Every finding on record at Osage Nursing & Rehabilitation Center

Based on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to store Resident (R)25's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) in a sanitary manner when not in use. The facility failed to ensure proper infection control standards were followed related to hand hygiene during catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for R32.Findings included:- On 07/06/2026 at 09:25 AM, R25's CPAP laid directly on the bedside table and was not in a container.On 07/07/2026 at 07:43 AM, R25's CPAP laid directly on the table next to her recliner and was not in a container. On 07/07/2026 at 10:30 AM, Licensed Nurse (LN) I donned personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) to perform catheter care for R32. LN I touched her hair, pushed R32's wheelchair from the bathroom to his bed, and she then closed the window blinds. LN I did not change her gloves or perform hand hygiene. LN I then cleaned R32's suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) with normal saline. LN I then doffed the glove from her right hand and donned a new glove without performing hand hygiene.On 07/07/2026 at 02:46 PM, R25's CPAP continued to lay directly on the table next to her recliner, not in a container.On 07/08/2026 at 09:10 AM, R25's CPAP laid directly on the table next to her recliner, not in a container.On 07/07/2026 at 10:48 AM, LN I stated the process for performing catheter care was to change the gloves between the soiled and clean parts of the care and washing hands between glove changes.On 07/08/2026 at 10:55 AM, Certified Nurse Aide (CNA) N stated the process for storing a CPAP mask between uses was to place it in a bag and keep it closed.On 07/08/2026 at 11:02 AM, LN H stated the process for the sanitary storage of R25's CPAP was that the mask should be taken apart, cleaned, dried then placed in the bag.On 07/08/2026 at 12:36 PM, Administrative Nurse D stated she expected hand hygiene to be performed between glove changes. She also stated that R25's CPAP's manufacturer did not recommend the mask to be stored in a bag. Administrative Nurse D stated R25 did not like to have the CPAP mask in a bag because she had difficulty getting it out of the bag.The facility was unable to provide a policy related respiratory equipment storage when not in use when requested on 07/08/2026.The facility's Hand Hygiene, dated 01/20/2026, documented all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility.

Based on observations, record review, and interviews, the facility failed to ensure pressure-reducing measures were implemented for Resident (R)12 when staff failed to float her heels per her orders and plan of care.Findings included:- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN-elevated blood pressure), chronic pain, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Modification of Significant Change Minimum Data Set (MDS) for R12, dated 05/12/2026, recorded a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R12 was dependent on staff for toileting and bathing. The MDS documented R12 was at risk for developing pressure ulcer/injury. The MDS documented R12 had one unhealed pressure ulcer/injury. The MDS documented R12 had one Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) during the observation period.R12's Pressure Ulcer/Injury Care Area Assessment (CAA), dated 05/12/2026, documented R12 was frequently incontinent of bowel and bladder, was at risk for skin breakdown, and had an existing pressure ulcer. The CAA documented R12 needed increased frequent skin monitoring, repositioning, hygiene care, and pressure relieving interventions to prevent further skin impairment.R12's Care Plan documented:05/18/2026 - R12 had potential for impairment for skin integrity of the peri area related to incontinence.Staff float R12's heels while in bed.Staff offer R12 Geri-sleeves (are soft, breathable, non-compression fabric tubes designed as a protective barrier) in the mornings.Nursing to perform weekly skin assessments.R12's EMR under Orders documented the following physicians' orders:Bilateral heels, gently cleanse with normal saline and pat dry; apply Skin-prep (liquid skin barrier) and allow to dry well every shift for skin tissue health, dated 02/19/2026.Float heels while in bed; every shift for skin protection, dated 04/14/2026.R12's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 10/08/2025 documented a score of 17 indicating at risk.On 07/08/2026 at 07:55 AM, R12 lay on her bed on her back with her eyes closed. R12's head was elevated, and her heels lay directly on her mattress; R12's heels were not floated.On 07/08/2026 at 07:42 AM, R12 lay on her bed on her back with her eyes closed. R12's heels lay directly on her mattress; R12's heels were not floated.On 07/08/2026 at 10:39 AM, Certified Nurse's Aide (CNA) M stated if a resident had a wound or needed their boots, the boots would be in the room. She stated a nurse would let her know if a resident should have their heels floated. CNA M stated the nurse does go behind the CNAs to ensure the residents have what they need in place. CNA M stated she did have access to the care plans, and if she was unsure what a resident needed, she would look at the care plan.On 07/08/2026 at 10:47 AM, Licensed Nurse (LN) G stated all nursing staff were responsible for the care of each resident. She stated all CNAs were encouraged to read the residents' care plans and know what interventions had been put in place. LNG stated each day before shift nursing staff meet for a High Five meeting to discuss any changes.On 07/08/2026 at 12:36 PM, Administrative Nurse D stated all nursing staff have access to all residents' care plans. She stated it was all nursing staff's responsibility to ensure interventions were in place before leaving a resident's room. Administrative Nurse D stated if a resident's heel needed floated it would also be on the EMR under the Treatment Administration Record (TAR).The facility's Pressure Injury Prevention and Management policy, dated 10/13/2025, documented the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of addition pressure ulcers/injuries.

Based on observations, record review, and interviews, the facility failed to ensure Resident (R)12's fall preventions were in place.Findings included:- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN-elevated blood pressure), chronic pain, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Modification of Significant Change Minimum Data Set (MDS) for R12, dated 05/12/2026, recorded a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R12 was dependent on staff for toileting and bathing. The MDS documented R12 had two or more non injury falls since admission or re-entry during the observation period.The Fall Care Area Assessment, dated 05/12/2026, documented R12 had a history of falls and received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication, and increased her risk for impaired safety, dizziness, sedation, and recurrent falls. The CAA documented R12 required ongoing monitoring and fall prevention interventions.R12's Care Plan documented the following fall interventions:03/05/2025 - Nonskid strips were to be placed under R12's recliner.05/18/2026 - R12 was at risk for falls related to being unable to ambulate long distances and would need a wheelchair.08/13/2025 - Staff were to encourage R12 to wear her Sketcher tennis shoes.08/18/2025 - A low bed with scoop mattress, and call light trigger pad to be placed in R12's bed.10/30/2025 - Keep R12's wheelchair was within her reach.12/01/2025 - R12 was to be assisted to her recliner after meals.01/12/2026 - R12 would be toileted mid-morning when she declines early morning rising.02/17/2026 - Physical therapy and Occupational therapy to treat if indicated.R12's Fall Risk Assessment dated 02/17/2026 documented a score of 14, indicating R12 was at risk.On 07/07/2026 at 07:52AM, R12 laid on her bed; the head of the bed was raised. R12's eyes were shut, and her bed was at waist height. R12's bed was not in a low position.On 07/08/2026 at 07:42 AM, R12 laid on her bed with her eyes shut. R12's bed was at waist height. R12's bed was not in a low position.On 07/08/2026 at 10:39 AM, Certified Nurse Aide (CNA) M stated that if there was a change in interventions, her nurse would let her know. She stated if a resident was a fall risk, the resident's door would have a leaf outside the resident's room. CNA M stated it was CNA's responsibility to ensure all residents' fall interventions were in place before leaving the residents' room.On 07/08/2026 at 10:47 AM, Licensed Nurse (LN) G stated all nursing staff were responsible for the care of each resident. She stated all CNAs were encouraged to read the residents' care plans and know what interventions had been put in place. LN G stated each day before shift, nursing talks about any changes with residents.On 07/08/2026 at 12:36 PM, Administrative Nurse D stated all nursing staff have access to all residents' care plans. She stated it was all nursing staff's responsibility to ensure interventions were in place before leaving a resident's room.The facility's Fall Prevention Program, dated 10/2025, documented each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

The facility reported a census of 39 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the resident kitchenette, on 09/03/24 at 09:39 AM, the following areas of concern were noted in the facility kitchen: 1. The inside of the microwave contained a dried-on food substance. 2. The stationary can opener contained a build-up of a sticky substance on the area which pierces the can and the handle of the opener. 3. The hand soap dispenser plate had a large amount of a dried, sticky substance. 4. The bottom shelf of one prep table contained food debris. The shelf held three, three-drawer plastic containers with each drawer containing serving utensils. The bottom inside of each of the nine drawers contained dust and small food particles. 5. The tracks of four sliding doors, which contained clean dishes, bowls, plastic containers for food, etc., had a build-up of a black, sticky substance. 6. The insides of the two-door reach-in refrigerator had food debris on the bottom shelf. 7. A wire cart holding clean plates, bowls and plate covers contained ground-in food on all four leg and wheels. The two wire tiers of the cart also contained ground-in food. 8. A wire rack holding clean pots and pans had a build-up of a sticky substance and dust. 9. A plastic three-drawer cart which contained coffee filters, hot chocolate packets and hot tea bags for the residents had a sticky substance on the inside bottom of each of the three drawers. 10. Four of the six wire shelves in the storeroom, used to store food and supplies, contained a build-up of dust. 11. The dish room had three, two door reach-in freezers with food debris on the bottom. One of the freezers contained a build-up of food debris in the rubber door seal. 12. One wire rack that held disposable plates, cups, bowls, napkins and eating utensils had a sticky substance and dust covered the racks. 13. Four plastic rolling carts used to transport clean and dirty dishes had a build-up of food and gunk on all four wheels and the grooves of the handles. On 09/05/24 at 09:34 AM, Administrative staff A stated the dietary staff were responsible for keeping the kitchen clean. The facility lacked a policy for kitchen cleanliness. The facility failed to prepare and serve food under sanitary conditions to the residents of the facility to prevent the potential for food borne bacteria.

The facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept close. Findings included: - During an initial tour of the kitchen on 09/03/24 at 09:39 AM, observation revealed the lid to the dumpster outside of the kitchen was left open. On 09/04/24 at 10:41 AM, observation revealed the lid to the dumpster outside of the kitchen was left open. On 09/03/24 at 10:00 AM, Dietary staff BB stated it was the expectation for the lids of the dumpster be kept always closed. The facility lacked a policy for keeping the lid of the dumpster closed. The facility failed to ensure the lid of the dumpster was kept always closed, as required.

The facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 11 dates between 04/01/23 and 06/30/23 and four dates between 07/01/23 and 09/30/23 as required. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 3, 2023 (04/01/23 thru 06/30/23) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 04/02/23, Sunday (SU), On 04/12/23, Wednesday (WE), On 04/15/23, Saturday (SA), On 04/16/23, SU, On 04/30/23, SU, On 05/13/23, SA, On 05/14/23, SU, On 05/28/23, SU, On 06/17/23, SA, On 06/24/23, SA, and on 06/30/23, Friday (FR). Review of the PBJ for FY, Quarter 4, 2023 (07/01/23-09/30/23), the following infraction dates the facility failed to have Licensed Nursing Coverage 24 hours/day included: On 07/02/23, Sunday (SU), On 07/08/23, Saturday (SA), On 08/12/23, SA, and On 09/02/23, SA. Interview, on 09/05/24 at 01:29 PM, with Consultant staff HH, revealed the facility initiated a new reporting program to mitigate erroneous calculation of PBJ Licensed Nurse hours. Consultant Staff HH stated it was possible the information regarding licensed nurse hours had not been submitted accurately but the facility did have 24/7 Licensed Nurse coverage. The facility policy for Payroll Based Journal, effective 2022, instructed staff to electronically submit to CMS complete and accurate direct care staffing information, which include information of agency and contract staff based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 11 dates between 04/01/23 and 06/30/23 and four dates between 07/01/23-09/30/23 as required.

