer to the left (prior wounds documented on the right) foot, which lacked measurements, and noted the wound care team was debriding the wound. The facility failed to perform any further assessments until 03/30/23. The Progress Note dated 03/08/23 by Consultant Wound Care Staff HH for R1 revealed the right outer foot wound measured 2.5 cm by 2.5 cm by 0.1 cm, a decrease in size, and continued to have 76-100 % slough and one to 25 % granulation (healing) tissue. The note included additional orders of clindamycin, 150 mg, oral capsule, one, by mouth, four times a day, for ten days, starting 03/08/23. Review of the resident's progress notes lacked any additional documentation related to the wounds until 03/22/23. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the order for the wound care center dated 02/22/23, on 03/10/23. The Progress Notes located in the EMR for R1 revealed on 03/15/22 at 12:59 PM an order for Lidocaine External Ointment (used to prevent and treat pain), apply to right outer foot wound, topically, one time a day, every Wednesday, for pain, 30 minutes before wound care arrived. Consultant Wound Care Staff HH arrived at 11:30 AM and would not wait 15 minutes for blood sugar check and insulin, and stated they would be back next Wednesday. The facility failed to perform a wound assessment for R1. The Progress Note dated 03/22/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 2.7 cm by 2.3 cm by 0.1 cm, an increase in the length and decrease in the width. The wound continued with 76-100 % slough and one to 25 % granulation. Consultant Wound Care Staff HH performed excisional/surgical debridement with post debridement measurements the same except a depth of 0.2 cm. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the wound care orders on 03/23/23 for 03/08/23. The Progress Note dated 03/29/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 3.0 cm by 2.0 cm by 0.1 cm, an increase in length and decrease in width, however, the wound bed had 26-50 % slough and 26-50 % granulation. The area appeared to have some hyper-granulation and the note lacked that surgical debridement occurred at this visit. Consultant Wound Care Staff HH changed the treatment orders to include Mysalt (Mesalt - used to absorb wound drainage to promote wound healing process) to the wound bed and changed the dressing change schedule to daily. Additionally, she prescribed silver nitrate applicators (used to stop bleeding after debridement or treat hyper-granulation of wounds and has antibacterial properties), topical, 75% - 25% stick, weekly, by Wound Care Plus, starting 03/28/23. The note included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Skin/Wound Condition assessment dated [DATE] for R1 revealed a stage 3 pressure ulcer to the left (rather than right) foot and the wound care team managed the wound. The assessment lacked notification to the physician and resident or responsible party. The EMR lacked further skin assessments for R1 until 04/13/23. The TAR dated March 2023 for R1 lacked changes to the treatment orders made by the wound care center on 03/29/23. The Progress Note dated 04/05/23 by Consultant Wound Care Staff HH revealed R1's right foot wound had the same length and width measurements however, the depth increased from 0.1 cm to 0.5 cm and there were no changes to the amount of slough and granulation. A chemical cautery of hyper-granulation tissue was performed using silver nitrate. The laboratory section of the note indicated bacteria identified in specimen by anaerobe culture (test done without letting oxygen get to the sample), fungus identified in specimen culture, bacteria identified in specimen by aerobe culture (allowing the culture to be exposed to air). There were no changes to the orders for this visit. The Progress Note dated 04/12/23 by Consultant Wound Care Staff HH for R1 revealed no changes to wound measurements from the prior week, no changes to slough or granulation. General notes included they rounded with Administrative Nurse E, hyper-granulation continues to wound, silver nitrate applied, no Mesalt available, spoke with staff about ordering, and staff were educated on orders. Procedures for this visit included chemical cautery (method used to burn or dissolve tissue) of hyper-granulation using silver nitrate. Additional orders included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Nurse's Notes dated 04/12/23 for R1 revealed the wound care center was at the facility and new orders received for the wound to the right foot, the orders were entered and sent to the primary care physician. The TAR dated April 2023 for R1 revealed the facility changed the treatment orders for the right foot to include the Mesalt on 04/12/23 (two weeks after the order) and the silver nitrate. The staff charted O indicating other see progress note on 04/12/23 and 04/13/23 and performed the treatment on 04/14/23. The staff changed the treatment from 09:00 PM to AM Pass on 04/16/23, the TAR was blank on 04/17/23, and the treatment time changed on 04/17/23 to PM Pass. On 04/17/23 for the treatment at the PM Pass time, which included the silver nitrate, had O charted for 04/17/23 and was blank on 04/18/23, 04/21/23, and 04/23/23. The facility failed to perform wound care to R1's foot wound for two days in a row. Additionally, the TAR included an order for silver nitrate, to the right foot wound, topically, daily starting 04/12/23 and discontinued on 04/14/23. The facility failed to enter the order correctly, as on 03/29/23, Consultant Wound Care Staff HH ordered the silver nitrate to be done weekly by Wound Care Plus. The TAR: revealed the staff coded O indicating other see progress note on 04/12/23 and 04/13/23 and documented administered on 04/14/23. An additional order was on the TAR for the silver nitrate daily, start 04/16/23 and discontinued 04/16/23 (Sunday), however, the staff did not sign that they administered the treatment. The order added to the TAR on 04/17/23 continued to include the silver nitrate, the staff documented administration of the treatment on 04/19/23, 04/20/23, 04/22/23, 04/24/23, 04/25/23, and 04/26/23. The order discontinued on 04/26/23 and a new order on the TAR dated 04/27/23 excluded the silver nitrate. The Progress Notes dated 04/13/23 at 06:37 AM for R1 revealed the treatment to the right foot was done by wound nurse today. The Progress Notes dated 04/13/23 at 06:38 AM for R1 revealed the silver nitrate was done by the wound nurse today. The Progress Note dated 04/13/23 at 08:19 PM revealed R1's wound was covered with a dressing, no drainage note, and no pain reported. The Skin/Wound Condition assessment dated [DATE] for R1 continued to reveal he had a stage three pressure ulcer to his left (rather than right) lateral foot, wound care done as ordered by the wound care center. The EMR lacked further skin assessments for R1 until 04/27/23 (14 days later). The Physician Order tab, located in the paper chart, revealed the primary care physician signed a wound care order on 04/13/23 for 04/12/23 to the right foot. The Progress Note dated 04/17/23 at 02:50 PM revealed the supplies for the wound care (which included the silver nitrate and Mesalt) were not available as ordered and the staff cleansed the wound with wound cleanser and applied a sterile dressing. The Progress Note dated 04/19/23 by Consultant Wound Care Staff HH revealed she rounded with Licensed Nurse (LN) H and Mesalt ordered per staff. The wound measured 2.3 cm by 2.2 cm by 0.3 cm, indicating decrease in length, increase in width, decrease in depth. The wound bed had one to 25 % slough and 51-75 % granulation. Post surgical debridement did not change the wound measurements. The Progress Note dated 04/26/23 by Consultant Wound Care Staff HH for R1 revealed rounded with a staff nurse and the Mesalt remained unavailable, staff educated on continued use of alginate until the Mesalt becomes available, discontinued the silver nitrate order, and educated staff on current orders. There were no changes to the slough or granulation, the wound measured 2 cm by 2 cm by 0.2 cm, indicating a decrease in the size of the wound. The Skin/Wound Condition assessment dated [DATE] for R1 continued to reveal a stage three pressure ulcer to the left (rather than right) foot and indicated the staff identified the wound on 02/16/23 (the staff found the wound on 12/26/23). The Assessment tab lacked any further assessments after this date through the time he transferred to the hospital on 06/04/23. The Physician Order tab located in the paper chart revealed the primary care provider signed the right foot wound care order dated 04/26/23 on 04/27/23. The Progress Note dated 05/03/23 by Consultant Wound Care Staff HH for R1 revealed the same measurements as the prior week with no change to slough and granulation. Surgical debridement performed with a post debridement depth of 0.5 cm. The Progress Note dated 05/10/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation persists, and revealed no changes to measurements, slough, or granulation. Chemical cautery of hyper-granulation tissue performed with use of silver nitrate. The records for R1 lacked a visit by Consultant Wound Care Staff HH on 05/17/23. The Skin Condition Note dated 05/18/23 at 07:30 AM revealed the open area continues to right side of foot, Wound Care Plus with treatment. The note lacked an assessment of the wound. The Progress Note dated 05/24/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation resolved, area deteriorated in size, staff reported drainage through dressing, orders updated, attempted to discuss order changes with Administrative Nurse D however, he was unavailable at the time of visit, and staff were educated on orders. The wound measured 2.0 cm by 3.5 cm by 0.2 cm, revealing an increase in the width of the wound, no change to slough or granulation, however, tendon (strong, flexible tissue which connects muscle to bone) exposed. Surgical debridement performed with no change to wound measurements. Consultant Wound Care Staff HH changed the treatment orders to included calcium alginate in the wound base, removed the Mesalt from the treatment orders, and cover with bordered gauze, and change daily. The EMR lacked notification to the physician and the responsible party regarding a decline in the wound, which now had tendon exposed. The Skin Condition Note dated 05/25/23 for R1 revealed a stage three pressure area to right foot and being seen by Wound Care Plus. The facility staff measured the wound at 2.5 cm by 3.5 cm by 0.3 cm, indicating an increase in length and depth. The wound had a small amount of bleeding at the site, foul odor, and moderate drainage. The note indicated staff performed wound care as ordered on 05/24/23 except for covering of the wound with a silicone bordered dressing rather than a gauze dressing, per wound care orders. The note lacked notification to the primary care physician and the resident or responsible party. The TAR dated May 2023 revealed an order dated 05/25/23 to cleanse with wound to the foot with wound cleanser, apply calcium alginate to wound base, cover with silicone bordered foam, three times a week on Tuesday, Thursday, and Saturday. This order did not match the order from the wound care center. The Skin Condition Note dated 05/29/23 at 08:40 AM for R1 revealed wound to the left (rather than right) foot measured 4.0 cm by 2.5 cm, hyper-granulation with moderate amount of drainage and moderate amount of maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) surrounding the skin. The note revealed R1 had a second wound now present measuring 3.0 cm by 3.0 cm with hyper-granulation and moderate amount of drainage with only 0.5 cm of intact skin between the two wounds. Areas cleansed with wound cleanser, skin protectant applied to peri-wound, foam dressing with hole cut out for offloading, covered with a six by six bordered gauze dressing, and wrapped with Kerlix. R1's foot placed in a moon boot with area cut out for offloading. The noted included Consultant Wound Care Staff HH scheduled to be at facility on Wednesday (two days later) and lacked notification of the change of condition to the right foot with an additional wound present, to the physician and the responsible party. The Skin Condition Note dated 05/30/23 for R1 revealed the wound dressing completely saturated with seropurulent (a combination of serous [clear] and purulent [producing or containing pus]) drainage that continued to be foul smelling and peri-wound continued with maceration. The staff called Administrative Nurse D to come visualize/assess the difference in R1's wound from Thursday to yesterday and today. A wound culture was taken of the purulent drainage, cleaned wounds and periwound with wound cleanser, applied hydroconductive (draws fluid away) wound dressing, then covered with six by six bordered gauze dressing. Then a hole was cut in an ABD dressing (abdominal - used to absorb heavily draining wounds) to offload and entire foot wrapped with Kerlix. The staff placed R1's foot in a foam moon boot and changed the wound care orders to daily. The note lacked notification to the responsible party. The Progress Note dated 05/31/23 by Consultant Wound Care Staff HH for R1 revealed a wound measurement to the right foot of 8.0 cm by 3.5 cm by 0.5 cm, with tendon exposed, a large amount of purulent drainage, which had a strong odor. The wound bed had 26-50 % granulation, 26-50 % slough, and 1-25 % epithelialization (a process of wound healing). The note included she rounded with LN H, the area deteriorated, a culture was pending, area was debrided, and spoke with Administrative Nurse D about need for x-ray for possible osteomyelitis. Surgical debridement performed with post debridement measurements the same with the exception of an increase in depth to 1.0 cm. Consultant Wound Care Staff HH changed the treatment orders to the right foot. The Physician Orders tab located in the hard chart revealed the primary care physician signed orders on 06/01/23 for the wound culture on 05/30/23 and the treatment to the right foot for 05/30/23. A fax communication sheet dated 06/02/23 to the primary care physician revealed x-ray results of the right foot were attached, please advise, and a request for pain medication to give prior to dressing changes. The physician responded 06/09/23 patient is admitted for osteomyelitis. The Nurse's Note dated 06/02/23 for R1 revealed a mobile x-ray company was at the facility to