Every finding on record at Medicalodges Fort Scott

The facility reported a census of 33 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for two of the five direct care staff reviewed.Findings included:- Review of five direct care staff's employment records Revealed the following: 1.Certified Nurse Aid (CNA) P, hired 11/01/22, lacked an up-to-date annual performance evaluation. The last evaluation was dated 10/03/24. 2.CNA Q, hired 08/06/03, lacked an up- to-date annual performance evaluation. The last evaluation was dated 10/08/24. On 02/18/2026 at 12:48 PM, Administrative Staff A verified above concerns and reported performance evaluations should be done annually. The facility did not provide a policy related to the completion of annual performance evaluations.

The facility identified a census of 33 residents. The sample included 14 residents. Based on observation, interviews and record review, the facility failed to maintain a clean, homelike environment Findings included:- On 02/16/2026 at 01:43 PM, R2 had multiple areas on his wall missing paint near the bed and there was a heavy odor of urine in his room and in the hallway outside his room. On 02/16/2026 at 02:11 PM, R32 sat in her room in her recliner. She reported she had to keep the door to her room closed because of noise from other residents' televisions. On 02/16/2026 at 02:41 PM, the [NAME] on the air conditioning unit in R19's room was broken and was not installed on the front of the unit. On 02/17/2026 at 07:45 AM, R2 was not in his room but his television volume was very loud. There was a strong urine odor noted outside the room in the hallway. On 02/17/2026 at 03:35 PM, R2 sat in his room in his wheelchair. His television volume was very loud and there was a strong urine odor noted. Administrative Staff A entered R2's room and educated R2 that his television volume was too loud and asked R2 to turn it down. R2 reported he would not be able to hear the television then. On 02/18/2026 at 01:00 PM, R2 was not in his room. R2's room had a strong urine odor, and the floor was sticky all around the room. There were areas of ground in dirt on the floor near the head of the bed. On 02/18/2026 at 02:37 PM, R26's threshold was missing the black strip. There was ground in dirt where the black strip was gone and the floor in R26's room was dirty, dull, and had several black scuff marks noted. On 02/18/2026 at 02:40 PM, the drain cover on the floor of the South Hall was not secured to the floor and exposed the drain when the cover was stepped on. On 02/18/2026 at 02:45 PM, R14's threshold was missing the black strip. There was ground in dirt where the black strip was gone and the floor in R14's room was dirty and several black scuff marks. During an interview on 02/18/2026 at 12:30 PM, Administrative Staff A reported R2 played his television gaming system loud, and regardless of the staff trying to remind R2 that the loudness of his gaming and music on the television disturbed other residents, R2 reported he could not hear when it was turned lower. Additionally, Administrative Staff A reported the facility had provided R2 with a headset for his television, and he broke them as he did not want to wear them. She confirmed R2 had not had hearing checked to determine if he would need assistive devices. Administrative Staff A reported the smell in R2's room was related to the resident behavior as R2 urinated on his floor. Administrative Staff A stated the housekeeping staff had increased deep cleaning his room from one time a month to weekly and they mop the floor in his room multiple times a day. During an interview on 02/18/2026 at 12:56 PM, Housekeeper Staff V reported R2's floor was mopped twice a day, and a deodorant spray would be used in his room too. Housekeeper Staff V reported R2 would not refuse the staff to clean his room. During an interview on 02/18/2026 at 12:59 PM, Certified Nurse Aide (CNA) S reported R2's room would smell like urine sometimes and said the staff had to check behind R2's bed as he would urinate on his floor. CNA S reported R2's floor was generally sticky, and the staff tried to keep his room clean. CNA S reported R2 would play his television loud, and the staff would ask him to turn it down and she reported that some residents had complained about the noise. During an interview on 02/18/2026 at 01:02 PM, Licensed Nurse (LN) G reported R2's room smells of urine quite often and his floor was always sticky. LN G reported that housekeeper would mop his room at least twice a day. LN G reported R2 would play his television loud, and the staff would ask him to turn it down, and he would not turn it down. LN G reported some residents had complained about the noise. During an interview on 02/18/2026 at 03:51 PM, Housekeeping Supervisor U reported R2's floor was an issue, and the floor was washed twice a day and stripped and waxed once a month and it did not work for the smell or the cleanliness. Housekeeping Supervisor U reported the cover of the air conditioner unit in R19's should be on the unit and reported the staff would communicate on the computer system TELS for maintenance and housekeeping concern in a residents' room. Housekeeping Supervisor U said the broken thresholds and the dirty floors observed were not acceptable. Housekeeping Supervisor U verified the loose drain floor cover of South Hall had been a concern for quite some time and the housekeeping staff had complained about it when they cleaned the floor. During an interview on 02/18/2026 at 04:05 PM, Administrative Staff A reported she expected the floor drain to be on correctly and it was not acceptable to have it come off. She expected the floors and thresholds to be clean and the facility to clean and homelike environment. The facility did not provide a policy on Clean/Safe/Comfortable/Homelike Environment.

The facility reported a census of 33 residents. Thirty medications administrations were observed with two medications errors identified resulting in a medications error rate of 6.67 percent. Based on observation, interview, and record review, the facility failed to ensure a medication error rates of five percent or less. - Resident (R)39's Physician Orders (POS) revealed orders for the following morning medication administration: Phenazopyridine HCL 200 milligrams (mg), by mouth, three times a day, after meals, ordered 02/13/26 Protonic oral tablet, 40 mg, delayed release tablet, give twice a day, 30 minutes to one-hour before meals. On 02/17/26 at 09:00 AM, Certified Medication Aide (CMA) R prepared the R39's medications. The phenazopyridine HCL 200 mg was omitted. She reported the phenazopyridine had not been available from the pharmacy for administration since it was ordered on admission [DATE]. On 2/17/26 at 09:08 AM, CMA R added the prescribed medication protonic oral tablet, 40 mg. She entered the resident's room and handed the medications to the resident R39 stated she had just finished eating. On 02/17/26 at 09:12AM, CMA R verified the above findings. She stated medications should be administered as ordered by the physician. On 02/18/2026 at 05:13 PM, Administrative Nurse D verified the above findings and stated she had not been made aware of the issue unavailable medication for R39. Administrative Nurse D reported that residents should receive their medications as ordered by the physician. The facility policy Medication ordering and Receiving from Pharmacy Provider, dated 01/2023, documentation included timely delivery of new orders is required so medication administration is not delayed. Promptly report omissions to the pharmacy and the charge nurse/supervisor. The facility Policy Liberalized Medication Administration, dated 12/2016, documentation included any medication with a specified time in the order is scheduled at the specific time. some medications must be taken before, after or with meals

The facility had a census of 33 residents. The sample included 14 residents with one reviewed for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy including duration for Resident (R) 2. Findings included:- R2's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and developmental disorder of scholastic skills (persistent difficulties that significantly impact academic achievement and daily functioning). R2's 10/30/25 Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. R2's Progress Note, dated 10/15/025, at 02:53 PM documented the resident was admitted to the hospital. R2's Progress Note, dated 10/16/25 at 10:25 AM, documented a verbal consent for a bed hold was received by R2's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to). During an interview on 02/18/26 at 01:02 PM, Licensed Nurse (LN) G reported the nurses obtained a verbal bed hold with the resident or family member. LN G reported the bed hold form was not sent with a resident when they went to the hospital. LN G reported that Administrative Staff B or Social Service Designee (SSD) X would give the written bed hold. During an interview on 02/18/26 at 01:10 PM, Administrative Staff B reported she would complete the bed hold with the family member and produced a bed hold which was completed verbally for R2 on 10/16/25. Administrative Staff B reported she would send the form to the family, and she was unable to show it was completed as she did not document or keep a record indicating she sent the bed hold. SSD X reported she wrote a note that a bed hold consent from DPOA was received verbally. SSD X reported she was not aware the resident or family member should receive a paper copy of bed hold. During an interview on 02/18/2026 at 01:15 PM, Administrative Staff A reported the facility had no way to show a resident/dpoa had received a bed hold form in writing if the form was completed verbally. The facility's Bed Hold Form Instructions, undated, documented ask the resident/responsible party if they would want to come into the facility to sign a bed hold or if they prefer the bed hold to be mailed. The response should be documented on the bed hold form and noted in the comments in the census line associated with the bed hold.

The facility identified a census of 33 residents. The sample included 13 residents. Based on record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) after identifying a decline in Resident (R) 1's status resulting in initiation of hospice services. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body), seizures, major depressive disorder (major mood disorder which causes persistent feelings of sadness), severe protein-calorie malnutrition, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R1's Quarterly MDS, dated 07/05/24, documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R1's MDS did not indicate he had less than six months to live or that he received hospice services. The Quarterly MDS, dated 10/04/24, documented a BIMS score of 10, which indicated moderately impaired cognition. R1 had upper extremity and lower extremity impairment on one side and used a wheelchair for mobility. R1's MDS documented he had less than six months to live, and he received hospice services. R1's EMR lacked a Significant Change MDS identifying R1's initiation of hospice services between 07/05/24 and 10/04/24. R1's Care Plan, initiated 09/25/24, documented R1 received hospice services related to his terminal diagnosis. R1's physician orders documented he admitted to hospice services on 08/14/24. On 02/18/26 at 10:18 AM, Administrative Nurse E stated R1 should have had a Significant Change MDS when he was placed on hospice services. On 02/18/26 at 10:47 AM, Administrative Nurse D stated the Significant Change MDS should have been completed when R1 was placed on hospice services. The facility reported they did not have a policy and utilized the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines dated October 2023. RAI guidelines instructed staff that the MDS must be submitted within 14 days after the determination that a significant change in the residents' status occurred.

The facility reported a census of 33 residents; the sample included 14 with five residents reviewed for unnecessary medications and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R) 2's lack of bowel movements. Findings included:- R2's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and developmental disorder of scholastic skills (persistent difficulties that significantly impact academic achievement and daily functioning). R2's 10/30/25 Significant Change Minimum Data Set (MDS) dated [DATE] which documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. R2's MDS documented he required total assistance with toileting hygiene and R2 was frequently incontinent of bowel. R2's 11/04/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R2 was administered numerous Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R2 was at risk of adverse effects, but none were noted at that time. R2's Care Plan dated 12/03/25 documented hospice covered medication bisacodyl (a common stimulant laxative) rectal suppository 10 milligrams (mg) insert one suppository rectally every 24 hours as needed for constipation (difficulty passing stools). Staff were instructed to call hospice before administration. R2's Care Plan dated 12/03/25 documented related to R2's need for assistance with personal care. Staff were instructed the hospice aide would document R2's bowel movements and report to nurse if three days or more since last bowel movement. R2's Care Plan dated 12/23/25 documented hospice covered medication hospice covered medication polyethylene glycol (medication used management and treatment of constipation) 3350 powder give 17 grams as needed every 24 hours for constipation R2's Physician Orders documented polyethylene glycol 3350 powder, administer 17 grams, by mouth as needed every 24 hours for constipation, date ordered 10/20/25. R2's Physician Orders documented bisacodyl rectal suppository 10 mg insert one suppository rectally every 24 hours as needed for constipation, call hospice before administration, date ordered 10/31/25. Review of R2's bowel movement frequency in the EMR dated 01/28/26 through 02/03/26 revealed the resident exceeded three days/72 hours without a bowel movement 01/28/26 through 02/03/26 (seven consecutive days). R2's 01/31/26 at 05:07 AM Electronic Medication Administration Record Note (EMAR) documented R2 was administered ondansetron (anti-nausea medication) 4mg table by mouth as needed for nausea. R2's 02/02/26 at 10:42 AM EMAR Note documented R2 was administered polyethylene glycol 3350 powder, administer 17 grams, by mouth as needed every 24 hours for constipation, no bowel movement for three days. R2's 02/03/26 at 07:40 AM EMAR Note documented ineffective results no bowel movement from as needed polyethylene glycol 3350 powder. R2's 02/03/26 at 07:45 AM EMAR Note documented R2 was administered polyethylene glycol 3350 powder, administer 17 grams, by mouth as needed every 24 hours for constipation, no bowel movement for three days. R2's 02/03/26 at 04:45 PM EMAR Note documented ineffective results no bowel movement from as needed polyethylene glycol 3350 powder. R2's 02/04/26 at 02:35 PM Progress Note documented R2 continued to be on the no bowel movement list. The nurse would attempt to contact hospice to administer a suppository. R2's 02/04/26 at 09:26 PM EMAR Note bisacodyl rectal suppository 10mg insert one suppository rectally every 24 hours as needed for constipation. Call hospice before administering as needed administration was effective R2 had an extra-large soft formed bowel movement. Review of R2's Progress Note 01/30/26 through 02/04/26 lacked any documentation of bowel/abdomen assessments were completed. Observation on 02/18/2026 at 10:00 AM R2 sat in his wheelchair in his room with the dental hygienist assessing his mouth. During an interview on 02/18/2026 at 12:59 PM Certified Nurse Aide (CNA) S reported R2 required toileting assistance and would refuse at times, and staff would reapproach him. She reported R2 was incontinent of bowel and bladder, and he did not toilet himself. CNA S reported she documented the bowel movements in EMR under the tasks. During an interview on 02/18/26 at 01:40 PM Licensed Nurse G reported residents bowel movements would be monitored with EMR dashboard which would send an alert for residents who had no bowel movement for three days documented. LN G reported residents orders would be reviewed for as needed medication for constipation to be administered. LN G revealed the EMR dashboard would only alert just three days, it did not alert a higher number of days for no bowel movements. LN G reported the provider would be called on day four and a bowel assessment would be completed and documented in EMR. LN G reported that would continue every day until the resident had a bowel movement. LN G reported she would not pull up a bowel movement record from the EMR. During an interview 02/18/2026 at 01:45 PM Certified Medication Aide (CMA) R reported she would administer a as needed bowel medication for constipation when directed by the charge nurse. CMA R reported she would educate the CNAs to make sure they document correctly in the EMR the resident's bowel movements to avoid administration of a medications for constipation. During an interview on 02/18/2026 at 02:13 PM Administrative Nurse D reported she expected the charge nurse to monitor bowel movements daily, if a resident did not have a bowel movement for three days the charge nurse would administer a as needed medication for constipation if ordered and if a resident did not have an as needed order the provider would be called. Administrative Nurse D reported that she expected the nurse to look at the dashboard on the EMR and print off a bowel movement list to assess actual last day a resident had a bowel movement. Administrative Nurse D expected the nurse to update the provider and document a bowel assessment in the EMR. Administrative Nurse D reported that it was a concern that R2 had no bowel movement for seven days. Administrative Nurse D reported there was no policy for bowel monitoring. The facility did not provide a policy.

