Every finding on record at Medicalodges Coffeyville on Midland

Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included:- Review of employee files on 04/08/26 at 03:52 PM revealed a lack of performance evaluations or skills check-off for two Certified Nurse Aides (CNAs), CNA OO and CNA PP. CNA OO had a date of hire of 11/10/23, and CNA PP had a date of hire of 07/29/24. On 04/08/26 PM, Administrative Staff A and Administrative Nurse D confirmed the employee evaluation documents provided to the survey team did not contain performance evaluations for CNA OO and CNA PP. Administrative Staff A stated she expected performance evaluations to be performed annually. The facility did not provide a policy related to annual performance evaluations as requested on 04/09/26.

Based on observation and interview, the facility failed to store and prepare food in the kitchen under sanitary conditions which placed the residents of the facility at risk for food borne illnesses. Findings included:- The initial tour of South Kitchen on 04/06/2026 at 08:44 AM, with Dietary Staff DD identified the following concerns:A handwashing sink and backsplash area had grime build-up.One double-door freezer lacked an internal thermometer. The Resource Refrigerator/Freezer Temperature Log signage on the freezer door included the temperature recorded for 04/06/26 as 20 degrees Fahrenheit (F) by Dietary Staff DD. Grime build-up in the alcove of the kitchen along the baseboard.Dry storage with bread unsealed and unlabeled.Refrigerator with two unsealed and unlabeled ham spread sandwiches.Two unlabeled salad dressing bottles.Unlabeled container of pancake batter with congealed white batter on the outside of the container.Unlabeled and unsealed bread/buns bag with two buns missing.Sanitizing strips are unavailable in the south kitchen upon request.Two unlabeled bags of potato chips were on a rack in the dry storage room. An open and undated bag of Cheetos.Plate covers stored on a storage room rack were not inverted, which allows debris to fall in.Two Fryer drop baskets were dirty; the fryer had oil in it with old fried food bits/pieces floating in it, covering the entire surface of the cooking oil in the fryer. Food pieces were also on the sides and outside of the fryer. The dipping spatula was greasy and dirty. The floor had dirt, grease, and food debris. The spike metal can opener had rust and debris on the spike that goes directly into the can and the adjacent mounting bracket.The ice machine had hard water and calcium build-up on the outside of the machine, and there were holes on the outer front-left surface of the ice chest. A cart labeled as clean only was sitting next to the ice machine, with an ice chest on the top shelf for passing ice to residents. The two bottom shelves of the cart were dirty and had food debris, dirty napkins, and unsheathed straws for drinking on the two bottom shelves. Dietary staff DD stated that food should be sealed and labeled with dates to ensure freshness and to prevent foodborne illnesses for residents. Additionally, he stated each refrigerator/freezer unit should have internal thermometers to monitor the temperature of the food to ensure the food remained fresh and did not spoil. Temperatures of those appliances should be checked daily and logged in on the individual appliance temperature log. He confirmed he had recorded the freezer temp on the Freezer temperature lag from another freezer, and not the temperature of that appliance, which was wrong. Additionally, she stated open food should be labelled, dated, and in sealed containers before storing the food item for further use to ensure the food remains fresh and safe for resident consumption. During the tour of the North Kitchen on 04/07/2026 at 10:32 AM, Dietary Staff CC identified the following concerns:Dietary Staff CC noted with a beard and no hair restraint, entering the kitchen food prep area.Deep Fat Fryer outside panel with grease build-up on the outside, measuring approximately two feet by four inches Food steamer with multiple crumbs at the bottom of the steamer door.The area to the left of the sink, next to the puree, has food debris all around the sink and on the counter next to the sink.A wooden board (approximately 18 inches) behind the faucet of the sink was dirty, stained, and wet, with a rusty tool for the garbage disposal lying on the sink. The counter was very dirty with food debris underneath, in front, to the sides, and behind the large, rectangular electric food steamer. On 04/07/2026 at 12:01 PM, Dietary Staff CC entered the North kitchen without a beard guard. He stood over the steam table and checked the temperature of the food, then Dietary Staff BB checked the temperature of the food in the steam table. Dietary Staff BB directed Dietary Staff CC to apply an appropriate beard guard/restraint. On 04/08/2026 at 02:20 PM, Dietary Staff BB stated all dietary staff should wear a beard guard if they have facial hair while in the kitchen. Stored food should be dated, labeled, and sealed, and expired food should be disposed of once it is past the use-by/expiration date. Dietary Staff BB also revealed that the maintenance and cleaning of the fryer is done by kitchen staff. Additionally, she stated staff should ensure a thermometer is maintained in each cooling unit and record the individual temperature in the unit on their separate log. Furthermore, the hospitality aids are responsible for cleaning the dirty cart by the ice maker near the South Kitchen, and the nursing aides are responsible for passing water to the residents. The Facility policy titled Food Storage (Dry, Refrigerated, and Frozen dated 2016 and Hair Restraints, dated 2011. The document included:Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items will be labelled to include the name of the food and the date by which it should be consumed or discarded. Follow and adhere to the guidance regarding proper storage temperatures and maximum length of storage. Place internal hanging thermometers in the warmest part of the refrigerator.Additionally, Staff should wear hair restraints in all food preparation and serving areas to prevent hair from contacting exposed foods.

Based on observation, interview, and record review, the facility failed to provide appropriate activity of daily living (ADL) cares to Resident (R)39 regarding an unshaven face, dried food on face and jagged, dirty fingernails; R6 regarding an unshaven face; R44 regarding an unshaven face and dirty clothing and R51 regarding jagged, dirty fingernails. Findings included:- R6's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R6's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He required substantial to maximal staff assistance for showering and personal hygiene. R6's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 10/24/25, documented the resident required substantial assistance of staff for bathing and personal hygiene. R6's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. He required substantial to maximal staff assistance with bathing and personal hygiene. R6's Care Plan, revised 01/16/26, instructed staff he had a diagnosis of dementia and required substantial assistance in the completion of ADLs. R6's EMR from 03/06/26 through 04/06/26 documented he required substantial/maximal assistance with personal hygiene. On 04/06/26 at 10:11 AM, the resident had long facial whiskers. On 04/07/26 at 08:30 AM, the resident remained with long facial whiskers. On 04/07/26 at 08:46 AM, Certified Nurse Aide (CNA) NN stated residents are to be shaven on their shower days, but the task does not always get done. CNA NN confirmed the resident needed to be shaved. On 04/08/26 at 09:43 AM, CNA O stated the residents did not always get shaven on their shower days. On 04/07/26 at 08:50 AM, Licensed Nurse (LN) G stated residents were to be shaven on shower days, but it did not always happen. On 04/06/26 at 01:30 PM, Administrative Nurse D stated residents were to be shaven on their shower days and as needed (PRN). The facility policy Your Rights and Protections as a Nursing Home Resident, undated, included: Residents have the right to be treated with dignity and respect. - R51's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R51's Annual Minimum Data Set (MDS), dated [DATE], documented the staff cognitive assessment revealed severe cognitive impairment. She was dependent on staff for personal hygiene. R51's Activity of Daily Living Care Area Assessment (CAA), dated 09/25/25, did not trigger. R51's Quarterly MDS, dated [DATE], documented the staff cognitive assessment revealed severe cognitive impairment. She was dependent on staff for personal hygiene. R51's Care Plan, revised 03/20/26, instructed staff to trim the resident's fingernails weekly. On 04/06/26 at 09:47 AM, the resident sat in her recliner in the commons area. Her fingernails were jagged and dirty. On 04/07/26 at 08:35 AM, the resident sat in her recliner in the commons area. Her fingernails were jagged and dirty. On 04/07/26 at 08:46 AM, Certified Nurse Aide (CNA) NN stated residents were to have their fingernails always trimmed, kept smooth, and clean. On 04/08/26 at 09:43 AM, CNA O stated staff were to clean, trim, and file the resident's fingernails at least weekly. On 04/07/26 at 08:50 AM, Licensed Nurse (LN) G stated residents were to have clean, smooth fingernails. On 04/06/26 at 01:30 PM, Administrative Nurse D stated staff were to ensure residents' fingernails were always kept clean and smooth. The facility policy Your Rights and Protections as a Nursing Home Resident, undated, included: Residents have the right to be treated with dignity and respect. - R44's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R44's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He was dependent on staff for his Activities of Daily Living (ADL). R44's ADL Care Area Assessment (CAA), dated 08/21/25, documented the resident required substantial assistance of staff for bathing and personal hygiene. R44's Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. He was dependent on staff for his Activities of Daily Living (ADL). On 04/06/26 at 10:23 AM, the resident sat in his recliner in the commons area. His face was unshaven, and he had dried-on food debris on the front of his t-shirt. On 04/06/26 at 02:07 PM, the resident's face remained unshaven, and he continued to have dried-on food debris on the front of his t-shirt. On 04/07/26 at 08:46 AM, Certified Nurse Aide (CNA) NN stated residents were to be shaven on their shower days, but the task does not always get done. CNA NN confirmed the resident needed to be shaven and was wearing a t-shirt with dried-on food substance on the front. On 04/08/26 at 09:43 AM, CNA O stated the residents did not always get shaven on their shower days, and their clothes would be changed anytime they were dirty. On 04/07/26 at 08:50 AM, Licensed Nurse (LN) G stated residents were to be shaven on shower days, but it did not always happen. The staff should make sure the residents have clean clothes. On 04/06/26 at 01:30 PM, Administrative Nurse D stated residents were to be shaven on their shower days and as needed (PRN), as well as have their clothes changed when dirty. The facility policy Your Rights and Protections as a Nursing Home Resident, undated, included: Residents have the right to be treated with dignity and respect. - R39's Electronic Medical Record (EMR) documented a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R39's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment revealed severe cognitive impairment. He was dependent on staff for personal hygiene. R39's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 12/31/25, documented the resident required staff assistance with completing ADLs. R39's Quarterly MDS, dated [DATE], documented the staff assessment revealed severe cognitive impairment. He was dependent on staff for personal hygiene. R39's Care Plan, revised 03/20/26, instructed staff the resident was dependent for completion of personal hygiene tasks. Staff were to offer to shave the resident when showering. R39's EMR from 03/06/26 through 04/06/26 documented he required substantial/maximal assistance with personal hygiene. On 04/06/26 at 10:07 AM, the resident was unshaven, and he had jagged, dirty fingernails. On 04/07/26 at 02:07 PM, the resident remained unshaven with jagged, dirty fingernails, and he had dried-on food on his face around his mouth. On 04/07/26 at 08:46 AM, Certified Nurse Aide (CNA) NN stated residents are to be shaven on their shower days, but the task does not always get done. CNA NN confirmed the resident needed to be shaven and had jagged, dirty fingernails. On 04/08/26 at 09:43 AM, CNA O stated the residents did not always get shaven on their shower days. Staff were to trim and file residents' fingernails weekly and make sure their faces were clean following meals. On 04/07/26 at 08:50 AM, Licensed Nurse (LN) G stated residents were to be shaven on shower days, but it did not always happen. Staff were to trim and file the resident's fingernails and ensure they had clean faces. On 04/06/26 at 01:30 PM, Administrative Nurse D stated residents were to be shaven on their shower days and as needed (PRN). Staff were also to ensure residents' fingernails were kept clean and smooth, and were to clean residents' faces following meals PRN. The facility policy Your Rights and Protections as a Nursing Home Resident, undated, included: Residents have the right to be treated with dignity and respect.

Based on observation, interview and record review, the facility failed to provide a resident specific activity program for Resident (R)4, R6, R39, R44, and R51. Findings included:- R4's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R4's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. It was very important for her to listen to music she liked, participate in her favorite activities, participate in religious services, and go outside to get fresh air when the weather was good. R4's Activity Care Area Assessment (CAA), dated 12/18/25, did not trigger. R4's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 99, indicating severe cognitive impairment. R4's Care Plan, revised 03/26/26, lacked staff instruction on the residents' preferred activities. R4's Activity Assessment, completed 03/18/26, documented the resident enjoyed attending church services, parties, watching westerns on TV, and listening to country music. Review of the resident's EMR from 03/06/26 through 04/06/26 documented the resident participated in one activity of a music program on 03/31/26. No other activities were documented. Review of the Activity Calendar on the wall of the memory unit documented the following scheduled activity: 04/06/26 at 02:00 PM, Afternoon Hand and Nail Spa On 04/06/26 at 02:07 PM, the resident rested in her bed with the door to her room shut. The scheduled activity was not provided. On 04/06/26 at 04:23 PM, Certified Nurse Aide (CNA) M stated the fingernail activity did not take place that afternoon. Instead, the staff handed out snacks to the residents. CNA M stated she was unsure why the scheduled activity did not take place, as scheduled. On 04/07/26 at 12:30 PM, Activity Staff Z stated the activities on the memory unit are done by the staff who work on the unit. On 04/07/26 at 12:35 PM, CNA N stated Activity Staff Z was responsible for creating the activity schedule for the memory unit and for ensuring the scheduled activity takes place. CNA confirmed there were not many activities on the memory unit, but staff would always make sure the TV was on for their entertainment. On 04/07/26 at 12:37 PM, Licensed Nurse (LN) G stated the memory unit did not have activities. Staff will pass out snacks each morning and each afternoon, and that was somewhat of an activity. On 04/06/26 at 01:30 PM, Administrative Nurse D stated Activity Staff Z was responsible for planning the activities for the memory unit, and the nurses working on the memory unit were responsible for executing the scheduled activities and documenting them in each resident's EMR. The facility policy for Activities and Resident Rights, dated 10/2019, included: The Activity Department staff are to provide an activity program that provides a positive self-esteem, a sense of well-being, and satisfaction with the facility's active lifestyle. - R51's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R51's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. It was very important for the resident to listen to music she liked, to do her favorite activities, to participate in religious activities, and to go outside to get fresh air when the weather was good. R51's Activity Care Area Assessment (CAA), dated 12/18/25, did not trigger. R51's Quarterly MDS, dated [DATE], documented the staff assessment for cognition, which revealed severely impaired cognition. R51's Care Plan, revised 03/20/26, lacked staff instruction on the residents' preferred activities. R51's Activity Assessment, completed03/20/26, documented she enjoyed attending church services, attending parties, having visitors, entertainment, and listening to all types of music. Review of the resident's EMR from 03/06/26 through 04/06/26 documented the resident participated in one activity of a music program on 03/31/26. No other activities were documented. Review of the Activity Calendar on the wall of the memory unit documented the following scheduled activity: 04/06/26 at 02:00 PM, Afternoon Hand and Nail Spa On 04/06/26 at 02:07 PM, the resident rested in her recliner in the commons area with her eyes closed. The scheduled activity was not provided. On 04/06/26 at 04:23 PM, Certified Nurse Aide (CNA) M stated the fingernail activity did not take place that afternoon. Instead, the staff handed out snacks to the residents. CNA M stated she was unsure why the scheduled activity did not take place, as scheduled. On 04/07/26 at 12:30 PM, Activity Staff Z stated the activities on the memory unit are done by the staff who work on the unit. On 04/07/26 at 12:35 PM, CNA N stated Activity Staff Z was responsible for creating the activity schedule for the memory unit and for ensuring the scheduled activity takes place. CNA confirmed there were not many activities on the memory unit, but staff would always make sure the TV was on for their entertainment. On 04/07/26 at 12:37 PM, Licensed Nurse (LN) G stated the memory unit did not have activities. Staff will pass out snacks each morning and each afternoon, and that was somewhat of an activity. On 04/06/26 at 01:30 PM, Administrative Nurse D stated Activity Staff Z was responsible for planning the activities for the memory unit, and the nurses working on the memory unit were responsible for executing the scheduled activities and documenting them in each resident's EMR. The facility policy for Activities and Resident Rights, dated 10/2019, included: The Activity Department staff are to provide an activity program that provides a positive self-esteem, a sense of well-being, and satisfaction with the facility's active lifestyle. - R44's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R44's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. His activity preferences were not assessed. R44's Activity Care Area Assessment (CAA), dated 08/21/25, did not trigger. R44's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 99, indicating severe cognitive impairment. R44's Care Plan, revised 02/05/26, lacked staff instruction on the residents' preferred activities. R44's Activity Assessment, completed 02/05/26, documented he enjoyed watching baseball and Westerns on TV, going for walks, and listening to country music. Review of the resident's EMR from 03/06/26 through 04/06/26 documented the resident participated in one activity of a music program on 03/31/26. No other activities were documented. Review of the Activity Calendar on the wall of the memory unit documented the following scheduled activity: 04/06/26 at 02:00 PM, Afternoon Hand and Nail Spa On 04/06/26 at 02:07 PM, the resident sat in his recliner in the commons area with his eyes closed. No scheduled activity was provided. On 04/06/26 at 04:23 PM, Certified Nurse Aide (CNA) M stated the fingernail activity did not take place that afternoon. Instead, the staff handed out snacks to the residents. CNA M stated she was unsure why the scheduled activity did not take place, as scheduled. On 04/07/26 at 12:30 PM, Activity Staff Z stated the activities on the memory unit are done by the staff who work on the unit. On 04/07/26 at 12:35 PM, CNA N stated Activity Staff Z was responsible for creating the activity schedule for the memory unit and for ensuring the scheduled activity takes place. CNA confirmed there were not many activities on the memory unit, but staff would always make sure the TV was on for their entertainment. On 04/07/26 at 12:37 PM, Licensed Nurse (LN) G stated the memory unit did not have activities. Staff will pass out snacks each morning and each afternoon, and that was somewhat of an activity. On 04/06/26 at 01:30 PM, Administrative Nurse D stated Activity Staff Z was responsible for planning the activities for the memory unit, and the nurses working on the memory unit were responsible for executing the scheduled activities and documenting them in each resident's EMR. The facility policy for Activities and Resident Rights, dated 10/2019, included: The Activity Department staff are to provide an activity program that provides a positive self-esteem, a sense of well-being, and satisfaction with the facility's active lifestyle. - R6's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R6's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. It was very important for him to take care of his personal belongings, listen to music he likes, and be around animals. R6's Activity Care Area Assessment (CAA), dated 12/18/25, did not trigger. R6's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. R6's Care Plan, revised 01/16/26, lacked staff instruction on the residents' preferred activities. R6's Activity Assessment, dated 01/16/25, documented he enjoyed church services, participating in parties, visiting with others, watching westerns on TV, listening to country music, and going outside when the weather was good. Review of the resident's EMR from 03/06/26 through 04/06/26 documented the resident participated in one activity of a music program on 03/31/26. No other activities were documented. Review of the Activity Calendar on the wall of the memory unit documented the following scheduled activity: 04/06/26 at 02:00 PM, Afternoon Hand and Nail Spa 04/06/26 at 02:00 PM, the resident sat at the dining room table. The scheduled activity was not provided. On 04/06/26 at 04:23 PM, Certified Nurse Aide (CNA) M stated the fingernail activity did not take place that afternoon. Instead, the staff handed out snacks to the residents. CNA M stated she was unsure why the scheduled activity did not take place, as scheduled. On 04/07/26 at 12:30 PM, Activity Staff Z stated the activities on the memory unit are done by the staff who work on the unit. On 04/07/26 at 12:35 PM, CNA N stated Activity Staff Z was responsible for creating the activity schedule for the memory unit and for ensuring the scheduled activity takes place. CNA confirmed there were not many activities on the memory unit, but staff would always make sure the TV was on for their entertainment. On 04/07/26 at 12:37 PM, Licensed Nurse (LN) G stated the memory unit did not have activities. Staff will pass out snacks each morning and each afternoon, and that was somewhat of an activity. On 04/06/26 at 01:30 PM, Administrative Nurse D stated Activity Staff Z was responsible for planning the activities for the memory unit, and the nurses working on the memory unit were responsible for executing the scheduled activities and documenting them in each resident's EMR. The facility policy for Activities and Resident Rights, dated 10/2019, included: The Activity Department staff are to provide an activity program that provides a positive self-esteem, a sense of well-being, and satisfaction with the facility's active lifestyle. - R39's Electronic Medical Record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R39's Annual Minimum Data Set (MDS), 12/31/25, documented the staff assessment for cognition revealed severe cognitive impairment. It was very important for him to take part in his favorite activities. 39's Activity Care Area Assessment (CAA), dated 12/31/25, did not trigger. R39's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. R39's Care Plan, revised 03/29/26, lacked staff instructions regarding the residents' preferred activities. Review of the resident's EMR from 03/06/26 through 04/06/26 documented the resident participated in one activity of a music program on 03/31/26. No other activities were documented. Review of the Activity Calendar on the wall of the memory unit documented the following scheduled activity: 04/06/26 at 02:00 PM, Afternoon Hand and Nail Spa On 04/06/26 at 02:07 PM, the resident wandered about the unit. The scheduled activity was not provided. On 04/06/26 at 04:23 PM, Certified Nurse Aide (CNA) M stated the fingernail activity did not take place that afternoon. Instead, the staff handed out snacks to the residents. CNA M stated she was unsure why the scheduled activity did not take place, as scheduled. On 04/07/26 at 12:30 PM, Activity Staff Z stated the activities on the memory unit are done by the staff who work on the unit. On 04/07/26 at 12:35 PM, CNA N stated Activity Staff Z was responsible for creating the activity schedule for the memory unit and for ensuring the scheduled activity takes place. CNA confirmed there were not many activities on the memory unit, but staff would always make sure the TV was on for their entertainment. On 04/07/26 at 12:37 PM, Licensed Nurse (LN) G stated the memory unit did not have activities. Staff will pass out snacks each morning and each afternoon, and that was somewhat of an activity. On 04/06/26 at 01:30 PM, Administrative Nurse D stated Activity Staff Z was responsible for planning the activities for the memory unit, and the nurses working on the memory unit were responsible for executing the scheduled activities and documenting them in each resident's EMR. The facility policy for Activities and Resident Rights, dated 10/2019, included: The Activity Department staff are to provide an activity program that provides a positive self-esteem, a sense of well-being, and satisfaction with the facility's active lifestyle.