The facility reported a census of 39 residents which included 18 residents sampled for review. Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment in the laundry. Findings included: - The laundry tour, on 09/05/24 at 08:34 AM, with Housekeeping/Laundry staff V revealed environmental concerns which included: 1. Two uncovered soiled linen barrels with soiled linens uncovered in the barrels. 2. The concrete floor throughout the laundry room had missing paint/sealant that exposed bare concrete which was unsanitizable. 3. The wall beside the washing machine with peeling sheetrock and a build-up of grime and dust. 4. The egress from the soiled linen/washroom to the clean linen room had grime build-up and rolled up tape on the floor for with grime and dust stuck to the tape. 5. The table used to fold clean laundry and linen was unsanitizable due to a missing laminate strip on the end of the folding surface, which exposed unsealed bare wood which was not sanitizable. On 09/05/24 at 09:45 AM, Administrative Staff A confirmed the above findings related to environmental concerns noted above. She reported the maintenance man was new and the administration was new but had been working on environmental concerns throughout the facility and she would ensure the maintenance man addressed the above identified laundry concerns. The facility lacked a policy related to maintenance and housekeeping in the laundry. The facility failed to provide a safe, functional, and sanitary environment in the laundry.

The facility reported a census of 39 residents which included 18 residents sampled for review. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents of the facility related to those that used the beauty shop. Findings Included: - On 09/05/24 at 09:32 AM, during tour of the beauty shop with Administrative Staff A the following concerns were identified: 1. The beauty shop lacked an operational negative pressure ventilation fan. 2. The filter on the free-standing dryer filter covered in lint. 3. The workstation cabinet contained unlabeled brush, comb, and a dual hair pick with comb that had hair in the brush bristles and the comb teeth. Administrative Staff A verified the findings above. She agreed the brush, comb, and hair pick was not sanitary and should not be used on multiple residents. Additionally, she stated she did not know what was wrong with the ventilation fan or how long it had not been operational to ensure the resident's comfort when the beautician used chemicals to process resident's hair. The facility lacked a policy to address the above findings to provide a safe, functional, sanitary, and comfortable environment for the residents of the facility related to those that used the beauty shop. The facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents of the facility related to those that used the beauty shop.

The facility reported a census of 39 residents. The sample of 18 residents included four residents reviewed for indwelling catheter and incontinence care/treatment. Based on observation, interview, and record review, the facility failed to provide catheter care/and treatment to prevent infection for four residents with indwelling catheters, Residents (R)27, R 14, R16, and R 2. Findings included: - Review of Resident (R) 27's undated Physician's Orders, dated 10/04/23 documentation included diagnoses of chronic kidney disease (CKD), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure) retention of urine, and cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The Significant Change of Status Minimum Data Set (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of 14 indicated cognitively intact. He did not report any mood indicators. R 27 was without functional limitation in range of motion to upper or lower extremities. He had an indwelling catheter (tubing inserted to drain the bladder) and ostomy (surgical opening through the abdomen to the intestines). The Quarterly MDS, dated [DATE], lacked changes from above. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/09/23, documented the resident had an indwelling catheter and was dependent on staff for toileting and personal hygiene which included catheter care. The Care Plan, (CP) dated 07/26/24 documentation included the resident at risk for infection due to catheter/colostomy use and CKD. He had sepsis (infection in the blood that spreads throughout the body) in the past year with stent placement and removal. The staff should change and care for his urinary catheter and colostomy per physician orders and facility protocol. Review of the residents Task: Catheter Care, documentation in the electronic medical record (EMR) dated revealed catheter care dated 08/13/24 through 08/31/24, staff provided daily catheter care for six out of eighteen (18) days. On 09/04/24 at 07:35 AM, R 27 sat in the wheelchair at the dining table. His urinary catheter tubing laid directly on the floor beneath the wheelchair. The resident's left shoed foot rested in direct contact on top of the urinary catheter tubing. On 09/04/24 at 09:27 AM, resident sat in his wheelchair beside the bed. He lacked an anchor or leg strap to position his catheter to prevent injury from the catheter tugging at the insertion site. He reported staff told him they did not have the anchors available on occasion. Additionally, the resident reported he had been treated for recurrent urinary tract infections. On 09/04/24 at 12:44 PM, Certified Nurse Aide (CNA) NN stated the staff should position the resident's catheter bag and tubing below the bladder and off the floor to prevent infection. Additionally, the resident should be provided an anchor on his thigh to position the catheter to prevent injury to the resident. On 09/04/24 at 02:05 PM, Licensed Nurse (LN) G stated staff should position the resident's catheter bag and tubing below the bladder and place the urinary collection bag inside the dignity bag to prevent the tubing and bag from direct contact with the floor. Additionally, the resident should be provided an anchor on his thigh to position the catheter to prevent injury to the resident. On 09/04/24 at 02:51 PM, Administrative Nurse D stated staff should position the resident's catheter bag and tubing below the bladder and placed the urinary collection bag inside the dignity bag to prevent the tubing and bag from direct contact with the floor. Additionally, the resident should be provided an anchor on his thigh to position the catheter to prevent injury to the resident. The facility policy Catheter Care), dated 10/2022, documentation included it is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care. The facility failed to provide catheter care/and treatment to prevent infection for this resident with an indwelling catheter. - Review of Resident (R) 14's undated Physician's Orders, dated 08/23/24 documentation included diagnoses of chronic kidney disease (CKD), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), retention of urine, and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Admission Minimum Data Set (MDS ) dated 01/17/24, documented the resident's Brief Interview for Mental Status, (BIMS) score of 12 indicated moderate cognitive impairment. He was without functional limitation in range of motion to upper or lower extremities. He had an indwelling catheter (tubing inserted to drain the bladder). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/09/23, documented the elder had a suprapubic indwelling catheter (S/P catheter-tubing surgically placed through the abdominal wall to the bladder) and was dependent on staff for toileting which included catheter care. The Care Plan (CP) dated 07/15/24, directed staff the resident had a suprapubic catheter and was at risk for infection due to catheter use and CKD The staff should change and care for his urinary catheter per physician orders and facility protocol. On 09/03/24 at 01:52 PM, the resident sat in the wheelchair with six to eight inches of the catheter tubing that dragged on the floor as he self-propelled his wheelchair to the smoking area. On 09/05/24 at 12:56 PM, the resident was in his bed on his left side with the catheter tubing placed through his jogging pants leg positioned below his bladder off the floor. On 09/04/24 at 12:44 PM, Certified Nurse Aide (CNA) NN, reported the staff should position the resident's catheter bag and tubing below the bladder and off the floor to prevent infection. On 09/04/24 at 02:05 PM, Licensed Nurse (LN) G stated staff should position the resident's catheter bag and tubing below the bladder and place the urinary collection bag inside the dignity bag to prevent the tubing and bag from direct contact with the floor. Additionally, the resident should be provided an anchor on his thigh to position the catheter to prevent injury to the resident. On 09/04/24 at 02:51 PM, Administrative Nurse D stated staff should position the resident's catheter bag and tubing below the bladder and placed the urinary collection bag inside the dignity bag to prevent the tubing and bag from direct contact with the floor. The facility policy Catheter Care, dated 10/2022, documentation included it is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care. The facility failed to provide catheter care/and treatment to prevent infection for this resident with a suprapubic indwelling catheters. 34056 - Review of Resident (R)2's electronic medical record (EMR) included the following diagnoses: neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He had limited range of motion (ROM) to his bilateral (both) lower extremities, had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was dependent on staff for toileting hygiene. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/10/23, documented the resident had a suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen, above the pubic bone) and was dependent on staff for toileting hygiene. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 13, indicating moderate cognitive impairment. He had limited ROM to his bilateral lower extremities, had an indwelling urinary catheter and was dependent on staff for toileting hygiene. The care plan for activities of daily living (ADL), revised 05/08/24, instructed staff the resident had impaired mobility related to paraplegia. The staff were instructed to ensure the tubing of the urinary catheter was not touching the floor at any time. Review of the resident's EMR revealed the following physician's order: Catheter care, every shift and as needed (PRN), ordered 08/11/24. On 09/03/24 at 12:47 PM, the resident sat in his wheelchair in the dining room eating lunch. The catheter tubing underneath his wheelchair rested directly on the floor of the dining room. On 09/04/24 at 09:11 AM, the resident sat in his wheelchair in the dining room eating breakfast. The catheter tubing underneath his wheelchair rested directly on the floor of the dining room. On 09/04/24 at 11:01 PM, the resident propelled himself in his wheelchair down the hall to his room. The catheter tubing underneath his wheelchair drug on the floor. On 09/04/24 at 09:00 AM, Certified Nurse Aide (CNA) Q stated the resident's catheter tubing should not touch the floor. On 09/04/24 at 02:53 PM, CNA P stated the staff were to ensure the resident's catheter tubing stayed inside of the dignity bag and did not drag on the floor. On 09/04/24 at 03:29 PM, Licensed Nurse (LN) G stated staff were to keep the resident's catheter tubing inside of the dignity bag. The catheter tubing should never be on the floor. On 09/05/24 at 09:37 AM, Administrative Nurse D stated the catheter tubing should not be on the floor. Staff were to ensure the tubing was kept inside of the dignity bag. The facility policy for Catheter Care, undated, included: It is the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The facility failed to ensure the catheter tubing for this dependent resident with an indwelling urinary catheter was kept inside of the dignity bag. 28560 - Review of Resident (R)16's medical record revealed diagnoses that included neuromuscular disorder of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), chronic kidney disease and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) dated [DATE], the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The resident utilized a walker and/or wheelchair for mobility and required substantial/maximal assistance for toileting hygiene. The resident could propel her wheelchair independently. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/24/24, assessed the resident had an indwelling urinary catheter and required substantial/maximal assistance with toilet transfers and toileting hygiene. The Care Plan reviewed 06/24/24, instructed staff to ensure the urinary was secure to prevent tugging and place the urine collection pouch in a dignity bag and ensure the tubing did not touch the floor. A Physician's Order dated 12/16/21, instructed staff to provide catheter and peri care every shift. A Physician's Order dated 05/22/24, instructed staff to change the urinary catheter with a size 16 French (Fr) with a 30 Cubic Centimeter (cc) balloon every month and as needed. A Physician's Order dated 08/12/24, instructed staff to ensure a catheter anchor was in place to prevent pulling and tugging of the catheter. Observation, on 09/03/24 at 02:07 PM, revealed the resident seated in her wheelchair, propelling herself from the dining room to her room. Approximately six inches of the catheter tubing lay directly on the floor. Observation, on 09/04/24 at 08:00 AM, revealed the resident seated in her wheelchair, propelling herself to the dining room. Approximately six inches of tubing lay directly on the floor. Observation, on 09/04/24 at 01:36 PM, revealed Certified Nurse Aide (CNA) MM, assisted resident with transfer to the toilet and noted the catheter anchor was not in place and was tangled on the lower portion of the urine drainage tubing. Interview on 09/04/24 at 01:40 PM, with Licensed Nurse (LN) G , revealed she would expect staff to ensure R16's catheter anchor was in place and functioning appropriately. LN G obtained a new catheter anchor for replacement. Observation on 09/04/24 at 01:56 PM, revealed CNA M assisted the resident to transfer from the toilet to her recliner. CNA M stated she did know how to attach a catheter anchor and would notify the nurse to apply a new one. Upon seated in her recliner, approximately six inches of the resident's catheter tubing lay directly on the floor. Interview on 09/04/24 at 02:30 PM with Administrative Nurse D, revealed she would expect staff to ensure catheter tubing was secured with an anchoring device, and maintain the tubing off the floor. The facility policy Catheter Care dated 2021, instructed staff to ensure the catheter anchor was in place to prevent pulling/tugging. Residents with an indwelling urinary catheter receive appropriate catheter care and maintain their dignity and privacy. The facility failed to ensure R16's urinary catheter was securely anchored, and tubing was maintained off the floor to prevent trauma and risk of infection.