The facility identified a census of 33 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were reviewed and addressed by the physician for Resident (R) 23 and R2. Findings included:- The Electronic Medical Record (EMR) for R23 documented a diagnosis of hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Annual Minimum Data Set (MDS), dated 01/23/26, documented R23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R23's MDS documented he required setup or clean-up assistance with showers/bathing himself and was independent with all other activities of daily living. R23's Care Plan, initiated 04/03/23, documented the pharmacist reviewed medication monthly and as needed. The plan of care directed staff to monitor labs and diagnostic tests as ordered by R23's physician and documented the pharmacy, physician, and psychiatrist would review medications per protocol and as needed, initiated 01/23/26. R23's EMR under the Orders tab revealed the following physician orders: Levothyroxine odium (hormone replacement therapy used to treat hypothyroidism) oral tablet 50 micrograms (mcg), give one tablet by mouth one time a day, every other day, related to hypothyroidism, revised on 05/06/24. Review of the Monthly Medication Review (MMR), dated 09/24/25, documented R23 received medications, which needed routine lab work. The MMR asked to check all labs that the physician would like ordered: Comprehensive Metabolic Panel (CMP), lipid panels (LIPIDS), thyroid-stimulating hormone (TSH- used to measure the level of this hormone in the blood to assess thyroid function), and please list below any additional labs or monitoring parameters not listed. The MMR was stamped as faxed but lacked evidence of physician follow-up. R23's EMR, reviewed from January 2025 through February 2026 lacked evidence a TSH was completed. On 02/17/26 at 09:14 AM, R23 laid in bed on his left side with his covers pulled up on his chest. On 02/17/26 at 01:35 PM, Administrative Nurse D stated she sent out the MMRs to the physicians and then waited for them to come back. Administrative Nurse D stated she had looked everywhere but could not find any physician follow-up to R23's MMR from 09/24/25. Administrative Nurse D stated she had recently changed the system for responding to the MMR due to a lack of physician response. Administrative Nurse D further revealed she was still working with a new physician to set up sending out the pharmacy recommendations and receiving them back from the physicians timelier. Administrative Nurse D stated she expected them to be back within a week to two weeks to ensure clarification of the pharmacy recommendations. The facility's Medication Monitoring Medication Regimen Review and Reporting policy, dated 2007, documented the nursing care center followed up on the recommendations to verify that appropriate actions were taken. The policy directed that recommendations should be acted upon within 30 calendar days or per facility-specific protocols. The policy documented issues that required a physician's intervention; the attending physician either accepted or acted upon the report and recommended or rejected all or some of the report. The policy documented the physician should document his or her rationale of why the recommendation was rejected in the resident's medical record. - Review of R2's diagnoses from the Electronic Health Record (EHR) included major depressive disorder (MDD – a major mood disorder which causes persistent feelings of sadness), amnesia (loss of memory caused by brain damage or severe emotional trauma), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and undifferentiated schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R2's 10/30/25 Significant Change Minimum Data Set (MDS), documented R2 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The resident had a total mood severity score of 00, which indicated no depression. The assessment documented R2 received antianxiety (class of medications that calm and relax people), antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), and antidepressant (class of medications used to treat mood disorders) medications. The 11/04/26 Psychotropic Drug Use Care Area Assessment (CAA), documented R2 took four psychotropic (alters mood or thought) medications, and the pharmacist reviewed his medications monthly and as needed. The 02/05/26 Quarterly MDS documented R2 had a BIMS score of 12, which indicated moderately impaired cognition. The resident had a total mood severity score of 00, which indicated no depression and no behaviors. The assessment documented R2 received antianxiety, antipsychotic, and antidepressant medications. The Care Plan, reviewed on 02/17/26, documented on 06/21/22 R2 had anxiety and documented the following interventions: On 06/21/22, staff would notify R2's family as needed. On 06/21/22, staff would notify the physician as needed. On 06/21/22, staff would provide reassurance and comfort. On 04/02/25, R2 took Xanax (alprazolam – an antianxiety medication) for his anxiety. The Care Plan, reviewed on 02/17/26, documented on 03/29/21, and revised on 11/26/25, R2 took therapeutic psychotropic medications to help regulate emotions and thought patterns. R2 took Risperdal (risperidone – an antipsychotic medication), Celexa (citalopram – an antidepressant medication), and trazodone (an antidepressant medication) for wandering and exit-seeking behaviors. R2 took Xanax (alprazolam) for tearfulness. The Care Plan documented the following interventions: On 03/29/21, staff would allow R2 to express his emotions without judgment or criticism. On 03/29/21 and revised on 10/18/22, staff would encourage R2 to attend offered activities and to offer again later or with a different staff member if refused. Staff would offer one-on-one activity visits if R2 declined to leave his room. On 10/18/22, R2 had a history of anxiety with tearfulness, wandering, and exit-seeking behaviors. On 10/18/22, staff would monitor for the effectiveness of the psychotropic medications and consult with the pharmacist and physician to adjust the medication dosages when clinically appropriate. Staff would also monitor for potential side effects and notify his family of adverse events. On 10/18/22 and revised on 08/27/25, staff would refer R2 to his physician for psychological referral as indicated, and R2 had a case worker who visited him. On 04/18/24, staff attempted a dose reduction with discontinuation of Xanax (alprazolam), with an increase in behaviors of throwing items on the floor in the dining area and talking to himself. On 05/28/24, R2 took Xanax (alprazolam) for his anxiety. On 06/30/25 and revised on 07/02/25, R2 had a history of making false accusations. Review of the EHR Physician's Orders documented the following: Risperdal (risperidone), one milligram (mg) tablet to be given orally, three times a day, related to bipolar disorder, dated 10/20/25 at 02:26 PM. Xanax (alprazolam) tablet 0.5mg to be given orally, three times daily, related to anxiety disorder, dated 10/20/25 at 07:00 PM. Celexa (citalopram) tablet 40mg to be given orally, daily at bedtime, related to bipolar disorder, dated 10/20/25 at 02:22 PM. Review of the monthly medication regimen review (MRR) revealed on 07/03/25, the consultant pharmacist conducted a MRR and documented R2 took Risperdal 0.5mg three times daily along with Xanax (alprazolam) and Celexa (citalopram), and suggested the physician consider a dose reduction. The facility did not provide a copy of the provider or facility's response to the consultant pharmacist's recommendation. During an observation on 02/16/26 at 01:44 PM, R2 rested in his bed watching television (TV). R2 appeared calm and relaxed. During an observation on 02/17/26 at 09:10 PM, R2 sat in his wheelchair less than three feet from his TV, watching TV at full volume. R2 appeared calm and relaxed. During an observation on 02/18/26 at 10:00 AM, R2 was in his room with contract dental staff present. R2 appeared calm and relaxed. During an interview on 02/17/26 at 03:03 PM, Administrative Nurse D revealed the facility was unable to locate the physician's response to the pharmacist's recommendation that was dated 07/03/25. Administrative Nurse D stated the facility did not receive the physician's response and stated the expectation was for providers to follow up with pharmacy recommendations within seven to 14 days to allow for any clarification (if required) prior to the 30-day response period required by the facility. Additionally, Administrative Nurse D confirmed the medications listed in the pharmacy recommendation dated 07/03/25 were all psychotropic medications. Administrative Nurse D stated she had recently changed the system for responding to the MMR due to a lack of physician response. Administrative Nurse D further revealed she was still working with a new physician to set up sending out the pharmacy recommendations and receiving them back from the physicians in a more timely manner. During an interview on 02/18/26 at 06:01 PM, Consultant GG revealed the expectation was for physicians to respond to the MRR and GDR reports. Consultant GG revealed the GDR request for R2, dated 07/03/25, was just for the Risperdal (risperidone) 0.5mg dose, and he included the Xanax (alprazolam) and Celexa (citalopram) to document to the physician that R2 was on other psychotropic medications. Consultant GG reported he did not receive a response from the physician, but rather noted the physician actually increased the dose from 0.5mg to 1mg, so he did not repeat the GDR request in the August 2025 MRR report. The facility's undated Medication Monitoring Medication Regimen Review and Reporting policy, dated 2007, documented the nursing care center followed up on the recommendations to verify that appropriate actions were taken. The policy directed that recommendations should be acted upon within 30 calendar days or per facility-specific protocols. The policy documented issues that required a physician's intervention; the attending physician either accepted or acted upon the report and recommended or rejected all or some of the report. The policy documented the physician should document his or her rationale for why the recommendation was rejected in the resident's medical record.

The facility identified a census of 33 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 23's thyroid (organ at the front of the neck that secretes hormones) hormone levels were monitored to determine the effectiveness of his ordered thyroid hormone replacement medication. Findings included:- The Electronic Medical Record (EMR) for R23 documented a diagnosis of hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Annual Minimum Data Set (MDS), dated 01/23/26, documented R23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R23's MDS documented he required setup or clean-up assistance with showers/bathing himself and was independent with all other activities of daily living. R23's Care Plan, initiated 04/03/23, documented the pharmacist reviewed medication monthly and as needed. The plan of care directed staff to monitor labs and diagnostic tests as ordered by R23's physician, and documented the pharmacy, physician, and psychiatrist would review medications per protocol and as needed, initiated 01/23/26. R23's EMR under the Orders tab revealed the following physician orders: Levothyroxine Sodium (hormone replacement therapy used to treat hypothyroidism) oral tablet 50 micrograms (mcg), give one tablet by mouth one time a day, every other day, related to hypothyroidism, revised on 05/06/24. R23's physician orders lacked an order for thyroid-stimulating hormone (TSH- used to measure the level of this hormone in the blood to assess thyroid function) lab. R23's EMR, reviewed from January 2025 through February 2026, lacked evidence that a TSH was completed. On 02/17/26 at 09:14 AM, R23 lay in bed on his left side with his covers pulled up on his chest. On 02/18/26 at 11:15 AM, Administrative Nurse D stated she expected labs to be ordered for residents who were on levothyroxine. The facility's Medication Monitoring Medication Regimen Review and Reporting policy, dated 2007, documented the Medication Regimen Review (MRR) had the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication.

The facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure an accurate and adequate system for monitoring and reconciliation of narcotic medications in the facility emergency kits (e-kit), putting the residents at risk of misappropriation of medications. Findings included: - A tour of the medication room on 07/02/25 at 09:09 AM with Licensed Nurse (LN) G revealed the following concerns: 1. A narcotic (a psychoactive compound with numbing or paralyzing properties) e-kit which contained 10 tablets (tabs) of hydrocodone-acetaminophen (a narcotic pain medication) 5-325 milligrams (mg); five tabs of hydrocodone-acetaminophen 7.5-325 mg; hydrocodone-acetaminophen 10-325 mg and a 15 milliliter (ml) bottle of morphine sulfate (MS) 20 mg/ml. The lock-out tag number did not match the number documented on the Controlled Medication Shift Count. 2. An e-kit which contained five tabs of alprazolam (an antianxiety medication) 0.25 mg; five tabs APAP-Codeine #3 (a pain medication); five tabs clonazepam (an antianxiety medication) 0.5 mg; five tabs lorazepam (antianxiety medication) 0.5 mg; five tabs zolpidem (a hypnotic-a class of medications used to induce sleep) 5 mg and Tramadol (a pain medication) 50 mg. The lock-out tag number did not match the number documented on the Controlled Medication Shift Count. A review of the Controlled Medication Shift Count sheet in the medication room revealed the staff signed off on the count and reconciliation of the e-kits three times from 06/01/25 to 07/01/25. On 07/02/25 at 09:13 AM, LN G stated the lock-out tags on the e-kits in the medication room were not checked and documented by the oncoming and off-going nurses at shift change. On 07/02/25 at 01:21 PM, Administrative Nurse D stated it was the facility's expectation for nurses to verify the lock-out tag number of all e-kits and compare them to the documented numbers on the Controlled Medication Reconciliation form at the beginning and end of each shift. Admin Nurse D said the nurses were to date and sign the form to indicate the e-kits had been reconciled. The facility policy for Controlled Medication Reconciliation, revised 11/2024, included: At each shift change or with a change in licensed nurse responsibility for the medication cart or storage area, the oncoming licensed nurse will verify the number of the Emergency kit tags on all emergency kits (refrigerated narcotic/insulin's emergency kit, narcotic emergency kit, regular emergency kit, and IV emergency kit) match the Pharmamerica Emergency Kit Lock Tracking Log.

The facility reported a census of 34 residents. The sample included three residents. Based on observation, interview, and record review the facility failed to provide protective measures for Resident (R)1 following an allegation of abuse. This placed the resident at risk for abuse. Findings included: - R1's Electronic Medical Record (EMR) included the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), major depressive disorder (MDD-major mood disorder that causes persistent feelings of sadness), intellectual disability (ID- a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and hallucinations (sensing things while awake that appear to be real, but the mind created). R1's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He had verbal behaviors for one to three days of the assessment period. The resident received antipsychotic (a class of drugs primarily used to treat psychosis, a condition where a person experiences a loss of contact with reality), antianxiety (drugs used to treat symptoms of anxiety and related disorders) and antidepressant (prescription drugs used to treat depression and other mental health conditions by affecting neurotransmitters in the brain) medications during the seven-day look-back period. R1's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/14/25, documented the resident had mild cognitive impairment. R1's Urinary Incontinence/Indwelling Catheter CAA, dated 03/14/25, documented the resident required extensive assistance with toileting as he was frequently incontinent (inability to hold bowel and bladder) of bowel and bladder and wore briefs for protection and dignity. R1's Behavioral Symptoms and Psychosocial Well-Being CAAs, dated 03/14/25, documented the resident had an increase in behaviors and rejection of care. R1's physician had been made aware of the increase in behaviors. R1's Quarterly MDS, dated 06/13/25, documented the resident had a BIMS score of 11, indicating moderate cognitive impairment. He had verbal behaviors for one to three days of the assessment period. The resident received antipsychotic, antianxiety, and antidepressant medications during the seven-day look-back period. R1's Care Plan, revised 07/02/25, instructed staff the resident could, at times, make false accusations against staff and was on psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications to assist in regulating his emotions and thought patterns. R1 was receiving psychiatric services through telemedicine and staff were to monitor him closely and redirect him to promote his safety. Staff were to utilize two staff members when providing care to the resident. A review of R1's EMR and information provided by the facility revealed on 06/29/25 the resident made an accusation of sexual abuse by staff while toileting. Staff approached the resident at approximately 11:15 in his room as the resident was in a chair watching TV and yelling. When staff entered R1's room, he yelled at them to get out. The resident was then heard by staff saying he was tired of the staff waking him up to play with his butthole and ding-dong and he was going to get them for sexual assault. Staff assessed R1 for physical and emotional safety at approximately 11:30 AM and he was stable with no signs of distress or harm. The facility was unable to provide evidence the alleged perpetrator of the abuse was removed from the facility and denied access to the residents during their investigation of the accusation. On 07/02/25 at 08:30 AM, R1 sat in his wheelchair in the front commons area with his peers. The resident was friendly and talkative and had no outward appearance of distress. On 07/02/25 at 08:57 AM, Certified Nurse Aide (CNA) O provided stand-by assistance while toileting R1. No other staff were in the room at the time of the care. On 07/02/25 at 11:21 AM, CNA M stated the resident would refuse care at times. CNA M stated the resident had an increase in behaviors and the nurse was aware of the changes. CNA M stated the resident was incontinent of bowel and bladder and required staff assistance with toileting. CNA M was not aware of the need to provide care to the resident in pairs. On 07/02/25 at 11:43 AM, Licensed Nurse (LN) G stated the resident had psychotic episodes which would include screaming and being aggressive towards staff verbally. LN G was not aware the staff was supposed to be providing resident care in pairs for the resident. On 07/02/25 at 01:17 PM, Administrative Staff A stated she was unaware the staff involved in the incident needed to be suspended, placed on leave, or otherwise formally denied access to the residents while the allegation was investigated. Administrative Staff A stated she was notified of the accusation immediately and was in the facility to begin the investigation within approximately 15 minutes. She reported the incident to the hotline via e-mail on 06/30/25. The facility policy for Abuse, Neglect and Exploitation, revised 10/2022, included: Any time a report of possible abuse, neglect or exploitation is made against an employee, that employee shall be immediately sent home and suspended without pay by the person in charge until a thorough investigation can be conducted by the DON and/or the Administrator.

The facility reported a census of 34 residents. The sample included three residents. Based on observation, interview, and record review the facility failed to update Resident (R) 1's Care Plan, putting the resident at risk for inadequate care due to uncommunicated care needs. Findings included: - R1's Electronic Medical Record (EMR) included the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), major depressive disorder (MDD-major mood disorder that causes persistent feelings of sadness), intellectual disability (ID- a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and hallucinations (sensing things while awake that appear to be real, but the mind created). R1's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He had verbal behaviors for one to three days of the assessment period. The resident received antipsychotic (a class of drugs primarily used to treat psychosis, a condition where a person experiences a loss of contact with reality), antianxiety (drugs used to treat symptoms of anxiety and related disorders) and antidepressant (prescription drugs used to treat depression and other mental health conditions by affecting neurotransmitters in the brain) medications during the seven-day look-back period. R1's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/14/25, documented the resident had mild cognitive impairment. R1's Urinary Incontinence/Indwelling Catheter CAA, dated 03/14/25, documented the resident required extensive assistance with toileting as he was frequently incontinent (inability to hold bowel and bladder) of bowel and bladder and wore briefs for protection and dignity. R1's Behavioral Symptoms and Psychosocial Well-Being CAAs, dated 03/14/25, documented the resident had an increase in behaviors and rejection of care. R1's physician had been made aware of the increase in behaviors. R1's Quarterly MDS, dated 06/13/25, documented the resident had a BIMS score of 11, indicating moderate cognitive impairment. He had verbal behaviors for one to three days of the assessment period. The resident received antipsychotic, antianxiety, and antidepressant medications during the seven-day look-back period. R1's Care Plan, revised 07/02/25, instructed staff the resident could, at times, make false accusations against staff and was on psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications to assist in regulating his emotions and thought patterns. R1 was receiving psychiatric services through telemedicine and staff were to monitor him closely and redirect him to promote his safety. Staff were to utilize two staff members when providing care to the resident. On 07/02/25 at 08:30 AM, R1 sat in his wheelchair in the front commons area with his peers. The resident was friendly and talkative and had no outward appearance of distress. On 07/02/25 at 08:57 AM, Certified Nurse Aide (CNA) O provided stand-by assistance while toileting R1. No other staff were in the room at the time of the care. On 07/02/25 at 11:21 AM, CNA M stated she was not aware of the need to provide care to the resident in pairs. On 07/02/25 at 11:30 AM, CNA N stated staff did care for the resident in pairs on the day he made the accusations of staff not treating him appropriately but had not been told to continue to do care in pairs after that day. On 07/02/25 at 11:37 AM, CNA O stated staff were to be doing care with the resident in pairs, but it was not always happening. On 07/02/25 at 11:43 AM, Licensed Nurse (LN) G stated she was not aware the staff was to be providing resident care in pairs for the resident. On 07/02/25 at 01:17 PM, Administrative Nurse D stated the resident's care plan had not been reviewed and revised to include staff instruction to complete the resident's care in pairs only until 07/02/25, while the incident took place 06/29/25. The facility's undated policy for Care Plans documented each resident's care plan would be reviewed and revised with any new interventions.

