Every finding on record at Peabody Health and Rehab

The facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one of one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 01/28/25 at 07:42 AM, In a three-door refrigerator, an unsealed plastic bag of yellow shredded cheese, an unlabeled updated 1 1/2-pound (lb.) plastic bag with white cheese, and an unlabeled, undated zip-lock plastic bag with two round slices of meat. A two-door silver freezer located in the storage room across the hall from the kitchen was an undated three-gallon container of orange sherbet with numerous different-sized dried orange substances around the outside of the container. An unsealed, approximately 3/4 full, 50 lb. bag of flour and an unsealed, approximately 1/4 full, 50 lb. bag of breadcrumbs. On 01/28/25 at 08:20 AM, Dietary Staff (DS) BB verified the above findings and stated staff should label and date food items before placing them in the refrigerator. DS BB stated staff should place flour and breadcrumbs in a sealed container after opening the bag. On 01/29/25 at 10:50 AM, the mopboard around the kitchen's perimeter had numerous different sizes of grayish-black substances on it. The pipes underneath the dishwasher, approximately two feet long, had numerous areas of different sizes of grayish-black substance. On 01/29/25 at 10:50 AM, DS CC verified the above finding and stated the dietary staff should clean the mopboard and the pipes underneath the dishwasher. On 01/30/25 at 09:55 AM, Administrative Nurse D stated the administrator was overseeing the dietary department until next week when the new dietary manager became employed at the facility. The facility's Food Safety Requirements Policy, revised 10/2024, documented that all foods stored in the refrigerator or freezer would be covered, labeled, and dated. The facility's Sanitation Policy, updated 10/2024, documented all kitchens, kitchen areas, and dining areas should be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Kitchen and dining room surfaces not in contact with food would be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The food services manager was responsible for scheduling staff for regular cleaning of the kitchen and dining areas. The facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for the 39 residents who received their meals from the facility's kitchen. This deficient practice placed the 39 residents at risk for foodborne illness.

The facility had a census of 39 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the correct CMS form 10123, Notice of Medicare Non-Coverage (NOMNC) for two residents, Resident (R) 1 and R23. The facility also failed to include the estimated cost to continue skilled services on CMS form 10055, Advanced Beneficiary Notice (ABN), to the resident or their representative for the two residents, R1 and R23. This deficient practice placed the two residents at risk for uninformed decisions regarding skilled care. Findings included: - The Medicare NOMNC informed beneficiaries of their discharge and their right to an expedited review of the determination to terminate skilled coverage. The ABN form informed the beneficiaries of the estimated cost to continue their services, The facility's Medicare NOMNC form was not provided to R1 (or their representative), and the ABN form staff provided to R1 (or their representative) lacked the estimated cost to continue services when the resident's skilled services ended on 10/25/24. The facility's Medicare NOMNC form was not provided to R23 (or their representative), and the ABN form staff provided to R23 (or their representative) lacked the estimated cost to continue services when the resident's skilled services ended on 08/19/24. On 01/29/25 at 10:00 AM, Administrative Nurse E stated he was not aware that he was supposed to provide the residents or their representatives with the NOMNC forms when skilled services ended. Administrative Nurse E stated the facility had recently changed therapy companies and was unsure of the estimated cost of continuing skilled services. The facility's Beneficiary Notices policy, dated revised 08/24, documented the skilled nursing facility must give notice to the beneficiary at least three days before termination of all Part A services when the beneficiary still had days left in the benefit period. The facility would use the Medicare Provider Non-Coverage, Form CM'S 10123, to inform the beneficiary on how to request an expedited redetermination. Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN), CMS 10055, must be issued to the resident if the resident intends to continue services and the facility had determined that the services may not be covered under Medicare. The resident must be informed of potential non-coverage and document in the record that the resident understands they are accepting financial liability. The facility failed to provide R1 and R23 the CMS 10123 as required and failed to provide R1 and R23 the estimated cost to continue skilled services. This deficient practice placed the residents at risk for uninformed decisions regarding skilled services.

The facility had a census of 39 residents. The sample included 12 residents, with two reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notice for facility-imitated transfer to the hospital for two residents, Resident (R) 4 and R19. This deficient practice placed the residents at risk for uninformed care choices. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin type 2), and dependence on supplemental oxygen. The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition. R4 was dependent upon staff for toileting, dressing, and personal hygiene. R4 required substantial assistance with showers and transfers. R4 was always incontinent of bladder and bowel, and R4 did not require supplemental oxygen use. R4's Medicare 5 Day MDS, dated 01/02/25, documented R4 had moderately impaired cognition. R4 was dependent upon staff for bathing, personal hygiene, toileting, and dressing. R4 was always incontinent of bladder and bowel and required supplemental oxygen use. R4's Care Plan dated 01/23/25, initiated on 10/04/24, directed staff to administer medication as ordered and monitor for effectiveness, elevate the head of the bed, provide oxygen as ordered, and position R4 with proper body alignment for optimal breathing pattern. The care plan directed staff to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. The Progress Note dated 12/28/24 at 10:10 AM documented R4 was admitted to the hospital for COPD exacerbation. Review of R4's clinical record lacked evidence the resident or representative was provided a written notice when she was transferred to the hospital. On 01/28/25 at 01:48 PM, R4 sat in her recliner, her feet elevated, and she had oxygen on. On 01/29/25 at 04:00 PM, Administrative Staff A verified the facility lacked documentation R4, or their representative was provided a written notice when the resident was transferred to the hospital. The facility's Emergency Transfer or Discharge policy, dated 08/21, documented the facility should make an emergency transfer or discharge when it was in the best interest of the resident. The facility would notify the resident's attending physician and notify the resident's representative. When the resident was transferred, the facility would prepare a transfer to send with the resident. The facility failed to provide R4 or her representative written notice regarding R4's facility-initiated transfer to the hospital. This deficient practice placed the resident and/or her representative at risk for uninformed care choices. - R19's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin type 2, and multiple sclerosis (MS-progressive disease of the nerve fibers of the brain and spinal cord). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had severely impaired cognition. R19 was dependent upon staff for all activities of daily living (ADL), was always incontinent of bladder and bowel, and did not require supplemental oxygen. R19's Significant Change MDS, dated 01/16/25, documented R19 had severely impaired cognition. R19 was dependent upon staff for all ADLs, was incontinent of bladder and bowel, and required supplemental oxygen. R19's Care Plan dated 01/21/25, initiated on 03/22/22, directed staff to administer supplemental oxygen as needed. The update, dated 10/22/24, directed staff to give medications as orders to monitor and document side effects and the effectiveness of medications. Staff were directed to monitor for signs and symptoms of respiratory distress and report to the physician as needed. The Progress Note, dated 04/06/24 at 02:54 AM, documented R19 was sent to the hospital. Review of R19's clinical record lacked evidence the resident or representative was provided written notice when she was transferred to the hospital. On 01/29/25 at 12:15 PM, R19 sat in her wheelchair, feet elevated, and she had oxygen on. On 01/29/25 at 04:00 PM, Administrative Staff A verified the facility lacked documentation R19, or their representative was provided a written notice when the resident was transferred to the hospital. The facility's Emergency Transfer or Discharge policy, dated 08/21, documented the facility should make an emergency transfer or discharge when it was in the best interest of the resident. The facility would notify the resident's attending physician and notify the resident's representative. When the resident was transferred, the facility would prepare a transfer to send with the resident. The facility failed to provide R19 or her representative written notice regarding R19's facility-initiated transfer to the hospital. This deficient practice placed the resident and/or her representative at risk for uninformed care choices.

The facility had a census of 39 residents. The sample included 12, with two reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide two residents, Resident (R) 4 and R19, with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed R4 and R19 at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin type 2), and dependence on supplemental oxygen. The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition. R4 was dependent upon staff for toileting, dressing, and personal hygiene. R4 required substantial assistance with showers and transfers. R4 was always incontinent of bladder and bowel, and R4 did not require supplemental oxygen use. R4's Medicare 5 Day MDS, dated [DATE], documented R4 had moderately impaired cognition. R4 was dependent upon staff for bathing, personal hygiene, toileting, and dressing. R4 was always incontinent of bladder and bowel and required supplemental oxygen use. R4's Care Plan dated [DATE], initiated on [DATE], directed staff to administer medication as ordered and monitor for effectiveness, elevate the head of the bed, provide oxygen as ordered, and position R4 with proper body alignment for optimal breathing pattern. The care plan directed staff to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. The Progress Note dated [DATE] at 10:10 AM documented R4 was admitted to the hospital for COPD exacerbation. Review of R4's clinical record lacked evidence a copy of the bed hold policy was provided to the resident or representative, and the facility was unable to provide evidence upon request. On [DATE] at 01:48 PM, R4 sat in her recliner, her feet elevated, and she had oxygen on. On [DATE] at 04:00 PM, Administrative Staff A verified the facility had not provided R4 or their representative was provided the bed hold notice when the resident was transferred to the hospital. The facility's Bed Hold policy, revised on 05/23, documented the community staff would inform residents upon admission and prior to a transfer for hospitalization of the bed hold policy. When emergency transfers were necessary, the facility would provide the resident or representative with information concerning our bed hold policy per state law as applicable. The bed hold days in excess of our state Medicaid plan are considered noncovered services; a resident would be required to pay for any additional days that he/she wished the facility to hold the bed. Medicaid residents whose bed hold days had expired would be required to provide the facility with written authorization to either reserve or release the bed space within 24 hours of the expiration of such bed hold days. The facility failed to provide R4 with a copy of the bed hold policy when she was transferred to the hospital. This deficient practice placed the resident at risk of not being permitted to return and resume residence in the nursing facility. - R19's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin type 2), and multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had severely impaired cognition. R19 was dependent upon staff for all activities of daily living (ADL), was always incontinent of bladder and bowel, and did not require supplemental oxygen. R19's Significant Change MDS, dated [DATE], documented R19 had severely impaired cognition. R19 was dependent upon staff for all ADLs, was incontinent of bladder and bowel, and required supplemental oxygen. R19's Care Plan dated [DATE], initiated on [DATE], directed staff to administer supplemental oxygen as needed. The update, dated [DATE], directed staff to give medications as orders to monitor and document the side effects and effectiveness of medications. Staff were directed to monitor for signs and symptoms of respiratory distress and report to the physician as needed. The Progress Note, dated [DATE] at 02:54 AM, documented R19 was sent to the hospital. Review of R19's clinical record lacked evidence a copy of the bed hold policy was provided to the resident or representative, and the facility was unable to provide evidence upon request. On [DATE] at 12:15 PM, R19 sat in her wheelchair, feet elevated, and she had oxygen on. On [DATE] at 04:00 PM, Administrative Staff A verified the facility had not provided R19, or their representative was provided the bed hold notice when the resident was transferred to the hospital. The facility's Bed Hold policy, revised on 05/23, documented the community staff would inform residents upon admission and prior to a transfer for hospitalization of the bed hold policy. When emergency transfers were necessary, the facility would provide the resident or representative with information concerning our bed hold policy per state law as applicable. The bed hold days in excess of our state Medicaid plan are considered noncovered services; a resident would be required to pay for any additional days that he/she wished the facility to hold the bed. Medicaid residents whose bed hold days had expired would be required to provide the facility with written authorization to either reserve or release the bed space within 24 hours of the expiration of such bed hold days. The facility failed to provide R19 with a copy of the bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

The facility had a census of 39 residents. The sample included 12 residents, with two reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R )25, who was admitted to hospice on 09/08/24, and R19, who was admitted on [DATE], which included a plan of care and a description of the services provided which included contact information, visit frequency, medications, and medical equipment. This deficient practice placed R25 and R19 at risk of not receiving needed care. Findings included: - R25's Electronic Health Record (EHR) revealed diagnoses of atherosclerotic heart disease (a condition that occurs when plaque (fatty material) builds up in the arteries of the heart), chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R25's Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had a Brief Interview of Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. The MDS document R25 was dependent on staff with toileting, showering, putting on and taking off footwear, and personal hygiene. R25 was partial to moderate assistance with oral hygiene, sitting to standing position, chair to bed/ bed to chair transfers, and toilet transfers. R25 required substantial to maximal staff assist with upper and lower body dressing, sitting to lying, supervision with eating, independent with bed mobility, and propelling in a wheelchair. R25's Care Plan, dated 12/16/24, recorded R39 required extensive assistance with most activities of daily living (ADLs). R25's Care Plan documented the resident was admitted to [hospice services] on 09/08/24. The care plan directed the staff to administer medications ordered and notify the physician if there is breakthrough pain, assist with supporting the function of ambulation and mobility to the extent needed, talk to the resident during all encounters to avoid isolation and encourage visits from family and friends. The care plan lacked instruction on the services provided by hospice, including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. A review of R25's clinical record revealed the resident was admitted to hospice care on 09/06/24. The facility lacked a hospice plan of care. The hospice agreement documented the hospice plan of care would specify the hospice care and hospice services necessary to meet the needs of the hospice resident. The agreement documented the resident and his/her family would be identified in the initial comprehensive care plan, and staff would update assessments as necessary for the palliation and management of the resident's terminal illness and related conditions. The hospice care plan would provide the frequency of service, interventions to manage pain, drugs, supplies, appliances, and clinical record documentation and would coordinate care with the facility. 01/28/25 at 02:53 PM, R25 self-propelled in a wheelchair to the activity room and sat quietly waiting to have nails done, no signs or symptoms of pain. 01/29/25 at 04:48 PM, Administrative Nurse D verified R25's clinical record lacked a hospice care plan. 01/30/25 at 12:19 PM, Administrative Nurse D verified the facility lacked R25's hospice care plan and stated she had faxed hospice today and requested it. Administrative Nurse D verified the resident's care plan lacked information regarding hospice visits, phone numbers, and medical supplies. Administrative Nurse D stated Administrative Nurse E was responsible for updating care plans. 01/30/25 at 12:19 PM, Administrative Nurse E verified he was responsible for updating the care plans and was unaware the hospice information regarding contact number, medical supplies, phone numbers, and hospice visits were to be included in R25's care plan. The facility's Hospice Program Policy, updated 10/2024, documented that hospice would identify in writing the services hospice would be providing, address in the resident's person-centered care plan, and the facility would provide collaboration and coordination of hospice care. The policy-documented facility would ensure the appropriate documents were readily available, which included the hospice plan of care. The facility failed to coordinate care between the facility and the hospice provider for R25, who received hospice services. This deficient practice placed him at risk for inadequate end-of-life care. 32360 - R19's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin type 2, and multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord). R19's Significant Change Minimum Data Set (MDS), dated [DATE], documented R19 had severely impaired cognition. R19 was dependent upon staff for all ADLs, was incontinent of bladder and bowel, and required supplemental oxygen. R19's Care Plan, dated 01/21/25, documented R19 received hospice services and directed staff to assist her with eating, provide comfort measures as ordered, listen to her concerns, and ensure her call light was in reach. The care plan lacked instruction on the services provided by hospice, including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. A review of R19's clinical record revealed the resident was admitted to hospice on 01/17/25. The facility lacked a hospice plan of care. The hospice agreement documented the hospice plan of care would specify the hospice care and hospice services necessary to meet the needs of the hospice resident. The agreement documented the resident and his/her family would be identified in the initial comprehensive care plan, and staff would update assessments as necessary for the palliation and management of the resident's terminal illness and related conditions. The hospice care plan would provide the frequency of service, interventions to manage pain, drugs, supplies, appliances, and clinical record documentation and would coordinate care with the facility. On 01/29/25 at 12:15 PM, R19 sat in her wheelchair, feet elevated, and she had oxygen on. 01/29/25 at 04:48 PM, Administrative Nurse D verified that R19's clinical record lacked a hospice care plan. 01/30/25 at 12:19 PM, Administrative Nurse D verified the facility lacked R19's hospice care plan and stated she had faxed hospice today and requested it. Administrative Nurse D verified the resident's care plan lacked information regarding hospice visits, phone numbers, and medical supplies. Administrative Nurse D stated Administrative Nurse E was responsible for updating care plans. 01/30/25 at 12:19 PM, Administrative Nurse E verified he was responsible for updating the care plans and was unaware the hospice information regarding contact number, medical supplies, phone numbers, and hospice visits were to be included in R19's care plan. The facility's Hospice Program Policy, updated 10/2024, documented hospice would identify in writing the services hospice would be providing, address in the resident's person-centered care plan, and the facility would provide collaboration and coordination of hospice care. The policy-documented facility would ensure the appropriate documents were readily available, which included the hospice plan of care. The facility failed to coordinate care between the facility and the hospice provider for R19, who received hospice services. This deficient practice placed her at risk for inadequate end-of-life care.

