Every finding on record at Medicalodges Iola

The facility reported a census of 43 residents. Based on interviews and record review, the facility failed to ensure the mandatory 12 hours of education were completed for Certified Nurse Aides (CNA) as required. This placed the residents at risk for decreased quality of care.Findings included:- Review of Certified Medication Aide (CMA) U's personnel and training records revealed CMA U had not completed any of the mandatory 12 hours of education in the last 12 months.On 07/23/05 at 08:46 AM, Administrative Staff A reported that she had performed her own investigation and discovered that CMA U had not completed the mandatory 12 hours of education. Administrative Staff A also reported that the facility did not have a policy related to education, and said the facility follows the regulations.On 07/23/25 at 09:00 AM, CMA U verified that she had not completed the mandatory 12 hours of education for the last 12-month period. The facility did not provide a policy.

The facility reported a census of 43 residents. Based on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) was trained and certified in infection prevention and control. This failure placed all 43 residents at increased risk for infectious disease. Findings included: - During an interview on 07/23/25 at 12:11 PM, Administrative Staff A revealed the facility did not have a certified IP. Administrative Staff A stated the previous certified IP left 06/01/25, and the current IP is not certified. During an interview on 07/22/25 at 03:10 PM, Administrative Nurse C, the facility-identified IP, confirmed he was not certified in infection control. The facility's Infection Control Surveillance policy dated 11/2023 documented that the infection control preventionist is to monitor compliance with state and federal regulatory standards as they pertain to infection prevention and control.

The facility reported a census of 43 residents. Based on interview and record review, the facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who were employed at the facility for more than 12 months. This placed the residents at risk for decreased quality of care.Findings included:- Review of personnel records on 07/22/25 at 07:25 AM revealed that Certified Medication Aide (CMA) T, CMA U, CNA M, CNA N, and CNA L did not have performance evaluations completed for the last 12 months of full-time employment.During an interview on 07/22/25 at 07:25 AM, Administrative Staff A stated that no performance evaluations were completed for the five CNAs selected for review. Administrative Staff A further stated that she was aware that evaluations should have been completed, but they were not.The facility's Employee Handbook, dated 05/24/20, documented that full and part-time employees should receive formal, written evaluations. Supervisors, administrators/managers/directors are requested to conduct annual performance evaluations. It further documented that every effort would be made to conduct a performance evaluation within two weeks of the employee's anniversary date.

The facility reported a census of 43 residents with two kitchens. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food-borne illness to the residents of the facility. This placed the residents at risk for food-borne illness.Findings included:- Initial tour of the kitchen on 07/021/25 at 08:40 AM with Dietary Manager BB revealed the following areas of concern:The top of the automated dishwasher had dried food debris on it.The ice maker had food particles on the top and sides of it, and food was stored on top of it in storage bags.The kitchen area had multiple fans placed throughout the kitchen., The fans were dirty and dusty and blowing into the food preparation area and the dish cleaning area.There were numerous food items and trash on the floor.The trash cans in the food preparation area were visibly dirty on the outside.The counter where the coffee pot sat had spilled coffee on it.The floors were sticky and slick.Observed on 07/21/25 at 03:50 PM, seven plastic cutting boards were marked and grooved throughout the cutting surface, three large baking sheets had baked-on grease areas in each corner of the cooking surface, and cut marks throughout the cooking surface.Observed on 07/22/25 at 10:05 AM, the counter with the coffee pots had spilled coffee, and the kitchen floor continued to be sticky. There was a broken tile around the clean-out drain by the stove. Observed on 07/22/25 at 10:10 AM, the automated dishwasher continued to have debris on it, and a dirty upright fan was blowing across a drying rack holding clean dishes.Observed on 07/22/25 at 10:20 AM, Dietary Aide CC filled a resident's cup with ice and did not perform hand hygiene or wear gloves before or after handling the cup, and then continued cooking food on the stove. There were food items and other trash on the kitchen floor.On 07/21/25 at 03:55 PM, Dietary Manager BB reported that the cutting boards were not sanitary any longer because they were cut up and the grooves can collect debris and bacteria, and they needed to be replaced. Dietary Manager BB said the stained baking sheets also needed to be replaced. Dietary Manager BB also stated that the fans should have been cleaned, and the automated dish washer should have been cleaned.On 07/22/25 at 10:05 AM, Dietary Aide CC reported that the kitchen was supposed to be cleaned throughout the day as staff worked. On 07/22/25 at 10:10 AM, Dietary Aide DD reported that there had not been a regular cleaning schedule for the automated dishwasher, but it should not have been dirty.On 07/22/25 at 11:07 AM, Maintenance X reported he was aware of the broken kitchen tile; it just had not been replaced yet.On 07/22/25 at 03:23 PM, Administrative Staff A stated that spills should have been cleaned immediately, and the ice maker should not have been dirty. Administrative Staff A also stated that the automated dish washer and fans should be cleaned regularly, and all equipment should be in clean and proper working order. Administrative Staff A further stated that the floors should have been cleaned at least daily, and maintenance should have been notified immediately to repair or replace any tiles. During an interview on 07/23/25 at 08:46 AM, Administrative Staff A reported that the kitchen floors should have been mopped and cleaned twice daily, and if anything had fallen on the floor, it should have been picked up immediately. Administrative Staff A also stated that staff should have regularly performed hand hygiene and should have performed hand hygiene at some point between filling a resident's cup with ice and returning to cooking.During an interview on 07/23/25 at 10:50 AM, Dietary Manager BB reported that the floor should have been mopped and cleaned at least twice daily, and any trash or food on the floor should have been picked up immediately. Dietary Manager BB further stated that hand hygiene should have been performed before and after gloving and before or after filling the ice cup and returning to cooking.The facility Infection Management Process, dated 11/2023, documented that dietary services would use Serve Safe and the Health Technologies Guidelines and Procedure Manual for reference on proper food preparation, management, and dining services. The policy further documented that routine cleaning and disinfection of frequently touched or visibly soiled surfaces in common areas, resident rooms, and at the time of discharge would occur.The facility The Sanitation of Dining and Food Service Areas guideline documented that the dining services staff would uphold sanitation of the dining areas according to a thorough, written schedule. It further documented that the dining services manager would record the necessary cleaning and sanitation tasks for the department, and that all staff would be trained on the frequency of cleaning, and that staff would be held responsible for all cleaning tasks.

The facility reported a census of 43 residents. The sample included 13 residents. Based on interviews, observation, and record review, the facility failed to ensure a safe, clean home-like environment in all areas of the facility, including the dining area. This deficient practice placed the residents at risk for tripping hazards and decreased comfort.Findings included:- During an observation on 07/21/25 at 09:26 AM, Resident (R) 2's fall mat and room floor had sticky food particles and debris on them. Licensed Nurse (LN) G acknowledged that the mat was filthy and the floor was very sticky and cleaned the mat at that time. During an observation on 07/22/25 at 10:05 AM, the floor area in the dining room had 44 tiles missing; no hazard sign or barrier was blocking the trip hazard.During an observation on 07/22/25 at 10:58 AM, the door on a resident room on the 400-hall displayed bubbling on the surface where the Veneer was separating. The door frames of the doors on the 400-hall had bubbled, chipped, and missing paint.During an observation on 07/22/25 at 11:02 AM, the door frames on the 300-hall had bubbled, chipped, and missing paint. The door on a resident room on the 300-hall displayed bubbling on the surface where the Veneer was separating. Observation on 07/22/25 at 11:02 AM, R2's fall mat had pieces of food on it with sticky areas.During an observation on 07/23/25 at 07:53 AM, the missing tile area in the dining room had no warning or hazard sign in place.During an observation on 07/23/24 at 11:15 AM, the door frames on the 100-hall had bubbled, chipped, and missing paint.On 07/22/25 at 10:05 AM, Dietary CC reported that the tiles in the dining room were removed three weeks ago due to a bathroom pipe leak.On 07/22/25 at 11:02 AM, Certified Nurse Aide (CNA) O reported that she was unsure how long the door frames had been chipped. CNA O also reported that maintenance would periodically repaint them.On 07/22/25 at 11:07 AM, Maintenance X reported that the dining room tiles were removed three weeks ago due to a sewer line blow-out in the service hallway bathroom. Maintenance X reported that he had ordered matching tiles and planned to replace and repair them within the next week. Maintenance X also stated he had been constantly repairing the door frames, at least monthly, and he had been aware of laminate on doors bubbling and had periodically re-glued it back. On 07/22/25 at 03:23 PM, Administrative staff A stated that the floors should have been cleaned at least daily and maintenance should have been notified immediately to repair or replace any tiles. Administrative Staff A said broken or missing tiles were a tripping hazard and should be marked as such to prevent injury.On 07/23/25 at 08:46 AM, Administrative Staff A reported that the door jams should have been maintained and re-painted at least monthly to keep them in proper condition. Administrative Staff A stated that she was unaware of the doors with bubbling laminate.The facility's Your Rights and Protections as a Nursing Home Resident policy documented that the residents would have the right to be treated with dignity and respect. The policy further documented that residents would have the right to get proper privacy, property, and living arrangements.

The facility reported a census of 43 residents. The sample included 13 residents. Based on observations, interviews, and record review, the facility failed to maintain an effective infection control program related to the Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). The facility failed to ensure adequate hand hygiene and personal protective equipment (PPE) when caring for residents. Additionally, staff failed to store respiratory equipment in a sanitary manner. This placed the residents at risk for infections.Findings included:- Observation on 07/21/25 at 11:49 AM, Resident (R)'s fall mat next to his bed had cracks and frayed areas exposing the inner foam.Observation on 07/21/25 at 11:52 AM, R7 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) with the collection bag resting on the floor next to his bed. There was no PPE for EBP located in or around the room, and no signage alerting staff to the EBP precautions.Observation on 07/21/25 at 01:22 PM, R5's bed was in the lowest position, and his catheter bag was on the floor. The dignity bag was wadded up beside it, partially under it. There was no PPE in or around the room, and no signs instructing staff on EBP.Observation on 07/21/25 at 1:40 PM, R39 had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder). There was no EBP PPE and no signage present.Observation on 07/22/25 at 8:05 AM, Certified Nurse Aide (CNA) O applied a gown and gloves and entered the room to care for R4. CNA O got out the supplies and uncovered R4. She looked for the trash can and retrieved it from the other side of the bed. CNA O removed the fasteners from the side of R4's brief closest to her, then picked up the trash can again and went to the other side of the bed. Wearing the same gloves, CNA O removed the fastener from that side of the brief and cleaned R4's buttocks. Wearing the same soiled gloves, CNA O placed a clean brief under the resident's dirty brief. CNA O then wiped the front peri-area and removed the soiled brief. CNA O adjusted the clean brief, wiped the peri area, and then applied new gloves without performing hand hygiene. CNA O then fastened the brief. CNA O continued dressing R4, then removed the gown and gloves and tied up the trash. She then washed her hands.Observation on 07/22/25 at 11:00 AM, R29's floor mattress was worn at the corners.Observation on 07/22/25 at 1:45 PM, R7's Foley bag rested on the floor. CNA L emptied the bag after washing her hands and donning gloves. CNA L did not apply a gown. CNA L hung the bag so that it was no longer touching the floor.Observation on 07/23/25 at 01:08 PM, CNA P and Certified Medication Aide (CMA) V assisted R5. R5 requested a tissue, and CMA V handed him a tissue. R5 blew his nose and handed the tissue to CNA P. CNA P grabbed the tissue with her ungloved hand and threw it away. CNA P continued assisting R5. She applied a gown without performing hand hygiene and hooked up the sling to the Hoyer lift (full-body mechanical lift). CNA P attached the Foley bag to the sling at shoulder level and transferred R5 to bed. CMA V placed the bag on the bed beside R5 as they continued. CNA N entered the room and applied a gown and gloves. CNA N rolled R5 and removed the sling. CNA N then lowered the bed, removed her gown and gloves, and placed the fall mat on the floor beside R5's bed. CNA N removed her gown and gloves. CMA P then washed her hands and applied a glove to her left hand only to empty the catheter bag. CMA P held the bag with her ungloved hand, opened the spout, and drained the urine. Observation on 07/23/25 at 01:08 PM, CNA P and CMA V assisted R5 to bed. His oxygen concentrator was beside his bed. The oxygen tubing lay on top of the oxygen concentrator, unbagged.On 07/21/25 at 09:26 AM, Licensed Nurse (LN) G stated that the floor mats and floor should be cleaned and disinfected routinely.On 07/22/25 at 01:45 PM, CNA L reported that the Foley tubing and bag should not be on the floor; it should be hanging but below the bladder for proper drainage. On 07/22/25 at 11:16 AM, Administrative Nurse C reported he was not aware of any guidelines concerning EBP for urinary catheters and said he would have to review the guidelines. Administrative Nurse C said the standard precautions were in place only if it was required. Administrative Nurse C verified there was no EBP PPE or signage. Administrative Nurse C confirmed that catheter bags should not touch the floor.On 07/22/25 at 01:53 PM, CNA O stated she caught herself grabbing the clean brief with her dirty gloves. She said she was not aware that hand hygiene should be performed when removing gloves.On 07/23/25 at 11:21 AM, Administrative Staff A reported EBP PPE should be in place with signage for Foley catheters, but suprapubic catheters do not fall under that. She said she expected staff to use proper hand washing, PPE, keep the floor mats clean and in good repair, and provide proper care of Foley catheters.On 07/23/25 at 03:10 PM, Administrative Nurse C reported that he expected the staff to follow infection control guidelines, which included proper hand washing and removal of gloves when going from a dirty area to a clean area, use of proper PPE, keeping the floor mats clean and in good repair, and proper care of Foley catheters. Administrative Nurse C said oxygen tubing should be in a bag when not in use.The facility's policy Infection Management Process documented that all residents' rooms will have standard cleaning services daily. Employees will be educated on proper hand hygiene. Posting to notify employees and visitors will be implemented to identify isolation precautions to be utilized, including the correct PPE to be used.

The facility reported a census of 43 residents. The sample included 13 residents, with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anxiolytic (medication used to treat symptoms of anxiety) and other psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses)) for Resident (R)14, R6, R42, R17 and R2. This placed the residents at risk for adverse side effects of the medications and uninformed decisions. Findings included:- R14's Electronic Medical Record (EMR) included the following diagnoses: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R14's EMR documented the following physician's orders:Sertraline (an antidepressant medication used to treat mood disorders), 50 milligrams (mg), by mouth daily for a diagnosis of depression, ordered 03/24/25.Trazodone (an antidepressant medication), 50 mg, daily at bedtime for a diagnosis of insomnia (difficulty sleeping) ordered 03/24/25.Buspirone (an anxiolytic medication used to treat symptoms of anxiety), 15 mg, three times daily for a diagnosis of anxiety, ordered 03/24/25.Seroquel (an antipsychotic medication used to treat major mental conditions that cause a break from reality), 12.5 mg, three times daily for a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), ordered 04/08/25.R14's EMR lacked documentation of informed consent for R14's psychotropic and antipsychotic medications.On 07/22/25 at 03:35 PM, Administrative Staff A stated the facility had not completed informed consents for R14's antipsychotic and psychotropic medications.The facility policy for Behavior Management & Psychotropic Medications, revised 04/2025, included: An informed consent shall be completed for the use of psychotropic medications prior to the initial administration of the medication and with a dose increase.- R6's Electronic Medical Record (EMR) included the following diagnoses: bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R6's EMR documented the following physician's orders:Seroquel (an antipsychotic medication used to treat major mental conditions that cause a break from reality), 12.5 milligrams (mg), every day at bedtime, for a diagnosis of bipolar disease, ordered 04/18/25.Trazodone (an antidepressant medication), 50 mg, daily at bedtime for a diagnosis of insomnia, ordered 04/18/25.Clonazepam (an anxiolytic medication used to treat symptoms of anxiety), 0.5 mg, twice daily for a diagnosis of anxiety, ordered 04/18/25.R6's EMR lacked documentation of informed consent for R6's psychotropic and antipsychotic medications.On 07/22/25 at 03:35 PM, Administrative Staff A stated the facility had not completed informed consents for R6's antipsychotic and psychotropic medications.The facility policy for Behavior Management & Psychotropic Medications, revised 04/2025, included: An informed consent shall be completed for the use of psychotropic medications prior to the initial administration of the medication and with a dose increase.- R42's Electronic Medical Record (EMR) included a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R42's EMR documented the following physician's order:Buspirone (an anxiolytic medication used to treat symptoms of anxiety), 1 milligram (mg), by mouth (three times daily for a diagnosis of anxiety, ordered 03/26/25.R42's EMR lacked documentation of informed consent for R42's psychotropic medications.On 07/22/25 at 03:35 PM, Administrative Staff A stated the facility had not completed informed consents for R42's psychotropic medications.The facility policy for Behavior Management & Psychotropic Medications, revised 04/2025, included: An informed consent shall be completed for the use of psychotropic medications prior to the initial administration of the medication and with a dose increase.- R17's Electronic Medical Record (EMR) included the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R17's EMR documented the following physician's orders:Hydroxyzine (an anxiolytic medication used to treat symptoms of anxiety), 25 milligrams (mg), every 21 hours as needed (PRN), for a diagnosis of anxiety, ordered 06/24/25.Duloxetine (an antidepressant medication), 50 mg, daily for a diagnosis of depression, ordered 05/14/25.Buspirone (an anxiolytic medication), 7.5 mg, by mouth three times daily for a diagnosis of anxiety, ordered 04/02/25.R17's EMR lacked documentation of informed consent for R17's psychotropic medications.On 07/22/25 at 03:35 PM, Administrative Staff A stated the facility had not completed informed consents for R17's psychotropic medications.The facility policy for Behavior Management & Psychotropic Medications, revised 04/2025, included: An informed consent shall be completed for the use of psychotropic medications prior to the initial administration of the medication and with a dose increase.- R2's Electronic Medical Record (EMR) included the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought)R2's EMR documented the following physician's orders:Buspirone (an anxiolytic medication), 10 milligrams (mg), twice daily for a diagnosis of anxiety, ordered 06/19/25.Seroquel (an antipsychotic medication used to treat major mental conditions that cause a break from reality), 50 mg, by mouth, three times daily for a diagnosis of schizoaffective disorder, ordered 06/24/25.Clonazepam (an anxiolytic medication), 0.5 mg, twice daily for a diagnosis of anxiety, ordered 07/15/25.R2's EMR lacked documentation of informed consent for R2's psychotropic medications.On 07/22/25 at 03:35 PM, Administrative Staff A stated the facility had not completed informed consents for R2's psychotropic and antipsychotic medications.The facility policy for Behavior Management & Psychotropic Medications, revised 04/2025, included: An informed consent shall be completed for the use of psychotropic medications prior to the initial administration of the medication and with a dose increase.

The facility reported a census of 43 residents; 13 residents were sampled, including one resident reviewed for pain. Based on observation, interview, and record review, the facility failed to administer pain medications for Resident (R) 6, who had a diagnosis of trigeminal neuralgia (a chronic painful disease that affects the nerve that carries sensation from the face to the brain). This placed the resident at risk of uncontrolled pain.Findings included:- R6's Electronic Medical Record (EMR) revealed a diagnosis of trigeminal neuralgia.R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received scheduled and as-needed (PRN) pain medications and reported she had occasional pain, which rarely affected her day-to-day activities and sleep. The MDS noted R6's worst pain in the past five days was rated at a five on a one to 10 pain scale (one being minimal pain and 10 the worst pain imaginable). The Pain Care Area Assessment (CAA), dated 05/21/25, did not trigger.R6's Care Plan, revised 05/14/25, instructed staff she received pain medications for her diagnosis of trigeminal neuralgia. The care plan lacked direction to staff regarding non-pharmacological interventions for pain.R6's EMR revealed the following physician's orders:Carbamazepine (a medication which works by decreasing nerve impulses that cause nerve pain, such as trigeminal neuralgia), 200 milligrams (mg), by mouth, twice daily for a diagnosis of trigeminal neuralgia, ordered 07/09/25.Lidocaine viscous HCI mouth/throat solution 2% (a local anesthetic used to numb painful areas of the mouth and throat), 5 milliliters (ml), swish and spit before meals and at bedtime for a diagnosis of trigeminal neuralgia, ordered 04/18/25.R6's July 2025 Medication Administration Record (MAR) documented R6 did not receive the bedtime dose of carbamazepine on 07/19/25, both scheduled doses on 7/21/25, and the morning dose on 07/21/25.R6's July 2025 MAR documented R6 did not receive the lidocaine viscous solution for the last two scheduled doses on 07/20/25 and the first two scheduled doses on 07/21/25.R6's Progress Notes in the EMR revealed documentation that staff notified the pharmacy of the need to refill the carbamazepine and lidocaine viscous solution on 07/20/25 and twice on 07/21/25.R6's EMR documented the resident's pain level was zero on a scale of one to 10 for both shifts on 07/20/25. Staff documented the resident's pain level was a nine on a one to 10 pain scale on the morning of 07/21/25.On 07/21/25 at 09:37 AM, R6 sat in her recliner in her room watching TV. The resident had facial grimacing as she visited with staff.On 07/21/25 at 09:37 AM, R6 stated she had not received her pain medication for her trigeminal neuralgia over the weekend and said she was experiencing an increase in pain.On 07/22/25 at 10:35 AM, Certified Medication Aide (CMA) T stated the two medications had not been reordered as they should have been, and the resident did not have them over the weekend. CMA T stated the resident had an increase in facial and mouth pain over the weekend due to not receiving her medications.On 07/22/25 at 02:21 PM, Certified Nurse Aide (CNA) K stated the resident had not complained to her of an increase in pain over the weekend. CNA K stated the resident was able to eat her evening meals without difficulty.On 07/22/25 at 03:35 PM, Administrative Staff A stated the facility expected staff to ensure all residents had sufficient pain medication to get through the weekend.The facility policy for Pain Management, revised 10/22, included: The facility shall develop an individualized treatment plan including pharmacologic and non-pharmacologic interventions for each resident with pain.

The facility reported a census of 43 residents; the sample included 13 residents. Based on interviews, observations, and record review, the facility failed to protect the dignity of three residents, Resident (R) 2, when R2 was transported from his room to the shower room via a shower chair only covered with a white sheet with his buttocks exposed. Additionally, staff entered the rooms of R2, R7, and R8 without knocking first and did not identify themselves or await acknowledgment from the resident. These deficient practices placed the residents at risk for negative psychosocial effects related to impaired dignity.Findings included:- During an observation on 07/21/25 at 09:58 AM, Certified Nurse Aide (CNA) O knocked on R8's door once and then entered the room without acknowledgement from R8 while he was being interviewed. R8 stated that staff frequently entered his room without knocking or waiting for permission.During an observation on 07/21/25 at 09:25 AM, R7's door was closed, and CNA O opened the door and entered R7's room without knocking or introducing herself.During an observation on 07/21/25 at 09:26 AM, Licensed Nurse (LN) G assisted R2 out of bed, to the toilet, and then assisted him to his chair. While R2 was receiving care, LN F opened R2's door without knocking and looked into the room, looking for another staff member. A few minutes later, CNA O pushed R2's door open without knocking and walked into the room with R2's food tray. During an observation on 07/23/24 at 11:15 AM, staff wheeled R2 from his room to the shower room in a shower chair past the dining room, where other residents were gathering. R2 had a sheet over his lap; his bare legs and bare buttocks were exposed.During an interview on 07/21/25 at 11:40 AM, R7 reported that sometimes staff would just enter her room, or sometimes they would knock first and then enter.During an interview on 07/22/25 at 10:36 AM, CNA L stated that before entering a resident's room, staff were supposed to knock and introduce themselves, then await acknowledgement from the resident before entering. During an interview on 07/22/25 at 10:41 AM, LN H stated that before entering a resident's room, staff should have introduced themselves and awaited resident acknowledgement.During an interview on 07/22/25 at 11:16 AM, Administrative Nurse C stated that staff should have knocked, introduced themselves, and awaited acknowledgement from the resident before entering their room.During an interview on 07/22/25 at 01:53 PM, CNA O stated that she was aware that she needed to be respectful and knock before entering a resident's room.During an interview on 07/23/25 11:21 AM, Administrative Staff A reported that residents should not be transported through the halls with their buttocks or any private areas exposed. During an interview on 07/23/25 at 11:44 AM, CNA N reported that normally, residents were moved from their room to the shower room in their wheelchairs. CNA N also stated that it was not dignified or appropriate to push residents down the hall with exposed privates or only a sheet covering their laps.During an interview on 07/23/25 at 11:50 AM, CNA P reported that it was not safe to push residents in a wheelchair or shower chair down the hall without foot pedals. CNA P also reported that you were not supposed to push residents in the hall on the shower chair, especially if they had exposed areas.The facility's Your Rights and Protections as a Nursing Home Resident policy documented that the residents would have the right to be treated with dignity and respect. The policy further documented that residents would have the right to get proper privacy, property, and living arrangements.

