Every finding on record at Overland Park Post Acute

Based on observations, interviews, and record review, the facility failed to ensure staff possessed the appropriate skills and knowledge to safely provide direct care and nursing services related to Resident (R) 1's care needs. Findings included:- A Medication Error report # 648 completed on 06/11/2026 at 09:35 PM by Licensed Nurse (LN) G documented R1 received the wrong medication from Certified Medication Aide (CMA) R. R1 was scheduled to received glargine (a long-acting insulin (hormone that lowers the level of glucose in the blood) used to manage blood sugar in type 1 and type 2 diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) , providing a steady insulin level for up to 24 hours) 65 units (U), but CMA R administered Novolog (a rapid-acting insulin used to control blood sugar in adults and children with DM, typically taken five to ten minutes before meals ) 45 U as CMA R reported. The immediate actions taken for R1 included assessing R1 who was documented to be alert and oriented at that time. The event was reported to Consultant GG and Administrative Nurse D. R1's Orders tab documented the following physician orders for insulin: Basaglar Kwik Pen solution pen-injector 100 units/ML (insulin Glargine) inject 65 U's subcutaneously (beneath the skin) at bedtime related to Type 1 DM without complications, hold for blood sugar less than 70 mmol/L or unable to eat. Notify the medical director if blood sugar is less than 70 mmol/L or more than 400 mmol/L, ordered on 04/07/2026. Novolog Flex Pen solution pen-injector 100 units/ML (insulin Aspart) inject 20 U's subcutaneously three times a day related to Type 1 DM without complications, hold for blood sugar less then 70 or unable to eat. Notify the medical director if blood sugar is less than 70 mmol/L or more than 400 mmol/L, ordered on 03/22/2023 On 06/11/2026 at approximately 08:00 PM, Certified Medication Aide (CMA) R's written statement documented CMA R took R1's blood sugar and proceeded to dial up her insulin. CMA R simply misread the order on the screen and grabbed the wrong insulin pen. CMA R documented the dose for 65 U and that is what CMA R dialed up in the pen. CMA R then injected R1 with the pen. CMA R documented that R1 did not get the entire amount, due to CMA R stopping the injection after realizing it was the wrong insulin pen. CMA R documented approximately more than half of the 65 U's were injected. CMA R dialed the remainder back into the pen and alerted the nurse. On 07/14/2026 at 12:52 PM, CMA R stated that LN G had instructed her to take the carts and pass the medications. CMA R stated she had asked if that meant the insulins and reported that LN G indicated to take one of the carts and do it pointing at the cart that CMA R reported had the insulins in it. On 07/13/2026 at 02:18 PM, LN H stated No, a CMA could not administer insulin to a resident. Only a nurse could do that, but if a resident had an order to self-administer, LN H thought a CMA could dial up the insulin and hand it to a resident for the resident to administer it themselves. On 07/14/2026 at 11:20 AM, LN G was unable to be reached via phone. On 07/13/2026 at 02:05 PM, Administrative Nurse D stated that when she found out about the medication error, she interviewed CMA R and let her know that this was not Missouri, and she could not administer insulin in this state. Administrative Nurse D further revealed that CMA R then informed Administrative Nurse D that she had given insulin in the facility in the past. Administrative Nurse D stated CMA R had been put as do not return (DNR) to the facility, as CMA R was an agency staff member. Administrative Nurse D provided a typed-up statement of the phone call that she reportedly had with CMA R, while handing over the typed statement, Administrative Nurse D revealed that she had just typed it up today (07/13/2026). The statement read: On 06/11/25, Administrative Nurse D spoke with CMA R on the phone regarding the insulin medication error that occurred with R1. Education was provided to CMA R that CMA's could not administer insulin in Kansas, despite their training. CMA R verbalized understanding and stated that it would not happen again. CMA R was prohibited from returning to the facility at that time. On 07/14/2026 at 01:50 PM, Administrative Nurse D stated that LN G was an employee of the facility and that she educated LN G that a CMA could not give insulin to the residents. The facility's Administering Medications policy, revised April 2019, directed that medications were administered in a safe and timely manner, and as prescribed. The policy further directed only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so.

Based on record review, interview, and observation, the facility failed to identify the lack of required staff, resulting in a fall for Resident (R) 2 as an allegation of neglect and report to the State Agency (SA) as required. Findings included:- R2's Electronic Medical Records (EMR) documented diagnoses of focal traumatic brain injury with loss of consciousness of 30 minutes or less, epilepsy (brain disorder characterized by repeated seizures), aphasia (condition with disordered or absent language function), need for assistance with personal care, dependence on wheelchair, lack of coordination, and muscle weakness. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, which indicates severely impaired cognition. The MDS documented R2 was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and bed mobility. R2's Activities of Daily Living Care Plan revised on 02/20/2024 documented R2 was totally dependent on two staff members for repositioning and turning in bed. The plan of care documented R2 was totally dependent on two staff members for dressing. R2's Fall Care Plan interventions initiated on 07/31/2024 directed staff to ensure R2 was positioned in the center of the bed. R2's intervention initiated on 08/27/2024 directed that R2 had fall mats at the side of the bed to decrease injury if a fall occurred. The Nurse's Note dated 06/24/2026 at 05:56 AM documented R2 experienced a fall from bed during morning care. Certified Nurse Aide (CNA) M assisted R2 with getting dressed for the day when R1 rolled unexpectedly from the bed and fell to the floor. R2's bed was approximately waist high and upon impact, R2 hit the posterior aspect of his head. Upon assessment, a laceration to the back of R2's head was located and found to be bleeding. Consultant GG and Administrative Nurse D were notified and Consultant GG ordered R2 to be sent out to the emergency room for further evaluation. On 07/13/2026 at 03:19 PM, R2 had no fall mats around his bed or in his room. On 07/14/2026 at 12:40 PM, R2 sat in his wheelchair at the dining room table with CNA N assisting him with his meal. R2 appeared clean and well groomed. On 07/14/2026 at 11:27 AM, CNA O stated she would not provide cares for R2 as a one person assist. CNA O stated she had worked with him when he was on a different hallway, and she always performed his cares with another staff member. On 07/24/3036 at 01:07 PM, CNA M stated that she was alone when she was getting R2 dressed for the day. CNA M further stated that R2 had rolled, and it was unexpected. On 07/14/2026 at 01:50 PM, Administrative Nurse D stated had she missed that R2 needed two staff members to assist R2 in getting dressed. Administrative Nurse D further stated that the CNAs not being able to see the care plans explained a lot of the facility falls. Administrative Nurse D revealed that this was an allegation of neglect, and it should have been reported to the SA. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation policy, revised September 2022, documented all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy further documented all allegations were thoroughly investigated.

Based on interviews, observations, and record review, the facility failed to ensure safe activities of daily living care while helping Resident (R) 2 get dressed for the day when there was only one staff member assisting R2 and R2 rolled off the bed and hit his head, resulting in a laceration, a hematoma, and being set out to the hospital for evaluation. Findings included:- R2's Electronic Medical Records (EMR) documented diagnoses of focal traumatic brain injury with loss of consciousness of 30 minutes or less, epilepsy (brain disorder characterized by repeated seizures), aphasia (condition with disordered or absent language function), need for assistance with personal care, dependence on wheelchair, lack of coordination, and muscle weakness. R2's Activities of Daily Living Care Plan revised on 02/20/2024 documented R2 was totally dependent on two staff members for repositioning and turning in bed. The plan of care documented R2 was totally dependent on two staff members for dressing. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, which indicates severely impaired cognition. The MDS documented R2 was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and bed mobility. R2's Fall Care Plan interventions initiated on 07/31/2024 directed staff to ensure R2 was positioned in the center of the bed. R2's intervention initiated on 08/27/2024 directed that R2 had fall mats at the side of the bed to decrease injury if a fall occurred. R2's Activities of Daily Living Care Plan revised on 02/20/2024 documented R2 was totally dependent on two staff members for repositioning and turning in bed. The plan of care documented R2 was totally dependent on two staff members for dressing. The Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form dated 06/24/2026 at 05:27 AM documented R2 had a laceration to the back of his head. The Interact Transfer Form dated 06/24/2026 documented R2 the reason for transfer/discharge was a fall. The form documented R2 had a laceration to the back of his head. Review of the Emergency Provider Report dated 06/24/2026 documented R2 presented at the emergency department for evaluation after falling out of bed at his care facility. The facility staff reported that they were changing R2, when rolling R2 onto his side, staff said he rolled too far and fell onto the floor and sustained a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the back of his head. A physical exam found a superoposterior scalp hematoma with minimal abrasion (scraping or rubbing away of skin) left of midline, tender to palpation, no depressions, or signs of a skull fracture. A computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) of R2's head without contrast and a cervical spine without contrast was ordered on 06/24/2026 at 05:40 AM. The impression of the brain was no evidence of acute intracranial abnormality. The impression of the cervical spine was no evidence of acute osseous abnormality involving the cervical spine. The Nurse's Note dated 06/24/2026 at 05:56 AM documented R2 experienced a fall from bed during morning care. The Certified Nurse Aide (CNA) M assisted R2 with getting dressed for the day when R1 rolled unexpectedly from the bed and fell to the floor. R2's bed was approximately waist high and upon impact R2 hit the posterior aspect of his head. Upon assessment, a laceration to the back of R2's head was located and found to be bleeding. Consultant GG and Administrative Nurse D were notified and Consultant GG ordered R2 to be sent out to the emergency room for further evaluation. On 07/13/2026 at 03:19 PM, R2 had no fall mats around his bed or in his room. On 07/14/2026 at 12:40 PM, R2 sat in his wheelchair at the dining room table with CNA N assisting him with his meal. R2 appeared clean and well groomed. On 07/14/2026 at 11:27 AM, CNA O stated she would not provide cares for R2 as a one person assist. CNA O stated she had worked with him when he was on a different hallway, and she always performed his cares with another staff member. On 07/14/2026 at 11:33 PM, CNA N stated that R2 only required one person while getting him dressed and then two people when getting him up into his wheelchair with the Hoyer (total body mechanical lift) lift. CNA N stated she would know what was needed for R2 in his chart or the nurses working would advise her. CNA N attempted to pull up R2's care plan and Kardex (nursing tool that gives a brief overview of the care needs of each resident) to verify R2's level of assistance required for his cares and could not see R2's care plan. R2's Kardex was located with no directions for the number of staff needed to provide R2 his activities of daily living. On 07/14/2026 at 01:07 PM, CNA M stated she was the one that was getting R2 up on the morning of 06/24/2026. CNA M stated she was getting him dressed by herself and the had rolled out of bed. CNA M stated she was not aware that he required two people to get him dressed for the day, or that he was supposed to have a fall mat by his bed. CNA M stated she had never seen one in R2's room. CNA M revealed that R2 did get a laceration from the fall and was bleeding. On 07/14/2026 at 11:41 AM, Licensed Nurse (LN) G pulled up R2's care plan and verified that R2 was to have fall mats beside his bed, and that he required assistance of two staff members with getting dressed. On 07/14/2026 at 11:44 AM, Administrative Nurse D stated R2's Kardex should have the cares that he needed in there to direct the CNAs. CNA N proceeded to open R2's Kardex for Administrative Nurse D and showed Administrative Nurse D only two interventions were listed in R2's Kardex, one being an intervention after the fall that occurred on 06/24/2026. Administrative Nurse D stated that the CNAs not being able to see the care plan is not new, they have never been able to see it, but they should be able to see the Kardex, and it should have interventions required to provide care for R2. Administrative Nurse D revealed she was not aware of the Kardex not having the information that the staff needed to know how to provide cares for the residents. On 07/14/2026 at 01:50 PM, Administrative Nurse D stated she missed that R2 needed two staff members to assist R2 in getting dressed. Administrative Nurse D further stated that the CNAs not being able to see the care plans explained a lot of the facility falls. The facility's Activities of Daily Living (ADL), Support policy, revised April 2025, documented residents were provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. The policy documented appropriate care, and services were provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, documented an objective to establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems.

Based on interview, record review, and observation, the facility failed to ensure Resident (R) 1 remained free from significant medication errors when staff administered fast acting insulin instead of the ordered long-acting insulin. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of shortness of breath, lack of coordination, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and type 1 diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The MDS documented R1 received insulin injections seven days out of the last seven days. The MDS documented R1 had high risk drug class for hypoglycemic (less than normal amount of sugar in the blood), including insulin. R1's Diabetes Mellitus Care Plan revised on 09/19/2023 directed staff to monitor for signs and symptoms of hyperglycemia (increased blood sugar, increased thirst, increased urination, and polyphagia (feeling of extreme, insatiable hunger). The plan of care directed staff to administer medications per the medical directors' order and monitor blood glucose finger stick per the medical directors' orders. R1's Orders tab documented the following physician orders for insulin:Glucagon (raises blood sugar and is used in diabetes to treat hypoglycemia) kit one milligram (mg), inject one mg intramuscularly (IM) and phone every 24 hours as needed for blood sugar below 50 mmol/L give one mg IM and notify the medical director related to DM without complications, ordered on 01/25/2022. Novolog (a rapid-acting insulin used to control blood sugar in adults and children with DM, typically taken five to ten minutes before meals) Flex Pen solution pen-injector 100 units/ML (insulin Aspart) inject 20 U's subcutaneously three times a day related to Type 1 DM without complications, hold for blood sugar less then 70 or unable to eat. Notify the medical director if blood sugar is less than 70 mmol/L or more than 400 mmol/L, ordered on 03/22/2023 Basaglar (a long-acting insulin used to manage blood sugar in type 1 and type 2 diabetes mellitus, providing a steady insulin level for up to 24 hours) Kwik Pen solution pen-injector 100 units/ML (insulin Glargine) inject 65 U's subcutaneously (beneath the skin) at bedtime related to Type 1 DM without complications, hold for blood sugar less than 70 mmol/L or unable to eat. Notify the medical director if blood sugar is less than 70 mmol/L or more than 400 mmol/L, ordered on 04/07/2026. Glucagon subcutaneous solution 1 mg/0.2 milliliter (mL) inject one mg/mL subcutaneously one time only for hypoglycemia for one day, ordered on 06/11/2026 The Nurse's Note dated 06/11/2026 at 10:33 PM documented the Certified Medication Aide (CMA) gave the wrong medication for R1. The scheduled medication was glargine insulin 65 U, but the CMA administered Novolog 45 U, per CMA report. R1 was assessed and found to be alert and oriented at that time. The note further documented the event was reported to Consultant GG and Administrative Nurse D. R1 reportedly had a blood sugar of 241 mmol/L at the time of the incident, and R1's blood sugar was checked every ten minutes as ordered by Consultant GG. R1's blood sugar at 10:32 PM was 132 mmol/L. The Electronic Medication Administration Note dated 06/11/2026 at 11:03 PM documented R1 received the wrong medication. The Nurse's Note dated 06/11/2026 at 11:44 PM documented glucagon one milligram subcutaneous was administered STAT (immediately) at 11:03 PM and R1's blood sugar went up from 104 mmol/L to 155 mmol/L after 30 minutes from administration. The Nurse's Note dated 06/12/2026 at 01:49 AM documented R1's blood sugar dropped down to 55 mmol/L. Consultant GG was called, and a voice message was left, and Administrative Nurse D was called to be informed. R1's level of cognition was still intact. R1 was given oral glucose gel, and a glass of milk. The Nurse's Note dated 06/12/2026 at 07:43 AM documented R1's blood sugar improved, her level of consciousness was intact, and at 06:00 AM her blood sugar was 140 00ol/L. Review of the Medication Error report # 648 completed on 06/11/2026 at 09:35 PM by Licensed Nurse (LN) G documented R1 received the wrong medication from CMA R. R1 was scheduled to received glargine used to manage blood sugar in type 1 and type 2 diabetes mellitus 65 units but CMA R administered Novolog 45 U as CMA R reported. The immediate actions taken for R1 included assessing R1 who was documented to be alert and oriented at that time. The event was reported to Consultant GG and Administrative Nurse D. On 06/11/2026 at approximately 08:00 PM, Certified Medication Aide (CMA) R's written statement documented CMA R took R1's blood sugar and proceeded to dial up her insulin. CMA R simply misread the order on the screen and grabbed the wrong insulin pen. CMA R documented the dose for 65 U and that is what CMA R dialed up in the pen. CMA R then injected R1 with the pen. CMA R documented that R1 did not get the entire amount, due to CMA R stopping the injection after realizing it was the wrong insulin pen. CMA R documented approximately more than half of the 65 U's were injected. CMA R dialed the remainder back into the pen and alerted the nurse. On 07/14/2026 at 12:52 PM, CMA R stated that she had given R1 the insulin, and while she was administering R1's insulin, she realized it was the wrong medication, and she stopped injecting it into R1 and removed it. CMA R stated R1 did not get the entire dose of insulin that she had dialed up. CMA R revealed she immediately informed the nurse about the medication error because she did not want anything bad to happen to R1. On 07/13/2026 at 02:18 PM, LN H stated a CMA could not administer insulin to a resident; only a nurse could do that, but if a resident had an order to self-administer, LN H thought a CMA could dial up the insulin and hand it to a resident for the resident to administer it themselves. On 07/14/2026 at 11:20 AM, LN G was unable to be reached via phone. On 07/14/2026 at 11:50 AM, LN I stated that a CMA could not administer insulins in the state of Kansas. LN I further stated it had been that way as long as she could remember. On 07/13/2026 at 02:05 PM, Administrative Nurse D stated that when she found out about the medication error, she interviewed CMA R and let her know that this was not Missouri, and she could not administer insulin in this state. Administrative Nurse D further revealed that CMA R then informed Administrative Nurse D that she had given insulin in the facility in the past. On 07/14/2026 at 01:50 PM, Administrative Nurse D stated that LN G was an employee of the facility and that she educated LN G that a CMA could not give insulin to the residents. Administrative Nurse D stated only LN G had documented training on not allowing a CMA to give insulins. Administrative Nurse D revealed that she has had conversations with different nurses on the floor, but did not have anything documented showing those conversations or education. The facility's Administering Medications policy, revised April 2019, directed that medications were administered in a sage and timely manner, and as prescribed. The policy further directed only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The facility's Adverse Consequences and Medication Errors policy, revised June 2025, documented a medication error was defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders. A significant medication-related error is defined as requiring treatment with a prescription medication.

Based on record review and interviews, the facility failed to prevent medication errors when they failed to reconcile pain medication orders from the hospital on readmission for Resident (R) 1. Findings included:- R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], transferred to the hospital on [DATE], returned to the facility on [DATE], and discharged to the hospital on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of low back pain, secondary malignant neoplasm (tumor) of bone, malignant neoplasm of prostate, and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated 03/24/26 documented R1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R1 received scheduled and as needed (PRN) pain medication. R1 complained of occasional pain with a highest pain rating of four out of 10 in the last five days. The Pain Care Area Assessment (CAA) dated 03/25/26 documented R1 complained of chronic lower back pain. R1's 04/10/26 Care Plan documented R1 had chronic pain related to cancer. The plan documented the following interventions:04/10/26- Staff administered analgesic medications per orders and half an hour before treatments or care.04/10/26- Staff anticipated R1's need for pain relief and responded immediately to any complaint of pain.04/10/26- Staff evaluated the effectiveness of pain interventions, reviewed compliance, alleviation of symptoms, dosing schedules, R1's satisfaction with results, impact on functional abilities, and impact on cognition.04/10/26- Staff monitored/documented for probable cause of each pain episode and removed or limited the cause where possible.04/10/26- Staff monitored/documented for side effects of pain medication.04/10/26- Staff notified R1's physician if his interventions were unsuccessful or if his current complaint of pain was a significant change from R1's past experience of pain. R1's EMR revealed the following: An order with a start date of 04/07/26 and a discontinued date of 05/04/26 for oxycodone hydrochloride (HCl) (opioid pain medication) 30 milligrams (mg) every 12 hours for moderate to severe pain. An order with a start date of 04/07/26 and a discontinued date of 05/04/26 for hydromorphone HCl (opioid pain medication), four mg every three hours as needed for excessive pain related to secondary malignant neoplasm of bone and malignant neoplasm of prostate. An order with a start date of 04/07/26 and a discontinued date of 05/04/26 for pregabalin (medication used to treat seizures and nerve pain) 250 mg two times a day for diabetic complications. An order with a start date of 05/04/26 for hydromorphone HCl, six mg every three hours as needed for excessive, cancer-related pain. Hospital paperwork, printed on 05/04/26 at 09:36 AM, documented R1's medication list had orders for R1 to start. The orders to start included hydromorphone six mg every six hours as needed for excessive cancer related pain, oxycodone 20 mg every eight hours for severe chronic pain requiring long-term opioid treatment, and pregabalin 300 mg twice daily for diabetic complication causing injury to some body nerves. An order with a start date of 05/04/26 and a discontinued date of 05/08/26 for oxycodone 30 mg every eight hours as needed for chronic pain. An admission Summary note on 05/04/26 at 04:26 PM documented R1 arrived at the facility at 02:20 PM and denied pain when asked. The nurse encouraged R1 to request a pain pill when needed. A Behavior Note on 05/04/26 at 05:13 PM documented R1 asked the nurse where his medications were, and the nurse educated R1 that his orders were in place and should arrive soon. R1 yelled at the nurse that he had withdrawals but refused to answer what symptoms he had when asked. An eMAR [electronic medication administration record]- Medication Administration Note on 05/04/26 at 06:58 PM documented R1 received hydromorphone HCl six mg for pain rated at a nine out of 10. A Nurse's Note on 05/05/26 at 04:30 AM documented R1 requested to be sent to the hospital due to acute pain in his legs, back, and chest with chills and sweat and withdrawal from hydromorphone. A Nurse's Note on 05/05/26 at 08:07 AM documented the emergency room (ER) called for report and asked why R1 was in the ER. Staff informed the ER of R1's concerns of uncontrolled pain and explained to the ER provider what medications R1 received over the night and that he had medications readily available. The nurse stated to the ER provider that R1 immediately claimed withdrawal when he admitted but he showed no signs or symptoms and he was not cooperative with staff to receive proper help. A Nurse's Note on 05/05/26 at 09:05 AM documented the hospital called to give report that they were sending R1 back with a scheduled order for Dilaudid (hydromorphone) so R1 could not argue about when he needed it for better pain control. A hospital After Visit Summary printed 05/05/26 at 09:06 AM documented R1's medications included hydromorphone six mg every three hours as needed for excessive cancer related pain, oxycodone 20 mg every eight hours for severe chronic pain requiring long-term opioid treatment, and pregabalin 300 mg twice daily for diabetic complication causing injury in some body nerves. A Nurse's Note on 05/05/26 at 09:28 AM documented the hospital called back to report they gave R1 baclofen (muscle relaxer medication), Lyrica (pregabalin), and Dilaudid for his back pain, and R1 stated he did feel relief. The nurse asked the ER if they were sending the orders, as the previous report said he was supposed to start scheduled Dilaudid. The ER nurse reported they could not do that as they just evaluated R1. The ER nurse asked what pharmacy to send the scheduled order to, and the nurse asked why the ER could not send the order to the facility, and the ER stated they just do not. The nurse notified Consultant GG of that information and asked how he wanted to proceed. Consultant GG instructed the nurse to evaluate R1 when he arrived, then call him. A Nurse's Note on 05/05/26 at 11:03 AM documented R1 arrived via ambulance. R1 asked for something for pain, and staff advised him that the ER report said he received pain medication prior to the transfer. R1's EMR lacked evidence the facility reconciled R1's medication list on 05/04/26 or 05/05/26 with hospital orders for scheduled oxycodone HCl and pregabalin. An order with a start date of 05/08/26 for oxycodone HCl extended release 20 mg three times a day for pain management. An order with a start date of 05/08/26 for pregabalin 300 mg two times a day related to secondary malignant neoplasm of bone and sciatica (pain that travels down the sciatic nerve). Review of R1's MAR for 05/04/26 to 05/09/26 revealed R1 received oxycodone 30 mg as needed on 05/04/26 at 08:48 PM; 05/07/26 at 03:24 AM, 02:11 PM, and 11:17 PM; and on 05/08/26 at 12:30 PM. R1 did not receive his scheduled oxycodone HCl 20 mg every eight hours as prescribed by the hospital from [DATE] on admission to 05/08/26 at 10:00 PM when he received his first dose. R1 did not receive his scheduled pregabalin 300 mg twice daily as prescribed by the hospital from [DATE] on admission to 05/08/26 at 05:00 PM when he received his first dose. The MAR documented the following pain levels out of 10: 05/04/26 Night- 10; 05/05/26 Day- 10, 05/05/26 Night- 10; 05/06/26 Day- seven, 05/06/26 Night- seven; 05/07/26 Day- eight, 05/07/26 Night- eight; 05/08/26 Day- 10, 05/08/26 Night- eight. R1's EMR lacked documentation as to why the oxycodone HCl 20 mg every eight hours and pregabalin 300 mg twice daily orders were not reconciled or started as ordered by the hospital. On 05/26/26 at 02:38 PM, Licensed Nurse (LN) G stated she remembered when R1 came back from the hospital, and there were two staff working on his admission. She stated she knew they were verifying all of his narcotic medications with the doctor. LN G stated when a resident admitted , an admission packet came in, and the floor nurse or Administrative Nurse E received it then reviewed it with the provider. On 05/26/26 at 02:43 PM, Administrative Nurse E stated when a resident returned from the hospital, she went through the resident's orders and checked the orders from the hospital to make sure they were accurate. She stated R1's oxycodone 20 mg should have been scheduled and she went through the orders with his palliative care team on 05/07/26 to make sure the orders matched what they had. Administrative Nurse E stated R1's oxycodone was changed to be scheduled after that because it had been PRN in the system. She stated usually within 24 hours of admission, the clinical team went over the admissions and they should have caught the discrepancy in R1's orders that next day. She stated she could not think of a reason why it did not get caught. Administrative Nurse E verified R1 missed four days of Lyrica, and he did not receive scheduled oxycodone, but he did have PRN oxycodone available if he asked. On 05/26/26 at 04:00 PM, Administrative Nurse D stated the lack of reconciliation of R1's scheduled oxycodone HCl 20 mg every eight hours and pregabalin 300 mg twice daily orders prescribed by the hospital were medication errors. She stated she talked to the Administrative Nurse F and Administrative Nurse E, and Administrative Nurse F stated she reviewed R1's hospital orders on 05/08/26 and discovered his oxycodone and pregabalin were not reconciled. Administrative Nurse D stated she educated Administrative Nurse F that it was a medication error and stated Administrative Nurse F should have notified Administrative Nurse D on 05/08/26. She stated the process at the time of R1's readmission to the facility was the nurse put the medications in and Administrative Nurse E completed the reconciliation but now the facility had an admissions nurse, Administrative Nurse F, who went over the medications with Administrative Nurse E. Administrative Nurse D stated she expected R1's medications to match the hospital orders and if there were any changes then the nurse should document as to why. The facility's Reconciliation of Medications on Admission policy, last revised July 2017, directed staff reviewed the medication list carefully to determine if there were any discrepancies or conflicts. If there were discrepancies or conflicts, the facility determined the most appropriate action to resolve the discrepancy such as contacting the referring facility, contacting the physician from the referring facility, contacting the resident's primary care physician in the community, contacting the admitting or attending physician, or discussing it with the resident or their family. The facility's Adverse Consequences and Medication Errors policy, last revised June 2025, directed a medication error included omission where a drug was ordered but not administered. When a resident received a new medication order, the facility reviewed the following: the dose, route of administration, duration, and monitoring consistent with current clinical practice; the written diagnosis supported the use of the medication; and documentation of the clinical rationale for using the medication if prescribed outside the accepted standard of practice.

The facility identified a census of 124 residents. The sample included five residents with three residents reviewed for wound care. Based on observation, record review, and interviews, the facility failed to transcribe and follow the wound care physician's orders for Resident (R) 1 related to her diabetic foot ulcer (an open wound on the foot caused by poor circulation, nerve damage, and high blood sugar). Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with foot ulcer, difficulty in walking, and generalized muscle weakness. The Annual Minimum Data Set (MDS) dated 09/05/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had no wounds. The Quarterly MDS dated 12/01/25, documented R1 had a BIMS score of 15, which indicated intact cognition. R1 had a diabetic foot ulcer. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 09/09/25, documented R1 was at risk for pressure ulcers due to decreased mobility and incontinence. R1's 11/12/25 Care Plan documented R1 had a diabetic foot ulcer to her left foot, and she was at risk for complications related to decreased mobility and delayed healing. The Care Plan documented the following interventions, which directed that:11/12/25 - Staff administered pain medications as ordered.11/12/25 - Staff administered treatments as ordered.11/12/25 - Staff obtained labs as ordered and reported abnormal findings to R1's physician.11/12/25 - Staff monitored/documented the wound's size and depth and documented the progress in wound healing on an ongoing basis.11/12/25 - Staff observed and reported signs of infections, such as fever, drainage, foul odor, swelling, redness, pain, or warmth.11/12/25 - Staff referred R1 to the dietitian as indicated.11/12/25 - Staff administered supplements per R1's physician's orders.11/12/25 - Staff utilized enhanced barrier precautions during high-contact resident care activities.11/12/25 - R1 visited weekly with the wound care provider.11/12/25 - The facility obtained a wound consult as indicated. R1's EMR revealed the following: Consultant GG's Physician Orders Details on 12/10/25, documented an order for R1 to use pneumatic compression pumps (medical device used to improve blood circulation and reduce swelling by using an electric pump to inflate sleeves, boots, or garments applied to the limbs) two to three times daily for one hour increments as tolerated. Consultant GG's Physician Orders Details on 01/07/26, documented an order for R1 to use pneumatic compression pumps two to three times daily for one hour increments as tolerated. Consultant GG's Physician Orders Details on 01/28/26, documented a left foot wound care order with instructions to soak gauze with Dakin's (wound cleanser) solution and place on the wound for three to five minutes; apply vitamin A and vitamin D (A&D) ointment around the wound; weave InterDry (specialized moisture-wicking textile infused with antimicrobial silver) between toes; apply Hydrofera Blue (a type of moist wound dressing that provides wound protection and addresses bacteria and yeast) to wound; apply Drawtex (highly absorbent, non-adherent dressing designed for moderate to heavy drainage) dressing and abdominal pad (ABD) pad to wound; and wrap with CoFlex calamine multi-layer compression wrap (two layer compression kit designed to treat patients with multiple wounds or other skin conditions). The wound care order directed the dressing change frequency as daily except on days R1 presented to the wound care center. The orders included an order for R1 to use pneumatic compression pumps two to three times daily for one hour increments as tolerated. A Nurse's Note on 01/28/26 at 06:42 PM documented R1 returned from the wound care provider with new lab orders and wound care orders. The note did not document what the wound care orders were. An order with a start date of 01/30/26 for left foot wound care with instructions to cleanse the wound with Dakin's solution, let soak for three to five minutes, pat dry, apply A&D ointment to dry skin, cover wound bed with Hydrofera Blue and cover with Drawtex then ABD pad, wrap with CoFlex calamine multi-layer compression wrap every Monday, Wednesday, and Friday. An order with a start date of 02/05/26 to apply lymphatic pumps to bilateral lower legs one time daily at night for 60 minutes with the set pressure of 35 per wound care. Upon request, the facility obtained and provided the wound care provider progress notes for February 2026 which revealed the following: Consultant GG's Progress Note Details on 02/04/26, documented R1 reported the facility did not utilize the Dakin's solution for wound cleansing as ordered. The note documented the durable medical equipment (DME) company confirmed R1's lymphedema (swelling caused by accumulation of lymph) pumps were delivered to the facility, but staff had not used them. Consultant GG ordered daily dressing changes to be completed at R1's facility, but R1 reported the facility continued two to three times a week dressing changes. The note documented a left foot wound care order with instructions to soak gauze with Dakin's solution and place on the wound for three to five minutes; apply A&D ointment around the wound; weave InterDry between toes; apply Hydrofera Blue to wound; apply Drawtex dressing and ABD pad to wound; and wrap with CoFlex calamine multi-layer compression wrap. The wound care order directed the dressing change frequency as daily except on days R1 presented to the wound care center. The orders included an order for R1 to use pneumatic compression pumps two to three times daily for one hour increments as tolerated. The note documented Consultant GG left several messages with the facility without a response. Upon request, the facility was unable to provide an order from the wound care provider for the compression pumps at the current frequency of nightly. On 02/24/26 at 01:18 PM, R1 sat in her wheelchair in her room and ate lunch. She wore a white compression stocking on her right leg, a brown colored compression wrap to her left leg, blue non-skid socks on both feet, and a tennis shoe on her right foot with no shoe worn on her left foot. R1 stated the facility did not change her left foot dressing daily like wound care ordered. She stated she was told by the facility that since she received a compression dressing, the dressing can stay on for a couple of days. R1 stated wound care wanted her to wear the compression pumps at a minimum of one hour a day and she heard about the pumps prior to the appointment on 01/28/26 but it took a while to schedule the set up with the facility. On 02/24/26 at 11:25 AM, Administrative Nurse D stated sometimes the wound care provider sent a progress note to the facility with wound care orders that same day. She stated R1's compression pumps were delivered, but the facility did not know they had been delivered until they were found at the front of the building. On 02/24/26 at 11:34 AM, Administrative Nurse E stated R1 received orders for compression pumps and the DME company representative stated when the pumps arrived, he would go to the facility to in-service the staff on how to use them. She stated the representative showed the nurses working that day how to use the pumps and the day nurses educated the night nurses. Administrative Nurse E stated most of the time, the nurses had to reach out to the wound care provider to request the wound care orders. She stated the wound care provider had to send an order to the DME company for the compression pumps. On 02/24/26 at 02:14 PM, Licensed Nurse (LN) G stated the wound care provider usually sent wound care orders back with R1 but sometimes they did not, and he called the wound care provider to get them. He stated when he received new wound care orders, he put them in the EMR. LN G stated R1's left foot dressing change was scheduled for Monday, Wednesday, and Friday. He confirmed from the Physician Orders Details on 01/28/26 that R1's dressing changes should be daily except on Wednesday when she went to the wound care provider. On 02/24/26 at 02:22 PM, Administrative Nurse E stated the DME representative read the settings off for the compression pumps and told her the frequency. On 02/24/26 at 02:25 PM, Administrative Nurse E stated R1's dressing changes were scheduled Monday, Wednesday, Friday, and as needed (PRN). She stated she received a paper from the wound care provider on 01/29/26 and she changed the order. She stated R1 saw the wound care provider on 01/28/26 and the nurses note documented R1 came back with new orders. Administrative Nurse E confirmed from the Physician Orders Details on 01/28/26 that R1's dressing changes should be daily except on days that R1 went to the wound care clinic. She stated the dressing change frequency did not get updated. She said the floor nurses put the orders in, and she normally went through the orders to verify them. On 02/24/26 at 02:41 PM, Administrative Nurse D stated when a resident returned from an appointment, the floor nurse put the new orders in. She stated the administrative team went over appointments in clinical, but the facility will be adding a second check on orders. She confirmed from the Physician Orders Details on 01/28/26, that R1's dressing changes should be daily except on days that R1 went to the wound care clinic. She stated if the wound care provider ordered compression pumps, the facility found out about it through the wound care notes like the Physician Orders Details. Administrative Nurse D stated she believed the wound care provider contacted the DME company about the compression pumps who then contacted Administrative Nurse E to set up the training. She stated the facility should have followed up with the wound care provider if they wanted the pumps started in December 2025. The facility's Wound Care policy, revised October 2010, directed in preparation for wound care, the facility they had a physician's order for the procedure. The facility's Medication and Treatment Orders policy, revised July 2016, directed the facility administered medications only upon the written order of a person duly licensed and authorized to prescribe such medications. The policy did not address order transcription after appointments.

The facility identified a census of 126. The sample included four residents with one sampled for pharmacy services. Based on observation, record review, and interviews, the facility failed to provide physician ordered Mounjaro (medication used to manage type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin)) to Resident (R) 1. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of pain in right knee, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), difficulty in walking, and diabetes mellitus. The admission Minimum Data Set (MDS) dated 12/02/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The Quarterly MDS dated 08/22/25, documented R1 had a BIMS score of eight, which indicated moderate cognitive impairment. The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA) dated 12/07/24, lacked an analysis of findings. R1's 01/15/26 Care Plan documented R1 had a diagnosis of diabetes. The Care Plan documented the following interventions:01/15/26- Staff administered medications as ordered.01/15/26- Staff encouraged activity and exercise as tolerated. R1's EMR revealed an order with a start date of 08/11/25 for Mounjaro 2.5 milligrams (mg)/0.5 milliliters (mL), inject 0.5 mL in the morning every Monday for diabetes. Review of R1's Treatment Administration Record (TAR) for 09/01/25 through 01/31/26, revealed the following documentation for Mounjaro 0.5 mL:Staff administered- two out of 22 scheduled administrations.Blank documentation- two out of 22 scheduled administrations. Other/See Nurses Notes- 18 out of 22 scheduled administrations. R1's EMR revealed the following: An eMAR (electronic Medication Administration Record)- Medication Administration Note on 09/15/25 at 09:56 AM documented Mounjaro was unavailable, and the facility waited for delivery. An eMAR- Medication Administration Note on 10/13/25 at 10:25 AM, documented the facility waited for the delivery of Mounjaro. An eMAR- Medication Administration Note on 10/20/25 at 11:59 AM, documented Mounjaro was unavailable, and the facility contacted the pharmacy and reordered Mounjaro. An eMAR- Medication Administration Note on 10/27/25 at 09:56 AM, documented Mounjaro was on order. An eMAR- Medication Administration Note on 11/03/25 at 10:38 AM, documented the facility awaited clarification on Mounjaro. The note did not address what the clarification was in regard to. An eMAR- Medication Administration Note on 11/10/25 at 11:00 AM, documented the facility notified the nurse practitioner (NP). The note did not address what the facility notified the NP about. An eMAR- Medication Administration Note on 12/15/25 at 09:20 AM, documented Mounjaro was unavailable. A Physician Progress Note (Narrative) on 12/17/25 at 10:54 AM, documented R1's fasting blood sugar reading was over 500 milligrams per deciliter (dL) that morning. Nursing staff denied R1 had any new problems. The provider increased R1's Lantus (insulin- a hormone that lowers the level of glucose in the blood) order to 100 units at bedtime and ordered an endocrinology (the study of endocrine glands and hormones) appointment for R1. The provider instructed the facility to continue R1's current medications and orders. The note did not address R1's Mounjaro. An eMAR- Medication Administration Note on 12/22/25 at 05:29 AM, documented Mounjaro was unavailable. An eMAR- Medication Administration Note on 12/29/25 at 09:38 AM, documented Mounjaro was unavailable. An eMAR- Medication Administration Note on 01/05/26 at 09:38 AM, documented Mounjaro was unavailable. An eMAR- Medication Administration Note on 01/12/26 at 09:36 AM, documented Mounjaro was unavailable. An eMAR- Medication Administration Note on 01/19/26 at 11:09 AM, documented Mounjaro was unavailable. An eMAR- Medication Administration Note on 01/26/26 at 09:45 AM, documented Mounjaro was unavailable. A Nurse's Note on 02/02/26 at 12:36 PM, documented the pharmacy advised Licensed Nurse (LN) G that R1's insurance would pay for Mounjaro at that time, then they would need a prior authorization for the next time. The pharmacy ordered R1's Mounjaro and would send it to the facility. A Nurse's Note on 02/02/26 at 01:43 PM, documented LN G notified Consultant GG of the above note on 02/02/26. Consultant GG advised LN G to discontinue R1's order. On 02/02/26 at 12:54 PM, R1 sat in her recliner in her room. She stated she had not received her Mounjaro injections, but she wanted to be on it. On 02/02/26 at 12:57 PM, LN G stated she had just called the pharmacy about R1's Mounjaro. She stated the Mounjaro needed a prior authorization to be paid for by her pharmacy. She stated the pharmacy approved for R1's Mounjaro to be paid this time but she would need a prior authorization next time. LN G stated if a resident needed a prior authorization, she put them into the provider's folder to be completed. She stated she documented in the resident's EMR if a resident needed a prior authorization. LN G stated if a resident had not received a medication, she called the provider and told them the reason why that resident had not received the medication, and asked what the provider wanted to do. On 02/02/26 at 01:40 PM, Administrative Nurse D stated she had not received any reports about R1 not receiving her Mounjaro. She stated she expected staff to bring it up to her or with the physician to get a prior authorization. She stated the pharmacy sent prior authorization requests electronically and she usually received a copy, but she had not seen one for R1's Mounjaro. Administrative Nurse D stated she expected staff to notify her and the physician after one missed dose of a medication and to document on it. On 02/02/26 at 02:06 PM, LN G stated she called Consultant GG and told him the pharmacy could send the Mounjaro that time, then they needed a prior authorization. She stated Consultant GG said to discontinue the order. LN G stated she did not talk to R1 about the order to see if she wanted to be on it prior to calling Consultant GG. The facility's Pharmacy Services Overview policy, revised April 2019, directed the residents had a sufficient supply of their prescribed medications and receive their medications in a timely manner.

The facility identified a census of 126 residents. The sample included four residents with one reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to provide necessary foot care and services for Resident (R) 1.Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of pain in right knee, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), difficulty in walking, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated 12/02/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The Quarterly MDS dated 08/22/25, documented R1 had a BIMS score of eight, which indicated moderate cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/07/24, lacked an analysis of findings. R1's 01/15/26 Care Plan documented R1 had actual risk for activities of daily living (ADL)/mobility decline and required assistance related to pain in the right knee, muscle weakness, and difficulty in walking. The Care Plan documented the following interventions:01/15/26- R1 required one staff set-up assistance with ambulation.01/15/26- R1 required one staff set-up assistance with transfers. R1's 01/15/26 Care Plan documented R1 had a diagnosis of diabetes. The Care Plan documented the following interventions:01/15/26- Staff encouraged activity and exercise as tolerated. R1's EMR revealed the following: A Nurse's Note on 10/29/25 at 02:13 PM documented the facility left a voicemail for the diabetic shoe provider and waited for a return call. A Podiatry Order Form, dated 11/03/25, documented an order for diabetic shoes and three pairs of heat molded diabetic insoles. A Nurse's Note on 11/04/25 at 11:30 AM, documented the diabetic shoe provider answered the phone and advised the facility they needed multiple documents. The facility nurse stated the facility sent the documents many, many times but would send the documents again. A Nurse's Note on 11/05/25 at 11:26 AM, documented the facility sent documents to the diabetic shoe provider again and waited for a return call to schedule an appointment. A Nurse's Note on 11/14/25 at 01:52 PM, documented the facility left another voicemail to set-up an appointment for R1's shoes and waited for a return call.R1's EMR lacked evidence the facility followed up with the diabetic shoe provider after 11/14/25. On 02/02/26 at 12:54 PM, R1 sat in her recliner in her room. She stated she still needed diabetic shoes. On 02/02/26 at 02:05 PM, R1 laid on her right side in her bed. She did not respond to knocking and appeared to be sleeping. R1's right heel had a rough, calloused appearance. On 02/02/26 at 12:57 PM, Licensed Nurse (LN) G stated the facility had been working on getting R1's diabetic shoes for a year and a half. She stated the facility received a form from podiatry for diabetic shoes and form insoles and the facility faxed the diabetic shoe provider back and forth, but they had not responded. On 02/02/26 at 01:40 PM, Administrative Nurse D stated she believed the facility was going to send R1 to the diabetic shoe provider to get her fitted for diabetic shoes, but Administrative Nurse D was unsure if R1 went. She stated she expected the nurse to do a weekly follow-up to figure out what was going on with the diabetic shoe provider appointment. Administrative Nurse D stated it sometimes took time to get a resident into the diabetic shoe provider but R1 should have at least gotten an appointment date set by now. She stated the facility should have followed up with the diabetic shoe provider by now. On 02/02/26 at 02:20 PM, Administrative Nurse D stated she found out more information about the diabetic shoe provider. She stated R1 had an appointment with the diabetic shoe provider on 08/13/25 and did not show up. She stated R1 had not wanted to reschedule the appointment but at the time, R1 had gone through psychosis (any major mental disorder characterized by a gross impairment in reality perception) and had an involuntary placement in a facility around that time. Administrative Nurse D stated the diabetic shoe provider stated they did not have any other information about any referrals after that and only had the one note from August 2025. The facility did not provide a policy on durable medical equipment or accommodation of needs.

