Every finding on record at Pine Village

The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in 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 05/04/25 at 08:34 AM, the silver upright freezer, located by the entrance door, inside the kitchen, had the following: A cardboard box had the plastic torn open, exposing four corn dogs. A cardboard box had the plastic torn open, exposing 19 (4-ounce (oz) beef burger patties. A cardboard box had the plastic torn open, exposing 16 (2.6oz) chicken patties. The walk-in fridge had an unlabeled, undated plastic bag with shredded radishes and a plastic bag with unlabeled, undated shredded carrots. On 05/04/25 at 08:34 AM, Dietary Staff (DS) CC verified the above findings and stated staff should cover food when placed in the freezer. DS CC stated that the shredded radishes and shredded carrots should have been labeled and dated. On 05/05/25 at 03:07 PM, Certified Dietary Manager (CDM) stated staff should not leave any stored food open to air and should label and date food items before placing them in the refrigerator or freezer. The facility's Food Storage Policy, revised 12/19/19, documented leftover food would be stored in covered containers or wrapped securely. Each item is clearly labeled and dated before being refrigerated. All foods should be covered, labeled, and dated.

The facility had a census of 66 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter (Q) 1 indicated no Registered nurse (RN) hours for four days in October 2024 and two days in November 2024. A review of the facility's staffing and RN hours of the days listed above revealed RN coverage. On 05/06/25 at 09:18 AM, Administrative Staff B stated that Q1 was the first time she'd submitted the information by herself. Administrative Staff B stated that there had been the appropriate number of staff, and it was possible that salaried staff did not pull over to be submitted. On 05/06/25 at 11:50 AM, Administrative Staff A stated that the facility always had RN coverage and more than enough staff, that she did not understand why the PBJ reported that there was not enough RN coverage. Administrative Staff A stated they had problems submitting information and had collaborated with CMS to find out what the problem was. Administrative Staff A stated that the facility ended up entering the staffing information by hand, but was unsure if Quarter 1 was part of that timeframe. The facility's Payroll Based Journal policy, dated 03/24/25, documented that it was the policy of the facility to electronically submit timely to CMS complete and accurate direct care staffing information. This information would include agency and contract staff, and other verifiable and auditable data in a uniform format according to specifications established by CMS.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to use appropriate barriers while sorting soiled laundry. This placed the residents at risk of infectious diseases. Findings included: - On 05/06/25 at 07:47 AM, while on tour of the laundry department, Maintenance/Housekeeping Staff U stated the soiled laundry was sorted by laundry staff using only gloves; unless there was obvious visual soilage, and then a gown would be worn. Maintenance/Housekeeping Staff U stated she had not thought about transferring soiled/potentially infectious laundry to the clean laundry. On 05/06/25 at 11:30 AM, Administrative Nurse D verified that laundry staff should wear clothing barrier and gloves while sorting soiled laundry. The facility's Laundry policy, dated 05/10/20, documents the facility launders linens and clothing in accordance with current Centers for Disease Control and Prevention (CDC) guidelines to prevent transmission of pathogens. Aligning with principles of standard precautions, staff shall consider all previously worn clothing and used linens as potentially contaminated. Soiled laundry shall be handled as little as possible with minimum agitation to avoid contamination of areas, surfaces, and persons. Laundry staff would be in-service on handling linens and laundry on a regular basis.