The facility reported a census of 43 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set for Resident (R) 5 and R14. This placed the resident at risk for impaired care due to unidentified care needs. Findings included:- R5's Electronic Medical Record (EMR) documented a diagnosis of Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion). R5’s 04/23/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severe cognitive impairment. R5 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) and was dependent on staff for assistance. The MDS documented R5 had one non-injury fall. R5’s 04/23/25 “Falls Care Area Assessment (CAA) documented R5 had a BIMS score of seven. He had disorganized thinking and was impulsive. R5 required total assistance with care and was transferred using a full-body lift. R5 took antidepressant and anticonvulsant medications and was unaware of safety issues. He had multiple falls before admission and has had one fall since return. R5’s “Fall Note” on 04/20/25 at 09:18 AM documented a noninjury fall. R5’s “Fall Note” on 04/22/25 at 02:25 PM documented a fall with skinned knees. Observation on 07/21/25 at 01:22 PM, R5 lay in bed. The bed was in the lowest position, and there was a fall mat beside the bed. R5’s feet were hanging over the end of the bed. On 07/23/25 at 01:50 PM, Administrative Nurse D stated the 04/23/25 Significant Change MDS for R5 was incorrect and should have documented two falls, one with a minor injury and one with no injuries. Administrative Nurse D said the facility uses the Resident Assessment Instrument (RAI- a comprehensive, standardized tool used in long-term care facilities to assess residents, guide care planning, and monitor quality of care) manual to direct MDS procedures. On 07/23/25 at 12:11 PM, Administrative Staff A stated she expected the MDS to be accurate and completed on time. The RAI Manual documents that it is a requirement that the RAI process accurately reflects the resident’s status. Falls are a leading cause of injury, morbidity, and mortality in older adults. A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. Persons with a history of falling may limit activities because of a fear of falling and should be evaluated for reversible causes of falling - R14's Electronic Medical Record included dementia (a progressive mental disorder characterized by failing memory and confusion). R14's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She did not receive anticoagulant medication (medications that decrease the body's ability to clot). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/30/25, documented that the resident was able to make her needs known at times. R14's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of eight, indicating severe cognitive impairment. She received an anticoagulant medication during the assessment period. R14's Care Plan instructed staff the resident experienced sundowning (a condition where a person tends to become confused or disoriented toward the end of the day) at times. R14's EMR included the following physician's order:Aspirin (ASA-an antiplatelet medication used to prevent platelets from sticking together and decrease the body's ability to form blood clots), 81 milligrams (mg), daily for health maintenance, ordered 03/24/25. R14's Medication Administration Record (MAR) for July 2025 documented that the resident received the medication daily, as ordered. On 07/23/25 at 09:11 AM, Administrative Nurse D stated R14's Quarterly MDS dated [DATE] was inaccurate. Administrative Nurse D said the resident did not receive an anticoagulant medication during the assessment period but had received an antiplatelet medication. On 07/22/25 at 03:35 PM, Administrative Staff A stated it was the expectation for staff to complete all MDS accurately. The facility utilized the Resident Assessment Instrument (RAI) Manual for accurate completion of the MDS.

The facility reported a census of 43 residents; the sample included 13 residents. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for Resident (R)6 regarding non-pharmacologic pain interventions and for R42 regarding oxygen use. This placed the residents at risk for impaired care due to uncommunicated care needs.Findings included:- R6's Electronic Medical Record (EMR) revealed a diagnosis of trigeminal neuralgia.R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received scheduled and as-needed (PRN) pain medications and reported she had occasional pain, which rarely affected her day-to-day activities and sleep. The MDS noted R6's worst pain in the past five days was rated at a five on a one to 10 pain scale (one being minimal pain and 10 the worst pain imaginable).The Pain Care Area Assessment (CAA), dated 05/21/25, did not trigger.R6's Care Plan, revised 05/14/25, lacked staff instruction for non-pharmacological interventions for pain.R6's EMR revealed the following physician's orders:Carbamazepine (a medication which works by decreasing nerve impulses that cause nerve pain, such as trigeminal neuralgia), 200 milligrams (mg), by mouth twice daily for a diagnosis of trigeminal neuralgia, ordered 07/09/25.Lidocaine viscous HCI mouth/throat solution 2% (a local anesthetic used to numb painful areas of the mouth and throat), 5 milliliters (ml), swish and spit before meals and at bedtime for a diagnosis of trigeminal neuralgia, ordered 04/18/25.R6's EMR documented the resident's pain level was zero on a scale of one to 10 for both shifts on 07/20/25. Staff documented the resident's pain level was a nine on a one to 10 pain scale on the morning of 07/21/25.On 07/21/25 at 09:37 AM, R6 sat in her recliner in her room watching TV. The resident had facial grimacing as she visited with staff.On 07/22/25 at 09:11 AM, Administrative Nurse D stated that non-pharmacological pain interventions should be included on the care plans of residents who have pain.The facility policy for Pain Management, revised 10/22, included: The facility shall implement individualized interventions for residents with pain and document the interventions in the care plan. - R42's Electronic Medical Record (EMR) documented a diagnosis of respiratory failure (a condition where the lungs cannot effectively take in enough oxygen for the blood).R42's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received oxygen during the assessment period.The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/01/25 did not trigger.R42's Quarterly MDS, dated [DATE], documented that the resident had a BIMS score of 13. She received oxygen during the assessment period.R42's Care Plan, revised 06/12/25, lacked staff instruction regarding oxygen use. The resident had no plans to discharge from the facility.R42's EMR documented the following physician's order:Oxygen per nasal cannula (NC), 3-4 liters (L), for a diagnosis of respiratory failure, ordered 03/26/25.On 07/21/25 at 09:47 AM, R42 sat in her room with the oxygen on per NC.On 07/22/25 at 10:19 AM, R42 sat in her room with the oxygen on per NC.On 07/23/25 at 09:11 AM, Administrative Nurse D stated oxygen should be included on the care plan.The facility policy for Electronic Care Plan, revised 12/2020, included: The facility shall develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional, and social well-being for each resident in the facility.

The facility identified a census of 43 residents. The sample included 13 residents, with one resident reviewed for urinary tract infections. Based on observation, interview, and record review, the facility failed to provide Resident (R) 5, who had an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag), with appropriate treatment and services to care for a catheter and to prevent urinary tract infections (UTI-an infection in any part of the urinary system). This deficient practice placed the resident at risk for UTI and other catheter-related complications.Findings included:- R5's Electronic Medical Record (EMR) documented a diagnosis of UTI, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion).R5's 04/23/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severe cognitive impairment. R5 had a Foley catheter and was dependent on staff for assistance.R5's 04/23/25 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R5 required total assistance with care and was transferred using a full body lift. R5 wore briefs and had a Foley catheter. Staff completed incontinence care and catheter care. The CAA noted staff would keep the urine drainage bag below the level of the bladder for dependent drainage. R5's Care Plan on 07/21/25 revealed R5 had an indwelling catheter with an intervention dated 03/31/25 that instructed staff to position the catheter bag and tubing below the level of the bladder. Observation on 07/23/25 at 01:08 PM, Certified Nurse Aide (CNA) P and Certified Medication Aide (CMA) V assisted R5 from the wheelchair to his bed using a Hoyer lift (full body mechanical lift). CNA P and CMA V donned a gown and gloves and hooked up the sling to the Hoyer lift. CNA P attached the Foley bag to the sling at R5's shoulder level, above the level of R5's bladder, and transferred R5 to bed. CMA V unhooked the bag and placed it on the bed beside R5, level to R5's bladder, as they continued. The bag was then attached to the bed frame.On 07/23/25 at 01:15 PM, CMA V stated she was aware that the catheter bag was to be below the level of the bladder at all times. She said she was not thinking about raising the bag for the transfers. On 07/23/25 at 01:35 PM, Licensed Nurse (LN) G stated the catheter drainage bag was to be below the level of the bladder at all times. LN G said the catheter should not be raised higher than the bladder, as that would allow urine to drain back into the bladder.On 07/23/25 at 03:10 PM, Administrative Nurse C said he expected the catheter drainage bag to remain below the level of the bladder. Administrative Nurse C said allowing urine to backflow into the bladder was an infection control issue and could cause urinary tract infections. The facility did not provide a policy for catheter care.