The facility identified a census of 126. The sample included four residents with one sample for respiratory services. Based on observation, record review, and interviews, the facility failed to obtain and provide a physician-ordered continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) machine for Resident (R) 1.Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated 12/02/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The Quarterly MDS dated 08/22/25, documented R1 had a BIMS score of eight, which indicated moderate cognitive impairment. The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA) dated 12/07/24, lacked an analysis of findings. R1's 01/15/26 Care Plan documented R1 required the use of continuous oxygen at two liters (L) related to COPD. The Care Plan documented the following interventions:01/15/26 - Staff changed R1's humidification and oxygen tubing as indicated.01/15/26 - Staff educated R1 on the importance of keeping oxygen on and at the prescribed setting.01/15/26 - Staff observed oxygen precautions.The Care Plan did not address her order for a CPAP. R1's EMR revealed the following: An order with a start date of 08/08/25 for CPAP setting, which instructed staff to set the CPAP per home settings at bedtime for CPAP. An order with a start date of 08/08/25 instructed staff to replace R1's distilled water in the humidifier prior to CPAP/BiPAP (device that helps you breathe by delivering air through a mask on your face) use at bedtime for CPAP/BiPAP. Review of R1's Treatment Administration Record (TAR) for 08/08/25 to 01/31/26 revealed the following documentation for the order of CPAP setting: per home settings at bedtime for CPAP:Staff administered- 110 out of 177 scheduled administrationsR1 refused- 37 out of 177 scheduled administrationsBlank documentation- 24 out of 177 scheduled administrationsHold/See Nurses Notes- two out of 177 scheduled administrationsOther/See Nurses Notes- three out of 177 scheduled administrationsAbsent from home- one out of 177 scheduled administrations Review of R1's TAR for 08/08/25 o 01/31/26 revealed the following documentation for the order to replace R1's distilled water in the humidifier prior to CPAP/BiPAP use at bedtime for CPAP/BiPAP:Staff administered- 111 out of 177 scheduled administrationsR1 refused- 35 out of 177 scheduled administrationsBlank documentation- 24 out of 177 scheduled administrationsHold/See Nurses Notes- four out of 177 scheduled administrationsOther/See Nurses Notes- two out of 177 scheduled administrationsAbsent from home- one out of 177 scheduled administrations R1's EMR revealed the following: An eMAR (electronic Medication Administration Record)- Medication Administration Note on 10/29/25 at 01:45 AM, documented R1 did not want to use the CPAP. R1 did not have her equipment in the facility. An eMAR- Medication Administration Note on 11/08/25 at 01:09 AM, documented R1 was non-compliant with use of CPAP. An eMAR- Medication Administration Note on 11/14/25 at 02:55 AM, documented R1 no longer wore the CPAP. An eMAR- Medication Administration Note on 12/15/25 at 10:30 PM, documented R1 verbalized she did not have a CPAP, and she did not use one. An eMAR- Medication Administration Note on 12/23/25 at 11:35 PM, documented R1 verbalized she did not have a CPAP, and the facility never got her a CPAP. On 02/02/26 at 12:54 PM, R1 sat in her recliner in her room. There was no CPAP visible in R1's room. R1 stated she does not have a CPAP machine because she never received one, but she does wear oxygen at night. On 02/02/26 at 12:57 PM, Licensed Nurse (LN) G stated R1 never had a CPAP in the facility, but she admitted to the facility with an order for a CPAP. LN G stated she marked R1's CPAP order as refused on the TAR. When asked how R1 could refuse something she never had, LN G stated she used refused for R1 not having a CPAP too. LN G stated that most residents who were admitted to the facility with a CPAP order brought a CPAP machine with them. She stated R1 had not voiced any concerns to her about having a CPAP. On 02/02/26 at 01:40 PM, Administrative Nurse D stated she did not know if R1 had a CPAP. She stated if a resident admitted to the facility with an order for a CPAP, they usually came with the CPAP machine, and the facility did not normally provide one. Administrative Nurse D stated if they did not have a machine, the facility worked with the physician to get approval and to set up a sleep study. She stated R1's CPAP order should have been discontinued if she did not have a CPAP. She stated she expected the nurse to let the physician know to get an order to hold or discontinue the order. The facility's CPAP/BiPAP Support policy, revised March 2015, directed the facility review the physician's order to determine the oxygen concentration and flow, and the pressure for the machine. The policy did not address providing a CPAP machine.

The facility identified a census of 106 residents. The sample included three residents reviewed for falls and accidents. Based on observation, record review, and interview, the facility failed to investigate, determine causative factors, and implement relevant interventions to prevent further falls for Resident (R) 1, after R1 was found lying face down on the floor, at the bedside, on 11/08/24. Subsequently, R1 had another fall from the bed on 04/10/25, which resulted in a left femur (thigh bone) fracture and placed the resident at risk for further injuries and related pain. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Lewy body dementia (type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), benign brain neoplasm (a non-cancerous tumor within the brain that usually grows slowly and does not spread), malignant neoplasm of the parietal lobe (a cancerous tumor located in the top and back of the brain), reduced mobility, weakness, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair and was dependent on staff for mobility. The MDS documented R1 was dependent on staff for bed mobility, transfers, and toileting. The MDS documented she had no falls since admission or the prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/29/25, documented R1 had diabetes (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), respiratory problems, and cancer as medical problems that could impact cognition. The CAA further documented R1's cognitive loss and dementia were addressed in the care plan. The Functional Abilities (Self-Care and Mobility) CAA, dated 01/29/25, documented R1 had changing cognitive status and mood decline as possible underlying problems that may affect function. The CAA further documented that functional abilities were addressed in the care plan. The Falls CAA did not trigger. R1's Care Plan, with an initiated date of 05/24/17, documented R1 had restless leg syndrome (a condition that causes a very strong urge to move the legs). R1's Care Plan with an initiated date of 04/21/19 documented R1 was at risk for falls related to deconditioning, gait, and balance problems. R1's Care Plan with an initiated date of 01/12/23, documented R1 had an activity of daily living (ADL) self-care performance deficit related to activity intolerance and dementia. An intervention with an initiated date of 01/11/24 documented R1 required two staff members to reposition and turn in bed. An intervention with an initiated date of 01/11/24 documented R1 required a mechanical Hoyer (total body mechanical lift) with the assistance of two staff for transfers. An intervention with an initiated date of 11/11/24 directed staff to send R1 to the hospital for evaluation and treatment. An intervention with an initiated date of 04/10/25 directed staff to keep R1s's bed in the lowest position. An intervention with an initiated date of 04/11/25 directed staff to place a call for the hospice nurse to come to the facility for further evaluation, a STAT x-ray was ordered, then canceled, and R1 was sent to the emergency room (ER) for evaluation and treatment. An intervention with an initiated date of 04/23/25 documented the intervention upon return from the hospital hospice would provide a bolster overly (type of mattress used to help prevent falls from bed) for the bed, fall mat at the bedside, and comfort medications for pain as needed (PRN). R1's Care Plan lacked evidence of additional fall interventions related to the fall that occurred on 11/08/24, where R1 was found face down, on the floor at the bedside. An Alert Note dated 11/08/24 at 07:19 PM documented staff observed R1 lying face down on the floor at the bedside. Staff assessed R1and no injuries were observed; the note further documented R1 could not do range of motion (ROM) as R1 stated she was in pain. The note documented R1 had no visible injury and her skin was intact. Staff obtained an order to send R1 to the hospital for evaluation. An IDT - Fall note dated 11/11/24 at 11:18 AM documented R1 had a fall on 11/08/24 at 06:30 PM. The note documented the root cause analysis (RCA) was R1 did not know what happened, and just rolled out of bed. The note recorded R1 was unable to describe what she was doing at the time of the fall. The note further documented a prior intervention was to keep R1's call light within reach. The note documented the current intervention was staff sent R1 to the hospital for evaluation and treatment. No other interventions were documented in the IDT - Fall note. A Nurse's Note dated 04/10/25 at 06:06 AM documented the charge nurse was called to R1's room by the certified nurse aide (CNA) on duty and informed R1 was on the floor. The note documented that upon entering the room, R1 was lying on the floor next to her bed. Staff assisted R1 back to bed and notified hospice of the fall. The note documented R1's complaint of pain in her left leg. Staff notified the provider of R1's fall, and left a message for R1's emergency contact. A Nurse's Note dated 04/11/25 at 03:23 AM documented staff contacted hospice regarding R1's continued complaint of pain in her left leg with movement due to her fall that morning. The note further documented hospice ordered a STAT (immediate) X-ray of R1's left hip and femur but then called back and recommended sending R1 to the hospital for evaluation and treatment. The note documented R1 was transported to the emergency room (ER) at 03:05 AM. R1's hospital document Trauma History and Physical Examination dated 04/11/25, documented R1 was activated as a Trauma Consult after sustaining a left femur fracture from an unwitnessed fall at R1's facility. The document further recorded the fall happened at approximately 06:00 AM the previous morning (04/10/25). R1 was a hospice patient and was evaluated by hospice twice on 04/10/25, and eventually made the decision to call Emergency Medical Services (EMS) to bring R1 to the ER because R1 continued to experience pain in her left leg. The document recorded R1 was a poor historian due to significant cognitive deficits. R1 was able to tell the provider her name and said pain when the provider touched R1's left leg. An Admission Summary (Admit/Re-admit) note dated 04/11/25 at 03:50 PM, documented R1 came back to the facility via stretcher with a diagnosis of a left femur fracture and blood clots. The note recorded R1's Durable Power of Attorney (DPOA) had a discussion with the hospital team and decided not to do aggressive treatment because the DPOA did not want R1 to be in pain. The note documented R1 was on comfort care with hospice and the hospice nurse was at the bedside. CNA M's Witness Statement notarized on 04/11/25, documented CNA M was in the hallway and suddenly heard R1 yelling; R1's call light was going off. CNA M went into R1's room and found R1 lying on the floor beside her bed, indicating R1 fell out of bed. CNA M documented staff helped R1 roll over onto her back and placed a pillow behind R1's head, then quickly left and got a nurse. Licensed Nurse (LN) G's Witness Statement notarized on 04/11/25, documented on 04/10/25 at approximately 05:50 AM, LN G was approached by the CNA taking care of R1, who stated they found R1 on the floor in R1's room. The statement documented that upon entering the room, R1 was lying on the floor next to her bed; R1 was slightly turned to her right side, facing the door. LN G documented she asked R1 what happened and how R1 fell , R1 hesitated and stated she did not know. LN G documented staff completed an assessment and obtained vital signs. LN G documented staff did not observe any visible injury, and R1 had responded no when asked if she was in pain. The statement further documented staff transferred R1 to bed, and while repositioning R1 in bed, R1 complained of pain in her left leg when it was moved. LN G documented they gave R1 pain medication and called hospice and the nurse practitioner regarding R1's fall. The facility was unable to provide an investigation related to R1's fall on 11/08/25. On 04/23/25 at 03:05 PM, an observation revealed R1 rested in bed. R1's bed had a bolstered mattress overly in place and a fall mat was on the floor beside R1's bed. On 04/23/25 at 01:44 PM, Administrative Nurse D stated R1 had one other unwitnessed fall on 11/08/24 and said she thought R1 had rolled out of bed then. Administrative Nurse D stated R1 was sent to the hospital for evaluation and treatment as R1 reported having pain. Administrative Nurse D stated there were no injuries from that fall, and the facility did not have floor mats in place prior to the fall on 11/08/24 or afterward; the fall mats were put in place only after the fall on 04/10/25. Administrative Nurse D reviewed R1's EMR and plan of care and verified the only fall intervention added, in relation to R1's fall out of bed on 11/08/24, was to send R1 out for evaluation. Administrative Nurse D stated she did not see any other interventions added in relation to that fall, on R1's Care Plan or in the EMR. She said R1 was not someone who had frequent falls. Administrative Nurse D stated, after a fall, staff should absolutely add fall interventions, and staff met each morning to review any falls and interventions. Administrative Nurse D stated there was no fall investigation for the fall on 11/08/24; however, the facility performed a risk assessment and had an interdisciplinary team (IDT) note that recorded an intervention to send the resident out for evaluation. Administrative Nurse D stated she did not see any other interventions documented in the IDT note. Administrative Nurse D stated there was no further documentation related to the fall on 11/08/24 aside from the IDT note dated 11/11/24 at 11:18 AM and the alert note dated 11/08/24 at 07:19 PM. On 04/23/25 at 03:13 PM, LN H stated he was not in the facility the day R1 fell on [DATE]. LN H stated when a resident fell , he would assess the resident for injury and pain, check ROM, perform neurological checks, assess alertness, and compare to the resident's baseline. LN H further stated he would contact the provider for potential orders, and notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the resident's emergency contact. LN H stated the nurse would perform a post-fall assessment and put fall interventions in place. LN H stated that a bolster mattress, a fall mat on the floor at the bedside, and having the bed in the lowest position would be appropriate interventions for a resident who fell out of bed. LN H stated it would be appropriate to add interventions after a resident's initial fall. LN H stated he believed the MDS coordinator updated the residents' care plan with fall interventions after the fall risk assessment was completed with recommended interventions. On 04/23/25 at 03:35 PM, Administrative Nurse D stated the MDS coordinator, herself, or the ADON updated the resident's care plan with fall interventions. Administrative Nurse D stated it would have been appropriate to add interventions related to R1's fall on 11/08/24 and believed the team must have missed adding them at the time. Administrative Nurse D stated she believed the fall on 11/08/24 was related to R1 having a urinary tract infection (UTI), and the fall on 04/10/25 was more so related to R1 having terminal restlessness. Administrative Nurse D stated R1 was not a frequent faller and only fell when R1 had something else going on, such as the UTI and restlessness. The facility's Falls and Fall Risk Managing policy with a revision date of March 2018, documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

The facility identified a census of 87 residents. The sample included 20 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure placed all 87 residents residing in the facility at risk for impaired care. Findings Included: - An inspection of the Facility assessment dated [DATE] provided by the facility revealed the following: The assessment did not identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each shift. The assessment did not identify staffing-specific skill sets for each resident unit based on the resident population assessed of that unit. The assessment lacked an informed contingency plan for events that do not require activation of the facility's emergency plan but have the potential to impact resident care. The assessment lacked a plan to maximize recruitment and retention of direct care staff. The assessment did not identify the means of input gathered from the residents and their representatives when formulating the assessment data. On 09/11/24 at 02:45 PM Administrative Nurse D stated the facility was currently in the process of updating the facility assessment. The facility did not provide a policy related to its facility assessment as requested. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure placed all 87 residents residing in the facility at risk for impaired care.

The facility identified a census of 87 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility further failed to provide a Legionella (Legionella is a bacterium that can cause pneumonia in vulnerable populations) water management program to assess and mitigate the risk of Legionella and failed to maintain water temperatures to effectively clean and disinfect laundry. The facility further failed to ensure staff performed adequate hand hygiene, respiratory equipment was stored in a sanitary manner and failed to transport linens in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - An initial walkthrough of the facility was completed on 09/09/24 at 07:15 AM. An inspection of Resident (R)24's room revealed no protective equipment (PPE) readily available for EBP. R24 had no signage or indicators R24 was on EBP. R24 had a percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). R24 had a suction cannula for suctioning the secretions in her throat. The cannula was in an undated, open bag that hung on her internal feeding pump. R24 had a nebulizer mask draped over her nebulizing machine. The mask was not in a sanitary container or clean barrier. An inspection of R57 's room revealed no readily available PPE for EBP. R57's room lacked signage or precaution indicators. R17 had a tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) and a PEG tube. R57's tracheal suction catheter was placed in an open bag which hung on R57's eternal feeding pole. R57's nebulizer sat on his bedside table, and the mask was without containment. An inspection of R58's room revealed no readily available PPE for EBP and lacked signage or precaution indicators. R58 had an intravenous (IV-administered directly into the bloodstream via a vein) catheter and a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). An inspection of R34's room revealed no readily available PPE for EBP and lacked signage or precaution indicators. R32 had a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart). An inspection of R70's room revealed no readily available PPE for EBP and lacked signage or precaution indicators. R70 had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder). An inspection of R69's room revealed readily available PPE for EBP and lacked signage or precaution indicators. R69 had a suprapubic catheter. An inspection of R37's room revealed readily available PPE for EBP and lacked signage or precaution indicators. R37 had a Foley catheter. An inspection of R60's room revealed readily available PPE for EBP and lacked signage or precaution indicators. R60 had a Foley catheter. On 09/09/24 at 08:12 AM R42's nasal cannula was wrapped around her oxygen canister, the cannula was uncontained in a sanitary manner. On 09/09/24 at 09:52 AM Certified Nursing Aide (CNA) PP carried unbagged wet sheets and clothing down the hall next to her clothing. On 09/10/24 at 07:01 AM on inspection of the laundry facilities, the washer temperature was reaching only 134 degrees Fahrenheit. Laundry Staff V stated the hot water, or boiler was not working properly. On 09/10/24 at 09:23 AM R39's CPAP mask laid directly on the CPAP machine unbagged. R39's oxygen tubing and nasal cannula were coiled and placed unbagged in the handle of the oxygen concentrator next to his bed. On 09/11/24 at 08:50 AM CNA PP and CNA QQ entered R14's room and donned gloves without performing hand hygiene first. CNA PP cleaned R14's front peri area and then rolled R14 to her side and cleaned her bottom wearing the same gloves. On 09/10/24 at 07:16 AM Maintenance Supervisor U stated the facility was in the process of getting a new boiler and there were issues with the hot water. Maintenance Supervisor U was unable to provide documentation that the water temperature was maintained at or above 165 degrees F. On 09/10/24 at 08:00 AM Administrative Staff A stated the facility was unable to provide a plan related to Legionella management and prevention. On 09/11/24 at 01:29 PM Administrative Nurse D stated hand hygiene should be performed when entering and leaving residents' rooms, and when going from clean to dirty. She stated soiled laundry should be bagged and never carried up the hall. Administrative Nurse D said she was not sure who should have EBP signage and PPE. On 09/11/24 at 02:29 PM Administrative Nurse D stated the EBP signage and PPE should be in every room for residents with EBP. She stated staff should never carry unbagged soiled laundry in the hall, and hand hygiene should be performed all the time, especially after patient care. The facility's Maintenance policy documented maintenance service shall be provided to all areas of the building, grounds, and equipment. The facility's Hand Hygiene policy documented This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The facility's Legionella Water Management Policy documented the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The facility's Enhanced Barrier Precautions policy documented the facility will identify all residents needing to be placed on enhanced barrier precautions. The facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility further failed to provide a Legionella water management program to assess and mitigate the risk of Legionella and failed to maintain water temperature to clean and disinfect laundry. The facility further failed to ensure staff performed adequate hand hygiene, respiratory equipment was stored in a sanitary manner and failed to transport linens in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 09/11/24 at 11:45 AM the facility was unable to provide proof of training records for agency staff. The staff reviewed were Certified Nurse's Aides (CNA) N, CNA O, and CNA P. On 09/11/24 at 02:40 PM Administrative Nurse D stated the facility did not keep records for the agency staff onsite. She stated the facility required the agency company to track their training and the facility did not verify or keep on record the agency staff's training or in-services. The facility was unable to provide the required training records as requested on 09/11/24. The facility's In-Service Training- All Staff policy (undated) indicated all staff were required to participate in regular in-service education. The policy noted agency or contractual staff were required to participate in orientation and annual in-service training. The facility failed to ensure the completion of the required communication training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 09/11/24 at 11:45 AM the facility was unable to provide proof of training records for agency staff. The staff reviewed were Certified Nurse's Aides (CNA) N, CNA O, and CNA P. On 09/11/24 at 02:40 PM Administrative Nurse D stated the facility did not keep records for the agency staff onsite. She stated the facility required the agency company to track their training and the facility did not verify or keep on record the agency staff's training or in-services. The facility was unable to provide the required training records as requested on 09/11/24. The facility's In-Service Training- All Staff policy (undated) indicated all staff were required to participate in regular in-service education. The policy noted agency or contractual staff were required to participate in orientation and annual in-service training. The facility failed to ensure the completion of the required resident rights training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 09/11/24 at 11:45 AM the facility was unable to provide proof of training records for agency staff. The staff reviewed were Certified Nurse's Aides (CNA) N, CNA O, and CNA P. On 09/11/24 at 02:40 PM Administrative Nurse D stated the facility did not keep records for the agency staff onsite. She stated the facility required the agency company to track their training and the facility did not verify or keep on record the agency staff's training or in-services. The facility was unable to provide the required training records as requested on 09/11/24. The facility's In-Service Training- All Staff policy (undated) indicated all staff were required to participate in regular in-service education. The policy noted agency or contractual staff were required to participate in orientation and annual in-service training. The facility failed to ensure the completion of the required infection control training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 87 residents. The facility had one main kitchen. Based on observation and interview, the facility failed to ensure staff stored food items in accordance with the professional standards for food service safety. The facility failed to ensure the high-temperature dishwasher was in proper working condition to wash and sanitize kitchenware and dishes. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food). Findings included: - The initial tour of the kitchen on 09/09/24 at 07:06 AM revealed a dark kitchen with no staff present. Upon turning on the lights it was observed that an area approximately 15 feet by about four feet of the kitchen flooring was missing the ceramic tiles with the cement flooring exposed underneath (This area had empty food carts in the area with the missing tiles). Observance of the freezer temperature logs revealed no temperature reading since 09/07/24. The clean plates, stored in a plate service cart, did not have a cover over the plates. Upon entry to the walk-in refrigerator and freezer area, the following items were noted without a label or date: one clear sealed container of what looked like about 10 to 15 pre-cooked hot dogs had no label or use by date, one clear sealed container of pre-cooked sausage links without a label or use by date; a clear sealed container of cooked roast beef slices that lacked a label or use by date; two opened gallon jugs of milk that lacked an open date, one milk jug was covered with aluminum foil. On 09/10/24 at 11:00 AM a return visit to the kitchen. Consultant II reported that the main dishwashing machine was not reaching the optimal temperature of at least 180 degrees during the rinse cycle and had reported to maintenance to come look at it for repair. On 09/09/24 at 07:20 AM Dietary Consultant BB stated she had just gotten to work and had not had a chance to get the food items discarded. On 09/10/24 at 11:00 AM Consultant II stated staff should be labeling and dating all items that have been opened and should be dated with the use by date. Consultant II stated all food items should be stored in a sealed bag or container. Consultant II stated that the facility was in the process of some renovations and fixing the flooring in the kitchen was one of the items on the list. Consultant II stated she notified the maintenance director of the dishwasher not reaching the correct temperature to sanitize the dishware. On 09/10/24 at 12:45 PM Administrative Staff A stated he contracted a specialist to come look at the dishwasher and said it would be fixed by the end of the day. The updated Food Receiving and Storage policy documented that food shall be received and stored in a manner that complies with safe food handling practices. All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Label food prepped in-house that has been made with previously cooked and stored food with the discard date of the previously cooked item. Foods past their use by date must be discarded and cannot be used in food prep. Food that has been prepared can only be stored for four days from the cook date. Other opened containers must be dated and sealed or covered during storage. The facility failed to ensure dietary staff stored food items and washed dishes in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination.

The facility identified a census of 87 residents. The facility had one main kitchen and three dining areas. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 09/10/24 at 11:29 AM Administrative Staff A stated that the facility was looking to employ a new CDM and more dietary staff. Administrative Staff A stated the Registered Dietician currently was at the facility at least twice a week but did there was not a CDM currently. The facility did not provide a policy regarding the CDM as requested. The facility failed to employ a full time director of food and nutrition services who had the required qualifications and/or a CDM. This placed residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 87 residents. The sample included 20 residents. Based on interviews and record reviews, the facility failed to provide activities on the weekends that met the residents' interests, social needs, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life. Findings included: - A review of the facility's Activity Calendar for July, August, and September 2024 was completed. The review revealed the residents were only offered self-led activities in August and September on Saturdays and Sundays. The calendar revealed there were no structured or group activity opportunities on the weekends. On 09/10/24 at 03:01 PM, the Resident Council reported the facility frequently did not provide activities on Saturdays and Sundays. The Council indicated there was no available staff to direct or assist with activity on the weekend. On 09/10/24 at 01:05 PM Activities Staff Z stated she worked Monday through Friday. She stated she had an assistant who provided activities and mail on weekends, but he no longer worked weekends. She stated she tried to come in on weekends but was unable to most weekends. On 09/11/24 at 01:06 PM, Certified Nurse's Aide (CNA) M stated activities staff were not in the facility on weekends and the residents were provided self-led activities without staff involvement. The facility's Activities policy revised 05/2013 indicated the facility would ensure residents were provided with activities that reflect their choices and interests. The policy indicates the facility will encourage each resident to attend activities that meet each resident's interests, hobbies, worship, beliefs, and social needs. The facility failed to provide activities on the weekends that met the residents' interests, social needs, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life.

The facility identified a census of 87 residents. The sample included 20 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a medication regimen review (MRR) was completed at least monthly for Resident (R) 31, R79, R28, R39, and R50. The facility further failed to ensure the Consultant Pharmacist (CP) identified and made recommendations for a Center for Medicaid and Medicare (CMS) approved indication or a gradual dose reduction (GDR) for antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications for R31 and R28. The facility failed to ensure the CP identified and reported R79 and R28's diclofenac (Voltaren- a topical medication that reduces pain and inflammation) lacked a dosage. The facility failed to ensure the CP identified and reported R39's antihypertensive (a class of medication used to treat high blood pressure) medication was given outside of the physician-ordered parameters. These failures placed the resident at risk for unnecessary medication effects. Findings included: - On 09/11/24 the facility was unable to provide the CP's MRRs from October 2023 to December 2023 for R31, R79, R28, R39, and R50. Review the Electronic Medical Record (EMR) for R31, R79, R28, R39, and R50 lacked evidence the MRR was completed from October 2023 through December 2023. On 09/2/24 at 02:25 PM Administrative Nurse D verified the facility was not able to locate the CP recommendations from October 2023 to December 2023. Administrative Nurse D stated she could not say what the previous owners and their staff might have done with those recommendations. The undated Medication Regimen Reviews policy documented that the CP would perform a medication MRR for every resident in the facility. The primary purpose of this review was to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility failed to ensure an MRR was completed at least monthly. This placed the affected residents at risk for unnecessary medications and related complications. - R31's Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN- elevated blood pressure), delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R31's Annual Minimum Data Set (MDS) dated [DATE] documented that R31 had both long and short-term memory problems. R31 had severely impaired cognitive skills for daily decision-making. R31 was dependent on staff for her activities of daily living (ADLs). R31 used a wheelchair for mobility that staff propelled. R31 routinely received an antipsychotic medication. A GDR had not been attempted or documented by the physician as clinically contraindicated. R31's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/09/24 lacked any documented analysis. R31's Care Plan last revised 08/19/24, directed staff to administer psychotropic medications as directed. Staff was directed to monitor R31 for behaviors such as being verbally inappropriate, hallucinations (sensing things while awake that appear to be real, but the mind created), or delusions. R31's 11/17/22 Psychiatric Initial Assessment documented her delusional disorder and vascular dementia was being treated with Seroquel. R31 was currently stable on the medication and was to continue the medication. R31's Order Summary Report documented an order dated 12/04/23 for Seroquel (an antipsychotic medication) 25 milligrams (mg) to give one tablet by mouth twice daily for vascular dementia. A review of R31's MRR from January 2024 to July 2024 lacked evidence the CP identified and recommended a CMS-approved indication and a GDR for Seroquel use. R31's clinical records lacked a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication for use. On 09/10/24 at 09:22 AM, R31 sat in her wheelchair at the dining table with other residents. R31 displayed no behaviors. On 09/11/24 at 01:18 PM, Administrative Nurse E stated that she had not done anything with the CP recommendations yet. On 09/2/24 at 02:25 PM Administrative Nurse D stated she and the CP had been working with the physicians to attempt to decrease the use of Seroquel and to ensure that an appropriate indication for use, and the risk versus benefit for the use of Seroquel was completed as well as a GDR. The undated Medication Regimen Reviews policy documented that the CP would perform a medication MRR for every resident in the facility. The primary purpose of this review was to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. As part of the MRR, the CP would: Evaluate whether any medications in a drug regimen present potentially significant drug-drug or drug-food interactions; Determine if the resident was receiving the correct medications as ordered; Determine if medications were administered at the prescribed times; Determine if medications were administered in the correct dosage and form; Be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences; and Identify medication errors, including those related to documentation. The CP would document his/her findings and recommendations on the monthly drug/medication regimen review report. The CP would provide a written report to physicians for each resident with an identified irregularity. The CP would provide the Director of Nursing Services and Medical Director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions. Copies of drug/medication regimen review reports, including physician responses, would be maintained as part of the permanent medical record. The facility failed to ensure the CP identified and reported that R31 lacked a CMS-approved indication or the required physician documentation, for use for antipsychotic medications without GDR attempts. This placed R31 at risk for unnecessary medication administration and possible adverse side effects. - R79's Electronic Medical Record (EMR) documented diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), Lewy body dementia (a progressive disorder that results from protein deposits in nerve cells of the brain affecting movement, thinking skills, mood, memory, and behavior), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R79's Admission Minimum Data Set (MDS) dated [DATE] documented he had both short and long-term memory problems. R79 had severely impaired cognitive skills for daily decision-making. R79 displayed disorganized thinking that fluctuated. R79 displayed behaviors of hallucinations. R79 required supervision for activities of daily living (ADLs). R79 received antipsychotic medications on a routine basis. A GDR had not been attempted on R79's medications. R79's Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R79 was dependent on staff for all functional abilities and care. R79 received antipsychotic medications on a routine basis. A GDR had not been attempted on R79's medications. R79's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/28/23 documented he used psychotropic medications to manage psychiatric illnesses. A licensed nurse would monitor R79 for medication side effects each shift. A pharmacist consultant would review R79's medications monthly and the physician would review medications with each visit. R79's Care Plan last revised 02/27/24 directed staff to administer psychotropic medications as ordered. Staff was directed to document all behaviors and evaluate the side effects of the medications. R79's Order Summary Report from 12/15/23 to 09/11/24 documented an order dated 12/15/23 for Seroquel (an antipsychotic medication) 12.5 milligrams (mg) one time a day for hallucinations. R79's Order Summary Report from 12/15/23 to 09/11/24 documented an order dated 02/15/24 for Seroquel 12.5 mg one time a day for agitation and hallucinations. R79's Order Summary Report from 12/15/23 to 09/11/24 documented an order dated 03/22/24 for Seroquel 50 (mg) one time a day for agitation and hallucination. R79's Order Summary Report from 12/15/23 to 09/10/24 documented an order dated 12/15/23 for diclofenac (Voltaren) gel to apply to knees topically four times a day related to arthritis. A review of R79's MRR from January 2024 to the present revealed the lack of a CP recommendation for a CMS-approved indication for use for Seroquel or a recommended GDR. R79's clinical records lacked a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication for use. The facility was unable to provide this information upon request. On 09/10/24 at 12:45 PM, R79 paced about the Serenity unit with a staff member. On 09/11/24 at 01:18 PM, Administrative Nurse E stated that she had not done anything with the CP recommendations yet. On 09/2/24 at 02:25 PM Administrative Nurse D stated the facility was not able to locate the CP recommendations from October 2023 to December 2023. Administrative Nurse D could not say what the previous owners and their staff might have done with those recommendations. Administrative Nurse D stated she and the CP had been working with the physicians to attempt to decrease the use of Seroquel unless contraindicated and ensure that an appropriate indication for use, and the risk versus benefit for the use of Seroquel was completed as well as a GDR. The undated Medication Regimen Reviews policy documented that the CP would perform a medication MRR for every resident in the facility. The primary purpose of this review was to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. As part of the MRR, the CP would: Evaluate whether any medications in a drug regimen present potentially significant drug-drug or drug-food interactions; Determine if the resident was receiving the correct medications as ordered; Determine if medications were administered at the prescribed times; Determine if medications were administered in the correct dosage and form; Be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences; and Identify medication errors, including those related to documentation. The CP would document his/her findings and recommendations on the monthly drug/medication regimen review report. The CP would provide a written report to physicians for each resident with an identified irregularity. The CP would provide the Director of Nursing Services and Medical Director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions. Copies of drug/medication regimen review reports, including physician responses, would be maintained as part of the permanent medical record. The facility failed to ensure the CP idenitfied and reported the lack of a CMS-approved indication or the required physician documentation, for use for antipsychotic medications without GDR attempts and failed to identify and report the lack of dosing instructions for Voltaren. This placed R79 at risk for unnecessary medication administration and possible adverse side effects. 41037 - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychosis (any major mental disorder characterized by gross impairment in reality perception). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 received antianxiety (a class of medications that calm and relax people) medication, anticoagulant (a class of medications used to prevent the blood from clotting) medication, and antipsychotic medication. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented R28 received antianxiety medication, anticoagulant medication, and antipsychotic medication. R28's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/20/24 lacked documentation of or analysis of the triggered CAA. R28's Care Plan dated 01/24/24 documented the staff would administer medication as ordered. R28's EMR under the Orders tab revealed the following physician orders: Diclofenac sodium (Voltaren-non-steroidal anti-inflammatory drug [NSAID]) external gel one percent (%) apply to affected area(s) topically two times a day for pain dated 04/23/24. The order lacked a dosing instruction. Quetiapine fumarate (antipsychotic) oral tablet 50 milligrams (mg) give one tablet by mouth three times a day related to anxiety disorder dated 01/18/24. A review of R28's Monthly Medication Review (MMR) from January 2024 through July 2024 lacked evidence the CP identified and reported the lack of dosing instructions for Voltaren. The MMRs also lacked a recommendation to the physician for a gradual dose reduction or an approved Center for Medicare and Medicaid Services (CMS) indication. On 09/10/24 at 09:09 AM R28 sat in his wheelchair in the dining room as he watched videos on his cell phone. On 09/11/24 at 01:23 PM, Administrative Nurse E stated every medication order including Voltaren should have dosing instructions. She stated the nurse should call and clarify the order if it lacked dosing instructions. She stated she expected the consultant pharmacist to notify the facility regarding missing dosing instructions on the resident's monthly medication review. On 09/11/24 at 02:25 PM, Administrative Nurse D stated she expected all medication orders would have dosing instructions to be administered included on the order, including Voltaren. Administrative Nurse D stated she had been working with CP regarding the facility's expectations since May 2024. The facility's Medication Regimen Reviews (MRR) policy last revised 04/2007 documented the Consultant Pharmacist would review the medication regimen of each resident at least monthly. The primary purpose of this review was to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. As part of the MRR, the CP would: determine if the resident was receiving the correct medications as ordered, are administered in the correct dosage and form. The CP would document his/her findings and recommendations on the monthly drug/medication regimen review report. Copies of drug/medication regimen review reports, including physician responses, would be maintained as part of the permanent medical record. The facility failed to ensure the CP identified and reported irregularities for a lack of dosing instructions for Voltaren gel and further failed to identify and recommend a GDR and a CMS-approved indication for R28's quetiapine. This deficient practice placed R28 at risk for unnecessary medication use, side effects, and physical complications. - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), and sleep apnea (a disorder of sleep characterized by periods without respirations). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS lacked documentation a monthly regimen review was completed during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS lacked documentation a monthly regimen review was completed during the observation period. R39's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/30/24 documented he was at an increased risk of adverse side effects and that staff would continue to monitor for adverse reactions to his medications. R39's Care Plan dated 12/27/23 documented staff would administer cardiac medication as ordered and monitor for side effects. The plan of care documented that staff would notify the physician of adverse reactions as needed. R39's EMR under the Orders tab revealed the following physician orders: Carvedilol (medication used to treat high blood pressure) tablet 12.5 milligrams (mg) give one tablet by mouth two times a day for HTN. Hold if systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg). Hold if heart rate < 60 beats per minute. Use right arm only dated 06/19/24. Torsemide (diuretic) tablet 20mg give one tablet by mouth in the morning for HTN Hold if SBP <110 mmHg or heart rate <60 beats dated 06/20/24. A review of R39's Medication Administration Record (MAR) from 06/01/24 to 09/09/24 (101 days) revealed Torsemide was given outside of the physician-ordered parameters on the following dates 06/20/24, 07/06/24, and 07/20/24. Carvedilol was given outside of the physician-ordered parameters on the following dates 06/22/24, 06/24/24, 06/27/24, 07/01/24, 07/02/24, 07/06/24, 07/20/24, 07/25/24, and 08/21/24. A review of R39's Monthly Medication Review (MMR) from January 2024 through July 2024 lacked evidence the CP identified and reported the antihypertensive and diuretic medication was administered outside the physician-ordered parameters. On 09/10/24 at 03:11 PM, R39 laid flat on his bed with his continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) on as he slept. On 09/11/24 at 01:23 PM, Administrative Nurse E stated every medication order should be administered as ordered. She stated if the blood pressure or heart rate was outside the physician-ordered parameters the medication should be held, and the physician should be notified. On 09/11/24 at 02:25 PM, Administrative Nurse D stated she expected all medications should be given as the physician had ordered. Administrative Nurse D stated she had been working with CP regarding the facility's expectations since May 2024. The facility's Medication Regimen Reviews (MRR) policy last revised 04/2007 documented the Consultant Pharmacist would review the medication regimen of each resident at least monthly. The primary purpose of this review was to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. As part of the MRR, the CP would: determine if the resident was receiving the correct medications as ordered, are administered in the correct dosage and form. The CP would document his/her findings and recommendations on the monthly drug/medication regimen review report. Copies of drug/medication regimen review reports, including physician responses, would be maintained as part of the permanent medical record. The facility failed to ensure the CP identified and reported irregularities for medications given outside the physician-ordered parameters for R39. This deficient practice placed R39 at risk for unnecessary medication use, side effects, and physical complications.

The facility identified a census of 87 residents. The sample included 20 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R)44's built-up utensils (foam grip on regular utensils), and a divided plate was provided. This deficient practice left R44 vulnerable to unmet care needs due to the inability to feed herself. Findings included: - R44's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), obesity due to excess calories, hypertension (HTN-elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), weakness, hypoxia (inadequate supply of oxygen) and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented that R44 was dependent on staff for eating. The MDS documented R44 was impaired on both sides of her body. R 44's Nutrition Care Area Assessment (CAA) dated 10/18/23 documented R44 required moderate assistance with activities of daily living (ADLs) and was incontinent of bowel and bladder. R44's Care Plan dated 08/09/24 documented R44 was able to hold a cup, self-feed, and eat finger foods independently. R44's plan of care documented R44 used a divided plate and built-up silverware; staff were to set up her tray. R44's EMR under the Orders tab documented a diet order dated 03/21/23 to give pureed texture with thin-consistency liquids. R44 was to have a lidded cup with a handle, a lip plate, and modified utensils- a foam grip on regular utensils. On 09/10/24 at 09:35 AM R44's had a plate of biscuits and gravy on her bedside table. The plate was a regular plate (not divided). There were two regular spoons, and the spoons did not have a foam grip. R44 did not receive a divided plate, R44 asked for a divided plate, and staff scraped her food from a regular plate to a divided plate. On 09/11/24 at 10:05 AM R44's had a tray with the lid sat on her bedside table. R44 had a regular spoon on the tray, the spoon did not have a foam grip. On 09/09/24 at 07:20 AM, R44 stated she was supposed to get a divided plate and gripped silverware. R44 stated she must ask for her plate and silverware. On 09/11/24 at 01:06 PM Certified Nurse's Aide (CMA) M stated dietary was supposed to make sure the residents got the right plates and silverware. On 09/11/24 at 01:19 PM, Licensed Nurse (LN) E stated she was unsure, but she thought dietary would send the plates and silverware, and nursing would ensure residents have what they need. On 09/11/24 at 02:19 PM, Certified Nurse Aide (CMA) D stated dietary and nursing staff were supposed to ensure each resident got what they needed to ensure they were able to do the most for themselves. On 08/14/24 at 12:58 PM Administrative Nurse D stated diet orders go to the dietary department, and the dietary department sends the plates. Administrative Nurse D said the nursing staff was to ensure the correct utensils were given to each resident. The facility did not provide an accommodation of needs policy. The facility failed to ensure R44's divided plate and built-up utensils were provided. This deficient practice left R44 vulnerable to unmet care needs due to the inability to feed herself.