x-ray the resident's right foot. The report showed abnormal cortical (outermost layer of the bone) erosion and bony lysis (destruction of area of bone) at the distal aspect of the right fifth metatarsal (bone of the foot) likely representing osteomyelitis. The staff faxed the final report to the primary care physician and awaiting wound culture results from the lab (done three days prior). The note lacked notification to the responsible party. The X-ray Examination dated 06/02/23 for R1 on the right foot revealed likely osteomyelitis and at the bottom of the report included a handwritten note faxed to PCP 06/02/23 noted 06/02/23. The facility failed to contact the physician with the critical x-ray results. The Culture report dated 06/03/23 of the right foot wound for R1 revealed moderate amount of five different organisms, one of which represented possible contamination of the culture. A note on the report revealed the staff faxed the report on 06/03/23 to the primary care physician. The Orders Note dated 06/03/23 for R1 revealed metronidazole (antibiotic) 500 mg, arrived from the pharmacy and initial dose given. The EMR lacked a progress note for the condition of the right foot wound for 06/03/23 or notification to the responsible party regarding the new medication order. The Nurse's Note dated 06/04/23 at 10:30 AM revealed R1's wound to foot had copious (abundant) amounts of very foul-smelling drainage, large, approximately 5.0 cm by 7.0 cm, fluid filled area on the medial lateral surface of the foot. Additionally, there were two small dime to quarter sized black areas medial to the large fluid filled area, moderate amount of slough to the wound bed, with redness around the entire foot. Administrative Nurse D called to room to visualize and assess. Responsible party notified of the deteriorating condition of the wounds, and she asked the staff to send R1 to the hospital. Administrative Nurse D notified the primary care physician and received orders to transfer R1 to the local hospital for evaluation. The Nurse's Note dated 06/04/23 at 04:02 PM for R1 revealed the facility received a call from the hospital that R1 admitted due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection, which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) with a WBC (white blood cells - part of the body's immune system, help fight infection) of 24 thousands per cubic milliliter (K/uL) (the upper level of normal range, varies per lab, typically 11 K/uL) indicating infection. The hospital reported the plan was to surgically debride the wound and start intravenous (IV) antibiotics. The hospital Operative Procedure dated 06/05/23 for R1 revealed R1's condition discussed in detail with the responsible party. Due to the extent of muscle necrosis and soft-tissue loss, recommendation was below the knee amputation. R1 would have a long battle to recover from this amount of damage and would not have a functional foot in the future, therefore, amputation would likely provide him with the fastest recovery and a minimal damage to other body systems in the process. The Hospital Progress Note dated 06/06/23 for R1 revealed the recommendation was for R1 to have a below the knee amputation in an effort to prevent R1 from losing his life, however the responsible party refused that option. R1 would be transferred at that time to more aggressive wound care instead of having the recommended surgery done. On 06/13/23 at 10:15 AM an unidentified family member stated the facility really did not update them on R1's condition, and stated they thought it was healing in the beginning. The family member recalled the facility saying a wound care team was brought in and said it was almost healed in February, but it was not. The facility commented they were not going to put the house shoes on the resident because it rubbed a spot. The family member stated she would try to visit weekly but at one-point visits were infrequent due to medical issues, and when she visited, he would have a sock on. She did not recall seeing any kind of protector to his foot until the Friday before he went out to the hospital. R1 was nonverbal due to his stroke and was pretty dependent on staff to move him around and dress him. The facility called her Sunday before church and wanted to send him to the emergency room . The physician for the nursing home told her he did not know anything about the wound. The family member stated the hospital wanted to amputate his foot. On 06/13/23 at 12:28 PM LN J stated weekly skin assessments were to be done weekly, some were charted under assessments and some as a skin condition progress note. The weekly skin assessments would show up on the TAR for when they were to be done and there was a list at the desk. Documentation would include if no skin issues were present. A wound care nurse came to the facility for any wounds that were stageable. LN H stated the facility should notify the physician and resident or responsible party if there was no progress to the wound, and anytime there was not progress the physician should be notified. LN J stated she worked the night shift, and this was her first day shift. On the night shift R1 would wear boots in bed on that shift and he had a wound on his right foot. LN J stated she had changed the dressing about a month and a half ago and at that time it was around the size of a golf ball, maybe smaller. The staff would reposition him every two to three hours and R1 would also move around on his own too, he would slide his legs off the bed and the staff would move him. LN J believed R1 was on a pressure reducing mattress. On 06/13/23 at 01:09 PM Administrative Nurse D stated a Consultant Wound Staff HH came to the facility from the wound center and did R1's weekly wound assessments. Administrative Nurse D stated Consultant Wound Staff HH would just cut and cut the wound on R1's foot and made it worse. Administrative Nurse D stated Consultant Wound Staff HH would write orders for wound care, they would be on her progress note that would be available usually in 24 hours and he would go the wound center site to get the progress notes. Consultant Wound Staff HH saw R1 from 02/22/23 through 05/21/23, and the facility used those assessments as their weekly wound assessments. Administrative Nurse D stated he was not sure if the facility kept R1's physician informed of the wound status, he ordered the wound care center, and they would take over from there. Administrative Nurse D stated he was not sure if the facility had notified the responsible party with changes in wound care of the status of the wounds. The facility staff were to do a weekly skin assessment, which show up on the TAR when it was to be done, and the licensed nurse were to chart in the skin/wound condition assessment, including if there were not any skin issues. On 06/13/23 at 01:39 PM Administrative Nurse D stated he became concerned with the condition of R1's wound about two weeks before he was sent out, however, he did not report to the primary care physician as Consultant Wound Staff H was midlevel and he was not a wound expert. Administrative Nurse D stated he goes to the wound care website to print the wound centers progress notes and to address the orders. On 06/13/23 at 03:16 PM Administrati[TRUNCATED]

The facility reported a census of 34 residents with three sampled and reviewed for skin and wound management. Based on record review and interview, the facility failed to ensure licensed nursing staff assessed a wound on Resident (R)1's right lateral foot weekly, from 12/21/22 to 02/16/23, failed to initiate a treatment for a wound identified on 12/26/23 until 01/27/23 (31 days later), failed to complete treatments as ordered, failed to notify the primary care physician when the wound deteriorated, and failed to notify the primary care physician in a timely manner with critical radiology results. The facility's lack of action led to the deterioration of the wound on R1's foot, which developed osteomyelitis and required hospitalization and possible amputation below the knee pending. This deficient practice placed this resident in immediate jeopardy and those in the facility which had wounds present. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, open wound of foot, long term use of insulin, and aphasia (condition with disordered or absent language function). The Minimum Data Set (MDS) tab for R1 revealed he entered the facility on 12/16/22. The Admission MDS dated [DATE] revealed R1 had absence of speech, could rarely make himself understood, rarely understood others, and had severely impaired decision making. The MDS lacked an assessment of his cognition. R1 required two or more staff to assist him with bed mobility, transfers, and dressing. He had range of motion impairment to the right side of his upper and lower extremity and used a wheelchair for mobility. He was at risk for developing pressure ulcers (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), has no ulcers or other wounds present, had a pressure relieving device for his chair and bed, was not on a turning and repositioning program, and had applications of ointments/medications other than to his feet. The Pressure Ulcer/Injury Care Area assessment dated [DATE] for R1 revealed he had no skin conditions but was at risk due to needing extensive to total assistance with mobility and repositioning. He had right side paralysis, severe cognitive and physical deficits, no current skin concerns, and had a pressure reducing mattress on the bed and chair. The Quarterly MDS dated [DATE] assessed R1 with a short and long-term memory problem, continued to have absence of speech and could rarely make himself understood and could rarely understand others. There was no change in his assistance needed for bed mobility, transfers, and dressing. R1 continued to have limited range of motion to one side of his upper and lower extremities and used a wheelchair for mobility. R1 continued to be at risk for pressure ulcers/injuries and had one stage three pressure ulcer (full thickness loss of skin usually over a bony prominence, a result of pressure, or pressure in combination with shear and/or friction) that was not present on admission. R1 had an infection of the foot, other open lesions on the foot, and did not have any diabetic ulcers. He continued to have a pressure reducing device for bed and chair and was not on a turning/repositioning program. R1 was on a nutrition/hydration program to manage skin problems, received pressure ulcer/injury care, received applications of ointments/medications other than to feet, and applications of dressings to feet (with or without topical medications). The Care Plan initiated 12/16/22 revealed R1 required staff extensive to total assistance with activities of daily living (ADLs) related to his physical limitations and right-side paralysis. R1 was at risk for skin breakdown due to incontinence and needing extensive to total assistance for positioning. The staff were to assist to alter his weight/body position, provide appropriate pressure relieving devices to the bed and wheelchair, monitor and report any changes while providing cares or assisting with bathing such as bruising or skin tears, and to provide skin assessments per protocol and as indicated. The staff were to contact R1's physician as needed if there were changes in his skin condition. Additions to the care plan included on 02/12/23 R1 had an open area to his right outer foot, on 02/14/23 to encourage and assist to consume all the offered flood/fluids to assist in maintaining adequate nutrition/hydration and to see the treatment administration record (TAR) for current skin concerns, orders, and treatments. Additionally, on 03/09/23, R1 was to receive Clindamycin (antibiotic which can be prescribed to treat skin infections), 150 milligrams (mg), four times a day, daily, for foot wound. The Clinical Health Review dated 12/16/22 for R1 revealed a Braden Pressure Ulcer Risk score of 10, indicating high risk for pressure ulcer development. The assessment identified a skin tear to his right hand and MASD (moisture associated skin damage - superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration). The Skin/Wound Condition assessment dated [DATE] for R1 revealed no new skin issues and lacked presence of the issues included in the Clinical Health Review on 12/16/22. The assessment tab lacked further Skin/Wound Condition Assessment completion by the licensed staff until 02/16/23. The facility failed to conduct a weekly skin inspection between 12/21/22 until 02/16/23, eight weeks total without a licensed nurse skin assessment. The Nurse's Note dated 12/26/22 for R1 revealed after his shower was given and staff noted two open areas on his right foot. The wound to the right great toe measured 0.8 centimeters (cm) by 0.5 cm and the right outer foot measured 1.9 cm by 0.9 cm. The areas were cleansed, and a staff applied a dry sterile dressing to each. The TAR and the Licensed Medication Administration Record (MAR) dated December 2022 for R1 lacked treatment orders for the right foot, for five days following the identification of the open areas. The TAR dated January 2023 for R1 revealed an order dated 01/27/23 to cleanse the open area to the right outer foot with normal saline, pat dry, apply calcium alginate (a highly moisture absorbent product/dressing), and cover with bordered gauze daily for the open area. R1 went 26 days in January 2023, for a total of 31 days without treatment to the right outer foot from 12/27/22 until 01/27/23. The TAR dated February 2023 for R1 included the order dated 01/27/23 for the treatment to the right foot and discontinued on 02/14/23. The TAR lacked signature on 02/06/23, 02/07/23, and 02/11/23 to verify the licensed nursing staff completed the physician ordered treatment. On 02/15/23, a new order instructed the staff to cleanse the open area to the right outer foot with normal saline, pat dry, apply Medihoney (gel used to wound to aid in wound healing and removal of necrotic [dead] tissue), and cover with border gauze daily for the open area. The Orders tab included an order dated 02/16/23 for R1 for a weekly skin assessment to be done on Thursday at AM Pass time. The Skin/Wound Condition assessment dated [DATE] for R1 revealed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown tissue]) and/or eschar (dead tissue that may be tan, brown, or black and appear scab like) to the wound bed of a pressure ulcer to