The facility reported a census of 36 residents, with four residents sampled, including three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)1. On 04/27/24 during the 05:45 PM to 06:00 AM shift, staff deactivated an exit door alarm on a hallway R1 did not reside on due to a storm causing the alarm to sound. On 04/28/24 at 03:57 PM, R1 attempted to exit a hallway door on the side of the facility the resident resided on, and staff redirected R1. On 04/28/24 at 03:59 PM, R1 sat in a chair in the activity area next to the nurse's station of the area of the facility he resided on. Shortly after, R1 exited the hallway door where the alarm had been deactivated. The facility staff did not know R1 was outside until a visitor in the community, in a house across the street, observed R1 having trouble with his walker going from the facility driveway to the street. The visitor then got in his car and drove over to the facility to report seeing a person outside walking down the street with a walker. At 04:03 PM, staff alerted the charge nurse on the walkie talkie that a resident had gotten outside without staff knowledge. The lack of functioning alarm doors to ensure resident safety and failure to provide appropriate supervision for a resident who displayed active exit seeking behaviors, placed R1 in immediate jeopardy and placed all five residents at risk for elopement. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR) for R1 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and hallucinations (sensing things while awake that appear to be real, but the mind created). The Admission Minimum Data Set, dated dated dated [DATE], assessed R1 with a Brief Interview of Mental Status (BIMS) score of four, indicating severe cognitive impairment. R1 wandered one to three days of the assessment period, used a walker for mobility, and with setup assistance he could walk 150 feet in the corridor on admission. The Behavioral Symptoms Care Area assessment dated [DATE] revealed R1 wandered at times and, when noted, the staff were to toilet him, feed him, sit him at the activity table and give colors for him to color. R1 also liked to watch Star Trek and old westerns. R1 was an elopement risk and needed to be monitored when he was wandering. The Care Plan initiated on 04/11/24, revealed R1 was an elopement risk/wanderer, had impaired safety awareness, and had cognitive loss that affected his memory. The staff were to provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The staff were to identify patterns of wandering to determine if it was purposeful, aimless, escapist, looking for something, or need for more exercise, and staff were to intervene as appropriate. The staff were to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. On 04/29/24, the facility added an intervention for 1:1 observation until further notice. R1 was also a risk for falls/injury. The Clinical Health Review dated 04/11/24, scored R1 at 21 indicating a high elopement risk level. R1 had wandering, exit seeking/door watcher, memory deficit, impaired safety awareness, had physical ability to open doors, able to exit doors independently with or without assistive device and impaired cognition. Elopement risk interventions included the facility had locked/coded doors. The Progress Note dated 04/12/24 at 04:40 PM, revealed R1 admitted to the facility from home, had a diagnosis of Alzheimer's, and tended to wander. Review of the Progress Notes dated 04/12/24 through 04/22/24 revealed R1 had periods of wandering, exit seeking, was witnessed leaving the building once, and had attempts to leave the facility. On 04/27/24 at 06:09 PM, a Code Red Weather Warning was sent out via text message per automated system for the city location of the facility for a severe thunderstorm warning until 07:00 PM. An additional alert was sent out at 10:25 PM until 11:30 PM. The Progress Note dated 04/28/24 at 04:36 PM revealed Licensed Nurse (LN) I heard staff on the walkie talkie at 04:03 PM say I think your resident got out. LN I went to the front of the building and observed two staff members walking R1 back to the facility front door. LN I last saw R1 with a Certified Nurse Aide (CNA) at 03:57 PM. After assessing R1 for injury and finding none, she placed R1 on one-on-one with staff. LN I assessed all doors with a unidentified Certified Mediation Aide (CMA) and found a hallway exit door on the other side of the facility where R1 resided was unlocked, causing the alarm to not sound. The facility Witness Statement dated 04/28/24 by LN H, revealed on 04/27/24 while working the 05:45 PM to 06:15 AM shift, there was a severe thunderstorm warning and tornado warning for the county of the facility location. The wind caused the door on a [deactivated door alarm hallway] to blow open, sounding the alarms. LN H checked the door and secured it making sure the door locked at that time. The facility Witness Statement dated 04/28/24 by CNA O, revealed they observed R1 walking the halls and walked down [deactivated door alarm hall] and R1 tried going out at 03:57 PM. CNA O told R1 it was too cold and would not be good to go out. R1 walked back to the activity room, where CNA O last saw him. The facility Witness Statement dated 04/28/24 by CNA Q, revealed she toileted R1 at 03:00 PM and at 03:59 PM she observed R1 in the activity room with other residents. At 04:16 PM, LN I informed CNA Q that R1 got outside and was back inside. The facility Witness Statement dated 04/28/24 by [Visiting Neighbor] revealed he got up from the couch and noticed a gentleman with a walker, walking in the parking lot. He observed R1 having trouble with the walker coming out of the entrance of the parking lot, so he went over to the facility to let them know, since R1 was not in the parking lot at the time. The statement lacked a time of the observation. The facility Witness Statement dated 04/28/24 by LN J, revealed she was charting at the nurse's desk on the other side of the facility R1 resided on. At approximately 04:30 PM, a gentleman came through the front door and reported an elderly man walking outside with his walker. LN J, CMA R, and CNA P went outside to find the resident and CMA R walked R1 back while CNA P contacted LN I. LN J observed the gentleman reporting get in a car and drive to a house across the street. The facility Witness Statement dated 04/28/24 by CMA R, revealed a gentleman came to the front desk and reported an elderly gentleman was walking down the road with a walker. CMA R, LN J, and another CNA immediately went out the front door to find the resident. CMA R observed R1 walking down the street with his walker going west. CMA R ran to him with the other CNA and R1 said he was enjoying the weather, when asked what he was up to. CMA R walked with resident back to the building through the front door. The statement lacked the time it was reported a resident outside, or the time CMA R observed R1 walking down the street. The facility Witness Statement dated 04/28/24 by CNA P, revealed she was at the desk with another CNA, a CMA, and a nurse when a guy came in the front door to the desk and informed staff there was a guy walking down the road with a walker. CNA P, the other CNA, and the CMA ran out the door to go get the resident. When they asked R1 what he was doing, he responded he was enjoying the weather. CNA P stated they walked with R1 inside while the nurse and alerted the nurse in charge of R1. The statement lacked a time of notification of the missing resident and the time they observed R1 walking down the street. The facility Witness Statement dated 04/28/24 by CMA S, revealed LN I told her R1 had escaped the building and none of the staff heard alarms on any of the doors go off. CMA S checked all the doors and found that the door on the (deactivated door alarm) hallway, was unlocked. Observation on 05/02/24 at 09:32 AM, during tour of the facility, revealed a stop sign secured with Velcro was across the hallway exit doors of four hallways. A key box by each door showed a red light on. Outside the door the facility found was unalarmed/unlocked, was an area of pavement approximately eight feet from the door with a sidewalk on each side of the building that extended from the paved area. Beyond the paved area was a grass area that extended out to a street on the east side of the facility. The double doors at the front of the facility by the nurse's desk required a key code to exit to the front lobby/office area by the front entrance doors of the facility. R1's room was located on another hall on the other side of the facility. Observation on 05/02/24 at 10:33 AM, revealed R1 walking with a front-wheeled walker, gait steady and slow, accompanied by Social Service Staff X, down the hall he resided on and to the activity area where other residents were playing a bag toss game with country music playing. R1 sat in a chair and began mouthing the words to the country song and participated in the game. Observation on 05/02/24 at 01:58 PM of the area outside of the hall door that was unlocked when R1 eloped, revealed the sidewalk extended south and adjoined the front parking lot. The end of the driveway to the east had a white sign that read Entrance and on the west side a white sign that read Exit. Observation on 05/02/24 at 03:00 PM, revealed the distance from the hall exit door the facility believed R1 went out to the location where found was approximately 435 feet measured with a GPS (Global Positioning System) device, the curb angles down from the front parking lot to where the Entry facility driveway located. During an interview on 05/02/24 at 11:31 AM, Maintenance Staff U stated for an alarm to not sound on the door, it would have to be shut off with a key, which the two charge nurses, dietary manager, and Maintenance Staff U have. A monitor was at each nurse's desk to identify the exit doors. If the light were on at the monitor, then the alarm was on. If the light was off, then the alarm was off. If the light blinked, then that indicated the alarm had been activated and would sound. Maintenance Staff U stated he checked the doors on 04/26/24 and they were all functioning and locked. During an interview on 05/02/25 at 12:59 PM, CMA R stated she worked on 04/28/24 from 02:00 PM to 10:00 PM on the other side of the facility where R1 resided. CMA R stated in the afternoon, she stood in front of the dining room at the nurse's desk when a gentleman came in the front door. CMA R stated she did not know who the gentleman was, and he stated, Ladies I am sorry to interrupt but there is a gentleman with a walker out front. CMA R stated she saw R1 walking as soon as she got to the front door, and he was 10 to 15 feet west of the white sign going west. CNA P accompanied her to look for R1. When approached, R1 stated he was going out for a stroll. CMA R stated R1 turned back around and walked back in the facility with her. CMA R stated she did not observe R1 on the hall prior to the elopement, nor had she heard a door alarm sound. During an interview on 05/02/24 at 01:06 PM, CNA Q stated she worked on 04/28/24 from 02:00 PM to 06:00 PM and was assigned to the area R1 resided on. CNA Q stated she toileted R1 around 03:00 PM and saw him around 03:57 PM to 03:59 PM sitting in a chair in the activity area by the nurse's desk, and he had his walker with him. CNA Q stated she then went in another resident room to provide cares and when she came out of the room at 04:16 PM, LN I reported to her R1 was discovered outside. CNA Q stated she did not hear a door alarm sound, and if it did, the alarm could be heard when inside a room. CNA Q stated she checks on R1 because he had tried to get out of the doors before. During an interview on 05/02/24 at 01:13 PM, CNA P stated she worked on 04/28/24 from around noon until 10:30 PM on the other side of the facility from where R1 resided. CNA P stated she did not see R1 on her side of the facility prior to the elopement, nor did she hear a door alarm. CNA P stated she was at the nurse's desk when a guy came in and said there was a guy walking down the road with a walker. CNA P went outside with CMA R and R1 returned inside with them. On 05/02/24 at 01:30 PM, an attempt for a phone interview with CMA S was unsuccessful. During an interview on 05/02/24 at 01:33 PM, LN J stated she worked 06:00 AM to 06:00 PM on 04/28/24 on the other side of the facility R1 resided on and had not seen R1 until supper time. LN J stated she had been at the desk charting and did not see R1 go by and had not heard an alarm go off. LN J was not aware of any unlocked exit doors. During an interview on 05/02/24 at 01:35 PM, LN I stated she worked on 04/28/24 from 06:00 AM to 06:00 PM and was the charge nurse for R1. LN I stated she last saw R1 around 03:57 PM, wandering around by the nurse's station (for the hall he resided on). LN I stated she was assisting another resident in a room when she was alerted over the walkie talkie around 04:05 PM by an unknown staff member saying I think your guy got out. She could not get a response back on the walkie when asking what and who, so she went to R1's room and he was not there so she ran up to the front doors and on the way out the front doors she saw two staff bringing R1 back and he was barely in the parking lot at that time. LN I stated she did not hear a door alarm sound prior to the elopement and it was found the alarm was off on one of the hall doors (specified the hall), not where R1 resided. LN I stated prior to this she tried to check on R1 every 15 minutes due to his risk for eloping and kept him busy in the activity area. During an interview on 05/02/24 at 01:45 PM, CNA O stated she worked on 04/28/24 from 02:00 PM to 08:00 PM on the side R1 resided on. CNA O stated she saw R1 walking the halls (specified two hallways) and she followed him. R1 was at the exit door on a different hall from where he resided but same side of building, he had reached around the Velcro stop sign and was about to open the door when she told him it was too cold to go out. CNA O stated she was able to get R1 to turn around and he went to the activity area. CNA O went into another resident room after that and after exiting the room she was told R1 had gotten outside. CNA O did not hear a door alarm sound. During an interview on 05/02/24 at 02:08 PM, CMA R stated R1 was 10 to 15 feet west of the Exit sign near the west driveway when she found him. On 05/02/24 at 02:29 PM, Administrative Staff A stated staff should notify her if there is a problem with a door alarm so maintenance could be notified to check it and not shut the alarm off. During an interview on 05/02/24 at 02:44 PM, with the male visitor who alerted staff of R1 being outside, revealed the visitor saw R1 at the east side of the driveway, right on the curb by the street and then the resident went west. He noticed R1 was having trouble with the curb with his walker, at the edge of the west side of the driveway, where it curves and goes west. The facility policy Resident Elopement dated December 2022 included the facility strives to promote a safe and secure environment to help minimize risk of residents leaving the premises or safe area without the necessary supervision or authorization to do so. The facility is to have a process to monitor security of the premises on a routine basis. The facility failed to provide adequate supervision and a safe environment to cognitively impaired and independently mobile R1, identified as an elopement risk, who eloped from the facility with his walker on 04/28/24 without the staff knowledge, until a visitor informed the facility of a man walking outside in the street. On 05/02/24 at 05:32 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure to provide adequate supervision to R1 and ensure the exit door alarms were on when R1 eloped from the facility on 04/28/24 after 03:59 PM, placed R1 in immediate Jeopardy. The immediate jeopardy was determined to first exist on 04/27/24 at 06:09 PM and the surveyor verified the facility identified and implemented corrective actions completed on 04/29/24 at 10:00 PM, when the facility completed the following: 1. The facility immediately placed R1 on one-to-one supervision with staff, after the nurse assessed for injuries when he returned back inside the building on 04/28/24 at approximately 04:05 PM. 2. A facility wide door check completed by maintenance to ensure all alarmed doors were in proper working order, completed on 04/28/24 at 04:46 PM. 3. On 04/29/24 at 09:20 AM, R1's elopement assessment updated, and all other residents has elopement assessment completed and care plan reviewed for accuracy and appropriateness on 04/29/24 by 12:00 PM. 4. Stop signs placed on hallway exit doors to remind resident to turn around on 04/29/24 at 03:00 PM. 5. The facility's Elopement book reviewed to ensure accurate content and completed on 04/29/24 at 03:08 PM. 6. The Administrator, Director of Nursing, and Medical Director held a QAPI (Quality Assurance Performance Improvement) meeting via phone on 04/29/24 at 04:48 PM. 7. All staff educated on elopement policy and resident incident starting on 04/28/24 and ending on 04/29/24 at 10:00 PM. Otherwise, employees were suspended pending required in-service. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 36 residents with four residents sampled. Based on observation, record review, and interview, the facility failed to protect Resident (R) 2 from further abuse and neglect. On 03/21/22 at 10:10 PM when staff failed to notify the administrator immediately of an allegation of abuse and neglect. R2 reported Certified Nurse Aide (CNA) M was rough with her when assisting her to bed around 06:30 PM to 07:00 PM. R2 stated CNA M threw her into her bed by having a hold of her legs and swung her on the bed, while in the lift sling, during the transfer from the wheelchair to her bed. Afterwards, R2 experienced dizziness, nausea, and difficulty breathing due to lying flat as the head of the bed was flat. R2 activated her call light and when nobody responded to the call light, R2 started yelling out. When CNA M responded to R2, she did so by yelling at R2 from the hallway saying R2 was not the only resident left to take care of. R2's bed remained flat and R2 lacked application of her supplemental oxygen for 3 to 3.5 hours, until CNA N arrived for the 10:00 PM shift. While rounding, R2 hollered out CNA N's name and before she could respond, CNA M yelled from approximately 34 feet away That's enough [R2]! CNA N responded to R2 and found the resident crying and upset. CNA N reported the concerns to Licensed Nurse (LN) G at 10:10 PM. CNA N and LN G failed to report the abuse and neglect to Administrative Staff A immediately and did not remove CNA M from working with residents. The administrator was not aware of the events until 03/22/24, several hours after her arrival, when reading the Report of Concern forms from LN G and CNA N that were placed under her door. CNA M remained on duty until 06:00 AM on 03/22/24, working the last eight hours of her scheduled 12-hour shift on the other side of the facility. This deficient practice placed R2 in immediate jeopardy and did not protect R2 from potential for further abuse and neglect by CNA M and placed any resident CNA M worked with for the next eight hours at risk for abuse and neglect. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR) for R2 included diagnoses of muscle weakness, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R2 required oxygen. R2 had a range of motion impairment to her upper extremity on one side, was dependent on staff to roll left and right and return to back when in bed, when moving from lying to sitting on the side of the bed, and transfers in and out of the bed. The Functional Abilities Care Area assessment dated [DATE], revealed R2 had limited use of her right arm, used the call light when she needed assistance, and required total assistance from two staff for transfers with the full body lift. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of 14, indicating intact cognition. R2 required oxygen and continued to have impairment to one side of her upper extremity range of motion. R2 required substantial/maximum assistance from staff for rolling left-to-right and to back when in bed, moving from lying to sitting on the side of the bed, and transfers to/from the bed. The Care Plan dated 01/16/24 revealed R2 required extensive assistance of two staff with bed mobility and transfers with the full body lift. R2 wore oxygen at night to assist with her breathing to keep her oxygen saturations above 90 percent. The User Learning education log dated 05/02/24 revealed CNA M completed education on abuse/neglect/exploitation on 12/05/23 and 02/17/24. The Physician Order tab located in the EMR revealed R2 had an order dated 04/22/22 for oxygen at two liters at bedtime to keep oxygen saturations above 90 percent. The facility Assignment Sheet dated 03/21/24 revealed CNA M was scheduled for 06:00 PM to 10:00 PM on R2's side of the facility and the other side of the facility for the night shift. From 04:00 PM to 08:00 PM, CNA O scheduled on R2' s side of the facility and LN G scheduled the second half of the evening shift on R2's side of the facility, then on night shift was the charge nurse for both sides of the facility. CMA S scheduled for medications on the evening shift and CNA N scheduled on the night shift on R2's side of the facility. The facility Report of Concern dated 03/21/24 by CNA N, revealed when CNA N first walked in to get report R2 was in her room crying and said when she was put to bed, the unidentified staff left her head down flat, and it made her feel dizzy and sick. R2 had put her call light on to ask for help but nobody ever answered her light so then she yelled for help and when CNA M came in, she told R2 she needed to wait and left without helping her. CNA N was getting report from CNA M when R2 yelled CNA N's name from her room and CNA M yelled back at her That's enough [R2] then continued talking. CNA N went to room and R2 was telling her about what had happened and spend the next 30 to 40 minutes crying on and off in her room. CNA N stated R2 was very upset about the situation. The facility Report of Concern dated 03/21/24 by LN G, revealed at 10:10 PM CNA M told her she had been in R2's room and R2 was crying and upset that CNA M and CNA O had put her to bed, CNA M was rude to her, etc. LN G had talked to R2 at 06:00 PM when sitting in her wheelchair next to the television room and she was smiling and happy and stated she had a good day. LN G stated when trying to talk to her later about what happened, R2 got upset and had a difficult time explaining. R2 did stated they just plopped her into bed and left, she put on her call light and after 20 minutes, they had not answered her light, so she called out with her voice. CNA M came in and was rude to her. LN G did not push the issue further with R2 as it caused her to get upset again. LN G explained R2 had not done anything wrong, and LN G would try to investigate the manner. The facility investigation revealed an interview with R2 stating she called out for help to put her to bed, she had rung the call light, and nobody came for 30 minutes or longer. When CNA M responded she stated she could not do it alone and she was the only one here, but R2 said CNA O was also on this side. R2 stated CNA M basically threw her in bed and she was sideways with her head towards the window and her feet towards the door with her head all the way down and lacked her oxygen. R2 started getting really dizzy and sick and used the call light and no one came, so she started yelling out and CNA M yelled from the hall that R2 was not the only resident they had to take care of and left. R2 stated her legs were all twisted in her blankets so she could not move herself and she kept getting dizzier, so she started yelling for help. R2 asked for help to untangle her legs so she could maybe get herself straightened up in bed, but nobody came. R2 stated CNA M was really rough with her and basically threw her in bed and she never sleeps with her bed flat because she cannot breathe. R2 was yelling for them to come back and finish and nobody ever came until the night shift got there, and CNA N came in. CNA N applied R2's oxygen first thing then helped R2 to get straight and elevate the head of her bed, then R2's dizziness stopped. R2 stated one time in her room CNA M yelled at her from the hallway and told her she needed to be quiet, or she was going to wake everyone up. R2 said all she wanted was for the CNA to help her, put her oxygen on, and raise the head of the bed up. The investigation included when Administrative Staff A and Administrative Nurse D interviewed CNA M and asked if she did all the things reported, CNA M answered yes. When asked if she felt like anything she had done was considered abuse, CNA M answered yes. The facility Witness Statement dated 03/22/24 by CNA Q, revealed on 03/21/24 she witnessed CNA M, after CNA O left, having multiple call lights on while CNA M remained sitting at the nurse's desk eating her food. The facility Witness Statement dated 03/22/24 by CNA N, revealed on 03/21/24 when first arriving for her shift, CNA M asked for help to pull R2 up in the bed. When walking in R2's room she was crying and would not respond to CNA N when trying to talk to her. CNA N then stated they left her room so CNA M could give CNA N report, and while talking, R2 started yelling CNA N's name and CNA M instead of checking on her yelled back at her down the hallway That's enough [R2] and went back to talking. CNA N went in to check on R2 and to ask what was wrong. While crying R2 said when she was put to bed, the staff had left her head down flat making her feel dizzy and sick. R2 told CNA N she pressed her call light to ask for help and waited but no one answered her light, so she then tried yelling for help. CNA M then came in and told her she needed to wait and left without helping R2. CNA N stated R2 continued crying on and off for the next 30 minutes or so and seemed to be very upset. CNA N told LN G and then filled out a Report of Concern form. The facility Witness Statement dated 03/22/24 by CNA M, revealed on 03/21/24 she arrived at the facility at 06:00 PM. Towards the end of the night close to 10:00 PM while charting R2's light came on and she called asking to be lifted up and CNA M told R2 she was going to need to wait a second for CNA N to get there to help. R2 stated she can't, and CNA N told her she was sorry and did not know what else she could do right then, and R2 seemed okay with the answer. CNA N came in and CNA M started giving report when R2 started to call out/holler and CNA M stated [R2] that's enough and asked CNA N to help lift R2 up. The statement lacked what occurred when assisting R2 to bed and any interactions after that until the request to be pulled up close to 10:00 PM. The facility Witness Statement dated 03/21/24 by LN G, revealed at approximately 10:10 PM CNA M, who came in at 10:00 PM, told LN G she had been in R2's room and R2 was crying and very upset. R2 had told CNA N that CNA M and CNA O put R2 to bed and they were rude to her and etc. LN G had seen her at 06:00 PM sitting in her wheelchair next to the television room smiling and happy and stated she had a very good day. When LN G tried to talk to her later to get an explanation of what happened to get her so upset, but R2 became upset again and had a hard time explaining with words. R2 did say they plopped her down into bed and left. R2 told LN G she put her call light back on and after 20 minutes no one answered her light, so she called out with her voice then CNA M came back into R2's room, was very rude to her, and then left the room. LN G did not push the issue with R2 any further as it was causing her great upset to recall the issue. LN G explained to R2 that R2 did not do anything wrong, and LN G would try to investigate the matter. The Licensed Medication Administration Record dated March 2024, revealed on 03/21/24 at hour of sleep, LN G documented R2's oxygen saturation level as 85 percent. All other days of the month R2's oxygen level was 93 percent or better except on 03/28/24 and 03/29/24 documented not applicable. The Vital Signs tab in the EMR revealed on 03/21/24 at 10:18 PM, LN G assessed R2's oxygen saturation level at 85 percent, eight minutes after CNA N reported R2's concerns to LN G. The Progress Note dated 03/22/24 at 02:00 PM revealed R2 alleged that an unidentified CNA on night shift last night was rough and spoke to her inappropriately. The facility Employee Warning Notice dated 03/25/24 revealed LN G did not follow the ANE (Abuse, Neglect, Exploitation) Policy - did not report ANE immediately. Observation on 05/06/24 at 08:57 AM, revealed R2 sat up in a wheelchair in the activity area with a lift sling under her. Her room was located approximately 34 feet from the east side of the nurse's desk. An unidentified staff member assisted her to her room for the interview. In R2's room, an oxygen concentrator was next to the head of the bed and a full body lift stored in her room. During an interview on 05/06/24 at 08:59 AM, R2 stated she thought on 03/21/24 at approximately 06:30 to 07:00 PM, CNA M and CNA O assisted her to bed using the lift and CNA M had a hold of her and just threw me into bed. R2 stated CNA M did not have a hold of the lift sling, she had a hold of her feet and slung me in there. R2 could not recall if she was crossways in the bed or not and stated both staff walked out after putting her to bed. R2 stated she has to have the head of the bed up; the staff lay it flat when she gets in to bed and then they put it up and she gets really dizzy if she lays flat. R2 stated she turned on her light to get help as she cannot run the bed controls due to her right side messed up and the staff run the controls. R2 stated her feet were all tangled up and everything. R2 stated she hollered out to get help and CNA M stated [R2] that is enough and stated CNA M was always nasty. R2 stated she was dizzy waiting for someone to help her and was nauseated too. R2 stated she was crying, and CNA N came to help her and put her head up. R2 stated she wears oxygen at night. R2 stated CNA O was nice to her that night and always is. On 05/06/24 at 09:25 AM, LN G reported she thought it was around 08:00 PM when R2 received assistance to go to bed and did not hear anything until 10:00 PM or a little later when CNA N came in. LN G stated CNA N reported to her she had just been in the room with R2, and she was crying and when they put her to bed, they just plopped her down and walked out. LN G stated that was basically all CNA N said, but thought it was important to know R2 was upset. LN G stated she went back into R2's room to talk to her, she was crying again and had a hard time getting anything out, R2 said they (did not specify who) came in there and plopped her on the bed and left and her call light had been on, and they did not come back. LN G stated R2 did not tell her about her head being flat, but she was breaking up when talking and she could not recall if R2 had told her anything that CNA M said to R2. LN G stated she did not report anything at that time to Administrative Staff A and she filled out a report of concern form and placed it under Administrative Staff A's office door. LN G stated when R2 talked to her it really did not sound like anything, she could not spit it out, and she was upset. On 05/06/24 at 10:09 AM, CNA N stated on 03/21/24 when she first walked in, CNA M immediately came up to her and asked if staff could help pull R2 up in the bed. CNA N stated she was in the breakroom dropping off her things before she came to the desk. CNA N stated when entering R2's room she was crying, avoiding eye contact, sniffling, and rubbing her face. CNA N stated it was unusual for R2 to cry. CNA N stated she could not recall if R2 had oxygen on at that time, CNA N stated they then left the room, CNA M started giving her report, they were standing in front of the desk and had just finished rounds and R2 started yelling CNA N's name. CNA M stated before she had a chance to say anything, CNA M stated That's enough [R2] and kept talking like nothing happened and walked off to the other side of the facility. CNA N went to go talk to R2, who was hysterically crying when she walked in and had said a lot about not being able to breathe, would not answer the call light and come help, and CNA M should know better. CNA N left the room and LN G was at the cart, so she went straight to her and told her about it. CNA N stated she filled out a report of concern form and left it under Administrative Staff A's door. CNA N stated she did not contact Administrative Staff A nor Administrative Nurse D as she knew LN G was writing her report and assumed she was going to notify them. On 05/06/24 at 10:48 AM, CNA M stated she worked 06:00 PM to 10:00 PM on R2's side of the building. CNA M stated it was around 06:30 to 07:00 PM when assisting R2 to bed. CNA M denied having a hold of R2's feet or legs during the lift transfer to bed and stated she guided the lift as CNA O was not to run the lift and helped her put R2 to bed. CNA M denied swinging R2 into bed and stated they placed R2 over the bed and lowered her and moved her up in the bed. CNA M could not recall if she or CNA O put R2's oxygen in place and stated R2 had them put her head up a little bit but not too much. CNA M stated R2 had her call light on a few times after that, one for her teeth and one for her drink, and then shortly after that to be pulled up. CNA M stated she had forgotten to take care of her teeth when they laid R2 down, so she went and ahead and took care of that. CNA M stated around 09:30 PM or closer to 10:00 PM, R2 wanted to be pulled up. CNA M stated R2 was hollering, she had put her call light on a few minutes before CNA N arrived and had told R2 that the nurse was busy, and CNA N was not here yet so it would be a few minutes before pulling her up. CNA M stated R2 did not like that answer and started crying and she told R2 she would have to wait, it would be a few minutes and as soon as R2 heard CNA N, she started hollering out into hallway screaming, while we were in the middle of giving report. CNA M said she raised her voice at R2 and said [R2] that is enough while standing at the desk. CNA M admitted she had gotten loud with R2 and after getting her situated she went over to the other side of the facility and worked until 06:00 AM on 03/22/24. On 05/06/24 at 11:20 AM Administrative Staff A stated on 03/22/24 there was a report of concern from LN G and CNA N under her door that she got to a few hours after arriving to the facility, which was usually 08:00 AM. Administrative Staff A stated she was not aware of R2's concerns prior to that and had she known, she would have suspended CNA M and if the staff truly felt CNA M yelled at R2 they should have called her. Administrative Staff A stated the staff were to call her immediately for allegations of abuse or neglect. On 05/06/24 at 01:14 PM Administrative Staff A stated she had interviewed CNA O and she did not hear or see anything that would be classified as abuse and did not collect a statement from her. The facility's policy for Abuse, Neglect, and Exploitation dated October 2022, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The facility policy was to treat each resident with respect, kindness, dignity, and care, to keep them free form abuse and neglect, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. All alleged violations involving abuse, neglect, exploitation, or mistreatment are to be reported immediately to the Administrator and/or their designated representative. Any time a report of possible abuse, neglect, or exploitation was made against an employee, that employee should be immediately sent home and suspended without by the person in charge until a thorough investigation could be conducted by the Director of Nursing/Administrator. The facility failed to report abuse and neglect to R2 on 03/21/24 by CNA M immediately to the administrator which allowed her to continue her shift for eight more hours placing other residents in the facility at risk for potential abuse and neglect. On 05/06/24 at 04:33 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure on 03/21/24 to protect R2 and other residents of the facility from potential further abuse and neglect after receiving an allegation of abuse and neglect regarding CMA M. The immediate jeopardy was determined to first exist on 03/21/24 at 10:10 PM when staff were made aware of the allegation and the surveyor verified the removal of the immediate jeopardy occurred on 03/22/24 at 10:00 PM with the facility implementation of the following actions: The immediate jeopardy was determined to first exist on 03/21/24 at 07:00 PM when CNA M roughly put R2 in bed. The surveyor verified the removal of the immediate jeopardy occurred on 03/22/24 at 10:00 PM with the facility implementation of the following actions: 1. Administrative Staff A and Administrative Nurse D interviewed R2 on 03/22/24 at 11:20 AM. R2 confirmed the allegations. 2. CNA M interviewed on 03/22/24 at 02:15 PM by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes!' and began crying. CNA M suspended. 3. CNA M interviewed by Administrative Staff A on 03/22/24 at 04:00 PM regarding the allegations against CNA N to R2. 4. The LN completed an assessment on 03/22/24. 5. Verbal discipline and education given to LN G for not reporting immediately on 03/22/24. 6. All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift on 03/22/24 at 10:00 PM. 7. Written discipline given to LN G on 03/25/24. 8. QAPI meeting held on 03/26/24 with the medical director. 9. On 03/27/24 at 05:11 PM CNA M terminated. Due to the corrective measures implemented prior to the onsite survey, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 36 residents with four residents sampled. Based on observation, record review, and interview, the facility failed to report abuse and neglect of R2 immediately on 03/21/22 at 10:10 PM. On 03/21/24, R2 reported Certified Nurse Aide (CNA) M was rough with her when assisting her to bed around 06:30 PM to 07:00 PM. R2 stated CNA M threw her into her bed by having a hold of her legs and swung her on the bed, while in the lift sling, during the transfer from the wheelchair to her bed. Afterwards, R2 experienced dizziness, nausea, and difficulty breathing due to lying flat as the head of the bed was flat. R2 activated her call light and when nobody responded to the call light, R2 started yelling out. When CNA M responded to R2, she did so by yelling at R2 from the hallway saying R2 was not the only resident left to take care of. R2's bed remained flat and R2 lacked application of her supplemental oxygen for 3 to 3.5 hours, until CNA N arrived for the 10:00 PM shift. While rounding, R2 hollered out CNA N's name and before she could respond, CNA M yelled from approximately 34 feet away That's enough [R2]! CNA N responded to R2 and found the resident crying and upset. CNA N reported the concerns to Licensed Nurse (LN) G at 10:10 PM. CNA N and LN G failed to report the abuse and neglect to Administrative Staff A immediately. The administrator was not aware of the events until 03/22/24, several hours after her arrival, when reading Report of Concern forms from LN G and CNA N that were placed under her door. CNA M remained on duty until 06:00 AM on 03/22/24, working the last eight hours of her scheduled 12-hour shift on the other side of the facility. This deficient practice placed R2 in immediate jeopardy and allowed potential for further abuse and neglect by CNA M to other residents in the facility for eight more hours. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR) for R2 included diagnoses of muscle weakness, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R2 required oxygen. R2 had a range of motion impairment to her upper extremity on one side, was dependent on staff to roll left and right and return to back when in bed, when moving from lying to sitting on the side of the bed, and transfers in and out of the bed. The Functional Abilities Care Area assessment dated [DATE], revealed R2 had limited use of her right arm, used the call light when she needed assistance, and required total assistance from two staff for transfers with the full body lift. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of 14, indicating intact cognition. R2 required oxygen and continued to have impairment to one side of her upper extremity range of motion. R2 required substantial/maximum assistance from staff for rolling left-to-right and to back when in bed, moving from lying to sitting on the side of the bed, and transfers to/from the bed. The Care Plan dated 01/16/24 revealed R2 required extensive assistance of two staff with bed mobility and transfers with the full body lift. R2 wore oxygen at night to assist with her breathing to keep her oxygen saturations above 90 percent. The User Learning education log dated 05/02/24 revealed CNA M completed education on abuse/neglect/exploitation on 12/05/23 and 02/17/24. The Physician Order tab located in the EMR revealed R2 had an order dated 04/22/22 for oxygen at two liters at bedtime to keep oxygen saturations above 90 percent. The facility Assignment Sheet dated 03/21/24 revealed CNA M was scheduled for 06:00 PM to 10:00 PM on R2's side of the facility and the other side of the facility for the night shift. From 04:00 PM to 08:00 PM, CNA O scheduled on R2' s side of the facility and LN G scheduled the second half of the evening shift on R2's side of the facility, then on night shift was the charge nurse for both sides of the facility. CMA S scheduled for medications on the evening shift and CNA N scheduled on the night shift on R2's side of the facility. The facility Report of Concern dated 03/21/24 by CNA N, revealed when CNA N first walked in to get report R2 was in her room crying and said when she was put to bed, the unidentified staff left her head down flat, and it made her feel dizzy and sick. R2 had put her call light on to ask for help but nobody ever answered her light so then she yelled for help and when CNA M came in, she told R2 she needed to wait and left without helping her. CNA N was getting report from CNA M when R2 yelled CNA N's name from her room and CNA M yelled back at her That's enough [R2] then continued talking. CNA N went to room and R2 was telling her about what had happened and spend the next 30 to 40 minutes crying on and off in her room. CNA N stated R2 was very upset about the situation. The facility Report of Concern dated 03/21/24 by LN G, revealed at 10:10 PM CNA M told her she had been in R2's room and R2 was crying and upset that CNA M and CNA O had put her to bed, CNA M was rude to her, etc. LN G had talked to R2 at 06:00 PM when sitting in her wheelchair next to the television room and she was smiling and happy and stated she had a good day. LN G stated when trying to talk to her later about what happened, R2 got upset and had a difficult time explaining. R2 did stated they just plopped her into bed and left, she put on her call light and after 20 minutes, they had not answered her light, so she called out with her voice. CNA M came in and was rude to her. LN G did not push the issue further with R2 as it caused her to get upset again. LN G explained R2 had not done anything wrong, and LN G would try to investigate the manner. The facility investigation revealed an interview with R2 stating she called out for help to put her to bed, she had rung the call light, and nobody came for 30 minutes or longer. When CNA M responded she stated she could not do it alone and she was the only one here, but R2 said CNA O was also on this side. R2 stated CNA M basically threw her in bed and she was sideways with her head towards the window and her feet towards the door with her head all the way down and lacked her oxygen. R2 started getting really dizzy and sick and used the call light and no one came, so she started yelling out and CNA M yelled from the hall that R2 was not the only resident they had to take care of and left. R2 stated her legs were all twisted in her blankets so she could not move herself and she kept getting dizzier, so she started yelling for help. R2 asked for help to untangle her legs so she could maybe get herself straightened up in bed, but nobody came. R2 stated CNA M was really rough with her and basically threw her in bed and she never sleeps with her bed flat because she cannot breathe. R2 was yelling for them to come back and finish and nobody ever came until the night shift got there, and CNA N came in. CNA N applied R2's oxygen first thing then helped R2 to get straight and elevate the head of her bed, then R2's dizziness stopped. R2 stated one time in her room CNA M yelled at her from the hallway and told her she needed to be quiet, or she was going to wake everyone up. R2 said all she wanted was for the CNA to help her, put her oxygen on, and raise the head of the bed up. The investigation included when Administrative Staff A and Administrative Nurse D interviewed CNA M and asked if she did all the things reported, CNA M answered yes. When asked if she felt like anything she had done was considered abuse, CNA M answered yes. The facility Witness Statement dated 03/22/24 by CNA Q, revealed on 03/21/24 she witnessed CNA M, after CNA O left, having multiple call lights on while CNA M remained sitting at the nurse's desk eating her food. The facility Witness Statement dated 03/22/24 by CNA N, revealed on 03/21/24 when first arriving for her shift, CNA M asked for help to pull R2 up in the bed. When walking in R2's room she was crying and would not respond to CNA N when trying to talk to her. CNA N then stated they left her room so CNA M could give CNA N report, and while talking, R2 started yelling CNA N's name and CNA M instead of checking on her yelled back at her down the hallway That's enough [R2] and went back to talking. CNA N went in to check on R2 and to ask what was wrong. While crying R2 said when she was put to bed, the staff had left her head down flat making her feel dizzy and sick. R2 told CNA N she pressed her call light to ask for help and waited but no one answered her light, so she then tried yelling for help. CNA M then came in and told her she needed to wait and left without helping R2. CNA N stated R2 continued crying on and off for the next 30 minutes or so and seemed to be very upset. CNA N told LN G and then filled out a Report of Concern form. The facility Witness Statement dated 03/22/24 by CNA M, revealed on 03/21/24 she arrived at the facility at 06:00 PM. Towards the end of the night close to 10:00 PM while charting R2's light came on and she called asking to be lifted up and CNA M told R2 she was going to need to wait a second for CNA N to get there to help. R2 stated she can't, and CNA N told her she was sorry and did not know what else she could do right then, and R2 seemed okay with the answer. CNA N came in and CNA M started giving report when R2 started to call out/holler and CNA M stated [R2] that's enough and asked CNA N to help lift R2 up. The statement lacked what occurred when assisting R2 to bed and any interactions after that until the request to be pulled up close to 10:00 PM. The facility Witness Statement dated 03/21/24 by LN G, revealed at approximately 10:10 PM CNA M, who came in at 10:00 PM, told LN G she had been in R2's room and R2 was crying and very upset. R2 had told CNA N that CNA M and CNA O put R2 to bed and they were rude to her and etc. LN G had seen her at 06:00 PM sitting in her wheelchair next to the television room smiling and happy and stated she had a very good day. When LN G tried to talk to her later to get an explanation of what happened to get her so upset, but R2 became upset again and had a hard time explaining with words. R2 did say they plopped her down into bed and left. R2 told LN G she put her call light back on and after 20 minutes no one answered her light, so she called out with her voice then CNA M came back into R2's room, was very rude to her, and then left the room. LN G did not push the issue with R2 any further as it was causing her great upset to recall the issue. LN G explained to R2 that R2 did not do anything wrong, and LN G would try to investigate the matter. The Licensed Medication Administration Record dated March 2024, revealed on 03/21/24 at hour of sleep, LN G documented R2's oxygen saturation level as 85 percent. All other days of the month R2's oxygen level was 93 percent or better except on 03/28/24 and 03/29/24 documented not applicable. The Vital Signs tab in the EMR revealed on 03/21/24 at 10:18 PM, LN G assessed R2's oxygen saturation level at 85 percent, eight minutes after CNA N reported R2's concerns to LN G. The Progress Note dated 03/22/24 at 02:00 PM revealed R2 alleged that an unidentified CNA on night shift last night was rough and spoke to her inappropriately. The facility Employee Warning Notice dated 03/25/24 revealed LN G did not follow the ANE (Abuse, Neglect, Exploitation) Policy - did not report ANE immediately. Observation on 05/06/24 at 08:57 AM, revealed R2 sat up in a wheelchair in the activity area with a lift sling under her. Her room was located approximately 34 feet from the east side of the nurse's desk. An unidentified staff member assisted her to her room for the interview. In R2's room, an oxygen concentrator was next to the head of the bed and a full body lift stored in her room. During an interview on 05/06/24 at 08:59 AM, R2 stated she thought on 03/21/24 at approximately 06:30 to 07:00 PM, CNA M and CNA O assisted her to bed using the lift and CNA M had a hold of her and just threw me into bed. R2 stated CNA M did not have a hold of the lift sling, she had a hold of her feet and slung me in there. R2 could not recall if she was crossways in the bed or not and stated both staff walked out after putting her to bed. R2 stated she has to have the head of the bed up; the staff lay it flat when she gets in to bed and then they put it up and she gets really dizzy if she lays flat. R2 stated she turned on her light to get help as she cannot run the bed controls due to her right side messed up and the staff run the controls. R2 stated her feet were all tangled up and everything. R2 stated she hollered out to get help and CNA M stated [R2] that is enough and stated CNA M was always nasty. R2 stated she was dizzy waiting for someone to help her and was nauseated too. R2 stated she was crying, and CNA N came to help her and put her head up. R2 stated she wears oxygen at night. R2 stated CNA O was nice to her that night and always is. On 05/06/24 at 09:25 AM, LN G reported she thought it was around 08:00 PM when R2 received assistance to go to bed and did not hear anything until 10:00 PM or a little later when CNA N came in. LN G stated CNA N reported to her she had just been in the room with R2, and she was crying and when they put her to bed, they just plopped her down and walked out. LN G stated that was basically all CNA N said, but thought it was important to know R2 was upset. LN G stated she went back into R2's room to talk to her, she was crying again and had a hard time getting anything out, R2 said they (did not specify who) came in there and plopped her on the bed and left and her call light had been on, and they did not come back. LN G stated R2 did not tell her about her head being flat, but she was breaking up when talking and she could not recall if R2 had told her anything that CNA M said to R2. LN G stated she did not report anything at that time to Administrative Staff A and she filled out a report of concern form and placed it under Administrative Staff A's office door. LN G stated when R2 talked to her it really did not sound like anything, she could not spit it out, and she was upset. On 05/06/24 at 10:09 AM, CNA N stated on 03/21/24 when she first walked in, CNA M immediately came up to her and asked if staff could help pull R2 up in the bed. CNA N stated she was in the breakroom dropping off her things before she came to the desk. CNA N stated when entering R2's room she was crying, avoiding eye contact, sniffling, and rubbing her face. CNA N stated it was unusual for R2 to cry. CNA N stated she could not recall if R2 had oxygen on at that time, CNA N stated they then left the room, CNA M started giving her report, they were standing in front of the desk and had just finished rounds and R2 started yelling CNA N's name. CNA M stated before she had a chance to say anything, CNA M stated That's enough [R2] and kept talking like nothing happened and walked off to the other side of the facility. CNA N went to go talk to R2, who was hysterically crying when she walked in and had said a lot about not being able to breathe, would not answer the call light and come help, and CNA M should know better. CNA N left the room and LN G was at the cart, so she went straight to her and told her about it. CNA N stated she filled out a report of concern form and left it under Administrative Staff A's door. CNA N stated she did not contact Administrative Staff A nor Administrative Nurse D as she knew LN G was writing her report and assumed she was going to notify them. On 05/06/24 at 10:48 AM, CNA M stated she worked 06:00 PM to 10:00 PM on R2's side of the building. CNA M stated it was around 06:30 to 07:00 PM when assisting R2 to bed. CNA M denied having a hold of R2's feet or legs during the lift transfer to bed and stated she guided the lift as CNA O was not to run the lift and helped her put R2 to bed. CNA M denied swinging R2 into bed and stated they placed R2 over the bed and lowered her and moved her up in the bed. CNA M could not recall if she or CNA O put R2's oxygen in place and stated R2 had them put her head up a little bit but not too much. CNA M stated R2 had her call light on a few times after that, one for her teeth and one for her drink, and then shortly after that to be pulled up. CNA M stated she had forgotten to take care of her teeth when they laid R2 down, so she went and ahead and took care of that. CNA M stated around 09:30 PM or closer to 10:00 PM, R2 wanted to be pulled up. CNA M stated R2 was hollering, she had put her call light on a few minutes before CNA N arrived and had told R2 that the nurse was busy, and CNA N was not here yet so it would be a few minutes before pulling her up. CNA M stated R2 did not like that answer and started crying and she told R2 she would have to wait, it would be a few minutes and as soon as R2 heard CNA N, she started hollering out into hallway screaming, while we were in the middle of giving report. CNA M said she raised her voice at R2 and said [R2] that is enough while standing at the desk. CNA M admitted she had gotten loud with R2 and after getting her situated she went over to the other side of the facility and worked until 06:00 AM on 03/22/24. On 05/06/24 at 11:20 AM Administrative Staff A stated on 03/22/24 there was a report of concern from LN G and CNA N under her door that she got to a few hours after arriving to the facility, which was usually 08:00 AM. Administrative Staff A stated she was not aware of R2's concerns prior to that and had she known, she would have suspended CNA M and if the staff truly felt CNA M yelled at R2 they should have called her. Administrative Staff A stated the staff were to call her immediately for allegations of abuse or neglect. On 05/06/24 at 01:14 PM Administrative Staff A stated she had interviewed CNA O and she did not hear or see anything that would be classified as abuse and did not collect a statement from her. The facility's policy for Abuse, Neglect, and Exploitation dated October 2022, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The facility policy was to treat each resident with respect, kindness, dignity, and care, to keep them free form abuse and neglect, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. All alleged violations involving abuse, neglect, exploitation, or mistreatment are to be reported immediately to the Administrator and/or their designated representative. Any time a report of possible abuse, neglect, or exploitation was made against an employee, that employee should be immediately sent home and suspended without by the person in charge until a thorough investigation could be conducted by the Director of Nursing/Administrator. The facility failed to report abuse and neglect to R2 on 03/21/24 by CNA M immediately to the administrator which allowed her to continue her shift for eight more hours placing other residents in the facility at risk for potential abuse and neglect. On 05/06/24 at 04:33 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure to prevent abuse and neglect on 03/21/24 to R2. The immediate jeopardy was determined to first exist on 03/21/24 at approximately 07:00 PM when CNA M roughly put R2 in bed. The surveyor verified the removal of the immediate jeopardy occurred on 03/22/24 at 10:00 PM with the facility implementation of the following actions: 1. Administrative Staff A and Administrative Nurse D interviewed R2 on 03/22/24 at 11:20 AM. R2 confirmed the allegations. 2. CNA M interviewed on 03/22/24 at 02:15 PM by Administrative Staff A and Administrative Nurse D and admitted to the allegations. The facility suspended CNA M. 3. CNA M interviewed by Administrative Staff A on 03/22/24 at 04:00 PM regarding the allegations against CNA N to R2. 4. The LN completed an assessment on 03/22/24. 5. Verbal discipline and education given to LN G for not reporting immediately on 03/22/24. 6. All staff training initiated immediately on reporting allegations of abuse, and completed at the start of each shift on 03/22/24 at 10:00 PM. 7. Written discipline given to LN G on 03/25/24. 8. QAPI meeting held on 03/26/24 with the medical director. 9. On 03/27/24 at 05:11 PM CNA M terminated. Due to the corrective measures implemented prior to the onsite survey, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 36 residents with four residents sampled. Based on observation, record review, and interview, the facility failed to prevent the physical abuse and neglect of R2. On 03/21/24, R2 reported Certified Nurse Aide (CNA) M was rough with her when assisting her to bed around 06:30 PM to 07:00 PM. R2 stated CNA M threw her into her bed by having a hold of her legs and swung her on the bed, while in the lift sling, during the transfer from the wheelchair to her bed. Afterwards, R2 experienced dizziness, nausea, and difficulty breathing due lying flat as the head of the bed was flat. R2 activated her call light and when nobody responded to the call light, R2 started yelling out. When CNA M responded to R2, she did so by yelling at R2 from the hallway saying R2 was not the only resident left to take care of. R2's bed remained flat and R2 lacked application of her supplemental oxygen for 3 to 3.5 hours, until CNA N arrived for the 10:00 PM shift. While rounding, R2 hollered out CNA N's name and before she could respond, CNA M yelled from approximately 34 feet away That's enough [R2]! CNA N responded to R2 and found the resident crying and upset. CNA N reported the concerns to Licensed Nurse (LN) G at 10:10 PM. CNA N and LN G failed to report the abuse and neglect to Administrative Staff A immediately. CNA M remained on duty until 06:00 AM on 03/22/24, working the last eight hours of her scheduled 12-hour shift on the other side of the facility. This deficient practice placed R2 in immediate jeopardy and other residents who resided in the facility at risk for abuse and neglect. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR) for R2 included diagnoses of muscle weakness, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R2 required oxygen. R2 had a range of motion impairment to her upper extremity on one side, was dependent on staff to roll left and right and return to back when in bed, when moving from lying to sitting on the side of the bed, and transfers in and out of the bed. The Functional Abilities Care Area assessment dated [DATE], revealed R2 had limited use of her right arm, used the call light when she needed assistance, and required total assistance from two staff for transfers with the full body lift. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of 14, indicating intact cognition. R2 required oxygen and continued to have impairment to one side of her upper extremity range of motion. R2 required substantial/maximum assistance from staff for rolling left-to-right and to back when in bed, moving from lying to sitting on the side of the bed, and transfers to/from the bed. The Care Plan dated 01/16/24 revealed R2 required extensive assistance of two staff with bed mobility and transfers with the full body lift. R2 wore oxygen at night to assist with her breathing to keep her oxygen saturations above 90 percent. The User Learning education log dated 05/02/24 revealed CNA M completed education on abuse/neglect/exploitation on 12/05/23 and 02/17/24. The Physician Order tab located in the EMR revealed R2 had an order dated 04/22/22 for oxygen at two liters at bedtime to keep oxygen saturations above 90 percent. The facility Assignment Sheet dated 03/21/24 revealed CNA M was scheduled for 06:00 PM to 10:00 PM on R2's side of the facility and the other side of the facility for the night shift. From 04:00 PM to 08:00 PM, CNA O scheduled on R2' s side of the facility and LN G scheduled the second half of the evening shift on R2's side of the facility, then on night shift was the charge nurse for both sides of the facility. CMA S scheduled for medications on the evening shift and CNA N scheduled on the night shift on R2's side of the facility. The facility Report of Concern dated 03/21/24 by CNA N, revealed when CNA N first walked in to get report R2 was in her room crying and said when she was put to bed, the unidentified staff left her head down flat, and it made her feel dizzy and sick. R2 had put her call light on to ask for help but nobody ever answered her light so then she yelled for help and when CNA M came in, she told R2 she needed to wait and left without helping her. CNA N was getting report from CNA M when R2 yelled CNA N's name from her room and CNA M yelled back at her That's enough [R2] then continued talking. CNA N went to room and R2 was telling her about what had happened and spend the next 30 to 40 minutes crying on and off in her room. CNA N stated R2 was very upset about the situation. The facility Report of Concern dated 03/21/24 by LN G, revealed at 10:10 PM CNA M told her she had been in R2's room and R2 was crying and upset that CNA M and CNA O had put her to bed, CNA M was rude to her, etc. LN G had talked to R2 at 06:00 PM when sitting in her wheelchair next to the television room and she was smiling and happy and stated she had a good day. LN G stated when trying to talk to her later about what happened, R2 got upset and had a difficult time explaining. R2 did stated they just plopped her into bed and left, she put on her call light and after 20 minutes, they had not answered her light, so she called out with her voice. CNA M came in and was rude to her. LN G did not push the issue further with R2 as it caused her to get upset again. LN G explained R2 had not done anything wrong, and LN G would try to investigate the manner. The facility investigation revealed an interview with R2 stating she called out for help to put her to bed, she had rung the call light, and nobody came for 30 minutes or longer. When CNA M responded she stated she could not do it alone and she was the only one here, but R2 said CNA O was also on this side. R2 stated CNA M basically threw her in bed and she was sideways with her head towards the window and her feet towards the door with her head all the way down and lacked her oxygen. R2 started getting really dizzy and sick and used the call light and no one came, so she started yelling out and CNA M yelled from the hall that R2 was not the only resident they had to take care of and left. R2 stated her legs were all twisted in her blankets so she could not move herself and she kept getting dizzier, so she started yelling for help. R2 asked for help to untangle her legs so she could maybe get herself straightened up in bed, but nobody came. R2 stated CNA M was really rough with her and basically threw her in bed and she never sleeps with her bed flat because she cannot breathe. R2 was yelling for them to come back and finish and nobody ever came until the night shift got there, and CNA N came in. CNA N applied R2's oxygen first thing then helped R2 to get straight and elevate the head of her bed, then R2's dizziness stopped. R2 stated one time in her room CNA M yelled at her from the hallway and told her she needed to be quiet, or she was going to wake everyone up. R2 said all she wanted was for the CNA to help her, put her oxygen on, and raise the head of the bed up. The investigation included when Administrative Staff A and Administrative Nurse D interviewed CNA M and asked if she did all the things reported, CNA M answered yes. When asked if she felt like anything she had done was considered abuse, CNA M answered yes. The facility Witness Statement dated 03/22/24 by CNA Q, revealed on 03/21/24 she witnessed CNA M, after CNA O left, having multiple call lights on while CNA M remained sitting at the nurse's desk eating her food. The facility Witness Statement dated 03/22/24 by CNA N, revealed on 03/21/24 when first arriving for her shift, CNA M asked for help to pull R2 up in the bed. When walking in R2's room she was crying and would not respond to CNA N when trying to talk to her. CNA N then stated they left her room so CNA M could give CNA N report, and while talking, R2 started yelling CNA N's name and CNA M instead of checking on her yelled back at her down the hallway That's enough [R2] and went back to talking. CNA N went in to check on R2 and to ask what was wrong. While crying R2 said when she was put to bed, the staff had left her head down flat making her feel dizzy and sick. R2 told CNA N she pressed her call light to ask for help and waited but no one answered her light, so she then tried yelling for help. CNA M then came in and told her she needed to wait and left without helping R2. CNA N stated R2 continued crying on and off for the next 30 minutes or so and seemed to be very upset. CNA N told LN G and then filled out a Report of Concern form. The facility Witness Statement dated 03/22/24 by CNA M, revealed on 03/21/24 she arrived at the facility at 06:00 PM. Towards the end of the night close to 10:00 PM while charting R2's light came on and she called asking to be lifted up and CNA M told R2 she was going to need to wait a second for CNA N to get there to help. R2 stated she can't, and CNA N told her she was sorry and did not know what else she could do right then, and R2 seemed okay with the answer. CNA N came in and CNA M started giving report when R2 started to call out/holler and CNA M stated [R2] that's enough and asked CNA N to help lift R2 up. The statement lacked what occurred when assisting R2 to bed and any interactions after that until the request to be pulled up close to 10:00 PM. The facility Witness Statement dated 03/21/24 by LN G, revealed at approximately 10:10 PM CNA M, who came in at 10:00 PM, told LN G she had been in R2's room and R2 was crying and very upset. R2 had told CNA N that CNA M and CNA O put R2 to bed and they were rude to her and etc. LN G had seen her at 06:00 PM sitting in her wheelchair next to the television room smiling and happy and stated she had a very good day. When LN G tried to talk to her later to get an explanation of what happened to get her so upset, but R2 became upset again and had a hard time explaining with words. R2 did say they plopped her down into bed and left. R2 told LN G she put her call light back on and after 20 minutes no one answered her light, so she called out with her voice then CNA M came back into R2's room, was very rude to her, and then left the room. LN G did not push the issue with R2 any further as it was causing her great upset to recall the issue. LN G explained to R2 that R2 did not do anything wrong, and LN G would try to investigate the matter. The Licensed Medication Administration Record dated March 2024, revealed on 03/21/24 at hour of sleep, LN G documented R2's oxygen saturation level as 85 percent. All other days of the month R2's oxygen level was 93 percent or better except on 03/28/24 and 03/29/24 documented not applicable. The Vital Signs tab in the EMR revealed on 03/21/24 at 10:18 PM, LN G assessed R2's oxygen saturation level at 85 percent, eight minutes after CNA N reported R2's concerns to LN G. The Progress Note dated 03/22/24 at 02:00 PM revealed R2 alleged that an unidentified CNA on night shift last night was rough and spoke to her inappropriately. The facility Employee Warning Notice dated 03/25/24 revealed LN G did not follow the ANE (Abuse, Neglect, Exploitation) Policy - did not report ANE immediately. Observation on 05/06/24 at 08:57 AM, revealed R2 sat up in a wheelchair in the activity area with a lift sling under her. Her room was located approximately 34 feet from the east side of the nurse's desk. An unidentified staff member assisted her to her room for the interview. In R2's room, an oxygen concentrator was next to the head of the bed and a full body lift stored in her room. During an interview on 05/06/24 at 08:59 AM, R2 stated she thought on 03/21/24 at approximately 06:30 to 07:00 PM, CNA M and CNA O assisted her to bed using the lift and CNA M had a hold of her and just threw me into bed. R2 stated CNA M did not have a hold of the lift sling, she had a hold of her feet and slung me in there. R2 could not recall if she was crossways in the bed or not and stated both staff walked out after putting her to bed. R2 stated she has to have the head of the bed up; the staff lay it flat when she gets in to bed and then they put it up and she gets really dizzy if she lays flat. R2 stated she turned on her light to get help as she cannot run the bed controls due to her right side messed up and the staff run the controls. R2 stated her feet were all tangled up and everything. R2 stated she hollered out to get help and CNA M stated [R2] that is enough and stated CNA M was always nasty. R2 stated she was dizzy waiting for someone to help her and was nauseated too. R2 stated she was crying, and CNA N came to help her and put her head up. R2 stated she wears oxygen at night. R2 stated CNA O was nice to her that night and always is. On 05/06/24 at 09:24 AM, an attempt to reach CNA O for interview was unsuccessful. On 05/06/24 at 09:25 AM, LN G reported she thought it was around 08:00 PM when R2 received assistance to go to bed and did not hear anything until 10:00 PM or a little later when CNA N came in. LN G stated CNA N reported to her she had just been in the room with R2, and she was crying and when they put her to bed, they just plopped her down and walked out. LN G stated that was basically all CNA N said, but thought it was important to know R2 was upset. LN G stated she went back into R2's room to talk to her, she was crying again and had a hard time getting anything out, R2 said they (did not specify who) came in there and plopped her on the bed and left and her call light had been on, and they did not come back. LN G stated R2 did not tell her about her head being flat, but she was breaking up when talking and she could not recall if R2 had told her anything that CNA M said to R2. LN G stated she did not report anything at that time to Administrative Staff A and she filled out a report of concern form and placed it under Administrative Staff A's office door. LN G stated when R2 talked to her it really did not sound like anything, she could not spit it out, and she was upset. On 05/06/24 at 10:09 AM, CNA N stated on 03/21/24 when she first walked in, CNA M immediately came up to her and asked if staff could help pull R2 up in the bed. CNA N stated she was in the breakroom dropping off her things before she came to the desk. CNA N stated when entering R2's room she was crying, avoiding eye contact, sniffling, and rubbing her face. CNA N stated it was unusual for R2 to cry. CNA N stated she could not recall if R2 had oxygen on at that time, CNA N stated they then left the room, CNA M started giving her report, they were standing in front of the desk and had just finished rounds and R2 started yelling CNA N's name. CNA M stated before she had a chance to say anything, CNA M stated That's enough [R2] and kept talking like nothing happened and walked off to the other side of the facility. CNA N went to go talk to R2, who was hysterically crying when she walked in and had said a lot about not being able to breathe, would not answer the call light and come help, and CNA M should know better. CNA N left the room and LN G was at the cart, so she went straight to her and told her about it. CNA N stated she filled out a report of concern form and left it under Administrative Staff A's door. CNA N stated she did not contact Administrative Staff A nor Administrative Nurse D as she knew LN G was writing her report and assumed she was going to notify them. On 05/06/24 at 10:48 AM, CNA M stated she worked 06:00 PM to 10:00 PM on R2's side of the building. CNA M stated it was around 06:30 to 07:00 PM when assisting R2 to bed. CNA M denied having a hold of R2's feet or legs during the lift transfer to bed and stated she guided the lift as CNA O was not to run the lift and helped her put R2 to bed. CNA M denied swinging R2 into bed and stated they placed R2 over the bed and lowered her and moved her up in the bed. CNA M could not recall if she or CNA O put R2's oxygen in place and stated R2 had them put her head up a little bit but not too much. CNA M stated R2 had her call light on a few times after that, one for her teeth and one for her drink, and then shortly after that to be pulled up. CNA M stated she had forgotten to take care of her teeth when they laid R2 down so she went and ahead and took care of that. CNA M stated around 09:30 PM or closer to 10:00 PM, R2 wanted to be pulled up. CNA M stated R2 was hollering, she had put her call light on a few minutes before CNA N arrived and had told R2 that the nurse was busy, and CNA N was not here yet so it would be a few minutes before pulling her up. CNA M stated R2 did not like that answer and started crying and she told R2 she would have to wait, it would be a few minutes and as soon as R2 heard CNA N, she started hollering out into hallway screaming, while we were in the middle of giving report. CNA M said she raised her voice at R2 and said [R2] that is enough while standing at the desk. CNA M admitted she had gotten loud with R2 and after getting her situated she went over to the other side of the facility and worked until 06:00 AM on 03/22/24. On 05/06/24 at 11:20 AM Administrative Staff A stated on 03/22/24 there was a report of concern from LN G and CNA N under her door that she got to a few hours after arriving to the facility, which was usually 08:00 AM. Administrative Staff A stated she was not aware of R2's concerns prior to that and had she known, she would have suspended CNA M and if the staff truly felt CNA M yelled at R2 they should have called her. Administrative Staff A stated the staff were to call her immediately for allegations of abuse or neglect. On 05/06/24 at 01:14 PM Administrative Staff A stated she had interviewed CNA O and she did not hear or see anything that would be classified as abuse and did not collect a statement from her. The facility's policy for Abuse, Neglect, and Exploitation dated October 2022, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The facility policy was to treat each resident with respect, kindness, dignity, and care, to keep them free form abuse and neglect, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. All alleged violations involving abuse, neglect, exploitation, or mistreatment are to be reported immediately to the Administrator and/or their designated representative. Any time a report of possible abuse, neglect, or exploitation was made against an employee, that employee should be immediately sent home and suspended without by the person in charge until a thorough investigation could be conducted by the Director of Nursing/Administrator. The facility failed to prevent physical and verbal abuse and neglect to R2 on 03/21/24 by CNA M and allowed her to continue her shift for eight more hours placing other residents in the facility for abuse and neglect. On 05/06/24 at 04:33 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified of the facility's failure to prevent abuse and neglect on 03/21/24 to R2. The immediate jeopardy was determined to first exist on 03/21/24 at approximately 07:00 PM when CNA M roughly put R2 in bed. The surveyor verified the removal of the immediate jeopardy occurred on 03/22/24 at 10:00 PM with the facility implementation of the following actions: 1. Administrative Staff A and Administrative Nurse D interviewed R2 on 03/22/24 at 11:20 AM. R2 confirmed the allegations. 2. CNA M interviewed on 03/22/24 at 02:15 PM by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes!' and began crying. CNA M suspended. 3. CNA M interviewed by Administrative Staff A on 03/22/24 at 04:00 PM regarding the allegations against CNA N to R2. 4. The LN completed an assessment on 03/22/24. 5. Verbal discipline and education given to LN G for not reporting immediately on 03/22/24. 6. All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift on 03/22/24 at 10:00 PM. 7. Written discipline given to LN G on 03/25/24. 8. QAPI meeting held on 03/26/24 with the medical director. 9. On 03/27/24 at 05:11 PM CNA M terminated. Due to the corrective measures implemented prior to the onsite survey, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The resident reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in the facility kitchen. Findings included: - During the initial tour of the kitchen on 01/24/24 at 07:53 AM, the following area of concern was noted: The parameter of the floor and the floor where the table legs rested had a heavy build-up of dirt, trash, and discolored grime. On 01/25/24 at 10:50 AM, Administrative Staff A confirmed the areas of concern. The facility policy for Sanitation of Dining and Food Service Areas, undated, documented the dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. Staff will be held responsible for all cleaning tasks. The facility failed to provide a safe, functional, sanitary, and comfortable environment for staff and residents in the facility kitchen.

