Every finding on record at Medicalodges Great Bend

Based on observation, record review, and interview, the facility failed to ensure there was sufficient nursing staff to the facility failed to ensure there was a sufficient number of staff as outlined in the Facility Assessment, when the full-time Director of Nursing (DON) also served as the facility's required part-time Infection Preventionist as well performing Minimum Data Set (MDS) duties. Findings included:- The Facility Assessment Tool, last updated on 12/02/2025, documented the facility was licensed to provide care for 51 residents. The current census was 46. The Assessment Tool's staffing plan documented staffing was based on the resident population and their needs for care and support and the general approach to staffing to meet the needs of the residents. The assessment tool documented the facility would have the following Administrative Nursing Staff: one DON, one Assistant Director of Nursing, and one MDS registered nurse. On 07/15/2026 at 10:15 AM, Administrative Nurse D stated for the past six or seven months she has been doing the job of the DON, assistant director of nursing (ADON), and MDS duties as well as being the facility's Infection Preventionist. Administrative Nurse D stated since the beginning of the year, the facility has gone through a lot of staff turnover, including administration, so it had been hard to always keep up with things. Administrative Nurse D stated the facility had hired a MDS person who started last week and had just hired an ADON this week so she should be able to focus more on her DON duties. The facility's Facility Assessment policy dated August 2024 documented the facility's intent was to evaluate the facility resident population and identify the resources needed to provide the necessary person-centered care and services the residents require during both day-to-day operations (including nights and weekends) and emergencies. The assessment tool was organized with three areas including: Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care; Services and care offered based on resident needs (includes types of care the resident population needs using evidence-based, data driven methods which consider types of diseases, conditions, physical and behavioral needs, cognitive disabilities, overall acuity consistent with resident assessments; Facility resources needed to provide competent care for residents, including facility staff, staffing plan, emergency and contingency staffing plan, staff training/education and competencies, policies and procedures for provision of care, medical providers, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community-based risk assessment, and other resources.

Based on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. Findings included:- On 07/13/2026 at 09:00 AM, observation revealed the following issues with the facility hallway carpet:1. Three pink stains in the carpet (one approximately 3 inches(in) by 4 inches, one approximately 4 by 4 in, and one approximately 3 in x 6 in) located by the entrance to the 100 halls.2. Numerous different-sized grayish stains in the carpet located by the entrance to the facility, where the 100 and 200 halls meet.3. Numerous white stains in front of the oxygen storage room located by the conference room.4. Numerous different-sized grey and pink stains throughout the 100, 200, 300, and 400 halls.5. Six, approximately 18 inches (in) by 18 in carpet squares, had numerous different-sized frayed carpets located by the 300-400 nurse's station. One of the carpet squares had a missing piece of carpet in the left-hand corner, approximately 3 in by 4 in. On 07/14/2026 at 08:53 AM, Administrative Staff verified the above findings and agreed that the above areas needed new carpet. She stated it was on her list of tasks to complete, but she had not contacted carpet installation businesses to get a bid on replacing the carpet yet. Upon request, the facility did not provide a policy regarding the environment.

Based on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law., or mistreatment. Findings included:- On 07/13/2026 at 02:30 PM, a review of staffing for background checks was completed for facility Staff. Upon request and review, the facility was unable to provide evidence that a criminal background check had been completed for Social Service Staff X, who had worked at the facility since 01/10/2022. On 07/13/2026 at 03:00 PM, Administrative Staff A stated the business manager would obtain criminal background/record checks on all employees prior to the employee working at the facility. Administrative Staff A verified she could not find a criminal record check for Social Service Staff X, and the business office manager who was at the facility when she was initially hired no longer worked at the facility. The facility's Background Screening Investigation dated October 2022 documented all new employees would be investigated prior to employment for a previous history of abuse, neglect, or exploitation. The appropriate certification and/or licensing agencies would be contacted for the current status of the employee's license or certification for employment. The person making the calls would document registry verification, and the written response would be maintained in the employee's personnel file/verification of work eligibility notebook. All non-licensed employees shall have a criminal background check as required by law and may be periodically checked. Results of background checks would be maintained in the employee's personnel file. All employees are hired on a probationary basis pending the result of their background check. Any employees who have passed their probationary status and who have a negative background check (when such are periodically checked) shall be subject to termination.

Based on observation, interview, and record review, the facility failed to discard expired stock medication from the 300 and 400 Hall medication cart. Findings included:- On 07/13/2026 at 08:30 AM, observation of the 300 and 400 Hall medication cart revealed the following:Famotidine (acid reducer) 10 milligrams (mg), 60 count, expiration 4/2026. On 07/13/26 at 08:35 AM, Certified Medication Aide (CMA) R verified the medication was expired, and the medication aides or nurses were to discard expired medications. On 07/13/26 at 2:45 PM, Administrative Nurse D verified the pharmacy consultant would check the medication carts monthly and verified the medication aides or nurses were to check the medication cart and discard expired medications. The facility's Storage of Medication policy, dated 01/2024, documented medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and recorded from the pharmacy, if a current order exists. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.

Based on observation, record review, and interview, the facility failed to provide accommodation of needs for Resident (R) 35 when staff failed to promptly provide him with access to local channels, which he paid for. Findings included:- On 07/13/2026 at 11:05 AM, observation revealed that when R35 used the TV remote to change the channel on his TV to local stations, the channels were glitchy (the screen or sound was acting strangely, often showing as flickering, weird lines, frozen pictures, or strange colors), and he was unable to determine what the program was on each channel. R35 stated he had reported the problem with the local channels to maintenance supervisor (MS) U, but nothing had been done to fix it. R35 stated he paid for the stations and was not happy that he was not receiving them. On 07/14/2026 at 08:53 AM, Administrative Staff A stated she was unaware R35 had an issue with his TV programming. Administrative Staff A stated she knew the cable company had been out the previous day to repair the cable TV in the dining room. On 07/14/2026 at 09:11 AM, MS U stated R35 had reported to him approximately two weeks ago the issue with his TV. MS U stated he called the cable company last week regarding the issue with R35's TV and the dining room TV. The cable company staff came to the facility yesterday and fixed the dining room TV and reported to him that they could only repair the cable for residential clients. MS U stated the cable company staff reported that MS U would have to rewire the cable to the toner, and he planned on starting the next day because it would take approximately eight hours to complete it. The facility's Your Rights and Protections as a Nursing Home Resident Policy, revised 04/2025, documented that residents had the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment. The nursing home must address the issue promptly.

Based on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)1's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications.Findings included:- R1's Electronic Health Record (EHR) revealed diagnoses of epilepsy (brain disorder characterized by repeated seizures), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, irrational fear), and hypertension (HTN-elevated blood pressure). R1's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R1 had moderately impaired cognition. The MDS recorded that he was independent with bed mobility and transfers. The MDS documented R1 received an antianxiety medication during the observation period. R1's Activities of Daily Living (ADL) Care Plan, dated 01/30/2026, recorded R3 was mostly independent with ADL cares, and required additional assistance during times of acute illness and following seizures. R1's Medication Use Care Plan dated 01/30/2026, documented the resident received Ativan (antianxiety medication) when he was having a seizure that lasted for more than 15 minutes. The care plan documented R1's Ativan, which was a Black Box Medication with a warning for increased side effects, adverse reactions, and staff would report concerns and changes to the nurse immediately. The care plan documented by the pharmacy consultant would review R1's medications monthly. R1's Physician's Order, dated 06/20/2026, directed staff to administer Ativan 0.5 milligrams (mg) every six hours as needed for seizure activity lasting 1-2 minutes related to convulsions. The order lacked a stop date. R1's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN Ativan. On 07/13/2026 at 12:15 PM, observation revealed R1 sat at the dining room table dressed in street clothes. He had a hard protective cap on his head and ate lunch independently. On 07/13/2026 at 03:00 PM, Administrative Nurse D verified the resident received Ativan PRN, with a physician order date of 06/20/2026. Administrative Nurse D verified the facility had not obtained the 14 day stop date or a reason for the continued use with the appropriate rationale with a definitive stop date. The Behavioral Management and Psychotropic Medications, policy dated April 2025, documented the facility would enhance the quality of life through behavioral interventions, minimize psychotropic medication use and off-label use of medication prescribed that affect brain activity and monitoring for adverse effects. The resident would be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to the psychotropic medication use and off-label use of medications prescribed that affect brain activity. Psychotropic medications and off-label use of medications prescribed that affect brain activity are not to be initiated or increased without prior communication and documentation of informed consent, including the physician, resident or responsible party, and the facility interdisciplinary team. Off-label and as needed (PRN) use of psychotropic medications and off-label use of medications prescribed that affect brain activity are to be discouraged for elderly residents with dementia. Physician orders to automatically reduce and discontinue an existing or newly initiated antipsychotic medication and off-label use of that medication that affect brain activity are to be considered at the time of the order received.

Based on observation, record review, and interview, the facility failed to ensure nursing staff followed appropriate infection control procedures related to disposal of soiled personal protective equipment, hand hygiene, and catheter care. Findings included:- On 07/14/2026 10:00 AM, Resident (R) 9 sat in a wheelchair in his room. Certified Nurse Aide (CNA) N and CNA O donned (put on) a gown, applied gloves, and entered R9's room with a Hoyer (total body mechanical lift) lift and asked R9 if he wanted to be transferred to the bed or chair, and R9 replied, his bed. CNA N and CNA O hooked the lift jacket to the machine and raised the lift over R9's bed and slowly lowered him to the bed. R9 voiced that he would like to be on his left side. Both assisted him in positioning on his left side. CNA O removed and discarded his gloves in the bathroom trash can. CNA N removed her gloves and gown, wadded them up in her right hand, and left the room. CNA N walked down the hall to the dirty utility room and then discarded the gown and gloves.On 07/14/2026 at 02:30 PM, R5 rested in bed with eyes open, playing a handheld game. CNA O donned a gown, applied gloves, and gathered a graduated cylinder from R5's bathroom, then asked R5 if he could empty his urinary catheter (tube placed in the bladder to drain urine into a collection bag). CNA O placed the graduated cylinder directly on the floor (no barrier was placed on the floor) below the urinary catheter on R5's bed, unlatched the port from the bag, opened the port, then let the urine flow into the graduated cylinder (without sanitizing the port). When the urine stopped flowing into the graduated cylinder from the catheter bag, CNA O closed the port and hooked the port back on the catheter bag (without sanitizing it).On 07/14/2026 at 10:05 AM, CNA N stated that she should have discarded the gown and gloves in R9's room and not carried them out of the room and down the hallway to the dirty utility room.On 07/14/2026 at 02:35 PM, CNA O stated that he had not placed a barrier on the floor under the graduated cylinder or used anything to sanitize the port of the catheter bag before he closed it and placed it back on the bag. CNA O stated sometimes he would sanitize the port or place a barrier on the floor. On 07/15/2026 at 10:15 AM, Administrative Nurse D, the facility's Infection Preventionist, stated that she would expect nursing staff to remove gloves and gowns in a resident's room and discard them in the trash in the resident's room. Administrative Nurse D stated it was infection standard of care to place a barrier down on the floor while emptying a catheter bag, so the graduated cylinder or the catheter bag did not contact the floor. Administrative Nurse D stated she has tried to keep her staff educated on proper EBP and catheter care, but she would review things with her staff again. Administrative Nurse D stated the facility followed CDC guidelines regarding EBP and standard precautions for catheter care.

The facility failed to provide Resident (R) 1, who was a known wanderer, adequate supervision to prevent R1 from wandering down three long hallways and being pushed four to five feet in the air by another resident, R2, which resulted in an injury fall. R1 sustained a left femoral neck fracture (a serious type of hip fracture, a break in the upper part of the thigh bone just below the ball of the hip joint). Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), panic disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), and fracture of the head of the left femur (thigh bone). R1's Quarterly Minimum Data Set, dated 01/12/26, documented R1 had a Brief Interview for Mental Status score of four, which indicated severely impaired cognition. The MDS documented R1 had physical behaviors directed towards others, verbal behaviors directed towards others, and wandering behaviors one to three days during the look-back period. The MDS documented R1 did not have any falls during the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/24/25, documented R1's cognition was a challenge. R1 required staff to make safe decisions for him daily. Staff directed to anticipate R1's needs and wants. R1 had communication challenges related to his dementia. The Fall CAA, dated 10/24/26, documented R1 had one fall during the look-back period when R1 stumbled over another resident's wheelchair pedals, and the intervention was for staff to monitor R1 when he was wandering. The Behavioral CAA, dated 10/24/25, documented R1 had behaviors documented during the look-back period of rejection of care and wandering. The Care Plan, initiated 11/12/24, documented R1 may wander or attempt to leave the building. The care plan directed staff to ask R1 why he was wandering, ask if R1 needed anything, and redirect R1. The care plan directed staff to ensure that R1's room was close to a busy staff-oversight location in the building (11/19/24). The care plan documented R1 was at risk for falls and directed staff to monitor R1 when he wandered, as he did not have safety awareness and needed cueing and frequent reminders due to his dementia diagnosis (10/18/25). The Fall Risk Assessment, dated 01/12/26, documented R1 was a high fall risk. The Behavior Note, dated 04/01/26, documented R1 was exit-seeking this morning. R1 was aggressive with staff. R1 stated I can do whatever I want to do. I just want to do my time and get out of here. The Fall Note, dated 04/08/26 at 06:29 AM, documented a Certified Nurse's Aide (CNA) M notified Licensed Nurse (LN) G at approximately 09:15 PM, R1 had fallen on the 100 hall. When LN G arrived, she found R1 lying supine (on his back) with his knees bent and a folded blanket under his head. The Emergency Medical Services (EMS) arrived at 09:20 PM. EMS left the facility at 09:26 PM. LN G notified Administrative Nurse D, R1's family, and R1's primary care physician of the situation and called report to the hospital. LN G learned while caring for R1, R3 had witnessed R1's fall. R3 stated R1 had been touching items on R2's door. R2 came out of room [ROOM NUMBER] and shoved R1 to the floor. R3 reported to LN G she had not pushed R1 down. R3's husband, R4, was in room [ROOM NUMBER] on the computer, heard the commotion, R3 re-entered room [ROOM NUMBER], and told R4 she had indeed pushed R1 down. R1 was scared and shaken and stated, She pushed and I fell. R1 had three skin tears on his left elbow. When R1's hips and legs were assessed, R1 complained of left leg and hip pain when he tried to move it. The Hospital Radiology Report, dated 04/08/26, documented R1 had sustained a comminuted (a fracture where a bone shatters into three or more pieces) transverse transcervical fracture (a break that runs horizontally across the middle, narrower portion of the femoral neck) with mild impaction (the broken ends are mildly driven into each other) and superior displacement (when the ball of the thigh bone shifts out of the hip socket) and moderate apex angulation and external rotation (when the bone has tilted and twisted out of its normal anatomical alignment). LN G's Notarized Witness Statement, dated 04/08/26, documented CNA M notified LN G at approximately 09:15 PM, R1 had fallen on the 100 hall. When LN G arrived, she observed R1 lying supine with his knees bent and a folded blanket under his head. R1 was scared and shaken. LN G asked R1 what had happened, and R1 stated, She pushed, and I fell to the floor. LN G assessed R1 and found no swelling to the back or sides of R1's head. R1 had three skin tears on his left elbow. LN G applied two Steri-strips (adhesive wound closures) to one of the skin tears. LN G assessed R1's range of motion, and R1 complained of left leg and hip pain when he tried to move it. LN G called LN H to assist. EMS came and took R1 to the hospital for further evaluation and treatment. During the care of R1, LN G learned R2 saw the fall. R2 told LN G R1 had touched items on R3 and R4's door, when R3 came out of their room and shoved R1 to the floor. LN G went to talk to R3, and R3 stated she did not push him. R4 then reported when he had been at his computer, R3 came into the room and told him she pushed him. CNA M's Notarized Witness Statement, dated 04/07/26, documented CNA M had been at the nurse's station up front when R2 walked towards her and waved her down the hall. CNA M walked towards R2 and then saw R1 lying on the ground at the end of 100 hall. CNA M ran to R1 and saw R1 on his left side. R1 was panicked. R2 said she witnessed R3 push R1, and he landed on the floor. On 05/20/26 at 10:30 AM, observation revealed R1 in his room and paced in a small triangle while a CNA tried to encourage him to go to the bathroom. Two other CNAs entered the room to assist. On 05/20/26 at 12:30 PM, Administrative Nurse D stated she did not know if there was anything the facility could have done to prevent the accident from happening besides making sure wheelchairs were not in the hall for R1 to stop and check out. Administrative Nurse D stated R1 ambulated all over the facility because he was one of those people who could not sit still. Administrative Nurse D stated when she watched the film of the accident, R1 had stopped in the hallway and was looking over R4's wheelchair that sat in the hall. R3 came out of her room, and Administrative Nurse D stated she could see R3 talking to R1. R1 turned to walk away when R3 shoved R1 four to five feet off the floor, and R1 landed in the hall. Administrative Nurse D stated R3 refused to admit she had pushed R1 and then finally did admit she had done it. Administrative Nurse D stated the police had waited to press charges against R3 to see if R1 made it through his surgery. On 05/20/26 at 01:30 PM, Administrative Staff A stated he did not know what the community could have done to prevent R1 from falling and breaking his hip. The facility's Fall Management policy, revised December 2017, documented the facility strives to minimize the risk for resident falls and to reduce injuries associated with resident falls. Residents are to be assessed in the first four hours of admission using a standardized fall risk assessment to identify individualized resident risk factors. Residents are to be reevaluated quarterly, with each fall and with any significant change. The facility interdisciplinary team is to review resident falls on a routine basis during Daily Clinical Excellence. The Director of Nursing or designee is responsible for reviewing falls on a routine basis to attempt to define the possible causes of the falls. Fall occurrences are to be documented in the clinical record, including environmental, situational, or psychological and situational factors, location, time found, position, adaptive equipment, actions taken, and new intervention implemented. The resident's plan of care is to be reviewed and revised with each fall occurrence and new interventions implemented. The facility completed corrective actions by 04/08/26, prior to the onsite survey. These actions included education with staff regarding keeping wheelchairs out of the halls, abuse, neglect, and exploitation, and behavioral management.

The facility identified a census of 43 residents, with six residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure six residents, Resident (R) 1, R2, R3, R4, R5, and R6, remained free from verbal and mental abuse when Certified Nurse's Aide (CNA) M exhibited aggressive behavior toward the residents. This failure resulted in R1, R2, R3, R4, R5, and R6 experiencing verbal/mental abuse, which likely caused embarrassment, humiliation, and a potential decreased quality of life using the reasonable person concept related to their psychosocial well-being. Findings included:- CNA N's Unnotarized Witness Statement, dated 12/11/25, documented CNA N and CNA M changed R1 in his room. CNA M looked at R1 and said, Ew, you smell like [expletive]. CNA N stated she tried to change the subject, and CNA M continued to speak about how R1 smelled. CNA M said, R1 smelled like he had a turd in his mouth. CNA M stated R1 probably smelled like that because of the chicken and dumplings he had last night, but R1 ate brown dumplings. CNA N said she did not know they even made brown dumplings. CNA M laughed at CNA N and said, That was sarcasm. I said it because his mouth smells like [expletive], [expletive] dumplings. CNA N stated she later saw CNA M wheel R2 in her wheelchair to eat breakfast, as R2 yelled. CNA M told R2 sternly to Stop it, people are sleeping right now, and you had better quit it. CNA N told Certified Medication Aide (CMA) R everything CNA M said, and CMA R instructed her to report what she had seen and heard. CNA N reported the incidents to administration later in the day.CMA R's Unnotarized Witness Statement, dated 12/11/25, documented sometime before 08:00 AM on 12/11/25, CMA R walked by R1's room and heard someone loudly talking and cussing. CNA N then waved CMA R into R1's room and told CMA R what happened. CMA R stated CNA M brought residents out to breakfast but was snappy and cold towards the residents. CMA R then stated earlier in the week R4 did not want to go to lunch, so CNA M wrapped her arms around R4's shoulders and tried to lift him up to the side of the bed. R4 pushed against CNA M and told her no, he did not want to go. CNA M tried several times to force R4 and manhandle him. CMA R told CNA M that was probably enough, and they could try later. CMA R's witness statement lacked evidence CMA R reported the incident to the administration.CNA O's Unnotarized Witness Statement, dated 12/11/25, documented earlier the same week CNA M and CNA O were getting residents up for supper, and CNA M worked in a rushed manner. She did not finish performing cares for residents, which included brushing hair, wiping hands or faces, and not changing soiled clothing. When the two CNAs got R5 up, CNA M made comments towards R5 about how nasty he was. CNA O stated she found CNA M's behavior unprofessional, hurtful to R5, and uncalled for. CNA O's witness statement lacked evidence CNA O reported the incident to the administration.Licensed Nurse (LN) G's Unnotarized Witness Statement, dated 12/11/25, documented on 12/11/25 at 06:30 AM, CNA M wheeled R6 to the nurse's station. R6 stated repeatedly she hurt and was in pain. CNA M said, Well, I don't know what to do for you. We are all in pain. LN G's witness statement lacked evidence LN G reported the incident to the administration.The Facility Incident Report, dated 12/17/25, documented an alleged cycle of abuse by CNA M. The initial incident occurred on 12/11/25 when CNA M and CNA N assisted residents up for breakfast. CNA M and CNA N were changing R1 when CNA M made repeated statements to and about R1 that he smelled. CNA M wheeled R2 to the dining room and yelled at R2. R2 was visibly upset in the dining room and kept repeating, I am not nice. Then CNA M and CNA N went to R3's room, where CNA M ranted and cussed about not being on the med cart. CNA N told CMA R what had happened, and CMA R told CNA N to report it. CMA R reported earlier in the week that she observed CNA M in R4's room. When R4 refused to go to the dining room, CNA M wrapped her arms around R4's shoulders to lift him to the side of the bed. R4 pushed against CNA M, and CNA M continued to try and force R4 to the side of the bed. CNA O stated earlier in the week she and CNA M were getting a resident up for supper, and CNA M was being aggressive and told R5 he was nasty. LN G witnessed CNA M tell R6, who was complaining of pain, I don't know what to do for you. We're all in pain.On 12/22/25 at 11:30 AM, observation revealed R1 sat in a wheelchair, watching other residents in the dining room while waiting for his lunch. R2 sat at an assisted table in the dining room, and people watched. Continued observation revealed R3 sat at a dining room table in his wheelchair, visiting with tablemates. R5 sat in his wheelchair at the assisted table at lunch time and was assisted with eating by staff. R6 sat in a wheelchair at the assisted resident dining room table, and staff assisted R6 to eat.On 12/22/25 at 01:30 PM, R4 laid in bed after lunch and waved his hands in the air.On 12/22/25 at 12:15 PM, CNA N stated she was just so overwhelmed with everything she witnessed from CNA M and trying to get everyone up for breakfast that when she finally got a chance to think, she told CMA R what had happened, and CMA R told her to go and tell the administrator. CNA N stated she was trained on ANE. On 12/22/25 at 12:30 PM, CNA O stated CNA M always seemed aggravated with residents while assisting with cares. CNA O stated she would tell CNA M to stop being rude to residents, but she did not want to start anything with someone she was working with, so she just let it go. CNA O stated R5 heard everything CNA M was saying about him, but he just let them continue to change him and get him ready for supper. CNA O stated she did not think R5 really understood what CNA M was saying.On 12/22/25 at 12:45 PM, CMA R stated when she saw CNA M trying to force R4 up and out of bed against his will, she did not report it because she thought it was an isolated incident. CNA M stated she realized she should have reported it. CMA R stated she was trained on ANE and knew she needed to report any suspected abuse.On 12/22/25 at 01:00 PM, LN G stated she did not suspect abuse at the time of the occurrence, but in retrospect, she should have notified someone CNA M was having a bad day. LN G stated she was trained in ANE and knew who to report suspected abuse to.On 12/22/25 at 01:15 PM, Administrative Nurse D stated she expected the staff to report any suspected incident of physical or verbal abuse to the administration when it occurred. Administrative Nurse D stated the good thing, if there was a good thing, was all of the residents this happened to were not alert and oriented, so even if they heard what CNA M said, they probably did not understand it.The facility's Abuse, Neglect, and Exploitation Policy, revised October 2022, documented the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. It is the policy of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect.The facility identified and implemented immediate corrective actions, which were completed on 12/12/25 and included: All nursing staff re-educated on Abuse, Neglect, and Exploitation Policy, an emergency Quality, Assurance, and Performance Improvement (QAPI) meeting was held with the facility's medical director. An emergency resident council meeting was conducted to discuss abuse and neglect. The local police department was contacted, and a report was filed. SSD will meet with each affected resident weekly for four weeks to check on any psychosocial impact. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliant at a G scope and severity to represent R1, R2, R3, R4, R5, and R6's potential psychosocial harm of embarrassment and/or humiliation.

The facility identified a census of 43 residents, with six residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to report suspected and observed abuse of Residents (R) 1, R2, R3, R4, R5, and R6 when Certified Nurse's Aide (CNA) M exhibited aggressive behavior toward the residents. Findings included:- CNA N's Unnotarized Witness Statement, dated 12/11/25, documented CNA N and CNA M changed R1 in his room. CNA M looked at R1 and said, Ew, you smell like [expletive]. CNA N stated she tried to change the subject, and CNA M continued to speak about how R1 smelled. CNA M said, R1 smelled like he had a turd in his mouth. CNA M stated R1 probably smelled like that because of the chicken and dumplings he had last night, but R1 ate brown dumplings. CNA N said she did not know they even made brown dumplings. CNA M laughed at CNA N and said, That was sarcasm. I said it because his mouth smells like [expletive], [expletive] dumplings. CNA N stated she later saw CNA M wheel R2 in her wheelchair to eat breakfast, as R2 yelled. CNA M told R2 sternly to Stop it, people are sleeping right now, and you had better quit it. CNA N told Certified Medication Aide (CMA) R everything CNA M said, and CMA R instructed her to report what she had seen and heard. CNA N reported the incidents to administration later in the day.CMA R's Unnotarized Witness Statement, dated 12/11/25, documented sometime before 08:00 AM on 12/11/25, CMA R walked by R1's room and heard someone loudly talking and cussing. CNA N then waved CMA R into R1's room and told CMA R what happened. CMA R stated CNA M brought residents out to breakfast but was snappy and cold towards the residents. CMA R then stated earlier in the week R4 did not want to go to lunch, so CNA M wrapped her arms around R4's shoulders and tried to lift him up to the side of the bed. R4 pushed against CNA M and told her no, he did not want to go. CNA M tried several times to force R4 and manhandle him. CMA R told CNA M that was probably enough, and they could try later. CMA R's witness statement lacked evidence CMA R reported the incident to the administration.CNA O's Unnotarized Witness Statement, dated 12/11/25, documented earlier the same week CNA M and CNA O were getting residents up for supper, and CNA M worked in a rushed manner. She did not finish performing cares for residents, which included brushing hair, wiping hands or faces, and not changing soiled clothing. When the two CNAs got R5 up, CNA M made comments towards R5 about how nasty he was. CNA O stated she found CNA M's behavior unprofessional, hurtful to R5, and uncalled for. CNA O's witness statement lacked evidence CNA O reported the incident to the administration.Licensed Nurse (LN) G's Unnotarized Witness Statement, dated 12/11/25, documented on 12/11/25 at 06:30 AM, CNA M wheeled R6 to the nurse's station. R6 stated repeatedly she hurt and was in pain. CNA M said, Well, I don't know what to do for you. We are all in pain. LN G's witness statement lacked evidence LN G reported the incident to the administration.The Facility Incident Report, dated 12/17/25, documented an alleged cycle of abuse by CNA M. The initial incident occurred on 12/11/25 when CNA M and CNA N assisted residents up for breakfast. CNA M and CNA N were changing R1 when CNA M made repeated statements to and about R1 that he smelled. CNA M wheeled R2 to the dining room and yelled at R2. R2 was visibly upset in the dining room and kept repeating, I am not nice. Then CNA M and CNA N went to R3's room, where CNA M ranted and cussed about not being on the med cart. CNA N told CMA R what had happened, and CMA R told CNA N to report it. CMA R reported earlier in the week that she observed CNA M in R4's room. When R4 refused to go to the dining room, CNA M wrapped her arms around R4's shoulders to lift him to the side of the bed. R4 pushed against CNA M, and CNA M continued to try and force R4 to the side of the bed. CNA O stated earlier in the week she and CNA M were getting a resident up for supper, and CNA M was being aggressive and told R5 he was nasty. LN G witnessed CNA M tell R6, who was complaining of pain, I don't know what to do for you. We're all in pain.On 12/22/25 at 11:30 AM, observation revealed R1 sat in a wheelchair, watching other residents in the dining room while waiting for his lunch. R2 sat at an assisted table in the dining room, and people watched. Continued observation revealed R3 sat at a dining room table in his wheelchair, visiting with tablemates. R5 sat in his wheelchair at the assisted table at lunch time and was assisted with eating by staff. R6 sat in a wheelchair at the assisted resident dining room table, and staff assisted R6 to eat.On 12/22/25 at 01:30 PM, R4 laid in bed after lunch and waved his hands in the air.On 12/22/25 at 12:15 PM, CNA N stated she was just so overwhelmed with everything she witnessed from CNA M and trying to get everyone up for breakfast that when she finally got a chance to think, she told CMA R what had happened, and CMA R told her to go and tell the administrator. CNA N stated she was trained on ANE. On 12/22/25 at 12:30 PM, CNA O stated CNA M always seemed aggravated with residents while assisting with cares. CNA O stated she would tell CNA M to stop being rude to residents, but she did not want to start anything with someone she was working with, so she just let it go. CNA O stated R5 heard everything CNA M was saying about him, but he just let them continue to change him and get him ready for supper. CNA O stated she did not think R5 really understood what CNA M was saying.On 12/22/25 at 12:45 PM, CMA R stated when she saw CNA M trying to force R4 up and out of bed against his will, she did not report it because she thought it was an isolated incident. CNA M stated she realized she should have reported it. CMA R stated she was trained on ANE and knew she needed to report any suspected abuse.On 12/22/25 at 01:00 PM, LN G stated she did not suspect abuse at the time of the occurrence, but in retrospect, she should have notified someone CNA M was having a bad day. LN G stated she was trained in ANE and knew who to report suspected abuse to.On 12/22/25 at 01:15 PM, Administrative Nurse D stated she expected the staff to report any suspected incident of physical or verbal abuse to the administration when it occurred. Administrative Nurse D stated the good thing, if there was a good thing, was all of the residents this happened to were not alert and oriented, so even if they heard what CNA M said, they probably did not understand it.The facility's Abuse, Neglect, and Exploitation Policy, revised October 2022, documented the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. It is the policy of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect.The facility identified and implemented immediate corrective actions, which were completed on 12/12/25 and included: All nursing staff re-educated on Abuse, Neglect, and Exploitation Policy, an emergency Quality, Assurance, and Performance Improvement (QAPI) meeting was held with the facility's medical director. An emergency resident council meeting was conducted to discuss abuse and neglect. The local police department was contacted, and a report was filed. SSD will meet with each affected resident weekly for four weeks to check on any psychosocial impact. Due to the corrective actions completed before the onsite survey, the citation was deemed past noncompliance at an F scope and severity to represent R1, R2, R3, R4, R5, and R6's potential psychological harm of embarrassment and/or humiliation.