the left (rather than right) lateral foot. The assessment included preventive measures of floating heels, heel/elbow protectors, and repositioning. The assessment lacked measurements of the area, notification to the physician, and notification to the resident or responsible party. The Physician Order tab located in the paper chart, revealed R1's primary care physician signed an order, dated 02/14/23 for wound treatment to the right outer foot. The Orders tab located in the electronic medical record (EMR) revealed a physician order for R1 dated 02/22/23 for Wound Care Plus (contracted wound care company) to evaluate and treat. The Wound Care Center Progress Note dated 02/22/23 for R1 revealed the wound to the right foot identified as a Wagner Grade 3 Diabetic Ulcer (an ulcer with bone involvement) and measured 2.5 cm by 2 cm by 0.1 cm with 76-100 percent (%) slough present to the wound bed. This assessment revealed an increase in size in the wound when measured by the facility on 12/26/23. Consultant Wound Care Staff HH performed a skin/subcutaneous tissue level excisional/surgical debridement (removal of dead tissue from the wound). The wound had signs and symptoms of infection, and she obtained a tissue culture for submission to microbiology. The Skin/Wound Condition assessment dated [DATE] revealed an open area to the right foot, treatment ordered by the wound center in place, and notification to the resident or responsible party and physician on 02/28/23. The Progress Note dated 03/01/23 by Consultant Wound Care Staff HH revealed R1's wound measured 3.0 cm by 3 cm by 0.1 cm and continued to have 76-100 % slough present in the wound bed. The note lacked results of the culture obtained from the wound on 02/22/23. The Skin/Wound Condition assessment dated [DATE] for R1 revealed he had a Stage three pressure ulcer to the left (prior wounds documented on the right) foot, which lacked measurements, and noted the wound care team was debriding the wound. The facility failed to perform any further assessments until 03/30/23. The Progress Note dated 03/08/23 by Consultant Wound Care Staff HH for R1 revealed the right outer foot wound measured 2.5 cm by 2.5 cm by 0.1 cm, a decrease in size, and continued to have 76-100 % slough and one to 25 % granulation (healing) tissue. The note included additional orders of clindamycin, 150 mg, oral capsule, one, by mouth, four times a day, for ten days, starting 03/08/23. Review of the resident's progress notes lacked any additional documentation related to the wounds until 03/22/23. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the order for the wound care center dated 02/22/23, on 03/10/23. The Progress Notes located in the EMR for R1 revealed on 03/15/22 at 12:59 PM an order for Lidocaine External Ointment (used to prevent and treat pain), apply to right outer foot wound, topically, one time a day, every Wednesday, for pain, 30 minutes before wound care arrived. Consultant Wound Care Staff HH arrived at 11:30 AM and would not wait 15 minutes for blood sugar check and insulin, and stated they would be back next Wednesday. The facility failed to perform a wound assessment for R1. The Progress Note dated 03/22/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 2.7 cm by 2.3 cm by 0.1 cm, an increase in the length and decrease in the width. The wound continued with 76-100 % slough and one to 25 % granulation. Consultant Wound Care Staff HH performed excisional/surgical debridement with post debridement measurements the same except a depth of 0.2 cm. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the wound care orders on 03/23/23 for 03/08/23. The Progress Note dated 03/29/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 3.0 cm by 2.0 cm by 0.1 cm, an increase in length and decrease in width, however, the wound bed had 26-50 % slough and 26-50 % granulation. The area appeared to have some hyper-granulation and the note lacked that surgical debridement occurred at this visit. Consultant Wound Care Staff HH changed the treatment orders to include Mysalt (Mesalt - used to absorb wound drainage to promote wound healing process) to the wound bed and changed the dressing change schedule to daily. Additionally, she prescribed silver nitrate applicators (used to stop bleeding after debridement or treat hyper-granulation of wounds and has antibacterial properties), topical, 75% - 25% stick, weekly, by Wound Care Plus, starting 03/28/23. The note included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Skin/Wound Condition assessment dated [DATE] for R1 revealed a stage 3 pressure ulcer to the left (rather than right) foot and the wound care team managed the wound. The assessment lacked notification to the physician and resident or responsible party. The EMR lacked further skin assessments for R1 until 04/13/23. The TAR dated March 2023 for R1 lacked changes to the treatment orders made by the wound care center on 03/29/23. The Progress Note dated 04/05/23 by Consultant Wound Care Staff HH revealed R1's right foot wound had the same length and width measurements however, the depth increased from 0.1 cm to 0.5 cm and there were no changes to the amount of slough and granulation. A chemical cautery of hyper-granulation tissue was performed using silver nitrate. The laboratory section of the note indicated bacteria identified in specimen by anaerobe culture (test done without letting oxygen get to the sample), fungus identified in specimen culture, bacteria identified in specimen by aerobe culture (allowing the culture to be exposed to air). There were no changes to the orders for this visit. The Progress Note dated 04/12/23 by Consultant Wound Care Staff HH for R1 revealed no changes to wound measurements from the prior week, no changes to slough or granulation. General notes included they rounded with Administrative Nurse E, hyper-granulation continues to wound, silver nitrate applied, no Mesalt available, spoke with staff about ordering, and staff were educated on orders. Procedures for this visit included chemical cautery (method used to burn or dissolve tissue) of hyper-granulation using silver nitrate. Additional orders included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Nurse's Notes dated 04/12/23 for R1 revealed the wound care center was at the facility and new orders received for the wound to the right foot, the orders were entered and sent to the primary care physician. The TAR dated April 2023 for R1 revealed the facility changed the treatment orders for the right foot to include the Mesalt on 04/12/23 (two weeks after the order) and the silver nitrate. The staff charted O indicating other see progress note on 04/12/23 and 04/13/23 and performed the treatment on 04/14/23. The staff changed the treatment from 09:00 PM to AM Pass on 04/16/23, the TAR was blank on 04/17/23, and the treatment time changed on 04/17/23 to PM Pass. On 04/17/23 for the treatment at the PM Pass time, which included the silver nitrate, had O charted for 04/17/23 and was blank on 04/18/23, 04/21/23, and 04/23/23. The facility failed to perform wound care to R1's foot wound for two days in a row. Additionally, the TAR included an order for silver nitrate, to the right foot wound, topically, daily starting 04/12/23 and discontinued on 04/14/23. The facility failed to enter the order correctly, as on 03/29/23, Consultant Wound Care Staff HH ordered the silver nitrate to be done weekly by Wound Care Plus. The TAR: revealed the staff coded O indicating other see progress note on 04/12/23 and 04/13/23 and documented administered on 04/14/23. An additional order was on the TAR for the silver nitrate daily, start 04/16/23 and discontinued 04/16/23 (Sunday), however, the staff did not sign that they administered the treatment. The order added to the TAR on 04/17/23 continued to include the silver nitrate, the staff documented administration of the treatment on 04/19/23, 04/20/23, 04/22/23, 04/24/23, 04/25/23, and 04/26/23. The order discontinued on 04/26/23 and a new order on the TAR dated 04/27/23 excluded the silver nitrate. The Progress Notes dated 04/13/23 at 06:37 AM for R1 revealed the treatment to the right foot was done by wound nurse today. The Progress Notes dated 04/13/23 at 06:38 AM for R1 revealed the silver nitrate was done by the wound nurse today. The Progress Note dated 04/13/23 at 08:19 PM revealed R1's wound was covered with a dressing, no drainage note, and no pain reported. The Skin/Wound Condition assessment dated [DATE] for R1 continued to reveal he had a stage three pressure ulcer to his left (rather than right) lateral foot, wound care done as ordered by the wound care center. The EMR lacked further skin assessments for R1 until 04/27/23 (14 days later). The Physician Order tab, located in the paper chart, revealed the primary care physician signed a wound care order on 04/13/23 for 04/12/23 to the right foot. The Progress Note dated 04/17/23 at 02:50 PM revealed the supplies for the wound care (which included the silver nitrate and Mesalt) were not available as ordered and the staff cleansed the wound with wound cleanser and applied a sterile dressing. The Progress Note dated 04/19/23 by Consultant Wound Care Staff HH revealed she rounded with Licensed Nurse (LN) H and Mesalt ordered per staff. The wound measured 2.3 cm by 2.2 cm by 0.3 cm, indicating decrease in length, increase in width, decrease in depth. The wound bed had one to 25 % slough and 51-75 % granulation. Post surgical debridement did not change the wound measurements. The Progress Note dated 04/26/23 by Consultant Wound Care Staff HH for R1 revealed rounded with a staff nurse and the Mesalt remained unavailable, staff educated on continued use of alginate until the Mesalt becomes available, discontinued the silver nitrate order, and educated staff on current orders. There were no changes to the slough or granulation, the wound measured 2 cm by 2 cm by 0.2 cm, indicating a decrease in the size of the wound. The Skin/Wound Condition assessment dated [DATE] for R1 continued to reveal a stage three pressure ulcer to the left (rather than right) foot and indicated the staff identified the wound on 02/16/23 (the staff found the wound on 12/26/23). The Assessment tab lacked any further assessments after this date through the time he transferred to the hospital on 06/04/23. The Physician Order tab located in the paper chart revealed the primary care provider signed the right foot wound care order dated 04/26/23 on 04/27/23. The Progress Note dated 05/03/23 by Consultant Wound Care Staff HH for R1 revealed the same measurements as the prior week with no change to slough and granulation. Surgical debridement performed with a post debridement depth of 0.5 cm. The Progress Note dated 05/10/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation persists, and revealed no changes to measurements, slough, or granulation. Chemical cautery of hyper-granulation tissue performed with use of silver nitrate. The records for R1 lacked a visit by Consultant Wound Care Staff HH on 05/17/23. The Skin Condition Note dated 05/18/23 at 07:30 AM revealed the open area continues to right side of foot, Wound Care Plus with treatment. The note lacked an assessment of the wound. The Progress Note dated 05/24/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation resolved, area deteriorated in size, staff reported drainage through dressing, orders updated, attempted to discuss order changes with Administrative Nurse D however, he was unavailable at the time of visit, and staff were educated on orders. The wound measured 2.0 cm by 3.5 cm by 0.2 cm, revealing an increase in the width of the wound, no change to slough or granulation, however, tendon (strong, flexible tissue which connects muscle to bone) exposed. Surgical debridement performed with no change to wound measurements. Consultant Wound Care Staff HH changed the treatment orders to included calcium alginate in the wound base, removed the Mesalt from the treatment orders, and cover with bordered gauze, and change daily. The EMR lacked notification to the physician and the responsible party regarding a decline in the wound, which now had tendon exposed. The Skin Condition Note dated 05/25/23 for R1 revealed a stage three pressure area to right foot and being seen by Wound Care Plus. The facility staff measured the wound at 2.5 cm by 3.5 cm by 0.3 cm, indicating an increase in length and depth. The wound had a small amount of bleeding at the site, foul odor, and moderate drainage. The note indicated staff performed wound care as ordered on 05/24/23 except for covering of the wound with a silicone bordered dressing rather than a gauze dressing, per wound care orders. The note lacked notification to the primary care physician and the resident or responsible party. The TAR dated May 2023 revealed an order dated 05/25/23 to cleanse with wound to the foot with wound cleanser, apply calcium alginate to wound base, cover with silicone bordered foam, three times a week on Tuesday, Thursday, and Saturday. This order did not match the order from the wound care center. The Skin Condition Note dated 05/29/23 at 08:40 AM for R1 revealed wound to the left (rather than right) foot measured 4.0 cm by 2.5 cm, hyper-granulation with moderate amount of drainage and moderate amount of maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) surrounding the skin. The note revealed R1 had a second wound now present measuring 3.0 cm by 3.0 cm with hyper-granulation and moderate amount of drainage with only 0.5 cm of intact skin between the two wounds. Areas cleansed with wound cleanser, skin protectant applied to peri-wound, foam dressing with hole cut out for offloading, covered with a six by six bordered gauze dressing, and wrapped with Kerlix. R1's foot placed in a moon boot with area cut out for offloading. The noted included Consultant Wound Care Staff HH scheduled to be at facility on Wednesday (two days later) and lacked notification of the change of condition to the right foot with an additional wound present, to the physician and the responsible party. The Skin Condition Note dated 05/30/23 for R1 revealed the wound dressing completely saturated with seropurulent (a combination of serous [clear] and purulent [producing or containing pus]) drainage that continued to be foul smelling and peri-wound continued with maceration. The staff called Administrative Nurse D to come visualize/assess the difference in R1's wound from Thursday to