The facility reported a census of 26. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), and ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), remain free from neglect when Certified Medication Aide (CMA) S continued to administer R1's morning medications despite R1's request to slow down because she was having a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying. Findings included: - (R)1's ''Physician Order Sheet'' (POS), dated 08/01/24, documented diagnoses which included: dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cognitive communication deficit (difficulty with communicating). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of seven, indicating severely impaired cognition. R1 required setup assistance for eating. R1 had swallowing disorders that included coughing or choking on meals, or when swallowing medications, and complaints of difficulty or pain with swallowing. She required a mechanically altered diet and had no natural teeth or tooth fragments. R1 had no speech therapy during the lookback period but had speech therapy from 11/16/23 to 01/21/24. The ''Cognitive Loss/Dementia Care Area Assessment'' (CAA), dated 02/19/24, the resident was alert with occasional confusion. The resident's speech was clear, and she was able to voice her wants and needs. The Functional abilities (self-care and mobility) Care Area Assessment (CAA), dated 02/19/24, the resident will get up for meals and assisted by staff. The Nutrition Care Area Assessment (CAA), dated 02/19/24, the resident assisted by staff assist with meals. She was able to make her own menu choices. R1's Activities of Daily Living Care Plan, dated 03/16/17, instructed nursing staff to administer R1 medications crushed. The Quarterly MDS dated [DATE], documented the resident had a BIMS score of three, which indicated severely impaired cognition. She continued to have swallowing disorders that included coughing and chocking during meals and swallowing medications. She had complaints with difficulty or pain with swallowing. She required a mechanically altered diet and had no natural teeth or tooth fragments. R1's Difficulty Swallowing Care Plan, dated 08/07/24, instructed staff to be patient and take time when administering R1 medications because R1 would become anxious and choke easily. Staff were to crush her medications and mix the medications with applesauce. Review of R1's Electronic Medication Administration Record for 08/02/24, revealed CMA S administered the following medications: MiraLAX Powder (laxative), 17 grams, one scoop by mouth, daily, for constipation, start date 01/30/2023. Bactrim-DS Oral Tablet (antibiotic folate antagonist), 400-80 milligram's (mg), one tablet by mouth, daily, for prophylaxis, start date 02/01/23. Colace Tablet (laxative), 100 mg, one tablet by mouth, twice daily, for constipation, start date 01/30/23. A Registered Dietitian (RD) Assessment, dated 02/23/24, documented the resident required pureed diet with nectar thick liquids. The residents had risk factors such as difficulty chewing, swallowing and dysphagia. She had an altered texture diet, and thickened liquids. On 08/15/24 at 10:00 AM, Outside Resource Staff EE, reported she witnessed CMA S administering the resident medications and the resident was telling CMA S to stop, I need to swallow. Housekeeping/CNA U was also in the resident's room telling the resident to take a drink. Outside Resource Staff EE observed CMA S continued to give the resident her medications even though the resident told her she needed to swallow. Outside Resource Staff EE reported that CMA S made the statement when she walked out of the resident's room it's over with now, you can quit your crying. Outside Resource Staff EE reported she should have reported this to Administrative Staff A and to her supervisor on 08/02/24 but failed to do so. On 08/15/24 at 11:36 AM, CMA S reported that she administered R1's medications on the morning of 08/02/24. The resident was talking and screaming between bites of applesauce with her crushed medications. CMA S reported that she did not remember her crying. Housekeeping/CNA U gave her drinks of thickened liquid between medication bites in the applesauce mixture. CMA S reported she wanted to make sure the resident had all her medication. CMA S reported she had too much on her mind and should not have administered the medications in that manner. On 08/15/24 at 12:40 PM, Review of Housekeeping/CNA U witness statement revealed she delivered laundry to resident's room the morning of 08/02/04. CMA S was administering R1's medications when she entered the residents room. R1 asked CMA S to stop giving her the medication. R1 was coughing and choking on the medication. CMA S kept administering her medication. She asked CMA S to wait before giving more medication and give the resident a chance to swallow and get some water. CMA S continued to administer the medication. After CMA S finished administering medications, she told the resident she was A crybaby. On 8/15/24 at 10:19 AM, Administrative Nurse D reported she was not aware of CMA S actions until 08/07/24, (five days later), when Housekeeping/CNA U reported the incident to her and Administrative Staff A. Administrative Nurse D reported Housekeeping/CNA U said she got busy and forgot and should have reported the incident on 08/02/24 at the time of the incident. On 08/15/24 at 10:35 AM, Administrative Staff A reported Housekeeping U reported this incident to her and Administrative Nurse D on 08/07/24, instead of when it occurred, because Housekeeping/CNA U forgot to report the occurrence. Administrative Staff A reported Outside Resource staff EE failed to report what she witnessed with CMA S and R1. The facility's Abuse and Neglect Policy, revised dated 10/2022, documented the facility should ensure the resident is free from neglect and to take precautions to ensure the residents safety and well-being. The facility failed to ensure dependent and cognitively impaired Resident (R) 1, remained free from neglect when CMA S continued to administer medications in applesauce, despite R1's request to slow down because she was had a difficult time swallowing, witnessed by Housekeeping Aide/CNA U and Outside Resource Staff EE. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying.

The facility reported a census of 26. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), remain from neglect when Housekeeping U and Outside Resource Staff EE failed to report to Administrative Staff A that Certified Medication Aide S continued to administer R1's morning medications despite R1's request to slow down because she was had a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying. Findings included: - (R)1's ''Physician Order Sheet'' (POS), dated 08/01/24, documented diagnoses which included: dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cognitive communication deficit (difficulty with communicating). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of seven, indicating severely impaired cognition. R1 required setup assistance for eating. R1 had swallowing disorders that included coughing or choking on meals, or when swallowing medications, and complaints of difficulty or pain with swallowing. She required a mechanically altered diet and had no natural teeth or tooth fragments. R1 had no speech therapy during the lookback period but had speech therapy from 11/16/23 to 01/21/24. The ''Cognitive Loss/Dementia Care Area Assessment'' (CAA), dated 02/19/24, the resident is alert with occasional confusion. The resident's speech was clear, and she is able to voice her wants and needs. The Functional abilities (self-care and mobility) Care Area Assessment (CAA), dated 02/19/24, the resident's will get up for meals and is assisted by staff. The Nutrition Care Area Assessment (CAA), dated 02/19/24, the resident assist by staff assist by meals. She was able to make her own menu choices. R1's Activities of Daily Living Care Plan, dated 03/16/17, instructed nursing staff to administer R1 medications crushed. The Quarterly MDS dated [DATE], documented the resident had a BIMS score of three, which indicated severely impaired cognition. She continued to have swallowing disorders that included coughing and chocking during meals and swallowing medications. She had complaints with difficulty or pain with swallowing. She required a mechanically altered diet and had no natural teeth or tooth fragments. R1's Difficulty Swallowing Care Plan, dated 08/07/24, instructed staff to be patient and take time when administering R1 medications because R1 would become anxious and choke easily. Staff were to crush her medications and mix the medications with applesauce. Review of R1's Electronic Medication Administration Record for 08/02/24, revealed CMA S administered the following medications: MiraLax Powder (laxative), 17 grams, one scoop by mouth, daily, for constipation, start date 01/30/2023. Bactrim-DS Oral Tablet (antibiotic folate antagonist), 400-80 milligrams (mg), one tablet by mouth, daily, for prophylaxis, start date 02/01/23. Colace Tablet (laxative), 100 mg, one tablet by mouth, twice daily, for constipation, start date 01/30/23. A Registered Dietitian Assessment, dated 02/23/24, documented the resident required pureed diet with nectar thick liquids. The residents had risk factors such as difficulty chewing, swallowing and dysphagia. She had an altered texture diet, and thickened liquids. On 08/15/24 at 10:00 AM, Outside Resource Staff EE, reported she witnessed CMA S administering the resident's medications and the resident was telling CMA S to stop, I need to swallow. Housekeeping/CNA U was also in the resident's room telling the resident to take a drink. Outside Resource Staff EE observed CMA S continued to give the resident her medications even though the resident told her she needed to swallow. Outside Resource Staff EE reported that CMA S made the statement when she walked out of the resident's room it's over with now, you can quit your crying. Outside Resource Staff EE reported she should have reported this to Administrative Staff A and her supervisor on 08/02/24 but failed to do so. On 08/15/24 at 11:36 AM, CMA S reported that she administered R1's medications on the morning of 08/02/24. The resident was talking and screaming between bites of applesauce with her crushed medications. CMA S reported that she did not remember her crying. Housekeeping/CNA U gave her drinks of thickened liquid between medication bites in the applesauce mixture. CMA S reported she wanted to make sure the resident had all her medication. CMA S reported she had too much on her mind and should not have administered the medications in that manner. On 08/15/24 at 12:40 PM, Review of Housekeeping/CNA U witness statement revealed she delivered laundry to resident's room the morning of 08/02/04. CMA S was administering R1's medications when she entered the residents room. R1 asked CMA S to stop giving her the medication. R1 was coughing and choking on the medication. CMA S kept administering her medication. She asked CMA S to wait before giving more medication and give the resident a chance to swallow and get some water. CMS continued to administer the medication. After CMA S finished administering medications, she told the resident she was A crybaby. On 8/15/24 at 10:19 AM, Administrative Nurse D reported she was not aware of CMA S actions until 08/07/24, (five days later), when Housekeeping/CNA U reported the incident to her and Administrative Staff A. Administrative Nurse D reported Housekeeping/CNA U said she got busy and forgot, and should have reported the incident on 08/02/24 at the time of the incident. On 08/15/24 at 10:35 AM Administrative Staff A reported Housekeeping U reported this incident to her and Administrative Nurse A on 08/07/24, instead of when it occurred, because Housekeeping/CNA U forgot to report the occurrence. Administrative Staff A reported Outside Resource staff EE failed to report what she witnessed with CMA S and R1. The facility's Abuse and Neglect Policy, revised dated 10/2022, documented the facility should ensure the resident is free from neglect, to take precautions to ensure the residents safety and well-being due to responsibility of every employee of the facility report any abuse and/or neglect The facility failed to ensure dependent and cognitively impaired Resident (R) 1 the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia, ileus and oropharyngeal phase, remain from neglect when Housekeeping U and Outside Resource Staff EE failed to report to Administrative Staff A that Certified Medication Aide S continued to administer R1's morning medications despite R1's request to slow down because she was had a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying.

The facility identified a census of 37 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. This placed the residents at risk for impaired mental and physical well-being. Findings included: - A review of the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) for Fiscal Year (FY) 2023 Quarter 4 and FY 2024 Quarter 1 revealed the facility triggered for excessively low weekend staffing. On 04/03/24 at 10:15 AM, Resident Council members reported activities rarely occurred on weekends compared to the weekdays. The council reported due to the low staffing in the facility there was no activity person on the weekend. The council reported they would like activities on the weekends, such as bingo or interactive groups on the weekend. On 04/03/24 at 10:37 AM Administrative Staff A stated the weekend staff was low at times related to call-ins and lack of staff. Administrative Staff A stated the weekend staff had improved. On 04/03/24 at 10:51 AM Activities Staff Z reported the facility did not have activities on the weekends. On 04/03/24 at 12:55 PM, Certified Nurses Aid (CNA) Q stated staff used to have activities on the weekends, but now there was only church on Sundays. CNA Q stated most of the residents watched TV on the weekends since that was all there was to do. On 04/03/24 at 02:30 PM, CNA O stated all shifts have low staffing at times. CNA O stated she had been the only CNA on the 2-10 shifts at times and it was hard to complete all her duties. On 04/03/24 at 02:43 PM Licensed Nurse (LN) G stated the facility had low weekend staff; one weekend staffing was lower than the other weekend. LN G stated it was difficult to complete all the nursing duties when there was not even staff to provide care. The facility did not provide a policy related to weekend staffing. The facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. This placed the residents at risk for impaired mental and physical well-being. (Refer to F679)

The facility had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA Q, hired on 11/24/98 had no yearly performance evaluations upon request. CNA M, hired on 05/14/19 had no yearly performance evaluations upon request. CNA BB, hired on 05/22/20 had no yearly performance evaluations upon request. CNA R, hired on 06/28/22 had no yearly performance evaluations upon request. CNA S, hired on 11/17/97 had no yearly performance evaluations upon request. On 04/02/24 at 04:02 PM Administrative Staff A stated the facility was unable to find any performance evaluations or the required in-service records for the above-mentioned staff. Administrative Staff A stated going forward each department head will conduct the yearly performance evaluation for their staff. On 04/03/24 at 03:30 PM Administrative Nurse D stated she had not conducted any performance evaluations since she had been in her position. She stated she was unable to find any performance evaluations or training for the above-mentioned staff. The facility did not provide a policy related to staff competency, staff training, or performance evaluation. The facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNAs) reviewed for 12 hours of required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA Q, hired on 11/24/98 had no hours of in-service training recorded. CNA M, hired on 05/14/19 had no hours of in-service training recorded. CNA BB, hired on 05/22/20 had no hours of in-service training recorded. CNA R, hired on 06/28/22 had no hours of in-service training recorded. CNA S, hired on 11/17/97 had no hours of in-service training recorded. On 04/02/24 at 04:05 PM Administrative Staff A stated the facility was unable to find any performance evaluations or the required in-service records for the above-mentioned staff. On 04/03/24 at 03:30 PM Administrative Nurse D stated she had not conducted any performance evaluations since she had been in her position. She stated she was unable to find any performance evaluations or training for the above-mentioned staff. The facility did not provide a policy related to staff competency, staff training, or performance evaluation. The facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care.