The facility identified a census of 38 residents, with four residents reviewed for elopements (when a resident leaves the premises or a specific safe area without authorization and/or necessary supervision). Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R) 1, who the facility identified as a high risk for elopement. On 04/05/24 at approximately 04:18 PM, R1 exited the facility's 200 hall through an unlocked door, which did not alarm. R1 walked approximately the length of a football field over cracked sidewalks, uneven grassy areas, a parking lot full of large potholes, and over several curbs before falling, between two apartment buildings, behind the facility. A community member living in the apartment building called 911 and reported R1 lying on the apartment complex lawn. At 04:45 PM, Certified Medication Aide (CMA) R saw an ambulance behind the facility and identified R1 on the ambulance stretcher. Emergency Medical Services (EMS) transported R1 to the local hospital for evaluation. The facility's failure to ensure R1 received adequate supervision to prevent an elopement which resulted in a fall outside of the facility, and the failure to ensure functioning door alarms and locks placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), unsteadiness on her feet, abnormalities of gait (manner or style of walk), and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R1 had physical and verbal behaviors directed towards others during the look-back period. The MDS documented R1 had episodes of wandering during the look-back period, and the wandering episodes placed R1 at significant risk of getting to a potentially dangerous place. The MDS documented R1 was dependent on staff for toileting, bathing, and personal hygiene; and required substantial staff assistance with dressing and donning and doffing footwear. The MDS documented R1 required supervision or touching assistance with transfers, ambulation, and bed mobility. The MDS documented R1 had one non-injury fall and one minor injury fall during the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/31/25, documented R1 had diagnoses of Alzheimer's disease, dementia, irritability, anger, and altered mental status. The CAA documented R1 displayed physical and verbal outbursts and wandering, and staff would redirect R1 as needed. The Falls CAA, dated 01/31/25, documented R1 had poor safety awareness and had fallen during the look-back period. The CAA directed staff to monitor R1 closely. R1's Care Plan documented R1 was independent most of the time with transfers, ambulation, and locomotion, but needed assistance at times when her gait was unsteady. The care plan documented R1 was at risk for falls and needed appropriate footwear. The plan directed staff to have R1's call light within reach. The plan directed staff to keep pathways in R1's room clear and unobstructed and when R1 had increased wandering, offer her activities to redirect her (12/13/22). The care plan documented R1 had cognitive deficits that affected her memory (02/15/24). The care plan directed staff to consider R1's physical needs when R1 was wandering (09/22/23). The Facility Incident Report, dated 04/07/25, documented on 04/05/25 at approximately 04:00 PM, CMA R reported she saw R1 at the front nurse's station. At 04:15 PM, video camera footage showed R1 pushing on the far-left side of the exit door on 200 hall. R1 pushed on the right side of the 200 hall exit door, and the door opened. R1 quickly exited the building and turned to shut the door. CMA R passed medication on the 400 hall at the back of the facility when she observed an ambulance behind the facility with someone on the stretcher with a purple jacket on. CMA R asked another CNA what color R1's jacket was, and the aide said purple. At that point, EMS turned the stretcher, and staff saw it was R1. CMA R ran down the hall, alerted LN G, ran back to the parking lot, and spoke to EMS personnel. At 04:47 PM, the ambulance pulled up in front of the facility to get a copy of R1's face sheet and told staff they were transporting R1 to the local hospital for testing and possible treatment. The emergency room Dismissal Instructions, dated 04/05/25, documented R1 had a urinary tract infection (UTI - an infection in any part of the urinary system) requiring antibiotics, and abrasions to her face due to a fall. The dismissal instructions directed R1 to take all of her antibiotics and to monitor the wounds on her face; keep the wound clean and dry, and if the wound started to have increased redness, purulent (producing or containing pus) drainage, or swelling, the wounds would need to be re-evaluated for infection. The dismissal instruction directed the facility that if R1 developed a fever, worsening altered mental state, or any other new, concerning symptoms, R1 should return to the emergency room for evaluation. CMA R's Notarized Witness Statement, dated 04/05/25, documented CMA R last saw R1 physically in the facility at 04:00 PM at the front nurse's station. CMA R stated she started her medication pass on the back hall at about 04:15 PM when CMA R started looking on the 400 hall to see if R1 was in one of the rooms. CMA R went into a room and saw an ambulance in the back parking lot, when she looked out the window. CMA R noted she saw EMS placing someone wearing a purple jacket on a stretcher. The statement documented CMA R asked another Certified Nurse Aide (CNA) what color jacket R1 had on, and she said Purple. EMS then turned the stretcher towards the window, and CMA R saw R1 lying on the stretcher. CMA R ran out to the parking lot and spoke with EMS personnel who told CMA R that R1 fell on the sidewalk. R1 was able to tell them her name. The statement recorded the ambulance came around to the front of the facility to get R1's face sheet around 04:47 PM. Certified Nurse Aide (CNA) M's Notarized Witness Statement, dated 04/05/25, documented CNA M saw R1 with another staff member, and then saw R1 headed around the corner with a nurse. The statement noted that after a while, CNA M asked a co-worker if she had seen R1 and the co-worker said she had not seen R1. CNA M noted she then kept her eye out for R1 and went to check with a co-worker if she had checked R1's room for her. CNA M's co-worker came out of R1's room and said R1 was not there. CNA M searched the front hall but saw no signs of R1, so CNA M went to the back hall to see if anyone had found R1. CNA M noted two aides came out of a room in a hurry, yelling something about R1. CNA M noted the ambulance was outside, and CNA M and another staff member stopped the ambulance, told them R1's name, and then ran back to the facility to report to the nurse. CNA N's Notarized Witness Statement, dated 04/05/25, documented CNA N saw R1 at approximately 04:00 PM, before staff started getting residents up. R1 stood at the end of the 400 hall with another resident. CNA N noted R1 stood at the end of 400 hall and CNA N called for R1 and then assisted R1 into a chair at the back nurse's station. CNA N documented that a co-worker approached her and asked if she had seen R1, so CNA N started looking for R1, but did not see R1. CNA N noted she and another aide went down the 400 hall looking for R1 when they saw an ambulance at the apartments behind the facility. CNA N noted she saw R1 being placed on the stretcher, and immediately notified the nurse. Licensed Nurse (LN) G's Notarized Witness Statement, dated 04/05/25, documented the last time LN G saw R1, R1 was walking down the 200 hall and had stopped around room [ROOM NUMBER], turned around and started walking north. LN G stated after the incident, she went down to the 200 hall exit door and attempted to open the door, but could not open the door using her whole body weight while she pushed the door handle. The Nurse's Note, dated 04/05/25, documented R1 arrived back at the facility via a private vehicle driven by R1's responsible party. A nurse-to-nurse report documented R1 had abrasions to her face and Bacitracin (antibiotic ointment) was applied to the abrasions; all the scans of R1's face and knees came back with no concerns. The note recorded R1 had a severe (UTI - an infection in any part of the urinary system) and received an injection of Rocephin (antibiotic) in the emergency room (ER). The Hospice Note, dated 04/06/25, documented R1 hurt her knee and had a lot of pain in the left knee. The note documented R1 had a hard time putting weight on her knee and used a wheelchair. R1 had a one-to-one CNA sitting with her. The note documented R1 had gotten out of the building and was brought to theER on [DATE]. R1 had abrasions on her forehead, the bridge and tip of her nose, and her inner left eye was bruised. On 04/21/25 at 10:00 AM, observation of the area around the facility in which R1 traversed on 04/05/25, revealed R1 walked approximately the length of a football field around the facility. Observation of the area revealed cracked sidewalks, an uneven grassy lawn to the back parking lot, and the parking lot was cracked and uneven, with several very large potholes. On 04/21/25 at 10:30 AM, observation revealed R1 sat in a wheelchair watching an activity where other residents were playing a game. R1 had a large yellow/green bruise on the entire left side of her face with two abrasions to her nose. When asked if her face hurt, R1 said, Well, what's wrong with my face? On 04/21/25 at 11:00 AM, CMA R stated she last saw R1 around 04:15 PM, and then when she went to look for R1, she could not find her so she asked other CNAs if they knew where R1 was but no one knew, so they started searching rooms. CMA R stated she was in a resident's room and saw an ambulance out back loading someone in the ambulance, so CMA R asked another staff member what color R1's jacket was, and they said purple. CMA R said that EMS swung the cot around at that point, and CMA R saw R1. CMA R stated she ran out to the EMS and told them R1's name, and they said they were going to pull around and get a face sheet at the front of the building. CMA R stated she had received training regarding elopement. On 04/21/25 at 09:30 AM, Administrative Staff A stated they thought contractors working in the facility had unhooked the door alarm sensors, and then, when they went out the door, they did not shut it tight, so the mag-lock did not engage. Administrative Staff A stated that 1200-pound mag-locks had been installed on all doors on 04/16/25, and the 1200-pound mag-locks would pull the doors shut if they were within two inches of shutting. Administrative Staff A stated the door at the end of 200 hall was immediately secured and the mag-lock was functioning; the alarm was rewired and was now in working order. Administrative Staff A said all staff were re-educated on the facility's elopement policy, stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done. Administrative Staff A stated the facility's elopement book was reviewed for accuracy, R1 was put on one-to-one over the weekend, and the findings of the incident were taken to an emergency Quality Assurance and Performance Improvement (QAPI) meeting. Administrative Staff A verified that all the door alarms and mag-locks were checked for functionality on 04/01/25. On 04/21/25 at 10:00 AM, Administrative Nurse D stated she thought contractors working on the back rooms down 200 hall had unhooked the door alarm from the censors, but the facility could not prove that. Administrative Nurse D verified the door alarm was not hooked up on 04/05/25. Administrative Nurse D showed the path staff thought R1 took when she exited the 200 hall. Administrative Nurse D stated R1 was on hospice and her ability to transfer and ambulate fluctuated from day to day; sometimes she was independent and all over the facility, and other days she was in a wheelchair. Administrative Nurse D stated R1 had been on 30-minute location checks because she was a high elopement risk. Administrative Nurse D stated all administrative staff were in the building fifteen to twenty minutes after R1 was seen outside, and all the doors were checked for functioning door alarms and mag locks. Administrative Nurse D stated that education on the Elopement Policy was started that day and that none of the staff could work before completing the education. Administrative Nurse D verified all education was completed on Wednesday, 04/09/25. The facility's Resident Elopement Policy and Procedure, revised December 2022, documented the facility strived to promote a safe and secure environment to help minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. Risk for elopement was to be identified for residents, and an individualized care plan was developed based on risk. Staff are to investigate and report instances of potential elopement. The facility is to have a process to monitor the security of the premises on a routine basis. On 04/21/25 at 01:31 PM, Administrative Staff A was provided the Immediate Jeopardy [IJ] Template and notified the facility's failure to provide adequate supervision to prevent an elopement for R1 placed the resident in immediate jeopardy. The facility identified and implemented immediate corrective actions, which were completed on 04/16/25 and included: 1200-pound mag-locks were installed on all doors on 04/16/25. The door at the end of 200 hall was immediately secured, and the mag-lock was functioning. The alarm was rewired and in working order. All staff were re-educated on the facility's elopement policy. Stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done. The facility's Elopement Book was reviewed for accuracy. R1 was put on one-to-one over the weekend. The findings of the incident were taken to an emergency QAPI. Because all corrective actions were completed before the onsite survey, the citation was deemed past noncompliance and existed at a J (isolated, immediate jeopardy) scope and severity.

The facility had a census of 37 residents. Based on record review and interview, the facility failed to ensure staff completed the required 12-hour in-service education for Certified Nurse Aide (CNA) N and CNA T, who were all employed by the facility for at least one year. This deficient practice placed the residents at risk of decreased quality of care. Findings included: - A review of the facility's 12-hour annual in-service documentation for five certified staff members who had been employed at the facility for at least one year revealed the following: CMA T lacked dementia care training. CNA N lacked had only completed three of the required 12 in-service hours. On 07/24/24 at 09:37 AM Administrative Nurse D reported the facility utilized an electronic education system for the required education. She confirmed the above staff did not have the required education topics and /or hours. Upon request, the facility did not provide a policy for required services. The facility failed to ensure required topics and 12-hours in-service education for CMA S and T and CNA N, which placed the residents at risk for decreased quality of care.

The facility identified a census of 37 residents. The sample included 12 residents with five residents sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when the facility failed to secure fully pressurized supplemental oxygen cylinders in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. The facility additionally failed to ensure interventions were put in place for 22 of Residents (R) 33's 41 falls. This deficient practice placed the residents at risk for preventable accidents, falls, and injuries. Findings included: - On 07/22/24 at 08:02 AM a walkthrough of the facility revealed an unsecured oxygen storage room. The room contained 38 fully pressurized supplemental oxygen cylinder tanks stored in floor racks. The room had a numerical keypad on the entry door. No facility staff was in the storage room area. The room's keypad door auto-locked when pulled closed. On 07/24/24 at 08:18 AM Certified Nurse Aide (CNA) O stated that the oxygen storage room should always remain locked to ensure a resident did not wander into the room. On 07/24/24 at 09:26 AM Licensed Nurse (LN) G stated the oxygen storage room should always be locked due to the wandering residents in that facility. LN G stated the door had a keypad lock. On 07/24/24 at 09:37 AM Administrative Nurse D stated the oxygen storage room should always remain locked unless a staff member was accessing the room. On 07/24/24 at 09:39 AM Administrative Nurse E stated on the morning of 07/22/24 a staff member was preparing a resident to go to the doctor and had just obtained a new oxygen bottle for that resident and must have mistakenly not gotten the door closed all the way when they exited the room. Administrative Nurse E stated staff have been educated to ensure the door was closed and always locked. On 07/24/24 at 12:15 PM Administrative Staff A stated the facility did not have a specific policy related to the oxygen storage room but that it was just a standard of care. The facility, upon request, did not provide a policy for oxygen cylinder storage. The facility failed to ensure an environment free from accident hazards when the facility failed to secure pressurized medical oxygen cylinder tanks in a safe, locked area, and out of reach of the five cognitively impaired, independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. 26768 - R33's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic pain, anxiety disorder (a mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), persistent mood disorders and insomnia (inability to sleep). R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented short- and long-term memory problems with moderately impaired decision-making, physical and verbal behaviors, and rejection of care. The MDS documented R33 required partial assistance for eating and was dependent on staff for all other activities of daily living (ADL) and mobility. The MDS documented R33 had two or more non-injury falls, two or more minor injury falls since the last MDS assessment, and received an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), an antianxiety (class of medications that calm and relax people) and a hypnotic (a class of medications used to induce sleep) medications. R33's Fall Care Plan, dated 06/10/24, stated R33 was at risk for falls due to wandering and psychotropic (alters mood or thought) medications. The care plan directed staff to encourage R33 to wait for assistance from staff before attempting to stand up. Staff were to ensure R33 had a high-low bed, and R33 needed to have it lower when he was in bed. The plan recorded he would sit on the floor to move things around and try to fix things. If no staff member witnessed him putting himself on the floor, nurses would treat the incident as a fall, including assessing him and completing neurological checks per protocol. Staff were to ensure he wore appropriate shoes and nonslip footwear. The plan directed to ask the pharmacist and physician to monitor R33's medications on an ongoing basis and to place the call light within his reach. The plan further directed the following interventions related to falls: Fall on 12/21/23 Assist R33 to the restroom before bed at night. Fall on 12/29/23 Encourage R33 to sit or lie down when he appears to be tired. Fall on 12/29/23 Encourage R33 to use a wheelchair if he appears to be weak or groggy, or if he was using the handrails in the hallways to support himself. Fall on 12/30/23 Keep the bathroom light or another light on in R33's room. Fall on 01/02/24 Encourage R33's to help staff with tasks to reduce wandering. Fall on 01/03/24 R33 was moved to a room closer to the nurse's station on 01/13/24. Fall on 01/06/24 Staff to set the brakes on his wheelchair when R33 is stationary. Fall on 01/10/24 Encourage R33 to sit near the nurse's station after dinner until he is ready to go to bed. Fall on 01/14/24 Staff should help lower the resident to the floor during a fall to avoid injury. Fall on 01/15/24 Encourage R33 to stand up straight if he is leaning while walking. Fall on 01/24/24 Assist R33 in putting non-skid socks back on when he takes them off. Fall on 01/25/24 Staff should pick up anything that R33 drops right away, and prompt him not to do it himself. Fall on 01/28/24 Place anti-roll-back bars on R33's wheelchair to prevent it from rolling backwards. Fall on 02/12/24 Staff were to assist R33 to get up and sit at the nursing station or dining room for meals. Please get him up early when possible. Fall on 02/01/24 Medication review with changes by the psychiatric provider. Fall on 02/04/24 Medication review with changes completed on 02/15/24 due to a fall on 02/13/24. Fall on 05/06/24 Staff were to offer R33 food at night when he is restless and trying to get out of bed. Fall on 05/23/24 A scoop mattress was placed on R33's bed to remind him not to roll over too far. Fall on 04/02/24 When R33's family leaves after a visit, staff need to monitor him on one or bring him to the nurse's desk where he can be seen by staff. R33's EMR documented 41 falls since admission on 12/04/23 and no care plan revision indicating new interventions for 22 of those falls. The Fall Note, dated 07/22/24 at 10:48 AM, documented that R33 sat upright in his wheelchair in a well-lit uncluttered walkway in the back hall next to the nurse's station. There was some commotion when the resident was observed falling to the floor from a standing position. On 07/22/24 at 01:35 PM, observation revealed R33 sat in a wheelchair by the nurse's desk. R33 wore non-skid socks and his feet rested on the floor. R33 appeared relaxed. At 01:43 PM, R33 continued to sit. He had his head down, and his eyes closed. Certified Medication Aide (CMA) R placed footrests on his wheelchair and took him to his room. Observation revealed a maintenance issue in his room, so the staff took him back to the nurse's desk area and gave him a snack. On 07/24/24 at 09:15 AM, Administrative Nurse E stated R33 had a lot of repetitive causes of falls due to attempting to stand. Administrative Nurse E verified the facility had not developed interventions and updated R33's plan of care with each fall to prevent further falls. The facility's Risk Management policy, dated 11/2023, stated with each event, the charge nurse would update the resident's care plan with a new intervention to prevent further occurrence of the event. The facility failed to identify and implement effective interventions to prevent further falls for R33, placing the resident at risk for further falls and injury.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent. This deficient practice placed Resident (R) 21 at risk for significant medication errors and resulted in a facility medication error rate of 7.69 percent (%) placing all residents who received medication at risk for medication errors. Findings included: - The Physician Order, dated 04/04/24, directed staff to administer amlodipine (blood pressure lowering medication)10 milligram (mg) daily and hold for a blood pressure less than 100/65 millimeters (mm) of Mercury (Hg) if either number is lower. The Physician Order, dated 04/04/24, directed staff to administer benazepril (blood pressure lowering medication),10 mg daily, and hold for blood pressure less than 100/65 mm/Hg if either number is lower. On 07/23/24 at 07:38 AM, observation revealed Certified Medication Aide (CMA) R obtained R21's blood pressure while he was seated in the dining room and then administered medications including amlodipine, 10 mg and benazepril, 10 mg to R21. CMA R crushed the pills and mixed them with water before giving them to R21. On 07/23/24 at 07:45 AM, R21's EMR documented a blood pressure of 128/60 mmHg. On 07/23/24 at 12:28 PM, CMA R verified the physician's orders to hold the amlodipine and benazepril for a blood pressure less than 100/65 and verified she should not have administered those medications that morning. On 07/23/24 at 12:47 PM, Licensed Nurse (LN) G verified the CMA should not have administered the amlodipine and benazepril due to the out-of-parameter blood pressure. Upon request, the facility did not provide a policy related to medication errors. The facility failed to administer medications with a less than five percent error rate placing R21 at risk for significant medication errors and resulting in a 7.69 % error rate. This placed all residents who received medications at risk for complications related to medication errors.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist (CP) identified and notified the facility and physician of the numerous times staff administered two blood pressure medications to Resident (R) 21 when the physician order indicated the medications should have been held (not administered) in April, May, and June 2024. This deficient practice placed R21 at risk for unintended results from medications. Findings included: - R21's Electronic Medical Record (EMR) recorded a diagnosis of hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R21 required set-up assistance for meals and was dependent on staff for all other activities of daily living (ADL) and mobility. R21's Medication Care Plan, dated 07/22/24, directed staff to administer R21's medications at about the same time each day and check the blood pressure before giving the medications. The care plan stated the pharmacist and physician were to review medications. The Physician Order, dated 04/04/24, directed staff to administer amlodipine (blood pressure lowering medication)10 milligram (mg) daily and hold for a blood pressure less than 100/65 millimeters (mm) of Mercury (Hg) if either number is lower. The Physician Order, dated 04/04/24, directed staff to administer benazepril (blood pressure lowering medication),10 mg daily, and hold for blood pressure less than 100/65 mm/Hg if either number is lower. R21's Medication Administration Record (MAR) revealed the following: April 5-30, 2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter 11 times. In May 2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter 16 times. In June 2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter 10 times. On July 1-23,2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter eight times. The Pharmacist Consultant Medication Regimen Reviews for April, May, and June 2024 lacked notes regarding the administration of benazepril and amlodipine when the blood pressures were out of the physician-ordered parameters. On 07/23/24 at 07:38 AM, observation revealed Certified Medication Aide (CMA) R obtained R21's blood pressure while he was seated in the dining room and then administered medications including amlodipine, 10 mg and benazepril, 10 mg to R21. CMA R crushed the pills and mixed them with water before giving them to R21. On 07/23/24 at 12:47 PM, Licensed Nurse (LN) G verified the CMA should not have administered the amlodipine and benazepril due to the out-of-parameter blood pressure. LN G verified the numerous times staff administered the two medications, April through the current time, that staff should have held the two medications. On 07/24/24 at 09:15 AM, Administrative Nurse E verified the facility's Consultant Pharmacist had not informed the facility of the ongoing medication errors. The facility's Medication Regimen Review (MRR) and Reporting policy, dated 2007, stated the medication regimen review included a review of the medical records in order to prevent, identify, report, and resolve medication-related problems, errors, or other irregularities. The findings would be communicated to the director of nursing and the medical director. Resident-specific MRR recommendations and findings would be documented and acted upon by the nursing care center and or the physician. The facility failed to ensure the CP identified and notified the facility and physician of the numerous times staff administered two blood pressure medications to R21 outside the physician ordered parameters. This deficient practice placed R21 at risk for unintended results from medications.

The facility had a census of 37 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to hold Resident (R) 21's blood pressure medication per the physician ordered blood pressure parameters. This deficient practice placed R21 at risk for unnecessary medications and related complications. Findings included: - R21's Electronic Medical Record (EMR) recorded a diagnosis of hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R21 required set-up assistance for meals and was dependent on staff for all other activities of daily living (ADL) and mobility. R21's Medication Care Plan, dated 07/22/24, directed staff to administer R21's medications at about the same time each day and check the blood pressure before giving the medications. The care plan stated the pharmacist and physician were to review medications. The Physician Order, dated 04/04/24, directed staff to administer amlodipine (blood pressure lowering medication)10 milligram (mg) daily and hold for a blood pressure less than 100/65 millimeters (mm) of Mercury (Hg) if either number is lower. The Physician Order, dated 04/04/24, directed staff to administer benazepril (blood pressure lowering medication),10 mg daily, and hold for blood pressure less than 100/65 mm/Hg if either number is lower. R21's Medication Administration Record (MAR) revealed the following: April 5-30, 2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter 11 times. In May 2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter 16 times. In June 2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter 10 times. On July 1-23,2024, staff administered amlodipine and benazepril when R21's blood pressure was lower than the physician-ordered parameter eight times. On 07/23/24 at 07:38 AM, observation revealed Certified Medication Aide (CMA) R obtained R21's blood pressure while he was seated in the dining room and then administered medications including amlodipine, 10 mg and benazepril, 10 mg to R21. CMA R crushed the pills and mixed them with water before giving them to R21. On 07/23/24 at 12:47 PM, Licensed Nurse (LN) G verified the CMA should not have administered the amlodipine and benazepril due to the out-of-parameter blood pressure. LN G verified the numerous times staff administered the two medications, April through the current time, that staff should have held the two medications. On 07/24/24 at 09:15 AM, Administrative Nurse E verified the ongoing medication error. Upon request, the facility did not provide a medication administration policy. The facility failed to hold R21's blood pressure medication per the physician ordered blood pressure parameters. This deficient practice placed R21 at risk for unnecessary medications and related complications.

The facility identified a census of 42 residents. The sample included three residents reviewed for therapeutic diets (a modification of a regular diet to fit the nutrition needs of a particular person and are modified for nutrients, texture, and/or food allergies or intolerances). Based on observations, record review, and interviews, the facility failed to provide the physician-ordered thickened liquids to Resident (R) 1, who had a history of dysphagia (difficulty swallowing) and aspiration (inhaling liquid or food into the lungs). On 01/07/24, Certified Nurse Aide (CNA) M served R1 thin liquids during breakfast instead of nectar thick liquids (mildly thickened liquids). Licensed Nurse (LN) G observed R1 coughing and choking afterward. LN H suctioned R1 multiple times but R1 continued to sound congested. Staff sent R1 to the emergency room (ER). R1 arrived at the hospital in obvious respiratory distress, with abnormal lung sounds, and required bilevel positive airway pressure (BiPAP-medical device which helps with breathing) treatment. R1 returned to the facility later that day on antibiotics (medications used to treat bacterial infections) to treat aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The facility's failure to follow R1's therapeutic diet order for thickened liquids placed her in immediate jeopardy. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), personal history of transient ischemic attacks (TIA- temporary episode of inadequate blood supply to the brain), dysphagia, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. R1 required supervision or touching assistance with eating and had coughing or choking during meals or when swallowing medications. The Annual MDS dated [DATE], documented R1 had a BIMS score of 13 which indicated intact cognition. R1 required set-up/clean-up assistance with eating and had coughing or choking during meals or when swallowing medications. The Activity of Daily Living Functional/Rehabilitation Care Area Assessment (CAA) dated 01/23/24, documented R1 was dependent on staff for almost all of her activities of daily living (ADLs). She was able to feed herself once it was set up. The Nutritional Status CAA dated 01/23/24, documented R1 was on a pureed diet (mechanically altered therapeutic diet) with thickened liquids due to choking and aspiration pneumonia. R1's Care Plan, last revised on 12/11/23, documented she had a risk for choking due to pocketing food in her mouth and was sent to the ER for suspected aspiration on 12/11/23. The care plan directed staff to remind R1 to take small bites, chew, and swallow before putting more in her mouth. R1's Care Plan, dated 01/21/21, documented R1 was at risk to lose or gain weight due to her disease process. The care plan documented an intervention, dated 01/21/21, that directed staff to provide R1 her meals as ordered by the physician. The care plan documented an intervention, dated 01/04/24, that directed R1 had a regular diet with pureed texture and nectar-thick fluid consistency. The Orders tab of R1's EMR documented an order with a start date of 12/27/23 and discontinued date of 01/11/24, for a controlled carbohydrate diet (CCHO- a diet that manages the number of carbohydrates and benefits people with diabetes) with pureed texture and nectar consistency for aspiration pneumonia. The Orders tab documented an order with a start date of 01/11/24 for a CCHO diet with pureed texture and honey consistency liquids (thickened liquids consistent with honey or a milkshake) for aspiration pneumonia. The facility's investigative report, dated 01/10/24, documented on 01/07/24, R1 was eating breakfast in the main dining room and started to cough. A CNA brought R1 to LN H who noted R1's upper lung sounds evidenced fluid. LN H suctioned R1 and removed fluid but R1 continued coughing with less congestion. Staff called Emergency Medical Services (EMS) and they arrived quickly and took R1 to the hospital for evaluation and treatment. Upon further investigation, it was discovered that staff gave R1 regular juice when she was on nectar-thick liquids. R1 returned from the hospital at 12:30 PM via EMS with an order for antibiotics for possible aspiration pneumonia. In LN G's notarized Witness Statement on 01/07/24, LN G stated she went to the big dining room to get a blood pressure on a resident when she saw R1 choking. She told staff R1 was choking. R1 stated she was fine, but her voice was gurgling and LN G heard fluid in her throat. LN G stated R1 drank regular liquids. She stated staff took R1 out of the dining room to LN H and she followed behind. LN G stated she told LN H that R1 choked and needed to go to the ER to be suctioned. She stated R1 needed to be at the assisted table so she would not choke. LN G stated LN H suctioned R1 and got quite a bit of fluid out. She stated R1 talked a little better but was still full of fluid in her throat, so EMS was called, and staff sent R1 to the ER for aspiration. The Notes tab of R1's EMR revealed the following: A Nurse's Note on 01/07/24 at 08:45 AM documented R1 ate and drank at breakfast when she started to cough. The CNA brought R1 to LN H who noted R1's upper lungs were filled with fluid. LN H suctioned R1 several times and removed fluid with R1 still coughing but less congested. R1 was a puree diet with nectar thick liquids. R1 drank regular fluids. R1 left the facility at 08:36 AM to the ER. A Nurse's Note on 01/07/24 at 12:47 PM documented the nurse called the ER and the ER nurse stated R1 was resting. ER nurse reported they placed a BiPAP on R1 earlier to help with breathing. The ER nurse reported R1 received an injection of antibiotics and would return with an order for oral antibiotics. A Nurse's Note on 01/07/24 at 03:19 PM documented R1 returned from the ER at 12:30 PM via EMS. The CNA assisted R1 back to bed and R1 answered questions appropriately. R1 was hungry and wanted to eat a late lunch. R1's bilateral lungs had crackles (abnormal lung sounds that occur as a result of small airways suddenly snapping open and may indicate a person's lungs have fluid inside them or are not inflating correctly). R1 had a new order for Zithromax (azithromycin- antibiotic) for five days and Augmenting (antibiotic) for 10 days. A Nurse's Note on 01/07/24 at 03:24 PM documented that education was given to CNAs about R1 being on thickened liquids with a pureed diet. R1 sat at assist table for meals to ensure she received the proper diet. Upon request, the facility provided R1's hospital documentation from 01/07/24. The ED Provider Notes, dated 01/07/24, documented R1 arrived at the ER with complaints of sudden onset respiratory distress. The facility stated she was a high aspiration risk and was supposed to have thickened liquids but did not get thickened liquids with breakfast and staff believed she aspirated. R1 was in respiratory distress and mildly hypoxic (not getting enough oxygen). Upon arrival, R1 was alert and would respond by shaking her head yes or no. R1's breathing was labored and tachypneic (abnormally rapid breathing), BiPAP was initiated prehospital and was continued. R1 displayed obvious respiratory distress and her lung sounds were heavy with rales (crackles) bilaterally. The note documented a clinical impression for R1 as aspiration pneumonia of both lungs and R1 received new medications of Augmentin 875 milligrams (mg)/125 mg every 12 hours for 10 days for lower respiratory infection and Zithromax 500 mg daily for five days for lower respiratory infection. On 02/06/24 at 12:02 PM, R1 sat in her wheelchair at the assisted table in the dining room. She ate a pureed diet with honey thick liquids. Staff assisted residents at the table. On 02/06/24 at 12:34 PM, Dietary BB stated she reviewed diet orders, care plans, and communications for thickened liquids. She stated the diet cards listed the diets along with if a resident was on thickened liquids. Dietary BB stated dietary staff made the thickened liquids and on 01/07/24, a new staff member had brought R1 into the dining room who was not aware R1 was on thickened liquids. She stated the staff placed R1 at a table with her back to Dietary BB, so she was unable to see that the staff served her a beverage. On 02/06/24, CNA M was unavailable for an interview. On 02/06/24 at 12:39 PM, CNA N stated she knew who was on thickened liquids by their diet chart, and the nurses and dietary let them know. She stated communication was sent out for diet changes. She stated she did not hand out beverages at mealtimes and the only resident on thickened liquids was R1. On 02/06/24 at 12:54 PM, LN G stated on 01/07/24, she went into the dining room to get vitals and happened to look over at R1. She saw R1 was choking/coughing and stated to staff in the room that R1 was choking. LN G stated she went over to R1 and asked her if she was okay and R1 shook her head. She stated she noticed R1's cup had red juice in it, but it was not thickened. She stated she asked the staff in the dining room who gave R1 the juice, but Dietary BB stated she did not know, and it was probably one of the CNAs. LN G stated she told Dietary BB that she believed R1 was supposed to have thickened liquids and Dietary BB stated the staff member probably did not know that. LN G stated staff took R1 out of the dining room to LN H, who assessed her. LN G stated LN H suctioned R1 and got red liquid out. She stated R1 went to the hospital and came back that day with a diagnosis of aspiration pneumonia. LN G stated dietary staff were supposed to pass the thickened liquids since they served the food, silverware, and everything else. LN G stated staff knew who was on thickened liquids by the list at the nurses' station and it was listed on their dietary cards as well. On 02/06/24 at 01:06 PM, Administrative Nurse D stated R1 was served regular liquids instead of thickened. She stated usually dietary did the thickened liquids including making and serving them. Administrative Nurse D stated staff knew who received thickened liquids by their diet cards and on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). She stated expected staff to look at the diet card or the Kardex before serving anything to a resident. On 02/06/24 at 1:16 PM, Administrative Staff A stated he expected dietary to provide thickened liquids. He stated because of the incident, the facility bought pre-thickened liquids for staff to have available at all times. He stated staff knew who received thickened liquids by their care plan, in Point of Care (POC- EMR system for CNAs), and the resident's dietary card. The facility's Thickening Fluids policy, dated 2011, directed the dining service staff were responsible for thickening and distributing all thickened liquids for meals, snacks, activities, medication pass, and resident rooms. The facility failed to provide R1 with physician-ordered thickened liquids on 01/07/24 when she received thin liquids and aspirated. The facility sent R1 to the ER for evaluation and treatment for aspiration and R1 returned with antibiotics for aspiration pneumonia. This deficient practice placed R1 in immediate jeopardy. The facility put the following corrections in place by 01/11/24: Dietary and Nursing staff were educated on diets and fluid consistencies on 01/08/24. R1 was evaluated by speech therapy with diet recommendations for puree with honey-thickened liquids on 01/09/24. CNA M received a written warning for failing to follow policy on 01/10/24. R1's diet order was changed to puree with honey-thickened liquids on 1/11/24. R1's Care Plan was updated on 01/11/24. All corrections were completed before the onsite survey therefore the deficient practice was cited as past noncompliance and remained at a scope and severity of J.

The facility identified a census of 42 residents. The sample included three residents with one reviewed for medications. Based on observations, record review, and interview, the facility failed to accurately transcribe and administer antibiotic (medications used to treat bacterial infections) orders for Resident (R) 1 upon her return from the emergency room (ER). This deficient practice placed R1 at risk for ineffective treatment for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) and unwarranted physical complications. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), personal history of transient ischemic attacks (TIA- temporary episode of inadequate blood supply to the brain), dysphagia, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R1 required set-up/clean-up assistance with eating and had coughing or choking during meals or when swallowing medications. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/23/24, documented R1 was dependent on staff for almost all of her activities of daily living (ADLs). She was able to feed herself once it was set up. The Nutritional Status CAA dated 01/23/24, documented R1 was on a pureed diet (mechanically altered therapeutic diet) with thickened liquids due to choking and aspiration pneumonia. R1's Care Plan, last revised on 12/11/23, documented she had a risk for choking due to pocketing food in her mouth and was sent to the ER for suspected aspiration on 12/11/23. The care plan directed staff to remind R1 to take small bites, chew, and swallow before putting more in her mouth. R1's Care Plan, dated 01/21/21, documented R1 was at risk of losing or gaining weight due to her disease process. The care plan documented an intervention, dated 01/21/21, that directed staff to provide R1 her meals as ordered by the physician. The care plan documented an intervention, dated 01/04/24, that directed R1 to have a regular diet with pureed texture and nectar-thick fluid consistency. The Orders tab of R1's EMR documented an order with a start date of 01/07/24 and discontinued date of 01/10/24 for azithromycin (antibiotic medication) 250 milligrams (mg) two tablets two times a day for aspiration pneumonia for five days, an order with a start date of 01/07/24 and discontinued date of 01/08/24 for amoxicillin (antibiotic medication) 875 mg one tablet every 12 hours for aspiration pneumonia, an order with a start date of 01/08/24 and discontinued date of 01/22/24 for amoxicillin 875 mg one tablet every 12 hours for aspiration pneumonia for 18 administrations; and an order with a start date of 01/10/24 and end date of 01/14/24, for azithromycin 250 mg one tablet one time a day for aspiration pneumonia for five days. A review of R1's Medication Administration Report for January 2024 revealed R1's amoxicillin 875 mg one tablet order, start date of 01/08/24 and discontinued date of 01/22/24, lacked documentation it was administered from 01/08/24 to the 01/21/24 morning administration; and the 01/21/24 evening administration and 01/22/24 morning administration had documentation of O which stood for Other See Nurse Notes. R1's azithromycin 250 mg one tablet order, start date of 01/10/24 and end date of 01/14/24, revealed the 01/11/24 to 01/14/24 administrations had documentation of O which stood for Other See Nurse Notes. The facility's investigative report, dated 01/10/24, documented on 01/07/24, R1 was eating breakfast in the main dining room and started to cough. A CNA brought R1 to LN H who noted R1's upper lung sounds evidenced fluid. LN H suctioned R1 and removed fluid but R1 continued coughing with less congestion. Staff called Emergency Medical Services (EMS) and they arrived quickly and took R1 to the hospital for evaluation and treatment. Upon further investigation, it was discovered that staff gave R1 regular juice when she was on nectar-thick liquids. R1 returned from the hospital at 12:30 PM via EMS with an order for antibiotics for possible aspiration pneumonia. The Notes tab of R1's EMR revealed the following: A Nurse's Note on 01/07/24 at 12:47 PM documented the nurse called the ER and the ER nurse stated R1 was resting. The ER nurse reported R1 received an injection of antibiotics and would return with an order for oral antibiotics. A Nurse's Note on 01/07/24 at 03:19 PM documented R1 returned from the ER at 12:30 PM via EMS. The CNA assisted R1 back to bed and R1 answered questions appropriately. R1 was hungry and wanted to eat a late lunch. R1's bilateral lungs had crackles (abnormal lung sounds that occur as a result of small airways suddenly snapping open and may indicate a person's lungs have fluid inside them or are not inflating correctly). R1 had a new order for Zithromax (azithromycin) for five days and Augmentin (antibiotic medication) for 10 days. A Default Progress Note (PN) Type for eMAR (electronic MAR) on 01/11/24 at 08:11 PM documented R1's azithromycin 250 mg one tablet medication was out of stock and on order. A Default PN Type for eMAR on 01/12/24 at 06:45 PM documented the facility waited on pharmacy for R1's azithromycin 250 mg one tablet medication. A Default PN Type for eMAR on 01/13/24 at 07:38 PM documented R1's azithromycin 250 mg one tablet medication was on order. A Default PN Type for eMAR on 01/21/24 at 09:01 PM documented the facility did not have R1's amoxicillin 875 mg. A Default PN Type for eMAR on 01/22/24 at 11:00 AM documented R1's amoxicillin 875 mg medication was on order. Upon request, the facility provided R1's hospital documentation from 01/07/24. The ED Provider Notes, dated 01/07/24, documented a clinical impression for R1 as aspiration pneumonia of both lungs and R1 received new medications of Augmentin (amoxicillin/clavulanate) 875 milligrams (mg)/125 mg every 12 hours for 10 days for lower respiratory infection and Zithromax 500 mg daily for five days for lower respiratory infection. On 02/06/24 at 12:02 PM, R1 sat in her wheelchair at the assisted table in the dining room. She ate a pureed diet with honey thick liquids. Staff assisted residents at the table. On 02/06/24 at 2:28 PM, LN G stated when a resident returned from the ER with paperwork, she went through the paperwork and if they had orders, she put them on the MAR. She stated when she reviewed ER orders, she noted and faxed the orders then put the paperwork in the new orders slot in the printer room. LN G stated it was not okay for a resident to go any days without starting a medication and she pulled medications from the emergency kit (Ekit) for antibiotics. She stated if a medication was not delivered then she called the pharmacy and if she was unable to get the medication then she notified the provider for a possible order change. On 02/06/24 at 02:37 PM, Administrative Nurse D stated when a resident returned from the ER, the floor nurse put the orders in and signed the paperwork as noted then placed it in Administrative Nurse E's box for her to check the orders. Administrative Nurse D stated if the medication was not delivered, the nurse called the pharmacy and could use the Ekit if the medication was really important. Administrative Nurse D confirmed R1's ER orders from 01/07/24 were not transcribed correctly and stated R1 was very congested when she returned. On 02/06/24 at 02:44 PM, Administrative Nurse E stated when a resident returned from the ER, one nurse put the orders in and a second nurse checked them. She stated if a floor nurse put the orders in, she had gone back in to check them. Administrative Nurse E stated the administrative nurses usually put the orders in and another nurse checked them. The facility did not provide a policy on following physician's orders. The facility failed to accurately transcribe and administer R1's antibiotic orders for aspiration pneumonia upon her return from theER on [DATE]. This deficient practice placed R1 at risk for ineffective treatment for aspiration pneumonia and unwarranted physical complications.