The facility reported a census of 35 residents which included three residents sampled for appropriate treatment and services for mental disorders and safety. The facility failed to ensure staff provided appropriate supervision, monitoring, and interventions in response to Resident (R)1's suicidal ideation/actions and self-harm. At an unknown time on 03/10/24, R1, who suffered from delusions and hallucinations, jumped from an open window in her room, falling 12 feet to the sidewalk, and sustained multiple injuries that required hospitalization and surgery. Staff last saw R1 between 09:00 PM and 09:30 PM and found R1 on the sidewalk underneath her window at 10:54 PM. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) documented R1 had diagnoses which included multiple sclerosis (MS - a progressive disease of the nerve fibers of the brain and spinal cord), severe bipolar (major mental illness that caused people to have episodes of severe high and low moods) disorder with psychotic (any major mental disorder characterized by a gross impairment in reality perception) features, suicidal ideations (contemplations, wishes and/or preoccupation with death and suicide), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and unspecified psychosis. The 12/15/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R1 had hallucinations and no behaviors directed towards self or others during the look-back period. R1 had a Patient Health Questionnaire (PHQ - a screening and diagnostic tool to assess for depression) score of eight, which indicated mild depression. The resident took antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions), antianxiety (a class of medications that calm and relax people), and antidepressants (a class of medications used to treat mood disorders) daily during the seven-day look-back period. The 12/15/23 Psychosocial Well-Being Care Area Assessment (CAA) documented the resident had the potential for manic (mood characterized by an unstable expansive emotional state, extreme excitement, hyperactivity) and depressive (a mood disorder that causes a persistent feeling of sadness and loss of interest) episodes and received antipsychotic and antidepressant medications. The 12/15/23 Falls CAA documented the resident was a high risk for falls due to her diagnoses of MS and bipolar disorder and knew of her current limitations. The 12/15/23 Psychotropic (classes of medications that alters mood or thought) Drug Use CAA documented the resident had a diagnosis of bipolar disorder with potential for manic and depressive episodes and received antidepressant and antipsychotic medications. The Care Plan included the following interventions: An intervention dated 12/14/23, revealed staff were to monitor for side effects of antidepressant medication, which included suicidal ideations, and report to the physician any ongoing symptoms unaltered by medication therapy. An intervention dated 12/14/23, revealed staff were to monitor for side effects of antipsychotic medication which included suicidal ideations and behavior not usual for the person, and to report to the physician. The Care Plan lacked further instructions for staff in the event of suicidal ideations or episodes of actual or attempted self-harm. The facility lacked a formal suicide risk assessment for R1. The Behavior Monitoring Record task, dated 03/01/24 to 03/10/24, directed staff to monitor for the following: crying, repetitive movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate behaviors, and rejection of care. The Behavior Monitoring Record task did not include monitoring for suicidal ideations/self-harm. The Progress Notes documented the following: On 12/18/23, the physician documented R1 had a history of suicidal ideations, but no current thoughts of self-harm. On 01/13/24 at 09:01 PM, staff documented R1 attempted to drown herself in the toilet water in her bathroom and R1 expressed suicidal intent. R1 made a contract with staff that she would make no further attempts at self-harm. The staff then placed R1 on increased observation and removed items that could potentially be used for self-harm from the resident's room. On 01/13/24 at 12:04 PM, the physician documented R1 had suicidal ideations but could not get to her therapist due to severe weather outside. On 02/02/24 at 10:43 AM, staff documented attempts were made to find alternate placement for the resident due to family request and the resident's recent behavior outbursts. Other facilities declined to accept the resident. On 02/06/24 at 03:11 PM, staff documented R1 could verbally commit to safety when asked and had delusions of persecution about her children. The staff were able to redirect the resident away from the delusional thought. On 02/11/24 at 06:28 PM, staff documented R1 had experienced delusions and displayed withdrawn behaviors and voiced suicidal ideations. Staff notified the provider and required an unspecified medication for anxiety. On 02/27/24 at 05:18 AM, staff documented R1 experienced delusions that her children were able to watch her through the heating/air-conditioning vent in the bathroom and remained fixated on this delusion despite multiple redirection attempts by staff. On 02/28/24 at 03:04 AM, staff documented R1 experienced delusions of persecution with people outside her window (second floor) and the people threatened to harm her. The resident expressed suicidal ideations and staff were able to partially redirect the resident away from delusion. The record lacked additional documentation related to suicidal ideations. On 02/29/24 at 08:23 AM, staff documented R1 attempted to cut her tongue out with the blunt end of a metal spring from her hairclip. Staff were able to redirect R1 and staff moved R1 to the common area for easy observation by staff. Additionally, staff documented R1 was able to commit to safety. On 03/10/24 at 04:23 AM, staff documented that at approximately 03:00 AM, R1 was found army crawling on the floor in the hallway to another resident's room and expressed delusions of persecution about her children. Staff were able to redirect R1 away from the delusional thoughts. On 03/10/24 at 11:04 AM, staff documented that R1 displayed behaviors of self-harm and pulled some of her hair out but was easily redirected and her physician was notified and ordered medication. The Medication Administration Record (MAR) revealed that hydroxyzine (an antihistamine medication that can be given to treat mild to moderate anxiety) 25 milligrams (mg) related to anxiety disorder was administered to R1. On 03/10/24 at 07:24 PM, staff documented R1 had not taken her evening medication doses but had put them in her cheek and later spit them out. R1 stated to the staff that the medication was for her son, and he needed to take them. R1 maintained this delusion and refused to take the medication as prescribed. On 03/11/24 at 12:28 AM, staff documented that on 03/10/24 at approximately 10:54 PM, CNA staff observed R1 was not in her room and was found on the ground, on the sidewalk, outside R1's room. Staff called 911 on 03/10/24 at 10:55 PM, and two staff members left the facility to render aid to the resident on the ground. Staff documented R1 was naked from the waist down, lying face down with obvious injuries with blood from an unseen wound on her head and an abrasion (scraping or rubbing away of skin) to her right knee. Staff further documented R1 clearly stated that she had attempted suicide and expressed delusions that an unseen person had told her to do it. Staff covered her with a sheet to protect her dignity and remained with R1 until emergency personnel arrived and assumed care of R1 and transported her to the hospital. Staff documented telephone notification of Administrative Nurse B and R1's durable power of attorney (DPOA- a person named in a legal document that named a person to make healthcare decisions when the resident was no longer able to). On 03/11/24 at 08:18 PM, staff documented that the facility called the hospital and were notified that the resident required surgery for her injuries and was in surgery and would be taken to the ICU (intensive care unit) after the operation was completed. On 03/11/24 at 12:54 PM, staff documented the facility called and spoke with R1's DPOA, who stated that seven days prior to the incident, R1 expressed to them that she was contemplating suicide by jumping from the window in her room and expressed regret that they had not notified the facility about the intent with a plan for self-harm. Review of the facility's investigation dated 03/11/24, revealed the cause of the incident was suicidal intent, and the root cause of the event was that the window was not secured correctly. Review of hospital records revealed R1 sustained the following injuries that required surgery and subsequent hospitalization : 1. A fracture (broken bone) of her 10th thoracic vertebra (bone of the spinal column) and was treated with a TLSO (Thoracic Lumbar Sacral Orthosis - a rigid brace that restricts movement of the trunk of the body) brace. 2. A right femur (thigh bone) head/neck fracture which required an open reduction internal fixation (ORIF - a surgery in which the broken bone is exposed and put back together with plates/screws/rods/etc.) surgery and she was non-weight bearing. 3. A left elbow olecranon (the bony formation at the top of the ulna [one of the bones in the forearm] that forms the point of the elbow) fracture, which required immobilization with a splint and sling. 4. A right radial head (the knobby end of the radius [one of the bones in the forearm] where it meets the elbow) fracture which required immobilization with a splint/sling. 5. A right patella (kneecap) fracture which required a knee immobilizer and ORIF. 6. A left patella fracture which required a knee immobilizer. 7. A facial laceration (a wound to the skin) that was three centimeters (cm) long and treated with four sutures (a medical device used to hold body tissues together to approximate wound edges after an injury or surgery). Review of weather data for the facility area from the National Weather Service (www.weather.gov) revealed on 03/10/24 at 10:00 PM, the temperature was 48 degrees Fahrenheit, winds were out of the south at 12 miles per hour (MPH) with clear skies and no precipitation. A facility tour on 03/13/24 at 08:15 AM with Administrative Nurse A revealed the area where staff found R1, after she had jumped or fallen from the window in her room. It was approximately 10-12 feet to a cement sidewalk on the ground. Maintenance Staff C stated the measured distance from the bottom of the window to the ground was 12 feet. On 03/18/24 at 12:10 PM, Certified Nurse Aide (CNA) E stated she arrived on shift on 03/10/24 at approximately 10:00 PM, and she and CNA G started the night ice and water pass with visual checks on all the residents. When staff got to R1's room, the resident was not in the room, so CNA E went and asked CNA G to verify that the resident was not in her room. Once CNA E went into the room, CNA E noticed that the window was open and verified by the other aide. CNA G ran to the window and saw the resident laying on the ground and verified by CNA E. CNA G then ran to get the nurse on duty, then ran outside to the resident with the nurse. CNA E stated she stayed in the room at the window and talked to the resident, who was responsive, then and dropped a blanket and gloves out the window to the staff that were outside. CNA E stated R1 was wearing only a sweater. On 03/18/24 at 12:17 PM, surveyor was unsuccessful at an attempted interview with CNA F via telephone, however, a written witness statement from CNA F in the facility's investigation revealed that she had checked on R1 during evening rounds on 03/10/24 between approximately 09:00 PM and 09:30 PM. On 03/18/24 at 12:45 PM, CNA G stated at approximately 10:45 PM when CNA E and CNA G were doing the night ice/water pass, CNA E noticed R1 was not in her room and her wheelchair sat empty in the room. Both aides searched the room and the bathroom and did not locate the resident. CNA E noticed the bedroom window was open, and CNA G went to the window and looked down and saw the resident laying on the sidewalk. R1 wore only a long-sleeve shirt and was naked from the waist down. CNA G stated she ran and notified the nurse that the resident was out the window. The nurse ran to the window to verify, then both the nurse and CNA G ran outside to the resident, while the nurse called 911. CNA G went back inside to get a sheet to cover the resident, while they waited for Emergency Medical Services (EMS). On 03/18/24 at 12:23 PM, Licensed Nurse (LN) H revealed after the CNA told her the resident was outside, on the ground, LN H went into the room and saw the open window and peered out. It was dark outside and with the aid of a flashlight, they saw how the resident was laying on the ground and immediately ran to the door and called 911 on the company cell phone. When LN H arrived to where the resident laid on the ground outside, LN H reported the resident was responsive. LN H briefly assessed for injuries and made the decision to not move R1 due to the potential for major injury. There was blood on the ground around R1's head coming from an unseen wound and abrasions to her knees. She wore a shirt, but otherwise had no clothing on. EMS transferred R1 to the hospital. R1 had documented instances of delusions prior to the incident in the progress notes. On 03/18/24 at 12:40 PM, Administrative Nurse B stated the staff's actions and reactions to the incident were appropriate, and nothing could have happened differently to prevent the incident from happening. However, Administrative Nurse B stated that immediately following the incident, window locks were placed on all the windows in the facility to prevent them from opening fully. Administrative Nurse B confirmed the facility lacked a formal suicide screening tool and had initiated a task for nursing staff to ask the resident to commit to safety daily. Administrative Nurse B confirmed that R1's care plan lacked interventions specific to suicide prevention and would be updated to reflect these changes when and if the resident returned to the facility. On 03/18/24 at 01:55 PM, Social Services Designee (SSD) C confirmed that R1's care plan lacked interventions specific to suicide prevention and said that residents whose PHQ score was greater than five (which indicated more than minimal depression) received a more specific safety assessment and the physician should be notified. SSD C confirmed that the facility lacked a formal suicide screening assessment tool. The facility's policy Behavior Assessment and Monitoring, dated 04/2023, documented that problematic behavior will be identified and managed appropriately. A resident with problematic behavior or mood would have ongoing reassessments of changes in behavior, mood, and function. The facility failed to ensure staff provided appropriate supervision, monitoring, and interventions in response to Resident (R)1's suicidal ideation/actions and self-harm when at an unknown time on 03/10/24, R1, who suffered from delusions and hallucinations, jumped from an open window in her room, falling 12 feet to the sidewalk, and sustained multiple injuries that required hospitalization and surgery. Staff last saw R1 between 09:00 and 09:30 PM and found R1 on the sidewalk underneath her window at 10:54 PM. This deficient practice placed R1 in immediate jeopardy. On 03/18/24 at 04:58 PM, Administrative Staff A and Administrative Nurse B were provided the Immediate Jeopardy (IJ) Template for failure ensure staff provided appropriate supervision, monitoring, and interventions in response to Resident (R)1's suicidal ideation/actions and self-harm. The facility immediately implemented corrective measures following R1's departure from the facility to the hospital. The facility's corrective measures included the following, which were verified by the surveyor on-site during the investigation: 1. The facility implemented education for all staff on QAPI Plan: Injury From Failure To Follow Care Plan which outlined steps and instructions for staff to follow immediately following an injury caused by failure to follow a resident's care plan and Behavior Assessment and Monitoring which outlined steps and instructions for staff to follow for residents with problematic behavior on 03/11/24 at 12:01 AM and completed with all employees on 03/12/24 at 10:00 PM. 2. The facility provided documentation that immediately following the event, all windows in the facility were secured with mechanical window locks to prevent the windows from opening more than 5 inches and completed at 03/11/24 at 02:00 AM. 3. The facility provided documentation of daily checks of the window locks from 03/11/24 to 03/13/24 and Maintenance staff D revealed that checks were to be performed daily for three weeks, then checked twice a week for two weeks, then weekly checks would continue indefinitely. 4. The facility performed a PHQ and suicide screen on all residents in the facility on 03/11/24 at unknown time and identified five additional residents with scores that indicated more than minimal depression and no additional residents with suicidal ideations or thoughts of self-harm. 6. The facility provided documentation of a Quality Assurance Process Improvement (QAPI) meeting that occurred on 03/11/24. All corrections were completed prior to the onsite survey, therefore the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility reported a census of 38 residents and identified one resident at risk for elopement. Based on observation, interview, and record review the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)1, identified as a moderate risk for elopement. On 11/01/23 at 06:45 PM, R1 exited the north door, unsupervised, which triggered the door alarm. The responding staff silenced the door alarm without checking outside the door to determine who/what triggered the alarm. R1 ambulated down six crumbling cement steps, around the facility approximately 450 feet and through an unfenced, unsecured courtyard, where staff found R1 approximately 53 minutes later, trying to re-enter the facility through a locked door. This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR) documented R1 had diagnoses which included alcohol dependence with alcohol-induced persisting dementia (a progressive mental disorder characterized by failing memory and confusion, difficulty in walking) and generalized weakness. The 02/09/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated R1 could not complete the interview. The resident wandered daily in the seven-day look-back period. R1 required the assistance of two or more staff for all cares, except eating and locomotion, which required supervision and setup. The MDS documented the resident was not steady with walking. The 08/08/23 Quarterly MDS documented a BIMS score of 99, which indicated the resident could not complete the interview. The resident wandered four to six days in the seven-day look-back period. R1 required the assistance of two or more staff for all cares except eating and locomotion, which required supervision and setup. The MDS documented the resident was not steady with walking. The Care Plan documented an intervention, dated 06/21/22, for staff to provide redirection when the resident ambulated in the facility. The Care Plan lacked interventions specific to elopement risk. The Wandering and Elopement Evaluation Assessments revealed the following for R1: A low risk on 02/03/22, 08/03/22, 08/24/22, 11/24/22, and 07/09/23. A moderate risk on 05/03/22, 02/24/23, 05/24/23, and 10/09/23. The Progress Notes on 10/22/23 at 09:59 PM documented R1 attempted to open an exit door and set off the alarm. The staff intervened and redirected the resident away from the door. The Progress Notes on 11/01/23 at 07:20 PM documented Certified Nurse Aide (CNA) C notified Licensed Nurse (LN) O the staff could not locate R1 within the facility. The Progress Notes on 11/01/23 at 07:32 PM documented CNA C and CNA E located R1 outside of the building in an unfenced courtyard area. Review of the facility investigation revealed on 11/01/23, at approximately 06:30 PM to 06:40 PM, CNA D observed R1 seated at a dining table after the evening meal. Administrative Staff A reviewed the camera footage and noted R1 pushed on the north exit door at 06:43 PM, which set off the exit door alarm, and R1 exited the building at 06:45 PM. At 06:47 PM, the camera revealed CNA C silenced the door alarm and looked out the windows but failed to exit the building to investigate who exited or why the door alarm was sounding. At 07:20 PM, CNA C discovered R1 was missing when staff could not locate R1 for his shower. CNA C notified LN O, who initiated the facility's elopement procedure. At 07:32 PM CNA C and CNA E located R1 outside of the building, in an unfenced courtyard area, attempting to reenter the building through a locked door. At 07:38 PM (53 minutes after the resident exited the facility door) CNA C and CNA E escorted R1 back into the building. On 11/06/23 at 10:00 AM, observation with Administrative Staff A revealed the area the resident traveled during the elopement on the evening of 11/01/23. Administrative Staff A explained the resident exited the building through the north alarmed exit door into an atrium. The atrium's secondary exit door lacked an alarm to alert staff of the resident leaving the facility. Immediately outside the exterior door was an elevated cement porch with multiple deep and uneven cracks and hand railings. R1 exited the porch down six cement stairs, with crumbling edges and hand railings down both sides. The handrails had rusted and broken rail supports with exposed jagged metal where the upright portions of the rails would have met the cement steps. R1 would have walked approximately 400 feet along the western exterior of the building which contained multiple elevated down-spouts that carry storm water an additional 10-15 feet out and away from the building. R1 would have then walked along the southern edge of the building, approximately 50 feet, in an area that contained grass and a cement sidewalk. R1 then walked north approximately 350 feet along the eastern exterior of the building. This side of the building also contained multiple elevated down-spouts, and multiple areas where fallen leaves collected along the edge of the building, creating potential trip hazards. The staff located R1 in an unfenced, unsecured courtyard. The resident was trying to re-enter the building through a locked door. The resident had to travel a total of approximately 800 feet around the building, in the dark, with multiple trip hazards along his way. Review of weather data for the facility area from Weather Underground (www.wundergound.com), on 11/01/23 at approximately 07:00 PM, revealed the Sun set at 06:29 PM, 16 minutes before the resident exited the building. The temperature was 45 degrees Fahrenheit, with a south wind of 10 miles per hour (mph). Observation of the area around the facility revealed a heavily traveled highway, approximately one-half mile to the north of the facility. On 11/06/23 at 10:00 AM, Administrative Staff A explained on the night of 11/01/23 the staff failed to search the outside vicinity of the alarming door, prior to silencing the alarm. Observation on 11/06/23 at 11:30 AM, revealed R1 ambulated with a slow shuffling gait (manner or style of walk) from the common area into the dining area with supervision from staff. The resident used no assistive devices to ambulate but appeared unsteady with his gait. On 11/06/23 at 01:10 PM, interview with CNA C verified her written witness statement regarding R1's elopement on 11/01/23. CNA C heard the exit door alarm sounding when she returned from her break at 06:45 PM. She walked to the door and silenced the alarm, but she failed to check outside of the exit door to determine who opened the door. She then failed to perform a head check of the residents in the facility to determine if anyone was missing. When CNA C found the resident later outside of the facility, he wore a long sleeve shirt without a jacket and was trying to reenter the facility through a locked door. On 11/06/23 at 01:22 PM, interview with CNA D verified her witness statement information regarding R1's elopement. The last time CNA D saw the resident was at approximately 06:30 PM to 06:40 PM on 11/01/23. CNA D reported she knew the resident had a history of exit seeking prior to the elopement. On 11/06/23 at 01:54 PM, interview with Administrative Nurse B revealed R1 did have previous exit seeking behavior and at one time used a WanderGuard (device worn which triggers an alarm to alert staff when the resident came within range of the transmitter, usually posted near an exit door ). The staff later reevaluated the resident and removed the WanderGuard on or around 07/09/2 3 and placed interventions of increased supervision and a locked building. Administrative Nurse B stated looking back on the removal of the WanderGuard, the resident should not have had the WanderGuard removed. Administrative Nurse B further explained the resident was not safe being on the stairs without assistance due to his slow, shuffling gait. On 11/07/23 at 11:20 AM , interview with LN L reported knowledge R1 had a history of wandering, with exit seeking behavior, prior to the elopement. The facility's Accidents - Elopement policy, dated 10/2022 documented all residents with a history of substance use disorder will be evaluated for elopement and wandering upon admission and quarterly and will be deemed no risk, low risk, moderate risk, or high risk. The facility failed to ensure staff responded appropriately to door alarms to prevent the elopement of cognitively impaired, independently mobile R1, identified as a moderate risk for elopement. On 11/01/23 at 06:45 PM, R1 exited the facility, unsupervised, setting off the door alarm and the responding staff silenced the door alarm without checking outside the door to determine what triggered the alarm. R1 remained outside the facility for approximately 53 minutes in the dark, which placed the resident in immediate jeopardy. The facility immediately implemented corrective measures following the resident's return into the facility. The facility corrective measures included the following, which were verified by the surveyor on-site during the investigation: 1. The facility implemented education for all staff on the elopement policy on 11/01/23 following the resident's return into the facility and completed 42 of the 50 employees on 11/02/23 at 04:18 PM. The remaining eight employees were required to complete the training before return to duty. 2. The facility provided documentation that staff placed a WanderGuard on the resident's right ankle upon return into the facility on [DATE]. 3. The facility provided documentation of testing completed on 11/01/23 for the WanderGuard system and exit door alarm system. 4. The facility completed Wandering/Elopement Assessments on all residents in the facility, completed by 11/02/23. 5. The facility provided documentation of a Quality Assurance Process Improvement meeting that occurred on 11/02/23. All corrections were completed prior to the onsite survey therefore the deficient practice was cited past noncompliance at a scope and severity of J.

The facility had a census of 40 residents. The sample included 12 residents, with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide nutritional support to prevent a significant weight loss of 10 lbs. or 6.36 percent in 21 days for Resident (R) 142. This failure placed the resident at ongoing risk for malnutrition and continued weight loss. Findings included: - R142's Electronic Medical Record (EMR) recorded he admitted to the facility on [DATE] with the only diagnosis of Huntington's (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder) disease. R142 had an admission weight of 157.2 pounds (lbs.). The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ADR) of 02/14/23, was not completed and remained in progress. The Care Area Assessment (CAA), associated with the 02/14/23 MDS, also remained in progress. R142's Baseline Care Plan, dated 02/06/23, documented to promote/maintain adequate gastrointestinal habits, monitor for signs and symptoms, and monitor meal intake per protocol. On 02/15/23, R142's Care Plan documented R142 was at risk for altered nutritional/hydration status related to Huntington's disease. The care plan directed staff to encourage consumption of fluids provided, provide adaptive equipment of weighted silverware, Kennedy (designed to be spill proof) cups with a straw, and a divided plate. It directed staff to provide and serve a regular diet, regular texture, and thin liquids as ordered, and monitor and record meal intake. Monitor/record/report to the Medical Doctor as needed for signs and symptoms of malnutrition: loss of three lbs. in one week or greater than five percent (%) in one month. The care plan further directed staff to honor R142's food preferences and update as needed; R142 loved cottage cheese, Dr. Pepper (soda drink), cheese, and sandwiches. Provide set-up and assistance with meals/snacks. The care plan further documented the Registered Dietician (RD) to evaluate and make recommendations as needed and physical, occupational, and speech therapy to evaluate and treat as needed. R142's Comprehensive Care Plan had not been completed. The Physician Order dated 02/06/23, documented dietary supplements may be used when determined appropriate by Interdisciplinary Team (IDT) or RD, and physical, occupational, and speech therapy to evaluate and treat. The Physician Order dated 02/07/23, directed staff to provide a regular diet, regular texture, and thin consistency liquids. The Nutrition: RD Admission assessment dated [DATE], documented R142's nutrition information, from the EMR, documented R142 was 71 inches tall and weighed 157.2 lbs. The assessment recorded the nursing admission note reported R142 had a recent weight loss, and the RD was unsure of details; per progress notes R142's diet was regular, but there was no physician ordered diet ordered yet. R412's meal intake was good at 76-100%, no special items were utilized. R142 independently fed himself and was ambulatory. On 02/07/23 R142's EMR recorded he weighed 156.0 lbs. (a 7.2 lb. difference) The Nutrition Progress Note, dated 02/07/23, documented R142's oral intake demonstrated he had a good appetite. He was edentulous (without teeth), no dentures, and had no nutrition recommendations at that time. The Progress Note dated 02/09/23 at 10:44 AM, documented R142 received orders for therapy. The nurse spoke with R142's Durable Power of Attorney (DPOA) who verbalized the desire to put therapy on hold and said the DPOA would let facility know when the DPOA was ready for the therapy to resume. The Task section of R142's EMR documented he received limited assistance of one-person physical assist with eating on 02/12/23 and 02/13/23 only. The Nutrition: Dietary Manager Initial (Admission) Evaluation, dated 02/14/23, recorded the source of the nutrition information evaluated as R142. R142's desired weight range was 150-160 lbs., he had a regular diet and thin liquids, and no specialized items utilized. R142's beverage preferences were water, coffee, milk, juice, and Dr. Pepper. R142 stated his appetite was good, his usual eating pattern was all three meals. He liked to snack between meals. The note recorded r142's self-feeding ability as he required supervision, oversight, and cueing. Family brought in snacks and drinks. R142 was not a picky eater, and before coming to facility would occasionally skip a meal and would eat snacks. The evaluation further documented R142 had Huntington's disease; he may burn extra calories due to body movements; he used weighted silverware and on occasion nursing would assist with feeding. The Dietary Admission Welcome and Interview Sheet, dated 02/14/23, documented R142 had a usual weight of 155 lbs. and a desired body weight of 150-160 lbs. R142 liked cottage cheese, cheese, Dr. Pepper, and sandwiches. He disliked broccoli. R142 was not picky, and he fed himself with weighted silverware. R142 had no difficulty with swallowing, chewing, or feeding himself with weighted silverware and some assistance from staff. On 02/20/23 the Weight Variance Note recorded R142 weighed 148.8 lbs. (5.34% loss in two weeks), and a nutritional supplement twice a day was initiated. The medical provider was notified of the weight loss. The goal for R142 was to encourage and or assist him at meals; R142 had snacks and drinks in his room and used weighted silverware. The Task section of R142's EMR documented he received limited assistance of one-person physical assist with eating on 02/12/23 and 02/13/23 only. The EMR dated 02/27/23 recorded R142's weighed 147.2 lbs., a continued loss of greater than 5%. On 02/22/23 at 12:30 PM observation revealed R142 sat in the dining room wearing a clothing protector. The meal served to R142 consisted of thin soup in a bowl, a biscuit, and mixed fruit. R142 used a weighted spoon and his fingers to eat chunks of vegetables and meat from soup. R142 had extensive continual involuntary movements in his arms, trunk, hands, neck, and head. After obtaining the biscuit and attempting to split it in half, R142 unintentionally flung the biscuit across the table, and it landed on the floor. R142 then placed the other half of the biscuit in the soup then did not eat it. During the process of eating, he continually tried to keep his clothing protector in place. R142 then placed the weighted spoon into the ice cream and withdrew over half the ice cream on the spoon and placed all of it into his mouth. Staff seated at the table offered no assistance to the resident with cueing, or meal intake, or placement/adjustment of his clothing protector. On 02/23/23 at 08:11 AM observation revealed R142 received a breakfast of French toast, hot cereal with brown sugar and bacon. R142 had continual involuntary movements. He poured syrup onto the hot cereal, picked up the whole slice of French toast and ate it with his fingers, and then picked up the bacon. He placed the bacon in his mouth and tore off large pieces to chew then, using the weighted spoon started, eating the hot cereal. While eating R142's clothing protector continually slipped to his lap, and he attempted numerous times to keep it over his chest area to protect his clothing. R142 was not successful and dropped cereal on his shirt. Staff seated at the table did not assist the resident with his clothing protector or help with eating. On 02/23/23 at 12:22 PM observation revealed R142 received a meal of whole boneless, barbecue chicken breast, peas in a bowl, and macaroni and cheese. R142 managed to cut the chicken breast in half despite the involuntary movements of his body. R142 took one half of the chicken breast into his mouth (resident has not teeth or dentures) and worked at chewing it to swallow. R142 then used his hands to cup the macaroni and cheese in his right hand to eat. R142 worked at eating all his macaroni and cheese and the other half of the chicken breast. Again, R142 was not able to keep clothing protector in place and dropped a great deal of food on his shirt. Staff present at the table did not assist R142 with eating or his clothing protector. On 02/23/23 at 01:12 PM Certified Nurse Aide (CNA) P stated R142 was new to the facility and ate almost anything put in front of him. CNA P reported R142 used of weighted silverware but was messy during meals. CNA P reported R142 had snacks and Dr. Pepper in his room, and since the resident was mostly independent, and he did not need assistance with snacks and drinks in the room. On 02/27/23 at 07:44 AM, Dietary Staff (DS) BB stated R142 received nutritional supplement two times a day. DS BB said Huntington's disease was new to her and was aware of constant flailing of arms and that she provided the resident with weighted silverware. DS BB verified she did the diet history and preference and R142's soup should have been in a cup. She also verified the resident was at risk for choking by placing half a chicken breast in his mouth and should have foods cut up. She reported dietary and nursing department could referred to therapy services. CDM also reported she had not observed resident's eating. On 02/27/23 08:45 AM Administrative Nurse D reported she had not observed meals for R142, she stated he was mostly independent. She verified staff should be mindful of the resident's struggle with clothing protector and assistance with cutting up food to prevent choking and involving therapy as an intervention due to R142 weight loss. Administrative Nurse D verified staff should assist the resident at meals to enhance dignity and prevent further weight loss. The facility's Nutrition(impaired)/Unplanned Weight Loss Clinical Protocol, dated 04/2021 documented assessment and recognition monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. As part of the initial assessment the IDT through the various assessments will define the individuals with anorexia, recent weight loss and significant risk for impaired nutrition. The threshold for significant unplanned and undesired weight loss will be based on the following criteria of one-month five percent (%) weight loss is significant and greater than five % is severe. For individuals with recent or rapid weight loss the IDT should consider possible fluid and electrolyte imbalances as a cause. IDT should attempt to identify conditions and medications that may be causing anorexia, weight loss, or increased the risk of weight loss. Closely monitor residents who have been identified as having impaired or risk factors for developing impaired nutrition. Identify pertinent interventions based on cause-specific interventions as indicated with careful consideration. The facility failed to provide nutritional support for R142 resulting in a significant weight loss of 10 lbs. or 6.36 percent in 21 days. This failure also placed R142 at ongoing risk for malnutrition and weight loss.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility' Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concerns for the 40 residents, who reside in the facility. Findings included: -Based on observation, record review, and interview, the facility failed to provide Resident (R) 142 with dignified dining. Refer to F550. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to include R29's Black Box Warning medications. Refer to F656. Based on observation, record review, and interview, the facility failed to update care plans following falls for R7 and R8, and lacked care plan invitation and participation for R14. Refer to F657. Based on observation, record review, and interview, the facility failed to find ways to communicate R 7 language barrier for activities of daily living. Refer to F676. Based on observation, record review, and interview, the facility failed to provided care planned toileting for R5 and meal assistance for R142. Refer to F677. Based on observation, record review, and interview, the facility failed provide comforting care for R7 while resident moaned in the living room. Refer to F684. Based on observation, record review, and interview, the facility failed to provide pressure reducing device for R7 who was left in a wheelchair for over 2 hours two days in a row. Refer to F686. Based on observation, record review, and interview, the facility failed to place intervention for R7 and R18 from falling and had not followed care planned toileting to prevent falls for R 5. Refer to F689. Based on observation, record review, and interview, the facility failed to prevent significant weight loss for R142. Refer to F692. Based on observation, record review, and interview, the facility failed to change R14's oxygen mask daily, placing the R14 at risk for respiratory infections. Refer to F695. On 02/27/23 at 01:37 PM, Administrative Staff A reported she collects data from the interdisciplinary team and other sources of information for the quality assessment and assurance program that meets on a monthly basis for formulate plans of improvement. The facility's QAPI Committee, Program Feedback, Data Systems and Monitoring policy, dated 10/2022, documented this facility shall establish and maintain a Quality Assessment and Assurance Committee (QAPI) that oversees the identification and handling of quality issues. The facility shall establish a system for program feedback, data collection systems and monitoring, to include adverse event monitoring. The facility failed identify multiple issues of concern for the 40 resident who reside in the facility placing the residents at risk for lack of quality care.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident 142, who was left unattended and unassisted while dropping food down on the front of his shirt. This placed R142 at risk for impaired dignity and decreased psychosocial wellbeing. Findings included: - R142's Electronic Medical Record (EMR) recorded he admitted to the facility on [DATE] with the only diagnosis of Huntington's (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder) disease. R142 had an admission weight of 157.2 pounds (lbs.). The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ADR) of 02/14/23, was not completed and remained in progress. The Care Area Assessment (CAA) also remained in progress. R142's Baseline Care Plan, dated 02/06/23, documented to promote/maintain adequate gastrointestinal habits, monitor for signs and symptoms and monitor meal intake per protocol. On 02/15/23 R142's Care Plan addition documented R142 was at risk for altered nutritional/hydration status related to Huntington's disease. The care plan directed staff to encourage consumption of fluids provided, provide adaptive equipment of weighted silverware, Kennedy (designed to be spill proof) cups with a straw, and a divided plate. It directed staff to provide and serve a regular diet, regular texture, and thin liquids as ordered, and monitor and record meal intake. Monitor/record/report to the Medical Doctor as needed for signs and symptoms of malnutrition: loss of three lbs. in one week or greater than five percent (%) in one month. The care plan directed staff to honor R142's food preferences and update as needed; R142 loved cottage cheese, Dr. Pepper (soda drink), cheese, and sandwiches. Provide set-up and assistance with meals/snacks. The care plan further documented the Registered Dietician (RD) to evaluate and make recommendations as needed and physical, occupational, and speech therapy to evaluate and treat as needed. R142's Comprehensive Care Plan had not been completed. On 02/22/23 at 12:30 PM observation revealed R142 sat in the dining room wearing a clothing protector. The meal served to R142 consisted of thin soup in a bowl, a biscuit, and mixed fruit. R142 used a weighted spoon and his fingers to eat chunks of vegetables and meat from soup. R142 had extensive continual involuntary movements in his arms, trunk, hands, neck, and head. After obtaining the biscuit and attempting to split it in half, R142 unintentionally flung the biscuit across the table, and it landed on the floor. R142 then placed the other half of the biscuit in the soup then did not eat it. During the process of eating, he continually tried to keep his clothing protector in place. R142 then placed the weighted spoon into the ice cream and withdrew over half the ice cream on the spoon and placed all of it into his mouth. Staff seated at the table offered no assistance to the resident with cueing, or meal intake, or placement/adjustment of his clothing protector. On 02/23/23 at 08:11 AM observation revealed R142 received a breakfast of French toast, hot cereal with brown sugar and bacon. R142 had continual involuntary movements. He poured syrup onto the hot cereal, picked up the whole slice of French toast and ate it with his fingers, and then picked up the bacon. He placed the bacon in his mouth and tore off large pieces to chew then, using the weighted spoon started, eating the hot cereal. While eating R142's clothing protector continually slipped to his lap, and he attempted numerous times to keep it over his chest area to protect his clothing. R142 was not successful and dropped cereal on his shirt. Staff seated at the table did not assist the resident with his clothing protector or help with eating. On 02/23/23 at 12:22 PM observation revealed R142 received a meal of whole boneless, barbecue chicken breast, peas in a bowl, and macaroni and cheese. R142 managed to cut the chicken breast in half despite the involuntary movements of his body. R142 took one half of the chicken breast into his mouth (resident has not teeth or dentures) and worked at chewing it to swallow. R142 then used his hands to cup the macaroni and cheese in his right hand to eat. R142 worked at eating all his macaroni and cheese and the other half of the chicken breast. Again, R142 was not able to keep clothing protector in place and dropped a great deal of food on his shirt. Staff present at the table did not assist R142 with eating or his clothing protector. On 02/23/23 at 01:12 PM Certified Nurse Aide (CNA) P stated R142 was new to the facility and ate almost anything put in front of him. CNA P reported R142 used of weighted silverware but was messy during meals. CNA P reported R142 had snacks and Dr. Pepper in his room, and since the resident was mostly independent, and he did not need assistance with snacks and drinks in the room. On 02/27/23 at 07:44 AM, Dietary Staff (DS) BB stated R142 received nutritional supplement two times a day. DS BB said Huntington's disease was new to her and was aware of constant flailing of arms and that she provided the resident with weighted silverware. DS BB verified she did the diet history and preference and R142's soup should have been in a cup. She also verified the resident was at risk for choking by placing half a chicken breast in his mouth and should have foods cut up. She reported dietary and nursing department could referred to therapy services. CDM also reported she had not observed resident's eating. On 02/27/23 08:45 AM Administrative Nurse D reported she had not observed meals for R142, she stated he was mostly independent. She verified staff should be mindful of the resident's struggle with clothing protector and assistance with cutting up food to prevent choking and involving therapy as an intervention due to R142 weight loss. Administrative Nurse D verified staff should assist the resident at meals to enhance dignity and prevent further weight loss. The facility's Quality of Life-Activities of Daily Living policy dated 11/2017, documented the community environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving independent functioning, dignity, and well-being. Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide a dignified dining experience by not assisting R142 with eating and his clothing protector and as a result R142 dropped food down the front of his shirt. This placed R142 at risk for impaired dignity and decreased psychosocial well-being.