The facility identified a census of 37 residents. The sample included 12 residents. Based on record review, observation, and interviews, the facility failed to post the State Survey Agency (SSA) contact information on how to report abuse in a manner accessible to the residents and their representatives. This deficient practice placed the residents at risk for ongoing abuse and other concerns. Findings Included: - On 04/01/24 at 07:20 AM a walkthrough of the facility was completed. Upon inspection of the facility's television area, a small 8-inch by 10-inch (8x10) poster with small black writing was posted by the main entry door to the room four feet high on the wall. The poster displayed the SSA contact information and instructions related to reporting complaints related to abuse. A walkthrough of the center hall revealed an 8x10 poster with a small black font on the wall placed behind two Hoyer lifts (total body mechanical lift). The poster was placed six feet away from the view of the hall. On 04/02/24 at 10:15 AM, the Resident Council members reported they were not aware of the location of the SSA contact information. On 04/03/23 at 12:45 PM Resident (R)16, a cognitively intact resident, sat in her wheelchair next to the piano in the lobby. Upon request, R16 attempted to read the state agency contact poster. R16 reported she could not read the poster from two feet away from it. R16 reported she could not read the state contact poster in the hallway behind the Hoyer lifts. On 04/03/24 at 02:30 PM, Licensed Nurse (LN) G reported the required contact posters should place in a highly visible area and big enough for everyone including the residents to read. She stated many of the residents have difficulty seeing small letters and require larger signs to read. On 04/03/24 at 03:30 PM Administrative Nurse D stated the required contact information should be posted in a manner visible and understandable to the residents. The facility's provided Your Rights and Protections as a Nursing Home Resident policy (undated) indicated the facility must provide the contact information to report mistreatment or concerns to the Long-Term Care Ombudsman, and State Survey Agency. The facility failed to post the SSA information in a manner accessible to the residents and their representatives. This deficient practice placed the residents at risk for ongoing abuse and unresolved grievances and concerns.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 04/02/24 at 08:00 AM an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 04/02/24 at 10:15 AM, the Resident Council members reported they were not aware if the facility provided a way to complete anonymous grievances. The council reported Administrative Staff A was responsible for complaints and grievances. The council reported they did not know of a grievance box or forms. On 04/03/24 at 11:45 AM Social Services X reported she was not aware of any way for the residents or their visitors to file grievances anonymously. On 04/03/24 at 03:50 PM Administrator A stated she handled the facility's grievances. She stated she currently did not have a posted grievance dropbox, but the residents could call the corporate complaint line to file a grievance. She stated staff could receive the grievances and file them for the residents as well. The facility's provided Grievance policy revised (undated) indicated the facility would ensure each resident's right to file a grievance in writing, verbally, or anonymously. The policy indicated the facility would ensure the grievances were documented and ensure all written decisions included corrective actions and prompt resolution. The policy noted the grievance documentation will be kept for three years beyond the written decision. The facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously within the facility. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan with resident-specific interventions for Resident (R)7, R10, R25, and R14. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of morbid obesity (severely overweight), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and respiratory failure. R7's Quarterly Minimum Data Assessment (MDS) completed 02/02/24 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated he required substantial to maximal assistance with bed mobility, transfers, personal hygiene, dressing, and bathing. The MDS indicated he had no pressure ulcers but was at risk for developing them. The MDS noted he was on a turning/repositioning program and received ointment and medications. The MDS noted he had pressure-relieving devices for his chair and bed. R7's Pressure Ulcer Care Area Assessment (CAA) completed 08/12/23 indicated he was at risk for pressure ulcer development due to his decreased mobility. The CAA noted he had a pressure-reducing cushion in his wheelchair and a pressure-relieving mattress on his bed. The CAA noted he used an overhead trapeze to assist with repositioning. The CAA indicated a care plan would be developed to minimize the risk of occurrences. R7's Care Plan initiated 09/01/17 indicated he was at risk for skin breakdown and pressure ulcers. The plan indicated he required assistance from staff to complete his activities of daily living (ADLs) due to his physical limitations. The plan indicated he should be repositioned every two hours to prevent skin breakdown. The plan noted he had no actual pressure-related injuries but was at risk. The plan lacked documentation related to his low air-loss mattress on his bed or the correct settings. A Skin/Wound Condition assessment completed on 03/15/24 noted no wound or skin conditions. The assessment indicated he had a low air-loss or alternating pressure air mattress as a preventative measure for pressure injuries. R7's EMR indicated he weighed 338 pounds (lbs.) on 03/27/24. R7's EMR lacked instructions related to his low air-loss mattress or pump settings. A review of the low air-loss mattress manufacturer's operation (Drive Model #14048) manual indicated the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range selected. The manual recommended the pump be set based on the resident's weight. The manual indicated the firmness of the mattress could be set within 50 lbs. weight intervals. On 04/01/24 at 07:05 AM R7 slept in his bed. His bed contained a low air-loss mattress and a Drive Model 14048 pump. The pump's weight range was [PHONE NUMBER] lbs. capacity with weight ranges set at 50 lb. increments. R7's pump was set up for 400-450 lbs. range. On 04/02/24 at 09:21 AM R7 sat in his recliner. He stated he had skin breakdown when he first arrived at the facility and the bed was brought in. He stated the bed could be uncomfortable and he was not sure if staff checked the settings on it. Observation revealed R7's pump was set at the 400-450lbs range. R7 stated he has never weighed 400lbs. On 04/02/24 at 11:45 AM Certified Nurses Aid (CNA) stated the pump instructions should be listed in the care plan to inform staff how it should be set. On 04/02/24 at 02:40 PM, Licensed Nurse (LN) G stated she was not sure if the care plan or orders contained instructions for his mattress pump. On 04/03/24 at 03:30 PM Administrative Nurse D stated all staff had access to the care plans. Administrative Nurse D stated she expected the care plan to be updated within one to two days after learning of new issues or interventions. Administrative Nurse D stated she expected all staff to review and follow the residents' plans. Administrative Nurse D acknowledged the care plans had not been updated as they should have before January and said it was a work in progress. The facility did not provide a policy related to care plan creation or revision. The facility failed to review and revise the care plan with resident-specific interventions for R7. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. 41037 - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (HTN-elevated blood pressure), and a contracture (abnormal permanent fixation of a joint or muscle). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented no upper or lower extremity impairment for R10 during the observation period. The MDS documented R10 was dependent on staff for most activities of daily living (ADL) but was able to feed himself after set-up assistance from staff. The Quarterly MDS dated [DATE] documented a BIMS score of 10 which indicated moderately impaired cognition. The MDS documented that R10 had upper and lower extremity impairment on one side during the observation period. The MDS documented R10 was dependent on staff for most ADL but was able to feed himself after set-up assistance from staff. R10's Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/26/23 documented he had impaired mobility and required extensive assistance from three staff members for transfers. R10's plan of care would direct staff to assist him in maintaining his level of care and prevent a decline in his ability to participate in his care. R10's Care Plan dated 05/18/22 directed staff to place a washcloth in R10's hand to protect his palm from his fingernails. The plan of care lacked direction for a left-hand splint. R10's EMR under the Documentation Survey Reports under Tasks documented: Restorative: Splint/brace- apply elbow brace, hand splint, and carrot daily to the left hand. The resident was to wear the splint throughout the day for contracture. R10's EMR under Tasks reviewed from 01/01/24 through 03/31/24 lacked documentation that the splint was applied to R10's left hand. On 04/01/24 at 09:53 AM R10 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in his room. R10's left contracted left hand laid on his chest with his fingers tightly gripped. R10's left hand did not have a washcloth or carrot in his palm or a splint/brace on his left elbow. R10 stated the staff had not placed a washcloth in his left palm for a long time and said he probably should have one in his hand. On 04/02/24 at 09:55 AM R10 sat slightly reclined in his Broda chair in the common area. R10's contracted left hand lay on his abdomen. R10's left hand did not have a washcloth or carrot in his palm and no splint/brace on his left elbow. On 04/03/24 at 02:30 PM, Certified Nurse Aide (CNA) O stated the dayshift would apply any splints or braces. CNA O stated she had not seen a splint for R10. CNA O stated she had not been told R10 should have a washcloth in his left hand. On 04/03/24 at 02:43 PM, Licensed Nurse (LN) G stated restorative service was provided depending on staffing levels. LN G stated she was not aware R10 was to wear a splint or brace. On 04/03/24 at 03:30 PM Administrative Nurse D stated all staff had access to the care plans. Administrative Nurse D stated she expected the care plan to be updated within one to two days after learning of new issues or interventions. Administrative Nurse D stated she expected all staff to review and follow the residents' plans. Administrative Nurse D acknowledged the care plans had not been updated as they should have before January and said it was a work in progress. The facility did not provide a policy related to care plan creation or revision. The facility failed to review and revise the care plan with resident-specific interventions for R10. This deficient practice placed the resident at risk for impaired care due to uncommunicated care needs. - R25's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (HTN-elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cognitive communication deficit. The Significant Change Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition. The MDS documented R25 was dependent on staff assistance for all activities of daily living. The MDS documented R25 had difficulty with his hearing and did not wear hearing aids during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R25 required substantial to maximum assistance with personal hygiene. The MDS documented R10's hearing was adequate with the assistance of his hearing aids. R25's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/24/23 documented R25 had severe cognitive impairment. R25's Care Plan dated 03/15/23 documented R25 had hearing aids that needed to be charged nightly. The plan of care lacked direction to the staff related to the application of R25's hearing aids. On 04/01/24 at 12:36 PM staff pushed R25 into the dining room table in his wheelchair and left the dining room. Another resident attempted to talk with R25. R25 stated he could not hear this resident because his hearing aids had been lost again. Certified Nurse Aide (CNA) Q entered the dining room and placed hearing aids into R25's ears. On 04/02/24 at 08:07 AM R25 sat in his wheelchair at the dining room table without his hearing aids. One of his table mates attempted to talk to R25. R25 was unable to hear what was said to him. R25 stated he could not hear; his hearing aids had been lost. On 04/03/24 at 09:57 AM, Administrative Nurse D stated R25 had lost a pair of hearing aids, but he currently had hearing aids to use. Administrative Nurse D stated she was not aware of any specific staff assigned to ensure R25's hearing aids were placed in his ears to assist him with being able to participate with his ADLs. Administrative Nurse D stated that R25 could understand if he was facing the person who was speaking. Administrative Nurse D stated R25 would stop by the nurse's desk if someone was there to ask for his hearing aids. Administrative Nurse D stated she was not aware that R25 believed his hearing aids had been lost. On 04/03/24 at 03:30 PM Administrative Nurse D stated all staff had access to the care plans. Administrative Nurse D stated she expected the care plan to be updated within one to two days after learning of new issues or interventions. Administrative Nurse D stated she expected all staff to review and follow the residents' plans. Administrative Nurse D acknowledged the care plans had not been updated as they should have before January and said it was a work in progress. The facility did not provide a policy related to care plan creation or revision. The facility failed to review and revise the care plan with resident-specific interventions for R25. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. 49634 - R14's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or never problems), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). The Significant Change Minimum Data Set (MDS) dated [DATE] did not document a Brief Interview of Mental Status (BIMS). The MDS documented that R14 required partial/moderate assistance with toileting, showers, and eating. The MDS documented R14 received a diuretic (medication to promote the formation and excretion of urine) during the observation period. R14's Communication Care Area Assessment (CAA) dated 02/09/24 documented R14 was alert to person and was nonverbal. He could indicate by nodding his head to yes or no questions. He also had a picture book where he could point to objects, which he seldom used. R14's Care Plan revised 08/25/22 documented R14 received a diuretic with a Black Box Warning (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration). The plan lacked direction related to weight monitoring for CHF. R14's EMR under the Orders tab dated 04/27/21 revealed the following physician orders: Lasix (diuretic) tablet 20 milligrams; give one tablet by mouth one time a day related to CHF. Daily weights every day dated 02/17/24, for the diagnosis of CHF. Review of R14's Medication Administration Record (MAR) from 02/17/24 to 04/03/24 (45 days) lacked evidence staff measured and recorded R14's weight on the following dates 02/17, 02/18, 02/21, 02/22, 2/26, 2/27, 03/01, 03/02, 03/03, 03/06, 03/07, 03/11, 03/12, 03/15, 03/16, 03/17, 03/20, 03/25, 03/26, 03/28, 03/29, 03/30, 03/31 and 04/02. R14's clinical record lacked documentation of physician notification the daily weight was not obtained and lacked evidence R14 refused to be weighed. On 04/02/24 at 09:19 AM R14 sat in his wheelchair playing hit the balloon with peers during an activity. On 04/03/24 at 02:20 PM, Certified Nursing Aide (CNA) O stated nursing would let the CNA staff know if ta residents needed to be weighed. CNA O stated the nurses usually made a list of residents who needed to be weighed. On 04/03/24 at 02:43 PM Licensed Nurse (LN) G stated that occasionally she did not have time to obtain weights. LN G stated if she did not have time to get the weight, she also did not have time to notify the physician of the missed weight. On 04/03/24 at 03:30 PM Administrative Nurse D stated all staff had access to the care plans. Administrative Nurse D stated she expected the care plan to be updated within one to two days after learning of new issues or interventions. Administrative Nurse D stated she expected all staff to review and follow the residents' plans. Administrative Nurse D acknowledged the care plans had not been updated as they should have before January and said it was a work in progress. The facility did not provide a policy related to care plan creation or revision. The facility failed to review and revise the care plan with resident-specific interventions for R14. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 37 residents. The sample includes 12 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being. Findings included: - A review of the facility's Activity Calendar for January, February, and March 2024 was completed. The review revealed no activities on Saturdays and Sundays. The calendar indicated church services were provided on Sunday afternoons. On 04/03/24 at 10:15 AM, Resident Council members reported activities rarely occurred on weekends compared to the weekdays. The council reported due to the low staffing in the facility there was no activity person on the weekend. The council reported they could read books, and there were extra coloring pages, or they could watch TV. The council reported they would like activities on the weekends, such as bingo or interactive groups on the weekend. On 04/03/24 at 12:55 PM, Certified Nurses Aid (CNA) Q stated staff used to have activities on the weekends, but now there was only church on Sundays. CNA Q stated most of the residents watched TV on the weekends, since that was all there was to do. On 04/03/24 at 10:51 AM Activities Staff Z reported the facility did not have activities on the weekends. Activities Staff Z stated there were things residents could do, like read books and there were always coloring pages left out for the residents. A review of the facility's Activities and Resident Rights policy revised 10/2019 indicated facility will promote and advocate the residents' rights in the provision of recreation services and to promote self-determination. The resident council is to be promoted and used as a way for soliciting new ideas and suggestion programs. The facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being.

The facility reported a census of 40, with one resident reviewed for accidents. Based on record review and interview, the facility failed to ensure staff safely secured Resident (R)1 in the resident's wheelchair during transport. On 05/23/23 Certified Nurse Aide (CNA) M failed to apply the seatbelt or the full four-point belt system to R1's wheelchair, and when CNA M applied brakes in the facility van during transport, caused R1 to slide out of her wheelchair and onto the floor of the facility van, landing on her bottom. The resident received a 13 centimeter (cm) in length by two cm in width laceration (wound to the skin) to her left knee and required transfer to the Emergency Department (ED) for treatment. The resident received 11 sutures to the laceration to her left knee. This failure placed the resident in immediate jeopardy. Findings included: - The signed Physician Order Sheet (POS), dated 03/03/23, documented R1 admitted to the facility on [DATE] with the following diagnoses; muscle weakness (feel weak and tired or your muscles may be sore), spondylosis (a small crack between two vertebrae [the bones in your spine] without myelopathy (a nervous system disorder that can permanently affect the spinal cord that causes a loss of sensation, loss of function, and pain or discomfort), radiculopathy lumbosacral region (a severe pain that radiates from the back into the hip and outer side of the leg caused by compression of the sciatic nerve), and morbid obesity (a disorder involving excessive body fat that increases the risk of health problems). The 12/19/22 Admission Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. She required one staff member for bed mobility, transfer, and toileting. She required extensive assistance of one staff member with ambulation, and supervision with locomotion. Her mobility devices included a walker and a wheelchair. She was not steady but could stabilize without staff assistance. The 12/22/22 Activities of Daily Living (ADL)/Functional Rehabilitation Potential Care Area Assessment (CAA), documented the resident had impaired mobility and required extensive assistance of one to two staff members with bed mobility, transfers, and toileting. The 12/22/22 Falls Care Area Assessment (CAA), documented the resident was unstable during transitional move and required staff assistance with transfers and toileting, which placed her at risk for falls. The 03/07/23 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. She required supervision with bed mobility, transfer, and locomotion. She required limited assistance with ambulation. Her mobility devices included a walker and a wheelchair. She was not steady but could stabilize without staff assistance. The resident's Activities of Daily Living Care Plan dated 12/13/22 included the resident could self-propel in her wheelchair. The resident required assistance with transfer with the gait belt. The revised care plan, dated 05/23/23, included the resident required two-staff assistance with transfer. The resident's Fall Care Plan, dated 12/13/22, included the resident would place herself on the floor when she became upset, or things did not go to her liking. The revised care plan, dated 05/23/23, directed the staff to ensure the resident to be safely secured in her wheelchair when in the facility van, and she required two staff assistance with transfer and ambulation. Review of the Nurse's Notes revealed on 05/23/23 at 10:28 AM, the resident was on her buttocks on the floor of the facility vehicle. The resident had a red drainage noted to her left knee. The resident reported to the nurse that she fell forward out of her wheelchair and hit her knee. The resident did not obtain other injuries. Staff transported the resident in the facility van to the Emergency Department (ED) for evaluation and treatment. The resident returned with 11 sutures to her left knee and a knee brace on her left knee. The physician ordered clindamycin (antibiotic that fights bacteria in the body) 300 milligrams (mg), by mouth, four times a day, for seven days. The physician also ordered hydrocodone/acetaminophen 5-325 mg, every six hours, as needed for moderate pain for three days. The sutures to the resident left knee to be removed in two weeks. On 05/30/23 at 01:39 PM, Certified Nurse Aide (CNA) M reported on 05/23/23 at 10:15 AM, she left the facility in the facility van with R1. CNA M attempted to transfer R1 alone into the front passenger seat of the facility van, as the resident requested. The resident became weak, and she lowered herself to the running boards of the van and then to the ground. CNA M called the facility for assistance. Licensed Nurse (LN) H and Social Services X assisted CNA M with the transfer to get the resident back into her wheelchair and into the facility van. After the resident was in the van, CNA M reported she locked the wheels of the resident's wheelchair and attached one hook on the van floor to the wheelchair. CNA M reported she failed to place the seatbelt on the resident and failed to attach the other three of the four-point hooks on the wheelchair to secure the resident and her wheelchair in place. CNA M reported she then drove out of the facility parking lot to the stop sign, approximately 1 1/2 blocks away. When she pushed on the brakes to stop, R1 slid forward out the wheelchair onto her bottom and received a large laceration to her left knee. CNA M reported she notified LN H she was on her way back to the facility due to the incident. She reported she drove back to the facility with the resident on the floor of the van. CNA M reported she should have stayed at the stop sign and should have called 911 and waited on the facility staff to arrive for assistance. When she returned to the facility, staff assisted the resident off the van floor and into her wheelchair. After securing the four-point hook safety system and the resident's seatbelt, staff then transported R1 to the ED accompanied by CNA M and Administrative Staff A. On 05/30/23 at 02:08 PM, Administrative Staff A reported CNA M failed to secure R1's wheelchair with the four-point hooks in the facility van and failed to place the seat belt on the resident prior to leaving the facility parking lot. The facility provided CNA M with education on Van Orientation and In-Service before she transported the resident to the ED. On 05/31/23 at 01:33 PM, Licensed Nurse (LN) G reported staff should not drive with a resident on the floor of the van CNA M unsafely transported the resident. The undated facility's Instruction for Van Safety Notebook, located in the facility van revealed the procedure for Van safety included: 1. The appropriate postings to match the tie down equipment the van used were printed and posted appropriately in the facility van. 2. All Drivers were trained and signed the Van Safety and Orientation In-Service sheet. 3. All Drivers are routinely scheduled at least annually for re-training and checkoff. On 05/30/23 at 05:23 PM, Administrative Staff A was provided a copy of the IJ template and notified the facility failure to safely secure the resident and her wheelchair during transport, where R1 fell forward out of her wheelchair onto the floor of the van and received a 13 cm by 2 cm laceration to her left knee that required the resident to receive 11 sutures, placed the resident immediate jeopardy. The facility identified and implemented the following corrective measures on 05/24/23 at 02:15 PM: 1. On 05/23/23 at approximately 10:45 AM, the facility provided CNA M immediate education on utilization of using the van's seatbelt and four-point safety hooking system with a return demonstration. 2. A Quality Assurance and Performance Improvement (QAPI) meeting held on 05/24/23 at 09:30 AM. 3. On 05/24/23 at 02:15 PM, the facility identified six staff members approved by corporate for driving ability. The facility completed the training including all staff authorized to drive the van for transportation received education and skills checks prior to driving the facility vehicles. The surveyor verified the implementation of the above corrective actions onsite on 05/31/at 08:00 AM. Due to the implemented corrective actions prior to the surveyor's arrival onsite, the deficient practice was deemed past-noncompliance and existed at a J scope and severity.