The facility identified a census of 102 residents. The sample included five residents reviewed for weight loss. Based on record review, observation, and interview, the facility failed to monitor oral intake, failed to ensure routine and consistent weight monitoring, and failed to implement further interventions such as fortified foods until after a significant weight loss for Resident (R)1. The facility further failed to ensure R1 received the necessary adaptive utensils required for eating. This deficient practice resulted in a loss of 15.57 percent in three months and placed R1 at risk for further loss and malnutrition. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and dementia with behavior disturbance (a decline in cognitive abilities that impacts a person's ability to perform everyday activities). The Admission Minimum Data Set (MDS), dated ,d+[DATE]/ 23, documented R1 had a Brief Interview for Mental Status score of two which indicated severely impaired cognition. The MDS documented R1 had no problems with functional mobility, and she ambulated without any assistive devices. R1 required supervision and touch assistance with eating. The MDS documented R1 weighed 122 pounds. R1 received an antidepressant (a class of medication used to treat mood disorders). The Nutritional Status Care Area Assessment [CAA] dated 10/12/ 23 recorded staff monitored the resident's weight weekly and monitored if other factors such as pain and/or functional ability were affecting food and/or fluid intake. The registered dietician (RD) would visit regularly to ensure nutritional needs and a care plan would be developed to ensure R1's nutritional needs. A Quarterly MDS dated [DATE], recorded no change in the resident cognitive and/or functional abilities. R1 weighed 117 lbs. R1's Care Plan, created 10/18/23 and revised 12/27/23, documented R1 was at risk for nutritional problems based on chronic conditions and directed staff to provide R1's diet as ordered. Staff were to monitor R1's intake and record each meal. The plan noted a registered dietician would evaluate and make diet change recommendations as needed. The plan directed staff to obtain and monitor lab and diagnostic work as ordered and report the results to the physician and follow up as indicated. R1's revised Care Plan dated 01/24/24directed staff to administer medications as ordered and monitor and document side effects and effectiveness. The plan directed staff to monitor, document, and report any signs or symptoms of dysphagia (difficulty swallowing) which included pocketing, choking, coughing, drooling, holding food in the mouth, and several attempts at swallowing. Staff were to monitor and report refusals to eat and the appearance of concern during meals. The plan directed staff to provide and serve R1's diet as ordered and provide and serve Magic Cup (frozen nutritional supplement) and house supplements twice daily. R1's Order Summary recorded the following orders dated 10/13/23: A regular diet with regular thin-consistency liquids. Magic cup with meals. House supplement 4 ounces twice daily. Mirtazapine (antidepressant) 30 milligrams (mg) daily for depression. R1's EMR recorded a Registered Dietician Note dated 10/18/23 that documented R1 was independent with meals. She received a regular diet and averaged a fair meal intake of 51 to 75 percent (%). The assessment recorded the RD was unable to fully assess R1 due to the lack of height and weight. R1's EMR under the Weights tab recorded R1 weighed 122 pounds on 10/19/23. R1's EMR lacked evidence she was weighed again on 11/09/23 when she weighed 119.5 pounds. R1's next recorded weight was on 12/11/23 when R1 weighed 117.2 pounds. R1's Order Summary listed an order dated 12/21/23 for a diet change to a regular mechanical soft diet with chopped meats and thin liquids. A Nurses Progress Note dated 12/22/23 at 08:08 AM documented during the evening meal on 12/21/23, R1 choked on a piece of chicken. Staff assisted in dislodging the chicken and were successful with no injury noted. R1 had a history of similar events but not in recent months. The note recorded staff would ensure the resident always ate in the dining room, and the aides attempted to prepare R1's plate with smaller bite-size portions. A message of notification was made to the resident's responsible party and physician. A Physician's Progress Note dated 12/29/23 documented an interim review of R1's current medical problems. The note recorded staff denied any new issues with R1. R1 denied any nausea, vomiting, diarrhea, or any other problems. The note documented to continue current orders. A Nutrition Evaluation Note dated 01/15/24 at 01:48 PM recorded R1's current weight was 117.2 pounds from 12/11/23 weight and noted R1 had not had a significant weight loss or gain in the last month or last six months. The note recorded R1's current diet order was mechanical soft chopped. The note documented R1's meal intakes were good, averaging 75-100% in the last seven days. The note recorded the resident received supplements. R1's EMR recorded a weight of 103 pounds on 01/15/24 at 05:12 PM, which reflected a loss of 12.12% in 35 days. R1's EMR lacked evidence of physician or RD notification of the significant weight loss at that time. R1's EMR recorded a weight of 101.4 pounds on 01/22/24. An IDT Meeting Note dated 01/25/24 at 01:09 PM documented an Interdisciplinary (IDT) Patient at Risk (PAR) UDA was completed on that date. R1 was at risk related to weights. R1's Care Plan was reviewed and updated as needed. R1 and her responsible party were notified of the plan of care and R1's physician was notified of her change in condition. R1's EMR recorded an order dated 01/25/24 for fortified foods with a mechanical soft, chopped meat diet. This order was discontinued on 01/31/24. R1's EMR recorded a weight of 100.8 pounds on 01/29/24. A Weight Change Note dated 01/31/24 at 01:24 PM recorded R1 triggered for a significant weight loss and her current weight of 103 pounds was down 14.2 pounds in the last 30 days. The note documented a recommendation to obtain a reweight to confirm the weight loss. The note recorded R1 received a house supplement twice daily and a Magic cup with meals. The note documented that staff continued to monitor weight trends, labs, and oral intake. R1's EMR recorded an order dated 01/31/24 for a regular mechanical soft diet with ground meat texture, thin liquids, weighted silverware, cottage cheese and applesauce with every meal, and fortified mashed potatoes at lunch and supper. R1's Order Summary documented an order dated 01/31/24 for mirtazapine 30 mg daily to be given with 7.5 mg for a total of 37.5 mg for depression. Another order for mirtazapine dated 01/31/24 directed staff to administer 7.5 mg one time daily for appetite and directed to give with the 30 mg dose for a total of 37.5 mg. R1's EMR recorded a weight of 92.2 pounds on 02/06/24. A Weight Change Note dated 02/09/24 at 09:22 AM recorded R1's weight was 92 pounds which reflected a loss of 25 pounds (21%). The note recorded R1 was started on an appetite stimulant and received supplements twice daily and a Magic cup with meals. The note recommended to reweigh R1 to verify loss and staff would continue to monitor weight trends, labs, and oral intakes. R1's Medication Administration Record/Treatment Administration Record MAR/TAR from October 2023 through February 2024 revealed staff documented R1 received her house supplement and Magic cup as ordered but did not document the percentage consumed. R1's clinical record lacked evidence staff routinely monitored the percentage of food R1 consumed at each meal. A Health Status Note dated 02/14/24 at 01:03 PM recorded staff notified R1's provider regarding R1's swallowing difficulty and the potential of weighted silverware. A Therapy Note dated 02/16/24 at 07:34 AM documented R1 was screened, and orders were requested for occupational and speech therapies secondary to increased difficulty with self-feeding and potential for choking. On 02/28/24 at 12:53 PM staff served R1 her lunch in the dining room. R1 began to eat but had visible difficulty due to tremors (uncontrolled shaking). R1 held her regular non-weighted fork in her right hand and used her left hand to try to stabilize the right hand. Administrative Nurse D approached R1 and asked R1 if she needed help. After several minutes and after assisting another resident, Administrative Nurse D sat next to R1 and R1 was receptive to her assistance. On 02/28/24 at 04:27 PM, Licensed Nurse (LN) G stated when residents were admitted to the unit, staff attempted to find food the residents liked to help encourage the residents to eat. LN G stated every staff member should monitor what was sent to the unit for the residents to eat. LN G stated if a resident had a supplement ordered, the percentage was documented or should be documented. LN G stated that Certified Nurse Aides (CNAs) were supposed to document how much residents ate at each meal. LN G stated the charge nurses on the unit were supposed to ensure the CNAs completed the documentation, which included the meal percentages, but LN G went on to say it was not always done as there was not always time. LN G stated if a resident had weight loss, especially a significant weight loss, staff should call the doctor and implement interventions to prevent more weight loss. On 02/28/24 at 04:37 PM, CNA M stated he could tell by looking at the residents if they appeared to be losing weight. CNA M stated when he observed the residents during the dining process, he watched to make sure the resident drank after a couple of bites and monitored if the resident swallowed the food or fluids. CNA M stated if a resident had trouble feeding themselves, he would assist or attempt to guide the residents' hands while the residents fed themselves. CNA M stated after the meals, he documented how much was consumed in the resident's record. On 02/28/24 at 05:04 PM Administrative Nurse E stated that the unit managers reviewed the CNAs' charting on meal intakes. Administrative Nurse E confirmed there should be a percentage documented for meals and supplemental fluids. Administrative Nurse E stated when documentation was missed, it alerted the system, but Administrative Nurse E could not confirm if the missed documentation for R1 had alerted staff. On 02/28/24 at 05:15 PM Administrative Nurse D stated she watched R1 eat from afar and allowed her to attempt to feed herself. Administrative Nurse D stated when she noticed R1 struggled, after allowing R1 time to attempt to feed herself, she would go and sit by the resident and assist R1 with eating. Administrative Nurse D stated since she had started to sit and help R1, R1 had gained weight. Administrative Nurse D stated R1 lost a lot of weight and confirmed the loss should have been addressed sooner. The facility's Weight Monitoring policy revised 12/13/23, documented: Based on the resident's comprehensive assessment, the facility will maintain acceptable parameters of nutritional status, such as usual body weight range and electrolyte balance unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The policy documented information gathered for the nutritional assessment(s) and current dietary standards of practice is used to develop an individualized care plan to address the resident specific nutritional concerns and preferences.; and interventions would be identified, implemented, monitored, and modified (as appropriate) consistent with the resident's assessed needs, choices, preferences, and goals. The policy further recorded that the physician would be informed of any significant change in weight and may order additional interventions and meal consumption information should be recorded and referenced by the interdisciplinary care team as needed. The facility failed to monitor oral intake, failed to ensure routine and consistent weight monitoring, and failed to implement further interventions such as fortified foods until after a significant weight loss for R1. The facility further failed to ensure R1 received the necessary adaptive utensils required for eating. This deficient practice resulted in a loss of 15.57% in three months and placed R1 at risk for further loss and malnutrition.

The facility identified a census of 102 residents. The sample included six residents reviewed for medication. Based on record review and interviews, the facility failed to prevent a significant medication error when Resident (R)1 received eight times the prescribed amount of morphine sulfate, (a narcotic pain reliever). On 12/06/22 at 02:53 AM, Licensed Nurse (LN) L administered forty milligrams (mg) of morphine sulfate (narcotic medication used to treat moderate to severe pain) instead of the physician ordered five mg. An assessment on 12/06/22 at 05:30 AM revealed a change in R1's breathing and level of consciousness. On 12/06/22 at 08:00 AM, R1 transferred to the hospital for emergent care related to the medication error . Findings included: - The electronic medical record (EMR) documented R1 admitted to the facility on [DATE], discharged to the hospital on 11/21/22, and readmitted to the facility on [DATE]. R1's EMR listed diagnoses under the Diagnosis tab of alcoholic cirrhosis of the liver with ascites (a destruction of normal liver tissue with a buildup of fluid in the abdomen); acute kidney failure (when the kidneys suddenly become unable to filter waste products from the blood) and encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood, due to disease.). The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment recorded R1 needed supervision with most activities of daily living (ADL) such as transfers, dressing, and toilet use. The assessment documented R1 received an antidepressant (medication to relieve feelings of sadness), antibiotic (medication used to treat infections), and diuretic (medication used to remove excess fluid from the body) medication during the seven-day look back period. R1's Care Plan dated 10/26/22 directed staff to administer medications as ordered and monitor for side effects. A Progress Note, dated 12/05/2022 at 01:32 PM, documented R1's return to the facility after hospital treatment for an exacerbation of existing medical conditions. The progress note recorded R1 was approved for treatment by hospice services and receive comfort medications. An Admission Evaluation dated 12/05/22 documented R1 was alert and oriented to person, place, and time. R1 could feed himself but required limited assistance of one to two persons with most ADL and used a wheelchair for ambulation. The Physicians Orders tab documented an order dated 12/06/22 which directed to administer morphine sulfate concentrate solution 20 mg per milliliter (ml); give five mg by mouth every six hours as needed for pain. The Medication Administration Record (MAR) documented R1 received the morphine sulfate once on 12/06/22 at 02:53 AM. A Progress Note dated 12/06/22 at 05:30 AM documented LN J was summoned by LN L to assess R1, due to LN L reported R1 was not at his baseline (a condition that is taken at an early time point and used for comparison over time to look for changes). LN J recorded R1 was responsive and communicated with the nurse; R1's skin was warm and dry; R1 had equal strength in both hands, denied having pain or headache, and maintained eye contact. LN J instructed LN L to monitor R1 and notify LN J and the hospice nurse if R1 had any change. A Progress Note, dated 12/06/2022 08:00 AM by LN L, documented at approximately 02:34 AM, LN L administered R1 too much morphine. The note recorded LN L was unaware of the error until the hospice nurse arrived. LN L documented she had LN J assess R1 because R1 had a problem breathing, and when the hospice nurse arrived, the medication error was discovered. On 12/06/22, facility review of R1's narcotic record (count sheet) revealed LN L recorded five ml (100 mg) was removed from R1's morphine sulfate bottle. (This notation was later determined inaccurate as only two ml (40 mg) was absent from the bottle.) The Facility Investigation of the medication error documented the following timeline on 12/06/22: 02:53 AM LN L administered morphine 40 mg to R1. 05:18 AM R1 was assessed for pain. 05:30 AM LN J assessed R1, who was reportedly not at his baseline. 05:35 AM staff notified hospice. 06:15 AM Consultant Nurse (CN) K arrived from hospice. Police arrived. 06:17 AM staff reassessed R1. 06:20 AM the medication error was identified; the physician was notified as well as 911. 06:30 AM emergency medical services (EMS) arrived. 07:17 AM facility staff notified R1's responsible party. The hospital emergency room Report dated 12/06/22 at 07:51 AM recorded R1 presented with altered mental status. The report recorded R1 was a limited historian at that moment; the nursing home stated to EMS that R1 was possibly overdosed on morphine at 02:30 AM that morning. In a Witness Statement dated 12/06/22 CN K performed an assessment for respiratory changes due to LN L gave R1 two ml of morphine at 02:34 AM, but documented that five ml were given. R1's vitals were as follows: breathing was shallow and oxygen saturation (level of oxygen in the blood, should be 90 % or greater) was at 86%. R1's blood pressure was decreased with a reading of 84/59 millimeters of mercury (mmHg-normal blood pressure 120/60 mmHg). R1's pulse/heart rate was elevated at 109 beats per minute (bpm). The statement noted CN K consulted with LN J, called 911, and R1 transferred to the hospital for evaluation. An undated Witness Statement by LN J recorded LN L administered two ml of morphine sulfate. After assessment, staff decided to send R1 to the hospital because R1 was a full code (desired full resuscitative measures) and R1 was not oriented enough to refuse transport. The statement further noted CN K decided against administering Narcan (medication used to immediately reverse the effects of opioids). Staff notified emergency services and R1 transferred to the hospital. LN J and CN K reviewed the morphine order and the remaining amount in the morphine bottle. The order was for 0.25 ml, but LN L documented five ml were given. LN J recorded that LN L stated repeatedly that she only administered two ml. LN L could not give a reason for documenting a different amount than what was given. During a telephone interview on 12/08/22 at 02:02 PM Consultant Pharmacist (CP) GG stated he confirmed (as best as could be without using a graduate) using the scale on the side of the bottle, the amount of morphine sulfate remaining was in fact 28 ml, with only two ml missing. CP GG stated this was consistent with the nurse having given two ml and not five ml as was recorded. CP GG had been evaluating the facility medications for several months and had not identified this type of situation at the facility before. During a telephone interview on 12/08/22 at 02:11 PM Consulting Practitioner HH stated the facility acted appropriately in that they immediately sought help for the resident and then notified Consultant Practitioner HH. Consultant Practitioner HH stated, in the future, he may consult with the pharmacy and write orders to reflect the number of milliliters to be given, as he felt LN L looked at the amount of liquid to be given instead of the milligrams. Interviewed on 12/08/22 at 01:27 PM, Administrative Nurse E stated the expectation of the nurse was to follow the physician's orders correctly, using the five rights of medication administration. Administrative Nurse E said LN L reported checking the order with the bottle, Administrative Nurse E felt LN L could not have checked because the bottle clearly stated give 0.25 ml. Administrative Nurse E stated LN L believed the policy was followed. Administrative Nurse E stated, after R1 was sent out to hospital, LN L was terminated and a notice of do not return provided to the nurse's staffing agency. Interviewed on 12/08/22 at 02:30 PM, Administrative Staff A acknowledged the errors in the nurse actions and noted the issue was being reviewed in Quality Assurance (QA), a performance improvement plan was implemented, and audits were conducted. The facility's Administrating Medications Oral policy revised 05/2022 directed staff to check the label on the medication and confirm the medication name and dose with the MAR; and check the medication dose; recheck to confirm the proper dose. The facility failed to prevent a significant medication error for R1, when LN L administered R1's pain relieving medication in an amount which exceeded the physician's order. R1's developed breathing difficulty and a decreased level of consciousness and required emergent hospitalization and monitoring. The facility completed the following corrective actions prior to the survey event: Immediate education was provided to all nurses, including administrative nurses as well as Administrative Staff A, regarding the right of medication administration, and correct dosing. All narcotic medications were reviewed and verified. All residents under LN L's care were immediately assessed. The incident was reported to the state agency and a QA meeting and plan was initiated. The deficient practice was cited as past non-compliance.

The facility had a census of 112 residents. The sample included 26 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to identify and implement preventative measures to prevent pressure ulcers and promote healing of pressure injuries for Resident (R) 46, who developed unstageable pressure ulcers on both of his heels and a stage two (shallow with a reddish base and have a break in the top two layers of the skin) pressure ulcer on his buttock. Findings included: - The Electronic Medical Record (EMR) for R46 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), pelvic fracture (damage to the hip bone, sacrum (a triangular bone in the lower back) or coccyx (a small triangular bone at the base of the spine), repeated falls, hypertension (high blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), and hip fracture (broken hip). The 5 Day Medicare Minimum Data Set (MDS), dated [DATE], documented R46 had severely impaired decision-making skills, was dependent upon one staff for toileting, dressing, and personal hygiene. He required limited assistance of one staff for bed mobility and did not ambulate. The MDS further documented R46 had no upper or lower functional impairment, was not at risk for skin breakdown, had no skin breakdown, but had pressure reducing devices for his bed and chair. The Pressure Ulcer Care Area Assessment (CAA), dated 10/25/22, documented R46 would receive assistance for pressure ulcer/injury needs. The Braden Scale Assessment, (formal assessment for predicting pressure ulcer risk) dated 10/19/22, documented a score of 16, indicating a low risk for pressure ulcer development. The Braden Scale Assessment, dated 10/26/22, documented a score of 17, indicating a low risk for pressure ulcer development. The Braden Scale Assessment, dated 11/16/22, documented a score of 12, indicating a high risk for pressure ulcer development. R46's Care Plan initiated on 10/22/22 directed staff the resident was at risk for altered nutrition due to a pelvic fracture, dementia, and depression. (This was revised on 11/22/22 to indicate the resident had compromised skin.) An intervention dated 10/22/22 directed staff to administer medications as ordered. R46's Care Plan dated 10/18/22 recorded the resident was at risk for falls. An intervention dated 10/18/22 directed staff to anticipate and meet R46's needs. The care plan was updated on 10/27/22 to indicate the residents was dependent on staff for all activities, cognitive stimulation, and social interaction due to his cognitive deficits. An intervention dated 10/28/22 directed staff R46 required staff assistance with activities of daily living (ADL) during activity. The care plan lacked direction to staff regarding prevention of pressure injuries and lacked direction to staff regarding the resident's assistance needs with ADL. R46's Care Plan updated on 11/16/22, after the development of pressure injuries. The care plan documented R46 had potential and actual impairment to skin integrity related to incontinence and sedentary since left hip fracture. The care plan documented R46 had a right heel blister, left heel deep tissue injury, and left buttock pressure ulcer. The care plan listed interventions dated 11/16/22 which directed staff to educate the resident/his family and caregivers of causative factors and measures to prevent skin injuries. It directed staff to encourage good nutrition and hydration to promote healthy skin, to keep skin clean and dry, and use lotion on dry skin. The care plan directed staff to monitor and document location, size and treatment of skin injury. It further directed staff to place a pressure relieving device in R46's bed and chair. The care plan lacked documentation of directions regarding heel protectors and positioning to address the current pressure injuries. R46's Care Plan recorded a focus dated 12/01/22, which documented R46 had an ADL self-care deficit due to his dementia. Interventions dated 12/01/22 directed staff the resident required assistance from staff with bed mobility. It further documented R46 was totally dependent upon staff for bathing, dressing, and transfers. The Nurse's Note, dated 11/04/22 at 06:47 PM, documented R46 arrived via stretcher from the hospital, alert, and oriented to himself only. He had no open areas on either leg except for the surgical incision on the left hip with three stitches. The Weekly Skin Condition Report, dated 11/15/22, documented R46 had an unstageable (base of the sore is covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black) blister on his right heel which measured 3.5-centimeter (cm) x 3 cm which was first observed on 11/14/22. The report further documented R46 had a suspected deep tissue injury (SDTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) to his left heel that measured 5 cm x 6 cm which was first observed on 11/14/22. The report directed staff to put foot boots (heel protectors) on when the resident was in bed. The report documented R46 had a stage 2 pressure ulcer on his left buttock which measured 1.5 cm by 1.5 cm. The Physician's Order, dated 11/15/22, directed staff to apply skin prep (a liquid film forming dressing that, upon application to intact skin and forms a protective film) and do not wash off except on shower day, every evening shift for skin care management. The Physician's Order, dated 11/15/22, directed staff to cleanse the left buttock wound with normal saline, cut Hydrofera Blue (a dressing that kills bacteria in a wound) to the size of the wound, and cover with a silicone bordered gauze (absorptive dressing consistent with three layers). The order further directed staff to change the dressing daily very evening shift and as needed. The order was discontinued on 11/30/22. The Physician's Order, dated 11/21/22, directed staff to apply Prafo boots (heel protectors) to bilateral feet for pressure relief. The Weekly Skin Condition Report, dated 11/22/22, documented a right heel blister, measured 3 cm by 0.5 cm and a left heel unstageable pressure ulcer, measured 2.5 cm by 4 cm. The report further documented R46 had a stage 3 (full thickness skin loss) left buttock pressure ulcer which measured 1 cm by 1 cm by 0.1 cm. The Weekly Skin Condition Report, dated 11/29/22, documented R46 had an unstageable pressure ulcer to her right heel, measured 1 cm by 1 cm and an unstageable pressure ulcer, measured 2 cm by 1.5 cm by 0.1 cm with black eschar (a dry, dark scab or falling away of dead skin). The report further documented R46 had a stage 2 pressure ulcer on his left buttock, which was healed. The Physician's Order, dated 11/29/22, directed staff to apply Santyl ointment (removes dead tissue from wounds to they can start to heal), 250 unit/gram to the left heel, every evening shift and cover with a silicone bordered foam dressing for wound management. The Physician's Order, dated 11/29/22, directed staff to apply skin prep to the right heel daily and do not wash off except on shower days every evening shift for skin care management. On 11/29/22 at 11:00 AM, observation revealed R46 sat in his wheelchair and did not have a pressure relieving cushion in his wheelchair. Further observation revealed R46 had bilateral heel protectors on, though the right heel protector hung off his right foot. On 11/29/22 at 11:15 AM, observation revealed R46, in bed, on his left side. Further observation revealed a pink area on his left buttock without a dressing. On 11/30/22 at 09:55 AM, observation revealed R46 in his wheelchair and no pressure relieving cushion in his wheelchair. On 11/30/22 at 11:52 AM Administrative Nurse F placed a pressure reducing cushion in the resident's wheelchair. On 12/01/22 at 02:30 PM Licensed Nurse (LN) MM washed her hands, gloved and removed the soiled dressing from R46's left heel. Further observation revealed LN MM removed her soiled gloves, washed her hands, donned clean gloves, and then cleansed the wound on his left heel. Continued observation revealed LN MM removed her soiled gloves, washed her hands, replaced her gloves and applied Santyl ointment to his left heel, and placed the bandage to his left heel. LN MM stated R46 did not have any treatment for his buttocks and had a new order for the left heel. On 11/30/22 at 11:36 AM, Consultant HH stated he expected the facility to follow the offloading protocol policy and further stated the facility should have placed a cushion in R46's wheelchair. On 11/30/22 at 11:52 AM, Administrative Nurse F stated therapy placed a cushion in the resident's wheelchair three times, but she was uncertain what happened to it. Administrative Nurse F further stated R46's buttocks wound healed and she did not know if there would be any further orders for preventative measures to make sure R46's buttock wound did not reopen. Administrative Nurse F verified there had not been any preventative measures in place prior to R46's skin breakdown. On 11/30/22 at 02:30 PM, Certified Nurse Aide (CNA) Q stated she did not know when R46 first obtained the skin breakdown on his buttocks and heels. CNA Q stated R46 wore the heel protectors all the time due to the areas on his heels. On 12/05/22 at 12:54 PM, Administrative Nurse C stated R46 was ambulating when he first came to the facility, was not sedentary, and staff felt he was a low risk for pressure ulcer development and therefore no care plan was developed to address pressure relief. The facility Pressure Injury Treatment Guidelines policy, dated August 2022, documented for the care of an existing pressure injury and the prevention of additional pressure injury, the facility verified there was a doctor order for treatment, the care plan was reviewed, current orders and a diagnosis to determine if there are special resident needs. The facility failed to identify risk and implement preventative measure for pressure ulcer development for cognitively impaired R46 who had decreased mobility due to a hip fracture. As a result, R46 developed unstageable pressure ulcers on his right and left heel as well as a stage two pressure injury to his coccyx. This placed the resident at risk for further skin breakdown.

The facility identified a census of 112 residents. The sample included three residents with three reviewed for diabetic services. Based on interview, record review, and observation the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to follow physician orders, and failed to ensure the licensed nurses possessed knowledge regarding insulin (hormone which regulates blood sugar)administration and monitoring of residents who received fast acting insulin. On 01/17/22 Resident (R)1 admitted to the facility with orders for sliding scale insulin 0-5 units four times daily dependent upon R1's blood glucose levels. The facility staff inaccurately entered an order to administer insulin [MEDICATION(S)] (fast acting insulin) 10 milliliters four times daily with no reference to the blood glucose level. Licensed nursing (LN) staff failed to identify the dose ordered, 10 ml equal to 1000 units, as a potentially lethal dose of insulin and failed to call the physician and clarify the order. LN staff administered an altered dose of 10 units, but failed to call the physician for clarification and failed to correct the order dosing. LN staff further failed to document the actual amount of insulin administered. LN staff failed to apply the standards of nursing practice when they administered the excessive dose of fast acting insulin on three occasions when R1's blood glucose was less than 100 milligrams per deciliter (mg/dl) (normal blood glucose levels range between 90 and 130 mg/dl). LN staff failed to assess R1's blood glucose level when he was identified as unconscious in the facility on 01/21/22 at 11:26 PM. Emergency responders assessed R1 and found his blood glucose level at 21 mg/dl. He required emergent transfer to the acute care hospital where he was admitted with profound [CONDITION(S)] (low blood glucose). These failures placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Five Day Minimum Data Set (MDS) dated [DATE] recorded R1's Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of one staff member for activities of daily living (ADL) including bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. R1 required supervision with set up help only for eating. The MDS documented R1 received injections of insulin three days during the look back period. The Care Plan initiated 01/20/22 directed staff to administer medications as ordered and monitor/document side effects and effectiveness. The Care Plan lacked interventions for diabetic management. The Hospital Discharge Orders dated 01/17/22 documented insulin [MEDICATION(S)] 100 units/milliliter (mL) injection one to five units subcutaneously (beneath the skin) four times daily before meals and nightly for diabetes mellitus type two. The hospital Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Blood glucose (BG) 0-120 mg/dl: Give 0 units. BG 121-150 mg/dl: Give 0 units. BG 151-200 mg/dl: Give 0 units. BG 201-250 mg/dl: Give 1 unit. BG 251-300 mg/dl: Give 2 units. BG 301-350 mg/dl: Give 3 units. BG 351-400 mg/dl: Give 4 units. BG greater than (>) 400 mg/dl: Give 5 units. R1's EMR lacked evidence facility nursing staff clarified the insulin orders with the discharging hospital or R1's physician upon admission. The Orders tab in R1's EMR documented the following orders: Accu-check (blood sugar-testing devices) four times daily before meals and nightly ordered 01/17/22. The order directed staff to call the physician if BG measured below 60 or above 400. Insulin [MEDICATION(S)] 100 units/mL ordered 01/17/22, inject 10 mL subcutaneously (SQ) before meals and at bedtime for diabetes mellitus, type two. R1's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 01/17/22 09:00 PM 10 ml insulin administered by LN K no BG recorded. 01/18/22 07:30 AM BG 130 mg/dl,10 ml insulin administered by LN L. 01/18/22 11:30 AM BG 271 mg/dl, 10 ml insulin administered by LN L. 01/18/22 04:30 PM BG 120 mg/dl, 10 ml insulin administered by LN P. 01/18/21 09:00 PM BG 133 mg/dl, 10 ml insulin administered by LN P. 01/19/22 07:30 AM BG 112 mg/dl, 10 ml insulin administered by LN Q. 01/19/22 11:30 AM BG 92 mg/dl, 10 ml insulin administered by LN Q. 01/19/22 04:30 PM BG 210 mg/dl, 10 ml insulin administered by LN P. 01/19/22 09:00 PM BG 210 mg/dl, 10 ml insulin administered by LN K. 01/20/22 07:30 AM BG 162 mg/dl, 10 ml insulin administered by LN R. 01/20/22 11:30 AM BG 112 mg/dl, insulin held by LN R for documented reason Not required. 01/20/22 04:30 PM BG 113 mg/dl, 10 ml insulin administered by LN K. 01/20/22 09:00 PM BG 200 mg/dl,10 ml insulin administered by LN K. 01/21/22 07:30 AM BG 97 mg/dl, 10 ml insulin administered by LN H. 01/21/22 11:30 AM BG 98 mg/dl, 10 ml insulin administered by LN H. 01/21/22 04:30 PM BG 117 mg/dl,10 ml insulin administered by LN G. 01/21/22 09:00 PM BG 107 mg/dl,10 ml insulin administered by LN G. The Progress Note dated 01/21/22 at 11:26 PM documented R1 found on his bed and unresponsive. Licensed Nurse (LN) I assessed R1's oxygen saturation levels as 99 percent and contacted emergency medical services (EMS). EMS arrived at the facility and measured R1's BG as 21 mg/dl. The note documented R1 did not respond to any commands. R1's responsible party requested R1 go to the hospital for treatment and evaluation. The Progress Notes lacked evidence facility staff assessed R1's blood glucose levels prior to arrival of EMS and lacked evidence staff took actions to identify and/or reverse R1's acute hypoglycemic condition other than EMS notification. The hospital History and Physical (HPI) from R1's admission on 01/22/22 at 12:32 AM recorded R1 presented to the emergency department from his nursing home with altered mental status. EMS measures a BG of 20. The HPI documented review of the facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The HPI recorded it was unclear how much insulin R1 received. The HP further documented there were significant discrepancies in R1's most recent discharge medication list and the medication list sent by the facility. The HPI listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/22 at 11:35 AM Administrative Nurse D stated when a resident admitted to the facility, the admitting nurse put in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D further stated that either herself or another administrative nurse would review the orders the following day. Administrative Nurse D then revealed there was no system in place to verify which newly admitted residents' orders were checked and verified by an administrative nurse. Administrative Nurse D stated if a resident admitted with unclear orders, the nurse was expected to call the physician to clarify the orders. On 01/27/22 at 01:48 PM LN G reviewed R1's insulin [MEDICATION(S)] order sand stated that although the insulin order read 10 mL, she only administered 10 units of insulin. LN G further revealed she had not held any insulin when she cared for R1. LN G reported she received training on insulin administration and care of diabetic patients in nursing school. LN G stated she did not assess R1's BG level when identifying he was unresponsive, because she had notified emergency services. On 01/27/22 at 12:39 PM Consultant Provider GG reviewed the insulin [MEDICATION(S)] order under the Orders tab and stated the nurses should have called to clarify that order. Consultant GG further stated that even 10 units seemed a bit excessive for a resident that had not previously been insulin dependent. On 01/27/22 at 01:53 PM LN H stated she would not have administered 10 mL of insulin to R1, and stated she was unsure what the order should have been. LN H reported she administered 10 units instead of 10 ml because ml and units were the same. LN H reported it never occurred to her to hold the fast-acting insulin and contact the physician based on a lower BG level. On 01/27/22 at 02:05 PM Consultant Nurse HH stated the nurse did the right thing by calling EMS, waiting for them to arrive, and not doing anything else to assess R1. Consultant HH stated when a resident was unconscious, it was appropriate to call emergency responders and then wait for them to arrive. On 01/27/22 at 2:20 PM Administrative Staff A stated that he expected Administrative Nurse D to be auditing the orders for admitting residents and following up on any discrepancies or administration concerns. The facility's Insulin Administration policy revised on 05/2021 recorded the type of insulin, dosage requirements, strength and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse should notify the physician if the resident has signs and symptoms of [CONDITION(S)] that are not resolved by following the facility protocol for [CONDITION(S)] management. The facility's Change in a Resident's Condition or Status policy revised 11/2017 directed staff to notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical, mental, or psychosocial status either in life-threatening conditions or clinical complications. The facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to follow physician orders, to administer insulin and monitor diabetic residents who receive fast acting insulin according to the standards of practice. This failure placed R1 in immediate jeopardy. The immediacy was removed when the facility implemented the following: An investigation started on 1/31/22. Staff identified as allegedly providing wrong dose of insulin has been suspended pending investigation. The Assistant Director of Nursing began education on 01/31/22 related to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Any licensed nurses not working were reeducated prior to their next shift. A Root Cause Analysis was performed in order to help identify and prevent further incidents of this nature. Any nurse transcribing any new insulin orders will have orders reviewed by a second licensed nurse prior to administering any insulin. The Director of Nursing or Designee will review all new medication orders during morning clinical meeting for accuracy. A skills competency check will take place for all licensed nurses prior to the administration of any insulin. The scope and severity of the deficient practice remained at a G.

The facility identified a census of 112 residents. The sample included three residents with three reviewed for diabetic services. Based on interview, record review, and observation the facility failed to prevent a significant medication error when the facility failed to ensure Resident (R) 1 received the correct physician ordered sliding scale insulin (hormone which regulates blood sugar). On 01/17/22 R1 admitted to the facility with orders for sliding scale insulin 0-5 units four times daily dependent upon R1's blood glucose levels. The facility inaccurately entered an order to administer 10 milliliters four times daily with no reference to the blood glucose level. Staff then administered 10 units of insulin on eleven occasions when no insulin was required per the correct order. Staff also administered 10 units of insulin on three occasions when only 1 unit was required, and one occasion when only 2 units were required. Subsequently, on 01/21/22 after staff administered the incorrect dose of 10 units of insulin, R1 was found unconscious with a blood glucose level of 21 milligrams per deciliter (mg/dl) (normal blood glucose levels range between 90 and 130 mg/dl). He required emergent transfer to the acute care hospital where he was admitted with profound [CONDITION(S)] (low blood glucose). This placed R1 in Immediate Jeopardy. The facilty further failed to prevent a medication error for R2, who received a double dose of the antipsychotic medication risperadone and received a dose of a medication used to lower blood pressure ([MEDICATION(S)]) that was not ordered by the physician. Findings included: - R1's Electronic Medical Record (EMR), under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Five Day Minimum Data Set (MDS) dated [DATE] recorded R1's Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1's required extensive assistance of one staff member for activities of daily living (ADL) including bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. R1 required supervision with set up help only for eating. The MDS documented R1 received injections of insulin three days during the look back period. The Care Plan initiated 01/20/22 directed staff to administer medications as ordered and monitor/document side effects and effectiveness. The Care Plan lacked interventions for diabetic management. The Hospital Discharge Orders dated 01/17/22 documented insulin [MEDICATION(S)] 100 units/milliliter (mL) injection one to five units subcutaneously (beneath the skin) four times daily before meals and nightly for diabetes mellitus type two. The hospital Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Blood glucose (BG) 0-120 mg/dl: Give 0 units BG 121-150 mg/dl: Give 0 units. BG 151-200 mg/dl: Give 0 units. BG 201-250 mg/dl: Give 1 unit. BG 251-300 mg/dl: Give 2 units. BG 301-350 mg/dl: Give 3 units. BG 351-400 mg/dl: Give 4 units. BG greater than (>) 400 mg/dl: Give 5 units. R1's EMR lacked evidence facility nursing staff clarified the insulin orders with the discharging hospital or R1's physician upon admission. The Orders tab in R1's EMR documented the following orders: Accu check (blood sugar-testing devices) four times daily before meals and nightly ordered 01/17/22. The order directed staff to call the physician if BG measured below 60 or above 400. Insulin [MEDICATION(S)] 100 units/mL ordered 01/17/22, inject 10 mL subcutaneously (SQ) before meals and at bedtime for diabetes mellitus type two. R1's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 01/17/22 09:00 PM 10 ml insulin administered by LN K no BG recorded. 01/18/22 07:30 AM BG 130 mg/dl,10 ml insulin administered by LN L 01/18/22 11:30 AM BG 271 mg/dl, 10 ml insulin administered by LN L 01/18/22 04:30 PM BG 120 mg/dl, 10 ml insulin administered by LN P 01/18/21 09:00 PM BG 133 mg/dl, 10 ml insulin administered by LN P 01/19/22 07:30 AM BG 112 mg/dl, 10 ml insulin administered by LN Q 01/19/22 11:30 AM BG 92 mg/dl, 10 ml insulin administered by LN Q 01/19/22 04:30 PM BG 210 mg/dl, 10 ml insulin administered by LN P 01/19/22 09:00 PM BG 210 mg/dl, 10 ml insulin administered by LN K 01/20/22 07:30 AM BG 162 mg/dl, 10 ml insulin administered by LN R 01/20/22 11:30 AM BG 112 mg/dl, insulin held by LN R for documented reason Not required' 01/20/22 04:30 PM BG 113 mg/dl, 10 ml insulin administered by LN K 01/20/22 09:00 PM BG 200 mg/dl,10 ml insulin administered by LN K 01/21/22 07:30 AM BG 97 mg/dl, 10 ml insulin administered by LN H 01/21/22 11:30 AM BG 98 mg/dl, 10 ml insulin administered by LN H 01/21/22 04:30 PM BG 117 mg/dl,10 ml insulin administered by LN G 01/21/22 09:00 PM BG 107 mg/dl,10 ml insulin administered by LN G The Progress Note dated 01/21/22 at 11:26 PM documented R1 was found on his bed and unresponsive. Licensed Nurse (LN) I assessed R1's oxygen saturation levels as 99 percent and contacted emergency medical services (EMS). EMS arrived at the facility and measured R1's BG as 21 mg/dl. The note documented R1 did not respond to any commands. R1's responsible party requested R1 go to the hospital for treatment and evaluation. The hospital History and Physical (HPI) from R1's admission on 01/22/22 at 12:32 AM recorded R1 presented to the emergency department from his nursing home with altered mental status. EMS measures a BG of 20. The HPI documented review of the facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The HPI recorded it was unclear how much insulin R1 received. The HP further documented there were significant discrepancies in R1's most recent discharge medication list and the medication list sent by the facility. The HPI listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/22 at 11:35 AM Administrative Nurse D stated when a resident admitted to the facility, the admitting nurse put in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D further stated that either herself or another administrative nurse would review the orders the following day. Administrative Nurse D then revealed there was no system in place to verify which newly admitted residents' orders were checked and verified by an administrative nurse. Administrative Nurse D stated if a resident admitted with unclear orders, the nurse was expected to call the physician to clarify the orders. On 01/27/22 at 01:48 PM LN G reviewed R1's insulin [MEDICATION(S)] order sand stated that although the insulin order read 10 mL, she only administered 10 units of insulin. LN G further revealed she had not held any insulin when she cared for R1. LN G reported she received training on insulin administration and care of diabetic patients in nursing school. LN G stated she did not assess R1's BG level when identifying he was unresponsive because she had notified emergency services. On 01/27/22 at 12:39 PM Consultant Provider GG reviewed the insulin [MEDICATION(S)] order under the Orders tab and stated the nurses should have called to clarify that order. Consultant GG further stated that even 10 units seemed a bit excessive for a resident that had not previously been insulin dependent. On 01/27/22 at 01:53 PM LN H stated she would not have administered 10 mL of insulin to R1, and stated she was unsure what the order should have been. LN H reported she administered 10 units instead of 10 ml because ml and units were the same. LN H reported it never occurred to her to hold the fast-acting insulin and contact the physician based on a lower BG level. On 01/27/22 at 2:20 PM Administrative Staff A stated that he expected Administrative Nurse D to be auditing the orders for admitting residents and following up on any discrepancies or administration concerns. The facility's Identifying and Managing Medication Errors and Adverse Consequences revised 04/2007 documented staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. The facility's Reconciliation of Medications of Admission revised 10/2010 documented this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The facility's Insulin Administration policy revised on 05/2021 recorded the type of insulin, dosage requirements, strength and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse should notify the physician if the resident has signs and symptoms of [CONDITION(S)] that are not resolved by following the facility protocol for [CONDITION(S)] management. The facility failed to prevent a significant medication error when the facility failed to ensure R1 received the correct physician ordered sliding scale insulin. R1 admitted to the facility with orders for sliding scale insulin 0-5 units four times daily dependent upon R1's blood glucose levels. The facility inaccurately entered an order to administer 10 milliliters four times daily with no reference to the blood glucose level. Staff then administered 10 units of insulin on eleven occasions when no insulin was required per the correct order. Subsequently, on 01/21/22 after staff administered the incorrect dose of 10 units of insulin, R1 was found unconscious with a blood glucose level of 21 milligrams per deciliter (mg/dl). He required emergent transfer to the acute care hospital where he was admitted with profound [CONDITION(S)] (low blood glucose). This placed R1 in Immediate Jeopardy. The immediacy was removed when the facility implemented the following: An investigation started on 1/31/22. Staff identified as allegedly providing wrong dose of insulin has been suspended pending investigation. The Assistant Director of Nursing began education on 01/31/22 related to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Any licensed nurses not working were reeducated prior to their next shift. An audit of all residents who require insulin was initiated on 1/31/2022 to ensure that orders are transcribed as written in a clear way. A Root Cause Analysis was performed in order to help identify and prevent further incidents of this nature. Any nurse transcribing any new insulin orders will have orders reviewed by a second licensed nurse prior to administering any insulin. Director of Nursing or Designee will review all new medication orders during morning clinical meeting for accuracy. The scope and severity of the deficient practice remained at a G. - R2's Electronic Medical Record (EMR), under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Entry Minimum Data Set (MDS) dated [DATE] documented R2 admitted to the facility. The Hospital Discharge Orders, dated 01/12/22, documented the following orders: Acetaminophen (used to treat mild to moderate pain) 650 milligrams (mg) take two tablets by mouth every eight hours. [MEDICATION(S)] (used to relieve pain and swelling) topical apply two grams topical to right knee four times daily. [MEDICATION(S)] (used to prevent chest pain) 240mg/24 hours capsule extended release take one by mouth daily [MEDICATION(S)] sulfate (used to treat or prevent low blood levels of iron) 325 mg tablet by mouth daily Losartan (used to treat high blood pressure) 50 mg by mouth daily Potassium chloride (medication used to prevent low amounts of potassium in the blood) 10 milliequivalent (mEq) by mouth daily [MEDICATION(S)] (used to help lower bad cholesterol and fats and raise good cholesterol in the blood) 40 mg by mouth daily [MEDICATION(S)] (used to treat a certain mental/mood disorder called [CONDITION(S)]) one mg by mouth at bedtime Tamsulosin (medication used by men to treat the symptoms of an enlarged prostate) 0.4 mg by mouth daily [MEDICATION(S)] (medication use for blood thinner) three mg by mouth daily, adjust to INR goal two to three. The Order tab documented the following orders: [MEDICATION(S)] (blood pressure medication) give 25 mg by mouth in the evening for hypertension ordered 01/12/22 [MEDICATION(S)] give one mg by mouth at bed time for depression ordered 01/12/22 [MEDICATION(S)] give one mg by mouth at bed time for depression ordered 01/13/22 Review of the January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's clinical record lacked evidence a physician ordered the [MEDICATION(S)]. The MAR further documented R2 received a duplicate dose of [MEDICATION(S)] 1 mg twice at bed time on 01/13/22 for a total of 2 mg The progress notes lacked documentation of medication orders to reflect a change from discharge orders R2 admitted with from the hospital. On 01/27/22 at 11:10 AM Licensed Nurse (LN) J stated that the orders were put in by the nurse that admits the resident to the facility. He further revealed that it was an administrative nurse that reviewed the orders for a second set of eyes. On 01/27/22 at 11:35 AM Administrative Nurse D stated when a resident admitted to the facility, the admitting nurse put in the orders that came with the resident. Administrative Nurse D further stated that either herself or another administrative nurse would review the orders the following day. Administrative Nurse D then revealed that there was no system in place to verify which resident had admitting orders double checked and which one hadn't received that oversight. Administrative Nurse D stated if a resident admitted with unclear orders, the nurse was expected to call the physician to clarify the orders. The facility's Reconciliation of Medications of Admission revised 10/2010 documented this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The facility failed to prevent a medication error when morders were transcribed inaccurately for R2 when the admitting nurse entered the [MEDICATION(S)] order twice and the [MEDICATION(S)] that was not ordered for R2 when he admitted to the facility.

