Every finding on record at Medicalodges Kinsley

The facility reported a census of 24 residents, with four residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and mistreatment. This deficient practice placed the resident at risk for fear and decreased quality of life.Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included unspecified dementia (a progressive mental disorder characterized by failing memory and confusion).R1's 12/13/24 Significant Change Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The assessment documented R1 utilized a wheelchair for locomotion and was dependent on staff for shower/bathing and toileting hygiene. R1 required substantial/maximal assistance for all other cares except eating, which was performed independently. The assessment documented R1 was frequently incontinent of bowel and bladder.The 12/13/24 Delirium CAA documented R1 was unable to focus attention and had disorganized thoughts.The 12/13/24 ADL Functional / Rehabilitation Potential CAA documented R1 needed assistance from staff.R1's 03/14/25 Quarterly MDS documented a BIMS score of 99 which indicated the assessment could not be completed. Staff assessed R1 to have memory problems with moderately impaired cognition. The assessment documented R1 was dependent on staff for shower/bathing and toileting hygiene. R1 required substantial/maximal assistance for all other cares except eating, which required setup/cleanup assistance. R1 was frequently incontinent of bowel and bladder.The EHR Progress Notes tab reviewed from 06/04/25 to 07/02/25 lacked documentation of the incident on 06/08/25.The facility's investigation documented on 06/08/25 at approximately 01:30 AM, Certified Nurse Aide (CNA) M and CNA O provided incontinence care to R1. R1 had feces on one hand, and when CNA O attempted to clean R1's hand, R1 reached for CNA M. CNA O reported that CNA M threatened R1 with physical violence if he touched her. CNA O informed CNA M that the speech was inappropriate and asked CNA M to leave the room.CNA O's undated and unnotarized Witness Statement documented on (the night of) 06/07/25, R1 had a loose bowel movement in bed, and CNA M and CNA O went into R1's room to clean him up. CNA O documented that CNA M was assisting R1 with standing so CNA O could clean the bed and the resident. CNA O documented CNA M said, If you touch me with that hand, I will head butt you to R1. CNA O documented that she informed CNA M that she could not say that to a resident.The facility did not obtain a witness statement from CNA M.During an observation on 07/02/25 at 11:40 AM, R1 self-propelled in his wheelchair in the front lobby of the building without an apparent destination.During an interview on 07/02/25 at 11:40 AM, R1 was unable to answer questions, responding with rambling speech. He indicated he wanted to go fishing after attending religious services.On 07/02/25 at 11:00 AM, CNA O was unavailable for interview, and no contact information was provided by the facility.During an interview on 07/02/25 at 11:30, CNA N revealed if she observed another staff member saying or doing anything inappropriate to a resident, she would intervene and ensure resident was safe then immediately report to the charge nurse, Administrative Staff A or Administrative Nurse D. CNA N confirmed education was provided by leadership staff since the incident that occurred on 06/08/25.During an interview on 07/02/25 at 11:42 AM, Certified Medication Aide (CMA) R revealed if they observed another staff saying or doing anything inappropriate to a resident, they would intervene and ensure the resident remained safe and then immediately report to the charge nurse, Administrative Nurse D or Administrative Staff A. CMA R confirmed education was provided by leadership since the incident that occurred 06/08/25.During an interview on 07/02/25 at 11:45 AM, Maintenance U revealed if another staff member was observed saying or doing anything inappropriate to a resident, he would intervene and ensure the resident was safe, then immediately report to Administrative Staff A. Maintenance U confirmed education had been provided by leadership since the incident that occurred on 06/08/25.During an interview on 07/02/25 at 11:50 AM, Dietary BB revealed if another staff was observed saying or doing anything inappropriate to a resident, their immediate reaction depended on what happened and would report the concern immediately to her supervisor and/or Administrative Staff A. Dietary BB revealed that no education had been provided by leadership since the incident on 06/08/25.During an interview on 07/02/25 at 11:55 AM, Dietary CC revealed if she witnessed anything she suspected was inappropriate, she would immediately report the situation to her supervisor and/or Administrative Staff A. Dietary CC revealed no education had been provided by leadership since the incident on 06/08/25.During an interview on 07/02/25 at 11:56 AM, Laundry W revealed if she saw or heard anything that she thought was inappropriate towards a resident, she would immediately report the situation to her supervisor or Administrative Staff A. Laundry W revealed no education was provided by leadership since the incident on 06/08/25During an interview on 07/02/25 at 12:00 PM, Administrative Staff A revealed on 06/11/25 at approximately 02:00 PM, Administrative Nurse D and a group of CNA staff had a meeting where CNA O revealed the statements made by CNA M to R1 on 06/08/25. Administrative Nurse D immediately notified Administrative Staff A, who initiated an investigation. Administrative Staff A revealed CNA M was telephoned and informed not to return to the facility as her employment was terminated due to the result of the investigation, as well as other concerns. Administrative Staff A reported that staff education was only provided to direct care staff, as the allegation of abuse was a nursing matter.The facility's 10/2022 Abuse, Neglect and Exploitation policy documented that the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy defined verbal abuse as oral language and provided an example of threats of harm.

The facility reported a census of 24 residents, with four residents reviewed for abuse. Based on observation, interview and record review, the facility failed to report an allegation of abuse for one resident, Resident (R) 1 when on 06/08/24 at approximately 01:30 AM, Certified Nurse Aide (CNA) M verbally threatened R1 with physical violence was witnessed by CNA O, however the incident was not reported to Administrative Nurse D until 06/11/25 at approximately 02:00 PM. This deficient practice allowed CNA M to work an additional three shifts, which had the potential to have a negative psychosocial impact for the residents in the facility.Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included unspecified dementia (a progressive mental disorder characterized by failing memory and confusion).R1's 12/13/24 Significant Change Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The assessment documented R1 utilized a wheelchair for locomotion and was dependent on staff for shower/bathing and toileting hygiene. R1 required substantial/maximal assistance for all other cares except eating, which was performed independently. The assessment documented R1 was frequently incontinent of bowel and bladder. The 12/13/24 Delirium CAA documented R1 was unable to focus attention and had disorganized thoughts.The 12/13/24 ADL Functional / Rehabilitation Potential CAA documented R1 needed assistance from staff.R1's 03/14/25 Quarterly MDS documented a BIMS score of 99, which indicated the assessment could not be completed. Staff assessed R1 to have memory problems with moderately impaired cognition. The assessment documented R1 was dependent on staff for shower/bathing and toileting hygiene. R1 required substantial/maximal assistance for all other cares except eating, which required setup/cleanup assistance. R1 was frequently incontinent of bowel and bladder. The EHR Progress Notes tab reviewed from 06/04/25 to 07/02/25 lacked documentation of the incident on 06/08/25.The facility's investigation documented on 06/08/25 at approximately 01:30 AM, Certified Nurse Aide (CNA) M and CNA O provided incontinence care to R1. R1 had feces on one hand, and when CNA O attempted to clean R1's hand, R1 reached for CNA M. CNA O reported that CNA M threatened R1 with physical violence if he touched her. CNA O informed CNA M the speech was inappropriate and asked CNA M to leave the room. CNA O's undated and unnotarized Witness Statement documented on (the night of) 06/07/25, R1 had a loose bowel movement in bed, and CNA M and CNA O went into R1's room to clean him up. CNA O documented that CNA M was assisting R1 with standing so CNA O could clean the bed and the resident. CNA O documented CNA M said, If you touch me with that hand, I will head butt you to R1. CNA O documented she informed CNA M that she could not say that to a resident. The facility did not obtain a witness statement from CNA M.Review of the facility's staffing schedule revealed CNA M worked 06/07/25, 06/08/25, 06/09/25, and 06/10/25. During an observation on 07/02/25 at 11:40 AM, R1 self-propelled in his wheelchair in the front lobby of the building without an apparent destination.During an interview on 07/02/25 at 11:40 AM, R1 was unable to answer questions, responding with rambling speech. He indicated he wanted to go fishing after attending religious services. On 07/02/25 at 11:00 AM, CNA O was unavailable for interview, and no contact information was provided by the facility.During an interview on 07/02/25 at 11:30 AM, CNA N revealed if she observed another staff member saying or doing anything inappropriate to a resident, she would intervene and ensure resident was safe then immediately report to the charge nurse, Administrative Staff A or Administrative Nurse D. CNA N confirmed education was provided by leadership staff since the incident that occurred on 06/08/25.During an interview on 07/02/25 at 11:42 AM, Certified Medication Aide (CMA) R revealed if they observed another staff saying or doing anything inappropriate to a resident, they would intervene and ensure the resident remained safe and then immediately report to the charge nurse, Administrative Nurse D or Administrative Staff A. CMA R confirmed education was provided by leadership since the incident that occurred 06/08/25.During an interview on 07/02/25 at 11:45 AM, Maintenance U revealed if another staff member was observed saying or doing anything inappropriate to a resident, he would intervene and ensure the resident was safe, then immediately report to Administrative Staff A. Maintenance U confirmed education had been provided by leadership since the incident that occurred on 06/08/25.During an interview on 07/02/25 at 11:50 AM, Dietary BB revealed if another staff was observed saying or doing anything that is inappropriate to a resident, their immediate reaction depended on what happened and would report the concern immediately to her supervisor and/or Administrative Staff A. Dietary BB revealed no education had been provided by leadership since the incident on 06/08/25.During an interview on 07/02/25 at 11:55 AM, Dietary CC revealed if she witnessed anything she suspected was inappropriate, she would immediately report the situation to her supervisor and/or Administrative Staff A. Dietary CC revealed no education had been provided by leadership since the incident on 06/08/25.During an interview on 07/02/25 at 11:56 AM, Laundry W revealed if she saw or heard anything that she thought was inappropriate towards a resident, she would immediately report the situation to her supervisor or Administrative Staff A. Laundry W revealed no education was provided by leadership since the incident on 06/08/25During an interview on 07/02/25 at 12:00 PM, Administrative Staff A revealed on 06/11/25 at approximately 02:00 PM, Administrative Nurse D and a group of CNA staff had a meeting where CNA O revealed the statements made by CNA M to R1 on 06/08/25. Administrative Nurse D immediately notified Administrative Staff A, who initiated an investigation. Administrative Staff A revealed CNA M was telephoned and informed not to return to the facility as her employment was terminated due to the result of the investigation, as well as other concerns. Administrative Staff A reported CNA O said the concern was not immediately reported to the nurse on duty because CNA O did not think it was abuse since nothing physical happened. Administrative Staff A reported that staff education was only provided to direct care staff, as the allegation of abuse was a nursing matter.The facility's 10/2022 Abuse, Neglect and Exploitation policy documented that the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. Additionally, the policy documented that every employee of the facility was responsible to report any abuse or allegations of abuse to the facility's administrator and/or the administrator's designee, the appropriate State Agency (SA), and, when applicable, law enforcement (LE). All allegations should be reported within two hours after the allegation is made if the allegation involves abuse or resulted in serious bodily injury.