The facility had a census of 66 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 30. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissue), and hypertension (high blood pressure). R30's Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition. The MDS documented R30 required partial staff assistance for oral hygiene, toileting hygiene, bathing, transfers, and did not ambulate. The MDS documented R30 received a diuretic (a medication to promote the formation and excretion of urine), antidepressant (a class of medication used to treat mood disorders), and antianxiety (a class of medication that calms and relaxes people). R30's Care Plan, dated 03/29/25, initiated on 08/06/22, directed staff to administer medications as ordered, monitor for adverse responses, and notify the physician of ineffectiveness. The Physician's Order, dated 08/06/22, directed staff to administer atenolol (high blood pressure medication), 50 milligrams (mg), by mouth, daily for hypertension. Hold the medication if the systolic blood pressure (SBP -the top number, the force your heart exerts on the walls of your arteries) was less than 110 millimeters of mercury (mmHg), if diastolic blood pressure (DBP - minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) was less than 60 mmHg. R30's Medication Administration Record (MAR) for April 2025 documented the following days R30 received the atenolol when SBP or DBP was under the ordered parameters: 04/01/25 - 118/51 04/02/25 - 137/58 04/17/25 - 110/56 04/21/25 - 128/52 04/27/25 - 102/80 On 05/04/25 at 02:30 PM, R30 sat in a chair in the activity area of the Special Care Unit (SCU), did not speak, but held out her hand to shake hands. R30 periodically closed her eyes to rest. On 05/05/25 at 03:02 PM, Certified Medication Aide (CMA) R verified that the atenolol medication was out of physician-ordered parameters and stated the medication should have been held. On 05/06/25 at 09:41 AM, Licensed Nurse (LN) H stated the CMA should notify her when the blood pressure was out of parameters so she could either wait and retake the blood pressure within the hour to see if it was within parameters for the medication. On 05/06/25 at 11:48 AM, Administrative Nurse D stated the CMA should notify the nurse when the blood pressure was out of parameters and hold the medication. The facility's Medication Administration policy, dated 02/09/18, documented all staff administering medications would follow the guidelines, check the vital signs on appropriate medications as ordered, and record it in the resident's chart.

The facility had a census of 72 residents. The sample included 18 residents. Based on record review and interview, the facility failed to complete performance reviews of all nurse aides, provide regular in-service education based on the outcome of these reviews, and ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for inadequate care. Findings included: - The facility's employment records documented the nurse aides who were employed at the facility for at least one year, review of the facility's in-service records documented one of the five Certified Nurse Aide (CNA) M lacked the required 12 hours of in-service training in the past year. On 08/30/23 at 09:30AM, Administrative Staff A and Administrative Nurse D stated CNA M had not completed the 12 hours of required in-service training in the last year. They stated the human resource personnel was responsible to keep track of the required hours. They stated the facility had staff turn-over in that department and did not monitor the staff completion of in-service hours or ensure completion of performance reviews of the nursing staff. The facility's Required Training for Staff and Volunteers dated 05/01/2021, documented the facility would ensure staff and volunteers are provided with training and continuing education related to the rights of persons served. The facility had developed, implemented, and maintained an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with defined and expected roles. The facility determines the amount and type of training necessary based on the Facility Assessment Training topics for all staff. All direct care staff are required to attend twelve (12) hours of continuing education annually including but not limited to: Dementia. Infection control, blood borne pathogens and Antibiotic Stewardship. HIPAA and confidentiality. Resident rights and facility responsibilities. Prevention of abuse, neglect exploitation and mistreatment of residents. Corporate compliance and ethics. Emergency preparedness. Quality Assurance /Performance Improvement (OAPI). Safety and Hazard training program. The Human Resources department would verify credentials and document verification at the time of employment and when credentials are renewed or updated. The facility Director of Nursing defines the competencies required of the staff providing care, treatment and services related to techniques, procedures and technology. The facility failed to ensure nurse aides employed at least one year completed 12 hours of required in-service education, placing the residents who resided in the facility at risk for receiving inadequate care.

The facility had a census of 72 residents. The sample included 18 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 71. This placed the resident at risk for missed care opportunities. Findings included: - R71's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R71's Admission Minimum Data Set (MDS), dated [DATE], documented R71 required limited staff assistance with activities of daily living (ADLs) except supervision with eating. The MD'S documented the resident expected to remain in the facility. The Return to Community Care Area Assessment (CAA) did not trigger. R71's Addendum to Baseline Care Plan, dated 06/05/23, documented an interdisciplinary evaluation to determine the support she needed to be safe and functioning at her highest level of ability while honoring her personal choices was conducted and R71's goal was to complete her rehab goals and transition to assisted living. The Nurse's Note, dated 06/23/23 at 02:45 PM, documented R71 was discharged from the facility to assisted living. Review of R72's EMR lacked a discharge summary which included a complete recapitulation of her stay. On 08/30/23 at 02:30PM, Administrative Staff A verified R71's discharge summary had an incomplete recapitulation of her stay and stated social service staff was responsible for completing the discharge summary. The facility's Discharge/Transfer Of The Resident Policy, revised 01/19/2002, documented staff should complete a discharge summary and post discharge plan of care form which included a list of medications with instructions in simple terms, include instructions for post discharge care and explain to the resident and/or representative. and have resident and/or representative or person responsible for care sign discharge summary and post discharge care form. The facility failed to develop a discharge summary that included a complete recapitulation of R71's stay and post discharge plan. This placed the resident at risk for missed care opportunities.