Based on observation, interview and record review, the facility failed to provide privacy for Resident (R)4, while she was in her room in bed. Findings included:- R4's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R4's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She was dependent on staff for all Activities of Daily Living (ADL). R4's ADL Care Area Assessment (CAA), dated 12/18/25, did not trigger. R4's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She was dependent on staff for all ADLs. R4's Care Plan, revised 03/26/26, instructed staff she was dependent on staff for all ADLs. On 04/06/26 at 10:03 AM, the resident rested in her bed, covered with blankets, and the door to her room was open to the hallway. R39 wandered into R4's room and began to move around the blankets covering her on the bed. License Nurse (LN) H assisted R39 out of R4's room when she received a report of R39 being in R4's room. On 04/06/26 at 04:23 PM, Certified Nurse Aide (CNA) M stated the residents were allowed to ambulate wherever they liked on the memory unit. On 04/06/26 at 10:03 AM, LN H stated on the memory care unit residents were permitted to go wherever they wanted. There were no boundaries for wandering on the unit. On 04/06/26 at 01:30 PM, Administrative Nurse D stated the idea of the memory care unit was to allow residents to wander wherever they wanted even if it meant going into and out of other resident rooms. The facility policy for Activities and Resident Rights, dated 10/2019, included: Resident dignity and privacy are to be respected.

Based on interview and record review, the facility failed to provide Resident (R) 3, and R7 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. Findings included: - R3's Electronic Health Record (EHR) documented diagnoses that included dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) R3's Discharge – Return Anticipated Minimum Data Set (MDS) dated [DATE] documented R1 had an unplanned discharge from the facility to a hospital on [DATE]. The EHR Progress Notes documented: On 01/11/26 at 05:42 PM, a Nurse's Note documented R3 was admitted to the hospital with a right hip fracture (broken bone) On 01/12/26 at 01:17 PM, a Social Service Progress Note documented the care plan meeting scheduled for the next day was cancelled due to the resident being in the hospital. R3's EHR Misc tab lacked evidence that the facility provided a written bed-hold documentation to R3 or R3's representative. On 04/07/26 at 04:20 PM, Licensed Nurse (LN) J stated that when a resident is transferred out from the facility, nursing staff has no part in giving the resident or the resident's representative a bed hold and that process is handled by someone in social services, but she wasn't sure who. On 04/07/26 at 04:30 PM, Social Services Y, Administrative Nurse D, and Administrative Staff A stated Administrative Staff C issued the bed-hold notices to residents or residents' representatives upon transfers or discharges. On 04/07/26 at 04:40 PM, Administrative Staff C stated she was notified via the dashboard in the EHR when a resident was transferred or discharged from the facility. Administrative Staff C stated she would fill out a bed-hold and then would give it to the resident or the resident's representative when they returned to the facility and obtained a signature then. If the resident didn't return to the facility after a couple of days, Administrative Staff C said she would mail the bed-hold to the resident's representatives with a self-addressed-stamped-envelope (SASE) for the representative to return the signed form to the facility. The facility's Notice of Bed Hold Policy and Returns policy, dated 12/14/17, documented the facility would provide a written notice to residents, residents' family members, or residents' representatives at the time of admission and again at the time of transfer to a hospital or therapeutic leave. The policy documented the charge nurse would send a blank Notice of Bed Holdy Policy and Returns with the resident at the time of discharge, and within 24 hours, administration staff would attempt to contact the resident or a responsible party to complete the form. The policy also documented the facility staff were expected to document multiple attempts to reach the resident or their representative and document the attempts on the form. R7's Electronic Medical Record (EMR) revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion), Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). R7's Nurse's Note dated 12/06/25 at 12:03 PM documented R7 had a temperature and was short of breath when he moved. R7 had chest pain when breathing. The on-call doctor gave the order to send him to the hospital. R7's Nurse's Note dated 12/06/25 at 06:08 PM documented R7 was admitted to the hospital with pneumonia (an infection in the lungs). R7's Nurse's Note dated 02/12/26 at 11:44 AM documented R7 became pale and weak and was diaphoretic (sweating heavily). R7 was not responsive for about 10 seconds. He was drooling. Vital signs were taken, and he had low blood pressure. The doctor gave the order to transfer R7 to the hospital. R7's Nurse's Note dated 02/12/26 at 05:00 PM documented R7 was admitted to the hospital for Pneumonia. R7's EMR lacked documentation of a written notification to the residents and/or the representative, which explained the reason for the transfer to the hospital. On 04/07/26 at 03:02 PM, Social Services X stated that the business office manager is the person who got the Bed Hold signed. Social Services X said she was unaware of the regulation to notify the residents in writing of the reason for the transfer. They did notify the ombudsman of transfers. On 04/08/26 at 02:15 PM, Administrative Nurse D and Administrative Staff A stated the bed hold should be completed and signed when a person was transferred out of the facility. Administrative Staff A said the facility does not notify the residents' representative in writing of a discharge or transfer. On 04/08/25 at 10:55 AM, Administrative Nurse D stated the facility did not have a discharge policy.

Based on observation, interviews and record reviews, the facility failed to ensure adequate catheter care within the standards of practice was provided for Resident (R) 59 when staff failed to secure the catheter tubing to R59's thigh to prevent pulling and/or dislodgement and also failed to empty the catheter bag before getting too full, to prevent catheter-related urinary tract infections (UTI). Findings included:- R59's Electronic Medical Record (EMR) from the Diagnosis tab documented Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease-stage three (CKD), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), atrial fibrillation (rapid, irregular heartbeat), obstructive uropathy, neurogenic bladder and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated minimally impaired cognition. The MDS documented R59 had an indwelling catheter during the observation period. The Functional Abilities Care Area Assessment (CAA) dated 03/18/26 documented staff assistance was required with activities of daily living (ADLs) due to R59's physical limitations and decreased safety awareness. The Urinary Incontinence CAA, dated 03/18/26, documented the need for a urinary catheter due to obstructive uropathy and to help prevent skin breakdown and risk of UTI. R59's Care Plan, dated 10/24/24, directed staff to encourage R59 to increase his fluid intake to reduce constipation. On 02/28/25, the plan documented the use of a urinary catheter, size 16Fr, to be used for acute urinary retention with obstruction of normal flow (of urine), with use of a Stat-lock (securement device for prevention of catheter removal) to hold the catheter in place and reduce tugging. The plan of care documented the staff would monitor the catheter output of urine every shift. During an observation on 04/06/26 at 10:00 AM, R59 began self-propelling his wheelchair slowly up the hallway. A few minutes later, a steady stream of what appeared to be urine was noted on the floor, where R59 was sitting, all the way up the hallway. Less than two minutes later, a male housekeeper arrived with a wet mop and began cleaning up the stream of urine, stating, I know who this belongs to. An observation conducted on 04/08/2026 at 10:37 AM with Certified Nursing Assistant (CNA) II and CNA Q revealed catheter care, which included emptying R59's catheter bag and noting the amount and color of the urine before discarding it. A CNA cleaned around the insertion site of the catheter and determined there were no catheter defects or skin issues that needed to be reported to the nurse. R59 did not have Stat-lock on his thigh to anchor his catheter tubing. Upon interviewing CNA II after the completion of this task, she stated they are supposed to empty the catheter at the end of our shift. When asked if a Stat-lock was supposed to be used, CNA II stated no, because he just takes them off. R59 was observed sitting patiently in the dining room on 04/07/26 at 03:42 PM in his wheelchair, with his feet resting on his foot pedals. A full, round catheter bag was noted, hanging under R59's wheelchair. A nursing staff member behind the desk was notified. During an interview on 04/08/26 at 11:00 AM with Licensed Nurse (LN) I stated CNA's typically empty the catheter bags at the end of their shift. She also stated all catheterized residents should have a stat lock on their leg, and there were four cases of them in stock. An interview on 04/08/26 with Administrative Nurse D at 11:22 AM, she revealed her expectations to be as the care plan dictates, which are to have the stat lock on the resident unless he cannot tolerate it, which should be documented in the Care Plan. The facility did not provide a policy related to catheter care. On 04/09/26 at 12:21 PM, Administrative Nurse D stated the facility did not have a policy for catheter care and followed the standards of practice.

Based on observation, interview and record review, the facility failed to offer non-pharmaceutical interventions for pain for one Resident (R)3, who had acute pain. Findings included:- R3's Electronic Medical Record (EMR) documented a diagnosis of a wedge compression fracture (a type of spinal fracture where the front of a vertebra collapses while the back remains intact) of the second lumbar vertebra. R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She received as-needed (PRN) pain medications and non-medication pain interventions during the assessment period. Pain was not assessed. She received opioid (narcotic pain medication) medication during the seven-day look-back period. The Pain Care Area Assessment (CAA), dated 01/19/26, did not trigger. The re-admission MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. The resident did not receive scheduled or PRN pain medications and did not utilize non-medication pain interventions during the look-back period. The resident reported occasional pain, with the worst pain in the past five days, being eight on the one to ten pain scale (a tool for patients to rate pain intensity, where 0 is no pain and 10 is the worst imaginable pain). She received opioid (narcotic pain medication) medication during the seven-day look-back period. R3's Care Plan, revised 03/31/26, instructed staff to utilize alternative methods of pain management such as massage, aroma therapy, warm packs, and distraction. R3's EMR included the following physician's orders: Ibuprofen (an over-the-counter, anti-inflammatory analgesic), 400 milligrams (mg), by mouth (po), every (Q) six hours, PRN, for a diagnosis of pain, ordered 03/17/26 Hydrocodone-Acetaminophen (an opioid medication), 7.5-325 mg, po, Q six hours, PRN, for a diagnosis of pain, ordered 03/17/26 R3's Medication Administration Record (MAR), for 04/01/26 through 04/07/26, documented the resident's pain to range from one to seven on the one to ten pain scale. Staff administered the physician's ordered pain medication with effective results documented. On 04/07/26 at 08:33 AM, the resident sat at the dining room table. The resident was tearful with clenched fists and facial grimacing. On 04/07/26 at 10:31 AM, Certified Nurse Aide (CNA) P and CNA NN transferred the resident from her wheelchair to the recliner using extensive assistance. The resident had facial grimacing and audible indicators of pain during the transfer. On 04/07/26 at 10:31 AM, CNA P stated the resident often complained of pain following a fall she had. CNA P stated he was not aware of any non-pharmacologic pain interventions being utilized for the resident. On 04/07/26 at 08:46 AM, CNA NN stated the resident had a lot of pain in her hips. CNA NN stated the nurse would give the resident pain medication, but CNA was unaware of any non-pharmacologic pain interventions for the resident. On 04/08/26 at 10:59 AM, Administrative Nurse D stated that, along with the scheduled and PRN pain medications, it was the expectation for staff to attempt non-pharmacologic pain interventions. Administrative Nurse D stated the facility did not have an actual policy for pain management, but used the standard of care.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to the Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing care. The facility also failed to store respiratory treatment devices in a sanitary manner. Findings included:- Observation on 04/06/26 10:36 AM, R20 oxygen tubing was wound around the portable oxygen tank. R20's nebulizer mouthpiece was attached to the medication bowl with a small amount of fluid in the medication bowl and attached to the nebulizer machine. On 04/08/26 at 10:35 AM, R1's nebulizer machine was attached to the face mask with the medication bowl attached with fluid in it. It laid on her chair beside her bed with the tubing wound up with a blacket, and her back brace laid on top of the nebulizer. An observation of catheter care was conducted on 04/08/2026 at 10:37 AM with Certified Nursing Assistant (CNA) II and CNA Q assisting R59 with toileting and catheter care. Both staff members entered R59's room, donned gloves, and wheeled R59 into the bathroom. This resident had a bowel movement, and CNA II assisted with cleaning the resident and changing his clothes into a clean pair of jeans and a shirt. The catheter bag was emptied into a plastic urinal and placed on the back of the toilet, with 600 milliliters of amber colored urine. After the catheter was emptied and the resident finished and dressed, he was assisted back into his wheelchair. The urine was emptied into the toilet, both CNAs removed their gloves, one CNA washed her hands, and the other CNA exited the room and escorted R59 down to the dining room. The CNAs were interviewed at 10:55 AM, and both stated they forgot to put on the Enhanced Barrier Precautions (EBP) gowns that were on the resident's door. CNA Q stated that washing was supposed to be done before and after handling a patient or a catheter. On 04/08/26 at 12:50 PM, Licensed Nurse (LN) K stated when she gave a resident a breathing treatment, she checked the order and got the breathing treatment out of the cart. She put the medication into the medication cup that was attached to the mouthpiece. LN K stated she rinsed out the cup if it was dirty (had drops of moisture in it). LN K stated she rinsed out the mask and dried it with a paper towel, then put it back together and placed it on the nebulizer when she finished breathing treatment. On 04/08/26 at 01:00 PM, LN K stated when a breathing treatment is complete, she turned it off and rinsed the mouthpiece and medication cup out. LN K stated they allowed it to air dry, then placed it in a plastic bag to prevent bacteria that could cause infection. On 04/08/26 at 01:27 PM, Administrative Nurse E stated the nurse was to clean out the mouthpiece and medication cup, allow it to dry, and place it in a bag for infection control. She expected staff to use proper EBP when caring for a resident with a wound or with a catheter. The facility's policy Infection Control Surveillance documented all staff are to be educated on infection control prevention practices as it relates to their job.

The facility reported a census of 65 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included:During the initial kitchen tour on 04/06/26 at 08:44 AM, with Dietary Staff BB, the following concerns were identified at the facility dumpster:Two used gloves lay on the ground beside the base of the dumpster.One broken metal and upholstered armchairFour cloth recliners with large black stain/substance on the fabric surface, which included one red recliner with the back pulled/broken off. A broken chest of drawers with broken shelving and top. On 04/06/26 at 08:54 AM, Dietary Staff BB confirmed the above findings and reported she was not aware of the trash and garbage accumulation around the dumpster and did not know what arrangements were made to pick up the trash and garbage. The maintenance department handled the disposal of trash, garbage, and refuse. On 04/08/26 at 02:20 PM, Maintenance staff U stated maintenance the staff were responsible for the maintenance and cleaning of the dumpster area. He put the chairs out by the dumpster to be disposed of in January 2026. Maintenance Staff U reported that the person who picked up and disposed of the garbage and trash around the dumpster just stopped doing it, and he had not found a replacement for that duty. He agreed that the dumpster area with debris and trash posed potential for rodent infestation, as well as the gloves posed a risk for cross-contamination and the spread of infection to the residents and staff of the facility. The undated facility policy Housekeeping, Laundry and Maintenance- Basic Services Provided documentation included storage areas must be kept neat and free of extraneous material such as refuse and discarded furniture.