The facility identified a census of 46 residents with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on record review, observation, and interview, the facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent Resident (R) 1, who was severely cognitively impaired and a high risk for elopement, from exiting the facility through the window. On 12/20/23 at 08:00 PM, Certified Nurse Aide (CNA) M assisted R1 to bed and then began the constant surveillance of R1's room from the nurse's station due to R1's high elopement risk and his multiple attempts to elope. At 09:10 PM CNA N observed R1 outside the front door, knocking over the patio furniture. The temperature outside was approximately 39 degrees Fahrenheit (F). Staff assisted R1 back into the facility and noted he had no injuries but was cool to touch. Staff returned R1 to his room and noted that R1's window was open and lacked a screen. The facility failed to identify and secure likely avenues of exit for R1, who was at high risk for elopement and falls. As a result of this failure, R1 eloped from the facility via his bedroom window. The deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, difficulty walking, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R1 had physical and verbal behaviors directed toward others for one to three days during the observation period. The MDS documented R1's behaviors put R1 at significant risk for physical illness or injury, significantly interfered with R1's care, and significantly interfered with R1's participation in activities or social interactions. The MDS documented R1's behaviors put others at significant risk for physical injury, significantly intruded on the privacy and activities of others, and significantly disrupted the living environment. The MDS documented R1 wandered for one to three days during the look back period and R1's wandering placed him at significant risk of getting to potentially dangerous places and intruded on the privacy of others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/15/23, documented R1 was unable to recall orientation questions or repeat words immediately or after five minutes. R1 had problems with wandering, physical, and verbal behaviors, and rejection of care. The CAA recorded a care plan would be initiated to provide orientation to R1 when able, assist him with cares, and remind him not to have aggressive or verbal behaviors. The Behavioral Symptoms CAA, dated 12/15/23, documented R1 wandered most of the day and when staff attempted to engage him in cares, he often rejected their cares. R1's Care Plan, dated 12/05/23, documented R1 as a high risk for elopement. The care plan directed staff to understand if R1 started packing his belongings it was a sign he was thinking about leaving. R1's Care Plan directed staff to report to the nurse increased wandering or pacing and try to determine triggers for R1's exit-seeking behaviors. The care plan directed staff to know where R1 was at all times and if R1 was in his room, staff were to sit near the nurse's station, watch the hallway, and be able to see if R1 exited his room. The Admission Progress Note, dated 12/04/23, documented R1 was only oriented to family. R1 wanted to leave the building, was exit-seeking, and would go to the door but not open it. The Nurse's Note, dated 12/07/23, documented R1 saw the hairdresser walking out the front door and followed behind her. As R1 was walking out the front door, staff from the business office saw him and followed behind R1. R1 was not outside alone. The business office staff held the front door open so the alarm would go off and staff responded and were able to get R1 back into the facility. The Nurse's Note, dated 12/09/23, documented R1 was up all day walking the halls. R1 tried to get out of the building and walked up to each door trying to push the doors open. The Nurse's Note, dated 12/14/23, documented R1 was restless all evening and was up until 01:30 AM. All evening, R1 was at the doors wanting to leave. R1 continuously walked into other residents' rooms. The Behavior Note, dated 12/20/23, documented CNA N found R1 at the front door. The back nurse's station was occupied the entire time, and no one saw R1 walking around after he was laid down. The door alarm never sounded. CNA M took R1 to his room and discovered the window was open with no screen. It was unclear if R1 took off the screen. R1 also turned all of the patio furniture upside down. R1 had stickers (burweed) in his socks and his skin was cool to the touch. The Elopement Risk Assessment, dated 12/21/23, documented R1 had dementia, exhibited wandering and exit-seeking behavior, was cognitively impaired, and had impaired safety awareness. The assessment documented R1 was able to open doors, able to activate the keypad, and was able to exit doors independently. R1's elopement risk score was 31, a high risk for elopement. The Fall Risk Assessment, dated 12/21/23, documented R1 had multiple falls over the last six months. R1 exhibited a loss of balance while standing and strayed off of a straight path when walking. R1's fall assessment score was 21, high risk for falls. The Facility Incident Report, dated 12/22/23, documented CNA M helped R1 to bed at approximately 08:00 PM. CNA M then went back to the nurse's station where he could monitor R1's room door. At approximately 08:30 PM CNA M went to the front of the facility to help the front hall staff. Licensed Nurse (LN) G remained at the nurse's station to monitor R1's door. At approximately 09:10 PM staff witnessed R1 outside on the front porch knocking the patio furniture over. Staff escorted R1 back into the facility and notified the charge nurse. Staff completed a full assessment with no injury or adverse effect found. The temperature at the time of the event was 39 degrees F. CNA N's Witness Statement, dated 12/21/23, documented CNA N saw R1 around 06:30 PM walking the halls with staff. CNA N documented she sat down to chart at 09:15 PM and happened to look at the front door and saw a man standing at the front door. CNA N documented she went to investigate, and saw it was R1. CNA N documented she called for other staff and got R1 back into the building. CNA M's Witness Statement, dated 12/22/23, documented CNA M put R1 to bed at 08:30 PM. CNA M documented he stayed at the nurse's station until about 09:00 PM and R1 had not left his room. CNA M documented he (CNA M) went to the front to help, and at 09:10 PM to 09:15 PM staff found R1 outside in front of the building. CNA M documented nobody saw R1 leave his room and when staff went to R1's room, R1's window was open, so staff suspected R1 climbed out of his window. On 01/10/24 at 11:00 AM, observations revealed R1 sat in a chair at the nurse's station with a tray table in front of him, eating. R1 wore a short-sleeved button-down shirt, and jeans, and had bare feet. On 01/10/24 at 10:45 AM, Licensed Nurse (LN) G stated R1 had not been doing much wandering lately because he was sick and not feeling well. LN G stated when R1 felt good, he was up wandering in the halls, into other residents' rooms, and exit seeking. On 01/10/24 at 11:30 AM, Administrative Staff A stated R1 was placed on elopement risk precautions immediately upon admission to the facility on [DATE]. Administrative Staff A stated the Elopement Risk Assessment was not completed on admission day. Administrative Staff A stated all residents who were at risk for elopement had their windows now fixed with shims to only allow the windows to open three to four inches. Administrative Staff A stated a facility-wide door check was completed to ensure all alarmed doors were in proper working order on 12/21/23. Administrative Staff A stated all staff were educated on the elopement policy and R1's elopement incident before working their next shift. Administrative Staff A stated all residents' elopement assessments and care plans were reviewed for accuracy and appropriateness on 12/21/23. Administrative Staff A stated the elopement book was reviewed to ensure accuracy on 12/21/23, and an unscheduled Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the incident. Administrative Staff A stated R1 was in a referral process for a locked unit. Administrative Staff A verified the facility failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. The facility's Resident Elopement Policy and Procedure, reviewed in December 2022, documented the facility strives to promote a safe and secure environment to help minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. Risk for elopement is to be identified for residents and an individualized care plan developed based on risk. Staff are to investigate and report instances of potential elopement. The facility is to have a process to monitor the security of the premises on a routine basis. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. As a result of this failure, R1 eloped from the facility via his bedroom window. The deficient practice placed R1 in immediate jeopardy. On 12/21/23 the facility identified and completed the following corrective actions: All residents at risk for elopement had their windows fixed with shims to only allow the windows to open three to four inches. The facility completed a facility-wide door check to ensure all alarmed doors were in proper working order. All staff received education on the elopement policy and R1's elopement incident before working their next shift. All residents' Elopement Assessments and care plans were reviewed for accuracy and appropriateness. The elopement book was reviewed to ensure accuracy, and an unscheduled QAPI meeting was held to discuss the incident. All actions were completed before the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a J scope and severity.

The facility identified a census of 44 residents. Based on observations, record review, and interviews, the facility failed to ensure oxygen tubing was stored properly, failed to ensure adequate hand hygiene, failed to prevent cross-contamination with sit-to-stand (mechanical lift that helps patient rise from a seated to a standing position) lift usage, failed to prevent cross-contamination with glucometer (device used to obtain a blood sugar level), and failed to ensure proper usage of personal protective equipment (PPE- gowns, face shields and/or eye glasses/goggles, and gloves). This deficient practice had the risk to spread illness and infection to all residents. Findings included: - On 08/30/23 at 09:52 AM, Resident (R) 1's oxygen tubing was coiled up and laid on her concentrator, not stored in a bag. On 08/30/23 at 09:58 AM, Certified Nurse Aide (CNA) M wore gloves and transported a red biohazard bag to the soiled utility room. She exited the soiled utility room within seconds, no longer wearing gloves. CNA M pushed a sit-to-stand lift into the clean storage room, exited within seconds, then proceeded down the hallway. Hand hygiene was not performed during this observation. On 08/30/23 at 10:02 AM, Certified Medication Aide (CMA) R prepared medications at the medication cart then entered R2's room and administered her medications using a spoon. She exited R2's room, went back to the medication cart, and pushed it down the hallway. Hand hygiene was not performed after administering R2's medications. On 08/30/23 at 10:06 AM, R3 was in droplet precautions (safeguards designed to reduce the risk of droplet transmission of infectious agents, spread primarily through coughing, sneezing and talking) for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) CNA M wore a KN-95 (higher level respirator mask) mask, donned (put on) gloves then an isolation gown. She entered R3's room without donning eye protection as required with droplet precautions. On 08/30/23 at 11:14 AM, CNA M and CNA N entered R5's room with the sit-to-stand lift. On 08/30/23 at 11:19 AM, CNA N exited R5's room with the sit-to-stand lift and a soiled trash bag, she pushed the sit-to-stand lift into the clean utility room without disinfecting the lift after usage. On 08/30/23 at 11:31 AM, Licensed Nurse (LN) G entered R6's room with a tray that contained a glucometer and glucometer supplies (lancets, alcohol pads, and glucometer strips). He donned gloves then cleansed the glucometer strip port on the glucometer but did not clean the entire device. LN G obtained R6's blood sugar then cleansed the glucometer strip port after use without disinfecting the entire device. He placed the glucometer back in the tray on top of the glucometer supplies, doffed (removed) gloves, and placed the tray on top of the nurses' cart. He did not perform hand hygiene after doffing gloves and before proceeding down the hallway with the glucometer tray to R7's room. On 08/30/23 at 11:35 AM, LN G entered R7's room with glucometer tray and donned gloves. He cleansed the glucometer strip port only then placed the glucometer on the bedside table without a barrier. He obtained R7's blood sugar then placed the glucometer in the tray on top of the supplies and doffed gloves without performing hand hygiene afterward. LN G exited R7's room with glucometer tray, placed on top of the nurses' cart, then into the top drawer. He did not disinfect the glucometer device after use. On 08/30/23 at 12:22 PM, R4 was on droplet precautions for COVID-19. CMA R wore a KN-95, donned an isolation gown and gloves then entered R4's room to administer medications. She did not wear eye protection into R4's room as required with droplet precautions. On 08/30/23 at 12:28 PM, CNA O wore a KN-95 mask, donned an isolation gown, placed a surgical mask over her KN-95 and entered R4's room with his lunch. She did not wear eye protection into R4's room as required with droplet precautions. On 08/30/23 at 01:06 PM, R1's oxygen tubing was coiled up and laid on top of her oxygen concentrator, not stored in a bag. On 08/30/23 at 11:38 AM, LN G stated he was told when disinfecting the glucometer device before and after use, there was a four-minute wet time required for disinfection, but he was curious what the required wet time was now. On 08/30/23 at 01:40 PM, CNA N stated hand hygiene was performed when entering and upon exiting rooms and after doffing gloves. She stated cross-contamination was prevented by disinfecting the mechanical lifts after use and the sanitizing wipes were kept in the clean utility room. CNA N stated she knew if a resident was on isolation by the computer charting and there was a sign on the door that said to ask the nurse before entering the room. She stated she talked to the nurse to find out what type of isolation the resident was on and what PPE was required. CNA N stated the PPE required for COVID-19 was isolation gown, mask, face shield, and gloves. The proper sequence for donning PPE for COVID-19 isolation was gown, gloves, face shield, and mask. She stated oxygen tubing was stored properly in a bag. On 08/30/23 at 01:46 PM, LN H stated hand hygiene was performed before entering and after exiting resident rooms and after doffing gloves. She stated cross-contamination was prevented by wiping the mechanical lifts with sanitizing wipes between each person. LN H stated cross-contamination was prevented with glucometer usage by cleansing the entire device before and after use and a barrier was used during the procedure. She stated she knew what residents were on isolation because staff discussed what residents were on isolation and a sign was on their door that stated to stop and see the nurse. LN H stated the PPE required for COVID-19 precautions was a gown, N-95 mask, gloves, and depending on how bad the infection was, a face shield. She stated the proper sequence for donning PPE was gloves, isolation gown, surgical mask over the N-95 she already wore, and face shield before going into the room. LN H stated oxygen tubing was stored in a bag when not in use. On 08/30/23 at 01:56 PM, Administrative Nurse D stated hand hygiene was performed anytime going into and coming out of a resident's room and before and after using gloves. She stated cross-contamination was prevented with mechanical lift usage by cleaning in between each use. Glucometers were cleansed before and after each use and when obtaining a blood sugar, the glucometer was cleaned before placed back in the glucometer tray. She stated she placed the glucometer in the tray during the procedure and she did not place it on the bedside table. Administrative Nurse D stated a resident's isolation status was located in their electronic medical record (EMR), there was a sign on their door, and an isolation cart outside their room. She stated the resident's main page listed what isolation they were on and what PPE staff were to wear. Administrative Nurse D stated the PPE required for COVID-19 precautions included isolation gown, gloves, N-95, and eye protection and the sequence for donning PPE was N95, gloves, gown, and eye protection. She stated oxygen tubing was stored in a bag when not in use. The facility's Infection Management Process policy, last revised October 2022, directed employees had available proper PPE to use during work time which included gloves, gowns, masks, and eye shields and employees were educated with orientation and at least yearly on proper hand hygiene to include hand washing and hand hygiene. The policy directed the Center for Disease Control (CDC) guidelines were the resource for the implementation of appropriate isolation procedures. Glucometers were properly sanitized between each use and staff were educated on appropriate drying time before using. The facility's Checklist for Controlling COVID-19 in Long-Term Care Facility policy, last revised 05/15/23, directed gloves, gowns, face masks, and eye protection were used when providing care to residents in droplet precautions. The facility failed to ensure oxygen tubing was stored properly, failed to ensure adequate hand hygiene, failed to prevent cross-contamination with sit-to-stand lift usage, failed to prevent cross-contamination with glucometer, and failed to ensure proper usage of PPE. This deficient practice had the risk to spread illness and infection to all residents.

The facility identified a census of 44 residents with three reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 to promote and maintain R1's highest level of health and wellbeing. R1 admitted to the facility on [DATE] with an order for losartan (medications used to lower blood pressure) 100 milligrams (mg) daily for hypertension (high blood pressure). The facility failed to administer the losartan for 12 days, until 04/29/23, when R1's representative noted the omission. On that same day, R1 had a high blood pressure of 244/110 millimeters of mercury (mmHg) (normal blood pressure range 120/80 mmHg) and fell . R1 went to the emergency room (ER) where it was determined he had a fractured right foot. R1 was placed in a controlled ankle movement (CAM) boot with orders for reduced mobility and non-weight bearing status. R1 returned to the facility and experienced ten falls between 04/29/23 and 05/20/23. Additionally, on 05/03/23, R1's physician evaluated and ordered a chopped meat diet and swallowing evaluation for R1. The facility failed to relay the swallowing evaluation order to Speech Therapy, therefore the evaluation was not completed. On 05/27/23, while eating ground ham and scalloped potatoes, R1 choked. Staff contacted 911 and attempted to perform the Heimlich maneuver, which did produce food items expelled from R1's airway. EMS arrived at the facility and attempted to suction the potatoes from R1's airway but were unsuccessful. R1 had respiratory arrest and was pronounced dead in the facility. The facility's cumulative neglect in providing the necessary care for R1 placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 was admitted to the facility on [DATE] with diagnoses of hypertension, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated R1 had moderate cognitive impairment. The MDS documented R1 required supervision with set-up help only for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. R1 was independent with walking in his room, locomotion on the unit, and eating. The MDS documented R1 did not have any falls in the six months prior to his admission to the facility. The Significant Change MDS, dated [DATE], documented R1 had a BIMS score of seven, which indicated R1 had severe cognitive impairment. The MDS documented R1 required extensive assistance of one to two staff for bed mobility, transfer, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. The MDS documented R1 had two or more falls with no injury, two or more falls with minor injury, and two or more falls with major injury. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/16/23 documented R1 had a BIMS of seven and had short term memory loss and wandered in his wheelchair at night looking for something or someone. The Activity of Daily Living [ADL]/Rehabilitation Potential CAA, dated 05/16/23, documented R1 required assistance with all his ADL due to weakness and a fractured foot. R1's Care Plan would be reviewed for staff to assist R1 as needed and to have R1 participate in self-care as much as possible. The Fall CAA, dated 05/16/23, documented R1 had an unsteady gait (manner or style of walking) and fell frequently. R1's family requested for him to have physical and occupational therapy and R1 was started on therapies. R1 had major injuries from falls of a fractured right foot and laceration to his head. The care plan would be reviewed for R1 to start therapy for strengthening and staff to toilet and check on R1 more often. The Activity of Daily Living Care Plan, dated 04/28/23, directed staff R1 required one staff assistance with dressing and grooming needs. It instructed staff to ensure R1's call light was in reach, and R1 wore glasses and to make sure the glasses were clean and on R1. The Fall Care Plan, dated 04/21/23, directed staff to offer to assist R1 to the bathroom during each of their rounds, place a fall mat by the bed when R1 slept, and encourage R1 to change positions slowly. It directed staff to round on R1 every two hours during the night and offer R1 assistance to the bathroom if R1 was awake; assist R1 to the bathroom at 02:00 AM every night shift due to frequent falls while trying to get to the bathroom. It directed staff to assist R1 to the bathroom at least every two hours while awake and every four hours while sleeping; give R1 reminders to call for help before getting up, ensure a high-low bed was used appropriately before leaving R1's room, keep commonly used items close to R1's reach, and ensure R1 wore appropriate shoes and non-skin footwear. The care plan directed staff to ensure R1's call light was within reach and encourage R1 to use the call light to ask for assistance and ensure the pathway in R1's room remained clean and unobstructed. The Hospice Care Plan, dated 04/21/23, directed staff to administer medications as ordered. The Code Status Care Plan, dated 04/17/23, documented R1 was a Do Not Resuscitate (DNR). If R1's heart stopped beating and/or R1's respiration ceased, do not perform life sustaining measures. The Nutrition Care Plan, dated 04/18/23, documented R1 was on a regular diet, regular texture, regular fluid consistency, staff to assist R1 as needed during meals, and staff to weigh R1 weekly. The facility lacked a care plan which addressed R1's hypertension. The facility Electronic Medication Administration Record (EMAR), dated April 2023, documented the high blood pressure medication, losartan 100 mg by mouth daily, was not administered to R1 from 04/18/23 thru 04/29/23. The facility EMR lacked any blood pressure readings for R1 from 04/18/23 thru 04/29/23. The Admission Orders, dated 04/17/23, documented R1's Primary Care Physician (PCP) ordered R1's admission to the facility, code status DNR, activity as tolerated, diet regular, and medications per list. The admission orders included staff to administer to R1 losartan, 100 mg by mouth daily. R1's PCP ordered for the facility to notify the physician of any blood pressures greater than 160/90 mmHg or less than 100/50 mmHg and to call for pulses greater than 120 beats per minute (bpm) or less than 50 bpm. The orders were noted by Licensed Nurse (LN) G on 04/14/23 at 01:45 PM. The Incident Note, dated 04/29/23 at 07:15 AM, revealed a Certified Nurse Aid (CNA) informed LN H that R1 was on the floor, she found R1 crawling on all fours from the bathroom, and there was urine on the floor. LN H went to R1's room and saw R1 seated on his bed with his pants around his knees. LN H obtained R1's vital signs and noted R1 had a red bruise with a bump on the right side of his head above his ear and a red bruised on the inner side of his right foot below R1's big toe. R1's seated blood pressure was 117/61 mmHg and R1's standing blood pressure was 122/66 mmHg. R1 stated he was going to the restroom and fell and denied pain. LN H assisted R1 to stand and noted R1 rubbed his right knee and seemed weak. LN H instructed the CNA to use the wheelchair when transferring R1. LN H began neurological assessments on R1. R1's representative came to visit R1, and LN H informed her of R1's fall. LN H reported R1's fall to hospice and the on-call nurse practitioner. The on-call nurse practitioner ordered LN H to let her know if R1's condition and instructed to continue neurological checks. The Incident Note, dated 04/29/23 at 03:00 PM, documented the CNA informed the LN H R1 fell . LN H went to R1's room and R1 was on the floor in front of his recliner leaning to the left side. R1 stated tried to go to the bathroom. LN H observed R1 had a bump on the left side of his forehead and some bruising to his left arm. LN H obtained R1's vital signs and had the CNA assist R1 up to his wheelchair. The CNA wheeled R1 to the nurse's station so LN H could keep an eye on him and perform neurological assessments. LN H called hospice, the on-call provider and R1's representative. R1's blood pressure was 214/110 mmHg. The on-call nurse practitioner ordered LN H to give R1 2.5 mg of amlodipine (medication used to lower blood pressure) and if R1's blood pressure did not go down in four hours, R1 should go to the ER. LN H gave R1 amlodipine 2.5 mg at 04:00 PM. LN H noted R1's blood pressure continued to rise, and at 05:50 PM, LN H called the on-call nurse practitioner and received orders to transfer R1 to the ER. LN H called R1's representative and she stated she would transport R1 to the ER. LN H called the ER nurse at 06:03 PM to give report on R1. At 06:30 PM, R1's representative arrived at the facility to transport R1 to the ER. The Incident Note, dated 04/30/23 at 12:07 AM, documented the CNAs on shift found R1 on the floor. The charge nurse went to R1's room and found R1 seated on the floor next to his bed. R1 stated he had rolled out of bed. The charge nurse noted R1 was incontinent of urine, had no visible signs of injuries, and had normal range of motion. Staff assisted R1 to his feet, cleaned and dressed him, applied non-skid socks, and assisted R1 back to bed. The charge nurse started neurological checks and R1's blood pressure was 117/61 mmHg. The Order Note, dated 04/30/23 at 03:15 AM, documented staff notified R1's hospice provider of the orders to start amlodipine 7.5 mg by mouth daily, and to notify R1's PCP if blood pressures were greater than 145/90 mmHg or less than 100/60 mmHg. The Nurse's Note, dated 04/30/23 at 10:12 AM, documented R1's pharmacy did not open until 10:00 AM and the facility needed amlodipine 7.5 mg, ordered the previous day. Staff called R1's pharmacy at 10:02 AM. R1's representative came to the nurse's station and stated the Certified Medication Aide (CMA) informed her R1 had not received his losartan for two weeks. The LN explained to R1's representative she was on the phone with R1's pharmacy to give the order for amlodipine and then the LN would investigate the other medication. The charge nurse gave the verbal order for amlodipine to the pharmacy and then confirmed losartan had been ordered upon R1's admission to the facility but it was not entered or administered. The charge nurse told R1's representative the losartan was reinstated. The Nurse's Note, dated 04/30/23 at 11:29 AM, documented the charge nurse spoke to the on-call nurse practitioner, who stated since the losartan was not administered for two weeks, to discontinue the amlodipine, and continue to monitor R1's blood pressure. The Nurse's Note, dated 04/30/23 at 01:52 PM, documented R1 continued fall follow up and had some swelling to his right ankle and a bruise above his left eye. R1 complained of pain and staff administered an as needed pain medication, which was effective. R1's blood pressure was 132/78 mmHg. The Nurse's Note, dated 05/01/23 at 01:19 AM, documented R1 continued fall follow up due to several falls on 04/29/23 and 04/30/23. R1 continued to have a bruised, small bump to the right side of his head and bruising noted around R1's left eye. R1's range of motion was normal and R1 denied any pain. Neurological checks were normal and R1's blood pressure was 136/77 mmHg. The Nurse's Note, dated 05/01/23 at 05:32 AM, documented R1's right foot in the metatarsal (bones in the foot) region was swollen and R1 complained of pain when he walked on the right foot. Staff contacted R1's hospice provider for an x-ray of R1's right foot and received orders for an x-ray of R1's ankle and foot. The RISK Progress Note, dated 05/01/23 at 10:33 AM, documented on 04/29/23, staff found R1 on the floor in his room. R1 told staff he tried to get to the bathroom. Upon assessment, the nurse found a bump on the right side of R1's head and a bruise on his right foot. The following day, staff noted swelling to R1's right foot and obtained an order for an x-ray. The RISK Progress Note, dated 05/01/23 at 10:39 AM, documented on 04/29/23 at approximately 03:00 PM R1 fell a second time that day. The nurse who assessed R1 noted a new bump on his head and bruising to his left arm. R1's blood pressure was in the 200's/100's mmHg, staff notified the on-call doctor and received an order to administer amlodipine and send R1 to the ER if his blood pressure did not come down with that medication. R1's family transported R1 to the ER approximately an hour later due to high blood pressure. The RISK Progress Note, dated 05/01/23 at 10:45 AM, documented on 04/30/23 at around 12:07 AM, staff found R1 on the floor for the third time in twenty-four hours. Upon assessment, the nurse on duty found no injuries, completed neurological checks, per protocol, and noted R1 was incontinent of urine. The Nurse's Note, dated 05/01/23 at 03:00 PM, documented the CNA alerted the nurse to R1's room. R1 had slid out of his recliner and did not hit his head. R1's blood pressure was 136/72 mmHg. The nurse performed a physical assessment and noted R1 did not have any injuries. Staff notified R1's representative and physician. The Nurse's Note, dated 05/01/23 at 05:36 PM, documented R1's x-ray results of his right foot and revealed R1 had sustained two fractures in his right foot. The results were faxed to R1's PCP and staff notified R1's representative of the results. The X-ray Results, dated 05/01/23, documented a non-displaced fracture of the right foot fifth metatarsal and an avulsion (when a bone fragment is p0ulled away from its main body by soft tissue that is attached to it) of the calcaneus inferior aspect (inner heel bone). The Nurse's Note, dated 05/01/23, at 06:47 PM documented R1's representative went to the facility to get R1 to take him to the ER for a Computed Tomography (CT-a radiological test showing detailed images of any part of the body). The Nurse's Note, dated 05/01/23 at 11:50 PM, documented R1 arrived back from the hospital accompanied by his representatives at 09:50 PM. A report from the local hospital documented the CT results showed findings of old infarcts (localized area of tissue death due to lack of blood supply). R1's blood pressure was high during his visit and the ER administered clonidine (blood pressure medication) and Tylenol (pain medication) and applied an orthopedic shoe to R1's right foot. The Nurse's Note, dated 05/02/23 at 06:02 PM, documented fall tracking continued for R1 status post two fractures to R1's right foot. R1 wore an orthopedic shoe and was non-weight bearing until R1 has an orthopedic appointment ordered by his PCP. The Fall Note, dated 05/03/23 at 01:46 AM, documented staff found R1 on the floor beside his bed. The charge nurse noted R1 laid on his left side with his head toward the foot of the bed. R1 did not appear to be in pain, responded to verbal commands, and the nurse noted feces on the floor and in R1's brief. Neurological checks were initiated due to being an unwitnessed fall. The Nurse's Note, dated 05/03/23 at 02:22 AM, documented the CNA notified the charge nurse R1 was almost out of bed again at this time. The CNA informed the charge nurse R1's legs were falling out of the bed and his arm hung out of bed. The charge nurse told the CNA to increase rounds and frequently monitor R1 to prevent further falls. The Skin Condition Note, dated 05/03/23 at 04:54 AM, documented a 5 centimeter (cm) by 6 cm bruise to the back of R1's head with a raised bump and a 3 cm by 4 cm scab to the right side of R1's head. The Nurse's Note, dated 05/03/23 at 09:09 AM, documented the facility called R1's PCP's nurse about R1's blood pressure being 178/84 mmHg. The nurse stated R1 had an appointment with the doctor that morning at 10:00 AM and they would address R1's high blood pressure then. R1's representatives were with R1 and would attend the appointment with him. The Doctor's Orders, dated 05/03/23, documented R1's blood pressure at his appointment was 178/84 mmHg. The doctor noted he saw R1 for fall follow up, right foot fracture, and high blood pressure. R1's PCP ordered physical therapy and occupational therapy to evaluate R1 due to weakness, gait, and coordination. R1's PCP ordered a diet change which directed chopped up meats, no bread with meats i.e., sandwich. The orders directed for a swallow evaluation with a speech therapist, change potassium to powdered packet instead of tablet, amlodipine 2.5 mg by mouth twice a day as needed for blood pressure greater than 150/80 mmHg, a mattress by his bed due to falls, and a foot boot on in morning and off at bedtime. The orders were noted by Administrative Nurse D on 05/03/23. The RISK Progress Noted, dated 05/03/23, documented staff found R1 on the floor next to his bed around midnight. The nurse did an assessment and did not find any signs of any new injuries. R1 had two fractures to his right foot prior to this fall. The note included the facility would reach out to hospice about obtaining a high/low bed and start using a mat on the floor next to R1's bed. The Nurse's Note, dated 05/04/23 at 05:03 PM, documented the CNA called the charge nurse to R1's room and the nurse found R1 on the floor next to the matt on floor in front of R1's room door. The door was closed and R1 stated he tried to go to the bathroom. The staff placed R1's ortho boot on his right foot and three staff assisted R1 to a wheelchair and then placed R1 on the toilet. The staff noted R1's pull-up was wet. R1 denied pain. R1's blood pressure was 151/90 mmHg. The Risk Progress Note, dated 05/04/23 at 05:55 PM, documented R1 was found on the mat on the floor of his room. The nurse did not note any new injuries. R1 had two fractures in his right foot from a prior fall. R1 was incontinent of urine before he was found. Staff would continue to remind R1 to use his call light and make sure it was within reach before leaving the room. The Nurses Note, dated 05/07/23 at 07:20 PM, documented R1 fell at 06:40 PM. Another resident alerted staff R1 was on the floor. The charge nurse went to R1's room and found R1 on his back between the recliner and the wall, and his head against the bedside table. R1's cookies and water were spilled all over the floor. R1 wore his ortho boot and one shoe at the time of the fall. R1's call light was not on, R1 could not verbalize what happened, and R1 complained his head hurt. The nurse noted a small laceration to the back of R1's head and no other injuries noted at the time. The staff notified R1's representative of the laceration and she stated if the doctor wanted R1 to go to the ER she preferred to transport R1. Staff notified R1's PCP and received verbal order to send R1 to the ER for evaluation. R1's representative arrived to the facility at 07:15 PM to transport R1 to the ER. The Nurse's Note, dated 05/08/23 at 03:16 AM, documented R1 arrived back to the facility at 08:15 PM with his representatives and the following orders: return to the nursing home, continue all previous orders as directed, follow-up with PCP as needed, clean wound per facility protocol until healed. The Nurse's Note, dated 05/08/23 at 08:15 AM, documented R1 was up all night. R1 was up in his wheelchair that morning and was fidgeting, restless, and refused to eat breakfast or drink fluids. The Nurse's Note, dated 05/08/23 at 10:29 AM, documented the charge nurse placed a call to R1's PCP to inform her R1 had increase confusion, anxiety, and decreased appetite. The Nurse's Note, dated 05/08/23 at 11:59 AM, documented R1's PCP ordered a urinalysis, mirtazapine (antidepressant used to stimulate appetite) 15 mg, discontinue as needed Buspar (medication used to treat anxiety) and start Buspar 5 mg twice a day scheduled. The Nurse's Note, dated 05/09/23, documented R1 continued to have multiple bruises to the left side of his body and forehead from previous falls. The Speech Therapy Evaluation and Plan of Treatment, dated 05/09/23, documented R1 was referred to speech therapy due to exacerbation of cognitive impairment and decreased ability to respond to cues/instruction placing R1 at risk for decreased ability to return to prior level of supervision, falls, and further decline in function. R1's goals for therapy were: R1 would follow 1-step verbal commands with 80% accuracy and occasional visual cues in order to enhance R1's ability to decrease falls; R1 would recall daily events using visual aids as needed with 80% accuracy of opportunities and occasional visual cues in order to promote independence and safely participate with activities of choice; R1 would recall novel information with 60% accuracy when given minimal cues in order to increase participation in daily activities; and R1 would participate in conversational exchanges with minimal cues in order to increase quality of living. Certification period for R1 to participate in speech therapy was 05/09/23 through 08/06/23. The Speech Therapy Evaluation and Plan of Treatment lacked evidence of a completed swallow conducted. The RISK Progress Note, dated 05/15/23, documented R1 was found on the floor at approximately 03:30 AM. On assessment the nurse found small abrasion to right elbow. As of 10:00 AM this morning neurological checks were within normal limits. Care plan was updated to include more frequent rounding on R1 during the night. The Fall Note, dated 05/16/23 at 03:10 AM, documented the CNA notified the charge nurse R1 fell . The charge nurse found R1 on his right side with his knees pulled up to his chest in the doorway of his restroom in his bedroom. R1 did not appear to be in pain and denied pain. Nursing staff to toilet R1 at 02:00 AM to 03:00 AM related to previous falls at similar time. R1 placed on fifteen-minute checks to observe for R1's location. The Fall Note, dated 05/20/23 at 07:07 AM, documented the CNA came to get the charge nurse at the nurse's station and reported R1 fell . Upon entry into R1's room, R1 laid on the fall mat next to his bed. R1's head rested against the wall and there was a dent in the wall directly above where R1's head was resting. R1 could not verbalize what happened. The Skin Condition Note, dated 05/21/23 at 04:58 AM, noted R1 had a bruise to his right shoulder measuring 5 cm by 6 cm. R1 had pain upon palpation. The Nurse's Note, dated 05/22/23 at 12:43 PM, documented R1 had an orthopedic appointment for his right foot fractures. New orders to continue to use wheelchair for long distances, weight bearing with transfers only with assistive device and staff, continue surgical shoe to right foot. A Nurse's Note, dated 05/27/23 at 01:07 PM, documented the charge nurse was called to the main dining room to help assist R1 as he was choking on scalloped potatoes. The CMA administered the Heimlich maneuver to R1 with assistance from the CNA. The charge nurse started performing the Heimlich maneuver while another nurse called 911 and obtained R1's code status. The note included some food came out of R1's mouth while staff did the maneuver. Staff laid R1 on the floor and R1 took a couple of breaths. Staff applied oxygen and noted food was still coming out of R1's mouth, and then R1 stopped breathing again. R1 was a DNR. The paramedics arrived and hooked R1 up to the heart monitor. The paramedics stopped what they were doing and pronounced R1 dead at 01:04 PM. A Nurse's Note, dated 05/27/23 at 05:02 PM, documented the nurse was called into the main dining room to help assist choking resident R1, around 12:40 PM. A CMA performed the Heimlich maneuver with assistance from a CNA. The nurse started to perform the Heimlich maneuver while the other nurse obtained R1's code status and called 911. More food came up and staff laid R1 down and R1 took a couple of respirations, and the nurse felt a pulse. Staff applied oxygen to R1 and food was still coming out of R1's mouth when R1 stopped breathing again. R1 had no pulse at that time. R1 was a DNR. Paramedics arrived and hooked R1 up to a heart monitor. One paramedic looked at the DNR paperwork and the other two paramedics suctioned R1 and were getting food out of R1's throat. The paramedic accepted the DNR paperwork and unhooked the heart monitor from R1 and pronounced R1 dead at 01:04 PM. On 06/12/23 at 10:00 AM, Physical Therapy Assistant (PTA) GG stated that physical therapy and occupational therapy started to work with R1 per doctor's orders but there was not much that physical therapy could do for gait and strengthening because R1 was non-weight bearing due to his right foot fracture. On 06/12/23 at 10:15 AM, Administrative Nurse E, stated that R1 had a Significant Change because he was taken off hospice care because R1's representatives were adamant R1 had declined tremendously since his admission to the facility and wanted R1 to have physical therapy and occupational therapy. On 06/12/23 at 10:30 AM, CNA M stated she never noticed R1 having difficulty with swallowing but did notice R1 had a decline after he started having multiple falls. On 06/12/23 at 10:45 AM, LN G stated he noticed R1 having difficulty swallowing his potassium pill and a request was made to R1's PCP to change the potassium to powder or liquid. LN G stated R1's blood pressure medication was not given to R1 for two weeks after R1 admitted , and R1's blood pressure did get high. LN G stated R1's representatives thought R1 had a stroke because of his rapid decline after not receiving his blood pressure medications. LN G stated prior to R1's decline, R1 was walking the halls with his cane, visiting with staff and residents, and joking around telling jokes. LN G stated after R1 started falling, R1's decline was obvious. On 06/12/23 at 11:00 AM, Dietary Staff (DS) BB stated on the day R1 choked on his food the menu was ham, scalloped potatoes, and boiled cauliflower. DS BB stated R1's ham was ground with gravy on top of it. DS BB stated she was unaware of R1 having any difficulty swallowing. On 06/12/23 at 11:40 AM, Speech Therapist (ST) HH stated she started working with R1 for cognition and memory. Upon learning of the physician order for a swallow evaluation, ST HH was shocked the order was for a swallowing evaluation and stated nursing staff informed ST HH the evaluation to treat was for cognition and memory. ST HH stated she had never seen R1 for a swallowing evaluation. ST HH stated therapy did not receive written orders, all orders come to therapy verbally by nursing staff. On 06/12/23 at 12:14 PM, R1's representative stated she and her sister had taken R1 to his follow up appointment with his primary care provider on 05/03/23. They informed R1's PCP R1 had choked on a sandwich recently and coughed and coughed and was finally able to bring up the food, so R1's PCP ordered a swallowing evaluation by speech therapy. She said R1's PCP also ordered physical therapy and occupational therapy to see R1 because he was having so many falls. R1's representative felt upset that R1 had not received his blood pressure medications as ordered and felt that this was the start of R1 progressive decline. On 06/12/23 at 01:00 PM, Administrative Nurse D stated she thought R1's blood pressure medication was placed in the computer but for some reason it came up Pending and the EMR did not show to administer R1's losartan. Administrative Nurse D stated the day shift nurses put the orders into the computer, night nurses checked the orders, and then medical records completed a third check, but R1's losartan was missed. Administrative Nurse D stated therapy orders were put in the computer by nursing staff and then nursing staff verbally communicated the orders to therapy. Administrative Nurse D was unaware R1 had an order for speech therapy to conduct a swallow evaluation for R1. On 06/12/23 at 02:00 PM, Administrative Staff A stated he just found out from Administrative Nurse D that R1 had an order to have speech therapy see R1 for a swallowing evaluation. Administrative Staff A stated the facility needed to come up with a better way of communicating orders to therapy rather than just verbally. Administrative Staff A stated due to R1's losartan order being missed, administrative LNs would input all new admission orders into the computer. On 06/12/23 at 02:15 PM, Consultant KK stated she had become aware of R1's losartan not being given on the follow up appointment on 05/03/23. R1's representatives told Consultant KK R1 had a choking episode with a sandwich but was able to get the food up, so Consultant KK ordered speech therapy for a swallowing evaluation. Consultant KK changed R1's dietary order to chopped meat without bread, for example sandwiches, pending the results of the swallowing evaluation. Consultant KK stated she expected the facility to follow the orders given to them. The facility's Abuse, Neglect, and Exploitation Policy, reviewed October 2022, documented the facility would treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. Neglect is the failure to provide the goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives lack of care in one or more areas. The facility failed to ensure R1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 to promote and maintain R1's highest level of health and wellbeing. This deficient practice placed R1 in Immediate Jeopardy. The facility implemented the following corrective actions to remove the immediacy: Staff were notified administrative nurses would input admission orders and conduct a second check on 05/03/23. Medical Records audits new admission medication reconciliation with each new admit or readmit and daily for order changes initiated on 05/03/23 Staff were educated on medication reconciliation on admission by two licensed nurses on 05/17/23 A Quality Assurance and Performance Improvement (QAPI) meeting held on 05/30/23. All diet orders reviewed for all residents, and verified consistent on their care plans on by 05/31/23. All employees and therapy educated on the Therapy Communication Form, medication reconciliation, fall prevention and root cause analysis, on 06/13/23. Staff educated on Abuse and Neglect on 06/13/23. After removal of the immediacy, the deficient practice remained at a scope and severity of a G.