The facility had a census of 72 residents. The sample included 18 residents of which 10 were reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when the facility failed to assess Resident (R)16 for safe use of an electric recliner. This placed the R16 at risk for injury due to preventable accidents and hazards. Findings included: - R16's Electronic Medical Record (EMR) recorded cerebral vascular accident (CVA-stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain,) hemiplegia (paralysis one side of the body,) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and essential tremors. R16's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R16 required extensive staff assistance with bed mobility and transfers and had two falls with minor injury. The Fall Care Area Assessment (CAA), dated 04/28/23 documented staff would assure medical stability, prevent decline, expect fluctuations due to right side pain, and weakness. The Fall Care Plan, dated 07/31/23, recorded R16 was at risk for falls due to impaired mobility, weakness, poor balance, and past falls. The care plan recorded R16 failed to use the call light and wait for staff assistance with transfers and staff would perform visual checks for safety when in her room. R16's clinical record lacked evidence the facility assessed the resident for safe use of an electric lift recliner. The Nurses Note, dated 03/28/23 at 04:25 PM, recorded R16 had an unwitnessed fall from her electric lift recliner and was observed in front of the recliner. R16 stated she pushed the button on the recliner too high and slid out of the recliner onto the floor. The resident was found sitting upright on her bottom, on the floor, in front of the recliner. She had no shoes or socks on. Her legs were in front of her. Staff educated R16 to wear nonslip footwear and wait for assistance before using the remote on the chair. No injuries were noted. On 08/28/23 at 03:45 PM, observation revealed R16 sat in her electric lift recliner and License Nurse (LN) G administered the residents morning medication. R16 was dressed in street clothes and shoes. On 08/30/23 at 02:30 PM Administrative Nurse D verified the resident had the electric lift recliner since admission to the facility and an electric lift chair safety assessment had not been completed on the resident's safe use of the chair. Administrative Nurse D verified the electric lift recliner assessments should be completed on admission, with a change in condition, and yearly. The facility's Falls Management policy, dated December 2017, stated all residents would be evaluated for fall risk upon admission, increased number of falls, quarterly reviews and significant change with appropriate interventions implemented to decrease the risk of falls. The falls are reviewed by the nurse manager, Administrator and Director of Nursing. The policy documented all departments are responsible for the safety of the residents. The facility failed to assess R16 for safe use of an electric lift chair, placing the resident at risk for preventable accidents or injury.

The facility had a census of 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)19, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and related side effects. Findings included: - R19's Electronic Medical Record (EMR) documented she had a diagnoses of dementia, paranoid personality disorder, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), visual (experienced through vision) and auditory (experienced through hearing) hallucinations (sensing things while awake that appear to be real, but the mind created) , and delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue). R19's Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe impaired cognition. The MDS documented the R19 required supervision with activities of daily living (ADLs). The MDS documented R19 received an antipsychotic and antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) medication every day during the lookback period. R19s Psychotropic Medication Care Plan, dated 07/26/23, instructed staff to observe, document, and report to physician if R19 showed signs or symptoms of drug related complications; notify social service staff if noting signs or symptoms of depressed mood or cognitive decline. The care plan instructed staff to address R19's mood, affect, and anxiety concerns with the interdisciplinary team (IDT) in weekly meetings, and monitor R19 for exacerbation of delusions and hallucinations. The care plan instructed staff to administer to R19 Seroquel (antipsychotic medication), 25 milligram (mg) every evening for hallucinations. The Physician Order, dated 10/04/22, instructed staff to administer Seroquel, 25 mg tablet, every evening for hallucinations. The Monthly Pharmacy Regimen Review documented the following: On 12/2/22 the pharmacist recommended the physician place an acceptable diagnosis for R19's Seroquel, and listed the acceptable diagnoses as schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), or Tourette's syndrome (involves uncontrollable repetitive movements or unwanted sounds (tics), such as repeatedly blinking the eyes, shrugging shoulders, or blurting out offensive words) and requested the physician pick one of them. The physician responded the resident had hallucinations but did not address placing the acceptable indication for use or the required documentation for the Seroquel. On 01/05/23 the pharmacist documented Seroquel 25 mg with a diagnoses of hallucinations was not an acceptable diagnosis and recommended the physician change to one of the appropriate diagnoses (schizophrenia, Huntington disease, or Tourette's syndrome). The physician responded R19 was receiving it for hallucinations and had not tolerated a reduction in the past. On 02/21/23 the pharmacist requested a gradual does reduction (GDR) for R19's Seroquel and requested an approved diagnosis for it. The physician responded no change in the dose, and noted the resident suffered from delusions and paranoia, and stopping the medicine would not be in her best interest but failed to address the request for changing the Seroquel diagnosis. On 03/19/23 the pharmacist requested the physician place an approved diagnosis for R19's Seroquel (schizophrenia, Huntington disease, or Tourette's). The physician responded