The facility reported a census of 34 residents with 14 selected for review, which included one resident reviewed for antibiotic use. Based on observation, interview and record review, the facility failed to ensure Resident (R)27 received an appropriate antibiotic, based on culture report. The facility failed to track and trend causative microorganisms for infections and use of appropriate antibiotics. Findings included: - Review of Resident (R)27's Physician Order Sheet, dated 01/02/24, revealed diagnoses that included rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), major depressive disorder (major mood disorder which causes persistent feelings pf sadness) and peripheral vascular disease (slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The resident was always continent of urine. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 03/01/23, assessed the resident required assistance on one person for ADLs. The Quarterly Minimum Data Set, dated dated dated [DATE], assessed the resident with a BIMS score of seven which indicated severe cognitive impairment. The resident was occasionally incontinent of urine. The Care Plan reviewed 11/08/23, instructed staff to monitor signs and symptoms of dehydration (when the body loses fluid without replacing it) which included concentrated urine, new onset of confusion, headache, fatigue, and weakness. A Nurse's Note, dated 12/05/23, indicated the resident had increased confusion. A family member requested a urinalysis. The nurse's failed to document if staff attempted to increase fluid consumption, assess temperature, or pain. On 12/06/23, the physician order instructed staff to administer Bactrim DS twice a day, for three days, for urinary tract infection. A culture report, dated 12/09/23, indicated no growth of bacteria in the resident's urine. Review of the Infection Surveillance Monthly Report (a report that documents infections in the facility by resident) for December 2023, revealed lack of identification of the causative microorganisms from culture reports. This report documented the resident had altered mental status and urinary complaints and received Bactrim DS for three days and the infection was resolved. The report did not indicate that a culture was done or the results of the culture. Review of the Infection Surveillance Monthly Report from February 2023 through December 2023, lacked identification of any causative microorganisms from culture reports if done. The January 2024 ongoing log was not available. Interview, on 01/25/24 at 01:00 PM, with Administrative Staff A, revealed infections were discussed in the QUAPI (Quality Assurance Performance Improvement) meetings with the Medical Director. The facility policy Infection Control Surveillance revised 11/2023, instructed the Infection Preventionist or designee to review the clinical record for diagnostic or lab results which support the use of the current antibiotic prescribed. The facility failed to identify causative organisms for infections on the Infection Surveillance Monthly Report to determine appropriate antibiotic usage, to identify trends and determine interventions to prevent the spread of infections as required.