The facility identified a census of 43 residents. The sample included two residents with two reviewed for quality of care. Based on record review and interview, the facility failed to ensure licensed nursing staff possessed the skills, and knowledge necessary to detect and respond to changes in a resident's condition. On the morning of [DATE] Certified Medication Aide (CMA) R reported Resident (R)1 had difficulty swallowing his pills and was dry heaving to Licensed Nurse (LN) H. R1's clinical record lacked evidence LN H performed an assessment or reported the situation to R1's physician. Around lunchtime, R1 (identified with severe cognitive impairment), was allowed outside by himself for an unknown amount of time, but not more than ,d+[DATE] minutes. The temperature outside was ,d+[DATE] degrees Fahrenheit (F). Upon returning to the facility, Therapy Consultant GG observed R1 outside, and saw R1 leaning to the side in his wheelchair. R1 could not make himself understood, nor did he appear to understand Consultant GG, who then brought R1 to LN H and asked that he be assessed. R1's clinical record lacked evidence LN H assessed and/or notified R1's physician of Consultant GG's concerns and/or observations. LN H documented, in a late entry note, R1 had stomach pain and hypoactive (slow) bowel sounds. R1 received a suppository (medication inserted into the rectum) as he had no recorded bowel movements for three days. The record lacked evidence the physician was notified regarding R1's condition. At 09:45 PM on [DATE], staff found R1 unresponsive, initiated cardiopulmonary resuscitation (CPR-emergency lifesaving procedure performed when the heart stops beating), and notified 911. R1 was pronounced dead in the facility at 10:00 PM. These failures of staff to detect, thoroughly assess, and respond to changes in the resident's condition which placed R1 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated R1 had severely impaired cognition. The MDS further documented R1 required extensive assistance of two staff for transfer, bed mobility, toileting, personal hygiene, and dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE] documented R1 had confusion, disorientation, and forgetfulness. The Code Status Care Plan, dated [DATE], documented R1 had chosen to be a full code (all life saving measure to be performed). The care plan directed staff to perform CPR on R1 when his heart ceased to beat and/or his respirations ceased, to notify R1's family immediately if CPR was initiated, and to call 911 with implementation of CPR. The Pain Care Plan, dated [DATE], directed staff to give R1 pain medications as ordered and to monitor for effectiveness and if R1 was having pain to be responsive, empathetic and listen to R1's concerns. The Progress Note, dated [DATE] at 09:45 PM, documented Certified Nurse's Aides (CNA's) reported to LN I that R1 was unresponsive, pale, and not breathing. LN I rushed to R1's room and R1 had no pulse and no respirations. A CNA called 911, while LN I performed CPR. Emergency Medical Services (EMS) arrived at 09:50 PM. R1 was pronounced dead at the facility. The Skilled Service Assessment Note, created on [DATE] at 07:53 AM by LN H (the day after R1's death) with an effective date of [DATE] at 06:18 PM, documented R1 received skilled services. The Skilled Service Assessment Note documented R1's vital signs as blood pressure of ,d+[DATE] millimeters of mercury (mm Hg), heart rate 95 beats per minute, respirations 18 breaths per minute, temperature of 98.0 degrees, oxygen saturation of 92 percent (%), and pain rating of zero. R1 had bowel sounds in all four quadrants but bowel sounds were weak. The staff administered a Dulcolax suppository (medicine to induce bowel movements) to R1 at 06:30 PM and noted R1's last bowel movement was medium on Wednesday. The note documented R1 had been nauseated and vomiting, with no appetite. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's Orders revealed R1 did not have an order entered for Dulcolax suppository to be administered. R1's EMR lacked any other nursing assessment or progress note regarding his stomach pain, nausea, vomiting, or dry heaves. R1's clinical recorded lacked evidence of a neurological assessment. On [DATE] at 10:00 AM, CMA R stated she went to give R1 his morning medications on [DATE], as R1 sat in the dining room. R1 was leaning over the table, gasping, and when he looked up at CMA R there were tears in R1's eyes, and he could not talk. R1 finally said, dry heave. CMA R stated it took R1 a long time to take his medications. CMA R stated she reported her observations and R1's statement to LN H after she gave R1 his medications. On [DATE] at 10:30 AM, Consultant GG stated she performed therapy with R1 on the morning of [DATE] and R1 complained of stomach pain. Consultant GG stated she reported R1's complaints of pain to LN H, and LN H stated it was probably due to a change in R1's pain medicine. Consultant GG stated she left the facility for an appointment around lunch time that same day, and when she left R1 was not outside. Consultant GG stated when she got back to the facility R1 was sitting outside by himself and leaning all the way to the left in his wheelchair. Consultant GG stated she tried to talk to R1 and R1 could not speak clearly, nor did he appear to understand what Consultant GG said. Consultant GG stated it took two other staff members and herself to get R1 back into the facility because he leaned to the left, so badly. Consultant GG stated she immediately took R1 to LN H and told LN H there was something wrong with R1, like maybe a stroke (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). Consultant GG stated she reported to LN H that R1 needed to be assessed. On [DATE] at 12:50 PM, LN H stated she did not recall a CMA report of R1 with dry heaves and difficulty taking his medications. LN H stated she did assess R1 after Consultant GG brought him in from outside, and LN H did not feel there was anything wrong with R1. LN H stated she gave R1 180 milliliters (ml) of water and got him into his recliner so he could rest. LN H stated she did not see any signs or symptoms of R1 being over heated. LN H stated she gave R1 a Dulcolax suppository at 06:30 PM that evening to assist him with having a bowel movement. LN H stated she realized there was no order for the administration of the suppository but thought she could get the order for the suppository later. On [DATE] at 01:23 PM, Consultant HH stated if a resident was having persistent nausea, vomiting, dry heaves, stomach pain and lack of appetite, he expected a nurse from the facility to inform him of the symptoms so an intervention could be implemented to ease symptoms and find out what was going on with the resident physically, that caused the symptoms. Consultant HH stated he was shocked when he learned of R1's death. On [DATE] at 01:45 PM, Administrative Nurse D stated LN H did not chart anything about her assessments of R1 because there was nothing wrong with R1, so there was nothing to chart. Administrative Nurse D stated she expected the nurses at the facility to listen to concerns other staff reported about a resident, assess the resident completely, and chart the findings. On [DATE] at 05:00 PM, LN I stated when LN H gave her report on the evening of [DATE], there was no indication or report that R1 was having any problems. The facility could not provide a change of condition policy or assessment policy. The facility failed to ensure licensed nursing staff possessed the skills, and knowledge necessary to detect and respond to changes in R1's condition. Staff failed to detect, thoroughly assess, and respond to changes in the resident's condition which placed R1 in Immediate Jeopardy. On [DATE] the facility implemented the following corrective actions: Licensed nursing staff were educated on completing and documenting assessments related to change of conditions and reporting concerns to the physician. Residents were assessed for change of condition and physician notified if appropriate. Education staff on documenting and reporting change of conditions to the nurse, and escalation of those concerns to Administrator and Director of nursing when appropriate. After removal of the immediacy, the deficient practice remained at a scope and severity of G.

The facility had a census of 44 residents. The sample included 16 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide weekly weights, failed to act on Registered Dietician (RD) recommendations, failed to monitor supplement and fortified food intake and failed to ensure staff offered fortified food and nutritional supplements to R9, who was at risk for unintended weight loss and had a significant unplanned weight loss of 10.94 percent in six months. The facility further failed to implement RD recommendations, provide and monitor nutritional supplements as ordered and consistently measure weights for R18 who was at risk for weight loss. This deficient practice placed the residents at increased risk for ongoing weight loss and related complications Findings included: - The Electronic Medical Record (EMR) for R9 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had severely impaired cognition, inattention, and disorganized thinking, and required limited assistance of one staff for all Activities of Daily Living (ADLs). The MDS documented R9 was 66 inches tall, weighed 121 pounds (lbs.), and had no weight loss. The Nutrition Care Area Assessment, dated 10/22/21, did not trigger. The Nutrition Care Plan, dated 04/28/22, documented R9 was at risk for weight loss or gain related to her disease process and directed staff to offer a regular diet, regular texture, and regular fluid consistency. The care plan further directed staff to monitor R9's weight and report to her physician as needed. The care plan directed staff to provide meals as ordered by R9's physician, refer her to the registered dietician (RD) as needed, provide house shakes three times a day. The plan recorded R9 often stood and wandered around while eating. The care plan lacked documentation of weekly weights and lacked direction R9 received fortified foods. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Vital Sign Log-Weights recorded the following weights: 01/01/22 128 lbs. 02/17/22 119 lbs. (7.3 percent [%] weight loss in 30 days) 03/03/22 121 lbs. 04/18/22 118 lbs. 05/09/22 112.8 lbs. 05/18/22 115.8 lbs. 05/27/22 116 lbs. 06/07/22 114 lbs. 06/16/22 114 lbs. 07/06/22 112.8 lbs. (10.94% weight loss in 180 days) The Registered Dietician Note, dated 01/12/22 at 08:23 AM, documented R9's weight was down 9.2% in three months and 4% in one month. The RD recommended adding a mighty shake (nutritional supplement) twice a day, encourage good intakes at meals and to honor her preferences. R9's clinical record lacked evidence the facility followed the RD's recommendation. The Weight Change Note, dated 02/23/22, documented R9 had a 10% weight loss in 60 days and her weight would be monitored weekly with fortified foods added to her meals. R9's clinical record lacked evidence R9 was weighed weekly. The Registered Dietician Note, dated 03/07/22 at 07:10 AM, documented R9's weight was down 9.4% in three months and 14.3% in 6 months, which was a significant loss. The note further documented R9 was offered fortified foods at meals. R9's meal intakes varied, and the RD recommended house shakes three times a day; staff should encourage or assist R9 with help to promote intake. The Note to the physician, dated 03/21/22 at 04:47 PM (14 days after the RD recommendation was received), documented the RD recommended a mighty shake three times a day and staff asked for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R9's clinical record clacked evidence the facility followed up when the physician did not respond to the request. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Registered Dietician Note, dated 05/15/22 at 07:25 PM, documented R9 had a 6.5% weight loss since 04/18/22 and documented R9 was offered fortified foods at meals and shakes three times a day. The RD recommended to monitor R9's weight and notify the RD to make additional recommendations as appropriate. The Registered Dietician Note, dated 06/20/22 at 09:46 AM, documented a significant weight loss since 01/01/2. The note recorded R9 was offered fortified foods at meals, mighty shakes were started on 05/06/22 to increase R9's calories and to stabilize R9's weight. The RD directed to monitor R9's weight trends and notify the RD to make additional recommendations as appropriate. The Registered Dietician Note, dated 07/18/22 at 11:39 AM, documented R9's weight was trending down. The note further documented R9 was offered fortified foods at meals and shakes three times a day after meals. The RD recommended Med Pass 2.0 (nutritional shake to supplement calories and protein). R9's clinical record lacked evidence the facility followed the RD's recommendation for the nutritional supplement. On 07/21/22 at 12:00 PM, Dietary Staff BB stated there were 10 resident's that received fortified foods. Dietary Staff BB stated the fortified food that day was chocolate milk. On 07/21/22 at 12:00 PM, observation revealed staff assisted R9 to sit down at the dining room table. R9 received barbeque chicken, potato bakers (small round potatoes), vegetable blend, and a small bowl with dessert. Further observation revealed Dietary Staff BB gave R9 a glass of fortified chocolate milk and a large glass of juice. Activity Staff Z sat beside the resident to assist her as needed, but did not offer, encourage, or assist R9 to drink her fortified milk or juice. R9 took her small bowl of dessert and held it up to her mouth, without silverware, and tried to eat the dessert. , R9 was given her fork, and she started to eat her chicken. Activity Staff Z left the table as R9 continued to eat her chicken, but at this time still has not taken a drink of her milk or juice. At 12:25 PM, Certified Nurse Aide (CNA) Q sat beside the resident as R9 reached for another resident's empty glass, CNA Q pushed the empty glass away, and brought R9's juice and fortified milk closer to her, but did not encourage or assist the resident to drink. CNA Q then left the table to go assist another resident as CNA M stood beside R9 and asked if R9 was finished. CNA M assisted R9 up and walked with her out of the dining room. R9 never received a drink of her fortified milk or juice the entire meal. On 07/21/22 at 12:40 PM, CNA Q stated she did not know why she did not assist the resident with her fluids and stated she did not know which residents received fortified meals. CNA Q further stated she was unaware that the fortified meal item was the chocolate milk. On 07/21/22 at 02:43 PM, Certified Medication Aide (CMA) S stated R9 received a mighty shake at 10:00 AM, 02:00 PM, and in the evening. CMA S further stated she forgot to give R9 the shake at 02:00 PM and stated she did not give her the 10:00 AM shake like she was supposed to. CMA S stated staff do not document the percentage of the mighty shakes the resident consumed, only that they gave it. Review of the EMR documented the resident had received the 10:00 AM shake, although CMA S stated it was not given. On 07/25/22 at 09:35 AM, Consultant GG stated staff were supposed to make sure they gave R9 her mighty shakes and the fortified foods to keep R9's weight up. Consultant GG stated she recommended Med Pass 2.0 the previous week. She then looked at the chart and said she would contact Dietary Staff BB to see if the supplements had been started yet. On 07/25/22 at 12:17 PM, Dietary Staff BB stated she periodically asked the CNA's if R9 was drinking her mighty shakes. Dietary Staff BB said stated if R9 did not drink her shakes, staff informed the nurse to document she refused. On 07/25/22 at 12:30 PM, Administrative Nurse D stated staff were trying to get R9's weight back up. She stated staff discussed R9 in the risk meetings weekly and monitored her weight. Administrative Nurse D stated staff tried to have different staff be responsible for obtaining R9's weight weekly, but have not been successful. Administrative Nurse D stated staff should have assisted R9 with her fortified milk and offered her assistance to drink her juice. On 07/26/22 at 01:59 PM, Consultant JJ stated she expected the facility to weigh the resident weekly and make all attempts to assist the resident to drink her mighty shakes. Consultant JJ expressed she was not made aware of the times the resident was not drinking the supplemental shakes. Consultant JJ further stated new orders were being sent to the facility to send R9's weights every week for medical review. The facility's Weight Assessment and Intervention policy, dated 2011, documented the team would strive to prevent, monitor, and intervene for the undesirable weight change of residents and a weight change of 3% or more since the previous weight assessment shall be retaken the same or next day to confirm If the weight was verified, nursing staff would notify the dining services, the registered dietician would review the weights monthly, trends would be evaluated by the team to determine whether or not a significant weight change has occurred. The facility would useg the criteria for weight loss as 5% in one month, 7.5% in three months, 10% in six months. If the weight was unplaced, the care plan would be reviewed by the team and updated, Unplaced weight change would be referred to the registered dietician for interventions for the undesirable weight change. The interventions shall be based on careful consideration of the nutrition and hydration needs of resident, function factors that may inhibit appetite or desire to participate in meals, use of supplementation and/or feeding tubes. The physician would be notified of significant weight changes. The facility failed to implement the Registered Dietician's recommendations in a timely manner, failed to provide mighty shakes and fortified foods and failed to consistently monitor weights for cognitively impaired R9, who had a 10.94% weight loss in six months, placing the resident at risk for further weight loss and decline. - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had intact cognition, required supervision and set up help with eating, had functional range of motion impairment of one side to upper and lower extremity. The MDS recorded R18 had no swallowing disorders, no nutritional approaches, unknown weight gain or loss; R18 weighed 165 pounds (lb.). The MDS further documented R18 received speech therapy. The Nutrition Care Assessment (CAA), dated 10/11/21, had not triggered on the annual assessment. The Care Plan, dated 05/27/22, instructed staff to provide one fortified food per meal, regular soft textured foods and regular liquids. The care plan documented R18 snacked frequently throughout the day and directed staff to notify the physician if R18 reported something caught in his throat. R18 frequently ate soup for lunch and supper, and staff encouraged R18 to come out of his room for meals. The care plan further instructed staff to provide a mighty shake three times a day, and to ensure R18 was out of bed and sitting upright when eating. The Physician Order, dated 03/23/22 directed staff to weigh R18 weekly. R18's EMR weight revealed the following weights obtained: 03/17/22 170.4 lbs. 04/05/22 167.2 lbs. 04/18/22 165.0 lbs. 05/09/22 167.0 lbs. 05/18/22 160.4 lbs. 06/03/22 160.8 lbs. 06/15/22 160.2 lbs. 07/08/22 159.6 lbs. The Physician Order, dated 04/06/22, instructed staff to give R18 a house shake three times a day. The Registered Dietician (RD) Assessment Progress Note, dated 04/02/22, documented a weight loss of three pounds since prior hospitalization , a diet of mechanical soft texture foods with shakes three times a day. The note recorded that R18's intake was variable with average of 50 percent (%) of meals. The RD recommended Med Pass 2.0 (high calorie protein supplement) of 120 milliliters (ml) twice a day to increase calories and stabilize weight. The Progress Note, dated 04/06/22, sent to the physician documented the RD had recommended Med Pass 2.0, 120 ml twice a day to increase calories. The note requested the order for the recommendation. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's clinical record lacked evidence the Med Pass was provided. The Weight Warning Progress Note dated 06/01/22, documented R18 weighed 160.8 lbs.; R18 ate small portions at meals, often only soup. The note documented the RD would be consulted for weight loss for further intervention recommendations. The RD Progress Note, date 06/20/22, documented weight loss during the past six months. R18's diet was mechanical soft with shakes three times a day. R18's intake was variable, and he would often only eat soup, usually skipped breakfast. The RD recommended Med Pass 120 ml two times a day. On 07/20/22 at 12:59 PM, observation revealed R18 sat in his wheelchair in his room. Observation further revealed a bowl of broth and a large glass of a chocolate drink on the bedside table next to the resident. On 07/21/22 at 12:40 PM, observation revealed R18 sat on the edge of his bed with feet almost touching the floor. He had a fork and used it to get the noodles out of the broth. On 07/21/22 at 01:01 PM, Certified Medication Aide (CMA) R stated R18 got shakes three times a day and he usually liked the chocolate ones. She reported he did not like snacks because of some choking issues in the past. CMA R stated the EMR only documented the resident got the shake and did not record the intake of the resident. CMA R said if the resident refused the shake, that was recorded in the EMR. CMA R verified the EMR did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/25/22 at 09:25 AM, Dietary Staff BB reported she followed the resident weights weekly. She stated the dietician recommended Med Pass but was unaware if the physician had signed the order for it. On 07/25/22 at 12:25 PM, Administrative Nurse D verified the order for weekly weights due to weight loss and said, due to agency staff, R18's weight was not obtained weekly. Administrative Nurse D stated she knew the RD recommended Med Pass but thought the physician had not signed the order for it. She stated if the physician signed the recommendation then it should be followed. On 07/25/22 at 09:44 AM, Consultant GG stated the facility staff reported R18 took most of his shakes but had not checked the EMR for refusals. Consultant GG reported she recommended Med Pass to introduce more calories for R18, which would benefit the resident. On 07/26/22 at 11:30 AM, Consultant II stated the lack of the Med Pass 2.0 ,as ordered in 04/2022, contributed to R18's weight loss. The facility's Weight Assessment and Intervention policy, dated 2011, documented the Registered Dietician will review weights monthly. Trends will be evaluated by the Interdisciplinary Team (IDT) to determine whether or not significant change has occurred. The Physician and IDT will identify conditions and medications that may increase risk of weight change. Interventions for undesirable weight loss shall be based on careful consideration of the resident's conditions. The facility failed to obtain weekly weights, act upon the RD recommendations, and monitor supplement intake for effectiveness which placed R18 at risk for continued unintended weight loss and malnutrition.

The facility documented a census of 41 residents. The sample included three residents with three reviewed for falls. Based on observation, record review, and interview, the facility failed to identify and implement resident centered interventions and evaluate resident's toileting needs and patterns in order to prevent falls for Resident (R) 1, who was at risk for falls. R1 had multiple falls, with three specifically related to toileting or bathroom needs, which resulted in bruising, hematoma, facial fractures, facial lacerations, and head injuries. Findings included: - R1's Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses of cerebral infarct (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), [CONDITION(S)] (paralysis of one side of the body), [CONDITION(S)] (muscular weakness of one half of the body), and benign [CONDITION(S)] of the prostate (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS further documented the resident required extensive assistance of two staff for bed mobility, transfer, toileting, and dressing. R1 required limited assistance of one staff for locomotion on and off the unit and personal hygiene. R1 required supervision with set up assistance for eating. The Activities of Daily Living Care Area Assessment (CAA), dated 11/28/21, documented R1 had impaired balance during transfers and functional impairment in activities. The CAA further documented R1 had generalized weakness and decreased safety awareness and was at risk for further activity of daily living decline, falls, incontinence, skin breakdown, and pain. The Urinary Incontinence CAA, dated 11/28/21, documented R1 needed assistance with toileting needs and incontinence episodes. The CAA further documented R1 had the following risk factors: weakness, impaired mobility, and cognitive loss. The CAA indicated a care plan would be initiated to improve/maintain current toileting skills, continence status, decrease fall risk, and decrease risk for urinary tract infections. The Fall CAA, dated 11/28/21, documented R1 had a history of falls prior to his admission, weakness and physical performance limitations affecting his balance, gait, strength, and muscle endurance. The CAA further documented a care plan would be initiated to improve/maintain current physical function as it related to activities of daily living, gait stability, strength and endurance, mobility, decrease fall risk and minimize injury related to falls. The Fall Risk Assessment, dated 11/22/21, documented R1 was at moderate risk for falls. The Fall Risk assessment dated [DATE], documented R1 was at high risk for falls. R1's clinical record lacked evidence the facility completed a voiding assessment or analysis of the resident's toileting needs and incontinence patterns. The Incontinence Care Plan revised on 12/13/21 directed staff to toilet R1 upon rising, before and after meals, at bedtime, and to check on toileting needs during nighttime rounds. The Fall Care Plan created on 12/10/21 recorded an intervention dated 12/13/21, which directed staff to provide toileting assistance upon rising, before and after meals, and check on R1 at night during rounds for toileting needs. An intervention dated 12/21/21 recorded R1 had a fall on 12/20/21 and was sent to the hospital. The intervention directed staff to reevaluate R1 for toileting assistance needs upon his return from the hospital. Another intervention created on 12/29/21 documented R1 had a fall on 12/08/21 and directed staff to check R1 at least every two hours and to toilet when needed. The Fall Investigation note dated 12/08/21 documented at around 09:10 PM the unidentified nurse passed medications outside of R1's room and heard a loud noise. The unidentified nurse looked into R1's room and found R1 on the floor. R1 was observed on the floor, incontinent of urine. He was in a planked position with blood dripping from his forehead. The note recorded R1 obtained a bruise to his right knee, a scrape to his left knee, two small lacerations and a bump to his forehead. The note documented R1's description of the event was he had to pee. The investigation listed incontinence as a predisposing factor for the fall. The clinical record lacked evidence the facility implemented an intervention that addressed toileting and incontinence needs until 12/13/21, 5 days after the fall. The Fall Investigation note dated 12/20/21 documented staff found R1 on the floor around 12:00 PM, laying in a supine position. His head leaned on the bathroom door. R1 bled from his nose and his forehead. Blood was observed on the bathroom floor. R1 was unable to tell staff what he was trying to do. The investigation documented R1 was sent to the emergency room for his injuries and would be reevaluated for his toileting assistance needs upon his return from the hospital. The investigation lacked information regarding when staff last toileted R1. The Nurses Note dated 12/21/21 documented R1 readmitted from an overnight stay in the hospital due to a fall resulting in multiple facial fractures. R1's clinical record lacked evidence the facility evaluated his toileting assistance needs as directed in his plan of care upon his return from the hospital. It further lacked evidence the facility assessed R1's individual incontinence patterns to prevent future toileting related falls. The Fall Investigation note dated 12/22/21 documented at 07:11 AM an unidentified Certified Nurse Aide (CNA) witnessed R1 attempting to self transfer. R1 fell before the CNA could get to him. R1 stated he wanted to use the bathroom. The investigation lacked information regarding when R1 was last toileted. The note further recorded R1 had no new injuries, but had existing bruises, swelling, and sutures to facial lacerations from a recent fall. The note further documents an intervention of a fall mat. The Nurses Note dated 12/22/21 documented R1 was sent to the emergency room for increased facial swelling from the 12/22/21, 07:11 AM fall. R1 returned to the facility with recommendations for frequent checks and continue to monitor R1 due to multiple head injuries. The Nurses Note dated 01/01/22 documented CNA's heard a crash in R1's room and the CNA then placed R1 in his wheelchair at the nurse's station. A large hematoma (an injury that causes blood to collect and pool under the skin) had formed on R1's left forehead and his speech was more slurred than normal. The note documented R1 was able to state his name and had symmetry when smiling. R1's pupils were equal and reactive to light. R1 was transferred to the emergency room per his son's request. The clinical record lacked evidence of a fall investigation related to this fall. The record further lacked information regarding when the resident was last toileted, or interventions or actions taken to prevent further falls. 01/12/22 at 11:00 AM observation revealed R1 sat in his wheelchair with a pommeled (saddle-like) cushion. R1 was positioned at the nurse's station leaning to the left and right looking at the floor. On 01/12/22 at 10:00 AM, CNA M stated R1 was not on a toileting program. The aides just took his cues for when he had to go to the bathroom. CNA M said sometimes R1 said he had to go to the bathroom and sometimes he was restless. CNA M further stated R1 normally sat in his wheelchair at the nurse's desk most of the day because he fell so much. On 01/12/22 at 11:00 AM Licensed Nurse (LN) G stated it was the facilities policy to perform a bowel and bladder assessment on newly admitted residents to see what their routine were and to prevent falls from occurring. On 01/12/22 at 01:30 PM, Administrative Nurse D verified that the bowel and bladder assessment had not been performed for R1. Administrative Nurse D stated that with the use of so many agency staff the bowel and bladder assessments had been missed. The facilities Fall Management policy, revised December 2017, documented the facility strives to minimize the risk for resident falls and to reduce injuries associated with resident falls. Residents are to be assessed in the first four hours of admission using a standardized fall risk assessment to identify individualized resident risk factors. Residents are to be reevaluated quarterly, with each fall and with any significant change. The facility interdisciplinary team is to review resident falls on a routine bases during Daily Clinical Excellence. The Director of Nursing or designee is responsible for reviewing falls on a routine basis to attempt to define the possible causes of the falls. Fall occurrences are to be documented in the clinical record including environmental, situational, or psychological and situational factors, location, time found, position, adaptive equipment, actions taken, and new intervention implemented. The resident's plan of care is to be reviewed and revised with each fall occurrence and new interventions implemented. The facilities Incontinence Management policy, revised on December 2017, documented the residents are to be assessed to identify a history and pattern of bowel and bladder function. The resident is to have completed a 3 Day Toileting Diary upon admission, annually, and significant change in health status. The resident is to have a determination of the type of bladder incontinence utilizing the 3 Day Toileting Diary. The plan of care will address individualized focus, goals, and interventions directed towards managing the resident's bowel and bladder incontinence. The facility failed to identify and implement resident centered interventions and evaluate resident's toileting needs and patterns in order to prevent falls for Resident (R) 1, who was at risk for falls. R1 had multiple falls, with three specifically related to toileting or bathroom needs, which resulted in bruising, hematoma, facial fractures, facial lacerations and head injuries.