The facility had a census of 40 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to develop a comprehensive care plan for Remeron (an antidepressant medication), Lasix (a diuretic medication), and Eliquis (an anticoagulant medication), which required a Black Box Warning for one sampled resident, Resident (R) 29. This placed the resident at risk for adverse side effects. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), chronic kidney disease (disease of the kidney's leading to kidney failure), diabetes mellitus type 1 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), artherosclerotic heart disease (a buildup of fats cholesterol and other substances in and on the artery walls) and atrial fibrillation (rapid, irregular heart beat). The Admission Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, ambulation, dressing, and personal hygiene. The MDS further documented R29 received an antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression), diuretic (medication to promote the formation and excretion of urine, anticoagulant (medication to prevent and treat clots in blood vessels and the heart), and an antibiotic ( a medication used to treat infections caused by bacteria and other microorganisms). R29's EMR lacked documentation of a Black Box Warning (BBW-indiates that the drug carries a significant risk of serious or even life threatening adverse effects) care plan for the use of the Remeron, Lasix, and Eliquis medications. The Physician Order, dated 01/26/23, directed staff to administer Remeron, 7.5 milligrams (mg), by mouth, daily for sleep disorder. The Physician Order, dated 01/26/23, directed staff to administer Eliquis, 5 mg, by mouth, twice daily, for artherosclerotic heart disease. The Physician Order, dated 01/27/23, directed staff to administer Lasix, 40 mg, by mouth, daily, for congestive heart failure. On 02/21/23 at 03:03 PM, observation revealed R29 independently ambulating with her walker down the hall. On 02/22/23 at 04:00 PM, Administrative Nurse E verified she had not developed a care plan for R29's medications that required a Black Box Warning. On 02/27/23 at 10:26 AM, Administrative Nurse D stated there should be a care plan completed for R29's medications. The facility Comprehensive Care Plans policy, dated August 2022, documented an individualized comprehensive person centered care plan that included measurable objectives and time frames to meet the residents medical, nursing, mental, cultural, and psychological needs was developed for each resident. The residents comprehensive care plan was developed within seven days of the completion of the residents comprehensive assessment. The care plan team was responsible for periodic review and updating of care plans when there was a significant change in condition, or when the desired out come was not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly. The facility failed to develop a comprehensive care plan for R29's Black Box Warning medications, placing her at risk for adverse side effects.

The facility had a census of 40 residents. The sample included 12 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with resident-centered interventions to prevent falls for two sampled residents, Resident (R) 7 and R18, and failed to notify and invite one sampled resident, R14 to her care plan meetings. This placed the affected residents at risk for uncommunicated and unmet care needs as well as decreased autonomy. Findings included: - The Electronic Medical Record (EMR) for R7 recorded diagnoses dementia with behavior disturbance (progressive mental disorder characterized by failing memory, confusion), unsteadiness on feet, cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain), muscle weakness, and dysphagia (swallowing difficulty). R7's Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had long and short-term memory impairment and required extensive assistance of two staff for bed mobility, transfers, ambulation, dressing and toileting. The MDS further documented R7 had unsteady balance, no functional impairment and had one non-injury fall. The Significant Change MDS, dated [DATE], documented R7 had long and short- term memory impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The MDS further documented R7 had unsteady balance, no functional impairment, and had no falls. The Fall Risk Assessments, dated 04/10/22, 07/10/22, 08/06/22, and 11/07/22 documented the resident was a high risk for falls. The Fall Care Plan, dated 01/10/23, originally dated 09/17/19, directed staff to ensure R7 wore appropriate footwear when ambulating, check and change upon rising in the morning, before and after meals, and prior to bedtime, and ensure R7 wore nonskid socks at night. The update, dated 05/01/21, directed staff to sit with the resident while in the dining room and redirect him as needed to stay seated. The update dated 08/20/22 directed staff to check alarm placement every two hours for correct positioning. The update, dated 01/26/23, directed staff to have resident in full view when not in bed and be aware of R7 when he wandered outside of the 200 hall and commons area to determine if the resident had any needs. The Fall Investigation, dated 02/15/22 at 05:42 PM, documented R7 stood from his wheelchair, appeared to be off balance, went to sit down and missed the seat of the wheelchair. The investigation further documented the fall was witnessed and the resident did not obtain any injuries. The Fall Investigation, dated 05/31/22 at 04:40 PM, documented R7 was observed on the floor in his room, lying on his back. The investigation further documented the fall was unwitnessed and the resident could not describe what he was doing at the time of the fall. The Fall Investigation, dated 08/06/22 at 06:35 PM, documented R7 slid out of his wheelchair on to the floor. The investigation further documented R7 tried to get up unassisted and was not wearing shoes or gripper socks. The investigation directed staff to make sure R7 wore shoes or gripper socks. The Fall Investigation, dated 08/20/22 at 03:00 PM, documented R7 was found on the floor in the activity room. The investigation further documented R7's chair alarm was not on, and education was given to staff to always keep the alarm on. The Fall Investigation, dated 01/20/23 at 07:30 PM, documented R7 was found in another resident's room on the floor. The investigation further documented staff were notified by another resident that R7 had fallen in his room. The investigation documented R7's alarm was not on and staff were educated to make sure the alarm was turned on after transfers and throughout the day. On 02/22/23 at 10:15 AM, observation revealed Certified Nurse Aide (CNA) M transferred the resident from his wheelchair to his bed without a gaitbelt. Further observation revealed R7 spoke to CNA M in Arabic, and she stated she did not know what he was saying. CNA M checked his incontinence brief and verified his buttocks were red and stated she would apply barrier cream after peri care. Observation revealed, CNA M could not find barrier cream and put a clean incontinence brief on R7, took his shoes off, and covered him up. On 02/22/23 at 10:15 AM, CNA M stated a lot of the time she did not know what the resident was saying as he spoke in Arabic and did not have any means to find out what he was saying. CNA M further stated staff made sure his bed was lowered, a bed alarm, and a fall mat was placed next to the bed to prevent further falls. On 02/27/23 at 07:49 AM, Licensed Nurse (LN) G stated R7 got restless when he required toileting and had received therapy in the past for his falls. On 02/27/23 at 10:26 AM, Administrative Nurse D stated staff checked his alarm every two hours to make sure it is on and verified there should be interventions in place after a resident fell . The facility Comprehensive Care Plans policy, dated August 2022, documented an individualized comprehensive person centered care plan that included measurable objectives and time frames to meet the residents medical, nursing, mental, cultural, and psychological needs was developed for each resident. The residents comprehensive care plan was developed within seven days of the completion of the residents comprehensive assessment. The care plan team was responsible for periodic review and updating of care plans when there was a significant change in condition, or when the desired out come was not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly. The facility failed to provide identify and implement resident centered interventions to the care plan to prevent falls for cognitively impaired R7, placing him at risk for further falls and injury. - The Electronic Medical Record (EMR) for R18 documented the resident had diagnoses of bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), cognitive communication deficit (may occur after a stroke, tumor, brain injury, or other neurological damage), traumatic brain injury (brain dysfunction caused by an outside force, usually a blow to the head), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R18's Admission Minimum Data Set (MDS), dated [DATE], documented R18 was admitted to the facility 08/30/22 and had moderately impaired cognition and required extensive assistance of two staff for transfers, and extensive assistance of one staff for bed mobility, ambulation, toileting, and personal hygiene. The assessment further documented R18 had unsteady balance, no functioning impairment, and had one fall since admission. The Quarterly MDS, dated [DATE], documented R18 had moderately impaired cognition and was dependent upon two staff for transfers, toileting, and extensive assistance of two staff for bed mobility, and toileting. The assessment further documented R18 did not ambulate, had unsteady balance, no functional impairment and had one non-injury fall. The Fall Assessments, dated 08/31/22, 11/07/22, and 02/09/23, documented R18 was a high risk for falls. The Nursing Evaluation, dated 08/30/22, documented R18 used a walker when ambulating with staff assistance, had full range of motion, and did not require the use of a mechanical lift for transfers. Review of the EMR lacked documentation a fall care plan was completed until 12/18/22. The Nurse's Note, dated 09/03/22 at 02:09 PM, documented R18 was lowered to the floor with two staff assistance and a gait belt. The note further documented R18 did not receive any injuries. Review of the EMR lacked further documentation regarding the fall. On 02/23/23 at 08:58 AM, observation revealed Licensed Nurse (LN) H and Certified Nurse Aide N attached the sling to the mechanical lift and lifted R18 up and lowered her onto the bed. On 02/23/23 at 09:00 AM, CNA N stated she was not aware of any falls prior to the most recent fall the resident had. CNA N laughed and stated the most recent fall happened as a CNA rolled the resident, and the resident kept rolling and fell out of bed. CNA N further stated R18 was not hurt and that she should not laugh about it, but it was funny. CNA N stated staff use a mechanical lift and two staff for her transfers. On 02/27/23 at 09:17 AM, LN G stated R18 was lowered to the ground by two staff, and the facility considered that a fall, but LN G was unable to find an incident report. On 02/27/23 at 10:26 AM, Administrative Nurse D verified she was unable to find any incident report related to staff lowering R18 to the floor and stated an incident report should have been completed as well as fall interventions for the resident The facility Comprehensive Care Plans policy, dated August 2022, documented an individualized comprehensive person centered care plan that included measurable objectives and time frames to meet the residents medical, nursing, mental, cultural, and psychological needs was developed for each resident. The residents comprehensive care plan was developed within seven days of the completion of the residents comprehensive assessment. The care plan team was responsible for periodic review and updating of care plans when there was a significant change in condition, or when the desired out come was not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly. The facility failed to identify and implement resident centered interventions for falls for R18, after staff lowered her to the ground, placing her at risk for further falls and injury. 37450 -R14's Electronic Medical Record (EMR) recorded diagnoses of acute and chronic respiratory failure, atrial fibrillation (rapid, irregular heart beat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, cerebral infarction (stoke), hemiplegia (paralysis of one side of the body), morbid (severe) obesity, and angina pectoris (chest pain). The Annual Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, no delirium or exhibited behaviors. R14 required extensive assistance of two staff for activities of daily living with the exception of eating which required limited assistance of one staff member. R14 had pain and pain treatment, shortness or trouble breathing with exertion and when lying flat. The MDS further documented R14 received oxygen and required non-invasive mechanical ventilator. The EMR Care Plan reviews were dated 03/17/22, 06/21/22, 09/20/22, and 12/20/22. Review of R14's Care Plan Invitation for 03/17/22 and 06/21/22 revealed the resident had been invited and signatures of the interdisciplinary team in attendance along with R14's signature. The 09/20/22 and 12/20/22 invitation did not include R14 had attended nor had R14's signature for attendance. On 02/21/23 during initial tour and resident interview, R14 reported she had not been invited or participated in the care planning process. On 02/23/23 at 04:29 PM Administrative Nurse E reported she was responsible for the care plan invitation, and she keeps the care plan conference invitation. The information sheet documented the letter was to inform that the resident or representative it was time for the care plan conference, and the interdisciplinary team would like to invite them to discuss the resident's care. Administrative Nurse E stated the goal at the facility was to work as a team with the residents and families to provide the best possible care. She said the form included a question as to whether the resident had been invited and signature lines for attendance. The facility's Comprehensive Care Plan policy, dated 08/2022, documented an individualized comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, cultural and psychological needs is developed for each resident. The facility's care planning/interdisciplinary team in coordination with the resident, his/her family or representative, develop and maintains a comprehensive care plan for each resident that identifies the highest level of function the resident may be expected to attain. The facility failed to invite R14 to participate in two of the last four care plan conferences, which placed the resident at risk for decreased autonomy.

The facility had a census of 40 residents. The sample included 12 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to identify and implement alternative communication methods for one sampled resident, Resident (R) 17, who had a diagnosis of cognitive communication deficit (difficulty with any aspect of communication that was affected by disruption of cognition) and spoke in Arabic. This placed the resident at risk for unmet needs, frustration, and loneliness. Findings Included: - The Electronic Medical Record (EMR) for R7 recorded diagnoses dementia with behavior disturbance (progressive mental disorder characterized by failing memory, confusion), unsteadiness on feet, cerebrovascular disease, conditions that affect blood flow and the blood vessels in the brain), muscle weakness, dysphasia (swallowing difficulty, colon cancer (a cancer of the colon or rectum, located at the digestive tract's lower end). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had long and short- term memory impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The MDS documented R7 sometimes made self-understood, had unclear speech. The MDS further documented R7 was on hospice services. The Care Area Assessment (CAA), dated 11/17/22, documented R7 was at risk for communication deficits related to his unclear speech. The CAA further documented staff anticipate and meet his needs as needed and he was able to communicate with body language and gestures most of the time. The Care Plan, dated 01/10/23, documented R7 was at risk for impaired communication related to being bilingual and inability to complete thoughts, observe his for nonverbal signs of distress to anticipate his needs, encourage R7 to speak in English, and documented a translation line was available should he need to speak in a foreign language. The EMR documented R7 was admitted to Hospice on 11/12/22 for the diagnosis of senile degeneration of the brain (dementia) and colon cancer. On 02/22/23 at 08:15 AM, observation revealed R7 in the small dining room, seated at the table with two other residents. Further observation revealed R7 speaking in his native language. Further observation revealed staff at the table did not acknowledge him or try to talk to him. Continued observation revealed R7 continued to talk in his native language throughout the meal without staff talking to him. On 02/22/23 at 08:51 AM, observation revealed, after breakfast, R7 sat in the living room area in his wheelchair, which did not have a pressure relieving cushion. R7 was very vocal, saying uh, uh, uh, and spoke in a different language than English. Further observation revealed R7 continued to say uh, uh, uh, and rested his chin in his hands and closed his eyes. R7 stated magahela, magahela, magahela, comarsh, comarsh. At 09:14 AM, R7 stated, look at me, look at me! R7 continued speaking saying ukahara, comarsh, comarsh, ummm, ummm, ya, ya. At 09:23 AM, R7 continued to holler out and would periodically close his eyes and at one point, his head dropped down causing him to wake up and then he began again saying comarsh, comarsh, sokahara, sokahara. At 09:39 AM, as R7 stated comarsh, comarsh Certified Medication Aide (CMA) R went to the resident and said what does that mean? I don't know what that means, and walked away. At 09:43 AM, R7 continued to repeat the same words over and over without staff offering assistance to see if they could provide care and reposition the resident as he had been in the wheelchair since before breakfast at 08:00 AM. At 10:06 AM, ongoing observation revealed R7 fell asleep in his wheelchair until 10:15 AM, when this surveyor asked CNA M to attend to the resident. On 02/22/23 at 10:15 AM, observation revealed CNA M transferred the resident from his wheelchair to his bed without a gaitbelt. Further observation revealed R7 spoke to CNA M in Arabic, and she stated she did not know what he was saying and did not know of any type of communication book or anything to help to understand what he was saying. CNA M checked R7's incontinence brief and verified his buttocks were red and stated she would apply barrier cream after peri care. Observation revealed CNA M could not find barrier cream, so she put a clean incontinence brief on R7, took his shoes off, and covered him up. Observation revealed there was not any documentation or phone number for a translation line as stated in the resident's care plan. On 02/22/23 at 12:12 PM, observation revealed R7 spoke his native language to CNA N, who was seated beside of him and she did not respond or try to speak to him. On 02/23/23 at 07:46 AM, observation revealed R7 in the small dining room, seated at the table with two other residents. Further observation revealed R7 stated, kolzar, kolzar, soblah, then laughed. Continued observation revealed CNA N did not talk with the resident during the meal. On 02/23/23 at 07:49 AM, another staff member, CNA O stated she was unsure what the resident was saying because he was speaking Arabic. CNA O stated she had tried, in the past, to use an online translator but was unable to put in the right words. CNA O stated, If only he could say it in English. On 02/23/23 at 08:41 AM, observation revealed staff pushed R7 into the living room area and left him facing the wall with his back towards other residents. Further observation revealed R7 would sigh and rest his head in his left hand. Continued observation revealed R7 sat in his wheelchair, without a pressure relieving cushion or repositioning until 10:15 AM, when the surveyor asked staff to attend to the resident. On 02/23/23 at 10:15 AM, observation revealed R7 held his hand out towards CNA N and she did not take his hand or acknowledge him. Further observation revealed CNA N placed a gaitbelt around R7's waist and she and CNA P transferred the resident into bed. CNA N stated she was going to break and said CNA P could finish with cares for R7. Observation revealed CNA P checked R7's incontinence brief and verified his buttocks were red, as R7 had had a bowel movement. CNA P stated he would put barrier cream on the resident. CNA P looked for the barrier cream and found a tube on the top shelf of the resident's closet in a basin (small plastic tub) and applied the cream after peri care. CNA P took off the resident's shoes and covered up the resident. On 02/23/23 at 10:15 AM, CNA P stated that he worked at the facility three days a week and sometimes could understand the resident because he knew some classic Arabic and it did not always cross over to the Arabic R7 spoke. On 02/27/23 at 07:52 AM, observation revealed R7 in the small dining room at the table with two other residents. Further observation revealed R7 started to eat his pureed food with his fingers and CNA sat down beside of him to mix up his food for him and handed him a spoon. R7 started talking in his native language, asalumya, asalumya, agumeal, agumeal, ooh, ah, ooh, ah, and the CNA did not speak to him nor did she ask him to speak in English. Continued observation revealed CNA N did not interact or try to converse with R7 throughout the entire breakfast. On 02/27/23 at 07:49 AM, Licensed Nurse (LN) N stated, that R7 spoke Hebrew or something, she was not quite sure but at times was able to speak in English. LN G further stated sometimes R7 spoke so fast, you were not able to understand and would ask him to please speak in English. On 02/27/23 at 10:26 AM, Administrative Nurse D stated he does speak in his language and was difficult for staff to understand and know his language. Administrative Nurse D further stated, she was unsure if therapy had ever tried any type of picture book or assistive devices to help the resident and staff with the language barrier. The facility Culturally Competent Care policy, dated October 2022, documented, if language assistance services was required, the interpreter or translator would be contacted. The resident's cultural beliefs, experiences, expectations, needs and values would be reviewed, documented, and added to the care plan so that they could be honored. If the resident was non-English speaking, staff identified how communication would occur with the resident, if indicated language assistance services would be arrange for the resident. The facility failed to effectively communicate with R7, placing the resident at risk for unmet needs, frustration and loneliness.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed provide Resident (R) 5 assistance with toileting as requested and care planned and failed to provide R142 with meal assistance. This placed R5 and R142 at risk for unmet care needs. Findings included: - R5's Electronic Medical Record (EMR) recorded diagnosis of type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, mood disorder, obsessive-compulsive personality (OCD - anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning) disorder, intellectual disabilities (characterized both by a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life, such as communication, self-care, getting along in social situations and school activities), bipolar (major mental illness that caused people to have episodes of severe high and low moods) disorder, dementia (progressive mental disorder characterized by failing memory, confusion), secondary Parkinsonism (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and unsteady on feet. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition, had verbal behavioral symptoms directed toward others, rejections of cares and wandering behaviors which occurred daily. R5 required extensive assistance of one staff for activities of daily living (ADL), was not steady with surface transition and balance and was only able to stabilize with staff assistance. The MDS further documented R5 had no toileting program, was always incontinent of urine and occasionally incontinent of bowel. R5 experienced shortness of breath with exertion and had two or more falls with no injury. R5 received an antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antianxiety (class of medication used to treat anxiety) , antidepressant (class of medication to treat depression), received daily. R5 had occupational and physical therapy services. The Urinary Incontinence Care Area Assessment (CAA), dated 06/02/22, documented R5 was incontinent of bowel and bladder, needed extensive assistance with toileting and hygiene, utilized adult pull ups during the day and adult briefs at night. The CAA further documented R5 was able to make staff aware when he has been incontinent. On 06/13/22 R5's Care Plan was updated following a fall, with an incontinence episode. On 06/09/22 the documented intervention was to educate staff to the importance of (incontinence) check and changes at night and early morning. On 07/21/22 the Accident Investigations root cause analysis documented R5 had decreased mobility and an intervention that staff were educated to offer toileting to R5. On 07/25/22 R5's Care Plan directed staff to offer to assist R5 to the toilet, upon R5 rising from bed, before and after meals, and before bed to decrease R5's risk of falling. The Progress Note, dated 08/06/22 at 08:30 PM, documented R5 had been on skilled services for medication management. R5 ambulated with a walker with supervision and cueing, was assisted by one staff with toileting as needed, was incontinent of bladder at times, wore pullups and fed self. The note further documented R5 was difficult to redirect and R5 attempted to open other resident's doors for staff. On 02/22/23 at 12:47 PM observation revealed R5 was assisted out of the dining room. At 02:15 PM R5 left the Bingo activity. Ongoing observation from the time R5 left the dining room to the Bingo activity revealed R5 was not offered toileting or check and changes. On 02/23/23 at 07:55 AM observation revealed R5 was pushed in a wheelchair by staff into the dining room. At 09:03 AM R5 was in the hallway trying to open a conference room door, staff within the room informed R5 could not enter due to a meeting. At 09:56 AM continued observation revealed R5 slept in his wheelchair in the commons area, when Certified Nurse Aide (CNA) P asked R5 if he wanted to rest in his recliner in his room. R5 was agreeable. CNA P assisted R5 into his recliner. During the ongoing observation from 07:55 AM to 09:56 AM, R5 had not been offered toileting or check and change by staff. On 02/27/23 at 07:28 AM, Certified Medication Aide (CMA) S reported R5 used his wheelchair mostly for mobility, and had a room move closer to where staff was. CMA S said staff were to make sure R5 had a call light, and R5 used a night light and keep door partially open for observation to prevent falls. On 02/27/23 at 08:43 AM Administrative Nurse G verified and expected staff to toilet R5 as care planned, to prevent falls and maintain skin integrity. The facility's Quality of Life-Activities of Daily Living policy dated 11/2017, documented the community environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving independent functioning, dignity, and well-being. Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to follow R5's specific care plan assistance with toileting which placed R5 at risk for unmet care needs. - R142's Electronic Medical Record (EMR) recorded he admitted to the facility on [DATE] with the only diagnosis of Huntington's (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder) disease. R142 had an admission weight of 157.2 pounds (lbs.). The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ADR) of 02/14/23, was not completed and remained in progress. The Care Area Assessment (CAA) also remained in progress. R142's Baseline Care Plan, dated 02/06/23, documented to promote/maintain adequate gastrointestinal habits, monitor for signs and symptoms and monitor meal intake per protocol. On 02/15/23 R142's Care Plan addition documented R142 was at risk for altered nutritional/hydration status related to Huntington's disease. The care plan directed staff to encourage consumption of fluids provided, provide adaptive equipment of weighted silverware, Kennedy (designed to be spill proof) cups with a straw, and a divided plate. It directed staff to provide and serve a regular diet, regular texture, and thin liquids as ordered, and monitor and record meal intake. Monitor/record/report to the Medical Doctor as needed for signs and symptoms of malnutrition: loss of three lbs. in one week or greater than five percent (%) in one month. The care plan directed staff to honor R142's food preferences and update as needed; R142 loved cottage cheese, Dr. Pepper (soda drink), cheese, and sandwiches. Provide set-up and assistance with meals/snacks. The care plan further documented the Registered Dietician (RD) to evaluate and make recommendations as needed and physical, occupational, and speech therapy to evaluate and treat as needed. R142's Comprehensive Care Plan had not been completed. The Physician Order dated 02/06/23, documented dietary supplements may be used when determined appropriate by Interdisciplinary Team (IDT) or RD, and physical, occupational, and speech therapy to evaluate and treat. The Physician Order dated 02/07/23, directed staff to provide a regular diet, regular texture and thin consistency liquids. The Nutrition: RD Admission assessment dated [DATE], documented R142's nutrition information, from the EMR, documented R142 was 71 inches tall and weighed 157.2 lbs. The assessment recorded the nursing admission note reported R142 had a recent weight loss and the RD was unsure of details; per progress notes R142's diet was regular, but there was no physician ordered diet ordered yet. R412's meal intake was good at 76-100%, no special items were utilized. R142 independently fed himself and was ambulatory. The Task section of R142's EMR documented he received limited assistance of one-person physical assist with eating on 02/12/23 and 02/13/23 only. The Nutrition: Dietary Manager Initial (Admission) Evaluation, dated 02/14/23, recorded the source of the nutrition information evaluated as R142. R142's desired weight range was 150-160 lbs., he had a regular diet and thin liquids, and no specialized items utilized. R142's beverage preferences were water, coffee, milk, juice and Dr. Pepper. R142 stated his appetite was good, his usual eating pattern was all three meals. He liked to snack between meals. The note recorded R142's self-feeding ability as he required supervision, oversight and cueing. Family brought in snacks and drinks. R142 was not a picky eater, and before coming to facility would occasionally skip a meal and would eat snacks. The evaluation further documented R142 had Huntington's disease; he may burn extra calories due to body movements, he used weighted silverware and on occasion nursing would assist with feeding. The Dietary Admission Welcome and Interview Sheet, dated 02/14/23, documented R142 had a usual weight of 155 lbs. and a desired body weight of 150-160 lbs. R142 liked cottage cheese, cheese, Dr. Pepper, and sandwiches. He disliked broccoli. R142 was not picky, and he fed himself with weighted silverware. R142 had no difficulty with swallowing, chewing, or feeding himself with weighted silverware and some assistance from staff. On 02/20/23 the Weight Variance Note recorded R142 weighed 148.8 lbs. (5.34% loss in two weeks), and a nutritional supplement twice a day was initiated. The medical provider was notified of the weight loss. The goal for R142 was to encourage and or assist him at meals; R142 had snacks and drinks in his room and used weighted silverware. The EMR dated 02/27/23 recorded R142's weighed 147.2 lbs., a continued loss of greater than 5% On 02/22/23 at 12:30 PM observation revealed R142 sat in the dining room wearing a clothing protector. The meal served to R142 consisted of thin soup in a bowl, a biscuit, and mixed fruit. R142 used a weighted spoon and his fingers to eat chunks of vegetables and meat from soup. R142 had extensive continual involuntary movements in his arms, trunk, hands, neck, and head. After obtaining the biscuit and attempting to split it in half, R142 unintentionally flung the biscuit across the table, and it landed on the floor. R142 then placed the other half of the biscuit in the soup then did not eat it. During the process of eating, he continually tried to keep his clothing protector in place. R142 then placed the weighted spoon into the ice cream and withdrew over half the ice cream on the spoon and placed all of it into his mouth. Staff seated at the table offered no assistance to the resident with cueing, or meal intake, or placement/adjustment of his clothing protector. On 02/23/23 at 08:11 AM observation revealed R142 received a breakfast of French toast, hot cereal with brown sugar and bacon. R142 had continual involuntary movements. He poured syrup onto the hot cereal, picked up the whole slice of French toast and ate it with his fingers, and then picked up the bacon. He placed the bacon in his mouth and tore off large pieces to chew then, using the weighted spoon started, eating the hot cereal. While eating R142's clothing protector continually slipped to his lap, and he attempted numerous times to keep it over his chest area to protect his clothing. R142 was not successful and dropped cereal on his shirt. Staff seated at the table did not assist the resident with his clothing protector or help with eating. On 02/23/23 at 12:22 PM observation revealed R142 received a meal of whole boneless, barbecue chicken breast, peas in a bowl, and macaroni and cheese. R142 managed to cut the chicken breast in half despite the involuntary movements of his body. R142 took one half of the chicken breast into his mouth (resident has not teeth or dentures) and worked at chewing it to swallow. R142 then used his hands to cup the macaroni and cheese in his right hand to eat. R142 worked at eating all his macaroni and cheese and the other half of the chicken breast. Again, R142 was not able to keep clothing protector in place and dropped a great deal of food on his shirt. Staff present at the table did not assist R142 with eating or his clothing protector. On 02/23/23 at 01:12 PM Certified Nurse Aide (CNA) P stated R142 was new to the facility and ate almost anything put in front of him. CNA P reported R142 used of weighted silverware but was messy during meals. CNA P reported R142 had snacks and Dr. Pepper in his room, and since the resident was mostly independent, and he did not need assistance with snacks and drinks in the room. On 02/27/23 at 07:44 AM, Dietary Staff (DS) BB stated R142 received nutritional supplement two times a day. DS BB said Huntington's disease was new to her and was aware of constant flailing of arms and that she provided the resident with weighted silverware. DS BB verified she did the diet history and preference and R142's soup should have been in a cup. She also verified the resident was at risk for choking by placing half a chicken breast in his mouth and should have foods cut up. She reported dietary and nursing department could referred to therapy services. CDM also reported she had not observed resident's eating. On 02/27/23 08:45 AM Administrative Nurse D reported she had not observed meals for R142, she stated he was mostly independent. She verified staff should be mindful of the resident's struggle with clothing protector and assistance with cutting up food to prevent choking and involving therapy as an intervention due to R142 weight loss. Administrative Nurse D verified staff should assist the resident at meals to enhance dignity and no further weight loss. The facility's Quality of Life-Activities of Daily Living policy dated 11/2017, documented the community environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving independent functioning, dignity, and well-being. Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide R142 assistance during meals which placed the resident at risk for unmet care needs.