R19 had failed a dose reduction of the medication in the past but did not address changing the Seroquel diagnosis. On 04/02/23 the pharmacist requested the physician indicate which diagnosis should be marked to the Seroquel order, as use of antipsychotics were discouraged. The pharmacist requested the physician choose a diagnosis from the list which included schizophrenia, Tourette's syndrome, Huntington disease, major depressive disorder, bipolar disorder, delusional disorder or Parkinson's disease psychosis. The physician checked delusional disorder due to medical condition. On 05/10/23, 06/03/23 and 07/04/23, the pharmacist did not address the inappropriate diagnoses for R19's Seroquel. R19's clinical record lacked a physician-signed rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic. On 08/29/23 at 12:00 PM, R19 sat in a chair at the dining room table and visited politely with other residents at the table. On 08/31/23 at 09:49 AM, Administrative Nurse D verified the physician had not placed an approved diagnosis for R19's Seroquel and stated staff should have followed up on the pharmacist recommendation and obtained an appropriate diagnosis. The facility's Antipsychotic Medication Policy, revised 12/15/21, documented all physician orders for antipsychotic medications would be clear and accurate and would include a diagnosis, condition, or indication for use. The facility failed to ensure an appropriate indication for use, or or the required documentation, for the continued of Seroquel for R19, who had dementia.This placed the resident at risk for unnecessary psychotropic medications.

The facility had a census of 63 residents. The sample included 16 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide one of the sampled residents, Resident (R) 115 (or their representative) the completed Notice of Medicare Non-Coverage (NOMNC) Form Centers for Medicare and Medicaid Services (CMS), and the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNF ABN) Form . Findings included: - The Medicare Form informed the beneficiary that Medicare may not pay for future skilled therapy. The form included detailed explanation of non-coverage and explained the appeal process The Medicare Form informed the beneficiary that Medicare may not pay for skilled therapy services and provided a cost estimate for continued services. It explained: (1) if Medicare does not pay, the resident would be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, would be responsible for payment for services, or (3) does not want the listed services. A provider must issue advance written notice to enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF). If an enrollee files an appeal, then the plan must deliver a detailed explanation of why services should end. The facility lacked documentation staff provided R115, or her representative, form which included detailed explanation of non-coverage and explained the appeal process , and form which included the estimated cost documentation for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing she may have to pay out of pocket. The resident's skilled services ended on 12/07/21. The facility did not get signed forms returned to the facility. On 12/22/21 at 01:30 PM, Administrative Staff A verified R115 was discharged from the facility on 12/07/21 and stated the resident's representative failed/refused to sign the forms before the resident was discharged . The facility's Medicare Denial Notice and Advance Benefit Notification (ABN) policy dated 12/29/20 recorded the facility would inform each resident before, or at the time of admission. And periodically during the resident's stay of services available in the facility and charges for those services including and charges for services not covered under Medicare by the facility's per diem rate. The facility would provide each resident with a written description of legal rights which includes a description of the manner of protecting personal funds. The policy documented the facility would provide written/oral notification to resident with necessary information to decide whether or not to appeal a decision to terminate Medicare care and services at least three days prior to the planned change in payor status or discharge. When the facility's Medicare Utilization Review Committee will meet weekly to discuss all resident's currently receiving Medicare benefits, the resident's progress toward stated goals, and goals toward discharge from Medicare services. The denial notice would be provided to the resident and/or responsible party no later than three calendar days prior to the planned discharge. Notification of non-coverage for a resident who is not competent will be made to the resident's legal representative (responsible party.) If the facility is unable to personally unable to deliver a denial letter to a person acting on behalf of Medicare resident, the facility representative will telephone the responsible party to advise him/her when the resident's services would no longer be covered. The date of the conversation is the date of receipt of notice. Confirmation of the telephone contact by written notice will be mailed on the same date of the telephone notification by certified mail, return receipt requested, the date the responsible party signs the receipt is the date of receipt. A dated copy of the notice would be placed in the resident's clinical record. If a notice is returned by the post office with no indication of a refusal date, the resident's liability starts on the second working day after the facility's mailing date. The facility notification would be provided on facility letter head. The denial notification would contain both CMS Form and including all denial notification with state appeal process, contact address and phone numbers and time frame requirements. Residents/responsible party must choose options to continue services or not continue services. Signature line where resident/responsible party must sign and date of receipt of CMS form and CMS form . The facility failed to obtain signed CMS form and by the resident's, or their representative, when discharged from skilled care for R115, which placed the resident, or their representative, at risk to make uninformed decisions about continuation of their skilled care.