yesterday and today. A wound culture was taken of the purulent drainage, cleaned wounds and periwound with wound cleanser, applied hydroconductive (draws fluid away) wound dressing, then covered with six by six bordered gauze dressing. Then a hole was cut in an ABD dressing (abdominal - used to absorb heavily draining wounds) to offload and entire foot wrapped with Kerlix. The staff placed R1's foot in a foam moon boot and changed the wound care orders to daily. The note lacked notification to the responsible party. The Progress Note dated 05/31/23 by Consultant Wound Care Staff HH for R1 revealed a wound measurement to the right foot of 8.0 cm by 3.5 cm by 0.5 cm, with tendon exposed, a large amount of purulent drainage, which had a strong odor. The wound bed had 26-50 % granulation, 26-50 % slough, and 1-25 % epithelialization (a process of wound healing). The note included she rounded with LN H, the area deteriorated, a culture was pending, area was debrided, and spoke with Administrative Nurse D about need for x-ray for possible osteomyelitis. Surgical debridement performed with post debridement measurements the same with the exception of an increase in depth to 1.0 cm. Consultant Wound Care Staff HH changed the treatment orders to the right foot. The Physician Orders tab located in the hard chart revealed the primary care physician signed orders on 06/01/23 for the wound culture on 05/30/23 and the treatment to the right foot for 05/30/23. A fax communication sheet dated 06/02/23 to the primary care physician revealed x-ray results of the right foot were attached, please advise, and a request for pain medication to give prior to dressing changes. The physician responded 06/09/23 patient is admitted for osteomyelitis. The Nurse's Note dated 06/02/23 for R1 revealed a mobile x-ray company was at the facility to x-ray the resident's right foot. The report showed abnormal cortical (outermost layer of the bone) erosion and bony lysis (destruction of area of bone) at the distal aspect of the right fifth metatarsal (bone of the foot) likely representing osteomyelitis. The staff faxed the final report to the primary care physician and awaiting wound culture results from the lab (done three days prior). The note lacked notification to the responsible party. The X-ray Examination dated 06/02/23 for R1 on the right foot revealed likely osteomyelitis and at the bottom of the report included a handwritten note faxed to PCP 06/02/23 noted 06/02/23. The facility failed to contact the physician with the critical x-ray results. The Culture report dated 06/03/23 of the right foot wound for R1 revealed moderate amount of five different organisms, one of which represented possible contamination of the culture. A note on the report revealed the staff faxed the report on 06/03/23 to the primary care physician. The Orders Note dated 06/03/23 for R1 revealed metronidazole (antibiotic) 500 mg, arrived from the pharmacy and initial dose given. The EMR lacked a progress note for the condition of the right foot wound for 06/03/23 or notification to the responsible party regarding the new medication order. The Nurse's Note dated 06/04/23 at 10:30 AM revealed R1's wound to foot had copious (abundant) amounts of very foul-smelling drainage, large, approximately 5.0 cm by 7.0 cm, fluid filled area on the medial lateral surface of the foot. Additionally, there were two small dime to quarter sized black areas medial to the large fluid filled area, moderate amount of slough to the wound bed, with redness around the entire foot. Administrative Nurse D called to room to visualize and assess. Responsible party notified of the deteriorating condition of the wounds, and she asked the staff to send R1 to the hospital. Administrative Nurse D notified the primary care physician and received orders to transfer R1 to the local hospital for evaluation. The Nurse's Note dated 06/04/23 at 04:02 PM for R1 revealed the facility received a call from the hospital that R1 admitted due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection, which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) with a WBC (white blood cells - part of the body's immune system, help fight infection) of 24 thousands per cubic milliliter (K/uL) (the upper level of normal range, varies per lab, typically 11 K/uL) indicating infection. The hospital reported the plan was to surgically debride the wound and start intravenous (IV) antibiotics. The hospital Operative Procedure dated 06/05/23 for R1 revealed R1's condition discussed in detail with the responsible party. Due to the extent of muscle necrosis and soft-tissue loss, recommendation was below the knee amputation. R1 would have a long battle to recover from this amount of damage and would not have a functional foot in the future, therefore, amputation would likely provide him with the fastest recovery and a minimal damage to other body systems in the process. The Hospital Progress Note dated 06/06/23 for R1 revealed the recommendation was for R1 to have a below the knee amputation in an effort to prevent R1 from losing his life, however the responsible party refused that option. R1 would be transferred at that time to more aggressive wound care instead of having the recommended surgery done. On 06/13/23 at 10:15 AM an unidentified family member stated the facility really did not update them on R1's condition, and stated they thought it was healing in the beginning. The family member recalled the facility saying a wound care team was brought in and said it was almost healed in February, but it was not. The facility commented they were not going to put the house shoes on the resident because it rubbed a spot. The family member stated she would try to visit weekly but at one-point visits were infrequent due to medical issues, and when she visited, he would have a sock on. She did not recall seeing any kind of protector to his foot until the Friday before he went out to the hospital. R1 was nonverbal due to his stroke and was pretty dependent on staff to move him around and dress him. The facility called her Sunday before church and wanted to send him to the emergency room . The physician for the nursing home told her he did not know anything about the wound. The family member stated the hospital wanted to amputate his foot. On 06/13/23 at 12:28 PM LN J stated weekly skin assessments were to be done weekly, some were charted under assessments and some as a skin condition progress note. The weekly skin assessments would show up on the TAR for when they were to be done and there was a list at the desk. Documentation would include if no skin issues were present. A wound care nurse came to the facility for any wounds that were stageable. LN H stated the facility should notify the physician and resident or responsible party if there was no progress to the wound, and anytime there was not progress the physician should be notified. LN J stated she worked the night shift, and this was her first day shift. On the night shift R1 would wear boots in bed on that shift and he had a wound on his right foot. LN J stated she had changed the dressing about a month and a half ago and at that time it was around the size of a golf ball, maybe smaller. The staff would reposition him every two to three hours and R1 would also move around on his own too, he would slide his legs off the bed and the staff would move him. LN J believed R1 was on a pressure reducing mattress. On 06/13/23 at 01:09 PM Administrative Nurse D stated a Consultant Wound Staff HH came to the facility from the wound center and did R1's weekly wound assessments. Administrative Nurse D stated Consultant Wound Staff HH would just cut and cut the wound on R1's foot and made it worse. Administrative Nurse D stated Consultant Wound Staff HH would write orders for wound care, they would be on her progress note that would be available usually in 24 hours and he would go the wound center site to get the progress notes. Consultant Wound Staff HH saw R1 from 02/22/23 through 05/21/23, and the facility used those assessments as their weekly wound assessments. Administrative Nurse D stated he was not sure if the facility kept R1's physician informed of the wound status, he ordered the wound care center, and they would take over from there. Administrative Nurse D stated he was not sure if the facility had notified the responsible party with changes in wound care of the status of the wounds. The facility staff were to do a weekly skin assessment, which show up on the TAR when it was to be done, and the licensed nurse were to chart in the skin/wound condition assessment, including if there were not any skin issues. On 06/13/23 at 01:39 PM Administrative Nurse D stated he became concerned with the condition of R1's wound about two weeks before he was sent out, however, he did not report to the primary care physician as Consultant Wound Staff H was midlevel and he was not a wound expert. Administrative Nurse D stated he goes to the wound care website to print the wound centers progress notes and to address the orders. On 06/13/23 at 03:16 PM Administrative Nurse D stated that blanks on the TAR[TRUNCATED]

The facility reported a census of 34 residents with two residents sampled for pressure ulcer (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as result of pressure, or pressure in combination with shear and/or friction) review. Based on observation, record review, and interview, the facility failed to monitor resident's skin thoroughly and perform treatments as ordered for Resident (R)2 who had an unstageable pressure ulcer to the third and fourth toe and failed to ensure R3 had physician ordered dressings in place to pressure areas on his coccyx and two pressure areas on his right buttocks. Findings included: - The Hospice Certification and Plan of Care dated 06/06/23 for R3 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), adult failure to thrive, and severe protein-calorie malnutrition. The Minimum Data Set (MDS) tab revealed R3 entered the facility on 06/05/23. The Care Plan initiated 06/06/23 revealed R3 required the assistance of two staff members for transfers using a mechanical lift, and R3 and staff propelled his wheelchair. R3 bruised easily due to medications and was at risk for skin breakdown. The staff were to encourage him to shift or alter his weight/body position. R3 required a pressure reducing/relieving mattress on his bed and a cushion to the seat of his wheelchair. The staff were to do skin assessments per protocol and keep his skin clean and dry. The care plan lacked any skin conditions present. The Clinical Health Review dated 06/05/23 for R3 had a status of in progress and lacked completion of the integumentary (skin, hair, nails, sweat and oil glands) system. The Orders tab revealed an order dated 06/05/23 for the licensed nurse to perform a skin assessment every evening shift on Thursday and to document the assessment on the Skin Condition Progress Note. The Nurse's Note dated 06/05/21 at 05:41 PM revealed R3 admitted to the facility and had excoriation (injury to the skin)/shearing (the separation of skin layers caused by friction or trauma) to his buttocks. The Skin/Wound Condition assessment dated [DATE] revealed R3 had severe skin shearing and moisture induced dermatitis to bilateral buttocks and coccyx (the area below the sacrum commonly known as the tailbone). The staff cleansed the site with wound cleanser, patted dry, and covered with a Zinc based protective cream. The assessment revealed R3 had moisture associated skin damage (MASD) to the bilateral buttocks, rectal area, and coccyx. R3 had a wheelchair cushion, pressure reducing/relieving mattress, heel/elbow protector, and repositioning in place as preventive measures. The assessment lacked notification of physician and responsible party of skin condition. The Nurse's Note dated 06/08/23 at 03:36 PM revealed hospice staff were in the facility to see R3 and left new orders for his wound to his coccyx. The staff were to continue with repositioning, and noted he had a low air loss mattress. The Orders tab revealed a new order on 06/08/23 for the staff to cleanse the wound to the coccyx with wound cleanser, rinse with warm water, pat dry, apply new Duoderm (wafer type moisture-retentive wound dressing used for partial and full-thickness wounds leaking fluids), every three days, and PRN (as needed), when soiled or missing, one time a day. The Skin Condition Note dated 06/09/23 at 12:06 AM revealed R3 admitted two days ago, had no new skin impairments and continued with barrier cream to coccyx to prevent breakdown. Review of the EMR lacked measurements for the wound to the coccyx and noted the staff were to treat it with a Duoderm dressing. The Electronic Medication Administration Record (e-MAR) note dated 06/13/23 at 09:04 AM revealed R3 did not have a dressing on in the AM, coccyx area cleansed, and Duoderm applied. The Skin Condition Note dated 06/13/23 at 09:31 AM revealed R3 had no new skin impairments and had shallow open areas on both buttocks with current treatments identified as using Duoderm. The assessment lacked measurements of the open areas. The licensed staff answered the section for notifications as na. The TAR dated June 2023 for R3 revealed the staff applied a PRN Duoderm to R3's coccyx wound on 06/13/23 at 09:04 AM. The Nurse's Note dated 06/14/23 at 07:07 PM revealed the staff spoke with hospice about getting R3's wound care supplies to the facility and the hospice nurse changed the order from Duoderm to bordered gauze due to not being able to get any Duoderm in the facility at that time. The EMR lacked wound measurements for R3 to the coccyx and to the right buttock areas. On 06/13/23 at 12:28 PM Licensed Nurse (LN) J stated R3 had a pressure area to his coccyx that he admitted with. On 06/14/23 at 08:02 AM observed R3 sitting up in a wheelchair, propelling himself, then he stopped, and said he was lost and looking for a bed. On 06/14/23 at 08:10 AM Administrative Nurse E, stated she was the charge nurse on duty along with Administrative Nurse D, and R3's dressing change was every three days, but it had only been two days since it was last changed. On 06/14/23 at 08:12 AM Certified Nurse Aide (CNA) M and CNA N transferred R3 from the wheelchair to his bed using the mechanical lift. When the resident turned in bed, his coccyx wound area lacked a dressing. Another open area was observed at that time with peeling skin around the open