The facility had a census of 40 residents. The sample included 12 residents, with one reviewed for Hospice (end of life) cares. Based on observation, record review, and interview, the facility failed to provide adequate end-of-life Hospice treatment and care for one resident, Resident (R)7, who was restless, hollering, and had the potential for skin breakdown. This placed the resident at risk for unmet needs and skin breakdown. Findings included: - The Electronic Medical Record (EMR) for R7 recorded diagnoses dementia with behavior disturbance (progressive mental disorder characterized by failing memory, confusion), unsteadiness on feet, cerebrovascular disease, conditions that affect blood flow and the blood vessels in the brain), muscle weakness, dysphasia (swallowing difficulty, colon cancer (a cancer of the colon or rectum, located at the digestive tract's lower end). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had long and short- term memory impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The MDS documented R7 sometimes made self-understood, had unclear speech, and risk for skin breakdown. The MDS further documented R7 was on hospice services. The Care Area Assessment (CAA), dated 11/17/22, documented R7 was at risk for communication deficits related to his unclear speech. The CAA further documented staff anticipate and meet his needs as needed and he was able to communicate with body language and gestures most of the time. The Care Plan, dated 01/10/23, documented R7 received hospice services and directed staff to work with the hospice team to ensure his spiritual, emotional, intellectual, physical, and social needs were met, and work with nursing staff to provide maximum comfort for the resident. The care plan further directed staff to observe R7 for non-verbal signs of distress, and staff should anticipate R7's needs, The EMR documented R7 was admitted to Hospice on 11/12/22 for the diagnosis of senile degeneration of the brain (dementia) and colon cancer. On 02/22/23 at 08:51 AM, observation revealed, after breakfast, R7 sat in the living room area in his wheelchair, which did not have a pressure relieving cushion. R7 was very vocal, saying uh, uh, uh, and spoke in a different language than English. Further observation revealed R7 continued to say uh, uh, uh, and rested his chin in his hands and closed his eyes. R7 stated magahela, magahela, magahela, comarsh, comarsh. At 09:14 AM, R7 stated, look at me, look at me! R7 continued speaking saying ukahara, comarsh, comarsh, ummm, ummm, ya, ya. At 09:23 AM, R7 continued to holler out and would periodically close his eyes and at one point, his head dropped down causing him to wake up andthen he began again saying comarsh, comarsh, sokahara, sokahara. At 09:39 AM, as R7 stated comarsh, comarsh Certified Medication Aide (CMA) R went to the resident and said what does that mean? I don't know what that means, and walked away. At 09:43 AM, R7 continued to repeat the same words over and over without staff offering assistance to see if they could provide care and reposition the resident as he had been in the wheelchair since before breakfast at 08:00 AM. At 10:06 AM, ongoing observation revealed R7 fell asleep in his wheelchair until 10:15 AM, when this surveyor asked Certified Nurse Aide (CNA) M to attend to the resident. On 02/22/23 at 10:15 AM, observation revealed CNA M transferred the resident from his wheelchair to his bed without a gaitbelt. Further observation revealed R7 spoke to CNA M in Arabic, and she stated she did not know what he was saying. CNA M checked R7's incontinence brief and verified his buttocks were red and stated she would apply barrier cream after peri care. Observation revealed CNA M could not find barrier cream, so she put a clean incontinence brief on R7, took his shoes off, and covered him up. On 02/23/23 at 08:41AM, observation revealed staff pushed R7 into the living room area and left him facing the wall with his back towards other residents. Further observation revealed R7 would sigh and rest his head in his left hand. Continued observation revealed R7 sat in his wheelchair, without a pressure relieving cushion or repositioning until 10:15 AM, when the surveyor asked staff to attend to the resident. On 02/23/23 at 10:15 AM, observation revealed R7 held his hand out towards CNA N and she did not take his hand or acknowledge him. Further observation revealed CNA N placed a gaitbelt around R7's waist and she and CNA P transferred the resident into bed. CNA N stated she was going to break and said CNA P could finish with cares for R7. Observation revealed CNA P checked R7's incontinence brief and verified his buttocks were red, as R7 had had a bowel movement. CNA P stated he would put barrier cream on the resident. CNA P looked for the barrier cream and found a tube on the top shelf of the resident's closet in a basin (small plastic tub) and applied the cream after peri care. CNA P took off the resident's shoes and covered up the resident. On 02/23/23 at 10:15 AM, CNA P stated R7 sometimes propelled himself around the facility after breakfast and did not want to lay down. CNA P said R7 should be repositioned every two hours and he did not know why R7 did not have a pressure reducing cushion in his wheelchair. On 02/27/23 at 07:49 AM, Licensed Nurse (LN) G stated, when R7 got restless, it would usually mean he needed toileted and should have been repositioned, either by lying down in bed or placed in the recliner. On 02/2723 at 10/26 AM, Administrative Nurse D stated R7 should be repositioned and checked to make sure he had not been incontinent. Administrative Nurse D stated staff should be more aware of R7's needs and not to sit in the wheelchair without a cushion for so long and said would contact Hospice for one to be sent for him. The facility Hospice Program policy, dated June 2021, documented the community retained the ultimate responsibility for the care plan and coordinates the plan of care with the hospice provider, community staff, the resident and family. The policy further documented the care plan should discuss the need for oral care, skin integrity, medical diagnostics treatment, symptom management, nutrition and hydration, activities, psychosocial needs, and interventions to manage pain and other symptoms of discomfort. The facility failed to provide adequate end of life care for R7 who was restless and sat in his wheelchair for an extended period of time without staff attention to his needs or intervention. This placed the resident at risk for unmet needs.

The facility had a census of 40 residents. The sample included 12 residents, with two 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 reposition one sampled resident in a manner consistent with the standards of care and failed to provide a pressure reducing cushion for Resident (R) 7, who was at risk for impaired skin integrity. This placed the resident at risk for skin breakdown. Findings included: - The Electronic Medical Record (EMR) for R7 recorded diagnoses dementia with behavior disturbance (progressive mental disorder characterized by failing memory, confusion), unsteadiness on feet, cerebrovascular disease, conditions that affect blood flow and the blood vessels in the brain), muscle weakness, dysphasia (swallowing difficulty, colon cancer (a cancer of the colon or rectum, located at the digestive tract's lower end). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had long and short- term memory impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The MDS documented R7 was at risk for pressure ulcers, had a pressure ulcer device in his bed and chair, and had ointment other that to his feet. The Pressure Ulcer Care Area Assessment (CAA), dated 11/17/22, documented R7 was at risk for impaired skin integrity related to impaired activities of daily living function and incontinence. The CAA further documented R7 had a pressure reducing mattress and pressure reducing wheelchair cushion to help with skin integrity and required extensive assist with bed mobility and repositioning, was incontinent of bowel/bladder. The CAA documented staff would monitor for skin breakdown during showers and report changes to charge nurse, the charge nurse would complete weekly skin and Braden assessments quarterly and as needed. The Care Plan, dated 01/10/23, R7 had a potential for altered skin integrity related to impaired immobility and incontinence and directed staff to apply barrier cream as needed to assist with skin integrity, complete weekly head to toe skin assessments, educate care givers to the causes of skin breakdown, including transfer and positioning requirement, to follow facility policies and procedures for the prevention and treatment of skin breakdown, pressure reducing mattress on his bed, extensive assistance of 1-2 staff for repositioning in bed to avoid shearing during positioning, transferring and turning, check and change the resident upon rising in the morning, before and after meals, and prior to bedtime. The Braden Scale Assessment, (assessment for predicting pressure ulcer risk) dated 01/10/23, documented a score of 15, which indicated low risk. The EMR documented R7 was admitted to Hospice on 11/12/22 for the diagnosis of senile degeneration of the brain (dementia) and colon cancer. On 02/22/23 at 07:45 AM, observation revealed R7, in his wheelchair in the living room area waiting for breakfast. Further observation revealed R7's wheelchair did not have a pressure relieving cushion. On 02/22/23 at 08:51 AM, observation revealed, after breakfast, R7 sat in the living room area in his wheelchair, which did not have a pressure relieving cushion. R7 was very vocal, saying uh, uh, uh, and spoke in a different language than English. Further observation revealed R7 continued to say uh, uh, uh, and rested his chin in his hands and closed his eyes. R7 stated magahela, magahela, magahela, comarsh, comarsh. At 09:14 AM, R7 stated, look at me, look at me! R7 continued speaking saying ukahara, comarsh, comarsh, ummm, ummm, ya, ya. At 09:23 AM, R7 continued to holler out and would periodically close his eyes and at one point, his head dropped down causing him to wake up andthen he began again saying comarsh, comarsh, sokahara, sokahara. At 09:39 AM, as R7 stated comarsh, comarsh Certified Medication Aide (CMA) R went to the resident and said what does that mean? I don't know what that means, and walked away. At 09:43 AM, R7 continued to repeat the same words over and over without staff offering assistance to see if they could provide care and reposition the resident as he had been in the wheelchair since before breakfast at 08:00 AM. At 10:06 AM, ongoing observation revealed R7 fell asleep in his wheelchair until 10:15 AM, when this surveyor asked Certified Nurse Aide (CNA) M to attend to the resident. On 02/22/23 at 10:15 AM, observation revealed CNA M transferred the resident from his wheelchair to his bed without a gaitbelt. Further observation revealed R7 spoke to CNA M in Arabic, and she stated she did not know what he was saying. CNA M checked R7's incontinence brief and verified his buttocks were red and stated she would apply barrier cream after peri care. Observation revealed CNA M could not find barrier cream, so she put a clean incontinence brief on R7, took his shoes off, and covered him up. On 02/23/23 at 07:46 AM, observation revealed R7, in his wheelchair in the living room area waiting for breakfast. Further observation revealed R7's wheelchair did not have a pressure relieving cushion. On 02/23/23 at 08:41 AM, observation revealed staff pushed R7 into the living room area and left him facing the wall with his back towards other residents. Further observation revealed R7 would sigh and rest his head in his left hand. Continued observation revealed R7 sat in his wheelchair, without a pressure relieving cushion or repositioning until 10:15 AM, when the surveyor asked staff to attend to the resident. On 02/23/23 at 10:15 AM, observation revealed R7 held his hand out towards CNA N and she did not take his hand or acknowledge him. Further observation revealed CNA N placed a gaitbelt around R7's waist and she and CNA P transferred the resident into bed. CNA N stated she was going to break and said CNA P could finish with cares for R7. Observation revealed CNA P checked R7's incontinence brief and verified his buttocks were red, as R7 had had a bowel movement. CNA P stated he would put barrier cream on the resident. CNA P looked for the barrier cream and found a tube on the top shelf of the resident's closet in a basin (small plastic tub) and applied the cream after peri care. CNA P took off the resident's shoes and covered up the resident. On 02/23/23 at 10:15 AM, CNA P stated R7 sometimes propelled himself around the facility after breakfast and did not want to lay down. CNA P said R7 should be repositioned every two hours and he did not know why R7 did not have a pressure reducing cushion in his wheelchair. On 02/27/23 at 07:49 AM, Licensed Nurse (LN) G stated, when R7 got restless, it would usually mean he needed toileted and should have been repositioned, either by lying down in bed or placed in the recliner. On 02/2723 at 10/26 AM, Administrative Nurse D stated R7 should be repositioned and checked to make sure he had not been incontinent. Administrative Nurse D stated staff should be more aware of R7's needs and not to sit in the wheelchair without a cushion for so long and said would contact Hospice for one to be sent for him. The facility Skin Integrity, Pressure Injuries Nursing Protocol policy, dated May 2021, documented the resident would receive care consistent with professional standards of practice to prevent pressure injuries and would not develop pressure injuries unless the individuals clinical condition demonstrated that they were unavoidable. The facility would implement and modify interventions to attempt to stabilize, reduce or remove underlying risk factors and use the Braden scale. The policy documented, based on the assessment and the residents clinical condition, choices and identification needs, basic or routine care could include but not limited to provide appropriate pressure redistribution support surfaces, redistribute pressure, minimize exposure to moisture and keep skin clean. The facility failed to reposition R7, who had the potential for skin breakdown, for over two hours. The facility further failed to ensure a pressure reducing cushion was used for R7 This place the resident at risk for skin breakdown.

The facility had a census of 40 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to implement care planned interventions for Resident (R)5 for toileting, and failed to identify and implement resident-centered interventions to prevent falls for R7 and R18 This palced the resident at risk for further falls and/or avoidable injuries. Findings included: - R5's Electronic Medical Record (EMR) recorded diagnosis of type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, mood disorder, obsessive-compulsive personality (OCD - anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning) disorder, intellectual disabilities (characterized both by a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life, such as communication, self-care, getting along in social situations and school activities), bipolar (major mental illness that caused people to have episodes of severe high and low moods) disorder, dementia (progressive mental disorder characterized by failing memory, confusion), secondary Parkinsonism (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and unsteady on feet. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition, had verbal behavioral symptoms directed toward others, rejections of cares and wandering behaviors which occurred daily. R5 required extensive assistance of one staff for activities of daily living (ADL), was not steady with surface transition and balance and was only able to stabilize with staff assistance. The MDS further documented R5 had no toileting program, was always incontinent of urine and occasionally incontinent of bowel. R5 experienced shortness of breath with exertion and had two or more falls with no injury. R5 received an antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antianxiety (class of medication used to treat anxiety) , antidepressant (class of medication to treat depression), received daily. R5 had occupational and physical therapy services. The Urinary Incontinence Care Area Assessment (CAA), dated 06/02/22, documented R5 was incontinent of bowel and bladder, needed extensive assistance with toileting and hygiene, utilized adult pull ups during the day and adult briefs at night. The CAA further documented R5 was able to make staff aware when he has been incontinent. The Fall Care Plan dated 05/13/22 documented R5 was at risk for falls related to an unsteady and shuffling gait. On 06/13/22 R5's Care Plan was updated following a fall, with an incontinence episode. On 06/09/22 the documented intervention was to educate staff to the importance of (incontinence) check and changes at night and early morning. On 07/21/22 the Accident Investigations root cause analysis documented R5 had decreased mobility and an intervention that staff were educated to offer toileting to R5. On 07/25/22 R5's Care Plan directed staff to offer to assist R5 to the toilet, upon R5 rising from bed, before and after meals, and before bed to decrease R5's risk of falling. The Progress Note, dated 08/06/22 at 08:30 PM, documented R5 had been on skilled services for medication management. R5 ambulated with a walker with supervision and cueing, was assisted by one staff with toileting as needed, was incontinent of bladder at times, wore pullups and fed self. The note further documented R5 was difficult to redirect and R5 attempted to open other resident's doors for staff. On 02/22/23 at 12:47 PM observation revealed R5 was assisted out of the dining room. At 02:15 PM R5 left the BINGO activity. Ongoing observation from the time R5 left the dining room to the Bingo activity revealed R5 was not offered toileting or check and changes. On 02/23/23 at 07:55 AM observation revealed R5 was pushed in a wheelchair by staff into the dining room. At 09:03 AM R5 was in the hallway trying to open a conference room door, staff within the room informed R5 could not enter due to a meeting. At 09:56 AM continued observation revealed R5 slept in his wheelchair in the commons area, when Certified Nurse Aide (CNA) P asked R5 if he wanted to rest in his recliner in his room. R5 was agreeable. CNA P assisted R5 into his recliner. During the ongoing observation from 07:55 AM to 09:56 AM, R5 had not been offered toileting or check and change by staff. On 02/27/23 at 07:28 AM, Certified Medication Aide (CMA) S reported R5 used his wheelchair mostly for mobility, and had a room move closer to where staff was. CMA S said staff were to make sure R5 had a call light, and R5 used a night light and keep door partially open for observation to prevent falls. On 02/27/23 at 08:43 AM Administrative Nurse G verified and expected staff to toilet R5 as care planned, to prevent falls and maintain skin integrity. The facility's Managing Falls and Fall Risk policy, dated 10/2022, documented based on previous evaluation 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 Interdisciplinary Team (IDT) will attempt to identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. The IDT will identify and implement relevant interventions to try to minimize serious consequences of falling. The facility failed to follow R5's specific interventions in place to prevent falls which placed the resident at risk for continued falls and possible injuries. 32360 - The Electronic Medical Record (EMR) for R7 recorded diagnoses dementia with behavior disturbance (progressive mental disorder characterized by failing memory, confusion), unsteadiness on feet, cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain), muscle weakness, and dysphagia (swallowing difficulty). R7's Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had long and short-term memory impairment and required extensive assistance of two staff for bed mobility, transfers, ambulation, dressing and toileting. The MDS further documented R7 had unsteady balance, no functional impairment and had one non-injury fall. The Significant Change MDS, dated [DATE], documented R7 had long and short- term memory impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The MDS further documented R7 had unsteady balance, no functional impairment, and had no falls. The Fall Risk Assessments, dated 04/10/22, 07/10/22, 08/06/22, and 11/07/22 documented the resident was a high risk for falls. The Fall Care Plan, dated 01/10/23, originally dated 09/17/19, directed staff to ensure R7 wore appropriate footwear when ambulating, check and change upon rising in the morning, before and after meals, and prior to bedtime, and ensure R7 wore nonskid socks at night. The update, dated 05/01/21, directed staff to sit with the resident while in the dining room and redirect him as needed to stay seated. The update dated 08/20/22 directed staff to check alarm placement every two hours for correct positioning. The update, dated 01/26/23, directed staff to have resident in full view when not in bed and be aware of R7 when he wandered outside of the 200 hall and commons area to determine if the resident had any needs. The Fall Investigation, dated 02/15/22 at 05:42 PM, documented R7 stood from his wheelchair, appeared to be off balance, went to sit down and missed the seat of the wheelchair. The investigation further documented the fall was witnessed and the resident did not obtain any injuries. The Fall Investigation, dated 05/31/22 at 04:40 PM, documented R7 was observed on the floor in his room, lying on his back. The investigation further documented the fall was unwitnessed and the resident could not describe what he was doing at the time of the fall. The Fall Investigation, dated 08/06/22 at 06:35 PM, documented R7 slid out of his wheelchair on to the floor. The investigation further documented R7 tried to get up unassisted and was not wearing shoes or gripper socks. The investigation directed staff to make sure R7 wore shoes or gripper socks. The Fall Investigation, dated 08/20/22 at 03:00 PM, documented R7 was found on the floor in the activity room. The investigation further documented R7's chair alarm was not on, and education was given to staff to always keep the alarm on. The Fall Investigation, dated 01/20/23 at 07:30 PM, documented R7 was found in another resident's room on the floor. The investigation further documented staff were notified by another resident that R7 had fallen in his room. The investigation documented R7's alarm was not on and staff were educated to make sure the alarm was turned on after transfers and throughout the day. On 02/22/23 at 10:15 AM, observation revealed Certified Nurse Aide (CNA) M transferred the resident from his wheelchair to his bed without a gaitbelt. Further observation revealed R7 spoke to CNA M in Arabic, and she stated she did not know what he was saying. CNA M checked his incontinence brief and verified his buttocks were red and stated she would apply barrier cream after peri care. Observation revealed, CNA M could not find barrier cream and put a clean incontinence brief on R7, took his shoes off, and covered him up. On 02/22/23 at 10:15 AM, CNA M stated a lot of the time she did not know what the resident was saying as he spoke in Arabic and did not have any means to find out what he was saying. CNA M further stated staff made sure his bed was lowered, a bed alarm, and a fall mat was placed next to the bed to prevent further falls. On 02/27/23 at 07:49 AM, Licensed Nurse (LN) G stated R7 got restless when he required toileting and had received therapy in the past for his falls. On 02/27/23 at 10:26 AM, Administrative Nurse D stated staff checked his alarm every two hours to make sure it is on and verified there should be interventions in place after a resident fell . The facility Fall and Fall Risk, Managing policy, dated October 2022, documented the definition of a fall was unintentionally coming to rest on the ground floor or other lower level but not as a result of an overwhelming external force. The policy further documented the team would attempt to identify appropriate interventions to reduce the risk of falls and if falling reoccurs, despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remained relevant. The facility failed to provide supervision, ensure R7's personal alarm was activated, and failed to implement interventions for cognitively impaired R7, placing him at risk for further falls and injury. - The Electronic Medical Record (EMR) for R18 documented the resident had diagnoses of bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), cognitive communication deficit (may occur after a stroke, tumor, brain injury, or other neurological damage), traumatic brain injury (brain dysfunction caused by an outside force, usually a blow to the head), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R18's Admission Minimum Data Set (MDS), dated [DATE], documented R18 was admitted to the facility 08/30/22 and had moderately impaired cognition and required extensive assistance of two staff for transfers, and extensive assistance of one staff for bed mobility, ambulation, toileting, and personal hygiene. The assessment further documented R18 had unsteady balance, no functioning impairment, and had one fall since admission. The Quarterly MDS, dated [DATE], documented R18 had moderately impaired cognition and was dependent upon two staff for transfers, toileting, and extensive assistance of two staff for bed mobility, and toileting. The assessment further documented R18 did not ambulate, had unsteady balance, no functional impairment and had one non-injury fall. The Fall Assessments, dated 08/31/22, 11/07/22, and 02/09/23, documented R18 was a high risk for falls. The Nursing Evaluation, dated 08/30/22, documented R18 used a walker when ambulating with staff assistance, had full range of motion, and did not require the use of a mechanical lift for transfers. Review of the EMR lacked documentation a fall care plan was completed until 12/18/22. The Nurse's Note, dated 09/03/22 at 02:09 PM, documented R18 was lowered to the floor with two staff assistance and a gait belt. The note further documented R18 did not receive any injuries. Review of the EMR lacked further documentation regarding the fall. On 02/23/23 at 08:58 AM, observation revealed Licensed Nurse (LN) H and Certified Nurse Aide N attached the sling to the mechanical lift and lifted R18 up and lowered her onto the bed. On 02/23/23 at 09:00 AM, CNA N stated she was not aware of any falls prior to the most recent fall the resident had. CNA N laughed and stated the most recent fall happened as a CNA rolled the resident, and the resident kept rolling and fell out of bed. CNA N further stated R18 was not hurt and that she should not laugh about it, but it was funny. CNA N stated staff use a mechanical lift and two staff for her transfers. On 02/27/23 at 09:17 AM, LN G stated R18 was lowered to the ground by two staff, and the facility considered that a fall, but LN G was unable to find an incident report. On 02/27/23 at 10:26 AM, Administrative Nurse D verified she was unable to find any incident report related to staff lowering R18 to the floor and stated an incident report should have been completed. The facility Fall and Fall Risk, Managing policy, dated October 2022, documented the definition of a fall was unintentionally coming to rest on the ground floor or other lower level but not as a result of an overwhelming external force. The policy further documented the team would attempt to identify appropriate interventions to reduce the risk of falls and if falling reoccurs, despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remained relevant. The facility failed to implement interventions for R18, who was lowered to the ground by staff. This placed the resident at risk for further falls and injury.