The facility reported a census of 34 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour on 01/24/24 at 07:53 AM, the following areas of concern were noted: 1. Six plastic cutting boards had deep grooves, making the boards unsanitizable. 2. One large cutting board was put away as clean but contained a large coffee stain. 3. A cabinet to store clean dishes had shelving paper which was stained brown in areas and had a build-up of dust along the edges of the cabinet. The cabinet also had multiple areas of a dried on food substance. 4. Six wire racks in one two-door reach-in refrigerator had the protective coating missing from the tips of the wire racks, making them unsanitizable. 5. The stationary can open had a build-up of a black, sticky substance around the point of the opener which goes into the can while opening. 6. An unopened cardboard box containing 1000 10 ounce (oz) styrofoam cups rested directly on the floor of the store room. The facility policy for Sanitation of Dining and Food Service Areas, undated, documented the dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. Staff will be held responsible for all cleaning tasks. On 01/25/24 at 10:50 AM, Administrative Staff A confirmed the above issues were of concern. The facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.

- Observation on 01/23/24 and 01/24/23 of Resident (R)1's room revealed the floor with multiple areas of a sticky substance. The over bed table contained rust and a build-up of grime on the base of the table. The room contained a recliner with multiple pillows without pillowcases, and the resident's dresser tops contained unorganized supplies and personal items. Interview, on 01/24/24 at 08:06 AM, Licensed Nurse (LN) H, revealed the resident remained in bed most of the time. LN H stated the floor was dirty and the room needed to be cleaned. Interview, on 01/24/24 at 10:37 AM, with Housekeeping Staff U, revealed housekeeping cleaned R1's room every other day as the resident was in isolation. Housekeeping Staff U stated nursing staff would be responsible for organization of items in the resident rooms. The facility policy Resident Room Cleaning undated, instructed staff to daily clean resident rooms, pick up all trash, mop the floor, move furniture and beds to thoroughly clean. The facility failed to ensure staff maintained this dependent resident's room in a sanitary and homelike manner to enhance the resident's sense of wellbeing. 34056 The facility reported a census of 34 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment in three resident rooms and one of two medication rooms. Findings included: - During the survey process, the following areas of concern were noted in the facility: 1. An unopened box of tube feeding supplies, quantity unknown, rested directly on the floor in the medication room. 2. One resident room had a fall mat with multiple tears which made it unsanitizable. The resident's room also had a build-up of dirt and grime around the parameter of the room. 3. One resident's room had a headboard with large areas of missing and/or chipped varnish, making it unsanitizable. The facility policy for Infection Management Process, revised 11/2023, included: All resident rooms will have standard housekeeping services at least daily. The facility failed to maintain a clean, comfortable and homelike environment in these resident rooms and medication room.

The facility reported a census of 36 residents with one resident reviewed, Resident (R)1, for accident hazards. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment as free of accidents as possible, when Social Service Staff X propelled R1 in her wheelchair backwards out of the facility's transport van, but failed to ensure the mechanical lift platform was in the proper up position. R1 flipped backwards in her wheelchair out of the van. The resident stated she could not breath as she was upside down having fell approximately two feet from the van door to the lift platform which was at ground level. R1 struck her shoulder and back on the lowered platform and her head on the ground. R1 required emergency medical transport for evaluation and treatment after the fall, where she was diagnosed with a concussion (damage to the brain caused by violent jarring or shaking, such as a blow). R1 had pain following the fall and suffered significant bruising to her shoulder, back, head, and elbow, had a laceration to her head, and nausea and vomiting, as well. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), muscle weakness, anxiety disorder (feelings of worry, anxiety, or fear strong enough to interfere with one's daily activities), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), need for assistance with personal care, Parkinsonism (brain condition causing slowed movements, tremors, and muscle stiffness), and atrial fibrillation (rapid, irregular heart beat). The Annual Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R1 required extensive assistance of two or more staff for locomotion on and off the unit, did not ambulate, and used a walker and a wheelchair for mobility. She had no falls since the prior assessment. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/25/23 revealed R1 required extensive assistance with most of her ADL's. The Quarterly MDS dated [DATE] assessed R1 with a BIMS score of 15 and she continued to use a manual wheelchair for mobility. R1 required partial/moderate assistance to wheel herself 50 feet with two turns once seated in the wheelchair. The Care Plan dated 12/06/23 included a revision dated 12/15/23 which revealed R1 fell from the van to the ground and had a concussion, swelling, bruising and pain. The Orders tab for R1 included an order dated for Pradaxa (medication that thins the blood), 150 milligrams (mg), by mouth, twice daily, for atrial fibrillation. The Official Transcript for the online computerized training program for Social Service Staff X revealed on 07/12/23 she completed the training Assisting Residents with Transportation. The Assisting Residents with Transportation released 12/21/18, the online computerized training program objective included use of a vehicle lift. The Nurse's Note dated 12/15/23 at 11:20 AM by Administrative Nurse D revealed while R1 was on an outing to a local restaurant with other residents for lunch, a staff member (unidentified in note) moved R1 in her wheelchair from inside the van the lift, which was not elevated. R1 fell in her wheelchair backwards to the ground striking her shoulders/upper back on the lift and her head on the ground. The staff onsite called 911. R1 was never unconscious, was alert and oriented to person, place, and time. The nurse on location held R1's head straight to keep her head from moving and the ambulance took R1 to the local hospital. The Nurse's Notes dated 12/15/23 at 02:39 PM by Administrative Nurse D revealed R1 arrived back at the facility with ice packs on her head and upper back. The ice packs could be applied to areas of swelling and bruising on the head and upper back, between the scapula (shoulder blade), every two hours for 20 minutes as needed for pain or discomfort. The hospital After Visit Summary dated 12/15/23 revealed R1 was evaluated due to a fall and included diagnoses of concussion without loss of consciousness and a scalp hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). Hospital staff administered Tylenol (analgesic medication), 650 milligrams (mg), at 01:10 PM, and Zofran (anti-nausea medication) oral disintegrating tablet, four mg, at 01:10 PM to R1. Instructions included to return for any further problems or concerns, follow-up with her doctor, and Tylenol, 650 mg, every six hours, as needed for pain or discomfort. The summary included to read the attached information (the information sheet about concussions, possible related symptoms, and what to look out for). The Nurse's Note dated 12/15/23 at 03:30 PM by Administrative Nurse D revealed R1 returned from the local hospital after treatment for a concussion. R1 complained of feeling stiff in her upper back and pain with movement of her arms when she returned. R1's swelling on her upper back was far more swollen than anything, where she hit the lift leaving waffle shaped raised areas. R1 rated her pain in that area as eight out of 10 on the pain scale, where 10 is the worst amount of pain. The Skin/Wound Condition assessment dated [DATE] by Administrative Nurse D revealed: 1. A 9.0 centimeter (cm) by 5.0 cm dark purplish red hard raised bruise to the right elbow. 2. An area 28.0 cm by 17 cm with waffle shaped bruises between the scapula of her upper back that were raised at different heights and the deepness of color varied. Some of the bruises were very dark purple and some were dark red. The bruises on the upper back were very raised and painful to touch. The waffle appearance was from the lift gate. 3. A 1.0 cm by 0.2 cm laceration to the back of R1's head, closed, with 2.0 cm by 1.0 cm raised, bruised area surrounding the laceration. This laceration did not require staples or sutures. 4. A 13.0 cm by 12.0 cm contusion to the crown of head/scalp with scattered petechiae (pinpoint-sized sports of bleeding under the skin), not a solid bruise or raised, and in the center of the crown the hair was missing. The Nurse's Note dated 12/16/23 at 10:12 PM revealed R1 required Mylanta (antacid medication) for complaint of upset stomach. The Nurse's Note dated 12/17/23 at 10:50 PM, revealed R1 required Tylenol for complaint of headache. The Nurse's Note dated 12/18/23 at 08:45 AM, revealed R1 complained of generalized pain between the shoulders, had bruising to the area, and required Tylenol for her discomfort. The Risk Progress Note dated 12/18/23 at 06:05 PM revealed R1 had bruising to her head and her upper back between her scapula, experienced headaches, nausea, and vomiting. R1 required Tylenol and ice packs. Observation on 12/20/23 at 09:24 AM, revealed R1 sat in the recliner in her room with her feet elevated. She wore short sleeves, and a large area of black/purple bruising to her right elbow, was visible. On 12/20/23 at 09:25 AM, R1 stated Social Service Staff X was moving her backwards out of the van and it felt like the lift dropped and she landed with her feet in the air first then down onto the lift landing on her right shoulder and eventually hitting her lower back on the lift, falling out of her chair on impact. R1 stated she had a backache and a headache, and it seemed forever to get her head down as it did not hit right away. R1 stated she had a scrape to the back of her head that did not bleed and was not as serious as the damage done to her back, however, nothing was broke. R1 currently stated her pain earlier was at a level eight and she had taken Tylenol about an hour ago and now her pain level was at a six. R1 stated her pain was at her lower back and her the pain in her head had pretty much gone away. R1 stated the day she fell she threw up twice in the emergency room and once the next day here. R1 stated she did not want to ride in the van again, she was scared to get on it. On 12/20/23 at 09:28 AM, during an interview with R1, she called for staff to assist to raise the back of her shirt for observation of the bruising. Observed yellow colored faded bruising across her upper back and an area of purple bruising at the right scapula area. On 12/20/23 at 09:57 AM, observed Maintenance Staff U measure the distance from the ground to the level of the lift platform (floorboard level of inside of van) which measured two feet and two inches. On 12/20/23 at 10:00 AM, Administrative Nurse E went outside to the facility van and stated when she arrived at the scene on 12/15/23, R1's head and the back of her shoulders were in contact with the lift platform and the rest of her body was against the wheelchair, her feet were at the seat of the chair. Administrative Nurse D stated the wheelchair was upside down with the handles wedged and hung up between the bumper and rubber door seal. Administrative Nurse D stated R1's wheelchair was wide and allowed for about an inch of space on each side of the wheel when on the lift platform. On 12/20/23 at 10:10 AM Administrative Nurse E stated on 12/15/23 around 11:10 AM she was with another resident walking to the restaurant and when arriving to the sidewalk she heard Oh my God, help, help, oh my God! and so after ensuring the resident that she was with was okay to keep walking, she rounded the facility van and observed R1 on the ground position demonstrated earlier. Administrative Nurse E stated she moved R1's wheelchair and then assessed her as R1 stated she could not breathe; her chin was tucked down to her chest. Administrative Nurse E stated she held her neck to keep it straight, R1 stated she had a little bit of a headache and knew who she was, where she was, and her name. Administrative Nurse E stated she had Social Service Staff X called 911, however she was extremely upset so she had Administrative Staff B finish up the call with 911. Administrative Nurse E stated Emergency Medical Services transported her to the emergency room and then she contacted the Administrator. On 12/20/23 at 10:20 AM, Activity Staff Z stated she had assisted residents out of the facility small van at the local restaurant and went to assist Social Service staff X with the facility large van. She moved one resident sitting in a wheelchair out of the back of the van, and as soon as the resident lowered to the ground via the lift, she took the resident straight inside the building because it was raining and left the lift in the lowered ground position. Before she got back outside, the incident with R1 had already happened, and when she saw R1, she was in a sitting position, but on her back and the wheelchair had been moved before she arrived. Administrative Nurse E held the back of R1's head, and R1 looked scared. On 12/20/23 at 11:16 AM, Social services Staff X stated while Activity Staff Z took another resident off the van using the lift, she unlocked R1's wheelchair so she could be wheeled out of the van. Social Services Staff X stated she assumed Activity Staff Z raised the lift back up, and when she had her hands on R1's armrests of the wheelchair moving her backwards, she was bent over and could not see over or around R1 to see the lift platform. Social Services Staff X stated when pushing her (backwards) she realized the wheel had nothing to grab and she lowered herself to the floorboard of the van to stop the wheelchair, she blanked out and realized the wheelchair was empty and R1 was on the lift platform on the ground flat on her back. Social services Staff X stated she began screaming for help. Social services staff X stated she should have climbed on a seat in the van to visualize the lift platform to ensure it was at the proper position before moving R1 out of the van. On 12/2023 at 12:40 PM, Volunteer M stated she was standing up on the inside of the van and saw Social Services Staff X push R1's wheelchair backwards, and then saw the chair fall backwards out of the van and heard R1 say she could not breathe. She then went into the restaurant to get help from the other staff that were in there and stayed inside the restaurant with the other residents. On 12/20/23 at 12:46 PM, Administrative Nurse D stated she expected Social services Staff X to look and see that the lift was in the proper position before moving R1 out of the van. On 12/20/23 at 12:49 PM, Administrative Staff A stated she expected Social services Staff X to make sure the lift was in the proper position before moving R1 off the van. The facility's policy for Van Safety Orientation and In-Service form dated 02/12/16 included when exiting the van, move the resident to the platform. The policy lacked to ensure the lift platform was in the proper position. The facility failed to ensure staff provided a safe environment as free of accidents as possible, resulting in harm to R1 when Social Services Staff X failed to ensure the van lift platform was at the proper position before moving R1 backwards out of the van, causing R1 to flip backwards in her wheelchair upside down, which resulted in injuries and placed the resident in immediate jeopardy. On 12/20/23 at 05:00 PM Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to provide a safe environment as free of accident as possible when Social Services Staff X propelled R1 in her wheelchair backwards out of the transport van without ensuring proper position of the lift platform, causing R1's wheelchair to flip backwards and her to fall out of the wheelchair. R1 required emergency medical transport for evaluation and treatment following the fall on 12/15/23 at 11:10 AM. The immediate jeopardy was determined to first exist on 12/15/23 and the surveyor verified the facility identified and implemented corrective actions completed on 12/16/23 at 10:00 PM, when the facility completed the following: 1. Social Services Staff X placed on suspension on 12/15/23 at 12:54 PM. 2. R1's Emergency Contact notified on 12/15/23 at 01:06 PM. 3. R1's physician notified of event on 12/15/23 at 01:37 PM. 4. Skin assessment completed upon return from the emergency roiagnom on [DATE] and the Care Plan revised. 5. On 12/15/23 at 05:00 PM, additional education of all staff who drove the van with demonstration of proper loading and unloading with skills check completed. 6. On 12/15/23 a QAPI (Quality Assurance Performance Improvement) meeting held regarding the incident. 7. All new staff hired with authorization to drive the van will have a skills check completed prior to authorizing the transportation of residents in the van. 8. Administrator and/or designee will audit monthly a random selection of staff on proper loading and unloading of residents. 9. The Van Safety Orientation and In-Service form will be utilized for skills checks and verified as completed before any new drivers are authorized to drive the van. 10. All authorized drivers and skills checks will be reviewed for compliance and results reported to the QAPI committee. 11. All staff in-serviced on Abuse, Neglect, and Exploitation completed on 12/16/23 at 10:00 PM. Any staff that had not completed in-service placed on suspension until completed. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 38 residents with 11 selected for review including three reviewed for risk of elopement (when a resident exits the building without staff awareness). Based on observation, record review, and interview, the facility failed to complete an elopement risk assessment for Resident (R)3 within 24 hours of admission, failed to complete an elopement assessment with exit seeking behaviors following admission on several occasions, and failed to implement a care plan addressing exit seeking behavior and elopement risk for R3, who had severe cognitive impairment. On 12/12/22, R3 eloped from the facility without staff awareness when it was dark outside, without her walker, and was found by the local police department approximately a half a mile away from the facility. This deficient practice placed the resident at risk for immediate jeopardy. Additionally, the facility identified R5 as a risk for elopement on 11/05/22 and failed to implement interventions for elopement risk until 12/13/22, when the facility completed an additional elopement risk assessment and R5 continued to be at risk for elopement. Findings included: - The Medical Diagnosis tab for Resident (R)3 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), other symptoms and signs involving cognitive functions and awareness, and amnesia (loss of memory caused by brain damage or severe emotional trauma). The Admission Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE]. R3 had a Brief Interview of Mental Status (BIMS) score of one, indicating severe cognitive impairment, and wandered one to three days during the seven-day lookback period of the assessment. The wandering placed R3 at significant risk of getting to a potentially dangerous place. R3 required supervision and setup from staff for transfers and for walking and used a walker and wheelchair for mobility. She did not have any range of motion impairments and did not use a wander/elopement alarm (a device/bracelet that sets off an alarm when a resident wearing one attempts to leaves the facility without staff supervision). The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/13/22 and completed late, revealed R3 had a BIMS score of one, had a wandering episode and diverted back to her room which she then threw her clothes out into the hall. The Behavioral Symptoms CAA dated 12/13/22 and completed late, revealed R3 had wandered one to three times, had thrown her clothes out into the hall once, and 15-minute checks were set up. The staff were to check in on her every time they went by her room. The Care Plan dated 12/13/22 revealed R3 may wander or attempt to leave the building on her own and she had dementia/cognitive issues. Interventions included one-to-one supervision until further notice, encourage activities to keep her busy, and report to the nurse if she had increased wandering or pacing. On 12/14/22 the staff added to the care plan R3 could wheel herself around the facility in her wheelchair, used a walker for short distances and a wheelchair for longer distances, and for the staff to provide supervision with Activities of Daily Living (ADL's) and R3 could complete most tasks independently. The facility failed to have an initial or comprehensive care plan in place for her elopement risk prior to 12/13/22. The Clinical Health Review dated 11/28/22 and locked on 12/13/22, revealed the staff failed to complete the elopement risk section of the assessment until 12/13/22. R3 scored a 33, indicating she was a high risk to elope from the facility. Interventions on the assessment included the facility had locked doors and one-to-one supervision until further notice. The Progress Note dated 12/02/22 at 01:44 PM revealed R3 was on isolation precautions for COVID-19 (a highly contagious respiratory disease caused by the coronavirus) and was not compliant. She refused to stay in her room and attempted to go out the front door. R3 threw all of her clothes from her room into the hallway stating she was moving out. The staff escorted her to the TV room in the front lobby per her wheelchair and transferred her to a recliner. The staff put a movie on and R3 became more cooperative. The staff checked on her frequently and she wanted to stay in the TV room. The Progress Note dated 12/07/22 at 02:04 AM revealed R3 had to be assisted by two staff after leaving her room and ambulating in the hallway nearly losing her balance. The staff escorted R3 to her room and assisted her to bed. She remained in her room, but tonight she had packed up all her belongings, removed pictures from walls, was trying to leave, and had to be redirected to her room three times. The Progress Note dated 12/08/22 at 05:20 PM revealed R3 had packed her belongings and attempted to leave the building stating she needed help getting out of here. R3 had her coat on and was carrying her purse, and the staff redirected her to her room as needed. The Progress Note dated 12/13/22 at 12:54 AM revealed the staff notified an agency nurse at 07:25 PM that R3 was not in her room. The staff noticed when entering her room, the window screen had been removed, and the window was wide open. The nurse notified the administrator and local law enforcement and delegated staff to begin searching inside and outside of the property. R3 did not have her walker with her. The police located her and brought her back to the facility. A head to toe skin assessment revealed a small abrasion to the back of her upper right thigh that did not require any treatment. R3's vital signs and neurological checks were in normal limits and she denied any pain or discomfort. Staff placed within arm's length of resident to meet any needs she may have and ensure her safety. The Progress Note dated 12/13/22 at 08:32 AM revealed Social Services Staff X on the evening of 12/12/22 received a call from the administrator that R3 had eloped and to go to the facility. When pulling up to the facility a patrol car was in front of the building with a police officer exiting the vehicle, opening the back door, and letting R3 out. The officer asked if Social Services Staff X worked at the facility and responded yes then asked if this was the missing resident and responded yes. Social Services Staff X then took over per the police officer's request and walked with her in the building and the officer drove off. Social Services Staff X took R3 to her room where the nurse did an assessment. The note revealed this was approximately at 07:43 PM. The Weatherunderground.com showed a temperature between 06:53 PM and 07:53 PM to be 46 degrees Fahrenheit with a 16 mile per hour wind from the east south east. The facility Witness Statement for the incident on 12/12/22 for R3 by Certified Medication Aide (CMA) R revealed R3 was last seen by CMA R at 07:10 PM while at the nurse's desk observing a Certified Nurse's Aide (CNA) redirecting her back to her room. On 12/12/22 at 07:25 PM CMA R went to R3's room to give her medication, the room lights were on, the windowpanes were sitting on the floor and the blinds were still attached. CMA R then immediately checked outside of the window and the bathroom to make sure she wasn't there and called for the nurse. CMA R stated she immediately went and looked outside, after checking around the building some other aides came out, so she went back inside to check other rooms per instructions of the nurse. The Witness Statement for the incident on 12/12/22 for R3 by CNA N revealed R3 last seen by him at 07:10 PM when she was trying to exit the building. R3 had said her husband made her mad. CNA N redirected R3 back to her room and was sitting in the recliner when he left the room. On 12/15/22 at 01:24 PM observation revealed R3's name outside of room door, R3 was not in her room. An alarm was present to both windows in her room. The room adjoined another room via a bathroom. The adjoining room had R3's spouse's name outside of the door and observed R3 sitting in a recliner in the room next to her spouse and another male resident was in the room with them visiting. On 12/15/22 at 02:22 PM Administrative Nurse D stated when a resident admits to the facility, a Clinical Health Review would be done which included an elopement risk assessment, and thought it needed to be completed within 24 hours of admission. Administrative Nurse D stated R3 was on 15-minute checks prior to the elopement but did not know where the checks were documented at or when they were started, the aides had said they were watching her every 15 minutes using their watches for an alarm. Administrative Nurse D stated a baseline care plan would be in the electronic record under Care Plans. The Clinical Health Review was not completed on 11/28/22 (day of admission) and the elopement assessment was not complete until 12/13/22. Administrative Nurse D stated on 12/13/22 she completed an elopement assessment on everybody. O 12/15/22 at 02:30 PM Licensed Nurse (LN) G stated an elopement risk was to be done when a resident admits to the facility, which was part of the Clinical Health Review and needed to be completed within 24 hours. The care plan or nurse's notes would have interventions if deemed an elopement risk and she would let the administrator and Administrative Nurse D know. LN G stated it was her opinion that anyone with any type of dementia who was ambulatory would be at risk for elopement and was not aware of a facility elopement book. If a resident had not been deemed at risk, but then started to have exit seeking behaviors, she would notify the administrator and the director of nursing if the facility had one and do 15-minute checks. LN G stated when 15-minute checks were done, there is a sheet the staff fill out they would sign when completing the check. On 12/15/22 at 02:51 PM, CNA M stated he was not aware that R3 was an elopement risk prior to 12/12/22 and stated there was a book at the nurse's desk with who was at risk for elopement. CNA M stated when R3 admitted she walked just fine with a walker however would walk around without it and we would have to remind her to use it. CNA M stated he worked the evening shift on 12/12/22 and R3 had went to the dining room for supper, which started around 04:30 PM, with her spouse and seemed fine. CNA M stated he worked with CNA N that evening and had reported he had to redirect R3 from going out of one of the exit doors. CNA M stated he had seen her after supper reading the newspaper, could not recall if it was her room or her spouses or what time, and had asked if she needed anything at that time. CNA M stated he was assisting another resident when the hospitality aide asked CNA N and himself if they had seen R3 and that she was gone. CNA M stated he checked around the building and walked around the block to see if he could see her. By the time he had checked the neighborhood to see if she was in someone's yard, CNA M returned to the facility and was not long after that when R3 was [NAME] back to the facility. R3 had on slacks, a denim-type blouse, shoes, and a [NAME] style jacket when she returned. On 12/15/22 at 03:08 PM CNA N stated on 12/12/22 around 07:10 PM, R3 was on her way to the exit door of the hall she resided on, she was fully dressed and had her purse. CNA N stated R3 told him her husband was mad at her and she was upset with him and needed to leave to get some fresh air. CNA N stated he redirected R3 back to her room and tried to calm her down and informed the charge nurse, who responded she would take care of it, however was in the middle of doing rounds and was super busy. CNA N stated he had provided R3 fluids and she was sitting in her recliner when he left the room. CNA N stated while assisting another resident with CNA M, CMA R alerted them that R3 was missing and he started searching all the rooms and then went outside and looked all around the block and came back in to see if she had come back or not and was not sure how she got back to the facility, however knew Social Services Staff X came in the building with her. On 12/15/22 at 03:22 PM observed R3 sitting in room with spouse and a hospitality aide sitting with them with a clipboard to document the one-to-one supervision on. On 12/15/22 at 03:24 PM R3 stated she did not remember leaving however remembered going out of a window several nights ago and it was dark. R3 stated she thought she was just out for a walk and then pointed to her spouse stating, I suppose he brought me back. R3 stated when she left the building she went to the library in Humboldt (a town approximately 10 miles away) and told them there she needed a place to stay, they took care of her and made her happy, then she came back to the building. When asked R3 what she would do if she wanted to leave the building, she stated I don't know, I have never done that before. On 12/15/22 at 03:33 PM Administrative Staff A stated the staff did not document 15-minute checks prior to R3's elopement on 12/12/22. Administrative Staff A stated some of the aides, however not on all shifts, were setting an alarm on their phone to check R3 every 15 minutes. Administrative Staff A stated a resident should have an elopement assessment done when admitted but was not sure of the timeline and referred that question to the Consultant Nurse. On 12/15/22 at 03:35 PM Consultant Nurse GG stated the elopement assessment is part of the Clinical Health Review and should be completed within the first 24 hours of admission. If a resident is deemed to be at risk for elopement, the staff were to implement interventions on the care plan, which would be the baseline care plan if identified in the first 24 hours. Consultant Nurse GG stated if a resident had not been previously identified at risk, then they show exit seeking behaviors, a new elopement assessment should be completed, and new interventions added to the care plan. Consultant Nurse GG confirmed R3 did not have an elopement risk assessment completed until 12/13/22, which was after she eloped, and did not have a care plan for elopement risk until 12/13/22. On 12/15/22 at 03:38 PM Administrative Staff A stated the police officer informed the facility R3 was at the corner of [NAME] and [NAME] streets at 07:41 PM on 12/12/22. On 12/15/22 at 03:57 PM CMA R stated before 12/12/22 R3 had exit seeking behaviors, she was always headed to the door at the end of the hall she resided on, she would pack her belongings and have them on the bed, and would say she was going home or going camping with her son. CMA R stated 15-minute checks were done before that however she had never documented any, and she personally was not doing 15-minute checks on R3 on 12/12/22. CMA R stated generally everyone would do them and one of the CNA's had set an alarm in the past but was not aware if any staff were doing so on 12/12/22. CMA R stated she seen R3 trying to go out the exit door on the hall she resided on at 07:10 PM on 12/12/22. CMA R stated CNA N went to R3, distracted her from the door, and took he back to her room, and that was the last time she seen R3. CMA R stated on 12/12/22 at 07:25 she went to R3's room to give her pills and when she opened the door the blind was blowing in her room, the screen to the window was in front of the heater, and the glass panel of the window was sitting on the side of the heater. CMA R stated R3's recliner was in front of the window, where it had been before. CMA R stated she immediately ran to the window, checked outside the window and around, it was dark, checked the bathroom, checked R3's spouse's room, then ran and got the nurse. CMA R stated then a perimeter check was done outside and the aides on duty were searching both sides of the facility. CMA R stated the police brought her to the facility around 07:55 PM and R3 entered the building with Social Services Staff X. CMA R stated R3 had a [NAME] style jacket, denim button up shirt, black athletic pants, tennis shoes, and was carrying her purse. On 12/15/22 at 05:00 PM observation of the outside of the facility to the area R3 was found by the police department revealed a sidewalk in the large yard area to the south of the facility that ran east and west and connected to the front paved lot to the east and a gravel parking lot to the west. The facility is in a residential area and lacked a sidewalk for a block west. [NAME] creek, a small creek observed west of the facility then at the end of the creek deepened to approximately six feet. Across the street from there was a park area, southwest of the facility which was slightly hilly. Once a block west of the facility there were sidewalks along the streets. The speed limit in the area from the facility to where she was found was 30 miles per hour. The facility policy Resident Elopement Policy and Procedure dated December 2019, revealed residents were to be assessed for elopement risk within the first 24 hours of admission, quarterly, annually, significant change, and with behavior indicating potential elopement risk. The staff were to document the assessment in the clinical record. If identified risk was present, the interventions implemented were to be documented on the care plan. The facility failed to complete an elopement risk assessment for R3, who had severe cognitive impairment, within 24 hours of admission, and with exit seeking behaviors on 12/02/22, 12/07/22, and 12/08/22. The facility failed to implement a care plan to identify the elopement risk and interventions to prevent elopement until after R3 exited the facility without staff awareness on 12/12/22 and wandered without any assistive device approximately a half a mile away from the facility. This deficient practice placed R3 in immediate jeopardy. On 12/19/22 at 10:26 AM Administrative Staff A was informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to complete and elopement risk assessment within 24 hours of admission and with subsequent exit seeking behaviors following admission, and failure to implement a care plan addressing the exit seeking behavior and elopement risk. This deficiency was cited as immediate jeopardy, past non-compliance as the facility completed the following, as of 12/13/22 at 06:15 PM: 1. R3's placed on one-to-one supervision upon return to the facility. 2. All residents had an elopement assessment done and care plan reviewed for accuracy on 12/13/22. 3. The elopement book assessed for accuracy on 12/13/22. 4. Facility wide door check completed on 12/13/22 to ensure all alarmed doors were in proper working order. 5. On 12/13/22 maintenance completed work on R3's room, her spouse's room, and all other windows to secure them from opening more than four inches on 12/13/22. 6. A QAPI (Quality Assurance and Performance Improvement) meeting was held on 12/13/22. 7. All staff educated on elopement policy and resident incident prior to working new shift. Education initiated immediately on 12/12/22 following the incident and completed on 12/13/22 at 06:15 PM. - The Medical Diagnosis tab, for Resident (R)5 included diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] for R5 assessed her with a Brief Interview of Mental Status (BIMS) score of three, indicating severe cognitive impairment. R5 had verbal and other behavior symptoms one to three days of the assessment look-back period, however did not wander. She required a wheelchair for mobility and limited assistance of one staff for locomotion on the unit and supervision and two or more staff for locomotion off the unit. R5 did not have any impairments to her range of motion and did not use a wander/elopement alarm. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/16/22 revealed R5 had more confusion in the evening and would holler if she wanted something and would also use the call light at times. The Behavioral Symptoms CAA dated 06/16/22 revealed R5 would holler and yell hey at times when she needed to use the bathroom or just wanted attention. Calling her children, offering coffee, or one-to-one may settle her. The Quarterly MDS dated [DATE], revealed R5 had a BIMS score of zero, indicating severe cognitive impairment. She had no behaviors or episodes of wandering and did not use a wander/elopement alarm. R5 continued to use a wheelchair for mobility and required supervision and one-person physical assist for locomotion on and off of the unit. The Care Plan revealed the staff added a new problem on 12/13/22 for the potential of R5 to wander or attempt to leave the building on her own and had dementia/cognitive issues. The Clinical Health Review revealed on 08/22/22, the resident was not at risk for elopement. On 11/05/22, R5 scored a 17, indicating high risk to wander, and on 12/13/22, she continued to have a score of 17. The facility failed to implement any interventions for elopement risk when identified on 11/05/22 until 12/13/22, a total of 40 days. On 12/19/22 at 03:10 PM, observed R5 sat in a wheelchair by the north nurse's desk and propelled herself over to another resident sitting in the area, then propelled herself back by the nurse's desk. On 12/15/22 at 03:55 PM, Consultant Nurse GG stated if a resident had not previously been identified as an elopement risk, new interventions should be added to the care plan when identified at risk. The facility policy Resident Elopement Policy and Procedure dated December 2019, revealed residents were to be assessed for elopement risk within the first 24 hours of admission, quarterly, annually, significant change, and with behavior indicating potential elopement risk. The staff were to document the assessment in the clinical record. If identified risk was present, the interventions implemented were to be documented on the care plan. The facility failed to implement interventions for elopement risk for this resident when the facility identified her as an elopement risk on 11/05/22, until 12/13/22 when an additional elopement assessment completed, which was 40 days later, which placed R5 at risk to exit the facility without staff awareness.