The facility reported a census of 47 residents with seven identified as elopement risks and three included in the sample. Based on observation, record review, and interview the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R) 2, who had a history of exit seeking, from exiting the building through a dining room window without staff knowledge. On 03/21/21 at approximately 09:00 PM, the resident opened a window in the dining room, removed the screen, and exited through the window. At approximately 09:45 PM (45 minutes later), people from the community notified the facility of the resident face down, on the ground next to the building. This deficient practice placed the resident in immediate jeopardy. Findings included: - R2's signed Physician Orders (PO), dated 03/05/21, documented the resident with diagnoses of senile degeneration of the brain (mental loss of intellectual ability that is associated with old age), dementia with behavioral disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and unspecified [CONDITION(S)] (impaired relationship with reality which may cause hallucinations or delusions). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The resident was ambulatory and had no wandering behaviors during the seven-day lookback period. The Behavioral Symptoms Care Area Assessment (CAA), dated 03/03/21, documented the resident as alert to person and environment. He wandered throughout the facility and occasionally became agitated with staff. He was non-compliant with care. The staff were to monitor his behaviors and notify his family and physician when needed. The Cognitive Loss/Dementia CAA, dated 03/03/21, documented the resident with a BIMS score of 2, but usually could make his wants and needs known to the staff. The staff were to assist the resident with daily decision making and to anticipate and provide for his daily needs. The Care Plan, dated 02/19/21, revealed R2 was at risk for wandering and might attempt to leave the building on his own. The resident's care plan listed the following interventions: 1. If I am exhibiting exit seeking behaviors (pacing, sitting close to the door, packing my belongings, talking about taking a trip, etc.) please place me on safety checks. (How often is to be determined by my treatment team). 2. Please ask me why I am wandering. Sometimes I may be wanting something that you can help me with or assure me and redirect me from exit seeking behavior (pain, hunger, toileting). 3. Please encourage me to attend activities to keep busy. 4. Please talk with me and offer 1:1 time when available. 5. Please talk with my family. They may know what has helped to decrease my wandering in the past. The care plan lacked further interventions to prevent elopement for this resident. 1. An Elopement Risk assessment, dated 02/18/21, documented the resident with a score of 10, which indicated a moderate risk of elopement. The resident had Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), short term and long-term memory deficits, cognitive impairment, and had poor safety awareness. Observation, on 04/13/2021 at 09:08 AM, revealed CNA Q and CNA LL entered the resident's room to reposition the resident in his bed. The resident was sleeping soundly without distress. The CNAs tried to wake him up during care but he did not respond. The CNAs positioned him on his left side and placed pillows behind his back and under his legs for comfort. The resident slept through care. A Behavior Note, dated 03/15/21 at 10:43 AM, documented Certified Nurse Aide (CNA) P found R2 opening a window in his wife's room. The resident stated he was going to take his wife and himself out of the window and they were going to leave. The resident was actively exit seeking and confused. This nurse closed and locked the window and made sure the resident's wife was safely in her chair. The CNA told the resident the weather was going to get bad with rain and his wife would get too cold outside. The staff were able to redirect the resident back to his room so he could look up the weather. The note identified the interventions as effective for the moment. The nurse writer would need to keep an eye on the resident as he was still actively seeking exit. Facility administration were made aware of the situation. A Behavior Note, dated 03/16/21 at 09:54 AM, revealed R2 actively tried to exit the building and pushed the Registered Nurse (RN) when she was at the front door to screen someone. He then pushed the buttons on the keypad to try to get out of the door. When the nurse came out to redirect him, he was in the dining room unlocking windows. R2 stated he wanted to get out of the facility and they would not let him, so he thought about breaking the window or cutting out the screen. The resident had confusion and was actively exit seeking, so staff redirected R2 to sit in a chair in the lobby. The nurse called R2's son to come visit. A Behavior Note, dated 03/21/21 at 09:56 AM, revealed R2 wanted the staff to call his son to have him come to the facility to pick R2 and his wife up and take them back to Wichita. R2 became agitated and stated he was stuck in a hotel and nobody would let him out. Once R2 spoke with his son on the phone, he calmed down and rested on the couch in the lobby after the phone call was over. A Behavior Note, dated 03/21/21 at 12:00 PM, revealed the resident did not actively exit seek, but was adamant about calling his son on the phone. A Nursing Note, dated 03/22/21 at 02:17 AM, revealed at approximately 09:45 PM on 03/21/21, CNA O reported to the nurse they received a phone call stating that someone was lying on the ground outside of the building. Staff found R2 lying face down outside of the small dining room window, with the window open, and the screen also on the ground. R2 wore a plaid shirt with a white T-shirt underneath, blue jeans, belt, shoes, and socks. Review of www.Accuweather.com weather history for March 21, 2021, revealed the weather was 56 degrees when the resident eloped from the facility. On 04/14/21 at 04:05 PM, Licensed Nurse (LN) G reported R2 had exit seeking behaviors since his admission in February 2021. His wife was also a resident at the facility and she sometimes triggered the resident's exit seeking behaviors. He would get aggressive and hateful with staff if they tried to take care of her. The staff tried to calm him down and redirect him, or call his son to come in and help when he was exit seeking. The majority of the time the staff could redirect him. The resident started trying to open the windows a week or two before his elopement. The staff caught him one time trying to get out of his wife's window, but he could not get the screen out. He stated he needed to get out of here or needed to break the window. Sometimes R2 thought he was in a hotel and tried to get out. LN G stated he fiddled with the dining room windows and tried to unlock them. She stated staff provided 1:1 intervention when he had exit seeking behaviors, which kept him from opening the windows. The CNAs monitored his location at least hourly and documented it in his chart. LN G reported she worked day shift the day he eloped and worked the following day. He was fairly calm during the day, talked about his need to take care of the animals, and she stated he was not exit seeking. When R2 eloped, he managed to push the window screen out and staff found him lying face down on the ground, with a scrape to his head. The facility placed alarms on the dining room windows after he eloped. On 04/14/21 at 04:48 PM, CNA M reported she worked the night he went outside through the window. CNA M stated the CNAs were supposed to check on him every hour. She said she checked on him at 08:00 PM and he was in his recliner watching tv. The CNAs documented hourly checks under the task bar in the computer and stated she should have documented when she saw him at that time. Instead, her documentation showed that she did not know his location at 08:00 PM. When CNA M saw him before he eloped, he did not exhibit any exit seeking behaviors. If he had exit seeking behaviors, the staff were 1:1 with him and notified the charge nurse. On 04/14/21 at 05:30 PM, CNA N reported she worked the night R2 eloped out of the window. When CNA N checked on him and knew where he was, she documented it in the hourly check log. CNA N saw him at 09:00 PM in his room watching tv on the night he eloped and reported she did not document that she saw him at that time on the hourly check log. After she checked on the resident, she helped assist other residents to bed. She heard the front door, doorbell ring about 09:45 PM and noted a lady at the door, who stated there was a man on the ground outside. Staff N went outside and found R2, then went and got Administrative Nurse D. CNA N did not think the resident realized what he did. It was not very cold outside that night and he had on all of his clothes and his jacket. R2 went to the behavioral health unit the next day because he was verbally/physically aggressive, abusive to the staff, and staff had difficulty redirecting R2 during those times. CNA N did not know when the alarms on the windows were added. She stated the alarms made a loud noise if somebody opened the window. Per a Witness Statement, dated 03/21/21, CNA O, documented she answered a phone call and spoke with a lady, who stated there was a man outside on the ground. CNA O and CNA N ran outside and found R2 lying on the ground. She asked R2 if he was okay and if he was hurt or hurting anywhere. R2 responded that he was okay. The charge nurse came out and assessed the resident. CNA O, with help of other staff, got R2 up off of the ground and back into the facility. Staff observed an open window in the small dining room with the screen lying on the ground. On 04/15/21 at 11:09 AM, Administrative Nurse D verified the resident had severely impaired cognition. R2 became agitated and would strike out at staff. There did not appear to be any certain thing that would trigger him to have exit seeking behaviors. The resident was on hourly checks and when needed received 1:1 with the staff. At times the staff could get him to talk about his cattle/horses to change his direction of thinking. R2 had one episode of agitation during the evening that he eloped, but calmed quickly. He did not wander during the evening hours, made no remarks about leaving, and displayed no exit seeking behaviors. At approximately 07:45 PM staff noted R2 in another resident's room. He became agitated, twisted a CNA's finger, and pushed her. Administrative Nurse D did not see R2 again until the facility received the phone call informing the facility he was outside laying on the ground. Administrative Nurse D assessed R2 for injuries and noted he had a few abrasions on his face. Two staff assisted R2 to his feet and he ambulated back into the building. R2's son came and sat with resident throughout the night. R2 continued on 1:1 with staff until he was sent out to the behavioral health unit the next day. On 04/14/21 at 02:15 PM, Administrative Staff A revealed the day R2 eloped, staff reported he had been agitated and wanted to call his son. His son came out to the facility and sat with him for a while to calm him down. The staff were supposed to check on him and his location every hour and document it in the log on the computer. CNA N reported she last saw the resident around 09:00 PM. At approximately 09:45 PM, two people drove by the facility and saw the resident on the ground between the building and the sign outside of the dining room window. One of the people called the building and another came to the door to tell the staff. R2 had a small abrasion to his face. R2 took the screen out of the window. Administrative Staff A stated the windows were locked, but they could be unlocked easily. He went out the window and was found lying on the ground. He was not strong enough to get himself back up. Staff went out to help and got him back into the facility. The facility policy, Resident Elopement Policy & Procedure, revised 12/19, documented .Risk for elopement is to be identified for residents and an individualized care plan developed based on risk Based on assessment findings and event investigation, the resident's care plan is to be reviewed and updated with any new interventions to prevent reoccurrence. The facility staff failed to provide adequate supervision to prevent R2 from exiting the building through a dining room window, without staff knowledge after displaying behaviors on 03/15/21 of attempting to open windows to leave the facility. The resident eloped through a dining room window on 03/21/21, at approximately 09:00 PM, when the resident who the facility identified as an elopement risk, left the facility by opening a window in the dining room, removing the screen, and exiting through the window. Approximately 45 minutes later people passing by notified the facility and staff found the resident face down on the ground next to the building. This deficient practice placed the resident in immediate jeopardy. This deficiency was cited as past non-compliance as the facility completed the following as of 03/22/21 at 6:55 PM: 1. QAPI meeting held on 03/22/21 at 9:00 AM with Interdisciplinary team with inclusion of the medical director by phone. 2. Alarms to the dining room and conference area windows (areas not in direct line of sight with the nurse's station) on 03/22/21 by 2:00 PM 3. One on one provided to resident by family member until 07:30 AM on 3/22/21 then provided by facility staff until 4:30 PM when resident transferred to the Behavioral Health Unit. All staff educated on elopement policy, resident incident, and 1 on 1 intervention prior to working a new shift. Education initiated immediately with all staff following the incident and completed on 03/22/21 at 6:55 PM.

The facility reported a census of 44 residents with 15 residents sampled, including four residents reviewed for pressure ulcers (PU). Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for two of the four residents, which included Resident (R)1 for the failure to reposition the dependent resident timely, failed to monitor and assess the wound for 27 days, and the resident developed a facility acquired a stage III PU (involves full-thickness skin loss). The facility also failed to reposition dependent R 30 timely and the resident developed a facility acquired stage III PU. Findings included: - The Physician order [REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented staff assessment for cognition revealed the resident had moderately impaired cognition. She required extensive assistance of two staff for bed mobility, transfers, and toilet use. She had functional impairment in range of motion (ROM) on one side of her lower extremity and used a wheelchair for mobility. She was at risk for developing pressure ulcers (PU), but had no unhealed PUs at the time of the assessment. Staff utilized pressure reducing devices for her bed and her chair, and the resident was on a turning and repositioning program. The Care Area Assessment for Pressure Ulcers, dated 02/06/21, documented the resident as at moderate risk for acquiring PUs. She was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility. The Significant Change 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, transfers, and toileting. She had functional impairment in ROM on one side of her lower extremity and required a wheelchair for mobility. She was at risk for developing PUs, but had no unhealed PUs at the time of the assessment. Staff utilized pressure reducing devices for her bed and her chair, and the resident was on a turning and repositioning program. The Pressure Ulcer Care Plan, dated 12/16/20, instructed staff to turn and reposition the resident every two hours and to ensure she had a pressure relieving cushion in her wheelchair. The resident had a pressure reducing mattress on her bed. The revised Pressure Ulcer Care Plan, dated 02/03/21, instructed staff to administer a multivitamin and calcium to assist in wound healing. The revised Pressure Ulcer Care Plan, dated 02/15/21, instructed staff to cleanse the open area to the resident's coccyx (a small triangular bone at the base of the spinal column) with wound cleanser, allow to dry, apply skin prep (prepares skin for an adhesive dressing), apply Santyl (an enzyme used to help the healing of skin wounds, and skin ulcers) nickel-sized thickness, and cover with a bordered gauze. Staff were to change the dressing daily and as needed (PRN). Review of the resident's electronic medical record (EMR), under the Assessments tab, revealed Braden assessments (shows risk of developing a PU), dated 11/14/20 and 02/06/21, which placed the resident at a moderate risk for developing PUs. Review of the resident's EMR, under the Assessment tab, revealed a Skin/Wound Condition Assessment, dated 01/08/21, which documented an open area to the resident's coccyx that measured 3.0 centimeters (cm) in length (L) by 3.0 cm in width (W). The facility lacked documentation of staging the pressure ulcer (an assessment system that classifies pressure ulcers based on the depth of soft-tissue damage). Staff treated the area with [MEDICATION NAME] (ointment that helps heal and prevent skin irritations and promotes healing for a variety of symptoms) and sprinkled with [MEDICATION NAME] powder (antifungal antibiotic powder for skin irritation). Review of the resident's Treatment Administration Record (TAR), dated 01/09/21, revealed a physician's orders [REDACTED]. Staff were to change the dressing daily and PRN. This order was discontinued (DC'd) on 01/15/21. Review of the resident's Progress Notes in the EMR, dated 01/11/21, revealed the resident's unstaged coccyx wound measured 3.3 cm L by 3.0 cm W by 0.5 cm in depth (D). Staff were educated on the need to reposition the resident at least every two hours and to keep the resident off of her buttocks as much as possible. Review of the resident's TAR, dated 01/16/21, revealed a physician's orders [REDACTED]. Staff were to change the dressing every 72 hours and PRN. This order was DC'd on 02/12/21. Review of the resident's Progress Notes in the EMR, dated 02/01/21, revealed the resident had an ongoing open area to her coccyx. Documentation lacked measurements and description of the wound . Review of the resident's Progress Notes in the EMR, dated 02/07/21, revealed the resident had an open area to her coccyx that measured 1.0 cm L by 0.5 cm W. Documentation lacked description of the wound. The facility lacked measurements of the wound for 27 days . Review of the resident's EMR, under the Assessment tab, revealed a Skin/Wound Condition Assessment, dated 02/14/21, which documented a PU to the resident's coccyx, measuring 1.2 cm L by 1.0 cm W by 0.2 cm D. This was the initial wound encounter with the wound consultant company by the facility. The wound was surgically debrided (the removal of damaged tissue from a wound) of slough (dead skin tissue that may have a yellow or white appearance) with a small amount of serosanguineous (discharge that contained both blood and a clear yellow liquid) drainage present. The wound was identified as a full thickness pressure injury. A new order directed staff to cleanse the area with Hyphochlorous Acid (a wound cleanser), allow to air dry, apply skin prep around the wound, apply Santyl, nickel -thick to the wound bed, and cover with a bordered gauze. Staff were to change the dressing daily and PRN. On 02/18/21 at 10:15 AM, the resident sat in her Broda chair (specialized wheelchair) in the activities room participating in a flower arranging activity. The resident remained in this position at 10:30 AM, 10:45 AM, and 11:00 AM. At 11:04 AM, activity staff Z took the resident to the front commons area of the facility to watch TV. The resident remained in this position at 11:15 AM, 11:30 AM, and 11:45 AM. At 12:00 PM, when staff took the resident to the dining room for lunch and sat her at the dining table in her Broda chair. The resident remained in this position at 12:15 PM and 12:30 PM. At 12:35 PM, staff served the resident her lunch and assisted her to eat. At 12:49 PM, the resident rested with her eyes closed in the Broda chair. The resident remained in this position until 01:06 PM (two hours and 51 minutes), when Licensed Nurse (LN) K informed staff the resident had been up in the Broda chair for almost three hours. LN K requested staff to lay the resident down. Certified Nurse Aides (CNAs) N and NN propelled the resident to her room and transferred her from the Broda chair to her bed. Staff completed peri-care with the resident. Her skin appeared pink and was blanchable. The resident had no further skin breakdown. Staff positioned the resident onto her left side and propped her back with pillows before leaving her room . On 02/23/21 at 09:45 AM, revealed the resident laid in her bed, on her back. LN G and LN J rolled the resident to her right side, lowered her pants, and removed her dry brief. The wound appeared to be approximately 1 centimeter round. Staff did not measure the wound. The resident had no further skin breakdown. Staff cleansed the wound with wound cleanser and allowed the wound cleanser to air dry. Staff applied skin prep to the peri wound and placed Santyl on the wound bed. The wound was then covered with a bordered gauze dressing. The wound presented as pink with tunneling (a wound that goes deep in the body and snakes through layers of tissue, creating a curved tunnel that makes the wound difficult to heal) and the peri-wound without redness . The LNs positioned the resident on her back before they left the room. The resident stayed in this position until 12:04 PM (a total of two hours and 19 minutes) when CNA NN and CNA N transferred the resident from her bed to the Broda chair. Staff utilized a full body mechanical lift when they transferred the resident . On 02/22/21 at 04:54 PM, CNA O stated, the resident should be turned and repositioned every two hours. Staff were not always able to turn and reposition the resident on time due to not having enough staff available. The resident currently had a PU to her coccyx. On 02/23/21 at 10:06 AM, CNA NN stated, the resident was to be turned and repositioned every two hours. Staff were unable to always get the resident turned every two hours. On 02/23/21 at 09:39 AM, LN G stated, the resident had an open area on her coccyx which was a PU, but LN G was not sure of the stage of the PU. The staff were to turn and reposition the resident every two hours, but LN G was unaware if staff was able to reposition the resident every two hours . On 02/23/21 at 11:02 AM, Consultant staff HH stated she classified the resident's PU as a stage III PU. Staff HH stated she did not stage a wound on the initial visit, but would stage a wound on the second visit. This was the company's practice. On 02/23/21 at 12:37 PM, Administrative Nurse D stated, the facility would initiate a treatment for [REDACTED]. If the wound did not heal or became worse, staff would notify the wound care consultants. The facility did not allow licensed nurses to stage or measure a PU. The licensed nurses were only to describe what the wound looked like in their documentation. This was why the wound was not classified as a PU until 02/14/21, when the wound care came into the facility to see the resident for the first time. Administrative Nurse D confirmed the pressure area was facility acquired. The facility policy for Wound Prevention and Management, revised 12/2018, included: Residents will be repositioned in order to meet individual resident needs. Individual repositioning needs will be identified on the care plan. Licensed Nurse will be responsible for weekly assessment of skin for all residents and document findings in the electronic medical record. The facility failed reposition this dependent resident timely to assess the wound for 27 days. The resident developed a facility acquired stage III PU. - The Physician order [REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. He required extensive assistance of two staff for bed mobility, transfers, and toileting. He had limited functional range of motion (ROM) on one side of his lower extremities and required a wheelchair for mobility. He was always incontinent of bowel and bladder. He was at risk for pressure ulcers (PU) with no unhealed PUs at the time of assessment. Staff utilized pressure reducing devices for the chair and the bed, and the resident was on a turning and repositioning program. The Care Area Assessment for Pressure Ulcers, dated 01/09/21, documented the resident was at a mild risk for PU development and was incontinent of bowel and bladder. Staff were to turn and reposition the resident every two hours due to impaired mobility. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. He required total assistance of two staff for bed mobility, transfers, and toilet use. He was at risk for the development of PUs, and the resident had no unhealed PUs at the time of the assessment. Staff utilized pressure reducing devices for his bed and his chair. The resident was on a turning and repositioning program. The Pressure Ulcer Care Plan, dated 02/10/21, instructed staff to turn and reposition the resident every two hours and assess the wound on the resident's buttocks for signs and symptoms of infection and treat the wound daily, as ordered. Review of the resident's electronic medical record (EMR), under the Assessment tab, revealed the Braden assessments (used to determine the likelihood of a resident to develop PUs), dated 01/05/21, which placed the resident at a mild risk for the development of PUs. Review of the resident's Progress Notes in the EMR, dated 01/30/21, documented two New open areas to the resident's left buttock that measured 0.5 length (L) by 1.0 width (W) centimeters (cm) on one of the open wounds, and 1.0 (L) by 1.5 (W) cm. on the second open wound. The facility lacked documentation of staging the pressure ulcer (an assessment system that classifies pressure ulcers based on the depth of soft-tissue damage). Physician orders [REDACTED]. Staff were to change the dressing every shift. This order was discontinued (DC'd) on 02/05/21. Review of the resident's medical record, revealed documentation from the wound care company contracted by the facility, dated 02/05/21, which documented the resident had an unstaged coccyx wound which measured 2.8 (L) by 2.5 (W) by 0.1 depth (D) cm. The peri-wound skin texture was normal. The wound had been surgically debrided (the removal of damaged tissue from a wound) of slough (dead skin tissue that may have a yellow or white appearance). Wound care providers included orders for staff to cleanse the wound with Hypochlorous Acid (a wound cleanser) and allow to air dry, apply Santyl (an enzyme used to help the healing of skin wounds, and skin ulcers), nickel thick to the wound bed, and cover with an absorbent dressing. Staff were to change the dressing every day and as needed (PRN). Review of the resident's EMR, under the Progress Notes tab, dated 02/08/21, revealed staff failed to provide treatment for [REDACTED]. Review of the resident's medical record, revealed documentation from the wound care company contracted by the facility, dated 02/12/21, documented the stage III left buttocks/coccyx wound measured 1.9 (L) by 2.5 (W) by 0.1 (D) cm. Wound care debrided the pressure ulcer of slough with post debridement measurements of 1.9 (L) by 2.5 (W) and 0.2 (D) cm. There was no order change in the resident's treatment. Review of the resident's medical record, revealed documentation from the wound care company contracted by the facility, dated 02/19/21, documented the stage III coccyx wound measured 1.8 (L) by 0.9 (W) by 0.1 (D) cm. The wound had a moderate amount of serosanguineous (discharge that contains both blood and a clear yellow liquid) drainage, with no odor. The wound bed contained 1-25 percent slough and 51-75 percent [MEDICATION NAME] (thin tissues that cover all the exposed surfaces of the body) tissue. There was no order change in the resident's treatment. On 02/18/21 at 02:00 PM, the resident rested in bed on his back. The resident remained in this position at 02:15 PM and 02:30 PM. At 02:34 PM, Certified Nurse Aide (CNA) OO and Certified Medication Aide (CMA) R entered the resident's room to provide cares. The wound to the resident's coccyx was red around the inside edge with the wound bed containing a yellow colored substance. Staff transferred the resident from the bed to the Broda chair (specialized wheelchair) with the use of a full body mechanical lift. On 02/18/21 at 03:43 PM, Administrative Nurse E and CNA OO entered the resident's room to treat the resident's wound. Staff positioned the resident on his left side and removed his brief and performed peri-care. Administrative Nurse E cleansed the wound with wound cleanser, applied Santyl, nickel thick to the wound bed and covered the wound with an adhesive dressing. The wound had a yellow center. Administrative Nurse E did not measure the wound. On 02/22/21 at 10:00 AM, the resident rested in bed turned slightly to the right and propped with pillows. He remained in this position at 10:15 AM, 10:30 AM, and 10:45 AM. At 10:57 AM, CNAs Q and M entered the resident's room to reposition him onto his left side. Resident tolerated the cares without visible evidence of distress . On 02/22/21 at 10:00 AM, CNA M stated, staff were to turn the resident every two to three hours. CNA M verified staff were not always able to get to the resident that often, but they Tried. On 02/22/21 at 04:54 PM, CNA O stated, staff should reposition the resident every two hours. CNA ) verified staff were not always able to turn and reposition the resident on time due to not having enough staff available. The resident currently had a PU to her coccyx. On 02/23/21 at 10:06 AM, CNA NN stated, the resident should be turned and repositioned every two hours. CNA NN verified Staff were unable to reposition the resident every two hours. On 02/23/21 at 11:02 AM, Consultant staff HH stated, she classified the resident's PU as a stage III PU (involves full-thickness skin loss). On 02/18/21 at 03:43 PM, Administrative Nurse E stated, the wound care company are the only ones who were allowed to measure the pressure wounds per the corporate. The resident was not able to turn and reposition himself. Staff had to turn and reposition the resident. On 02/23/21 at 12:19 PM, Consultant II stated, Staff should turn and reposition the resident every two hours. Turning and repositioning the resident would definitely help reduce the resident's risk of developing PUs. On 02/23/21 at 12:37 PM, Administrative Nurse D stated, staff were to turn and reposition the resident every two hours and verified the guidance was documented in the resident's care plan. The facility policy for Wound Prevention and Management, revised 12/2018, included: Residents would be repositioned to meet individual resident needs. Individual repositioning needs will be identified on the care plan. The facility failed to treat this dependent resident's PU as ordered when staff failed to lay the resident down for treatment of [REDACTED].