The facility had a census 40 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to obtain and replace Resident (R) 14's oxygen mask as physician ordered placing R14 at risk for respiratory infection. Findings included: -R14's Electronic Medical Record (EMR) recorded diagnoses of acute and chronic respiratory failure, atrial fibrillation (rapid, irregular heart beat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, cerebral infarction (stoke), hemiplegia (paralysis of one side of the body), morbid (severe) obesity, and angina pectoris (chest pain). The Annual Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, no delirium or exhibited behaviors. R14 required extensive assistance of two staff for activities of daily living with the exception of eating which required limited assistance of one staff member. R14 had pain and pain treatment, shortness or trouble breathing with exertion and when lying flat. The MDS further documented R14 received oxygen and required non-invasive mechanical ventilator. R14's Care Plan documented R14 had difficulty breathing at times related to chronic respiratory failure and required the use of supplemental oxygen. The care plan directed staff to administer oxygen to home ventilation and nebulizer treatments, change oxygen mask daily and nurse to assess for respiratory distress. The Physician Order, dated 10/22/20, directed staff to administer oxygen at two to six liters (l) to maintain oxygen saturation range between 92 and 98 percent (%), and change oxygen mask daily every night shift. Record review of R14's Treatment Administration Record (TAR) revealed dates of coded 3 which indicated a supply was not available and had been reordered for: December 22, 23, 24, 25, 29, and 31, 2022. (six days) January 1, 3, 4, 5, 6, 7, 8, 2023. (seven days) February 13, 14, 15, 17, 18, 19, 20 and 22, 2023. (eight days) The Progress Note, dated 02/02/23 at 09:49 AM, documented R14 appeared in no apparent distress, alert with oxygen via mask. On 02/21/23 during initial tour/interview observation revealed R14 was in her room in bed with a visibly soiled oxygen mask on her face. On 02/27/23 at 09:03 AM Administrative Nurse D stated R14's mask should have been changed daily. Administrative Nurse D reported at times the masks had been back ordered, but the facility had two cases of mask in supply storage and the nursing staff needed to be educated where to find the oxygen masks and open the boxes for replacement. Administrative Nurse D stated the oxygen masked should have been cleaned when supply was not available but lacked documentation of cleansing the masks. The facility's Oxygen Administration policy, dated 06/2021, documented the purpose of this procedure is to provide guidelines for safe oxygen administration. The facility failed to replace R14's oxygen mask daily as ordered placing R14 at risk for respiratory infections.

The facility reported a census of 41 residents. Based on observation and interview, the facility failed to ensure a clean and sanitary environment for the residents of the facility in five resident rooms, located in two of three resident halls. Findings included: - On 09/02/21 at 09:08 AM, an environmental tour of the facility had the following areas of concern: 1. A resident room had approximately two inches of loosened baseboard by the entrance to the bathroom. The perimeter around a toilet had approximate two-inch to four-inch areas that lacked floor covering. The areas had a large build-up of dark colored grime. 2. A resident room had approximately an inch of dark grime build=up in the corners around the door frames of the room and the bathroom. 3. A resident room had approximately an inch of dark grime around the edges of the baseboard. 4. A resident room had approximately eight inches of loose baseboard in the entrance of the room, with approximately a two-inch band of grime build-up on the floor. The corners of the doorframes to the room and bathroom had approximately two inches of dirt/ grime accumulation, and approximately one half inch of grime at the base of the moldings from the door to the bathroom. 5. A resident room had approximately one-inch build-up of grime around the edges of the floor at the baseboard. The bathroom lacked two triangular shaped areas of flooring that measured approximately two by two inches on the shorter sides, and these areas contained a dark grime build-up. In addition, the floor covering lacked an additional area, approximate three by three inch, and the area had a grime build-up. There was approximately a half-inch of grime build-up in front and all around the baseboard of the bathroom and approximately two inches of grime build-up behind the sink. On 09/03/21 at 08:20 AM, Administrative Staff A stated the expectation of the facility's environment should be clean, and without grime around the edges or in the corners and the floors around the toilets to be intact so the floors could be cleaned and disinfected properly. A facility policy addressing maintaining floors free from grime was unavailable. The facility failed to ensure a clean and sanitary environment for the residents of the facility in five resident rooms, located in two of three resident halls.

The facility reported a census of 41 residents with 13 residents sampled, including five residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to ensure three dependent residents had appropriate assistance with ADLs, including Resident (R)18, regarding appropriate nail care and R 20 and R 40, regarding lack of personal hygiene. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. She had no rejection of care and required extensive staff assistance of one for personal hygiene. The Activities of Daily Living (ADL)/Functional Rehabilitation Potential Care Area Assessment (CAA), dated 11/03/21, documented the resident required extensive staff assistance with ADLs. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 10, indicating she had moderately impaired cognition. She had no rejection of care and required extensive staff assistance of one for personal hygiene The care plan for ADLs, updated 08/13/21, instructed staff the nurse would do the resident's nail care. On 09/01/21 at 08:36 AM, the resident was in the dining room for breakfast. Her fingernails were long and dirty. Her fingernails had a dried tannish substance underneath them. On 09/02/21 at 08:43 AM, the resident was in the dining room for breakfast. Her fingernails remained long and dirty. The dried tannish substance remained underneath her fingernails. On 09/02/21 at 12:38 PM, Licensed Nurse (LN) H stated he had never cleaned the resident's fingernails. On 09/03/21 at 09:29 AM, Consultant staff GG stated, it was the expectation that staff clean resident's fingernails. The facility policy for Quality of Life ADLS, dated 05/2021, included: Residents who are unable to carry out ADLs will receive the necessary care and services to maintain grooming. The facility failed to ensure appropriate nail care for this dependent resident. - Review of Resident (R)40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident had impaired cognitive status and required extensive assistance of one staff for personal hygiene. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 10/15/20, assessed the resident at risk for impaired ADL and required extensive assistance with personal hygiene. The Care Plan, reviewed 08/17/21, instructed staff the resident required assistance of one staff for personal hygiene. The resident received a shower twice a week. The Bath Sheet, dated 08/15/21, documented staff shaved the resident. Observation, on 08/31/21 at 11:00 AM, revealed the resident seated in a chair in the dining area. The resident had several days' worth of facial hair. When asked if the facial hair caused itching the resident answered yes. The resident remained with facial hair on 09/01 through 09/02/21. Interview, on 09/02/21 at 01:40 PM, with Certified Nurse Aide (CNA) NN, revealed staff should shave the resident on bath days (Monday and Thursday evenings.) If staff do not shave him on those days, then the best time to shave him is after a nap when he is more cooperative. Interview, on 09/02/21 at 04:00 PM with CNA N, revealed she usually shaved the resident when she provided a bath to him, but she was off the previous week. Interview, on 09/03/21 at 11:28 AM, with Consulting Nurse GG, revealed she would expect staff to provide shaving to residents per their preferences, usually on bath days. The facility policy Quality of Life Activities of Daily Living, reviewed 05/2021, instructed staff for residents whom are unable to carry out ADL, receive the necessary care and services to maintain good nutrition, grooming and personal and oral hygiene. The facility failed to provide shaving opportunities for this resident who required staff assistance to maintain personal hygiene in a manner as a normal person would expect. - Review of Resident (R)20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13 (Normal cognition score 13-15.) The resident had verbal behaviors and rejection of care one to three days of the seven day look back period. The resident required extensive assistance of two staff for bed mobility, transfers, toileting and personal hygiene. The resident had no impairment in range of motion in the upper or lower extremities. The ADL (Activity of Daily Living) Functional/ Rehabilitation Potential Care Area Assessment (CAA), dated 11/14/20, assessed the resident was at risk for impaired ADL function related to history of stroke, [CONDITION(S)] and right below the knee amputation. The resident required limited to extensive assistance of one to two staff for ADL. The Care Plan, reviewed 05/25/21, instructed staff the resident was at increased risk for impaired skin integrity related to impaired mobility. Staff were to complete a weekly skin assessment and provide a skin check during showers. Observation, on 08/31/21 at 10:30 AM, revealed the resident in his wheelchair in his room. The resident's face contained several days' worth of facial hair. Observation on 09/01/21 revealed continued facial hair until 09/02/21 at which time the resident was shaven. Interview, on 09/01/21 at 09:23 AM, with Certified Nurse Aide (CNA) O revealed the resident required assistance for ADL's and usually CNA N shaved him on evening shift. Interview, on 09/01/21 at 03:56 PM, with CNA PP, revealed the resident could get combative at times. Interview, on 09/02/21 at 01:40 PM, with Certified Nurse Aide (CNA) NN, revealed staff should shave the resident on bath days. If staff do not shave him on those days, then the best time to shave him is after a nap when he is more cooperative. Interview, on 09/02/21 at 04:00 PM with CNA N, revealed she usually shaved the resident on bath days or when they needed to be shaved. Interview, on 09/03/21 at 11:28 AM, with Consulting Nurse GG, revealed she would expect staff to provide shaving to residents per their preferences, usually on bath days. The facility policy Quality of Life Activities of Daily Living, reviewed 05/2021, instructed staff for residents whom are unable to carry out ADL, receive the necessary care and services to maintain good nutrition, grooming and personal and oral hygiene. The facility failed to provide shaving opportunities for this resident who required staff assistance to maintain personal hygiene in a manner as a normal person would expect.

The facility had a census of 45 residents, of which 10 resided in the special care unit. Based on observation, interview, and record review the facility failed to protect the residents who resided in the special care unit from Resident #1, who inappropriately touched cognitively impaired Residents #3 and #5 in a sexual manner. The facility's failure to provide protection to the 10 residents who reside in the special care unit from Resident #1, placed the 10 residents who resided in the special care unit in immediate jeopardy for continued abuse. Findings included: - The medical record revealed the facility admitted Resident #1 on 4/15/16. The 4/20/16 physician progress notes [REDACTED]. associated with personality, behavior and language). The admission (MDS) Minimum Data Set assessment was pending completion. The 4/15/16 admission nursing assessment indicated the resident was independent with his/her (ADLs) Activities of Daily Living, alert and oriented, had no wandering behaviors, and family reported a memory problem. The 4/15/16 admission care plan informed staff the resident was an emergency admission into the facility, and instructed staff to provide a secure unit placement. The 4/18/16 care plan update informed staff the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and verbally inappropriate behaviors, with no instruction for intervention. The 4/19/16 care plan update indicated the resident had sexually inappropriate behaviors, and instructed staff to provide 1 to 1 supervision. The 4/20/16 care plan update informed staff the physician ordered antidepressant medication. The 4/20/16 update informed staff the resident continued to have inappropriate verbal, physical, and sexual behaviors, and choose not to take his/her medications, or follow recommendations from the staff. The care plan lacked any new instruction to staff to manage the behaviors. The 3/13/16 psychiatric consultation indicated the resident had multiple prior medication trials, and frequently refused medications and treatment. The consultation further indicated the resident's family member reported the resident heard voices and had delusional [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing), auditory and visual hallucinations, disorganized speech, and paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) with a severity of 7/10 (10 being the worst). The 4/15/16 at 4:01 PM, nurse's note indicated staff admitted the resident as an emergency admission from home and he/she had major health problems that included: [MEDICAL CONDITION] (psychiatric or neurological symptoms that arise from damage to or disease in the brain) The 4/15/16 physician orders [REDACTED]. - [MEDICATION NAME] (antianxiety), 2 (mg) milligrams, every 4 hours as needed. The 4/17/16 at 1:44 PM, nurse's note indicated the resident refused his/her medications, and rummaged through his/her roommate's belongings. The note further indicated when staff asked the resident not to go through the roommate's belongings the resident would slap his/her fist into the palm of his/her hand. The 4/18/16 at 10:40 AM, nurse's note indicated the resident had delusional thoughts during the morning shift, and the resident stated he/she was a nurse, a karate expert, and not a drug addict, drunk, etc. The note indicated the resident paced around the special care unit, walked and talked with another resident, and rubbed the other resident's shoulders and arms. The note further indicated staff observed the resident hugging other residents, and staff informed the resident not to touch the other resident because the other resident may not understand his/her intentions. The note indicated the resident verbalized understanding, but stated it did not matter, he/she would do whatever he/she wanted to do. The note indicated staff informed the resident not to touch other residents, and the resident stated ok. The 4/18/16 at 5:12 PM, nurse's note indicated in regards to the resident's recent behavior, staff implemented 15 minute checks on Resident #1 when he/she was awake. The 4/19/16 at 12:55 AM, nurse's note indicated staff observed the resident pacing the halls in the special care unit, and at 10:30 PM, staff administered [MEDICATION NAME] to the resident. The note further indicated staff performed 15 minute visual checks, and observed no inappropriate physical touching by the resident. The 4/19/16 at 7:36 AM, nurse's note indicated the resident yelled in another resident's room. The note indicated staff went to the room and observed Resident #1 lying in another resident's bed, yelling at the other resident, and staff asked him/her to get out of the other resident's bed. The note further indicated staff observed the resident be verbally inappropriate to the other resident. Staff redirected the resident to his/her room, and the resident continued to yell inappropriately at staff. The 4/19/16 at 2:48 PM, nurse's note indicated at 1:30 PM, staff observed Resident #1 seated next to Resident #3, and grabbed the groin of Resident #3. Staff observed Resident #1 take Resident #3's hand to place on Resident #1's chest. The note indicated Resident #3 resisted, and Resident #1 verbalized inappropriate sexual remarks to Resident #3. The note further indicated staff attempted to intervene and Resident #1 refused to remove his/her hand from Resident #3's groin area, staff moved in between the 2 chairs and Resident #1 released Resident #3 but continued to make inappropriate sexual remarks to Resident #3. The note indicated when staff attempted to talk to Resident #1 about the incident, he/she stated he/she had a black belt in karate, and attempted to kick staff unsuccessfully. The note further indicated staff provided 1 to 1 supervision to Resident #1. The 4/19/16 at 5:13 PM, nurse's note indicated 4 psychiatric facilities refused to admit the resident. The 4/19/16 at 6:04 PM, nurse's note indicated 2 psychiatric facilities refused to admit the resident, and staff continued to provide 1 to 1 supervision. The note further indicated the resident was angry with the 1 to 1 staff and hit the wall 3 times. The 4/20/16 staff in-service informed staff the resident was delusional and instructed staff to redirect inappropriate behavior. The in-service instructed staff to allow the resident to vent, and not to let the resident sit next to residents of the opposite gender. The 4/20/16 at 9:44 AM, nurse's note indicated staff provided 1 to 1 supervision to the resident, and he/she required redirection 7 times, including redirection when the resident touched another resident's face. The note indicated the resident refused his/her medications, had delusions, and punched his/her fist into the other hand. The 4/20/16 physician's orders [REDACTED]. - [MEDICATION NAME] (an antidepressant) 10 mg, daily x 1 week, then increase to 20 mg, daily. - [MEDICATION NAME] (an antipsychotic) 50 mg, twice daily. The 4/21/16 at 2:32 PM, nurse's note indicated the resident refused all medications, was very hard to redirect, and got angry when told to stay away from residents of the opposite gender. The note further indicated the resident tried to take care of a resident of the opposite gender. The 4/22/16 at 2:56 AM, nurse's note indicated staff reported the resident entered the room of a resident of the opposite sex and staff observed him/her rubbing his/her back and arms. The note indicated staff instructed the resident to keep his/her hands to him/herself, and the resident appeared agitated and slapped one hand in the other. The note further indicated the resident answered the facility's phone, and told the caller he/she was a nurse. The note indicated the resident was currently pacing, and had refused his/her medications. The 4/22/16 at 7:30 PM, nurse's note indicated the resident was outside in a secured fence and chose not to come inside the facility. The note indicated the resident stated he/she does not need to be baby sat, and made a fist and punched his/her other hand as staff walked by. The note further indicated staff performed 15 minute checks, and at 8:30 PM, the resident was back in the facility. The 4/24/16 physician's progress note indicated the provider attempted to interact with the resident and he/she would not respond, and when he/she did, it would not be useful or insightful information. The note indicated staff reported the resident will refuse his/her medications, can be a behavior problem, and became agitated or sexually inappropriate trying to grab staff and other residents genitals. The note indicated the physician planned to replace the [MEDICATION NAME] with [MEDICATION NAME] for labile mood, and medications were ineffective due to the resident not taking oral medications to determine tolerability, and may consider changing to a long acting injectable due to compliance issues. The 4/25/16 at 3:24 PM, social services admission psychological assessment indicated the resident reported he/she was angry, sad, depressed, and wanted to go home. The assessment indicated the resident refused to visit with a psychiatrist, and stated he/she had problems interacting with staff and peers. The 4/25/16 physician's orders [REDACTED]. The 4/26/16 at 1:50 PM, social services note indicated social services visited with the resident in regards to not rummaging through his/her roommate's belongings. The note indicated social services showed the resident the belongings which belonged to his/her roommate, and the resident stated they were his/hers and left the room. On 4/26/16 at 8:50 AM, observation revealed Resident #1 seated with Resident #5 at a table in the dining room of the special care unit with no staff present. Continued observation revealed at 8:54 AM, staff opened a resident's door, looked into the dining room, and shut the door again. At 8:55 AM, observation revealed staff returned to the commons area. On 4/26/16 at 11:12 AM, observation revealed Resident #1 ambulated independently into the dining room of the special care unit, and sat in between Resident #2 and Resident #6 (both residents of the opposite gender), and across from Resident #5. Continued observation revealed, the resident was not in continuous view of staff multiple times during the meal. At 12:17 PM, Resident #1 leaned over and asked Resident #6 what his/her shirt says, and attempted to pull back his/her clothing protector to look. Observation revealed Medication Aide A stood between the 2 residents, and Resident #1 turned and made an angry face. At 12:22 PM, continuous observation revealed Resident #1 grabbed for Resident #6's hand, and Resident #6 pulled away, and scooted his/her wheelchair back. Resident #1 attempted to assist Resident #6, and he/she pushed Resident #1 away. Further observation revealed no staff intervention, and Resident #6 went from smiling, to withdrawn, and without a facial expression when Resident #1 would talk to or touch him/her. On 4/26/16 at 1:49 PM, observation revealed Resident #1 and Resident #2 (opposite gender of Resident #1) ambulated down the hallway into the dining room in the special care unit. Further observation revealed the residents sat down together at a table and had iced tea. Continued observation revealed at 1:53 PM, no staff supervision of the 2 residents in the special care unit dining room for several minutes and no observations of the residents being inappropriate at this time. At 2:07 PM, observation revealed Resident #1 stood directly in front of Resident #3 seated in a recliner, looked around the room, then walked away down the hall without staff supervision. On 4/26/16 at 2:18 PM, observation revealed staff assisted Resident #3 to his/her room to use the bathroom, and left multiple residents in the special care unit commons area unattended. Further observation revealed Resident #1 ambulated independently into the commons area, and wandered around the unit. Continued observation revealed Resident #2 and Resident #7 (both residents of the opposite gender as Resident #1), followed Resident #1 as he/she wandered the unit without staff supervision until 2:25 PM. Further observation revealed Resident #7 needed assistance, and staff went into his/her room, shut the door, and left the commons area unattended with Resident #1 and Resident #5 seated in the dining room until 2:28 PM. Further observation revealed Resident #1 continued to wander throughout the special care unit without continuous observation of the staff. On 4/26/16 at 3:38 PM, observation revealed Resident #1 ambulated down the hallway, kicked his/her leg above his/her head, and made a karate chop move with both his/her hands at staff. Further observation revealed Resident #1 sat down in a recliner in the commons area of the special care unit and had a conversation with his/herself, asking and answering him/her own questions. On 4/27/16 at 11:29 AM, observation revealed Resident #1 and a resident of the opposite gender sat in the dining room at a table next to one another. Continued observation until 11:55 AM, revealed the resident was not in continuous supervision of staff. On 4/27/16 at 2:05 PM, observation revealed Resident #1 seated with Resident #5, and Resident #2 in the dining room of the special care unit without staff supervision. Continued observation revealed at 2:35 PM, Resident #1 and Resident #2 wandered together throughout the special care unit without direct staff supervision. At 2:40 PM, observation revealed staff assisted a resident in his/her room, shut the door, and left Resident #1, Resident #2, Resident #3, Resident #5, and Resident #6 unattended in the commons area of the special care unit. Continued observation revealed at 2:43 PM, staff checked on the residents in the commons area, and returned to the resident's room and close the door. Further observation revealed Resident #1 and Resident #2 wandered throughout the special care unit without staff supervision. At 2:49 PM, staff entered in the dining room, and Resident #5 reported to staff that Resident #1 sexually assaulted him/her last night and the night before, and he/she does not like it. Resident #5 continued to inform staff that Resident #1 will not stay out of his/her room. On 4/26/16 at 11:12 AM, Medication Aide A stated he/she did not know what else to do with seating in the dining room, because residents sit where they want to. Medication Aide A stated Resident #1 is ok seated next to Resident #6 because Resident #6 will not let Resident #1 touch him/her. Medication Aide A verified Resident #1 touched Resident #6 on 4/25/16, and he/she told staff right away. Medication Aide A further verified Resident #1 got right by Resident #3 the other day, and he/she just stood in between them. Medication Aide A stated he/she did not know what else to do, and verified it was almost impossible to redirect Resident #1. On 4/26/16 at 12:29 PM, Medication Aide A verified the day of the incident with Resident #3 on 4/19/16, Resident #1 had sat on the floor in front of Resident #3, and staff had him/her move to a recliner prior to the incident. Medication Aide A further verified Resident #1 touched Resident #6 on the belly, Resident #6 does not like it, and staff told Resident #1 to keep his/her hands to him/herself. Medication Aide A stated Resident #2 follows Resident #1 around all the time, and has written him/her love letters. Medication Aide A stated if they are only talking he/she will not interrupt unless they start touching each other. Medication Aide A verified staff do not provide 1 to 1 staff supervision for Resident #1, but do provide 15 minute checks. On 4/26/16 at 12:35 PM, Nurse Aide C stated he/she did not witness the incident with Resident #1 and Resident #3 on 4/19/16, he/she was at the sink in the dining room. Resident #1 was seated next to Resident #3 in the living area, and had pulled his/her recliner closer to Resident #3. Nurse Aide C further stated Resident #6 tells Resident #1 not to touch him/her, and Resident #1 kissed Resident #6 on the forehead on 4/25/16. Nurse Aide C further verified the resident was 1 to 1 supervision on the evening shift, but stated there was not enough staff to do 1 to 1 supervision, so staff provide 15 minute checks. On 4/26/16 at 2:45 PM, Medication Aide D stated on 4/19/16 Resident #1 told Resident #3, you want me, you know you do?, and Resident #1 put his/her hand down Resident #3's pants. Medication Aide D verified staff try to keep a visual, but Resident #1 is not on 1 to 1 staff supervision. Medication Aide D further verified Resident #1 does not like to be redirected, and towards the evening Resident #1 and Resident #2 will walk and talk. Staff try to keep close attention to the conversation, and as long as it is appropriate, staff allow it. On 4/26/16 at 2:50 PM, Nurse Aide E verified on 4/18/16 that Resident #1 and Resident #2 were holding hands and rubbing each other, prior to the incident. On 4/26/16 at 2:58 PM, Nurse F verified staff perform 15 minute checks, and can not keep Resident #1 and Resident #2 separated. Nurse F further verified Resident #1 kissed Resident #6 on the forehead the day before, and Resident #6 told Resident #1 to get away from him/her. Nurse F stated he/she does not know if Resident #1 is going to be inappropriate until it happens. Nurse F verified staff tried to provide 1 to 1 supervision and Resident #1 didn't like it, and they do not have enough staff to do it. On 4/27/16 at 1:40 PM, Administrative Nurse G stated staff only performed 1 to 1 supervision right after the incident, and now staff perform 15 minute checks. Administrative Nurse G verified staff are to keep the resident in constant visual to keep the other residents safe in the special care unit, and verified there could be times the resident was not in constant visual. Administrative Nurse G stated staff should call for someone to come into the unit so staff can provide cares to other residents, and not leave the resident unattended. Administrative Nurse G stated the facility admitted the resident on a Friday afternoon, he/she was not involved in the admission process, and after the incident on 4/19/16, he/she felt Resident #1 was inappropriately admitted into the facility and needed medication adjustments. On 4/27/16 at 3:10 PM, Resident #5 verified on the evening of 4/25/16, he/she was lying in bed in his/her room, and Resident #1 came in and rubbed his/her buttocks, and stated hi sweetheart. Resident #5 stated Resident #1 kissed him/her on the cheek, and rubbed his/her arm in the past. Resident #5 stated on 4/25/16 he/she informed Nurse Aide B he/she was inappropriately touched. Resident #5 further stated Resident #1 goes into rooms of residents who are of the opposite sex, all the time. Resident #5 stated Resident #1 kisses Resident #2, and Resident #6 tells Resident #1 not touch him/her, but Resident #1 does it anyway. On 4/27/16 at 3:32 PM, Nurse Aide B verified Resident #5 notified him/her on 4/25/16 that Resident #1 inappropriately touched him/her. Nurse Aide B further verified he/she notified the medication aide in charge that evening, so he/she could write it down on paper. Nurse Aide B further verified he/she had witnessed Resident #1 kiss Resident #2 on the cheek, walk arm and arm, and observed Resident #1 rub Resident #3's feet. Nurse Aide B stated when staff tell Resident #1 his/her behavior is inappropriate, he/she gets upset. On 4/27/16 at 3:38 PM, Medication Aide I stated on 4/25/16, he/she was not notified that Resident #5 reported he/she was inappropriately touched by Resident #1. Medication Aide I stated staff perform 15 minute checks on the residents to monitor for inappropriate behaviors. On 4/27/16 at 4:06 PM, Administrative Nurse G verified he/she was not aware of an incident occurring on 4/25/16 with Resident #1 and Resident #5. Administrative Nurse G further verified he/she was aware Resident #1 approached Resident #6 and grabbed his/her hand, but did not know it went any further than that. Administrative Nurse G verified both incidents were not reported or investigated by administrative staff. On 4/28/16 at 3:30 PM, Administrative Staff H verified he/she interviewed Resident #5 on 4/22/16, and he/she had no concerns with inappropriate behaviors of Resident #1, but reported Resident #1 kissed him/her on the cheek. The facility's 9/2012 Preventing Resident Abuse policy instructed staff to assess a resident with signs and symptoms of a behavior problem and develop and implement a care plan to address behavioral issues. The facility's 9/2012 Protection of Residents During Abuse Investigations policy directed staff if the alleged abuse involved another resident, the accused resident's representative and attending physician would be notified and that there may be restrictions on the accused resident's ability to visit in other resident rooms without supervision. If necessary, the accused resident's family members may be required to help meet this requirement. The facility's 3/2016 Reporting Abuse policy instructed staff inquiries concerning resident abuse should be referred to the director of nursing or to the administrator. The facility failed to provide protection to the 10 residents, who resided in the special care unit, from Resident #1, who displayed inappropriate sexual behaviors to residents. This deficient practice placed the 10 residents in immediate jeopardy for continued abuse. The facility abated the immediate jeopardy on 4/29/16 after completion of training of all staff regarding protection of residents after inappropriate touching in a sexual manner, by a resident, and implementation of 1 to 1 as needed. The training also included the importance of following the reviewed abuse, neglect and exploitation policy, reporting, and protection of residents. The facility also provided 1 to 1 supervision of Resident #1 and protected the residents on the unit. The facility also failed to investigate and report some of the incidents to the state agency. The deficient practice remained at the scope and severity of an E.