The facility reported a census of 72 residents with four residents sampled and one resident reviewed for neglect. Based on observation, interview, and record review, the facility failed to prevent the neglect of cognitively impaired Resident (R)2, who displayed a recent increase in behaviors. On 08/26/24 at 10:12 PM, Licensed Nurse (LN) G completed a skin assessment on R2 and documented her skin as clean, dry, intact, and without new skin conditions. On 08/27/24 at 10:45 AM, staff observed blood on a tissue after wiping R2 and failed to notify the LN in charge of R2's care. On 08/27/24 at 11:15 AM, Social Service Staff X and Administrative Staff B took R2 out of town to a senior behavioral unit. Upon arrival to the emergency room , R2 expressed the need to use the bathroom and when assisted by facility staff, R2's brief had two dime size spots of blood in it, and she had blood at the front of her peri-area. On 08/27/24 at 02:45 PM, hospital staff began a skin assessment on R2 after she arrived at the behavioral intake area from the emergency room . The assessment revealed R2 had multiple areas of bruising, bleeding, and genital trauma (possible indicators of sexual assault). On 08/27/24 at 08:30 PM, Consultant Staff GG performed a sexual assault examination, which revealed R2 had possible sexual and genital trauma, was having a bloody discharge, had evidence of abrasions to her major and minor labia, evidence of possible penetration, and vaginal edema. Prior to 08/27/24, R2 had increased behaviors, however, the multiple areas of bruising, bleeding, and genital trauma (possible indicators of sexual assault) for R2 were not discovered until they were observed by the hospital staff on 08/27/24, one day after the LN documented no skin issues. This deficient practice placed R2 in immediate jeopardy for neglect and a negative psychosocial impact to R2's sense of safety, protection, health, and well-being. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cognitive communication deficit, muscle weakness, major depressive disorder (major mood disorder which causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set, dated dated dated [DATE], assessed R2 with a Brief Interview for Mental Status score of five, indicating severe cognitive impairment. She did not reject cares and had behaviors symptoms directed towards others that did not interfere with care or put her at risk for significant illness or injury for one to three days of the assessment period. R2 used a walker for mobility and required partial/moderate staff assistance for walking up to 50 feet, transfers, lower body dressing/undressing, and setup assistance for upper body dressing/undressing. R2 was frequently incontinent of urine, occasionally incontinent of bowel, and she did not have any skin issues. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/03/24, revealed R2 had recall deficits with a contributing factor of dementia and risk factors, which included self-care deficits, falls, injuries, incontinence, decreased socialization, and skin breakdown. The Functional Abilities CAA dated 07/03/24, revealed R2 required assistance with her activities of daily living (ADLs) with contributing factors of generalized weakness and decreased safety awareness with risk factors of further ADL decline, falls, incontinence, and skin breakdown. The Urinary Incontinence and Indwelling Catheter CAA dated 07/03/24, revealed R2 had incontinent episodes and required assistance with toileting. The Behavioral Symptoms CAA dated 07/03/24, revealed R2 had dementia and wandered with risk factors of injuring self/others, decreased socialization, and anxiety. The Pressure Ulcer/Injury CAA dated 07/03/24, revealed a LN was to assess R2's skin each week and put in proper interventions to prevent skin breakdown., Caregivers were to assess R2's skin with each bath and when dressing her. The staff were to notify the physician of any abnormal findings. The Care Plan dated 07/03/24, revealed R2 required staff assistance with ADLs related to physical limitations. R2 required psychotropic (alters mood or thought) medications, which included an antianxiety (class of medications that calm and relax people) for restlessness, and an antidepressant (class of medications used to treat mood disorders) for self-isolation. On 08/09/24, the facility added R2 often made statements about the building burning down or some other emergency occurring. On 08/23/24, the facility added R2 required an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) for behaviors of continuous screaming or yelling, negative delusions, and extreme fear. The Licensed Medication Administration Record (MAR) for August 2024, revealed R2's physician order for as needed (PRN) Ativan (antianxiety medication) changed from every 24 hours to every four hours as needed for anxiety on 08/11/24. R2 continued to have an order for scheduled Ativan twice daily. The Progress Notes dated 08/12/24 at 01:40 AM, by LN I revealed R2 attempted to rise from a sitting position in a recliner with the footrest extended, leaned forward, and fell to the floor. The fall note lacked documentation noting any injuries that occurred from the fall. The Skin Condition Note dated 08/19/24 at 02:42 PM, by LN L revealed R2's skin was clean, dry, intact, and the resident had no new skin issues. The Progress Notes dated 08/20/24, revealed Consultant Staff II saw R2 in the facility due to frequent behaviors and anxiety related to her dementia. Consultant Staff II ordered Aricept (medication used for treatment of dementia), 10 milligrams (mg), daily. The Progress Notes dated 08/23/24 at 02:45 PM, revealed R2 received a new physician order for Seroquel (antipsychotic medication), 25 mg, three times a day. The Progress Notes dated 08/26/24 at 11:22 AM, revealed R2 had a referral for geriatric-psych to evaluate and treat. The Skin Condition Note dated 08/26/24 at 10:12 PM, by LN G revealed R2's skin was clean, dry, intact, and she had no new skin conditions. The Task tab for skin observations every shift, dated 08/06/24 through 08/27/24, revealed documentation of none of the above observed or not applicable for any scratched, red areas, discoloration, skin tears, or open areas. The Progress Notes dated 08/27/24 at 05:09 PM, by Social Service Staff X revealed at 11:00 AM, she left with R2 and Administrative Staff B to a behavior unit. Review of the progress notes for 08/27/24 lacked any documentation of R2 having any redness, bruising, abrasions, or bleeding. The behavioral health Admission Note which lacked a date, but included a time of 02:45 PM, revealed R2 was brought to the unit from the emergency room and a patient assessment was started. R2 had swelling with a knot on her right cheek, bruising to her left forearm and left hand, bruising and redness under her right breast, redness between both inner thigh creases, purple/black/blue bruising with open cut on both labia with blood present and a foul odor, redness near anus and on coccyx area, bruising on both knees, and right and left great toe had bruising. Additionally, R2 had blood present inside of her vaginal opening, which was slightly spilling out and bright red blood present in her brief. The vaginal blood was discovered when Consultant Staff JJ performed a straight catheter to obtain a urine sample, Consultant Staff KK and Consultant Staff LL were also present at that time. The staff notified Consultant Staff GG of findings who approved to continue with the straight catheter procedure. The Sexual Assault Physician Exam dated 08/27/24 at 08:30 PM, for R2 revealed the reason for the exam was suspected sexual encounter of a nursing home patient. R2 had possible sexual and genital trauma upon evaluation of a straight catheter procedure for urinalysis per protocol in the senior behavioral unit. R2 had bloody discharge and evidence of abrasions of her labia, both major and minor, and evidence of possible penetration. Two vaginal swabs were obtained and due to R2 having so much atrophy and edema from injury a vaginal exam was not able to be performed. Consultant Staff GG completed the sexual assault kit to the best of her ability and gave it to one of the three chaperones present during the examination to transport to county law enforcement with jurisdiction of the facility, since suspected the event occurred at the facility prior to arrival and a male nurse cared for R2 during the night shift. The facility Nurses Schedule dated 08/08/24 through 09/04/24 revealed a male LN staff on was on duty on 08/26/24 from 06:00 PM to 06:00 AM. The facility CNA Schedule dated 08/08/24 through 09/04/24 revealed no male staff on duty on 08/26/24 from 10:00 PM to 06:00 AM. The facility Witness Statement dated 09/03/24, by CNA M, revealed on 08/27/24, CNA N and CNA M assisted R2 to the bathroom around 10:45 AM. When CNA M wiped R2, she observed blood so she reported to the nurse (lacked name) who came in and observed R2, stating it may be her hemorrhoids on her rectum. The facility Witness Statement undated, by LN H revealed on 08/27/24 the staff (lacked name) called her into the bathroom and reported when they wiped R2 they witnessed some blood. LN H assessed R2's rectum and observed what appeared to be a hemorrhoid and LN H did not see any blood at that time. The facility Witness Statement undated, by Administrative Staff B, revealed on 08/27/24, she assisted R2 with Social Service Staff X in the restroom, noticed a small amount of blood in her brief, assisted with wiping once R2 had finished, and discovered red blood. Administrative Staff B asked Social Service Staff X to trade places so she could do a skin assessment to see if R2 had any sores or open areas and Social Service Staff X noted blood, but no sores or wounds. After cleaning R2 up, Administrative Staff B and Social Service Staff X informed behavioral unit Consultant Staff MM of the discovery. The facility Witness Statement undated, by Social Service Staff X, revealed on 08/27/24 upon arrival to the emergency room (lacked time) for R2's admission to the behavioral unit, R2 was assisted to the bathroom per her request by Social Service Staff X and Administrative Staff A. When changing R2's brief, there were two small blood spots in her brief. Social Service Staff X looked for any sore spots on R2 and found none. R2 had a small amount of blood dripping from her vaginal area, and they passed that information on to behavioral unit Consultant Staff MM. Observation, on 09/03/24 at 11:32 AM, revealed R2's room to be located approximately 25 feet from the nurse's station, her bed was made, and a wheelchair was parked next to the bed. R2 had a roommate according to signage by the room door. No residents were in the room at this time. R2 had not returned to the facility. On 09/03/24 at 02:54 PM, Consultant Staff JJ stated R2 came from the emergency room to the intake area at 02:45 PM, and when she started to do a skin assessment, she noticed some bruising. Consultant Staff JJ stated she found redness and bruising to R2's right breast, redness in between her inner thigh creases, purple/black/blue bruising on her labia, redness near her anus, bruising to her right and left great toes, swelling and a knot to her right cheek, and bruising to both knees. Consultant Staff JJ stated when emergency room staff pulled down R2's pants to perform a straight catheter, there was bright red blood in R2's brief and a smell I cannot describe so Consultant Staff JJ started looking for wounds. R2 had what appeared to be an open wound on the right labia and she did not touch the area until Consultant Staff GG could examine. Consultant Staff JJ stated when she received report from the facility nurse taking care of R2 (could not recall who), it was reported R2 had no skin issues. On 09/04/24 at 12:18 PM, CNA M stated on 08/27/24 around 10:45 AM, her and CNA N toileted R2, who was on their unit because R2 was going to be leaving. CNA M stated when standing R2 up, R2's pants were wet, so she had another staff member bring a dry pair of pants and R2 voided in the toilet. CNA M stated when wiping R2, there was red blood on the tissue, however she did not see any on R2's brief. CNA M stated LN H came in to examine R2, CNA M wiped R2 again, but there was no blood. CNA M stated LN H looked at R2 and said it was probably just hemorrhoids. On 09/04/24 at 02:45 PM, Social Service Staff X stated on 08/27/24 she arrived to get R2 to take her out of the facility and the nurse (LN H) reported R2 had just been toileted. Social Service Staff X stated LN H did not mention R2 having any blood present when wiped and she left with her and Administrative Staff B around 11:15 AM. Social Service Staff X stated when they arrived at the hospital, R2 needed to use the bathroom and they noted two dime size spots of blood in R2's brief and blood coming from the front of R2's peri-area. Social Service Staff X stated they reported to Consultant Staff MM about the blood and that they did not know anything about it, so assumed that was something new. On 09/04/24 at 03:06 PM, LN G stated she thought R2's skin was intact when she did her skin assessment on 08/26/24, and thought she performed the assessment when staff went to change her. LN G stated she tried to look at her breast and under the best she could, but it was hard to get a good view, she did not see anything wrong with R2's toes and was not able to see her peri-area. LN G stated she could only see R2's bottom and belly, the bigger more seen areas and it was difficult to get a good assessment of R2. LN G stated she could not recall if R2 had any hemorrhoids or not, however, she had some redness to her bottom, possibly from sitting up all day, but not any bruising. On 09/04/24 at 03:26 PM, LN H stated on 08/27/24 staff informed her R2 had blood they did not know where it was coming from and asked LN H to take a look, so LN H went in the bathroom. LN H stated she did not see any blood anywhere, observed possible hemorrhoids, and thought maybe that was what caused the bleeding. LN H stated she did not get a chance to tell the charge nurse responsible for R2 that day because she hurried down the hall to finish her work and Social Service Staff X came up to her and said they were taking R2. On 09/04/24 at 04:16 PM, LN L stated she was the charge nurse for R2 on 08/27/24 and did not receive any reports of blood in R2's brief or when staff wiped her. LN L stated she called the behavior unit to give report on R2, which included her recent behaviors and no skin issues. LN L stated one of R2's several falls resulted in bruising to one of her knees, and typically bruises would not be in the skin condition note because it was in a previous assessment. On 09/05/24 at 08:54 AM, Administrative Nurse D stated if the staff were unable to complete a full skin assessment due to behaviors or other reasons, the LN should document that in the skin condition notes. If a bruise was previously identified, the bruise should be included in the skin condition note, not as a new injury, but documented somewhere in the note. On 09/15/24 at 09:14 AM, attempts to interview Consultant Staff GG were unsuccessful. The facility policy Abuse, Neglect and Exploitation dated October 2022 revealed it was the policy of the facility to keep residents free from abuse and neglect. The resident had the right to be free from verbal, sexual, physical and mental abuse. Sexual abuse included, but was not limited to, sexual harassment, sexual coercion, or sexual assault. The policy documented neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives lack of care in one or more areas. The facility failed to prevent the neglect of cognitively impaired R2 who had multiple areas of bruising and redness, bleeding, and genital trauma observed and discovered by hospital staff on 08/27/24, less than 17 hours after the facility LN documented no skin issues for R2. The presence of R2's bruising, bleeding, and genital trauma prompted completion of a sexual assault kit by the hospital staff. This deficient practice placed R2 in immediate jeopardy. On 09/05/24 at 04:28 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to prevent neglect of R2 when hospital staff observed and identified multiple areas of bruising and redness, bleeding and genital trauma on 08/27/24 at 02:45 PM, less than 17 hours after the facility assessed R2's skin to be clean, dry, intact, and with no new skin issues. The facility provided an acceptable plan for removal of the immediacy on 09/05/24 at 06:43 PM which included the following: 1. R2 admitted to the hospital on 08/27/24. 2. R2's responsible party contacted on 09/03/24 at 11:52 AM and had already been made aware by the police department. 3. The facility contacted R2's physician on 09/03/24 at 10:05 AM. 4. The facility began interviewing staff and residents on 09/03/24 for any indications of abuse and neglect. 5. Staff in-service began on 09/03/24 on abuse, neglect and exploitation and education completed on 09/05/24 by 05:00 PM. 6. On 09/03/24 the facility held a quality assurance performance improvement (QAPI) meeting. 7. Starting on 09/05/24 at 05:30 PM, the facility educated staff to provide care in pairs for all residents until further notice and initiated immediately. 8. A skin sweep of all residents in the building initiated on 09/05/24 with care plans revised and physician and responsible party notified with any findings from assessments. 9. R2's responsible party informed the facility on 09/05/24 that R2 would not be returning. 10. On 09/05/24 the facility held a resident council meeting to review abuse, neglect, and exploitation. The onsite surveyor verified the implementation of the above corrective actions on 09/09/24 at 04:10 PM and the deficient practice remained at a G scope and severity.

The facility reported a census of 99 residents with three residents sampled and one resident reviewed for abuse. Based on observation, interview, and record review, the facility failed to prevent the verbal and physical abuse of cognitively impaired Resident (R) 2 on 07/13/24 and again on 07/19/24. On 07/13/24, Non-Certified Staff N observed Certified Nurse Aide (CNA) O grab R2's arms near her wrists and pushed them to R2's chest. CNA O then stated to R2, You are [explicit language] with the wrong person. I will hit you back. CNA O then turned and walked away. Non-certified Staff N failed to report her observation immediately and CNA O continued to work her scheduled shift and additional shifts following 07/13/24. On 07/19/24, CNA M was in the hallway and heard CNA O and R2 yelling back and forth from R2's room. CNA M went to assist and saw R2 attempt to hit CNA O, and CNA O grabbed R2's arms and put them forcefully against R2's chest. CNA O stated to R2, You chose the right [explicit language] one, you will not hit me. When R2 saw CNA M entering the bathroom she stated, She is beating and hurting me. CNA M offered to take over cares and CNA O stated No, you didn't want to [explicit language] help when she [R2] was trying to get up. CNA M failed to report the observation immediately, instead she wrote her concern about CNA O on a piece of paper and slid it under Administrative Nurse E's door on 07/19/24 (Friday). Administrative Nurse E did not see the note until 07/22/24 (Monday). This deficient practice placed R2 in immediate jeopardy, caused a negative psychosocial impact to R2's safety and wellbeing, and placed 15 residents in the memory care unit at risk for abuse. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 99, indicating she could not complete the interview. The staff assessment for R2's mental status identified her as having a short-term and long-term memory recall deficits and severely impaired decision-making abilities. R2 did not reject cares but had other behavioral symptoms not directed towards others one to three days of the assessment period. R2 required a walker for mobility and partial/moderate assistance for walking up to 150 feet, moving from sitting to standing, and toileting hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/11/24, revealed R2 had memory deficits and a contributing factor included a diagnosis of advanced dementia. The Behavioral Symptoms CAA dated 12/11/24, revealed R2 had physically aggressive behaviors at times and a decreased ability to understand others due to Alzheimer's disease. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of two, indicating severe cognitive impairment. R2 did not reject cares but had other behavioral symptoms not directed towards others one to three days of the assessment period. R2 required a walker for mobility and substantial/maximal assistance with walking up to 150 feet, moving from sitting to standing, and toileting hygiene. The resident's Care Plan dated 06/11/24, revealed R2 required staff assistance with activities of daily living (ADL's) related to physical limitations and had a deficit in cognitive functioning. The staff were to explain to her what they were doing prior to beginning any activity. The staff were to provide activities R2 enjoyed in an attempt to redirect her and/or improve her mood. On 07/23/24, the facility added an additional intervention for the social service designee to follow up with resident weekly for four weeks. The Report of Concern note dated 07/19/24, by CNA M, revealed on an undated night R2 had aggressive behaviors while being assisted in the bathroom, and she tried to hit CNA O. CNA O grabbed R2's arms and held them on her chest, got in R2's face, and said You chose the right [explicit language] one, you are not going to hit me. CNA M donned gloves and told CNA O she would help R2 to bed. R2 looked at CNA M and stated, She is yelling and beating me. CNA O stated to R2 Don't [explicit language] look at her, she doesn't tell me what to do. CNA O told CNA M she did not want her help because CNA M did not want to help when R2 was getting out of her chair. CNA M was in another resident's room assisting them to bed when R2's behaviors started. The facility Incident Information for 07/13/24 and 07/19/24 for alleged abuse of R2 revealed on 07/22/24, at approximately 01:45 PM, Administrative Staff A received two concerns of alleged abuse, by CNA O to R2, from CNA M and Non-certified Staff N. The staff failed to report the allegations of abuse immediately when the abuse occurred. The facility Witness Statement dated 07/22/24, by Non-certified Staff N, revealed on 07/13/24, Non-Certified Staff N was standing in the living room while the residents were getting up from dinner, meanwhile, R2 tried to get up from her chair without help. CNA O went over to R2 and R2 tried to hit CNA O, then CNA O got in R2's face and stated, You are [explicit language] with the wrong person. I will hit you back. Non-Certified Staff N documented in her statement she didn't know how to react with what had occurred. The facility Witness Statement dated 07/22/24, by CNA M, revealed on 07/19/24she was in the hallway of the memory care unit and CNA O was with R2 in the bathroom of R2's room. CNA M could hear CNA O and R2 yelling back and forth so she went to assist. R2 tried to hit CNA O, CNA O grabbed R2's arms, and put them forcefully against R2's chest and yelled at R2 You chose the right [explicit language] one, you will not hit me. R2 saw CNA M coming in, and said, She is beating and hurting me. CNA O then yelled at R2 stating She does not control me or tell me what to do. CNA M offered to take over to assist R2 and CNA O stated No, you didn't want to [explicit language] help when she was trying to get up. The facility Daily Assignment Sheet revealed the facility scheduled CNA O on the memory care unit, where R2 resided, for the 02:00 PM to 10:00 PM shift on 07/13/24, 07/14/24, 07/15/24, 07/17/24, 07/18/24, and 07/19/24. The facility Timecard dated 07/13/24 to 07/22/24, for CNA O, revealed the following dates and times she clocked in and out: 1. On 07/13/24, she clocked in at 01:51 PM and out at 09:37 PM. 2. On 07/14/24, she clocked in at 01:52 PM and out at 09:19 PM. 3. On 07/15/24, she clocked in at 01:44 PM and out at 09:57 PM. 4. On 07/17/24, she clocked in at 02:02 PM and out at 10:04 PM. 5. On 07/18/24, she clocked in at 01:49 PM and out at 06:54 PM. 6. On 07/22/24, the facility suspended R2 at 02:00 PM. The Progress Notes dated 07/26/24 at 11:55 AM, by Administrative Staff A revealed on 07/22/24, Administrative Staff A received two reports of concern involving the same CNA (lacked name) of alleged abuse. The facility immediately suspended the CNA and all staff received Abuse, Neglect Exploitation (ANE) education. The facility reported the incident to the local police department. The facility left a voicemail for R2's family on 07/22/24, who called back the morning of 07/23/24. The facility reviewed R2's care plan and updated it to include social service to follow up weekly for four weeks for psychosocial well-being. Observation on 08/14/24 at 03:23 PM, revealed R2 sitting calmly in a recliner in the living room area of the memory care unit and was looking at a magazine on her lap. Two unidentified staff members were standing by her. On 08/14/24 at 03:24 PM, R2 stated she was doing pretty good and smiled. On 08/13/24 at 04:35 PM, Administrative Staff A stated when she suspended CNA O on 07/22/24, she told CNA O there were reports of her talking mean, being mean, and saying the F word (explicit language) to residents. Administrative Staff A stated CNA O just stared at her then threw her hands up, said residents? and then the F word (explicit language) started flying out of her mouth. Administrative Staff A stated she did not ask CNA O to write a statement at that time, however, she called CNA O a few days later and asked her to come in and CNA O yelled and cussed at Administrative Staff A. Administrative Staff A stated CNA O did not return to the facility. On 08/14/24 at 09:06 AM, attempted to reach CNA O for an interview, which was unsuccessful. On 08/14/24 at 12:16 PM, CNA M stated on 07/19/24 after 06:00 PM, but before 08:00 PM, she went down the hall of the memory care unit and heard R2 and CNA O yelling at each other. CNA M stated she went to go help, as sometimes if someone else tried, R2's behaviors would improve. CNA M stated she went in the room and applied gloves and CNA O did not realize CNA M was there. CNA M stated she heard R2 state Help, she is hurting me. CNA M stated R2 tried to hit CNA O and then CNA O grabbed R2's arms and pushed R2's crossed arms up against R2's chest. CNA M stated R2 started to say something, and CNA O interrupted her. CNA M could not recall exactly what CNA O said, however, said it was in the witness statement she wrote for the facility. CNA M stated she offered to finish R2's cares but CNA O told her no because she did not want to help R2 when she was trying to get up. CNA M stated she had been in another room assisting another resident at that time. CNA M stated after CNA O declined to help, CNA M removed her gloves and went back to the living room area to assist other residents and left CNA O in the bathroom with R2. CNA M stated when CNA O brought R2 back out to the living room area, R2 seemed more irritated. CNA M stated she did not tell the charge nurse or Administrative Nurse E at the time; she was afraid of retaliation by CNA O. CNA M stated she wrote a report of concern note on 07/19/24 (Friday) and slid it under Administrative Nurse E's door. The lack of reporting allowed CNA O to continue working until she clocked out at 06:54 PM. On 08/12/24 at 12:50 PM, Non-certified Staff N stated on 07/13/24 around 05:30 PM she was in the living room to get something, CNA O walked over to R2, and R2 was repeatedly trying to hit CNA O. CNA O grabbed R2's arms just below the wrists with both hands and held them in place to R2's chest for approximately five seconds or so, until CNA O finished telling R2, You are [explicit language] with the wrong person. I will hit you back. Non-Certified Staff N stated after CNA O let go of R2's arms, CNA O turned around and looked at Non-Certified Staff N and walked away. Non-Certified Staff N stated she did not try to stop CNA O, or say anything to CNA O, because she did not know what CNA O would try to do to her. Non-Certified Staff N stated what happened shocked her. Non-Certified Staff N stated she did not report her observation at that time to the charge nurse or Administrative Staff. Non-Certified Staff N stated the day or so after she told CNA M about it, who said she had seen a situation like that before. On 08/14/24 at 01:41 PM Administrative Staff A stated she received CNA M's report of concern on 07/22/24 at 01:45 PM when Administrative Nurse E gave her the form, which she slid under her door. Administrative Staff A reported there were 15 residents in the memory care unit. On 08/14/24 at 01:43 PM, Administrative Nurse E stated she had received a text message from CNA M about concerns with CNA O's treatment of staff but lacked any concerns about treatment of residents. Administrative Nurse E stated she instructed CNA M to write a report of concern and put it under her door. Administrative Nurse E stated she was reading the note and when she seen it was also about a resident, she passed it on to Administrative Staff B because she knew something needed to be done immediately. On 08/14/24 at 01:50 PM, Administrative Nurse D stated CNA M and Non-Certified Staff N should have reported CNA O immediately to Administrative Staff A, the charge nurse, or Administrative Nurse D, and CNA O should have been removed from the building on 07/13/24 and 07/19/24. On 08/14/24 at 01:55 PM, Administrative Staff A stated Non-Certified Staff N should have reported CNA O immediately on 07/13/24 and CNA M should have reported the incidents with CNA O immediately on 07/19/24. The facility policy Abuse, Neglect, and Exploitation dated October 2022 revealed 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. The facility failed to prevent abuse on 07/13/24 when CNA O grabbed R2's arms near her wrist and pushed them to her chest and then verbally threatened/abused her. Then again, on 07/19/24 when CNA O grabbed R2's arms and moved them forcefully to R2's chest and verbally threatened R2. R2 reported to CNA M She is beating and hurting me. CNA O continued working her shift on 07/13/24 and following shifts through 07/19/24, placing the 15 residents in the memory care unit at risk for abuse. On 08/14/24 at 05:25 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to prevent verbal and physical abuse of R2 by CNA O on 07/13/24 and on 07/19/24. The immediate jeopardy was determined to first exist on 07/13/24 at approximately 05:30 PM and the surveyor verified the removal of the immediate jeopardy occurred on 07/23/24 at 12:00 PM, prior to the surveyor entrance, which deemed the deficient practice as past non-compliance when the facility completed the following: 1. The facility suspended CNA O on 07/22/24 at 02:00 PM. 2. The facility conducted a skin assessment of R2 on 07/22/24 at 05:01 PM. 3. The facility notified the responsible party and left a voicemail on 07/22/4 at 04:10 PM. 4. The facility provided additional education to CNA M and Non-Certified Staff N on 07/22/24. 5. The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director on 07/22/24. 6. The facility began education with all staff on 07/22/24 and completed on 07/23/24 at 12:00 PM. 7. The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks on 07/23/24 at 08:00 AM. The deficient practice existed at a J scope and severity following the removal of the immediate jeopardy.