Based on observation, interview, and record review, the facility failed to implement Centers for Medicare and Medicaid Services (CMS) infection control techniques in order to prevent the introduction and spread of diseases, including but not limited to COVID-19, to the residents of the facility. Facility staff failed to implement a screening method to ensure that visitors to the facility received prompt and thorough screening, including measuring of temperatures. On 4/14/20 at 8:10am, a Federal surveyor entered the facility through the front door into the common area, where approximately 15 residents sat eating breakfast. Five facility staff were in the immediate vicinity, and all failed to screen the Federal surveyor, who walked in the facility for approximately five minutes, before going to the nursing station to initiate the screening process. The facility failed to ensure that all staff wore facemasks, when the five staff in the facility at 8:15am on 4/14/20 failed to correctly apply or wear facemasks. Two of these staff passed breakfast trays to residents, two were seated at the nursing station, and one walked throughout the facility. Additionally, the facility failed to implement a method of surveillance to thoroughly identify, track, and trend infections in the facility, as required. A determination was made that the facility's noncompliance with one or more requirements of participation at F880 placed all residents in the facility in immediate jeopardy. On 4/14/20 at 11:00am, the Administrator was informed of the immediate jeopardy. Findings included: 1. Review of CMS guidance, titled COVID-19 Long-Term Care Facility Guidance, released on 4/2/20, documented that: 3. Long-term care facilities should immediately implement symptom screening for all. In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. Facilities should limit access points and ensure that all accessible entrances have a screening station . For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. On 4/14/20 at 8:10am, the Federal surveyor approached the locked front door of the facility, wearing a facemask. A sign at the door documented that visitors must ring the doorbell for entry. The surveyor rang the doorbell, and was allowed entry to the facility by the Maintenance Supervisor, who wore a mask. A sign-in sheet was on a small table next to the door. No further screening information or equipment was available. The common area that the entrance led into was occupied by approximately 15 residents, who were seated at individual tables. The surveyor walked in the common area, to the dining room, and up and down the beginning of two hallways for several minutes. Several facility staff made visual contact with the surveyor, but failed to ask for identification, failed to complete the screening process, and failed to intercept the surveyor from walking near the residents. Upon entry to the facility, five facility staff were observed without proper facemask application, and walked amongst the residents, in the commons area, and in the hallways of the building. Nurse Aide (NA1) delivered breakfast trays from the kitchen to residents, and had a disposable surgical mask that was pulled down beneath her chin, leaving her mouth and nose totally exposed. NA2, also delivering meal trays to residents, wore a mask briefly, but then removed it. Licensed Practical Nurse (LPN1), walking down the hallway, wore a mask inappropriately, were the mask failed to cover her nose. LPN 2, seated at the nursing station, also failed to appropriately wear her mask, and had her nose exposed. Maintenance staff (MS1) walked in the common area and hallway of the facility, and failed to wear a facemask. On 4/14/20 at approximately 8:15am, the surveyor approached the nursing station. LPN2, seated at the nursing station, and LPN1, standing next to the nursing station, continued to inappropriately wear their facemasks. The surveyor identified herself and the reason and purpose of the visit. After this, LPN1 and LPN2 corrected their masks. LPN2 looked underneath a stack of papers, retrieved a black binder that contained screening forms, and finally completed the screening process. The Federal surveyor had been in the building for several minutes, walking near residents and staff, by the time screening was completed. On 4/14/20 at 8:20am, LPN2 indicated that when staff and visitors enter the building, they sign in, then walk through the common area to the nursing station to be screened. On 4/14/20 at approximately 8:45am, NA2 loudly indicated to another facility staff member that she did not want to wear a facemask, because it was uncomfortable. On 4/14/20 at 8:55am, the Social Services Designee (SSD) entered the facility and signed in. The SSD failed to wear a facemask. The SSD walked over to the nursing station, completed a screening form, and then walked to her office. The SSD was in the immediate vicinity of residents while failing to wear a facemask. On 4/14/20 at 9:00am, the SSD indicated that her facemask was in her office, in a paper bag. The SSD indicated that she entered the facility in her normal routine, completing the sign-in at the door, filling out the form at the nursing station, and then going to her office to retrieve her facemask. On 4/14/20 at 9:35am, the Assistant Director of Nursing (ADON) indicated that she oversaw the infection control program. The ADON indicated that the facility recently experienced an increase in respiratory infections. None of the residents had COVID-19. The ADON indicated that facility staff did not always wear their facemasks appropriately, and that the screening process was supposed to happen at the front door, not the nursing station, because screening at the nursing station may potentially expose residents to illnesses or disease. On 4/14/20 at 10:06am, Medication Aide (MA1) indicated that when staff report for work, they were screened at the nursing station. MA1 indicated that on 4/13/20 at 4:00am, NA3 failed to wear a facemask. MA1 indicated that NA3 failing to wear a facemask could spread illness or disease to the residents that NA3 worked with. MA1 indicated that facility staff failed to appropriately wear facemasks on multiple occasions. On 4/14/20 at 10:40am, the Dietary Manager stated that screening took place at the nursing station, after staff entered the facility. Staff must walk from the door to the nursing station to be screened. On 4/14/20 at 2:20pm, LPN3 indicated that facility staff failed to correctly wear facemasks, and that she had witnessed the failure on more than one occasion. On 4/14/20 at 3:00pm, the Administrator and the Director of Nursing (DON) indicated that facility staff were supposed to be screened at the front door, not at the nursing station. Facility staff must wear masks at all times while in the facility. 2. Review of the facility's infection control logs, dated January, 2020, documented that the facility logged 14 infections for the month. Of the 14 infections, only two received a culture or sensitivity test, six lacked resolution dates, all lacked an admitted for the afflicted resident, ten lacked documentation of signs or symptoms of infection, five lacked a site of infection, and all lacked identification of the causative organism. The facility failed to track if the ordered antibiotic was effective in treating the infection. There were no respiratory infections in the month of January. Review of a urine culture and sensitivity test, dated 1/28/20, documented that one resident (R1), received the test due to symptoms of a urinary tract infection. The infection control log failed to include this resident as having an infection. The test results documented that R1's physician ordered antibiotics on 2/4/20. Review of the facility's infection control logs, dated February, 2020, documented the facility logged 12 infections for the month. Of the 12 infections, none had documented signs or symptoms of infection, none had an admitted for the afflicted resident, none had documented causative organism for the infection, three lacked initiation dates for antibiotics, eight lacked resolution dates, and infection received an x-ray for diagnostic reasons. There were three respiratory infections in the month of February. The facility documented that R1 developed his infection on 2/4/20, then his physician prescribed antibiotics, despite documentation that R1 was symptomatic on 1/28/20. Review of the facility's infection control logs, dated March, 2020, documented the facility logged 25 infections for the month. Of the 25 infections, three received an x-ray for diagnostic reasons, and none of the infections had a culture or sensitivity test completed. Eighteen of the infections lacked documentation of signs and symptoms of infection, two lacked a site of infection, all lacked identification of a causative organism, and all lacked resolution dates. There were six respiratory infections in the month of March. On 4/14/20 at 1:00pm, the ADON indicated that she was informed of new infections usually by nursing staff or by new antibiotic prescriptions. The ADON indicated that the nursing staff did not always tell her when a resident was developing signs or symptoms of a possible infection, and so she had to rely on tracking new antibiotic prescriptions at times. The ADON indicated that she trended infections in the building by color-coding infections on a floor map of the facility and received an antibiotic usage report from the pharmacies. The ADON indicated that she identified an increase in the number of respiratory infections, discussed the increase with the facility medical director and the individual resident's physician, and instituted a handwashing check-off in April, 2020. The ADON could not recall any further interventions implemented. The ADON indicated that she was aware that the infection control logs failed to document multiple areas of required information, and indicated that she could not spend an adequate amount of time tracking and trending infections in the facility, due to other responsibilities. Reveiw of the facility policy, dated 12/2019, titled Infection Management Process, documented: The infection Management Process will assist the facility with preventing and managing infection events. . Infection events will be placed on the Infection Control Surveillance Log to assist with monitoring types, locations, and resolution. The facility will review and evaluate infection events weekly during Risk Committee Meeting and monthly during QAPI meeting. The immediate jeopardy was removed on 4/14/20 after the Federal surveyor identified implementation of a removal plan. The scope and severity was lowered to an F.