The facility had a census of 45 residents, of which 10 resided in the special care unit. Based on observation, interview, and record review the facility failed to protect the residents who resided in the special care unit from Resident #1, who inappropriately touched cognitively impaired Residents #3 and #5 in a sexual manner. The facility's failure to provide protection to the 10 residents who reside in the special care unit from Resident #1, placed the 10 residents who resided in the special care unit in immediate jeopardy. Findings included: - The medical record revealed the facility admitted Resident #1 on 4/15/16. The 4/20/16 physician progress notes [REDACTED]. associated with personality, behavior and language). The admission (MDS) Minimum Data Set assessment was pending completion. The 4/15/16 admission nursing assessment indicated the resident was independent with his/her (ADLs) Activities of Daily Living, alert and oriented, had no wandering behaviors, and family reported a memory problem. The 4/15/16 admission care plan informed staff the resident was an emergency admission into the facility, and instructed staff to provide a secure unit placement. The 4/18/16 care plan update informed staff the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and verbally inappropriate behaviors, with no instruction for intervention. The 4/19/16 care plan update indicated the resident had sexually inappropriate behaviors, and instructed staff to provide 1 to 1 supervision. The 4/20/16 care plan update informed staff the physician ordered antidepressant medication. The 4/20/16 update informed staff the resident continued to have inappropriate verbal, physical, and sexual behaviors, and choose not to take his/her medications, or follow recommendations from the staff. The care plan lacked any new instruction to staff to manage the behaviors. The 3/13/16 psychiatric consultation indicated the resident had multiple prior medication trials, and frequently refused medications and treatment. The consultation further indicated the resident's family member reported the resident heard voices and had delusional [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing), auditory and visual hallucinations, disorganized speech, and paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) with a severity of 7/10 (10 being the worst). The 4/15/16 at 4:01 PM, nurse's note indicated staff admitted the resident as an emergency admission from home and he/she had major health problems that included: [MEDICAL CONDITION] (psychiatric or neurological symptoms that arise from damage to or disease in the brain) The 4/15/16 physician orders [REDACTED]. - [MEDICATION NAME] (antianxiety), 2 (mg) milligrams, every 4 hours as needed. The 4/17/16 at 1:44 PM, nurse's note indicated the resident refused his/her medications, and rummaged through his/her roommate's belongings. The note further indicated when staff asked the resident not to go through the roommate's belongings the resident would slap his/her fist into the palm of his/her hand. The 4/18/16 at 10:40 AM, nurse's note indicated the resident had delusional thoughts during the morning shift, and the resident stated he/she was a nurse, a karate expert, and not a drug addict, drunk, etc. The note indicated the resident paced around the special care unit, walked and talked with another resident, and rubbed the other resident's shoulders and arms. The note further indicated staff observed the resident hugging other residents, and staff informed the resident not to touch the other resident because the other resident may not understand his/her intentions. The note indicated the resident verbalized understanding, but stated it did not matter, he/she would do whatever he/she wanted to do. The note indicated staff informed the resident not to touch other residents, and the resident stated ok. The 4/18/16 at 5:12 PM, nurse's note indicated in regards to the resident's recent behavior, staff implemented 15 minute checks on Resident #1 when he/she was awake. The 4/19/16 at 12:55 AM, nurse's note indicated staff observed the resident pacing the halls in the special care unit, and at 10:30 PM, staff administered [MEDICATION NAME] to the resident. The note further indicated staff performed 15 minute visual checks, and observed no inappropriate physical touching by the resident. The 4/19/16 at 7:36 AM, nurse's note indicated the resident yelled in another resident's room. The note indicated staff went to the room and observed Resident #1 lying in another resident's bed, yelling at the other resident, and staff asked him/her to get out of the other resident's bed. The note further indicated staff observed the resident be verbally inappropriate to the other resident. Staff redirected the resident to his/her room, and the resident continued to yell inappropriately at staff. The 4/19/16 at 2:48 PM, nurse's note indicated at 1:30 PM, staff observed Resident #1 seated next to Resident #3, and grabbed the groin of Resident #3. Staff observed Resident #1 take Resident #3's hand to place on Resident #1's chest. The note indicated Resident #3 resisted, and Resident #1 verbalized inappropriate sexual remarks to Resident #3. The note further indicated staff attempted to intervene and Resident #1 refused to remove his/her hand from Resident #3's groin area, staff moved in between the 2 chairs and Resident #1 released Resident #3 but continued to make inappropriate sexual remarks to Resident #3. The note indicated when staff attempted to talk to Resident #1 about the incident, he/she stated he/she had a black belt in karate, and attempted to kick staff unsuccessfully. The note further indicated staff provided 1 to 1 supervision to Resident #1. The 4/19/16 at 5:13 PM, nurse's note indicated 4 psychiatric facilities refused to admit the resident. The 4/19/16 at 6:04 PM, nurse's note indicated 2 psychiatric facilities refused to admit the resident, and staff continued to provide 1 to 1 supervision. The note further indicated the resident was angry with the 1 to 1 staff and hit the wall 3 times. The 4/20/16 staff in-service informed staff the resident was delusional and instructed staff to redirect inappropriate behavior. The in-service instructed staff to allow the resident to vent, and not to let the resident sit next to residents of the opposite gender. The 4/20/16 at 9:44 AM, nurse's note indicated staff provided 1 to 1 supervision to the resident, and he/she required redirection 7 times, including redirection when the resident touched another resident's face. The note indicated the resident refused his/her medications, had delusions, and punched his/her fist into the other hand. The 4/20/16 physician's orders [REDACTED]. - [MEDICATION NAME] (an antidepressant) 10 mg, daily x 1 week, then increase to 20 mg, daily. - [MEDICATION NAME] (an antipsychotic) 50 mg, twice daily. The 4/21/16 at 2:32 PM, nurse's note indicated the resident refused all medications, was very hard to redirect, and got angry when told to stay away from residents of the opposite gender. The note further indicated the resident tried to take care of a resident of the opposite gender. The 4/22/16 at 2:56 AM, nurse's note indicated staff reported the resident entered the room of a resident of the opposite sex and staff observed him/her rubbing his/her back and arms. The note indicated staff instructed the resident to keep his/her hands to him/herself, and the resident appeared agitated and slapped one hand in the other. The note further indicated the resident answered the facility's phone, and told the caller he/she was a nurse. The note indicated the resident was currently pacing, and had refused his/her medications. The 4/22/16 at 7:30 PM, nurse's note indicated the resident was outside in a secured fence and chose not to come inside the facility. The note indicated the resident stated he/she does not need to be baby sat, and made a fist and punched his/her other hand as staff walked by. The note further indicated staff performed 15 minute checks, and at 8:30 PM, the resident was back in the facility. The 4/24/16 physician's progress note indicated the provider attempted to interact with the resident and he/she would not respond, and when he/she did, it would not be useful or insightful information. The note indicated staff reported the resident will refuse his/her medications, can be a behavior problem, and became agitated or sexually inappropriate trying to grab staff and other residents genitals. The note indicated the physician planned to replace the [MEDICATION NAME] with [MEDICATION NAME] for labile mood, and medications were ineffective due to the resident not taking oral medications to determine tolerability, and may consider changing to a long acting injectable due to compliance issues. The 4/25/16 at 3:24 PM, social services admission psychological assessment indicated the resident reported he/she was angry, sad, depressed, and wanted to go home. The assessment indicated the resident refused to visit with a psychiatrist, and stated he/she had problems interacting with staff and peers. The 4/25/16 physician's orders [REDACTED]. The 4/26/16 at 1:50 PM, social services note indicated social services visited with the resident in regards to not rummaging through his/her roommate's belongings. The note indicated social services showed the resident the belongings which belonged to his/her roommate, and the resident stated they were his/hers and left the room. On 4/26/16 at 8:50 AM, observation revealed Resident #1 seated with Resident #5 at a table in the dining room of the special care unit with no staff present. Continued observation revealed at 8:54 AM, staff opened a resident's door, looked into the dining room, and shut the door again. At 8:55 AM, observation revealed staff returned to the commons area. On 4/26/16 at 11:12 AM, observation revealed Resident #1 ambulated independently into the dining room of the special care unit, and sat in between Resident #2 and Resident #6 (both residents of the opposite gender), and across from Resident #5. Continued observation revealed, the resident was not in continuous view of staff multiple times during the meal. At 12:17 PM, Resident #1 leaned over and asked Resident #6 what his/her shirt says, and attempted to pull back his/her clothing protector to look. Observation revealed Medication Aide A stood between the 2 residents, and Resident #1 turned and made an angry face. At 12:22 PM, continuous observation revealed Resident #1 grabbed for Resident #6's hand, and Resident #6 pulled away, and scooted his/her wheelchair back. Resident #1 attempted to assist Resident #6, and he/she pushed Resident #1 away. Further observation revealed no staff intervention, and Resident #6 went from smiling, to withdrawn, and without a facial expression when Resident #1 would talk to or touch him/her. On 4/26/16 at 1:49 PM, observation revealed Resident #1 and Resident #2 (opposite gender of Resident #1) ambulated down the hallway into the dining room in the special care unit. Further observation revealed the residents sat down together at a table and had iced tea. Continued observation revealed at 1:53 PM, no staff supervision of the 2 residents in the special care unit dining room for several minutes and no observations of the residents being inappropriate at this time. At 2:07 PM, observation revealed Resident #1 stood directly in front of Resident #3 seated in a recliner, looked around the room, then walked away down the hall without staff supervision. On 4/26/16 at 2:18 PM, observation revealed staff assisted Resident #3 to his/her room to use the bathroom, and left multiple residents in the special care unit commons area unattended. Further observation revealed Resident #1 ambulated independently into the commons area, and wandered around the unit. Continued observation revealed Resident #2 and Resident #7 (both residents of the opposite gender as Resident #1), followed Resident #1 as he/she wandered the unit without staff supervision until 2:25 PM. Further observation revealed Resident #7 needed assistance, and staff went into his/her room, shut the door, and left the commons area unattended with Resident #1 and Resident #5 seated in the dining room until 2:28 PM. Further observation revealed Resident #1 continued to wander throughout the special care unit without continuous observation of the staff. On 4/26/16 at 3:38 PM, observation revealed Resident #1 ambulated down the hallway, kicked his/her leg above his/her head, and made a karate chop move with both his/her hands at staff. Further observation revealed Resident #1 sat down in a recliner in the commons area of the special care unit and had a conversation with his/herself, asking and answering him/her own questions. On 4/27/16 at 11:29 AM, observation revealed Resident #1 and a resident of the opposite gender sat in the dining room at a table next to one another. Continued observation until 11:55 AM, revealed the resident was not in continuous supervision of staff. On 4/27/16 at 2:05 PM, observation revealed Resident #1 seated with Resident #5, and Resident #2 in the dining room of the special care unit without staff supervision. Continued observation revealed at 2:35 PM, Resident #1 and Resident #2 wandered together throughout the special care unit without direct staff supervision. At 2:40 PM, observation revealed staff assisted a resident in his/her room, shut the door, and left Resident #1, Resident #2, Resident #3, Resident #5, and Resident #6 unattended in the commons area of the special care unit. Continued observation revealed at 2:43 PM, staff checked on the residents in the commons area, and returned to the resident's room and close the door. Further observation revealed Resident #1 and Resident #2 wandered throughout the special care unit without staff supervision. At 2:49 PM, staff entered in the dining room, and Resident #5 reported to staff that Resident #1 sexually assaulted him/her last night and the night before, and he/she does not like it. Resident #5 continued to inform staff that Resident #1 will not stay out of his/her room. On 4/26/16 at 11:12 AM, Medication Aide A stated he/she did not know what else to do with seating in the dining room, because residents sit where they want to. Medication Aide A stated Resident #1 is ok seated next to Resident #6 because Resident #6 will not let Resident #1 touch him/her. Medication Aide A verified Resident #1 touched Resident #6 on 4/25/16, and he/she told staff right away. Medication Aide A further verified Resident #1 got right by Resident #3 the other day, and he/she just stood in between them. Medication Aide A stated he/she did not know what else to do, and verified it was almost impossible to redirect Resident #1. On 4/26/16 at 12:29 PM, Medication Aide A verified the day of the incident with Resident #3 on 4/19/16, Resident #1 had sat on the floor in front of Resident #3, and staff had him/her move to a recliner prior to the incident. Medication Aide A further verified Resident #1 touched Resident #6 on the belly, Resident #6 does not like it, and staff told Resident #1 to keep his/her hands to him/herself. Medication Aide A stated Resident #2 follows Resident #1 around all the time, and has written him/her love letters. Medication Aide A stated if they are only talking he/she will not interrupt unless they start touching each other. Medication Aide A verified staff do not provide 1 to 1 staff supervision for Resident #1, but do provide 15 minute checks. On 4/26/16 at 12:35 PM, Nurse Aide C stated he/she did not witness the incident with Resident #1 and Resident #3 on 4/19/16, he/she was at the sink in the dining room. Resident #1 was seated next to Resident #3 in the living area, and had pulled his/her recliner closer to Resident #3. Nurse Aide C further stated Resident #6 tells Resident #1 not to touch him/her, and Resident #1 kissed Resident #6 on the forehead on 4/25/16. Nurse Aide C further verified the resident was 1 to 1 supervision on the evening shift, but stated there was not enough staff to do 1 to 1 supervision, so staff provide 15 minute checks. On 4/26/16 at 2:45 PM, Medication Aide D stated on 4/19/16 Resident #1 told Resident #3, you want me, you know you do?, and Resident #1 put his/her hand down Resident #3's pants. Medication Aide D verified staff try to keep a visual, but Resident #1 is not on 1 to 1 staff supervision. Medication Aide D further verified Resident #1 does not like to be redirected, and towards the evening Resident #1 and Resident #2 will walk and talk. Staff try to keep close attention to the conversation, and as long as it is appropriate, staff allow it. On 4/26/16 at 2:50 PM, Nurse Aide E verified on 4/18/16 that Resident #1 and Resident #2 were holding hands and rubbing each other, prior to the incident. On 4/26/16 at 2:58 PM, Nurse F verified staff perform 15 minute checks, and can not keep Resident #1 and Resident #2 separated. Nurse F further verified Resident #1 kissed Resident #6 on the forehead the day before, and Resident #6 told Resident #1 to get away from him/her. Nurse F stated he/she does not know if Resident #1 is going to be inappropriate until it happens. Nurse F verified staff tried to provide 1 to 1 supervision and Resident #1 didn't like it, and they do not have enough staff to do it. On 4/27/16 at 1:40 PM, Administrative Nurse G stated staff only performed 1 to 1 supervision right after the incident, and now staff perform 15 minute checks. Administrative Nurse G verified staff are to keep the resident in constant visual to keep the other residents safe in the special care unit, and verified there could be times the resident was not in constant visual. Administrative Nurse G stated staff should call for someone to come into the unit so staff can provide cares to other residents, and not leave the resident unattended. Administrative Nurse G stated the facility admitted the resident on a Friday afternoon, he/she was not involved in the admission process, and after the incident on 4/19/16, he/she felt Resident #1 was inappropriately admitted into the facility and needed medication adjustments. On 4/27/16 at 3:10 PM, Resident #5 verified on the evening of 4/25/16, he/she was lying in bed in his/her room, and Resident #1 came in and rubbed his/her buttocks, and stated hi sweetheart. Resident #5 stated Resident #1 kissed him/her on the cheek, and rubbed his/her arm in the past. Resident #5 stated on 4/25/16 he/she informed Nurse Aide B he/she was inappropriately touched. Resident #5 further stated Resident #1 goes into rooms of residents who are of the opposite sex, all the time. Resident #5 stated Resident #1 kisses Resident #2, and Resident #6 tells Resident #1 not touch him/her, but Resident #1 does it anyway. On 4/27/16 at 3:32 PM, Nurse Aide B verified Resident #5 notified him/her on 4/25/16 that Resident #1 inappropriately touched him/her. Nurse Aide B further verified he/she notified the medication aide in charge that evening, so he/she could write it down on paper. Nurse Aide B further verified he/she had witnessed Resident #1 kiss Resident #2 on the cheek, walk arm and arm, and observed Resident #1 rub Resident #3's feet. Nurse Aide B stated when staff tell Resident #1 his/her behavior is inappropriate, he/she gets upset. On 4/27/16 at 3:38 PM, Medication Aide I stated on 4/25/16, he/she was not notified that Resident #5 reported he/she was inappropriately touched by Resident #1. Medication Aide I stated staff perform 15 minute checks on the residents to monitor for inappropriate behaviors. On 4/27/16 at 4:06 PM, Administrative Nurse G verified he/she was not aware of an incident occurring on 4/25/16 with Resident #1 and Resident #5. Administrative Nurse G further verified he/she was aware Resident #1 approached Resident #6 and grabbed his/her hand, but did not know it went any further than that. Administrative Nurse G verified both incidents were not reported or investigated by administrative staff. On 4/28/16 at 3:30 PM, Administrative Staff H verified he/she interviewed Resident #5 on 4/22/16, and he/she had no concerns with inappropriate behaviors of Resident #1, but reported Resident #1 kissed him/her on the cheek. The facility's 9/2012 Preventing Resident Abuse policy instructed staff to assess a resident with signs and symptoms of a behavior problem and develop and implement a care plan to address behavioral issues. The facility's 9/2012 Protection of Residents During Abuse Investigations policy directed staff if the alleged abuse involved another resident, the accused resident's representative and attending physician would be notified and that there may be restrictions on the accused resident's ability to visit in other resident rooms without supervision. If necessary, the accused resident's family members may be required to help meet this requirement. The facility's 3/2016 Reporting Abuse policy instructed staff inquiries concerning resident abuse should be referred to the director of nursing or to the administrator. The facility failed to provide protection to the 10 residents, who resided in the special care unit, from Resident #1, who displayed inappropriate sexual behaviors to residents. This deficient practice placed the 10 residents in immediate jeopardy. The facility abated the immediate jeopardy on 4/29/16 after completion of training of all staff regarding protection of residents after inappropriate touching in a sexual manner, by a resident, and implementation of 1 to 1 as needed. The training also included the importance of following the reviewed abuse, neglect and exploitation policy, reporting, and protection of residents. The facility also provided 1 to 1 supervision of Resident #1 and protected the residents on the unit. The facility also failed to investigate and report some of the incidents to the state agency. The deficient practice remained at the scope and severity of an E.