The facility identified a census of 93 residents. The sample included six residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 received the care and services he required when staff left him alone in the shower room for an extended period. Staff left R1, who required staff assistance with activities of daily living, which included showering, alone in a shower chair, naked, wet, and cold at the change of shift. R1, who had bilateral amputations (surgical removal) of the legs, could not self-propel the shower chair out of the stall in order to reach a call light. R1 sat in the shower room alone, calling for help, sliding from the chair and feeling afraid for almost 2.5 hours until staff noted his absence and located him in the shower room. This deficient practice placed R1 in immediate jeopardy. Findings include: - R1's Electronic Medical Record (EMR), under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), pressure ulcer of right hip stage four, chronic pain, and [CONDITION(S)] (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required limited assistance of one staff member for activities of daily living (ADLs) and bathing. The ADL/ Functional Care Area Assessment (CAA) dated 09/20/21 documented R1 needed assistance form staff with mobility/ambulation and completion of ADLs. The Falls CAA dated 09/20/21 documented R1 was a fall risk and had two reported falls that quarter. The Pressure Ulcer CAA dated 09/20/21 documented R1 was at risk for injury due to his reduced mobility. The Care Plan dated 06/07/21 documented R1 preferred to shower on Wednesday and Saturday evenings. The Care Plan dated 10/31/20 documented R1 had chronic pain related to chronic physical disability and wounds and staff were directed to assist/remind R1 to reposition. It further directed staff to remind/assist R1 to turn/reposition at least every two hours or more often as needed. The Care Plan lacked directions for staff to assist with ADLs for R1. It recorded an intervention dated 06/07/21 which directed R1 preferred to shower on Wednesday and Saturday evenings. The Progress Notes lacked documentation of R1 being left unattended in the shower room, or evidence a physical assessment was completed after being located. Review of the Grievance Report dated 10/14/21 documented R1 reported to Administrative Nurse D that he was left in the shower for two to three hours and no one knew he was there. The documentation of the investigation revealed the facility suspended Certified Nurse Aide (CNA) N pending completion of the investigation and R1's showers would not be done on the overnight shift. A Witness Statement dated 10/14/21 documented Licensed Nurse (LN) G was on duty at around 01:10 AM on 10/14/21 LN G and was unaware of any residents being in the shower. After report, he made rounds and at around 01:10 AM he asked for R1 because LN G could not see him out smoking or in his room. CNA N, who was working with LN G informed LN G that CNA N was told that R1 received a shower and came out of shower during shift change report. LN G went and checked in the shower and found R1. LN G asked R1 if someone had been taking care of him. R1 stated he didn't know. LN G assessed R1 and checked vital signs. R1 self-propelled in his wheelchair. A Witness Statement from CNA N dated 10/14/21 documented CNA N received report from [unidentified] evening shift CNAs. During that report, staff reported to CNA N that R1 received a shower and was on his way out of the shower. CNA N finished change of shift report and started rounds. CNA N noted R1 was not in his room, but it didn't seem odd because R1 frequently went out to smoke or visited another resident on the second floor. CNA N stated during the second rounds, she noted R1 still was not in his room. CNA N reported this to LN G, and they began searching for R1. R1 was found in the shower room around 01:15 AM. R1 appeared to be dozing while still in the shower chair. CNA N and LN G helped R1 to his wheelchair, and R1 wheeled himself back to his room. LN G performed a nurse assessment on R1. A Witness Statement from CNA M dated 10/15/21 documented at approximately 10:50 PM CNA M helped CNA O, who was assigned to R1, transfer R1 to a shower chair in preparation for R1's shower. After the transfer CNA O stayed with R1 in the shower room for about 20-25 minutes. CNA O then exited the shower room and stated she needed to go home. This was at approximately 11:25 PM. CNA O questioned CNA M about who was to receive report. CNA M directed CNA O to give report to CNA N. CNA O reported to CNA N and explained that R1 was in the shower room. CNA O further explained to CNA N that R1 wanted to take a 45 -60minute shower. CNA O reported R1 needed help/assistance with his transfer into his wheelchair. CNA N agreed to check on R1 and assist R1 as soon as he finished bathing. On 10/19/21 at 10:25 AM R1 laid in bed on his right side. He had bilateral amputation of the lower extremities. R1 rubbed his left thigh with his left hand and winced in pain. He stated he was left in the shower chair, alone, in the shower room. He revealed that he could not move the shower chair without risk of tipping it and there was no call light within reach. He stated he yelled for help in 10 to 15 minutes increments. R1 stated he believed he even fell asleep while waiting for someone to locate him. R1 stated that he was very, very upset about being left in the shower. He stated it should never have happened. R1 further revealed that at one point he slipped in the chair. R1 stated that he believed that this made his wound on his coccyx worse. He stated that during the time he was alone in the shower room, he was uncomfortable, in pain, cold and wet, and he also reported feeling afraid. On 10/19/21 at 12:00 PM Administrative Nurse D stated that she expected documentation of the incident of what happened to be in the EMR. Administrative Nurse D further stated that CNA N had been reassigned to a different hall while Administrative Nurse D investigated the report. CNA N was informed that the move to a different hall was based on the accusations that she had left the R1 unattended in the shower room. Administrative Nurse D stated she did not believe there was potential for CNA N to repeat any neglect related to R1 being left in the shower room. On 10/19/21 at 12:06 PM Administrative Staff A stated he made the call to suspend CNA N even though the information was conflicting. On 10/19/21 at 01:30 PM R1 stated that he is reluctant to take a shower due to the incident. He stated he worried that he may be forgotten in the shower room again. R1 further the incident caused him embarrassment because he was in the shower chair for as long as he was because he was naked and could not cover himself. The facility policy Shower/Tub Bath revised 10/2010 documented staff should stay with the resident throughout the bath and never leave the resident unattended in the tub or shower. The facility failed to ensure staff provided the necessary care and services to ensure R1's physical and psychosocial wellbeing when they left R1 alone in the shower for 2.5 hours. The deficient practice placed R1 in immediate jeopardy based on the severe impairment of his psychosocial wellbeing as well as the likelihood of physical injury or adverse outcomes related to the neglect. The facility completed the following immediate actions to ensure staff provide the necessary care and services to maintain residents physical and psychosocial wellbeing and to prevent further episodes of neglect Any residents in need of assistance with bathing will be identified on the unit shower/bathing sheets. Charge Nurse is responsible for assigning aids to showers and providing guidance as to the level of oversight / assistance needed. Charge nurse will ensure that aids assigned are providing the appropriate level of oversight / assistance during baths/showers. Any resident in need of assistance during the shower and bathing process will always be monitored while in the shower room, unless their preference indicates otherwise. Director of Nursing began education on 10/15/2021 related to shower process and the need to monitor. Re-education will be completed on 10/19/2021 with all staff. Any staff not working will be reeducated before their next duty assignment. R1 will be offered psychosocial services on 10/19/2021. Social Services will meet with R1 as needed to assess psychosocial needs beginning 10/19/2021 and R1 will routinely be reassessed to determine need for ongoing assistance. Root Cause Analysis will be performed in order to help identify and prevent further incidents of this nature. This will be complete by 10/19/2021. The deficient practice remained at the scope and severity of a G

The facility reported a census of 93 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent elopement. R1 was identified as an elopement risk and moved to a locked memory unit on 08/07/21. On 09/07/21 at 03:40 R1 exited the facility via an alarmed fire exit door on the end of the hallway of the locked unit. He went down the stairs and exited the facility via an unalarmed door. Facility staff heard and then canceled the alarm on the fire exit. When facility staff identified R1 was missing 20-30 minutes after the alarm was canceled, staff failed to notify administrative staff and implement facility protocol for missing residents for another 30 minutes. R1 was later found by law enforcement at a restaurant 1.3 miles south of the facility. While R1's exact route is unknown, R1 walked along heavily traveled roads during evening rush hour with traffic moving at 45 miles per hour and would have crossed a highway to reach his end destination. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), disorientation, and altered mental status (state of awareness that was different from the normal awareness of a person ). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated moderately impaired cognition. R1 walked in his room and corridor with supervision and set up help only. R1 wandered daily during the seven day look back period. The Cognitive Loss Care Area Assessment (CAA) dated 08/12/21 documented R1 was confused and disoriented most of the time. The Behavioral Symptoms CAA dated 08/12/21 did not trigger. The Wandering & Elopement Evaluation dated 08/05/21 documented R1 had a score of two which indicated a low risk for elopement. The Wandering & Elopement Evaluation dated 08/06/21 documented R1 had a score of 13 which indicated a high risk for elopement. The Care Plan initiated 08/10/21 for elopement directed staff to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. The Care Plan further directed staff to identify a pattern of wandering for R1. The Care Plan lacked a cognitive care plan related to R1's BIMS score of six on admission until after 09/08/21. The Progress Note dated 08/18/21 at 08:10 AM documented R1 repeatedly went to the exit door and set off the alarms. The Progress Note dated 08/21/21 at 01:17 PM documented R1 set off the alarm on the stairwell doors on the nursing unit. Staff were able to redirect R1 and provided close monitoring throughout the shift. R1 requested several times to leave the facility. The Progress Note dated 08/23/21 at 08:31 AM documented R1 had been pacing and looking for an exit out. The Progress Note dated 09/07/21 at 08:36 PM documented R1 returned to the facility at 08:15 PM and was assessed with no injuries noted. R1 denied any pain. The nurse practitioner, legal representative and Administrative Nurse D were notified of his return. Staff placed R1 on one-on-one observation upon return. The Facility Investigation dated 09/08/21 documented Certified Nurse Aid (CNA) M stated she heard the stairwell alarm sounding at 03:40 PM while CNA M was in the common hallway. CNA N, assigned to work the hallway as well, had left for a break. Upon CNA N's return at approximately 04:20 PM CNA M stated she could not locate R1. CNA N performed a sweep of the hallway, noted R1 could not be located and notified Administrative Staff A and Administrative Nurse D. CNA M's undated Written Statement documented she saw R1 while getting snacks ready to be passed out. R1 refused a snack and left the nourishment room. At 03:40 PM, CNA M passed snacks and drinks to the dining room and heard the door at the end of the hall alarming. CNA M documented she shut the alarm off and did not think anything was wrong. CNA M then began to round residents up for dinner and noted R1 was missing. CNA M asked Administrative Nurse D to call CNA N back from his break. Upon his return CNA M informed CNA N stated she could not locate R1. CNA N looked for R1 in and out of the unit. CNA N's Written Statement dated 09/07/21 documented at 04:30 PM CNA M informed him CNA M could not locate R1. CNA N stated he checked all the rooms and went out the exit door R1 was thought to exit. CNA N documented he thought R1 would have went out the exit door at the bottom of the stairs because CNA N opened the door. CNA N immediately notified Administrative Staff A and Administrative Nurse D. On 09/09/21 at 09:30 AM CNA O stated she was not aware which door R1 exited, but since R1 came back to the building she had been through training on responding to elopement drills and the policy for elopements. CNA O further stated she had been educated to look out what ever door had the alarm sounding before turning off the alarm. On 09/09/21 at 09:35 AM R1 sat on his bed with an unidentified staff member seated beside him. R1 stated he would love to get a pair of glasses to help with his vision, as he had lost his glasses. On 09/09/21 at 09:40 AM Maintenance U stated the alarm on the fire escape door sounded when someone pushed on the door and then when the door released as well. In order to shut off the alarm, staff had to key in the code on the keypad. He also stated that the doorway at the bottom of the stair well was not alarmed and would not sound if someone went out of that doorway. On 09/09/21 at 09:43 AM the fire door on the dementia unit located at the back of the west facing hallway alarmed when the door release bar was pushed. The door led into a stairwell that had one flight of stairs down to the ground floor with a switchback halfway. The stairwell led to another doorway that opened to the back of the building. That door opened with no alarm. On 09/09/21 at 11:40 AM Administrative Staff A stated that once he was alerted that R1 was missing staff were divided into groups and staff searched the building and outside around the building. Staff fanned out into the trees to search and staff drove around the area. Administrative Staff A stated that he also contacted the police and filed a missing persons alert. He stated the police called stating R1 had been located at a local restaurant, 1.3 miles away from the facility. When R1 returned Administrative Staff A asked how R1 got1 got to the restaurant, and R1 stated he walked. R1 was immediately placed on one-on-one status, and staff were educated about finding replacements on the unit if they were going to break. CNA M and CNA N were immediately educated on looking out the doorway if it was sounding to see if anyone exitedanyone exited the doorway. The facility's policy Elopement revised 08/2020 documented staff shall evaluate, investigate and report all cases of missing residents. It directed staff to promptly report any resident suspected of being missing to the charge nurse or Director of Nursing. Staff were directed to initiate a search of the building and premises if resident was not authorized to leave. The facility failed to ensure R1 received adequate supervision and appropriate interventions to prevent elopement. On 09/07/21 at 03:40 PM R1 exited the facility via an alarmed fire exit door on the end of the hallway of the locked unit. He went down the stairs and exited the facility via an unalarmed door. This placed R1 in immediate jeopardy. The facility corrected the deficient practice on 09/08/21when they implemented the following; Facility conducted a root cause analysis (RCA) to identify causative factors. Staff were educated on elopement policy and procedure for responding to door alarms. Staff were educated on unit staffing needs and reeducated on the need to have appropriate staff coverage on the unit during staff breaks. Staff were educated on notification of appropriate administrative staff during emergencies including elopement and/or missing residents. The corrections were completed on 09/08/21 therefore the deficient practice was cited as past noncompliance.

The facility identified a census of 121 residents. The sampled included 27 residents. Based on record review, observation and interviews the facility failed to thoroughly investigate, protect residents during an investigation and report allegations of sexual abuse to the state agency for two sampled residents (#24 and #25). This deficient practice placed all the residents in the facility in immediate jeopardy. Findings included: - Resident #23's electronic medical record (EMR), documented the resident had [DIAGNOSES REDACTED]. The 5/1/2018 Minimum Data Set (MDS) assessment documented staff assessed resident #23 with a Brief Interview for Mental status (BIMS) score of 7 (impaired cognition) and documented he/she was unable to complete the interview. The MDS recorded the resident did not exhibit any behaviors, was independent with activities of daily living (ADLs) such as transfers, walking, toileting and dressing. He/she was 6 feet, five inches in height and weighed 257 pounds and received antipsychotic (medications to treat [MEDICAL CONDITION], dementia, and mental health conditions) and antidepressant medications (medications used to relieve feelings of sadness, anxiety disorders and other disorders). The 5/1/18 care area assessment dated [DATE] for cognition recorded the resident was alert and oriented to him/herself and others, his/her surroundings, was able to make his/her needs known and had no behaviors through the review period. The CAA did not trigger behaviors to be reviewed. The 11/21/18 quarterly MDS documented staff assessed the resident with a BIMS of 15 (a marked increase in clarity over the 5/1/18 MDS) which indicated his/her cognition was intact and no changes in his/her functional abilities. Review of the (MONTH) 2019 physician's orders [REDACTED]. [REDACTED]. The resident care plan last revised on 1/19/19 documented the resident had the potential to become aggressive and episodic sexual inappropriateness, hit another resident on 1/19/19, was sent to the hospital and returned with antibiotic use. The care plan directed staff to provided 1:1 supervision of the resident, distract him/her with activities of interest, document all behaviors, attempt to identify pattern behaviors and evaluate any side effects of medications. The care plan lacked documentation to note any sexual activity and/or interventions to address sexual inappropriateness in the facility. Review of the nurse's progress notes dated 12/22/18 at 8:21 P.M. documented resident #23 was observed at approximately 8:00 P.M. following behind a (resident name redacted) attempting to snatch a brown leather jacket from the (resident name redacted) wheelchair. When resident #23 snatched leather jacket, the (resident name redacted) snatched the leather jacket back and fell back into door entering his/her room. (resident name redacted) was heard yelling by this writer, That's my jacket, we traded, and (he/she) is just mad because I will not have sex with (him/her). I'm done with that. Resident #23 continued to say, (He/she) has my jacket. Resident also stated that (resident name redacted) had his/her tie dye shirt. Resident #23 was separated from (resident name redacted). The electronic record lacked documentation the resident's physician was notified and/or any further documentation of this incident. The nurses' notes dated 1/24/2019 at 6:00 P.M. documented: (unnamed facility staff) Met with resident (#23) regarding his/her desire to have consensual sex with another resident. Resident reported he/she had consensual sex with 2 residents over the past several weeks. Explained to resident that if they choose to continue to have sexual relations, he/she must notify the nurse and a private place will be made available for them. Resident voiced understanding. The electronic record lacked documentation the resident's physician was notified of any sexual activities. On 1/28/19 at 8:45 A.M. licensed nursing staff J reported areas the facility needed to improve on and stated, you also need to look into the resident that was sexually assaulted by another resident. Observation on 1/29/10 at 12:02 P.M. revealed resident #23 sat on his/her bed and in no apparent distress. His/her, speech was disjointed, and he/she was not easily understood. Interviewed on 1/29/10 at 12:02 P.M. resident #23 stated, They got a lot of stuff on me, stuff like smoking and all this other stuff, two women tried to say . complained. The resident stated, he/she had two girlfriends. One I got from here and one x-girlfriend (resident #25) came out of here. (Resident #24) was nothing, (he/she's) just, uh, I don't know what (he/she) is. Resident #23 stated he/she had intimate relations with them but nothing now, Wednesday or Thursday (1/24/19) was all that stuff. Interviewed on 1/29/19 at 12:22 P.M. licensed nurse H stated, He/she remembered an incident last week where (resident #23) wanted to go out to smoke right after he/she ate, and he/she got into an argument with a staff member and this prevented the staff member from assisting in the dining room. Licensed nurse H stated he/she was not working at the time of alleged sexual encounters but, had heard that resident #23 raped someone, (resident #24) who used to be upstairs, was moved to the lower level for that reason. Nurse H stated if that were reported to him/her-he/she would immediately report it to the director of nursing and the administrator. Interviewed on 1/29/19 at 4:14 P.M. social services staff X stated, On Thursday or Friday (1/24/19 or 1/25/19 it was reported residents #23, #24, and #25 were having a consensual relationship. Social services X stated he/she did not remember who reported the incident but (unnamed facility staff) interviewed the residents and it was consensual all the way around. On Friday (1/25/19) (resident #24 said the situation was rape and convinced (resident #25) it was rape. Social services X stated, both residents (#24 and #25 were having relationships and Resident #25 called 911 and reported he/she was raped. And all three residents #23, #24, #25 have a BIMS of 15. The police came and interviewed the residents. I interviewed (resident #25) who stated that it was not rape and /he she felt (resident#24) was jealous. Social services X stated he/she did not know how long the relationships had be going on and that Administrator A spoke with the police. On 1/29/19 at 2:49 P.M. Licensed nurse L notarized witness statement documented: (MONTH) 24th (resident # 24) was at Heritage nursing station, extremely anxious, asking to speak to (staff member Z) who spoke with (resident #24) and then (resident #24) wanted to speak with a nurse. I took the resident, staff Z and administrative licensed nurse D into office. (Resident #24) began to tell us all that a resident (resident (#23) had been coming to his/her room and asking him/her to come to his/her room to perform oral sex on him/her. (Resident #24) stated he/she told him/her NO, on many occasions and he/she continued to ask. When asked (resident #24) denied this was wanted by him/her. (Resident #23) would continue to ask and (resident #24) stated (resident #23) pleased him/herself in front of him/her. Resident denied telling anyone of this at this point and stated it had been going on about a week. (Resident #24) was concerned of backlash from (resident (#23). He/she was assured by all, this would not happen. (Resident #25) also gave a statement that (resident #23) and him/herself had intercourse after he/she pressured him/her several times and (resident #23) gave him/her alcohol. (Resident #25) stated that he/she and (resident #23) had sexual intercourse one time, and he/she performed oral sex on him/her one time and (resident #25) performed oral sex on him/her one time. (Resident #23 pleased him/herself in front of (resident#25) (Resident #25) stated he/she felt like he/she had to do this. (Resident #25) stated he/she told (resident#23) many times to leave him/her alone. Resident #25) also stated he/she thought sexual acts were happening between resident #23 and another resident (name redacted). Interviewed on 1/29/18 at 3:00 P.M. Licensed nurse L expressed he/she was uncomfortable reporting to the surveyors, fearful of retaliation from the (facility). On 1/29/19 at 5:08 P.M. administrative licensed nurse D indicated he/she was aware of the reported instance of sexual activity but had no direct knowledge of it. Nurse D stated, he/she was new to the facility, the facility did not conduct a Quality Assurance meeting since he/she started but, the facility staff had a stand-up meeting daily to discuss resident concerns. Nurse D confided regarding allegations of abuse neglect and/or mistreatment it depended on who was present (administration wise) whether he/she could offer any input. Interviewed on 1/28/19 at 3:19 PM Administrator A stated, (regarding alleged sexual assault(s) he/she gathered all the information and we noted that this was consensual by all three residents. The only reason that (resident #25) got upset was that (resident #24) was also getting with (resident #23) I started looking into this when the 2 (resident's) came forward and stated they were sexually assaulted. I did not call it into the hotline because we investigated and noted that it was consensual and so that is why I did not call it in. The following morning it was noted that (resident #25) called the police. The police noted that it was consensual as well. We then decided to call the state because (resident #25) called the cops. It was not called to the state when the residents reported it because we investigated it and it was found to be consensual. We ended up moving (Resident #24) to the first floor because we did not want (resident #24) to cause any problems between (resident #25) and (resident #23) was moved upstairs because of the resident to resident that happened, and we had to move him/her so there were not any more problems. On 1/29/19 at 8:21 A.M. the Kansas Department for Aging and Disability services Complaint Department received a report of alleged sexual abuse within the facility. This report was filed 5 days after the event allegedly occurred and 1 day after the surveyors brought the allegation to the attention of administration. The report indicated on (MONTH) 24 facility administration received information three residents had sexual contact. Facility administration reported, the three residents involved were interviewed and the sexual encounter(s) were determined consensual. (unnamed facility staff) informed residents if they would like a private area to let the nurse know and (unnamed facility staff) would be happy to do so. (unnamed facility staff) also informed them (residents involved) (unnamed facility staff) could provide them condoms it needed. Sexual diseases were also discussed. This afternoon one (no date or time given). of the residents decided to call the police. (Resident #25) was the resident that called the police. He/she decided that the consensual sex turned into non-consensual. The report concluded an investigation would be submitted. Review of the facility report/investigation (received on site on 1/29/19 at 6:00 P.M.) had a handwritten notation reading sent to State 1/25/19) This same investigation contained only assessment and care planning data for residents #23, #24, and #25. The investigation lacked documentation of any staff interviewed, residents (other than the three listed) and contained only the narrator's summary of events. The facility's policy Analyzing Occurrences of Abuse, Neglect, Mistreatment, and Theft/Misappropriation of Resident Property, and Exploitation revised (MONTH) (YEAR), documented: Assure the facility would not condone any form of resident abuse and would continually monitor the facilities policy, procedures, training programs, systems etcetera to assist in preventing resident abuse, it is the facility's goal to achieve and maintain an abuse free environment. The policy revised (MONTH) (YEAR) recorded for Protection of Residents during Abuse investigation recorded: Assure residents are protected during investigations of Abuse allegations. The policy recorded a procedural method, management members responsibilities, to implement interventions and to notify authorities should the results indicate that abuse occurred. The single intervention for an accused resident was: Informs the accused resident's representative and attending physician of the alleged abuse incident. That accused resident would not be permitted to make visits to other residents' rooms unattended. If necessary, the accused resident's family members may be required to provide assistance in meeting this requirement. The facilities abuse policies lacked documentation specific to any interventions to protect residents during an investigation. The facilities abuse policies lacked documentation specific to how investigations were conducted. This policy revised (MONTH) (YEAR), recorded for Rape Suspected Cases or Incidents of Rape recorded: Assure all suspected cases or incidents of rape are reported to the Administrator, Director of Nursing Director of Social Work and/or Designee. Again, the policy recorded, a procedural method, management members responsibilities, to implement interventions and to Verbally notify the proper authorities (i.e., Police, Attending Physician, Resident's Representative, Department of Health, and others as necessary. This policy revised (MONTH) (YEAR) recorded for Reporting Abuse to State Agencies and Other Entities/individuals recorded: Assure all alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other individuals required by law. The facility failed to protect residents during an investigation, investigate, and timely report to (The state Agency) incidence/allegations of sexual abuse incidence of sexual assault when resident #23 allegedly coerced and harassed residents #24 and #25. This deficient practice placed all the facility residents in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 1/29/19 at 6:48 PM.As of 1/31/19 at 7:30 pm, the immediate jeopardy remained uncorrected.

The facility reported a census of 121 residents. The sample included 27 residents. Based on record review, observations and interviews the facility failed to provide care and services for 1 sampled resident (#8) related to providing the resident a sense of satisfaction with his/herself, the care received, accomplishment of desired goals and control over his/her life. The facility also failed to provide care and services to enhance the quality of life for other residents in the facility. This deficient practice placed the residents in the facility in immediate jeopardy. Findings included: - The facility admitted Resident #8 with [DIAGNOSES REDACTED]. The 5/17/18 significant change minimum data set assessment MDS Assessment documented staff assessed the resident with a Brief interview for Mental Status score of 15 which indicated he/she had intact cognition, was able to understand and easily understood. He/she had no behaviors, required extensive assistance of one to two staff, was confined to a bed and/or modified wheelchair had an indwelling Foley catheter and was incontinent of bowel. The resident had 1 stage 3 pressure sore with protection measures in place and received antidepressant medication daily. The 5/17/18 significant change care area assessment (CAA) documented the resident triggered for Activities of daily Living (ADLs), urinary incontinence, falls, nutritional status, pressure ulcer, [MEDICAL CONDITION] medications and restraint use. The 5/17/18 CAA documented: For ADL's, Resident was alert and oriented x4 and able to make his/her needs known to staff. He/she was total assist x1-2 with her ADL's. He/she used an electric wheelchair for locomotion and was able to propel him herself A care plan will be developed to address these areas. For Urinary Incontinence, Resident was incontinent of bowel and has a Foley for bladder. He/she is a check and change every 2 hours and as needed. He/she was free from any sign and/or symptoms of infections at this time care plan will be developed to address these areas. For Nutrition, the resident received a regular diet and was independent with feeding. He/she has a stage III on her right buttocks with treatments as ordered. He/she received supplements as ordered. The RD (Registered Dietician) reviewed his/her status on 4/4/18. Will continue with weights as ordered. A care plan will be developed to address these areas. For Pressure ulcers, the resident had a stage III on right buttocks with treatment as ordered. He/she has a pressure reducing mattress and a pressure reducing cushion. He/she was repositioned every 1-2 hours and as needed. A care plan will be developed to address these areas. The 12/14/18 quarterly assessment documented little change in the resident cognitive and/or functional ability however the resident now presented with 2 Stage 3 Pressure sores. The most recent Physicians Orders recorded the following: 12/11/18 Change Foley as needed (PRN) 12/11/18 Foley Cath care every shift PRN 12/11/18 Record Foley Cath output every shift 12/13/18 1) Urinalysis with culture and sensitivity 2) Tylenol 650mg by mouth every 6hrs 12/31/18 [MEDICATION NAME] (antibiotic) 1gm IM (intramuscular) mixed with 1.2 milliliters (ml) [MEDICATION NAME] daily for 5 days (Order noted on 1/4/19 at 3:30 PM by LPN) (4 days after ordered) 1/2/19 STAT KUB (x-ray of the kidneys, ureters, and bladder), no bowel movement for 10 days, abdomen distended. 1/7/19 at 11:10 AM [MEDICATION NAME] 1gm IM mixed with 2.1 ml [MEDICATION NAME] daily x 5 days, discontinue previous [MEDICATION NAME] order 1/14/19 1) STAT (immediate) portable chest x-ray 2 views and 2) Tylenol 650 milligrams (mg) PO three times daily x5 days Review of the resident's nurses progress notes revealed the following chronologically: 12/26/2018 at 8:22 p.m. Nursing Progress CNA notified this nurse that resident complained of chest pressure. Upon assessment, VS BP (blood pressure) 157/91 HR (heart rate) 62 O2 sats (oxygen saturation) 98% on RA (room air) and 8/10 (10 being worst pain/pressure) pressure to the chest. Resident described the pressure as if someone was giving her a tight hug. No c/o or radiating pain to the left upper extremity HR to be in regular rhythm. This nurse instructed the resident to decrease the stimulation in the room and would recheck vitals in 30mins. Upon reassessment, resident stated the tightness was getting better at a 6/10, (pain scale) VS BP 116/65 HR 67 O2 sats 98% on RA. Resident resting well at this time. Will continue to monitor. The electronic medical record lacked documentation the physician was notified. 1/2/2019 7:30 p.m. Nursing Progress Note (Nurse) went to give (resident) his/her 5:00 P.M. medications and (resident voiced that he/she had not had a bowel movement in 10 days. (resident) complained of discomfort in his/her abdomen. Bowel sounds present in all 4 quadrants, abdomen was soft and tender to touch. Staff reported that when (resident) has a bowel movement, he/she has small ones and said that he/she does not finish. Call placed to advanced registered nurse practitioner (APRN) KK and new order for for STAT KUB (abdominal x-ray) Review of the direct care staff tasks charting reveled the resident was documented as having normal bowel movements. 1/3/2019 03:38 a.m. Results received on abdominal x-ray. no findings to suggest acute mechanical obstruction or perforation 1/4/2019 at 4:30 p.m. Culture and sensitivity results from UA came back from lab, APRN notified. New orders for [MEDICATION NAME] 1GM give IM with 1.2ml [MEDICATION NAME] QD x 5 days. (an antibiotic medication given intramuscularly after application of [MEDICATION NAME] - a synthetic compound used as a local anesthetic. Order faxed to pharmacy Continued review of the EMR revealed the ARNP order for [MEDICATION NAME] was originally written on 12/31/18 and transcribed to the treatment assessment record (TAR) on 1/4/18 (4 days after the initial order) The order was rewritten and Transcribed to the TAR on 1/7/18 and the Resident received a first dose on 1/8/109 -8 days after it was originally ordered. Observation on 1/29/19 8:30 AM revealed the resident lying in his/her bed, on his/her back. His/her facial expression was sad. Observation on 1/29/19 at 4:01 P.M. revealed the resident in his/her bed with head of bed raised to view television. Interviewed on 1/29/19 at 8:30 A.M. resident stated, It is horrible here. Missed complete doses of [MEDICATION NAME] and [MEDICATION NAME] and blood pressure medications last night. They only had 1 nurse and 1 medication aide on the floor. The staff is very frustrated, and I cannot blame them. There is a lot to do and not enough help. My 9 pm meds are given around midnight or 12:30 A.M. medications have been given late a lot lately and that makes my pain/spasms worse. There are not enough showers being done only 1 a week in the last few weeks and I have to fight to get that. Interviewed on 1/29/19 at 4:01 p.m. The resident reported (recent illness) there was something in left lung it was bad, particle spots, and I was on a Z -pack (an oral antibiotic) and another antibiotic but I never got another x ray, after the antibiotic to see if it cleared. Now I have a chirping in my head, constant noise. This started about three weeks ago. The physician ordered me medicine (starts with an A or something) it was ordered on the 31st. Last Monday and it was going to be faxed to pharmacy and me were to take for one week and if the noise was not gone, go to an ear nose and throat specialist. I asked several nurses and they never followed up and (ARNP) told me yesterday they never gave me the med, and ARNP came in this A.M. and went out and got my chart and no one ever came back. Resident #8 stated he/she takes his/her medications at 9 am, 1 pm, 5 pm, 9, pm, and the last 3 days staff have been late with his /her medications. I waited for my 1 p.m. medications until 3 p.m. and received my 9 p.m. meds at midnight I take a medication to help me sleep at night and I have not been getting it. This new company, got rid of Medication aides and then (direct care staff) and nurses call in and so staffing has been really short. The facility failed to provide care and services to enhance the quality of life regarding monitoring bowel movements, nurse and direct care staffing, timely antibiotic and other medication administration, and follow-up assessments. These deficient practices placed this alert and oriented immobile resident in immediate jeopardy. - An interview on 1/29/19 at 3:03 PM with resident #4 revealed that recently he/she kept asking the 3pm-11pm staff if the draw sheet he/she was lying on was soiled (with his/her own feces). He/she stated the staff stated it was dry. When the 7am-3pm staff arrived in resident #4's room he/she revealed the staff were upset that the resident was lying on a very soiled draw sheet. At that time, the resident stated he/she made a comment to the staff about wanting to be dead rather than lying in feces and asked the staff to take a picture of it with the residents' phone. He/she revealed the facility staff put him/her on a watch and said someone had to be in my room at all times for 72 hours. The resident stated that during the 3 nights staff were not in his/her room. Resident #4 stated he/she told the staff he/she could have killed himself/herself at any time since there was no one in the room. Resident #4 stated that he/she couldn't eat his/her evening meal that night, due to the smell of the soiled draw sheet, was making her sick. Resident #4 further stated he/she had a place to move to prior to this and was told my staff social services staff X that he/she was not able to leave now due to the suicide had to be on file and no one {facility} would take him/her. He/she then stated, now I will never get out of this {explicit} hole. The facility failed to ensure adequate supervision for cognitively impaired independently mobile resident #18, with a history of and assessed at high risk for falls, received adequate supervision when he/she left the locked unit through an unsecure stairway, unattended by staff and was found approximately 1-2 hours later on a different floor in the facility multiple times. This deficient practice placed the resident in immediate jeopardy. The facility failed to assure sufficient qualified nursing staff were available at all times to meet the residents needs. During an observation on 1/24/19 at 11:45 AM, direct care staff T answered resident #5's call light. The door to the room was open and resident #5 could be seen from the hallway laying in his/her bed unclothed with the curtains to the room open. Resident #5 was on the telephone with an unidentified person stating this place is a (expletive) hole. Resident #5 finished the phone conversation and staff T asked if he/she wanted to get out of bed. Resident #5 stated I wanted out hours ago. He/she was moved to the side of the bed and his/her robe was placed backwards to cover the resident. The resident was transferred by one staff to his/her wheelchair. Staff T placed the residents urinary catheter bag on the floor during transfer and then placed it in the dignity bag. Staff T and resident #5 began to exchange in a conversation regarding the time he/she would like to get up, eat breakfast, shower and other daily cares. Resident #5 explained that he had not had breakfast at this time. Upon observation of the room, resident #5's breakfast was sitting on a small stool near the entry of the room, untouched. Staff T confirmed that was resident #5's uneaten breakfast, that the resident only liked to eat when in his/her wheelchair and staff had not helped him consume his morning meal. Resident #5 then stated he/she had not received his 9 AM medications at this time. On 1/29/18 at 3:00 PM the facility's Resident Council minutes for the last three months were reviewed. The minutes stated the same complaints made by residents each month which included the shortage of staff, call lights not being answered timely (which included wait time over an hour), medications not being given on time or at all and meals being late. During an observation on 1/28/19 at 2:45 PM, the warm food cart was being pushed out of the kitchen to the first floor dining room. A resident's family member confirmed that the was the noon meal. He/she further revealed that lunch is never on time and that the residents and families do not know when it would be served because times change. At this time an unidentified staff member started to pass the noon meal trays. On 1/29/19 at approximately 4:00 PM the survey team was provided a hand-written note by a sampled resident who at this time wished to be anonymous, the resident started the letter by saying, Don't ask me how I am. In brief, the letter stated that he/she was tired of having to remain in bed for long periods of time if the facility was short on staff. He/she was tired of lousy meals and not knowing when or where they would be served. He/she was tired of feeling that he/she was not important no matter how many grievances he/she filed, phone calls that were made or conversation that were had with the top administration. He/she confirmed nothing changes, the grievance system doesn't work. Interview on 1/24/19 at 11:50 AM, licensed staff I confirmed that resident #5 had not received his/her 9AM medications. Interview on 1/24/19 at 2:16 P.M., resident #10 revealed he/she had been in the facility approximately one year. He/she stated that meals are served at random times, either very early or very late in the upstairs dining room. He/she further revealed that medications were late and often do not have the medications that are needed. This resident revealed that he/she hunts down the staff to get his/her scheduled medications. Interview on 1/24/19 at 2:24 AM with licensed staff J revealed that there were normally 1 nurse and 2 certified medication aides (CMA) on the Heritage unit, and at this time there was 1 nurse and 1 CMA which led to increase work load for the nurse in charge. During an interview on 1/24/19 3:15 PM, administrative staff A revealed that the facility was not aware of complaints from residents or families on being short of staff. He/she revealed the goal of the facility was to grow their own staff. During this same interview consultant staff GG stated that the facility cut agency staff from 78% to under 50%, and in the last 2 months added management staff and done a lot to attract staffing in the last few weeks. During an interview on 1/24/19 at 9:22 AM, direct care staff R stated that staffing was short normally, they (administrative staff) called in extra today to make it look good. Direct care staff R reported that the staff was cut, and the residents were getting their medications late, and were overall not happy. During an interview on 1/24/19 at 9:30 AM, an unsampled resident's family member revealed that there was often only one nurse, the medications are often 2 hours late and his/her resident received anti-[MEDICAL CONDITION] medication. The family member further revealed that on one occasion when an agency nurse came into give the medications the staff called this resident by his/her roommates name. The family member revealed that he/she was removing his/her loved one from the facility as it was not safe in the facility due to the staff not being able to complete their work. The facility failed to change resident #7's wound vac as ordered in order to prevent infection in the resident's stage 4 pressure ulcer. This deficient practice placed resident #7 in immediate jeopardy. The facility failed to ensure an accurate reconciliation and storage of narcotic medications (at risk for diversion - the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use, as adapted from the Uniform Controlled Substance Act.) were stored securely and inaccessible to unauthorized individuals while awaiting destruction from the consultant pharmacist or return to pharmacy for credit. This deficient practice placed the resident in immediate jeopardy. The facility failed to provide care and services to enhance the quality of life for the residents residing in the facility. This deficient practice placed the residents in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 1/29/19 at 6:48 PM.As of 1/31/19 at 7:30 pm, the immediate jeopardy remained uncorrected.