The facility reported a census of 22 residents with 10 residents sampled and one resident reviewed for pain management and two additional residents reviewed for unnecessary medication use. Based on observation, interview, and record review the facility failed to assess pain and failed to take appropriate action to manage severe pain despite repeated complaints from Resident (R)74. Additionally, the facility lacked effective communication between nurses, doctors, and other healthcare providers regarding R74's pain management. This failure led to R74 reporting waves of severe pain over approximately a month, until her death on [DATE], and placed R74 in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR), documented R74 had diagnoses of incisional hernia (occurs when the abdominal muscles or connective tissue weaken or gap at the site of a surgical incision, allowing abdominal contents to protrude. This can happen weeks, months, or years after the surgery) and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The [DATE] Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. R74 was independent with transfers and bed mobility, she required set up for oral care and eating. R74 required supervision for ambulation, dressing, toileting, personal hygiene, footwear, and maximum assistance required for bathing. The resident reported her pain at a level 5 out of 10, that occurred occasionally and affected her sleep. The [DATE] Annual MDS lacked a BIMS score and lacked a staff interview; cognition was not assessed. Depression was not assessed. R74 required maximal assistance with activities of daily living (ADL) such as bathing and bed mobility. She required supervision assistance with ambulation, toileting, dressing, personal hygiene, and footwear. R74 rated her pain at a six out of 10, which occasionally affected her sleep. The [DATE] Cognitive Loss/Dementia CAA documented R74 triggered for cognitive loss related to rejection of care on occasion. The [DATE] Pain CAA triggered related to R74 had occasional pain. The resident's Care Plan documented the following: [DATE] - Staff were instructed to recognize the resident's pain tolerance and her level of discomfort as real and painful for her. [DATE] - Staff were instructed to use alternative methods for pain management such as massage, aroma therapy, warm packs, and distraction. [DATE] - Staff were educated to monitor for nonverbal cues of pain such as facial grimace, guarding, and moaning. Review of the Physician Orders documented the following: Acetaminophen 325 milligram (mg) tablet, give two tablets by mouth, every six hours as needed for pain, date ordered [DATE]. Acetaminophen 325 mg tablet, give two tablets by mouth, three times a day for moderate pain, date ordered [DATE]. Review of the Medication Administration Record dated [DATE] thru [DATE] documented staff administered R74's Acetaminophen on the following days: On [DATE] at 11:25 PM, reported pain level of five, with effective results noted. On [DATE] at 11:20 PM, reported pain level of five, with effective results noted. On [DATE] at 11:31 AM, reported pain level of four, with undetermined results noted. On [DATE] at 05:52 AM, reported pain level of seven, with ineffective results noted. On [DATE] at 02:46 AM, reported pain level of six, with ineffective results noted. On [DATE] at 04:11 AM, reported pain level of eight, with ineffective results noted. The [DATE] at 03:51 PM Progress Note revealed R74 complained of stomach discomfort. The on-call provider was notified and gave and order for Simethicone (medication used to relieve the painful symptoms of too much gas in the stomach and intestines) 80 mg three times, daily. The [DATE] at 11:23 PM Progress Note revealed R74 reported abdominal pain at a level of six out of 10 for last three days. R74 experienced polyuria (is when your body makes too much urine) more than baseline. R74 requested assistance to the bathroom multiple times an hour on top of having multiple incontinent episodes. R74 was very restless and unable to rest for more than 15 to 20 minutes without yelling out or pressing her call light. Urinalysis (lab analysis of urine) was to be collected on [DATE] in the morning when the lab was open. The [DATE] at12:09 PM Progress Note revealed R74 complained frequently to several staff that her stomach hurt. R74's blood pressure was elevated to ,d+[DATE] millimeters of mercury (mmHg) and staff administered an as needed dose of clonidine (medication for high blood pressure). The writer informed the provider via the telephone at 11:30 AM regarding the resident's elevated blood pressure and complaint of stomach pain. The provider did not give any new orders to address the resident's complaints of pain. The [DATE] at 08:35 AM Progress Note revealed staff sent a communication to R74 's provider regarding her continued complaints of abdominal discomfort and new complaints of nausea, confusion, dizziness, and the shakes. The provider gave an order to obtain a urinalysis and give four mg of Zofran (is a medication that prevents nausea and vomiting). The note lacked evidence the provider addressed the resident's pain. The [DATE] at 11:32 AM Progress Note revealed a communication was sent to the resident's provider, R74 continued to not feel well, the facility received orders for R74 to have a computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) and outpatient labs. The [DATE] at 04:59 PM Progress Note revealed R74 had a partially strangulated hernia (occurs when the blood supply to the herniated (an abnormal condition or process in which an organ or other tissue protrudes through an opening tissue) has been decreased in flow) and she was sent to the hospital per provider. The [DATE] at 08:32 PM Progress Note revealed R74 returned from the hospital with no new orders. The resident had no complaints of pain upon her return. Review of the resident's record from [DATE] through [DATE] lacked any follow up progress notes after R74's hospital visit. The [DATE] at 02:53 AM Progress Note revealed staff found R74 on the floor with no injuries noted. The [DATE] at 11:44 PM Progress Note R74 used her call light up to 30 times in an hour. R74 continued to call out help me God, help me up. I cannot do those things R74 was very restless, and as needed acetaminophen was utilized multiple times, but the resident had no changes in behaviors. R74 yelled at staff for the past two days when staff attempted to help her. R74's confusion and anger increased, and her urinalysis came back negative. R74 screamed No when transferred to the wheelchair. Staff sent a fax to the resident's provider to please advise. The [DATE] at 09:01 AM Progress Note revealed R74 up was up and self-propelled around in her wheelchair with no complaints of pain expressed. The [DATE] at 03:20 PM Progress Note revealed R74 was found on the floor in her room with no injuries noted. R74 repeatedly stated God help me and she had no complaints of pain associated with fall. The [DATE] at 11:43 PM Progress Note revealed R74 continued to be very restless, would lay down in bed, and yell God help me, God help me up. When R74 was assisted up to a wheelchair R74 would continue to yell God help me, I need to lay down. R74 could not be redirected and continued to push her call light when staff was in the room. Day shift reported R74 exhibited the same behaviors, and staff administered as needed acetaminophen multiple times. The resident had no changes in behavior or relief noted. The writer noted multiple faxes were sent to the resident's provider. The [DATE] at 01:19 PM Progress Note revealed R74 was seen by the provider, noted R74 wanted to go home, and the provider ordered a urinalysis. The [DATE] at 02:22 PM Progress Note revealed R74 was not herself, she was lethargic, incontinent with loose stools, had a temperature of 98.0 degrees Fahrenheit, a pulse of 58 beats per minute, respirations at16, blood pressure measured ,d+[DATE] (low) and oxygen saturations (percentage of oxygen in the blood) was 93% on room air. R74 was slightly pale in color and her provider was notified of a suspicion of sepsis. Labs were ordered and a chest Xray if wheezing or cough was noted. Labs were obtained and sent to lab for processing. The [DATE] at 05:09 PM Progress Note revealed lab results were received and reported to the resident's provider. New orders were given to change the resident's antibiotic to Bactrim DS twice a day for seven days and the order for Macrobid (antibiotic) was discontinued. The [DATE] at 02:33 AM Progress Note revealed R74 required three staff members to transfer her to the wheelchair as R74 was unable to assist. R74 was hunched over in her wheelchair and could not sit up erect. R74 was assisted to the toilet and was unable to stand once at the toilet, R74 leaned over sideways, and her upper body leaned up against the wall as she began to have dry heaves. R74 was assisted back to bed after she received care. R74 yelled and moaned the entire time. R74 responded that she had pain in her back. The resident's vital signs were out of limits, R74's respiration's fluctuated from 18 to 28 breaths per minute, her oxygen saturation was 86%- to91% on room air and R74 laid in her bed with her eyes closed. Review of the [DATE] Hospital Visit documentation confirmed the resident went to the hospital, the EHR lacked evidence of the residents transfer to the hospital. The hospital paperwork in R74's paper chart documented R74 was there for a little over an hour and all of her medications were discontinued except for Acetaminophen and Bactrim DS. The facility was to consult hospice for R74 for anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) and gastrointestinal bleeding (bleeding into the stomach and/or digestive tract). R74's full code was changed to a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest). The [DATE] 09:17 AM Progress Note revealed R74 had her eyes open and made eye contact when spoken to. The [DATE] at 10:21 AM Progress Note revealed R74 passed away at 09:56 AM. The [DATE] at 10:29 AM Discharge Note revealed Hospice services were ordered, but not completed before R74 passed away. All medications were discontinued during the hospital visit during the night except for Acetaminophen and Bactrim DS. During an interview on [DATE] at 02:12 PM, Certified Nurse Aide (CNA) M reported if a resident complained of pain, staff were to notify the charge nurse. CNA M could not recall R74 complaining of pain, she did report R74 would sometimes yell out for help. During an interview on [DATE] at 01:37 PM Administrative Nurse B reported R74 received an order for hospice services when she transferred back from the hospital on [DATE] but she passed away prior to hospice consult being completed. Administrative Nurse B reported R74 could not have anything stronger than Acetaminophen for pain, when Administrative Nurse B was asked why, she could not recall why she could not have a stronger pain medication. Additionally, Administrative Nurse B reported she was instructed on what she could and could not chart in the resident's progress notes. When Administrative Nurse B was asked what kind of notes that she could not document, she commented They are old and are going to die anyways that is what was said to her when some of the providers were contacted for residents' concerns. Administrative Nurse B did not identify which provided stated that. Additionally, she reported she could not jump over the providers heads and call the medical director as the on-call providers would get mad. Administrative Nurse B confirmed that R74's progress notes lacked abdominal assessments and follow through with complaints that R74 had with her pain. During an interview on [DATE] at 02:45 PM, Licensed Nurse (LN) G reported if a resident did not have relief from a scheduled or as needed pain medication, the provider should be notified and updated on resident's condition and should receive new orders. LN G reported that there were some residents that would drug seek for pain medications so they may not receive new orders. The facility policy Pain Management dated ,d+[DATE] documented to provide a systematic approach for identifying residents at risk for pain and develop interventions to decrease the effect of pain on the resident's quality of life. To provide guidelines for assessment and individualized treatment plan including pharmacological and non-pharmacological interventions. The facility is to review all residents with unmanaged pain weekly. If there is a decline in the effectiveness of pain management, the plan of care is to be reviewed for appropriateness and revised as needed. The physician and responsible party are to be notified of the need to changed pain management interventions and plan of care. The facility failed to assess pain and failed to take appropriate action to manage severe pain despite repeated complaints from Resident (R) 74. Additionally, the facility lacked communication between nurses, doctors, and other healthcare providers regarding R74's pain management. This failure placed R74 in immediate jeopardy. On [DATE] at 10:25 AM, Administrative Staff A and Consultant Staff T were provided the Immediate Jeopardy (IJ) template and notified the facility failure to ensure staff identified, updated providers and responded appropriately to complaints of R74's pain that was consistently left without an effective pain medication being administered, leading to signs of distress, such as moaning, yelling and agitation which significantly impacts their quality of life and could potentially result in further complications if not addressed and R74's unrelieved pain could be a possible indicator of a returned strangulated hernia or other significant disease processes. The facility submitted an acceptable plan for removal of the immediate jeopardy on [DATE] at 02:35 PM which included the following: 1. R74 died on [DATE]. Residents will have a pain assessment including assessment of areas identified completed with physician intervention if appropriate and the care plan updated on [DATE]. 2. Pain assessed every shift by licensing nursing with staff interventions if applicable date started [DATE]. 3. Immediate Quality Assurance and Performance Improvement (QAPI is a data-driven approach to improving the quality of care and services provided to patients) meeting held with the Medical Director, Administrative Staff A and Administrative Nurse B completed on [DATE]. 4. License staff will receive education on pain assessment including assessment of areas identified with pharmacological and non-pharmacological interventions and verbal notification on [DATE]. 5. Administrative Nurse B or designee will audit pain goals and reported pain with interventions through clinical excellence on [DATE] 6. Physician and responsible party are to be notified and documentation of the need to change pain management interventions and plan of care on [DATE] 7. Results of audits findings will be reviewed during QAPI meeting monthly. The surveyor verified the above corrective actions were implemented while on-site on [DATE]. This deficient practice remained at a scope and severity of a G.

The facility reported a census of 22 resident. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all nursing personnel by the required deadline. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid services (CMS) for Fiscal Year (FY) 2024 Quarter 1, documented the facility failed to have Licensed Nursing Coverage 24 hour/day on 10/01/24, 10/04/24, 11/23/24, and 12/31/24. Upon review of printed staffing days sheet provided by the facility, the date above it was revealed the facility had proof of RN hours and LN hours for the dates of 10/4/24, 11/23/24, and 12/31/24 but lacked eight hours of RN coverage on 10/01/24. Interview on 11/19/24 a 09:44 AM with Administrative Staff A reported the Director of Nursing can count as RN coverage if the census was less than 60 residents. Administrative Staff A stated 10/01/24 was the only day the facility did not have eight consecutive hours of RN coverage. Administrative Staff A reported she fills out agency sheets, then sends to the corporation and they complete the PBJ reporting. The facility failed to provide a policy regarding reporting Payroll-Based Journal, as requested on 11/20/24. The facility failed to accurately submit staffing information to the Payroll Based Journaling (PBJ) for Quarter 1 of Fiscal Year 2024.

The facility reported a census of 22 residents. The sample included 10 residents. Based on interview and record review, the facility failed to issue accurate and complete Beneficiary Protection Notification forms to Resident (R) 16. Findings included: - On 11/04/24 review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-20052 (SNFABN) and the Notification of Medicare Non-Coverage Form 10123(NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service). The SNFABN had the incorrect dates on the form and lacked cognitively intact R16's signature, the family member signed the form. The facility lacked a signed NOMNC for R16. During an interview on 11/14/24 at 07:45 AM, Administrative Staff A reported there was no NOMNC issued for R16 when discharged from therapy. She reported R16 started therapy 06/06/24 and last cover day was 06/27/24 from therapy. A SNFABN was given to resident with the incorrect dates of 07/22/24 to pay out of pocket. The SNFABN form was signed on 07/16/24 by family member and was not sure why R16 did not sign the form. Administrative Staff A reported that was the old Social Service Designee who is no longer worked at the facility as she had problems completing the required paperwork. The facility did not provide a policy for Medicare Advance Beneficiary and Medicare Non-Coverage Notices, as requested. The facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to R16, as required.