The facility had a census of 50 residents. The sample included 3 residents and all 3 reviewed for elopement. Based on observation, record review and interview, the facility failed to ensure 1 of 3 residents (#1) had adequate supervision to prevent the resident from eloping leaving the facility without staff knowledge and has not been located. This failure placed the resident in immediate jeopardy. Findings included: - Resident #1's (POS) physician order [REDACTED]. (a psychiatric disorder characterized by obsessive thoughts and compulsive actions), dysphasia (difficulty or discomfort in swallowing), and deformity of the tongue. The quarterly (MDS) Minimum Data Set assessment, dated 5/26/15, indicated the resident had a (BIMS) Brief Interview for Mental Status Score of 15 which indicated intact cognition. The assessment revealed the resident had verbal and physical behaviors towards others. The assessment further revealed the resident required set-up assistance with supervision for bed mobility, transfers, and ambulation in his/her room and corridor, and no wandering behavior during the assessment period. The annual MDS, dated [DATE], indicated the resident had a BIMS score of 15 which indicated intact cognition. The assessment revealed the resident had physical behaviors toward others, behaviors that put the resident at risk for injury, and significant disruption of the environment. The assessment further revealed the resident required set-up assistance with supervision for bed mobility, transfers, and ambulation in his/her room and corridor, and no wandering behavior during the assessment period. The 1/1/15 (CAA) Care Area Assessment for behavior stated the resident had physical and other behaviors directed towards others which put the resident at risk for injury and disrupted the living environment. The CAA further stated the staff considered the resident an elopement risk and he/she resided in the secured (SCU) special care unit. The 6/10/15 care plan indicated the resident paced continuously, could be physically abusive, was sometimes anxious and worried. The care plan directed staff to attempt to keep the other residents separate from Resident #1, who caused increased behaviors when they were in the same room. The care plan directed the staff to encourage the resident to express him/herself through the use of a computer communicator, writing messages in a notebook, or pointing to the letters on the sign language sheet. The updated 8/19/15 care plan stated the resident was at risk for elopement and directed staff to distract him/her with activities when he/she was exit seeking or in a bad mood. The 8/11/15 quarterly MDS evaluation indicated the resident required supervision when ambulating and did not have any wandering behaviors. The 6/25/15 at 4:53 AM, nurse's note stated the resident attempted to open the outside gate in the SCU patio area but was unsuccessful. The note further stated the resident asked another resident to assist him/her to open the gate. Staff intervened before the residents opened the gate. The note stated staff instructed the resident to stay indoors and initiated 15 minute visual checks on the resident. The 6/25/15 at 5:13 PM, nurse's note stated the resident had been seen kicking and hitting the wooden gate in the patio on the SCU. The note further stated the nursing staff were instructed to frequently monitor the resident. The 6/25/15 at 8:49 PM, nurse's note stated the resident continued to want to exit the gate in the outside patio area of the special care unit. The note stated staff redirected the resident and would continue to monitor. The 6/26/15 at 4:48 PM, nurse's note stated the resident attempted to go outside unaccompanied and staff went outside and stayed with the resident. The 7/10/15 at 1:30 PM, nurse's note stated the resident went outside in the enclosed patio and was not wanting to come back in. The note further stated the resident hit a staff member in the face with a 3 pound weight and kicked the staff member. The note stated the resident again wanted to go outside and staff stated he/she had lost his/her privileges because he/she tried to escape. The 7/16/15 at 2:26 AM, nurse's note stated the resident went outside, unsupervised. The resident walked to the gate, unlocked it, and exited through the gate. The note further stated the nurse aide went outside and told the resident to come back in. The note stated the resident came back inside, then went back out to the patio and attempted to go out the gate again. The note stated the resident became combative and attempted to hit the nurse aide. The note stated another nurse aide came to assist and placed his/her arms around the resident to prevent the resident from hitting the other nurse aide, and guided the resident back inside the SCU. The 7/20/15 at 1:43 PM, nurse's note stated the facility planned to transfer the resident to a hospital behavioral unit. The 7/20/15 hospital history and physical noted the behavioral unit admitted the resident due to agitation, aggression, and elopement risk. The History and Physical further stated the resident had not been accepting redirection and had a history of [REDACTED]. The 7/20/15 hospital Psychiatric Evaluation noted the resident had escalating behaviors and had been trying to elope from the facility. The evaluation further stated the resident was alert and oriented times 3, cooperative and willing to answers questions by writing on paper. The evaluation stated the resident appeared withdrawn, depressed, and his/her insight and judgment appeared to be impaired. The evaluation stated the plan was to stabilize the resident, review his/her medications, and limit his/her stimuli due to agitation and aggression. The 7/29/15 hospital discharge summary stated the resident was stable and his/her insight and judgement had improved. The summary further stated the resident would continue to improve if he/she was compliant with the treatment plan. The 7/29/15 at 2:26 PM, stated the facility readmitted the resident with a [DIAGNOSES REDACTED]. The facility readmitted the resident on 7/29/15 with orders directing the staff to administer the following medications: [REDACTED] Lorazapam, (an antianxiety medication) 0.5 (mg) milligrams, by mouth, three times a day. Trazadone, (an antidepressant medication), 100 mg, by mouth, at bedtime. Zyprexa, (an antipsychotic medication), 5 mg, 3 tablets, by mouth, twice a day. The 7/30/15 physician's orders [REDACTED]. The 7/31/15 at 6:12 PM, nurse's note stated staff reminded the resident he/she may only go outside with staff supervision due to his/her history of exit seeking behavior. The 8/18/15 at 1:17 AM, nurse's note stated at 9:45 PM on 8/17/15, Licensed Nurse C and Medication Aide D were on the SCU, when the resident came out of his/her room wearing a black hoodie sweatshirt, athletic shorts, and tennis shoes. The resident went outside to the patio, as usual, with no staff. The note further stated at 9:50 PM, Nurse Aide B came into the SCU and informed staff someone was seen going over the fence of the SCU and running across the lawn. Licensed Nurse C sent Nurse Aide B outside to search around the facility and neighborhood block while he/she and Medication Aide D went out separate doors on the SCU to the outside patio. The note stated the resident was not on the patio, and at 9:55 PM Licensed Nurse C contacted the facility administrator, and the local police at 10:00 PM. Administrative Staff A sent multiple staff to search for the resident throughout the facility and the neighborhood. The note further stated the local police, fire department, and facility staff searched the town and ended the search at 1:00 AM. On 8/19/15 at 1:30 PM, observation revealed the 2 SCU patio gates had the combination to unlock the gates written in black marker on the fence by the locks. Further observation revealed the door to the patio alarmed until shut, then reset without staff manually entering a code. On 8/19/15 at 11:24 AM, Licensed Nurse C stated he/she was doing the end of the shift report with Medication Aide D, when the resident went out the patio door. Licensed Nurse C stated Nurse Aide B from the nursing floor came into the SCU and stated a visitor and another resident saw someone in dark clothing climb over the SCU fence. Licensed Nurse C stated Medication Aide D and him/herself checked the patio and did not see the resident. Licensed Nurse C and Nurse Aide B went outside to search for the resident and left Medication Aide D to search the rooms in the SCU. Licensed Nurse C stated he/she contacted the facility administrator and the local police and was told to keep the evening shift at the facility to do a room to room search. On 8/19/15 at 12:06 PM, Medication Aide D stated he/she was meeting with Licensed Nurse C when the resident went out the patio door at 9:50 PM. Medication Aide D stated Nurse Aide B came into the SCU and stated a resident had jumped the SCU fence and was fleeing. Medication Aide D stated the nurse had called the authorities and searched the special care unit to make sure the resident was not hiding anywhere. Medication Aide D stated he/she had looked at the gates to see if the resident went out of the gate, but both gates were locked. Medication Aide D gave report to the night shift staff and then went downstairs to check the apartments and rooms to make sure the resident wasn't hiding downstairs. Medication Aide D stated he/she thought the resident could go outside unsupervised. On 8/19/15 at 1:00 PM, Administrative Nurse K stated the elopement care plan was written today due to he/she had forgotten to add it the day the resident had returned from his/her recent hospitalization in the behavioral unit. (7/29/15) Administrative Nurse K stated the resident was an elopement risk and had previously attempted to elope from the facility. On 8/19/15 at 12:35 PM, Administrative Staff A stated nursing staff notified him/her on 8/17/15 at 9:56 PM that the resident had jumped the SCU fence and he/she asked the evening staff to do a search of the building. Administrative Staff A stated he/she arrived at the facility at 10:08 PM. Administrative Staff A called all staff that lived in town to assist in the search of the town and posted a staff member by the highway to make sure the resident did not try to get a ride. Administrative Staff A stated the local police arrived and he/she told the officer about the resident and his/her fear that people would be scared of the resident due to the residents inability to talk and his/her excessive drooling. Administrative Staff A and multiple staff members searched vacant buildings and called off the search at 12:30 AM. Administrative Staff A stated the search resumed the next morning and staff placed flyers in local businesses and homes. Administrative Staff A stated he/she did not feel the resident eloped due to his/her intact cognition and purpose for leaving the facility, even with the previous attempts to leave and, the resident was just unhappy he/she could not eat regular consistency foods. Administrative Staff A stated he/she planned to continue to search for the resident. On 8/19/15 at 10:05 PM, Nurse Aide F stated the resident tried to get through the gate in the SCU during the night in July. Nurse Aide F stated the combination for the locks on the gates were where the resident could see them and stated the resident was able to read, so he/she was able to unlock the gate. Nurse Aide F stated the resident was an elopement risk and was not to be left unsupervised when he/she was outside on the SCU patio. On 8/19/15 at 10:15 PM, Nurse Aide G stated the resident was up a lot at night and wanted to go outside but he/she would tell the resident he/she could not go outside unsupervised because the aide couldn't leave the unit to supervise him/her. Nurse Aide G further stated during the evening shift, the staff were not to let the resident outside without staff because of his/her previous attempts to elope. On 8/1915 at 10:30 PM, Licensed Nurse H stated the resident was not to be outside on the SCU patio without supervision because he/she was an elopement risk. On 8/20/15 at 8:57 AM, Nurse Aide I stated the staff were instructed not to let the resident out on the SCU patio unsupervised because he/she had tried to get through the gates and leave the facility. Nurse Aide I stated the staff were told to continue sitting outside with him/her after the resident returned from the recent hospital visit. On 8/20/15 at 9:45 AM, Administrative Staff A stated the resident did not have his/her medications, the resident was unsupervised in the community, leaving him/her unsafe. On 8/24/15 at 9:50 AM, Physician J stated he/she felt the resident should have had supervision when he/she was outside and was an elopement risk. The undated facility's Wandering/Elopement Policy stated all potential admissions to the facility would be screened per review of the History and Physical, and interview with family/responsible party, for a history of wandering, and conditions or [DIAGNOSES REDACTED]. The policy further stated any identified residents would be placed in rooms that allowed for increased supervision by facility staff and if the facility was unable to meet a resident's safety needs, the family/responsible party would be informed and would be assisted in finding appropriate alternative placement. The facility failed to ensure adequate supervision for Resident #1, who left the facility unsupervised and was not located as of 8/27/2015. This deficient practice placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy on August 21, 2015, when the facility provided an inservice on the elopement policy and procedure to all staff, and completed wandering assessments on all SCU residents to identify if they required supervision on the patio. The Director of Nursing or designee would monitor residents at risk for elopement upon admission, quarterly, annually and with significant changes. The facility placed alarms on the interior SCU doors out of the reach of residents, and the doors sound when the patio door opens and will continue to sound until manually reset by staff. The deficient practice remains at a scope and severity of a D.

The facility had a census of 50 residents. The sample included 3 residents, which were reviewed for therapeutic diets. The facility reported 12 residents received mechanically altered diets. Based on observation, interview and record review the facility failed to provide appropriate food consistency for 1 of 3 sampled residents, out of 12 residents who received a mechanically altered diet, which placed Resident #1 in immediate jeopardy for harm to occur from choking. Findings included: - Resident #1's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 1/1/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 6, and he/she required total staff assistance for all (ADLs) Activities of Daily Living, including eating. The MDS indicated the resident had loss of liquids/solids from his/her mouth when eating or drinking, received a mechanically altered diet, and had no dental problems. The 5/15/14 (CAA) Care Area Assessment summary for nutrition stated in the last year, the facility received new or clarification orders for diet upgrade to a regular diet with mechanical soft consistency (all foods are allowed that can be made easier to chew and swallow by using machines to blend, puree, grind, or finely chop) with ground meat and gravy/sauce, pureed as requested, and the resident needs supervision, cueing, or assistance with eating. The 1/14/15 care plan for nutrition indicated the resident required a mechanically altered diet related to impaired swallowing and difficulty making decisions related to dementia. The care plan directed staff to provide a regular diet, with mechanical soft consistency, ground meat with gravy/sauce, and offer pureed if requested. The care plan directed staff to offer substitutes to the resident if he/she has problems with the foods being served and monitor the resident's need for diet advancement. Encourage him/her to eat and drink and provide supervision and/or assistance at meals. The 3/12/15 POS (Physician order [REDACTED]. (initiated 9/12/13) The 12/29/14 speech therapy Altered Diet Screen stated the resident's current diet texture was safe and effective to support intake by mouth at this time. No diet texture was indicated on the screen, but the physician order [REDACTED]. The 3/15/15 at 11:06 AM, registered dietician note stated the annual review indicated the resident continued to receive a mechanical soft diet with ground meat and puree foods only if he/she requests it. The note indicated the resident's appetite was 25-75% at meals in the assisted dining room and he/she required cueing and encouragement and many times refused meals. The note indicated the resident refused to wear his/her dentures, but was maintaining his/her weight. The note directed staff to continue with the same diet regimen. The 3/16/15 at 2:57 PM, nurse's note for the weekly assessment indicated the resident alert and oriented to person/place and had poor safety awareness. The note stated the resident required total staff assistance with ADLs, but was able to feed him/herself with staff providing verbal cues to eat. The note indicated the resident ate in the assisted dining room and did not wear his/her dentures. The 3/19/15 at 7:00 PM, nurse's note by Nurse A indicated staff brought the resident to the nurse's station and reported the resident was choking on food. The note indicated the resident was responsive, alert and able to follow commands, but his/her respirations were shallow and irregular with audible wheezing heard. The staff took the resident to his/her room and staff saw visible food particles present in the resident's mouth. The note indicated the resident was unable to cough strong enough to expel any food and his/her level of oxygen in the blood decreased from 94% to 70%, indicating the resident was not getting enough oxygen. The staff administered oxygen and suctioned the visible food out of the resident's mouth. The note indicated the resident continued to be moving air and wheezing, but became less alert, still responsive but not following commands. The staff contacted the EMS (Emergency Medical Service) and continued to attempt to remove visible food from the resident's airway. The staff attempted to provide the [MEDICATION NAME] maneuver (emergency procedure for dislodging food or obstruction from the airway) while the resident was still in his/her wheelchair. The resident was able to expel a small amount, EMS arrived and the resident immediately became cyanotic (bluish color of skin caused by low oxygen) upon lying flat. Staff immediately elevated the head of the gurney to 30 degrees and the resident then regained normal color. The resident was transported by ambulance to the ER (emergency room ) at the hospital. The 3/19/15 ER physician documentation indicated the primary [DIAGNOSES REDACTED]. The chest x-ray indicated significant infiltrates (foreign material) throughout the left lung. The 3/20/15 at 2:53 AM, nurse's note by Nurse C indicated he/she received a phone call from the hospital, at approximately 10:30 PM on 3/19/15, and the hospital nurse stated the resident was being admitted to the hospital with [REDACTED]. No observations of the resident were possible due to the resident residing in another facility. On 6/11/15 at 2:54 PM, Dietary Staff E stated if a resident had mechanical soft diet orders he/she would serve soft food, ground meat, and would grind the lettuce and vegetables, but not to a pureed consistency. Dietary Staff E stated he/she was cooking/serving when the resident choked. Dietary Staff E stated he/she served the resident's meal and stated the resident choked on the chopped, but not ground, lettuce. Dietary Staff E stated at that time he/she did not know the lettuce should be ground. On 6/11/15 at 3:07 PM, Dietary Manager F verified the resident was on a mechanical soft diet and lettuce needed to be ground. He/she stated the speech therapist had advised him/her and one cook that lettuce had to be ground. Dietary Manager F stated it was not a scheduled in-service so he/she did not document the information. He/she stated the speech therapist just happened to be there and noticed, in March prior to the choking incident, that the staff were not grinding the lettuce fine enough so the speech therapist demonstrated, using the food processor in the kitchen. He/she reported 12 residents received a mechanically altered diet. On 6/11/15 at 3:30 PM, Nurse Aide B stated the resident was in the assisted dining room independently eating when he/she came into the room. Nurse Aide B stated he/she noted the resident did not look right and cued the resident to take a drink of water. He/She stated the resident did not follow the instruction as he/she normally would, so Nurse Aide B wheeled the resident to the nurse for assessment. Nurse Aide B stated the resident normally fed him/herself and just required cueing with meals. Nurse Aide B stated he/she could not remember what the resident was eating when he/she choked. On 6/11/15 at 3:44 PM, Nurse Aide G stated he/she was in the assisted dining room assisting 2 other residents with their meal when Nurse Aide B came into the dining room and asked him/her if he/she thought Resident #1 looked okay. Nurse Aide G stated he/she looked at the resident and saw his/her face was red and he/she did not look normal. Nurse Aide G stated Nurse Aide B offered the resident a drink, which he/she did not take and then wheeled the resident to the nurse's station for help. On 6/11/15 at 4:10 PM, Administrative Nurse H verified he/she did not know what the resident had been eating during the meal. On 6/15/15 at 9:20 AM, Speech Therapist P stated he/she provided ongoing education to staff regarding diet consistency, but there was frequently a new staff person in the dietary department. On 6/15/15 at 10:45 AM, Physician J stated the resident was on a mechanical soft diet, but could request pureed foods. He/She stated if the resident ate slowly and carefully, they were not any higher aspiration risk than with pureed foods. If the resident was alert and had a sandwich, he/she would be okay to eat that. Physician J stated the resident could manage sandwiches on some days and stated a mechanical soft diet might include sandwiches with ground meat or peanut butter, but not lettuce. He/She was unsure if a soft taco would be on a mechanical soft diet. He/She stated the resident continued to be a huge aspiration risk and now resides at another facility. Physician J stated the resident was not capable of deciding if he/she needed pureed food versus mechanical soft food. On 6/15/15 at 11:38 AM, Dietary Aide K stated the residents on a mechanical soft diet are not to be served chips, corn, baby carrots, crunchy taco shells, or lettuce unless ground. He/she stated the dietary manager had informed the staff that lettuce needed to be ground for mechanical soft diets, but he/she was unsure when that was. Dietary Aide K stated he/she had been educated on diets when trained. On 6/15/15 at 11:44 AM, Nurse Aide L stated if he/she noted inappropriate items on the resident's meal, he/she would send it back to dietary for something else. On 6/15/15 at 12:30 PM, Registered Dietician N stated a resident on a mechanical soft diet should not receive lettuce and should have ground meat. He/She stated the dietary manager had contacted him/her (possibly in April) to ask if lettuce and rice could be served on a mechanical soft diet. Registered Dietician N stated he/she did not document the conversation or the date. On 6/15/15 at 12:45 PM, Dietary Manager F stated the residents were all served the residents' choice meal on 3/19/15, of soft taco, Spanish rice, refried beans, salsa and chips. He/She stated the soft tacos contained shredded lettuce, tomato, sour cream and shredded cheese. The residents with mechanical soft diets were not served chips or tomatoes. Dietary Manager F stated the resident was on a Regular Mechanical Soft Diet and Dysphagia Advanced Diet (level 3- regular diet with soft fruits, vegetable and ground meat. Fresh fruits and vegetables are finely chopped, breads and bakery products are well moistened, slurried or gelled). Dietary Manager F stated the dietician or speech therapist normally educate residents as to what they may have on special diets. Dietary Manager F stated the Speech Therapist met with him/her on the spur of the moment one day to discuss and show him/her how to grind lettuce for the mechanical soft diets. Dietary Manager F stated prior to the resident's choking incident he/she did not know lettuce could be run through the food processor. On 6/15/15 at 2:00 PM, Nurse O verified he/she was in the facility when the resident was brought to the nurse's station, while choking, on 3/19/15. He/She reported the nurse aide reported the resident was choking and Nurse C asked the resident if he/she was choking. Nurse O verified the resident nodded yes and spit out some type of mixed tortilla and lettuce and was in obvious respiratory distress. Nurse O stated the nurse voiced his/her concern that he/she saw more food in the resident's mouth. The other nurse and aide took the resident to his/her room and attempted the [MEDICATION NAME] maneuver (emergency procedure for dislodging food or obstruction) without success. The staff requested this nurse to get oxygen and to call 911 while they worked with the resident. Nurse O stated the resident had a soft taco that night, but the staff did not open it up to see if the lettuce was ground and stated the cook that evening was new. On 6/15/15 at 1:03 PM, Dietary Staff E stated he/she was trained by another cook for a week when he/she started working at the facility in March. He/She stated the cook went over diets and what was acceptable for a mechanical soft diet and stated he/she may or may not have been told that lettuce should be ground for mechanical soft diets, he/she could not remember. Dietary Staff E verified the residents had a soft taco the evening of 3/19/15, but did not know if the resident's taco had lettuce in it. On 6/15/15 at 3:27 PM, Nurse C stated the resident still had air exchange while they attempted to get out whatever was causing him/her choke. He/She stated the resident's cough was not strong enough to push whatever was in there out and the resident was wheezing. Nurse C stated he/she tried the [MEDICATION NAME] maneuver and suctioning and got some type of food out but stated he/she did not look at it to determine what it was. Nurse C stated he/she had not observed the resident have problems swallowing his/her food prior to the incident. He/she stated the resident was on a mechanical soft diet due to chewing issues and would not wear his/her dentures. Nurse C reported he/she could not recall educating or documenting any education to the resident regarding food choices or the risks of eating food not on his/her diet (resident had severe cognitive impairment). He/she stated the aides are informed of residents' diets through the care plan, report from nurses, and written on a form in the resident's room. He/she stated the speech therapist usually decides the appropriate diet for the resident. On 6/15/15 at 4: 27 PM, Administrative Staff D stated the diet order was listed on the daily menu sheets and if a diet is changed the kitchen was notified and the diet sheet changed. He/she stated speech therapy was normally involved with diet changes. He/she stated the diet order of mechanical with ground meats as requested means that when the resident requests, a certain meat will be ground. Administrative Staff D stated all staff should be responsible to look at the resident's menu choices to check if the consistency is right. He/She stated the menu choices with the diet listed, are on the counter during the meals. On 6/16/15 at 12:02 PM, Administrative Staff D stated the facility policy is to provide the physician ordered diet. On 6/18/15 at 11:15 PM, Physician Q, verified he/she had treated the resident for choking on 3/19/15. He/she verified the facility staff and EMS reported the resident had choked on a sandwich during a meal and stated the resident came in with respiratory distress and mild hypoxemia. Physician Q stated he/she conferred with 2 other physicians and it was determined the resident required a [MEDICATION NAME] (procedure in which a video camera on a tube is inserted into a person's airway to visualize the airway down into the lungs), to be done in the morning, due to his/her continued mild hypoxemia and abnormal breath sounds. He/she stated the admission [DIAGNOSES REDACTED]. Physician Q stated the [MEDICATION NAME] showed a large bolus (clump) in the resident's lung and a larger scope was required to be able to get it out of his/her lungs. He/she stated the bolus appeared consistent with food. On 6/22/15 at 1:35 PM, Nurse O stated the resident had days that his/her cognition was better than other days and he/she did not like the texture of some foods. Staff could request pureed for the resident, but the nurse would assess the resident's cognition level, pain level and if the resident needed pureed foods. He/She stated the resident liked foods that he/she could hold and feed him/herself and occasionally had finely chopped lettuce in a salad. Nurse O stated he/she was not in the assisted dining room and did not know if the staff cut up the soft taco. Nurse O stated what he/she observed the resident cough up was very little lettuce in small shredded pieces, and it was mostly a gummy looking tortilla shell in an approximately ½ to 1 inch. Nurse O stated the resident was able to gum foods without his/her dentures, which he/she refused to wear. The facility's 3/2012 Therapeutic Diet policy stated therapeutic diets shall be prescribed by the attending physician and the facility will strive for the fewest possible dietary restrictions. The policy stated mechanically altered diets will be considered therapeutic diets. The clinical dietician, nursing staff and the physician will review the need for, and resident acceptance of, prescribed diets. Routine menus are planned by the food services manager and the regular menu will be modified by the registered dietician for therapeutic diets, with input from the dietary manager for feasibility of kitchen production. The food services manager will establish and use a tray identification system to ensure that each resident receives his/her diet as ordered. The staff will document significant information relating to the resident's response to his/her therapeutic diet. Residents on therapeutic diets will not receive modifications that are not part of the diet unless approved by the physician in conjunction with the dietician. The facility's undated policy for mechanically altered diets stated mechanically altered diets are determined by speech therapy and the physician and an order for [REDACTED]. The facility menus and recipes reflect the modifications needed for the mechanical soft and puree consistency diets. The facility reported they had no specific recipe for soft tacos for mechanical soft diets. The facility served menu items that were not the right consistency for the resident's physician ordered diet. This placed the resident in immediate jeopardy. The resident choked and was in respiratory distress requiring emergency hospitalization and treatment. The facility abated the immediate jeopardy on 6/19/15 at 3:41 PM, when they completed the following: The administrator/designee will complete an audit of specialized diets to establish residents' dietary needs are being followed. Dietary staff will be educated by administrator/designee on mechanically altered diets. Community/PAR team will meet weekly to review specialized diets to maintain that diets are being followed by dietary staff. The deficient practice remains at a scope and severity of a G.