The facility identified a census of 121 residents. There were 6 medication carts that contained a locked box for narcotics (any of a class of substances that [MEDICATION NAME] the senses; and in large quantities produce euphoria, stupor, or coma, that when used constantly can cause habituation or addiction, and that are used in medicine to relieve pain, cause sedation, and induce sleep) and 3 medication rooms. Based on interview, observation and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and to determine the drug records were in order and all controlled drugs were accounted for, maintained and periodically reconciled in a manner to prevent drug diversion, for all resident in the facility. This deficient practice placed the residents in immediate jeopardy. Findings included: - Observation on 1/28/19 at 7:40 AM, revealed licensed nursing staff G and licensed nursing staff H performed an end-of-shift narcotics count on 2 medication carts on the upstairs hallways. Observation revealed a narcotic ([MEDICATION NAME], a pain medication, 50 milligrams (mg)) had been punched out of the bubble card and then taped back in. The bubble pack contained 23 of tablets. On 1/28/19 at 8:15 AM, narcotic reconciliation with direct care staff M on 2 medication carts located on the main floor revealed 4 narcotic cards with [MEDICATION NAME] (pain medication) 10 mg which contained 22 pills, [MEDICATION NAME] (antianxiety, class of medications that calm and relax people with excessive anxiety, nervousness, or tension) 0.5 mg which contained 17 pills, [MEDICATION NAME] (antianxiety) 0.5mg which contained 60 pills and [MEDICATION NAME] (antianxiety) 0.5mg which contained 17 pills. Bubble pack cards of 99 pills had 5 medication bubbles popped out and the medication was taped back into the card. On 1/28/19 at 8:18 AM, direct care staff M stated, he/she was not sure what to do if a narcotic was taped back in the bubble pack. On 1/28/19 at 8:20 AM, direct care staff M asked licensed nursing staff J what to do if medications were taped into a narcotic card. Licensed nursing staff J stated to not accept the medication cart when counting, with no further explanation or direction what to do. On 1/28/19 at 8:25 AM, during narcotic reconciliation count with licensed nursing staff I on the medication cart located on the locked unit, licensed nursing staff I stated that there are 7 narcotic cards and 7 vials of intramuscular [MEDICATION NAME] (antianxiety) 2 mg in the refrigerator in the medication room on the dementia unit that are not counted. The 7 vials of [MEDICATION NAME] 2 mg originally had 2 more vials of [MEDICATION NAME] that were ½ full (with 1mg remaining) and when I came in around the 12th of (MONTH) those 2 ½ vials were now gone. I notified the weekend supervisor. It would have been last Monday (1/21/19) that he/she would have called. Weekend supervisor, licensed nursing staff K, then contacted administrative nursing staff D and reportedly told the weekend supervisor that administrative staff D had removed the narcotics and then licensed nursing staff K signed the narcotic count sheet indicating the removable of those 2 ½ vials. None of these narcotics were counted from shift to shift, they were just in here. I have told administrator nursing staff D and they were to be removed last week, but as you can see the medications were still in the locked fridge in the medication room. Observation on 1/28/19 at 8:35 AM, revealed the bin for discontinued narcotics could not be pulled opened when it was pulled, indicating a full bin with no narcotic medication cards or narcotic count sheets with in line of sight. On 1/28/19 at 8:45 AM, Licensed nursing staff J stated that he/she was aware of missing narcotics and informed administrative staff D. Licensed nursing staff J further revealed that the narcotic discard bin had been full for some time and that the door would open far enough for someone to reach in and grab discontinued narcotic cards out with your hand. Observation on 1/28/19 at 8:35 AM, revealed the bin for discontinued narcotics bin that was partially opened, and could be pulled open further where it was noted that a hand could reach into the narcotic discontinued bin and grab onto discontinued narcotic cards located in the bin. On 1/24/19 at 10:45 AM, administrative nursing staff E stated, 'We are working on that, currently there is not a system in place to track narcotic medication coming in, being used and to assure that the count is correct.' Review of pharmacy delivered medications noted that [MEDICATION NAME] sulfate solution 100 mg per 5 milliliters (30mL) had been delivered for resident #11 on 1/7/19 and was not found in any narcotic box, and could not be located by administrative nursing staff E. Review of the narcotic count books revealed a master index sheet had a signature line for the nurse accepting the narcotics and the nurse returning the narcotics, a space to indicate the number of narcotic card and or bottles accounted for, and a space to indicate when a medication was added to or removed from the count. In 6 of 6 narcotic count books the master sheet lacked complete documentation to indicate continuity of the count and turning the responsibility over shift to shift. Review of medical records from (MONTH) (YEAR) and (MONTH) 2019 indicated that 5 residents had [MEDICATION NAME] sulfate solution 100mg/5mL (30mls) ordered but the facility could only locate 1 resident's [MEDICATION NAME] sulfate solution 100mg/5mL in the building. There was only 1 count sheet for resident # 20, a discontinued [MEDICATION NAME] sulfate solution 100mg/5mL located. The facility lacked evidence of the prescribed [MEDICATION NAME] sulfate solution 100mg/5ml (30mls) for residents' #11, #21 and #22. On 1/29/19 at 11:36 AM, administrative nursing staff D stated he/she 'knew nothing until yesterday about missing narcotics. There was one night that I received a call that staff thought some cards were missing, but the cards in the cart were verified with the medications ordered on the eMAR (electronic medical administration record) and everything was accurate. I can not remember if the discontinued medications were in the narcotic box or not. I really cannot remember, and I have no idea what happened to the [MEDICATION NAME] (generic name for [MEDICATION NAME] [MEDICATION NAME]).' On 1/29/19 at 4:25PM, administrative staff E revealed that he/she emptied all of the discontinued narcotic bins, that morning, to see if the missing medications could be located. Administrative staff E further stated that they were looking into where the narcotics could be stored so that that were under double lock. On 1/29/19 at 6:01 PM, administrative staff A stated he/she became aware just today that there were missing narcotics. He/she revealed that administrative staff were in the process to attempt to reach the nurse that accepted the medication but had not been successful yet. The facility lacked documentation and evidence [MEDICATION NAME] sulfate solution 100mg/5mL (30 mls in each bottle when delivered) was discarded or stored appropriately for 4 of the 5 residents noted with the order. The facility's Medication Storage policy, undated, lacked guidance to staff on how to properly store narcotic medications. The facility's Narcotic Management policy, dated 5/2018, instructed the license nurse to log the medication upon arrival into the master index log and if discontinued and needing to be removed from the narcotic count it directed the licensed nurse to complete the mediation destroyed section of the page and that the master index must also reflect the removal and destruction of the medication as it is no longer part of the narcotic count. According to dea.gov, (drug-enforcement agency) Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. [MEDICATION NAME] is a Schedule II drugs. According to FDA.com (Food and Drug Administration) [MEDICATION NAME] Oral Solution has a black box warning that this medication exposes users to risks of addiction, abuse, and misuse, which can lead to overdose and death. [MEDICATION NAME] Oral Solution can be abused and is subject to misuse, addiction, and criminal diversion. The facility failed to ensure an accurate reconciliation and storage of narcotic medications (at risk for diversion - the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use, as adapted from the Uniform Controlled Substance Act.) were stored securely and inaccessible to unauthorized individuals while awaiting destruction from the consultant pharmacist or return to pharmacy for credit. This deficient practice placed the resident in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 1/29/19 at 6:48 PM.As of 1/31/19 at 7:30 pm, the immediate jeopardy remained uncorrected.

The facility reported a census of 121 residents. The sample included 27 residents. Based on observation and interviews, the facility failed to provide adequate wound care for 1 (#7) resident sampled for wound vac (machine used to treat wounds) treatments, provide adequate assistance for cleaning wound drainage for 1 (#3) of 3 residents sampled for wounds, and provide safe handling of a catheter (a device used to drain urine from the bladder) bag (#5); to provide a safe, sanitary, and comfortable environment to help prevent the development and transmissions of communicable diseases and infections. This deficient practice placed the resident #7 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) for resident #7 listed [DIAGNOSES REDACTED].). The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (MDS) score of 14, which indicated intact cognition. The resident required extensive staff assistance with his/her Activities of Daily Living (ADLs). The resident had 1 Stage 4 pressure ulcer which was present on admission. The quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required extensive staff assistance with his/her ADLs. The resident 1 stage 4 ulcer present on admission. The Care Area Assessment (CAA) for ADLs dated 10/12/18 documented the resident could make his/her needs known and required extensive staff assistance with his/her ADLs. The wound CAA documented the resident had a coccyx (area at the bottom of the spine) wound. The skin impairment care plan dated 12/24/18 documented the resident had impaired skin condition to his/her coccyx. The facility staff treated the wounds per the physician's orders [REDACTED]. The weekly wound assessment dated [DATE] documented a wound to the sacrum 3.7 centimeters (cms.) X 2 cms. X 3.5 cms. The wound care clinic physician's orders [REDACTED]. Apply negative pressure wound therapy (wound vac). Change every Monday, Wednesday, and Friday. The wound vac should be set at 150 millimeters of mercury (mmHg). Do not leave wound vac dressing in place over 72 hours. The Treatment Administration Record (TAR) reviewed 1/18/19 through 1/29/19 documented the wound vac dressing was not changed 3 of 4 days ordered, which resulted in 10 days without a wound vac dressing change. On 1/29/19 at 8:00 AM the resident was not in the facility related to a recent admission to a local hospital. On 1/29/19 at 9:46 AM licensed staff II stated the resident's wound vac leaked at times and then not reapplied. He/she had not changed the wound vac and had not received training on how to do so. On 1/29/19 at 5:30 PM administrative staff D stated he/she expected nurses to follow the physician's orders [REDACTED]. If he/she knew the wound vac dressings were not being done he/she would have changed the wounds dressings him/herself. The facility failed to change resident #7's wound vac as ordered in order to prevent infection in the resident's stage 4 pressure ulcer. This deficient practice placed resident #7 in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 1/29/19 at 6:48 PM. As of 1/31/19 at 7:30 PM, the immediate jeopardy remained uncorrected. - The Electronic Medical Record (EMR) for resident #3 documented [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (MDS) score of 15, which indicated intact cognition. The resident required set up to limited assistance with his/her Activities of Daily Living (ADLs). The resident had 2 venous/arterial ulcers (wounds to skin caused by poor circulation). Facility staff applied non-surgical dressings to the wounds. The Care Area Assessment (CAA) for skin care dated 9/11/18 documented the resident did not have pressure wounds during the look back period. The vascular wound care plan dated 10/22/18 documented the resident had wounds to his/her right and left legs related to [MEDICAL CONDITION], impaired mobility, and [MEDICAL CONDITION] (abnormal condition affecting the blood vessels). The facility staff followed physician orders [REDACTED]. The (MONTH) (YEAR) physician order [REDACTED]. On 1/24/19 at 4:10 PM the resident sat in his/her room. Dressings to both lower legs appeared clean and dry. On 1/28/19 at 9:08 AM, the resident stated he/she had open wounds on his/her legs which drained on the floor. The floor became slick with the drainage and he/she feared falling. A facility staff member gave him/her a Clorox wipe to clean the drainage off the floor. The resident used a reacher and Clorox wipe to clean the floor to avoid a fall when he/she stood up. The facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmissions of communicable diseases and infections when facility staff directed resident #3 to clean wound drainage from the floor with a Clorox wipe. - The Electronic Medical Record (EMR) for resident #5 documented [MEDICAL CONDITION] (a condition with low heart output and the body becomes congested with fluid) and retention of urine. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive to total staff assistance for his/her Activities of Daily Living (ADLs). The resident had a urinary catheter (tube in bladder to drain urine from the body). The quarterly MDS dated [DATE] documented a BIMS score of 15. The resident required extensive staff assistance with his/her ADLs. The resident had a urinary catheter. The Care Area Assessment (CAAs) for urinary continence dated 2/16/18 documented the resident had a suprapubic catheter (urinary bladder catheter inserted through the skin) and needed total staff assistance with toileting needs. The catheter care plan dated 5/27/18 documented the catheter's urine collection bag and tubing should be positioned below the level of the bladder. On 1/24/19 at 11:45 AM direct care staff T placed the catheter bag on the floor, transferred the resident to a wheelchair and then placed the catheter bag in a covered bag under the resident's wheelchair. On 1/24/19 at 3:30 PM administrative nursing staff D confirmed facility staff should not place catheter bags on the floor. The facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmissions of communicable diseases and infections when facility staff placed resident #5's catheter collection bag on the floor. - During an initial tour on 1/24/19 at 11:30 A.M., the facility was noted to have two floors and one locked unit. Multiple rooms on the first floor were noted to have debris on the floor such as needle caps, used gloves and bags of trash outside sitting outside the doors. The first floor also revealed a strong smell of urine. The second floor was noted to have multiple rooms with notable trash on the floor in resident rooms. Bags of trash with feces on the floor outside of resident rooms. An interview on 1/24/19 at 2:16 PM resident #10 revealed that the facility was not clean. He/she stated that common areas and rooms are not swept or mopped routinely. On 1/24/19 at 3:30 PM administrative staff E and administrative nursing staff D confirmed that facility should provide a sanitary environment for residents. The facility failed to provide a safe, sanitary and comfortable environment for the facility residents.

The facility identified a census of 121 residents. The sampled included 27 residents. Based on record review, observation and interviews the facility failed to identify and prevent incidence/allegations of sexual abuse for two sampled residents (#24 and #25) when resident #23 made unsolicited sexual advances toward resident #24 and engaged in non-consensual oral sex and intercourse with resident #25. This deficient practice placed residents #24 and #25 in immediate jeopardy. Findings included: - Resident #24's electronic medical record (EMR), documented the resident had [DIAGNOSES REDACTED]. and depression), and cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit). The 11/16/18 admission Minimum Data Set assessment for resident #24 documented staff assessed the resident with a Brief Interview for Mental Status score of 7 (impaired cognition), no behaviors, and required supervision while ambulating on the unit. The resident did not use any assistive devices and received daily antidepressant medication. The 11/16/18 care area assessment (CAA) for cognition documented the resident had impaired decision-making abilities, was able to make his/ her needs known to staff and had one behavior noted through this review period with intervention in place as ordered. The 11/16/CAA did not trigger behaviors and/or [MEDICAL CONDITION] medications for review. The 12/18/18 quarterly MDS assessment documented a BIMS score of 7 (impaired cognition), no behaviors, he/she walked with use of a rolling walker and required supervision with most activities of daily living. The resident received antidepressant medication daily. Review of the (MONTH) 2019 physician's orders [REDACTED]. [REDACTED]. The resident care plan for depression/mental Illness, documented that he/she had short-and long-term memory impairment and directed staff to discuss his/her concerns about confusion, disease process, nursing home placement and keep his/her care consistent as much as possible to decrease confusion This same care plan documented the resident had only wandering behaviors and was identified as an elopement risk. The care plan lacked documentation related to sexual encounters with other residents and/or interventions to address sexual activities. A nurse's progress note dated 1/24/2019 at 6:02 P.M. documented: (unnamed facility staff) met with resident regarding his/her report of having sex with another resident. During interview, resident acknowledged that the sex was consensual. Explained to resident that if she continued to desire to have sexual relations, he/she must notify the nurse and a private place will be made available for them. Resident voiced understanding. A social service note dated 1/26/2019 at 7:42 P.M. (unnamed facility staff) documented: Spoke with resident #24's (family member) earlier today regarding the events from yesterday regarding (resident #24) having consensual sex with another resident. (family member and spouse) stated resident was raped and was not able to make these kinds of decisions and according to resident #24's Psychiatrist, he/she also stated this. I explained that, in fact that, if this is true, then resident #24 would need to be deemed incompetent by two Physicians. In other words, resident #24 is his/her own person and able to make his/her own decisions. I also explained that if resident #24 would indeed like to have sex with another resident that we would provide protection and a private room for the consenting residents. (Family member) stated (resident #24) was very upset by this. (Family member) stated that he/she would like for the resident to be moved. I spoke with the director of nursing and we discussed that we could move resident #24 to room (number) for the night and then tomorrow there would be a room open on Heritage unit that resident could move to permanently. (Family member and sibling) would like to set up a meeting with the team and I said that I would speak with the team on Monday morning and would get back with them to set up a meeting for the team to meet with them. (Family member) stated he/she was going to speak with the Psychiatrist about resident) not being able to make his/her own decisions. The electronic record lacked documentation the resident's physician was notified of any sexual activities. Observed on 1/28/19 at 11:45 A.M. the resident was seated on his/her bed in his/her room on the lower level. Interviewed on 1/28/19 at 11:45 AM Resident #24 stated, I did not feel safe the other night. I felt that (resident #23) would come to my room and do something with me. I was scared. I did not feel safe and I wanted to go to my (family member) I remember (resident #23) taking my hand and saying come on, come on, you are going with me. I don't know if I was in his/her room or my room. I sat down, and he/she gave me a Dr. pepper. He grabbed my breast. I was not ok with that, because he pinched it. I was scared to tell anyone because I didn't know what he/she would do. I have (nurses name) as a friend here and a lady (resident name). I did not know what to do. I told someone that he/she put Vaseline on my anus and asked me if he/she could have anal sex with me and I said no I've never done that. Now I am kind of scared because he/she acts kind of cold and he/she does not talk of anything and I do not want him/her to come after me at night. I told (nurse) when I got scared I wanted to go to my (family members). No one is following up to make sure that everything is going ok in this room. I would talk to (staff member Z) he/she works here. Interviewed on 1/29/19 at 4:39 P.M. Resident #24 stated (resident #23) is not a friend. He/she thinks he/she is, but he/she follows me all around and I don't like that. I was never in a relationship with him/her. He/she never really hurt me, just makes me uncomfortable You know I can tell he/she wants to have sex with me, but I told him/her I'm not a whore. He/she asked me, I don't know how many times. He/she was upstairs. I've never been to his/her room and he/she has never been to mine. The facility's policy Analyzing Occurrences of Abuse, Neglect, Mistreatment, and Theft/Misappropriation of Resident Property, and Exploitation revised (MONTH) (YEAR), documented: Assure the facility would not condone any form of resident abuse and would continually monitor the facilities policy, procedures, training programs, systems etcetera to assist in preventing resident abuse, it is the facility's goal to achieve and maintain an abuse free environment. The facility failed to prevent and identify incidence of sexual assault when resident #23 allegedly coerced and harassed resident's #24. This deficient practice placed residents #24 in Immediate Jeopardy. - Resident #25's electronic medical record (EMR) documented the resident had [DIAGNOSES REDACTED].). The resident's 12/15/18 admission minimum data set assessment documented staff assessed the resident with a Brief Interview for Mental Status score of 15 which indicated his/her cognition was intact and had no behaviors. The MDS recorded the resident required supervision to limited assistance with activities of daily living, he/she walked with a rolling walker and received diuretic (medication to remove excess fluid from the body) and antidepressant medication. The 12/15/18 care area assessment for [MEDICAL CONDITION] medications recorded the resident was diagnosed with [REDACTED]. The 12/24/18 quarterly MDS documented no cognitive, behavioral and/or functional changes for the resident. Review of the (MONTH) 2019 physician's orders [REDACTED]. [REDACTED]. The resident's care plan for behaviors lacked any specific behaviors to be monitored but directed staff to ensure the resident seeks out staff/caregiver when agitation occurs, administer [MEDICAL CONDITION] meds as ordered, determine causes of behavior and remove resident, document all behaviors and attempt to identify pattern to target interventions. A nurse note dated 12/22/2018 at 9:04 P.M. documented (resident#25) was observed by this writer walking down hall to room standing behind pushing his/her wheelchair, when a male resident was walking behind him/her and attempted to snatch a brown leather jacket off chair. Resident fell into door in room while trying to snatch jacket back from the male resident. This writer intervened and attempted to calm both residents down and (resident #25) stated, That's my jacket, we traded and he'/she is just mad because I won't have sex with him, I'm done with that. Resident #25 verbalized to this writer that she has had sex with (resident #23) 1, time, oral sex 2 times and had fondled (resident23) multiple times. Resident #25 stated, (He/she) never wants to chill and watch movies on the couch and just wants sex, but when I don't want to (he/she) gets very mad. Resident #25 refused to give resident his/her brown leather jacket and take his/her black leather jacket back from (resident23) due to both residents trading items. (Resident #25) had no injuries noted. No complaints of pain voiced. Notified nurse unit supervisor E, Advanced registered nurse practitioner (ARNP) KK, and left message for resident's (family member). The electronic record lacked documentation the resident's physician was notified of any sexual activities. Resident #25 called the police on 1/24/19 to report she had been sexually assaulted and did not feel safe. Observed on 1/29/19 at 4:24 P.M. resident #25 entered the facility from the designated smoking area, walking with use of front wheeled walker, sat in an occasional chair and after introductions, began to cry. Interviewed on 1/29/19 at 4:24 P.M. resident # 25 stated resident #23 was not a friend or acquaintance anymore; I keep my distance. He/she is not good people; he/she does not have a good heart; he/she is a user and a taker and uses people. He/she is just a selfish, put's his/her weight around until you give him/her what he wants, when he/she takes you into his/her web. He/she was my boyfriend for a while a couple time on and off. He/she did not want to respect any of it. He/she thought I was just some whore that he/she could do what he/she wanted to with, like a bimbo or something. I hate sex. I hate it with all my [MEDICATION NAME], I hate it. I was in a sex slave ring for human, trafficking I came from, until I had my stroke and then I was no good to them anymore. Resident #25 stated, I said no all the time. I finally felt whipped down and just said ok just get it over-with let me out. I felt taken advantage of; I felt like I had .when I made it out the door with a no he kept knocking on my door over and over. I don't know what the outcome was (Police) I did not call for me, I called for a friend of mine, while we were still dating (Resident#23) did it to him/her too and another girl. If I wanted to have sex, they provide a . what is the other word for condoms ([MEDICATION NAME])? Yeah, they provide and provide a room for undisturbed visit. Resident #25 referred to his/her friend (resident #24) stating, he/she is scared to come out of his/her room. (Resident #23) smokes too and he/she comes behind (resident#24) and (resident #24) shakes when he/she stands (behind him/her), and he/she will come behind (resident#24) and say that's my girl and take cigarettes from pack. I did not tell nurse or administration. If they (nurse or administration would have (come to me) I would have been straight with them, but no one ever came to me. Everything they questioned me on they did not even tell the state before they questioned me on it. The facility's policy Analyzing Occurrences of Abuse, Neglect, Mistreatment, and Theft/Misappropriation of Resident Property, and Exploitation revised (MONTH) (YEAR), documented: Assure the facility would not condone any form of resident abuse and would continually monitor the facilities policy, procedures, training programs, systems etcetera to assist in preventing resident abuse, it is the facility's goal to achieve and maintain an abuse free environment. The facility failed to prevent and identify incidence of sexual assault when resident #23 allegedly coerced and harassed resident #25. This deficient practice placed residents #25 in Immediate Jeopardy. The facility was notified of the Immediate Jeopardy on 1/29/19 at 6:48 PM.As of 1/31/19 at 7:30 pm, the immediate jeopardy remained uncorrected.

The facility reported a census of 121 residents with 24 residents residing on the locked Arcadia unit. The sample included 3 residents reviewed for accidents and hazards. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent 1 resident (#18) from leaving the locked unit, without staff supervision and was found on the second floor in a closed section of the facility. This deficient practice placed resident #18 in immediate jeopardy. Findings included: - Resident #18 admitted to the first floor of the facility on 11/21/18. The 12/18/18 physicians order sheet revealed the following Diagnoses: [REDACTED]. The 11/21/18 Admission Minimum Data Set (MDS) revealed the resident had clear speech, was usually understood and could understand. The resident's Brief Interview for Mental status (BIMS) (assessment for cognitive function) was not assessed. The MDS revealed the resident had inattention and disorganized thinking, no hallucination or delusions, no physical or verbal behavior was exhibited and no wandering behavior. The resident required assist of 2 staff for bed mobility, transfer and limited assistance of 1 staff for walking in the room, corridor and locomotion and off and on the unit. It further revealed the resident was not able to stabilize without staff assistance or for moving from seated to standing position, walking and moving surface to surface. The 11/21/18 Care Area Assessment (CAA) for falls revealed the resident had a history of [REDACTED]. The resident had one non-injury fall since admission. Therapy screen was implemented, and program recommended. The 11/23/18 admission care plan revealed the staff needed to monitor the resident for confounding problems due to decline in cognitive status, mood, decline in activities of daily living (ADLs), limited physical mobility and to engage the resident in fall/injury prevention interventions. The 11/23/18 care plan lacked documentation that the resident was at risk for wandering. Resident #18's 11/25/18 fall assessment revealed the resident was high risk for falls. The 12/19/18 fall assessment revealed the resident was high risk for falls. The resident's Elopement Risk assessment dated [DATE] revealed a score of 8 which indicated low risk. The comprehensive care path note dated 11/21/19 at 1:19 P.M., licensed nursing staff N revealed the resident was oriented to person, place and time. The note further revealed the resident continued to wander and required redirection. The cognition/behavior portion of the assessment revealed the resident was oriented to person only, required staff orientation, cueing, redirection and monitoring of activity and whereabouts. Resident was transferred to secured unit for wandering. The progress note dated 11/22/18 at 11:36 AM, licensed nursing staff O revealed the resident wandered through the facility going in and out of residents' rooms. The resident yelled at peers and staff for no apparent reason. He/she was exit seeking trying to leave the facility. Staff attempted to redirect and educate him/her that leaving the facility was not feasible. The note further revealed the resident refused to stay in his/her wheelchair and insisted on walking. The resident was moved to the Arcadia unit (first floor locked memory care) at this time. A progress note dated 11/22/18 at 2:53 PM, licensed nursing staff I revealed resident #18 moved to the locked unit due to wandering and exit seeking. He/she wandered into rooms and was difficult to redirect. A progress note dated 12/14/18 at 8:05 AM, licensed nursing staff N revealed that neuro checks were within normal limits (WNL) due to a fall that took place at 5:15 AM from the left side of resident #18's bed. He/she was noted to have blood on the left side of his/her head in the hair and was picking at the wound and smearing the blood on his/her hands and gown. The note revealed the resident had a laceration to the left side of his/her forehead, in a triangular shape that measured 1-centimeter (cm)x 1cm x 1cm. The bleeding was stopped, and the area was dressed and cleaned and the area would most likely need some closure with sutures or staples. The note revealed a skin tear to the right forearm that measured 3cm x 1.5 cm and was irregular shaped. The area was cleansed, and a band-aide was applied. A message was left for the physician and the residents sibling. Resident #18 was sent out by stretcher to the emergency room . A progress note dated 12/19/18 at 2:21 AM, licensed nurse N documented that the resident returned to the facility on [DATE] during the 7am-3pm shift. At 12:15 AM the resident was found by staff lying on the right side of his/her bed in a supine position, with his/her right leg remaining on the bed. No injuries were noted. The note further revealed the resident ambulated and attempted to get out of wheel chair without assistance. The resident continued to have impulsive behavior at this time and is one on one with direct care staff. A note dated 1/10/19 at 7:52 PM licensed nurse P recorded staff found the resident on the floor next to an unoccupied bed. Resident #18 sustained a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting in trauma) to the right side of his/her head with blood present. Resident was sent to the emergency room for evaluation. In progress noted dated 1/22/18 at 12:55 AM marked late entry, licensed nursing staff G revealed resident #18 made his/her way off the unit and was found sitting in a chair in the upstairs dining room unharmed. The note further revealed the resident made his/her way off the unit without alarms sounding on the locked unit. Staff assisted resident #18 back to the unit by staff and notified administration. A progress note dated 1/23/19 at 8:03 PM, administrative nursing staff D revealed that at approximately 8:30 PM - 8:45 PM during routine checks the resident was noted to be out of bed. At 9:30 P.M., approximately one hour later, staff noted the resident ambulating in the post -acute dining room (located on the second floor). The note further revealed the resident was currently resting in bed with eyes closed in no distress. Observation on 1/28/19 at 3:00 PM a tour with licensed staff I on the first-floor locked unit revealed 2 doors that accessed stairwells that can be opened, the alarm briefly sounded then stopped with the door open. Licensed staff I revealed someone had been working on the door to the stairwell and turned the alarm off. Staff I used a key to turn the alarm back on. An observation on 1/28/19 at 2:45 PM revealed a vacant unit on the second floor. The door opened without a code being entered and no alarm sounded. Observation revealed the unit had an opened fire sprinkler room that was unlocked and contained several cans of paint and 6 cans of spray paint. Another large open room had boxes of equipment and supplies and broken glass on the floor. Observation on 1/28/19 at 4:15 PM, revealed resident #18 sat at the end of the hallway on the locked unit. He/she was unkempt, hair was uncombed, his/her left arm was placed through the neck hole of his/her t-shirt exposing the chest area. The resident wore pajama pants that drug the ground, with a slipper sock on the right foot and without a sock on the left. The resident had a WanderGaurd bracelet (device that sets off an alarm when residents wearing one attempt to exit the building without an escort) placed on his/her right ankle. Resident #18 began to ambulate in the hallway without assistance, he/she opened the door to a resident's room and the resident yelled at him/her to get out. Resident #18 came out of the room and continued down the hallway without assistance. An interview on 1/28/19 at 7:52 AM with direct care staff R revealed that a resident was missing recently, and staff were not aware. The emergency system sounded but the staff on the unit did not do a head count. Direct care staff R stated he/she was not working on the unit at that time but was on an adjacent unit. An interview on 1/28/19 at 8:30 AM with licensed nursing staff I revealed upon arrival to work on or around 1/26/19 the alarm was sounding in the locked unit. He/she stated that on Tuesday or Wednesday staff were unable to locate resident #18 on the locked unit. He/she revealed staff looked for the resident for a couple of hours before the resident was found in an empty unit upstairs. Staff I revealed at that time he/she placed a Wander Guard on the resident. An interview on 1/28/19 at 4:15 PM direct care staff Q revealed that resident #18 was able to leave the locked unit. Staff Q was aware that he/she had left recently but was unsure of the date. Staff Q revealed that there were 3 staff on the unit and the staff was not sure what door he/she walked out of, but the resident was found upstairs. Staff Q was unsure how long the resident had been off the locked unit. An interview on 1/29/19 at 8:00 AM with administrative nursing staff E revealed that resident # 18 had been getting out the east stairwell door (on the locked unit) and administrative staff was aware of this. An interview on 1/29/19 at 5:05 PM with administrative nursing staff D revealed that resident wandered on the locked unit and was found in an upstairs dining room after staff had looked for him/her for 30-45 minutes. Administrative nursing staff D revealed he/she was unaware that the resident had been found outside the locked unit in an unused unit found to have hazardous chemicals. Interview on 1/29/19 at 5:56 PM administrative staff A revealed that resident #18 left the locked unit and was found on the second floor and that the alarm was not working. He/she further indicated that a soft file (facility investigation that is not reported to the state agency) was made and through their investigation it was revealed a housekeeper accidentally let the resident off the locked unit even though the staff member did not see the resident exit. Training on going in and out of the Arcadia unit was began and the investigation closed. Staff A reported he/she was unaware that the resident had been found outside the locked unit in an unused unit found to have hazardous chemicals. The facilities Elopement, Risk Prevention and the Management of Missing Residents policy last updated on 9/2018 revealed that the facility would maintain a process to assess all residents for risk of elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission, and conduct a missing resident procedure. The policy revealed that when a resident was determined to be missing the following should occur: A code grey will be announced over the intercom alerting other staff of the emergency, the unit involved, room number of the missing resident and the time the resident was determined missing. The staff will verify if the resident had signed out and the administrator and director of nursing would be notified. All areas of the building, grounds and neighboring streets are systematically searched when a resident is missing or eloped. When the resident is located the code grey is cleared, the resident is escorted to the unit, examined for injuries by a licensed nurse, the attending physician is notified of the resident's status, the residents responsible party is notified, safety checks are initiated, the clinical record will be updated. The policy stated that documentation in the record all elopement attempts and events, including objective and factual statements. The facility failed to ensure adequate supervision for cognitively impaired independently mobile resident #18, with a history of and assessed at high risk for falls, received adequate supervision when he/she left the locked unit through an unsecure stairway, unattended by staff and was found approximately 1-2 hours later a different floor in the facility multiple times. This deficient practice placed the resident in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 1/29/19 at 6:48 PM.As of 1/31/19 at 7:30 pm, the immediate jeopardy remained uncorrected.

The facility had a census of 113 residents with 14 residents sampled for review and 2 reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to identify and monitor an abrasion with scabbing to the lateral left knee (bony prominence, at risk for pressure) and implement timely interventions to promote healing for resident #17 who was at risk for pressure ulcer development and had a facility acquired stage III pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the right knee. The facility also failed to ensure timely repositioning and placement of heel protector boots for resident #40 who was at risk for pressure ulcer development and had a facility acquired stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.) to the right ischium (the lower of the three major bones that constitute each half of the pelvis, hip bone). Findings included: - Resident #17's current EMR (electronic medical record) [DIAGNOSES REDACTED]. The 7/13/18 admission Minimum Data Set (MDS) assessment revealed the resident had moderately impaired cognition with short and long-term memory problems and no behavioral issues. He/she required extensive assistance of 1 person for bed mobility, transfers, dressing, and personal hygiene. The assessment indicated the resident was at risk for development of pressure ulcers and admitted with 3 stage III pressure ulcers. He/she used pressure reduction devices in his/her bed and chair, received nutrition/hydration interventions to manage skin problems, and staff provided pressure ulcer care. The 7/13/18 pressure ulcer CAA (care area assessment) stated the resident admitted with chronic stage III wounds. He/she needed extensive assistance of 1 person for bed mobility. Staff would continue to monitor and proceed with the plan of care. The resident's 12/21/18 Quarterly MDS assessment revealed the resident had moderately impaired cognition with short and long-term memory problems and no behavioral issues. The resident required extensive assistance of 2 persons for bed mobility, transfers, dressing, and personal hygiene. The resident had an indwelling urinary catheter (tube inserted in to the bladder to drain urine) and was frequently incontinent of bowel. The resident was at risk for pressure ulcer development and had 1 stage III pressure ulcer not present on admission and 1 stage IV pressure ulcer that was present on admission. The resident used a pressure relief device in his/her chair and on the bed. The resident also received nutrition/hydration interventions to promote healing and pressure ulcer care. The 6/27/18 care plan indicated the resident had a potential impairment to skin related to his/her history of wounds. The care plan directed staff to educate and encourage good nutrition and hydration to promote skin integrity. The care plan further instructed staff to observe skin, keep skin clean and dry, and hydrate with lotion as needed. Any skin alterations should be reported to the nurse. The care plan also identified an actual pressure ulcer to the left ischium, stage IV initiated 10/19/18. The care plan directed staff to assess the wound weekly, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue. Monitor wound for signs of infection. Monitor/document/report to physician as needed of changes in skin status, appearance,e color, wound healing, signs of infection, wound size, and stage. A low-air loss mattress was initiated on 12/26/18. The care plan lacked identification of the stage III pressure ulcer on the resident's right knee or the scabbed area on the left knee. Review of the (MONTH) TAR (treatment administration record) included a weekly skin assessment on Fridays. The box for staff to initial completion of the skin assessment for 2/1/19 and 2/8/19 were blank. A wound assessment dated [DATE] revealed the resident had a Stage III pressure ulcer on the right knee that measured 5.5 centimeters (cm) by 2.5 cm and 0.1 cm in depth. The assessment described a moderate amount of serosanguineous drainage (blood tinged fluid), with no odor. The wound bed consisted of 35% [MEDICATION NAME] tissue (new skin growing in a superficial wound) and 65% granulation tissue (intermediate step in the process of full-thickness wounds, shiny red and granular in appearance). Although requested, the facility failed to provide a wound assessment for 2/13/19. A physician progress notes [REDACTED]. The resident reported to the provider that the area was there for a long time. The resident reported he/she acquired this after a shearing (forces moving in opposite directions applied to tissues) event while being moved, well before admitting to this facility. On 2/13/19 at 9:26 a.m., licensed nurse G prepared supplies to change the dressing on the resident's right knee. The resident was laying on his/her abdomen. The resident had a scabbed area on his/her left lateral knee. Nurse G was unaware the area was there and verified the wound was not being treated or monitored. Nurse G measured the scabbed area as 1.5 cm (centimeters) by 1 cm. Nurse G then removed the old dressing from the right knee. The wound bed was clean with no odors. Nurse G stated the wound looked better. He/she cleansed and dressed the wound as ordered. Nurse G indicated staff measured the wound weekly. The resident asked to be repositioned and nurse G assisted him/her. Interview on 2/14/19 at 10:11 a.m. with licensed nurse H revealed he/she was not aware of the area on the resident's left knee and verified staff was not monitoring or treating the left lateral knee wound. On 2/14/19 at 12:19 p.m., direct care staff U stated the resident preferred to lay on his/her stomach and had the ability to move the upper body, but needed their help to move and position his/her legs. Staff U stated they used pillows to position his/her legs, under and in between. An interview on 2/14/19 at 1:14 p.m. with licensed nurse N revealed the licensed nurses completed weekly skin assessments and the wound nurse measured wounds weekly. Nurse N was unaware of any wounds on the resident's left knee and did not know how long the resident had the wound. The 11/2014 Pressure Ulcer Treatment policy provided guidelines for the care of existing pressure ulcers and the prevention of additional ulcers. The policy lacked guidance for weekly skin monitoring. The facility failed to identify and monitor a wound located on the resident's left knee (bony prominence) and implement interventions to promote healing. The facility also failed to monitor weekly skin assessments and document weekly wound measurements for the resident's existing stage III pressure ulcer on the right knee. - Resident #40's current electronic medical record included [DIAGNOSES REDACTED]. The resident's 10/24/18 admission minimum data set (MDS) assessment revealed the resident had severely impaired cognition and no behavioral concerns. He/she required extensive assistance of 2 persons for bed mobility, transfers, toilet use, and personal hygiene. The resident had functional limitations in range of motion on both sides of both upper and lower extremities. The resident weighed 129 pounds, had a history of [REDACTED]. The assessment identified the resident as at risk for pressure ulcer development with 1 unhealed stage I (non-blanchable redness of intact skin) pressure ulcer. The resident received hospice services. The 2/17/18 pressure ulcer care area assessment (CAA) stated the resident admitted with a stage I pressure ulcer on his/her buttock with treatment in place and identified contributing factors as urinary incontinence and immobility. The 10/18/18 nursing care plan identified the resident was at risk for impaired skin integrity. The care plan directed staff to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets, as needed. The care plan instructed staff to use skin breakdown prevention devices, but did not specify the devices being used. The care plan included skin observation as an intervention, but lacked frequency of skin assessments. The care plan also indicated the resident had impaired skin integrity with a full thickness wound to the buttock. The care plan directed staff to apply treatment as ordered, evaluate the wound for size, depth, and margins, air mattress, and to refer to the appropriate medical specialist as needed for evaluation and treatment. The care plan lacked direction and frequency for turning and repositioning. Review of the (MONTH) TAR (treatment administration record) included a weekly skin assessment on Tuesdays. The box for staff to initial completion of the skin assessment for 2/5/19 and 2/12/19 were blank. A skin assessment was initialed as completed on Friday 2/1/19 on the 3 p.m. to 11 p.m. shift. Wound documentation in the nurses' progress notes dated 1/30/19 at 2:46 p.m. stated the right buttock wound measured 1.4 cm (centimeters) by 1.3 cm with a depth of 0.1 cm. The note indicated there was a small amount of serosanguineous (blood tinged fluid) drainage without an odor. The note did not describe the condition of the wound bed. The 2/6/19 at 10:45 a.m. wound documentation in the progress notes of the right buttock included measurements of 2.6 cm by 2.1 cm, with a depth of 0.1 cm, stage III. There was a moderate amount of serosanguineous drainage, with no odor. The note did not describe the condition of the wound bed. Observations on 2/14/19 at 7:35 a.m. revealed the resident was in bed, positioned on his/her left side with pillows on an air mattress. During subsequent observations at 8:00 a.m., 8:21 a.m., 9:00 a.m., 9:30 a.m., and 10:00 a.m., the resident remained in the same position. At 10:14 a.m., licensed nurse H entered the room and prepared supplies for a dressing change. The resident was awake, however, non-verbal. The resident did not have heel protector boots in place as they were in the resident's chair. He resident remained in the same position for over 2 hours and 39 minutes. Nurse H pulled back the blankets for the dressing change. The resident's left foot was on the mattress and the resident's ankles were rubbing together. Nurse H removed the old dressing from the right buttock wound. The dressing had brownish drainage, with no odor. The nurse cleansed the wound and applied the physician ordered dressing. The wound bed had 85% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist). Nurse H reported he/she measured the wound on 2/13/19. After changing the dressing, nurse H examined the resident's heels. The skin was intact on both heels. (Review of the progress notes lacked wound documentation and measurements for 2/13/19) A 2/15/19 weekly skin monitoring form provided by the facility on 2/18/19, completed by licensed nurse G, included the following skin alterations: Coccyx (tailbone) Stage II (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer), 4 cm by 6 cm; Left ear, scabbed area noted inner ear 0.6 (by) 0.4 open area near lobe of left ear 0.4 (by) 0.2 reddened area base of ear opening 0.2 (by) 0.2 (no unit of measure documented); Left hand (back), dressings intact and looking clean; Right gluteal fold, dressings intact. nurse G checked the box on the form no new skin alteration noted. (The wound log provided by the facility on 2/13/19 only included the buttock wound.) On 2/14/19 at 10:30 a.m., licensed nurse H reported skin assessments should be done weekly and he/she measured the wounds weekly. Interview on 2/14/19 at 12:19 p.m., direct care staff U stated the resident was dependent on staff for everything including repositioning. Staff U indicated the resident should be repositioned every 2 hours and he/she should wear the heel protector boots at all times. They (staff) use pillows to keep the resident's feet from rubbing together. On 2/14/19 at 1:14 p.m., licensed nurse N verified skin assessments should be completed weekly. He/she further confirmed the resident needed repositioning by staff every 2 hours and should have the protective boots in place. The 11/2014 Pressure Ulcer Treatment policy provided guidelines for the care of existing pressure ulcers and the prevention of additional ulcers. The policy lacked guidance for turning/repositioning and use of protective equipment. The facility failed to monitor cognitively impaired, dependent resident #40's skin condition, monitor existing pressure ulcers, reposition in a timely manner, and provide heel protection to prevent pressure ulcers.