The facility reported a census of 22 residents with 10 residents sampled. Based on observation, interview, and record review the facility failed to identify a significant change and complete an assessment for two residents reviewed for significant change assessments. Resident (R) 19 had a decline with ambulation, toileting hygiene, transfers, bed mobility and dressing. R11 had a decline with ambulation, transfers, toileting hygiene, and bed mobility. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - Resident (R)19's Electronic Health Record (EHR) revealed a diagnosis, which included dementia (progressive mental disorder characterized by failing memory, confusion). The 06/26/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R19 had a total mood severity score of 00, indicating no depression and he had no behaviors noted. R19 required set up for eating and required supervision assistance with ADLs such as ambulation 150 feet, toileting, dressing, footwear, and personal hygiene. R19 was independent with ambulation 10 feet, transfers and bed mobility. He required moderate assistance with bathing. History of falls and R19 did not use a wheelchair. The Functional Abilities/Functional Rehabilitation Care Area Assessment (CAA) dated 06/26/24, documented R19 triggered the functional CAA due to needing assistance from staff. The Cognitive Loss/Dementia CAA dated 06/26/24, documented R19 triggered the cognitive CAA due to having a low BIMS score. The 09/20/24 Quarterly MDS documented R19 had a BIMS score of five, which indicated severely impaired cognition. R19 had behaviors noted 1-3 days of kicking, hitting, wandering, refusal of care, pushing, and grabbing captured in the seven day lookback. R19 required maximal assistance with bed mobility, transfers, oral care, and personal hygiene. No ambulation was captured in the seven day lookback period. R19 was dependent for toileting hygiene. Bathing, dressing, and footwear were not assessed on the MDS. One fall non-injury. The Care Plan documented the following: Staff were instructed to provide more assistance for completing ADLs if R19 had pain, dated 06/20/24. Staff were instructed to provide one staff assistance for dressing and personal care. Additionally, staff were instructed to provide two staff assistance with transfers and R19 was independent with wheelchair mobility, dated 10/16/24. The Physician Orders Physical Therapy evaluation and treat, date ordered 10/08/24. The 08/04/24 at 06:20 PM Progress Note documented R19 had increased confusion and was unable to dress himself, he required assistance with toileting hygiene and adjustment of clothes, R19 was unable to follow verbal cues when instructed what he needed to do. R19 was unsteady with ambulation and would attempt to stand up and sat back down. The 08/05/24 at 05:38 PM Progress Note documented provider reported R19's urinalysis was unremarkable, therefore suspected behavior represented a progression of known dementia. The 08/19/24 at 12:05 PM Progress Note documented R19 confused and would not cooperate with staff when they attempted to provide care with ADLs. The floor had a large amount of urine on it as if he had sat on the side of the bed and urinated. The 09/29/24 at 05:05 PM Progress Note documented R19 found o floor in front of his wheelchair at the nurse's station. The 10/03/24 at 11:27 AM Progress Note documented a request had been made by therapy to obtain an order for physical therapy as R19 declined in strength and difficulty noted with ambulation. During an observation on 11/12/24 R19 was seated in his chair in his room, an unidentified therapist assisted R19 to a standing position. She reported that R19 started therapy the second week of October 2024 to strengthen his legs. During an observation on 11/13/24 at 08:30 AM and 12:25 PM, R19 was seated in his wheelchair in the dining room eating his lunch. During an interview on 11/13/24 at 02:15 PM, Certified Nurse Aide (CNA) M reported R19 had a decline with ambulation and doing care by himself over a couple of months ago, she reported that was easier for R19 to get around in his wheelchair and that he does not walk unless staff walk him. CNA M reported she would communicate with the charge nurse if there was a decline of ADLs for any resident when noticed. During an observation on 11/13/24 at 02:18 PM, R19 was seated in a wheelchair in television lounge, he held onto the handrail on the wall in front of him with one hand. During an observation on 11/13/24 at 02:26 PM, R19 was found ambulating independently in the television lounge approximately 20 feet from his wheelchair, his gait was unsteady and R19 almost fell as he started to lean towards his left side. Dietary Manager C moved quickly toward R19 and assisted him back to his wheelchair. Dietary Manager C reported R19 had not ambulated like that for a few months and reported R19 used to ambulate all over the facility when he was first admitted . During an interview on 11/14/24 at 10:00 AM, CNA M reported R19 had a decline in his ADL's since he was admitted . CNA M reported R19 ambulated all over the facility and he was more independent with his ADL's, she reported that R19 started to decline in 08/2024. CNA M reported that the staff have to assist R19 with is ADLs as he could not complete them like he had in the past. CNA M revealed that if a resident had a decline for a few days, she would report that information to the charge nurse. During an interview on 11/14/24 at 10:30 AM, Licensed Nurse (LN) H reported that R19 had a decline on walking and performing ADLs over the past couple of months. She said that a therapy consult would be obtained and reported that R19 had started physical therapy sometime last month. During an interview on 11/14/24 at 02:48 PM, Administrative Nurse A reported that she did not complete R19's MDS on 09/20/24 and did not agree that R19 had a decline is his ADLs. She reported that R19 could still walk and that he uses his legs to propel his wheelchair independently and that R19 can dress himself too. Reviewed the MDS completed in EHR and continued to report that R19 had no decline and she commented that she needed assistance to complete the MDS's in the facility as she had fell behind and that she should have just completed the MDS's herself so they would be correct. On 11/14/24, Administrative Staff A stated that the RAI manual is used as their policy. The facility failed to identify a significant change and complete an assessment for R19 he had a decline with ambulation, toileting hygiene, transfers, bed mobility and dressing. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. - Resident (R) 11's Electronic Health Record (EHR) revealed diagnoses, which included repeated falls, fatigue, weakness, and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The 03/07/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R11 had a total mood severity score of 00, indicating no depression and he had no behaviors noted. R11 required set up for eating and oral care. He required supervision assistance with activities of daily living (ADL) such as toileting hygiene, bed mobility, and transfers. R11 required moderate assistance for dressing, personal hygiene, and ambulation. He required maximum assistance for bathing, footwear, car transfer and mobility. R11 was frequently incontinent of bladder and continent of bowel. He had a history of falls and one minor injury fall. R11 had no oxygen or continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep). The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 03/07/24, documented R11 triggered the functional CAA due to needing assistance from staff. The Cognitive Loss and Dementia CAA dated 03/07/24, documented R11 triggered the cognitive CAA due to having a BIMS score of 10. The 09/06/24 Quarterly MDS R11 BIMS score and depression were not assessed. No behaviors noted in lookback period. R11 required total dependence on staff for personal hygiene, toileting hygiene, bed mobility, and transfers. R11 was non-ambulatory and wheelchair mobility was not assessed. R11 had frequent incontinence of bladder and bowel. R11 had two or more injury falls. The Care Plan documented the following: Staff were instructed to provide more assistance for completing ADLs if R19 had pain, dated 04/11/24. Staff were instructed to provide assistance as needed for toileting, dated 04/29/24. Staff were instructed to provide peri care as needed, dated 04/29/24. Staff were instructed to utilize mechanical lift for transfers, dated 10/16/24. The Physician Orders lacked any orders for ADLs. The 03/03/24 at 08:03 PM Progress Note documented R11 found on the bathroom floor, R11 reported he lost his balance when he turned around and fell . The 05/28/24 at 01:30 PM Progress Note documented R11 found on floor in his room, he reported his knee gave out and he fell . The 06/11/24 at 10:08 AM Progress Note documented R11 found on floor in room, he reported he bent over to pick up a piece of paper. The 06/17/24 at 09:17 AM Progress Note documented R11 confused and ambulated by himself in hallway, called provider for a urinalysis (lab analysis of urine) order. The 07/19/24 at 09:53 AM Progress Note documented R11 ambulated 15 feet with restorative aide he complained of pain. The 08/04/24 at 06:35 PM Progress Note documented R11 stayed in bed longer during the morning, refused to be assisted out of bed. R11 had difficulty with transfers, complained of pain, and did not want to bear weight. Three staff assisted R11 with a transfer out of bed to wheelchair. The 08/16/24 at 09:56 AM Progress Note documented R11 would not ambulate and complained of pain in his back. The 09/19/24 at 07:13 AM Progress Note revealed R11 had declined with ambulation and required a sit-to-stand lift for transfers. During an interview on 11/12/24 at 04:56 PM R11's family member reported that R11 used to walk, and now required a mechanical lift for all his transfers. R11's family member said R11 required increased staff assistance since he moved into the facility in June of 24, with bathing, dressing and toileting. During an observation on 11/13/24 at 09:30 AM, R11 self-propelled in his wheelchair from dining room to his room, no concerns noted. During an interview on 11/14/24 at 10:00 AM, Certified Nurse Aide (CNA) L reported R11 had a decline with ambulation a few months ago, she reported that R11 is now a mechanical lift and he required more assistance with ADLs. CNA L reported she would communicate with the charge nurse if there was a decline of ADLs for any resident when noticed. During an interview on 11/14/24 at 02:51 PM, Administrative Nurse A reported that she did not complete R11's MDS on 09/06/24 and did not agree that R11 had a decline is his ADLs. She reported that R11 could walk when he was admitted to facility. Administrative Nurse B reported she was unsure if R11 was a true significant change as she required assistance to complete the MDS's in the facility as she had fell behind and that she should have just completed the MDS's herself so they would be correct. On 11/14/24 Administrative Staff A stated the facility used the RAI manual as their policy for MDSs. The facility failed to identify a significant change and complete an assessment for R11 who had a decline with ambulation, toileting hygiene, transfers, bed mobility and personal hygiene. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

The facility reported a census of 22 residents with 10 residents sampled. Based on observation, interview, and record review the facility failed to complete a weekly skin assessment for one resident. Observation during the survey revealed Resident (19) with a dressing on his right elbow and no skin notes, or progress notes in the Electronic Health Record (EHR) regarding the right elbow dressing. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - Resident (R) 19's Electronic Health Record (EHR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The 06/26/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R19 had a total mood severity score of 00, indicating no depression and no behaviors noted. R19 required set up for eating and required supervision assistance with ADLs such as ambulating 150 feet, toileting, dressing, footwear, and personal hygiene. R19 was independent with ambulating 10 feet, transfers, and bed mobility. He required moderate assistance with bathing. R19 had a history of falls and no skin issues noted. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 06/26/24, documented R19 triggered the functional CAA due to needing assistance from staff. The Cognitive Loss and Dementia CAA dated 06/26/24, documented R19 triggered the cognitive CAA due to having a low BIMS score. The 09/20/24 Quarterly MDS documented R19 had a BIMS score of five, which indicated severely impaired cognition. R19 had behaviors noted 1-3 days of kicking, hitting, wandering, refusal of care, pushing, and grabbing captured in the seven day lookback. R19 required maximal assistance with bed mobility, transfers, oral care, and personal hygiene. No ambulation was captured in the seven day lookback period. R19 was dependent for toileting hygiene, had one fall non-injury, with no skin issues noted. The Care Plan included a 10/17/24 intervention, which instructed staff to inspect R19's skin with bathing and daily care and report changes to the nurse. Review of the Physician Orders lacked any orders for wound care for R19. The 10/16/24 at 03:26 PM Progress Note revealed R19 had a fall earlier in the morning and a v shaped skin tear was noted on left elbow that measured at 0.8 centimeters on each side of the skin tear. The 10/17/24 at 12:37 AM Skin/Wound Assessment revealed R19 has a skin tear (a traumatic wound that occurs when the skin separates from the underlying layers) that measured two centimeters length by one and a half centimeters wide on right elbow. The EHR did not contain further skin assessments regarding R19's right elbow dressing from 10/18/24 through 11/18/24. During an observation on 11/19/24 at 01:05 PM R19 had no dressing noted on right elbow, but a healing abrasion area red in color approximate size of three centimeters (cm) by one and a half cm. Licensed Nurse (LN) I confirmed the skin area on right elbow and reported that she did not know R19 had a skin issue. During an interview on 11/19/24 at 09:44 AM, Administrative Staff A reported the skin/wound condition assessment would be completed weekly by the charge nurse. Administrative Staff A confirmed R19's last skin wound assessment completed was on 10/17/24 and did not know why R19 would have had a dressing on his right elbow. During an interview on 11/19/24 at 01:20 PM Certified Nurse Aide (CNA) K reported that she did not know why R19 had a dressing on his right elbow the other day and stated maybe it was a skin tear. She reported she first noticed the dressing on R19's right elbow about two weeks ago. CNA K reported is a resident had a new skin issue the charge nurse would be updated. During an interview on 11/19/24 at 01:38 PM LN I reported that the charge nurse were responsible to complete the skin condition notes on every resident weekly and are they assigned to the charge nurse. LN I reported that it would be on the resident's treatment administration record in EHR for the nurse to know when to complete the skin note. LN I reported that R19 did not have that placed in the orders so it would not be on the administration record. LN I revealed a handwritten assignment sheet in a book for nurses to look for skin note calendar and reported that R19 was to have his skin note completed on Monday evening shift. She then confirmed that R19's last skin condition note was completed in the EHR on 09/11/24 and reported that the agency nurses do not always look in the book. LN I reported there were two different types of skin notes that could be documented in EHR. She reported the skin wound condition assessment would be completed if a resident had a wound that was monitored, and that assessment would be completed weekly also by the charge nurse or by Administrative Nurse B. LN I confirmed that R19's last skin wound condition note was 10/17/24. The facility's policy Wound Prevent and Management dated 12/2018, documented the following: Providing guidelines for optimal care to promote healing for residents with all identified skin alterations. Licensed nurses would be responsible for weekly assessments of skin for all residents and document finding in the EHR in skin condition note. The facility failed to complete a weekly skin assessment for R19, who was observed with a dressing on his right elbow on 11/12/24 and no recent skin notes, or progress notes in EHR regarding the dressing. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