area. The incontinent brief was dry at that time and R3 had a urinary catheter in place. On 06/14/23 at 08:15 AM CNA N stated R3 did not have a dressing in place to the area when they got him up approximately 30 minutes prior and the nurse was not around to tell. Both CNAs assisted to position R3 on his side before exiting the room. R3 had an air mattress with a sheet covering it, a draw sheet, and a cloth incontinence pad. On 06/14/23 at 08:21 AM CNA N told Administrative Nurse E that R3's wounds lacked a dressing when they got him up this morning and asked if Nurse E could help with that. On 06/14/23 at 08:34 AM Administrative Nurse D and Administrative Nurse E were observed performing wound care. R3 had an open area to the coccyx and two open areas on his right buttocks, the skin surrounding the open areas was red, however blanchable when Administrative Nurse D assessed. Areas measured by Administrative Nurse D, the coccyx are measured 4.0 centimeters (cm) by 1.5 cm, the upper area on right buttocks measured 1.8 cm by 1.1 cm, and the area on the lower right buttocks measured 0.6 cm by 1.0 cm. Administrative Nurse D applied a bordered gauze dressing rather than the physician ordered Duoderm, which covered the three open areas. On 06/14/23 at 08:53 AM Administrative Nurse D stated he observed R3 on admission and the areas to is skin are worse compared to when R3 admitted . At time of admission there were no open areas, only excoriation. On 06/14/23 at 08:58 AM Administrative Nurse E stated hospice would be at the facility and bring the Duoderm, so staff used the gauze dressing to keep it covered until the ordered supplies arrived. On 06/14/2 at 11:00 AM Administrative Staff A stated a licensed nurse could measure wounds and should once a week, the facility usually had a wound nurse but did not at this time. On 06/15/23 at 11:09 AM LN I stated she was in training last week and was taught how to do a skin assessment. LN I stated she was observing the nurse, who was tending to his site of his feeding tube and did not see his coccyx or buttocks area, and had not seen it since he came in. On 06/15/23 at 11:48 AM CNA N stated she worked last week and put barrier cream on R3 when she changed him, his buttocks and coccyx area were red with little open spots and she did not notice any rash areas until this week. CNA N stated the sheet on the mattress should not be folded under, there were clips on the mattress to use to keep it in place and did not feel like the sheet, a draw sheet, and a cloth incontinence pad would add any increased pressure to R3's skin. On 06/15/23 at 01:08 PM Administrative Nurse D stated R3 admitted with excoriation just to the coccyx and top of buttocks and they applied barrier cream every time the staff changed him, which was the standard of practice with incontinent cares. Administrative Nurse D stated he did not know what type of linens should be used on the air mattress, however, a sheet, draw sheet, and incontinence pad seemed like too much for the air mattress. The facility policy Wound Prevention and Management dated December 2018 revealed the Director of Nursing or designee would complete an assessment of all wounds weekly using the Skin/Wound Condition Assessment in the electronic record until resolved. Wounds included all stage one through four, unstageable pressure ulcers, deep tissue injury, diabetic ulcers, arterial/venous ulcers, surgical wounds, and skin tears. The Director of Nursing or designee would review the resident care plan and revise as indicated with each weekly review. The responsible party and physician would be notified of any changes in status. The Licensed Nurse would be responsible for weekly assessment of skin for all residents and document findings in the electronic Skin Condition Note. The Director of Nursing or designee would be responsible to review the Skin Condition progress notes. Resident responsible party and physician would be notified of any new wound or change in wound status. Physician would be notified when wounds show no signs of healing or shows decliner in order to evaluate current treatment and need for change in treatment. Minimal linen should be used between areas prone to skin breakdown and support surfaces (cushions, mattresses). Residents will be observed daily by the CNA for changes in skin condition. The CNA will be responsible to report to the licensed nurse and document in the electronic record any identified changes. The Licensed Nurse will document findings utilizing the Skin Condition Note in the electronic record and notify the Director of Nursing or designee. The facility failed to document changes in R3's skin, failed to notify the LN in a timely manner when a dressing was not in place, failed to conduct a thorough skin assessment for R3, who admitted with excoriation to the coccyx and buttocks, and developed three pressure areas after admission. - The Medical Diagnoses tab for R2 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The Significant Change Minimum Data Set (MDS) dated [DATE] for R2 revealed she had short/long term memory problem with moderately impaired decision making. R2 required extensive assistance of two or more staff for bed mobility and extensive assistance of one staff for dressing. R2 was at risk for developing pressure ulcers and had no pressure areas, other ulcers, or skin problems present. R2 required a pressure reducing device to her chair and bed, did not require a turning/repositioning program, and received application of ointments/medications other than to feet and did not receive any application of dressings to her feet. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 12/20/22 for R2 revealed no concerns with her skin integrity but she was at risk for breakdown due to reduced mobility, incontinence, and fragile aging skin. The Activities of Daily Living [ADL] CAA dated 12/20/22 for R2 revealed she was non wight bearing to her right lower extremity due to two spiral fractures. R2 had advancing dementia and now required extensive assistance with her ADL's. The Quarterly MDS dated [DATE] assessed R2 as having severely impaired decision making and continued to have short/long term memory problem. R2 required extensive assistance of two or more for bed mobility and transfers and she continued to be at risk for pressure ulcers. R2 did not have any pressure ulcers, other ulcers, or wounds present. She continued to require a pressure reducing device for the bed and chair, did not require a turning/repositioning program, received applications of ointments/medications other than to feet but did not require application of dressings to feet. The Care Plan dated 12/20/22 for R2 revealed she had a risk for skin breakdown and had a chronic open area on her inner left great toe, it would resolve and return over and over R2 was to use heel protectors as indicated and wished to use an air mattress on her bed. The nurse would provide preventive care as directed and instructed the staff to see the TAR (Treatment Administration Record) for complete orders. R2 required staff participation, extensive assistance of one or two, to turn and reposition in bed and physical assistance to dress. The care plan lacked presence of any pressure ulcers. The Orders tab included a physician order dated 10/07/22 with instructions for the Licensed Nurse (LN) to perform weekly skin assessments on Thursday on the night shift. The Orders tab included an order dated 01/16/23 for R2 for the staff to apply a padded sponge to the left inner great toe open area to prevent breakdown one time a day. The Clinical Health Review dated 02/05/23 for R2 revealed a Braden Pressure Ulcer Risk score of 13 indicating moderate risk for pressure ulcer development. The Skin Condition Notes dated 05/04/23, 05/11/23, 05/18/23, 05/25/23, and 06/02/23 for R2 revealed no new skin impairments noted. The Clinical Health Review dated 06/04/23 for R2 revealed a Braden score of 15, indicating a mild risk for pressure ulcer development and R2 did not have any skin issues present. The Skin Condition Note dated 06/09/23 at 12:13 AM revealed R2 had no new skin conditions at this time. The Nurse's Note dated 06/09/23 at 02:09 PM (almost 14 hours later) revealed R2 had a pressure ulcer that was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown tissue] and/or eschar (dead tissue that may be tan, brown, or black and appear scab like) to her third and fourth toe of the right foot. The note lacked a thorough assessment of the ulcers including measurements. The note revealed the staff soaked R2's foot in Espom salt for 15 minutes, patted dry the areas with gauze, applied betadine (topical antiseptic used to provide protection against infection), and notified the doctor to request orders for betadine twice daily until healed. The Physician Orders tab located in the paper chart revealed a fax sent to the physician for the treatment to the unstageable pressure ulcers, the physician responded on 06/12/23 okay if not healing see doc. The signed order included to keep a sock off the right foot until healed. The visit notes by Consultant Physician Extender Staff JJ for visit date 06/14/23 revealed R2 had unstageable pressure ulcers present over her third and fourth proximal interphalangeal joints of the right foot with no active drainage, areas with eschar and pink borders. Consultant Physician Extender Staff JJ recommended to continue the current treatment with betadine twice daily until healed. On 06/14/23 at 08:22 AM observed R2 sitting up in a wheelchair in the dining room with blue boots in place to both feet, boots resting on pedals of wheelchair, and no socks in place to her feet. On 06/14/2 at 11:00 AM Administrative Staff A stated a licensed nurse could measure wounds and should once a week, the facility usually had a wound nurse but did not at this time. On 06/15/23 at 10:24 AM LN G stated she completed the treatment for R2 today, she had two small scabs, nothing open, they did not look like pressure ulcers, and applied a padded sponge to the left inner great toe to prevent breakdown, it will get red then a tiny scabbed area. The top of R2's foot is not getting padded, just using sponges between the toes per nursing judgement, some of her toes criss cross. LN G stated she was not sure how the areas developed to the top of her toes because she does not lay on her stomach and during the day she wears boots in bed. LN G stated before the scabs presented, she wore socks and the blue boots. On 06/15/23 at 10:34 AM Administrative Nurse D questioned the cause of the areas to the third and fourth toe of her right foot and stated those issues were just found and he stated he was not aware the previous skin assessment done the same day indicated there were not skin issues. On 06/15/23 at 10:37 AM Certified Nurse Aide (CNA) N stated she did not now how long the areas to her toes had been there, she wore boots when assisted to bed, and they just started looking at her feet last week, they had soaked them. On 06/15/23 at 11:02 AM observed R2's toes of right foot with Administrative Nurse D. R2 was sitting up in a wheelchair in her room with blue boots in place to both feet and did not have socks in place. The top of the third and fourth each had one area that was dark brown appearing like scabbed areas, betadine appeared present to areas as skin was orange around the areas. The third toe had a smaller scab that was approx. 0.2 cm round below it, toes were in a slightly bent position. Administrative Nurse D stated the area on the third toe looked larger than one centimeter, the measurement that was documented on the facility wound log on 06/09/23 and 06/14/23. The left foot had padding in place between the second and third toe and lacked padding between to the left great inner toe (per physician order). The third toe on the left foot appeared red and Administrative Nurse D stated the padding was to protect as she would get sores there. On 06/15/23 at 11:09 AM LN I stated she trained last week, and she remembered doing a skin assessment and looking at R2's feet but could not recall if she had any skin issues, however, stated if R2 had skin issues she would have documented those on a skin assessment. On 06/15/23 at 01:05 PM CNA M applied a clean pair of boots to R2's feet while she was in bed and covered her back up and tucked the covers in under the foot of the mattress. When questioned if the blankets were putting pressure on the resident's toes, CNA M untucked the blankets and loosened them over her feet. The facility policy Wound Prevention and Management dated December 2018 revealed Administrative Nurse D or designee would complete an assessment of all wounds weekly using the Skin/Wound Condition Assessment in the electronic record until resolved. Wounds included all stage one through four, unstageable pressure ulcers, deep tissue injury, diabetic ulcers, arterial/venous ulcers, surgical wounds, and skin tears. Administrative Nurse D or designee would review the resident care plan and revise as indicated with each weekly review. The responsible party and physician would be notified of any changes in status. The Licensed Nurse would be responsible for weekly assessment of skin for all residents and document findings in the electronic Skin Condition Note. Administrative Nurse D or designee would be responsible to review the Skin Condition progress notes. Resident responsible party and physician would be notified of any new wound or change in wound status. Physician would be notified when wounds show no signs of healing or shows decline in order to evaluate current treatment and need for change in treatment. Minimal linen should be used between areas prone to skin breakdown and support surfaces (cushions, mattresses). If identified at risk or with actual alterations in skin integrity of feet, footwear would be addressed for appropriateness. Residents will be observed daily by the CNA for changes in skin condition. The CNA will be responsible to report to the licensed nurse and document in the electronic record any identified changes. The LN will document findings utilizing the Skin Condition Note in the electronic record and notify Administrative Nurse D or designee. The facility failed to conduct a thorough skin assessment for R2 who developed two unstageable pressure ulcers to the third and fourth toe of her right foot and failed to provide physician ordered treatment to prevent skin breakdown to the left great toe of the left foot.