The facility had a census of 113 residents with 14 residents sampled for review and 2 reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to identify and monitor an abrasion with scabbing to the lateral left knee (bony prominence, at risk for pressure) and implement timely interventions to promote healing for resident #17 who was at risk for pressure ulcer development and had a facility acquired stage III pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the right knee. The facility also failed to ensure timely repositioning and placement of heel protector boots for resident #40 who was at risk for pressure ulcer development and had a facility acquired stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.) to the right ischium (the lower of the three major bones that constitute each half of the pelvis, hip bone). Findings included: - Resident #17's current EMR (electronic medical record) [DIAGNOSES REDACTED]. The 7/13/18 admission Minimum Data Set (MDS) assessment revealed the resident had moderately impaired cognition with short and long-term memory problems and no behavioral issues. He/she required extensive assistance of 1 person for bed mobility, transfers, dressing, and personal hygiene. The assessment indicated the resident was at risk for development of pressure ulcers and admitted with 3 stage III pressure ulcers. He/she used pressure reduction devices in his/her bed and chair, received nutrition/hydration interventions to manage skin problems, and staff provided pressure ulcer care. The 7/13/18 pressure ulcer CAA (care area assessment) stated the resident admitted with chronic stage III wounds. He/she needed extensive assistance of 1 person for bed mobility. Staff would continue to monitor and proceed with the plan of care. The resident's 12/21/18 Quarterly MDS assessment revealed the resident had moderately impaired cognition with short and long-term memory problems and no behavioral issues. The resident required extensive assistance of 2 persons for bed mobility, transfers, dressing, and personal hygiene. The resident had an indwelling urinary catheter (tube inserted in to the bladder to drain urine) and was frequently incontinent of bowel. The resident was at risk for pressure ulcer development and had 1 stage III pressure ulcer not present on admission and 1 stage IV pressure ulcer that was present on admission. The resident used a pressure relief device in his/her chair and on the bed. The resident also received nutrition/hydration interventions to promote healing and pressure ulcer care. The 6/27/18 care plan indicated the resident had a potential impairment to skin related to his/her history of wounds. The care plan directed staff to educate and encourage good nutrition and hydration to promote skin integrity. The care plan further instructed staff to observe skin, keep skin clean and dry, and hydrate with lotion as needed. Any skin alterations should be reported to the nurse. The care plan also identified an actual pressure ulcer to the left ischium, stage IV initiated 10/19/18. The care plan directed staff to assess the wound weekly, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue. Monitor wound for signs of infection. Monitor/document/report to physician as needed of changes in skin status, appearance,e color, wound healing, signs of infection, wound size, and stage. A low-air loss mattress was initiated on 12/26/18. The care plan lacked identification of the stage III pressure ulcer on the resident's right knee or the scabbed area on the left knee. Review of the February TAR (treatment administration record) included a weekly skin assessment on Fridays. The box for staff to initial completion of the skin assessment for 2/1/19 and 2/8/19 were blank. A wound assessment dated [DATE] revealed the resident had a Stage III pressure ulcer on the right knee that measured 5.5 centimeters (cm) by 2.5 cm and 0.1 cm in depth. The assessment described a moderate amount of serosanguineous drainage (blood tinged fluid), with no odor. The wound bed consisted of 35% [MEDICATION NAME] tissue (new skin growing in a superficial wound) and 65% granulation tissue (intermediate step in the process of full-thickness wounds, shiny red and granular in appearance). Although requested, the facility failed to provide a wound assessment for 2/13/19. A physician progress notes [REDACTED]. The resident reported to the provider that the area was there for a long time. The resident reported he/she acquired this after a shearing (forces moving in opposite directions applied to tissues) event while being moved, well before admitting to this facility. On 2/13/19 at 9:26 a.m., licensed nurse G prepared supplies to change the dressing on the resident's right knee. The resident was laying on his/her abdomen. The resident had a scabbed area on his/her left lateral knee. Nurse G was unaware the area was there and verified the wound was not being treated or monitored. Nurse G measured the scabbed area as 1.5 cm (centimeters) by 1 cm. Nurse G then removed the old dressing from the right knee. The wound bed was clean with no odors. Nurse G stated the wound looked better. He/she cleansed and dressed the wound as ordered. Nurse G indicated staff measured the wound weekly. The resident asked to be repositioned and nurse G assisted him/her. Interview on 2/14/19 at 10:11 a.m. with licensed nurse H revealed he/she was not aware of the area on the resident's left knee and verified staff was not monitoring or treating the left lateral knee wound. On 2/14/19 at 12:19 p.m., direct care staff U stated the resident preferred to lay on his/her stomach and had the ability to move the upper body, but needed their help to move and position his/her legs. Staff U stated they used pillows to position his/her legs, under and in between. An interview on 2/14/19 at 1:14 p.m. with licensed nurse N revealed the licensed nurses completed weekly skin assessments and the wound nurse measured wounds weekly. Nurse N was unaware of any wounds on the resident's left knee and did not know how long the resident had the wound. The 11/2014 Pressure Ulcer Treatment policy provided guidelines for the care of existing pressure ulcers and the prevention of additional ulcers. The policy lacked guidance for weekly skin monitoring. The facility failed to identify and monitor a wound located on the resident's left knee (bony prominence) and implement interventions to promote healing. The facility also failed to monitor weekly skin assessments and document weekly wound measurements for the resident's existing stage III pressure ulcer on the right knee. - Resident #40's current electronic medical record included [DIAGNOSES REDACTED]. The resident's 10/24/18 admission minimum data set (MDS) assessment revealed the resident had severely impaired cognition and no behavioral concerns. He/she required extensive assistance of 2 persons for bed mobility, transfers, toilet use, and personal hygiene. The resident had functional limitations in range of motion on both sides of both upper and lower extremities. The resident weighed 129 pounds, had a history of [REDACTED]. The assessment identified the resident as at risk for pressure ulcer development with 1 unhealed stage I (non-blanchable redness of intact skin) pressure ulcer. The resident received hospice services. The 2/17/18 pressure ulcer care area assessment (CAA) stated the resident admitted with a stage I pressure ulcer on his/her buttock with treatment in place and identified contributing factors as urinary incontinence and immobility. The 10/18/18 nursing care plan identified the resident was at risk for impaired skin integrity. The care plan directed staff to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets, as needed. The care plan instructed staff to use skin breakdown prevention devices, but did not specify the devices being used. The care plan included skin observation as an intervention, but lacked frequency of skin assessments. The care plan also indicated the resident had impaired skin integrity with a full thickness wound to the buttock. The care plan directed staff to apply treatment as ordered, evaluate the wound for size, depth, and margins, air mattress, and to refer to the appropriate medical specialist as needed for evaluation and treatment. The care plan lacked direction and frequency for turning and repositioning. Review of the February TAR (treatment administration record) included a weekly skin assessment on Tuesdays. The box for staff to initial completion of the skin assessment for 2/5/19 and 2/12/19 were blank. A skin assessment was initialed as completed on Friday 2/1/19 on the 3 p.m. to 11 p.m. shift. Wound documentation in the nurses' progress notes dated 1/30/19 at 2:46 p.m. stated the right buttock wound measured 1.4 cm (centimeters) by 1.3 cm with a depth of 0.1 cm. The note indicated there was a small amount of serosanguineous (blood tinged fluid) drainage without an odor. The note did not describe the condition of the wound bed. The 2/6/19 at 10:45 a.m. wound documentation in the progress notes of the right buttock included measurements of 2.6 cm by 2.1 cm, with a depth of 0.1 cm, stage III. There was a moderate amount of serosanguineous drainage, with no odor. The note did not describe the condition of the wound bed. Observations on 2/14/19 at 7:35 a.m. revealed the resident was in bed, positioned on his/her left side with pillows on an air mattress. During subsequent observations at 8:00 a.m., 8:21 a.m., 9:00 a.m., 9:30 a.m., and 10:00 a.m., the resident remained in the same position. At 10:14 a.m., licensed nurse H entered the room and prepared supplies for a dressing change. The resident was awake, however, non-verbal. The resident did not have heel protector boots in place as they were in the resident's chair. He resident remained in the same position for over 2 hours and 39 minutes. Nurse H pulled back the blankets for the dressing change. The resident's left foot was on the mattress and the resident's ankles were rubbing together. Nurse H removed the old dressing from the right buttock wound. The dressing had brownish drainage, with no odor. The nurse cleansed the wound and applied the physician ordered dressing. The wound bed had 85% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist). Nurse H reported he/she measured the wound on 2/13/19. After changing the dressing, nurse H examined the resident's heels. The skin was intact on both heels. (Review of the progress notes lacked wound documentation and measurements for 2/13/19) A 2/15/19 weekly skin monitoring form provided by the facility on 2/18/19, completed by licensed nurse G, included the following skin alterations: Coccyx (tailbone) Stage II (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer), 4 cm by 6 cm; Left ear, scabbed area noted inner ear 0.6 (by) 0.4 open area near lobe of left ear 0.4 (by) 0.2 reddened area base of ear opening 0.2 (by) 0.2 (no unit of measure documented); Left hand (back), dressings intact and looking clean; Right gluteal fold, dressings intact. nurse G checked the box on the form no new skin alteration noted. (The wound log provided by the facility on 2/13/19 only included the buttock wound.) On 2/14/19 at 10:30 a.m., licensed nurse H reported skin assessments should be done weekly and he/she measured the wounds weekly. Interview on 2/14/19 at 12:19 p.m., direct care staff U stated the resident was dependent on staff for everything including repositioning. Staff U indicated the resident should be repositioned every 2 hours and he/she should wear the heel protector boots at all times. They (staff) use pillows to keep the resident's feet from rubbing together. On 2/14/19 at 1:14 p.m., licensed nurse N verified skin assessments should be completed weekly. He/she further confirmed the resident needed repositioning by staff every 2 hours and should have the protective boots in place. The 11/2014 Pressure Ulcer Treatment policy provided guidelines for the care of existing pressure ulcers and the prevention of additional ulcers. The policy lacked guidance for turning/repositioning and use of protective equipment. The facility failed to monitor cognitively impaired, dependent resident #40's skin condition, monitor existing pressure ulcers, reposition in a timely manner, and provide heel protection to prevent pressure ulcers.

The facility identified a census of 117 residents. The sample included 2 residents. Based on observation, record review, and interview, the facility failed to protect the residents on the post-acute unit after resident #3 alleged direct care staff M poured water on his/her head and the left side of his/her body, twisted his/her arm, and twisted his/her nipples. This deficient practice placed the residents of the facility in immediate jeopardy. Findings included: - The electronic medical record for resident #3 documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive to total dependence with Activities of Daily Living (ADLs). The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required extensive to total dependence with ADLs. The Care Area Assessments (CAAs) dated 2/16/18 for cognition directed the reader to review the behavior notes and plan of care. The CAA for ADLs dated 2/16/18 documented the resident was alert and oriented and able to make his/her needs known to staff. He/she needed total to extensive assistance for his/her ADLs. The care plan dated 5/27/18 directed staff to encourage the resident to use the call light to request assistance, provide reminders as needed, and to encourage the resident to discuss feelings about his/her self-care deficit. Staffing schedule for 6/4/18 documented direct care staff M was scheduled to work on the resident's unit. The facility's time sheet for direct care staff M documented he/she clocked in on 6/4/18 at 11:15 PM and clocked out on 6/5/18 at 7:16 AM. On 6/4/18 at 11:18 AM, the resident sat in a wheelchair in his/her room. He/she was alert and calm. On 6/4/18 at 11:18 AM, the resident stated he/she was afraid of direct care staff M. He/she said staff M poured cold water on his/her head and the left side of his/her body, twisted his/her arm, and twisted his/her nipples. The resident stated he/she reported the incident to administrative staff A and administrative nursing staff D. On 6/4/18 at 11:30 AM, administrative staff A stated he/she did not know about this incident. He/she stated he/she would suspend direct care staff M. On 6/5/18 at 8:20 AM, the resident reported to the state complaint intake specialist that direct care staff provided care for him/her last night. On 6/5/18 at 9:15 AM, administrative staff A stated the facility had difficulty contacting direct care staff M's agency, and confirmed direct care staff M worked last night. On 6/5/18 at 1:01 PM, regional nursing staff E stated direct care staff M did not work for an agency, but rather for the facility. (This conflicts with administrative staff A's interview.) On 6/5/18 at 1:20 PM, the resident confirmed direct care staff M provided care for him/her last night. The resident stated direct care staff M left him/her undressed all night. On 6/5/18 at 2:08 PM, direct care staff M confirmed the facts of his/her undated witness statement, which documented the resident threw a pitcher of water on him/her. The witness statement also documented staff M denied mistreatment of [REDACTED]. The facility's policy Protection of Residents During Abuse Investigations, updated (MONTH) (YEAR), documented the employee accused of participating in the alleged abuse may be suspended. The facility failed to provide protection for residents after resident #3 alleged direct care staff M poured water on his/her head and the left side of his/her body, twisted his/her arm, and twisted his/her nipples. This deficient practice placed the residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 6/5/18 at 5:15 PM, when it initiated the following: Direct care staff M suspended on 6/5/18; administrative staff A suspended on 6/5/18 for failure to report; administrative staff D suspended on 6/5/18 for failure to suspend direct care staff M and initiate investigation; educated management staff and supervisors about abuse, neglect, and exploitation identification and the need to suspend the alleged perpetrator immediately; all staff educated by 6/6/18 by 12:00 AM on the policy and procedure entitled Abuse/Behavior to identify and report allegations of abuse/neglect; new staff will receive education in orientation, and agency staff will receive education prior to being on the floor with residents; staff on vacation, part-time or as needed will not be allowed to work until abuse training has been accomplished; educate agency staff on whom to contact upon observing potential violations; post names and numbers of staff to contact to report allegations of abuse, neglect, and exploitation; regional team will randomly interview 3 residents every 2 weeks for 1 month, then monthly for 2 months to follow up on grievances and staff to resident customer service, and all findings will be reported to the QAPI committee for review and comment. The deficient practice remained at a scope and severity of an F.

The facility identified a census of 102 residents. The sample included six residents reviewed for elopement risk (when a resident leaves the facility without staff knowledge). Based on record review and interview, the facility failed to ensure one resident (#1) received adequate supervision and appropriate interventions to prevent elopement when the resident exited the facility on 2/27/18 at an undetermined time. Staff last observed the resident on 2/27/18 at 12:00 A.M. He/she walked 1.0 miles in a suburban metropolitan area, became disoriented, and returned to the facility escorted by police at 2:18 A.M. This deficient practice placed resident #1 in immediate jeopardy. The facility further failed to provide adequate supervision and timely interventions to prevent a fall with injury for one (#6) of six residents sampled for accident hazards. Resident #6 fell from the wheelchair, had frequent complaints of right ankle pain, and 12 days after the fall, an x-ray documented the resident sustained [REDACTED]. Findings included: - The electronic medical record (EMR) for resident #1 included [DIAGNOSES REDACTED]. The 5-Day Admission Minimum Data Set (MDS), dated [DATE], documented staff assessed the resident with long term and short-term memory problems. The MDS recorded the resident had inattention, disorganized thinking, did not experience episodes of wandering during the assessment period, and could walk with the use of a rolling walker. The resident received anti-psychotic medications (medication used for mental illness) and anti-anxiety medications (medication used to relieve anxiousness, and restlessness). The 2/22/18 MDS lacked analysis of the care area assessments (CAA-a narrative assessment of resident characteristics). The EMR lacked documentation of an elopement risk assessment prior to the resident's elopement on 2/27/18. The initial care plan, dated 2/15/18, documented the resident had safety needs due to a fall risk, but lacked documentation of the resident's risk for elopement from the facility. This care plan further lacked revisions of any new interventions after the resident eloped from the facility on 2/27/18. A progress note, dated 2/27/18 at 9:34 A.M., by licensed nurse H documented the resident left the faciity on foot at approximately 2:00 A.M. and walked to a convenience store. Once at the convenience store, he/she called the police, told the police he/she made a mistake, and asked them to bring him/her back to the facility. When he/she returned to the facility, staff asked the resident how he/she got out of the building, and the resident stated that he/she read the sign on the front door, and that God told him/her to leave the facility. The sign indicated if someone pushed on the door for 15 seconds, the door would open. Prior to this incident, the resident refused his/her scheduled medications for the entire day, which may have caused his/her behavior to escalate. He/she was verbally aggressive while pacing back and forth. The staff notified the physician and administrative licensed nursing staff E, called emergency services, and sent the resident to the hospital for an inpatient psychiatric evaluation. When emergency services arrived, the resident became aggressive, threatened them, and they contacted the police to escort him/her out of the facility at 3:15 A.M. The facility's investigation contained only the above nurse's progress note as a description of the incident. The investigation lacked documentation to address what witnesses observed/heard, or a root cause analysis (a method of problem solving used for identifying the root causes of faults or problems) for the resident's elopement. According to www.Wunderground.com, on 2/27/18 at 1:53 A.M., the outside temperature was 43.0 degrees Fahrenheit with a wind chill of 36.0 degrees Fahrenheit, southerly winds at 6.9 miles per hour (mph) and clear skies. On 3/1/18 at 12:30 P.M., observation of the area traveled by the resident revealed a metropolitan, suburban area with hazards, such as changing slopes, curbed concrete sidewalks, trees, ravines, construction zones, irregular traffic patterns, and four lane main roads at 35 mph. The convenience store was 1.0 mile from the facility. On 3/1/18 at 9:00 A.M., licensed nursing staff E stated the police informed licensed nursing staff H that they had the resident and would bring him/her back to the facility. Nurse E stated the resident called the police and told them he/she made a mistake. Nurse H reported he/she did not know where the police found the resident and he/she immediately informed administrative licensed nurse E. Nurse E further stated licensed nurse H reported he/she assumed the resident went out the front door, but did not hear, or respond to, any alarm. On 3/1/18 at 9:50 A.M., maintenance director X stated he/she conducted weekly alarm checks on all doors and when he/she checked it on 2/27/18 (after the resident returned) it was working properly. On 3/1/18 at 1:49 P.M., administrative licensed nurse E stated staff assessed residents for risk for elopement by an elopement assessment, completed on admission and quarterly if needed. Nurse E stated staff notified him/her the resident stated God told him/her to exit the facility, and upon his/her return, staff placed the resident on 15-minute checks. Staff completed a head-to-toe assessment and the physician gave an order for [REDACTED]. Staff O reported to nurse E that the resident was in his/her room and wore pajama pants, a scrub top, and a hospital gown. Nurse E stated he/she attempted to interview other agency staff, but they did not return his/her calls. Nurse E stated that licensed nursing staff L reported he/she did not hear an alarm that night. On 3/1/18 at 3:20 P.M., administrative licensed nurse D stated he/she expected staff to complete elopement assessments on all new admissions, residents with any significant change and quarterly. Nurse D stated the electronic software, however placed almost all residents at risk for elopement, so the facility was working with the information technology (IT) department to correct this problem. Nurse D stated staff called him/her to report the resident left the building, went to a convenience store, called the police, and asked the police to bring him/her back to the facility. Nurse D stated the facility investigated the incident to see if any alarms went off, why staff did not respond to the alarms, and when staff last saw the resident. Administrative licensed nurse D stated staff's witness statements were difficult to obtain because many staff on duty at the time were agency (temporary employees hired from a health care staffing agency), and these staff had not returned the facility's calls. Nurse D stated he/she was unsure why interviews with staff were not completed at the time of the incident. The facility's Elopements policy, revised 12/2007, documented staff should investigate and report all cases of missing residents. The policy lacked documentation regarding the process of identifying at risk residents, elopement assessments and/or measures to prevent a resident's elopement. The facility failed to ensure this cognitively impaired resident received adequate supervision and appropriate interventions to prevent an elopement on 2/27/17. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 3/5/18 when it implemented the following: 1. The resident was assessed by the registered nurse (RN) upon return to the facility at on 2/27/18 at approximately 2:45 A.M. and he/she had no adverse effects. 2. Staff placed the resident on 15-minute checks upon return to facility. 3. The physician was notified of the resident's return to the facility by the RN on 2/27/18 at approximately 2:45 A.M. and the physician gave an order to transport the resident to the emergency department for assessment for in-patient psychiatric treatment. 4. The resident was transported to emergency department for evaluation and treatment on 2/27/18 at approximately 3:15 A.M. by emergency personnel. 5. Staff completed an elopement risk assessment on 2/27/18. 6. The Director of Nursing (DON) and/or designee would review any admission/re-admission related to resident #1 to ensure he/she had an immediate elopement risk assessment completed should he/she come back to the facility. 7. The charge nurse received a corrective action for failure to complete an elopement risk assessment upon admission for this resident. 8. Staff completed an elopement risk assessment on 100% of all residents in the facility on 3/2/18. 9. An alarm technician evaluated the alarm system on 2/27/18, with no negative findings. 10. Elopement education was provided in an all-staff in-service on 3/1/18. 11. Alarm Responsiveness education was provided to all staff on 3/5/18. 12. The DON/Designee would initiate audits on all new admissions for the past 30 days to ensure elopement assessment were in place beginning 3/2/18. 13. The DON/Designee would audit 100% of all new admissions within 24 hours of admission to ensure elopement risk assessment was completed for 3 months. The findings would be taken to the facility Quality Assurance Committee and the frequency of these audits would be determined by the QA Committee. This deficient practice remained at the scope and severity of a D. - Resident #6's (YEAR) electronic medical record (EMR) documented [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident required extensive assistance of 1 staff member with bed mobility and transfers and he/she had one fall since admission. The quarterly MDS, dated [DATE], documented a BIMS score of 15, which indicated intact cognition. The resident required extensive assistance of 1 staff member with bed mobility and transfers and he/she had one fall since the previous quarterly assessment. The 14-Day MDS, dated [DATE], documented a BIMS of 9, which indicated moderately impaired cognition. The resident required extensive assistance of 1 staff member for bed mobility and total staff assistance for transfers. He/she had multiple falls since admission, and one fall with major injury. The Care Area Assessment (CAA), dated 5/12/2017, for cognitive loss documented the resident had some confusion and social services visited with the resident related to any issues he/she had. The CAA, dated 5/12/17, for activities of daily living (ADLs) function documented the resident required assist of one staff for bed mobility and transfers, and he/she used a motorized wheelchair for mobility. The CAA, dated 5/12/17, for falls documented the resident was at risk for falls and had a non-injury fall. The care plan, revised 2/11/18, documented the resident was at risk for falls, had four documented falls, and directed staff to encourage the resident to wear non-skid footwear, to use his/her call light, to place non-skid strips at the bedside, and to place a mattress at the bedside for safety. On 1/4/18, a revision documented the resident was educated to utilize a seatbelt while using his/her motorized wheelchair. The care plan lacked documentation of falls sustained on 12/31/17, 1/3/18, and 2/13/18, and lacked interventions for the causative factors of his/her falls. The care plan further lacked revision to remove discontinued interventions, including the seatbelt and motorized wheelchair, and lacked documentation of interventions after the facility had knowledge of the resident's fractured right ankle. The fall risk assessments dated 1/4/18, 1/9/18, and 2/11/18 documented the resident was at high risk for falls. The clinical record lacked documentation of fall risk assessments after each of the resident's falls on 4/16/17, 9/12/17, 12/31/17, 1/3/18, and 2/13/18. A physician's orders [REDACTED]. Review of the right ankle x-ray results documented an acute minimally displaced [MEDICAL CONDITION] malleolus (the prominence on the inner side of the ankle, formed by the lower end of the tibia). A progress note, dated 12/31/17 at 10:32 A.M., documented staff found the resident on the floor. The resident reported he/she fell as he/she tried to walk to his/her motorized wheelchair. A progress note, dated 1/3/18 at 9:40 P.M., documented staff found the resident on the floor near his/her door at approximately 5:20 P.M. The resident reported he/she pressed the call light, but staff did not observe his/her call light to be activated. A progress note, dated 1/4/18 at 2:28 P.M., documented staff found the resident lying face down on the floor. The resident had an abrasion on his/her forehead, nose, and a bruise on the left wrist. The resident complained of pain to the right inner ankle, left hip, and left wrist. A progress note, dated 1/9/18 at 5:26 P.M., documented the resident complained of pain in his/her right ankle and hip. A progress note, dated 1/10/18 at 4:16 P.M., documented the resident had right ankle pain and requested to have his/her ankle wrapped with an ace wrap. Staff advised the resident it was better to keep his/her ankle moving. A therapy progress note, dated 1/11/18, documented the resident had a decline in mobility and was not able to stand or ambulate. A progress note, dated 2/4/18 at 10:19 A.M., documented the resident did not appear to be able to use his/her motorized wheelchair correctly and staff provided him/her with a manual wheelchair. A progress note, dated 2/13/18 at 3:11 A.M., documented staff found the resident on the floor, scooting around the room on his/her bottom. Four staff were required to transfer the resident onto the mattress on his/her floor and the resident became combative toward staff and unhooked his/her [MEDICATION NAME]. On 3/1/2018 at 4:00 PM, administrative licensed nursing staff D stated that resident #6 did have a fall with a major injury, but that was months ago. He/she was known to have behaviors of putting him/herself on the floor. Staff D stated he/she expected staff to complete the fall packet, which included fall risk assessments. The facility's Managing Falls and Fall Risk policy, dated (MONTH) 2007, documented that nursing would identify appropriate interventions to reduce the risks of falls. If falling recurs despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. The facility failed to identify appropriate interventions to reduce the risks of falls. The facility further failed to implement additional or different interventions per the facility policy, which resulted in a fall and a fracture for this resident.

The facility identified a census of 102 residents. The sample included 6 residents reviewed for medication errors. Based on record review and interview, the facility failed to ensure 1 resident (#1) received physician prescribed medications for 12 days after admission to the facility when facility staff failed to transcribe, order, and administer medications listed on the hospital transfer orders. This deficient practice represented a significant medication error for the resident who was subsequently re-hospitalized with a blood clot and uncontrolled mental agitation, which required law enforcement intervention. Findings included: - The electronic medical record (EMR) for resident #1 included [DIAGNOSES REDACTED]. The 5-Day Admission Minimum Data Set (MDS), dated [DATE], documented staff assessed the resident with long-term and short-term memory problems. The MDS lacked evidence the resident received anticoagulant medications (medication used to thin the blood to prevent or reduce coagulation of blood, prolonging the clotting time) during the assessment period. The 5-Day Admission MDS, dated [DATE], lacked documentation of the Care Area Assessment related to the resident's use of [MEDICAL CONDITION] and/or anticoagulant medications. The EMR lacked documentation of a pharmacist review of the resident's medications. The EMR further lacked documentation of a baseline Abnormal Involuntary Movement Scale (AIMS) or Dyskinesia Identification System Condensed User Scale (DISCUS) (an assessment tool used to assess the occurrence of tardive dyskinesia (a disorder that results in involuntary, repetitive body movements that may be caused by use of antipsychotic medications). The initial care plan, dated 2/15/18, lacked documentation of any medications, potential side effects, and/or warning labels. Review of the hospital transfer orders (to the facility), dated 2/15/2018 and timed 3:26 P.M. documented the following orders: Xeralto 15 milligrams (mg) (a prescription medicine used to reduce the risk of stroke and blood clots in people with [MEDICAL CONDITION]); 15 mg PO 2 times daily through 2/22/18, then change to 20 mg daily for [MEDICAL CONDITION] embolism (blood clot in the lungs) prevention. [MEDICATION NAME] liquid 250 mg per 5 milliliters (mL) (a medication used to treat [MEDICAL CONDITION] disorders, mental/mood conditions such as manic phase of [MEDICAL CONDITION] disorder), and to prevent migraine headaches); 250 mL PO every twelve hours for [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type (mental illness). Review of the (MONTH) (YEAR) physician order [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the nurses' progress notes dated 2/26/18 at 11:41 P.M. documented the resident refused all medications this shift. The resident called police this evening who showed up to do a welfare check on resident after he called police to tell them he refused a shower. Review of the nurses' progress notes dated 2/27/18 at 8:31 A.M. documented the resident left the faciity on foot at approximately 2:00 A.M. and walked to a convenience store. Prior to this incident, the resident refused all his/her scheduled medications for the entire day, which may have caused his/her behavior to escalate. On 3/1/18 at 3:08 P.M., family member S stated the resident had a history of [REDACTED]. He/she stated the resident was discharged to the hospital from a State mental institution because he/she had blood clots in his/her lungs and legs. Family member S stated when the resident did not receive his/her medications, his/her behavior could not be predicted. On 3/1/18 at 4:00 P.M., licensed nurse I stated the hospital transfer orders arrived on two different pages noting medications to be continued and medications to be discontinued. Nurse I stated he/she inadvertently omitted the medications listed at the top of the page, because he/she thought they had been discontinued. On 3/1/18 at 5:00 P.M., administrative licensed nurse D acknowledged there was a transcription error with the resident's transfer medication orders on admission. Nurse D stated he/she was not aware of the error until today, and stated the nurse who transcribed the resident's orders must have overlooked the medications listed on the top page of the transfer sheet. On 3/5/18 at 1:08 P.M., consultant nurse practitioner AA stated it was difficult to determine if the resident suffered an escalation of his/her condition due to not receiving the prescribed medications because the physician did not see the resident after his/her re-hospitalization on [DATE]. Consultant nurse practitioner AA stated he/she expected nursing staff to follow the physician's orders [REDACTED]. The facility's Administering Medications policy, dated (MONTH) 2012, and Anticoagulation Medications protocol, dated (MONTH) 2012, lacked documentation related to transcription errors and the resident's omitted medications. The facility lacked a requested policy related to medication order transcription and/or ensuring the confirmation of hospital transfer orders. The facility failed to ensure staff transcribed, ordered, and administered medications per physician's orders [REDACTED].

The facility identified a census of 85 residents. The sample included one resident reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards from on 1/3/17 through 6/22/17 when resident #8 exhibited unsafe smoking behaviors by lighting cigarettes inside the facility and within close proximity of an oxygen tank. This deficient practice placed the residents of that unit in immediate jeopardy. Findings included: - The clinical record documented resident #8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The annual Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, had no behaviors, and used a wheelchair for mobility. The quarterly MDS dated [DATE] documented the resident had a BIMS score of 15, which indicated intact cognition, had no behaviors, and used a wheelchair for mobility. The Care Area Assessment (CAA) for Activities of Daily Living (ADLs) dated 12/21/16 documented the resident used a wheelchair for mobility and was able to propel him/herself independently. The CAA for Behavioral Symptoms did not trigger for further review. The care plan dated 10/14/14 documented the resident was a smoker and directed staff to complete a smoking evaluation per the facility guidelines. An intervention dated 11/30/15 documented staff discussed the resident's smoking habits and developed a smoking plan with the resident and family. An intervention dated 10/4/16 documented the resident would abide by the facility's smoking policy. An intervention dated 1/3/17 documented the resident attempted to light his/her cigarettes indoors prior to going outside to smoke and staff educated the resident on the smoking policy. The care plan dated 10/14/14 documented the resident was non-compliant with facility smoking guidelines and boundaries and documented a designated location for smoking had been established. On 3/22/17, staff revised the care plan with the following interventions: staff educated and encouraged the resident not to light cigarettes inside the building, the resident had a history of [REDACTED]. The resident could smoke at scheduled times and could smoke between scheduled times when staff was available. Staff informed the family when they brought in cigarettes and lighters, they must be given to the receptionist or charge nurse. An intervention dated 3/28/17 documented the resident required one-on-one supervision related to smoking policy non-compliance and refusal to relinquish smoking materials. Review of the Smoking Risk Review dated 10/4/16 documented the resident was able to independently handle his/her smoking materials. Review of the Smoking Risk Review dated 1/26/17 documented staff noted the resident consistently broke the smoking policy, lit cigarettes indoors before he/she exited to the smoking patio, broke plates on the smoking patio, and placed sugar packets in the cigarette ashtray. The resident acknowledged and signed the smoking agreement, but he/she continued to display unsafe smoking behaviors and staff placed the resident on supervised smoking. Review of the Smoking Risk Review dated 3/8/17 documented the resident continued to be non-compliant with the facility policy. On 3/8/17, the resident threw dishes outside on the smoking patio, put paper towels in the cigarette ashtray and tried to light them on fire, and staff observed the resident light his/her cigarette inside the facility near a tank of oxygen. Staff educated the resident about the facility's smoking policy and was deemed not capable of even supervised smoking. Review of the Smoking Risk Review dated 6/7/17 documented the resident was aware of the smoking rules, had no history of unsafe smoking behaviors (contradicted by the 3/8/17 smoking risk review), and could independently handle smoking materials. Review of the undated Smoker's Schedule documented the designated smoking area was the Courtyard at 9:00 A.M., 11:00 A.M., 1:30 P.M., 4:00 P.M., and 7:30 P.M. The Smoker Schedule documented 10 unsupervised smokers and 4 supervised smokers. The supervised smoking list included resident #8 and with an assigned, designated staff to each smoking time on each day of the week. A progress note dated 1/6/17 at 11:17 A.M. documented staff called the resident's spouse to discuss his/her behaviors related to breaking plates in the courtyard, trying to light cigarettes inside the facility prior to going outside to smoke, and putting paper in the cigarette container outside. A progress note dated 1/9/17 at 2:10 P.M. documented staff held a care plan meeting to discuss the resident's behaviors of non-compliance with the smoking policy. Staff observed the resident lighting cigarettes inside the facility, dropping mouthwash and other liquids on the smoking patio, breaking plates on the patio, turning over furniture, and stuffing outside cigarette containers with tissues and placing lit items on top of the tissues. The resident agreed to comply with the facility policy and the consequences for non-compliance were supervised smoking and to discharge him/her to another facility. A progress note dated 1/24/17 at 8:33 A.M. documented staff observed the resident lighting his/her cigarette inside the facility. Other residents reported the resident broke plates in the courtyard and lit cigarettes boxes on fire. Staff notified administrative staff B of the resident's behaviors. Review of progress notes from 1/26/17 through 2/3/17 documented the resident was non-compliant with the facility's smoking policy, went outside to smoke unsupervised, had smoking materials on his/her person and in his/her room, and staff observed the resident light cigarettes inside facility. Administrative staff B and administrative nursing staff F were aware of the resident's non-compliance. A progress note dated 1/26/17 at 4:09 P.M. documented staff placed the resident on supervised smoking. A progress note dated 2/3/17 at 4:22 P.M. documented the resident's spouse reported he/she observed the resident fill the cigarette bin with paper and light his/her cigarette inside the facility. A progress note dated 2/6/17 at 11:25 A.M. documented staff observed the resident light a cigarette inside the building within 5 feet of a resident who used oxygen. Review of the progress notes from 2/6/17 through 3/8/17 documented the resident continued to be non-compliant with the facility's smoking policy, went outside to smoke unsupervised, and had smoking materials on his/her person and in his/her room. Staff observed the resident smoke in the dining room, light cigarettes inside the facility, break plates on the patio, and overturn patio furniture. A progress note dated 3/2/17 at 9:48 A.M. documented staff discussed the resident's behaviors with consultant physician JJ, who stated the resident was capable of making his/her own decisions and understood the smoking policies. A progress note dated 3/8/17 at 10:07 P.M. documented staff observed the resident smoking outside unsupervised, breaking dishes on the patio, and overturning patio furniture. Staff notified the nurse practitioner of the resident's behaviors and indicated the resident was not safe to smoke. A progress note dated 3/21/17 at 5:18 P.M. documented staff held a care plan meeting with the ombudsman (an official appointed to investigate individual's complaints against maladministration) in attendance to formulate a new smoking plan. Staff offered the resident a nicotine patch or other smoking cessation medication of his/her choice, but he/she declined. The resident indicated he/she lit the cigarettes inside the facility because it was windy outside and he/she could not use his/her left arm or hand to shield the wind. The new smoking plan documented the resident could smoke unsupervised as long as staff lit the cigarette for him/her and that all lighters and cigarettes would be handed in to staff. Review of the progress notes from 3/22/17 through 5/28/17 documented the resident smoked unsupervised, was on 15 minute checks, and kept smoking materials on his/her person and in his/her room. On 3/28/17, staff placed the resident on one-on-one supervision. Review of the clinical record documented a hospitalization for behaviors from 5/11/17 through 5/26/17 regarding the resident's non-compliance and unsafe smoking practices. A progress note dated 5/30/17 at 6:13 A.M. documented the one-on-one status was discontinued as it was only for 72 hours from readmission to the facility. A progress note dated 6/3/17 at 2:54 A.M. documented the resident remained on one-on-one observation, but the facility did not have any staff available. Staff instructed the direct care staff assigned to the resident's unit to check the resident every 5 minutes while awake and every 15 minutes while asleep. A progress note dated 6/3/17 at 12:12 P.M. documented staff discontinued the one-on-one observation and the resident remained on 15-minute checks. A progress note dated 6/7/17 documented staff instructed the resident was to check his/her smoking materials in and out through the nursing staff until further notice. On 6/19/17 at 2:15 P.M., the resident sat outside and smoked. Staff were not present in the area. A pack of cigarettes and lighter were visible in the resident's shirt pocket. On 6/20/17 at 9:50 A.M., the resident propelled his/her wheelchair from the smoking area into the hallway toward his/her room. A pack of cigarettes and lighter remained visible in the resident's shirt pocket. He/she did not turn the smoking materials in to staff. On 6/21/17 1:50 P.M., the resident sat outside and smoked with four other residents without staff present in the area. At 2:35 P.M., the resident propelled his/her wheelchair into the facility, and passed two staff, which sat at the nursing station. He/she had smoking materials visible in his/her shirt pocket and did not turn the cigarettes or lighter in to the staff. A half-smoked cigarette sat visible on the seat of the resident's wheelchair near his/her right leg. On 6/21/17 at 1:05 P.M., direct care staff T stated he/she did not know the smoking schedule or which residents required staff supervision. Direct care staff T stated he/she thought resident #8 smoked without supervision because he/she had not seen staff with the resident when he/she smoked. On 6/21/17 at 1:18 P.M., direct care staff U stated resident #8 smoked unsupervised and should check his/her smoking material in and out with the staff at the medication cart. On 6/21/17 at 2:05 P.M., direct care staff V stated staff provided one-on-one observation for the resident because he/she was non-compliant with safe smoking procedures since January 2017. Direct care staff V stated the main concern was that resident #8 lit his/her cigarettes inside the facility near resident #15's oxygen tank. He/she stated staff reassessed when he/she returned from the hospital and allowed the resident to smoke by him/herself. Direct care staff V stated the only residents who required supervision when smoking were those that could not get outside on their own. He/she stated there was a smoking schedule that residents should follow and there was an assigned staff to monitor each smoking session. On 6/21/17 at 2:10 P.M., resident #14 stated he/she wore oxygen but did not smoke. Resident #14 stated he/she observed resident #8 light his/her cigarette inside the facility. On 6/21/17 at 2:20 P.M., resident #15 stated he/she wore oxygen, and was a smoker. He/she stated the facility allowed him/her to leave his/her wheelchair with the oxygen tank inside the dining room while he/she transferred to another wheelchair without a tank to go outside to smoke. Resident #15 stated resident #8 was dangerous and he/she observed resident #8 break dishes in the courtyard, light paper on fire in the ashtrays, and light his/her cigarettes inside the facility next to resident #15's oxygen tank. He/she stated administrative staff B was aware of the resident's behavior and would tell him/her not to do it anymore. On 6/21/17 at 2:40 P.M., resident #8 stated he/she only lit cigarettes inside the dining room prior to going outside when it was windy outside because there was no way to block the wind. He/she denied smoking inside his/her room, bathroom, or other common areas. When resident #8 returned from the hospital last month, he/she was told he/she could smoke outside by him/herself but had to check all smoking materials in and out with the staff. Resident #8 stated his/her smoking materials were in his/her pocket because there were not any staff present at the medication cart (which contradicted by the observation documented above). He/she further denied breaking dishes in the courtyard or lighting paper or sugar packets on fire. On 6/21/17 at 4:10 P.M., administrative staff A and administrative nursing staff D stated on 6/7/17, resident #8 spoke to them about not having his/her smoking materials. Administrative staff A stated they did not know his/her history and told the resident they would have a nurse complete a smoking assessment to ensure he/she was safe to have smoking materials. Administrative staff A and administrative nursing staff D stated they were unaware of the extent of the resident's non-compliance with the smoking policy and confirmed the smoking assessment completed on 6/7/17 by the agency nurse was inaccurate. Administrative nursing staff D stated smoking evaluations should be completed outside while the resident was smoking to ensure the assessment was thorough. On 6/22/17 at 7:45 A.M., licensed nursing staff N stated he/she participated in the daily morning meetings when staff reviewed resident #8's non-compliance with smoking procedures since January 2017. Licensed nursing staff N stated he/she had witnessed the resident light his/her cigarettes inside the building. He/she stated administrative staff B and administrative nursing staff E had never enforced the smoking policy with this resident. On 6/22/17 at 9:50 A.M., licensed nursing staff M stated he/she had observed the resident light cigarettes inside the building and had concerns about the proximity of the oxygen tank in the dining room. He/she stated other residents reported they were afraid of resident #8 when they were outside smoking because he/she broke dishes and set paper products on fire in the ashtray. On 6/29/17 at 2:57 P.M., consultant physician JJ stated he/she was aware of the resident's non-compliance with the facility's smoking policy, he/she had observed the resident smoke in his/her room, and the family continued to provide the resident with smoking materials despite having a smoking plan in place. Review of the Resident Smoking Policy dated 3/9/16 documented smoking times were established for those residents who smoke and there might be times when staff could not supervise due to work. Residents were not permitted to smoke unattended at any time and must be supervised by a staff member. All residents must be assessed for the ability to smoke, able to use their hands and fingers, and may be assessed to wear a smoking apron. Residents who smoke were not permitted to have any smoking materials, including lighters, on their person. All resident were asked to dispose of their used cigarettes in the proper container in the courtyard. Any violation of these policies would result in a 30-day discharge notice. The facility failed to monitor the resident's unsafe smoking practices, which led to him/her lighting cigarettes in the dining area of the facility and smoking within 5 feet of an oxygen tank, which placed the residents in that unit of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 6/22/17 at 11:59 P.M., when it initiated the following: The facility collected all of resident #8's cigarettes, lighters, and smoking materials on 6/21/17, and locked them in a medication cart. The Director of Nursing (DON)/designee would complete a new smoking assessment on 6/21/17 to include the physical observation of resident #8 smoking in a designated smoking area, so a proper safety evaluation could be determined. Furthermore, notes from resident #8's chart related to smoking would be considered in this smoking evaluation. Should resident #8 be assessed to be unsafe to smoke without supervision, licensed nursing staff would be responsible to ensure all smoking materials were returned safely and locked back up immediately after his/her smoke breaks. This would be accomplished by staff lighting his/her cigarette for him/her and maintain smoking materials in their possession at all times. The DON/designee would update resident #8's care plan according to the smoking assessment results on 6/21/17. The nurse/designee would contact resident #8's family to inform them that they were to give any/all smoking material to the charge nurse if they brought it into the facility at any time. The DON/designee would provide written education to all nursing staff on 6/21/17 of this resident's safety plan related to smoking to ensure that this resident was able to smoke safely. The DON/designee would sweep the resident's room daily to ensure smoking items and materials were not in his/her room. The DON/designee would complete a smoking risk review on all residents who smoke by 6/22/17 and care plans would be immediately updated accordingly. The DON/designee would educate all staff on 6/22/17 about the facility smoking policy, supervised smoking expectations, and smoking assessments. The DON/designee would randomly audit resident #8's smoking practices to ensure safeguards were in place five times per week for four weeks. Any adverse findings would be immediately reported to the facility's administrator and then to the facility's Quality Assurance Committee. This deficient practice remained a scope and severity of D.