The facility had a census of 63 residents. The sample included 16 residents, with one reviewed for Pre-Admission Screening and Annual Resident Review (PASARR). Based on observation, interviews, and record review the facililty failed to ensure a referral was made promptly by the nursing home to the state PASARR program for a Level 2 Resident Review for Resident (R) 63 who had a documented a mental illness (MI) or intellectual disability (ID). Findings include: - R63's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R63's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact. The MDS documented the resident had no delusions and no behavior symptoms. The MDS further documented the resident had a wander guard alarm and elopement alarm. The Behavior Care Plan, dated 11/24/21, indicated the resident had impaired behavior and could become agitated and demanding to leave the facility and required a wander guard alarm. The Care Plan directed staff to intervene as necessary to ensure safety of residents and others and divert attention from stimuli that agitated the resident. Review of the resident's Electronic Medical Record revealed it lacked evidence a referral was made or a PASRR screen was completed. On 12/16/21 at 02:30 PM, observation revealed R63 sat in a recliner in his room and read a book. He was dressed and appeared comfortable. On 12/20/21 at 09:50 AM, Administrative Nurse D verified the resident lacked a PASARR assessment. The facility's Preadmission Screening and Annual Resident Review (PASARR) policy dated 12/29/20 documented the policy would ensure that individuals with mental and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR would be evaluated annually and upon asignificant change for those individuals identified. It is the policy of the facility to follow Kansas Department of Aging and Disabilities Level 1 care manual. The facility will participate in or complete the Level 1 CARE Assessment screen for all potential admission regardless of payor source to determine if the individual meets the criteria for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based on the Level 1 Care Assessment, if an individual is determined to meet the above criteria, the facility would not admit an individual, the facility will refer the potential admission to the State PASARR Representative for the Level II screening process. Upon completion of the Level II screen the facility would review the screening recommendations and determine the facility's ability to provide the specialized services outlined. Admission decision would be determined and notification to the State PASSAR representative, the potential resident and/or representative will be completed. Upon admission, the facility will include the PASSAR Level ll determination and evaluation report into the resident's assessment, comprehensive care plan and transitions care plan. The facility failed to adequately assess the resident for placement in the facility by completing a PASARR screening, placing R63 at risk for inadequate facility care and treatment.