The facility reported a census of 99 residents with three residents sampled and one resident reviewed for abuse. Based on observation, interview, and record review, the facility failed to immediately report incidents of verbal and physical abuse of cognitively impaired Resident (R) 2 on 07/13/24 and again on 07/19/24. On 07/13/24, Non-Certified Staff N observed Certified Nurse Aide (CNA) O grab R2's arms near her wrists and pushed them to R2's chest. CNA O then stated to R2, You are [explicit language] with the wrong person. I will hit you back. CNA O then turned and walked away. Non-certified Staff N failed to report her observation immediately and CNA O continued to work her scheduled shift and additional shifts following 07/13/24. On 07/19/24, CNA M was in the hallway and heard CNA O and R2 yelling back and forth from R2's room. CNA M went to assist and saw R2 attempt to hit CNA O, and CNA O grabbed R2's arms and put them forcefully against R2's chest. CNA O stated to R2, You chose the right [explicit language] one, you will not hit me. When R2 saw CNA M entering the bathroom she stated, She is beating and hurting me. CNA M offered to take over cares and CNA O stated No, you didn't want to [explicit language] help when she [R2] was trying to get up. CNA M failed to report the observation immediately, instead she wrote her concern about CNA O on a piece of paper and slid it under Administrative Nurse E's door on 07/19/24 (Friday). Administrative Nurse E did not see the note until 07/22/24 (Monday). This deficient practice placed R2 in immediate jeopardy, caused a negative psychosocial impact to R2's safety and wellbeing, and placed 15 residents in the memory care unit at risk for abuse. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 99, indicating she could not complete the interview. The staff assessment for R2's mental status identified her as having a short-term and long-term memory recall deficits and severely impaired decision-making abilities. R2 did not reject cares but had other behavioral symptoms not directed towards others one to three days of the assessment period. R2 required a walker for mobility and partial/moderate assistance for walking up to 150 feet, moving from sitting to standing, and toileting hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/11/24, revealed R2 had memory deficits and a contributing factor included a diagnosis of advanced dementia. The Behavioral Symptoms CAA dated 12/11/24, revealed R2 had physically aggressive behaviors at times and a decreased ability to understand others due to Alzheimer's disease. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of two, indicating severe cognitive impairment. R2 did not reject cares but had other behavioral symptoms not directed towards others one to three days of the assessment period. R2 required a walker for mobility and substantial/maximal assistance with walking up to 150 feet, moving from sitting to standing, and toileting hygiene. The resident's Care Plan dated 06/11/24, revealed R2 required staff assistance with activities of daily living (ADL's) related to physical limitations and had a deficit in cognitive functioning. The staff were to explain to her what they were doing prior to beginning any activity. The staff were to provide activities R2 enjoyed in an attempt to redirect her and/or improve her mood. On 07/23/24, the facility added an additional intervention for the social service designee to follow up with resident weekly for four weeks. The Report of Concern note dated 07/19/24, by CNA M, revealed on an undated night R2 had aggressive behaviors while being assisted in the bathroom, and she tried to hit CNA O. CNA O grabbed R2's arms and held them on her chest, got in R2's face, and said You chose the right [explicit language] one, you are not going to hit me. CNA M donned gloves and told CNA O she would help R2 to bed. R2 looked at CNA M and stated, She is yelling and beating me. CNA O stated to R2 Don't [explicit language] look at her, she doesn't tell me what to do. CNA O told CNA M she did not want her help because CNA M did not want to help when R2 was getting out of her chair. CNA M was in another resident's room assisting them to bed when R2's behaviors started. The facility Incident Information for 07/13/24 and 07/19/24 for alleged abuse of R2 revealed on 07/22/24, at approximately 01:45 PM, Administrative Staff A received two concerns of alleged abuse, by CNA O to R2, from CNA M and Non-certified Staff N. The staff failed to report the allegations of abuse immediately when the abuse occurred. The facility Witness Statement dated 07/22/24, by Non-certified Staff N, revealed on 07/13/24, Non-Certified Staff N was standing in the living room while the residents were getting up from dinner, meanwhile, R2 tried to get up from her chair without help. CNA O went over to R2 and R2 tried to hit CNA O, then CNA O got in R2's face and stated, You are [explicit language] with the wrong person. I will hit you back. Non-Certified Staff N documented in her statement she didn't know how to react with what had occurred. The facility Witness Statement dated 07/22/24, by CNA M, revealed on 07/19/24she was in the hallway of the memory care unit and CNA O was with R2 in the bathroom of R2's room. CNA M could hear CNA O and R2 yelling back and forth so she went to assist. R2 tried to hit CNA O, CNA O grabbed R2's arms, and put them forcefully against R2's chest and yelled at R2 You chose the right [explicit language] one, you will not hit me. R2 saw CNA M coming in, and said, She is beating and hurting me. CNA O then yelled at R2 stating She does not control me or tell me what to do. CNA M offered to take over to assist R2 and CNA O stated No, you didn't want to [explicit language] help when she was trying to get up. The facility Daily Assignment Sheet revealed the facility scheduled CNA O on the memory care unit, where R2 resided, for the 02:00 PM to 10:00 PM shift on 07/13/24, 07/14/24, 07/15/24, 07/17/24, 07/18/24, and 07/19/24. The facility Timecard dated 07/13/24 to 07/22/24, for CNA O, revealed the following dates and times she clocked in and out: 1. On 07/13/24, she clocked in at 01:51 PM and out at 09:37 PM. 2. On 07/14/24, she clocked in at 01:52 PM and out at 09:19 PM. 3. On 07/15/24, she clocked in at 01:44 PM and out at 09:57 PM. 4. On 07/17/24, she clocked in at 02:02 PM and out at 10:04 PM. 5. On 07/18/24, she clocked in at 01:49 PM and out at 06:54 PM. 6. On 07/22/24, the facility suspended R2 at 02:00 PM. The Progress Notes dated 07/26/24 at 11:55 AM, by Administrative Staff A revealed on 07/22/24, Administrative Staff A received two reports of concern involving the same CNA (lacked name) of alleged abuse. The facility immediately suspended the CNA and all staff received Abuse, Neglect Exploitation (ANE) education. The facility reported the incident to the local police department. The facility left a voicemail for R2's family on 07/22/24, who called back the morning of 07/23/24. The facility reviewed R2's care plan and updated it to include social service to follow up weekly for four weeks for psychosocial well-being. Observation on 08/14/24 at 03:23 PM, revealed R2 sitting calmly in a recliner in the living room area of the memory care unit and was looking at a magazine on her lap. Two unidentified staff members were standing by her. On 08/14/24 at 03:24 PM, R2 stated she was doing pretty good and smiled. On 08/13/24 at 04:35 PM, Administrative Staff A stated when she suspended CNA O on 07/22/24, she told CNA O there were reports of her talking mean, being mean, and saying the F word (explicit language) to residents. Administrative Staff A stated CNA O just stared at her then threw her hands up, said residents? and then the F word (explicit language) started flying out of her mouth. Administrative Staff A stated she did not ask CNA O to write a statement at that time, however, she called CNA O a few days later and asked her to come in and CNA O yelled and cussed at Administrative Staff A. Administrative Staff A stated CNA O did not return to the facility. On 08/14/24 at 09:06 AM, attempted to reach CNA O for an interview, which was unsuccessful. On 08/14/24 at 12:16 PM, CNA M stated on 07/19/24 after 06:00 PM, but before 08:00 PM, she went down the hall of the memory care unit and heard R2 and CNA O yelling at each other. CNA M stated she went to go help, as sometimes if someone else tried, R2's behaviors would improve. CNA M stated she went in the room and applied gloves and CNA O did not realize CNA M was there. CNA M stated she heard R2 state Help, she is hurting me. CNA M stated R2 tried to hit CNA O and then CNA O grabbed R2's arms and pushed R2's crossed arms up against R2's chest. CNA M stated R2 started to say something, and CNA O interrupted her. CNA M could not recall exactly what CNA O said, however, said it was in the witness statement she wrote for the facility. CNA M stated she offered to finish R2's cares but CNA O told her no because she did not want to help R2 when she was trying to get up. CNA M stated she had been in another room assisting another resident at that time. CNA M stated after CNA O declined to help, CNA M removed her gloves and went back to the living room area to assist other residents and left CNA O in the bathroom with R2. CNA M stated when CNA O brought R2 back out to the living room area, R2 seemed more irritated. CNA M stated she did not tell the charge nurse or Administrative Nurse E at the time; she was afraid of retaliation by CNA O. CNA M stated she wrote a report of concern note on 07/19/24 (Friday) and slid it under Administrative Nurse E's door. The lack of reporting allowed CNA O to continue working until she clocked out at 06:54 PM. On 08/12/24 at 12:50 PM, Non-certified Staff N stated on 07/13/24 around 05:30 PM she was in the living room to get something, CNA O walked over to R2, and R2 was repeatedly trying to hit CNA O. CNA O grabbed R2's arms just below the wrists with both hands and held them in place to R2's chest for approximately five seconds or so, until CNA O finished telling R2, You are [explicit language] with the wrong person. I will hit you back. Non-Certified Staff N stated after CNA O let go of R2's arms, CNA O turned around and looked at Non-Certified Staff N and walked away. Non-Certified Staff N stated she did not try to stop CNA O, or say anything to CNA O, because she did not know what CNA O would try to do to her. Non-Certified Staff N stated what happened shocked her. Non-Certified Staff N stated she did not report her observation at that time to the charge nurse or Administrative Staff. Non-Certified Staff N stated the day or so after she told CNA M about it, who said she had seen a situation like that before. On 08/14/24 at 01:41 PM Administrative Staff A stated she received CNA M's report of concern on 07/22/24 at 01:45 PM when Administrative Nurse E gave her the form, which she slid under her door. Administrative Staff A reported there were 15 residents in the memory care unit. On 08/14/24 at 01:43 PM, Administrative Nurse E stated she had received a text message from CNA M about concerns with CNA O's treatment of staff but lacked any concerns about treatment of residents. Administrative Nurse E stated she instructed CNA M to write a report of concern and put it under her door. Administrative Nurse E stated she was reading the note and when she seen it was also about a resident, she passed it on to Administrative Staff B because she knew something needed to be done immediately. On 08/14/24 at 01:50 PM, Administrative Nurse D stated CNA M and Non-Certified Staff N should have reported CNA O immediately to Administrative Staff A, the charge nurse, or Administrative Nurse D, and CNA O should have been removed from the building on 07/13/24 and 07/19/24. On 08/14/24 at 01:55 PM, Administrative Staff A stated Non-Certified Staff N should have reported CNA O immediately on 07/13/24 and CNA M should have reported the incidents with CNA O immediately on 07/19/24. The facility policy Abuse, Neglect, and Exploitation dated October 2022 revealed 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. The facility failed to ensure staff reported all instances of abuse to prevent abuse on 07/13/24 when CNA O grabbed R2's arms near her wrist and pushed them to her chest and then verbally threatened/abused her. Then again, on 07/19/24 when CNA O grabbed R2's arms and moved them forcefully to R2's chest and verbally threatened R2. R2 reported to CNA N She is beating and hurting me. CNA O continued working her shift on 07/13/24 and following shifts through 07/19/24, placing the 15 residents in the memory care unit at risk for abuse. On 08/14/24 at 05:25 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to prevent verbal and physical abuse of R2 by CNA O on 07/13/24 and on 07/19/24. The immediate jeopardy was determined to first exist on 07/13/24 at approximately 05:30 PM and the surveyor verified the removal of the immediate jeopardy occurred on 07/23/24 at 12:00 PM, prior to the surveyor entrance, which deemed the deficient practice as past non-compliance when the facility completed the following: 1. The facility suspended CNA O on 07/22/24 at 02:00 PM. 2. The facility conducted a skin assessment of R2 on 07/22/24 at 05:01 PM. 3. The facility notified the responsible party and left a voicemail on 07/22/4 at 04:10 PM. 4. The facility provided additional education to CNA M and Non-Certified Staff N on 07/22/24. 5. The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director on 07/22/24. 6. The facility began education with all staff on 07/22/24 and completed on 07/23/24 at 12:00 PM. 7. The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks on 07/23/24 at 08:00 AM. The deficient practice existed at a J scope and severity following the removal of the immediate jeopardy.