The facility reported a census of 43 residents, with 3 reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure 1 (#01) of the 3 residents reviewed received necessary supervision/assistive devices to prevent falls. Staff transferred resident #01 without care planned gait belt assistance. The resident fell and sustained a fractured (broken bone) clavicle (collarbone). Findings included: - The electronic medical record evidenced the facility admitted resident #01 on 3/22/2017. The physician documented [DIAGNOSES REDACTED]. The 12/6/17 Significant change in status MDS (minimum data set) assessment identified the resident with a BIMS (brief interview for mental status) score of 03, which indicated severe cognitive impairment. The assessment identified the resident needed extensive assistance of 2 staff with transfers and did not walk in the seven day look back period. The 3/7/18 Quarterly MDS identified the resident with a BIMS score of 05, which indicated severe cognitive impairment. He/she needed extensive assistance of 2 staff with walking and he/she fell since the prior assessment, with major injury. (Fall on 3/6/18, which resulted in a fractured clavicle.) The Cognition Care Area Assessment (CAA), dated 12/6/17, documented he/she was able to make some needs known and other needs were met by observation. He/she may need several reminders to complete task or keep on task. He/she had a decline as he/she was showing increased confusion and needed directions frequently. The Fall CAA, dated 12/6/17, included, the resident needed assistance with balance by staff. He/she had a PPA (personal pressure alarm) on at all times and staff reminded him/her to call for staff assistance. He/she had STM (short term memory) problems and was unaware of safety issues. He/she was a candidate for falls. The facility completed a quarterly fall assessment, dated 3/4/18, and the resident scored 14, (total scores of 10 or more indicated a high risk for falls). The resident's care plan, dated 2/15/18, included, he/she was mobile per wheelchair; may walk with a walker with staff assistance with a gait belt; and was on a walk to dine program. Progress notes, dated 3/6/18 at 10:20 P.M., documented direct care staff D walked the resident into his/her room and toward the bathroom. Staff D turned away to open the bathroom door when the resident lost his/her balance and fell hitting the walker, and then went down onto the floor. Licensed nursing staff C provided a head to toe assessment which revealed decreased range of motion to the left arm with a complaint of left shoulder pain, a small abrasion (scraping or rubbing away of a surface, such as skin, by friction) on the left ear and left elbow. Staff notified the physician and received orders to transport the resident to the emergency room . X-ray at the hospital displayed a closed nondisplaced [MEDICAL CONDITION] clavicle. The notes documented the hospital staff applied a sling to the resident's left arm and the resident returned to the facility. On 4/19/18 at 1:30 P.M., direct care staff E and F walked the resident down the hall with a gait belt to his/her room and into the bathroom. The resident walked without hesitation or balance problems noted with a front wheeled walker. On 4/19/18 at 9:09 A.M. licensed nursing staff B acknowledged the facility investigated the fall on 3/6/18 related to resident #01. On 3/7/18, direct care staff D wrote and signed a statement for administrative staff A. He/she verified he/she walked the resident into the room. Staff D then turned to open the bathroom door and the resident lost his/her balance and fell backwards onto the floor. At that point, direct care D realized he/she forgot to use the gait belt as care planned. Licensed nursing staff C, on 4/19/18 at 9:10 A.M., verified he/she worked with direct care staff D and did not observe the incident but assessed the resident while on the floor. Staff C acknowledged they (staff C and D) placed a gait belt on the resident, while on the floor to move him/her into a chair. The facility policy (undated) included: All nursing staff must have a gait belt on them and use it for any transfer of a resident that required assistance with transfers or ambulation. The facility staff failed to utilize a gait belt as planned to walk safely with resident #01, who fell and sustained a left fractured clavicle.

The facility reported a census of 38 residents, with 19 selected for review, including 4 residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to implement effective interventions to prevent the development of pressure ulcers for 2 of the 4 residents reviewed for pressure ulcers including; (#16) who developed an unstageable pressure ulcer and (#48) who developed a stage 3 and a stage 2 pressure ulcer. Findings included: - Resident 48's physician orders [REDACTED]. The admission MDS (minimum data set), dated 10/26/16, revealed the resident had a BIMS (brief interview for mental status) score of 5, indicating severely impaired cognition. The resident required limited staff assistance for bed mobility, transfers, dressing, and personal hygiene; and supervision for toileting, ambulation, and locomotion. The MDS included the resident was occasionally incontinent of bladder. The resident was not at risk for developing pressure ulcers, with MASD (moisture associated skin damage) and with a pressure reducing device to the bed. The pressure ulcer CAA (care area assessment), dated 11/1/16, included the resident was able to get in and out of bed on his/her own, but required limited staff assistance at times with moving himself/herself up in bed. The resident had a couple of MASD areas on the buttocks and staff used moisture barrier cream to help protect the area, due to a potential for skin breakdown. The Braden Scale for Predicting Pressure Sore Risk Assessment, dated 10/19/16, recorded the resident with a score of 22. A score of 18 or lower indicated the resident was at risk for skin breakdown. The admission care plan, dated 10/20/16, advised the staff the resident was independent in bed mobility, transfers, toilet use, dressing, and personal hygiene; and required supervision with toileting. The resident was independent with mobility and used a cane, incontinent of urine, and lacked interventions initiated prevention of skin breakdown. The 7 day look back assessment (a computerized nurse assessment), with an opened date of 10/19/16, recorded under skin assessment to contact the wound care nurse for direction. The physician ordered on [DATE], Multivitamin-iron-folic acid, 1 by mouth daily for vitamin deficiency. The physician ordered on [DATE], [MEDICATION NAME] (moisture barrier cream) to the right and left gluteal (buttocks) crease daily and PRN (as needed) until healed. A skin assessment dated [DATE], recorded the following: the skin issue which measured approximately 5 cm (centimeter) in length by 2.7 cm width, circular purple area which was not open, was non-blanchable and tender to the residents left gluteal crease. The surrounding skin was intact. Also, the resident with a 3.4 cm by 3.2 cm circular area, which was not open, purple in color and was non-blanchable, to the right of the gluteal fold, and the surrounding skin intact. Review of the residents progress note dated 10/21/16, documented the resident had a pressure ulcer on his/her buttocks in the gluteal crease, without stage A skin assessment dated [DATE], recorded the following: the skin issue as other skin to the right gluteal crease which measured 3.4 cm by 3.2 cm circular area, which was not open, purple in color, non-blanchable, with maceration (occurs when the skin is exposed to moisture for extended periods of time). The medical record lacked further documentation of the resident's skin issues until 12/1/16. The resident's care plan, with a start date of 10/24/16, advised the resident was at risk for skin breakdown related to MASD when admitted , with the goal the resident would not have any new skin breakdown over the next 90 days. The interventions included: the resident with pressure reducing mattress to his/her bed, and a pressure reducing cushion in his/her mobility chair. The resident was able to make some position changed for comfort, but he/she needed staff assistance with moving up in the bed and sitting up in the bed. The care plan directed staff to check the resident's skin during cares and report changes to the charge nurse. Revision on 11/1/16, advised to apply moisture barrier cream to the resident's buttocks and peri area as needed. Revision on 12/1/16, included the resident with a stage 2 pressure area to his/her right gluteal crease, and the resident with a pressure relieving gel cushion to his/her recliner. The care plan lacked further individualized interventions for pressure ulcers for this resident. Review of the Braden Scale for Predicting Pressure Sore Risk Assessment, dated 12/1/16, with a score of 18, indicating the resident was at risk for skin break down. The residents progress notes dated 12/1/16 at 2:29 PM, documented the resident with a stage 2 pressure ulcer noted to the right gluteal crease approximately 1.5 cm in length, by 1 cm in width, with the surrounding tissue (skin) purple and non-blanchable, and without drainage. The area cleansed with normal saline, applied duoderm (a protective dressing), and the staff instructed to change the dressing every 3-5 days and PRN (as needed). The staff notified the physician and requested Vitamin C, 500 mg (milligrams), twice a day, and Zinc, 50 mg, daily. The resident was currently on a multivitamin daily, a gel cushion was applied to the residents recliner, and an air mattress to the bed. The skin assessment dated [DATE], documented the resident had Stage 2, a partial thickness wound, to the left upper buttock. The area cleansed with normal saline and duoderm applied, and to change the duoderm every 3-5 days and PRN. The area measured 2 cm in length by 1.2 cm width, the area was open with non-blanchable purple colored tissue surrounding the open area, and with [MEDICATION NAME] tissue (tissue covers the outside of the body). The progress notes, dated 12/13/16 at 3:35 PM, revealed an appointment made for the resident to be seen at the residents past wound care clinic on 12/21/16 at 10:00 AM. The physician ordered on [DATE], a wound care consult, with an initial visit scheduled for 12/17/16. The resident's medical record lacked further documentation of the residents wound until 12/27/16. The wound care specialist report, dated 12/27/16, revealed the wound to the right medial buttock was a pressure ulcer. Wound #1 was a Stage 3 pressure ulcer, measured 1.6 cm in length, by 1.2 cm in width, by 0.1 cm in depth. The wound described as an initial encounter, the wound margin well defined, and with slough (dead tissue, usually cream or yellow in color). Wound #2, a stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed), to the left medial buttock, measured 0.5 cm in length by 2.3 cm width, and 0.1 cm in depth with slough present. The wound clinic ordered for wound #1, to right medial buttock ordered to keep pressure off of bottom as much as possible. The staff to cleanse wound gently with normal saline, and do not scrub [MEDICATION NAME] off. Apply cutimed hydroactive B (a medicated dressing) one time prior to the next wound clinic visit. The wound clinic also ordered, Vitamin C, 500 mg, by mouth twice a day, and supplement with a daily multivitamin. The resident required a wheelchair cushion to sit on to elevate pressure. The resident to lift seat or shift position in chair every 15 minutes. The wound clinic ordered for the #2 wound to the left medial buttock, keep pressure off of the residents bottom as much as possible. Cleanse the wound gently with normal saline, do not scrub [MEDICATION NAME] off. Apply [MEDICATION NAME] every day, and apply skin prep ( a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) on the good skin around the wound #1 before applying a new dressing. Also ordered Vitamin C, 500 mg, by mouth twice a day and supplement with a daily vitamin. The wound care specialist report, dated 1/3/17, documented that wound #1 to the right medial buttock was a Stage 3 pressure ulcer. The area measured 2.3 cm in length, by 2.7 cm width, and a depth of 0.1 cm. The wound with moderate sero-sanguineous exudate (semi-thick reddish drainage), the surrounding skin with maceration, and the wound with slough. Wound #2 to the left medial buttock was a Stage 2 pressure ulcer. The wound measured 2.5 cm in length by 2.8 cm in width, and depth 0.1 cm. The wound with sero-sanguineous exudate, surrounding skin with maceration, and slough noted. The wound clinic ordered to cleanse the wound gently with normal saline, [MEDICATION NAME] for peri wound (the tissue surrounding the wound) with every dressing change. Apply [MEDICATION NAME] AG (an absorbent dressing), [MEDICATION NAME] tape (specialized tape) to secure in place and the facility to change 2 times before the next wound clinic visit, and [MEDICATION NAME] for peri wound with every dressing change The resident required increased protein intake. For wound #2, the wound clinic ordered to cleanse the wound gently with normal saline, apply [MEDICATION NAME] to peri wound with every dressing change, and [MEDICATION NAME] AG, [MEDICATION NAME] tape to secure in place, and the facility to change 2 times before the next wound clinic visit. The physician ordered on [DATE], protein shakes twice daily between meals to increase protein intake. The wound clinic ordered on [DATE] at 8:14 PM, to right medial buttock: cleanse wound with normal saline, apply [MEDICATION NAME] to peri wound with every dressing change. Apply [MEDICATION NAME] AG, secure with Medipor tape, the facility to change 2 times before the next wound clinic. The left medial buttock: the staff to remove [MEDICATION NAME] AG and collagen on 1/6/17. Then only apply [MEDICATION NAME] daily to the wound. On 1/15/17 at 11:40 AM, the resident transferred to the hospital due to reasons other than skin issues. Interview, on 2/9/17 at 4:22 PM, direct care staff I stated the resident was initially incontinent of urine when admitted , provided peri care, other than that the resident did not require much staff assistance. The resident was alert with some confusion. Staff I thought the resident had an air mattress, but was not sure. The resident repositioned himself/herself initially and then direct care staff had to remind the resident to reposition himself/herself, every hour he/she thought, and was unsure if the resident had any cushions for the wheelchair or the recliner. The resident did have dressings on his/her bottom, the dressing were changed daily, and the resident did receive a supplement at supper. On 2/14/17 at 11:16 AM, direct care staff L stated when the resident was initially admitted the resident would help with peri care. Then the resident started needing more assistance. The resident was able to get up from his/her recliner or wheelchair on his/her own initially, and then the resident required more staff assistance. The resident liked to sit in his/her recliner all the time. Direct care staff had to encourage the resident to reposition every hour, and the resident received a supplement. On 2/13/17 at 12:35 PM, licensed nursing staff G stated the resident with some dementia, ambulated until he/she went to the hospital. The resident would take himself/herself to the bathroom, and then would take his/her wet incontinence pads and put them into an empty popcorn bag. The resident would also pull the duoderm off his/her buttocks. The resident would not sleep in his/her bed and even when the facility brought in a special mattress the resident would not sleep in his/her bed. The resident with a gel cushion in his/her recliner, and repositioned himself/herself. The resident was placed on vitamin C and protein shakes twice a day with meals. On 2/13/17 at 3:41 PM, licensed nursing staff F stated the resident's 2 pressure ulcers on his/her buttocks were, right across from each other when he/she was admitted . The resident was constantly walking, did not like to sleep in his/her bed. The resident had a cushion she brought in for his/her chair. When the resident started having skin issues staff obtained a gel cushion was for the recliner. Therapy gave the resident a special cushion later also for the residents chair and recliner. The staff were told to move it from chair to chair. The resident received a protein shake and was pretty sure the resident received a multivitamin, vitamin C. The nurses were to assess and measure the wound weekly and document under the skin conditions assessment. On 2/14/17 at 10:29 AM, licensed nursing staff G stated he/she was unsure if the resident had a regular pressure reducing mattress, but did receive an air mattress overlay later, but the resident did not like to sleep in his/her bed. Staff G was unsure if anything put in place when the resident was admitted . Staff G would say the resident was at risk for skin breakdown. The nursing staff were to complete skin assessments weekly, unless there was a change in condition. If there was a change in the skin or healed, he/she would document this in the skin assessment. Staff G reviewed the skin assessments from 10/19/16 to 12/1/16 and verified none completed since 10/19/16, but the resident would have been monitored on the treatment sheet. The nurses should take measurements of a wound weekly. The resident actually had his/her own little foam type cushion in the recliner when he/she was admitted , and later the facility placed an overlay on his/her bed. The seat lift or chair repositioning every 15 minutes were documented in the treatment book, and he/she would monitor the staff to make sure the resident repositioned every 15 minutes. On 2/14/17 at 12:30 PM, licensed nursing staff G stated at the nurses desk is a calendar which list the resident and what shift the nurse was to complete weekly skin checks. On 2/14/17 at 10:55 AM, administrative nursing staff A stated the nurses are to complete weekly skin assessments on all the residents, and was unaware the nursing staff had not completed weekly skin assessment on this resident. The resident was at risk for pressure ulcers. Staff A would recommend wound consult related to the area on the residents buttocks when he/she was first admitted , and was unaware a wound care nurse was marked on the 7 day look back. The wound care clinic at the hospital is the facility wound care nurse. The facility would send the residents to the clinic sooner than 6 weeks, unless the staff were treating it ourselves. Weekly skin measurement should be done for skin issues under skin assessments in the computer. He/she was not aware the staff failed to complete the resident's weekly skin assessments. The resident was ambulatory so that was what was so surprising, he/she was up and down constantly. The facility policy for pressure ulcers dated 4/1/11, documented the prevention and reduction of development of pressure ulcers through education and supervision. The intervention, maintenance, and improvement of tissue tolerance to pressure. The possible interventions may include turning and repositioning schedule would be at a minimum of every 2 hours. This will be monitored by nursing supervision. Application of pressure reduction relief devices, such as special mattresses, air overlays, gel pads or specialty beds. It is the policy of the facility to provide quality care to all residents, to prevent a reoccurrence of a pressure ulcer, representative measures will be taken to eliminate the cause. Routine repositioning, skin care and reduction of excessive moisture will be done per done by CNA (certified nurses aide). The facility policy for documentation guidelines pertaining to [MEDICAL CONDITION], such as decubitus ulcers, should include the progress, deterioration, or the development of new problems. The facility failed to promote the healing of a pressure ulcer, failed to develop and implement interventions to prevent the development of a new stage 3 and stage 2 pressure ulcer for this cognitively impaired resident with a history of pressure ulcers. - Review of resident #16 physician order [REDACTED]. The admission MDS (minimum data set), dated 1-25-17, assessed the resident with moderately impaired cognitive status, required extensive assistance with bed mobility, transfer, dressing, locomotion, toilet use and personal hygiene, and impairment on one side of upper and lower extremity. This MDS assessed the resident at risk for pressure ulcers with pressure reducing device in chair, bed and on a turning and repositioning program. This MDS assessed the resident with 9 vascular ulcers. The care plan, dated 2-3-17, advised staff the resident was at risk for skin breakdown with [DIAGNOSES REDACTED]. Staff advised the resident had a pressure reducing mattress on his/her bed, pressure reducing cushion in the mobility chair, able to make some position changes for comfort, and staff advised to check the resident's skin during cares and report changes to the charge nurse. Staff advised to monitor the right groin and right upper leg bruise until healed. An update to the care plan, dated 2-11-17, advised staff the resident had a pressure ulcer to his/her right hip and the resident needed repositioned off the right hip as much as tolerated, had an air mattress to off load pressure, and staff to apply skin prep to the right hip three times a day. The physician order [REDACTED]. The Braden scale (an assessment to determine risk of pressure ulcer development), dated 2-1-17, assessed the resident with a score of 15 indicating at risk for pressure ulcer development ( score of 18 or less consider at risk). The Braden scale score, on 2-11-17, assessed the resident with a score of 12 (10-12 high risk for pressure ulcer development). The admission skin assessment, dated 1-18-17, assessed the resident with a blanchable 4.5 by 3 cm (centimeter) reddened area to the resident's right buttock and documented the area on the anatomical (body) diagram. The skin assessment, dated 2-7-17, documented a 5 by 1.5 cm purple bruise to the resident's right hip and documented this on the anatomical (body) diagram in a different area from the 1-18-17 diagram. The skin assessment, dated 2-11-17, documented a full thickness unstageable pressure ulcer 1 by 0.4 cm blanchable, and a 1.2 by 0.4 cm full thickness unstageable pressure ulcers and illustrated this in the same area as the documentation on 2-7-17. The registered dietician note, dated 1-24-17, documented the resident refused adequate nourishment and had stasis wounds on bilateral lower extremities. This note documented the resident received a multivitamin, vitamin C, and a sugar free supplement every meal, for additional protein. Observation, on 2-9-17 at 10:15 am, revealed the resident positioned on his/her back, in bed, with an air mattress inflated on the bed. Interview, on 2-9-17 at 1:19 pm, with direct care staff U, revealed the resident did walk prior to readmission to the facility on [DATE]. Staff U stated at this time the resident received passive range of motion to his/her left extremities, and generally kept his/her left leg drawn up. Observation, on 2-13-17 at 9:27 am, revealed direct care staff M and N, transferred the resident from his/her wheelchair into his/her bed with the hoyer lift. The resident was incontinent of urine, soaking through the incontinence brief, clothing and onto the foam cushions on the resident's bilateral hips. Direct care staff N stated the resident received check and change for incontinence care. Staff N proceeded to provide peri care to the resident and stated he/she did not know when the resident developed the pressure areas on his/her right hip. Staff N stated the resident preferred to lay on his/her right side, with his/her left leg drawn up. The resident at this time stated the mattress had a bump in it and staff verified that the air mattress was inflated. Observation, on 2-14-17 at 8:04 am, revealed direct care staff J provided passive range of motion to the resident's left arm and leg at this time. Observation revealed multiple ulcerations on the resident's toes and lateral foot area (vascular ulcers). Interview, on 2-14-17 at 9:30 am, with licensed nursing staff H, revealed the resident received treatments for vascular ulcers on his/her left foot and had an unstageable pressure ulcer on his/her right hip. Observation, on 2-14-17 at 11:32 am, revealed a red, blanchable area 2.5 by 4.4 cm (centimeter). This area contained an area 1.5 by 1 cm and 2 by 0.6 cm of dark purple/black eschar (hard dead tissue). Staff H cleansed the area and applied skin prep to the entire area. Staff H stated the resident could move his/herself in bed but preferred to lay upon his/her right hip due to pain in the left foot. Staff should reposition the resident frequently. Staff H stated the resident did have an inflated air mattress. Interview, on 2-14-17 at 11:41 pm, with direct care staff M, revealed the resident was able to reposition him/herself at times, and preferred to lay upon the right hip. Interview, on 2-14-17 at 4:35 pm, with administrative nursing staff A, stated the resident did have a current air mattress on his/her bed, but still developed the pressure ulcer. Staff A stated he/she would need to reevaluate the resident's care plan and make interventions for the prevention/treatment of [REDACTED]. The facility policy for pressure ulcers, revised 4-1-11, advised staff to apply special pressure reduction relief devices, air overlays, gel pads or specialty bed . Staff advised to provide a repositioning schedule. The facility failed to evaluate the consequences of this cognitively impaired resident's preference for positioning on his/her right side and air mattress performance and failed to completely document the anatomical location of intramuscular injections of an antibiotic to avoid possible tissue injury, to ensure this resident risks for pressure ulcers were minimized to the extent possible.