The facility had a census of 49 residents. The sample included 14 residents with four reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to implement interventions to prevent pressure ulcers for two of four sampled residents, Resident (R) 49, whose unstageable pressure ulcer (full thickness skin, muscle loss with slough and/or eschar (dead tissue) present in the base of the pressure ulcer, preventing from seeing true depth of ulcer) on his vertebrae (an arched, hollow section through which the spinal cord passes) which originally measured 2.5 centimeters (cm) x 2.5 cm x 3.0 cm increased in size and worsened to 4 cm x 3 cm. R49 also developed a new stage two pressure ulcer (partial thickness loss of skin presenting as a shallow open area with a red/pink wound bed) below the original pressure ulcer on the residents mid vertebrae, which measured 0.5 cm x 1 cm x 0.1. R39 developed a facility acquired stage two pressure ulcer to the right buttock, which measured 0.4 cm x 1.8 cm. Findings included: - R49's Physician order [REDACTED]. The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, dressing, and toilet use, staff supervision with eating, and ambulation did not occur. The MDS documented the resident had lower extremity impairment on one side and used a wheelchair for mobility. The Alteration in Skin Integrity Care Plan, dated 11/13/20, directed staff to encourage the resident to eat protein, inspect the resident's skin with bathing and daily care, and report changes to the licensed nurse. The revised care plan dated 01/20/21 implemented an air mattress and a cushion in his wheelchair. The Nurse's Note, dated 12/05/20 at 02:54 PM, documented the resident fell in his room and his right leg looked to be at a slightly unusual angle, rotated outward, and he could not move his right leg. The note documented the resident had right hip pain, staff notified the physician, and transferred the resident to the emergency room . The Admission to Hospital Note, dated 12/05/20 (untimed), lacked documentation the resident had a pressure ulcer. The Progress Note, dated 12/09/20 at 10:05 AM, from the nurse practitioner at the hospital documented the resident had a stage 3 pressure ulcer (full thickness loss of skin with fat visible in the ulcer) to the [MEDICATION NAME] region of the spine (area of spine from base of neck down to abdomen) secondary to pressure. The facility's Admission Assessment, dated 12/11/20 at 02:41 PM, documented the facility readmitted the resident from the hospital with ability to walk severely limited or non-existent due to the resident not able to bear his own weight and must be assisted into wheelchair. The assessment documented the resident very limited in ability to change and control body position, could make occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. The assessment documented the resident had a stage one pressure ulcer to his mid vertebrae which measured 2.5 cm x 2.5 cm x 3.0 cm (inconsistent with the nurse practitioner's hospital progress note on 12/09/20). The Skin/Wound Assessments documented the following: On 12/16/20 R49 had a mid back pressure ulcer on his upper vertebrae that measured 2.5 cm x 2.3 cm. The preventative measure in place instructed staff to apply [MEDICATION NAME] (a rich formula formulated to that seals in moisture to help heal very dry, sensitive skin) cream to the resident's dry skin. On 12/18/20 the resident had an upper mid back unstageable pressure ulcer measured 2.5 cm x 2.3 cm and no preventative measures in place. The medical record revealed no skin assessment documentation between 12/18/20 and 01/06/21. On 01/06/21 R49 had an unstageable mid back pressure ulcer on his upper vertebrae that measured 3.9 cm x 2.7 cm with no depth. The preventative measures in place included provide the resident pressure ulcer care, float his heels, and ensure the resident had on special boots. On 01/13/21 the resident had an unstageable mid back pressure ulcer on his upper vertebrae that measured 2.5 cm x 4 cm. 0.2 cm and a new stage two pressure ulcer on his lower mid back that measured 0.5 cm x 1 cm x 0.1 cm. The preventative measures in place included float heels and have the resident wear special boots. On 01/21/21 the resident had on his upper mid vertebrae an unstageable pressure ulcer which measured 4 cm x 3 cm and a lower mid vertebrae stage two pressure ulcer which measured 1.1 cm x 0.9 cm. The wound assessment documented the preventative measures in place included pressure ulcer care, low air mattress, float heels, heel/elbow protectors, special boots, repositioning, calorie and protein supplement, and multivitamin. On 01/27/21 at 02:21 PM, observation revealed Licensed Nurse (LN) H applied gloves, removed the resident's dressing on his mid upper back, discarded the dressing in the trash, then removed and discarded her gloves. The area around the open wound was reddish purple in color, wound bed had yellow slough (dead tissue, usually cream or yellow in color), edges around the wound bed had pink granulation. Observation revealed approximately two to three inches below the wound was a pea size open area. Observation revealed LN H applied new gloves, measured the top wound at 5.1 cm x 3.3 cm, cleansed both wounds with wound wash with separate two by two gauze pads, removed, and discarded her gloves. LN I then applied new gloves, applied skin prep (a liquid that when applied to the skin forms a protective film or barrier) around the wounds edges, applied calcium alginate (a dressing that absorb fluids and promotes healing) dressing on the top wound, then covered both wounds with a heart shaped Allevyn dressing (hydrocelluar foam dressing). On 01/27/21 at 12:51 PM, Administrative Nurse D verified interventions to prevent the increase of the resident's upper mid back pressure ulcer and development of a new pressure ulcer were not put in place until 01/20/21. Administrative Nurse D stated staff should have implemented an air mattress on the resident's bed, pressure relieving cushion on the seat of his wheelchair, and turning reposition program when he readmitted from the hospital on [DATE], after a [MEDICAL CONDITION] repair. On 01/27/21 at 02:31 PM, Physician GG stated he would have expected staff to immediately place an air mattress on the resident's bed, cushion in chair, and turning and repositioning program, when the resident was admitted back to the facility after a [MEDICAL CONDITION] repair and was non weight bearing. Physician GG stated the interventions would have helped in preventing the resident's upper mid back pressure ulcer from worsening and developing a lower mid back pressure ulcer but was not sure if they would have prevented them. On 02/03/21 at 11:48 AM, Licensed Nurse (LN) J verified the Admission assessment dated [DATE] at 02:41 PM documentation incorrectly identified the pressure ulcer as a stage one upon admission to the facility and should have documented the pressure ulcer as a stage three. The facility's Wound Prevention and Management policy, dated December 2018, documented the facility would develop a system to review all residents at risk for pressure ulcers weekly. The residents' plan of care would address problems, goals and interventions directed towards prevention of pressure ulcers and skin integrity concerns. The facility failed to implement interventions to prevent the worsening of an unstageable pressure ulcer and development of a lower mid back stage two pressure ulcer for R49, placing the resident at risk for further skin breakdown. - Resident (R) 39's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS documented the resident was independent with eating, required staff supervision for bed mobility, transfers, toileting, and hygiene. The resident was frequently incontinent of urine, at risk for pressure ulcer (PU), and no current PU. Pressure relief measures included a device for his bed, dressings, and ointment to areas other than his feet. The Quarterly MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident required supervision with eating, limited assistance of one staff for bed mobility, transfers, toileting, walking,and extensive assistance of two staff for dressing. The resident was frequently incontinent of urine, at risk for PU, no current PU, and had an open lesion on his foot. Pressure relief measures included a device for his bed, nutrition interventions, and dressings to areas other than his feet. The Pressure Ulcer Care Area Assessment (CAA), dated 09/14/20, documented the resident had frequent incontinence and was at risk of developing pressure ulcers. The resident currently had a non-pressure related open area being treated per physician order. Resident will have no skin breakdown during the next review period. Encourage resident to consume all of the offered food/fluids to assist in maintaining adequate nutrition/hydration. Provide skin assessments per protocol and as indicated. Resident used a pressure reducing/relieving mattress on his bed. The Skin Care Plan, dated 12/14/20, directed staff to encourage the resident to consume all of the offered food/fluids to assist in maintaining adequate nutrition/hydration. The care plan documented R39 had an open area on the right buttock and directed staff to apply Medi-honey (wound care treatment) and cover with [MEDICATION NAME] (specialized wound dressing) dressing to the right buttock wound daily. The resident had extremely dry cracked heels especially the left, apply [MEDICATION NAME] (protects skin and locks in moisture to help repair and heal dry, cracked skin) and cover with [MEDICATION NAME] dressing to the left heel for protection. I need encouragement to shift or alter my weight/body position. The Physician Order, dated 12/15/20, directed staff to apply [MEDICATION NAME] (skin barrier product) to the buttocks twice daily to prevent skin breakdown. The Wound Assessment, dated 01/13/21, documented a new, facility acquired Stage 2 PU (Partial thickness loss of skin, presenting as a shallow open ulcer with a red pink wound bed) to the right buttock, which measured 0.4 x 1.8 centimeters (cm), found 01/12/21. The assessment indicated no preventive measures in place, and nutritional measures included protein supplement, and multivitamin (MVI). The 01/13/21 Fax to his physician requested a change in orders for the left heel for protection. The Physician Order, dated 01/13/21, directed staff to clean the right buttock with wound cleanser, apply skin prep peri wound, apply [MEDICATION NAME] dressing and change every three days and as needed (PRN) for the Stage 2 PU. The Wound Assessment, dated 01/20/21, documented the right buttock Stage 2 PU measured 0.5 cm x 0.3 cm, had 100% granulation (tissue formed during wound healing). Preventive measures listed pressure reducing mattress, repositioning, protein supplement, and MVI. On 01/26/21 at 02:51 PM, Licensed Nurse (LN) L stated the resident had a duoderm on his right buttock over the PU and was not due to have it changed. It should be changed every 3 days and if we remove it early the skin may be damaged unnecessarily. She stated R39 did not have any ulcers or wounds on his feet. On 01/27/21 at 11:27 AM, LN L performed a check of R39's skin. Observation revealed no dressing on the right buttock which had a small pink/red area, approximately 0.3 cm round. R39 jumped when the nurse touched his left heel and he stated it was sore. The heel had no dressing for protection, as ordered, and observation revealed the skin on the back edge of his heel a little darker pink than surrounding heel skin. Further observation revealed the shoes he normally wore were beside his bed and the back lip of the left shoe was bent down inside the shoe. On 01/27/21 at 11:27 AM, LN L stated staff were to ensure a dressing in place on the right buttock and left heel. She verified the care plan should have pressure ulcer preventions listed. The facility's Wound Prevention and Management policy, dated December 2018, documented the Director of Nursing or designee would be responsible for monitoring all wounds on a weekly basis. The policy stated if a resident was identified at risk or with actual alterations in skin integrity of feet, footwear would be addressed for appropriateness. The facility failed to ensure placement of pressure ulcer dressings, as physician ordered for R39, who developed a Stage 2 PU while in care of the facility, placing the resident at risk for worsening of pressure ulcers.

The facility had a census of 51 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to provide needed care and services and professional standards of practice to assess the resident's,critically low blood sugars, provide appropriate interventions to increase the resident's blood sugar, or notify the resident's physician in a timely manner, placing the resident in immediate jeopardy. (#151) Findings included: - Resident #151's 5/16/19 physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 5/23/19, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 3, indicating severely impaired cognition. The resident required extensive assistance with bed mobility and transfers, and limited assistance with eating. The MDS lacked a (CAA) Care Area Assessment for (ADL) Activities of Daily Living. The MDS recorded a CAA for cognitive loss which stated the resident had impaired decision making skills related to an intellectual disability. The 5/16/19 admission care plan recorded the resident at risk for [DIAGNOSES REDACTED] (low blood glucose) and directed staff to assess the resident for change in level of consciousness and drowsiness. The 5/16/19 physician order [REDACTED]. The 5/21/19 physician order [REDACTED]. Review of the Accu-chek result log recorded on 5/21/19 documented the resident had a blood glucose of 42 mg/dl (milligrams per deciliter) and lacked documentation of a resident assessment and interventions. The 5/22/19 at 6:00 PM, nurse's note recorded the resident's Accu-Chek result 29 mg/dl at 4:00 PM, and the resident unresponsive. The nurse's note further recorded the nurse administered the resident sugar mixed in water with chocolate syrup. The nurse then attempted to notify the physician by calling the local hospital, urgent care and an out of town hospital, but was unable to reach the physician. The nurse then notified EMS (emergency medical services), who came to the facility and administered IV (intravenous) [MEDICATION NAME] (sugar water) to the resident raising the blood glucose level to 211 mg/dl. The resident remained in the facility. The 5/25/19 10:35 PM, nurse's note recorded the resident's Accu-Chek result 47 mg/dl at 9:30 PM. The nurse's note recorded the resident responded to verbal stimuli but had difficulty staying awake, and the nurse administered 1 spoonful of honey due to not being able to find the glucose gel. The noted recorded the resident became more responsive, the nurse provided the resident 8 ounces of orange juice with 2 packets of sugar and 1 spoonful of peanut butter, rechecked the blood glucose and obtained a result of 90 mg/dl. The record lacked documentation of continued assessment of the resident's blood glucose or physician notification. On 5/29/19 at 11:40 AM, observation revealed the resident sat in his/her wheelchair in the dining room, and a staff member sat beside the resident. Further observation revealed the resident able to feed his/her self. On 5/30/19 at 8:50 AM, Administrative Nurse D verified the resident's 5/22/19 at 4:00 PM accu-check result of 29 mg/dl, stated he/she was aware the glucose gel was unavailable, and stated Nurse H was unable to obtain the [MEDICATION NAME] from the RX machine (emergency kit). Administrative Nurse D verified no follow up assessment was completed for accu-chek results on 5/25/19, and facility protocol for [DIAGNOSES REDACTED] was not followed on 5/22/19 and 5/25/19. Administrative Nurse D verified continued assessment of the resident's blood glucose should have been done. On 5/30/29 at 10:20 AM, Nurse I stated if a resident's accu-chek result was lower than 70 mg/dl to give glucose gel, and stated the glucose gel used to be available in the medication carts but had not been in the carts recently. On 5/30/19 at 2:30 PM, a notarized (a written statement authorized with signature from a notary public witnessing the signature) statement from Nurse H stated on 5/22/19 at 4:00 PM, the resident's blood sugar was 29/mg/dl, the resident asleep and unresponsive. The statement documented Nurse H mixed sugar in water and placed a teaspoon in the resident's mouth with chocolate syrup, went to the emergency kit to obtain glucose gel or the [MEDICATION NAME] (a hormone to treat severe low blood sugar) and the machine jammed and unable to obtain the medication. The statement documented Nurse H called the local hospital, urgent care clinic and an out of town hospital, but was unable to speak with the physician. Nurse H called Administrative Nurse D and was instructed to call 911. EMS arrived at the facility and administered IV [MEDICATION NAME] to the resident, which raised his/her blood sugar to 200 mg/dl. The statement documented Nurse H called again, was able to speak to the resident's physician, he/she was instructed not to wait so long and send the resident to the ER next time. Nurse H verified no follow up documentation and assessment of the resident after the blood glucose result of 29 mg/dl. The facility's 12/2017 Diabetic Hypo/Hyperglycemic policy stated blood glucose level will be checked for any resident with diabetes showing signs and symptoms of [DIAGNOSES REDACTED], if a resident has a blood sugar less than 70 mg/dl the physician is to be notified. The procedure for a blood glucose less than 70 mg/dl is to give one tube of glucose gel (15 gm) orally, wait ten minutes and recheck blood sugar, if level is slightly below 70 mg/dl notify physician and administer another tube of glucose gel. Monitor blood sugar every 4 hours when the blood sugar remains stable above 70 mg/dl, notify responsible party. A blood glucose below 40 mg/dl, inject 1 mg of [MEDICATION NAME] SQ (subcutaneous, an injection,applied under the skin) in the abdomen, if the resident is unresponsive, immediately call 911 and the physician,and notify responsible party. The facility failed to provide needed care and services for Resident #151 with a low blood sugar, failed to assess the resident's, critically low blood sugars, provide appropriate interventions to increase the resident's blood sugar, or notify the resident's physician in a timely manner, placing the resident in immediate jeopardy. The facility abated the immediate jeopardy on 5/30/19 at 6:38 PM, when the facility completed training and education for all licensed nurses on regarding [DIAGNOSES REDACTED] Protocol, storage of supplies needed to carry out protocol and required notifications when change of condition is identified in a resident, Agency staff were also provided access information upon arrival each shift by off going nurses. Glucose gel was placed in both medication carts and placed on the order to come on a cycle, Nurse H was counseled on physician notification, Point Click Care risk event completed and investigation initiated reported to state agency. Audit completed of all diabetic residents insulin and blood glucose order for accuracy, audit completed of all diabetic residents care plans for individualized hypoglycemic care and needs on audits to be completed through daily clinical excellence on blood glucose monitoring of diabetic residents to ensure compliance. QAPI meeting held regarding incident and included medical director on 5/30/19. The deficient practice remains at a scope and severity of a G.

The facility had a census of 51 residents. The sample included 17 residents, with 5 reviewed for pressure ulcers. Based on observation, record review, and interview the facility failed to provide necessary treatment and services to promote healing and prevent the development of pressure ulcers for 2 of 5 sampled residents), Resident #23, who had developed two facility acquired pressure ulcers, the facility failed to obtain new treatment orders for 52 days, failed to develop appropriate intervention to prevent pressure ulcers and implement nutritional interventions for healing pressure ulcers. (#23, #39) Findings Included: - Resident 23's physician order [REDACTED]. The admission (MDS) Minimum Data Set, dated dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status score of 2 (severely impaired cognition), inattention, and altered level of consciousness. The MDS recorded the resident required extensive staff assistance with bed mobility, transfers, toileting and personal hygiene. The MDS further recorded the resident was at risk for pressure ulcers and had (MASD) Moisture Associated Skin Damage (inflammation or skin erosion caused by prolonged exposure to a source such as urine, stool, sweat, or wound drainage). The 3/19/19 admission (CAA) Care Area Assessment for pressure ulcers recorded the resident had MASD, pressure relieving mattress and wheelchair cushion (not observed during the 4 day survey process). The 4/09/19 revised care plan recorded the resident was incontinent of bowel and urine, and directed staff to provide the resident with a check and change program (periodic assessment for incontinence and provision of incontinent cares). The care plan recorded the resident had an open area on the right gluteal fold (inner medial buttock), directed staff to apply barrier ointment as needed, and notify the physician of adverse changes in the resident's skin condition. The care plan lacked documentation staff identified and implemented new interventions to promote healing and prevent the development of pressure ulcers after 4/09/19. The 4/07/19 at 6:41 AM, progress note recorded staff assessed a 0.5 (cm) centimeter by 1.5 cm open area on the resident's coccyx (small triangular bone at the base of the spine). The progress note directed staff to position the resident on his/her side in bed to offload pressure to the wound site, and reposition the resident every 2 hours (this intervention was not added to the resident's care plan). The 4/07/19 at 1:34 PM, skin condition progress note recorded the 1.0 cm by 0.75 open area on the resident's coccyx was MASD due to the resident's incontinence, and directed staff to apply barrier ointment to the open area as needed. The 04/08/19 (RD) Registered Dietician Note recorded the resident had nutritional risk and recommended fortified food at each meal and fortified snacks 2 times a day. The RD note lacked documentation about the resident's wound, or the need for added nutrition for wound healing. The 4/10/19 at 4:00 PM, progress note recorded the resident was discharged from (OT) Occupational Therapy and (PT) Physical Therapy due to recent declines in his/her (ADL) Activity of Daily Living function, and not improving with therapy services. The 4/20/19 at 3:38 AM, progress note recorded staff cleansed and applied barrier ointment to the open area on the resident's coccyx. The 4/29/19 at 5:36 PM, skin condition progress note recorded the resident had a 2 cm open area on his/her coccyx, and staff applied barrier ointment to the wound. The 5/15/19 at 5:35 PM, progress note recorded the open area on the resident's coccyx measured 6 cm by 2 cm and staff continued the barrier ointment treatment. The 5/23/19 physician's orders [REDACTED].). The 5/27/19 at 8:04 AM, skin condition progress note recorded the resident had a 3 cm by 1 cm open area on his/her coccyx and skin breakdown on the left gluteal inner buttock. The progress note directed staff to lay the resident down on his/her side after every meal and reposition him/her every 2 hours (this intervention was not added to the resident's care plan). The 5/29/19 Skin/Wound Condition Assessment recorded the resident had an open fissure (a split or tear in the skin) on the coccyx, an excoriated (injury to skin) area on the inner left buttock, and the surrounding skin was reddened from overexposure to moisture. The 5/30/19 physician communication note recorded staff assessed the open area on the coccyx as worsening with increased inflammation and irritation. The note requested a dressing change to better protect the resident's wound, and improve healing. On 05/29/19 at 10:21 AM, observation revealed the resident rested quietly in a wheelchair in his/her room, and the wheelchair had no pressure relief cushion. On 5/29/19 at 1:44 PM, observation revealed the resident rested quietly in a recliner in his/her room, and the recliner had no pressure relief cushion. On 5/30/19 at 11:01 AM, observation revealed Nurse G changed the resident's dressing after his/her bath. Continued observation revealed the resident had an approximate 2 to 3 cm vertical slit on the coccyx, with a beefy red center and slough (dead tissue, usually cream or yellow in color) along the edges, an approximate 1 cm open area on the inner left buttock, and the surrounding skin on both buttocks was reddened. Multiple observations, during the survey process on 5/29/19 and 5/30/19, revealed the resident sat in a wheelchair or recliner in his/her room between meals, and staff had not placed the resident in bed to offload the pressure to the resident's wound sites. On 5/30/19 at 9:26 AM, Nurse Aide R stated the resident required extensive staff assistance with all ADLs, and staff used a sit to stand lift to transfer the resident. Nurse Aide R stated the resident had a wound on his/her coccyx, no cushion for the wheelchair or recliner, and he/she was not aware to place the resident in bed between meals. On 5/30/19 at 10:05 AM, Nurse Aide Q stated the confused resident required extensive staff assistance with all ADLs, including repositioning and transfers. Nurse Aide R stated the resident had a wound on his/her coccyx, no cushion for the wheelchair or recliner, and he/she was not aware to place the resident in bed between meals. On 6/03/19 at 10:09 AM, Administrative Nurse D stated the resident developed an open area on his/her coccyx on 4/07/19, and staff had not revised the care plan to protect the wound and improve healing. Administrative Nurse D stated staff had not notified the physician to change the treatment for [REDACTED]. The facility's 12/2018 Wound Prevention and Management Policy directed staff to identify risk and revise the care plan to prevent wound, protect wounds and improve healing of wounds. The policy directed staff to monitor wounds weekly, and notify the Registered Dietician and physician of the development or worsened condition of a wound. The facility failed to obtain new treatment orders for 52 days, failed to develop appropriate intervention to prevent pressure ulcers and implement nutritional interventions for healing pressure ulcers for Resident #23, who developed two facility acquired pressure ulcers and was at risk for further skin breakdown and infection. - Resident #39's (POS) physician order [REDACTED]. The 5-day Medicare (MDS) Minimum Data Set assessment, dated 1/9/19, documented the resident had a (BIMS) Briefs Interview for Mental Status Score of 15, indicating intact cognition. The assessment documented the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting and dressing. The assessment further documented the resident was at risk for pressure ulcers, had a pressure relieving device for his/her bed and chair, on a turning and repositioning program, and did not have any pressure ulcers. The quarterly MDS, dated [DATE], documented the resident had a BIMS of 14, indicating intact cognition. The assessment documented the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting, and dressing. The assessment further documented the resident had (MASD) Moisture Associated Skin Damage (inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture), and had a pressure relieving device for his/her bed and chair. The 1/9/19 (CAA) Care Area Assessment for pressure ulcers documented the resident was unable to reposition him/herself and had excess exposure to moisture, placing the resident at a higher risk for skin breakdown. The 5/8/19 (initiated on 2/6/18) care plan directed staff to reposition the resident frequently. The care plan lacked documentation of interventions to prevent further skin breakdown. The 4/18/19 Braden Assessment recorded the resident was a moderate risk for pressure ulcer. The 4/25/19 at 12:06 PM, skin condition sheet documented the resident had a 1.0 (cm) centimeter x 1.0 cm open area on his/her left buttocks. Staff applied barrier cream, covered the area with a padded dressing, encouraged the resident to eat and drink, and documented the resident needed a cushion in his/her wheelchair and recliner. The 4/26/19 at 10:59 AM, fax communication with the physician documented the resident asked for a different treatment for [REDACTED]. The resident had a cushion for his/her wheelchair and recliner but stated nothing helped the pain. The 4/29/19 physician's orders [REDACTED]. The 5/2/19 at 6:42 PM, skin condition sheet documented the resident had an open area to his/her buttocks, staff cleaned the wound with wound cleanser, applied durable barrier cream, and covered with a dressing. The 5/5/19 Registered Dietician assessment documented the resident had a recent weight loss due to illness and fluid shifts, and received treatments to an open area on his/her buttocks. The assessment further documented the dietician recommended a multivitamin daily and liquid protein, 30 (ml) milliliters, twice a day to promote healing. The 5/16/19 at 1:39 PM, skin condition sheet documented the resident had a small open sore on his/her buttocks, measured 1 cm x 1 cm, staff monitored and off loaded the pressure to the resident's buttocks. The 5/21/19 physician's orders [REDACTED]. On 5/29/19 at 7:30 AM, observation during personal cares revealed the resident had a small scabbed area to his/her left gluteal fold (a prominent fold that marks the upper limit of the thigh and the lower limit of the buttock), a reddened around the scab, and Nurse Aide M applied barrier cream. Continued observation revealed the resident did not have a pressure relieving cushion in his/her recliner. On 5/30/19 at 11:38 AM, observation revealed no pressure relieving cushion in the resident's recliner. On 5/29/19 at 7:40 AM, Nurse Aide M stated the resident had the wound for a month and staff applied barrier cream after personal cares. Nurse Aide M further stated the resident sat in his/her recliner most of the day and did not have a pressure relieving cushion in his/her recliner. On 6/3/19 at 3:45 PM, observation revealed a small area on the resident's left gluteal fold which measured 0.75 cm x 0.75 cm and slight pink around the area, with no dressing. Further observation revealed Administrative Nurse D applied barrier cream to the wound and stated he/she would contact the physician for different treatment orders. On 5/30/19 at 3:30 PM, Administrative Nurse D stated the cushion in the resident's wheelchair should be moved to the recliner when he/she was transferred from wheelchair to recliner. Administrative Nurse D had not seen the wound recently, but thought it was healed. On 6/3/19 at 11:09 AM, Resident #39 stated he/she received a new cushion in his/her wheelchair the previous day and would like a different treatment to his/her bottom because it was sore and rated the pain at a 7 (scale 0-10) when seated. The facility's Wound Prevention and Management policy, dated 12/18, documented if there was an identified risk present, intervention were implemented and documented in the care plan. Resident's utilizing a wheelchair as a mode of transportation will have a pressure reducing cushion and a pressure redistribution mattress would be used on all residents at risk. The (DON) Director of Nursing or designee would complete a push tool until the wound was healed, review and revise the care plan with each weekly review and be responsible for completing weekly rounds. The facility failed to provide interventions to prevent the development of an open area on Resident #39's buttocks, who was identified at risk for pressure ulcers and had a history of [REDACTED].

The facility had a census of 51 residents. The sample included 17 residents, with 5 reviewed for nutrition. Based on observation, record review, and interview the facility failed to adequately monitor weights and nutritional intake to prevent significant weight loss for 1 of 5 sampled residents. (#23) Findings Included: - Resident 23's physician order [REDACTED]. The admission (MDS) Minimum Data Set, dated dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status score of 2 (severely impaired cognition), inattention, and altered level of consciousness. The MDS recorded the resident required staff assistance with eating, weighed 169 (lbs) pounds, and received a mechanical altered (finely chopped to assist chewing and/or swallowing) and therapeutic diet. The MDS further recorded the resident was at risk for the development of pressure ulcers and had (MASD) Moisture Associated Skin Damage (inflammation or skin erosion caused by prolonged exposure to a source such as urine, stool, sweat, or wound drainage). The 3/19/19 admission (CAA) Care Area Assessment for nutrition recorded the resident received a mechanical altered and therapeutic diet. The care plan, dated 3/29/19, recorded the resident was at risk to lose weight due to his/her disease process, and directed staff to monitor the resident's weight and nutritional status. The care plan recorded the resident received a regular diet with regular fluid consistency, and directed staff to cue and assist the resident as needed at meals. The resident's weight record documented the following weights: 3/12/19 169.4 lbs - admission 3/21/19 165.2 lbs 3/27/19 160.0 lbs 4/05/19 163.4 lbs 5/22/19 151.8 lbs (11.6 lbs or 7.1% significant weight loss in 47 days) The 04/08/19 (RD) Registered Dietician Note recorded the resident weighed 163.4 lbs, received a regular diet with regular liquids, and his/her average meal intake was 50-75%. The note recorded the RD recommended fortified food at each meal, and fortified snacks 2 times a day. The note directed staff to monitor the resident's weight and notify the RD as needed. The facility's (MONTH) 2019 meal intake record documented the following: 41 times, refused or 0% 21 times, 0-25% 19 times, 26-50% 9 times, 51-75% 0 times, 76-100% The facility's (MONTH) 2019 snack of choice record documented the resident refused or staff failed to document 59 of 90 snacks. The facility's (MONTH) 2019 (5/01 - 5/28) meal intake record documented the following: 42 times, refused or 0% 21 times, 0-25% 19 times, 26-50% 9 times, 51-75% 0 times, 76-100% The facility's (MONTH) 2019 (5/01-5/28) snack of choice record documented the resident refused or staff failed to document 63 of 81 snacks. The 4/10/19 at 4:00 PM, progress note recorded the resident was discharged from (OT) Occupational Therapy and (PT) Physical Therapy due to recent declines in his/her (ADL) Activity of Daily Living function, and not improving with therapy services. The 4/14/19 at 4:42 PM, progress note recorded the resident coughed after drinking liquids. The 5/28/19 at 9:51 AM, dietary progress note recorded the resident had a recent weight loss, his/her average meal intake was 38%, and staff would notify the RD for recommendations. The 5/30/19 RD progress note recorded the resident's appetite recently decreased, and the resident had a 7.1% weight loss since his/her last weight. The progress note recorded the resident received a regular diet with regular liquids, fortified foods at meals and house shakes 2 times a day. The progress note recorded staff notified the physician for nutritional supplements for wound healing, and directed staff to weigh the resident weekly. On 5/29/19 at 12:38 PM, observation revealed the resident sat in a wheelchair at the dining table, the resident was served hamburger steak with mushroom gravy, hashbrowns, green beans, and a small glass of water, no supplement was served. Staff provided the resident extensive assistance for the resident to eat and drink. Continued observation revealed the resident coughed multiple times during the meal and ate a few bites. On 5/30/19 at 8:21 AM, observation revealed the resident sat in a wheelchair at the dining table, and was served 240 cc of water, 180 cc of orange juice, pancakes, scrambled eggs and a sausage patty. Staff provided the resident extensive assistance for the resident to eat and drink. Continued observation revealed the resident coughed multiple times during the meal and ate approximately 25%. On 5/30/19 at 10:09 AM, observation revealed the resident sat in a wheelchair in his/her room, and staff placed a health shake on the overbed table next to the wheelchair. Continued observation revealed staff did not assist the resident and the resident made no attempts to drink his/her supplement. On 5/30/19 at 9:16 AM, Dietary staff BB stated the resident appetite was poor and he/she eats less than 50% at meals, nursing was to provide a snack but stated he/she was unsure if staff monitored snack intake. Dietary staff BB also stated nursing staff monitored the resident weights and staff notified the RD if the resident had a weight loss. On 5/30/19 at 9:26 AM, Nurse Aide R stated the resident required extensive staff assistance with all ADLs, including eating. Nurse Aide R stated the resident had a poor appetite, and staff encouraged the resident to eat and drink. Nurse Aide R further stated staff recorded the delivery of snacks, but not the intake. On 5/30/19 at 10:05 AM, Nurse Aide Q stated the resident recently required more assistance at meals, and the resident's appetite had decreased. Nurse Aide Q stated the resident was coughing more when drinking fluids, and he/she reported to the nurse. Nurse Aide Q stated staff delivered snacks to the residents between meals, but did not record the snack intake. On 6/03/19 at 10:09 AM, Administrative Nurse D stated staff recently reported the resident required more assistance with eating and drinking, his/her appetite decreased, and the resident was coughing and having more difficulty swallowing at meals. Administrative Nurse D stated the resident was a risk for weight loss and should be weighed weekly. On 6/5/19 at 9:40 AM, Dietary Consultant II stated the resident should have been weighed more frequently to monitor the resident's weight. Verified on 5/28/19 med pass was to be provided at snack time and bedtime. Dietary Consultant II verified the resident has had a significant weight loss. The facility's undated Weight Assessment and Intervention policy directed staff to identify residents with nutrition risk and/or changes in condition, and closely monitor the resident's weight and nutritional status. The policy directed staff to notify the RD and physician when a resident had significant weight loss. The facility failed adequately monitor weights and nutritional intake to prevent significant weight loss for Resident #23, placing the resident at risk for continued weight loss.