The facility reported a census of 39 residents with 18 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)22, when staff failed to assist the resident with changing her clothing when her shirt became soiled with food. Findings included: - Review of Resident (R)22's electronic medical record (EMR) revealed a diagnosis of major depressive disorder (MDD-major mood disorder which causes persistent feelings pf sadness) with psychotic features (major mental disorder characterized by a gross impairment in reality perception). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had no limitation in range of motion (ROM) and required partial to moderate staff assistance with dressing her upper and lower body. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/07/23, documented the resident required extensive assistance of staff with dressing. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 13, indicating intact cognition. She had no limitation in ROM and was independent with dressing her upper and lower body. The care plan, revised 06/12/24, instructed staff the resident was mostly independent with ADLs, but staff were to remind the resident to change her clothing when soiled. Review of the resident's EMR from 08/07/24 through 09/04/24, revealed the resident required supervision to partial staff assistance with dressing. On 09/03/24 at 12:25 PM, the resident sat in a chair in the front commons area. She wore a T-shirt which had dried-on food on the front. On 09/03/24 at 02:27 PM, the resident sat in the front commons area and continued to wear the same dirty top with the dried-on food. On 09/04/24 at 09:13 AM, the resident fed herself breakfast in the dining room. While eating, the resident dribbled food onto the front of her clean T-shirt. Following breakfast, the resident went to sit in a chair in the front commons area. On 09/04/24 at 11:47 AM, the resident ambulated to the dining room for lunch. She continued to wear the same dirty T-shirt as she sat down to eat lunch with her peers. On 09/03/24 at 12:25 PM, the resident stated she required staff assistance with changing clothes at times. It was important for her to be neat and clean. On 09/04/24 at 08:45 AM, Certified Nurse Aide (CNA) O stated the resident required assistance with dressing at times. CNA O confirmed the resident's clothing should be changed when soiled with food. On 09/04/24 at 01:07 PM, CNA Q stated the resident required assistance with dressing at times. On 09/04/24 at 02:53 PM, CNA P stated if a resident was wearing dirty clothing, staff would need to prompt her to change. CNA P stated the resident does feed herself and will often dribble food on the front of her shirt. CNA P stated she had seen the resident with food dried to the top of her shirt, but staff did not change her clothing until before the resident went to bed. On 09/04/24 at 03:29 PM, Licensed Nurse (LN) G stated the resident feeds herself and tended to get food on the front of her shirt. Staff should change residents when their clothing became dirty. On 09/05/24 at 09:37 AM, Administrative Nurse D stated it was the expectation for staff to change resident's clothing when they were soiled. The facility policy for Dignity, revised August 2009, included: Each resident shall be cared for in a manner which promotes quality of life, dignity, respect and individuality. The facility failed to assist this resident with changing her clothing when her shirt became soiled with food.

The facility reported a census of 39 residents with 18 residents included in the sample. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one Resident (R)12, regarding risk of elopements. Findings included: - Review of Resident (R)12's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He had wandering behavior one to three days of the assessment period. He had no limitation in range of motion (ROM) and used a walker with supervision while walking 10 to 150 feet. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/23/24, documented the resident had short and long-term memory loss. The Fall CAA, dated 07/23/24, documented the resident had issues with safety awareness. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. He had wandering behavior one to three days of the assessment period. He had no impairment in ROM and used a walker for walking 10 to 150 feet with staff providing verbal cues or touching/steadying assist. The care plan, revised 06/06/24, lacked staff instruction regarding wandering behaviors. Review of the resident's EMR, revealed Elopement Evaluations which placed the resident at a high risk for elopement on 11/29/23, 12/29/23, and 03/02/24. An Elopement Evaluation, completed 06/01/24, put the resident at no risk for elopement. Review of the resident's EMR, on 08/23/24, revealed documentation the resident attempted to elope from an east exit door. Staff redirected the resident. No further documentation was available regarding the event. Review of behavior documentation, from 08/07/24 through 09/05/24, revealed wandering behaviors 13 times. On 09/03/24 at 10:59 AM, the resident sat in the front commons area with his walker in front of him. No wandering behavior noted at that time. On 09/04/24 at 08:55 AM, the resident rested in his room. No wandering behavior noted at that time. On 09/04/24 at 01:07 PM, Certified Nurse Aide (CNA) Q stated the resident required staff redirection at times with his cares. CNA Q stated she was unsure if the resident was at risk for elopement and was unsure how to find out which residents were at risk for elopement. On 09/04/24 at 02:53 PM, CNA P stated she was unsure which residents were at risk for elopement and was unsure how to find out which residents were at risk for elopement. On 09/04/24 at 03:17 PM, Housekeeping/Maintenance Staff U stated the resident was not at risk for elopement. Staff would need to review the resident's care plans to know which residents were at risk for elopement. On 09/04/24 at 03:29 PM, Licensed Nurse (LN) G stated elopement assessments were completed upon admission and again if a resident would attempt to elope. If a resident were found to be at a risk for elopement it would be added to the care plan. LN G stated the resident was not at risk for elopement. On 09/05/24 at 09:37 AM, Administrative Nurse D stated the resident did not wander into other resident's rooms. Staff are able to identify which residents are at risk for elopement by looking in the care plans. If a resident had a change in their status in regard to wandering, it would be included in their care plans. The facility policy for Elopements and Wandering Residents, undated, included: The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Interventions to increase staff awareness of the resident's risk will be added to the resident's care plan and communicated to appropriate staff. The facility failed to complete a comprehensive care plan for this resident with staff instruction regarding wandering behaviors and risk of elopement.

The facility reported a census of 39 residents. The sample of 18 residents included eight residents sampled for activities of daily living (ADLs). Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for the one sampled Resident (R)27s, related to bathing and shaving. Findings included: - Review of Resident (R) 27's undated Physician's Orders, dated 10/04/23 documentation included diagnoses of chronic kidney disease, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure) retention of urine, and cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth). The Significant Change of Status Minimum Data Set (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of 14 indicated cognitively intact. He did not report any mood indicators. R 27 reported it was very important to make choices regarding bathing and personal hygiene. The resident was without functional limitation in range of motion to upper or lower extremities. He had an indwelling catheter (tubing inserted to drain the bladder) and ostomy (surgical opening through the abdomen to the intestines). He did not receive therapy or restorative nursing programs (RNP). The Quarterly MDS, dated [DATE], lacked changes from above. The Functional Abilities (Self-Care and Mobility Care Area Assessment (CAA), dated 11/09/23, documented the elder had a decline in activities of daily living (ADL) and required staff assistance from to complete his ADL's. The Care Plan, (CP) dated 07/26/24 , directed staff to provide set-up and assistance for shaving during showers. Review of the electronic medical record (EMR) dated 08/31/24 through 09/04/24 documented the resident had not been offered an opportunity to bath and receive a corresponding shave since 08/31/24. On 09/04/24 at 09:27 AM, Resident (R)27 sat in the wheelchair with scraggly facial hair approximately one fourth of an inch or more covering his face and chin and upper lip. His overall appearance was unkept. On inquiry, he reported would like to get shaved because food gets caught in his beard. He stated he liked a trimmed mustache but liked his face shaved. The staff were told to get a mirror and put on the side of the sink and get an electric razor. The nurses tried to get the certified nurse aides (CNA's) to teach him how to stand in front of the mirror and shave, because the mirror was not low enough to see to shave while he sat in his wheelchair. The staff shaved him last on Tuesday, 08/27/24 (seven days prior). R 27 stated he needed an electric razor and mirror to shave himself the only facial hair he wanted was a mustache which he wanted trimmed. His beard was shaggy, and he would have to cut his beard with the scissors so he could eat. Additionally, he reported he would prefer bathing after lunch and prior to supper on Monday, Wednesday, and Saturday. On 09/04/24 at 10:26 AM, CNA Q verified the resident needed staff to help with his ADLs which included baths and shaving. She reported the resident should get shaved on his scheduled shower days and as needed between showers and receive showers according to his preferences. CNA Q reported the facility staff had access to a razor for shave on shower days of his choice. He could shave himself with a regular shaver. Staff have a razor in the shower room for use to shave the residents. On 09/04/24 at 02:05 PM, Licensed Nurse (LN ) G stated staff should bath residents and provide personal hygiene according to the resident's preferences and should provide assistance and set up for shaving when needed. She reported R 27 required staff assistance with his ADLS to include bathing and shaving. Residents should bathe according to their preferences and should be shaved on their scheduled shower days and in between shower days if needed. Verified resident needed a shave. On 09/04/24 at 02:51 PM, Administrative Nurse D verified R27 required assistance with his ADLS which included set up and assist with shaves. She reported his bathing preferences should be considered when his schedule was set up. She reported the staff should assist R27 with his shaves with his baths and or when needed between his scheduled bath days. The facility policy Activities of Daily Living (ADLs), dated 10/2022, documentation included a resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming and personal hygiene. The facility failed to ensure necessary services to maintain good personal hygiene for this resident related to bathing and shaving.