The facility had a census of 63 residents. The sample included 16 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to follow toileting and fall interventions as directed in the resident's plan of care care for one sampled resident, Resident (R) 29, who had several falls. Findings included: - R29's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of one staff for bed mobility, transfers, toileting and limited assistance of one staff for ambulation in room. The MDS further documented the resident, occasionally incontinent of bladder, unsteady gait, had no upper or lower functional impairment, had one non- injury fall since admission, and did not use any alarms. The Quarterly MDS, dated [DATE], documented the resident had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, toileting, and ambulation in room and hallways. The MDS further documented the resident was frequently incontinent of bladder, had unsteady gait, had no upper or lower functional impairment, had two non-injury and one injury fall since the prior assessment, and used a motion detector daily. The revised Fall Care Plan, dated 09/22/21, originally dated 06/15/21, directed staff to offer assistance to the bathroom whenever the resident was awake at night, and to ensure safety while honoring choices and preferences. The update, dated 06/17/21, documented R29 fell taking himself to the bathroom and a motion sensor was initiated when R29 was alone in his room. An update, dated 08/26/21, documented R29 fell while going to the bathroom. Staff were reeducated on R29's two-hour toileting program which was recorded on the Medication Administration Record (MAR). An intervention, dated 09/09/21, directed staff to offer toileting more frequently in the afternoon. An intervention, dated 10/29/21, documented staff were provided reeducation regarding the resident's bladder and bowel incontinence. The Fall Risk Assessment, dated 06/04/21, 08/08/21, 09/06/21, and 12/13/21, documented the resident at high risk for falls. The Physician Orders, dated 08/26/21, directed staff to take R29 to the bathroom at 06:00 AM, 08:00 AM, 10:00 AM, 12:00 PM, 02:00 PM, 04:00 PM, 06:00 PM, 08:00 PM, and 10:00 PM. The Nurse's Note, dated 08/26/21 at 01:14 PM, documented the resident was on the floor in the doorway of his bathroom. The resident was incontinent of urine at the time of the fall and his pants and undergarments were changed. The note documented the staff were reeducated of the two hour toileting program. The Nurse's Note, dated 09/09/21 at 02:36 PM, documented the resident was on the floor in his room in front of his recliner with his pants at his ankles. The resident stated he needed to go to the bathroom. The note further documented the resident's pull-up was wet. The September 2021 MAR lacked documentation R29 was toileted at 02:00 PM. The Nurse's Note, dated 09/18/21 at 04:39 PM, documented R29 laid on his back in front of his recliner. The resident stated he was trying to get into bed when he fell . The note further documented the motion sensor was not in place nor activated at the time of the fall. The note documented R29 had bruising and swelling to the back of his head and the physician directed staff to obtain and monitor neurological tests (a test to evaluate a person's nervous system) on the resident. The Nurse's Note, dated 10/29/21 at 04:00 PM, documented the resident laid on his left side in the bathroom. The note documented R29 did not hit his head or receive any injury from the fall. The note further documented the resident's motion sensor was near his recliner but had not been turned on. The Nurse's Note, dated 12/11/21 at 06:05 AM, documented the resident laid on the floor in front of his bed. The note further documented the resident's brief was wet and fell off of him as he stood up and walked to the bathroom. The note documented the resident had a small abrasion (a scrape) to his left knee which measured 1.8 centimeter (cm) x 0.5 cm. The note directed staff to ensure the motion sensor was in proper placement. On 12/16/21 at 11:10 AM, observation revealed Certified Nurse Aide (CNA) M put a gait belt on R29, stand him up in front of his wheelchair in preparation to walk down the hall with his walker. Further observation revealed R29 ambulated down the hall before he got tired. On 12/21/21 at 09:15 AM, observation revealed an X on R29's floor where the motion sensor was to be placed. Further observation revealed, the motion sensor was on the floor by the end of the bed, not on the X. On 12/16/21 at 11:15 AM, CNA M stated R29 had a lot of falls because he liked to get up on his own all the time. On 12/21/21 at 09:15 AM, Certified Medication Aide (CMA) R stated the motion sensor was to be placed on the X when R29 was in bed to make sure that it alarmed when R29 got out of bed. CMA R further stated staff asked R29 if he needed to go to the bathroom every two hours,usually, and CMA R did not know of any falls related to R29's toileting schedule or the motion sensor not used appropriately. On 12/21/21 at 09:27 AM, Licensed Nurse (LN) G stated the CNAs tell the CMA or the nurse when R29 was last toileted but the MAR does not reflect the exact time. LN G stated R29 was able to tell staff if he needed to go to the bathroom. LN G could not recall if any of R29's falls were related to the motion sensor not being turned on. On 12/21/21 at 01:30 PM, Administrative Nurse D verified the motion sensor was not turned on or placed appropriately for some of R29's falls and verified R29's toileting had been a problem so they put it on the MAR. Administrative Nurse D stated the MAR charting would only reflect if the resident refused toileting and what time the refusal was. The facility's Falls policy, dated 12/11/17, documented all residents would be evaluated for fall risk upon admission, quarterly, and significant change and appropriate interventions would be implemented to decrease the risk for falls. The policy documented, after a new fall, preventative interventions are placed on the care plan update sheet and if the resident continued to fall, only those interventions that were still appropriate would be continued. The facility failed to follow R29's interventions for toileting and motion sensor use to prevent falls, placing the resident at risk for further falls and/or injuries related to falls.