The facility reported a census of 99 residents with three residents sampled and one resident reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure the staff protected residents from abuse when staff did not immediately report incidents of verbal and physical abuse of cognitively impaired Resident (R) 2 on 07/13/24 and again on 07/19/24. On 07/13/24, Non-Certified Staff N observed Certified Nurse Aide (CNA) O grab R2's arms near her wrists and pushed them to R2's chest. CNA O then stated to R2, You are [explicit language] with the wrong person. I will hit you back. CNA O then turned and walked away. Non-certified Staff N failed to report her observation immediately and CNA O continued to work her scheduled shift and additional shifts following 07/13/24. On 07/19/24, CNA M was in the hallway and heard CNA O and R2 yelling back and forth from R2's room. CNA M went to assist and saw R2 attempt to hit CNA O, and CNA O grabbed R2's arms and put them forcefully against R2's chest. CNA O stated to R2, You chose the right [explicit language] one, you will not hit me. When R2 saw CNA M entering the bathroom she stated, She is beating and hurting me. CNA M offered to take over cares and CNA O stated No, you didn't want to [explicit language] help when she [R2] was trying to get up. CNA M failed to report the observation immediately, instead she wrote her concern about CNA O on a piece of paper and slid it under Administrative Nurse E's door on 07/19/24 (Friday). Administrative Nurse E did not see the note until 07/22/24 (Monday). This deficient practice placed R2 in immediate jeopardy, caused a negative psychosocial impact to R2's safety and wellbeing, and placed 15 residents in the memory care unit at risk for abuse. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 99, indicating she could not complete the interview. The staff assessment for R2's mental status identified her as having a short-term and long-term memory recall deficits and severely impaired decision-making abilities. R2 did not reject cares but had other behavioral symptoms not directed towards others one to three days of the assessment period. R2 required a walker for mobility and partial/moderate assistance for walking up to 150 feet, moving from sitting to standing, and toileting hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/11/24, revealed R2 had memory deficits and a contributing factor included a diagnosis of advanced dementia. The Behavioral Symptoms CAA dated 12/11/24, revealed R2 had physically aggressive behaviors at times and a decreased ability to understand others due to Alzheimer's disease. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of two, indicating severe cognitive impairment. R2 did not reject cares but had other behavioral symptoms not directed towards others one to three days of the assessment period. R2 required a walker for mobility and substantial/maximal assistance with walking up to 150 feet, moving from sitting to standing, and toileting hygiene. The resident's Care Plan dated 06/11/24, revealed R2 required staff assistance with activities of daily living (ADL's) related to physical limitations and had a deficit in cognitive functioning. The staff were to explain to her what they were doing prior to beginning any activity. The staff were to provide activities R2 enjoyed in an attempt to redirect her and/or improve her mood. On 07/23/24, the facility added an additional intervention for the social service designee to follow up with resident weekly for four weeks. The Report of Concern note dated 07/19/24, by CNA M, revealed on an undated night R2 had aggressive behaviors while being assisted in the bathroom, and she tried to hit CNA O. CNA O grabbed R2's arms and held them on her chest, got in R2's face, and said You chose the right [explicit language] one, you are not going to hit me. CNA M donned gloves and told CNA O she would help R2 to bed. R2 looked at CNA M and stated, She is yelling and beating me. CNA O stated to R2 Don't [explicit language] look at her, she doesn't tell me what to do. CNA O told CNA M she did not want her help because CNA M did not want to help when R2 was getting out of her chair. CNA M was in another resident's room assisting them to bed when R2's behaviors started. The facility Incident Information for 07/13/24 and 07/19/24 for alleged abuse of R2 revealed on 07/22/24, at approximately 01:45 PM, Administrative Staff A received two concerns of alleged abuse, by CNA O to R2, from CNA M and Non-certified Staff N. The staff failed to report the allegations of abuse immediately when the abuse occurred. The facility Witness Statement dated 07/22/24, by Non-certified Staff N, revealed on 07/13/24, Non-Certified Staff N was standing in the living room while the residents were getting up from dinner, meanwhile, R2 tried to get up from her chair without help. CNA O went over to R2 and R2 tried to hit CNA O, then CNA O got in R2's face and stated, You are [explicit language] with the wrong person. I will hit you back. Non-Certified Staff N documented in her statement she didn't know how to react with what had occurred. The facility Witness Statement dated 07/22/24, by CNA M, revealed on 07/19/24she was in the hallway of the memory care unit and CNA O was with R2 in the bathroom of R2's room. CNA M could hear CNA O and R2 yelling back and forth so she went to assist. R2 tried to hit CNA O, CNA O grabbed R2's arms, and put them forcefully against R2's chest and yelled at R2 You chose the right [explicit language] one, you will not hit me. R2 saw CNA M coming in, and said, She is beating and hurting me. CNA O then yelled at R2 stating She does not control me or tell me what to do. CNA M offered to take over to assist R2 and CNA O stated No, you didn't want to [explicit language] help when she was trying to get up. The facility Daily Assignment Sheet revealed the facility scheduled CNA O on the memory care unit, where R2 resided, for the 02:00 PM to 10:00 PM shift on 07/13/24, 07/14/24, 07/15/24, 07/17/24, 07/18/24, and 07/19/24. The facility Timecard dated 07/13/24 to 07/22/24, for CNA O, revealed the following dates and times she clocked in and out: 1. On 07/13/24, she clocked in at 01:51 PM and out at 09:37 PM. 2. On 07/14/24, she clocked in at 01:52 PM and out at 09:19 PM. 3. On 07/15/24, she clocked in at 01:44 PM and out at 09:57 PM. 4. On 07/17/24, she clocked in at 02:02 PM and out at 10:04 PM. 5. On 07/18/24, she clocked in at 01:49 PM and out at 06:54 PM. 6. On 07/22/24, the facility suspended R2 at 02:00 PM. The Progress Notes dated 07/26/24 at 11:55 AM, by Administrative Staff A revealed on 07/22/24, Administrative Staff A received two reports of concern involving the same CNA (lacked name) of alleged abuse. The facility immediately suspended the CNA and all staff received Abuse, Neglect Exploitation (ANE) education. The facility reported the incident to the local police department. The facility left a voicemail for R2's family on 07/22/24, who called back the morning of 07/23/24. The facility reviewed R2's care plan and updated it to include social service to follow up weekly for four weeks for psychosocial well-being. Observation on 08/14/24 at 03:23 PM, revealed R2 sitting calmly in a recliner in the living room area of the memory care unit and was looking at a magazine on her lap. Two unidentified staff members were standing by her. On 08/14/24 at 03:24 PM, R2 stated she was doing pretty good and smiled. On 08/13/24 at 04:35 PM, Administrative Staff A stated when she suspended CNA O on 07/22/24, she told CNA O there were reports of her talking mean, being mean, and saying the F word (explicit language) to residents. Administrative Staff A stated CNA O just stared at her then threw her hands up, said residents? and then the F word (explicit language) started flying out of her mouth. Administrative Staff A stated she did not ask CNA O to write a statement at that time, however, she called CNA O a few days later and asked her to come in and CNA O yelled and cussed at Administrative Staff A. Administrative Staff A stated CNA O did not return to the facility. On 08/14/24 at 09:06 AM, attempted to reach CNA O for an interview, which was unsuccessful. On 08/14/24 at 12:16 PM, CNA M stated on 07/19/24 after 06:00 PM, but before 08:00 PM, she went down the hall of the memory care unit and heard R2 and CNA O yelling at each other. CNA M stated she went to go help, as sometimes if someone else tried, R2's behaviors would improve. CNA M stated she went in the room and applied gloves and CNA O did not realize CNA M was there. CNA M stated she heard R2 state Help, she is hurting me. CNA M stated R2 tried to hit CNA O and then CNA O grabbed R2's arms and pushed R2's crossed arms up against R2's chest. CNA M stated R2 started to say something, and CNA O interrupted her. CNA M could not recall exactly what CNA O said, however, said it was in the witness statement she wrote for the facility. CNA M stated she offered to finish R2's cares but CNA O told her no because she did not want to help R2 when she was trying to get up. CNA M stated she had been in another room assisting another resident at that time. CNA M stated after CNA O declined to help, CNA M removed her gloves and went back to the living room area to assist other residents and left CNA O in the bathroom with R2. CNA M stated when CNA O brought R2 back out to the living room area, R2 seemed more irritated. CNA M stated she did not tell the charge nurse or Administrative Nurse E at the time; she was afraid of retaliation by CNA O. CNA M stated she wrote a report of concern note on 07/19/24 (Friday) and slid it under Administrative Nurse E's door. The lack of reporting allowed CNA O to continue working until she clocked out at 06:54 PM. On 08/12/24 at 12:50 PM, Non-certified Staff N stated on 07/13/24 around 05:30 PM she was in the living room to get something, CNA O walked over to R2, and R2 was repeatedly trying to hit CNA O. CNA O grabbed R2's arms just below the wrists with both hands and held them in place to R2's chest for approximately five seconds or so, until CNA O finished telling R2, You are [explicit language] with the wrong person. I will hit you back. Non-Certified Staff N stated after CNA O let go of R2's arms, CNA O turned around and looked at Non-Certified Staff N and walked away. Non-Certified Staff N stated she did not try to stop CNA O, or say anything to CNA O, because she did not know what CNA O would try to do to her. Non-Certified Staff N stated what happened shocked her. Non-Certified Staff N stated she did not report her observation at that time to the charge nurse or Administrative Staff. Non-Certified Staff N stated the day or so after she told CNA M about it, who said she had seen a situation like that before. On 08/14/24 at 01:41 PM Administrative Staff A stated she received CNA M's report of concern on 07/22/24 at 01:45 PM when Administrative Nurse E gave her the form, which she slid under her door. Administrative Staff A reported there were 15 residents in the memory care unit. On 08/14/24 at 01:43 PM, Administrative Nurse E stated she had received a text message from CNA M about concerns with CNA O's treatment of staff but lacked any concerns about treatment of residents. Administrative Nurse E stated she instructed CNA M to write a report of concern and put it under her door. Administrative Nurse E stated she was reading the note and when she seen it was also about a resident, she passed it on to Administrative Staff B because she knew something needed to be done immediately. On 08/14/24 at 01:50 PM, Administrative Nurse D stated CNA M and Non-Certified Staff N should have reported CNA O immediately to Administrative Staff A, the charge nurse, or Administrative Nurse D, and CNA O should have been removed from the building on 07/13/24 and 07/19/24. On 08/14/24 at 01:55 PM, Administrative Staff A stated Non-Certified Staff N should have reported CNA O immediately on 07/13/24 and CNA M should have reported the incidents with CNA O immediately on 07/19/24. The facility policy Abuse, Neglect, and Exploitation dated October 2022 revealed 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. The facility failed to protect residents from abuse when staff did not immediately report incidents of verbal and physical abuse on 07/13/24 when CNA O grabbed R2's arms near her wrist and pushed them to her chest and then verbally threatened/abused her. Then again, on 07/19/24 when CNA O grabbed R2's arms and moved them forcefully to R2's chest and verbally threatened R2. R2 reported to CNA M She is beating and hurting me. CNA O continued working her shift on 07/13/24 and following shifts through 07/19/24, placing the 15 residents in the memory care unit at risk for abuse. On 08/14/24 at 05:25 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to prevent verbal and physical abuse of R2 by CNA O on 07/13/24 and on 07/19/24. The immediate jeopardy was determined to first exist on 07/13/24 at approximately 05:30 PM and the surveyor verified the removal of the immediate jeopardy occurred on 07/23/24 at 12:00 PM, prior to the surveyor entrance, which deemed the deficient practice as past non-compliance when the facility completed the following: 1. The facility suspended CNA O on 07/22/24 at 02:00 PM. 2. The facility conducted a skin assessment of R2 on 07/22/24 at 05:01 PM. 3. The facility notified the responsible party and left a voicemail on 07/22/4 at 04:10 PM. 4. The facility provided additional education to CNA M and Non-Certified Staff N on 07/22/24. 5. The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director on 07/22/24. 6. The facility began education with all staff on 07/22/24 and completed on 07/23/24 at 12:00 PM. 7. The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks on 07/23/24 at 08:00 AM. The deficient practice existed at a J scope and severity following the removal of the immediate jeopardy.

The facility reported a census of 81 residents, with 20 in the sample, and two residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to ensure pertinent and timely interventions were implemented as ordered to prevent Resident (R)13's significant weight loss of 25.11 percent (%) in 141 days. The facility did not weigh R13 monthly and did not identify and assess R13 when meal intake consistently declined between 10/2023 and 02/2024. This failure resulted in a R13 losing 29.4 pounds (lbs.)/25.11% body weight, in 141 days. Additionally, the facility failed to monitor R13 for effectiveness of their treatment plan which resulted in an additional weight loss of 11.2 lbs in an additional 42 days which was a total of 40.6 lbs/29.64% over 182 days and placed the resident at risk for continued decline in nutritional status and at risk for the development of life-threatening symptoms, which could negatively affect the mental, physical, and psychosocial well-being of R13. Findings Included: - R13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type 2 (DM type 2, when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), unspecified pain, and dorsalgia (pain in the bones of the spine, usually the upper back). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 12, which indicated moderately impaired cognition. The MDS documented R13 had no identified concerns with swallowing, was edentulous (no natural teeth), and was dependent on staff for all cares except eating which required setup and supervision. The ADL (activities of daily living - activities such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 10/17/23 documented that R13 required assistance with ADL activities due to generalized weakness. The Nutritional Status CAA dated 10/17/23 documented that R13 was at risk for weight instability due to therapeutic diet related to DM type 2 management. The Quarterly MDS dated [DATE], documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R13 had no identified concerns with swallowing and was dependent on staff for all cares except eating which required setup and supervision. Additionally, the MDS documented that R13 had not experienced weight loss with a modification on 03/28/24 that indicated weight loss. The 05/08/24 Care Plan, initiated on 11/17/22 documented the resident required staff assistance with ADLs due to physical limitations and was at risk for weight loss due to diabetic disease processes and included the following interventions: On 11/17/22, R13 would at times require more assistance in completing ADL tasks due to pain. On 11/17/22, initiated on 06/09/23 and revised on 04/27/24, instructed staff that R13 required assistance of one staff during mealtimes for eating. On 11/21/22, R13 was on a regular, LCS (low concentrated sweet - a diet specific for people with DM2) with fortified foods with double proteins and included a supplement. On 11/21/22, staff were to monitor R13's weight and report to the physician as needed. On 03/14/24, staff were to provide prostat (a protein rich shake supplement) and multivitamin supplement for weight management. On 03/29/24, staff were to weigh R13 weekly for one month to monitor for weight loss. The Physician's Orders included: On 07/27/23, staff were to provide house supplement (a product similar to prostat) three times per day for a supplement. On 03/14/24, staff were to provide prostat two times per day for supplement and for wound healing. On 04/03/24, staff were to obtain monthly weights every fourth week on Wednesdays. The Progress Notes documented: On 10/24/23, the Registered Dietitian (RD - Dietary Consultant E) documented R13 weighed 137 lbs on 10/06/24 but that her ideal body weight was 153-185 lbs. R13 received a LCS diet with fortified foods with adequate meal intakes that varied between 76-100%, received a house supplement three times daily and recommended to continue current plan of care. On 01/11/24, Dietary Consultant E documented R13 weighed 137 lbs on 10/06/24, meal intakes varied 76-100%, she received a house supplement three times daily and recommended to continue current plan of care. On 02/19/24, Dietary Consultant E documented R13 did not have a current weight, meal intakes varied between 25-100% and were fair. R13 received a house supplement three times daily and recommended to continue current plan of care. On 03/04/24, Dietary Consultant E documented the resident weighed 107.6 lbs on 02/23/24, meal intakes varied between 25-75% and were fair. Dietary Consultant E documented that resident had lost 29.4 lbs since previous weight on 10/06/23, recommended the addition of a multivitamin and prostat two times per day to assist with weight gain and recommended that staff were to monitor the resident's weights and meal intakes. On 04/01/24, Dietary Consultant E documented R13 weighed 97.6 lbs on 03/28/24, diet included fortified foods, double portions and protein added with intakes that varied between 25-75% and received house supplement three times daily and prostat twice per day. Additionally documented that R13 had an additional 10 lb weight loss in the 30-day look-back period and recommended changing R13's diet to liberalized geriatric in order to provide optimal nutrition and variety with continued recommendation for staff to monitor the resident's weights and meal intakes. On 05/07/24, the RD documented R13 weighed 102.6 lbs and diet included liberalized geriatric with fortified foods, double portions and protein added to assist with weight gain. Further documented that meal intakes had improved to 51-100%, received house supplement three times daily and prostat twice daily. Additionally documented that R13 had a weight gain of 6.2 lbs in the 30-day look-back period and recommended that staff continue the current plan of care. Review of the EHR Weights documented the following: On 10/06/23 at 05:33 PM, R13 weighed 137 lbs. On 02/23/24 at 09:46 AM, R13 weighed 107.6 lbs. On 03/28/24 at 03:45 PM, R13 weighed 97.6 lbs. On 04/04/24 at 08:37 PM, R13 weighed 96.4 lbs. On 05/03/24 at 10:00 AM, R13 weighed 102.6 lbs. Review of the EHR revealed no lab results or physician orders for lab work since 11/30/23 to monitor R13's nutritional status. During an observation on 05/08/24 at 12:27 PM, R13 sat in her wheelchair in the dining area with peers. R13 independently fed herself beef stew, cornbread, and peas. During an observation on 05/08/24 at 12:40 PM, R13 requested Administrative Staff FF remove her meal tray and stated she was done eating. Administrative Staff FF recorded R13 consumed 25% of the main meal, 50% of the ice cream, and 0% of the chocolate cake. Administrative Staff FF or Certified Nurse Aide (CNA) GG did not offer R13 an alternative food selection. During an interview on 05/08/24 at 12:18 PM, CNA GG stated that resident weights were obtained whenever the task populated in POC (point of care, a part of the EHR) or if the nurse asked for a weight. During an interview on 05/09/24 at 08:49 AM, CNA X stated if residents refused all or part of the meals offered then snacks should be offered. During an interview on 05/09/24 at 11:03 AM, Licensed Nurse (LN) DD stated the facility standard was all residents were weighed monthly unless the provider had specifically ordered weights to be obtained more often. During an interview on 05/09/24 at 11:10 AM, LN Y stated residents who had weight loss were encouraged to take more supplements and staff would provide more assistance during mealtimes. LN Y stated exceptionally low weights were reported to Administrative Nurse B for follow up and/or referral to the physician. During an interview on 05/09/24 at 12:34 PM, Administrative Nurse B confirmed the physician and the facility had not monitored R13's weight loss as evidenced by no labs drawn since 11/29/23 and confirmed the facility failed to obtain weights on R13 in 11/2023, 12/2023 and 01/2024. Administrative Nurse B said she expected staff to obtain weights on residents following the physician's orders. During an interview on 05/13/24 at 12:58 PM, Dietary Consultant E confirmed that the facility failed to obtain monthly weights for R13 and that prior to R13's weight loss, her expectation was for staff to obtain weight measurements on residents at least monthly. The facility did not provide a policy related to weight loss and monitoring of weights as requested on 05/09/24. The facility failed to ensure pertinent and timely interventions were implemented as ordered to prevent R13's significant weight loss was a total of 40.6 lbs/29.64% over 182 days and placed the resident at risk for continued decline in nutritional status and at risk for the development of life-threatening symptoms, which could negatively affect the mental, physical, and psychosocial well-being of R13.

The facility reported a census of 81 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen, on 05/07/24 at 10:55 AM, the following areas of concern were noted: The hand-washing sink trashcan lacked a cover. The refrigerator contained 11 dressing cups which were unlabeled. Three gelatin parfaits which were unlabeled. A gallon container of peach slices, dated 05/01/24, was not properly covered. A bag of 12 baked potatoes, which were unlabeled. Three of the racks in the refrigerator contained dried-on food substances and rust. The outside dumpster contained garbage bags and was not closed. A five-gallon container of flour contained grime on top of the lid. A five-gallon container of dried milk contained grime on top of the lid. On 05/07/24 at 11:28 AM, Dietary Consultant E verified the above issues. The facility lacked a policy for the kitchen. The facility failed to prepare and serve food under sanitary conditions to the residents of the facility. 31078 - Observation on 05/07/24 at 12:28 PM, Dietary Staff N began serving the lunch meal for the memory care unit. She had a hair cover in place during the serving although front hair on temples and forehead were not covered and hung loosely during serving. The dietary staff wore the same pair of blue gloves and as she served the plates touched the eating surfaces of the plates. Dietary Staff N touched the food placed on several plates with her thumb and then served the plate to the residents. Interview on 05/07/24 at 12:40 PM, following serving of the noon meal Dietary Staff N reported she was aware of the proper way to handle the plates, so she did not come in contact with the food but the way she served the plates today was an old bad habit and was hard to break. She was aware of the need for all her hair to be in her cap during serving and acknowledged it was not like that today. Review of the facility policy for Proper Hand Washing and Glove Use dated 2020 revealed all employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. The facility failed to serve food in a sanitary manner by having hair out of the hairnet and failure to serve plates without touching of the plate eating surface or food.