The facility reported a census of 59 residents. The sample included 21 residents, including 3 reviewed for nutrition. Based on observation, interview, and record review, the facility failed to implement dietary recommendations, which later resulted in a 14.5% weight loss, between 4/24/18 and 5/9/18, for one (#20) of the 3 residents reviewed. Findings included: - Resident #20's signed physician's orders [REDACTED]. The resident's admission MDS (minimum data set), dated 12/14/17, revealed the resident with a BIMS (brief interview for mental status) of 9, indicating moderately impaired cognition. The resident required extensive assistance of one to two staff for completing his/her ADLs (activities of daily living). The resident could eat meals independently, and had no natural teeth, but was free of swallowing difficulties. The resident weighed 94 lb (pounds) at admission, and was free of weight loss. The CAAS (care area assessment summary), for nutritional status, dated 12/19/17, documented the resident at risk of nutritional decline. The resident required a NAS (no added salt) diet, with regular texture. Staff required to document nutritional intake at each meal. The resident's quarterly MDS, dated [DATE], revealed the resident weighed 95 lb. The care plan, reviewed 5/30/18, documented the resident at risk of altered nutrition due to depression. On 5/24/18, the facility updated the care plan to include the resident required fortified foods. On 6/21/18, the facility updated the care plan to include the resident required health shakes (a premade drink similar to a milkshake, with extra calories and nutrients) three times a day, related to weight loss. On 8/2/18, the facility updated the care plan to include the resident required ice cream at lunch and supper. The resident required encouragement to consume all of his/her meals. The resident's signed physician's orders [REDACTED]. On 6/21/18, the physician ordered health shakes to be given to the resident three times a day, for weight loss. Review of the resident's dietary profile assessment, dated 12/14/17, documented the resident required a NAS diet, with regular texture. The resident preferred a large dessert spoon at all meals. Review of a dietary note, dated 12/14/17 at 2:14 PM, revealed the resident required encouragement at meals, and was a picky eater. The resident weighed 94 lb at admission. Review of a dietary note, dated 1/19/18 at 9:14 AM, documented the resident's weight increased, but stabilized. The resident was a picky eater. Review of the resident's RD (registered dietician) note, dated 1/30/18 at 9:46 AM, documented that the RD recommended that the resident recieve a fortified diet and double portions of protein at breakfast, as that was the resident's best consumed meal. Review of a RD note, dated 5/16/18 at 1:59 PM, revealed that the resident weighed 94 lb, and the RD recommended that the resident recieve a fortified diet and double portions of protein at breakfast, the same recommendation made on 1/30/18. Review of the resident's weights revealed that on 3/19/18, the resident weighed 111 lb. On 4/24/18, the resident weighed 110 lb. On 5/9/18, 15 days later, the resident weighed 94 lb, a loss of 16 lb, or 14.5% of his/her body weight, constituting a severe loss of weight. On 5/21/18, the resident weighed 95 lb, and on 6/21/18 the resident weighed 93 lb. Review of a weight change note, dated 5/24/18 at 9:39 AM, revealed the facility added fortified foods to the resident's diet. The RD initially recommended a fortified diet on 1/30/18, 4 months previously. Review of the resident's laboratory results, dated 6/18/18, revealed that the resident's total protein level (a blood test, often used to diagnose nutritional problems) was 5.9 g/dL (grams per deciliter), below the normal range. Normal total protein levels range from 6.6 to 8.7 g/dL. Review of the resident's meal intake percentages from 7/24/18 to 8/22/18 revealed that the resident consumed less than 50% of his/her meal on 26 occasions. The resident consumed greater than 50% of his/her meals on 62 occasions. Further review revealed that the resident did not eat his/her offered snack 35 times over 30 days, from 7/24/18 to 8/22/18. On 8/21/18 at 12:06 PM, the resident sat in his/her wheelchair in the dining area, and staff provided the resident with his/her lunch, consisting of hamburger steak, fried potatoes, cake, baked beans, and cheesy mashed potatoes. The resident did not recieve his/her ice cream. At 12:40 PM, staff provided the resident with a health shake, and encouraged him/her to drink all of it. At 12:45 PM, the resident stated that he/she was done with his/her meal. The resident consumed less than 25% of his/her meal, eaten less than 2 bites of the cheesy mashed potatoes, and drank two drinks from the health shake. Staff observed the resident's plate, and then assisted the resident away from the table. The facility staff failed to encourage the resident to eat more of his/her meal, failed to offer the resident his/her ice cream, and failed to offer any alternative menu items. On 8/21/18 at 12:59 PM, dietary staff Q explained he/she served the resident his/her meal at lunch, and that the fortified menu item for the meal was cheesy mashed potatoes. Staff Q confirmed that he/she failed to provide the resident with his/her ice cream. The resident's diet card required that the resident receive ice cream at lunch and supper. On 8/22/18 at 5:33 PM, the resident sat in his/her wheelchair in the dining area, drinking coffee. At 5:40 PM, dietary staff served the resident his/her supper, consisting of chicken strips, mixed fruit, cottage cheese, white milk, and water. The resident received his/her ice cream. At 6:10 PM, staff provided the resident with a health shake, and encouraged him/her to drink all of it. At 6:15 PM, the resident stated that he/she was done with his/her meal. The resident had consumed 75% of his/her meal. On 8/23/18 at 9:18 AM, dietary staff R confirmed that he/she oversaw the dietary department, and reported that the fortified food for supper on 8/22/18 was chocolate milk. Staff R confirmed that the facility failed to provide the fortified chocolate milk to the resident, as required. Staff R explained that all residents had individual diet cards, which contained nutritional interventions. The facility staff discussed the resident in a weekly risk meeting, and were aware of the resident's weight loss from 4/24/18 to 5/9/18. Staff R confirmed that the facility failed to implement the RD's recommendation on 1/30/18 until 5/24/18, and was unaware of why the recommendation was missed. On 8/23/18 at 9:32 AM, licensed nursing staff P recalled that the resident had lost a significant amount of weight, and received health shakes three times a day, at meals. Staff P explained that the resident required a lot of encouragement to finish his/her meals. On 8/23/18 at 10:57 AM, consultant staff S confirmed that he/she began visiting the facility monthly recently and made dietary recommendations for the residents of the facility. A different person visited in 1/2018. Staff S stated that he/she had not reviewed prior recommendations made by the prior RD, but would expect that the facility staff would recognize the duplicate recommendations from 1/30/18 and 5/16/18. Staff S explained that his/her expectation of the facility would be that the recommendation would have been implemented on 1/30/18, when originally made, not on 5/24/18. Staff S confirmed that he/she noted the severe decrease in the resident's weight when he/she visited on 5/16/18, but that the facility failed to notify him/her of the loss before his/her visit. Staff S explained that he/she expected that the facility would notify him/her of such a significant loss in weight immediately. On 8/23/18 at 11:28 AM, physician's office staff T confirmed that he/she was aware of the resident's weights. On 8/23/18 at 1:19 PM, administrative nursing staff B explained that the resident was very picky, and resisted interventions. Staff B confirmed that he/she was aware of the resident's weights, and discussed the resident in the weekly risk meetings. Staff B stated that he/she was unaware that the RD recommendation was made twice, but stated that he/she reviewed the monthly recommendations from the RD with the dietary manager. On 8/23/18 at 4:31 PM, consultant staff V explained that the facility had a weight management policy that should have been followed, and confirmed that the facility failed to implement the RD recommendation from 1/30/18. The facility policy, dated 2011, documented that a weight loss of more than 5% in one month would be considered severe, and unplanned weight changes would be reported to the RD. Weight loss interventions would be discussed by the IDT (interdisciplinary team). The facility failed to ensure this resident maintained acceptable parameters of weight, by failing to implement recommended interventions, until after the resident had already experienced a severe weight loss of 14.5% of his/her body weight, and with continued failure to ensure the resident recieved those interventions to prevent continued weight loss.

The facility reported a census of 59 residents. The sample included 21 residents, including 4 reviewed for pain management. Based on observation, interview, and record review, the facility failed to provide adequate pain management to 2 (#48 and #30) of the 4 residents reviewed. Findings included: - Resident #48's signed physician's orders [REDACTED].) The resident's significant change MDS (minimum data set), dated 7/28/18, revealed the resident with a BIMS (brief interview for mental status) of 8, indicating moderately impaired cognition. The resident required extensive assistance of 1 to 2 staff for ADLs (activities of daily living.) The resident had a life expectancy of 6 months or less, received hospice services, and experienced frequent pain, rated at a 4, that interfered with sleeping. The resident received scheduled pain medications over the lookback period, but received no as-needed or non-medication interventions for pain. The CAAS (care area assessment summary) for pain, dated 8/2/18, documented the resident experienced pain in the lookback period, and received scheduled pain medication. Facility staff would monitor the effectiveness of the resident's scheduled pain medication, and would contact the physician if the resident's medications required adjustment. The resident required encouragement to ask for his/her as needed pain medications, if his/her pain continued after receiving his/her scheduled medications. The care plan, reviewed 7/24/18, documented the resident experienced pain, and had an acceptable pain goal of 6 or less. Staff required to administer pain medications as ordered, monitor the use of as-needed pain medications, and refer to the resident's physician for any changes in pain medication to best manage the resident's pain. The resident's signed physician's orders [REDACTED]. [MEDICATION NAME] (a medication for nerve pain), 50 mg, by mouth, twice daily (6/1/18). [MEDICATION NAME] (a pain medication), 50 mg, by mouth, every 8 hours as needed, and Tylenol 500 mg, by mouth, every 6 hours as needed (6/4/18). Staff required to assess the resident's pain each shift (6/13/18). The resident began receiving hospice services on 7/17/18. Review of the resident's Clinical Health Assessment, dated 7/27/18, documented that the resident experienced pain frequently. The resident's pain was episodic and intermittent, and felt throbbing and shooting. The resident's pain medication regimen was not effective at managing the resident's pain at an acceptable level. The facility failed to notify the physician of this finding. Review of the resident's MAR (medication administration record) for the month of June, (YEAR), revealed that facility staff assessed the resident's pain each time the resident received his/her scheduled Tylenol Extra Strength. On 5 days, the resident rated his/her pain at a 10 out of 10. On 6 days, the resident rated his/her pain at an 8/10. Facility staff documented pain assessments each shift, with results ranging from 0 to 5. The resident received his/her as-needed Tylenol or [MEDICATION NAME] on 14 days of the month. Review of the resident's MAR for July, (YEAR), revealed that facility staff assessed the resident's pain each time the resident received his/her scheduled Tylenol Extra Strength. On 3 days, the resident rated his/her pain at a 10. On 4 days, the resident rated his/her pain at an 8. On 1 day, the resident rated his/her pain at a 7, and on 5 days, the resident's pain was at a 6. Facility staff documented pain assessments each shift, with results ranging from 0 to 5. The resident received his/her as-needed Tylenol or [MEDICATION NAME] on 19 days of the month. Review of the resident's MAR for August, (YEAR), revealed that facility staff assessed the resident's pain each time the resident received his/her scheduled Tylenol Extra Strength. On 5 days, the resident rated his/her pain at a 10. On 1 day, the resident rated his/her pain at a 9. On 7 days, the resident rated his/her pain at an 8. On 2 days, the resident rated his/her pain at a 7. Facility staff documented pain assessments each shift, with results ranging from 0 to 5. The resident received his/her as-needed Tylenol or [MEDICATION NAME] on 12 days of the month, as of 8/22/18. Review of the resident's vital sign charting revealed documentation that the resident exceeded his/her acceptable pain threshold of 6 on 17 days in June, 20 days in July, and 17 days in August. This totaled 54 out of 83 days, or 65%, that the resident experienced pain that was above his/her acceptable pain threshold. On 8/20/18 at 2:07 PM, the resident reported that his/her back hurt all of the time. The resident recalled that he/she had Tylenol and [MEDICATION NAME], but that those medications didn't help enough, and wished the facility could do something different. On 8/21/18 at 11:06 AM, the resident rested in his/her bed. He/she stated that he/she could not sleep last night, because of the pain in his/her legs. The resident explained that he/she requested an as-needed pain medication, which lessened his/her pain so that he/she could sleep for a little while. The resident stated that he/she still felt tired. On 8/21/18 at 4:33 PM, direct care staff N recalled that the resident routinely mentioned that his/her back hurt. Staff N reported that the resident would sometimes not request pain medication, even though his/her back hurt a lot. Staff reported the pain to the nurse on duty. On 8/22/18 at 8:55 AM, direct care staff O reported that the resident routinely experienced severe back pain, and always requested a pillow behind his/her back when sitting in his/her recliner. The resident received a scheduled pain pill for the pain. On 8/23/18 at 9:32 AM, licensed nursing staff P explained that if a resident routinely requested as-needed pain medications, and reported pain above their acceptable pain threshold, staff would notify the physician and request changes. Staff P recalled that the resident always reported pain from an 8 to a 10, ever since he/she admitted to the facility, so staff would assess the resident's pain using the FLACC scale (a method to assess pain in patients who cannot communicate verbally). Staff P explained that when staff used the FLACC scale, staff assessed the resident's pain as being between 0 to 4, not 8 to 10. Staff P confirmed that the resident was alert, and could make his/her needs known. Staff P confirmed that the resident's pain was not adequately controlled, and that the facility failed to notify the resident's physician. On 8/23/18 at 1:19 PM, administrative nursing staff B reported that pain assessments depended on what resident was being assessed. Staff B stated that the facility had several residents, including resident #48, that routinely reported high levels of pain, but that facility staff doubted the authenticity of the resident's reports. Staff B explained that he/she would expect nursing staff to notify the physician if a resident routinely reported pain above his/her pain threshold, and confirmed that the resident's pain control regimen was not adequate. On 8/27/18 at 9:29 AM, physician's office staff U explained that the facility rarely called about the resident. Staff U could find nothing in the resident's office chart regarding pain, which indicated the facility failed to contact the physician's office about pain. The facility policy, dated 12/2015, for pain management, documented that residents experiencing pain were to be evaluated for the need of routine pain management, and that as-needed pain medications would be evaluated on a routine basis for effectiveness, and need for routine pain management. The facility failed to adequately manage pain for this dependent resident, for whom uncontrolled back pain negatively impacted his/her quality of life. - This deficient practice also affected resident #30, as the facility failed to adequately manage the resident's right shoulder pain.

The facility reported a census of 58 residents, and the sample included 3 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide interventions as planned to keep 1 (#1) of the 3 residents reviewed as safe as possible, to prevent a fall, which resulted in a fracture to the resident's left hip. Findings included: - The facility admitted resident #1 on 11/20/17, with [DIAGNOSES REDACTED]. Review of the admission MDS (minimum data set), dated 11/27/17, documented the resident had severely impaired cognition. The resident usually made him/herself-understood, and usually understood others. The resident had continuous inattention and altered level of consciousness. The resident required extensive assistance of 2 staff for transfers, and ambulation. The resident's balance was unsteady, and he/she had no limitations in range of motion. He/she required a walker and wheelchair for mobility. The resident had a fall before admission to the facility, and no falls since admission to the facility. He/she received OT (occupational therapy), and PT (physical therapy). The CAA (care area assessment), dated 11/27/17, did not trigger for ADL's (activity of daily living). Review of the clinical health assessment, dated 11/20/17, scored 19, that indicated a high risk for falls. Review of the care plan, dated 11/21/17, documented staff should anticipate the resident's toileting need, and staff should keep the call light within the resident's reach when he/she was in the room. Staff placed a fall mat next to the resident's bed and next to his/her chair. In addition, staff should set a toileting schedule, dated 12/11/17, after a fall on 12/10/17. Review of the nurse's progress notes, from 12/12/17 to 12/15/17, documented the resident received PT, and OT. On 12/15/17 at 2:14 pm, the resident fell in his/her room, and staff transferred the resident to the hospital because the resident complained of left hip pain. On 12/18/17 at 11:56 am, the risk progress note's late entry, evidenced the resident completed therapy, and staff sat the resident in his/her room while the resident sat in his/her wheelchair. Review of the fall investigation, dated 12/22/17, documented therapy staff completed therapy on the resident, propelled the resident to his/her room, and left the severely impaired cognitive resident in the wheelchair, without placement of the call light within the resident's reach, and staff exited the room. The resident fell from his/her wheelchair, and fractured his/her left hip. Review of the notarized statement, dated 12/23/17, documented consultant staff G left the resident's room, and he/she failed to place the resident's nurse call light next to the resident before he/she exited the resident's room. Observations were unavailable, as the resident no longer resided at the facility. On 1/11/18 at 1:45 pm, direct care staff E, reported the resident required 2 staff assistance for transfer, and the resident fell and broke his/her hip after therapy. Staff should transfer the resident from his/her wheelchair to a recliner or to his/her bed, because he/she should not be left alone in a wheelchair in his/her room. On 1/11/18 at 1:56 pm, direct care staff F, reported therapy worked with the resident, and left the resident in his/her room. On 1/11/18 at 2:11 pm, consultant staff H, reported therapy should always leave the resident where you found them. If a resident was in a recliner chair with his/her feet up, then after staff completed therapy, the resident should be left in a recliner with his/her feet up. If a resident had dementia, staff should not leave the resident alone. Consultant staff H was unaware of any individualized safety measures of a resident. On 1/11/18 at 2:30 pm, administrative nursing staff B, reported the resident had a history of [REDACTED]. Therapy staff should ask the direct care staff for a resident's safety instructions. The facility's policy for falls management, dated 12/2015, documented fall interventions were to be communicated to facility staff through the plan of care. The facility failed to provide planned interventions to prevent repeated falls for this severely cognitively impaired dependent resident that resulted in a left [MEDICAL CONDITION]. This deficiency was cited as past non-compliance, as of 01/09/18 at 1:30 pm when the facility ensured completion of the following: 1). Education of therapy staff regarding ensuring any resident he/she was treating were safe and the residents call light was within reach before leaving the resident, on 12/15/17 following the incident, and on 12/20/17 and 01/04/18 by the consultant staff's supervisor(s). 2). Informed the facility medical director on 12/15/17 of the incident. 3). Began monitoring of call l ight placement during daily rounds by administrative staff, on 12/15/17 with no further incidents regarding call light placement found. 4). The QAPI (Quality Assessment Performance Improvement) team reviewed the incident and completed root cause analysis on 12/18/17. 5). Education of facility staff regarding call light placement and answering of call lights promptly, on 01/09/18 at 1:30 pm.