The facility reported a census of 22 residents with 10 included in the sample and five residents reviewed for unnecessary medication use. Based on observation, interview and record review the facility failed to ensure the consultant pharmacist identified Residents (R) 16 lacked administration for heart medication. Findings included: - The Physicians Orders dated 06/08/24 revealed the diagnosis of atrioventricular block (a slow heart rate that occurs because of a malfunction with the heart's electrical system). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The resident required assistance with toileting, showers, and mobility. The Medication Administration Record (MAR) reviewed from 07/01/24 to 10/31/24 revealed an order for vericiguat (a medication used in adults for heart failure) five milligram (mg) daily. The MAR lacked documentation for 70 days of the review period, which indicated staff did not administer the medication to the resident and did not notify the physician. The Progress Notes from 07/01/24 to 10/31/24 indicated the facility was either waiting for delivery of medication or medication were not available during the times the resident did not received the ordered dose of vericiguat. The documentation also lacked a notification to the resident's physician. Review of the Pharmacy Consultant Notes from 07/01/24 to 11/06/24 lacked documentation regarding the resident not receiving her vericiguat as ordered. During an interview on 11/14/24 at 08:35 AM with Licensed Nurse (LN) H revealed if a resident did not have a medication available, she would chart the reason, notify the physician, and call the pharmacy. During an interview on 11/14/24 at 03:25 PM with Administrative Staff A and B revealed the medication, vericiguat 5 mg, was a sample medication that was provided by his physician, and the facility was unable to get the medication due to the expense. They reported they were aware the medication was not given, and further verified the physician was not aware. During an interview on 11/20/24 at 03:24 PM with Consulting Staff Pharmacist U revealed she was not aware the resident's progress notes included documentation indicating a medication was not given. Consultant Staff U only looked at the MAR and thought the 0 marked meant the medication was administered and she was unaware how to look at the progress notes (MAR) to determine if a medication was not given and/or waiting for delivery of the medication. The facility's policy Medication Monitoring Medication Regimen Review and Reporting dated 01/2024 the consultant pharmacist reviews the medication regimen and medical charts of each resident at least monthly to appropriately monitor the medication regimen and ensure that mediation each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes and nurse's notes. Information from the nursing care center staff and other health professionals involved in the resident's care. The facility failed to ensure the consultant pharmacies identified Residents (R) 16 lacked of administration for heart medication.

The facility reported a census of 22 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - Observation of the kitchen and food storage areas on 11/12/24 at 12:30 PM, revealed the following areas of concern: Bowls placed upright and not covered on the cart. There were no foot operated trash cans by the hand washing area. Dry cereal container was not labeled with a date. Apple Cider vinegar was not labeled with a date. A bread bag was opened without a date. An opened and not labeled bag of cream of wheat. Several bags of pasta were opened and were not labeled with an opened date. Opened box of individually wrapped cookies that were not dated when they were opened and were past the expiration date of 11/06/24. The freezers had assorted cookie batter or muffin batter without a date or a label. The freezer had assorted ice treats that were not labeled with a date when box was opened. The refrigerator contained strawberries and vegetables not dated. An opened bag of mozzarella cheese that was not labeled or dated. An opened tube of icing that was not dated. During an interview on 11/12/14 at 12:50 PM, Dietary Manager C, confirmed the above items were concerns and she had worked with staff to label items when received and when opened. During an observation on 11/13/24 at 11:25 AM, Dietary Staff W washed her hands in the kitchen, she dried her hands off, then took the damp disposable towel and wiped the countertop of the sink off. Dietary Staff W then walked across the kitchen, lifted the lid on garbage can with her left hand, and threw out the paper towels. During an interview 11/13/24 at 11:28 AM with Dietary Manager C, she confirmed that wiping off the sink after washing hands was not appropriate, she reported the kitchen used to have a garbage can with a foot pedal. She had another staff member locate a garbage can with a foot control and verbally educated the kitchen staff to use the foot pedal garbage can after washing their hands. During an observation on 11/13/24 at 12:04 PM Dietary Staff W laid a knife on the cookbook while retrieving supplies to puree the custard. She then picked the knife back up off the recipe book and used that knife to cut the pieces of pie out of the pan before pureeing them. During an observation on 11/13/24 at 12:10 PM the drain for the ice maker was not off the floor it was lying directly on the drain cover on the floor that was visibly dirty. Dietary Manager C reported she was unaware that the ice machine drain had to be off the floor and confirmed the floor and drain were quite dirty and she reported she would let maintenance know. During an observation on 11/13/24 at 12:18 PM the ovens had black colored debris on the bottom of them. The air vent above the stove had grease and dust stuck to them. The curtains had grease and were covered in a thick amount of dust that were on a window right above the prep area for food. Additionally, there was a cart in front of that window with dishes that faced upright and not covered. The staff walked back and forth in front of that window. There were several cutting boards that had scratches, gouges and a melted area. The potholders were worn and the inner batting was exposed. During an Interview on 11/13/24 at 12:30 PM Dietary Manager C acknowledged the ovens and surface areas had dust and black colored debris noted on the bottom of oven. She reported that they were cleaned weekly. She reported the dishes are usually covered. Dietary Manager C confirmed that the knife should not have been placed on the recipe book that everyone touched when cooking. During an interview on 11/19/24 at 09:44 AM Administrative Staff A confirmed all the concerns in the kitchen were an issue and Dietary Manager C had started to work on the concerns. The facility's Food Storage policy dated 2011 documented food shall store at appropriate methods to ensure the highest level of food safety. Label all food items held longer that 24 hours. The label must include the name of the food and the date by which it should be consumed or discarded. Discard food that has passed the expiration date. Wrap food properly, never leave any food item uncovered and not labeled. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 20 residents. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 hours a day, seven days a week, as required, for five days of the six months reviewed. This had the potential to affect all residents. Findings included: - Review of the nursing schedule and staffing sheets on 03/13/22, 03/26/22, 04/23/22, 05/08/22 and 05/21/22, revealed no Registered Nurse (RN) worked. The documentation revealed Licensed Practical Nurses scheduled. Interview with Administrative Nurse B on 01/19/23 at 11:50 AM, Administrative Nurse B reported the facility attempted to have a Registered Nurse for 8 hours a day and verified the facility lacked the required RN coverage. The facility did not provide a policy for Staffing 0n 01/19/23. The facility failed to ensure the use of a Registered Nurse as required, for five of the 6 month reviewed, to ensure the provision of adequate cares to the residents of the facility.

The facility reported a census of 20 residents with 12 included in the sample. that included one resident reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care and services on the one Resident (R)10 reviewed, who required inhalation respiratory treatments, to prevent possible respiratory illness. Findings included: - The Physician Orders for Resident (R)10, dated 12/22 revealed the following diagnosis chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The annual Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. R10 required extensive assistance with one-person physical assistance with transfers, limited assistance with one -person physical assist with dressing, toilet use, and personal hygiene. Review of the Care Plan revealed R10's nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) kit and tubing were to be changed every Friday night. The care plan lacked guidance regarding cleansing of the nebulizer chambers or storage of the nebulizer tubing/chambers/ mouthpiece. The Electronic Medical Record (EMR)indicated R10 received Ipratropium-Albuterol Solution (medication used to treat and prevent symptoms of wheezing and shortness of breath caused by ongoing lung disease) 0.5-2.5 milligrams (mg) in three milliliters (ml), inhalation, four times a day, related to chronic obstructive pulmonary disease, ordered 09/17/22. Observation on 01/17/23 at 01:16 PM revealed Certified Nurse Aide (CMA) R provided the inhaled treatment to R10 with the nebulizer and a mask. At 01:30 PM, CMA R returned to the room, removed the mask from the resident, and placed the mask and nebulizer back on the nebulizer equipment on R10's bed side table. The chamber contained droplets of the nebulizer treatment. CMA R failed to rinse the medication from the nebulizer. Observation on 01/18/23 at 09:15 AM, revealed the mask and nebulizer chamber stored directly to the inhalation machine. The nebulizer chamber had droplets in the chamber. Observation on 01/18/23 at 11:45 AM, revealed the nebulizer and mask remained attached to the machine and had droplets in the nebulizer chamber. Interview with CMA R on 01/18/23 at 11:59 AM, reported staff should rinse the nebulizer out, place the nebulizer pieces a paper towel to air dry, then place the nebulizer parts in a bag for storage. Interview with Administrative Nurse B on 01/19/23 at 11:35 AM, revealed staff should rinse the nebulizer after each use, air dry, then placed in a bag for storage. The facility failed to provide a policy regarding Respirator Care/ Nebulizer as requested on 01/19/23. The facility failed to ensure necessary respiratory care and services for this resident that required inhalation respiratory treatments.

The facility reported a census of 23 residents, with five selected for sample. The facility managed funds for 10 residents and the sample included five of those residents. Based on interview and record review, the facility failed to provide the resident and/or durable power of attorneys (DPOAs) with quarterly resident funds statements for one of five residents reviewed. (Resident (R) 1) Findings included: - R1's clinical record included an 05/28/21 Quarterly Minimum Data Set (MDS) which identified her with severe cognitive impairment (Brief Interview for Mental Status score of seven). Trust Statements for R1 personal funds account included evidence the facility provided R1 with a quarterly account statement on 01/08/21. Review of additional funds documents revealed no evidence staff provided the resident and DPOA with quarterly statements since January 2021, a time period of more than six months. During an interview on 08/02/21 at 02:00 PM, Business Office Staff B confirmed she failed to give R1 and her DPOA quarterly statements within the past six months. The facility's 06/03/2014 policy and procedure, Admission, Transfer, Discharge - Resident Funds Trust Account included, The resident or the individual signing the above forms will be mailed two copies of the accounting of the resident's Trust Account on a quarterly basis. One copy must be signed and returned, showing approval of the quarterly transactions. This copy must be kept on file for five years post discharge. The facility failed to provide R1 and her DPOA with quarterly statements of resident funds account activity and balances.