The facility reported a census of 51 residents with 17 selected for sample review, including 2 residents (# 1 and 84) for pain and 3 residents (# 48, 53, and 78) for skin monitoring. Based on observation, interview, and record review, the facility failed to ensure the residents received licensed nurse assessments for pain and skin conditions. Findings included: - Resident #1's EMR (electronic medical record) evidenced [DIAGNOSES REDACTED]. The resident's annual MDS (minimum data set) assessment, dated 2/18/15, identified the resident scored 99 on the Brief Interview for Mental Status, with the staff assessment completed and identifying long and short term memory impairment and severely impaired of daily decision making skills. The assessment identified the resident needed extensive assistance for ADL's (Activities of Daily Living) of 1 or 2 staff, including 2 staff for toileting, transferring, bed mobility and personal hygiene. The assessment additionally identified the resident received hospice services with routine and PRN (as needed) pain management. The 5/6/15 quarterly MDS indicated the resident without changes since the comprehensive assessment. The resident's care plan, dated 12/10/14, instructed staff the resident received hospice services related to [MEDICAL CONDITION] and failure to thrive. Additionally, the care plan instructed staff to monitor the resident for pain and/or symptoms of distress or anxiety, and to notify the nurse and the hospice nurse, of pain. The care plan included directions to use topical pain spray to the breast area and roxinal PRN. The care plan lacked instruction in transfer instructions for this dependent resident. Review of the residents physician orders [REDACTED].>[MEDICATION NAME], 7.5 mg (milligrams) per 500 mg per 15 ml (milliliters) orally, bid (twice daily), ordered 2/27/14 for pain. [MEDICATION NAME], 325 mg , 2 tablets, orally, every 4 hours, PRN, ordered 11/7/12, for pain. [MEDICATION NAME] concentrate, 100 mg/5 ml, orally sublingual, every 2 hours, PRN, ordered 11/5/12, for pain. [MEDICATION NAME] 2% spray, 1 mg/1 ml, topically, qid (4 times daily), ordered 8/23/14, for pain of untreated [MEDICAL CONDITION]. Review of the July, 2015 MAR (medication administration record) lacked identification of the resident receiving any PRN medications. Observation of the resident, on 7/1/15 at 8:46 AM, identified direct care staff V and N assisted the resident out of the wheelchair, using a gait belt to the resident's torso. Staff lifted the resident with the gait belt and the resident non-weight bearing, onto the bed. The resident moaned during the transfer, as though with discomfort, however, after settling the resident into the bed, the resident quieted. Further intermittent observations of the resident on 7/1/15 at 10:23 AM, 12:30 PM, 1:45 PM, 2:00 PM and 2:30 PM and 3:15 PM identified the resident appearing comfortable in their positioning. On 7/1/15 at 3:36 PM, observation identified direct care staff W, repositioned the resident's dangling legs, while the resident remained seated in the recliner. Again, the resident appeared comfortable and without vocalization of discomfort. At 4:13 PM, direct care staff U and W used a gait belt to transfer the resident from the recliner into the wheelchair for toileting and a skin check. As staff placed the gait belt to the residents torso, the resident called out to the staff to not hurt him/her. The staff reassured the resident they would not hurt him/her then used the gait belt, as it slipped up on the resident's torso, the resident moaned out and cried loudly, No!. After seated into the wheelchair the staff propelled the resident in the wheelchair to the resident's room and again used the gait belt to transfer the resident onto the toilet. The resident screamed out louder during the transfer onto the toilet, crying out in pain, vocalizing OWW!. Staff lifted the resident off the toilet, again using the gait belt, with the resident screaming in pain. Staff U reported, at that time, this was normal for the resident who had sores around his/her torso. Staff U and W reported being unaware if other methods of lifting the resident, to decrease the resident's pain, had been attempted. Observation, on 7/6/15 at 2:15 PM, identified the resident moaning/crying out in pain during a transfer in the residents toilet. The residents cries were heard through a partially open bedroom door and a partially closed bathroom door. Observation, on 7/7/15 at 11:25 AM, identified licensed nursing staff O completed a treatment to the residents breast and chest area, related to the untreated [MEDICAL CONDITION] and Paget's disease of the nipple. The area evidenced redness to the skin encompassing the right breast and extending approximately 10 inches wide by 5 inches tall from rib cage to rib cage. The reddened areas included numerous various sized areas of scabbing with minimal drainage noted. The resident had white tee shirt on under the outer shirt, which stuck to areas of the reddened, weeping skin, which required moistening prior to lifting the shirt, per the staff member, to eliminate the pain for the resident. Staff then cleansed and dried the area and sprayed the [MEDICATION NAME] spray over the area. Staff O reported care must be taken with cares to reduce the risk of pain to the resident, including ensuring placement of the gait belt low on the residents abdomen and tight enough to prevent slipping. The staff confirmed that anytime a resident complained of pain during a transfer or cares, staff are required to report this to the nurse and indicated the resident rarely received any pain medication due to not reporting of pain from the staff or observing the pain. On 7/1/15 at 5:05 PM licensed nurse P, reported the staff had not reported the resident experiencing increased pain and believed the resident transferred with the use of a mechanical lift, to alleviate the use of a gait belt to the resident's torso where the resident had open wounds. On 7/6/15 at 3:06 PM direct care staff U reported that any resident experiencing/reporting pain should be reported to the charge nurse and further indicated the resident usually only exhibited pain with transfers. Staff reported, when asked about the resident's pain on 7/1/15, at 3:36 PM during the toileting experience, that was worse than usual for the resident. On 7/7/15 at 4:45 PM interview with administrative nursing staff B described the resident as often apprehensive, but unaware of the resident having increased pain. Physician LL, reported on 7/9/15 at 10:40 AM, the resident had pain medication ordered routinely and PRN. The physician noted the facility had occupational therapy involved, at one point, to ensure the best transfer method, however, the doctor concurred that, at this time the best preventative for increased pain for this resident involved making sure that whenever staff are transferring the resident that transfers were done with staff ensuring the gait belt was securely fastened around the residents waist to prevent the belt from rising to the residents upper torso area. The PRN Medication Policy review for Pain, dated 12/14 included that pain is taken very seriously; and when a resident had pain the charge nurse would be notified with an assessment completed. The resident experienced harm when the facility failed to provide appropriate transfers for this resident, with the resident experiencing increased pain, on 2 different occasions. - Resident #48's significant change MDS (minimum data set) assessment, dated 5/5/15, identified the resident scored 13/15 on the Brief Interview for Mental Status, indicating intact cognition. The assessment additionally identified the resident needed extensive assistance of 1 or 2 staff for ADL's (activities of daily living) including mobility and transfers. The 5/7/15 CAA (care area assessment) for ADL's included the resident required 2 person extensive assistance with bed mobility, transfers, dressing and toileting, requiring assistance related to weakness. A quarterly 6/17/15 MDS identified the resident continued to require 2 person assistance with transfers and 1 person assistance for personal hygiene and bathing. The resident's care plan, dated 3/31/15, instructed staff: 1. The resident needed extensive assist of 2 with most ADL's and used a wheelchair with 2 pedals that staff propelled. 2. Monitor the resident for adverse reactions, such as unusual or easily bruised skin. 3. Use an electric razor to minimize nicked skin during shaving. 4. Take special care when providing cares/transfers to guard against bumps and bruises. Review of the EMR (electronic medical record) included nursing documentation on 3/18/15 noting the resident had bilateral discolored hands. Additionally, a skin assessment, dated 3/18/15 noted a heel callus, however, lacked identification of bruising noted to the resident's arms. A telephone order, on 6/2/15 at 10:59 PM, noted to discontinue daily aspirin use and discontinue lab work for PT ([MEDICATION NAME]) and INR (international ratio). Observation, on 6/30/15 at 8:23 AM, identified the resident resting in bed, with geri-sleeves on but pulled up, exposing the residents forearms covered in various colored and sized bruises. On 6/30/15 at 4:15 PM, the resident sat in a wheelchair in the television area, with geri-sleeves noted to bilateral forearms. Direct care staff U reported, on 7/6/15 at 3:14 PM, reported the resident's bruising was possibly caused by the resident's random movements in bed, as sometimes the resident sat him/her self up onto the edge of the bed and had a transfer bar at the head of the bed. The staff reported the resident wore geri-sleeves to help prevent bruising. Direct care staff AA, reported on 7/7/15 at 8:40 AM, the resident had bruising on his/her arms upon admission and that often just touching the resident on the arm, caused a bruise. We try to be very careful with cares and also put geri-sleeves on the resident's arms for preventative measures. On 7/7/15 at 2:58 PM, licensed nursing staff Q, reported all resident skin issues should be addressed in the ECR (electronic clinical record), however, upon review of the record failed to identify any noted bruising. On 7/7/15 at 4:56 PM, administrative nursing staff B reported that weekly skin assessments are initiated when a direct care staff noted during cares skin issues. The staff indicated then a licensed nurse assesses the areas and document this into the ECR with weekly followup assessments and measurements taken. The facility policy, labeled for skin, falls, and bruising, dated 1/30/15, included the facility maintained a record of any incident that occurred on the premises and any changes in the condition of the resident are reported and evaluation of incidents completed to prevent reoccurrence. The facility failed to provide monitoring and assessment of bruising to the residents skin, to ensure resolution of the bruising without complications. - The POS (physician order [REDACTED].#78, not dated, but signed and faxed to facility on 06/29/2015, documented the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS (minimum data set), dated 3/4/2015, documented the resident BIMS (brief interview for mental status) score of 6, indicating severely impaired cognition and required extensive assistance of 2 staff for ADLs (activities of daily living). The assessment documented the resident had no skin conditions and used anticoagulant medication. The CAA (care area assessment), dated 03/11/2015, identified the care area of cognition, and documented the resident with severely impaired cognition. The CAA also identified the care area of ADLs, and documented the resident required extensive assist of 2 staff with all ADLs. The Quarterly MDS, dated [DATE], revealed no changes from the previous assessment. The care plan, dated 03/05/2015, directed staff the resident was at risk for complications from the blood thinning medication [MEDICATION NAME], to monitor for adverse reactions, and to take special care during cares and transfers to guard against bumps and bruises. The physician's orders [REDACTED]. The only skin assessments available, dated 2/26/15 at 7:22 PM, 3/27/15 at 2:56 PM, 4/11/15 at 1:17 PM, 4/22/15 at 1:28 PM, 6/28/15 at 4:53 AM, and 7/4/15 at 12:48 AM lacked any documentation of bruising. The June 2015 and July 2015 treatment administration record, lacked any documentation of monitoring or treatment for [REDACTED]. Observation, on 06/30/15 at 7:40 AM, revealed purple bruising on both arms in various sizes. Observation, on 06/30/2015 at 4:25 PM, revealed the resident with scattered purple bruises on the arms. Observation, on 7/6/15 at 7:36 AM, revealed the resident sitting in the wheelchair at the dining room table eating breakfast. Bruising noted on both forearms, in various stages of healing. On 07/06/2015 at 12:04 PM, the resident stated he/she had the bruises on the arm for quite a while now. The resident had no idea what happened to cause them and does not remember bumping into anything to cause them. The resident reported he/she often bruises, and eventually the bruises heal. The resident stated the nurse's have never asked the resident about the bruises, or checked on the bruises and that nobody ever seems to notice the bruises. On 7/7/15 at 8:41 AM, Direct Care Staff D reported for bruises, staff are expected notify the nurse, only if they have not seen the bruise before. Staff reported the resident had a few bruises on the arms and chest. The resident gets bruises frequently, and staff do not really know what they are from. Staff D stated they had not paid attention to whether the resident had new bruising today. On 7/7/15 at 2:47 PM, Direct Care Staff K reported skin conditions are to be reported to the nurse when staff notice something new, like a bruise or redness. Staff K stated the resident does not have any bruises. Staff then went to the resident, observed and confirmed there were multiple bruises on the resident's left forearm. Staff K stated the bruises should have been reported to the nurse and documented. Staff K stated, in spite of providing care for the resident today, Staff K did not noticed the bruises. On 7/7/15 at 1:10 PM, Licensed Nursing Staff C reported any staff who sees any bruising have to let the nurse know. The nurse will fax the physician that a bruise was noted and monitor the bruise every shift for changes. The nurse will also do weekly skin assessments for that resident, to track and follow up on the bruises. Bruises are monitored this way and measured weekly. Staff C stated if the resident had bruising on the arms, it should be documented on a skin assessment, even if staff knew, for instance, it was from a lab draw. Staff C stated he/she was not aware of any bruises on the resident, and no staff had notified him/her of any bruising on the resident. On 7/7/15 at 3:00 PM, Licensed Nursing Staff C confirmed and measured the following bruises on the residents left forearm: 1.) 2 cm (centimeter) x 2 cm, #2) 2 cm x 2.5 cm, #3) 1.5 cm x 2.5 cm, #4) 1.8 cm x 2.5 cm, #5) 1 cm x 1 cm and #6) 1 cm x 0.8 cm. Staff C described the six bruises as black with fading green colored tissue surrounding all of the black areas and stated the bruises look several days old and should have been identified before today. Staff C confirmed that the resident is on [MEDICATION NAME] and at increased risk for bruising. On 7/7/15 3:28 PM, Administrative Nursing Staff B reported the expectation of staff regarding bruising is to document when the bruises are found, investigate to find out what happened and what the facility can do to prevent further bruising. Staff B was not aware the resident had bruising on the arm. Staff C stated the resident was supposed to be getting monitored closely for bruising at this time, related to a recent fall. The facility provided policy, for Accident and Incident Reports (including skin conditions, falls and bruising), dated 1/30/15, documented the purpose was for the facility to maintain a record of any accident or incident that occurs on the premises, to report any changes in the condition of the resident to the physician and to study and evaluate accidents/incidents to prevent reoccurrence. The facility failed to identify and monitor six bruises on the left arm of this resident, identified as at risk for increased bleeding and/or bruising related to anticoagulant use. - The POS (physician order [REDACTED].#53 admitted to the facility with [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 6-03-15, documented the resident had a BIMS (brief interview for mental status) of 15, indicating the resident was cognitivelly intact. The resident required extensive assist of 1-2 for ADLs (activity of daily living). The MDS did not record any skin concerns. The care plan, dated 6-10-15, documented the resident had a habit of hitting him/herself out of anger and frustration at times. Staff are to treat any skin injury per protocol or doctors orders. Review of the treatment record and nurses notes, as of 7-01-15, revealed there was no documentation of skin problems. Observation, on 7-01-15 at 8:39 a.m., revealed the resident had an area under his/her left eye approximatelly 0.5 X 1.0 cm (centimeters) and an area approximatelly 1.0 X 0.5 cm on the resident's left ear. The areas had a scab-like appearance and without drainage coming from the open skin areas. On 7-06-15 at 3:45 p.m., licensed staff C stated, the areas on the resident's face are not monitored because they happened when the resident hit him/herself at some point when he/she was angry. Licensed staff C stated he/she was unaware of the areas to the resident's face until this time. On 7-07-15 at 10:45 a.m., administrative nursing staff B verified the areas to the resident's face were not being treated. Staff B stated all skin issues should be monitored and treated per the facility protocol. The facility policy, dated 1-30-15, for accident and incident reports, including skin conditions, falls and bruising, instructs that the purpose of the policy is to maintain a record of any accident of incident that occurs on the premises; to report any changes in the condition of the resident to his/her attending physician and/or responsible family member; and to study and evaluate accidents/incidents to prevent reoccurrence. The facility failed to identify and monitor skin issues to ensure resolution for this dependent resident. - The physician order [REDACTED].#84 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and generalized pain. The admission MDS (minimum data set), dated 5-26-15, documented the resident required extensive assistance of 1-2 with ADLs (activity of daily living). The resident had functional limitation in range of motion in both lower extremities. The resident received both scheduled and as needed pain meds. The staff assessment revealed indicators of pain of facial expressions and protective body movements or postures 1-2 days of the assessment period. The CAA (care area assessment) for pain, dated 5-26-15, documented the resident wore a routine pain patch and also received as needed pain meds. Staff were to observe for signs and symptoms of pain as the resident was not able to make his/her needs known. The care plan, dated 6-10-15, instructed staff to give the resident the routine medication for pain and to give the as needed medications as needed to bring the pain level down to zero. Staff are to assess pain level before and after the pain medications are given to assess effectiveness. The doctor is to be notified if the pain medications are not effective. Review of the pain assessments on the treatment sheets, reveals the resident had no pain in the month of June or July. On 7-06-15 at 7:15 a.m., the resident stated, My back hurts. Direct care staff G stated she had not heard the resident state this at that time. Staff G stated he/she had not heard the resident state this. On 7-06-15 at 7:27 a.m., direct care staff H and G were giving cares to the resident. The resident yelled, screamed and cursed at the staff while being moved around in his/her bed. When questioned by surveyor MM, at this time, related to the resident's pain, staff G stated he/she would report the pain to licensed staff C when the cares were completed. On 7-06-15 at 3:11 p.m., direct care staff E stated, the resident gets mad at the staff when they are doing peri-care and move him/her around. The resident likes to scream and cuss at them. Staff E stated the resident does not have any pain which they are aware of. On 7-06-15 at 9:09 a.m., licensened nursing staff C stated, the resident does not complain of pain. The resident currently has an order for [REDACTED]. Staff C stated, the resident will randomly say, Oh, G-- d---, or get the cat out of my room. Staff C has never been in the resident's room while cares were being given, she he/she can not say if the cursing is related to pain. Staff C gave the resident his/her as needed pain medication of Tylenol 650 milligrams by mouth every 6 hours, after staff H informed him/her the resident was experiencing pain. On 7-07-15 at 9:04 a.m., administrative nursing staff B stated, the resident's pain assessment, dated 5-20-15, documents the resident had intermittent pain which is expressed by facial expressions, moaning, and yelling out. Staff are trained to look for and recognize pain in the CNA class they take to become CNAs. Staff have not had a pain recognition class at the facility. The resident's weekly assessments are done on the 6-2 shift each week. Staff B stated the resident should have received more than one as needed pain medication in the month of June if he/she were experiencing intermittent pain. Staff B stated he/she thought the staff was more adept at recognizing pain. The facility policy for pain management, dated 10-01-01, documents it is the policy of the facility to achieve comprehensive pain management through timely assessment; appropriate application of interventions and continued follow through by nursng staff. The facility failed to ensure this dependent resident had sufficient pain management.