The facility reported a census of 36 residents. Based on interview, record review, and observation, the facility failed to ensure an adequate call light pager system, on three of three resident hallways, that alerted the direct care staff when residents required cares or assistance. This placed the 36 residents of the facility in immediate jeopardy, without the ability to contact the staff, when needed. Findings included: - Observation on 01/22/2020 at approximately 01:00 PM, revealed the call light pager system was not functioning properly. When residents pushed their call lights, the computer screens at the nurses' stations indicated the call light was on, however staff who were supposed to carry pagers to alert them to call lights being turned on by residents, did not have access to pagers. Review of the facility call light log, from 01/01/2020 at 11:17 AM through 01/22/2020 at 05:10 PM, revealed residents initiated a total of 1,113 call lights, with staff not responding to 440 (39.5%) of those call lights within 10 minutes. Staff did not respond at all to 137 (12.3%) of these call lights. On 02/22/2020 at 12:58 PM, 01:00 PM, and 01:08 PM, no staff member stood watch for activated call lights at the nurses' desk on the computer screen. On 01/22/2020 at 12:58 PM, Certified Nurse Aide (CNA) NN stated, she had not had a pager to use at work for a couple of weeks. CNA NN had not told administration she did not have a pager. On 01/22/2020 at 01:00 PM, CNA OO stated, she had not had a pager for about a week. On 01/22/2020 at 2:45 PM, CNA VV stated, she had not had a pager for quite awhile, but had been given one earlier in the shift by Administrative Nurse D. On 01/22/2020 at 02:46 PM, CNA PP stated, he was working his second shift at the facility and had not had a pager since beginning the job at the facility. On 01/22/2020 at 02:52 PM, CNA QQ stated, he had to work at times without a pager. On 01/23/2020 at 03:18 PM, CNA RR stated, staff had pagers on that day, but had gone for a long time without pagers being available. She had not told anybody about not having a pager to use. On 01/22/2020 at 02:42 PM, Licensed Nurse (LN) G stated, CNAs had not told her that they did not have pagers. The CNAs were to pass their pagers on to the oncoming shift when their shift ended. On 01/22/2020 at 02:52 PM, LN [NAME] stated, she was unaware of staff only having one pager. CNAs would check the computer screens at the nurses' desk to see which call lights were activated. On 01/22/2020 at 03:00 PM, Administrative Nurse D stated, she had not known that the staff did not have pagers. Staff had not informed her of the lack of pagers. On 01/22/20 at 01:08 PM, Administrative Staff A stated, the facility received two new pagers on 12/26/19. All staff should have a pager while working the floor. Administrative Staff A was unaware of staff not having pagers. On 01/22/2020 at approximately 01:10 PM, Administrative Nurse D, asked staff about the lack of pagers and discovered none of the staff on the floor had a pager, at that time. Nurse D discovered a pager in the nurses' station and gave it to a CN[NAME] This was the only available pager. On 01/28/2020 at 02:20 PM, Administrative Staff A stated, the last time she was certain there were pagers available to staff on the floor was on 12/26/19, when new pagers came in. The facility received several new pagers on 01/23/2020, so that all staff working the floor then had access to a pager. Staff were to sign the pager in and out with the nurse when they began and ended their shifts. On 01/21/20 at 10:30 AM, R1 stated she has had to sit on the toilet for an hour waiting for staff to respond to her call light. During a resident council meeting with a surveyor, on 01/22/2020 at 10:30 AM, 4 alert and oriented residents who all stated it took a long time for staff to answer call lights. The facility lacked a policy regarding the use of pagers and the call light system. The facility failed to ensure a functioning call light pager system, placing all residents at the facility in immediate jeopardy, without the ability to contact the staff, when needed. Staff would also be unable to get emergency help, if needed. The facility removed the immediate jeopardy when they completed the following on 01/22/2020 at 03:00 PM, when the facility management: 1. Stationed a staff member at the computer monitor screen showing when a call light was initiated. 2. Provided education to all nursing staff on call light monitoring and check-in/check-out system for pagers. Education with all staff was completed by, 01/24/2020 at 05:50 AM. 3. New pagers were ordered on [DATE] and were scheduled to be delivered on 01/23/2020. 4. The Director of Nursing will perform random audits to ensure all floor staff are carrying pagers. 5. Education was provided to the maintenance staff and the administrator on testing the call light pager system. Maintenance will perform weekly function testing on the call light pager system. 6. A QAPI meeting was held with the medical director regarding this event on 01/23/2020 at 09:06 AM. The scope and severity remained at an F.

The facility reported a census of 36 residents with 15 selected for review which included four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure staff provided adequate fall prevention measures for one of the four residents reviewed, Resident (R) 23, who experienced repeated falls and sustained a [MEDICAL CONDITION] which required four sutures. Findings included: - Review of R 23's, Physician order [REDACTED]. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status score (BIMS) of 05, (0-7 indicated severe cognitive impairment) fluctuating inattention, and physical and verbal behaviors one to three days of the 7 day look back period. The resident required extensive assistance of two persons for bed mobility, transfers, ambulation in the room, dressing and toilet use. The resident's balance was unsteady and required staff assistance to stabilize. The resident had no impairment in functional range of motion in the upper or lower extremities. The resident was not on a toileting program and was frequently incontinent of bladder and always continent of bowel. The resident received no antianxiety medications and had no falls since the last assessment. The ADL (Activities of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/15/19, assessed the resident had a decline in ADLs. The resident was on hospice services. This assessment documented the resident had good days and could ambulate with staff and had bad days when it took two staff to transfer the resident. The Falls CAA, dated 06/15/19, assessed the resident at risk for falls related to medication, weakness, incontinence, and history of falls. The Fall Risk Assessment score of 12 indicated moderate risk for falls (0-5 low risk, 6-13 moderate risk, greater than 13 high risk for falls). The Urinary Incontinence and Indwelling Catheter CAA, dated 06/15/19, assessed the resident as frequently incontinent of bladder and required staff assistance with toileting. The Quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 04 (severe cognitive impairment) with inattention. The resident required extensive assistance of 1 person for transfers, toilet use, and ambulation. The resident's balance was unsteady and required staff assistance for stabilization. The resident had no impairment in functional range of motion of the upper or lower extremities. The resident was not on a toileting plan and frequently incontinent of bowel and bladder. The resident had two or more falls since the prior assessment, and one fall with injury (except major). The current care plan instructed staff to follow these updated interventions: 06/16/19 The resident needed to wear appropriate shoes and nonslip footwear. 08/23/19 Prompt the resident to toilet upon rising, before or after meals, at bedtime, and anytime she wandered or paced. 08/30/19 The resident always needed to wear appropriate shoes or nonslip footwear, as the resident often tried to ambulate independently. 08/30/2019 Fall mat beside the resident's bed when occupied. 08/30/2019 The resident's bed should be in the lowest position when occupied. 09/15/2019 Do not use wheelchair foot pedals unless staff assist the resident. 09/15/2019 Ensure the resident's wheelchair has anti-roll back brakes and anti-tip bars. 09/16/2019 Place the resident's locked wheelchair beside her bed when she is in bed so she can use it if she tries to ambulate. 12/17/19 Keep the resident's bathroom light on at night when in bed. The Fall Risk Assessment scores (0-5 low risk, 6-13 moderate risk, greater than 13 high risk) in the electronic medical record documented the following: 08/20/19 score of 11, moderate risk 08/23/19 score of 11, moderate risk 08/30/19 score of 13, moderate risk 09/15/19 score of 16, high risk 10/09/19 score of 19 high risk 12/15/19 score of16, high risk The TENA (an incontinent product brand) Bowel and Bladder Assessment, dated 02/13/19, in the electronic medical record Assessment tab, documented the resident was currently continent of bowel and bladder with severe cognitive impairment. The resident had a three day voiding diary, dated 02/19/19, which indicated continence. The facility Fall Reports documented the following falls: 06/16/19 at 11:18 AM, Staff found the resident seated on her buttocks in front of her bed without pants or socks on and her walker in the bathroom. The resident sustained [REDACTED]. 08/20/19 at 07:04 PM, Staff found the resident seated on her buttocks in front of her bed. The resident told staff she rolled out of bed. The resident had one shoe on and one shoe halfway off. The intervention was to place a fall mat beside her bed. 08/23/19 at 06:00AM, Staff found the resident sitting on her buttocks in the bathroom. The resident lacked shoes or socks and there was urine on the floor. The resident stated she slipped when she stood up. The intervention was to remove the fall mat as the resident transferred herself and staff instructed to implement a scheduled prompted (question the resident at timed intervals if she had a need to toilet) toilet plan. 08/30/19 at 08:10 PM, Staff found the resident sitting on the floor. One non-skid sock on and one sock on her bed. The immediate intervention was to place a fall mat by the resident's bed and low bed when occupied. A Risk Team Note, dated 09/13/19, documented the resident had a low bed, fall mat, nonslip footwear and staff instructed to intercede if the resident ambulated independently. A Fall Investigation Note, for a fall on 09/15/19 at 05:45PM, documented staff found the resident on the floor in front of her wheelchair with the right lower extremity over the wheelchair pedal. The resident did not have shoes on. The intervention included removal of the wheelchair pedals unless staff propelled the resident and application of roll back and anti-tip devices to the wheelchair. No injury noted. A Fall Note, dated 09/17/19, described the fall on 09/16/19 at 11:10 PM. Certified Nurse Aide (CNA) SS and TT found the resident seated on the floor inside her closed door beside her roommate's bedside table. The resident sustained [REDACTED]. The resident's wheelchair and walker were near her bed and the call light within her reach when in bed. The resident did not have shoes or nonskid socks on. Staff contacted the physician, family, and emergency medical service for transport to acute care. A signed, notarized Witness Statement by CNA TT, dated 09/16/19, documented the resident had fall interventions followed except for the nonslip socks. CNA TT was unable to be reached for interview. A Faxed Note to the physician, dated 09/17/19, documented the resident fell in her room and received a laceration to her forehead. Staff sent the resident to the emergency room and the resident received four sutures to the laceration. The resident had some bruising to her forehead. A Physician Visit form, dated 12/19/19, instructed staff to discontinue the [MEDICATION NAME] ([MEDICATION NAME], a medication used to prevent clots with the side effect of bleeding) due to the resident's high risk for bleeding. The physician instructed staff to place the resident on fall risk precautions such as an alarm on her bed and a lock on the wheelchair as the resident was a very high risk for falls . Observation, on 01/21/20 at 3:40 PM, Surveyor A and B were walking down the hall and noticed the resident standing in her room by her recliner with the locked wheelchair adjacent to the recliner. The call light on the recliner was not activated. The resident had boots on both feet. The resident attempted to take several steps unassisted with an unsteady balance. The resident was confused to person place and time. Surveyor A stood beside the resident for support and balance and Surveyor B notified staff of the resident's movements . Interview on 01/22/2020 at 03:33 PM with CNA P revealed the resident needed cueing for meals and toileting. CNA P stated he toilets the resident every two hours and checks on the resident every one to two hours. CNA P stated the resident slept in a low bed with a fall mat beside it. Interview 01/27/2020 at 09:27 AM with Licensed Nurse (LN) G revealed the resident usually does not try to get up out of her wheelchair. LN G stated the staff moved the resident's room closer to the nurses' station so staff could see the resident when in bed. LN G stated the resident did not always notify staff of the need to toilet and was frequently incontinent and staff toilet the resident every two hours. Interview on 01/27/20 at 12:31 PM with CNA N revealed she toileted the resident and the resident was continent in the commode. CNA N stated staff toilet the resident every two hours. CNA N stated the resident should have non-skid socks on when in bed and staff were to keep the bed in a low position with a fall mat beside it. CNA N stated she had not known the resident to remove her socks when in bed. Interview on 01/27/20 at 10:39 AM with CNA O revealed staff toilet the resident at every one and one half to two hour intervals and the resident was continent when toileted. Interview on 01/27/2020 at 11:00 AM with Nurse Consultant II indicated the three day voiding diary, dated 02/19/19, was the only voiding diary. There were no further assessment for continency (Tena Bowel and Bladder Assessment) in the electronic medical record as of 01/27/2020. Interview on 01/27/2020 at 04:15 PM with Administrative Nurse D confirmed staff found the resident on the floor in her room on 09/16/19 and the resident sustained [REDACTED]. Administrative Nurse D did not comment if the resident did or did not keep her non-skid socks on, or if staff established a voiding pattern for the resident. Administrative Nurse D stated the facility did not use alarms. (see Physician Visit form, dated 12/19/19, where the physician recommended to place the resident on fall risk precautions such as an alarm on her bed and a lock on the wheelchair as the resident was a very high risk for falls . ) and the facility did not have an alternative intervention, but did move the resident to a room closer to the nurses' desk for partial visualization of the resident when in bed. Interview on 01/27/20 at 05:25 PM with LN H revealed the resident did not have her nonskid socks on, but did have a history of taking them off. LN H did not recall seeing the socks on the bed or floor, however LN H focused on urgent care for the resident's bleeding laceration. Interview 01/28/20 at 06:06 AM with CNA T revealed the resident usually slept during the night and the resident did not take her non-skid socks off. Interview on 01/28/20 at 09:48 AM with Administrative Staff A confirmed the resident fell during the night of 09/16/19 and sustained a laceration to her head. The previous Administrative Nurse suspended CNA TT, until the investigation was completed and did not know the outcome of the investigation, but did confirm the resident's lack of non-skid socks. Interview on 01/28/20 at 09:54 AM with CNA SS revealed she found the resident on the floor in her room on 09/16/19 at 11:10 PM. The resident got up and shut her door, and she opened the door and found the resident on the floor. CNA SS did not remember if the resident had socks on, but did state the resident did take her socks off or they slid off with movement and staff would find them tangled in her bed sheets. Interview on 01/28/2020 at 10:02 AM with Consulting Physician HH office nurse, confirmed the resident was a high risk for falls and he discontinued the resident's [MEDICATION NAME] due to risk of bleeding and he would expect staff to follow all interventions to prevent falls for this resident. The facility policy for Falls Management, dated 12/2017, instructed staff that the facility strives to minimize the risk for resident falls and to reduce injuries associated with resident falls. Staff instructed the plan of care should address individualized resident focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls. The facility failed to reevaluate the use of the planned nonskid socks to determine resident use efficacy, and failed to determine the need for an individualized toileting plan to provide adequate fall prevention interventions for this cognitively impaired resident with unsteady balance. The resident sustained [REDACTED]. A fall on 09/16/19, in which the resident lacked the planned non-skid socks, resulted in a [MEDICAL CONDITION] that required four sutures.