The facility had a census of 53 residents. The sample included 23 residents of which 4 residents were reviewed for nutrition. Based on observation, record review, and interview the facility failed to develop and implement interventions in a timely manner to prevent significant weight loss of 8.16% weight loss in 3 months and an 8.84% weight loss in 4 months for Resident #2 and a weight loss for Resident #19. Findings included: - Resident #2's medical record revealed the following [DIAGNOSES REDACTED]. It affects memory, thinking, language, judgment, and behavior), [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The quarterly (MDS) Minimum Data Set, dated dated [DATE], indicated the resident scored 5, on the (BIMS) Brief Interview for Mental Status, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required limited assistance of 1 staff with dressing, grooming, and supervision with set up help only for eating. The MDS indicated the resident weighed 176 pounds, and received a mechanically altered diet. The nutritional (CAA) Care Area Assessment, dated 6/11/14, indicated the resident required supervision and/or set-up help for eating, and received a mechanical soft diet with syrup-thick liquids. The CAA indicated the resident weighed 181 pounds. The care plan, dated 11/19/14, indicated the resident received a pureed consistency diet and honey thickened liquids. The care plan directed the staff to weigh the resident monthly and to monitor and record the resident's food and fluid intake. The care plan directed the staff to encourage the resident to eat/drink, and provide supervision and/or assistance with meals. Review of the medical record revealed a physician's standing order, dated 10/17/14, stating any residents identified by the (DON) Director of Nursing, Dietary Manager or Consultant Dietician, to be at risk for malnutrition due to poor food intake, significant weight loss, or increased nutritional requirement, would be placed on a supplemental foods program. These residents who needed additional intake would be placed on a choice of house supplements, 4 ounces, 2 or 3 times a day. Staff would obtain monthly weights on residents unless otherwise ordered by the physician or the DON. Further review of the medical record revealed a nutritional supplement was not implemented for the resident even though he/she had lost 7.3 lbs. from September 3, 2014 to October 3, 2014. The 6/20/14 (RD) Registered Dietician nutrition assessment indicated the resident's admission weight of 182.6 pounds and, with no decrease in food intake or weight loss. The assessment indicated the resident ate on his/her own, 3 meals a day, and received a mechanical soft diet with honey thickened liquids. The assessment indicated the resident was a new admit with a [DIAGNOSES REDACTED]. The weight record revealed the following: 9/3/14-183.50# 9/29/14-177.50# 10/3/14-176.20# No weights for November 2014 (The weight record revealed a 7.3 pound weight loss from 9/3/14-10/3/14 and no further weights obtained). 12/5/14- 163# (8.16% weight loss in 3 months, 2 months since last weight) 1/6/15 -161.2# 1/14/15-161.8# The clinical record lacked evidence the facility developed or implemented any interventions to prevent future weight loss. The clinical record further lacked documentation the facility notified the physician of the weight loss until 12/23/14. The 11/29/14 at 7:20 PM nurse's notes, stated the resident fed him/herself with supervision, had a good appetite, and continued on a pureed diet with thickened liquids. The 12/10/14 at 3:58 PM dietary manager notes, stated the resident's current weight was 176.2 pounds, down 7 pounds in 30 days. The notes indicated the kitchen served the resident a regular diet, pureed consistency and he/she ate 90-100% of most meals. The 12/23/14, RD evaluation recommended Med Pass 2.0 (nutritional supplement) 60 (cc) cubic centimeters, four times a day, to increase calories and stabilize resident's weight due to the resident's current weight at 163 pounds, which was down 13.4 pounds in 60 days, weight down 20 pounds in 3 months, and resident's weight was down 18 pounds in 6 months. The notes indicated the resident received a pureed diet with thickened liquids, and the RD would monitor the resident's weight trends, and intake, and make recommendations as needed. The resident's physician approved the supplement order on 12/30/14. On 1/18/15 at 10:31 PM, Registered Dietician note's stated the resident's most recent weight was161.8 lbs., which was increased slightly since the beginning of the month and stable in the past 4 weeks since the 2 cal supplement, 60 cc, 4 times a day was started on 12/27/14 On 1/12/15 at 12:23 PM, observation revealed the resident, sat in his/her wheelchair, at the dining room table. Staff served the resident thickened 90 (cc) cubic centimeters of milk shake,120 cc of thickened cranberry juice and 240 cc thickened water. At 12:30 PM, staff served him/her pureed hamburger soup, pureed green beans, pureed mashed potatoes with gravy, in a divided plate, and a bowl of applesauce. Observation revealed the resident, sat for a few minutes, prior to picking up his/her spoon, but did not start to eat. At 12:32 PM, observation revealed staff asked the resident if he/she was going to eat. At 12:38 PM the resident started to eat the meal served 15 minutes earlier. At 1:04 PM, the resident had eaten 3/4 of all of the meal, drank all of the milk shake, a few sips of the cranberry juice and water, then to propelled him/herself out of the room. On 1/15/15 at 10:15 AM, Nurse C stated the resident had a recent weight loss. Nurse C stated staff weighed residents monthly or weekly as the physician ordered. The day nurse entered the resident's weight in the computer. If the nurse noticed a weight difference of 1-3 pounds, the nurse reported the weight loss to the DON or (ADON) Assistant Director of Nursing. Nurse C stated the day nurse also notified the dietary manager and the resident's physician. Nurse C stated the staff added the resident to the weekly weight list on 1/12/15 and verified the resident's physician was not notified of the resident's weight loss until 12/23/14. On 1/15/15 at 4:32 PM, Dietary Staff D, stated nursing had not notified him/her of the resident's weight loss. On 1/20/15 at 11:30 AM, Administrative Nurse A verified the staff did not notify the physician of the weight loss until 12/23/14, when the registered dietician notified the physician. Administrative Nurse A also verified the staff did not weigh the resident at all in November 2014 and the resident had a significant weight loss from September 2014 until December 15, 2014. Administrative Nurse A stated the (CNAs) certified nurse's aides obtained the resident's weekly or monthly weights and the nurses recorded the resident's weights in the computer. Administrative Nurse A stated he/she was ultimately responsible for the resident's care and should have been reviewing the weights also. Administrative Nurse A stated he/she expected the dietary manager to inform the DON of any resident's weight loss. Administrative Nurse A verified the standing order to start Med Pass, 4 ounces, 2-3 times a day was not implemented for this resident until 12/30/14. On 1/16/15 at 2:47 PM, Nurse Practitioner F stated he/she had told the DON to have both nursing and the dietary manager oversee the weights but not just the dietary manager. Nurse Practitioner F stated the facility policy was to have the residents weighed monthly and if there was a 3% weight variance either way, the resident was to be put on weekly weights and to immediately notify the physician. Nurse Practitioner F verified staff should have initiated weekly weights for the resident a long time ago. The undated nursing documentation weight meeting policy stated staff weighed and reviewed all the residents weights by the Skin and Weight Committee on a monthly basis. The policy stated if a resident who demonstrated a significant weight/loss/gain or gradual, consistent weight loss will be placed on weekly weights until stability is demonstrated and maintained for at least 4 weeks. The team, however, must ensure timely notification of the attending physician. All facility residents will be weighed and reviewed by the Skin and Weight Committee on a monthly basis. The facility failed to implement interventions to prevent Resident #2 from having an 8.16% weight loss in 3 months or an 8.84% weight loss in 4 months or to notify the dietician or the resident's physician of the significant weight loss. - Resident #19's admission (MDS) Minimum Data Set assessment, dated 12/15/14, indicated the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 14, required supervision with all (ADLs) Activities of Daily Living, had no skin problems, but received skin treatments including a nutrition/hydration program and dressings other than to feet. The MDS indicated the resident had no swallowing problems, weighed 221 (lb) pounds, had a weight gain, and received a therapeutic diet. The 12/5/14 (CAA) Care Area Assessment summary for nutrition indicated the resident's 12/11/14 blood laboratory revealed [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) level at 1.5 (normal range is 3.4-5), and the total protein level at 4.5 (6.4-8.2). The summary indicated the resident received a regular diet with regular consistency, and a protein shake at noon due to his/her critically low [MEDICATION NAME] level. The CAA indicated the resident currently weighed 221 lb. and had gained 17.4 lbs recently. The 12/17/14 care plan for nutrition directed the staff to provide a regular diet, regular consistency, a protein shake at noon, and offer food substitutes if he/she had problems with the food being served. The care plan directed the staff to notify the physician and family of any significant weight changes, monitor food and fluid intake, provide supervision and/or assistance at meals, and obtain a dietary consultation as needed. The 12/12/14 physician's orders [REDACTED]. Review of the medical record revealed no dietary consult, no dietary progress notes, and no registered dietician assessment. On 1/13/15 at 7:45 AM, observation revealed the resident seated at the table, in the commons area, independently drinking a cup of coffee. At 8:06 AM, staff served the resident a double portion of scrambled eggs, 4 pieces of toast, 2 sausage links, 240 (ml) milliliters of coffee, and 180 ml of water. Further observation revealed the resident ate 100% of the meal. On 1/14/15 at 9:35 AM, Dietary Staff D stated the facility admitted the resident from the assisted living unit on 12/3/14. Dietary Staff D stated he/she did not inform the registered dietician of the resident's admission. He/She verified the registered dietician had not reviewed the resident's chart, on 12/26/14, when the registered dietician was at the facility. Dietary Staff D stated he/she was unaware the resident had wounds and significant weight loss and verified the resident had a significant weight loss of 21 pounds from 12/5 to 12/22/14 and lost an additional 9 pounds the following week. Dietary Staff D stated the aides weigh the residents weekly, for 4 weeks, the first month after admission, and the dietary manager and the director of nursing review the weights weekly at a skin/weight meeting and notify the registered dietician if a resident has a significant weight loss. Dietary Staff D stated he/she reviewed weights on the weight variance report, which indicated a significant weight loss automatically, but the program did not trigger a significant weight loss unless 30 days are passed and the report did not indicate Resident #19's significant weight loss. Dietary Staff D stated nursing had not informed him/her of the resident's non-healing wounds. Dietary Staff D verified he/she had not informed the registered dietician of the resident's significant weight loss or his/her non-healing wounds. On 1/14/15 at 10:30 AM, Administrative Nurse A stated he/she reviewed the residents' weight weekly and notifies the registered dietician of weight loss if it is 5% in one month. He/She stated the registered dietician just comes on scheduled visits and that is when he/she notifies the registered dietician of any wound issues. Administrative Nurse A verified he/she did not notify the registered dietician of the significant weight loss or wounds and had not asked for nutritional recommendations from the registered dietician. He/She verified nursing had not weighed the resident from 12/5/14 to 12/22/14 (16 days), per facility policy. On 1/15/15 at 4:15 PM, (RD) Registered Dietician E stated he/she normally assessed a resident's nutritional status at admission, annually, and if the resident developed a wound. He/She stated the facility gave him/her a list of residents to review each visit. Registered Dietician E verified he/she had not been asked to review Resident #19, and had not performed a comprehensive nutritional assessment at admission for him/her. Registered Dietician E stated he/she had not been informed the resident had non-healing skin issues and stated he/she had not been made aware of the resident's significant weight loss. The facility's undated Skin and Weight monitoring policy stated all new admissions to the facility must be weighed weekly for the first 4 weeks of their stay and must be discussed in the weekly weight and skin meetings. The policy stated residents who demonstrate a significant weight loss will be reviewed using the Weight/Skin Condition Review form. The team must ensure timely notification of the attending physician. The facility failed to provide a thorough nutritional assessment to establish the nutritional needs of Resident #19, who had significant weight loss and a non-healing wound.

The facility had a census of 41 residents. The sample included 6 residents who resided in the facility and a closed record for a discharged resident. Based on observation, record review and interview, the facility failed to provide care and services to prevent pressure ulcers for 1 of 4 sampled residents reviewed for pressure ulcers. Resident #4 develped an avoidable pressure ulcer with eschar with deep open area exposing white tissue on his/her left calf. Findings included: - Resident #4's medical record revealed signed physician progress notes [REDACTED]. The 8/10/11 Admission Nursing Assessment revealed the resident had a small reddened area on his/her coccyx area. The assessment had no documentation concerning the residents' left calf. The admission (MDS) Minimum Data Set 3.0 assessment, with an (ARD) Assessment Reference Date of 8/24/11, indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of 1 staff for bed mobility, dressing, hygiene and total dependence of 2 staff for transfers, toileting, bathing and supervision with eating. The MDS indicated the resident had one Stage 1 pressure ulcer and a pressure reducing device for his/her chair or bed. The 8/30/11 care plan indicated the resident at risk for pressuress ulcers related to diabetes, bed mobility and need for assitance with positioning, and bed to chair existence. The care plan indicated the resident had left sided paralysis and a long history of lower extremity [MEDICAL CONDITION]. The MDS instructed staff to provide 2 staff assistance with transfers using the Hoyer Lift. Continued review of the care plan revealed no insturctions to staff regarding a repositioning program for the resident or instructions for care and treatment for [REDACTED]. On 10/25/11 at 9:30 AM, observation revealed Nurse B changed the dressing on a pressure ulcer on the outer aspect of the resident's left calf. Observation revealed the measurement of the pressure ulcer at 5.0 (cm) centimeters by 3.0 cm and had black eschar over the area with exception of approximately 0.5 cm x 0.7 cm area that revealed deep white tissue. The 9/10/11 at 2:01 PM, nurse's notes revealed the resident had a blister on the back of his/her left calf with yellow drainage and a small spot of blood noted on the resident's bedding. The notes further indicated the staff contacted the physician for a dressing order for the resident's left calf wound. The 9/13/11 at 2:51 PM, nurse's notes revealed the resident's Stage 2 pressure ulcer on his/her left calf, was 3 cm in size and had a red wound bed with no odor. The 9/13/11 at 3:35 PM, nurse's notes confirmed a physician's orders [REDACTED]. The 9/18/11 skin assessment revealed the resident's left calf wound bed red with a small amount of odorless drainage and 4 cm in diameter. (1.0 cm larger in 5 days) Review of the nurse's notes revealed no documentation staff informed the resident's physician the Stage 2 pressure ulcer on the resident's left calf had increased in size. The 9/24/11 skin assessment revealed the resident's left calf open area measured 4 cm by 4 cm with slough yellow or white tissue. The assessment indicated the area was a blister had opened, with moderate purulent drainage with a foul odor and soaked through the pad, Ted hose and onto the bedding. Review of the nurse's notes revealed no documentation staff informed the resident's physician that State 2 pressure ulcer on the resident's left calf had an increase in drainage to a moderate purulent drainage with a foul odor. The 9/30/11 at 5:41 PM, nurses's notes revealed the physician visited the resident directed the staff to apply a pixie dust dressing to the resident's left calf wound twice daily. The 10/7/11 at 5:46 PM, nurse's notes revealed the residents open area on the left calf at approximately 4cm in daimeter, with scabbing over the area and no drainage noted. On 10/25/11 at 5:00 PM, Nurse C verified Resident #4 acquired a pressure ulcer at the facility which had not improved with no plan of care direction to the staff for prevention of pressure ulcers or care and treatment for [REDACTED]. The facility failed to provide necessary treament and service to prevent the development of pressure ulcers for the resident and promote healing.

The facility had a census of 41 residents. The sample included 7 residents of which 4 were reviewed for nutrition. Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional status such as body weight for 2 of 4 sampled residents. (#1 and #2). Resident #1 had an avoidable 7.2% weight loss in 32 days. Resident #2 had an avoidable 7.5 % weight loss in 22 days and avoidable 11% weight loss in approximately 63 days. Findings included: - Resident #1's medical record revealed [DIAGNOSES REDACTED]. The Initial (MDS) Minimum Data Set 3.0 with (ARD) Assessment Reference Date of 9/8/11, indicated the resident had severe cognitive impairment on the (BIMS) Brief Interview of Mental Status.The MDS also indicated the resident received limited assistance of 1 person for bed mobility, ambulating in room, toileting and grooming, extensive assistance of 1 person for transfers, dressing and bathing and supervision with set up for eating.The MDS also indicated the resident was 68 inches and weighed 203 lbs and the resident had a therapeutic diet and no teeth. The Nutrition (CAAs) Care Area Assessment, dated 9/14/11, indicated the resident at risk for weight loss related to [DIAGNOSES REDACTED]. The 8/30/11, initial care plan instructed the staff the resident independent with eating but needed set up assistance. The care plan instructed the staff when the resident was upset and would not eat to offer alternative foods when he/she calmed down. On 10/24/11 at 11:38 AM, observation revealed the resident seated in the dining room eating a lunch of Salisbury steak, mixed vegetables, scalloped potatoes and peach cobbler, independently, with his/her spouse present. The resident's spouse frequently cued the resident to continue to eat the meal. The 9/1/11 physician's admission orders [REDACTED]. The Initial MDS 3.0 with ARD 9/8/11, indicated the resident received a therapeutic diet rather than a regular diet. Review of the resident's weight record revealed the following: 9/1/11-202.6# (pounds) admission weight 9/26/11-194# (8.6 # or 4.2 % in 25 days.) 10/3/11-188# (14.6# or 7.2% weight loss in 32 days.) 10/10/11-187# 10/24/11-187# (A 7.4% percent significant weight loss in less than 60 days.) The facility's standing orders directed the staff to provide 4 ounces of house supplement 2-3 times a day to a resident with a significant weight loss. Review of the dietary records revealed the Registered Dietician had not assessed the resident since his/her admission on 9/1/11 to the facility. On 10/26/11 at 4:12 PM Dietary Staff H verified the facility's director of nursing notified Dietary Staff H of residents with weight loss, new admissions and new pressure ulcers. Dietary Staff H verified the dietary manager was not there on 10/3/11 and had checked with one of the nurses and was given a list of 3 new residents, this resident was not on the list. Review of the medical record revealed the staff had not implemented any dietary interventions although the resident had a 4.2% weight loss in 25 days, a 7.2% weight loss in 32 days and continued to lose weight. Review of the resident's Dietary Intake Record revealed the following findings: October 2011 Dietary Intake Record- the resident refused 12 meals and no documentation for dinner on 10/6, 10/7, 10/8, 10/14, 10/17 and 10/22/11. Review of the medical record revealed no documentation the staff had offered alternative foods at a later time as directed by the plan of care. September 2011 Dietary Intake Record: 1) No documentation of meal intake from 9/1/11 to 9/21/11 (21 days). 2) From 9/22/11 to 9/30/11 averaged 25-100 % for most meals with exception of no documentation for meal intake for 4 meals. review of the resident's medical record revealed [REDACTED]. On 10/25/11 at 1:57 PM, Nurse C verified the (CNAs) Certified Nurses Aides weighed residents weekly in the special care unit and were to report any weight losses to the (DON) (Director of Nursing). Nurse C further verified the facility's standing orders directed staff to provide 4 ounces two or three times daily of house supplement to the residents with significant weight loss. Nurse C verified the registered dietician provided services to the facility monthly and would review the resident's weight loss and make further suggestions to the physician. Nurse C verified staff were to record meal percentage and supplement intake for the resident. Nurse C verified the procedures were not followed by staff and no nuturitional supplement was provided per the facility's standing orders. On 10/25/11 at 3:08 PM Dietary Staff A verified no dietary nutritional assessment done for this resident since admission on 9/1/11. (1 month, 23 days) The facility failed to provide the necessary dietary assessments and interventions to maintain acceptable parameters of nutritional status and prevent a significant weight loss for Resident # 1. - Resident #2's resident medical record revealed [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set 3.0 with (ARD) Assessment Reference Date of 9/14/11 revealed the resident had short and long term memory loss and moderately impaired cognitive decision making.The MDS also indicated the resident was independent with bed mobility, ambulating in room, eating, toileting, needed supervision of 1 for transfers, walking in corridor, locomotion on unit and bathing with limited assistance of 1 for grooming and dressing.The quarterly MDS with ARD of 7/6/11, also indicated the resident height of 72 inches and weighed 194 lbs, wore glasses and had short and long term memory loss and moderately impaired cognitive decision making. The quarterly MDS with ARD of 7/6/11 revealed the resident unable to complete the (BIMS) Brief Interview of Mental Status compared to the quarterly MDS with ARD of 4/5/11, which revealed the resident scored 10 on the BIMS which indicated moderate cognitive impairment. The annual MDS with ARD of 12/27/10, indicated a BIMS score of 6. The 1/5/11 Nutrition Care Plan dated 1/5/11 informed the staff of the fact the resident did not wear dentures and appetite remains good and he/she takes adequate fluids. The resident's accuchecks are done fasting and ac supper on Mondays and Thursdays. HGAIC is done every 3 months. The care plan also revealed the resident's current diet is mechanical soft with ground meat and low concentrated sugars and instructed the staff to offer the resident fluids at snacks times. On 10/25/11 at 11:45 AM, observation revealed the resident eating lunch which consisted of 2 meatballs, cooked carrots, sweet potatoes, chocolate cake and 3 glasses of 240 (cc) cubic centimeters of fluids which the resident ate all of the meal and drank all of the fluids. Review of the Resident's Weights revealed the following: 8/15/11-195# 9/6/11-180.4# (7.5 % significant weight loss in 22 days.) 10/17/11-173# (11 % significant weight loss in approximately 63 days.) The facility's standing orders directed the staff to provide 4 ounces of house supplement 2-3 times a day to a resident with a significant weight loss. Review of the medical record revealed the staff had not implemented any dietary interventions as directed by the facility's standing orders although the resident had a 7.5% weight loss in 22 days, an 11 % weight loss in approximately 63 days. The 10/3/11 Registered Dietician indicated on the resident's Nutrition Assessment/Reassessment the following: 1) Resident's current weight 180 lbs. and weight is declining. Down 13 lbs. from last year. The resident claims he/she eats well. Some question about accuracy of scale being used. Abdominal weight but no [MEDICAL CONDITION]. The resident is edentulous (no teeth). 2) Estimated nutritional needs of Calories per kilogram 2113 Kcal, 81 grams of Protein and 2430 cc (cubic centimeters) of fluid daily. 3) The resident's diet is appropriate. The resident is able to state preferences-dislikes spinach. Weight is fine-will monitor for further weight loss and plan to watch weight. review of the resident's medical record revealed [REDACTED]. The Registered Dietician questioned the accuracy of the scale and directed the staff to monitor the resident's weight. Further review of the record revealed no re-weigh of the resident and no check of the accuracy of the scale although on 10/3/11, the Registered Dietician questioned it's accuracy. Review of the resident's Dietary Intake Record for 8/11, 9/11 and 10/11 revealed no documentation concerning missed meals and meal intake. review of the resident's medical record revealed [REDACTED]. On 10/25/11 at 1:57 PM, Nurse C verified the (CNAs) Certified Nurses Aides weighed residents monthly unless ordered otherwise by physician and were to report any weight losses to the (DON) (Director of Nursing). Nurse C further verified the facility's standing orders directed staff to provide 4 ounces two or three times daily of house supplement to the residents with significant weight loss. Nurse C verified the registered dietician provided services to the facility monthly and would review the resident's weight loss and make further suggestions to the physician. Nurse C verified staff were to record meal percentage and supplement intake for the resident. Nurse C verified the procedures were not followed by staff and no nuturitional supplement was provided per the facility's standing orders. The facility failed to provide the necessary dietary interventions to maintain acceptable parameters of nutritional status and prevent a significant weight loss for Resident #2.

The facility had a census of 39 residents. The sample included 11 residents. Based on record review and interview the facility failed to monitor, reassess and intervene for Resident #15, who had a significant weight loss of approximately 29 pounds in 21 days.(#15) Findings included: - Resident #15's medical record revealed [DIAGNOSES REDACTED]. The 6/17/10 admission assessment indicated the resident weighed 167 pounds with no [MEDICAL CONDITION] noted. The 6/17/10 (RD) Registered Dietician's nutrition assessment indicated the resident weighed 167 pounds and the resident's weight was stable. The RD's nutrition assessment also indicated the resident alert and oriented and ate independently without any assistive devices. The RD's nutrition assessment further indicated that per the 6/15/10 Hematology laboratory test the resident had a low (3.0) [MEDICATION NAME] level (a protein that is formed within the liver and makes up approximately 60 per cent of the total protein). The admission (MDS) Minimum Data Set 2.0 assessment, dated 6/23/10, indicated the resident had short and long term memory problems and modified independent decision making skills. The MDS also indicated the resident required supervision and setup assistance with eating. The MDS further indicated the resident weighed 157 pounds and had no weight change in the last 7 days. On 06/24/10 the resident's weight flow sheet revealed the resident weighed 157 pounds (10 pounds and or 6.4 percent weight loss in 7 days since the resident's admission). The 6/30/10 plan of care directed the staff to setup the resident's meals and cue/encourage the resident's meal intake. The care plan also directed the staff to monitor the resident's meal intake and to weigh the resident every week. The 07/01/10 (RD) Registered Dietician's Nutrition Progress Note indicated the resident weighed 157 pounds and the resident's current diet met the resident's calorie and protein needs. The RD's progress note also directed the staff to continue to monitor the resident's weekly weights. Further review of the RD's progress note revealed no documentation to address the resident's 10 pound weight loss since admission to the facility on [DATE]. On 07/01/10 the resident's weight flow sheet revealed the resident weighed 146 pounds although the Registered Dietician's progress note, dated 7/1/10, indicated the resident weighed 157 pounds which nursing had documented on 6/24/10. On 07/08/10 the resident's weight flow sheet revealed the resident weighed 138 pounds (29 pounds and/or 21 percent weight loss in 21 days since the resident's admission). The resident's weight flow sheet also revealed the resident had an 8 pound weight loss in one week after the RD had assessed the resident. review of the resident's medical record revealed [REDACTED]. weight loss (21 percent weight loss in 21 days). On 09/20/10 at 12:48 PM, Nurse M verified the nursing staff and the RD had not adequately monitored the resident's weight. Nurse M also verified the RD had not addressed the resident's significant weight loss and the facility had not notified the resident's physician regarding the resident's significant weight loss. The facility failed to accurately and adequately monitor the weekly weights of Resident #15's significant weight loss.