The facility had a census of 63 residents. The sample included 16 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to accurately assess Resident (R) 5's side rails for safe use, placing R5 at risk for accident and injury. Findings included: - R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating moderately impaired cognition. The MDS documented the resident required extensive assistance of onestaff with bed mobility, transfer and locomotion on and off the unit. The MDS lacked documentation the resident had bedrails. The Activities of Daily Living (ADL) Care Plan, dated 12/13/21, indicated one staff assisted the resident with bed mobility. R5 utilized a quarter side rail (a structural support attached to the frame of the bed and intended to prevent a patient from falling and assist with transfers) to assist with repositioning and bed mobility. The Side Rail assessment dated [DATE], recorded the side rail was not a restraint. The assessment documented the side rail had been measured and the gaps between the rails and the gap between the side rails were conducive to the resident's safety based on the individual resident. The assessment documented a visual review had been performed and staff assessed the mattress did not shift or slide which would allow an increased gap between the bed and the side rail. The review resulted in no safety issues or concerns. On 12/15/21 at 04:10 PM, observation revealed the resident lying in bed on her back with her right hand through the bedrail opening, eyes closed and light off in the room. Continued observation revealed a one-third siderail on both the right and left sides of the bed with the upper opening of 25.5 inches x 3.5 inches, and an opening 25.5 inches x 3.5 inches on the bottom of the rail. Continued observation revealed the one-third siderail attached to two metal bars with a width opening of 7.5 inches x 10 inches that were secured to the bed. On 12/22/21 at 09:30 AM, Administrative Nurse D verified the bedrails should not be on the R5's bed and verified the rails had too large of openings. Administrative Nurse D verified the bed had been brought into the facility from the storage shed when R5 was moved into the room. The facility's Bed Inspection policy, dated 12/29/20 recorded the facility would conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of potential entrapment or other safety hazards. The facility would comply with approaches to risk identification and prevention of entrapment or other related safety hazards. This would serve as key component of care plan development including appropriate assessment of safety risk of each resident, implementation of appropriate interventions to reduce identified risk, monitoring for effectiveness of planned interventions and modifying interventions as indicated. It is the policy of the facility to prevent entrapment and other safety hazards associated with resident bed rails, bed frames, mattresses, and other bed mobility devices. The facility leadership are responsible for providing employees appropriate information, education, and training pertaining to entrapment and other safety hazards associated with resident bed rails, frames, mattresses and other bed mobility enhancing devices with potential entrapment risk. The policy documented any open space between the perimeter of the rail can present a risk of head entrapment FDA recommends space less than 4 and ¾ inches. Facility maintenance staff will conduct bed inspections in accordance with providing a safe, clean, comfortable and homelike environment. The facility failed to accurately assess siderail and identify safety risks, placing R5 at risk for accident and injury.