The facility reported a census of 23 residents, with five selected for sample. The facility managed funds for 10 residents and the sample included five of those residents. Based on interview and record review, the facility failed to have a system in place to ensure notification of resident and/or durable powers of attorney (DPOA) when the balance in the resident's funds account reached within $200 of the Supplemental Security Income (SSI) resource limit of $2,000 for one of five residents. (Resident (R) 3). The facility also failed to have a system in place to ensure conveyance of remaining funds in resident funds accounts to the appropriate person/agency within 30 days of death for two of five sampled residents. (R4, R5) Findings included: - R3's clinical record listed Medicaid as her primary payor source. The facility's Trust Ledger for resident funds accounts revealed the balance in R3's account remained in excess of $2000.00 since [DATE], a time period of more than 12 months, as follows: On [DATE] R3 had an account balance of $3.720.86. On [DATE] R3 had an account balance of $2,241.92 On [DATE] R3 had an account balance of $2,303.92 On [DATE] R3 had an account balance of $2,366.08 On [DATE] R3 had an account balance of $2,428.13 On [DATE] R3 had an account balance of $2,490.13 On [DATE] R3 had an account balance of $2,552.25 On [DATE] R3 had an account balance of $4,175.31 On [DATE] R3 had an account balance of $2,696,31 On [DATE] R3 had an account balance of $2,778.42 On [DATE] R3 had an account balance of $2,860.49 On [DATE] R3 had an account balance of $2,942.58 On [DATE] R3 had an account balance of $3,024.58 On [DATE] R3 had an account balance of $3,106.72 Review of the clinical record and accounting documents revealed no evidence of resident, family or DPOA notification of balances within $200 of the SSI limits or over the SSI limit. During an interview on [DATE] at 02:00 PM, Business Office Staff B confirmed R3's personal funds account remained at balances more than $2,000 for at least the past 12 months. Business Office Staff B also confirmed she failed to issue notice to the DPOA or family when the balances were within $200 of the SSI limit. The facility's [DATE] policy and procedure, Admission, Transfer, Discharge - Resident Funds Trust Account included, Residents with accumulated funds will be counseled by the Administrator and/or Social Worker as to the expenditure of such funds. Residents receiving Medicaid benefits will be notified when their account reaches an amount $200.00 less than the SSI resource limit for one person. These residents will also be notified they may lose eligibility for Medicaid or SSI when the amount of the account, in addition to the value of other nonexempt resources, reaches the SSI resource limit for one person. The facility failed to have a system in place to ensure notification of the DPOA/family when the balance in R3's resident funds account was within $200 of the Supplemental Security Income (SSI) resource limit or over the limit of $2,000. - The facility provided a Trust - Current Account Balance document which listed all resident funds accounts managed by the facility. Of the 10 names on the list, two (R4 and R5) no longer resided in the facility. Information from the clinical records included: 1. R4 expired on [DATE], approximately 8 ,d+[DATE] months previously 2. R5 expired on [DATE], 48 days previously The Trust - Current Account Balance document listed balances as follows as of [DATE]: 1. R4's funds account had a balance of $176.34 2. R5's funds account had a balance of $35.00 In an interview on [DATE], Business Office Staff B confirmed R4 and R5 both expired more than 30 days previously and money remained in the resident funds accounts. Business Office Staff B reported R4 still owes the facility money so I didn't know what to do with her money. The facility's [DATE] policy and procedure, Admission, Transfer, Discharge - Resident Funds Trust Account failed to include information related to conveyance of resident funds within 30 days of discharge or death. The facility failed to have a system in place to ensure conveyance of money remaining in resident funds accounts to the appropriate agency/people within 30 days of death for R4 and R5.

The facility reported a census of 21 residents. The facility had one main kitchen where food was stored and prepared for one dining room. Based on observation, interview, and record review the facility failed to ensure dietary staff who worked in the kitchen wore a hairnet. The facility also failed to properly store food items in a refrigerator and freezers by the failure to ensure all food items were dated after being opened. These failures had the ability to affect all residents in the facility. Findings included: - During the initial environmental tour of the dietary department on 05/06/21 at 08:21 AM the following concerns identified: 1. Twenty-four chocolate shakes with instructions printed on the carton to keep no longer than 14 days unfrozen, were found in the 2-door refrigerator in the kitchen area, thawed and not dated. 2. Two opened bags of what appeared to be chicken nuggets with no open date marked on the bags were found in the two-door stainless steel freezer located in the dry storage room. 3. An open bag of tater tots with no open date marked on the bag was found in the two-door Victory freezer located in the dry goods storage room. During the follow-up kitchen tour on 05/11/21 at 10:03 AM revealed the following concerns identified: 1. An open package of four boiled eggs found with no open date, in the two-door refrigerator in the kitchen area. 2. An opened bag of what appeared to be chicken nuggets, and an opened bag with two portions of Oven Ready Whole Grain Breaded Fish Sandwich Portion found with no open date marked on the packaging. 3. An opened bag of what appeared to be biscuits, found with no open date marked on the packaging. 4. An observation on 05/11/21 at 10:42 AM revealed Dietary Staff (DS) H was in the dishwashing, storage, and food preparation areas of the kitchen without a hairnet in place. At 11:48 AM, DS H put on a hairnet but still had strands of hair not fully covered by the hairnet. During an interview on 05/12/21 at 08:57 AM, Dietary Manager (DM) I stated it was her expectation that all food opened food items located in the refrigerator or freezer should be dated. DM I also stated she expected supplemental shakes that needed to be used within 14 days of being thawed should be dated as to when they were thawed. DM I stated she expected any staff who passed through the door and entered the kitchen to wear a hairnet and make sure all strands of hair be covered to the best of their ability. Review of the Hair Restraints policy revealed, Staff shall wear hair restraints in all food production, dishwashing and serving areas. Review of the Food Storage (Dry, Refrigerated, and Frozen policy revealed, All food items will be labeled. The label must include the name of the food and the date by which it should be .consumed, or discarded. The facility failed to properly store food items and ensure staff wore hairnets.

The facility census totaled 21 residents. Based on interview and record review, the facility failed to ensure that all facility staff were trained in Abuse, Neglect, and Exploitation ([NAME]) annually. Findings included: - Review of staff training records for Certified Nurse Aide (CNA) D lacked [NAME] training evidence from 04/01/20 through 04/01/2021. Interview with Administrative Nurse A and Administrative Staff B on 05/12/21 at 01:03 PM revealed staff receive prompts on what trainings to complete each month through an online training service. Administrative Staff B monitored all trainings via audits, but it was the responsibility of the staff member to complete the trainings. CNA D was reminded about completing the [NAME] training as it was past-due. The [NAME] training was also discussed at a staff meeting, which CNA D did not attend. Review of the 09/2017 facility policy entitled Abuse, Neglect and Exploitation Policy revealed all new employees shall have training during orientation, and all employees shall receive training at least annually, and as the need arose. Verification of training will be maintained in the employee's personnel file and/or the in-service records. The facility failed to ensure all staff received training over [NAME] annually.

The facility identified a census of 27 residents with 12 residents included in the sample. Based on observation, record review, and interview the facility failed to have a system in place for residents to file a grievance anonymously. Findings included: - Observations during survey dates 08/21/19 through 08/27/19 revealed the lack of accessible grievance forms and a designated location for residents to discretely file a grievance anonymously within the facility. An interview on 08/22/19 at 01:15 PM with the resident council group stated there were no grievance forms and residents verbally informed staff of concerns. The resident council group stated there was no way to formally file a grievance anonymously within the facility. An interview on 08/27/19 at 11:52 AM with Certified Nurse Aide (CNA) G stated she verbally communicated complaints and/or grievances regarding residents to the nursing and administrative staff. An interview on 08/27/19 at 02:23 PM with Licensed Nurse (LN) C stated complaints and grievances regarding residents were handled verbally and she was unaware of any form designated for communicating and/or documenting grievances. An interview on 08/27/19 at 12:15 PM with Social Service Designee (SSD) H stated she wrote up grievances that were reported to her and gave them to the grievance officer, Administrator A. An interview on 08/27/19 at 12:55 PM with Administrative Staff A stated grievance forms were located at the nurse's station and residents would need to request a form from staff. An interview on 08/27/19 at 03:57 PM with Administrative Staff A confirmed there was no system for residents to file grievances anonymously within the facility. The facility's policy titled, Grievance Policy & Procedure, dated 01/2017 documented, The resident has the right to voice grievances anonymously. The policy documented that grievances, concerns or issues voiced by residents were recorded by facility personnel when the resident wished to remain anonymous. The policy lacked information and/or instruction on how residents would file a grievance anonymously and without involving facility personnel. The facility failed to ensure the right of the residents to file a grievance anonymously.

The facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to utilize the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings included: - Review of the daily nurse staffing hours and working staff schedule from 05/01/19 to 08/22/19 revealed there was no RN coverage for eight consecutive hours per day on 05/02/19, 06/08/19, 06/09/19, and 06/23/19. An interview on 08/22/19 at 01:00 PM with Administrator A confirmed there was no RN coverage on 05/02/19, 06/08/19, 06/09/19, and 06/23/19. The facility did not provide a staffing policy. The facility failed to utilize the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week.

The facility had a census of 27 residents with one main kitchen that served one dining room. Based on observation, interviews, and record review the facility failed to properly store food items placed in a refrigerator by the failure to ensure two dessert items were dated. Findings included: - During the follow-up environmental tour of the kitchen on 08/27/19 at approximately 12:00 PM, an undated large pan of what appeared to be a green gelatin dessert and a smaller undated pan of sliced bananas and orange gelatin dessert were found in a refrigerator. During an interview on 08/27/19 at 10:37 PM, Dietary Manager (DM) [NAME] stated she expected the pans of dessert found in the refrigerator to be dated. Review of the Labeling and Dating Foods (Date Marking) policy dated (YEAR) revealed, All foods stored will be properly labeled . The facility failed to properly store food items placed in a refrigerator by not ensuring the food items were dated.

The facility reported a census of 27 residents with five cognitively impaired, mobile residents who resided on the 300 Hall. Based on observation and interview the facility failed to provide an environment free from accident hazards when facility staff left chemicals in an unlocked cabinet of the soiled utility closet to which residents had access. Findings included: - During a follow-up environmental tour of the facility on 08/27/19 at 03:13 PM observation revealed a container of PDI Sani-cloth Bleach Germicidal Disposable Wipe (Orange top) in an unlocked cabinet in the unlocked soiled utility room on the 300 Hall. The product label noted the disposable wipe as a physical or chemical hazard for use on hard surfaces only- not a skin wipe. During an interview on 08/27/19 at 03:29 PM, Environmental Services Manager (ESM) D stated the staff always kept the soiled utility closet on the 300 Hall unlocked. ESM D stated the germicidal wipes found in the unlocked cabinet have been stored in a locked room by the nurses' station. ESM D stated he did not know why the wipes were in the soiled utility closet and he removed the germicidal wipes. A policy concerning chemical storage was requested on 08/27/19 but Administrative Nurse B stated there was not a policy for chemical storage. The facility failed to provide an environment free from accident hazards when facility staff left chemicals in an unlocked cabinet of the soiled utility closet to which residents had access.

The facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to inform and provide R16 with the opportunity to make decisions regarding the alternative treatment option of having suprapubic catheter (urinary bladder catheter inserted through the skin). Findings included: - The facility's electronic medical record (EMR) [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for significant change dated 04/12/19 documented R16 had no speech. The MDS indicated moderately impaired cognition and no issues were identified concerning short memory, long-term memory, or recall ability for R16. The Care Area Assessment (CAA), dated 04/12/19, for Cognitive Loss/Dementia documented R16 was nonverbal and only able to answer yes or no questions with head nods. The CAA for Dehydration/Fluid Maintenance documented R16 was hospitalized and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) placed for [MEDICAL CONDITION] (lack of ability to urinate and empty the bladder) with a plan to follow up with a urologist (a physician who specializes in diseases of the urinary organs). The Care Plan dated 07/12/19, documented R16 was nonverbal but received and understood verbal communication. The care plan documented R16 had a communication board in his room and instructed staff to encourage R16 to use gestures, pointing, facial expressions to convey messages. The care plan documented a [DIAGNOSES REDACTED]. The quarterly social service note dated 12/26/18 at 06:39 PM documented R16 understood conversation but was aphasic (condition with disordered or absent language function). The social service progress note dated 05/2/2019 at 08:20 AM documented R16 had an appointment with urology for [MEDICAL CONDITION]. The social service progress note dated 05/29/2019 at 03:18 PM documented R16 had a urodynamics study (tests that assess how the bladder and urethra are performing their job of storing and releasing urine) done. Review of the progress notes lacked documentation regarding attempts to discuss with and encourage R16 to participate in future health care treatment options and alternatives regarding the urinary catheter. An observation on 08/22/19 at 10:10 AM revealed R16 sat upright in his wheelchair in hallway near the nurse's station. R16 appeared alert, well-groomed, made eye-contact, and smiled as others greeted him as they passed by. R16 did not talk or make any vocal sounds. An interview on 08/21/19 at 10:58 AM with unidentified resident representative stated the urologist recommended a suprapubic catheter due to deteriorating health and agreed; however, after discussion and response from the facility felt that the facility was against the suprapubic catheter due to past experiences of suprapubic catheters and their preferences. The unidentified resident representative stated no one discussed the urologist's recommendations for a suprapubic catheter with R16 or provided R16 with the opportunity to choose what he preferred. An interview on 08/27/19 at 11:52 AM with Certified Nurse Aide (CNA) G stated R16 did not talk but pointed or used yes or no gestures to answer questions. CNA G stated she knew how to care for residents when she referred to the resident's plan of care. CNA reviewed the plan of care and unable to verify whether or not R16 had possession of communication materials or picture boards that would facilitate communication and/or conversation with staff and others. An interview 08/26/19 at 03:25 PM with CNA I and Certified Medication Aide (CMA) J stated R16 wore a pendent around his neck that he could push if he could not get to his call light. When asked CNA I and CMA J if R16 had a communication board or pictures, they were unable to confirm without checking the room for evidence and found a communication book that contained several pages with pictures and tools to facilitate communication. An interview on 08/27/19 at 02:23 PM with Licensed Nurse (LN) C stated R16 was non-verbal, able to answer yes or no questions, had a communication book, and did better when he pointed at things. LN C stated she knew how to care for residents when she referred to the resident's care plan. LN C stated she assumed the guardian did not want R16 to have a suprapubic catheter since R16 still did not have a suprapubic catheter. An interview on 08/27/19 at 12:39 PM with Social Service Designee (SSD) H stated R16 understood everything, answered yes or no questions, and used magazines and pictures to share interests with others. SSD H used laminated pages with words or sentences to assist R16 with answering MDS questions and believed R16 understood the sentences on the laminated pages. SSD H stated R16 did not have a communication or picture board to facilitate communication or conversation with others. An interview on 08/27/19 at 03:30 PM with Administrative Nurse B stated R16 understood others, was cognitively intact, and had a communication board that facilitated communication when he pointed at the pictures, but nobody in the facility discussed healthcare options regarding the suprapubic catheter with R16. Administrative Nurse B reported the facility's physician was against it due to personal preference and the facility was waiting for the guardian to get a second opinion and make the decision on whether he/she wanted R16 to have the suprapubic catheter. When asked if anyone attempted to use the communication book or if anyone tried to discuss the option for a suprapubic catheter with R16, Administrative Nurse B replied, Nobody has done that with him. The facility did not provide a communication policy. The facility's Admission Packet document titled, Resident Rights, documented the resident shall be allowed to obtain information concerning their total health status . and shall be afforded the opportunity to refuse medication and/or treatment after being fully informed of and understanding the consequences of such actions. The facility failed to inform and provide R16 with the opportunity to make decisions regarding the alternative treatment option for a suprapubic catheter.

The facility had a census of 22 residents, with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to immediately report one allegation of staff to resident abuse of resident #1 to the State survey and certification agency, failed to complete a thorough investigation, failed to protect all residents from abuse during an ongoing abuse investigation, and failed to submit the results of the investigation to the State Survey and Certification agency within 5 working days. At least two staff members reported allegations of physical and/or verbal abuse to Administrative Nursing Staff and they failed to take action. A staff member then reported an allegation of physical abuse to the Administrator, and he/she failed to report the allegation to the State Survey and Certification agency, failed to complete a thorough investigation, failed to protect all residents during an ongoing investigation, and failed to submit the results of the investigation to the State Survey and Certification agency within 5 working days. The alleged perpetrator (staff member accused of abuse) continued to work and provided direct care to facility residents for a time period of up to two months. Facility failure to protect all residents during an ongoing abuse investigation placed all 22 facility residents in immediate jeopardy. Findings included: - Resident #1's clinical record included a 4/8/16 Annual MDS (Minimum Data Set) which identified the resident with moderate cognitive impairment (Brief Interview for Mental Status score of 9), total dependence on staff for bed mobility and transfers, an inability to ambulate, and frequent bowel and bladder incontinence. The 7/1/16 Quarterly MDS identified the resident with improved cognitive abilities (Brief Interview for Mental Status score of 12), continued total dependence on staff for bed mobility and transfers, an inability to ambulate, and frequent bowel and bladder incontinence. CAAs (Care Area Assessments) completed on 4/14/16 included: Cognitive Loss: Described the resident's mild confusion with orientation to himself/herself, current situation, time of day, time of meals, location of room, and staff names and faces. Communication: Described the resident ' s history [MEDICAL CONDITION](the sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain) with right sided paralysis (loss of muscle function and/or sensation) and [MEDICAL CONDITION] (condition with disordered or absent language function). According to the CAA, the resident experienced difficulty speaking words and/or sentences and subsequent frustration with the inability to speak normally. ADLs (activities of daily living): Described the resident's right sided paralysis and need for extensive assistance with all ADLs. The 7/7/16 care plan included: Altered communication: Described how the resident had favorite staff and treated them well but occasionally treated other staff in a rude and hateful manner. The care plan also directed staff to allow the resident time to find the correct words in order to communicate his/her needs. ADLs self-care deficit: Described the resident's occasional resistance to care and need for much encouragement for incontinence care. The care plan noted the presence of bowel and bladder incontinence, a need for a mechanical lift for transfers, and extensive staff assistance for bed mobility. During an observation on 9/29/16 at 1:40 p.m., resident #1 had total dependence of two staff and a mechanical lift for a transfer from the motorized scooter to the recliner. The resident lacked the ability to move his/her left arm or left leg, and had an inability to verbalize responses without extreme effort. The resident did not exhibit resistive behaviors during the transfer or when staff changed the resident's incontinence pad and provided incontinence care prior to transfer to the recliner. During an interview on 9/29/16 at 8:45 a.m., resident #1 had extreme difficulty with verbalization due to [MEDICAL CONDITION]. When asked if any staff member abused or mistreated him/her, the resident nodded his/her head up and down in an affirmative motion. The resident lacked the ability to say the name of the staff member/members who abused him/her. During a follow up interview on 9/29/16 at 10:53 a.m., when asked if Direct Care Staff C abused or mistreated him/her, resident #1 became very animated, nodded his/her head, and gestured with a shoving type motion and a scrubbing type motion. When asked if he/she was trying to indicate Direct Care Staff abused/mistreated him/her, resident #1 again nodded his/her head up and down in an affirmative motion. When asked if he/she considered Direct Care Staff C's treatment abuse or rough treatment, resident #1 responded verbally by saying, Yes, abuse. During interviews on 9/29/16 at 8:30 a.m. and 11:45 a.m., Administrative Staff A confirmed Direct Care Staff B reported an allegation of resident abuse around the end of August. According to Administrative Staff A, Staff B reported Direct Care Staff C was rough when he/she provided care to resident #1, and although Staff B reported the incident previously to the former Director of Nursing, and the former Director of Nursing failed to do anything about it. After he/she learned of the incident, Administrative Staff A reported he/she talked to resident #1 and determined the resident did not like Direct Care Staff C. Administrative Staff A then spoke to Direct Care Staff C who said resident #1 just complained because Staff C made sure to clean the resident's perineal area properly after incontinence. After the conversation with the resident and Direct Care Staff C, Administrative Staff A reported he/she directed Staff C to refrain from providing care to resident #1 in the future. Administrative Staff A also reported Direct Care Staff C continued to work 2 or 3 shifts per week in the time period since the allegation of abuse, and provided care to all facility residents except resident #1. During an interview on 9/29/16 at 12:30 p.m., Direct Care Staff B reported he/she witnessed Direct Care Staff C abuse resident #1 probably around the end of July. According to Staff B, he/she and Staff C were in the process of finishing up tasks at the end of their shift when resident #1 needed changed due to bowel incontinence. Staff B reported Staff C got really mad and repeatedly told resident #1 how ridiculous it was for the resident to be soiled like that. Then, when Staff C provided perineal cleaning, Staff C got real rough and stuck (his/her) whole hand up in the resident ' s perineal area. Staff B reported resident #1 cried when Staff C cleaned him/her in such a rough manner, and had tears running down his/her cheeks. Staff B reported resident #1's tears seemed to make Direct Care Staff C even more upset, and Staff C then took a disposable wipe with stool on it and placed it directly in front of the resident's face and said, See, I'm still getting poop out of there. Immediately after the incident, Staff B reported he/she told Licensed Nurse D, the charge nurse, about the abuse and also told Administrative Nurse E, the former Director of Nursing. Staff B recalled Administrative Nurse E said I will take care of it. Then, when nothing happened after a couple of days, Staff B reported he/she went to talk to Administrative Staff A about the incident of abuse and learned that Staff A knew nothing about it. Administrative Staff A told Staff B he/she would address the issue. According to Staff B, nothing happened to Staff C and he/she continued to work and provide care to facility residents. Staff B also recalled another incident between Staff C and resident #1 which occurred when the resident wanted something in his/her room but lacked the ability to tell staff what he/she wanted. At times like that, Staff B reported it just takes times to point to different things to figure out what the resident wants, but Staff C became upset with the resident, yanked a drawer completely out of the dresser, took it over to the resident and said, I don't have time for this (inappropriate word). Point to what you want. At that point, Staff B recalled resident #1 became very upset, pointed to the door, and told Staff C to get out. Staff B reported he/she told the charge nurse about the incident but did not know if anything happened. During an interview on 9/29/16 at 1:01 p.m., Direct Care Staff C reported he/she and resident #1 never got along very well and the resident expected staff to treat him/her like a (Queen/King). Staff C recalled an incident about two months ago when resident #1 experienced bowel incontinence and complained about roughness during perineal care. Staff C recalled he/she was in the room with Staff B and Staff B failed to properly clean the resident, so he/she took over. According to Staff C, I have to make sure (he's/she's) clean. That's my job. Staff C confirmed he/she placed a disposable wipe covered with stool in front of the resident's face during the incident and explained he/she just intended to prove to the resident why he/she required additional cleaning. Several days after the incident, Staff C recalled Administrative Staff A spoke to him/her about it and I told (him/her) the same story I just told you. I was just cleaning the resident. After that conversation, Administrative Staff A directed Staff C to stay out of resident #1's room in order to protect himself/herself. Staff C confirmed he/she continued to provide care to the other 21 residents in the facility after the incident. When asked about the incident where he/she allegedly abruptly pulled resident #1's drawer out of a piece of furniture, presented it to the resident and said, I don't have time for this (inappropriate word., Staff C said he/she could not recall saying that but I might have. Staff C reported resident #1's frequent pointing at items in order to tell staff what he/she wants gets very frustrating so he/she may have made that statement. During an interview on 9/29/16 at 3:00 p.m., Direct Care Staff F reported he/she occasionally worked with Staff C and found him/her rough, impatient, and easily aggravated when he/she cared for residents. According to Staff F, when a resident did not like the way Staff C did something for them like perineal care, Staff C responded by going at it harder. According to Staff F, Staff C frequently told several residents he/she did not have time for their (inappropriate word). Staff F reported he/she advised Administrative Nurse E, the former Director of Nursing, of his/her concerns and Nurse E ensured him/her the issue would be taken care of. During an interview on 9/29/16 at 4:00 p.m., Licensed Nurse D recalled Staff B told him/her of an incident of staff to resident abuse between Staff C and resident #1 one evening near the end of the shift. Since Administrative Nurse E, the former Director of Nursing, was still in the building at that time, Nurse D told Staff B to go talk to Nurse E about the incident. Nurse D remembered Staff B immediately went and talked to Administrative Nurse E after told to do so. According to Nurse D, he/she later talked to Administrative Nurse E about the allegation of abuse and Nurse E said he/she would take care of it. The facility's June 2015 Abuse, Neglect and Exploitation policy, defined abuse as the willful infliction of injury, the unreasonable confinement, neglect, intimidation of punishment with resulting physical harm, pain or mental anguish or deprivation by an individual (including a caretaker) of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. The policy defined verbal abuse as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability. According to the policy, The resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion. Furthermore, the policy described the duty of the facility to treat each resident with respect, kindness, dignity and care, and to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate (make a formal decision about a problem) alleged resident abuse and neglect. The policy provided guidance to immediately send home and suspend without pay any employee accused of abuse, neglect or exploitation. The facility failed to immediately report one allegation of staff to resident abuse of resident #1 to the State survey and certification agency, failed to complete a thorough investigation, failed to protect all residents from abuse during an ongoing abuse investigation, and failed to submit the results of the investigation to the State Survey and Certification agency within 5 working days. At least two staff members reported allegations of physical and/or verbal abuse to Administrative Nursing Staff and they failed to take action. A staff member then reported an allegation of physical abuse to the Administrator, and he/she failed to report the allegation to the State Survey and Certification agency, failed to complete a thorough investigation, failed to protect all residents during an ongoing investigation, and failed to submit the results of the investigation to the State Survey and Certification agency within 5 working days. The alleged perpetrator (staff member accused of abuse) continued to work and provided direct care to facility residents for a time period of up to two months. Facility failure to protect all residents during an ongoing abuse investigation placed all 22 facility residents in immediate jeopardy. The facility abated the immediate jeopardy on 9/29/16 by implementation of the following corrective actions: Education of residents regarding reporting abuse allegations Education of staff regarding reporting and investigation of abuse allegations Implementation of a plan for monitoring the facility ' s compliance with reporting and implementation of immediate interventions following incidents of ANE (abuse/neglect/exploitation) Suspension of Direct Care Staff C After abatement, the deficient practice remained at a scope/severity of an F.