The facility had a census of 45 residents. The sample included 3 residents, of which 3 were reviewed for abuse. Based on observation, interview, and record review the facility failed to implement policies and procedures to protect residents and prevent abuse after Medication Aide M grabbed Resident #1's wrist, which caused bruising. Nurse G witnessed the incident and stated they did not report the incident to their supervisor until the next day and Medication Aide M continued working his/her shift. This deficient practice placed the residents in the facility in immediate jeopardy. (#1) Findings included: - Resident #1's 14-day (MDS) Minimum Data Set assessment, dated 9/26/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15, indicating intact cognition and no behaviors. The MDS recorded the resident required limited assistance of 1 staff for transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, limited assistance with setup help only for bathing, supervision of 1 staff for bed mobility, and supervision with setup help only for eating and personal hygiene. The MDS recorded the resident's balance was steady at all times, used a walker for mobility, was occasionally incontinent of bladder, and always continent of bowel. The MDS recorded the resident received (PRN) as needed pain medications, and occasionally had pain, rating 6 (scale 0-10, 0 being no pain, 10 being terrible pain). The 9/20/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident required supervision and set up help for eating, limited assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, hygiene and bathing. The CAA recorded the resident was not steady but able to stabilize self with staff assistance for ambulation, transfers, and was able to make needs known. The behavioral CAA did not trigger. The 9/19/18 ADL care plan recorded the resident required staff assistance with ADLs related to weakness. The care plan recorded the resident required more staff assistance if he/she had pain, including one staff assistance for dressing, setup help for eating, bed mobility, and grooming needs, non-weight bearing assistance with transfers and toileting, and he/she used a walker for ambulation. The care plan lacked behavior monitoring or interventions prior to the 12/11/18 incident. The 12/11/18 at 9:20 PM, behavior nurse's note documented the resident displayed threatening behaviors towards staff, resident yelled, cussed, attempted to hit staff with his/her walker, and attempted to go into other resident's rooms looking for staff. Once the resident found staff in another resident's room, he/she yelled and demanded his/her pain medications. The note documented around 9:15 PM, the resident came out of his/her room looking for Nurse G to get his/her pain medication. The note documented the resident yelled and stated he/she had not received any pain medication all day. When staff reassured the resident that he/she received pain medication at supper time, the resident yelled at staff and stated he/she had not had any pain medications, that we were all idiots, and lied to him/her. The note recorded Nurse G and Medication Aide M explained to the resident he/she received his/her pain medication, but the resident stormed off to his/her room, came back later, and attempted to enter other resident's rooms looking for staff and demanded his/her pain medications. The note documented the resident came to his/her room door, and once he/she saw staff members, yelled for his/her medication, then got very angry, lifted his/her walker, and attempted to hit staff members. The note recorded Medication Aide M grabbed the resident's wrist while Nurse G took the resident's walker away to where he/she could not hit staff with it. The note documented Nurse G and Medication Aide M explained to the resident that he/she needed to calm down, go to his/her room, and wait for Nurse G to bring his/her pain medication. The note recorded the resident turned around, stomped off towards his/her room and refused to take his/her walker when Medication Aide M offered it to him/her. The note documented the resident walked to the TV lounge and sat in a chair, pouted about how staff were idiots and were not treating him/her right. The note documented Nurse G later administered the resident's medication with his/her other bedtime medication, and upon entering the resident's room, the resident stated to Nurse G, Is that my pain pills you b****? The note documented Nurse G placed the resident's medications on his/her table and left as the resident was taking his/her medications, the resident had no further behaviors that night. The note documented staff notified the resident's physician that morning and Administrative Nurse D, who directed Nurse G to chart all behaviors that were related to the resident not getting what he/she wanted and what he/she did in relation to him/her getting or wanting his/her pain medication. The 12/12/18 at 12:09 AM behavior nurse's note documented the resident displayed threatening behavior, yelled, cursed, and attempted to hit staff with his/her walker. The note documented at 9:15 PM the resident came down the hallway yelling for Nurse G to give him/her pain medication, and told staff they were idiots for not giving his/her medication in a timely manner, I never got a pain pill at supper! The note documented staff reaffirmed the resident that he/she received a pain pill at supper. The note documented Medication Aide M grabbed the resident's wrists and the resident dropped his/her walker, and Medication Aide M told the resident to go to his/her room. The note documented the resident stomped off without his/her walker and called Medication Aide M a big giant bully. Medication Aide M followed the resident with his/her walker, but the resident refused to take it, then sat down in the TV room, pouted, and told Medication Aide M how stupid staff and the facility rules were. The 12/12/18 at 12:26 PM, nurse's note documented while staff assisted the resident to the bathroom, the resident showed the staff member his/her bruises on his/her right forearm, measuring 8 (cm) centimeters x 4 cm, and 2.5 cm x 2.5 cm. The note documented the resident stated staff grabbed him/her and drug him/her to a chair out front, and he/she was upset with the staff member because they kept telling the resident he/she would get his/her pain medications, but it was getting late. The note documented the resident stated he/she tried to use the walker to hit staff, and they took it away from him/her. The 12/12/18 at 1:05 PM, nurse's note documented the resident stated he/she was very upset with staff last night, about wanting his/her pain medication. The note documented the resident stated he/she was going to other resident's rooms looking for staff, then tried hitting the staff members with his/her walker. The note documented the resident stated staff grabbed his/her wrist, and then took away his/her walker, noted 2 bruises above the resident's right wrist measuring 8 cm x 4 cm and 2.5 cm x 2 cm. Staff notified the residents representative, physician, and (DON) Director of Nursing. The 12/13/18 at 5:32 PM, nurse's note documented the resident's physician responded, stating the resident needed a behavioral health evaluation, either inpatient or outpatient, and asked if there was any other explanation for the bruises on the resident's forearm. Review of the resident's behavior monitoring from (MONTH) 1-17 recorded the resident displayed behaviors of wandering and abusive language on the night shift prior to 12/11/18. The 12/12/18 skin assessment recorded the following: left knee (front) abrasion measuring 3 cm x 2.2 cm right upper arm bruising measuring 8 cm x 4 cm right hand (back) bruising measuring 2.5 cm x 2 cm left forearm bruising measuring 1 cm x 0.8 cm On 12/17/18 at 4:45 PM, observation revealed the resident ambulated with his/her walker, to the dining room for supper, gait and balance steady, and the resident joked with the surveyor as he/she walked by. Per the facility's witness statement made by Medication Aide M, dated 12/18/18, Medication Aide M documented he/she and Nurse G were on the 200 Hall checking the residents, when Resident #1 came towards us yelling and demanding he/she wanted his/her medications. Medication Aide M documented both he/she and Nurse G told Resident #1 that he/she would get his/her medication when Nurse G got to him/her. Medication Aide M documented Resident #1 yelled, I haven't had any pain pills for a long time. I want my pills NOW!! raised his/her walker to throw at Medication Aide M and Nurse G when Medication Aide M grabbed him/her by the wrist and told Resident #1 to put his/her walker down and calm down. Medication Aide M documented Resident #1 dropped the walker and twisted his/her arms to remove himself/herself. Medication Aide M stated he/she released Resident #1's hands and Resident #1 raised his/her arm as if to strike Medication Aide M, so Medication Aide M stated, Resident #1 you need to calm down, you are over-reacting to this. Resident #1 said, Over-reacting? You people are idiots and you're always making some excuse why I can't have my pills! I WANT THEM NOW!! Medication Aide M documented he/she and Nurse G told Resident #1 to lower his/her voice and go to his/her room. Resident #1 stomped off without his/her walker toward his/her room. Medication Aide M documented he/she followed Resident #1 with his/her walker telling Resident #1 he/she needed to use it to walk. Resident #1 replied, Shove it up your a**. Medication Aide M documented he/she told Resident #1 to sit down in the front sitting room and calm down. Resident #1 stated to Medication Aide M, You're nothing but a big ole bully! Medication Aide M documented he/she attempted to explain to Resident #1 that he/she was only allowed a certain number of pain pills and at a certain time. Medication Aide M documented Resident #1 would not listen, and stated, You people always come up with some excuse why you can't do your jobs and I am just tired of it. Medication Aide M documented he/she told Resident #1 he/she needed to calm down and lower his/her voice because other people were sleeping, Resident #1 stated, Oh to h*** with the other people, I want my pills NOW! Medication Aide M documented he/she walked away from Resident #1. On 12/17/18 5:25 PM, Administrative Staff A stated Medication Aide M finished working his/her night shift on 12/11/18, and was suspended on 12/12/18 after 5:30 PM. On 12/18/18 at 8:23 AM, Administrative Staff A stated staff did not follow the policy, he/she was not informed of the incident until 12/12/18 around 5:00 PM, and Medication Aide M was not immediately sent home. On 12/18/18 at 8:30 AM, Administrative Nurse D stated he/she was first informed about the incident from day shift staff on 12/12/18 around 1:00 PM. Administrative Nurse D stated night shift staff reported the incident to the day shift, and day shift staff filled out a staff to resident risk management report. Administrative Nurse D stated the incident was initially explained to him/her as a resident to staff altercation, but after reading the risk management report, realized it was a staff to resident abuse situation. Administrative Nurse D stated after he/she read the risk management report, he/she immediately reported it to Administrative Staff A. Administrative Nurse D stated he/she did a full body skin assessment on the resident on 12/12/18. Administrative Nurse D stated Nurse G did not follow the policy, he/she should have sent Medication Aide M home and immediately notified the DON and Administrator. On 12/18/18 at 10:58 AM, Nurse G stated on 12/11/18 he/she passed medications on the 100-200 Hall when Resident #1 approached him/her and stated he/she had not received his/her supper medication. Nurse G stated he/she checked the (MAR) Medication Administration Record [REDACTED]. Resident #1 became upset, returned to his/her room, and continued to state he/she had not received his/her pain medication at supper time. Nurse G stated about 5 minutes later, while he/she was in another resident's room, Resident #1 came back down the hallway, yelled and asked for pain medications again. Nurse G stated Medication Aide M told Resident #1, staff would assist him/her in a few minutes. Nurse G stated about 5-10 minutes later, he/she heard Resident #1 and Medication Aide M yelling, so Nurse G walked down the hallway and saw Resident #1 lift up his/her walker, so Medication Aide M and Nurse G intervened. Nurse G stated he/she observed Medication Aide M reached up and grabbed Resident #1's arms, Nurse G set the resident's walker down in front of him/her and Nurse G told Resident #1 he/she would be right with him/her, then Nurse G went into another resident's room. The facility's Abuse, Neglect, and Exploitation policy, dated (MONTH) (YEAR), documented abuse is the willful infliction injury, intimidation or punishment with resulting physical harm, pain or mental anguish. Any time a report of possible abuse, neglect or exploitation is made against an employee, that employee should be immediately sent home and suspended without pay by the person in charge until a thorough investigation can be conducted by the DON/Administrator. The resident involved shall be immediately assessed for injury, assured of protection from further harm, and monitored closely with both medical and social service intervention as indicated. All alleged violations involving abuse, neglect, exploitation or mistreatment, are to be reported immediately to the Administrator and/or their designated representative, the appropriate state agency, and when applicable, law enforcement. The facility failed to implement policies and procedures to protect residents and prevent abuse after Medication Aide M grabbed Resident #1's wrist, which caused bruising, and Nurse G failed to report and allowed the staff member to continue working the floor. This deficient practice placed the residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 12/18/18 after in-service of all staff on the abuse, neglect, and exploitation policy. The facility terminated the alleged perpetrator on 12/18/18. The deficient practice remains at a scope and severity of an F.

The facility had a census of 45 residents. The sample included 3 residents, of which 3 were reviewed for abuse. Based on observation, interview, and record review the facility failed to provide a safe environment free from abuse for 1 of 3 sampled resident, when Medication Aide M grabbed the resident's wrist, which caused bruising. Nurse G witnessed the incident and stated they did not report the incident to their supervisor until the next day and Medication Aide M continued working his/her shift. This deficient practice placed the resident in immediate jeopardy. (#1) Findings included: - Resident #1's 14-day (MDS) Minimum Data Set assessment, dated 9/26/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15, indicating intact cognition and no behaviors. The MDS recorded the resident required limited assistance of 1 staff for transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, limited assistance with setup help only for bathing, supervision of 1 staff for bed mobility, and supervision with setup help only for eating and personal hygiene. The MDS recorded the resident's balance was steady at all times, used a walker for mobility, was occasionally incontinent of bladder, and always continent of bowel. The MDS recorded the resident received (PRN) as needed pain medications, and occasionally had pain, rating 6 (scale 0-10, 0 being no pain, 10 being terrible pain). The 9/20/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident required supervision and set up help for eating, limited assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, hygiene and bathing. The CAA recorded the resident was not steady but able to stabilize self with staff assistance for ambulation, transfers, and was able to make needs known. The behavioral CAA did not trigger. The 9/19/18 ADL care plan recorded the resident required staff assistance with ADLs related to weakness. The care plan recorded the resident required more staff assistance if he/she had pain, including one staff assistance for dressing, setup help for eating, bed mobility, and grooming needs, non-weight bearing assistance with transfers and toileting, and he/she used a walker for ambulation. The care plan lacked behavior monitoring or interventions prior to the 12/11/18 incident. The 12/11/18 at 9:20 PM, behavior nurse's note documented the resident displayed threatening behaviors towards staff, resident yelled, cussed, attempted to hit staff with his/her walker, and attempted to go into other resident's rooms looking for staff. Once the resident found staff in another resident's room, he/she yelled and demanded his/her pain medications. The note documented around 9:15 PM, the resident came out of his/her room looking for Nurse G to get his/her pain medication. The note documented the resident yelled and stated he/she had not received any pain medication all day. When staff reassured the resident that he/she received pain medication at supper time, the resident yelled at staff and stated he/she had not had any pain medications, that we were all idiots, and lied to him/her. The note recorded Nurse G and Medication Aide M explained to the resident he/she received his/her pain medication, but the resident stormed off to his/her room, came back later, and attempted to enter other resident's rooms looking for staff and demanded his/her pain medications. The note documented the resident came to his/her room door, and once he/she saw staff members, yelled for his/her medication, then got very angry, lifted his/her walker, and attempted to hit staff members. The note recorded Medication Aide M grabbed the resident's wrist while Nurse G took the resident's walker away to where he/she could not hit staff with it. The note documented Nurse G and Medication Aide M explained to the resident that he/she needed to calm down, go to his/her room, and wait for Nurse G to bring his/her pain medication. The note recorded the resident turned around, stomped off towards his/her room and refused to take his/her walker when Medication Aide M offered it to him/her. The note documented the resident walked to the TV lounge and sat in a chair, pouted about how staff were idiots and were not treating him/her right. The note documented Nurse G later administered the resident's medication with his/her other bedtime medication, and upon entering the resident's room, the resident stated to Nurse G, Is that my pain pills you b****? The note documented Nurse G placed the resident's medications on his/her table and left as the resident was taking his/her medications, the resident had no further behaviors that night. The note documented staff notified the resident's physician that morning and Administrative Nurse D, who directed Nurse G to chart all behaviors that were related to the resident not getting what he/she wanted and what he/she did in relation to him/her getting or wanting his/her pain medication. The 12/12/18 at 12:09 AM behavior nurse's note documented the resident displayed threatening behavior, yelled, cursed, and attempted to hit staff with his/her walker. The note documented at 9:15 PM the resident came down the hallway yelling for Nurse G to give him/her pain medication, and told staff they were idiots for not giving his/her medication in a timely manner, I never got a pain pill at supper! The note documented staff reaffirmed the resident that he/she received a pain pill at supper. The note documented Medication Aide M grabbed the resident's wrists and the resident dropped his/her walker, and Medication Aide M told the resident to go to his/her room. The note documented the resident stomped off without his/her walker and called Medication Aide M a big giant bully. Medication Aide M followed the resident with his/her walker, but the resident refused to take it, then sat down in the TV room, pouted, and told Medication Aide M how stupid staff and the facility rules were. The 12/12/18 at 12:26 PM, nurse's note documented while staff assisted the resident to the bathroom, the resident showed the staff member his/her bruises on his/her right forearm, measuring 8 (cm) centimeters x 4 cm, and 2.5 cm x 2.5 cm. The note documented the resident stated staff grabbed him/her and drug him/her to a chair out front, and he/she was upset with the staff member because they kept telling the resident he/she would get his/her pain medications, but it was getting late. The note documented the resident stated he/she tried to use the walker to hit staff, and they took it away from him/her. The 12/12/18 at 1:05 PM, nurse's note documented the resident stated he/she was very upset with staff last night, about wanting his/her pain medication. The note documented the resident stated he/she was going to other resident's rooms looking for staff, then tried hitting the staff members with his/her walker. The note documented the resident stated staff grabbed his/her wrist, and then took away his/her walker, noted 2 bruises above the resident's right wrist measuring 8 cm x 4 cm and 2.5 cm x 2 cm. Staff notified the residents representative, physician, and (DON) Director of Nursing. The 12/13/18 at 5:32 PM, nurse's note documented the resident's physician responded, stating the resident needed a behavioral health evaluation, either inpatient or outpatient, and asked if there was any other explanation for the bruises on the resident's forearm. Review of the resident's behavior monitoring from (MONTH) 1-17 recorded the resident displayed behaviors of wandering and abusive language on the night shift prior to 12/11/18. The 12/12/18 skin assessment recorded the following: left knee (front) abrasion measuring 3 cm x 2.2 cm right upper arm bruising measuring 8 cm x 4 cm right hand (back) bruising measuring 2.5 cm x 2 cm left forearm bruising measuring 1 cm x 0.8 cm On 12/17/18 at 4:45 PM, observation revealed the resident ambulated with his/her walker, to the dining room for supper, gait and balance steady, and the resident joked with the surveyor as he/she walked by. Per the facility's witness statement made by Medication Aide M, dated 12/18/18, Medication Aide M documented he/she and Nurse G were on the 200 Hall checking the residents, when Resident #1 came towards us yelling and demanding he/she wanted his/her medications. Medication Aide M documented both he/she and Nurse G told Resident #1 that he/she would get his/her medication when Nurse G got to him/her. Medication Aide M documented Resident #1 yelled, I haven't had any pain pills for a long time. I want my pills NOW!! raised his/her walker to throw at Medication Aide M and Nurse G when Medication Aide M grabbed him/her by the wrist and told Resident #1 to put his/her walker down and calm down. Medication Aide M documented Resident #1 dropped the walker and twisted his/her arms to remove himself/herself. Medication Aide M stated he/she released Resident #1's hands and Resident #1 raised his/her arm as if to strike Medication Aide M, so Medication Aide M stated, Resident #1 you need to calm down, you are over-reacting to this. Resident #1 said, Over-reacting? You people are idiots and you're always making some excuse why I can't have my pills! I WANT THEM NOW!! Medication Aide M documented he/she and Nurse G told Resident #1 to lower his/her voice and go to his/her room. Resident #1 stomped off without his/her walker toward his/her room. Medication Aide M documented he/she followed Resident #1 with his/her walker telling Resident #1 he/she needed to use it to walk. Resident #1 replied, Shove it up your a**. Medication Aide M documented he/she told Resident #1 to sit down in the front sitting room and calm down. Resident #1 stated to Medication Aide M, You're nothing but a big ole bully! Medication Aide M documented he/she attempted to explain to Resident #1 that he/she was only allowed a certain number of pain pills and at a certain time. Medication Aide M documented Resident #1 would not listen, and stated, You people always come up with some excuse why you can't do your jobs and I am just tired of it. Medication Aide M documented he/she told Resident #1 he/she needed to calm down and lower his/her voice because other people were sleeping, Resident #1 stated, Oh to h*** with the other people, I want my pills NOW! Medication Aide M documented he/she walked away from Resident #1. On 12/17/18 5:25 PM, Administrative Staff A stated Medication Aide M finished working his/her night shift on 12/11/18, and was suspended on 12/12/18 after 5:30 PM. On 12/18/18 at 8:30 AM, Administrative Nurse D stated he/she was first informed about the incident from day shift staff on 12/12/18 around 1:00 PM. Administrative Nurse D stated night shift staff reported the incident to the day shift, and day shift staff filled out a staff to resident risk management report. Administrative Nurse D stated the incident was initially explained to him/her as a resident to staff altercation, but after reading the risk management report, realized it was a staff to resident abuse situation. Administrative Nurse D stated after he/she read the risk management report, he/she immediately reported it to Administrative Staff A. Administrative Nurse D stated he/she did a full body skin assessment on the resident on 12/12/18. Administrative Nurse D stated Nurse G should have sent Medication Aide M home and immediately notified the DON and Administrator. On 12/18/18 at 10:58 AM, Nurse G stated on 12/11/18 he/she passed medications on the 100-200 Hall when Resident #1 approached him/her and stated he/she had not received his/her supper medication. Nurse G stated he/she checked the (MAR) Medication Administration Record [REDACTED]. Resident #1 became upset, returned to his/her room, and continued to state he/she had not received his/her pain medication at supper time. Nurse G stated about 5 minutes later, while he/she was in another resident's room, Resident #1 came back down the hallway, yelled and asked for pain medications again. Nurse G stated Medication Aide M told Resident #1, staff would assist him/her in a few minutes. Nurse G stated about 5-10 minutes later, he/she heard Resident #1 and Medication Aide M yelling, so Nurse G walked down the hallway and saw Resident #1 lift up his/her walker, so Medication Aide M and Nurse G intervened. Nurse G stated he/she observed Medication Aide M reached up and grabbed Resident #1's arms, Nurse G set the resident's walker down in front of him/her and Nurse G told Resident #1 he/she would be right with him/her, then Nurse G went into another resident's room. The facility's Abuse, Neglect, and Exploitation policy, dated (MONTH) (YEAR), documented abuse is the willful infliction injury, intimidation or punishment with resulting physical harm, pain or mental anguish. Any time a report of possible abuse, neglect or exploitation is made against an employee, that employee should be immediately sent home and suspended without pay by the person in charge until a thorough investigation can be conducted by the DON/Administrator. The resident involved shall be immediately assessed for injury, assured of protection from further harm, and monitored closely with both medical and social service intervention as indicated. All alleged violations involving abuse, neglect, exploitation or mistreatment, are to be reported immediately to the Administrator and/or their designated representative, the appropriate state agency, and when applicable, law enforcement. The facility failed to provide Resident #1 with an environment free from abuse, when Medication Aide M grabbed Resident #1's wrist, which caused bruising. This deficient practice placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 12/18/18 after in-service of all staff on the abuse, neglect, and exploitation policy. The facility terminated the alleged perpetrator on 12/18/18. The deficient practice remains at a scope and severity of a G.

The facility had a census of 62 residents. The sample included 4 residents, of which 3 were reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to assess and provide timely and effective interventions to prevent the development of skin breakdown for 1 of 3 residents reviewed for pressure ulcers. Resident #1 developed large blisters 5 days after admission to the facility and large open areas of skin developed within 8 days of admission. Findings included: - The facility admitted Resident #1 on 7/12/17. The admission (MDS) Minimum Data Set assessment, dated 7/18/17, documented the resident as cognitively impaired, with a (BIMS) Brief Interview for Mental Status score of 6. He/she required supervision with eating, limited staff assistance with dressing, hygiene, extensive assistance of 2 staff with toileting, bed mobility, transfers, and did not walk. The assessment documented the resident had a urinary catheter (hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), had no pressure ulcers or other skin problems, and staff provided pressure relief devices to the resident's chair and bed. The 7/18/17 (CAA) Care Area Assessment summary for urinary incontinence, catheter, or pressure ulcers stated the resident discharged to the hospital on [DATE]. The CAAs documented no further information. The initial care plan, dated 7/12/17, for impaired skin integrity, directed staff to provide assistance with bed mobility, transfers, dressing, hygiene, toileting, and catheter care. The care plan lacked staff direction for care of the rashes observed on 7/12/17. The 7/20/17 update documented the rashes changed to blister areas, 1 on the left inner thigh and 2 on the left anterior (front) thigh. The 7/21/17 care plan update directed staff to clean the blistered area with water and antibacterial soap, cover with [MEDICATION NAME] (dry non-absorbent dressing pad that will not stick to the wound), and secure with tape until new physician orders [REDACTED]. The 7/12/17 hospital discharge summary documented: towards the end of the hospital stay the resident had [MEDICAL CONDITION] (occurs when urine cannot drain) which required catheterization. Several attempts were made to discontinue the catheter, without success, and the catheter remained in. The summary lacked any mention of skin issues or impairment on the resident's thighs. The facility's 7/12/17 admission screen documented the resident's left anterior thigh had a rash (6 (cm) centimeters by 3 cm), the left inner thigh had a rash (6 cm by 7 cm), and the right stomach area had a rash. The 7/12/17 Braden Scale (for predicting pressure ulcer risk) documented the resident had a score of 15, indicated the resident at risk for pressure ulcers. (15-18=at risk, 13-14=moderate risk, 10-12=high risk, 9 or below = very high risk) The 7/17/17 skin observation tool (5 days after admission) documented blisters on the resident's left thigh, measuring 5 cm by 2 cm, and inner left thigh, measuring 5 cm by 3.5 cm. The note documented both blisters were fluid filled. The 7/18/17 facility fax notified the physician of the blisters (the day after staff found the blisters). The 7/18/17 at 6:33 PM, nurse's notes documented the resident continued to have fluid-filled blisters on both upper thighs (even though previous documentation recorded blisters to the resident's left thigh) and staff applied skin prep (protective dressing forms a barrier between the patient's skin and adhesives to help preserve skin integrity) to the areas. The medical record lacked assessment of the resident's blisters on 7/19/17. The 7/19/17 Braden score 15, the same as 7/12/17 (at risk). The 7/20/17 skin assessment documented the following: #1 wound: left anterior thigh (acquired 7/19/17) blister with granulation tissue (healing process in which lumpy, pink tissue containing new connective tissue) present, dry, no drainage, and no odor. Measured 0.7 cm x 4 cm x 0 cm, irregular shaped with rolled edges (popped blister), and no inflammation. The assessment documented no treatment plan in place, family notified on 7/19/17 (2 days after the blisters noted). #2 wound: left anterior thigh blister with granulation, 25% slough (dead tissue), no drainage, no odor, and measured 5 cm x 17 cm x 0 cm, with irregular/rolled edges (popped blister). No treatment plan in place #3 wound: inner left thigh blister with granulation tissue, moist, no drainage or odor, 5.5 cm x 3 cm x 0 cm, irregular/rolled edges (popped blister), no inflammation, and no treatment plan in place. The 7/20/17 at 10:15 AM, nurse's note documented staff noted blood and raw areas (no measurements documented) on the resident's genital(s) and called and left message for the physician. At 1:45 PM, nurse's notes documented staff received, in response to the phone call, an order to change the resident's catheter, drain his/her fluid filled blisters, and apply triple antibiotic ointment to the open areas. (3 days after the staff first noted the large blisters) The July 2017 (MAR) Medication Administration Record documented, on 7/21/17 the above order was initiated (4 days after the staff first noted the blisters). No other skin treatments were documented on the MAR. The 7/22/17 at 7:33 AM, nurse's note documented the wound on the left inner, upper thigh was green in color. The medical record lacked any further documentation of physician notification regarding the large open blisters, one with green color (potential infection). The 7/24/17 at 8:22 PM, nurse's note documented, at approximately 3:00 PM, the resident had a fairly large emesis (vomit). The note documented staff notified the physician, who gave a verbal order to ensure the resident had nothing by mouth for 4 hours and to send the resident to the emergency room if the emesis continued. The note further documented the resident started having diarrhea (liquid stool) and his/her temperature rose. Shortly after, the resident became cold, sweaty, and felt he/she could not breathe. The resident's oxygen level was 88% (normal is 90-100%) on room air. The note documented staff called (EMS) Emergency Medical Services at 7:00 PM, and EMS transported the resident to the hospital at 7:20 PM. The 7/24/17 at 11:05 PM, hospital skin assessment documented abrasions on the left thigh, inner left thigh, right mid abdomen, and genitals. The 7/25/17 at 11:13 AM, physical therapy evaluation for wound care documented the resident had various leg and genital ulcerations. The evaluation documented the resident had a catheter and the ulcerations are new from his/her last admission, particularly the left anterior thigh ulcer. The largest and most inflamed area is the left anterior thigh at 15 cm x 8 cm x .2 cm. The left inner thigh wound had eschar (dry, dark scab) measured at 4 cm x 2 cm. The right inner thigh had a small ulcer measured 1.5 x .6 cm x .1 cm deep. The physical therapy note documented the therapist performed sharp debridement (removal of damaged tissue) done on the left anterior thigh to remove a 1 cm x 1 cm dried, yellow slough. The skin breakdown on the genital(s) was approximately 2 cm x 2 cm. The therapist documented the wounds seemed to be related to positioning of the catheter tubing for long periods of time. On 8/2/17 at 12:40 PM, observation revealed Nurse G observed the wounds on the resident's thighs. On the inner left thigh the resident had an irregularly shaped, oblong wound approximately 7 cm x 2 cm wide x 0.2 deep, with slough and granulation visible. The resident had a linear shaped, oblong wound, approximately 17 cm x 2.5 cm wide, on the front of the left thigh, and 3 other ulcers near the large oblong ulcer, each approximately 1.2 cm x 0.5 cm. On 8/1/17 at 5:10 PM, Administrative Staff A stated the facility admitted the resident with scars on his/her thighs, possibly where catheter tubing had lain, and a rash on his/her abdomen and inner thigh. Administrative Staff A stated shortly after the resident came, the blisters developed, then popped, and staff informed the physician they thought it was a skin reaction to the catheter. On 8/2/17 at 11:30 AM, Physical Therapist H stated the resident's previous wounds had been healed prior to his/her admission to the nursing facility on 7/12/17. Physical Therapist H stated the resident returned to the hospital on [DATE], from the nursing facility, with deep tissue wounds. Physical Therapist H stated the wounds did not appear to be from a spill and were linear across his/her left thigh, where the catheter tubing would lie. Physical Therapist H stated the wound on inside of the resident's left thigh was black, with eschar, 4.5 cm x 1.5 wide, and he/she had a wound on the genital(s). Physical Therapist H stated the resident had no signs of rash or blisters and currently had a catheter in. On 8/2/17 at 11:47 AM, hospital Nurse J stated, upon admission to the hospital, the resident's left thigh, right under the catheter tubing, had a wound with yellowish skin with some eschar. Nurse J stated the catheter leg strap was slimy when removed and the right groin area wound had a top layer of skin missing. On 8/2/17 at 1:18 PM, Nurse Aide F stated the resident had blisters on his/her thigh and when one popped, he/she immediately informed the nurse. Nurse Aide F stated the resident had leg strap to hold the catheter tubing in place, and large blisters inside his/her thighs, where strap was. Nurse Aide F stated the leg strap was not tight. On 8/2/17 at 4:03 PM, Nurse E stated on admission the resident had redness on his/her thighs and a leg strap for the catheter tubing. Nurse E stated later when he/she took care of the resident again, he/she noted the leg strap not placed anymore and staff performed daily dressing changes on his/her thighs. Nurse E stated on 7/24/17 he/she thought the wounds looked better, without infection or inflammation. Nurse E stated he/she sent the resident to the emergency room for vomiting, sweating, chills, and oxygen level dropping to 88%. On 8/2/17 at 4:17 PM, Nurse C (wound nurse) stated he/she did not observe the resident's skin rashes at admission, and did not assess the resident until 7/20/17 (8 days after admission and 3 days after the large blisters formed). Nurse C stated he/she observed 2 scars similar to the blisters, a long blister, half fluid filled (had popped), a smaller popped blister proximal (above the large one), and the inner thigh had a completely fluid filled blister. Nurse C stated the resident had no skin breakdown on the back of his/her legs. Nurse C stated the resident had a catheter tubing leg strap. Nurse C stated staff discussed the blisters, removed the leg strap, and notified the physician on 7/20/17. Nurse C stated when he/she first observed the wound on 7/20/17, no treatment had been initiated for the resident's blisters, which were first noted on 7/17/17. Nurse C stated the nurse on duty called the physician for wound care orders. On 8/3/17 at 9:30 AM, Nurse D stated the resident was admitted with areas that appeared to be mottling (uneven discolored patches of skin) on his/her thighs and abdomen. Nurse D stated the area on the inner left thigh, and right abdomen looked the same, and some of the skin was bright red in patches. Nurse D verified staff did not initiate interventions to protect the resident's skin upon admission to the facility. Nurse D stated when the resident developed blistered areas on the inner thighs on both legs, he/she received an order to change the resident's catheter, and he/she removed the leg strap, and covered the thigh blister, which had drained. Nurse D stated he/she covered the wound with a dressing and taped the catheter tubing to the dressing. Nurse D stated he/she passed the wound information to the next shift by mouth, but did not document the intervention. Nurse D verified the facility lacked documentation the physician was notified on 7/17/17, when staff first noted the large blisters. On 8/3/17 at 10:20 AM, Administrative Nurse B verified staff should have notified the physician when they found the large blisters and when the nurse observed green color in the wound. On 8/8/17 at 1:20 PM, Physician L stated catheter tubing should not be allowed to lie on compromised skin and staff should have moved the catheter tubing, even a few inches, so it did not lie on the resident's blistered area. The facility's undated catheter care policy instructed staff to check for leaks and excoriation around the insertion area, and wash the resident's perineal (genital) area with soap and water or personal wipes once each shift and as needed. The 7/12/17 physician's standing orders for ulcers instructed staff to follow facility protocol until further orders are obtained and call the physician for breaks in skin 5 centimeters and over for treatment orders. The facility's undated skin integrity policy documented the admitting nurse will complete a head to toe assessment and appropriate interventions for problems are to be implemented. The facility's undated pressure ulcer prevention policy documented intervention for prevention would be evaluated for appropriateness through care planning. Upon identification of skin impairment, nursing staff will implement facility protocol for treatment, notify the physician, and record the treatment on the medical administration record. Upon request the facility did not provide a protocol for skin treatment. The facility failed to assess and provide timely interventions to prevent the development of skin breakdown for Resident #1, who developed large blisters 5 days after admission, no treatment was documented until 4 days after the blisters were observed, and the blisters developed into wounds measured at 15 cm x 8 cm x .2 cm, 4 cm x 2 cm, and 2 smaller wounds. The facility placed the resident at risk for infection related to skin breakdown.