The facility reported a census of 39 residents with 18 residents selected for review, which included one resident reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure sanitary pressure ulcer care for Resident (R)1. Findings included: - Review of Resident (R)1's medical record revealed diagnoses that included multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), urinary incontinence and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident had one stage three pressure ulcer (full thickness pressure injury extending through the skin into the tissue below) present upon admission and one surgical wound. The resident was always incontinent of bowel and bladder. The resident received hospice services. The Pressure Ulcer Care Area Assessment (CAA), dated 08/12/24, assessed the resident with a pressure ulcer and surgical wound. Contributing factors included incontinence, pain, and impairment of mobility. The Care Plan reviewed 08/12/24, instructed staff R1 was incontinent of bowel and bladder and required repositioning and brief change every two hours. The resident had history of moisture associated skin damage with skin breakdown to heels and the gluteal fold (area beneath the buttocks) The resident had muscle atrophy (wasting or decrease in size of a part of the body) with spasms and schizophrenia with behaviors. A Physician Order dated 08/09/24 instructed staff to cleanse the inferior sacrum (lower part of the spine just above the buttock) wound with wound cleanser, apply collagen (a substance that enhances wound healing) particles to the base of the wound and secure with bordered foam dressing daily and as needed. A Physician Order dated 08/26/24, instructed staff to cleanse the left ischium wound (area beneath the buttock cheek) with wound cleanser and apply calcium alginate (a substance that forms a gel on the surface of the wound which absorbs moisture) to the wound bed and apply an absorbent dressing. Observation, on 09/04/24 at 09:10 AM, revealed Certified Nurse Aide (CNA) O and CNA N transferred R1 from her broda chair (a type of pressure relieving wheelchair) with a full body mechanical lift into her bed. CNA O stated she did not know if the resident was on Enhanced Barrier Precautions (EBP) and neither CNA O nor CNA N donned Personal Protective Equipment (PPE). CNA O and N then observed the resident was incontinent of urine and positioned the resident onto her side. The resident lacked dressings to her sacrum and ischium. CNA O stated Licensed Nurse G would need to apply the dressings. Observation, on 09/04/24 at 09:22 AM, revealed LN G and LN H, donned gowns, gloves, and masks, and entered R1's room to provide wound care. LNG stated the resident was on EBP due to wounds, and CNA should have donned PPE and did not know how long the wounds were without dressings. LN G cleansed the ischial wound with wound cleanser and noted the wound had a beefy red appearance and was approximately 3 by 2 Centimeters (cm). LN G then changed gloves without sanitizing her hands and cleansed the sacral wound which was yellow/white in color and approximately 0.5 by 1 cm. LN G changed gloves and applied calcium alginate and telfa (a type of gauze that does not adhere to a wound) to the ischial wound and with the same gloves, applied calcium alginate to the sacral wound and covered the area with telfa. Interview on 09/05/24 at 08:30 AM, with Administrative Nurse D, revealed she would expect staff to ensure dressings remained intact to the resident's pressure ulcer and surgical wound and provide wound care with appropriate hand hygiene, gloving and PPE for EBP as required. The facility policy Clean Dressing Change dated 2023, instructed staff to wash hands and put on clean gloves after removing the soiled dressing, after cleansing the wound, and prior to applying medication and dressing. The facility failed to ensure staff provided sanitary wound care to R1's sacral pressure ulcer and ischial surgical wound to prevent infection and enhance wound healing.

The facility reported a census of 39 residents with 18 sampled, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to initiate interventions to ensure a safe and secure environment for one Resident (R)12, with a history of wandering behaviors. Findings Included: - Review of Resident (R)12's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He had wandering behavior one to three days of the assessment period. He had no limitation in range of motion (ROM) and used a walker with supervision while walking 10 to 150 feet. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/23/24, documented the resident had short and long-term memory loss. The Fall CAA, dated 07/23/24, documented the resident had issues with safety awareness. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. He had wandering behavior one to three days of the assessment period. He had no impairment in ROM and used a walker for walking 10 to 150 feet with staff providing verbal cues or touching/steadying assist. The care plan, revised 06/06/24, lacked staff instruction regarding wandering behaviors. Review of the resident's EMR, revealed Elopement Evaluations which placed the resident at a high risk for elopement on 11/29/23, 12/29/23, and 03/02/24. An Elopement Evaluation, completed 06/01/24, put the resident at no risk for elopement. Review of the resident's EMR, on 08/23/24, revealed documentation the resident attempted to elope from an east exit door. Staff redirected the resident. No further documentation was available regarding the event. Review of behavior documentation, from 08/07/24 through 09/05/24, revealed wandering behaviors 13 times. On 09/03/24 at 10:59 AM, the resident sat in the front commons area with his walker in front of him. No wandering behavior noted at that time. On 09/04/24 at 08:55 AM, the resident rested in his room. No wandering behavior noted at that time. On 09/04/24 at 01:07 PM, Certified Nurse Aide (CNA) Q stated the resident required staff redirection at times with his cares. CNA Q stated she was unsure if the resident was at risk for elopement and was unsure how to find out which residents were at risk for elopement. On 09/04/24 at 02:53 PM, CNA P stated she was unsure which residents were at risk for elopement and was unsure how to find out which residents were at risk for elopement. On 09/04/24 at 03:17 PM, Housekeeping/Maintenance Staff U stated the resident was not at risk for elopement. Staff would need to review the resident's care plans to know which residents were at risk for elopement. On 09/04/24 at 03:29 PM, Licensed Nurse (LN) G stated elopement assessments were completed upon admission and again if a resident would attempt to elope. If a resident were found to be at a risk for elopement it would be added to the care plan. LN G stated the resident was not at risk for elopement. On 09/05/24 at 09:37 AM, Administrative Nurse D stated the resident did not wander into other resident's rooms. Staff are able to identify which residents are at risk for elopement by looking in the care plans. If a resident had a change in their status in regards to wandering it would be included in their care plans. The facility policy for Elopements and Wandering Residents, undated, included: The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Interventions to increase staff awareness of the resident's risk will be added to the resident's care plan and communicated to appropriate staff. The facility failed to initiate interventions to ensure a safe and secure environment for this resident with a history of wandering behaviors.

The facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for one Resident (R)1 with chronic wounds to prevent the spread of infection as required. Findings included: - Review of Resident (R)1's medical record revealed diagnoses that included multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), urinary incontinence and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident had one stage three pressure ulcer (full thickness pressure injury extending through the skin into the tissue below) present upon admission and one surgical wound. The resident was always incontinent of bowel and bladder. The resident received hospice services. The Pressure Ulcer Care Area Assessment (CAA), dated 08/12/24, assessed the resident with a pressure ulcer and surgical wound. Contributing factors included incontinence, pain, and impairment of mobility. The Care Plan reviewed 08/12/24, instructed staff R1 was incontinent of bowel and bladder and required repositioning and brief change every two hours. The resident had history of moisture associated skin damage with skin breakdown to heels and the gluteal fold (area beneath the buttocks) The resident had muscle atrophy (wasting or decrease in size of a part of the body) with spasms and schizophrenia with behaviors. A Physician Order dated 08/09/24 instructed staff to cleanse the inferior sacrum (lower part of the spine just above the buttock) wound with wound cleanser, apply collagen (a substance that enhances wound healing) particles to the base of the wound and secure with bordered foam dressing daily and as needed. A Physician Order dated 08/26/24, instructed staff to cleanse the left ischium wound (area beneath the buttock cheek) with wound cleanser and apply calcium alginate (a substance that forms a gel on the surface of the wound which absorbs moisture) to the wound bed and apply an absorbent dressing. Observation, on 09/04/24 at 09:10 AM, revealed Certified Nurse Aide (CNA) O and CNA N transferred R1 from her broda chair (a type of pressure relieving wheelchair) with a full body mechanical lift into her bed. CNA O stated she did not know if the resident was on Enhanced Barrier Precautions (EBP) and neither CNA O nor CNA N donned Personal Protective Equipment (PPE). CNA O and N then observed the resident was incontinent of urine and positioned the resident onto her side. The resident lacked dressings to her sacrum and ischium. CNA O stated Licensed Nurse G would need to apply the dressings. Observation, on 09/04/24 at 09:22 AM, revealed LN G and LN H, donned gowns, gloves, and masks, and entered R1's room to provide wound care. LNG stated the resident was on EBP due to wounds, and CNA should have donned PPE when providing the transfer and incontinence care. Interview on 09/05/24 at 08:30 AM, with Administrative Nurse D, revealed she would expect staff to follow EBP for R1 due to wounds and had informed staff recently about the procedures for donning and doffing PPE for this resident. The facility policy Enhanced Barrier Precautions dated 2024, instructed staff to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms during high contact resident care activities. The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for one Resident (R)1 with chronic wounds to prevent the spread of infection as required.