The facility identified a census of 85 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to provide an environment free from physical and sexual abuse from resident #4 from 3/14/17 until 4/6/17. Resident #4 had a known history of sexual abuse prior to admission and placed his/her hands on the inside of resident #5's clothing and touched his/her chest and abdomen. This deficient practice placed resident #5 in immediate jeopardy. The facility failed to provide an environment free from physical abuse from resident #5 from 3/4/17 until 6/10/17. Resident #5 slapped resident #10 in the face, punched resident #9 in the chest, leaving a bruise, and pushed resident #7, causing a head injury that required staples to approximate the wound. Staff also documented resident #5 was physically abusive toward other residents on at least two other documented occasions. These deficient practices placed residents #10, #9, and #7 in immediate jeopardy. The facility failed to provide an environment free from sexual and verbal abuse from resident #6 from 6/10/17 through 6/18/17. Resident #6 sexually and verbally abused resident #12 on 6/10/17 and resident #13 on 6/11/17. These deficient practices placed residents #12 and #13 in immediate jeopardy. Findings included: - The clinical record documented resident #4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. activities), and dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion with psychological symptoms and behavioral abnormalities such as depression, anxiety, [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality)), and agitation (a stated of anxiety or nervous excitement), aggression, disinhibition, and sleep disturbances. The admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 7, which indicated severely impaired cognition. The resident had physical behavioral symptoms directed toward others, which occurred daily and put others at significant risk of physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. The assessment also revealed the resident had wandering behavior that occurred 1 to 3 days of the look back period and used a wheelchair for mobility. The Care Area Assessment (CAA) dated 3/20/17 for Cognitive Loss and Dementia documented the resident had behaviors, which included sexually inappropriate touching. The CAA dated 3/20/17 for Behavioral Symptoms documented the resident had a history of [REDACTED]. The care plan dated 3/14/17 documented the resident had a history of [REDACTED]. A revision on 3/15/17 documented the resident started on a medication to decrease the urge for sexual contact and placed him/her on 15-minute checks by staff. A revision on 3/20/17 documented staff was to transfer the resident from his/her wheelchair to a stationary chair in the dining room during meals to decrease the resident's access to other residents and decrease the occurrence of sexually inappropriate behaviors. A progress note dated 3/14/17 at 11:35 A.M. by licensed nursing staff G documented the resident admitted to the secured unit and had a history of [REDACTED]. He/she required one-on-one staff observation at his/her previous facility. A progress note dated 3/15/17 at 7:41 P.M. by licensed nursing staff H documented staff observed the resident trying to touch the chest and thighs of residents of the opposite gender in a sexually inappropriate manner. The staff attempted to separate the resident from other residents but the intervention was ineffective because the resident was able to propel his/her wheelchair around the unit. A progress note dated 3/15/17 at 10:19 A.M. by licensed nursing staff G documented staff placed the resident on 15-minute safety checks for sexually inappropriate and aggressive behaviors. After breakfast, the resident attempted to touch the inner thigh and leg of an unidentified resident of the opposite gender while in the dining room. At 10:15 A.M., the resident sat with resident #5, touching his/her back and holding his/her hands. At 10:38 A.M., a direct care staff reported he/she observed resident #4 touch resident #5's chest and abdomen under his/her clothing. Staff separated the residents and notified administrative nursing staff E and administrative nursing staff F of the incident. A progress note dated 3/16/17 at 1:59 P.M. by licensed nursing staff I documented staff placed the resident on one-on-one observation when outside his/her room until the spouse arrived at noon. The spouse informed staff he/she could only be at the facility on Tuesday, Thursday, and Saturday from approximately 1:00 P.M. until dinner. The nurse encouraged the spouse to arrive at the facility as early as he/she was able until the resident no longer displayed inappropriate sexual behavior. A progress note dated 3/16/17 at 2:43 P.M. documented staff discussed the resident's sexual inappropriateness toward the opposite gender with the spouse and he/she stated the resident had a history of [REDACTED]. A progress note dated 3/21/17 at 11:01 A.M. by administrative nursing staff F documented staff were to continue 15-minute checks, instructed to keep the resident away from residents of the opposite gender at all times, and to transfer the resident to a dining room chair during meals to reduce the risk of sexually inappropriate behaviors. A progress note dated 3/22/17 at 11:40 A.M. by licensed nursing staff G documented staff separated the resident from residents of the opposite gender all morning. A progress note dated 3/23/17 at 2:15 P.M. by administrative nursing staff F documented staff moved the resident from the secured unit to another unit for a quieter environment and a decreased number of residents of the opposite gender (however, this did not eliminate the residents contact with opposite gender residents, it merely changed the residents he/she had contact with). A progress note dated 4/6/17 at 11:25 A.M. by licensed nursing staff J documented the resident discharged to a hospital per family request. Review of the clinical record lacked documentation of 15-minute checks and/or one-on-one staff observation sheets for all three shifts on 3/23/17, 3/24/17, and 3/25/17. Furthermore, the clinical record lacked evidence of documentation of 15-minute checks and/or one-on-one observation sheets for 3/30/17 through 4/6/17. On 6/20/17 at 6:40 A.M., licensed nursing staff H stated the resident exhibited sexually inappropriate behaviors toward residents of the opposite gender and constantly touched the chests and legs of other residents. Licensed nursing staff H stated the resident was difficult to redirect and the 15-minute checks were not effective to keep the other residents safe. On 6/20/17 at 1:00 P.M., licensed nursing staff G stated when the resident admitted to the secured unit, he/she was told in nursing report the resident exhibited inappropriate sexual behaviors, required one-on-one staff observation, and the resident's clinical record documented the resident required a same-gender unit (which the facility was unable to provide). Licensed nursing staff G stated he/she and licensed nursing staff I reported their concern for keeping the other residents safe to administrative nursing staff E and F and were told to keep the resident on 15-minute checks. On 6/20/17 at 1:32 P.M., licensed nursing staff I stated when he/she received report during the resident's admission, staff from another facility reported the resident required one-on-one staff observation for sexually inappropriate behaviors that targeted residents of the opposite gender and the admission paperwork documented the resident was recommended for a same-gender unit. Licensed nursing staff I stated there was no way to complete 15-minute checks on the resident because he/she was able to self-propel the wheelchair and could have been anywhere. He/she stated the 15-minute checks were not effective and he/she had a concern that the intervention placed by administration to transfer the resident to a stationary chair during meal times was a restraint. Licensed nursing staff I stated administrative nursing staff E and F made the decision to move the resident from the secured unit to an unsecured unit because the opposite gender residents on the unsecured unit were alert, oriented, and could verbalize if abuse occurred, unlike those on the secured unit. On 6/20/17 at 2:00 P.M., consultant physician KK stated he/she had some input regarding the decision to move the resident from the secured unit. He/she stated administrative staff felt the resident would do better on the unsecured unit because there was less stimuli. On 6/22/17 at 6:00 P.M., administrative staff A and administrative nursing staff D stated they were not familiar with the resident. Review of the undated facility provided Abuse and Neglect policy documented all alleged violations would be reported to the administrator immediately. If the perpetrator was another resident, the residents would be separated so they did not have access to each other until the circumstances of the alleged could be determined. In the event that the resident required one-on-one monitoring, the staffing coordinator would find staff to provide the one-on-one monitoring. The facility failed to provide an environment free from sexual abuse from resident #4. This deficient practice placed resident #5 in immediate jeopardy. The facility abated the immediate jeopardy on 6/22/17 at 11:59 P.M. by documenting the resident was discharged on [DATE] and the administrator would review admission of the resident to the facility should a referral be made in the future. The Director of Nursing (DON) and/or Interdisciplinary Team (IDT) would implement a behavior plan upon admission for anyone admitting with a known history of behaviors, which would include reasonable identification of the behaviors, interventions to reduce them, and goals for reducing the monitoring if possible. The DON/designee would ensure immediate and appropriate interventions and safeguards were in place should a resident exhibit any abusive behavior toward another resident and if an incident occurred when the DON was not in the building. The IDT would evaluate the incident the next day to develop and implement a comprehensive behavior monitoring plan, which would include reasonable identification of the cause of behaviors, interventions to reduce them, and goals for the titration of monitoring if possible. The DON/designee would educate all staff about the Abuse, Neglect policy beginning 6/22/17. The DON/designee would educate staff on 6/22/17 about timely and appropriate reporting procedures and immediate interventions, in the event a resident exhibited behaviors toward another resident. The Administrator/designee would audit two new admissions per week x 4 weeks to monitor the effectiveness of the behavior plan and report findings to the facility's Quality Assurance Committee. The deficient practice remained a scope and severity of H. - The clinical record documented resident #5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status score of 1, which indicated severely impaired cognition. He/she had physical behavioral symptoms directed toward others 4 to 6 days of the assessment period, wandering that occurred daily, and used no mobility devices for locomotion. The quarterly MDS dated [DATE] documented the resident had a BIMS score of 0, which indicated severely impaired cognition. He/she had behavioral symptoms 1 to 3 days of the assessment period and used no mobility devices for locomotion. The Care Area Assessment (CAA) for Activities of Daily Living (ADLs) dated 2/14/17 documented the resident resided on the secured unit, ambulated independently, was combative at times, and difficult to redirect. The CAA for Cognitive Loss and Dementia and Behavioral Symptoms dated 2/14/17 directed staff to refer to social service notes. The care plan dated 2/16/17 documented the resident had dementia and directed staff to involve the resident in appropriate groups to promote enhanced orientation and meaningful interaction. An intervention dated 3/27/17 documented as of 3/15/17 to keep the resident at least an arm's length from residents of the opposite gender and for staff to place the resident on 15-minute safety checks. The care plan dated 6/9/17 documented the resident had aggressive behaviors related to his/her dementia and indicated the resident hit another resident on 6/9/17 and pushed a resident on 6/10/17. An intervention dated 6/9/17 directed staff to redirect the resident during times of agitation to prevent his/her behavior from escalating and to frequently check and monitor the resident for behaviors of aggression or agitation. An intervention dated 6/12/17 documented the facility sent the resident to the hospital on [DATE] for evaluation and treatment of [REDACTED]. A progress note dated 3/4/17 at 12:06 P.M. by licensed nursing staff G documented at 11:45 A.M., the resident ambulated in the hallway and an unidentified resident stated resident #5 hit him/her on the right side of his/her lower back. Licensed nursing staff G reported the incident to administrative nursing staff F. A progress note dated 4/11/17 at 2:01 P.M. by licensed nursing staff G documented an activity staff observed resident #5 hit an unidentified resident who sat in a wheelchair in the hallway. A progress note dated 5/28/17 at 11:45 A.M. by licensed nursing staff G documented resident #5 hit resident #9 in the chest as he/she walked in the hallway. A progress noted dated 6/9/17 at 1:58 P.M. by licensed nursing staff G documented the resident slapped resident #10 in the face during lunch. A progress note dated 6/10/17 at 2:26 P.M. by licensed nursing staff G documented the resident pushed resident #7 in the hallway. A piece of resident #7's scalp was adhered to the wall, he/she was sent to the hospital for treatment, and required staples to approximate (pull together) his/her head injury. Review of resident #7's clinical record revealed a hospital emergency room report dated 6/10/17, which documented resident #7 received staples to approximate the scalp laceration. A progress note dated 6/10/17 at 5:22 P.M. by administrative nursing staff D documented resident #5 was sent to the hospital for treatment of [REDACTED]. Review of the clinical record from 3/4/17 through 6/10/17 lacked evidence of documentation of 15-minute checks or one-on-one staff observation sheets for 3/4/17, 3/9/17 through 4/14/17, and 4/19/17 through 6/10/17. The clinical record lacked evidence of monitoring for all three shifts on 3/5/17, 3/6/17, 3/8/17, 4/17/17, and 4/18/17. On 6/20/17 at 6:35 A.M., direct care staff O stated the resident had confusion, agitation, and was combative toward other residents. Direct care staff O stated administration instructed staff to monitor the resident every 15-minutes and stated all staff on the secured unit took turns watching the resident to ensure he/she did not have physical aggression directed toward other residents. Direct care staff O stated the 15-minute checks should be documented on a paper form that staff signed when completing the check, turned in to the nurse, and placed in the clinical record. On 6/20/17 at 6:45 A.M., licensed nursing staff H stated the resident's aggression occurred mostly on day and evening shifts and the resident should have been placed on one-on-one monitoring or 15-minute checks, but stated the unit was too busy to have a staff member assigned for a one-to-one observation. Licensed nursing staff H stated the documentation of the one-on-one observation and the 15-minute checks should be documented by staff on specific paper documentation sheets. On 6/20/17 at 7:15 A.M., resident # 11 stated he/she observed resident #5 push resident #7 in the hallway and it made him/her scared of resident #5 because resident #7 was crying and bleeding from his/her head. On 6/20/17 at 7:25 A.M., licensed nursing staff G stated the resident was extremely confused and when staff attempted to redirect his/her behaviors, he/she became more confused and combative. Licensed nursing staff G stated resident #5's incidents of physical abuse were unprovoked and he/she was on 15-minute checks every day. Licensed nursing staff G stated the incidents happened so quickly and there were so many of them that the 15-minute checks were not effective. Licensed nursing staff G stated resident #9 verbalized he/she was afraid of resident #5. On 6/20/17 at 7:50 A.M., resident #9 stated resident #5 was very dangerous because he/she hit and pushed other residents. Resident #9 stated resident #5 hit him/her with a closed fist in the right chest area, which hurt and caused a bruise. He/she stated resident #5 terrorized other residents but most of the residents could not verbalize their fear, so they hurried past resident #5 in the hallway or turned around to avoid him/her. On 6/20/17 at 10:15 A.M., social services staff K stated the resident was very ill with his/her psychiatric [DIAGNOSES REDACTED]. Social services staff K stated if the staff kept the resident occupied with activities, the behaviors would decrease. On 6/20/17 at 10:55 A.M., administrative nursing staff D stated he/she was not familiar with any incidents of physical abuse from resident #5 prior to 6/7/17. Administrative nursing staff D stated all allegations and incidents of physical abuse should be reported to the state agency and investigated. Administrative nursing staff D stated he/she was not present in the building on 6/10/17, but was immediately notified by staff when resident #5 pushed resident #7. He/she stated the staff immediately separated the residents, provided first aide, notified the physician and responsible parties, transported resident #7 to the hospital for evaluation and treatment, and placed resident #5 on one-on-one staff observation until he/she was transported to the psychiatric hospital for evaluation and treatment. Administrative nursing staff D confirmed that when resident #5 pushed resident #7, a portion of resident #7's scalp adhered to the wall and he/she required staples to approximate the head injury. On 6/20/17 at 2:00 P.M., consultant physician KK stated resident #5 was acutely ill with psychiatric issues and was sent to the hospital for treatment. Consultant physician KK did not respond when asked if he/she was aware of incidents of physical aggression that started on 3/4/17. He/she stated placing the resident on 15-minute checks was an effective measure until staff could determine the cause of the behaviors. On 6/21/17 at 9:00 A.M., direct care staff P stated staff did not monitor the resident's behaviors every 15-minutes because he/she would follow staff up and down the hallway, so staff were always nearby. Direct care staff P stated the resident would slap, hit, or punch whomever he/she came in contact with in the hallway or dining room. On 6/21/17 at 9:30 A.M., direct care staff Q stated he/she observed the resident hit other residents on several occasions. He/she stated the 15-minute checks were not effective to manage or prevent resident #5's behaviors. Review of the undated facility provided Abuse and Neglect policy documented all alleged violations were reported to the administrator immediately. If the perpetrator was another resident, the residents were separated so they did not have access to each other until the circumstances of the allegation could be determined. In the event that the resident required one-on-one monitoring, the staffing coordinator would find staff to provide the one-on-one monitoring. The facility failed to provide an environment free from physical abuse from resident #5. This deficient practice placed residents #10, #9, and #7 in immediate jeopardy. The facility abated the immediate jeopardy on 6/22/17 at 11:59 P.M. by transferring the resident to a behavioral treatment hospital on [DATE] immediately following the incident of physical aggression on that day. The resident had not returned to the facility. The Social Worker/designee would continue to seek other more sustainable placement for the resident. The family was agreeable to considering another facility and was looking at different placement at this time. Should the resident re-admit to the facility, he/she would immediately be placed on one-on-one supervision until a behavior plan could be established by the Interdisciplinary Team (IDT). This plan will include identification of causes and behaviors, interventions to reduce them, and goals for titration and reduction in monitoring if possible. The Director of Nursing (DON)/designee would ensure immediate and appropriate interventions and safeguards were in place should a resident exhibit any abusive behavior toward another resident should the incident occur when the DON was not in the building. The IDT would evaluate the incident the next day to develop and implement a comprehensive behavior monitoring plan, which would include reasonable identification of the cause of the behaviors, interventions to reduce them, and goals for titration of monitoring if possible. The DON/designee educated all staff about the Abuse, Neglect policy beginning 6/22/17. The DON/designee educated staff on 6/22/17 about timely and appropriate reporting procedures and immediate interventions, in the event a resident becomes aggressive with another resident. The DON/designee would audit interventions for three residents with care-planned behaviors 1 x weekly for 4 weeks to ensure interventions were appropriate and effective and report findings to the facility's Quality Assurance Committee. The deficient practice remained a scope and severity of H. - The clinical record documented resident #6 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident had physical behavioral symptoms directed toward others that occurred 1 to 3 days of the assessment period, which significantly intruded on the privacy of others. The resident required supervision for locomotion on and off the unit and used a wheelchair for mobility. The 14-Day MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required supervision for locomotion on and off the unit and used a wheelchair for mobility. The Care Area Assessment for Behavioral Symptoms dated 5/30/17 documented the resident had a history of [REDACTED]. Nursing staff expressed the resident showed symptoms of forgetfulness with increased sexual behaviors in the evening. The care plan dated 5/23/17 documented the resident had impaired cognition (which differs from the documentation in the MDS) and directed staff to provide redirection if he/she exhibited inappropriate physical, verbal, or sexual behaviors. An intervention dated 6/11/17 documented for staff to monitor and document any changes in mood or behavior and to notify the physician. The care plan dated 5/26/17 documented the resident had a history of [REDACTED]. The following interventions were placed on the care plan on 6/11/17: the resident was sent to the hospital for evaluation and treatment of [REDACTED]. administrator when the resident exhibited physical and verbal behaviors, staff were to provide one-on-one caregivers, and staff were to provide 15-minute checks when he/she was not on one-on-one observation with staff. Review of the staffing schedule on 6/11/17 documented the facility assigned direct care staff R to provide one-on-one observation for the resident upon his/her return from the hospital. Direct care staff R's assignment also included care for the five residents who resided in the Assisted Living (AL) Facility (making it impossible to provide 1:1 supervision for resident #6 when any of the five AL residents needed assistance from direct care staff R). Review of the staffing schedule from 6/12/17 through 6/18/17 lacked documentation of staff assigned to provide one-on-one supervision with resident #6 for all three shifts on 6/14/17, 6/15/17, 6/16/17, 6/17/17, and 6/18/17. Review of the One-on-One Observation sheets lacked evidence of documentation from 7:00 A.M. through 2:30 P.M. on 6/14/17 and 6/15/17. The clinical record lacked evidence of documentation of One-on-One Observation sheets for 6/11/17, 6/12/17, 6/13/17, 6/17/17, and 6/18/17. Review of the clinical record from 6/11/17 through 6/18/17 lacked evidence of documentation of 15-minute checks. A progress note dated 6/11/17 at 11:09 A.M. by licensed nursing staff L documented staff reported the resident exhibited inappropriate behaviors and touching of residents #12 and #13. Staff notified the physician and obtained an order for [REDACTED]. A progress note dated 6/11/17 at 12:16 P.M. by licensed nursing staff M documented that resident #12 reported to him/her that when going to breakfast on 6/10/17, resident #6 placed his/her hand underneath resident #12's clothing and made a derogatory comment regarding resident #12's genitalia. Today, staff S observed resident #6 trying to touch resident #13's genitalia. A progress note dated 6/11/17 at 11:32 P.M. documented the resident returned from the hospital and was placed in the Assisted Living Facility (ALF) for one-on-one observation until it was time for him/her to sleep. Review of progress notes dated 6/13/17, 6/14/17, 6/15/17, and 6/18/17 documented the resident was on one-on-one staff observation due to inappropriate sexual behaviors. A physician progress notes [REDACTED]. Resident #6 adamantly denied contact and was recently ill with a urinary tract infection, so it was possible he/she was unaware of where he/she placed his/her hands or he/she never had contact with another resident. A progress note dated 6/18/17 at 5:49 P.M. by licensed nursing staff J documented the facility discharged the resident home at 4:00 P.M A notarized witness statement dated 6/15/17 by direct care staff S documented on 6/11/17 at approximately 8:30 A.M., he/she was pushing residents in wheelchairs when he/she heard resident #13 tell resident #6 his/her behavior was not appropriate and to stop touching him/her. Direct care staff S turned around and observed resident #13 pushing resident #6's hand off his/her leg. He/she immediately separated the residents and reported the incident to the nurse. A notarized witness statement dated 6/16/17 by licensed nursing staff M documented on 6/11/17, resident #12 reported that on the morning of 6/10/17, resident #6 reached inside resident #12's clothing and made a derogatory comment regarding his/her genitalia. At that time, direct care staff S reported he/she just observed resident #6 grab resident #13's genitalia. The manager on duty, physicians, and families for all residents were notified of the incidents and staff obtained an order to send the resident to the hospital for treatment. A notarized witness statement dated 6/16/17 by administrative nursing staff D documented on 6/7/17, he/she and administrative staff A were informed about resident #6's sexual behaviors directed only toward staff. On 6/11/17, he/she was notified by the manager on duty that resident #6 placed his/her hand inside resident #12's clothing and attempted to touch resident #13's pelvic area but was stopped by staff before making contact with resident #13's genitalia. Staff placed him/her on one-on-one observation when out of his/her room and on 15-minute checks when in his/her room. On 6/15/17 at 9:10 A.M., administrative staff A stated staff immediately placed resident #6 on one-on-one observation and sent the resident to the hospital for evaluation and treatment. When the resident returned to the facility, he/she remained on one-on-one observation. Administrative staff A stated the resident admitted to the police that he/she had touched the other resident's clothing and he/she would not do that again. On 6/15/17 at 10:40 A.M., resident #12 stated on 6/10/17, resident #6 lifted up his/her clothing and made a derogatory comment regarding his/her genitalia. Resident #12 stated he/she was afraid of resident #6 and the incident really bothered him/her because he/she had been raped twice in his/her past. On 6/15/17 at 11:03 A.M., resident #13 stated resident #6 was a pain and not a good friend. He/she denied allegations that he/she had been touched by resident #6. On 6/19/17 at 10:10 A.M., resident #12 reiterated that on 6/10/17, resident #6 stuck his/her hand inside resident #12's clothing and made a derogatory comment regarding resident #12's genitalia. Resident #12 stated he/she was upset because he/she had been raped twice in his/her past, was very uncomfortable around resident #6, and did not want him/her to touch him/her again. Resident #12 stated he/she did not tell staff about the incident until 6/11/17 because when he/she previously discussed concerns with the social worker, the social worker told resident #12 that he/she had a behavior problem. On 6/19/17 at 12:48 P.M., administrative nursing staff D confirmed the clinical record lacked documentation of one-on-one observation sheets for all shifts 6/11/17 through 6/18/17. He/she stated the 15-minute checks were never implemented because the resident went out to the hospital and staff monitored him/her one-on-one until he/she di(TRUNCATED)

The facility reported a census of 87 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to protect residents from abuse when staff failed to report an allegation of sexual abuse to administrative facility staff. Resident #1 reported to the local police he/she was inappropriately touched by an (opposite gender) staff member on 4/15/2017. The police responded to the facility to investigate, and the staff members present failed to report the allegation to administrative facility staff. The staff member named in the allegation of abuse (licensed nursing staff J) continued working the remainder of his/her shift (approximately 8 hours after the allegation). This deficient practice placed the 16 opposite gender residents of this unit in immediate jeopardy. Findings included: - The physician's electronic record dated 3/31/17 listed Resident #1 [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] documented the resident had a Brief Interview for Mental Status score of 10 which indicated moderately impaired cognition, did not have signs or symptoms of [MEDICAL CONDITION], required extensive assist of one person for bed mobility, extensive assistance of 2+ persons for transfers, extensive assistance from 1 person for locomotion on and off the unit, limited assistance from one person for dressing, extensive assistance from 1 person for toilet use, personal hygiene. He/she had functional limitation in range of motion impairment on both lower extremities. The Care Area Assessment (CAA) dated 12/5/16 for ADLs (Activities of Daily Living) revealed the resident had alteration in self-care and required staff assistance with ADLs. He/she was alert and oriented with some confusion and able to make needs and requests known without difficulty. The Cognitive Loss/Dementia CAA dated 12/5/16 documented the staff would continue to monitor the resident for safety, physical and mental health issues. This included regular facility physician visits scheduled with each psychiatrist, doctor on a monthly basis and/or as needed. The Care Plan dated 10/18/16 revealed the resident had episodes of making negative/derogatory statements to staff and other residents during periods of agitation. He/she had become agitated with other residents who were in his/her way or who were not behaving as he/she felt was appropriate. He/she would swing and hit at staff when redirected. The nurse's note dated 4/15/17 at 3:15 P.M. documented the writer observed resident #1 go into the clean linen room and grab several blankets and sheets, at this time staff verbally redirected the resident. The writer told the resident that he/she was to ask a staff member for assistance if he/she needed something from the locked rooms. The resident yelled at this writer and stated oh (expletive) you, you (expletive) (expletive). He/she hit this writer several times. This writer told the resident that hitting at staff was unacceptable. The intervention was ineffective, the resident continued to hit this writer, cussing and yelling out loud. This writer told the resident there were 4 staff members at the nurse's station and he/she needed to ask a staff member for any supplies that he/she may need. The resident wheeled off in his/her wheelchair, cussing, and went to his/her room. The staff were to monitor his/her behaviors. The nurse's note dated 4/15/17 at 11:40 PM documented licensed nursing staff J went to the resident's room to give his/her HS (hour of sleep) medicine, the resident requested a pain pill for a bruise on his/her face, and licensed nursing staff J obtained a pain pill which he/she administered to the resident. The nurse noted the resident had urinated on the bed, this nurse asked him/her to step out of the bed so the bedding could be changed. The resident agreed and left the room to go outside to smoke. Later on that night the resident called the police and told them this nurse had touched him/her inappropriately, which this nurse didn't touch the resident. The police questioned this nurse, the resident, another resident, and the nurse on the 2nd floor before they left the building. The police did not leave a police report left in the building. Observation on 4/27/17 at 8:33 A.M. revealed the resident sat in bed and had a discoloration on his/her left cheek. When asked what happened he/she stated, I was sitting in my wheel chair watching TV and fell out and bumped my cheek. On 4/27/17 at 12:25 PM licensed nursing staff H stated he/she would immediately call the administrator and Director of Nursing (DON) if a resident said they had been abused by a staff member or another resident, and they would instruct him/her on what to do next. He/she had never had a resident tell him/her about any type of abuse they had suffered. He/she furthered stated resident #1 and resident #2 can have delusional thoughts and often exaggerate when telling stories, but neither had told staff H of any type of abuse. On 4/27/17 at 2:26 P.M. direct care staff P stated he/she worked the night that resident #1 called the police. Staff P saw 3 police officers come in and talk to different people. Staff P further stated he/she told one police officer he/she worked on another hall and didn't know or hear anything about the incident. Staff P knew the police talked to licensed nursing staff J but did not know what they discussed. On 4/27/17 at 3:45 P.M. licensed staff I stated he/she had worked the 3-11 P.M. shift on April 15, 2017. Resident #1's behaviors had escalated all day. Staff I noticed resident #1 in the linen closet, pulling out linen and tried to educate him/her that he/she needed to ask a staff member for help. Resident #1 hit staff I several times. Staff I stated License nursing staff J stepped in to help. Resident #1 cussed at licensed nurse I. Around 11:00 P.M. licensed nurse I came downstairs and heard resident #1 talking in the front lobby area. Resident #1 was on the phone and stated, Yes, the head nurse, sat on bed next to me and patted my back, and saying shhh, and there was inappropriate touching. A few minutes later the police arrived and questioned licensed nursing staff I and J. On 4/27/17 at 8:48 A.M. administrative nursing staff D denied any awareness of the police being in the building regarding resident #1 on the 4/15/17. Further interview with administrative staff D at 10:54 A.M. revealed he/she would have expected to be notified of the allegation of sexual abuse of staff toward the resident and as well as the administrator. Staff D stated the staff had been trained regarding reporting allegations of abuse and licensed staff J did not follow the facility policy. On 4/27/17 at 3:30 P.M. resident #1 stated he/she did not recall calling the police or making the allegation about the nurse touching him/her. The facility Abuse, Neglect and Exploitation policy dated 12/2015, documented residents will be free of physical, emotional, and sexual abuse, neglectful treatment and misappropriation of funds and resources. Any signs of abuse and neglect will be reported to the Administrator and/or DON immediately, if in their absence report to charge nurse and/or designee who will conduct the investigation. The facility failed to protect the opposite gender residents when licensed nursing staff J continued to work after resident #1 made an allegation of sexual abuse on 4/15/2017. The police responded to the facility to investigate, and the staff members present failed to report the allegation to administrative facility staff. This deficient practice placed the 16 opposite gender residents of this unit in immediate jeopardy. The facility abated the immediate jeopardy on 4/28/2017 at 7:41 A.M. by initiating the following: 1. Abuse education is conducted in orientation upon hire 2. Clinical management staff educated facility staff on abuse on 4/20/17, 4/21/17, and 4/27/17. 3. A consultant group provided an additional education session to staff on abuse reporting on 4/28/2017. 4. Abuse education will be on-going and quarterly, at a minimum. The education will be open to all staff. But not required. 5. Any staff member accused of an abuse allegation is suspended immediately. 6. Education also consists of company Standards of Behavior for staff. Staff are expected to conduct themselves in a professional manner and abide by the policies (which includes the Abuse, Neglect, and Exploitation Policy and Procedure). 7. A weekly audit is being conducted to ensure that residents are provided protective oversight and feel safe. The Administrator or designee will conduct audits to include that staff and residents are aware of the abuse reporting regulations. 8. Staff will not be allowed to work until education has been completed. 9. Agency staff are trained to be mandated reporters which includes abuse reporting before they are allowed to work at the agency and the facility. 10. The facility suspended the nurse that was alleged to have inappropriately touched the resident. 11. The resident involved has been interviewed and states that he/she feels safe in the building 12. The medical director has been notified of the allegation and investigation 13. Staff notified the state of the allegation on 4/27/ 4. Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QUAPI), overseen by the Administrator and the Medical Director. This deficient practice remained at a scope and severity of an E.

The facility identified a census of 91 residents. The sample included 24 residents. Based on observation, record review, and interview the facility failed to develop and implement timely and effective interventions to prevent accidents for 1 of 1 resident reviewed for falls. (#28) The resident fell and sustained a scalp laceration which required staples and treatment at the hospital. Findings included: - The August 2016 signed physician's orders [REDACTED].#28 listed [DIAGNOSES REDACTED].), macular degeneration (progressive deterioration of the retina), and history of falls and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The 11/20/15 quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required supervision with transfers, personal hygiene, toilet use and locomotion on and off the unit. The resident required one person limited assist with walking in the room and corridor and one person physical assist with bathing. The resident was not steady but able to stabilize with human assistance when moving from a seated to a standing position, while walking, while turning around and facing the opposite direction, and when moving on and off the toilet and with surface to surface transfers. The resident did not have range of motion limitations with upper or lower extremities, and used a walker and a wheelchair for ambulation. The Care Area Assessment (CAA) dated 11/20/2015 for vision function revealed the resident had impaired vision related to macular degeneration and he/she could see shapes and light and dark and staff needed to ensure his/her needs were met. The resident was able to navigate in the community but needed assistance to identify small items such as food on his/her plate. The CAA for communication revealed the resident had moderate hearing impairment and staff needed to face the resident and speak to him/her in a loud voice. The resident was alert, oriented and able to make his/her needs known to staff. The CAA for activities revealed the resident required limited assistance with walking and transfers and used a walker with one-person staff assistance. He/she had limited mobility and the primary method of mobility was the use of a wheelchair within the facility. The CAA for falls revealed the resident had no falls since the last MDS assessment. He/she had decreased safety awareness which increased his/her risk for falls. The 2/20/16 quarterly MDS recorded a BIMS of 6, which indicated severe cognitive impairment. The resident required supervision with transfers, person hygiene, toilet use and locomotion. The resident required supervision with walking and physical assistance of one staff for bathing. The resident exhibited unsteady balance and only able to stabilize with staff assistance. The resident had no range of motion limitations with upper or lower extremities, and used a walker and a wheelchair for ambulation. The 5/1/16 quarterly MDS recorded a BIMS of 5, indicating severe cognitive impairment. The resident required staff supervision with transfers, personal hygiene, and one person limited assistance with toileting and locomotion. The resident required extensive assistance with walking and bathing. The resident exhibited unsteady balance and only able to stabilize with staff assistance. The resident used a walker or a wheelchair for ambulation. The quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating severe cognitive impairment. The resident exhibited fluctuating inattention, disorganized thinking and trouble concentrating. The resident required supervision with transfers, locomotion, toileting, personal hygiene, and assistance of one staff for bathing and dressing. The resident was totally dependent on staff for ambulation. The resident exhibited unsteady balance and only able to stabilize with staff assistance. The resident did not have range of motion limitations with upper or lower extremities, and used a walker and a wheelchair for ambulation. The care plan initiated 11/22/10 and last reviewed 8/8/16 revealed the resident had self-care deficits as evidenced by needing assistance related to physical limitations and impairment. Staff assisted the resident with daily hygiene, grooming, dressing, oral care and eating. The resident had impaired vision as evidenced by his/her [DIAGNOSES REDACTED]. He/she was at risk for alterations in cognitive status due to his/her [DIAGNOSES REDACTED]. Resident #28 was a high risk for falls related to confusion, gait/balance deficits, incontinence, poor safety awareness and poor vision and hearing. Staff anticipated anticipate the resident's needs, kept the call light within reach, encouraged the resident use the call light, responded promptly to all requests for assistance, educated the resident about safety and what to do if he/she fell . Staff encouraged the resident to participate in activities that promote exercise and physical activity, followed the facility's fall protocol, reviewed information on past falls and attempted to determine the cause of this resident's falls, recorded possible root causes and educated the resident on the causes. Staff would educate the resident and encourage him/her to wear rubber soled shoes, non-skid socks, keep his/her environment safe with even floors, free from spills and or clutter, adequate glare-free light, a working reachable call light, bed in low position at night, side rails as ordered, handrails on walls and personal items within reach. On 4/5/16 a non-injury fall when the resident stood up from the wheelchair, attempted to make bed and fell to the floor. Staff implemented a one-way slide (seat cushion made of non-skid material which maintains good seated posture and prevents the individual from slipping back down). On 6/2/16 a non-injury fall occurred when the resident was transferring him/herself from the wheelchair to the bed after toileting and slipped out of the bed. The care plan lacked interventions that were directly related to that fall. On 7/25/16 noted the resident had a fall with a wrist fracture and scalp laceration. The resident woke with confusion and attempted to transfer from the bed to the wheelchair which was not locked and rolled. The resident fell and hit his/her head on the bedside dresser and landed on the floor. Interventions included one-way slide to wheelchair, staff to assist resident with bed making, brake extenders placed on wheelchair with bright colored knobs for visual reminder, and continue interventions on the at-risk plan. Provide reminders to the resident upon waking and going to bed to lock the brakes on his/her wheelchair. Physical therapy would provide consult for strength and mobility. The resident refused anti-roll back brakes. Review of the Occupational Therapy report dated 4/18/16 to 6/17/16 documented the resident could stand up and had numerous falls during this task. The resident wanted to be able to continue to make his/her bed at his/her highest level of independence. Instruction: facilitation of functional reaching/bending during activities of daily living (ADL) techniques to increase safety for ADL in sitting, techniques to increase safety for ADL in standing, safety training during transitional movements, safety training during functional mobility for ADL, training in safety procedures during task performance, instruction in hygiene/grooming techniques, toileting/ clothing management techniques, wheelchair seating and positioning and safe transfer techniques. Nursing note dated 12/16/15 at 7:20 A.M. revealed staff found the resident kneeling next to his/her bed. Nursing note dated 12/16/15 documented staff continued to encourage the resident to use the call light and ask for help with transfers. Nursing note dated 4/5/16 at 9:25 A.M. recorded staff found the resident sitting on the floor beside his/her bed. He/she had attempted to get up on his/her own. The resident stated he/she was making his/her bed and went to sit down in his/her wheelchair, sat on the edge of the wheelchair seat and slid to the floor. Staff updated the care plan with a new intervention of a one-way slide. Nursing note dated 4/19/16 revealed staff placed a one-way slide in the resident's wheelchair to prevent the resident from sliding off the seat, educated the resident and he/she agreed to use the device. Nursing note dated 6/2/16 at 2:20 A.M. recorded staff responded to the resident's call light and found the resident sitting on the floor next to his/her bed. The resident stated he/she slipped from his/her bed. The facility failed to complete a root cause analysis to determine the cause of the fall and implement appropriate interventions to prevent future falls. Nursing note dated 7/25/16 approximately 3:00 A.M. staff responded to the resident's call light found the resident sitting on the floor between his/her bed and the recliner bleeding from his/her head and nose. The resident stated his/her alarm went off so he/she thought it was time to get up so he/she got dressed and tried to transfer his/herself to his/her wheelchair. He/she got dizzy when he/she stood up, tried to hold on to his/her wheelchair but the brakes were not locked so it rolled and he/she hit his/her head on the dresser. He/she crawled over to recliner and pressed the call light. Staff noted a deep laceration to the resident's head and scrape to the nasal. Staff placed a call to the physician who ordered to send the resident to the hospital. Nursing note dated 7/26/16 recorded the resident returned from the hospital with 4 staples in his/her scalp, alert to person, confused, disoriented, bruise to the back of the right hand and left kneecap, and a skin tear to the left shin, and bridge of the nose. Nursing note dated 7/26/16 recorded staff padded the edge of the dresser for protection. Nursing note dated 7/26/16 recorded the resident had confusion and thought he/she was still at the hospital. The resident was found self-propelling self out of front door before dinner and after dinner was found up and down the hallway and in other resident's rooms. Review of the facility fall investigation report noted the resident had a non-observed fall without injury on 12/16/15 at 7:20 A.M. The staff found the resident kneeling next to his/her bed and assisted him/her on to his/her bed. The resident stated he/she was making his/her bed when his/her feet slipped out from under him/her. He/she stated the floor was too slippery. The facility investigated and reported that the floor was dry and there was adequate lighting in the room. The report indicated staff would encourage the resident to ask for assistance when he/she wanted to make the bed. The report confirmed resident had hearing and vision impairment. Review of the facility's fall investigation report noted the resident had a non-observed fall without injury on 4/5/16 at 9:35 A.M. The staff found the resident sitting on his/her buttocks with his/her legs in front of him/her and bent and the knees. The resident stated he/she stood from his/her wheelchair and was making the bed. When he/she went to sit back down in the wheelchair he/she fell to the floor. The report indicated staff would initiate a one-way slide for his/her wheelchair to prevent the resident from sliding out of the wheelchair even if he/she sat on the front edge of the wheelchair seat. Review of the facility's fall investigation report noted the resident had a non-observed fall with a fracture to the left wrist and lacerations to the face and scalp on 7/25/16. The report documented staff found the resident on the floor of his/her room between the bed, the recliner, and the wheelchair. The resident used the call light to get assistance from staff. Licensed nursing staff performed a head-to-toe assessment noting a laceration to the resident's scalp and his/her nose was bleeding. The resident's physician gave orders to take the resident to the hospital for evaluation. The report noted staff updated the resident's care plan indicating the facility would place brake extenders on the resident's wheelchair with bright colored tape on the brake handles for visual reminders, and staff would encourage the resident to use his/her call light, reminders to lock the brakes to the wheelchair upon rising from bed in the morning and before going to bed at night and to orient the resident to the bright colored brake extenders. Review of the electronic skin assessment record dated 7/26/16 revealed the resident had a laceration on the resident's scalp, secured with 4 staples. During an observation on 8/18/16 at approximately 1:30 P.M. the resident self-propelled in his/her wheelchair with a brace on his/her left wrist and discoloration to the right cheekbone. During an observation on 8/22/16 at 8:45 A.M. the resident sat upright in his/her wheelchair and wore a brace on his/her left wrist. The wheelchair did not have a one-way slide on the wheelchair. During an observation on 8/22/16 at 9:55 A.M. the resident did not have a one way slide in place on the seat of his/her wheelchair. The resident self-propelled over to his/her bed and started to stand up and then sat back down in the wheelchair. The resident then self- propelled him/herself over to the wall between the dresser and the doorway with the back side of the wheelchair against the wall. The resident secured the brake after having difficulty finding the break; using touch to locate the brake and moving the coffee cup holder that was blocking the brake to the side. The resident then self-propelled him/herself to the side of the bed and attempted to get up out of the wheelchair to transfer him/herself to the bed. The bed moved when the resident sat on the bed. He/she did not use his/her call light. The resident was approximately 12 inches away from the bed during the attempt. The bed was not in the lowest position. During an observation on 8/22/16 at 3:27 P.M. maintenance staff member U inspected the resident's bed and confirmed that the bed was too high because the wheels on the bed where engaged and allowed the bed to move. An observation on 8/23/16 at 10:49 A.M. revealed black protective corner pads were on 3 of 4 dresser corners. Maintenance staff member U confirmed that the front corners of both dressers should be covered with the corner protectors which had adhesive tape on the back. Three corner protectors were found in the resident's room and not affixed to any dresser corners. The protective pads were not included on the resident's care plan. During an interview on 8/22/16 at 9:55:06 AM resident #28 stated that he/she knew he/she was supposed to use his/her call light but he/she did not like to wait so he/she ended up doing for him/herself. She stated that the wheelchair brake did not hold the wheelchair enough. The resident stated that the bed was not supposed to move and that the coffee mug holder should not move so much. During an interview on 8/18/16 at 4:10 P.M. direct care staff S stated that although staff remind him/her to use his/her call light he/she still tried to do things him/herself sometimes. He/she reported that the resident had poor vision and needed to be assisted especially when getting out of bed. During an interview on 08/22/16 at 9:30:41 A.M. direct care staff T stated that the resident had some falls and believed most of them occurred during the night. He/she stated that staff encouraged the resident to use his/her call light. During an interview on 8/22/16 at 9:55 A.M. direct care staff R confirmed that the resident's bed should not move and that he/she would notify the maintenance director that the bed needed to be adjusted. He/she would also notify him/her to tighten the screws to the drink holder so that it did not move and prevent the brake from being fully engaged. During an interview on 8/16/16 at 3:05 P.M. licensed staff member F confirmed the resident fell in his/her room on 7/25/16 which resulted in a major injury requiring the resident to go to the hospital. During an interview on 8/18/16 at 1:45 P.M. licensed staff member F reported he/she did not know the exact root cause of resident #28 falls and confirmed the resident was a high fall risk. He/she reported that the resident still tried to get out of bed on his/her own at times but that staff continued to encouraged him/her to use his/her call light when he/she needed assistance. He/she reported that the resident understood why he/she should use his/her call light and had used it more recently. During an interview on 8/23/16 at 11:27 A.M. licensed staff member F stated the resident did not need a one-way slide because that was not the source of his/her falls. During an interview on 8/23/16 at 10:51 A.M. maintenance staff member U stated that all four corners (two front corners of two dressers) that were closest to the resident should be covered and that only three were covered at that time. During an interview on 8/25/16 at 1:45 P.M. administrative nursing staff D revealed the expectation for staff when identifying appropriate interventions for any resident, including a cognitively impaired resident with vision impairment, would be to identify and implement interventions that were directly related to specific reason contributing to the fall and that these interventions should be put into place within 24 hours of a resident's fall. All falls should be immediately reported to the Director of Nursing (DON) and collaboration would take place with team members comprised of the MDS coordinator, social services, the restorative aid, activities and therapy and to pass interventions along to the nurse and the aides working with the resident. The administrative staff D verified that relying on a cognitively impaired resident with vision impairment to use his/her call light was not an appropriate intervention. Administrative staff D was unable to confirm the resident used a one-way slide for his/her wheelchair but confirmed this intervention was implemented after the resident fell when attempting to stand up from the wheelchair and slid out. Administrative staff D stated this intervention was not necessary on the resident's care plan at this time and that if it was still listed as an intervention, it should be removed. During an interview on 8/22/16 at 8:49 A.M. consultant GG stated the resident was a high fall risk and that the resident was last seen on 7/11/16. He/she believed after record review and the short time he/she has had to familiarizing his/herself with this resident, the root cause of the resident's falls was mostly attributable to his/her impulsivity, although he/she had weakness and balance deficit. He/she stated that because of the resident's insurance situation he/she can only evaluate the resident through interview and not physical screening. The Accidents and Incidents -Investigating and Reporting policy provided by the facility and revised December 2011 directed all accidents or incidents involving residents occurring on the premises shall be investigated and reported to the Administrator. The facility will be in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. The Falls and Fall Risk Management policy provided by the facility and revised December 2007 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The Fall Risk Assessment policy provided by the facility and revised December 2007 directed the nursing staff, in conjunction with the Attending Physician, Consultant, Pharmacist, therapy staff, and others, would seek to identify and document resident risk factors for falls. The facility failed to develop and implement timely and effective interventions to prevent falls for this cognitively impaired resident who had multiple falls and fell and sustained a head laceration which required staples.