The facility reported a census of 61 residents with 3 selected for review for accidents. Based on observation, interview and record review, the facility failed to ensure safety measures for transportation of residents in wheelchairs in the facility van for 1 (#4) of the 3 residents reviewed. The resident fell and experienced a laceration to the head, which required emergency treatment and 4 staples to close the wound. Findings included: Review of resident #4's physician order [REDACTED]. The annual MDS (minimum data set), dated 12-31-16, assess the resident with a BIMS (brief interview for mental status) score of 8, indicating moderate cognitive function (8-12), required extensive assistance with transfers, limited assistance with locomotion on and off the unit, no falls and no impairment in range of motion of upper or lower extremities. The CAA (care area assessment), dated 12-31-16, for falls, assessed the resident at risk for falls, required staff assistance for transfers and primarily used a wheelchair for mobility, propelled by staff or the resident. The resident's quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 9, required limited assistance with locomotion on and off the unit and used a wheelchair or walker for mobility, and no impairment of range of motion of the upper or lower extremities. Review of the nurses' note, dated 6-10-17 at 3:09 pm, documented the resident sustained [REDACTED]. The resident required emergency room evaluation and 4 staples to the laceration. The resident sustained [REDACTED]. Review of the emergency room provider report, dated 6-10-17, revealed the resident sustained [REDACTED]. The laceration required 4 staples, and the assessment included a CT (computerized tomography) scan of his/her brain, pelvis and bilateral hips (which revealed no other acute injury). Observation, on 6-27-17 at 8:30 am, revealed direct care staff B, positioned resident # 5 (seated in his/her wheelchair) in the facility van for transport for an appointment. Staff B positioned the resident's wheelchair facing the front of the van and secured it with 4 secure straps and applied the seat belt. Interview, on 6-27-17 at 8:30 am, with direct care staff B, revealed he/she positioned the residents in the facility van facing forward, secured the wheelchair with 4 secure straps, and applied a seat belt. Staff B stated staff could transport 2 residents in wheelchairs with 4 secure straps each. Staff B stated prior to resident #4's tip over, the van contained 5 straps, and if staff transported 2 residents in wheelchairs, they applied 3 secure straps to one wheelchair and 2 straps to the other. Staff B stated the facility obtained 3 additional straps after resident #4's mishap. Staff B stated the facility banned transport of 2 wheelchairs until the facility obtained the additional straps. Interview, on 6-27-17 at 9:35 am, with administrative staff A, revealed he/she responded to the van driver's request for assistance at the time of the accident (6-10-17 at 11:30 am), and called emergency response. Staff A stated he/she investigated the mishap and determined staff positioned the resident in his/her wheelchair, facing the side window, secured with 2 secure straps. Staff A stated the driver remembered feeling a bump before making a left hand turn, perhaps dislodging one of the two securing straps, leading to the chair to tip over. Staff A stated he/she requisitioned 3 additional secure straps, via e mail to the facility's home office on 6-12-17, and received them via overnight mail. Staff A stated the facility lacked a policy for safe transport of residents in wheelchairs but provided education to the van drivers on 6-14-17. Interview, on 6-27-17 at 10:00 am, with maintenance staff C, revealed he/she did not receive in-service training on use of the secure straps until after the event on 6-10-17. Staff C stated he/she did not know the van lacked 3 secure straps. Staff C stated staff secured residents in wheelchairs with 4 secure straps and residents should face forward. Staff C stated his/her department was responsible for the maintenance of the van and did not know of a policy for staff to follow regarding safe transportation of residents. Interview, on 6-27-17 at 10:45 am, with direct care staff D, revealed he/she drove the facility's van, and transported resident #4 on 6-10-17. Staff D stated he/she transported two residents in wheelchairs at the time, and had only 5 secure straps available to secure the two residents. Staff D stated resident #4 requested to face the window. Staff D stated he/she did not have training on the use of the secure straps upon hire at this facility, but did have previous experience in transporting residents from previous employment. Staff D confirmed he/she applied 3 secure straps to one resident's wheelchair and 2 secure straps to resident #4's wheelchair and applied the seat belt. Staff D stated when he/she turned a corner, the resident tipped backwards and hit his/her head on the hydraulic lift grate and sustained a laceration to his/her back of head. Staff D stated administrative staff B instructed the van drivers to limit transport to 1 resident in a wheelchair at a time until the facility obtained the additional straps. Staff D stated he/she did not know residents could not be transported facing the side windows. Observation, on 6-27-17 at 11: 15 am with resident #4, revealed he/she remembered going for a ride in the facility van and ending up with a cut on his/her head. The resident stated he/she requested to position facing the side window of the facility van. The resident reports the van driver secured his/her wheelchair with 2 secure straps and a seat belt. The resident stated the secure straps did not hold the wheelchair in place when the van driver made a left turn and he/she fell backward while in the wheelchair and sustained a cut on the back of his/her head. The operation instruction for the sure-lok systems, revised 02/11, instructed staff to position the wheelchair and occupant facing forward, apply the wheelchair brake, and attach the front and rear tie-downs (2 in front and 2 in rear of the wheelchair) and pull on all four of the tie down assemblies to ensure proper attachment. The guidance advised staff improper securing the wheelchair may result in injury or death. The facility failed to properly apply four securing straps to this resident's wheelchair during transportation in the facility van, resulting in a head laceration requiring staples in the emergency room . The investigation revealed the facility was in past-noncompliance as of 6/14/17, as the facility: 1.) The staff assessed the van and that section of the van was put out of commission until additional straps were ordered and put into place. The staff only transported one wheelchair at a time with adequate securing straps, until the time of the van correction. Additional straps were put into the van on 6/14/17. 2.) All staff authorized to drive the facility van for transportation were educated and completed a skills checklist with completion date of 6/14/17. 3.) All new staff hired, with authorization to drive the van, will have a skills check completed prior to authorizing the transportation of residents in the facility van. The Van Safety Orientation and In-Service form will be utilized for skills checks and verified completed before any new drivers are authorized to drive the facility van. 4.) The administrator and/or designee will monitor the wheelchair straps in the facility van monthly. 5.) An emergency QAPI meeting was conducted on 6/10/17, which included the facility medical director to discuss the incident. the medical director was made aware of the findings and facility plans for education/monitoring of the facility van drivers. A formal QAPI meeting was conducted on 6/12/17, with the entire committee to discuss the incident. 6.) All authorized drivers and skills checks will be reviewed for compliance and results reported to the QAPI committee.

The facility reported a census of 62 residents. Based on observation, interview and record review, the facility failed to immediately put measures in place to protect 34 other gender residents, after report of staff to resident sexual abuse by direct care staff H. Findings included: - Resident #1's annual MDS (minimum data set), dated 5-7-16 assessed the resident with a BIMS (brief interview for mental status) score of 8 indicating moderate cognitive impairment. This MDS assessed the resident required extensive assistance with bed mobility, and personal hygiene, and was totally dependent on staff for dressing and toilet use, with impairment in range of motion in the upper extremities bilaterally, no impairment in lower extremities and was always incontinent of bowel and bladder, The CAA (care area assessment) for urinary incontinence, dated 5-7-16, assessed the resident as always incontinent of bowel and bladder and was on a check and change incontinence program. The care plan, revised 8-16-16, advised staff the resident was incontinent of bowel and bladder, required 2 staff to provide incontinence care on a check and change basis. The resident required 2 staff assistance with dressing and bed mobility, and required a Hoyer (a mechanical device for lifting a resident) lift for transfer from the bed to wheelchair. A BIMS assessment, on 9-27-16, assessed the resident with a BIMS score of 12, indicating moderately impaired cognitive function. Review of the nurses' notes, dated 9-26-16 at @ 6:00 pm, revealed resident #1's family member (resident #4), asked licensed nursing staff I, what could be done to keep direct care staff H away from resident #1. Resident #4 stated that direct care staff H was messing around with resident #1. Licensed nursing staff I documented he/she instructed direct care staff H not provide care to resident #1. Resident # 4 stated direct care staff H, touched his/her family member (resident #1) inappropriately a few nights ago. Residents #1 and #4 reside together in the same room. Resident #4's BIMS assessed in the annual MDS, dated [DATE] was 07, indicating severe cognitive impairment. The licensed social worker note, dated 9-27-16, documented the events, on 9-26-16 at 6:00 pm, and initiated an interview of residents #1 and #4. This note documented resident #4 stated he/she saw direct care staff H touch resident #1 inappropriately. The resident (#4) stated the events occurred 2 times on other nights. There was no evidence resident #4 reported these other 2 occurrences to facility staff. The administrative nursing note, dated 9-26-16 at 6:00 pm, documented, he/she instructed direct care staff H to work on another unit with direct care staff G. Interview, on 9-29-16 at 8:10 am, with administrative staff A revealed licensed nursing staff I notified him/her of the events on 9-26-16 at 6:00 pm. Staff A confirmed the alleged perpetrator was not immediately suspended from contact with the other gender residents of the facility. Staff a stated direct care staff H worked until 10 pm, approximately 3.5 hours after the allegation, with another same gender direct care staff. Interview, on 9-29-16 at 1:15 pm, with direct care staff H, revealed he/she provided no care to resident #1 on 9-26-16. Staff H stated the resident required 2 staff for transfers, position change and perineal care and the resident was on a check and change incontinence program. Staff H stated he/she, alone, did check the resident ' s incontinence brief for signs of wetness (the blue line on the incontinence product turns green with wetness) at times, however always had another staff present to provide perineal care. Staff H stated after resident #4 reported the alleged incident, licensed nursing staff I reassigned him/her to another hall with instruction to work with direct care staff G for the remainder of the shift (approximately 4 hours minus 30 minute break). Interview, on 9-29-16 at 1:45 pm, with direct care staff G, revealed he/she worked with direct care staff H for approximately 3 and half hours, on 9-26-16, from 6 pm to 10 pm, minus a 30 minute break. The facility policy for Abuse, Neglect and Exploitation, da ted August 2016, instructed staff that when a report of possible abuse was made against an employee, the employee should be immediately sent home and suspended by the person in charge until a thorough investigation can be conducted by administrative staff. The facility failed to protect the other 34 other gender residents of the facility following an allegation of sexual abuse, placing all 34 of the other gender residents in immediate jeopardy. The facility abated the immediate jeopardy on 9-29-16 at 12:00 pm, as follows: The facility conducted an in-service on abuse, neglect and exploitation for all nursing and ancillary staff beginning on 9-27-16, and completed on 9-28-16, with the exception of 4 employees who were each educated by 12:00 pm on 9-29-16, prior to working. The facility suspended direct care staff H on 9-27-16 prior to working another shift. Development of a plan for follow up including: 1. Weekly monitoring, for 4 weeks, of the alleged resident victim (resident #1) by the licensed social worker. 2. Resident interviews (3 per week) will be conducted for the next 90 days to assess for resident complaints/concerns of staff treatment of [REDACTED]. 3. Staff interviews (3 per week) will be conducted for the next 90 days to assess for resident complaints and staff treatment of [REDACTED]. 4. Review of the facility's incident investigations by the regional Vice President and Clinical Nurse Consultant. This deficiency was cited as past noncompliance.

The facility reported a census of 55 residents. Based on observation, record review and interview, the facility failed to ensure adequate supervision and /or assistive devices to prevent repeated falls for 2 of 3 sampled residents reviewed for accidents, including (#2) and (#1) who fell and sustained a hip fracture. Findings included: - The physician signed orders on 1/31/14 for resident #2, documented the resident admitted to the facility on [DATE], and included paralysis agitans, (a slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, forward flexion of the trunk, loss of postural reflexes and muscle rigidity and weakness), hypertension (high blood pressure) and dementia (a deterioration of intellectual functions and other cognitive skills). The 2/17/14 MDS (minimum data set) assessment identified the resident with a moderate cognitive deficit, required extensive assist with all activities of daily living including, bed mobility and transfers. The care area assessment dated [DATE] included: ADL) activities of daily living) ending 2/7/14 , documented the resident required extensive assistance for bed mobility, transfers, locomotion, dressing, toileting, hygiene and total assist for showers. Falls: Identified the resident at risk for falls with a history of falls at home per social service designee assessment dated [DATE] , and with a fall assessment is 20, which indicated increased risk for falls related to poor memory, medications, impaired balance, incontinent, dementia r/t Parkinson's, delusional disorder, and hypertension per history and physical on 1/30/13. Skilled charting in look back period states floor mat and personal alarm in use, needs assist for transfers and is receiving PT/OT/ST. The 2/18/14, plan of care included, instructions to the staff to use a personal alarm and an alarmed fall mat beside the bed, the resident is at risk for falls r/t (related to) history of falls. unsteadiness/impaired balance, memory problems and medications. Interventions included, personal and fall mat alarm in use, assess assistive devices for proper fit and use, orient and reorient on an ongoing basis to room and unit. Per the facility accident investigation, on 2/23/14 at approximately 1:00 P.M., the resident was found lying on the floor in the restorative dining room, off the main dining room. He/she apparently tried to stand without staff assist from the wheelchair. Licensed staff C was summoned to the dining room and found the resident on the floor. At that time the resident's personal alarm was not in place. The resident had full range of motion of the extremities and stood up without any complaint of pain. Staff transported the resident per wheelchair to his/her room and was assisted to bed. The staff, at that time, found the resident's personal alarm in the resident's room. Following arrival at the room, licensed nursing staff D with assist walked the resident several steps to bed and applied the personal alarm on the resident. Nurses notes documented the resident seated near the nurses desk, on 2/24/14, at 9:00 A.M., and when questioned about pain by licensed nursing staff D, the resident complained of right leg pain. The nurse notified the physician and received orders to send the resident to the hospital for x-rays. The 2/25/14 hospital x-ray report documented, results which included, the resident experienced a proximal right femoral neck fracture (hip) with mild impaction (bone pushed together). On 4/9/14 at 12:45 P.M., administrative staff A reported upon investigation of the fall, staff members were questioned and could not remember who or if they transported the resident to the dining room without the personal alarm on 2/24/14. The direct care staff reported they routinely do so many everyday they could not remember about that day and that particular time. Administrative staff also questioned family members who reportedly left the facility prior to the staff assisting the resident to the dining room for lunch. According to the administrative staff A, one staff member remained in the main dining room adjacent to the restorative dining room, where the resident fell . However, none of the staff member in the dining rooms, during the noon meal service, noticed the resident lacked the attachment of the planned personal alarm. On 4/9/14 at 12:15 PM, the resident sat in the wheelchair in the room. A bedside table in front of the resident held the resident's noon meal. A personal alarm was attached to the resident and to the wheelchair. On 4/9/14 at 2:00 P.M., the resident rested in the bed with a family member at the bedside. The resident had a personal alarm in place and a mat alarm which the family member reportedly pushed under the edge of the bed. The family member reported they never left without the floor mat alarm pulled back out beside the resident's bed, if the resident remained in the bed. On 4/9/14 at 3:00 PM, a physical therapy staff worked with the resident who lifted weights with the upper extremities while on bed. The resident's personal alarm remained on during these exercises. On 4/9/14 at 1:10 P.M., licensed nursing staff C reported the family often removed the personal alarm when they visited. On 4/9/14 at 2:00 P.M., certified nursing staff F and G reported the family at times, asked for the alarm not to be on the resident while they visited. On 4/9/14 at 5:00 PM, licensed nursing staff E reported the resident's family members would often ask for the alrm to be taken off while they visited. Since the resident's fall and fracture the staff educated the family members not to remove the alarm while they visited the resident. The facility failed to provide adequate supervision and assistive devices to prevent this confused resident with a high risk for falls, from attempting to stand without assistance. The resident fell and sustained injury with a fracture left hip. - The physician signed orders, dated 3/13/14, documented resident #1 admitted to the facility on [DATE], and included [DIAGNOSES REDACTED]. The 2/15/14, MDS ( minimum data set) assessment identified the resident with severe cognitive impairment, need for extensive assist with transfers and with a history of one fall. The CAA (care area assessment), dated 2/15/14 included: Cognition score on BIMS (brief interview for mental status) score of 6 which indicated severely impaired cognition r/t (related /to) [DIAGNOSES REDACTED]. Has history of believing and telling staff they vare moving out and someone is coming to pick them up per staff interview. The resident also gets times of the day mixed up (often thinks is is morning during the middle of the night) per staff interview. The resident needs assistance with ADL (activities of daily living) per ADL sheets. He/she uses a w/c (wheelchair) as the primary mode of mobility and propels self. He/she is able to assist some with bed mobility and uses the hand rail to assist with positioning per resident review on 2/4/14. He/she is frequently incontinent of bladder and occasionally incontinent of bowel per 3 day bowel and bladder assessment from 2/5/14 to 2/7/14. The resident needs assist with toileting and wears briefs. The resident feeds self after set-up and usually eats in dining room. The resident ambulates short distance in room with assist and uses a walker. The resident has a restorative nursing program but rarely chooses to participate. The resident is at high risk for falls per fall assessment 2/11/14. The resident fell while attempting to get clothes out of his closet unassisted sustaining a skin tear during the fall per fall note 2/11/14. Staff reports that he/she gets up unassisted often and does not call for assist. He/she has a personal alarm in place and often removes it. He/she also has a fall mat alarm. The resident needs assist with transfers and ambulation. The current undated plan of care instructed the staff, the resident is not usually compliant with calling for assist. Make checks as needed. Personal alarm as of 2/13/13 and floor mat alarm added 3/18/13. Most mobility is per wheelchair. Remind the resident to lock brakes on chair prior to transfer and check wheelchair brakes PRN (as needed) on rounds. If the fall alarm is sounding attempt to find if there is an unmet need. Addition, on 2/11/14, instructed staff to use tarp ties to both ends of the personal alarm to help alarm stay attached to Bob's shirt and bed/chair/wheelchair. On 3/9/14, at 8:50 A.M., nurses notes documented, the resident yelled and staff found the resident laying on the floor on his/her left side. Licensed staff D and C assessed the resident. The resident reported he/she did not hit head on the floor. Nursing staff C, D, and G assisted the resident to a standing position. The resident was able to bear weight on both legs without any discomfort or pain. The resident sat down in the wheelchair. The resident's personal alarm was located on the counter near the sink, across the room from the bed. The walker was noted folded up behind the recliner. The wheelchair was next to the sink and counter. It was determined the resident removed the personal alarm and placed it on the counter. Around 10:00 A.M., after the fall, licensed staff D ask the resident if he/she wanted to lay down. Upon slight outward movement of the left knee, the resident complained of pain. On 3/9/14 at 11:00 A.M., per physician's orders [REDACTED]. The resident was admitted to the hospital with [REDACTED]. The hospital x-ray report, dated 3/9/13, documented, the femoral head appeared somewhat moth-eaten and fracture being a pathologic fracture cannot be excluded. On 4/9/14 at 1:15 P.M., 1:30 P.M., and 3:30 P.M., nursing staff B, C, E, and H all reported the resident previously known for removing the personal alarm at times. However, the facility staff verified the failure to implement another appropriate intervention, to prevent the resident from repeated falls. Observation on 4/9/14 at 2:00 P.M. and 4:30 P.M., revealed the confused resident positioned in the wheelchair with a personal alarm attached to the back of the shirt with a special fastener. The facility failed to provide adequate supervision and assistive devices to prevent this resident from falling. This resident fell and sustained an injury to the left hip.