The facility had a census of 22 residents, with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents the right to be free from physical and verbal abuse. Resident #1 experienced rough treatment/abuse during care, witnessed by another staff member, which caused the resident to cry. Staff immediately reported the abuse to a charge nurse and the Director of Nursing. The Director of Nursing failed to take action and failed to report the incident to the Administrator. A few days later a staff member became concerned the Director of Nursing failed to take action, and the staff member then reported the incident to the Administrator. Rather than suspend the alleged perpetrator as directed by facility policy, Administrative staff restricted him/her from providing care to resident #1 and allowed him/her to continue to provide care to the other 21 facility residents for a time period of up to two months. Facility failure to take appropriate/adequate actions to prevent abuse placed resident #1 in immediate jeopardy. Findings included: - Resident #1's clinical record included a 4/8/16 Annual MDS (Minimum Data Set) which identified the resident with moderate cognitive impairment (Brief Interview for Mental Status score of 9), total dependence on staff for bed mobility and transfers, an inability to ambulate, and frequent bowel and bladder incontinence. The 7/1/16 Quarterly MDS identified the resident with improved cognitive abilities (Brief Interview for Mental Status score of 12), continued total dependence on staff for bed mobility and transfers, an inability to ambulate, and frequent bowel and bladder incontinence. CAAs (Care Area Assessments) completed on 4/14/16 included: Cognitive Loss: Described the resident's mild confusion with orientation to himself/herself, current situation, time of day, time of meals, location of room, and staff names and faces. Communication: Described the resident ' s history [MEDICAL CONDITION]([MEDICAL CONDITION]/the sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain) with right sided paralysis (loss of muscle function and/or sensation) and [MEDICAL CONDITION] (condition with disordered or absent language function). According to the CAA, the resident experienced difficulty speaking words and/or sentences and subsequent frustration with the inability to speak normally. ADLs (activities of daily living): Described the resident's right sided paralysis and need for extensive assistance with all ADLs. The 7/7/16 care plan included: Altered communication: Described how the resident had favorite staff and treated them well but occasionally treated other staff in a rude and hateful manner. The care plan also directed staff to allow the resident time to find the correct words in order to communicate his/her needs. ADLs self-care deficit: Described the resident's occasional resistance to care and need for much encouragement for incontinence care. The care plan noted the presence of bowel and bladder incontinence, a need for a mechanical lift for transfers, and extensive staff assistance for bed mobility. During an observation on 9/29/16 at 1:40 p.m., resident #1 had total dependence on two staff and a mechanical lift for a transfer from the motorized scooter to the recliner. The resident lacked the ability to move his/her left arm or left leg, and had an inability to verbalize responses without extreme effort. The resident did not exhibit resistive behaviors during the transfer or when staff changed the resident's incontinence pad and provided incontinence care prior to transfer to the recliner. During an interview on 9/29/16 at 8:45 a.m., resident #1 had extreme difficulty with verbalization due to [MEDICAL CONDITION]. When asked if any staff member abused or mistreated him/her, the resident nodded his/her head up and down in an affirmative motion. The resident lacked the ability to say the name of the staff member/members who abused him/her. During a follow up interview on 9/29/16 at 10:53 a.m., when asked if Direct Care Staff C abused or mistreated him/her, resident #1 became very animated, nodded his/her head, and gestured with a shoving type motion and a scrubbing type motion. When asked if he/she was trying to indicate Direct Care Staff abused/mistreated him/her, resident #1 again nodded his/her head up and down in an affirmative motion. When asked if he/she considered Direct Care Staff C's treatment abuse or rough treatment, resident #1 responded verbally by saying, Yes, abuse. During interviews on 9/29/16 at 8:30 a.m. and 11:45 a.m., Administrative Staff A confirmed Direct Care Staff B reported an allegation of resident abuse around the end of August. According to Administrative Staff A, Staff B reported Direct Care Staff C was rough when he/she provided care to resident #1, and although Staff B reported the incident previously to the former Director of Nursing, and the former Director of Nursing failed to do anything about it. After he/she learned of the incident, Administrative Staff A reported he/she talked to resident #1 and determined the resident did not like Staff C. Administrative Staff A then spoke to Staff C who said resident #1 just complained because Staff C made sure to clean the resident's perineal area properly after incontinence. After the conversation with the resident and Staff C, Administrative Staff A reported he/she directed Staff C to refrain from providing care to resident #1 in the future. Administrative Staff A also reported Staff C continued to work 2 or 3 shifts per week in the time period since the allegation of abuse, and provided care to all facility residents except resident #1. During an interview on 9/29/16 at 12:30 p.m., Direct Care Staff B reported he/she witnessed Direct Care Staff C abuse resident #1 probably around the end of July. According to Staff B, he/she and Staff C were in the process of finishing up tasks at the end of their shift when resident #1 needed changed due to bowel incontinence. Staff B reported Staff C got really mad and repeatedly told resident #1 how ridiculous it was for the resident to be soiled like that. Then, when Staff C provided perineal cleaning, Staff C got real rough and stuck (his/her) whole hand up in the resident ' s perineal area. Staff B reported resident #1 cried when Staff C cleaned him/her in such a rough manner, and had tears running down his/her cheeks. Staff B reported resident #1's tears seemed to make Staff C even more upset, and Staff C then took a disposable wipe with stool on it and placed it directly in front of the resident's face and said, See, I'm still getting poop out of there. Immediately after the incident, Staff B reported he/she told Licensed Nurse D, the charge nurse, about the abuse and also told Administrative Nurse E, the former Director of Nursing. Staff B recalled Administrative Nurse E said I will take care of it. Then, when nothing happened after a couple of days, Staff B reported he/she went to talk to Administrative Staff A about the incident of abuse and learned that Staff A knew nothing about it. Administrative Staff A told Direct Care Staff B he/she would address the issue. According to Staff B, nothing happened to Staff C and he/she continued to work and provide care to facility residents. Staff B also recalled another incident between Staff C and resident #1 which occurred when the resident wanted something in his/her room but lacked the ability to tell staff what he/she wanted. At times like that, Staff B reported it just takes times to point to different things to figure out what the resident wants, but Staff C became upset with the resident, yanked a drawer completely out of the dresser, took it over to the resident and said, I don't have time for this (inappropriate word). Point to what you want. At that point, Staff B recalled resident #1 became very upset, pointed to the door, and told Staff C to get out. Staff B reported he/she told the charge nurse about the incident but did not know if anything happened. During an interview on 9/29/16 at 1:01 p.m., Direct Care Staff C reported he/she and resident #1 never got along very well and the resident expected staff to treat him/her like a (Queen/King). Staff C recalled an incident about two months ago when resident #1 experienced bowel incontinence and complained about roughness during perineal care. Staff C recalled he/she was in the room with Direct Care Staff B and Staff B failed to properly clean the resident, so he/she took over. According to Staff C, I have to make sure (he's/she's) clean. That's my job. Staff C confirmed he/she placed a disposable wipe covered with stool in front of the resident's face during the incident and explained he/she just intended to prove to the resident why he/she required additional cleaning. Several days after the incident, Staff C recalled Administrative Staff A spoke to him/her about it and I told (him/her) the same story I just told you. I was just cleaning the resident. After that conversation, Administrative Staff A directed Staff C to stay out of resident #1's room in order to protect himself/herself. Staff C confirmed he/she continued to provide care to the other 21 residents in the facility after the incident. When asked about the incident where he/she allegedly abruptly pulled resident #1's drawer out of a piece of furniture, presented it to the resident and said, I don't have time for this (inappropriate word., Staff C said he/she could not recall saying that but I might have. Staff C reported resident #1's frequent pointing at items in order to tell staff what he/she wants gets very frustrating so he/she may have made that statement. During an interview on 9/29/16 at 3:00 p.m., Direct Care Staff F reported he/she occasionally worked with Direct Care Staff C and found him/her rough, impatient, and easily aggravated when he/she cared for residents. According to Staff F, when a resident did not like the way Staff C did something for them like perineal care, Staff C responded by going at it harder. According to Staff F, Staff C frequently told several residents he/she did not have time for their (inappropriate word). Staff F reported he/she advised Administrative Nurse E, the former Director of Nursing, of his/her concerns and Nurse E ensured him/her the issue would be taken care of. During an interview on 9/29/16 at 4:00 p.m., Licensed Nurse D recalled Direct Care Staff B told him/her of an incident of staff to resident abuse between Direct Care Staff C and resident #1 one evening near the end of the shift. Since Administrative Nurse E, the former Direct of Nursing, was still in the building at that time, Licensed Nurse D told Staff B to go talk to Nurse E about the incident. Nurse D remembered Staff B immediately went and talked to Administrative Nurse E after told to do so. According to Nurse D, he/she later talked to Administrative Nurse E about the allegation of abuse and Nurse E said he/she would take care of it. The facility's June 2015 Abuse, Neglect and Exploitation policy, defined abuse as the willful infliction of injury, the unreasonable confinement, neglect, intimidation of punishment with resulting physical harm, pain or mental anguish or deprivation by an individual (including a caretaker) of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. The policy defined verbal abuse as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability. According to the policy, The resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion. Furthermore, the policy described the duty of the facility to treat each resident with respect, kindness, dignity and care, and to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate (make a formal decision about a problem) alleged resident abuse and neglect. The policy provided guidance to immediately send home and suspend without pay any employee accused of abuse, neglect or exploitation. The facility failed to ensure resident #1 the right to be free from physical and verbal abuse. Resident #1 experienced rough treatment during care at the hands of Direct Care Staff C, witnessed by another staff member, which caused the resident to cry. Direct Care Staff C also made derogatory statements/actions directed toward resident #1 and other residents. Staff reported the allegations of abuse and mistreatment to the former Director of Nursing and Administrative Staff A. Rather than suspend Direct Care Staff C as directed by facility policy, Administrative Staff A restricted Staff C from providing care to resident #1, and allowed Staff C to continue to provide care to the other 21 facility residents for a time period of up to two months. The facility abated the immediate jeopardy on 9/29/16 by implementation of the following corrective actions: Education of residents regarding reporting abuse allegations Education of staff regarding reporting and investigation of abuse allegations Implementation of a plan for monitoring the facility ' s compliance with reporting and implementation of immediate interventions following incidents of ANE (abuse/neglect/exploitation) Suspension of Direct Care Staff C After abatement, the deficient practice remained at a scope/severity of G.