The facility's census totaled 141 residents with 11 residents sampled. Based on observation, record review and interviews, the facility failed to provide interventions to treat and prevent weight loss for 2 of 3 residents (#7 and #8) sampled with a history of weight loss. Findings included: - Resident #7's Physician order [REDACTED]. The annual Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident Brief Interview for Mental Status (BIMS) scored 3 which indicated the resident with severe cognitive impairment. The MDS documented the resident weighed 141 pounds, had no weight loss or gain, and required supervision with eating. The nutritional Care Area assessment dated [DATE] documented the resident was overweight, but age appropriate. The registered dietician had no nutritional concerns at this time. The quarterly MDS dated [DATE] did not the assess the resident's cognitive status, documented the resident required limited assistance of 1 staff member with eating, the resident had no swallowing disorder or dental problems, weighed 113 pounds, with a weight loss, not on a prescribed weight loss program, and received a therapeutic diet. The initial care plan related to nutrition was dated 2/1/13 and revised on 6/3/14 related to nutrition documented the resident with inadequate oral food and beverage intake related to general functional decline as evidenced by a weight loss history of 30 pounds in the past 90 days (equal to 18 percent (%). The interventions included: a liberalized regular diet, chocolate milk with all meals, Ensure Plus (supplement) every day between breakfast and lunch, orange juice every day between lunch and dinner and throughout the day, monitor the resident's intake trends, and monitor the resident's weight. The clinical record documented the weights: 12/3/13 - 146.6 pounds (#) 1/6/14 - 141.2 # 2/3/14 - 134 # 3/3/14 - 128# 4/3/14 - 126.4 # 5/5/14 - 117.4 # 6/3/14 - 111.4 # 6/23/14 - 106.3 # (Consisting of a 40.3 pound or 27.48 % weight loss in 6 months). Nutritional assessment dated [DATE] revealed the registered dietitian had no new nutritional concerns at this time. The 2/6/14 nutrition note documented the resident lost 7 # in the past 30 days. He/she recommended enhanced foods and provide chocolate milk two times a day between meals. The 3/7/14 nutrition note documented the resident lost 19.6 # in the past 90 days. The dietician recommended Ensure Plus 1 can every day between the lunch and dinner meal. Dietary Consult staff HH documented on 6/3/2014 the resident's weight continued to trend down with current weight of 111 pounds-down 6 pounds in 30 days (5 percent), and 30 pounds in 180 days (21 percent). The resident had severe dementia, appeared pleasantly confused, ambulated around unit throughout the day, and appeared quite active. The resident would not accept any feeding assistance or the enhanced food items, had an intake of 10 percent for all meals, and drank chocolate milk, orange juice and Ensure Plus. The dietician recommended to continue the liberalized regular diet but discontinued the enhanced foods, and recommended chocolate milk with all meals, and recommended the Ensure Plus between breakfast and lunch and the orange juice between lunch and dinner. On 6/25/14 at 12:45 P.M. the resident walked into the dining room and started to eat immediately. Direct care staff O sat beside the resident at 12:50 P.M. and started to assist the resident with his/her meal. The resident ate 3 bites of goulash, 2 bites of bread, no broccoli, all the applesauce, and approximately 4 ounces of apple juice, and then he/she got up and left the dining room independently. The resident did not receive chocolate milk with his/her meal and the staff did not offer any substitutes for the uneaten food. On 6/25/14 at 5:50 P.M. the resident sat at the dining room table with his/her head hanging down and no food or fluids in front of him/her. Staff gave the resident a glass of water and a glass of orange juice at 6:25 P.M. The staff served the resident a chicken caesar wrap and french fries at 6:30 P.M.. Staff pushed the resident's chair up to the table and told the resident his/her food was there. The resident looked up and then put his/her head back down. The resident left the table at 7:00 P.M. without eating or drinking. The resident did not receive chocolate milk or the dessert of ice cream. The staff also did not provide cueing or assist the resident with the evening meal. No substitute or cueing provided. On 6/26/14 at 8:20 A.M. the resident walked into the dining room and sat at the table. The resident received a bowl of oatmeal and a glass of orange juice at 8:35 A.M. and immediately picked up the bowl of oatmeal, ate all the oatmeal and then drank all the orange juice. The resident received the rest of the breakfast of pancakes and sausage 20 minutes after he/she finished the cereal, he/she ate half of a sausage link, and then left the dining room. The resident did not receive chocolate milk, staff did not assist or cue the resident with the breakfast meal, and did not provide additional food. On 6/26/14 at 11:40 A.M. direct care staff P revealed the morning supplements/snacks (Ensure Plus) were not delivered to the residents as the kitchen had not provided the snacks. Administrative nursing staff D on 6/27/14 at 3:08 P.M. stated the facility did not document the intake of the supplements or if the resident even received the supplements. On 6/26/14 at 9:45 A.M. interview with consulting physician II revealed he/she expected the dietary staff to provide the diets and supplements as ordered for this resident. The consulting physician II was not aware the facility did not provide the diet and supplement as ordered. Consulting physician II expected the facility to report to him/her if a resident had a weight loss. The physician progress notes [REDACTED]. The April 2005 facility policy "Assessment of Nutritional Status" documented the facility to develop or review the care plan to determine if problems and approaches identified in the nutritional assessment were included in the care plan and the care plan reflected the current status of the resident. The undated facility "Weight Management Process Flowchart": documented if a resident had a weight loss, the registered dietitian and other disciplines would be notified. The registered dietitian would do a nutritional assessment. The facility failed to provide timely assessments and interventions as planned for the prevention of weight loss for this cognitively impaired resident that had a significant weight loss. - Resident #8's Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident weighed 147 pounds, identified no weight loss, and the resident received a therapeutic diet. The significant change MDS dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident with severe cognitive impairment, the resident required supervision and set up help for eating, the resident had no swallowing problems, weighed 129 pounds, had a weight loss, and not on prescribed weight loss regimen. The nutritional Care Area assessment dated [DATE] documented the resident had significant weight loss and received enhanced foods. The resident's weight appeared to be trending down with current weight of 129 pounds with 38 pound weight loss in the past 6 months (23 percent). The resident was able to feed self, would not allow staff to feed him/her, and required an increased amount of redirecting. The current diet order was a liberalized regular diet with enhanced foods and a house shake daily between lunch and dinner. The registered dietitian recommended a regular diet and try Ensure Plus (supplement) twice a day between meals. The main nutritional concern was inadequate oral food and beverage intake related to advanced age and dementia (progressive mental disorder characterized by failing memory, confusion), as evidenced by the resident's weight history. The nutritional care plan revised on 6/4/14 documented the resident was at a nutritional risk due to inadequate oral food and beverage intake related to advanced dementia/age as evidenced by 27 pound weight loss in the past 3 months and intake records. The interventions included to provide a liberalized regular diet, Ensure Plus two times a day between meals, honor food preferences, monitor weight, monitor intake, and laboratory values for significant changes, encourage fluids, and provide chocolate milk with all meals. The clinical record documented the following weights: 12/2/13 - 163 pounds (#) 1/15/14 - 168.4 # 2/3/14 - 153 # 3/3/14 - 146.6 # (transferred to a geriatric psychiatric unit on 3/20/14 and readmitted on [DATE]). 4/3/14 - 141 # 5/5/14 - 129 # 6/3/14 - 118.2 # (Consisting of a 44.8 pound or 27.48 % weight loss in 6 months). Dietary Consult staff HH documented on 2/17/14 at 9:45 A.M. the resident ate breakfast at the time of his/her visit. The resident was alert and pleasantly confused and ate 100% of his/her breakfast. The resident's weight appeared to be trending down and questioned the accuracy of the weight history: 12/2 166#, 1/4 168#, 1/6 157#, 2/3 153#, per nursing the resident appeared to be declining somewhat. Dietary consult staff HH recommended Enhanced Foods and House Shake every day between lunch and dinner to prevent weight loss. Dietary Consult staff HH documented on 6/4/2014 at 2:02 P.M. the resident's weight continued to trend down with a loss of 11 pounds this month (8%), and 27 pounds lost the past 90 days (18%). The resident was able to tolerate a regular diet texture and received a regular diet with Ensure Plus two times a day between meals. The resident would only take a few bites of food at meals, liked sweets but would only eat 1-2 bites. The resident would sometimes drink chocolate milk. The resident would not accept any feeding assistance from the staff. The resident appeared to enjoy soda and the family provided diet coke for the resident. The dietician recommended lemon-lime soda between meals and as needed. On 6/25/14 at 12:30 P.M. the resident sat in a Broda chair (high back reclining moveable chair) in the dining room. Staff served the lunch tray and left the tray covered in front of the resident. The resident picked up a wrapped slice of bread and played with it, sat the bread down, and picked up the napkin and played with the napkin. The plate was uncovered at 12:37 P.M. and the resident picked up a glass of water and drank the water. Direct care staff Q sat next to the resident at 12:40 P.M. and assisted the resident with his/her lunch tray. The resident ate 2 bites of goulash (macaroni and hamburger mixture), 2 bites of apple crisp, and refused anymore. Direct care staff Q tried several times to get the resident to eat more and the resident refused. Direct care staff Q asked the resident if he/she would like some milk and the resident replied yes. Direct care staff Q obtained Ensure Plus and the resident drank approximately 2 ounces and said he/she had enough. The resident did not receive chocolate milk as planned with his/her meal. Staff did not cue the resident, redirect as planned, or provide substitutes. On 6/25/14 at 6:40 P.M. the resident laid in bed. Direct care staff R took a supper tray to the resident's room and asked the resident if he/she wanted anything to eat. The resident replied yes and ate 3 bites of bean soup (said it was too spicy), 1 large bite of a slice of pork from a sandwich, and half of a French fry, then refused the rest of the meal. Direct care staff R asked the resident if he/she wanted some chocolate milk and the resident replied yes a little. Direct care staff R left the room and returned with strawberry ice cream. The resident ate all the ice cream. Administrative nursing staff D obtained the chocolate milk from the kitchen as dietary did not serve any with the resident's tray. Staff did not cue the resident or redirect the resident as planned. On 6/26/14 at 8:40 A.M. staff served the resident his/her tray in the dining room which contained 2 pancakes, 2 link sausages, and a bowl of cream of wheat. Direct care staff S gave the resident orange juice and water. Direct care staff S stood to the right of the resident to assist with the meal. The resident ate both the sausage links and three bites of the pancakes, and then refused anymore. The resident picked up the glass of water, drank all the water, then picked up the orange juice and drank half of the juice. Chocolate milk was not available and not offered (no chocolate milk in the refrigerator or brought by the kitchen with the breakfast trays). Staff did not redirect the resident or offer substitutes. On 6/26/14 at 11:40 A.M. direct care staff P revealed the morning supplements/snacks were not delivered to the residents as the kitchen had not provided the snacks. Administrative nursing staff D on 6/27/14 at 3:08 P.M. stated the facility did not document the intake of the supplements or if the resident even received the supplements. On 6/26/14 at 9:45 A.M. interview with consulting physician II revealed he/she expected the dietary staff to provide the diets and supplements as ordered. The consulting physician II was not aware the facility did not provide the diet and supplement as ordered for this resident. Consulting physician II expected the facility to report to him/her if a resident had a weight loss. The physician's progress noted dated 3/14/14 documented nursing stated the resident was doing fair and lacked reference to weight loss. The April 2005 facility policy "Assessment of Nutritional Status" documented the facility to develop or review the care plan to determine if problems and approaches identified in the nutritional assessment were included in the care plan and the care plan reflected the current status of the resident. The undated facility "Weight Management Process Flowchart": documented if a resident had a weight loss, the registered dietitian and other disciplines were notified. The registered dietitian would do a nutritional assessment. The facility failed to provide timely assessments and interventions as planned for the prevention of weight loss for this cognitively impaired resident that had a significant weight loss.

The facility reported a census of 128 residents and the sample was 6. Based on observation, record review, and interview the facility failed to develop and implement effective interventions to prevent falls for one sampled resident (#1) who fell and sustained a leg fracture. Findings included: - Resident #1's significant change Minimum Data Set (MDS) 3.0 dated 4/5/13 recorded the resident's Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. The MDS recorded the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS documented the resident was frequently incontinent of bladder. The Care Area Assessment (CAA) dated 4/8/13 for delirium recorded the resident recently admitted to hospice services. The resident was able to make his/her needs known, however his/her response time had decreased. A decline was expected due to stopping dialysis (filtration of the blood to rid the body of harmful wastes). The Care Area Assessment (CAA) dated 4/8/13 for activities of daily living (ADLs) triggered due to an increased extensive assistance for ADLs. The Care Area Assessment (CAA) dated 4/8/13 for falls recorded the resident had impaired mobility with an unsteady gait. The resident refused dialysis, became weaker, was impulsive due to confusion/delirium, and would attempt to walk without staff assistance. The care plan dated 3/6/13 recorded the resident was at risk for falls and staff would encourage the resident to use the call light, observe and report changes in gait and balance, provide a low bed, and assist the resident to the bathroom as he/she allowed. The care plan dated 3/6/13 lacked a plan for the resident's urinary incontinence. A readmission assessment on 3/5/13 documented bladder incontinence with a plan for an individual toileting plan. The chart lacked a toileting plan or an evaluation of a toileting diary for this resident. A nurse's note documented on 3/7/13 at 6:00 A.M. the resident fell while in the bathroom. The staff left the resident sitting on the toilet. The undated fall intervention included the resident would have supervision while in the bathroom. A nurse's note documented on 3/21/13 at 3:49 P.M. the resident appeared to be weak and confused. The resident walked to the side of his/her roommate's bed and urinated on the floor. An untimed nurse's note documented on 3/24/13 the resident requested to stop dialysis and start hospice. A fall investigation on 3/27/13 documented at 9:30 A.M. the resident was found walking in the doorway of his/her room, the resident was agitated and confused. The resident's bed was soaked with urine. The resident requested the staff take him/her to the bathroom while staff changed the sheets. When staff assisted there resident to the toilet, he/she fell forward, hitting his/her head on the bathroom door. At 11:00 A.M. the resident was found on his/her hands and knees next to his/her bed. The interdisciplinary team reviewed the interventions and agreed they were appropriate. A nurse's note on 4/6/13 at 8:18 A.M. stated the resident was found in the bathroom twice during the shift unassisted. A fall investigation on 4/9/13 documented at 11:00 P.M. the resident fell while trying to go to the bathroom unassisted. The resident had a large gash on his/her head. The bleeding was stopped and neurological checks were started. The fall intervention was an environmental audit. At 1:30 A.M. the resident was found getting out of bed and on the way to the bathroom. A nurse's note on 4/12/13 at 8:09 A.M. documented the resident was found sitting on the floor next to his/her bed with a call light attached to his/her gown. The resident was sent to the hospital. The care plan was updated to state when doing rounds encourage resident to toilet. A X-ray report dated 4/12/13 concluded an acute fracture involving the right distal femur (lower part of the thigh bone). An interview with direct care staff D on 5/9/13 at 11:15 A.M. stated the resident had mats on the sides of his/her bed and that he/she would mostly fall on evening shift. An interview with licensed staff B on 5/9/13 at 11:25 A.M. stated the resident refused dialysis and would not use the call light. The bed was in a low position and the staff made sure that his/her table was within his/her reach because he/she always used the table. An interview with licensed staff C on 5/9/13 at 2:12 P.M. stated the resident did not use his/her call light so the staff would sit the resident at the nurses station. The resident was not steady when he/she walked and was impulsive in getting up from his/her chair. An interview with direct care staff F on 5/9/13 at 3:10 P.M. stated the resident would get agitated at times. The resident was incontinent at times also the resident was really confused. An interview with direct care staff E on 5/9/13 at 3:14 P.M. stated the resident was confused and the staff would keep him/her at the nurses' station to keep an eye on him/her. Staff stated he/she sat with the resident for 30 minutes but was not able to stay longer even though staff wanted to, because the resident was not on a one to one program. The resident was not on a special toileting plan, we would check him/her every 2 hours especially towards the end. There was a time when we found the bed soaked with urine but the facility never did a toileting diary for this resident. An interview with administrative licensed staff G on 5/9/13 at 3:19 P.M. stated the staff initiated a bladder diary if the staff felt a bladder program would benefit the resident. Sometimes the staff use the bladder program for a fall intervention. This resident was extremely disoriented and the staff could not redirect him/her. This resident was incontinent and sometimes he/she would say he/she would have to go to the bathroom and then he/she would not. Administrative licensed staff A on 5/9/13 at 3:42 P.M. stated the staff monitored the resident frequently but he/she was impulsive and would get up by him/herself. Staff A did not think there was anything else staff could have done to keep him/her from falling. Staff would not have initiated a bladder diary on this resident because he/she was able to tell us when he/she needed to urinate. The facility failed to assess the resident for a toileting program, develop and implement effective interventions to prevent falls for this cognitively impaired dependant resident with a history of falls who fell and sustained a fracture. .

The facility reported a census of 150 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed provide timely pressure ulcer treatment for 2 of 3 residents sampled for pressure ulcers. (#1002, #1004) Findings included: - The physician's orders [REDACTED]. The initial Minimum Data Set 3.0 (MDS) assessment with an assessment reference date of 10/27/11, recorded the resident with a BIMS (Basic Interview for Mental Status) score of 10 which indicated moderate cognitive impairment. The MDS documented the resident required extensive assistance of one to two staff with transfers, bed mobility and other activities of daily living (ADLs). The MDS further documented the resident was incontinent of bladder, occasional bowel incontinence and use of a wheelchair as his/her primary mode of transportation. The pressure ulcer Care Area Assessment (CAA) dated 10/27/11 recorded the resident hospitalized after a fall with [MEDICAL CONDITION] and admitted for skilled nursing and rehabilitation, with the presence of a coccyx pressure ulcer. This same care assessment however, lacked any specifics regarding the resident's pressure sore, i.e. measurements, treatment, preventative measures, etc. The initial nursing skin assessment dated [DATE] lacked any descriptive account of the resident's coccyx wound. Staff circled the area of the coccyx but failed to document measurements or what the skin concern was. The skilled nursing assessment Braden scale, (an assessment tool used to determine the potential for developing pressure sores) dated 10/25/11, recorded a score of 16, which indicated the resident was at moderate risk for the development of pressure ulcers. The resident's initial care plan dated 10/31/11 (10 days after admission) recorded the resident with a coccyx pressure sore related to recent hip surgery and listed interventions including: dietary supplement and fortified foods as ordered, observe skin condition with ADL care daily and report abnormalities, encourage and assist to turn and reposition every 2 hours and as needed, and suspend heels as able. The care plan lacked any specific information regarding the resident's wound, i.e. location (coccyx), condition (size, drainage, soreness) etc. Review of the initial nurses progress notes dated 10/21/11 documented the resident with a stage 2 pressure ulcer on the coccyx, "slight opening" appeared as pinpoint. Review of the dietician note of 10/24/11 recorded the resident received a regular diet and recommend change diet to controlled carbohydrate and add multivitamin with minerals and Prostat for wound healing. The medical record lacked evidence the facility implemented this recommendation. Review of the nurse's data assessment and the facility's weekly wound sheets revealed the first measurement of the resident's coccyx wound was on 10/25/11, 4 days after admission. According to the weekly pressure ulcer healing chart (PUSH tool) dated 10/25/11, the resident's coccyx wound measured 4.1 cm (centimeters) length and 8.0 cm width and less than 0.3 cm in depth. Review of the clinical record revealed a physician's orders [REDACTED]. Observation on 11/23/11 at 7:30 A.M., during dressing change, revealed the resident with an approximately 4.0 cm circular open area directly over the coccyx with a red center, pink surrounding tissue and less than 0.3 cm in depth. On 11/23/11 at 7:30 A.M. interview with licensed nurse E stated the resident admitted with a coccyx wound. The facility policy entitled HCR Manor Care Skin Practice Guide revised July 2008 documented: "review hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for pressure ulcers. Interview the patient, family or responsible party about the patient's history of skin ulcers and risk factors. If an alteration in the skin integrity is identified on admission, a designated member of the wound team evaluates the status of the wound (ideally within 24 hours of admission) and collaborates with the licensed nurse, physician or advanced practice nurse to determine the type of alteration present. Treatment orders are obtained, noted and initiated as ordered with the identification of alteration in skin integrity. Patients admitted with skin alterations or those who develop new alterations are ideally evaluated by a qualified health professional, physician's assistant or certified wound specialist within 24 hours, or as soon as practicable, after admission or skin alteration identification." The facility failed to provide an accurate initial assessment and enact prompt treatment and failed to implement dietary recommendations for this dependent resident who admitted to the facility with a pressure ulcer. - Resident #1002's [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 Assessment (MDS) with an Assessment Reference Date (ARD) of 9-9-11 documented the resident with a Brief Interview for Mental Status (BIMS) score of 14 which revealed the resident independent with decision making skills, required extensive assistance with activities of daily living, incontinent of bowel and bladder, and admitted with 2 unstageable pressure ulcers due to slough (yellow tissue that adheres to the ulcer bed in strings or thick clumps). The 9-14-11 Pressure Ulcer Care Area Assessment Summary (CAA) documented the resident was paraplegic, had multiple pressure ulcers and was at risk for pressure ulcers related to his/her extensive assistance required for bed mobility, bowel incontinence, immobility and presence of other pressure sores. The 9-14-11 care plan documented the resident with a pressure ulcer on the resident's right gluteal fold midline and inner aspect and directed staff to administer treatment as ordered by the physician and to evaluate and record the wound status per the facility guidelines until healed. The care plan also included providing a special mattress, offer fortified foods and use of positioning devices. The 9-2-11 Nurses Admission Assessment documented the resident with a wound on his/her right buttock. The 9-2-11 Braden Assessment documented a score of 15 which indicated the resident was at low risk for developing a pressure ulcer. Record review revealed an order on 9-2-11 on the hospital transfer form documented a right ischial stage II superficial pressure shear wound and ordered Allevyn gentle border (a type of dressing used for wounds) for treatment. Record review of the nurse's note dated 9-7-11 at 12:00 P.M. documented the resident admitted with pressure ulcers to the right gluteal fold-midline and inner aspect midline the right gluteal fold and measured 5.6 centimeters (cm) x 4 cm with slough in the wound bed and the peri wound was macerated with heavy serosanginous drainage with no depth, tunneling, or undermining with a PUSH (Pressure Ulcer Healing Chart tool used to measure pressure ulcers) tool score of 15. The right gluteal fold inner aspect measured 3.5 cm x 4 cm and was unstageable with a PUSH tool score of 15 and the peri wound macerated with heavy serosanginous drainage. During the assessment 3 blisters were noted on the left buttock and measured as follows: The proximal blister measured 3.3 cm x 3.0 cm with a PUSH tool score of 8. The left buttock midline blister measured 3.5 cm x 3.0 cm with a PUSH tool score of 8. The left buttock distal measured 3.7 cm x 3.0 cm with a PUSH tool score of 8. At this time staff reviewed the plan of care with the resident and the physician. Interventions included a gel cushion to the wheelchair, an alternating pressure mattress, and an extended wear dressing to promote healing. Review of the physician progress notes [REDACTED]. Record review of the September 2011 Treatment Assessment Record (TAR) documented an order dated 9-2-11 to cleanse the wound to the right gluteal fold with normal saline, apply skin prep to the periwound, cover with [MEDICATION NAME] AG mesh, cover with a 4 x 4 gauze dressing and change every 2 days. Further review revealed the first date documented the resident received treatment was on 9-7-11 and again on 9-11-11. Further review of the TAR revealed on order dated 9-7-11 to cleanse the left buttock wound with normal saline, apply skin prep to the periwound, cover with foam dressing and change every 2 days and as needed (PRN). The TAR lacked documentation staff provided treatment on 9-9-11 as ordered by the physician. Review of the 9-13-11 Nurse's note at 4:30 P.M. documented the weekly assessment of the following: Pressure ulcer of the left buttock with a PUSH tool score of 9 and other left buttock wound healed. Right gluteal fold midline and inner aspect with a PUSH tool score of 15. Resident had new ulcer to left gluteal fold with a PUSH tool score of 11 and measured 2.0 cm x 2.0 cm and staff notified the physician. Further review of the medical record lacked evidence staff provided treatment to the resident's documented pressure ulcers before 9-7-11. Observation was not available as this resident discharged from the facility. During staff interview on 11-23-11 at 4:09 P.M. licensed nurse E acknowledged the resident admitted to the facility on [DATE] and acknowledged the TAR and medical record lacked documentation staff provided any treatment to the resident's pressure ulcers before 9-7-11. He/she stated the resident came into the facility with a pressure ulcer of the right ischial and had a lot of slough. During staff interview on 9-23-11 at 4:22 P.M. licensed administrative nurse F acknowledged the resident's record lacked evidence he/she received treatment for [REDACTED]. The facility provided 07/2008 Skin Practice Guide directed staff to review the hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for pressure ulcers. The guide directed staff to interview the patient, family or responsible party about the patient's history of skin ulcers and risk factors. The Guide further directed staff to complete the Nursing Admission Evaluation, including a head to toe full body audit to identify the presence of pressure ulcers or other skin alteration and document the finding on the Nursing Admission Evaluation. If an alteration in the skin integrity was identified on admission, a designated member of the wound team evaluated the status of the wound (ideally within 24 hours of admission) and collaborated with the licensed nurse, physician or advanced practice nurse to determine the type of alteration present and staff obtained treatment orders. If a pressure ulcer was identified, wound team staff initiated the PUSH (Pressure Ulcer Healing Chart) tool. Staff also completed a comprehensive evaluation documented it in the patient's clinical record and included, but not limited to: depthappearance of surrounding skinpresence and location of tunneling and or underminingevidence of infectionpain Patients admitted with skin alterations or those who developed new alterations should be evaluated by a qualified health professional, physician's assistant or certified wound specialist within 24 hours, or as soon as practicable, after admission or skin alteration identification. Upon completion of the wound evaluation, staff notified the physician/family/responsible party and developed the initial plan of care. The procedure also documented the licensed nurse provided wound treatments as ordered by the physician or advanced nurse practitioner and documented completion of the treatment(s) on the Treatment Administration Record (TAR). Daily observation and evaluation of the wound included status of the dressing and the surrounding skin. Licensed staff also completed a daily head to toe skin evaluation to identify additional skin changes. The facility failed to provide pressure ulcer treatment to this dependent resident, who admitted to the facility with a pressure ulcer, for 5 days following admission to the facility.

- Resident #1002 ' s [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 Assessment (MDS) with an Assessment Reference Date (ARD) of 9-9-11 documented the resident with a Brief Interview for Mental Status (BIMS) score of 14 which revealed the resident independent with decision making skills, required extensive assistance with activities of daily living, incontinent of bowel and bladder, and admitted with 2 unstageable pressure ulcers due to slough (yellow tissue that adheres to the ulcer bed in strings or thick clumps). The 9-14-11 Pressure Ulcer Care Area Assessment Summary (CAA) documented the resident was paraplegic due to a benign spinal tumor, had multiple pressure ulcers and was at risk for pressure ulcers related to his/her extensive assistance of bed mobility, bowel incontinence, immobility and presence of other pressure sores. The 9-14-11 care plan documented the resident with a pressure ulcer on the resident ' s right gluteal fold midline and inner aspect and directed staff to administer treatment as ordered by the physician evaluate and record the wound status per the facility guidelines until healed. The care plan also included providing a special mattress, offer fortified foods and use of positioning devices. The 9-2-11 Nurses Admission Assessment documented the resident with a wound on his/her right buttock. The 9-2-11 Braden Assessment documented a score of 15 which indicated the resident was at low risk for developing a pressure ulcer. Record review revealed an order on 9-2-11 on the hospital transfer form documented a right Ischial stage II superficial pressure shear wound and ordered Allevyn gentle border (a type of dressing used for wounds) for treatment. Record review of the nurse ' s note dated 9-7-11 at 12:00 P.M. documented the resident admitted with pressure ulcers to the right gluteal fold-midline and inner aspect midline the right gluteal fold and measured 5.6 centimeters (cm) x 4 cm with slough in the wound bed and the peri wound was macerated with heavy serosanginous drainage with no depth, tunneling, or undermining with a PUSH (Pressure Ulcer Healing Chart tool used to measure pressure ulcers) tool score of 15. The right gluteal fold inner aspect measured 3.5 cm x 4 cm and was unstageable with a PUSH tool score of 15 and the peri wound macerated with heavy serosanginous drainage. During the assessment 3 blisters were noted on the left buttock and measured as follows: The proximal blister measured 3.3 cm x 3.0 cm with a PUSH tool score of 8. The left buttock midline blister measured 3.5 cm x 3.0 cm with a PUSH tool score of 8. The left buttock distal measured 3.7 cm x 3.0 cm with a PUSH tool score of 8. At this time staff reviewed the plan of care with the resident and the Physician. Interventions included a gel cushion to the wheelchair, an alternating pressure mattress, and an extended wear dressing to promote healing. Review of the physician progress notes [REDACTED]. Record review of the September 2011 Treatment Assessment Record (TAR) documented an order dated 9-2-11 to cleanse the wound to the right gluteal fold with normal saline, apply skin prep to the periwound, cover with [MEDICATION NAME] AG mesh, cover with a 4 x 4 gauze dressing and change every 2 days. Further review revealed the first date documented the resident received treatment was on 9-7-11 and again on 9-11-11. Further review of the TAR revealed on order dated 9-7-11 to cleanse the left buttock wound with normal saline, apply skin prep to the periwound, cover with foam dressing and change every 2 days and as needed (PRN). The TAR lacked documentation staff provided treatment on 9-9-11. Review of the 9-13-11 Nurse ' s note at 4:30 P.M. documented the weekly assessment of the following: Pressure ulcer of the left buttock with a PUSH tool score of 9 and other left buttock wound healed. Right gluteal fold midline and inner aspect with a PUSH tool score of 15. Resident had new ulcer to left gluteal fold with a PUSH tool score of 11 and measured 2.0 cm x 2.0 cm and staff notified the physician. Further review of the medical record lacked evidence staff provided treatment to the resident ' s documented pressure ulcers before 9-7-11. The resident no longer resided at the facility during this investigation. During staff interview on 11-23-11 at 4:09 P.M. licensed nurse E acknowledged the resident admitted to the facility on [DATE] and acknowledged the TAR and medical record lacked documentation staff provided any treatment to the resident ' s pressure ulcers before 9-7-11. He/she stated the resident came into the facility with a pressure ulcer of the right Ischial and had a lot of slough. During staff interview on 9-23-11 at 4:22 P.M. licensed administrative nurse F acknowledged the resident ' s record lacked evidence he/she received treatment for [REDACTED]. The facility provided 07/2008 Skin Practice Guide directed staff to review the hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for pressure ulcers. The guide directed staff to interview the patient, family or responsible party about the patient's history of skin ulcers and risk factors. The Guide further directed staff to complete the Nursing Admission Evaluation, including a head to toe full body audit to identify the presence of pressure ulcers or other skin alteration and document the finding on the Nursing Admission Evaluation. If an alteration in the skin integrity was identified on admission, a designated member of the wound team evaluated the status of the wound (ideally within 24 hours of admission) and collaborated with the licensed nurse, physician or advanced practice nurse to determine the type of alteration present and staff obtained treatment orders. If a pressure ulcer was identified, wound team staff initiated the PUSH (Pressure Ulcer Healing Chart) tool. Staff also completed a comprehensive evaluation documented it in the patient's clinical record and included, but not limited to: depthappearance of surrounding skinpresence and location of tunneling and or underminingevidence of infectionpain Patients admitted with skin alterations or those who developed new alterations should be evaluated by a qualified health professional, physician's assistant or certified wound specialist within 24 hours, or as soon as practicable, after admission or skin alteration identification. Upon completion of the wound evaluation, staff notified the physician/family/responsible party and developed the initial plan of care. The procedure also documented the licensed nurse provided wound treatments as ordered by the physician or advanced nurse practitioner and documented completion of the treatment(s) on the Treatment Administration Record (TAR). Daily observation and evaluation of the wound included status of the dressing and the surrounding skin. Licensed staff also completed a daily head to toe skin evaluation to identify additional skin changes. The facility failed to provide pressure ulcer treatment to this dependent resident, who was admitted to the facility with a pressure ulcer, for 5 days following admission to the facility.

The facility documented a census of 147 residents. The sample included 3 residents. Based on observation, record review and interviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (#1, #2, and #3). Findings included: - Resident #1's Physician order [REDACTED]. The significant change Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the Brief Interview of Mental Status (BIMS) score of 2 which revealed severe cognitive impairment. The MDS further documented the resident required extensive assistance of 2 staff with transfers, toilet use, and extensive assistance of 1 staff with bed mobility, walking, locomotion, dressing and personal hygiene. The MDS documented the resident with 5 falls (since prior assessment of 6/30/11) of theses falls 2 were non injury, 2 were with injury (except major), and 1 with major injury. The Care Area Assessment (CAA) dated 10/7/11 documented under the falls CAA to refer to the CAA related to activities of daily living (ADL) narrative for description of resident's needs. The ADL documented that at time of assessment, the resident had greater than 4 falls recorded since his/her most recent MDS assessment. The care plan updated on 9/20/11 documented the resident at risk for falls related to cognitive impairment, poor safety awareness, impulsiveness, impaired balance/poor coordination, and history of frequent falls. The interventions included: provide assist to transfer and ambulate as needed. Notify physician and family/responsible party of any falls. Check on patient frequently, encourage him/her to call for help when transferring, and utilizing call light. Re-educate patient to call for help prior to getting out of bed and to use call light. Encourage and assist as needed to wear proper and non slip footwear. Ensure that alarm is in place on bed when in bed and wheelchair. Have commonly used articles within easy reach. Minimize environmental clutter. Added 1/29/11 check room frequently for food in room, low bed, and review medication regimen, by psych as needed. Encourage him/her to ask for assistance. Encourage resident to lay down in bed when tired; encourage him/her not to lay on the floor when he/she is tired. Scoop mattress. Requested family to provide right sized shoe for patient to minimize falls. Monitor for and report changes in gait. Monitor for and report development of pain, bruises, changes in mental status, ADL function, appetite, or neurological status per facility guidelines post fall. Monitor that resident is not dis-engaging his/her alarms on bed and/or wheelchair. Encourage resident to sit with staff when anxious and agitated. Added 5/2/11 Bed in low position. Added 5/29/11 Reinforce wheelchair safety as needed such as locking brakes before attempt to stand up. Added 8/22/11 Provide education related to risks/benefits to family and resident about use of adaptive/preventative measures. Added 9/15/11 Floor mats on either side of bed. Have in room that is visible from nurses station. Added 9/20/11 Review medications due to agitation. The fall assessment dated [DATE] documented the resident had difficulty maintaining standing position, impaired balance during transitions, gait problem, and received the following medications: [REDACTED] The nurses notes documented the following falls: 1) On 8/20/11 at 11:30 P.M. the resident was found on the floor with a skin tear on his/her forehead. 2) On 9/2/11 at 12:30 P.M. the resident was found on the floor with a small laceration to right forehead. 3) On 9/15/11 at 5:40 A.M. the resident was found on the floor with a gash to left side of forehead and the facility sent the resident to the emergency room (ER) for sutures. 4) On 9/19/11 at 12:09 A.M. the resident was found on floor with his/her head bleeding and the previous sutures were not there . The resident was again sent to ER for sutures. The 4/2008 facility policy "Falls Practice Guide" documented the purpose was to describe the process for identification of patient fall risk factors and interventions and systems that may be used to manage falls. The fall management focused on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. On 10/20/11 at 8:37 A.M. licensed nursing staff E revealed that the nursing staff tried to figure out the cause of the fall and also monitor the resident to see what they could do to prevent further falls. The facility failed to assess and provide timely and effective interventions for the prevention of falls for this resident who fell with injuries. - Resident #2's Physician order [REDACTED]. The admission Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the brief interview for mental status score 15 which indicated cognitively intact. The MDS further documented the resident required total dependence of 2 staff with bed mobility, transfers, total dependence of 1 staff with locomotion, dressing, personal hygiene, extensive assist of 2 staff with toilet use, and extensive assistance of 1 staff with eating. The resident's balance of moving from seated to standing position, walking and turning around- did not occur, moving on and off toilet and surface to surface transfer- not steady, and only able to stabilize with human assistance. The MDS documented no falls. The Care Area Assessment (CAA) for activities of daily living (ADL) dated 8/19/11 documented the resident had a [DIAGNOSES REDACTED]. The resident required total assist with mobility and ADLs. Staff transferred by Hoyer lift (mechanical lift). The resident had a private duty nurse's aide for 24 hour care. The updated 8/7/10 care plan addressed the resident at risk for falls due to impaired mobility. The interventions included a Broda chair (specialized reclining chair) for improved sitting balance/comfort. Notify physician and family/responsible party of any falls. Observe for and report development of pain, bruises, and any changes in mental status, ADL function, appetite, or neurological status per facility guidelines post fall. Added 8/29 Bed in low position. Added 9/12 Analyze previous falls to determine whether pattern/ trend could be addressed. Added 9/29 Reinforce wheelchair safety as needed such as locking brakes. The nurse's notes dated 8/27/11 at 5:00 A.M. documented the staff found the resident lying on his/her left side beside his/her bed with a skin tear on his/her head and on his/her left hand near his/her elbow. On 9/1/11 an untimed entry documented that mats remain on the floor by the bed. The resident continues to slide forward in his/her wheelchair. The staff must watch continuously if care givers not here. On 9/2/11 at 11:30 P.M. the resident slid out of his/her seat and fell on his/her left side. On 9/10/11 an untimed entry documented the resident's sitter reported the resident rolled out of his/her bed. On 10/5/11 at 8:20 P.M. the staff found the resident on the floor in a prone position in front of the nurses station. The resident was sent to hospital per the doctor's orders related to laceration on head. The facility investigation dated 9/28/11 at 4:00 P.M. documented staff helped the resident to sit on the floor and then helped him/her back into his/her chair. The facility investigation for the fall on 10/5/11 documented the direct care staff F checked on the resident frequently before he/she fell because he/she was so agitated because his/her caregiver was late. The 4/2008 facility policy "Falls Practice Guide" documented the purpose was to describe the process for identification of patient fall risk factors and interventions and systems that may be used to manage falls. The fall management focused on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. On 10/20/11 at 2:54 P.M. administrative nursing staff B revealed that the resident did have outside staff that were paid to stay with the resident 24 hours a day. The paid outside staff left the resident unattended at the nurses station. The resident did get anxious when left alone. The facility staff should try to keep an eye on him/her as the staff from room to room checking the other residents. On 10/20/11 at 4:35 P.M. administrative nursing staff B acknowledged the resident's chart lacked any documentation related to incident on 9/28/11. Hospital information dated 10/5/11 obtained on 10/21/11 documented the resident received 6 sutures to his/her head laceration from a fall then admitted to hospital for pneumonia. The facility failed to ensure this resident received adequate supervision and assistive devices to prevent falls with injury for resident #2. - Resident #3's Physician order [REDACTED]. The significant change Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had severe cognitive impairment. The resident required extensive assist of 2 staff for bed mobility, transfers, and extensive assistance of 1 for staff walking, locomotion, dressing, eating, toilet use and personal hygiene. The resident's balance identified as not steady, and only able to stabilize with human assistance. The resident had no falls. The quarterly MDS dated [DATE] revealed the resident had falls. The falls documented as 1 with no injury and 1 with injury (except major) The Care Area Assessment CAA dated 3/31/11 for falls documented a fracture discovered after a fall on 3/17/11. The resident had multiple other recorded falls including on the following dates 1/2, 2/8, 2/11, and 2/23. The staff maintained the bed in a low position, floor mats in place and bed and wheelchair alarms in place. The fall assessment dated [DATE] documented the resident needed to rock body or push off on arms of chair when standing up from chair and the resident medications included antipsychotics. The care plan dated 12/25/10 documented the resident at risk for falls due to unsteady gait and history of falls. The interventions included to encourage the resident to attend the supervised activity programs, encourage to transfer and change positions slowly, minimize environmental clutter, monitor for and report changes in gait, notify physician and family/responsible party of any falls, and reinforce need to call for assistance. Added 1/2/11 Encourage and assist as needed to wear proper non-skid footwear. Added 2/8/11 occupational therapy (OT) evaluation and treatment per orders. Added 4/27/11 Administer pain medication as ordered and observe effectiveness. Added 5/20/11 Physical Therapy (PT) evaluation and treatment per physician's orders [REDACTED]. Added 6/2/11 Scoop mattress. Added 6/9/11 Redirect the resident when he/she goes to other patients' room or to unfamiliar areas. Added 9/1/11 Observe for and report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status per facility guidelines. Added 9/15/11 Moved to another room. Added 10/10/11 Do frequent rounds. Review Medication regimen. The chart review of the nurses' notes documented the following falls: 1) On 5/20/11 at 7:15 A.M. staff found the resident on the floor with a laceration above the right eye. The facility sent the resident to the emergency room and the resident received sutures. 2) On 6/1/11 at 10:00 A.M. the staff found the resident on the floor with a bump on his/her forehead. 3) On 6/8/11 at 7:30 P.M. the staff found the resident on the floor with a skin tear on his/her left elbow. 4) On 7/14/11 at 10:00 A.M. the staff found the resident on the floor with no injuries. 5) On 8/23/11 at 10:30 A.M. the staff found the resident on the floor with a small skin tear to his/her forehead and the bridge of the nose. 6) On 9/1/11 at 8:30 P.M. the staff found the resident on the floor with no injuries. 7) On 9/11/11 at 2:30 P.M. the staff found the resident on the floor with a bump on the back of his/her head. 8) On 9/14/11 at 10:40 A.M. the staff found the resident on the floor with no injuries. 9) On 9/25/11 at 9:45 A.M. the staff found the resident on the floor with a bump on the back of his/her head and bleeding. 10) On 10/8/11 at 2:30 P.M. the staff found the resident sitting on the floor next to his/her bed with no injuries. 11) On 10/10/11 at 4:15 P.M. the resident was found on floor with a laceration to the right side of his/her forehead. On 10/20/11 at 8:30 A.M. observed the resident in bed sleeping with a dressing to right side of his/her forehead. The resident's room was right across the hall from the nurses' station. On 10/20/11 at 11:55 A.M. observed the resident up in a wheelchair and rolling the wheelchair backwards. The resident stopped next to another resident, took his/her walker and then started rolling self backwards again. No staff were in the hallway to observe this incident. The social worker tried talking with this resident but the resident continued to roll their wheelchair backwards. The social worker then pushed the resident into the dining room and placed him/her up to the table. On 10/20/11 at 12:05 P.M. the resident sat in a wheelchair and grabbed another resident's upright chair and tried to pull himself/herself out of the wheelchair. The other resident turned around and told this resident to "leave me alone". The social worker then took the resident out of the dining room and pushed him/her around on the unit. On 10/20/11 at 12:10 P.M. licensed nursing staff E ambulated the resident by 1 hand to the dining room table, resident gait was steady. On 10/20/11 at 12:13 P.M. the resident stood and grabbed a therapist's arm and the therapist walked the resident out of the dining room. On 10/20/11 at 12:30 P.M. the resident laid in bed. Licensed nursing staff E revealed that the resident wanted to lay down. The 4/2008 facility policy "Falls Practice Guide" documented the purpose was to describe the process for identification of patient fall risk factors and interventions and systems that may be used to manage falls. The fall management focused on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. On 10/20/11 at 8:37 A.M. licensed nursing staff E revealed that the nursing staff tried to figure out the cause of the falls and also monitored the resident to see what we can do to prevent further falls. The facility failed to implement timely and effective interventions after the 4/27/11 fall. The resident fell on [DATE] and required sutures in the emergency room .