The facility reported a census of 81 residents. Based on observation and interview, the facility failed to ensure staff performed hand hygiene during meals, failed to ensure sanitary storage of oxygen concentrators with tubing, failed to ensure staff performed hand hygiene during dressing change, failed to ensure sanitary glucometer cleaning for two glucometers used by three residents, and failed to ensure staff provided enhanced barrier precautions for two Residents (R) 5 and R22 with the use of urinary catheters. Findings included: - Observation, on 05/08/24 at 12:37 PM, revealed Certified Nurse Aide (CNA) U assisted Residents (R) 61 and R3 with their noon meal. CNA U positioned the pedals of R61's wheelchair and placed her feet upon them, then without performing hand hygiene, picked up a glass of fluid, handled the straw in the glass and offered it to R3. CNA U removed R3's clothing protector, wiped her mouth with her napkin, placed the napkin in the soiled linen bin, then without performing hand hygiene, repositioned R61 in her chair and assisted her out of the dining room. Observation, on 05/08/24 at 12:53 PM, revealed two unlabeled oxygen concentrators with the tubing and cannula attached but not stored in a sanitary manner, and one cannula rested directly on the floor. Interview, at that time with Consultant Nurse W confirmed the oxygen tubing and concentrators were infection control concerns. Observation, on 05/09/24 at 08:27 AM, revealed CNA W assisting two unidentified residents and failed to perform hand hygiene between the two residents. CNA W manipulated her glasses, scratched her nose, coughed into her hand, and failed to perform hand hygiene. Interview, on 05/09/24 at 08:50 AM, with Licensed Nurse Y, revealed she would expect staff to perform hand hygiene between residents and themselves. Observation, on 05/09/24 at 09:20 AM, revealed CNA U picked up a glass of cranberry juice by the top rim and handed it to R32, then left the dining room and did not sanitize their hands. Interview, on 05/13/24 at 03:30 PM, with Nurse Consultant W, revealed she would expect staff to ensure sanitary storage of oxygen concentrators and tubing, and would expect staff to perform hand hygiene to prevent the spread of infection. The facility policy Infection Management Process instructed staff to provide education on hand hygiene to include hand washing and hand sanitation to prevent infection events. The facility failed to ensure staff performed hand hygiene during meals and failed to ensure sanitary storage of oxygen concentrators with tubing. - Observation, on 05/08/24 at 02:10 PM, revealed Licensed Nurse (LN) Y, provided Resident (R) 34 with right heel pressure ulcer dressing change, and did not perform hand hygiene after removing gloves, and donning a new pair to continue with the dressing change. Interview, on 05/09/24 at 02:00 PM, with Administrative Nurse B, revealed she would expect staff to provide hand sanitation between gloving. The facility policy Procedure for Dressing Change undated, instructed staff to remove gloves and perform hand hygiene before donning a new pair of gloves. The facility policy Infection Management Process instructed staff to provide education on hand hygiene to include hand washing and hand sanitation to prevent infection events. The facility failed to ensure staff performed hand hygiene during a dressing change. - Observation, on 05/08/24 at 11:03 AM revealed Licensed Nurse (LN) CC, obtained Resident (R) 5's blood glucose (sugar) level with a glucometer. Upon obtaining the sample, LN CC did not sanitize her hands, and used an alcohol wipe to sanitize the glucometer. Interview, at that time revealed two other residents used the glucometer on this unit, and the facility had Sani-wipes to sanitize the glucometer, but LN CC did not find them in the cart. Observation, on 05/09/24 at 06:26 AM, revealed LN DD obtained R5's blood glucose with a glucometer. LN DD wiped the glucometer with a Sani-wipe and stated the wet time was one minute. LN DD then read the container of Sani-wipes and confirmed the wet time as four minutes. LN DD stated two other residents used the glucometer. Observation, on 05/09/24 at 06:59 AM, revealed LN CC obtained R22's blood glucose with a glucometer. LN CC proceeded to sanitize the glucometer with an alcohol wipe. Interview, at that time with LN CC revealed two other residents on this unit utilized the glucometer and they would look for a Sani-wipe to sanitize the glucometer. Interview, on 05/09/24 at 11:00 AM with Administrative Nurse B, revealed she would expect staff to follow manufacture's instructions for sanitation of the glucometers and confirmed the glucometers were potentially used by multiple residents depending on the unit. The facility policy Infection Management Process revised 11/2023, instructed staff to properly sanitize the glucometers between each use. The device will be wiped with products that kill clostridium spores and blood borne pathogens. Staff will be educated on appropriate drying time before using. The glucometer User Instruction Manual instructed staff to use a commercially available EPA (environmental protection agency) registered germicidal wipe and follow the product label instructions to disinfect the meter. The facility failed to ensure staff sanitized the glucometer used by multiple residents to prevent the spread of blood borne pathogens. - Observation, on 05/09/24 at 01:30 PM, revealed Certified Nurse Aide (CNA) S, provided care to Resident (R) 22's when they emptied R22's urine collection bag. CNA S donned gloves and drained the urine from the collection bag into a urinal, which was stored in a plastic bag hanging in the resident's bathroom. Interview, at that time with CNA S, revealed she did not know what enhanced barrier precautions were, or what personal protective equipment was needed for R22's urine. Interview, on 05/09/24 at 01:40 PM , with LN T, revealed enhanced barrier precautions were implemented within the last few weeks and staff should wear a gown and gloves to empty a catheter. Observation, on 05/09/24 at 01:45 PM, revealed CNA U, prepared to empty R5's urine collection bag. CNA U donned a gown and gloves and proceeded to drain the urine from the collection bag into a urinal which was stored in a plastic bag hanging on the wall in the shared bathroom. After flushing the urine down the toilet in the resident's bathroom CNA U placed the urinal into the plastic bag. Interview, at that time, with CNA U revealed she should rinse the urinal in the soiled utility room and obtain a clean bag for the urinal. Interview, on 05/09/24 at 02:30 PM, with Administrative Nurse B, revealed she was in the process of implementing enhanced barrier precautions and utilized the CDC (center for disease control) recommendations. The CDC Summary of Personal Protective Equipment Use and Room Restriction When Caring for Residents in Nursing Homes undated. Instructed staff that enhanced barrier precautions required staff to wear gloves and gowns for high contact care activity for urinary catheters. The facility failed to ensure staff provided enhanced barrier precautions for these two residents with urinary catheters to prevent the spread of infection as required.

The facility reported a census of 81 residents. Based on observation, interview, and record review the facility failed to ensure residents had a right to voice grievances with respect to care and treatment, the behavior of staff, other residents, and other concerns regarding their long-term care stay. Additionally, the facility failed to make prompt efforts resolve the grievances the residents had and provide a written decision regarding his or her grievance. Findings included: - During an interview with Resident (R) 5 on 05/07/24 at 03:27 PM, he reported food could be better and he noted the facility would run out of food. R5 reported the food was cold at times and he just ate it, but sometimes would get aggravated and send it back. The facility did not have a cook for grill orders in the event residents did not want what was on the main menu. R5 reported the facility had a lot of changes in the kitchen. He stated he reported his concerns to Social Service Designee (SSD) F as well as voiced his concerns in Resident Council, but nothing changed. No one from the facility would come back to the council with an action plan, they just said they were working on it. He stated that he went to resident council most of the time and the residents were very outspoken. During the Resident Council Meeting on 05/08/24 at 01:10 PM 14 residents were in attendance and two staff members, which included Certified Nurse Aide (CNA)/Activity Director (AD) X and Social Services Designee (SSD) F. R5 voiced concerns, which included food related issues such as temperature, food availability, and receiving requested menu items. AD X asked the residents about their meals and associated concerns related to the facility meeting their expectations. The 14 residents in attendance unanimously complained about the food temperature, needing more variety, and lack of ethnic choices such as Japanese/Chinese cuisine. During the Resident Council Meeting on 05/08/24 at 02:08 PM, R5 stated residents had to eat what the facility gave them and not what they asked for. R 80 also spoke up and stated her tomato soup was ice cold and her pancakes were not hot enough at breakfast. On 05/09/24 at 09:23 AM, Social Service Designee (SSD) G stated the resident's reported concerns in the resident council meeting. She verified the concerns were communicated through e-mail to the appropriate department head for follow up after. SSD G stated she assumed the administrator tracked and logged the concerns to identify trends and patterns and ensure the residents received response to their concerns. She stated she did not track, maintain a log, nor check on follow up for resolution related to grievances expressed in Resident Council or on an individual basis. Review of the Grievance Logs dated 02/2023 through 05/07/24, revealed a lack of tracking and action plans for the resident's reoccurring grievances noted in the Resident Council meetings and lacked documentation of action plans and reviewed with residents. The concerns regarding food dissatisfaction lacked any indication they were addressed throughout the logs. On 05/09/24 10:17 AM, Administrative Staff A, confirmed the facility lacked evidence of action plans and follow-up with residents regarding their concerns as noted above. She verified Resident Council members grievances and concerns were not addressed with the residents to include an action plan to resolve the concerns to their satisfaction. She reported the facility failed to follow-up with the residents to give them a voice in the provision of their care related to their concerns. Additionally, she reported she had not received concerns from the resident council meetings. The facility policy Grievance Policy and Procedure, dated 03/2024, documentation included the facility was to provide a forum for residents and others to voice grievances to the facility and to have prompt efforts made by the facility to resolve grievances in a timely manner. The facility would follow-up within seven days. The policy failed to address grievances reported to resident Council. The facility failed to ensure residents had a right to voice grievances with respect to care and treatment, the behavior of staff, other residents, and other concerns regarding their long-term care stay. Additionally, the facility failed to make prompt efforts resolve the grievances the residents had and provide a written decision regarding his or her grievance.

The facility reported a census of 81 residents. Based on observation, interview, and record review the facility failed to ensure the resident had a right to organize and participate in resident groups in the facility, respond to written requests that resulted from group meetings, consider the views of a resident or family group, and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Additionally, the facility failed to demonstrate their response and rationale for such response to resident's concerns voiced in resident council. Findings included: - During an interview with Resident (R) 5 on 05/07/24 at 03:27 PM, he reported food could be better and he noted the facility would run out of food. R5 reported the food was cold at times and he just ate it, but sometimes would get aggravated and send it back. The facility did do not always have a cook for grill orders in the event residents did not want what was on the main menu. R5 reported the facility had a lot of changes in the kitchen. He stated he reported his concerns to Social Service Designee (SSD) F as well as voiced his concerns in Resident Council, but nothing changed. No one from the facility would come back to the council with an action plan, they just said they were working on it. He stated that he went to resident council most of the time and the residents were very outspoken. During the Resident Council Meeting on 05/08/24 at 01:10 PM 14 residents were in attendance along with two staff members, which included Certified Nurse Aide (CNA)/Activity Director (AD) X and Social Services Designee (SSD) F. R5 voiced concerns over food related issues such as temperature of the food, food availability, and receiving requested menu items. AD X asked the residents about their meals and associated concerns related to the facility meeting their expectations. The 14 residents in attendance unanimously voiced concerns about food temperatures, needing more variety of foods, and a lack of ethnic choices such as Japanese/Chinese cuisine. During the Resident Council Meeting on 05/08/24 at 02:08 PM, R5 stated residents had to eat what the facility gave them and not what they asked for. R80 also stated her tomato soup was ice cold and her pancakes were not hot enough at breakfast. Review of an e-mail dated 05/09/24 at 08:02 AM, titled Resident Council to Administrative Staff A from Social Services (SSD) F revealed it failed to address all of the concerns expressed by the residents regarding food. Review of the Resident Council Meeting Minutes, documentation for 01/2023 through 05/2024 revealed the facility lacked evidence of a Resident Council monthly group meeting and/or any associated concerns, grievances, and follow-up for 02/2023 through 07/2023 (seven consecutive months), 11/2023, 02/2024, and 04/2024. Review of the Resident Council Meeting Minutes for 08/2023 through 10/2023, and 12/2023, lacked any plan of action or follow up and/or a timely response to residents regarding the facility's actions to resolve grievances expressed by residents in the resident Council Meeting. The 10/19/23, Resident Council Minutes documented the resident's dissatisfaction with facility meals and the menu which included residents saying the food was cold and residents voicing that the food was not good. The concerns identified in the minutes lacked a plan of action and/or any follow-up by the facility. The 12/13/23, Resident Council Minutes documented the residents dissatisfaction with meals and menu, which included residents saying they did not have enough food, the facility ran out of things a lot, and residents were told they could not have something they wanted or seconds when they asked because the truck didn't bring enough. On 05/09/24 09:23 AM, Social Service Designee (SSD) G stated resident council should meet once a month and the facility should follow-up on the resident's concerns and get back with the resident. SSD G reported someone else should have kept the minutes for resident council. She confirmed the facility lacked evidence of resident Council meetings 02/23 through 07/2023, as well as social worker should do the minutes to confirm lack of resident council and cannot find minutes. She stated the resident should get a should expect a resolution within a week. The department heads should email response., but she did not know who tracked if that was done or not. the department should go to the resident to address the concern. On 05/09/24 10:17 AM, Administrative Staff A, confirmed the facility lacked evidence of monthly Resident Council meetings. She verified Resident Council members grievances and concerns were not addressed with the residents to include an action plan to resolve the concerns to their satisfaction. She reported the facility failed to follow-up with the residents to give them a voice in the provision of their care related to their concerns. Additionally, she reported she had not received concerns from the resident council meetings. The facility policy Grievance Policy and Procedure, dated 03/2024, documentation included the facility was to provide a forum for residents and others to voice grievances to the facility and to have prompt efforts made by the facility to resolve grievances in a timely manner. The facility would follow-up within seven days. The policy failed to address grievances reported to resident Council. The facility failed to ensure resident's rights to organize and participate in resident groups in the facility, respond to written requests that resulted from group meetings, consider the views of a resident or family groups, and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Additionally, the facility failed to demonstrate their response and rationale for such response to resident's concerns voiced in resident council.

The facility identified a census of 81 residents, which included 31 residents with active trusts held by the facility. Based on observations, interviews, and record review, the facility failed to provide quarterly statements for the 31 residents in facility. The facility further failed to establish and maintain a system that assured a full complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. Findings included: - Review of trust transaction history of all 31 residents identified that there were no copies of the quarterly statement available to review. On 05/09/24 at 02:36 PM, Administrative Staff O stated it was the facility's policy to offer trust statements quarterly based on the calendar year. Administrative O stated she has been at this post for a little over a week and was not sure what the previous business office manager did. Administrative Staff O stated she normally printed off three copies of the resident statements and sent two to the representative with a self-addressed stamped envelope and a request that the representative sign and return one copy to the facility. Administrative Staff O could not locate any copies of quarterly statements for any of the 31 residents that had trust funds managed by the facility at that time. On 05/13/24 at 11:06 AM, Administrative Staff A stated quarterly statements should be sent to residents or their responsible party. A copy of the statement should be obtained and maintained in the resident's file. Administrative Staff A stated that a trust fund statement could be given to a resident and or responsible party as requested. The updated policy Resident Funds Trust Account documented: The trust account is set up for the purpose of providing residents with a cash source for items such as facility monthly services, haircuts, pop money, personal care items and other items which are properly approved. The trust will be maintained at a local bank in an interest-bearing checking account. A signed invoice, cash register receipt or a paid-out voucher for individual items purchased must be kept on file for each resident. The resident or responsible party signing the forms will be mailed two copies of the accounting of resident's trust account on a quarterly basis. One copy must be signed and returned, showing approval of the quarterly transactions. This copy must be kept on file for five years post discharge. The facility failed to establish and maintain a system that assured a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.

The facility reported a census of 91 residents, with three residents sampled for accidents. Based on observations, record review, and interview, the facility failed to provide the care planned assistive device of a mechanical lift to prevent a fall for Resident (R2), when Certified Nurse Aide (CNA) M attempted to transfer the resident with a walker by herself. The resident fell from his recliner to the floor, on his face, and the resident sustained a fracture to his right ankle and bruising to his right eye area. Findings included: - R2's signed Physician Order Sheet, dated 06/08/23, documented the facility admitted the resident on 05/02/23. The resident's diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), artificial hip joint (artificial implant in the hip joint), and fracture of the right calcaneus (bone of the tarsus of the foot which constitutes the heel). The 05/08/23 Admission Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. He required two-person extensive assistance with bed mobility, toileting, and transfers. The resident did not ambulate. The resident was not steady, and only able to stabilize with staff assistance. He had impairment to both sides of his upper extremity and used a wheelchair for a mobility device. The resident had no falls. He received physical and occupation therapy during the look back period. The 05/15/23 Activities of Daily Functional (ADL)/ Rehabilitation Potential Care Area Assessment (CAA), documented the resident had impaired balance and transition during transfer. The 05/15/23 Falls Care Area Assessment (CAA), documented the resident had impaired gait and mobility that required assistance with transfers. The 05/02/23 ADL Care Plan documented the resident required two staff assistance with a sit to stand (mechanical) lift. The Care Plan revised on 05/04/23 documented the resident required extensive to total assistance of two staff using a Hoyer lift (full body mechanical lift), or a sit to stand with knobs to grip (clarify with nurse which sit to stand is appropriate). The Nursing Note's revealed on 06/02/23 at 07:40 AM, the resident was assisted by one staff member from the recliner to his wheelchair when the resident's knees weakened, and the resident fell to the floor. The resident continued to fall forward and landed on his face causing bruising to the right side of his temple. Emergency Medical Services (EMS) arrived and transported the resident to the Emergency Department for evaluation. On 06/02/23, a mobile X-ray revealed the resident sustained a subtle avulsion fracture (a bone fracture that occurred when a fragment of bone tears away from the main mass of bone because of physical trauma) of the lateral (side) aspect of the left calcaneus (heel bone). On 06/02/23, the computed tomography (CT) scan report revealed right supraorbital (pertaining to eye socket region) forehead soft tissue hematoma (abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel). The Clinical Health Review Fall Assessment, dated 05/02/23, revealed a score of nine, which indicated moderate risk for falls. The Fall Risk assessment dated [DATE], revealed a score of seven , which indicated moderate risk for fall. Review of the facility Investigation dated 06/06/23, revealed on 06/02/23 at 07:40 AM, the resident fell on his face when Certified Nurse Aide (CNA) M transferred the resident from his recliner to his wheelchair. R2 reported he fell on his face. The resident was initially sent to an acute hospital for evaluation regarding facial bruising. The resident returned with no new orders. `The resident had bruising and swelling to his right ankle and X-ray showed a fracture to the right ankle. The facility determined the root cause to be CNA M failed to follow the resident's care plan during transfer. The resident reported CNA M was the only staff assisting the resident in his room. Review of CNA M's witness statement on 06/02/23, documented a CNA M asked another CNA P for assistance. The other staff member advised CNA M that R2 was able to transfer with a walker. CNA P informed CNA M to keep the wheelchair close to the bed. CNA P assisted with pulling up his pants and reported to CNA M that you should be good now and left the resident's room. The resident took a step to get to his wheelchair and fell to his knees. CNA M yelled for help and put the call assistance light on, then she went to the door and yelled help again. Before she could get back to him, he fell completely to the floor, hitting the right side of his head and eye. On 06/13/23 at 04:09 PM, Certified Nurse Aide N and Certified Nurse Aide O transferred R2 with a full body mechanical lift with no concerns. On 6/12/23 at 12:21 PM, R2 reported CNA M tried to transfer him without another staff member and he fell and hit his head on the floor. He was sent to the hospital by EMS and an x-ray was done, revealing he had a fracture to his right ankle. He reported another staff member also transferred him without help. On 6/12/23 at 03:09 PM, Social Services Designee X, reported CNA M hollered for help from the resident's room. The resident slid out of his chair. On 06/13/23 at 09:32 AM Administrative Nurse D reported CNA M did not follow the resident's care plan by transferring the resident without a mechanical lift. She reported this resident required two staff and a mechanical lift for transfers. On 06/13/23 at 10:01 AM Administrative Staff A verified that CNA M did not follow the residents care plan by transferring the resident by herself and not using the mechanical lift On 06/15/23 at 09:45 AM, CNA P reported she received a report that R2 had been working with therapy and was transferring with a walker. She reported R2 previously transferred very well with his walker . She reported she had not verified his change in transfer status with his care plan or the charge nurse. On 06/15/23 at 10:09 AM, per phone conversation, CNA M reported she received a report that R2 was able to transfer with a walker. The previous week the resident's transfer status was a sit to stand or full body mechanical lift with three staff members due to weakness. She verified she did not review the resident's current care plan and check with the charge nurse for the change in transfer status and should have. She reported when she attempted to assist R2 to stand, he slid out of his recliner to his knee and landed on his face on the floor. He had bruising and began bleeding to the right side of his face. She stated she called out for help, and the social worker and the Charge Nurse came to assist her. EMS transferred to the ED for evaluation. The facilities policy for Fall Management, dated 12/2022, documented the staff will minimize the risk for resident falls and to reduce injuries associated with resident falls. The facility failed to provide the care planned assistive device of a mechanical lift to prevent a fall for R2, when a Certified Nurse Aide (CNA) M attempted to transfer the resident with a walker by herself. The resident fell from his recliner to the floor on his face, sustained a fracture to his right ankle and hematoma to his right eye area.