The facility reported a census of 43 residents, with two included in the sample. Based on observation, interview, and record review the facility failed to ensure the protection of the residents from Abuse, Neglect, and Exploitation (ANE) when the facility did not implement any care planned interventions to address the hypersexualized behaviors of bed bound Resident (R)2 (a resident with traumatic brain injury) and did not implement any care planned interventions to address the behaviors of independently mobile R1 (with a history of imprisonment due to the sexually predatory behavior), who was found twice naked in/around R2's room. This failure placed all residents in immediate jeopardy. Findings included: - On 05/31/23 an on-site visit was conducted in the facility regarding KS00180480 reporting R1 was found naked and masturbating at the bedside of bedbound resident R2. The allegation included semen was on the bed and floor of R2. Review of the facility investigation dated 05/31/23 revealed R1 received Hospice services for chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). He always required oxygen (O2). He could walk very short distances holding onto his wheelchair. Regarding the incident on 05/30/23 Certified Nurse Aide (CNA) D finished rounds on the north hall when CNA D heard R1 on north hall yelling for help. R1 stood in his doorway hunched over his wheelchair gasping for air. R1 was naked and his brief was at his feet in the doorway. R1's O2 tubing laid on the floor in the hallway behind him and was not attached to his concentrator. CNA D asked R1 what he was doing, and R1 reported he got turned around looking for the bathroom. CNA D assisted him to his wheelchair and reapplied his O2. CNA D asked if he made it to his bathroom or someone else's and R1 reported he thought his, but was not sure. R1's tubing was across the hallway, on the floor and in the doorway of R2's room. R2 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment and a diagnosis of traumatic brain injury (TBI), hemiplegia, hemiparesis (inability to use one side of body), and inappropriate sexual behavior. R2 had a history of making inappropriate sexual comments to the staff. The staff found R2 lying in bed covered with his blanket, and the lights were out. The nurse asked if there had been a man in his room and R2 answered yes. The nurse asked what the man was doing, and R2 said he was jerking off and made a hand gesture. The nurse asked R2 if the man touched him, and R2 said yes and pointed to his arm. The nurse examined his arm and no marks or redness found. R2 was incontinent of both bowel and bladder and staff changed his brief at approximately 03:00AM and at 05:00AM and his brief was undisturbed. The staff found liquid on the floor of R2's room and left it for Administrative Nurse B to examine. During an interview from Administrative Nurse B, the resident (R2) further claimed the man had sexually assaulted him, even though R2's brief was intact. Administrative Nurse B cleaned the fluid up from the floor and reported it was yellow and smelled like ammonia. There was urine in R2's toilet, even though R2 could not get out of bed and did not use the toilet in his room. Review of R1's Care Plan dated 12/01/22 revealed the resident had mental health behaviors with a history of violence, drug, and alcohol abuse. The Care Plan lacked interventions regarding R1's history of sexual offense involving a minor, which required a served prison sentence and the resident currently involved with a parole officer. Review of the Nurse's Notes dated 05/30/23 revealed the nurse notified the resident's guardian of last night's occurrence. The notes failed to include details to describe what the occurrence was and/or who were involved. Review of R2's EMR on 05/31/23 revealed the diagnoses of traumatic brain injury (a serious condition that affects the brain's function). Review of R2's Care Plan dated 03/01/23 revealed the resident required assistance from staff for activities of daily living (ADL) due to a history of brain injury. The Care Plan included the resident had a history of being sexually inappropriate and grabbing both male and female staff and addressed the staff should provide all cares in pairs. The Care Plan lacked interventions to protect resident from R2's sexually inappropriate behaviors. On 05/31/23 at 01:50 PM attempt made to interview R2, but he refused to talk about the incident shaking his head and would not say what happened. The resident got angry and yelled no. On 05/31/23 at 02:15 PM attempt made to interview R1, but he refused to talk to the surveyor and started cussing. During an interview on 05/31/23 at 03:30 PM CNA G reported the night of the incident she was up in front doing paperwork when she heard R1 yell for help. CNA D went and asked R1 what he was doing. R1 was in his room and reported he got confused trying to find the bathroom. His O2 tubing laid in the hall. CNA D told CNA G he asked R2 what was going on and R2 told him R1 was in his room jacking off. She did not go down the hall and stayed up front charting. Interview on 05/31/23 at 02:05 PM revealed Hospice Staff E reported he talked to R1 about the incident but R1 said he was sleepwalking when the incident occurred and was looking for the bathroom. An interview on 05/31/23 at 06:07 PM revealed CNA D reported he heard R1 yelling for help. He went and found R1 naked, with nothing on. His O2 tubing was across the hall in the doorway of R2's room. CNA D asked the resident why he was screaming and how his O2 tubing got across the hall. R1 told CNA D he got turned around looking for the bathroom. When CNA D asked him if he went into the other resident's room to use the bathroom, R1 stated he might have but did not remember. CNA D assisted R1 back to bed and placed his O2 back on. CNA D said he then went across the hall and talked to R2, and R2 told him R1 came in his room and stood by his bed and was jacking off. R2 also reported R1 reached over and touched his hand. The CNA noted there was yellow liquid on the floor, so he left the room and went to get the charge nurse. He also reported this was not the first time this had happened. CNA D stated R1 was seen coming out of R2's room naked a couple of weeks ago, but he did not know exactly when, and no one ever talked to CNA D about it, so he thought they had dealt with it until R1 did it again. On 05/31/23 at 01:20 PM, Administrative Nurse B reported the night of 05/30/23 a resident alleged that another resident sexually abused him in his room. She reported the facility tried to contact KDADS but had to send an e-mail reporting it. She reported the physician was notified when it happened and Administrative Nurse B acknowledged they had not documented any of the occurrence in the chart. The police department were notified and provided a case number and R1's parole officer was also notified. The resident was placed on 1:1 supervision pending the investigation. On 05/31/23 at 01:35 PM Interim Administrative Staff A reported she was just writing the complaint up and had just talked to KDADS but had been trying to get a hold of them. She did send an e-mail when this happened and waited for a return call. Interim Administrative Staff A stated based on the interviews with residents and staff, and the exam by law enforcement and practitioner, no abuse could be substantiated. Interview on 05/31/23 at 03:00 PM Nurse Practitioner H reported both men were his clients and he thoroughly checked R2 for any injury, bruises, or trauma. The resident had no injuries. The R2 denied to the NP anything happened with the other resident. The NP reported R2 had a TBI and had a history of sexual fantasies and behaviors and it was documented in his record, he had done this before. NP H said they attempted to do a gradual dose reduction (GDR) on some of his medications and would need to see what might cause his behaviors. NP H reported he was the practitioner for R1 and with his poor medical condition due to severe chronic obstructive pulmonary disease he did not think it was realistic to think he could do anything like that, as weak and short of air as he is. NP H said there was some concern that semen was found on the floor, but the way it was described by nursing staff, it sounded like it was possibly urine. R1 did have times where he became confused when he tried to get up on his own, but he doubted he could sexually perform. An interview on 06/01/23 at 07:15 AM with Licensed Nurse (LN) C revealed the night of 05/30/23 she heard CNA D down the north hall asking R1 what he was doing, at about 03:15 AM. She then went down the hall and observed R1 standing in his doorway, at the foot of his bed, holding onto his wheelchair. His O2 was off, and the tubing was unplugged from the concentrator. CNA D replaced the resident's O2 tubing. The resident only had a shirt on, his brief was off and lying on the floor, by his feet. R1 told LN C he was looking for the bathroom and did not know if he went in the other resident's room. LN C then went across the hall and asked R2 if there was anyone who came into his room. R2 reported R1 had come in and stood by his bed and jacked off. LN C reported R2 was very sexually driven and had always made comments to staff in a sexual nature. LN C said R2 did report R1 touched his arm. LN C did see fluid on the floor, but it was not by the resident's bed, it was by the second bed in the room. LN C stated it looked like urine to her, but she left it for Administrative Nurse B to see. LN C said Administrative Nurse B told her to write all the incident on paper in a witness statement, so she got the impression she was not to chart it in the Electronic Medical Record (EMR). LN C stated about two weeks ago, just as the night shift was getting ready to leave the building at the end of their shift, a CNA came to the nurse's station and reported staff saw R1 come out of R2's room, naked. The day nurse said she would take care of it, so LN C left for home. When LN C came on duty the next night there had been nothing done or documented about the incident. When this current incident happened, she asked Administrative Nurse B what was going to happen since this was the second time it had happened. She got no reply from Administrative Nurse B. On 06/01/23 at 08:12 AM Administrative Nurse B reported she was aware of the first incident with the resident being seen in the hall without his clothes on and directed staff to take the resident back to his room. Administrative Nurse B stated no investigation or follow-up was done on that incident. 0n 06/01/23 at 08:31 AM Hospice Nurse I reported LN J told her the incident happened around 03:30 AM. LN J told her the fluid looked like semen and that CNA D found R1 naked. R2 stated that R1 was touching his arm while touching himself. When hospice Nurse I asked R1 about it he stated he could not have gotten up. Review of the Facility Policy for Abuse, Neglect and Exploitation dated 03/31/20 revealed Prevention, Identification, Investigation and Protection from abuse. The policy stated facility staff would be educated and trained in abuse upon hire. The care plans would be developed for each applicable resident that identify specific interventions for dealing with residents with behaviors. All facility employees and volunteers are educated to report all alleged or suspected abuse immediately to Administrator or DON. Investigation will be conducted, and administrator will contact KDADS within 24 hours of incident or if meets certain criteria within 2 hours. The facility failed to ensure the protection of the residents from ANE when the facility did not implement any care planned interventions to address the hypersexualized behaviors of bed bound R2 (a resident with traumatic brain injury) and did not implement any care planned interventions to address the behaviors of independently mobile R1 (with a history of imprisonment due to the sexually predatory behavior), who was found twice naked in/around R2's room. On 06/01/23 at 09:38 AM Interim Administrator A and Administrative Nurse B were provided a copy of the Immediate Jeopardy (IJ) template and were informed the failure of the facility to protect the residents from ANE allegations placed all residents in immediate jeopardy. The facilty provided an acceptable plan for removal of the IJ on 06/05/23 at 07:48 AM, which included the following corrective actions: 1. Review/modify current policies as applicable to ensure appropriate procedures nare in place to prevent harm/potential harm on 06/01/23. 2.Checklists and monitoring tools used to verify compliance was ongoing. 3.Educate necessary staff on facility procedures with return demonstration, where applicable. 100% re-education on facility ANE policy and reporting procedures. Written policy and procedures provided to every staff member on 06/01/23. 4.100% care plan review to assure residents with a history of sexual abuses, behaviors or convictions are care planned to indicate interventions for inappropriate behavior. 06/01/23 5. Relocation of R2 from room N20 to W19 and placed in a private room. 6. Room directly across from R1 to remain empty and R1 to continues in a private room on 06/01/23. On 06/05/23 at 02:50 PM the surveyor validated the implementation of the removal plan. The deficient practice remained at a F scope and severity.