The facility reported a census of 34 residents and identified one resident that required a tube feeding. Based on observation, interview and record review, the facility to ensure the one resident, Resident (R) 1 remained free from neglect, when facility staff failed to follow written physician's orders [REDACTED]. Facility staff failed to administer the tube feedings at least 15 of the 36 ordered feedings, from 12/06/19 through 12/12/19. R1 lost 5.2 pounds (2.83%) in five days, from 12/07/19 through 12/12/19. Findings included: - The Electronic Medical Record evidenced the facility readmitted R1 on 07/19/19. The primary care physician documented [DIAGNOSES REDACTED]. The facility admitted the resident with hospice care for senile dementia of the brain (a progressive mental disorder characterized by failing memory, confusion.) The admission Minimum Data Set (MDS), dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of nine with moderately impaired cognition. He also required total assistance for all activities of daily living, which included feeding through a feeding tube and a weight of 194 pounds. A quarterly MDS dated [DATE], identified his BIMS score of seven with severely impaired cognition, and with feeding through a feeding tube and a weight of 190 pounds. The cognitive loss/Dementia Care Area Assessment (CAA), dated 07/31/19. revealed the resident had a cognitive decline related to senile degeneration of the brain and [MEDICAL CONDITION] (a [MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought.) The CAA for nutrition, dated 07/31/10, revealed he was NPO (nothing per mouth) which made him at risk for dehydration and nutritional problems. The registered dietician will evaluate his progress routinely and PRN (as needed). The Nutritional Summary included, the resident needed tube feedings to meet total nutritional needs related to dysphagia. The resident's ordered tube feedings would provide 2400 calories, 99 grams of protein, 1200 milliliters of free fluids with the Omolite 1 .5 (a nutritional supplement formula) as ordered. The Care Plan, initiated on 09/19/19 included, R1 was at risk for nutritional decline related to recent [DEVICE] placement and NPO. Instructions for staff included to not offer any food or drink and weigh twice a week. A physician order, dated 09/16/2019, instructed the facility staff to administer per feeding tube, one can [MEDICATION NAME] 1.5 calorie liquid (Nutritional Supplement), give 237 cubic centimeters (cc) via PEG- tube ( Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) every four hours for calories/nutrition, one can of [MEDICATION NAME]. Another physician order, dated 09/16/19, instructed the facility staff to flush the feeding tube with 100 cc water after each feeding, every four hours, for hydration. The Treatment Administration Record (TAR) documented the [MEDICATION NAME] 1.5 calorie, 237 cc (cubic centimeters) liquid administered per bolus feeding, every four hours, around the clock, as ordered, except with blanks (indicating not provided), on 12/11/19 at 08:00 AM, 12:00 PM, and 06:00 PM. Therefore , the facility staff failed to administer the tube feedings on three of the six ordered occasions on 12/11/19. The Facility Self Investigation documented on 12/12/19 at 12:30 PM, Certified Nurse Aide (CNA) [NAME] reported to Administrative Nurse B, she had noticed there were not any tube feeding items, in the resident's room trash cans, when emptied. The CNA then weighed the resident per request of Administrative Nurse B and reported the resident weight, on 12/12/19 at 178.8 pounds. Administrative Nurse B compared the findings to a previous weight of 184 pounds on 12/07/19. The resident experienced a weight loss of 5.2 pounds in five days. On 12/26/19 at 10:15 AM, Administrative Staff A and Administrative Nurse B, explained that on 12/12/19 at 02:43 PM, Staff B counted the tube feeding containers of formula in the medication room, with a total of 35 containers of [MEDICATION NAME] present. On that day, Licensed Nurse (LN) C worked the evening/night shift (06:00 PM to 06:00 AM). LN C documented on the TAR she administered the resident's ordered tube feedings at 08:00 PM, 12:00 AM, and 04:00 AM. However, Staff B's audit of the supplement supply, on 12/13/19 at 08:00 AM, revealed three extra containers of the [MEDICATION NAME] feeding formula left in storage. Therefore, LN C failed to administer three tube feedings of the [MEDICATION NAME] to R1, on her shift. Administrative Staff A and Administrative Nurse B proceeded to evaluate LN C's shifts between 12/06/19 and 12/13/19 and determined per video surveillance that the resident did not receive at least 15 of the ordered [MEDICATION NAME] tube feedings. Administrative staff A and Administrative Nurse staff A further explained that the facility suspended LN C on 12/13/19 and terminated her on 12/16/19. Observation, on 12/26/19 at 10:30 AM revealed, CNA D and F, used a mechanical lift to transfer the resident with upper and lower extremity contractures, from the bed into a high backed wheelchair. The resident's only skin issue involved an area around his big toe nails. The resident wore protective bilateral boots. His skin, lips and mouth were moist. The staff weighed the resident at 190 pounds. The resident mumbled a few words but was difficult to understand. The facility policy, revised on (MONTH) (YEAR), for Abuse, Neglect and Exploitation, included the definition as, .Neglect is failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident received lack of care in one or more areas, such as absence of frequent monitoring of a resident known to be incontinent resulting in the resident being left to lie in urine or feces . The facility failed to ensure R1 remained free from neglect, when facility staff failed to follow written physician's orders [REDACTED]. Facility staff failed to administer the tube feedings at least 15 of the 36 ordered feedings, from 12/06/19 through 12/12/19. R1 lost 5.2 pounds (2.83%) in five days, from 12/07/19 through 12/12/19. This deficiency was cited as past non-compliance as of 12/17/19 at 10:00 AM, when the facility completed the following: 1) On 12/12/19 administrative staff reviewed the resident's hallway recorded video from [MEDICAL CONDITION] to [MEDICAL CONDITION] to determine if staff entered the resident's room to provide the scheduled tube feedings. 2) On 12/12/19 at 2:00 PM, administrative staff conducted a count of the resident's tube feeding formula containers. 3) On 12/13/19 at 8:00 AM, administrative staff conducted another count of the resident's tube feeding formula containers for comparison to identify staff failure to provide the resident with 3 of the overnight scheduled tube feedings 4) On 12/13/19, administrative staff suspended the night shift nurse that documented administration of the tube feedings but failed to provide them to the resident related to the current formula count. 5) On 12/13/19 at 4:15 PM, the administrative staff conducted a telephone QAA meeting with the medical director related to the failure to provide the ordered tube feedings. 6) On 12/17/19 at 10:00 AM, the administrative staff, departments heads, and the medical director conducted an inhouse QAA meeting related to this incident with plans of how to monitor for compliance. Administrative staff implemented daily counts of the tube feeding formula containers and to weigh the resident twice a week. Also if the count or weight changed the administrative staff would review the hallway videos to ensure the tube feedings were provided. The Director of Nursing would also do random checks of nurses providing the feedings in other areas not visible by the video. 7) On 12/17/19 at 4:00 PM, the Director of Nursing completed the last nursing staff training inservice related to tube feedings. In addition any newly hired nurses would received the training/inservice on hire.

The facility reported a census of 39 residents, with 17 residents sampled. Based on observation, record review, and interview, the facility failed to implement effective interventions to prevent the development of pressure ulcers for 1 (#6) of 2 residents sampled. Resident #6 developed 1 stage 2 pressure which worsened to a stage 3 pressure ulcer. Resident #6 developed 1 stage 2 (pressure ulcer is superficial with a pale pink wound bed and present itself as an abrasion or blister or shallow crater) pressure ulcer which worsened to a stage 3 pressure ulcer. Findings included: - Resident #6's signed physician orders, dated 11/1/17, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 6/17/17, identified the resident had a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The resident required extensive staff assistance for bed mobility, transfers, walking in his/her room, locomotion, toilet use, and personal hygiene; and was independent with eating. For mobility, the resident required staff assistance of 1 for a walker and a wheelchair. The resident was frequently incontinent of bladder and always incontinent of bowel. The resident received a scheduled pain medication regimen, and received a non-medication intervention for pain. The resident had frequent with pain. The resident was at risk of developing a pressure ulcer, used a pressure reducing device for the chair and the bed,had a turning and repositioning program, application of nonsurgical dressings other than to feet, and applications of ointments and medications other than to the feet. The CAA (care area assessment) for pressure ulcers, dated 6/28/17, documented the resident was at risk for pressure ulcers related to weakness, weight loss, and loose stools. The resident had preventative duoderm (a [MEDICATION NAME], moisture-retentive wound dressing used for partial and full-thickness wounds) in place. The braden scale (an assessment of the risk for pressure ulcer development), with a score of 13, indicating moderate risk for pressure ulcer. The Braden score dated 8/31/17, with a score of 13, which indicated the resident was at risk for pressure ulcer development. The quarterly MDS, dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The resident required extensive staff assistance of 2 for bed mobility, transfers, walk in room, locomotion, dressing, toilet use, and personal hygiene; and independent with eating. For mobility the resident required a wheelchair. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The resident was at risk for a pressure ulcer, with a Stage 2 pressure ulcer (pressure ulcer is superficial with a pale pink wound bed and present itself as an abrasion or blister or shallow crater), with a start date of 8/14/17, and [MEDICATION NAME] (covers the outside of the body) tissue present. The resident had a pressure reducing device for the chair and bed, turning and repositioning program, pressure ulcer care, and application of nonsurgical dressings other than to feet. The care plan for pressure ulcer's, reviewed on 11/30/17, advised the staff the resident with a pressure ulcer on his/her sacrum, and was prone to further skin breakdown related to impaired mobility with the following interventions with start dates: --Nursing will administer skin treatments to the resident's wounds per current physician's orders [REDACTED]. --Nursing will monitor my skin condition weekly. 12/14/16 --Encourage the resident to drink plenty of fluids and have good nutritional intake. The resident really enjoyed chocolate milkshakes. 7/26/17 --The resident required staff assistance with repositioning every 1-2 hours. The resident would often refuse to change position and enjoyed sitting in his/her wheelchair watching others. 9/14/17 --The resident refused to reposition related to pain from the hardware in his/her hip having come loose. He/she saw by an orthopedic doctor. The doctor ordered an MRI (Magnetic resonance imaging, medical imaging used to view soft tissue), but the resident was unable to complete due to pain. 9/14/17 --Nursing will administer wound treatments per current physician's orders [REDACTED]. --The resident with a winged air mattress to prevent skin breakdown and/or pressure areas. 11/29/17 --Nursing staff and primary care physician (PCP) recommended Pro-stat to aid with wound healing, but he/she declined due to the taste. The resident agreed to drink Chocolate boost. 