The facility reported a census of 89 residents with 20 selected for review including three residents reviewed for pressure ulcers. (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) Based on observation, record review, and interview, the facility failed to prevent the development of and promote healing of a pressure ulcer diagnosed as a stage three (full thickness loss of skin usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R)41. In addition, the facility failed to perform a dressing change with sanitary conditions related to infection control. Furthermore, the facility failed to prevent the development of and promote healing of three pressure areas diagnosed as a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without sloughing or bruising and may also present as an intact or open/ruptured blister) for R68, with two of the areas merging into one pressure area and advancing to a stage three pressure ulcer. Findings included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R68 with having a short-term and a long-term memory problem, severely impaired decision making, and the resident did not reject care. She required extensive assistance of two or more staff for bed mobility, transfers, and toileting. She was always incontinent of her bowel and bladder, and she was not on a scheduled toileting program. R68 was at risk for pressure ulcers and had no pressure ulcers present. She had a pressure reducing device for her bed, she was not on a turning/repositioning program, and had ointments/medications applied other than to her feet. The Significant Change MDS dated [DATE], assessed R68 with no changes to her cognitive status or rejection of care. She continued to require extensive assistance with bed mobility, transfers, and toileting. She was always incontinent of bladder and frequently of bowels and she was not on a scheduled toileting program. R68 was at risk for developing pressure ulcers and had two stage two pressure areas that were not present on admission. She did not have a pressure reducing device for her chair, although she had a pressure reliving device for her bed. She was not on a turning/repositioning program and did not receive nutrition/hydration interventions to manage her skin problems. R68 received pressure ulcer care, application of non-surgical dressing (with or without topical medications) other than to her feet and application of ointments/medications other than to her feet. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 07/01/22, revealed R68 was incontinent of bowel and bladder so she wore an adult brief and the staff assisted by checking her and changing her. She required extensive assist of two staff for toilet use. The Pressure Ulcer CAA dated 07/01/22, revealed R68 had a significant change assessment done due to the development of two pressure ulcers. She had memory impairment and impaired decision making as well as difficulty understanding verbal communication at times and making herself understood. R68 required extensive assistance from two staff for bed mobility, transfers and toilet use. Staff inspected her skin with bathing and daily cares, would apply a barrier cream for prevention of skin breakdown, and she had a pressure distributing mattress. These interventions did not prevent development of two stage two pressure ulcers to her buttocks. The staff first noted the areas to have worsened to a stage two on 06/09/22. The Care Plan located in the care plan book, dated 04/18/22, revealed R68 was at risk for pressure ulcers due to her decreased mobility and inadequate nutrition. The staff were to monitor her skin with routine cares and report any red/opened areas to the nurse. The staff were to keep her skin clean, dry, and moisturized, and to encourage her to change positions frequently. A pressure relieving device was on her bed, sugar free shakes provided twice daily to help with nutrition and prevent skin issues. Staff were to reposition her every two hours. She had frequent episodes of incontinence and always wore a brief. The staff were to check her every two hours and change her and she was on a scheduled toileting plan. The Care Plan, located in the EMR, dated 05/10/22 revealed R68 had an alteration in skin integrity related to pressure wounds. The staff were to assess the wounds for signs and symptoms of infection in or around the wound. On 05/19/22, skin barrier added for prevention of wounds. The Skin/Wound Condition Assessments revealed the following: 1. On 06/01/22, the staff observed no skin issues. 2. On 06/08/22, a scratch to the coccyx measured 0.5 centimeters (cm) by 0.5 cm. R68 continued to have a small area that had dry skin around an area, which looked like it had been scratched. Her fingernails were cut to prevent any further scratching. 3. On 06/09/22, one day later, the assessments identified a stage two pressure area to the coccyx, which measured 1.5 cm by 1.0 cm. The staff cleansed, dried, applied Polymem (a multifunctional dressing), and covered it with [MEDICATION(S)] (a thin clear dressing). The staff identified the pressure ulcer on 06/09/22. The assessment lacked a description of the wound and surrounding tissue. 4. On 06/14/22, the resident's right buttock had an area of shearing (force or pressure exerted against the surface and layers of the skin as the tissues slide in opposite planes) that measured 1.5 cm by 1.5 cm and the left buttocks had an area of shearing that measured 0.5 cm by 0.5 cm. The document lacked an assessment of the coccyx (a small triangular bone at the base of the spine) wound. 5. On 06/22/22, the pressure area to the coccyx advanced to a stage three pressure area and measured 1.0 by 1.5 cm. An additional note revealed a stage two coccyx pressure area that measured 1.5 cm x 1.0 cm. The document lacked an assessment of the right and left buttocks and a description of the wounds and surrounding tissue. 6. On 06/28/22, revealed an incomplete assessment that lacked documentation. 7. On 06/29/22, revealed a stage two pressure area to the right buttocks that measured 0.5 cm by 0.5 cm and a stage two area to the left buttocks that measured 0.5 cm by 0.5 cm. The assessment included the staff observed no further skin conditions and lacked if the coccyx wound had been resolved or a description of the wounds and surrounding tissue. 8. On 07/06/22, revealed the stage two pressure area to the right buttocks measured 2.5 cm by 1.0 cm and the stage two area to the left buttocks measured 0.5 cm by 0.5 cm. The assessment lacked a description of the wounds and surrounding tissue. 9. On 07/09/22, the right buttock stage two pressure area measured 0.5 cm by 0.3 cm by 0.1 cm deep. The stage two area to the left buttocks measured 1.7 cm by 0.7 cm by 0.1 cm deep. The stage two area to the coccyx measured 1.5 cm by 0.5 cm by 0.1 cm deep. The assessment included a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment included no signs and symptoms of infection and lacked a description of the wounds and surrounding tissue. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (skin barrier ointment) to the coccyx every shift for skin condition, dated 04/26/22. 2. House supplement (nutritional drink) one time a day, dated 04/26/22. 3. Clean coccyx with a wound cleanser, dry area, apply [MEDICATION(S)], change every three days and as needed if (the dressing) becomes soiled, is not placed properly, or is removed, every shift, assess every shift, until healed, dated 06/16/22. The Progress Notes dated 06/07/22 at 09:44 AM revealed R68 had a scratched area to the inside of her right buttocks that the staff cleansed and applied [MEDICATION(S)] to. R68 had a pressure relieving cushion on the dining room chair, a preventive equipment area mat on her bed, and staff repositioned her every two hours. The Progress Notes dated 06/08/22 at 09:28 AM revealed [MEDICATION(S)] continued to the resident's buttock. Dry, flakey skin present. The Progress Notes dated 06/09/22 at 11:39 AM revealed the staff was monitored the right inner buttock related to an Abrasion (scraping or rubbing away of a surface, such as skin, by friction). The Progress Notes dated 06/09/22 at 07:22 PM, revealed the coccyx condition worsened and measured 1.5 cm by 1.0 cm. The staff treated the area by cleaning with wound cleanser, drying, applying Polymem, and covering with [MEDICATION(S)]. At 07:29 PM a note revealed the staff notified the doctor of the skin condition. The Progress Notes dated 06/14/22 at 04:16 PM revealed the open area on the right buttock increased in size and there was a new pinpoint area to R68's coccyx. The treatment changed to cleanse with wound cleanser, pat dry, and apply [MEDICATION(S)], change every three days and as needed. R68 was to have a pressure relieving cushion while in her wheelchair or recliner. The Progress Note dated 07/11/22 revealed the physician gave approval for consult with Wound Care Plus. On 07/11/22 at 10:20 AM observed R68's bed with an air mattress overlay in place to her bed. On 07/11/22 at 01:23 PM observed R68 sitting in a recliner with a gel type cushion in the seat of the recliner. On 07/11/22 at 03:08 PM an unidentified family member stated R68 had an abrasion to her buttocks and was not sure how long it had been there, the facility was Doctoring it. On 07/12/22 at 08:55 AM Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R assisted R68 to transfer from the wheelchair to a recliner placing a gel cushion to the recliner and elevating her feet. On 07/12/22 at 08:58 AM Licensed Nurse (LN) G stated R68 had three different open areas that the charge nurse measured weekly, and the dressing was intact this morning. On 07/12/22 continuous observation revealed R68 remained in the recliner with her feet elevated from 08:55 AM until 11:30 AM, a total of two hours and 35 minutes. The resident did not shift her weight around while she sat in the recliner. On 07/12/22 at 11:30 AM, CNA M and CMA R transferred R68 from the recliner to the wheelchair (two hours and 35 minutes after transferring to the recliner) then from the wheelchair to the dining room chair with a gel cushion in place. CNA M and CMA R did not toilet R68 before taking her into the dining room. The staff failed to reposition the resident every two hours, per the care plan and failed to check her for incontinence at that time. On 07/12/22 at 01:27 PM, CNA M and CMA R transferred R68 from the dining room chair to her wheelchair, then to a recliner, moving the gel cushion to the recliner seat. The staff failed to toilet her at this time or check the brief to see if she needed to be changed, resulting in observations of four hours and 32 minutes without R68 being checked for presence of incontinence. On 07/12/22 at 01:33 PM, CMA R stated she assisted R68 to the toilet after breakfast before assisting her to the recliner. The staff were to check R68 three times during the day shift and she was a Heavy wetter. The staff should check her before breakfast, and after breakfast she is assisted to sit on the bedside commode, then again right before lunch. R68 has a patch on her bottom and staff should make sure it is in place. Staff usually felt the brief to be able to tell if it was wet or staff could smell if she had a bowel movement. CMA R stated the brief was felt when they transferred her to the recliner, and it was Crinkly indicating it was dry. CMA R stated R68 was to be repositioned every two hours. On 07/12/22 at 02:21 PM, CNA N and CNA O transferred R68 from the recliner to her wheelchair, then to the toilet in her personal bathroom. Observed the dressing to her coccyx to have wrinkles and was loose in places. The incontinent brief removed observed to be wet and had bowel movement streaks. CNA O commented to CNA N that the nurse needed to be told R68 needed a new Patch. On 07/12/22 at 02:32 PM, CNA N and CNA O transferred R68 back to the wheelchair, then transferred her to the recliner in the living room area. On 07/12/22 at 02:36 PM, CNA O notified LN H the dressing was still in place, but loose in places. On 07/12/22 at 02:59 PM, LN H stated she would be doing a dressing change for R68 and was gathering supplies while the staff assisted her to the bed. On 07/12/22 at 03:13 PM, CNA O and CNA N transferred R68 from the wheelchair to the bed. LN H removed the dressing from R68's coccyx area, removed her gloves, and applied a new pair without performing hand hygiene. LN H then used gauze pads she had sprayed with wound cleanser and dabbed the pressure areas several times. Observed an open area to the coccyx that merged with the area to the left buttocks and an open area to the right buttocks. LN H measured the right buttocks as 0.7 cm by 0.5 cm and the area to the coccyx/left buttock as 3.0 cm by 0.5 cm and stated they were both stage two areas. LN H then applied a new dressing that covered the left buttock/coccyx area and a separate one to cover the right buttock. On 07/12/22 at 03:23 PM, LN H stated last week the area on the coccyx had started merging with the other area and that she documented it as the coccyx area. LN H stated that hand hygiene should have been performed after removing her gloves before applying a new pair to clean the wounds. When asked how the areas developed, LN H stated that the old briefs used before the new company took over pulled the moisture away better than the new briefs and R68 had declined and did not walk as much, and the staff have to reposition her and check and change her every two hours. The staff were to make sure she was dry, and they should visibly check the brief and not rely on feeling the brief for Crinkling as an indicator she is dry. On 07/12/22 at 09:52 AM, CNA P and CMA R transferred R68 from the wheelchair to the bedside commode. R68's brief was wet and had bowel movement smears in it, and the coccyx and left and right buttocks lacked a dressing. There were bowel movement smears to the wipes during cleansing where the pressure ulcers were. On 07/17/22 at 09:54 AM, CNA P stated R68's dressing got Ripped off before breakfast which was around 07:00 AM when they got her up for the day and toileted her. The dressing had not been replaced because the nurse Got busy. On 07/12/22 at 10:00 AM, CNA P and CMA R transferred R68 to the wheelchair, then to the bed. Staff positioned the resident with her tilted to her right side with a pillow placed behind her back/bottom. On 07/12/22 at 10:31 AM, LN H entered R68's room with Administrative Nurse E to replace the dressing. This was approximately three-and-a-half hours after the dressing was no longer in place. On 07/12/22 at 10:42 AM, LN H stated the staff told her the dressing was off a Little before breakfast and it should have been done as soon as they told me. On 07/14/22 at 09:43 AM, Administrative Nurse D stated the staff should follow the care plan for repositioning and toileting, and the staff did not reposition her and toilet her in a timely manner on 07/12/22. If the dressing comes off, it should be replaced as soon as possible and should have been applied sooner on 07/13/22 when it had come off. Administrative Nurse D stated hand hygiene should be performed before applying a new pair of gloves during dressing changes. The facility policy Wound Prevention and Management dated 12/2018, revealed the resident would be repositioned in order to meet individual needs and those needs would be identified on the care plan. Incontinent care should be provided to meet the individual resident needs. The facility failed to prevent the occurrence of three pressure areas and failed to reposition, toilet, change the incontinent product, and replace the dressing in a timely manner for R68 to assist with wound management and prevention in development of further wounds. Furthermore, the facility failed to use appropriate infection control practices when providing wound care to prevent contamination to the wound, increasing the risk for infection. - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had moderately impaired cognition. She required extensive assistance of two staff for bed mobility and transfers. The resident used a wheelchair for locomotion. She was independent with eating and had no significant weight gain or loss. She was at risk for the development of 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) with one stage II (partial-thickness loss of skin with exposed dermis) unhealed PU, not present on admission. She received pressure ulcer care. The Pressure Ulcer Care Area Assessment (CAA), dated 05/05/22, documented the staff were to treat the resident's PU per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a pressure relieving device to her wheelchair and a pressure relieving mattress. The quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She required extensive assistance of two staff for bed mobility and transfers. She used a wheelchair for locomotion. She was frequently incontinent of bowel and bladder. She was independent with eating and had no significant weight gain or loss. She was at risk for the development of PU with no unhealed PUs at the time of the assessment. She had a pressure reducing device for her wheelchair and bed and received nutritional interventions for her skin. The care plan for Bowel and Bladder, updated 05/19/22, instructed staff the resident was incontinent of bowel and bladder. Staff were to perform proper peri-care (cleansing of the genitals). The care plan for Activities of Daily Living (ADL), updated 05/19/22, informed staff the resident required extensive assistance of two staff for bed mobility. The care plan for Skin Integrity, updated 05/19/22, instructed staff the resident was at risk for the development of pressure ulcers. The resident required encouragement and assistance to shift or alter her body while in her wheelchair or bed. Review of the resident's electronic medical record (EMR), under the Misc (miscellaneous) tab, revealed documentation, dated 07/05/22, 12/29/21 and 03/18/22, which documented the staff would do weekly skin assessments, per the facility protocol. On 05/05/22, documentation in the resident's EMR, under the Progress Notes tab, revealed the resident had an open area to her coccyx (small triangular bone at the base of the spine), which measured 5.0 width (W) by 0.25 length (L) by 0.25 depth (D) centimeters (cm). The area had red outer edges with a black/purplish coloring on the wound bed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to reposition the resident from side to side every two hours. Further documentation on 05/05/22, revealed the resident had a stage II (partial thickness skin loss involving the dermis), which measured 3.5 L by 2.5 W cm. Review of the resident's EMR, under the, Skin/Wound Condition Assessment, under the Assessments tab, revealed the following: On 05/19/22, the resident had a stage II PU to her coccyx which measured 3.5 W by 2.5 L by 0.1 D, cm. The resident had a wheelchair cushion and staff were repositioning the resident. On 06/26/22, documentation revealed staff were to cleanse the wound with wound cleanser and apply Thera Honey (help create a moist wound environment conducive to wound healing) every day and as needed (PRN), until healed. Documentation lacked measurements or description of the wound. On 07/07/22, documentation revealed coccyx. No other documentation was available regarding the wound. On 07/13/22, documentation revealed the resident had a stage III (involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue), which measured 1.0 L by 0.5 W by 0.4 D cm. The area was noted to have red granulation tissue (new vascular tissue in granular form on an ulcer or the healing surface of a wound) on the wound bed with the edges slightly rolled. The wound had no drainage. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No further wound documentation was available. On 07/12/22 at 08:30 AM, the resident sat in her wheelchair, with a gel cushion, in the TV room. The resident had a slumped body position. At 08:58 AM, Certified Nurse Aide (CNA) QQ, attempted to reposition the resident in the wheelchair by holding onto the waist band of the resident's pants and pulling her back in the chair. The resident's buttocks did not rise above the seat cushion during the attempt at repositioning. The resident then slumped back down into the chair. At 11:11 AM, the resident remained in the same slumped position. This surveyor requested staff do a skin check as the resident had not been repositioned in over two and a half hours. CNA QQ and RR transferred the resident from her wheelchair to the bed with the use of the Hoyer lift (a full body mechanical lift). Licensed Nurse (LN) J entered the room to assess the resident's wound. Staff removed the resident's brief which revealed a foam dressing, dated 07/10/22, to the resident's coccyx. LN J removed the dressing to reveal the wound, which measured 2.1 L by 0.2 W by 0.9 D cm. Slough (dead tissue, usually cream or yellow in color) was present from 10 o'clock to 12 o'clock position with a small amount present on the wound bed. On 07/12/22 at 11:18 AM, CNA QQ stated she thought the resident was lying down in bed and did not realize she had been up in her chair for so long. Staff were to turn and reposition the resident at least every two hours but verified she had not done so that morning. On 07/12/22 at 11:19 AM, CNA RR stated staff were to turn and reposition the resident every two hours due to her having a PU. On 07/13/22 at 07:36 AM, CNA RRR stated the resident was total care. Staff were to turn and reposition her every two hours due to the PU on her bottom. On 07/12/22 at 11:29 AM, LN J stated the facility had a nurse from the wound care come to the facility each week. They had not seen this resident's wound yet. Staff were to turn and reposition the resident at least every two hours, but that did not always happen. The PU was facility acquired. The resident was unable to reposition herself. LN J was unsure of who was to document on wounds in the EMR. LN J stated she only did the dressing changes and did not typically measure or document on the wound. On 07/13/22 at 06:53 AM, LN K stated staff were to turn and reposition the resident every three to four hours. The resident was unable to reposition herself. On 07/13/22 at 01:42 PM, LN I stated she had not notified the physician of the resident's worsening PU and was unsure of who was in charge of contacting the physician. Staff were to turn and reposition the resident every two hours. On 07/14/22 at 11:55 AM, Administrative Nurse D stated the wound care staff would see the resident for the first time that day. The facility only obtained the order for the wound care consult on 07/13/22 as they were unaware of the worsening of the wound to a stage III PU. Administrative Nurse D was unsure of where the skin assessments to predict the development of pressure ulcers were located for this resident. The nursing staff failed to measure and document the skin assessments as they should have been. There was no other wound documentation available. The facility policy for Wound Prevention and Management, revised 12/2018, included: DON or Designee will complete an assessment of all wounds weekly using the Skin/Wound Condition Assessment in the electronic medical record, until resolved. Residents will be repositioned in order to meet their individual needs. The facility failed to ensure appropriate services to prevent the development of a stage III PU on this dependent resident's coccyx.