The facility reported a census of 43 residents, with two included in the sample. Based on observation, interview, and record review the facility failed to ensure the protection of the residents from Abuse, Neglect, and Exploitation (ANE) when the facility did not implement any care planned interventions to address the hypersexualized behaviors of bed bound Resident (R)2 (a resident with traumatic brain injury) and did not implement any care planned interventions to address the behaviors of independently mobile R1 (with a history of imprisonment due to the sexually predatory behavior), who was found twice naked in/around R2's room. This failure placed all residents in immediate jeopardy. Findings included: - On 05/31/23 an on-site visit was conducted in the facility regarding KS00180480 reporting R1 was found naked and masturbating at the bedside of bedbound resident R2. The allegation included semen was on the bed and floor of R2. Review of the facility investigation dated 05/31/23 revealed R1 received Hospice services for chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). He always required oxygen (O2). He could walk very short distances holding onto his wheelchair. Regarding the incident on 05/30/23 Certified Nurse Aide (CNA) D finished rounds on the north hall when CNA D heard R1 on north hall yelling for help. R1 stood in his doorway hunched over his wheelchair gasping for air. R1 was naked and his brief was at his feet in the doorway. R1's O2 tubing laid on the floor in the hallway behind him and was not attached to his concentrator. CNA D asked R1 what he was doing, and R1 reported he got turned around looking for the bathroom. CNA D assisted him to his wheelchair and reapplied his O2. CNA D asked if he made it to his bathroom or someone else's and R1 reported he thought his, but was not sure. R1's tubing was across the hallway, on the floor and in the doorway of R2's room. R2 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment and a diagnosis of traumatic brain injury (TBI), hemiplegia, hemiparesis (inability to use one side of body), and inappropriate sexual behavior. R2 had a history of making inappropriate sexual comments to the staff. The staff found R2 lying in bed covered with his blanket, and the lights were out. The nurse asked if there had been a man in his room and R2 answered yes. The nurse asked what the man was doing, and R2 said he was jerking off and made a hand gesture. The nurse asked R2 if the man touched him, and R2 said yes and pointed to his arm. The nurse examined his arm and no marks or redness found. R2 was incontinent of both bowel and bladder and staff changed his brief at approximately 03:00AM and at 05:00AM and his brief was undisturbed. The staff found liquid on the floor of R2's room and left it for Administrative Nurse B to examine. During an interview from Administrative Nurse B, the resident (R2) further claimed the man had sexually assaulted him, even though R2's brief was intact. Administrative Nurse B cleaned the fluid up from the floor and reported it was yellow and smelled like ammonia. There was urine in R2's toilet, even though R2 could not get out of bed and did not use the toilet in his room. Review of R1's Care Plan dated 12/01/22 revealed the resident had mental health behaviors with a history of violence, drug, and alcohol abuse. The Care Plan lacked interventions regarding R1's history of sexual offense involving a minor, which required a served prison sentence and the resident currently involved with a parole officer. Review of the Nurse's Notes dated 05/30/23 revealed the nurse notified the resident's guardian of last night's occurrence. The notes failed to include details to describe what the occurrence was and/or who were involved. Review of R2's EMR on 05/31/23 revealed the diagnoses of traumatic brain injury (a serious condition that affects the brain's function). Review of R2's Care Plan dated 03/01/23 revealed the resident required assistance from staff for activities of daily living (ADL) due to a history of brain injury. The Care Plan included the resident had a history of being sexually inappropriate and grabbing both male and female staff and addressed the staff should provide all cares in pairs. The Care Plan lacked interventions to protect resident from R2's sexually inappropriate behaviors. On 05/31/23 at 01:50 PM attempt made to interview R2, but he refused to talk about the incident shaking his head and would not say what happened. The resident got angry and yelled no. On 05/31/23 at 02:15 PM attempt made to interview R1, but he refused to talk to the surveyor and started cussing. During an interview on 05/31/23 at 03:30 PM CNA G reported the night of the incident she was up in front doing paperwork when she heard R1 yell for help. CNA D went and asked R1 what he was doing. R1 was in his room and reported he got confused trying to find the bathroom. His O2 tubing laid in the hall. CNA D told CNA G he asked R2 what was going on and R2 told him R1 was in his room jacking off. She did not go down the hall and stayed up front charting. Interview on 05/31/23 at 02:05 PM revealed Hospice Staff E reported he talked to R1 about the incident but R1 said he was sleepwalking when the incident occurred and was looking for the bathroom. An interview on 05/31/23 at 06:07 PM revealed CNA D reported he heard R1 yelling for help. He went and found R1 naked, with nothing on. His O2 tubing was across the hall in the doorway of R2's room. CNA D asked the resident why he was screaming and how his O2 tubing got across the hall. R1 told CNA D he got turned around looking for the bathroom. When CNA D asked him if he went into the other resident's room to use the bathroom, R1 stated he might have but did not remember. CNA D assisted R1 back to bed and placed his O2 back on. CNA D said he then went across the hall and talked to R2, and R2 told him R1 came in his room and stood by his bed and was jacking off. R2 also reported R1 reached over and touched his hand. The CNA noted there was yellow liquid on the floor, so he left the room and went to get the charge nurse. He also reported this was not the first time this had happened. CNA D stated R1 was seen coming out of R2's room naked a couple of weeks ago, but he did not know exactly when, and no one ever talked to CNA D about it, so he thought they had dealt with it until R1 did it again. On 05/31/23 at 01:20 PM, Administrative Nurse B reported the night of 05/30/23 a resident alleged that another resident sexually abused him in his room. She reported the facility tried to contact KDADS but had to send an e-mail reporting it. She reported the physician was notified when it happened and Administrative Nurse B acknowledged they had not documented any of the occurrence in the chart. The police department were notified and provided a case number and R1's parole officer was also notified. The resident was placed on 1:1 supervision pending the investigation. On 05/31/23 at 01:35 PM Interim Administrative Staff A reported she was just writing the complaint up and had just talked to KDADS but had been trying to get a hold of them. She did send an e-mail when this happened and waited for a return call. Interim Administrative Staff A stated based on the interviews with residents and staff, and the exam by law enforcement and practitioner, no abuse could be substantiated. Interview on 05/31/23 at 03:00 PM Nurse Practitioner H reported both men were his clients and he thoroughly checked R2 for any injury, bruises, or trauma. The resident had no injuries. The R2 denied to the NP anything happened with the other resident. The NP reported R2 had a TBI and had a history of sexual fantasies and behaviors and it was documented in his record, he had done this before. NP H said they attempted to do a gradual dose reduction (GDR) on some of his medications and would need to see what might cause his behaviors. NP H reported he was the practitioner for R1 and with his poor medical condition due to severe chronic obstructive pulmonary disease he did not think it was realistic to think he could do anything like that, as weak and short of air as he is. NP H said there was some concern that semen was found on the floor, but the way it was described by nursing staff, it sounded like it was possibly urine. R1 did have times where he became confused when he tried to get up on his own, but he doubted he could sexually perform. An interview on 06/01/23 at 07:15 AM with Licensed Nurse (LN) C revealed the night of 05/30/23 she heard CNA D down the north hall asking R1 what he was doing, at about 03:15 AM. She then went down the hall and observed R1 standing in his doorway, at the foot of his bed, holding onto his wheelchair. His O2 was off, and the tubing was unplugged from the concentrator. CNA D replaced the resident's O2 tubing. The resident only had a shirt on, his brief was off and lying on the floor, by his feet. R1 told LN C he was looking for the bathroom and did not know if he went in the other resident's room. LN C then went across the hall and asked R2 if there was anyone who came into his room. R2 reported R1 had come in and stood by his bed and jacked off. LN C reported R2 was very sexually driven and had always made comments to staff in a sexual nature. LN C said R2 did report R1 touched his arm. LN C did see fluid on the floor, but it was not by the resident's bed, it was by the second bed in the room. LN C stated it looked like urine to her, but she left it for Administrative Nurse B to see. LN C said Administrative Nurse B told her to write all the incident on paper in a witness statement, so she got the impression she was not to chart it in the Electronic Medical Record (EMR). LN C stated about two weeks ago, just as the night shift was getting ready to leave the building at the end of their shift, a CNA came to the nurse's station and reported staff saw R1 come out of R2's room, naked. The day nurse said she would take care of it, so LN C left for home. When LN C came on duty the next night there had been nothing done or documented about the incident. When this current incident happened, she asked Administrative Nurse B what was going to happen since this was the second time it had happened. She got no reply from Administrative Nurse B. On 06/01/23 at 08:12 AM Administrative Nurse B reported she was aware of the first incident with the resident being seen in the hall without his clothes on and directed staff to take the resident back to his room. Administrative Nurse B stated no investigation or follow-up was done on that incident. 0n 06/01/23 at 08:31 AM Hospice Nurse I reported LN J told her the incident happened around 03:30 AM. LN J told her the fluid looked like semen and that CNA D found R1 naked. R2 stated that R1 was touching his arm while touching himself. When hospice Nurse I asked R1 about it he stated he could not have gotten up. Review of the Facility Policy for Abuse, Neglect and Exploitation dated 03/31/20 revealed Prevention, Identification, Investigation and Protection from abuse. The policy stated facility staff would be educated and trained in abuse upon hire. The care plans would be developed for each applicable resident that identify specific interventions for dealing with residents with behaviors. All facility employees and volunteers are educated to report all alleged or suspected abuse immediately to Administrator or DON. Investigation will be conducted, and administrator will contact KDADS within 24 hours of incident or if meets certain criteria within 2 hours. The facility failed to ensure the protection of the residents from ANE when the facility did not implement any care planned interventions to address the hypersexualized behaviors of bed bound R2 (a resident with traumatic brain injury) and did not implement any care planned interventions to address the behaviors of independently mobile R1 (with a history of imprisonment due to the sexually predatory behavior), who was found twice naked in/around R2's room. On 06/01/23 at 09:38 AM Interim Administrator A and Administrative Nurse B were provided a copy of the Immediate Jeopardy (IJ) template and were informed the failure of the facility to protect the residents from ANE allegations placed all residents in immediate jeopardy. The facilty provided an acceptable plan for removal of the IJ on 06/05/23 at 07:48 AM, which included the following corrective actions: 1. Review/modify current policies as applicable to ensure appropriate procedures nare in place to prevent harm/potential harm on 06/01/23. 2.Checklists and monitoring tools used to verify compliance was ongoing. 3.Educate necessary staff on facility procedures with return demonstration, where applicable. 100% re-education on facility ANE policy and reporting procedures. Written policy and procedures provided to every staff member on 06/01/23. 4.100% care plan review to assure residents with a history of sexual abuses, behaviors or convictions are care planned to indicate interventions for inappropriate behavior. 06/01/23 5. Relocation of R2 from room N20 to W19 and placed in a private room. 6. Room directly across from R1 to remain empty and R1 to continues in a private room on 06/01/23. On 06/05/23 at 02:50 PM the surveyor validated the implementation of the removal plan. The deficient practice remained at a F scope and severity.

The facility identified a census of 44 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of RN assessment and oversight of care. Findings included: - Review of the nursing schedule from 09/01/22 through 12/04/22 revealed a lack of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 09/05/22, 09/11/22, 09/25/22, 10/23/22, 10/30/22, 11/13/22, 11/20/22, 11/24/22, 11/27/22, and 12/04/22. On 12/07/22 at 04:45 PM Administrative Staff A stated the facility was unable to provide documentation of Registered Nurse coverage eight consecutive hours for the ten days. On 12/08/22 at 03:08 PM Administrative Nurse D stated she was the person responsible for staffing and the person that who provided Registered Nurse coverage. Administrative Nurse D stated she was not able to provide documentation that she had coverage eight consecutive hours. Administrative Nurse D stated she could show charting documentation she did on some of the dates above. She also stated she could show what time she entered the facility from temperature, screening device. She stated she tracked the hours she worked in her planner as well. On 12/12/22 the facility provided Covid (highly contagious respiratory virus) screening times from the Accushield (electronic symptom and health surveillance device) pasted into two notepad documents for Administrative Nurse D and Administrative Nurse E. The facility further offered the Payroll Based Journal (PBJ) submitted for the months in question, daily schedules, and/or review of medical record chart notes as verification of the presence of an RN in the facility but was unable to provide verification of the consecutive hours as required. The facility's Nursing Services-Registered Nurse (RN) policy undated documented the facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, as required. This placed the residents who resided in the facility at risk of lack of RN assessment and oversight of care.

The facility identified a census of 44 residents. The sample included 15 residents. Based on observations, record review, and interviews, the facility failed to ensure staff treated Resident (R) 91 with dignity. This deficient practice had the risk for decreased self-esteem and dignity for R91. Findings included: - On 12/08/22 at 09:26 AM an unidentified hospice staff and Certified Nurse Aide (CNA) M propelled R91 in the shower chair from his room across the hall to the shower room. R91 was covered with a bath blanket on the front of his body but the side of his legs and buttocks were visible. R91's scrotum was visible underneath the shower chair. On 12/08/22 at 01:36 PM, CNA M stated she treated residents with dignity by making sure they were covered up all the way in the shower chair. She stated she tried to leave a gown on them or wrap a bath blanket all around the back. CNA M stated it was inappropriate to transfer R91 in the shower chair without being covered up. On 12/08/22 at 02:26 PM, Licensed Nurse (LN) G stated residents were treated with dignity by being covered completely in the shower head except for their head because she did not want them to be cold or exposed. On 12/08/22 at 03:07 PM, Administrative Nurse D stated staff made sure they still wore a gown or had a blanket on when transferring in the shower chair. She stated residents were covered top to bottom, as well as their sides and buttocks. The facility's Quality of Life- Dignity policy, last revised August 2009, directed staff promoted, maintained, and protected resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The facility failed to ensure staff treated R91 with dignity. This deficient practice had the risk for decreased self-esteem and dignity for R91.