The facility reported a census of 52 residents with 27 selected for review. Based on observation, interview and record review, the facility failed to provide supervision and assistive devices for 2(#67 and #79) selected residents for the prevention of falls,failed to keep hazardous chemicals not accessible to the facility identified 7 self mobile confused residents and failed to ensure no accident hazards in 28 resident bathrooms. Findings included: - The physician's orders [REDACTED]. The quarterly MDS (minimum data set), dated 10/12/12, recorded the resident had a BIMS (brief interview for mental status) score of 5, indicating severely impaired cognition. For ADL's (activities of daily living) the resident required extensive staff assistance of 2 for bed mobility, transfers, walk in room, and toilet use; locomotion on/off the unit required extensive staff assistance of 1. The resident balance unsteady, had no functional limitation in range of motion and mobility per wheelchair. The record documented the resident had 3 falls since admission, 2 non injury and 1 injury (except major). The significant change MDS 3.0 dated 12/28/12, revealed the resident with a BIMS score of 8, indicating moderately impaired cognition. No change in ADL's, balance and range of motion. The resident used a walker and wheelchair for mobility. The record documented pain present, rarely, and intensity of a 3 (on scale of 0-10). The resident has a fracture related to a fall in the 6 months prior to admission. The CAA'S (care area assessment summary), for cognition dated 12/28/12, revealed he/she is able to make needs known. His/her BIMS score has gone from severe impairment to moderately impaired cognitively. He/she has some short/long term memory problem and has a [DIAGNOSES REDACTED]. All procedures are explained to him/her before and while being done. On the ADL's care area assessment, staff recorded, PT/OT (physical therapy/occupational therapy) are working with resident. He/she is extensive assist of 2 with bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. He/she is propelled by staff in wheelchair. He/she does not ambulate at this time related to hip fracture. He/she is encouraged to assist with cares when he/she is able. Staff recorded on the fall care area assessment, he/she needs assist with balancing, he/she is a 2 person assist with transfers. On the fall risk, he/she is not at high risk for falls. He/she is to wear non skid socks/shoes. He/she has a fall mat next to bed. Staff scored the resident with a score of 19 on the resident's fall assessment (a score of 10 or above indicated the resident at high risk for falls). On 12/17/12, the staff scored the resident with a score of 20 on the resident's fall assessment. The care plan reviewed on 1/9/13, documented for cognition; I am able to verbalize needs. I do have episodes of forgetfulness. Explain all procedures to me before starting them. I have some problems with communication related to cognitive loss. I may loose part of the content of what is said to me. Please repeat things if I do not understand. For ADL's, I need extensive assist of 1-2 staff with transfers. I am mobile per wheelchair. My family visits me frequently, they are very helpful and they do help with my cares when they are here. The care plan for falls, related to past falls and due to my impulsiveness documented the following: I need shoes on when transferring or ambulating. I have fall mat beside bed. I will have my call light in reach at all times. I do not always remember to use the call light. On 8/29/12, the resident says he/she just sat himself/herself on floor very carefully on purpose. Cue him/her to use his/her call light for assist to floor if he/she chooses to sit on the floor. On 9/5/12, I have a PPA/PBA (personal pressure alarm/personal body alarm) on at all times. On 10/10/12, keep PPA out of recliner pocket so it sounds louder. On 10/29/12, use PPA instead of PBA in wheelchair. It sounds quicker and louder. On 11/7/12, educate family on importance of moving the PPA from recliner to wheelchair to wheelchair to recliner. The care plan lacked instructions for the staff regarding what the staff should do once the spouse leaves, since They (the staff) are aware he/she forgets to transfer the alarm. The interdisciplinary notes dated 12/17/12 at 10:00 AM, documented, "Elder had a fall in room today at 9:10 AM. This writer was called to the residents room. Observed elder lying on the floor in the doorway. Elder stated, "I'm Ok, I knew I shouldn't have stood up." Elder voiced complaints of pain in right hip, helped elder to bed. Called to physician, received order to sent to emergency room per ambulance for evaluation. Notified the durable power of attorney, the physician, director of nursing, and administrator." 12/17/12, no times given, called to check on elder. The nurse in the emergency room stated, "Elder fracture of right hip and was being sent to Wichita." On 1/22/13, review of the CNA (certified nurse aide) non notarized statements dated 12/17/12, at 9:10 AM as follow: "Direct care staff E documented, " I was coming out of another room when I saw resident laying in the doorway of his/her room. I did not witness his/her fall. I screamed for my nurse who did his/her assessment." Direct care staff D documented, " I was in assisting another resident when I became aware of this incident the charge nurse (licensed nursing staff B) was already in with resident." On 1/22/13, review of the licensed nursing staff B documented on a non notarized form, dated 12/17/12 at 9:10 AM, "This writer was called to room 203. Observed elder lying on floor in doorway. Sent to ER (emergency room ) for evaluation." The Incident/Accident Description form, dated 12/17/12, documented,"This writer (licensed nursing staff B) was called to room 203. Observed elder lying on the floor in the doorway of room. Elder states "I'm okay, I knew I shouldn't stood up." Assessed elder, elder voiced complaint of right hip pain upon moving. Transferred elder to bed. Notified DPOA (durable power of attorney), physician, director of nursing, and administrator. Received order to send elder to emergency room for evaluation per ambulance. Vital signs, blood pressure 102/60, pulse 71, respirations 20, and temperature of 96.5 degrees Fahrenheit. The alarm on floor with elder, spouse had just left, spouse generally transfers elder from recliner to wheelchair for breakfast each morning. Alarm not sounding as spouse generally forgets to transfer alarm or turn on. Spouse educated in past on importance of transferring alarm and making sure it is on." The physician orders, dated 12/21/12, check alarm placement after family visits, related to personal history of fall. On 1/9/13, the interdisciplinary notes documented, "Care conference done: "...Needs assist with ADL's. Can ambulate with staff assist. Uses wheelchair with 2 pedals. Family enjoys to help assist with cares. ...Had fall that resulted in fracture. Low bed/fall mat/call light/PPA/PBA at all times. Family forgets to transfer or put alarms on. Staff will check alarms after family leaves as well as education of alarms." Review of the resident's December 2012 TAR (treatment record) documented: no initials in the box, indicating the staff had checked the alarm after the spouse left for December 20th, 21st, and 22nd. On 1/22/13 at 7:15 AM, direct care staff F and licensed nursing staff C transferred the resident from his/her bed to the recliner. A gait belt in place, followed simple 1 step instructions, able to take several steps to the chair. No verbal complaints pain or discomfort. The pressure pad alarm in the recliner and turned on, a green light blinking, indicating the alarm is working. Placed in the pocket of the recliner. On 1/22/13 at 8:31 AM, the resident sitting in a wheelchair in his/her room. The pressure pad alarm not in wheelchair, it is lying in the seat of the recliner. (The spouse had been in between 8:00 and 8:30 AM). The resident's pressure pad alarm to the recliner started sounding at 8:50 AM. At 8:52 AM, direct care staff F reported, "The spouse must not have turned it all the way off when he/she transferred the resident from the recliner to the wheelchair. At 8:54 AM, direct care staff F verified the resident without an alarm in the wheelchair. At 8:57 AM, direct care staff F and G, transferred the resident from the wheelchair to the recliner. The personal pad alarm in place, light blinking green, and placed in the pocket of the recliner. On 1/22/13 at 7:04 AM, direct care staff F reported, "The spouse would come in and transfer him/her for to the wheelchair for breakfast. He/she was pretty good about moving the alarm. He/she did not tell us when he/she left. We would try to get back in the room and check his/her alarm when we noticed he/she left. " On 1/22/13 at 7:33 AM, direct care staff F reported, "We know the alarms are on because of the blinking green light. When we do rounds we check to make sure the alarms are working. We document on the Kiosk (computer documentation for direct care staff) they are working." On 1/23/12 at 9:48 AM, direct care staff D, opened the Kiosk to this resident showed this surveyor where they document the resident with an alarm and mark that it is working. Furthermore, direct care staff D reported, "We document at the end of the shift on the kiosk whether it works or not. No it does not say to go back and check the resident after the spouse leaves." The care plan area of the kiosk lacked documentation to instruct CNA's to monitor the resident's alarms after the spouse leaves. On 1/23/13 at 11:40 AM, direct care staff E reported "I was working that day. I honestly don't know if I helped get him/her up or not. I remember seeing something on the floor, thinking it was a pillow. The closer I came I saw it was the resident, I called for the nurse. I saw the alarm behind the chair, not sounding. I don't know if the spouse was here that day or not. He/she does transfer him/her from the recliner to a wheelchair, and not put the alarm in place, or tell us when he/she leaves." On 1/23/13 at 12:00 PM, direct care staff D reported, "I don't remember much of anything. I remember the spouse had been here, he/she usually is in the morning for breakfast. He/she transfers him/her from the recliner to the wheelchair and forgets to put the alarm on frequently. I would try to remember to go and check on him/her alarm after his/her spouse left." On 1/22/13 8:55 AM, licensed nursing staff C reported, "The spouse is to let us know when he/she leaves so we can check on him/her. (Explained the resident without any alarms, they (the alarms) in the recliner and bed, and staff alerted because of the alarm sounding, as if the spouse did not turn it off). Furthermore, will have to get with him/her about this. He/she is to notify us when he/she leaves." The resident observed without an alarm for approximately 25 minutes. On 1/23/13 at 12:15 PM, licensed nursing staff B reported, "The resident fell that day (12/17/12). The spouse had been in here for breakfast. I believe he/she transferred the resident from the recliner to the wheelchair. The alarm not on or sounding. We have educated him/her on not forgetting to turn on the alarm or putting the alarm on. He/she is always so busy, that is why he/she forgets things. We try to go back and make sure it is on. We made it an intervention. " On 1/22/13 at 9:30 AM, administrative staff A verified the staff to check on the resident after the spouse leaves, to make sure the resident with a alarm on. We have educated and educated the spouse to let us know when he/she leaves, so we can check the resident." The facility Accident Policy for Residents revised on 8/20/09, documented the following: "Policy: It is the policy of the facility to ensure that the resident environment is free from accident hazards as is possible over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: 1.) Fall assessments will be conducted upon admission to facility and at least quarterly for monitoring and modifying process that include evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of an intervention. 2.) Assistive devices will be used in an attempt to keep the resident safe from accidents. Such devices may include/but not limited to grab bars, hi/lo beds, fall/landing mats, alarm systems such as Personal Body Alarm or Personal Pressure Alarm, motion activated sensors. 3.) Develop a plan of care that it individualized to meet the safety needs of a resident. 4.) Facility based interventions may include, but not limited to, educating staff, repairing the device/equipment, and develop or revise policies and procedures as the need arises." The facility failed to develop and implement effective fall intervention to prevent accidents for this resident who sustained a fractured hip. - Record review revealed resident #79 admitted to the facility 10-22-12 per the facility admission face sheet. [DIAGNOSES REDACTED]. The 5 day admission MDS (minimum data set) assessment, dated 10-29-12 assessed the resident with a BIMS (brief interview of mental status) score of 09 indicating moderately impaired cognitive status.(8-12 moderately impaired cognition), requiring extensive assistance with bed mobility, transfer, walking in room, dressing toileting, and locomotion on and off the unit. This MDS, assessed the resident with functional limitation in range of motion on one side, lower extremity and balance not steady, only able to stabilize with staff assistance when moving from a seated to standing position and walking. The CAA (care area assessment), dated 11-11-12, advised staff of the resident's need for extensive assistance of 1-2 staff for all activities of daily living with mobility by wheelchair, at risk for falls, with no falls since admission, physical and occupational therapy for strengthening and adaptation to limitations. The 60 day MDS, dated [DATE], assessed the resident with a BIMS score of 06 indicating severely impaired cognition ( 0-7 severely impaired cognitive status) requiring extensive assistance with bed mobility, transfer and locomotion on the unit. Balance assessed as not steady only able to stabilize with staff assistance when walking and moving from a seated to standing position and functional limitations in range of motion in lower extremity on one side. The resident experience one non injury fall since the last MDS. The care plan updated 1-9-13, advised staff of weakness in the right hip due to fracture, requiring extensive assistance with bed mobility, transfer and locomotion. Staff advised the resident able to propel self in wheelchair with feet, and the resident at risk for falls, needing assistance with balance, keep call light within reach at all times, encourage the resident to ask for assistance with transfers, keep fall mat on the floor. The fall risk assessment dated [DATE] assessed the resident with a score of 18 ( with 10 or above high risk for falls). The resident fell at home prior to admission. The resident sustained [REDACTED]. Nurses' note, dated 10-22-12 untimed, advised use of the pressure alarm as a safety measure. Nurses' notes dated 1-16-13, at 02:10 am, revealed "ambulate with FWW (front wheeled walker) and stand by assistance from bed to bathroom with slow steady gait. PPA (personal pressure alarm) on at all times." Observation, on 1-16-13 at 4:15 pm, revealed the resident ambulating alone in the hallway pushing their wheelchair in front of them with a personal pressure alarm in place in the wheelchair and the sounding device turned off. Licensed nursing staff K, and direct care staff L, assisted the resident into the wheelchair, and turned the pressure alarm on. Staff L proceeded to the resident's room and noted the bed alarm off. Staff L stated the resident should have the pressure alarm on at all times. Nurses' noted, dated 1-18-13 at 12:33 pm, revealed the resident "...will arise from his bed or chair without asking for assistance for ambulation." Nurses' note, dated 1-21-13 untimed, indicated "PPA on at all times." Interview, on 1-22-13 at 8:30 am, with direct care staff E, revealed the resident to have the pressure alarm on at all times, and stated the resident does attempt to get up on their own. Interview, on 1-22-13 at 2:30 pm, with licensed staff K, revealed the resident should have the personal alarm on at all times, and acknowledged the lack of documentation on the care plan for this intervention. Staff K stated the use of the personal alarm should be on the Kiosk (computerized documentation record for the direct care staff) alerting staff of this intervention. Staff K stated the charge nurse has access to update the Kiosk for interventions and did not know why the PPA not on the Kiosk, but stated staff aware of the intervention. Interview, on 1-22-13 at 3:00 pm, with licensed administrative staff A, revealed the interventions for residents are updated by administrative nursing staff. Interview, on 1-23-13 at 08:15 am, with consulting therapy staff M, revealed the the resident physically able to ambulate but due to safety issues related to cognition, not safe to ambulate by self. Staff M stated the facility instituted the use of the personal pressure alarm at all times. Interview, on 1-23-13 at 8:40 am, with direct care staff N, revealed the resident to have the PPA on at all times. Observation, on 1-23-13 at 9:25 am, revealed the resident ambulating in the hallway with walker, and consulting therapy staff O in stand by position. Staff O instructing the resident not to lean forward with ambulation. Interview, on 1-23-13 at 2:20 pm, with direct care staff E, revealed the resident requires the PPA on at all times as he/she attempts to get up by self. The facility policy for accidents, revised 8-20-09, advised staff "....to modify and evaluate the effectivness of an intervention." The facility failed to ensure the use of the personal pressure alarm remained in place and activated for this resident at risk for falls. - Observation, on 1-16-13 at 9:30 am during the initial tour of the facility revealed an unlocked kitchen supply closet containing 1/4 gallon and 2 full gallons of Q-San, 1 gallon of Rinse Clear HW and several unopened cartons of cleaning chemicals all with "keep out of reach of children" on the box/labels. Observation, on 1-16-13 at 12:57 pm, revealed the unlocked, unstaffed activity room with an unlocked cupboard containing an 11 ounce can of insect repellant indicating "hazardous to animals and humans", and a 12 ounce can of spray paint, with labeling indicating "keep out of reach of children". Interview, on 1-16-13 at 1:05 pm, with activity staff P, revealed the activity room is opened during the day time without staff present, and the cupboard containing the spray paint and insect repellant should be locked at all times, and felt the staff last night may have not locked it. Observation, on 1-16-13 at 2:50 pm, revealed an unlocked kitchen supply closet with the above listed chemicals, interview with dietary staff Q, revealed the closet should be locked, and they had just been in it and forgot to lock it. Interview, on 1-16-13 at 3:15 pm, with housekeeping staff R, revealed the kitchen supply closet should be locked at all times, and this was the responsibility of the kitchen staff to keep it locked. Staff R stated the access from the north and south hallway to this connecting corridor where the closet is located is unlocked. Interview, on 1-23-13 at 10:30 am, with maintenance staff I, revealed the kitchen supply closet should be locked at all times. The facility failed to ensure hazardous chemical remained locked to prevent the 7 confused self mobile residents from ingestion. - Observation, on 1-15-13, 1-16-13 and 1-23-13, at various times, revealed 4 resident bathrooms on the 400 hall, 9 resident bathrooms on the 300 hall, 2 on the 100 hall and 13 on the 200 hall with toilet bolts extending up at lengths of 1-1.5 inches uncovered from the bilateral bases of the toilets. Interview, on 1-23-13 at 10:00 am, with administrative staff J and maintenance staff I, acknowledged the presence of the exposed toilet bolts in multiple resident rooms. Staff I verified these accident hazards and stated they would order covers for the exposed bolts. The facility failed to ensure the facility remained free of potential accident hazards for the residents of this facility.

The facility reported a census of 52 residents with 7 residents reviewed. Based on observation, interview, and record review, the facility failed to provide care and services to prevent the development and worsening of pressure ulcers. The resident experienced harm as the staff failed to reposition the resident for 3 hours and 45 minutes and 4 hours respectively, failed to provide pressure relieving devices, as planned, and further failed to obtain physician's orders [REDACTED]. Findings included: - The 2/28/11 nursing summary notes, for resident # 101, admitted on [DATE], reflected the resident required total care, related to [MEDICAL CONDITION], and diabetes mellitus. A skin risk note, dated 2/28/11 identified bruises/abrasions and instructed staff to reposition the resident every 2 hours, and apply [MEDICATION NAME] scrotal area, and a cushion to the chair. Nursing notes, dated 2/28/11 at 1620 (4:20 p.m.) evidenced the resident, "Arrived to facility per pov (private owned vehicle)" documented a head to toe assessment, however, lacked documentation of skin issues noted to buttocks, except, "gualding/redness" to the resident's perineal (front and back) areas. An initial care plan, dated 2/28/11, identified the resident with bruises and abrasions and instructed staff to reposition the resident every 2 hours and provide a cushion to the chair. The Braden skin risk assessment, dated 3/1/11, documented a score of 14, indicating the resident at moderate risk. Observation, on 3/8/11 at 8:30 a.m., revealed the resident sat in a recliner, with oxygen in place, feet elevated, and with the spouse at side. The chair lacked a cushion in the seat. Intermittent observation on 3/8/11 at approximately 9:00, 9:30, 10:00, 10:30, 11:15 a.m., revealed the resident remained in the chair. At 11:45 a.m., following a physician visit, certified nursing staff M and K, transferred the resident from the recliner into the bed. After transferring the resident onto the bed, the staff changed the resident's incontinence brief. Observation revealed open stage II areas to the resident's buttocks, one circular area to the right cheek and four circular areas on the left cheek, with one slit-type area to the coccyx area. Staff M, reported at that time, "The areas are bigger than when observed earlier in the shift." Following cleansing of the resident's perineal area, the staff applied moisture barrier cream and a clean brief. Following completion of cares, the staff left the resident on his/her back, failing to relieve pressure from the buttocks after sitting upright for 3 hours and 45 minutes. Intermittent observations, with spouse at bedside, on 3/8/11 from 12:15, 12:40, 1:10, and 1:45 p.m., revealed the resident rested in the same position until 1:50 p.m., when certified nursing staff M and licensed nursing staff D, checked and changed the resident for incontinence and placement of medication patches. At that time, licensed staff D provided perineal care, following a loose bowel movement, and after observation of the open areas, reported the areas as new to his/her knowledge, as the staff member had been off duty for the past 4 days. The nurse indicated the previous staff nurse failed to notify the on-coming shift of the open areas. Following cares, the staff again placed the resident onto his/her back. Observation on 3/9/11 at 7:00 a.m., revealed the resident rested in a recliner, with their feet elevated, oxygen in place and alert to person. Certified nursing staff N, at that time, reported transferring the resident into the chair at approximately 6:15 a.m. Observation at that time revealed the chair lacked a pressure relieving cushion. Intermittent observations, from 7:00 a.m. until 9:40 a.m., revealed at 8:35 a.m., on 3/9/11 certified nursing staff G and L, pulled the resident up right in the recliner, for breakfast, however, failed to significantly change the pressure to the buttocks and coccyx area. Intermittent observations continued from 8:35 a.m. to 9:40 a.m., at which time the resident remained in the same position, with spouse at side. CNA staff G, indicated the resident had remained in that position without staff intervention for position change. Interview at approximately 9:00 a.m., with licensed nursing staff B and C, indicated the staff unaware of the excoriated areas, being open. Review of nursing notes and physician notification, at that time, revealed a lack of reporting/documentation of the areas. Staff B reported an assessment of the areas, "Will be done." Certified nursing staff H, on 3/9/11 at 10:09 a.m., reported the resident had a pressure reducing cushion in the chair, prior to going to the emergency roiagnom on [DATE]. At that time the resident required a different wheel chair and the cushion failed to be transferred to the new chair at that time. The staff member agreed the resident lacked a pressure relieving cushion from 3/3/11 to 3/9/11, a total of 6 days. Continued intermitten observations from 9:40 a.m., until 10:15 a.m., on 3/9/11, revealed certified nursing staff G and L, transferred the resident from the chair onto the bed. The staff provided perineal care following a loose bowel movement and incontinence of urine, then applied moisture barrier cream to the buttocks and scrotal area. Observation revealed the open areas remained, surrounded by reddened non-blanchable skin. Observation revealed one staff member left the room and returned with a waffle type blow up air cushion, and placed that into the resident's chair. Following cares the staff positioned the resident on his back, after sitting upright in the recliner chair for 4 hours. At 10:15 a.m., on 3/9/11, certified nursing staff G, reported the resident required total care, and required 2 staff assistance for bed mobility and transferring. At 10:30 a.m., certified nursing staff L, reported the area on his bottom is bigger than earlier in the week. On 3/9/11 11:05 a.m., licensed nursing staff B and C, turned resident to assess the areas on the coccyx and buttocks. Measurements of 4 areas in total included a area, measuring 0.8 x 0.5 centimeter on the left cheek, 0.4 x 0.4 centimeter to the right upper cheek and 0.9 x 2.1 (combined areas) and center coccyx area measured 0.2 x 0.2 centimeter, and staged all the areas as stage II. The resident moaned several times during cares, and the nurse offered pain medication to the resident, and the resident requested pain medication at that time. Inquiry of licensed nursing staff B at approximately 11:20 a.m., regarding why the previous nurses' failed to assess the areas, notify the physician and obtain proper treatments for the areas, reported, " I can only say they were reporting excoriated areas, not open areas. " The nurse agreed the previous on-duty charge nurse's should have notified the physician and obtained treatment orders, and agreed the resident required a cushion to the chair and required every 2 hour repositioning. The facility failed to provide a pressure relieving device in the resident's chair, as planned, and failed to provide timely position changes on two occasions for 3 hours and 45 minutes, and 4 hours respectively, and failed to notify licensed staff and the physician in a timely manner for treatment. The resident developed 4 stage II pressure ulcers, in house.

The facility reported a census of 46 residents, with 16 selected for review. Based on record review and interviews, the facility failed to assess and provide adequate care for 1 resident (#46) that developed urosepsis. Findings included: - The facility admitted resident #46 on 9/9/10. [DIAGNOSES REDACTED]. The 11/1/10, MDS (minimum data set), significant change assessment identified the resident with severe cognitive impairment, in need of assistance with all activities of daily living, with a stage II pressure ulcer and limited range of motion. The 9/24/10 plan of care included, "I am unable to verbalize my needs...I am total assist with bed mobility, transfers, locomotion, dressing, eating, personal hygiene and bathing with 2 assist...I am a check and change before meals after meals upon getting up and lying down I am checked q (every) 2-3 hours at night...I use incontinent briefs...I have history of UTI'S (urinary tract infections). Observe for s/s (signs/symptoms) of UTI. Notify Dr. (doctor) for UA (urinary analysis) as needed..." On 1/8/11 the nursing staff documented the resident's monthly vitals, temperature 98.3 degrees, pulse 78, respirations 18, blood pressure 120/76, and weight of 123.4 pounds. On 1/11/11 (no time) the facility nursing staff C notified the primary care physician by fax, that the resident's urine contained a strong malodor with a small amount of blood noted in the urine. However, the nursing staff failed to document this assessment in the nurses notes on 1/11/11. The nurses notes failed to contain any follow up or documentation for this resident on 1/11/11. Nurses notes documented the following: On 1/12/11 at 9:50 P.M., "...Didn't eat, took liquids poorly, refused meds, unable to wake.." On 1/13/11 at 5:00 A.M., "...Emesis x 3, lg (large) amt (amount) dark rusty brown in color. Res. (resident) not responding to verbal or physical stimuli until at 4:30 A.M. and eyes open at that time. 2 voidings this shift -first voiding large amt (amount) and rusty in appearance. 2 nd voiding small appears to have brighter red bleeding... having snoring type respirations/non responsive. Abd (abdomen) firm..." 1/13/11 at 12:30 P.M., "...temp 97.2." 1/13/11 at 2:15 P.M., "New order received per (physician) may send to ER for evaluation d/t (due/to) lethargy, vomiting et mod (moderate) amt (amount) of bloody vaginal drainage." 1/13/11 at 2:45 P.M., "Called for amb (ambulance) to transport to ER (emergency room )." The transfer form, dated 1/13/11 (no time), documentation included, "Projectile vomiting x 3 yesterday. Large amount bloody, mucous discharge today, very malodorous. No intake today and very lethargic. Vital signs 99.5 - 104-20, 128/67." On 1/13/11 at 6:00 P.M., nurse's notes documented the facility received notification the resident had been admitted to the hospital with [REDACTED]. emergency room documentation, dated 1/13/11 at 3:15 P.M., revealed the resident's assessment included an elevated temperature of 101.3, pulse 108, respirations 22, with an oxygen saturation level of 95 %. The resident also demonstrated 2 + [MEDICAL CONDITION]. The hospital nursing staff inserted a foley urinary catheter and obtained 2300 cc (cubic centimeters) return of retained urine. On 1/20/11 at 9:35 A.M. licensed nurse C described the resident as non-verbal with good vital signs. no [MEDICAL CONDITION] or change in the abdomen or skin at the time of transfer to the hospital. On 1/20/11 at 9:50 A.M., licensed nurse A described the resident as unresponsive, not diaphoric, without [MEDICAL CONDITION], and the abdomen enlarged, but not hard, when the nurse provided direct care provided on the 1/13/11. Review of the fluid intake records, documented by nurse aides, on the electronically computerized system revealed the resident's intake as 2,620 cc for 1/11/11, as 2,130 cc on 1/12/11, and no oral intake on 1/13/11. Review of the bladder output records, documented by nurse aides, on the electronically computerized system revealed the residents output as incontinent last, on 1/12/11 at 1:13 A.M. The John W. Hole Human Anatomy and Physiology 2 nd edition 1981 documented, "Although the urinary bladder may hold as much as 600 ml (milliliters) of urine, the desire to urinate is usually experienced when it contains about 150 ml." (equal to 150 cubic centimeter). The facility failed to adequately assess and monitor this resident's urinary output and enlarged abdomen, as well as elevated temperature. The resident demonstrated an elevated temperature, [MEDICAL CONDITION] and an enlarged abdomen, with [MEDICAL CONDITION] of 2300 cc during evaluation in the emergency room .