The facility reported a census of 33 residents, with three residents sampled for accidents. Based on observation, interview, and record review, the facility failed to ensure one of the three sampled residents, Resident (R1), remained safe from falls when staff left the resident unattended on the toilet, the resident fell twice in two days, and sustained a fracture of the left knee. Findings included: - The signed Physician Order Sheet (POS) for Resident (R1), dated 08/01/21, revealed the following diagnoses; Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), [CONDITION(S)] (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and [CONDITION(S)] ([CONDITION(S)], sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain.) The Significant Change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of six, indicating severely impaired cognition. She required two-person extensive assistance with transfers and toileting. The resident required a wheelchair as her mobility device. The resident had no falls since the prior assessment. The Activities of Daily Living/Functional Care Area Assessment, dated 01/21/21, documented the resident required two-person extensive assistance with transfers and toileting. She required one-person extensive assistance with locomotion utilizing a wheelchair. She required one-person extensive assistance with personal hygiene. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, which indicated the resident had moderately impaired cognition. She required one-person extensive assistance with transfers and toileting. She had impairment on one side of her upper and lower extremities. She required one-person extensive assistance with locomotion with her wheelchair . The resident had no falls since the prior assessment. The revised Activities of Daily Living and Rehabilitation Potential Care Plan, dated 07/07/21, documented the resident required one to two-person extensive assistance with transfers, toileting, and personal hygiene. The resident utilized a wheelchair with one-person limited assistance. The resident was non-ambulatory. Review of the Facility Investigation, on 08/15/21 at 03:15 PM, Certified Nurse Aide (CNA) MM assisted the resident in the community resident bathroom with toileting. The community restroom areas were divided by a privacy wall by the toilet. CNA MM verified she placed the resident in her wheelchair in front of the toilet, and stepped away from the resident, leaving her unattended, went around the wall to obtain toileting supplies from the cabinet and CNA MM heard the resident fall. The intervention for this fall was the (moderately impaired cognitive) resident should verbalize to staff when she was ready to be transferred to the toilet before attempting to stand on her own. Review of Facility Investigation on 08/16/21 at 10:15 PM, revealed CNA NN propelled the resident to her restroom in her room where she had the second fall. CNA NN stood behind R1's unlocked wheelchair at the toilet. CNA NN removed the resident's unlocked wheelchair from behind the resident. The resident held onto the grab bars on the wall next to the toilet when the resident stood to transfer without staff assistance to the toilet. The resident missed the toilet and slid down the wall onto the floor. The resident complained of left knee pain . CNA NN advised during prior transfers with toileting for this dependent resident, she completed transfers by standing behind the wheelchair as the resident did hold on to the grab [NAME] while she removed the unlocked wheelchair from behind the resident. Nursing Notes on 08/17/21 at 8:34 PM, documented the resident complained of sharp stabbing pain in her left knee. The Mobile X-ray Report of the left knee received on 08/18/21, revealed a fracture that involved the proximal tibia (larger of the two bones in the lower leg) with possible extension into the articular eminence (knee fracture). Nursing Notes on 08/19/21, stated the resident returned from the orthopedic (bone specialist) physician due to tibia and fibula (smaller bone in the lower leg) fracture. The resident had a cast on her left leg from her thigh to the bottom of her feet. Observation an, on 09/07/21 at 09:36 AM, revealed R 1 sat in a locked wheelchair in the commons area participating in an activity. Her foot pedals were secure on her wheelchair and her bilateral lower extremities placed on the foot pedals. On 09/07/21 at 01:07 PM, revealed CNA M and CNA N transferred the resident with a full body mechanical lift. The resident was non-weight bearing. On 09/07/21 at 03:19 PM, revealed R1, CNA O, CNA P and CNA OO transferred R1 from her bed to her wheelchair with a full body mechanical lift. On 09/07/21 at 11:07 AM, LN G advised R1 fell on [DATE] in her restroom in her room when the resident stood up by herself at the toilet and fell . LN G advised R1 fell again on 08/16/21, in the community residents' restroom while staff left her unattended. On 09/07/21 at 1:43 PM, CNA Q advised that the resident needed two-person extensive assistance with bed mobility, transfers, and toileting. She cannot be left unsupervised in the restroom. On 09/07 /21 at 1:53 PM CNA N advised that resident needed one-person extensive assistance with a gait belt for bed mobility, transfers, and toileting. The resident wheelchair should always be locked during transfers. CNA N stated she stood beside her to transfer her and she should always be supervised in the restroom. On 09/07/21 at 1:57 pm CNA N advised the resident required two-person extensive assistance with bed mobility, transfers, and toileting. She does not stand behind the wheelchair and let her transfer herself. On 09/07/21 at 03:20 PM CNA P advised the resident needed limited to one-person extensive assistance prior to her fall. She had a [CONDITION(S)] with left side weakness. There are many days that she required two-person assistance due to the [CONDITION(S)]. At this time, she required two-person extensive assistance with toileting, bed mobility, and transfers. She needed supervision in the restroom and cannot be left alone due to her impulsiveness to transfer to the toilet and left sided weakness. On 09/07/21 at 03:33 PM, Administrative A staff advised that R1's ADL care plan updated to one to two-person extensive assistance due to increased needs related to her [CONDITION(S)] and left sided weakness. The resident fell on [DATE] in the residents' community restroom, when a staff member left her unattended at the toilet. On 08/16/21, she had another fall in her restroom when a staff member was behind the resident's locked wheelchair as the resident had a hold of the grab bars and transferred herself to the toilet without staff assistance. An x-ray of her left knee obtained after she fell on [DATE] revealed a fracture to her left knee. On 09/07/21 at 4:00 PM, CNA MM, advised on 08/16/21 at approximately 03:15 PM, she propelled R1 into the resident's community bathroom from the commons area. The community bathroom was two small rooms divided by a wall with the toilet behind the wall that allowed privacy from the entrance door. CNA MM advised that she placed R1 in her wheelchair at the toilet and she stepped around the wall to obtain toileting supplies for the resident. CNA MM advised when she stepped away from the resident and around the wall, she heard the resident fall. On 09/07/21 at 02:08 PM CNA NN reported on 08/16/21 at approximately 10:15 PM, she propelled resident into her bathroom into her room and she instructed the resident to pull herself up on the transfer hand rails (without staff assistance), while she was behind the locked wheelchair. The resident was unable to hold herself in an upright position and fell . The facility's Accident and Incident Reports policy, dated 02/21/19, documented the resident's care plan will be updated with the immediate intervention implemented to prevent another accident. The facility failed to ensure this confused resident who required extensive assistance with transfers and toileting, received necessary staff assistance when the resident had two falls within two days, in the bathroom. On 08/15/21 staff left the resident unattended while gathering supplies and the resident fell . On 08/16/21, staff failed to provide the needed assistance to transfer from a wheelchair to the toilet and the resident fell and sustained a fracture of the left knee.

The facility reported a census of 129 residents. Based on observation, interview, and record review, the facility failed to provide supervision to prevent elopement, (an act or instance of running off secretly), from the facility for 1 (#1) of the residents sampled for elopement. The resident left the facility unsupervised at approximately 10:00 p.m., and ambulated 2 1/2 blocks from the door he/she exited. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's POS (physician's orders [REDACTED]. from impaired blood flow to the brain and included behaviors). The annual MDS (Minimum Data Set), dated 5-13-16, revealed the resident had a BIMS (Brief Interview for Mental Status) of 8, indicating the resident had moderately impaired cognition. The resident's mood score was 17, indicating the resident had moderate to severe depression. The resident had no episodes of psychosis, rejection of care or wandering. His/her locomotion on the unit required supervision and locomotion off of the unit was independent. He/she had no limitation in his/her functional range of motion. The resident used a walker for ambulation. The resident received an antipsychotic medication 5 out of 7 days and an antidepressant medication 7 of the 7 days of the assessment period. The ADL (Activities of Daily Living) CAA (Care Area Assessment), dated 5-13-16, documented the resident was independent with ambulation. Behaviors did not trigger for further assessment. The readmission MDS, dated [DATE], documented the staff assessed the resident with moderately impaired cognitive skills for daily decision making. The resident had fluctuating disorganized thinking present, hallucinations (sensing things while awake that appear to be real, but the mind created), and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident had behavioral symptoms which included verbal behavioral symptoms directed towards others and behavioral symptoms not directed towards others, which occurred 4-6 days of the assessment period. Wandering behavior was present 1-3 days and rejection of care was present 4-6 days. The resident received an antipsychotic medication 4 of the 7 days and an antidepressant medication 7 of the 7 days. The care plan, dated 5-20-16, informed staff the resident made poor decisions at times related to a psychotic disorder. The resident ambulated with the use of a 4 wheeled walker. The care plan instructed staff to intervene as needed to ensure the resident's safety. The resident liked to smoke several times a day and enjoyed going outside if the weather was nice. Staff were to remind the resident to turn off his/her oxygen tank while smoking. On 5-30-16, an addition to the care plan directed staff to accompany the resident when he/she went outside. An addition to the care plan on 7-11-16, after the resident eloped on 7-10-16, instructed staff the resident had a tendency to wander related to dementia (progressive mental disorder characterized by failing memory, confusion). Staff were to provide supervision for the resident and check his/her Code Alert bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) every shift. Staff were to provide regular opportunities for the resident to go outside with supervision. An e-mail, sent 6-02-16 at 11:21 a.m., from administrative nursing staff B, to all staff directed, the resident was not allowed to go outside to smoke by him/herself. All staff were to be made aware of this. Record review revealed elopement assessments completed on 5-30-15, 6-17-15, 6-26-15, 8-25-15, 10-19-15, 5-06-16, and 7-07-16, which all determined the resident to be at risk for elopement. Record review revealed a Code Alert bracelet was not placed on the resident until 7-11-16, after the resident left the building unattended. Review of nursing notes included the following: A nurses' note on 5-30-16 at 10:15 p.m., stated that at 10:00 p.m., the resident went out to the courtyard to smoke. Staff saw the resident walking in the facility parking lot and accompanied him/her back inside. No Code Alert bracelet was placed on the resident at this time. A nurses' note on 6-14-16 at 12:38 p.m., stated that on 6-08-16 the resident became upset and placed a large sum of clothing over his/her walker. The resident stated he/she was refusing to stay, but could not verbalize what had upset him/her. Staff redirected the resident. A nurses' note on 6-16-16 at 9:33 a.m., stated the resident ambulated in the halls at 9:30 a.m. and was easily agitated and disoriented. The resident stated he/she was looking for the car. Staff were unable to redirect the resident. The physician ordered a UA with C&S (urinalysis with culture and sensitivity to check for a urinary tract infection), if indicated. A nurses note on 6-18-16, the UA results evidenced there was no need for a C&S, indicating the resident did not have a urinary tract infection. A nurses note on 6-18-16 at 9:13 p.m., at 8:00 p.m., the resident removed all of his/her clothing from the closet and piled it on the floor. The resident stated he/she was leaving. Staff attempts to redirect the resident were not successful. About 10 minutes later, the resident became calm and cooperative. A nurses note on 6-21-16 at 3:27 a.m., documented at 2:30 a.m., the resident removed everything from his/her closet and dresser drawers and piled it in the middle of his/her floor. A nurses note on 6-21-16 at 4:52 p.m., documented an order from physician M for a geri-psych evaluation. A nurses note on 6-22-16, recorded at 1:23 p.m., at 1:20 p.m., the facility transferred the resident to a geri-psych center for evaluation. Nursing note on 7-07-16 at 3:32 p.m., recorded at 1:10 p.m., resident #1 returned to the facility. A nurses note on 7-10-16 at 10:15 p.m., recorded staff observed the resident walking two blocks east of the facility. (Direct care staff J, K, and L, returned the resident to the facility after seeing him/her after leaving work that evening.) The resident was brought back to the facility without difficulty. The resident stated he/she was on his/her way to go home. The outside temperature was 84 degrees Farenheit, verified according to wunderground.com. A witness statement reviewed on 7-26-16, revealed direct care staff O stated, he/she saw the resident in the lobby at approximately 9:50 p.m., the evening of 7-10-16. On 7-26-16 at 3:02 p.m., administrative nursing staff B stated, the speed limit of the three nearest streets was 30 MPH (miles per hour), and the connecting streets had street lights. Staff B stated the resident was out of the facility for approximately 4 minutes. On 7-26-16 at 10:03 a.m. the resident ate breakfast at the dining room table with another resident. The Code Alert bracelet was visible to the resident's right wrist. The resident had no behaviors, at that time. On 7-26-16 at 3:00 p.m., the resident ambulated in the hall with his/her walker and a steady gait to the inside resident smoking room. The Code Alert bracelet remained attached to the resident's right wrist. On 7-27-16 at 10:27 a.m., direct care staff H stated, on 7-10-16, he/she came to work for the night shift. He/she mostly worked in the special care unit, but was filling in on another unit that night. Shortly after 10:00 p.m. that evening, the resident approached staff H and stated he/she had forgotten the code to the door and needed to go out to get folding chairs he/she left outside during a fireworks display the facility had that evening. Staff H stated he/she let the resident out of the doors, on the northwest side of the building and did not realize the person was a resident of the facility. A few minutes later, another direct care staff asked staff H if he/she had seen the resident. Staff H described the person he/she had let out of the door then realized the person was a resident of the facility. At that time, several staff members went outside to look for the resident. The resident was not seen on the street north of the building. When staff H returned to the parking lot of the facility, he/she was notified the resident had been located. Staff H stated he/she was not familiar with residents on other units than the special care unit, which was a closed unit. Staff H stated there was no book, at that time, to identify which residents were assessed at risk for elopement. On 7-26-16 at 1:21 p.m., direct care staff G stated, information on residents at risk for elopement was passed on in report with the nurses or in report with other direct care staff. That was the only way they know when a resident was at risk of elopement. If staff were unsure of which resident's were at risk for elopement, they can look in the resident's chart. Staff G does not get report from other staff because he/she does restorative work. Staff G stated if he/she saw a resident go outside unsupervised, he/she would not know if the resident was supposed to do so or not. Staff G stated he/she would go and get the resident and then find out if they could be outside on their own. Staff G stated they have nothing to do with the Code Alert bracelets. On 7-26-16 at 1:25 p.m., direct care staff F sated, the staff could look at the resident's care plan to see who has a Code Alert bracelet. If a resident came over to the unit he/she worked on from another unit, if staff were not able to see the bracelet, indicating the resident is a wanderer, he/she does not know how the resident would be identified as a wanderer. On 7-26-16 at 4:59 p.m., direct care staff K stated, he/she left work on 7-10-16, shortly after 10:00 p.m., with two other co-workers when they saw the resident walking on the street, 1/2 block from the southeast side of the campus, 2 1/2 blocks from the door the door the resident exited. The resident walked on the side of the road, with his/her walker. On 7-26-16 at 4:59 p.m., direct care staff L stated, he/she rode in the car with two other co-workers following their shifts at the facility on 7-10-16, shortly after 10:00 p.m. when they observed the resident walking in the street 1/2 block from the facility campus. Direct care staff stopped the car and asked the resident what he/she was doing. The resident responded that he/she was going home. Staff K called the facility and let them know the resident's location. Direct care staff then drove the resident back to the facility. On 7-26-16 at 4:59 p.m., direct care staff J stated, he/she rode in the car with two other co-workers on 7-10-16, shortly after 10:00 p.m.when they saw the resident walking on the street. The resident had no injuries and was in a happy mood and giggling. The resident got into the car without difficulty and staff brought him/her back to the facility. On 7-26-16 at 3:02 p.m., administrative licensed staff B stated, the resident left the facility without supervision on 7-10-16 at approximately 10:10 p.m. Staff B stated direct care staff H let the resident out of the doors on the northeast unit without knowing the resident was a wanderer. Three other staff members saw the resident 1/2 block from the campus walking in the street and notified the facility. The staff members brought the resident back to the facility. Staff B was unable to say why the resident did not have a Code Alert bracelet on as he/she was assessed at risk for elopement. On 7-26-16 at 1:07 p.m., licensed nursing staff C stated, documentation of the monitoring of the placement of the Code Alert bracelets was on the TAR (treatment administrative record). The placement of the Code Alert bracelets was checked each shift. The nursing staff check placement of the Code Alert bracelets, but do not check the door alarms or check to ensure the Code Alert bracelets work properly. On 7-26-16 at 2:35 p.m., licensed staff D stated, the resident's with Code Alert bracelets were care planned for checking the placement of the Code Alert bracelets each shift, however, it is not on the resident's TAR to check if the Code Alert bracelet was working. Staff D stated when an elopement assessment was completed and the resident was found to be at risk for elopement, he/she would notify the director of nursing. An e-mail was sent to all of the licensed staff and all of the direct care staff to notify them of the resident's risk for elopement. On 7-26-16 at 2:39 p.m., licensed staff E stated, the nurses checked the Code Alert bracelets to ensure they were working properly before putting them on the resident. That was the only time the nurses checked to ensure the Code Alert bracelets were working properly. On 7-26-16 at 3:02 p.m., administrative nursing staff B stated, he/she does not believe there was a set person who checked the Code Alert bracelets, and was not sure how often the bracelets needed to be replaced. Staff B stated he/she does not know why the resident did not have a Code Alert bracelet in place until 7-11-16. It was staff B's expectation the nurse who completed the elopement assessment discussed with their team if the resident should have a Code Alert bracelet. Staff B stated there was not a book or sheet which notified staff of which residents were assessed at risk for elopement. The facility policy for elopement, revised 5-23-06, included, prior to or at admission, each resident will be assessed by the Unit Manager and/or Charge Person on the admitting unit. A licensed nurse performed a potential for elopement assessment. Specific interventions were developed and implemented on the day of admission for residents with a known history of wandering. If it was determined that the resident was at risk for elopement, preventative measures were implemented immediately. A Code Alert bracelet was placed on each resident assessed at risk for elopement. The charge nurse applied this bracelet during the initial elopement assessment process. The facility policy for Code Alert bracelets, effective 9-01-98, directed any resident identified, either at admission or at any time during residency, at risk of wandering was provided with a Code Alert bracelet. Monitoring of door alarms was checked by the maintenance department staff every Friday and a log book was maintained by the maintenance supervisor. Personal code alert bracelets were monitored by restorative aides monthly to ascertain they are functioning properly. Results were documented in the MAR (medication administration record). The facility failed to develop and implement a system to ensure all staff were aware of which residents were at risk for elopement. This placed the resident in immediate jeopardy as staff let the resident out of the facility at approximately 10:00 p.m. and the resident walked 2 1/2 blocks away from the door he/she exited from. Furthermore, the facility failed to have a system to ensure the code alert bracelets were in working order. The facility abated the immediate jeopardy, on 7-30-16 at 8:00 p.m., by initiating the following: * Revision of facility policy and procedure for elopements, completed on 7-30-16. * In service of all staff, on 7-29-16 and 7-30-16, regarding identification and monitoring of residents at risk for elopement. Last inservice completed on 07/30/16 at 8:00 p.m. * Development of a system to monitor function of the Code Alert bracelets on 7-30-16 at 8:00 p.m. The deficient practice remained at a scope and severity of a D.