The facility had a census of 36 residents. The sample included 3 residents, who were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide necessary services and treatment to promote healing, prevent infection, and prevent new pressure ulcers from developing for 2 of 3 sampled residents. Resident #1 admitted to the facility on [DATE] with no pressure ulcers, and admitted to the hospital on [DATE] with seven Stage II (partial thickness loss of dermis presenting as a shallow wound) pressure ulcers, seven Stage III (full thickness tissue loss, subcutaneous fat may be visible) pressure ulcers and one suspected deep tissue injury, all which developed while he/she resided in facility. This deficient practice placed Resident #1 in immediate jeopardy. Resident #2 admitted to the facility with no pressure ulcers, and developed two areas of (MASD) moisture associated skin damage (general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture) while he/she resided in the facility. Findings Included: - The 2/10/17 signed physician orders [REDACTED]. (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbances, and abdominal aortic aneurysm (main blood vessel that supplies blood to the abdomen, pelvis, and legs, which becomes very large or balloons out) rupture repair. Resident #1's admission (MDS) Minimum Data Set assessment, dated 2/17/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 9 (moderately impaired cognition). The MDS recorded the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting, extensive assistance of 1 staff for locomotion on and off unit, dressing, eating, personal hygiene, and total assistance of 2 staff for bathing. The MDS further indicated the resident had a urinary catheter (a thin, sterile tube inserted into the bladder to drain urine), and was always incontinent of his/her bowels. The MDS documented the resident had no pressure ulcers, he/she was at risk for developing pressure ulcers, and used a pressure reducing device for his/her wheelchair and bed. The MDS lacked documentation the resident was on a turning and repositioning program. The MDS indicated the resident used a wheelchair for mobility. The 2/17/17 (CAA) Care Area Assessment for pressure ulcers documented the resident required extensive assistance of 2 staff members with bed mobility. The CAA also documented the resident was incontinent of his/her bowels, and was at moderate risk for developing pressure ulcers. The CAA lacked documentation of any skin impairment. The CAA lacked documentation the resident was on a turning and repositioning program. The 2/10/17 initial care plan revealed the resident had impaired skin on admission, but lacked documentation which described the skin impairment, interventions for treatment, and he/she refused cares. The 2/23/17 comprehensive care plan documented the resident was at risk for developing pressure ulcers, had a pressure reducing device for his/her chair and bed, and directed staff to complete weekly skin assessments. The care plan lacked documentation the resident had any skin impairment, or if he/she was on a turning and repositioning program. The comprehensive care plan lacked documentation the resident refused cares. The 3/4/17 updated care plan revealed the resident had actual impairment to his/her skin, described as moisture related damaged skin to the left gluteal cleft (groove between the buttocks) and scabbed areas on the tip of his/her left and right great toes. The care plan directed staff to apply antibiotic ointment to both great toes, and clean the left gluteal cleft wound with wound cleanser, pat dry, apply skin prep, bordered Hydrogel (dressing that is gel based and helps keep the wound moist, protects from infection and promotes healing) and secure the dressing with tape. The care plan directed staff to provide extensive assistance of two staff to turn and reposition the resident every 2 hours and as needed. The care plan lacked information of other areas of the resident's impaired skin, including the left lower leg, left calf, right hand, back, right gluteal fold, and sacrum (large triangular bone between the two hip bones). The care plan lacked documentation that the resident refused cares. The 2/10/17 admission summary documented the resident had tiny scabs on the tips of both of his/her great toes. The admission summary lacked documentation of other pressure ulcers. The admission Braden Scale assessment (a tool that helps assess a patient's risk of developing a pressure ulcer) dated 2/10/17, indicated the resident at moderate risk for developing pressure ulcers. The 2/14/17 weekly skin assessment documented the resident had the following: calloused (hard) area on the left great toe that measured 0.4 (cm) centimeters by 0.5 cm, diabetic blister and suspected deep tissue injury on the right great toe that measured 1.0 cm by 1.1 cm, and a moisture related area on the left gluteal fold that measured 0.3 cm by 0.5 cm. The 2/14/17 facility fax to the physician documented the resident had the following skin issues: 1. Abrasions to bilateral chin 7.3 (cm) centimeters by 3.0 cm, and 7.3 cm by 7.2 cm. The wound edges are irregular and wound beds have various areas of newly formed scabbing and dried blood. The drainage is minimal, none to sanguineous (bloody drainage) to serosanguineous (semi-thick reddish drainage). The note stated the resident's family reported he/she was on a ventilator while in the hospital. 2. Moisture/sheared area on the left gluteal cleft measured as 0.3 cm by 0.5 cm. The fax stated the facility requested treatment to cleanse the area with wound cleanser, pat dry, apply skin prep (a solution that forms a protective waterproof barrier to the skin) to the periwound (the skin surrounding the wound), apply bordered Hydrogel, secure with tape, and change the dressing daily. 3. The resident admitted with scabbed areas on his/her left great toe measured (0.4 cm by 0.5 cm), and right great toe measured (1.0 cm by 1.1 cm). The areas were not draining, with irregular wound edges, and redness of the periwound to the right great toe. The fax asked the physician how he/she would like to treat these areas. The physician's orders [REDACTED]. The 2/21/17 weekly skin assessment documented the resident had an open calloused area on his/her left great toe (measured 0.5 cm by 0.4 cm), and a diabetic blister on the right great toe that measured (0.9 cm by 1.0 cm.) The clinical record lacked evidence staff revised the care plan after identifying new skin concerns. The 2/22/17, nurses's note stated the physician's assistant examined the resident in the facility and directed the staff to discontinue the use of [MEDICATION NAME] powder (antifungal antibiotic used to treat skin infections caused by yeast) to the resident's feet. The note lacked documentation the physician's assistant addressed the resident's skin. The 2/28/17 weekly skin assessment documented the resident had a new moisture related area on his/her right buttock that measured 2.9 cm by 1.5 cm, moisture related areas on the left buttock that measured 4.0 cm by 2.5 cm and 3.5 cm by 2.0 cm, right lower leg abrasion that measured 1.9 cm by 2.9 cm, left great toe calloused area that measured 0.3 cm by 0.4 cm and a right great toe diabetic blister that measured 0.9 cm by 1.0 cm. The clinical record lacked evidence that staff revised the care plan after identifying new skin issues. The 3/7/17 weekly skin assessment documented the resident's left buttock wounds measured 3.0 cm by 2.0 cm and stated the other left buttock area was healed, the right lower leg abrasion measured 1.0 cm by 2.6 cm, the left great toe calloused area measured 0.5 cm by 0.5 cm, right great toe diabetic blister measured 1.2 cm by 1.3 cm, a new area on the resident's back left thigh that was moisture related measured 1.0 cm by 1.0 cm and the left gluteal fold area measured 1.0 cm by 1.0 cm. The clinical record lacked evidence that staff revised the care plan after identifying new skin conditions. The 3/7/17 at 12:27 PM, facility fax to the physician documented the resident's skin and moisture related skin damage, and requested the physician address the areas of concern and provide a treatment plan: [REDACTED] 1. Top of sacrum wound measured 1.3 cm by 0.5 cm with 90% slough (dead tissue, usually cream or yellow in color), 10 % granulation (tissue formed during wound healing) and minimal drainage. 2. Left buttock wound measured 3.0 cm by 2.0 cm, with beefy red granulation tissue and no drainage. 3. Left thigh wound measured 1.0 cm by 1.0 cm with beefy red granulation tissue and no drainage. 4. Low sacrum wound measured 2.0 cm x 0.7 cm, 90% slough, 10% granulation tissue and minimal drainage, right great toe with diabetic blister, stable, with intact eschar (dead tissue). 5. Left great toe with open callous area measured 0.5 cm by 0.5 cm with no current treatment. The 3/14/17 weekly skin assessment documented the left buttock wound measured 1.0 cm by 1.7 cm, the calloused area on the left great toe measured 1.7 cm by 2.0 cm, the diabetic ulcer on the right great toe measured 1.1 cm by 1.3 cm, the left gluteal fold area measured 0.4 cm by 0.6 cm. The clinical record lacked evidence that staff revised the care plan after identifying new skin concerns. The 3/14/17 at 1:18 PM, facility fax to the physician documented the resident had a diabetic blister (diagnosed by the facility wound nurse) to his/her left great toe, and requested he/she sign an order for [REDACTED]. The physician order, dated 3/15/17, directed staff to clean all areas of moisture associated skin damage on the resident's buttocks with wound cleanser or normal saline, pat dry, apply skin prep to the periwound, apply 2 inch by 3 inch bordered Hydrogel, cut slightly larger than the wound bed, and secure the dressing with Opsite (transparent, adhesive film with a wound measurement grid, used to provide a moist wound healing environment). The 3/21/17 weekly skin assessment documented the left buttock wound measured 0.5 cm by 0.2 cm, the left great toe calloused area measured 1.4 cm by 1.3 cm and the right great toe diabetic blister measured 0.5 cm by 1.4 cm. The assessment documented a new area of shearing on the resident's upper, mid back that measured 2.3 cm by 0.2 cm. The clinical record lacked evidence that staff revised the care plan after identifying new skin concerns. The 3/21/17 at 1:23 PM, facility fax to the physician documented staff notified the physician and requested him/her to review and sign for dressing change orders for shearing on the resident's mid back, to include: cleanse with normal saline or wound cleanser, pat dry, skin prep to the periwound hydrogel, secure with bordered dressing and change daily, The fax also documented the resident had a diabetic blister (diagnosed by the facility wound nurse) on his/her right great toe and requested orders to cleanse the area with normal saline or wound cleanser, pat dry, apply skin prep to the periwound, Elsatogel (highly absorbent wound dressing that will not dry out or stick to the wound) to the wound bed, and secure with absorption pad and tape. The note requested orders for treatment of [REDACTED]. The 3/21/17 physician's orders [REDACTED]. The 3/21/17 at 7:53 PM office/clinic note documented the physician examined the resident at the facility during nursing home rounds (39 days after admission). The note recorded the physician assessed the resident's skin and noted the scabs on his/her face have fully resolved, [MEDICAL CONDITION] in the lower extremity, no skin rashes, and anasarca (medical term used to describe the general swelling of the whole body, usually due to abnormal fluid retention in the tissues). The note lacked documentation addressing any pressure ulcers or open areas of the resident's skin. The 3/22/17 physician orders [REDACTED]. The 3/28/17 weekly skin assessment documented, the left great toe calloused area measured 1.2 cm by 1.1 cm, the right great toe diabetic blister measured 1.0 cm by 0.7 cm, and the mid back shearing area measured 0.6 cm by 1.5 cm. The assessment documented the wound on the left buttock had healed. The 3/29/17 physician's orders [REDACTED]. The 4/3/17 at 3:25 PM, nurse's note documented the resident had a red, painful, tender area on his/her left calf, with 4+ [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissue demonstrated by application of pressure to the swollen area with a finger which causes an indentation that persists for some time). The note documented the physician recommended staff send the resident to the emergency room to be assessed. The 4/3/17 at 6:32 PM, nurse's note documented staff spoke with the emergency room staff, and the resident had [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) in his/her left lower leg, and the physician ordered [MEDICATION NAME] (antibiotic), 300 (mg) milligrams, 1 tablet by mouth, every 8 hours for 10 days. The note documented the resident returned to the facility the same day. The 4/4/17 weekly skin assessment (3 days before the resident was admitted to the hospital) documented the right lower leg abrasion measured 0.9 cm by 0.4 cm, the left great toe calloused area measured 1.0 cm by 1.2 cm, the right great toe diabetic blister measured 1.0 cm by 0.8 cm, and the mid back sheared area measured 2.3 cm by 1.0 cm width by 0.2 cm depth. The assessment documented a new skin tear on the back of the resident's right hand that measured 4.9 cm in length. The 4/4/17 physician orders [REDACTED]. The 4/7/17 at 4:25 PM, nurse's note documented staff received notification from the physician's office of the resident's admission to the hospital. The 4/7/17 physician's office note documented the resident was seen for right leg pain and swelling. The noted documented the resident's skin was warm, dry and ashy in color. The note further documented the resident had a roughly 3 inch skin tear on his/her right hand with scabbing, a pressure ulcer on the mid [MEDICATION NAME] (mid to upper back), roughly 2 (mm) millimeter in diameter with a white colored center, Stage II right and left gluteal pressure wounds with [DIAGNOSES REDACTED]tous (redness or inflammation of the skin) centers, the right required debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) by the hospital physical therapist, the left great distal (away from the farthest point of origin or attachment) toe had a pressure wound with purulent (producing or containing pus) drainage and blood expressed, roughly 1mm in diameter; the right great distal toe has a pressure sore with [DIAGNOSES REDACTED]tous center and no exudate (fluid that leaks out of body vessels and tissues) that measured 0.5 mm in diameter; the lateral (pertaining to the side, away from the middle) has a pressure sore that was 1mm in diameter with a [DIAGNOSES REDACTED]tous center. There are other pressure sores noted on the physical therapy examination. The right anterior (front) leg has [DIAGNOSES REDACTED] and swelling noted. The physical therapy note, dated 4/7/17, documented the resident had multiple pressure injuries of multiple stages, listed as the following: Wound #1, left distal great toe, Stage III pressure ulcer. The wound appears to be due to continuous pressure from blankets over the toe. Wound #2, left lateral great toe, Stage II pressure ulcer. The wound appears to be due to continuous blankets over the toe. Wound #3, left lateral proximal lower leg, Stage II pressure ulcer. Wound #4, left posterior calf, suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister, due to damage of underlying soft tissue from pressure and/or shear). The wound is non-blanchable, unsure of the cause of pressure to this area. Wound #5, right distal great toe, Stage II pressure ulcer. The wound appears to be due to continuous pressure from blankets over the toe. Wound #6, right anterior lateral proximal lower leg, Stage II pressure ulcer. Wound #7, right anterior medical proximal lower leg, Stage II pressure ulcer. Wound #8, right dorsal (back) hand, Stage III pressure ulcer. The wound looks as if the resident's hand had been shut in an opening, such as in a door, or pinched in his/her wheelchair wheel. Wound #9, midline mid back on spinous process (bony projection off the posterior (back) of each vertebra), Stage III pressure ulcer. The wound appears to be due to decreased pressure to the area with an air floatation mattress. Wound #10, right inferior angle of scapula (shoulder blade), Stage II pressure ulcer. Wound #11, right lateral gluteal fold, Stage II pressure ulcer. The wound appears to be a pressure injury due to shearing forces over the ischial tuberosity (part of the hip bone). Wound #12, right medical gluteal fold, Stage III pressure ulcer. The wound appears to be a pressure injury due to shearing forces over the ischial tuberosity. Wound #13, midline of sacrum, Stage III pressure ulcer. The wound appears to be due to sacral sitting pressure. Wound #14, apex of sacrum, Stage III pressure ulcer. The wound appears to be due to sacral sitting pressure, this wound is just slightly left and inferior of the other sacral wound which is at midline. Wound #15, left gluteal fold, Stage II pressure ulcer. The wound appears to be a pressure injury due to shearing forces over the ischial tuberosity. The facility assessment and the hospital staff's assessment of the wounds is as follows: Left distal great toe was assessed as a calloused area by the facility and a stage 3 pressure ulcer by the hospital staff. Left lateral great toe was assessed as a calloused area by the facility and a stage 2 pressure ulcer by the hospital staff. Right distal great toe was assessed as a diabetic blister by the facility and a stage 3 pressure ulcer by the hospital staff. Midline back spinous process was assessed as shearing by the facility and a stage 3 pressure ulcer by the hospital staff. Right inferior angle of the scapula (shoulder blade) was not identified by the facility and was assessed as a stage 2 by the hospital staff. Left gluteal fold was assessed as moisture associated skin damage by the facility and a stage 2 pressure ulcer by the hospital staff. Right medical gluteal fold was assessed as moisture associated skin damage by the facility and a stage 3 pressure ulcer by the hospital staff. Midline sacrum was assessed as moisture associated skin damage by the facility and a stage 3 pressure ulcer by the hospital staff. Left aspect of the sacrum was assessed as moisture associated skin damage by the facility and a stage 3 pressure ulcer by the hospital staff. Left gluteal fold was assessed as moisture related skin damage by the facility and a stage 2 pressure ulcer by the facility. Right dorsal hand was assessed as a skin tear and bruising by the facility and a stage 3 pressure ulcer by the hospital staff. The hospital physical therapist note indicated the treatment plan included patient education, selective debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) and wound care. The 4/9/17 at 3:42 PM, hospital discharge summary documented the resident admitted with multiple pressure ulcers, and arterial insufficiently with ischemic (decreased supply of [MEDICATION NAME] blood to a body part) ulcer. The note further documented physical therapy was consulted for wound care. On 4/18/17 at 10:10 AM, Nurse B stated the resident was admitted to the facility on [DATE] with no pressure ulcers or open areas on his/her skin, except for some red areas on his/her buttocks, sacral area and small, scabbed areas on the tips of his/her right and left great toes. Nurse B verified all the resident's wounds were facility acquired. Nurse B stated he/she performed weekly skin assessments, documented measurements and described each wound. Nurse B stated he/she did not document any wound as pressure ulcers, and all the areas were from moisture associated skin damage, diabetic blisters, shearing or skin tears. Nurse B stated he/she faxed the resident's physician multiple times with wound information and provided a treatment plan and asked the physician to approve and sign the order for the treatment plan. Nurse B stated the physician saw the resident at the facility on 3/21/17, but he/she did not address any of the resident's wounds, and he/she did not think the physician assessed the wounds. Nurse B stated he/she had not worked as a wound nurse prior to February 2017, and the training he/she received for wound care consisted of a half day in-service with a certified wound nurse. Nurse B stated he/she assessed the resident's wounds and used his/her medical [DIAGNOSES REDACTED]. Nurse B stated he/she diagnosed the resident's left and right great toe wounds as diabetic blisters because of the resident's [DIAGNOSES REDACTED]. On 4/19/17 at 11:15 AM, Nurse Aide E stated the resident had sores on his/her bottom and toes, and the ones on his/her bottom looked horrible. Nurse Aide E stated staff was supposed to turn and reposition the resident every two hours, the resident would refuse at times, and stated we tried not to let him/her lay in bed all day. On 4/19/17 at 2:20 PM, Nurse F verified the resident admitted to the facility on [DATE], and the physician saw him/her on rounds at the facility on 3/21/17, but the clinical note did not address the resident's wounds. Nurse F verified there were no further physician office notes for the resident. On 4/17/17 at 3:32 PM, Administrative Nurse A stated he/she could not comment on the resident's wounds because he/she never saw them. Administrative Nurse A stated he/she felt the wound nurse provided appropriate wound assessment and care of the resident, and staff did everything they could for the resident. On 4/17/17 at 4:15 PM, Hospital Staff I verified he/she was consulted on 4/7/17, by Medical Staff G, to assess the resident's wounds. Hospital Staff I stated he/she verified the resident had 15 wounds on his/her body, most of them Stage II or III pressure ulcers. Hospital Staff I stated the resident's skin was in poor condition and he/she received permission from the resident to take pictures of all the wounds for documentation. On 4/20/17 at 9:00 AM, Medical Staff G stated he/she saw the resident in the physician's office on 4/7/17, and admitted the resident to the hospital. Medical Staff G stated the resident's skin was in very poor condition, and he/she had multiple pressure ulcers, most of them Stage II and Stage III. Medical Staff G stated it was his/her opinion the resident had not been turned and repositioned, which contributed to the condition of his/her skin. Medical Staff G stated he/she would have expected facility staff to notify the physician when the resident's wounds did not improve or got worse. The facility's undated Pressure Ulcer Prevention Policy, documented a resident who entered the facility without pressure sores, would not develop pressure sores, unless the individual's clinical condition demonstrated they are unavoidable. The policy indicated residents who had pressure sores would receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. The policy indicated each resident would be evaluated upon admission for the risk of developing pressure sores, using the Braden Scale system, and re-assessed quarterly, and with the development of any pressure sores or significant change in status. The facility failed to develop and implement timely and effective interventions to prevent the development of pressure ulcers, then failed to develop and implement timely and effective interventions for Resident #1, who required extensive assistance from staff for mobility, admitted to the facility without pressure sores, and developed seven stage II, seven stage III, and one suspected deep tissue injury while he/she resided in the facility. This deficient practice placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 4/21/17, after completion of a wound in-service for all nursing, certified nurses aides, and certified medication aides. This deficient practice remained at a scope and severity of a G. - Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 3/8/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment. The MDS revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, toilet use, bathing, and extensive assistance of 1 staff for locomotion on and off unit, dressing, and personal hygiene. The MDS revealed the resident's balance was not steady, only able to stabilize with staff assistance, had no functional limitation in (ROM) Range of Motion in upper and lower extremities, required a wheelchair for mobility, and always continent of bowel and bladder. The MDS revealed the resident was at risk for pressure ulcers, had skin tears, and (MASD) Moisture Associated Skin Damage. The MDS revealed the resident had a pressure reducing device for chair and bed, on a turning/repositioning program, and had nutrition or hydration interventions to manage skin problems. The Pressure Ulcer (CAA) Care Area Assessment, dated 9/5/16, documented the resident required extensive assistance with bed mobility and documented the goal was to have no skin breakdown through the next review date. The (ADL) Activities of Daily Living CAA, dated 9/5/16, documented the resident required limited assistance with dressing and hygiene, and extensive assistance with bed mobility, transfers, toileting, and bathing. The CAA documented the resident required staff assistance to stabilize self with transfers, and was unable to ambulate. The 3/23/17 care plan documented the resident was at risk for pressure ulcers related to immobility. The care plan instructed staff to place a pressure reducing cushion in the resident's wheelchair, a pressure relieving mattress on the bed, and perform weekly skin assessments. The care plan documented the resident had potential/actual skin impairment of the left gluteal cleft (pertaining to the left buttocks or buttocks muscles related to moisture). The care plan directed staff to reposition the resident every 2 hours, initiated 2/13/17, and dietary recommendations included: LiquaCel liquid protein daily, multivitamin with minerals at breakfast, Vitamin C 500 (mg) milligrams daily at lunch, and Zinc 220 mg daily, initiated 2/8/17. The care plan directed staff to perform daily dressing changes, weekly documentation of each area of skin breakdown which include width, length, depth, type of tissue, exudate (fluid that leaks out of body vessels and tissues), and any other notable changes or observations. The 1/19/17 Weekly Skin Assessment documented the resident had shearing (an applied force that tends to cause an opposite but parallel sliding motion of the planes of an object. Such motions cause tissues and blood vessels to move in such a way that blood flow may be interrupted, placing the patient at risk for pressure ulcers) to left and right buttock and documented staff applied skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and films) to areas and would continue until healed. The medical record lacked documentation the physician was notified of the shearing to the resident's left and right buttock. The 2/1/17 Weekly Wound Assessment documented the resident had a wound to his/her left buttock/left gluteal cleft, acquired 1/26/17, moisture shearing, with the following measurements: 2/1/17 - 1.9 (cm) centimeters x 1 cm 2/7/17 - 2.1 cm x 1.3 cm 2/14/17 - 2.4 cm x 0.9 cm 2/21/17 - 5.5 cm x 5.5 cm 2/28/17 - 1.4 cm x 1.3 cm 3/7/17 - 1 cm x 1.3 cm 3/14/17 - 1.4 cm x 1.7 cm 4/4/17 - 3.4 cm x 2.3 cm 4/11/17 - 1.1 cm x 0.8 cm The 2/7/17 Weekly Wound Assessment documented the resident had a wound to his/her right buttock/right gluteal cleft, acquired 2/7/17, healed and reacquired on 3/21/17, moisture, with the following measurements: 2/7/17 - 0.3 cm x 0.3 cm 2/14/17 - 0.3 cm x 0.4 cm 2/21/17 - area is healed 3/21/17 - 0.2 cm x 0.4 cm x 0.2 cm 3/28/17 - 1 cm x 0.6 cm x 0.1 cm 4/4/17 - 1.5 cm x 2.0 cm 4/11/17 - 0.9 cm x 0.8 cm The Braden Scale assessment (assessment to predict risk for pressure ulcers) documented the resident had the following scores: 8/29/16 - 18, at risk 9/5/16 - 17, at risk 9/12/16 - 17, at risk 9/19/16 - 17, at risk 12/6/16 - 15, at risk 1/24/17 - 14, moderate risk 3/8/17 - 15, at risk The 2/7/17 fax to the physician revealed the resident had moisture breakdown on the right and left gluteal cleft, requested a wound consult (19 days after staff identified skin breakdown) for dressing order recommendations, and requested the physician review and sign diet orders for wounds. The fax documented the Standing Orders for wound care - Stage 1 included: Multivitamin with minerals at breakfast, Vitamin C 500 mg at lunch, liquacel liquid protein, and Zinc 220 mg daily. The 2/10/17 Wound Consultant note documented the resident's wound to his/her left gluteal cleft/buttock, full thickness, measuring 2.1 cm x 1.3 cm x <0.2 cm, with irregular wound edges. The note directed staff to cleanse the left gluteal cleft wound with (NS) Normal Saline or (WC) Wound Cleanser, and pat dry. The note further directed staff to apply powdered collagen (component of connective tissue giving it strength and flexibility) mixed with NS to form a paste, cover with hydrogel sheet (a moist and soothing wet dressing applied to the skin to help with wound healing), cover with bordered absorption dressing (used to absorb drainage, mucus (slimy drainage), and fluids from a wound), and change daily. The 2/20/17 Wound Consultant note document(TRUNCATED)

The facility had a census of 38 residents. The sample included 3 residents who were reviewed for elopement risk. The special care unit had a census of 18 residents, of which 7 the facility assessed as elopement risk. Based on observation, interview, and record review the facility failed to provide care and services to prevent 1 of 3 residents reviewed from leaving the facility without staff knowledge at 2:28 AM, the temperture was 20 degrees. The resident was outside the building for approximately 6 minutes, crossed 2 streets with the approximate distance of 75 feet from the facility, with a speed limit of 30 (mph) miles per hour, and was dressed in a nightgown, slippers, and a coat. The resident fell in the street and sustained abraisions to his/her face and right hand. This failure placed the resident in immediate jeopardy. (#1) Findings included - Resident #1's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 12/4/15, indicated severe cognitive impairment with a (BIMS) Brief Interview for Mental status score of 3, and inattention, disorganized thinking, and wandering behaviors. The MDS further indicated the resident required limited assistance of 1 staff for dressing, and toilet use, and was independent with bed mobility, and walking in his/her room, and required supervision of 1 staff for locomotion off the unit. The MDS indicated the resident's balance was steady at all times, and he/she did not use an assistive mobility device. The 9/7/15 Behavior (CAA) Care Area Assessment indicated the resident was alert and oriented to his/herself, wandered during the day, and required cueing from staff to know where him/her room was. The 12/5/15 care plan indicated the resident was an elopement risk related to wandering aimlessly, and directed staff to assess for fall risk, and distract the resident from wandering by offering diversions such as structured activities, food, conversation, television, or books. The 12/17/15 at 8:24 PM, nurse's note indicated the resident was more exit seeking than usual, and continuously wandered in and out of other residents' rooms more than usual. The 12/25/15 at 3:50 AM, nurse's note indicated staff found the resident outside with an abrasion to the right upper eyebrow and nose, his/her right hand was sore to the touch on the middle finger, and was hard to bend. The note further indicated the resident's right palm was red and had a purple dot in the center. The resident's vital signs at 2:40 AM, were the following: blood pressure 170/92 (normal 120/80), and pulse 111 (normal 60-100). At 2:45 AM the resident's vital signs were the following: blood pressure 131/101, and temperature 95.1 (normal 98.3). At 3:00 AM the resident's temperature measured 96.6, and at 3:15 AM the resident's blood pressure was 155/89. The 12/25/15 emergency room report indicated the resident had wandered, found his/her way out of the facility early that morning, and had presented with complaints of facial pain and right hand pain and swelling. The report indicated the resident had a lot of soft tissue swelling and edema around the right eye, and his/her nose bridge had an abrasion, redness, and swelling present. The report further indicated the resident's right hand was very swollen and bruised over the (MCP) metacarpophalangeal (the 5 bones between the fingers and the wrist, and the small bones of the fingers) joint region and dorsally (back surface) and anteriorly (closer to the front). The note indicated there were no facial or hand fractures. On 12/29/15 at 11:15 AM, observation revealed the resident lying in bed in his/her room, and looking around the room. Further observation revealed the resident had an approximate 3 inch long pink to red in color healing laceration above his/her right eyebrow. On 12/29/15 at 11:15 AM, Administrative Staff F verified he/she reviewed the video footage when the resident left the building unattended on 12/25/15. Administrative Staff F verified the video revealed the resdient was restless that evening, walking up and down the halls, and in and out of other residents' rooms. Administrative Staff F stated the aides had walked past the resident, in different directions, and the resident stopped at the enclosed courtyard door, in which he/she stood for a few minutes. At approximately 2:00 AM, the resident went out the courtyard door. Administrative Staff F verified there was no video surveillance in the courtyard, but a couple minutes later the video recorded the resident wandering in the activity room, for approximately 25 minutes. The activity room was under construction, and was usually locked, but the construction workers had left it unlocked and the resident was able to enter the room. Administrative Staff F stated at 2:28 AM video revealed the resident left the activity room to exit outside of the building and he/she was no longer under surveillance by video. Administrative Staff F further verified when the resident left the activity room unattended, he/she walked through the grass to around the front of the building, through the parking lots, and crossed the street. On 12/29/15 at 12:53 PM, Administrative Nurse E verified the resident was an elopement risk prior to the incident, and the intervention to protect the resident was to place him/her in the secured special care unit. On 12/29/15 at 2:00 PM, Nurse C stated the resident was wandering more than usual the night of the elopement, and staff were to just let him/her wander. Nurse C stated the resident had gotten out of the secured unit into the medical hall around 10:30 PM or 11:00 that night. Nurse C further stated he/she saw the resident walking outside of the secured unit, and was unsure how he/she got out. Nurse C stated he/she returned the resident back to the secured unit without difficulty and informed the staff to watch the resident more closely. Nurse C stated at approximately 2:00 AM or 2:05 AM, staff noticed the resident was not wandering or in his/her room. Nurse C verified he/she instructed staff to look in all the rooms, bathrooms, and closets. Nurse C stated another nurse left the building and found the resident outside, and the resident had a scratch on his/her face and nose. Nurse C stated he/she called the family and they chose to wait until morning to send the resident to the emergency room . Nurse C stated he/she notified the physician by fax, about the elopement and the injuries, even though the office was closed for the next 4 days. Nurse C stated if the activity room had not been unlocked this would not have happened, and staff would have found the resident in the courtyard when they looked. On 12/29/15 at 3:39 PM, Nurse Aide B verified the courtyard door on the special care unit had been unlocked continuously and the residents in the secured unit were able to go out as they wanted. On 12/29/15 at 3:54 PM, Nurse D stated Nurse C notified him/her the resident was missing and unable to be located by the staff. Nurse D stated he/she walked outside, got into his/her personal vehicle, and saw some movement out of the corner of his/her eye. Nurse D stated he/she drove over approximately a half of a block directly in front of the facility, across 2 streets, and found the resident seated on the street and partially on the curb. Nurse D stated the resident stated he/she was scared and wanted to go back to the facility. Nurse D stated he/she could not tell if the resident was injured, since it was dark, and stated he/she assisted the resident from the ground into his/her car, and took the resident back to the facility. Nurse D verified the resident crossed two streets to the location where he/she was found by staff. On 12/30/15 at 8:35 AM, Nurse Aide A stated he/she saw the resident wandering in the hall while performing 1:00 AM bed checks in the locked special care unit. Nurse Aide A verified staff usually just allowed the resident to wander, as long as he/she was safe. Nurse Aide A, was unsure but stated he/she last saw the resident at approximately 1:45 AM. Nurse Aide A stated after performing the bed checks he/she noticed the resident was not wandering, and he/she checked and the resident was not in his/her room. Nurse Aide A stated he/she checked all the rooms and could not find him/her, so he/she notified the charge nurse and was instructed to look in all the rooms, closets, and bathrooms again. Nurse Aide A verified at this time the door to the courtyard was always unlocked, and the residents were able to go out whenever they wanted. Nurse Aide A further verified the door does not have a continuous alarm on it, and would turn off when the door was closed. Nurse Aide A stated that night prior to the resident missing, the doors into the secured unit were having issues and making the alarms go off multiple times. Nurse Aide A stated he/she heard alarms sounding, and he/she had reset them without looking to verify a resident had not left the secured unit unattended by staff or even which door was alarming. Nurse Aide A further verified earlier in his/her shift the nurse instructed him/her to perform 15-30 minute checks on the resident, because the charge nurse found the resident walking on another hall in the facility, and returned him/her to the secured special care unit. The facility's undated Elopement policy instructed staff to use and listen for the door alarm monitors if there is a resident who is wandering, and all staff should make it practice to look at the panels to make sure the alarms are operating properly during the course of regular duties. The policy further instructed staff to search the facility building and grounds promptly. The facility failed to ensure adequate supervision for Resident #1, who left the facility unsupervised, at 2:28 AM, when 20 degrees outside, for approximately 6 minutes outside the building, crossed 2 streets approximately 75 feet with a speed limit of 30 (mph) miles per hour, and dressed in his/her nightgown, slippers, and a coat, where the resident fell and sustained abraisions to his/her face and hand. This deficient practice placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy on December 31, 2015, when the facility provided an inservice on the elopement policy and procedure to all staff, and recognition of possible elopement behaviors. The facility locked the courtyard door, and ensured placement of a continuous door alarm. The facility placed an automatic lock on the activity room door, and ordered a key pad lock for the door. The (QA) Quality Assurance committee will randomly check the door to assure compliance of locking and unlocking. The deficient practice remains at a scope and severity of a D.