The facility census totaled 24 residents with 10 included in the sample. Based on observation, interview and record review the facility failed to complete a root cause analysis and develop and implement timely and appropriate interventions to prevent further falls for 1 of 3 residents reviewed for falls. The resident experienced 27 falls within 13 months, one resulting in a laceration requiring 6 sutures to the forehead. (#16) Findings included: - Review of resident #16's signed physician orders [REDACTED]. Review of the quarterly MDS (minimum data set) dated 5/13/16 revealed a BIMS (brief interview for mental status) score of 13, indicating normal cognition. The resident required extensive assistance of two staff for transfers and toileting, extensive assistance of one staff with mobility on and off unit and dressing and limited assist of one with mobility. The resident was unsteady and required staff assistance to steady. The resident had frequent urinary incontinence and occasional bowel incontinence with no toileting program. The resident had 2 or more non-injury falls and one fall with minor injury since the last MDS. The resident received a restorative program for ambulation 7 days and dressing 6 days of the 7 day observation period. Review of the annual MDS dated [DATE] revealed a BIMS score of 14, indicating normal cognition. The resident required extensive assist of two staff for bed mobility, transfers, ambulation, dressing, toilet use and limited assist of one staff for locomotion. The resident was unsteady and only able to steady with staff assistance. The resident had frequent urinary and bowel incontinence with no toileting program. The resident had 2 or more non-injury falls and 1 fall with minor injury since last assessment. The resident received restorative services for walking 6 days and dressing 7 days of the 7 day observation period. Review of the ADL (activities of daily living) CAA (care area assessment) dated 8/12/16 revealed the following: the resident required assistance of 2 staff for most ADLs including ambulation, bathing, dressing, personal hygiene, bed mobility and transfers. He/she had incontinence of bowel and bladder at times. Review of the Fall CAA dated 8/12/16 revealed the resident required assistance with his/her ADLs because of leg/knee weakness due to a fall and a fracture prior to admission to the facility. He/she ambulated with one staff and use of a walker and gait belt with another staff following behind with the resident's wheelchair. The resident had a hi/low bed with fall mats on the floor next to the bed. The bed was in the lowest position when he/she was in bed. The call light was within reach. The resident propelled him/herself in a wheelchair for long distances. The resident had a toilet riser and grab bars next to the toilet for safety, and a chair alarm in his/her recliner. Review of the fall risk assessment dated [DATE] revealed a score of 11 indicating moderate fall risk. Review of the bowel and bladder assessment dated [DATE] revealed the resident experienced urinary incontinence. The resident had impaired mobility and staff were instructed to take the resident to the toilet before and after meals, and if he/she called. The resident did not have an individualized toileting plan developed. Review of the care plan with a date of 8/31/15 revealed the resident was at risk for falls and included the following interventions: At times, the resident put him/herself from the side of the bed onto the floor mat next to his/her bed and sat up. Staff on all shifts was to remind the resident to use his/her call light when he/she needed to use the bathroom for assistance with getting up. CNA (certified nurse aides) were to prioritize the resident due to high fall risk. Education provided to resident for reduction in falls and safety concerns. Grab bar to one side of bed to assist resident with transfers. Fall mat placed on the floor next to the resident's bed. Keep commonly used items within his/her reach. The resident was to use a wheelchair for mobilization in his/her room and to the dining room. Keep the resident's glasses within reach. Please make sure the call light remained within reach and encourage the resident to use it to ask for assistance Please ask the pharmacist and his/her physician to monitor the resident's medications on an ongoing basis. The facility gave the resident a grab stick to reach things on the floor and reminded the resident to use call light for assistance when transferring. Staff explained the risk for injury to the resident, and staff were to toilet the resident after meals. Care plan updates included the following: 2/7/16 - non-skid strips to threshold of door, staff educated the resident to call for assistance, maintenance put anti-rollback locks on the resident's wheelchair, then took the locks back off due to other safety issues for resident. 2/27/16 - Resident re-educated on need to wait for staff. 3/20/16 - PT (physical therapy) ordered/restorative to work with fine motor skills 4/5/16 - 1 staff member assigned to make sure the resident toilets before he/she leaves the room to other activities. 4/21/16 - Staff educated not to leave resident alone when assisting him/her with cares in his/her bathroom 4/23/16 - The resident had his/her brakes locked. The resident pushed back on the wheelchair and the wheelchair flipped. 5/25/16 - Educate resident about his/her condition and not eating so much, elevate head of bed and continue current fall precautions. 6/3/16 - Room rearranged with bed against the wall to enable resident more movement with less risk. Resident re-educated on the risk of not calling for assistance. Staff re-educate of safety risks. 8/3/16- on knees in his/her room, education provided to resident on use of his/her wrist pendant with return demonstration from resident. Maintenance and environmental department checked the resident's room for any issues. Skid strips replaced in front of recliner. 8/17/16- on his/her knees in front of walker with hands resting on the cross bar of walker. Approaches included 8/17/16- 1.) Skid strips in front of bathroom door. 2.) Education provided to resident on safety, use of his/her pendant to call for staff assist for any/all ADLs. 9/10/16- resident sitting on floor with walker in front of him/her. An approach dated-9/10/16 revealed teaching provided by nursing staff with return demonstration by the resident on use of pendant and call light use. Review of the resident's fall history from admission on 8/28/15 until present revealed the resident fell 27 times during that period. Of those falls 10 were on the day shift, 12 were on the evening shift, and 5 on the night shift. Of those falls, 11 were in his/her bathroom or while the resident attempted to self-toilet. Review of the fall investigations revealed the following: 8/28/15 -The resident stated he/she tried to stand up when asked why the resident stated why not. Staff placed alarms on the bed and wheelchair. 9/4/15 - The resident knelt on the floor, facing the door. The resident refused to describe the incident. 9/18/15 - The resident lay on floor in bathroom lying on right side with small scrape on top of right hand and top of scalp. The resident stated his/her wheelchair (w/c) folded up on him/her. 9/19/15 Staff found the resident on the bathroom floor on his/her left side. He/she stated he/she tried to pull his/her pants up after going to the bathroom Staff educated the resident to use call light. 9/24/15 - The resident was on the floor on his/her left side in his/her bathroom near toilet. The resident reported he/she tried to get off toilet. 9/24/15 - The resident was on the floor with his/her wheelchair beside him/her. 10/1/15 - Staff found the resident on the floor beside bed. He/she reported he/she was trying to get his/her glasses. 10/2/15 - Staff found the resident on the floor in bathroom, and stated he/she was trying to go to the bathroom. 10/4/15 - Staff found the resident on the floor in front of his/her recliner holding him/herself up with his/her arms. The resident stated he/she was trying to get his/her urinal. 10/11/15 - The resident was on the bathroom floor and stated he/she just fell 10/29/15 - The resident was on his/her knees on the cushioned pad next to the bed. He/she stated he/she was trying to get his/her television remote. 11/22/15 - The resident was on bathroom floor after toileting him/herself. Stated he/she was transferring back to his/her wheelchair from the toilet and he/she missed the bar causing him/her to fall. Abrasion to scalp that 3 cm (centimeter) x 2 cm where skin and hair rubbed off. 11/25/15 - The resident fell in his/her room witnessed by CNA who could not get to him/her fast enough. He/she stated he/she tried to get to his/her recliner from the wheelchair. 12/27/15 - The resident lay on floor on his/her right side gestured he/she was going from w/c to recliner. When asked about his/her wrist call button, stated it did not work. 12/31/15 - The resident was lying on floor in front of toilet with w/c turned on its side. Resident stated staff was busy and he/she was trying to help and fell over. 2/7/16 - The resident stated he/she lost his/her balance and the wheelchair rolled back. Staff found that the grab bar next to the toilet the resident used had a loose screw, which maintenance repaired. 2/27/16 - Staff found the resident partially on the floor mat, call light activated, the floor was wet and his/her water pitcher turned upside down. Staff re-educated the resident on the need to wait for staff. 3/20/16 - The resident bent over to pick up candy off the floor he/she had dropped. (the resident fell ?) Nursing suspected a fine motor skill decline. 4/5/16 - The resident said he/she was bending forward and the wheelchair turned over sideways. Based on items observed near the chair, the resident was possibly changing soiled clothing. The resident did not activate the call light. 4/21/16 - A CNA was assisting the resident with toilet, left resident alone to go get denture tabs and the resident attempted to stand up on his/her own and fell . Staff educated not to leave the resident alone. 5/25/16 - The resident ate a large meal, lay down too soon, needed to vomit and when he/she rolled to edge of bed and slid out. 6/3/16 - The resident had a fall at 3:55 a.m., the resident stated he/she needed to pee . The resident had a laceration across the bridge of the nose, and abrasions on knees. The resident got out of the side of the bed that he/she did not normally use which made his/her movements awkward. Staff rearranged the resident's room following the fall. The nurse on duty sent the resident to ER for laceration noted on the right/middle side of his/her forehead measuring 3 cm x 1.5 cm requiring sutures. Staff found the resident on the floor in his/her room between his/her roommate's bed and his/hers. The resident bled from his/her forehead and the bridge of his/her nose. EMS (emergency medical services) transported resident to the ER (emergency room ) at 4:35 a.m. Review of the nurse's progress notes dated 6/3/16 at 8:53 a.m. revealed the resident returned from the ER. The resident sat at the nurses station, with a bandage to his/her right forehead covering the sutures and a cut across the bridge of his/her nose. The resident was alert and talking with staff. Review of the nurse progress notes dated 6/3/16 at 9:07 a.m. revealed at 8:20 a.m. the resident returned from the ER. The resident had a 1.4 cm laceration on the bridge of his/her nose. Further fall investigations revealed: 8/3/16 - Staff found the resident on his/her knees in front of his/her chair holding onto the walker. The resident stood up on his/her own stating he/she did not fall. Staff reminded the resident to use call light for assistance. 8/17/16 - Staff found the resident on his/her knees in front of the bathroom door holding onto his/her walker. The resident stated he/she would not have fallen if the bathroom door not had been shut. Staff reminded the resident to use his/her call light. 9/10/16 - The housekeeper found the resident sitting on the floor. The resident fell with his/her walker and was sitting on floor. The resident stated he/she did not know what happened. The resident had a skin tear to the back of his/her right hand. Review of all the fall investigations revealed staff failed to complete a root cause analysis to determine new workable interventions to the care plan to prevent further falls. Observation on 9/20/16 at 12:50 p.m. revealed staff C wheeled the resident to his/her room and stopped in the hall and instructed the resident to lock his/her brakes. Staff C then put a gait belt on the resident and ambulated the resident to his/her recliner. Staff C offered no toileting. During a conversation on 9/20/16 at 3:20 p.m., the resident reported staff assisted him/her. The resident reported if he/she pushed the button on a watch looking band on his/her wrist staff came but he/she did not like to use it and could get up by him/herself but staff did not want him/her to get up by him/herself During an interview on 9/20/16 at 12:50 p.m., direct care staff C reported the resident did not have any kind of a toileting program and most of the resident's falls were unwitnessed. Staff were supposed to stay in the bathroom with him/her but did not always do that and the resident did not want to call for assistance. Staff transferred him/her to a regular chair in the dining room so he/she had to wait for help to get back in his/her wheelchair then staff followed the resident back to his/her room to provide care and transfer him/her to the recliner. During an interview on 9/20/16 at 2:50 p.m., direct care staff D reported the resident did not have a toileting program. Staff just checked on him/her after meals to see if he/she needed the toilet. During an interview on 9/21/16 at 7:36 a.m., direct care staff E reported the resident required extensive assist of one staff to toilet and extensive assistance of 2 for walking. To prevent the resident from falling, staff needed to catch him/her as soon as he/she finished with meals in the dining room and transfer him/her to his/her recliner or the resident would transfer him/herself. Direct care staff D reported he/she did not know if the resident had a toileting program. During an interview on 9/21/16 at 3:42 p.m., licensed nurse F reported the resident had a call light and wore a call pendant. Staff were to keep the fall mat on the floor and his/her walker and wheelchair out of sight of the resident. Staff asked the resident if he/she had to use the bathroom but he/she did not have a toileting plan. During an interview on 9/22/16 at 8:25 a.m. administrative nurse B reported the facility no longer did 3 day voiding diaries on residents on admission. Since the facility started with electronic records they used the direct care staff charting for the first 7 days after admission to determine if the resident experienced incontinence. The nursing staff completed quarterly bladder assessments in the electronic record. Nurse B also reported he/she was responsible for the resident's care plan. Nurse B reported he/she did not know the steps to initiate a toileting program that was specific to the resident but acknowledged if staff would toilet the resident when he/she needed to use the bathroom he/she might not have fallen so frequently. During an interview on 9/22/16 at 8:05 a.m., physician H, reported he/she did not realize the resident had fallen as often as the resident had. The falls resulted in abrasions and bruises with one fall requiring a transfer by EMS and sutures to a laceration located on the resident's forehead. The physician reported the resident had no physical problems contributing to the resident needing to urinate more frequently. The physician agreed if the resident had been on a formal toileting schedule, to catch the resident before the resident tried to self-toilet, it might have prevented some of the 10 falls in the bathroom including the fall with injury when the resident reported he/she had to pee. Review of the facility's policy for Fall Management dated 12/2015 revealed the facility strived to minimize the risk for resident falls and to reduce injuries associated with resident falls. Assessment was to be within the first 4 hours of admission, quarterly, significant change and with each fall occurrence using a standardized fall risk assessment. Fall prevention interventions were communicated to facility staff through the care plan. With each fall occurrence nursing updated the care plan with new interventions to prevent further falls. The facility failed to complete a root analysis and develop and implement interventions to prevent falls for 1 (#16) resident who experienced 27 falls, one which resulted in a laceration requiring 6 sutures to the forehead.