12/6/17 The skin/wound assessment, dated 8/16/17 at 3:36 PM, revealed a pressure area, Stage 2 pressure ulcer (a superficial with a pale pink wound bed and present itself as an abrasion or blister or shallow crater) to the coccyx (commonly referred to as the tailbone), measured 2.0 cm (centimeters) by 2.0 cm, by 0.1 cm. Date of oldest pressure ulcer identified, 8/14/17. Interventions in place were wheelchair cushion, pressure reducing/relieving mattress, and repositioning. The physician ordered on [DATE], Duoderm to the coccyx, and change every 3 days until healed. The skin/wound assessment, dated 8/25/17, identified the resident with a unstageable (skin covered with slough or eschar (piece of dead tissue that is cast off from the surface of the skin) are by definition ) pressure ulcer to the coccyx which measured 1.0 cm by 1.2 cm by 0.2 cm, and had yellow slough in the wound, and the wound with unstageable pink borders. Preventative measures included: Pressure ulcer care, off loaded with padded gauze. Preventive interventions, included, wheelchair cushion, pressure reducing and/or relieving mattress, and repositioning. The staff notified the physician of the pressure ulcer. The facility identified the resident's Stage 2 pressure ulcer worsened to an unstageable pressure ulcer (localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough or eschar). The skin/wound assessment, dated 8/31/17, identified a Stage 2 pressure ulcer to the coccyx, which measured 1.2 cm by 1.7 cm by 0.2 cm. A treatment of [REDACTED]. Preventive interventions included a wheelchair cushion, float heels, and repositioning. The facility identified the resident's pressure ulcer as not unstageable. The facility lacked a skin/wound assessment for the week of 9/7/17. The skin/wound assessment, dated 9/14/17, identified the unstageable pressure ulcer to the sacrum (coccyx), which measured 2.0 cm by 2.0 cm by 0.8 cm, with yellow slough to the wound bed. Preventive measures included: a wheelchair cushion, pressure reducing/relieving mattress, low air loss or alternating pressure air mattress, float heels, and repositioning. A delivery ticket, dated 9/14/17, revealed a low air-loss alternating pressure mattress ordered and delivered for the resident, 21 days after the facility identified the stage 2 pressure ulcer as an unstageable pressure ulcer. The facility lacked a skin/wound assessment for the week of 9/21/17. The physician ordered, on 9/19/17, Boost (nutritional supplement) bid (twice daily) for a supplement for the resident. The skin/wound assessments, dated 9/26/17 and 9/28/17, identified the pressure ulcer on the sacrum (coccyx)continued to be unstageable, and measured 1.6 cm by 1.0 cm, by 0.5 cm, which decreased in size. Preventive measures included: wheelchair cushion, pressure reducing/relieving mattress, low air loss or alternating pressure air mattress, float heels, and repositioning. The physician ordered on [DATE], clean wound with normal saline and gauze, pack with [MEDICATION NAME], cover with ABD and secure with [MEDICATION NAME] tape. Change on Monday, Wednesday, Friday, and PRN (as needed) until healed. Notify the physician if any signs of redness, drainage, swelling and pain to the wound. The skin/wound assessment, dated 10/4/17, identified the sacrum (coccyx) pressure ulcer was unstageable and measured 1.2 cm by 1.4 cm by 0.3 cm. The wound was healing and becoming smaller with less drainage. The peri wound is pink, the wound bed with 50% slough, 50% granulation tissue (blood vessels that form on the surfaces of a wound during the healing process). The wound required less packing than last week. Preventive measures included a wheelchair cushion, low air loss or alternating pressure air mattress, and repositioning. The skin/wound assessment, dated 10/9/17, identified the sacrum (coccyx) pressure ulcer, measured 1.0 cm by 1 cm 0.1 cm, and is now a Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling.). Full thickness tissue loss, slough present, tunneling to wound at 2 o'clock, measuring 1.8 cm. Preventive measures indicated wheelchair cushion, low air loss or alternating pressure air mattress, repositioning, and pillows to support while in bed. The physician ordered on [DATE], to clean the wound with wound cleanser and gauze, pat dry with [MEDICATION NAME] AG rope, cover with ABD (dressing used for wounds) and secure with tape. Change on Monday, Wednesday, Friday and PRN. Tunneling at 2 o'clock, pack with about 3 cm of AG rope. Notify the physician if any increased signs of redness, drainage, swelling or pain. The physician communication form, dated 10/9/17, documented the wound to the sacrum (coccyx) is a Stage 3 at that time and the dressing was being changed every other day. The wound is getting smaller: Assessed the wound to the bony prominence on sacrum at this time, a full thickness tissue loss, slough present. Tunneling continued to the wound at 2 o'clock, measuring 1.8 cm. The physician responded if the wound was getting smaller, continue the present treatment, and if not better by next week, the resident needed to be seen. The skin/wound assessment, 10/16/17, documented the Stage 3 pressure ulcer to the sacrum (coccyx) measured 0.8 cm by 0.8 cm by 0.1 cm. Full thickness tissue loss, slough present with tunneling to the wound at 2 o'clock and measured 1.0 cm. Preventative measure of repositioning. The physician ordered on [DATE], Boost (high protein, high calorie drink), give one unit bid (2 times a day) for weight (also ordered on [DATE]), and vitamin supplement. The facility electronic MAR's, documented for (MONTH) (YEAR), the resident declined the Boost 1 time a day, however would take the Boost 1 time a day. The skin/wound assessment, dated 10/26/17, identified the Stage 3 pressure ulcer to the sacrum (coccyx) measured 0.8 cm by 0.8 cm by 1.0 cm, and is now a healing Stage 3. Preventative measures included a air mattress, appropriate wheelchair cushion, and repositioning. The skin/wound assessment dated [DATE], documented the resident with a Stage 3 pressure ulcer to the coccyx, which measured 0.1 cm by 0.1 cm by 0.1 cm, a healing Stage 3 pressure ulcer, very close to healed. Unable to observe the wound bed at that time as tissue is very near to closed. Preventive measures included a wheelchair cushion, pressure reducing/relieving mattress, low air loss or alternating pressure air mattress, float heels, and repositioning. The resident is currently walking and standing more frequently, and gaining more strength. The physician ordered on [DATE], to clean the wound with wound cleanser and gauze, pat dry the wound and pack with [MEDICATION NAME] ag rope, cover with a ABD pad, and secure with tape. Change every Monday, Wednesday, Friday and PRN. Noted tunneling at 2 o'clock, and pack with about 3 cm of AG rope one time a day every Monday, Wednesday, Friday. The skin/wound assessment dated [DATE], documented the Stage 3 pressure ulcer to the coccyx, measured 1.0 cm by 1.1 cm by 0.2 cm. Redness around coccyx. Preventive measures included a wheelchair cushion, pressure reducing/relieving mattress, low air loss or alternating pressure air mattress, and repositioning. The resident's wound measurements to the coccyx, increased in size in 2 weeks. The skin/wound assessment dated [DATE], documented the Stage 3 pressure ulcer to the coccyx measured 0.8 cm by 0.5 cm by 0.1 cm. Preventive measures included a wheelchair cushion, pressure reducing/relieving mattress, low air loss or alternating pressure air mattress, and repositioning. The skin/wound assessment dated [DATE], documented the Stage 3 pressure ulcer to the coccyx measured 0.9 cm by 0.4 cm by 0.3 cm, a healing Stage 3. The peri wound measured 4.0 cm by 2.7 cm, and reddened area. Preventive measures included a wheelchair cushion, pressure reducing/relieving mattress, low air loss or alternating pressure air mattress, and repositioning. The resident declined Prostat for supplement. On 12/6/17 at 10:36 AM, licensed nursing staff D and Y completed a dressing change to the resident's pressure ulcer. The resident's Stage 3 pressure ulcer to the coccyx measured 4 cm by 3.2 cm for the total redness (peri wound) and blanched; the open area is 0.8 L (length) by 0.4 W (width) by 0.3 D (depth) cm. Tunneling was present at the 12 o'clock position, measuring 0.4 cm. The resident tolerated the treatment without complaint of pain or discomfort. Staff Y and D repositioned the resident before leaving the room. On 12/7/17 at 8:27 AM, the resident rested quietly in bed (low air loss mattress) with eyes closed, call light in reach, head of bed elevated, and laying on his/her back. At 8:45 AM, 9:00 AM, 9:15 AM, 9:30 AM, 9:45 AM, 10:00 AM, 10:15 AM, no change. At 10:30 AM, direct care staff K went into the resident's room and asked the resident if he/she wanted to get up now and the resident verbalized yes, and staff K proceeded to get the resident up. On 12/11/17 at 9:37 AM, the resident sat in the wheelchair with a Roho cushion (special cushion to sit on for pressure relief) in the seat. The resident propelled his/her wheelchair to the bed with direct care staff L beside him/her. The resident took the right arm off the wheelchair, and he/she used the positioning bar, and transferred himself/herself to the bed. Once on the bed the resident lifted his/her feet and took off his/her shoes, then swung his/her legs onto the mattress. Staff L assisted the resident to lay on his/her left side, with a pillow behind his/her back and between his/her knees. On 12/11/17 at 9:48 AM, licensed nursing staff D entered the resident's room and provided dressing treatment change to the pressure ulcer. Licensed nursing staff D measured the area to the resident's coccyx, 0.9 cm by 0.3 cm, 0.4 cm depth. Tunneling noted at 12 o'clock, and measured 0.2 cm. The center of the wound with the appearance of slough, and per staff D decreased slightly in size. Direct care staff L assisted by holding the resident's buttock/coccyx area during the treatment. On 12/11/17 at 2:00 PM, the resident sat in his/her wheelchair outside the building on the sidewalk. At 2:15 PM, 2:30 PM, 2:45 PM, 3:00 PM, 3:15 PM, 3:30 PM no change in position. At 3: 45 PM, the resident remained in the wheelchair, and sat in the dining room visiting with other residents. At 4:00 PM, 4:15 PM, 4:30 PM, no change. At 4:45 PM (2 hours and 45 minutes), the resident observed propelling himself/herself back from his/her room and reported he/she just toileted. On 12/6/17 at 9:30 AM, the resident stated he/she does not reposition in the bed because there was not enough staff at night, and he/she could not lay on one side for long. On 12/10/17 at 9:53 PM, direct care staff T stated the resident was occasionally incontinent of urine, repositioned every 2 hours in bed, and had a cushion to his/her wheelchair, and did not complain of pain. On 12/11/17 at 9:45 AM, direct care staff L stated he/she supervised the resident when transferring from the bed to the wheelchair. The resident propelled himself/herself to the bathroom where the resident would toilet and then provide any peri care. The resident was occasionally incontinent of urine. The resident with a cushion in his/her wheelchair, and a low air loss mattress. The resident repositioned without difficulty when in bed with staff assistance of 1, sleeps late into the morning, then wakes up around 10:00 AM. The resident usually stays up for the day. The resident informed the staff of when he/she required toileting. On 12/11/17 at 3:15 PM, direct care staff J stated the resident was usually up for the day when he/she comes to work at 2:00 PM, and toileted either before or after supper. The resident was not incontinent of bowel and bladder, and used a Roho cushion. The resident turned and repositioned himself/herself in bed. On 12-6-17 at 10:35 AM, licensed nursing staff D stated the order was to clean with wound cleanser, dry and pack with [MEDICATION NAME] and put on the duoderm. Staff not packed the wound before yesterday. The wound was a Stage III. Staff were previously packing the wound and the wound got to where it was barely open, and then the wound reopened yesterday or the day before. That is why the physician ordered the new treatment. On 12/10/17 at 9:25 PM, licensed nursing staff U stated the resident's treatment for [REDACTED]. The resident repositions himself/herself a bit, could not totally repositioned himself/herself once he/she got into bed. The resident stayed up late and got up late. Once the resident was up he/she was up for the day. The resident used a low air loss mattress, a cushion in his/her wheelchair, and received boost as a supplement. On 12/11/17 at 11:40 AM, licensed nursing staff D stated the resident had an open area before due to diarrhea. At that time the treatment order was for duoderm. He/she did not have the exact date of when the low air loss mattress intervention started, however staff D knew it was after August. The resident does not go to a wound clinic, and he/she was unsure if the facility had a wound nurse. The resident received Boost. It was reported the resident refused it Friday at lunch because he/she was too full. The resident received a fortified diet also. The resident never eats breakfast, however does eat lunch and supper. Staff measured the wound weekly. The wound had some drainage before, but not now. The resident used a Roho cushion to his/her wheelchair. On 12/11/17 at 3:52 PM, licensed nursing staff W stated the pressure ulcer was the same one that the resident had initially. To reposition the resident, staff reminded him/her to reposition. The resident would refuse to turn. Sometimes the resident was incontinent, used a Roho cushion in the chair, received boost breeze supplement (protein shake), and staff W thought the resident also received health shakes. The resident does not complain of pain with the pressure ulcer. On 12/11/17 at 1:40 PM, administrative nursing staff B stated he/she was the wound nurse, and did the measurements. The wound was almost healed, then opened again. It had tunneling a little now. The treatment of [REDACTED]. There is a little white yellow tissue to the wound. Staff B did not know if the wound needed a debridement for the slough, and was not sure what might be underneath the slough. Staff B was unsure when the facility changed the resident's pressure relieving mattress to a low air loss mattress. On 12/12/17 at 10:40 AM, administrative nursing staff B stated according to the algorithm (is a defined set of step-by-step procedures) for wounds a resident with a Stage 2 pressure ulcer required a standard pressure reducing/relieving mattress. When a resident would have a Stage 3 or unstageable pressure ulcer then it was appropriate for the resident to have a low air loss mattress. Staff B stated once a resident had a stage 3 pressure ulcer, then the stage could not be changed, but can add healing to it. The low air loss mattress delivered to the facility on [DATE]. The skin/wound assessments should be completed once a week. Staff B confirmed there was not a skin/wound assessment for the week of 8/31/17- 9/14/17, or 9/14/17-9/26/17. The wound was almost closed and then reopened. The facility policy for wound prevention and management, dated 12/15, documented The facility will develop a system to review all residents at risk on a weekly basis. The DON (director of nursing) or designee will be responsible for monitoring all wounds on a weekly basis using the Skin Condition Assessment. The DON or designee responsible for Referrals should be made to therapy for specialized positioning or special devices or restorative plan according to individualized resident needs. Referrals to wound care specialists as needed. DON or designee will review the resident care plan and revise as indicated. The facility failed to place appropriate interventions in a timely manner to promote healing of pressure ulcers and also failed to develop and implement interventions to prevent the pressure ulcer from declining from a Stage 2 to a unstageable pressure ulcer in a timely manner for this resident.