The facility identified a census of 44 residents. The sample included 15 residents. Based on observations, record review, and interviews, the facility failed to ensure adequate equipment was available and used during wheelchair locomotion for Resident (R) 11 and R35. This deficient practice placed the affected residents at risk for unmet needs. Findings included: - On 12/06/22 at 08:00 AM, Certified Medication Aide (CMA) S propelled R35 in her wheelchair into the dining room. There were no foot pedals on her wheelchair and her feet dragged on the ground. The Quarterly MDS dated [DATE], documented R35 was independent with no setup help with locomotion. On 12/06/22 at 10:52 AM, Consultant HH propelled R11 in his wheelchair from the dining room to the lobby area. There were no foot pedals on the wheelchair and R11's feet dragged on the floor. On 12/07/22 at 09:48 AM, Consultant HH propelled R11 in his wheelchair from the dining room to the nurse's station. There were no foot pedals on the wheelchair and R11's feet dragged on the ground. The Significant MDS dated [DATE], documented R11 required extensive physical assistance with one staff for locomotion. On 12/08/22 at 01:36 PM, Certified Nurse Aide (CNA) M stated she kept residents safe during wheelchair propulsion by making sure they were sat all the way back in the wheelchair and using foot pedals. She stated it was not safe to push a resident in a wheelchair without foot pedals. On 12/08/22 at 02:26 PM, Licensed Nurse (LN) G stated she kept residents safe during wheelchair propulsion by not going too fast and having foot pedals on wheelchairs if they were not able to keep their feet up. She stated if the resident's feet dragged a bit then they needed to have foot pedals on. On 12/08/22 at 03:07 PM, Administrative Nurse D stated there were some residents that used foot pedals and some that did not. She stated staff had residents lift their feet up but recently discovered that was not okay to do and she needed to provide education on that. The facility's Accommodation of Needs policy, not dated, directed the facility made efforts to reasonably accommodate the needs and preferences of the resident as they made use of their physical environment. The facility failed to ensure adequate equipment was available and used during wheelchair locomotion for R11 and R35. This deficient practice placed the affected residents at risk for unmet care needs.