The facility had a census of 66 residents. The sample included 3 residents. Based on record review and interview, the facility failed to prevent the development of pressure ulcers on both heels (scabbed area on right heel and unstageable area on left heel) for Resident #1, who the facility admitted with an immobilizer (splint) in place on his/her left lower leg and the staff assessed as high risk for developing pressure ulcers. Findings included: - Resident #1's admission (MDS) Minimum Data Set 3.0 assessment, dated 12/11/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 4 (severely impaired cognition). The MDS also indicated the resident required extensive assistance with bed mobility and total assistance with transfers. The MDS further indicated the resident had no pressure ulcers, but was a risk to develop pressure ulcers. The 12/18/13 care plan indicated the resident had impaired mobility due to a left tibia fracture and directed the staff to place an immobilizer with Ace wrap (stretchable, cloth dressing) on the resident's left lower leg. The care plan also directed two staff to transfer the resident with a sling lift and provide extensive assistance with dressing and grooming. The care plan further directed the staff to inspect the resident's skin on a regular basis. Continued review of the resident's care plan and/or medical record revealed no documentation to direct the staff to reposition the resident's legs per a schedule, although the MDS indicated he/she required extensive assistance for bed mobility. Further review of the care plan revealed no interventions/preventative measures such as float his/her heels or apply heel protectors/protective boots to prevent the development of pressure ulcers for the at risk resident.. The 12/04/13 at 2:15 PM, nurse's note indicated the facility admitted the resident post surgery after he/she had a left tibia fracture. The nurse's note also indicated the resident had an immobilizer on his/her left leg. The 12/05/13 Braden Scale (an assessment to identify residents at risk for development of a pressure ulcer) indicated the resident had a total score of 12 (high risk to develop a pressure ulcer). The facility's 12/10/13 Body Audit/Skin Assessment indicated the resident had a surgical wound below the left knee and no other skin problems. The 12/14/13 at 3:08 PM, nurse's note indicated the resident had a hard,"dime size" scab on the resident's right heel. The note also indicated the resident stated "hurts a little." review of the resident's medical record revealed [REDACTED]. The 12/15/13 at 3:19 PM, nurse's note indicated the resident's left ankle was swollen and staff applied the immobilizer with ace wrap to the resident's left lower leg. The note also indicated the resident had a hard, "dime size" scab on his/her right heel. The 12/25/13 at 5:54 PM, nurse's note indicated the staff transferred the resident with a sling lift and the resident had the immobilizer on his/her left lower leg. The 12/28/13 at 2:58 PM, nurse's note indicated the staff transferred the resident to a recliner and the immobilizer was in place on the resident's left lower leg. The 01/06/14 at 1:27 PM, nurse's note indicated the staff applied lotion to the dry, cracked skin on both of the resident's lower legs The 01/19/14 at 11:01 AM, nurse's note indicated the resident had a 1 (cm) centimeter by 1 cm scabbed area, with no drainage noted, on the resident's left heel. The nurse's note indicated the resident had a "half dollar" size reddened area on his/her left heel and staff covered the area with a [MEDICATION NAME] dressing (clear adhesive dressing). The 01/20/14 at 8:39 AM, nurse's note indicated the resident had a "fifty cent size reddish-black filled blister" on his/her left heel. The note also indicated the staff placed a heel protector on the resident's left heel and placed a pillow under the resident's legs. review of the resident's medical record revealed [REDACTED]. since admission. The 01/22/14 at 11:33 AM, nurse's note indicated the following physician orders: 1) Heel protectors at all times 2) Measure left heel pressure ulcer daily and "CALL IF INCREASE IN SIZE NOTED" 3) Move legs every 2 hours to prevent the development of new pressure ulcers 4) Avoid pressure to right Achilles (tendon posterior to the ankle)area 5) [MEDICATION NAME] cream (moisturizer) to bilateral lower extremities every day The 01/23/14 at 9:08 AM, nurse's note indicated the resident had a 1 cm by 1 cm scabbed area with no drainage on his/her right upper heel. The note indicated the resident had a 8 cm by 8 cm dark red area, with no drainage, surrounded by red, scaly tissue on his/her left heel. The nurse's note also indicated the staff applied a [MEDICATION NAME] dressing on the resident's left heel, placed heel protectors on both the resident's feet and floated the resident's heels. The 01/24/14 at 9:45 AM, nurse's notes indicated the resident had a 1 cm by 1 cm scabbed area on his/her right heel and a 8 cm by 8 cm black and hardened area on his/her left heel. The 01/28/14 Body Audit/Skin Assessment indicated the resident had a surgical wound on his/her left knee and pressure ulcers on his/her left and right heels. The 01/30/14 at 11:30 AM, nurse's note indicated the resident had a 5 cm by 5 cm blister with "scabbed appearance" on his/her left foot. The 02/11/14 facility's discharge orders for the resident to return to disability services/group home indicated the resident required home health services for wound care. The 02/13/14 at 11:15 AM, nurse's note indicated the facility discharged the resident per wheelchair to the disability services van and staff. The 02/14/14 disability services nurse's note indicated the resident had been discharged from the facility the previous day with a "blister" on his/her left heel per the facility staff report/description. The note indicated the resident had a "quarter size" scab on the back of his/her right heel. The note indicated the resident had a 3 inch by 3 inch pressure ulcer on the outer aspect of his/her left heel. The note indicated the resident's pressure ulcer had "black, puckered skin" with "mushy tissue underneath" and a red hardened ridge around the edges of the pressure ulcer. The 02/17/14 disability services nurse's note indicated the resident's physician was not aware of the "extent" of the resident's left heel pressure ulcer and the physician referred the resident to a wound specialist. On 02/24/14 at 10:17 AM, Nurse A stated the facility discharged the resident from the facility, on 02/13/14, with orders for home health for physical therapy and wound care (facility staff reported a blister on the resident's left heel). Nurse A stated he/she assessed the resident's left heel pressure ulcer, on 02/14/14, and noted a 3 inch by 3 inch area with blackened skin and mushy tissue underneath (unstageable pressure ulcer). Nurse A stated he/she notified the resident's physician on the status of the resident's pressure ulcer and the physician referred the resident to a wound specialist On 02/24/14 at 2:37 PM, Nurse Aide B stated the resident had a brace on his/her left lower leg and required extensive assistance to reposition and total assistance with a lift to transfer. Nurse Aide B stated the resident developed pressure ulcers on both heels. Nurse Aide B stated the staff had not floated the resident's heels or provided heel protectors to the resident before the pressure ulcers developed. On 02/24/14 at 2:59 PM, Nurse D stated the facility admitted the resident from the hospital with impaired mobility related to surgery for [REDACTED]. Nurse D stated the facility had no care plan and/or documentation to direct the staff to float the resident's heels or provide heel protectors for the resident before the resident developed pressure ulcers on his/her heels. On 02/24/14 at 4:14 PM, Nurse E stated the resident had a left tibia leg fracture with an immobilizer on his/her left lower leg and was a high risk to develop pressure ulcers. Nurse E stated the resident preferred to be on his/her back in bed most of the time. Nurse E stated the resident had no care plan or physician orders [REDACTED]. On 02/24/14 at 4:28 PM, Nurse Aide C stated the resident required total assistance with a lift to transfer and extensive assistance to reposition. Nurse Aide C stated the resident preferred to be in bed on his/her back most of the time. Nurse Aide C stated the staff had not floated the resident's heels or placed heel protectors on the resident before the resident developed pressure ulcers on his/her heels. On 02/25/14 at 10:45 AM, Therapy Staff F stated the resident wore gripper socks for therapy due to the resident's [MEDICAL CONDITION]/swelling of his/her left lower leg and foot and had an immobilizer on his/her left lower leg. Therapy Staff F stated the facility placed heel protectors on the resident after he/she developed pressure ulcers on his/her heels. On 02/27/15 at 9:45 AM, Physician G stated the resident was a high risk to develop pressure ulcers and the facility should provide at least a daily assessments to prevent skin problems and/or tissue damage. Physician G also stated it would have been a reasonable expectation for the facility staff to float the resident's heels and/or place heel protectors on the resident after he/she was admitted . The facility's 01/24/12 Pressure Ulcer Prevention Policy directed the staff to evaluate the resident upon admission for the risk of development of pressure ulcers and to implement appropriate interventions. The facility failed to prevent the development of pressure ulcers on both heels (scabbed area on right heel and unstageable area on left heel) for Resident #1, who the facility admitted with an immobilizer (splint) in place on his/her left lower leg and the staff assessed as high risk for developing pressure ulcers. .

The facility had a census of 37 residents. The sample included 5 residents, of which 4 were sampled for potential abuse issues. Based on observation, record review, and interview, the facility failed to ensure 1 of 4 residents was free from verbal abuse. (Resident #1) Findings included: - Resident #1 ' s annual (MDS) Minimum Data Set 3.0 assessment, dated 5/24/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. Resident #2's admission (MDS) Minimum Data Set 3.0 assessment, dated 8/6/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The 8/13/13 statement from Administrative Nurse C indicated Resident #3 had reported the staff had not responded to his/her call light in a timely manner. Administrative Nurse C stated during the same shift another resident reported a staff member had been rude to him/her. The statement revealed Administrative Nurse C had counseled the aides regarding their tone of voice, stance, and how their behavior is perceived by the residents. The statement further indicated Administrative Nurse C stated " the resident is always right " , however the statement had no mention Administrative Nurse C talked with residents, ensured the residents safety, or completed an investigation of the incident. Administrative Nurse C verified he/she had not suspended the alleged perpetrator or implemented any other measures to provide protection from further verbal abuse for any of the 19 residents who reside on the medical hall of the facility. On 8/14/13 at 4:30 PM, observation revealed Resident #1 seated in his/her wheelchair, a newspaper on his/her lap, head bent forward and his/her eyes closed. Further observation revealed the resident clean, dressed appropriately, with no wetness or odors noted. On 8/14/13 at 3:15 PM, observation revealed Nurse Aide Staff E at the nurse's station talking to the charge nurse. On 8/14/13 at 3:50 PM, observation revealed Nurse Aide Staff E propelled a resident in his/her wheelchair down the main hall, out to the facility ' s van. On 8/14/13 at 2:30 PM, alert and oriented Resident #1, verified an evening/night staff person, identified as Nurse Aide Staff E, had been rude and yelled at him/her for wetting the bed. Resident #1 stated he/she doesn ' t feel like the staff takes care of him/her as they should. Resident #1 further stated he/she believed the staff despises him/her for reporting what happened to him/her the other night with Nurse Aide Staff E. On 8/14/13 at 3:15 PM, Nurse B verified Resident #1 had reported to him/her on 8/13/13, that on the evening of 8/12/13, a CNA (Certified Nurse Aide), identified as Nurse Aide Staff E, had been rude and had yelled at the resident. Nurse B verified he/she followed the chain of command, and reported the incident to the Director of Nursing on 8/13/13. On 8/14/13 at 3:30 PM, Nurse A stated on 8/13/13, Resident #2, the roommate of Resident #1, reported an incident that occurred the evening of 8/12/13, in their room. Nurse A stated Resident #2 was very upset, and told Nurse A an evening staff member, identified as Nurse Aide Staff E, had yelled at Resident #1 for wetting the bed. Nurse A stated Resident #2 reported the staff member was very loud and angry and he/she hollared at the staff member to stop yelling at Resident #1. Nurse A stated he/she reported this to the Director of Nursing on 8/13/13. On 8/14/13 at 4:30 PM, Resident #1 verified Nurse Aide Staff E, had been rude and yelled at him/her in a loud, angry tone of voice for wetting his/her bed. Resident #1 stated Nurse Aide Staff E made him/her feel " stupid " . Resident #1 further stated his/her roommate had intervened, and told Nurse Aide Staff E to stop yelling at him/her. On 8/14/13 at 4:45 PM, Resident #2 verified Nurse Aide Staff E, who worked the evening shift on 8/12/13, had been very rude, angry, and yelled at Resident #1 for wetting his/her bed. Resident #2 verified Nurse Aide Staff E used a loud and angry tone of voice and told Resident #1 " now I have to change your bed. " Resident #2 verified he/she couldn ' t listen to the yelling anymore and he/she then hollered out at Nurse Aide Staff E to stop yelling at his/her roommate. Resident #2 verified he/she had to yell to be heard over the loud voice of Nurse Aide Staff E, and after he/she hollered at the CNA to stop yelling, the CNA calmed down and left the room. On 8/14/13 at 5:15 PM, during a meeting with Administrative Nurse C and Administrative Staff D, Administrative Nurse C verified he/she was not aware of any allegations of physical or verbal abuse toward any of the residents. Administrative Nurse C then stated, on 8/13/13, a staff nurse had reported to him/her a resident had reported a CNA had been rude and yelled at him/her the previous evening (8/12/13). Administrative Nurse C verified an incident on the 8/12/13 evening shift had been reported to him/her by an unidentified resident, regarding concerns of a staff member being rude and yelling at his/her roommate on the evening shift of 8/12/13. Administrative Nurse C verified the resident identified the staff member as Nurse Aide Staff E, and when he/she came in to work the evening shift on 8/13/13, he/she talked with the CNA regarding the 8/12/13 incident, and his/her attitude. Administrative Nurse C verified Nurse Aide Staff E worked the evening shift on 8/12/13, and was currently at work at this time on 8/13/13. Administrative Staff D stated Nurse Aide Staff E would be suspended immediately and the facility would begin an investigation of the incident, including interviews with Resident #1, Resident #2, other residents and staff. Administrative Nurse C verified he/she had not visited with Resident #1, nor had he/she talked to Resident #2, regarding the incident between Resident #1 and the nurse aide, which occurred the previous night. Administrative Nurse C further verified he/she had not done any investigation, or visited with any residents or staff about the incident. A review of the August 2013 nursing schedule revealed Nurse Aide Staff E on the schedule to work 3:00 PM-11:00 PM on August 12, 13 and 14. On 8/14/13 at 5:17 PM, Administrative Staff D verified Nurse Aide Staff E was in the facility at this time, and scheduled to work 3:00 PM-11:00 PM on the hall where Resident #1 resides. On 8/19/13 at 1:10 PM, Administrative Staff D verified Nurse Aide Staff E continued to be suspended until the investigation is complete. The 4/20/11 facility policy, (ANE) Abuse, Neglect and Exploitation Policy and Procedure, section VI, states when a staff is suspect, the suspected staff person shall not be in the facility working until or unless they are cleared. The policy also states the facility will have reporters turn in a written description of what they saw or suspect, with dates and times, the facility will interview the resident if possible, and will physically assess the resident and document any findings or absence of finding. Section XIX of the policy states each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of property. The policy goes on to define verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy defines mental abuse as including, but not limited to humiliation, harassment, and threats of punishment or deprivation. The facility failed to ensure Resident #1 was free from verbal abuse when the resident reported and the facility failed to investigate an allegation of abuse and allowed the staff member named in the allegation to continue providing care for the residents in the facility.

The facility had a census of 34 residents. The sample included 19 residents of which 3 residents were reviewed for accidents. Based on observation, record review and interview the facility failed to provide supervision and assistive devices to prevent accidents for 3 of 3 sampled residents and provide a safe environment for 11 of 17 cognitively impaired independently mobile residents on the special care unit when the residents had access to hazardous chemicals. Staff found Resident #18, who was missing for an undetermined amount of time, sitting inside a dark housekeeping closet with two housekeeping carts containing hazardous chemicals, which placed the resident in immediate jeopardy for potential injury to occur when staff failed to provide adequate supervision for the cognitively impaired resident. The facility failed to implement interventions for fall prevention as planned for resident #45 who experienced falls. The facility failed to implement interventions for fall prevention as planned for resident #24 who experienced falls. The facility failed to ensure safe handrails in 1 of the 2 halls were 17 residents reside. Findings included: - Resident #18's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 1/12/13, indicated the resident scored 3, on the (BIMS) Brief Interview for Mental Status, which is a severe cognitive impairment. The MDS indicated the resident had other behaviors, not directed towards others daily, and wandering behavior daily. The MDS indicated the resident required extensive assistance of 1 staff for ambulating off the unit, dressing, grooming and limited assistance of 1 staff for toileting. The MDS indicated the resident's balance during transition and walking was unsteady, but he/she was able to stabilize without human assistance. The MDS indicated the resident had a fall in the last 2-6 months resulting in a fracture, with no falls since the prior assessment completed. The quarterly MDS, dated [DATE], indicated the resident displayed inattention, disorganized thinking, behaviors that fluctuated, wandering behavior daily, and displayed delusions. The MDS indicated the resident required extensive assistance with 1 staff for locomotion off the unit, and limited assistance with 1 staff for toileting. The MDS indicated the resident's balance during transitions and walking was steady at all times and not steady but able to stabilize without human assistance when turning around and facing the opposite direction while walking. The MDS indicated the resident ambulated with a walker, had no functional limitations and the resident had 1 non-injury fall since the prior MDS. The 1/25/13 care plan, instructed the staff to ensure the shoes the resident wore were appropriate or gripper socks were worn. The care plan instructed the staff to ensure the resident was using the walker appropriately and when the resident had been ambulating/wandering for long periods of time the staff should encourage supervised rest periods so the resident did not become fatigued and off balance. The care plan instructed the staff to escort the resident when he/she was off the unit and to monitor the resident's room for trip hazards and remove any obstacles. The 1/5/13 fall assessment indicated the resident was at high risk for falls. The 1/18/13 at 6:26 PM, nurse's notes indicated a (CNA) Certified Nurse Aide informed the nurse the resident had been found in the "closet". When the nurse arrived in the resident's room, the nurse was directed next door to the housekeeping closet. The nurse's notes stated the staff found the resident seated on the floor, with his/her legs out stretched in front of him/her and the resident's 4 wheeled walker straddled over his/her legs. The resident had his/her call button pendant in place and had on his/her shoes. The nurse's notes indicated the resident denied any pain except where his/her pants were creased into his/her anterior abdomen and denied hitting his/her head. The nurse's notes indicated the resident had no bumps, scrapes, bruises or skin tears present and after the staff assisted the resident to stand and he/she with staff assistance exited the housekeeping closet, he/she denied pain. The 1/18/13 Post Fall Assessment indicated the resident alert, had a history of [REDACTED]. The assessment stated the staff heard the resident calling through the door of the housekeeping closet, "Let me out of here". The staff documented they had found the resident in the housekeeping closet with no light on and the resident stated "Don't know" when staff asked him/her what caused him/her to fall. The staff documented on the assessment form, the plan to prevent further falls was to change the lock on the door of the housekeeping closet to one that automatically locked. The assessment form was marked "no", by the staff in response to the question of whether the care plan was updated. review of the resident's medical record revealed [REDACTED]. Review of the resident's monthly behavior sheets from January 18, 2013 to the present revealed numerous times the resident displayed wandering behaviors and increased restlessness and anxiety at meal times. The 4/24/13 at 7:20 AM, nurse's notes indicated a nurse aide found the resident sitting on the floor in his/her room at 6:30 AM. The note stated the resident ambulated independent with his/her walker and had a shuffling gait and unsteady balance at times. The 4/28/13 at 4:57 PM, nurse's notes indicated the staff observed the resident walking down the hallway, very disoriented and the nurse observed the resident walking into the housekeeping closet located at the end of the hallway, next to his/her room. The nurse's notes indicated the nurse was too far down the hallway, for the resident to hear the nurse calling out for him/her, not to go into the room and the resident was observed by the nurse entering the room with his/her 4 wheeled walker but was unable to shut the door before the nurse arrived. The nurse cued the resident to exit the room. The nurse's notes further indicated the resident was upset and agitated with the nurse but did do what the nurse asked him/her to do. The nurse's notes indicated the nurse locked the room door from the inside and assisted the resident to his/her room. On 4/29/13 at 1:14 PM, observation revealed the resident ambulated, with non-skid shoes on, and a 4 wheeled walker from the (DR) dining room on the unit back to his/her room, located one door in front of the unlocked/unsecured housekeeping closet, turned around and returned to the DR and sat back down at the table. Further observation revealed the resident's call light pendant was hanging on the wall in his/her room and unavailable to the resident. On 4/30/13 at 11:18 AM, Nurse F stated he/she was working on 1/18/13, when the resident was found by the nurse aide sitting in the unlocked housekeeping closet located, next to the resident's room. Nurse F stated he/she had been doing the afternoon treatments that started at 2:00 PM and would have finished doing the treatments between 4:00 and 4:30 PM. Nurse F stated this resident did not have a treatment but his/her roommate did, as did the resident across the hall, Nurse F could not recall if Resident # 18 was in his/her room at that time. Nurse F stated the resident was found in the housekeeping closet sitting on the floor, painting his/her fingernails, right before dinner and the staff were already looking for him/her. Nurse F stated none of the chemicals were noted to have tops off them and the fingernail polish was used by one of the housekeepers to mark certain items. Nurse F stated there were no injuries to the resident. On 4/30/13 at 1:53 PM, Anciliary Staff H stated the housekeeping closet at the end of the hall, on the unit, was always locked and only 2 housekeeping carts were stored in this closet. On 4/30/13 at 1:55 PM, observation revealed Anciliary Staff A demonstrated pushing even lightly on the door to the housekeeping closet, allowed the door to automatically open. Anciliary Staff A stated he/she was unaware a resident had entered the housekeeping closet and had been found sitting on the floor. Anciliary Staff A stated the housekeeping carts had cleaning solutions stored on them which were not secured and easily accessible. Auxiliary Staff A stated one of the other housekeepers had just told him/her that the housekeeping door could be opened by pushing on it lightly. Nurse F was walking by and Auxiliary Staff A again demonstrated how easy the housekeeping closet opened. Nurse F stated he/she did not know the door could be pushed open easily even if it was locked. On 4/30/13 at 2:00 PM, Maintenance Staff M verified the housekeeping closet door was not secured and it had been unsecured for awhile (undetermined amount of time) and could be an accident hazard for the residents who reside in the special care unit. On 4/30/13 at 3:51 PM, Administrative Staff B stated he/she was unaware the housekeeping closet at the end of the special care unit hallway did not lock properly. Administrative Staff B also stated he/she was unaware staff had found a resident, in the unlocked housekeeping closet, at the end of the unit's hallway with the door shut. On 4/30/13 at 4:06 PM, Administrative Nurse C stated he/she thought the door lock on the housekeeping closet at the end of the special care unit hall had been fixed. When questioned further he/she stated the door lock had not been repaired so it would automatically lock when shut after the 1/18/13 incident. On 5/1/13 at 8:10 AM, Anciliary Staff H, who usually cleaned the rooms on the special care unit, and used housekeeper cart # 3, verified the cart contained 1-19 ounce can of Lysol disinfectant, 1-17 ounce can of Lemon Furniture Polish, 1-14 ounce can of Asepticare disinfectant, and a liquid package of Spic and Span which all but the Spic and Span had the warning to keep out of reach of children on the labels. On 5/1/13 at 8:35 AM, Anciliary Staff I stated housekeeping carts # 3 and # 4, were the 2 carts kept in the housekeeping closet at the end of the hall in the special care unit. Anciliary Staff I stated the 2 housekeeping carts with the chemicals, were pushed straight into the housekeeping closet next to the walls and there was approximately a 1 foot space between the carts. On 5/1/13 at 8:38 AM, observation revealed the housekeeping cart # 3 had a door over the storage area for chemicals but was not locked, and housekeeping cart # 4 had a door over the chemical storage area that was missing half of the door and had not covered the chemical area. Auxiliary Staff A was present and verified all the above observations. On 5/1/13 at 3:25 PM, Nurse D indicated 11 of the 17 residents, who resided on the unit, were cognitively impaired and independently mobile. On 5/2/13 at 12:55 PM, Nurse Aide P verified he/she found the resident in the housekeeping closet on 1/18/13, after the staff were going down the hall hollering for the resident by name and the resident hollered back "Let me out of here". Nurse Aide P stated he/she thought the resident was in the resident's bathroom as it was located next to the housekeeping closet. Nurse Aide P stated after looking for the resident in his/her bathroom, he/she went back out into the hallway and called the resident by his/her name and determined the resident was in the housekeeping closet with the door shut. Nurse Aide P stated the housekeeping closet door was not locked. Nurse Aide P stated he/she could not recall seeing the resident from the time he/she started his/her shift at 2:45 PM, until the staff started looking for him/her for the evening meal between 5:00 and 5:30 PM. On 5/2/13 at 3:30 PM, Nurse Aide T stated he/she had taken a break and had seen the resident wandering in the halls around 4:30 PM on 1/18/13. Nurse Aide T stated he/she had all the residents in the dining room but Resident # 18 and he/she went to locate him/her around 5:15 PM. Nurse Aide T indicated he/she along with Nurse Aide P, had gone down the hall calling Resident # 18's name when they discovered the resident in the housekeeping closet. The 1/26/11 facility accident-incident/falls policy stated the facility was to provide adequate care, treatment and prevention of further falls or injuries for the residents who have sustained an accident, fall or injury. The facility failed to provide adequate supervision for cognitively impaired Resident # 18, who resided on a special care unit, and was found by staff, sitting in a dark, locked housekeeping closet between the housekeeping carts with hazardous chemicals on them. The immediate jeopardy was abated on May 2, 2013 when the facility implemented a policy/procedure for safety on the (SCU) special care unit regarding daily maintenance checks to ensure all doors/locks and alarms are working properly and a 24 hour nursing responsibility by the off going and oncoming nurses regarding safety check of the unit, and an observation grid for the staff to document every 30 minutes they have visually seen the residents. The facility in-serviced the staff on May 2nd at 6:00 PM, regarding the new safety policies/procedures and completed the in-service on 5/3/13. The deficient practice remains at a scope and severity of a D. The facility failed to ensure this cognitively impaired resident was accounted for and without access to hazardous chemicals, when he/she was found in a dark unlocked housekeeping closet in the facility, and the facility failed to ensure the cognitively impaired independently mobile residents on the special care unit did not have access to hazardous chemicals. - Resident #24's annual (MDS) Minimum Data Set 3.0 assessment, dated 2/15/2013, indicated the resident had severe impaired cognition and was totally dependent on staff with his/her activities of daily living. Continued review revealed the resident had a history of [REDACTED]. The 4/17/2013, updated care plan (prior care plan was not available) directed the staff to monitor the resident for restlessness and anticipate the resident's needs for fluids, food or toileting. The care plan directed the staff to transfer the resident with the assistance of 1 staff and a gait belt and to assist the resident to ambulate using a front wheeled walker. Continued care plan review indicated the resident was a high fall risk and the staff would ensure the resident had on the appropriate shoes or gripper socks. The care plan indicated the resident had his/her pressure alarm on at all times and directed the staff to ensure the alarm was working. The care plan directed the staff to ensure a scoop mattress was on the resident's bed and a fall mat on the floor. The 1/18/2013 Fall Risk Assessment had a score of 29 that indicated a high fall risk. The 3/22/2013 at 12:13 PM, nurse's notes indicated the staff found the resident in the hallway with his/her knees on the floor, his/her right arm behind his/her back, and right leg tangled in the wheelchair pedals. The nurse's note revealed the resident's forehead was resting directly on the floor. Upon examination, the resident complained of left shoulder pain with a reddened area measuring 3 (cm) centimeter x 3.8 cm. A skin tear on the resident's left hand measuring 1.8 cm x 2.9 cm surrounded by purple bruising measuring 5.7 cm x 2.7 cm and he/she complained of "stinging" in this area. The resident's left knee had an open lesion measuring 1 cm x 0.8 cm that was pink in color. The left outer knee had shearing, red/white in color and measured 3.5 cm x 1 cm. The resident's left side of his/her forehead had a bruise that was red and measured 4 cm x 1.3 cm and mild pain with touch in the area. The 3/22/2013 at 11:15 PM, nurse's notes indicated the resident sat in the dining room and ate a snack before bed. The resident was alert and denied pain. On 4/29/2013 at 8:56 AM, observation revealed Nurse Aide L transferred the resident from his/her wheelchair to the toilet with a gaitbelt and two assist. Continued observation revealed the pressure alarm was on. On 4/30/2013 at 11:05 AM, Nurse B stated the resident had an unwitnessed fall in the sun room with injury and there was no investigation of the fall and he/she was unable to locate the communication sheet documenting/investigating the resident's fall. Nurse B stated he/she was unsure as to whether the resident had appropriate shoes or gripper socks on or if the personal alarm was on as outlined in the current care plan. Nurse B further verified he/she was not sure what interventions were in place at the time of the unwitnessed fall. The undated facility fall policy stated the facility operated with a minimum of physical restraints and thus allow maximum freedom of movement. Continued policy review stated, Alzheimer's and related dementia residents are at a higher risk for falls that result in injury or involve incident reports. The reasons for the high fall risk involve the specific nature of the disease process that result in the gradual loss of all motor skills and possibly other medical conditions. The fall policy indicated the facility incident and procedure will be used for serious incidents with injury of unknown origin. The facility failed to provide supervision and assistance for Resident #24 when left unattended in the sun room. - Resident # 45's admission (MDS) Minimum Data Set 3.0 assessment, dated 4/10/13, indicated the resident had poor short and long term memory and moderately impaired daily decision making skills. Further review of the MDS revealed the resident required extensive staff assistance with all (ADLs) Activities of Daily Living. The MDS also indicated the resident had falls prior to his/her admission to the facility. The 4/10/13 (CAA) Care Area Assessment for ADL function indicated the resident needed extensive assistance with dressing, grooming, and transfers to and from his/her wheelchair. The 4/17/13 fall risk assessment revealed a score of 20, which indicated the resident was at high risk for falls. The 4/17/13 care plan, directed the staff to assist the resident with transfers and mobility. Further review of the care plan directed the staff to use a pad alarm when the resident was in bed or seated in the recliner chair. The 4/4/13 at 6:30 PM, nurse's notes revealed the resident had a fall and was on the floor in the hallway and another resident had alerted the staff the resident needed help. On 4/24/13 at 7:40AM, observation of the resident revealed the resident seated on a brown recliner chair, the foot of the recliner was elevated and the resident was attempting to crawl over the side of the arm of the recliner. Further observation revealed the resident's chair started to tip to the side. No chair alarm was sounding and the resident was hollering loudly, "Someone get me out of here," no staff observed near the resident, and the surveyor alerted the staff, the resident needed assistance. On 4/24/13 at 2:20 PM, observation revealed the resident seated in the brown recliner chair, and the foot of the recliner was elevated. Further observation revealed the resident had the lift control for the recliner chair in his/her hand. Observation revealed the resident was leaning and tipping the chair to the side, no chair alarm was sounding, and the surveyor again alerted the staff. On 4/24/13 at 3:45 PM, observation revealed the resident seated in a brown recliner chair, the foot of the chair elevated., hand chair control in his/her right hand and the resident was beating the control on the wall. Continued observation revealed the recliner chair seat began to rise up. Further observation revealed the resident leaning over the side of the recliner chair with his/her head down near the floor, no chair alarm sounded, and the surveyor alerted staff the resident needed assistance. On 4/24/2013 at 3:45 PM, Nurse aide U verified the resident's chair alarm was not sounding, when the resident attempted to rise from his/her recliner. On 4/24/13 at 1:15 PM, Administrative Nurse C verified the facility did not do a safety assessment for the resident to use a lift chair and the resident had moderately impaired decision making skills. Administrative Nurse C also verified the resident was at high risk for falls. The undated facility policy for falls stated, safety protocols will be used for the residents with advice from family, therapy, physician and nursing. The facility failed to evaluate and assess safety measures for resident # 45 which was at high risk for falls. - On 4/23/13 at 8:30 AM, during the initial tour of the special care unit, observation revealed: 1). A hammer in the top drawer of the nurse's station, accessible to the residents. 2). An unlocked soiled utility room which contained a gallon bottle of Clorox bleach and 1 unidentified spray bottle of green colored liquid. On 4/30/13 at 2:00 PM, during the environmental tour, observation revealed the following: 1) The handrail outside of Room 300 had a screw hanging out of the handrail about an inch in length with the wood chipped and splintered. On 4/23/13 at 8:50 AM, Nurse G verified the door to the soiled utility room was to be locked and further verified the hammer should not be in the drawer. On 4/30/2013 at 2:00 PM, during the environmental tour the housekeeping storage closet in the special cares unit was unsecured and the door easily pushed open, and when shut could not be opened from the inside. On 4/30/13 at 2:00 PM, Maintenance staff M verified the housekeeping closet room door was not secured and it had been unsecured for a while, and could be an accident hazard for the residents who reside in the special care unit. Maintenance staff M further verified the handrail outside of room 300 had been repaired after it came loose from the wall and verified the splintered wood and the screw could be an accident hazard. On 5/1/12 at 3:00 PM, Nurse C verified 11 cognitively impaired, independently mobile residents reside on the special care unit. The facility failed to maintain an environment free of accident hazards for the 34 residents who reside in the facility and the 11 cognitively impaired residents on the special care unit.

The facility had a census of 32 residents. The sample included 8 residents of which 3 residents were reviewed for accidents. Based on observation, interview and record review the facility failed to provide supervision to prevent accidents for 1 of 3 sampled residents, #18, and provide a safe environment free of chemical hazards for 11 cognitively impaired, independently mobile residents who reside in the nursing facility. Findings included: - Resident # 18's quarterly (MDS) Data Set 3.0 assessment, dated 4/12/13, indicated the resident displayed inattention, disorganized thinking, behaviors that fluctuated, wandering behavior daily, and delusions. The MDS indicated the resident required extensive assistance with 1 staff for locomotion off the unit, limited assistance with 1 staff for toileting and was independent with set up help for eating. The MDS indicated the resident's balance during transitions and walking was steady at all times, and not steady but able to stabilize without human assistance when turning around and facing the opposite direction while walking. The MDS indicated the resident ambulated with a walker, had no functional limitations, and the resident had 1 non-injury fall since the prior MDS. The 4/30/13 care plan, instructed the staff to ensure the resident's shoes were appropriate or gripper socks were worn. The care plan instructed the staff to ensure the resident was using the walker appropriately and when the resident had been ambulating/wandering for long periods of time the staff should encourage supervised rest periods so the resident did not become fatigued and off balance. The care plan instructed the staff to escort the resident when he/she was off the unit, monitor the resident's room for trip hazards, and remove any obstacles. Review of the resident's monthly behavior sheets from June 1, 2013 to the present (June 24, 2013) revealed numerous times the resident displayed wandering behaviors and increased restlessness and anxiety throughout the day but mainly in the evenings. Further review of the current care plan revealed no individualized interventions for the resident's increased anxiety, restlessness and wandering during the evening as demonstrated by the monthly behavior sheets. The 30 minute visual checks form revealed no documentation on: 6/13/13 at 11:00 PM and 11:30 PM 6/16/13 at 12:00 AM through 6:30 AM and 11:30 PM 6/22/13 at 12:00 AM through 6:00 AM and 11:30 PM On 6/19/13 at 8:45 AM, observation revealed the staff walked beside the resident with his/her walker from the resident's room to the dining room. The 6/19/13 at 10:24 PM, nurse's notes indicated the resident independently left the locked and secure special care unit and was independently ambulating with his/her walker in another hallway. The nurse's notes stated the resident was easily redirected by the staff back onto the unit, and the staff notified the Administrator and (DON) Director of Nursing of the incident. On 6/24/13 at 4:01 PM, Nurse Aide B verified the resident did get out of the special care unit last week, around 9:00 PM or 9:30 PM, while he/she was working on the other hall, which was the medical side of the facility. Nurse Aide B stated he/she thought it was the nurse working on the facility's medical hall who found the resident out of the special care unit in the hallway and stated the resident did not leave the facility. Nurse Aide B stated the resident wanders up and down the halls all of the time and would be unable to get out of the special care unit unless someone else was entering or leaving the unit. On 6/25/13 at 7:14 AM, Nurse C stated the resident had exited the special care unit last week in the evening around 9:00 PM while he/she was working. Nurse C stated he/she thought the resident got out when another resident's family left and this resident apparently got out while the door was still open as he/she wanders and paces the floor a lot of the time and also will stand and look out the double doors that exit the unit. Nurse C stated he/she thought one of the aides who was working the medical side had found the resident in the hallway by the dining room and redirected the resident back into the locked unit. Nurse C verified the resident had not left the facility. On 6/25/13 at 12:25 PM, Administrative Nurse E verified the resident had left the special care unit behind another resident's family and the staff found the resident in the hallway by the dining room and the staff were able to redirect the resident's back to the unit last week. Administrative Nurse E was uncertain as to who the visitors were or which resident they were visiting at the time. On 6/25/13 at 12:26 PM, Administrative Staff D verified Nurse C had called and reported the resident had left the locked secured unit last week behind another resident's family members when they left the unit and the staff was able to redirect the resident back into the unit. Administrative Staff D stated he/she had asked Nurse C if the resident was agitated and was told the resident wasn't agitated and was easily redirected back into the unit. Administrative Staff D stated he/she had not done any further investigation as the resident was easily redirected back to the unit, he/she was not agitated and the resident had not exited the facility. Administrative Staff D stated the unit was a secure unit. Administrative Staff D was uncertain as to who the visitors were or which resident they were visiting at the time nor did he/she know which staff member assisted the resident back into the secured unit. On 6/25/13 at 2:05 PM, Nurse F stated the follow up investigation revealed the west double door to the special care unit was not locking down securely. A locksmith who worked on the door stated due to the weather changes it made the doors not lock completely. Nurse F stated after the locksmith worked on the door it now locks the double doors correctly. On 6/25/13 at 2:25 PM, Administrative Staff D stated the resident stands in front of the double locked doors to the unit and looks out more than he/she has in the past. Administrative Staff D stated the facility had the doors checked to ensure the double doors locked correctly and completely and stated nothing was wrong with the doors. Administrative Staff D stated there were extra people and activity during the day the resident had gotten out of the locked unit. On 6/25/13 at 3:10 PM, Administrative Nurse E stated the charge nurse was responsible for ensuring the resident's visual grid was completed by the aides prior to the aides going home at the end of their shift. The facility failed to ensure the cognitively impaired Resident # 18 who staff identified had increased restlessness, anxiety and wandering, was provided adequate supervision in the secured unit, and he/she left the locked unit without the staff's knowledge. - On 6/24/13 at 3:25 PM, observation revealed the housekeeping cart unattended by the main dining room for approximately 4 minutes. Further observation revealed a bucket containing Clorox Clean Up 32 fluid, ounces. which stated, " Keep out of reach of children, a spray bottle of Cleen Floor (which is Clorox Clean Up and water) diluted to clean the bathroom floors, and a 1 liter power sprayer, with a small amount of Spic and Span, to a clean the kitchen floors. On 6/24/13 at 3:28 PM, Auxiliary Staff I, verified the chemicals on the housekeeping cart were to be kept in the locked cabinet on the housekeeping cart and the cart was not to be left unattended. The facility failed to ensure the 11 cognitively impaired independently mobile residents, who resided in the nursing facility, did not have access to hazardous chemicals.