The facility reported a census of 43 residents and the sample included 3 residents for falls. Based on observation, record review, and interviews, the facility failed to provide interventions for the prevention of falls as planned for 2 (#2, and #3) with falls, and failed to reassess to develop effective interventions for 1 (#1) resident with numerous falls and brain hematoma. Findings included: - Resident #1's quarterly Minimum Data Set (MDS) 3.0 dated 7/26/12 recorded the resident had a BIMS (Brief Interview for Mental Status) score of 9 (mildly impaired), had signs/symptoms of delirium such as inattention and altered level of consciousness, had verbal behavioral symptoms directed towards others, did not reject care, needed extensive assistance with bed mobility, transfer, walk in room, locomotion on and off unit, dressing, toilet use and personal hygiene. The MDS recorded the resident was only able to stabilize with the assistance of staff when turning around, when moving from seated to standing position, when walking, when moving on/off toilet, and during surface to surface transfer. Mobility devices included wheel chair and walker. The MDS recorded the resident was frequently incontinent of bladder. The MDS recorded the resident had [DIAGNOSES REDACTED]. The MDS recorded the resident had 2 non injury falls. The Fall Risk assessment dated [DATE] recorded a score of 25 (over 10 equaled a high risk for falls)and recorded the resident had intermittent confusion, had 3 or more falls in the last 3 months, had balance problems while standing/walking, jerking or unstable when making turns and required the use of assistive devices. The care plan dated 9/20/11 and last reviewed 8/21/12 recorded the resident used a wheel chair to get around, walked to meals, needed to have someone walk with him/her so he/she did not fall, but sometimes would not wait for staff. The care plan recorded the resident knew he/she was supposed to have someone with him/her during transfer but the resident wanted to do it on his/her own and would not ask for help. The care plan recorded the resident had grab bars in the bathroom, and the staff used a gait belt for all transfers/ambulation. The care plan recorded the resident knew when he/she needed to go to the bathroom, and would let someone know so they could come and help, and the nurses had a toileting schedule for the resident. The care plan for safety dated 9/20/11 and last reviewed 8/21/12 recorded the following: "please keep my call light in reach so I can call for assist when I need something, I am alert/oriented with intermittent confusion and forgetfulness, I do not always use my call light, if you find me up without assist please come and help me and re-educate me on the importance of having someone with me for all transfers, when I am in my room please make sure I am not sitting in my wheel chair, assist me into my recliner, make sure my feet are elevated with recliner remote placed back in the pocket so it did not fall on the floor, I will try and reach for it, per family request keep wheel chair, walker by my closet after assisting me into my chair." The facility placed call light pad in the recliner, (no date recorded), "5/7/12 I fell when I got up/lost balance, found on floor at 11:15 A.M. wheel chair/walker on top of my head, recliner up in the standing position and call pad in place and activated, 2 falls on 6/2/12, fell on [DATE] I tried to get up from my wheel chair holding onto the bedside table, when I stood up the table rolled away causing me to fall, I hit my head on the air conditioner," The care plan recorded the resident received a 4 centimeter (cm), and a ? cm to my right elbow and the regular call light went off due to I have a call light pad on my chair." On 8/17/12 the facility started Seroquel (an anti-psychotic)25 milligrams (mg) daily. The care plan recorded the resident on 8/20/12 had an unwitnessed fall, and was transported to the hospital for evaluation/treatment. A physician visit dated 6/27/12, recorded the resident mentally had very bad short term memory issues, was very forgetful, could actually respond on an immediate basis and made some sense but will not remember minutes later what we talked about. The resident was a fall risk and fell many times before and was not supposed to get up unless assisted. Nurse's Notes dated 6/30/12 at 10:45 A.M. staff heard resident's room mate yelling from the resident's room, and found resident on his/her back on the floor with the wheel chair tipped over in front of him/her. The resident said he/she tried to move his/her wheel chair and thought he/she did not need help. The call light pad was activated, after assessment, 2 staff assisted the resident into the recliner, and initiated neurological assessment. The notes recorded the resident sat in his/her recliner 5 minutes earlier. The care plan lacked any additional interventions for the prevention of falls. The Interdisciplinary Team (IDT) notes dated 7/2/12 recorded on 6/30/12 the staff found the resident on the floor at 10:45 A.M. in his/her room, on his/her back, wheel chair tipped in front of the resident and the resident's call pad in the recliner was activated. The care plan lacked any additional interventions for the prevention of falls. IDT notes dated 8/10/12, recorded on 8/9/12 staff heard a crashing noise, went to investigate the noise, found the resident on the floor, and turned on the green light for assist, resident had a call light pad, which did go off, resident stated he/she went to ambulate and held on to the bedside table and the table rolled away causing the resident to fall. The resident hit his/her head on the air conditioner and received a skin tear to his/her right elbow. When the staff found the resident he/she lay on his/her right side. The facility will give the resident a non movable table. IDT notes dated 8/15/12, (no time) recorded on 8/14/12 at 2:15 P.M. the housekeeper walked by the resident's room and saw the resident up, the staff went to get a nurse to assist the resident. "The resident's call light was going off due to call pad." The resident stated he/she saw his/her wheel chair and walker across the room and went to get it. The nurse found the resident on the floor in front of the recliner. Staff recorded IDT would educate non nursing staff what to do for this type of situation. IDT notes dated 8/15/12 recorded the facility would re-check urine for UTI, recorded the resident just completed antibiotic (ABT) for UTI. IDT notes dated 8/21/12 at 12:30 P.M. recorded IDT met to review fall on 8/20/12. Resident's call light was on, staff went to his/her room, and found him/her sitting on his/her bottom with the back against the air conditioner unit, at 10:00 A.M. As the day progressed resident's blood pressure gradually increased, he/she complained of a head ache and leaned to his/her right. The resident vomited at lunch and became less responsive with cares. The facility sent the resident to the emergency room by ambulance. The hospital discharge summary recorded they admitted the resident on 8/20/12 with an acute subdural hemorrhage. (this is a subdural bleeding that develops shortly after a serious blow to the head, blood collects very fast in this injury and may cause the pressure to rise within the brain, if not diagnosed and treated promptly severe brain injury or death may occur). The facility investigation dated 8/21/12 recorded the resident had an unwitnessed fall that occurred on 8/20/12 at 10:05 A.M., The facility said the resident was alert and confused, had muscle weakness, Alzheimer's disease, difficulty walking, and was aphasic. The facility recorded the resident fell in his/her room, the call light sounded when he/she rose from his/her chair and the staff found the resident sitting on the floor with legs extended in front. The nurse assessed the resident and initially found the resident to be uninjured, the nurse initiated neurological assessment and as the morning progressed they noted that his/her condition worsened. The facility transferred the resident to the hospital at 1:20 P.M., and the admitting [DIAGNOSES REDACTED]. Interview on 9/12/12 at 2:42 PM with administrative nursing staff C and licensed nursing staff E stated the resident was confused most of the time. Interventions after each fall included nursing did 15 minute, 30 minute or 1 hour checks in combination with neurological checks. Also the more confused the resident was the more often they checked on the resident, they placed the wheel chair and the walker out of reach to lessen his/her temptation, they had a psychological evaluation and the consultant said that the resident believed that what he/she saw on TV was his/her reality. The resident liked to watch cable news so that was always on, and the resident used to get really agitated, thought his/her family was killed. The resident thought he/she needed to go to the family, got up to remedy what he/she saw on TV, thought it was happening to him/her. The staff said once they figured that out they changed the cannel to animal planet. The staff did not remember when they changed the TV shows but said they thought the resident, after that, was no longer in a rescue mode. Other interventions included non skid strips in front of the recliner, everything within reach, chair pad call light in the recliner where he/she also slept. The staff said the resident was able to get out of the recliner on their own and used the chair remote to do so. The staff said the resident's chair pad call light sounded the same as the call light. The staff could not distinguish between the two sounds as they were the same. The facility failed to provide effective interventions for the prevention of falls for this dependent and confused resident with frequent falls with injury. - Resident #3's admission Minimum Data Set (MDS) 3.0, dated 8/15/12 recorded the resident rarely/never understood others or made self understood, had short-and long-term memory deficits, had severely impaired cognitive skills for daily decision making, was inattentive, had no behavioral problems, rejected care and wandered 1-3 days during the assessment period, needed extensive assistance of 2 staff for bed mobility, transfer, hygiene, toilet use, and dressing, and needed extensive assistance of 1 staff for locomotion on the unit. The MDS recorded the resident was only able to stabilize with the assistance of staff when moving from seated to standing position, when walking, when moving on/off toilet, and during surface to surface transfer. The resident had limitation in range of motion of lower extremities, used a wheel chair, was frequently incontinent of bladder, had falls in the past month, past 2-6 months prior to admission, and had 1 injury fall since admission. The Care Area Assessment (CAA) for cognitive loss dated 9/13/12 recorded the resident was a new admission from another nursing facility and had profound dementia and his/her ability to make needs known was severely impaired. The resident became restless and fidgety in the early afternoon and the family reported this to staff on admission. The resident could become resistant to showering, and was known to wander in the wheel chair. The CAA for falls dated 9/13/12 recorded the resident was an actual fall risk and had a history of [REDACTED]. The resident's safety awareness was poor and he/she liked to get up on his/her own. The resident's bed was hi/low with a mat on the floor next to the bed, and a call light alarm on his/her bed to alert staff when he/she got up. Therapy worked with the resident to gain strength and endurance to help prevent falls. The Fall Risk assessment dated [DATE] recorded a score of 16, on 8/10/12 a score of 20, and on 9/3/12 a score of 22 with a score of 10 or above equaled a high risk for falls. The admission care plan dated 8/3/12 recorded: "I am a high fall risk please do not leave me unattended in the bathroom, on 8/8/12 Seroquel (an anti-psychotic) 25 milligrams (mg) daily, skin tears to upper extremity, above and below elbow on 8/4/12, on 8/20/12 leave gait belt on when in wheel chair or other chair due to spontaneously getting up and multiple falls, on 8/21/12 due to fall in room 30 minute visuals when in bed, high/low bed, matt by bed, on 8/3/12 call light pad on bed to alert staff that I am going to get up, on 8/5/12 physical therapy/occupational therapy times 30 days, on 8/17/12 change time of Seroquel to bedtime, on 8/29/12 discontinue Seroquel, start Depakote 9/12/12 250 mg three times daily." The care plan for safety dated 8/21/12 recorded: "I am a high fall risk and have a history of falling, I have profound dementia and when I get up my gait is unsteady, I do not have safety awareness to know I need help when I am up, don't leave me unattended in the bath room, I need someone with me at all times in the bath room, I sleep in a high/low bed with matt by the bed, keep bed in the lowest position, I have a call light pad on my bed to help alert nursing staff when I am getting up, due to falling in my room check on me every 30 minutes while I am in bed, I try to get up on my own." The care plan included an individualized toileting plan. On 8/20/12 transport to the emergency room . The care plan for mental wellness dated 8/21/12 recorded "you will usually see me in the lobby area with legs elevated, will nap on/off during the day, I depend on staff to take care of me, due to having advanced dementia I am unable to voice my needs, I receive meds for behaviors and Alzheimer's disease, I have occasional combative behaviors, when I'm receiving cares, I am more restless in the evening times, I frequently get up on my own, I am known for falling prior to admission here, and I have been falling here, please leave a gait belt on when I am sitting up at all times, this can keep nursing staff better able to prevent me from falling when I spontaneously get up." Nurse's Notes (NN) dated 8/4/12 at 7:00 P.M. recorded the staff saw the resident stumble in lobby/lounge near book shelf, and by the time the staff got there, the resident was on the floor bumped his/her head on the book case. Assessment revealed 2 skin tears, 1 was 11 x 8 centimeter (cm) on the upper right arm at the elbow and one was on the lower right arm 11 x 8 cm at the elbow, range of motion within normal limits, staff initiated neurological checks and vitals, the facility initiated bed and chair alarms. The resident complained of pain to the skin tear sight, offered him/her Tylenol which he/she refused to take. NN 8/5/12 at 11:15 A.M. recorded that the facility had no available bed and chair alarms, staff would notify therapy on 8/6/12 to discuss call light alarm while in bed. NN 8/5/12 at 7:00 P.M. the resident continued to try to stand up from the wheel chair, staff would continue to monitor and provide support. Interdisciplinary team (IDT) notes dated 8/6/12 recorded the team met to review fall on 8/4/12. The resident got up on his/her own from the wheel chair and fell into a cabinet hitting his/her head and received 2 skin tears on the right arm, therapy would re-evaluate wheel chair for positioning and self propelling. Care plan meeting to discuss ways to keep the resident's daily routine structured the same as much as possible. NN 8/7/12 at 6:30 P.M. resident sat in his/her wheel chair in the lobby, attempted to stand up and fell to the floor on the right side hitting his/her head on the edge of the end table. The nurse assessed the resident, recorded vitals, pupils sluggish, confused per his/her norm, agitated and combative. The resident received a skin tear to his/her right ear, right hand and wrist and 2 to the left hand. The staff initiated neurological checks, and notified the family and the physician. physician progress notes [REDACTED]. Apparently he/she was a high risk for falls, tended to get up and try to walk and he/she really could not. Assessment: obviously dementia was his/her major problem. Plan: get records, due to his/her irritability and behavioral issues and hallucinations we would increase Seroquel to 25 mg daily, an increase from 12.5 mg. IDT notes dated 8/10/12 the resident got up on his/her own on 8/7/12 from the wheel chair and fell into the table and hit his/her head, received skin tears to both hands and the right ear, team to continue to evaluate activity level and his/her routine i.e. what activities keep him/her busy and what he/she liked to do. NN 8/11/12 at 8:30 P.M. the resident continued to try to get up and walk by self, combative at times. NN 8/13/12 at 2:15 P.M. the resident continued to receive Physical, Occupational and Speech therapy (PT/OT/ST) for gait and transfer training, and therapeutic exercises. The resident continued to require extensive assistance with all activities of daily living, and continued to be resistive to therapy and cares. NN 8/18/12 at 2:45 P.M. the resident continued to receive PT/OT/ST for transfer training, therapeutic exercises and balance. The resident continued to attempt to get up from the wheel chair, was not easily redirected, was compliant with cares, and transferred with 2 staff. NN 8/20/12 at 3:45 P.M. recorded "nurses were summoned at 6:05 am (A.M.) to resident room to find the resident laying on the floor face down. The resident has bed call light alarm which summoned staff to the room." The resident had blood on his/her face and left forearm, 2 skin tears to the back of the left hand and a laceration to the bridge of the nose and to the mid forehead. The facility informed the family and the physician of the fall with injury. The ambulance transported the resident to the emergency room (ER). ER reported the hospital repaired the laceration to the nose and forehead and sutured one skin tear on the left hand. The resident returned per ambulance at 2:00 P.M. The facility reported to the state agency and investigated this unwitnessed fall. ER notes dated 8/20/12 recorded the CT (computed tomography) scan of the head revealed the resident had comminuted acute minimally displaced bilateral nasal bone fractures with surrounding soft tissue swelling. IDT notes dated 8/21/12 recorded the team met to review the fall on 8/20/12, the call pad alarm sounded and staff found the resident lay face down on the floor in the center of the room with blood on the floor. The resident received lacerations to the forehead, bridge of nose and to the left hand. The facility transferred the resident via ambulance to the hospital. The resident returned with [DIAGNOSES REDACTED]. The facility applied non- skid socks to the residents' feet when he/she had shoes off, and 30 minute visuals when in bed. NN 9/4/12 at 11:20 A.M. recorded the resident had a non injury fall on 9/1/12 at 4:00 P.M. direct care staff reported that as he/she came out of the resident's bathroom he/she observed the resident slowly falling to the floor between the bed and wheel chair. The staff noted no injury. IDT 9/4/12 met to review fall on 9/1/12, the direct care staff helped the resident's room mate in the bathroom when he/she looked and saw the resident attempt to get out of bed. The staff hit the emergency light for help, but the resident was on the floor when staff responded to the emergency light. The charge nurse assessed the resident and noted no injury. The intervention included to assess voiding/bowel pattern and to restart voiding diary, visual checks while resident was in bed and speak to family regarding history of activities. An observation on 9/3/12 at 7:50 A.M. direct care staff G and H prepared to get the resident up for breakfast. The resident was incontinent of urine, had non skid socks on in bed, and was in a low bed with the matt by the bed. After the staff provided personal hygiene care to the resident, they placed a gait belt on and assisted the resident into the wheel chair. No call light alarm sounded as the resident left the bed. Direct care staff G said at 8:20 A.M. you can hear a beep when they get the resident up from the bed, but could not hear one, and also the call light goes on outside the door. The staff checked the bed call light device and found that one of the plugs were not attached to the alarm or to the wall. The staff removed the gait belt once the resident sat in the wheel chair, and after the staff completed all A.M. cares they wheeled the resident to breakfast. Observation at 9:00 A.M., 9:30 A.M., and at 10:15 A.M. the resident sat in an easy chair in the front lobby/lounge with his/her legs elevated napping. Observation at 11:20 A.M. the resident sat in the easy chair in the lounge without a gait belt on, and staff interview at the time with administrative nursing staff C said the resident needed the gait belt on except when in the dining room and when in bed. The facility failed to provide interventions as planned for this resident with frequent falls with injury and fracture. - Resident #2's quarterly Minimum Data Set (MDS) 3.0 dated 7/19/12 recorded the resident was cognitively intact, had mild depression, needed limited assistance with bed mobility and transfer, needed extensive assistance with toileting and personal hygiene, had 1 injury fall since last assessment, and had [DIAGNOSES REDACTED]. The fall risk assessment dated [DATE] recorded a score of 19, with a score of 10 or above equaled a high risk for falls. The assessment recorded the resident had 1 to 2 falls in the past 3 months. The care plan dated 2/16/12 and last reviewed 8/23/12 recorded on 6/27/12 Physical and Occupational therapy (PT/OT) were to evaluate/treat for decreased strength and endurance, and change in mobility status. On 7/1/12 I am coming out of my room more attending activities, and participating in therapy. On 7/19/12 I had a non injury fall while trying to pick up something from off the floor, I have been weaker and I do not use my call light to ask for help as I should, call light pad on bed. Therapy currently working with the resident. On 8/2/12 non skid strips next to the bed, I do not always remember to use my call light, remind me and make sure it is within reach, I do have a call light pad on my bed to notify staff if I do not remember to use my call light. On 8/2/12 I had a non injury fall yesterday while I was getting myself out of bed, staff placed non skid strips next to my bed. On 8/23/12 I am using a wheel chair and can propel myself most of the times, also a 4 wheeled walker when working with therapy. On 8/23/12 I have gotten weaker so I need 1-2 staff for transfer, I need help getting my feet in my bed. Interdisciplinary team (IDT) met on 7/20/12 and recorded the resident fell on [DATE], he/she sat on the edge of bed, leaned forward to pick something up from the floor, lost his/her balance, had a non injury fall, staff will put call light pad in bed, and therapy will work on dynamic balance. IDT met on 8/3/12 and recorded on 8/2/12 at 4:30 P.M. direct care staff answered resident's call light and found him/her sitting on the floor next to the bed. The resident stated he/she was tired of laying down. The resident had no shoes or slipper sox on. The intervention was to put non skid strips in front of the bed. IDT notes 8/24/12 at 9:45 A.M. recorded the resident fell on [DATE], worked with OT in the bath room on proper transfer technique, resident's legs began to give out and the staff lowered him/her with gait belt to the floor. The resident received no injuries. An observation on 9/13/12 at 11:50 A.M. direct care staff G and H assisted the resident out of bed. The resident had a low bed with non skid strips on the floor next to the bed. The resident was dressed and had his/her shoes on in bed. The staff helped the resident sit up, and used a gait belt to transfer the resident to the wheel chair. The resident was able to take a couple of steps with the help of 2 staff. There was no call light pad in the resident's bed. An interview on 9/13/12 at 2:00 P.M. with direct care staff G said he/she had worked in the facility since June of this year and during that time the resident had not used a fall pad alarm in his/her bed. An interview 9/13/12 at 2:30 P.M. licensed nursing staff E said the resident did not have a fall pad alarm currently, and that it might have been a trial intervention and they opted for something else. The facility failed to provide fall prevention interventions as planned for this resident with frequent falls.