The facility had a census of 63 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure appropriate diagnoses for the use of antipsychotic medications (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental illness conditions) for three sampled residents, Residents (R) 9, R29 and R14. This placed the residents at increased risk for inappropriate treatment and risk for adverse outcomes associated with antipsychotic medications Findings included: - R9's Physician Order Sheet (POS), dated 11/02/21, documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had severely impaired cognition, and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and hygiene. The MDS further documented R9 had continuous disorganized thinking and received antipsychotic medications all seven days of the look back period. The [CONDITION(S)] [alters mood or thought] Drug Use Care Plan, dated 09/22/21, directed staff to consult with pharmacy and physician to consider dosage reduction when clinically appropriate, address [CONDITION(S)] medication changes and psychiatric signs and symptoms with the team weekly, monitor for side effects, and address mood affect and anxiety from antipsychotics. The Medication Side Effects Care Plan, dated 09/22/21, documented [MEDICATION(S)] (antipsychotic medication) was associated with increased mortality (death) in older adults and these agents were not approved for treatment of behavioral symptoms in older adults with dementia related [CONDITION(S)] and to use only when benefit outweighed risk. The Physician Orders, dated 08/06/21, directed staff to administer [MEDICATION(S)], 12.5 milligrams (mg), by mouth, at bedtime for the diagnosis of depression. On 12/20/21 at 02:00 PM, observation revealed the resident sat by the nurse's station in his wheelchair, waved and smiled. On 12/21/21 at 09:15 AM, Licensed Nurse (LN) G stated a member of the management team send the physician any recommendations from the pharmacist. LN g was not sure what happened after that. On 12/20/21 at 01:30 PM, Administrative Nurse D stated the facilty staff knew depression was not an appropriate diagnosis for the [MEDICATION(S)] medication and sent documentation from the pharmacist to the physician requesting to change the diagnosis. The facility's Medication Monitoring policy, dated 07/27/12, documented each elder was provided only those medications that are clinically indicated in the dose and for the duration to meet his/her assessed needs. The effects of medications on elders are monitored to assess the effectiveness of the medication therapy and to minimize the occurrence of adverse events. The LN or Certified Medication Aide (CMA) administering medications evaluated the elder continuously for effectiveness and adverse effects of medications as indicated on the medication care plan. The facility failed to ensure an appropriate diagnosis for R9's antipsychotic medication, placing the resident at risk for adverse side effects. - R29's Physician Order Sheet (POS), dated 12/08/21, documented diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and hallucinations (sensing things while awake that appear to be real, but the mind created). The Quarterly Minimum Data Set' (MDS), dated [DATE], documented R29 had impaired cognition, and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene and eating. The MDS further documented R29 had inattention, disorganized thinking, hallucinations and received antipsychotic, and antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medications all seven days of the look back period. The [CONDITION(S)] [alters mood or thought] Drug Use Care Plan, dated 10/20/21, directed staff to consult with pharmacy and physician to consider dosage reduction when clinically appropriate, to address [CONDITION(S)] medication changes and psychiatric signs and symptoms with the team weekly, monitor for side effects, and address mood affect and anxiety from antipsychotics. The Medication Side Effect Care Plan, dated 10/20/21, documented the pharmacist monthly review referred to the medication administration record and POS for current listing of all medications, corresponding diagnoses, risk versus benefit, and side effects for the use of [MEDICATION(S)] (antipsychotic) medication. The Physician Order, dated 11/18/20, directed staff to administer [MEDICATION(S)], 0.5 milligrams (mg), by mouth, at bedtime, for the diagnosis of hallucinations. On 12/20/21 at 02:00 PM, observation revealed the resident seated in his recliner with his eyes closed. On 12/21/21 at 09:15 AM, Licensed Nurse (LN) G stated someone from the management team send the physician any recommendations from the pharmacist. LN G was not sure what happened after that. On 12/20/21 at 01:30 PM, Administrative Nurse D stated hallucinations was not an appropriate diagnosis for the [MEDICATION(S)] medication and requested the physician change the diagnosis. The facility's Medication Monitoring policy, dated 07/27/12, documented each elder was provided only those medications that are clinically indicated in the dose and for the duration to meet his/her assessed needs. The effects of medications on elders are monitored to assess the effectiveness of the medication therapy and to minimize the occurrence of adverse events. The LN or Certified Medication Aide (CMA) administering medications evaluated the elder continuously for effectiveness and adverse effects of medications as indicated on the medication care plan. The facility failed to ensure an appropriate diagnosis for R29's [MEDICATION(S)], placing the resident at risk for adverse side effects. - Resident (R) 14's Physician Order Sheet (POS), dated 11/22/21, recorded the diagnoses of Major Depressive Disorder (MDD-a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS recorded R14 required one staff assist with bed mobility and transfers and recorded R14 received antipsychotic medication on a daily basis. The Antipsychotic Care Plan, dated 09/24/21, directed staff to monitor the resident for side effects of the medication. The Care Plan recorded R14 received [MEDICATION(S)] (an antipsychotic medication) for depression and to contact the physician and consulting pharmacist to consider gradual dose reduction when clinically appropriate. The Physician Order, dated 10/28/21, directed the staff to administer [MEDICATION(S)], 50 milligrams (mg) by mouth twice daily. On 12/15/21 at 12:20 PM, observation revealed R14 stood in her doorway, awaiting staff to deliver lunch. The resident had a flat affect. On 12/20/21 at 01:00 PM, Administrative Nurse D verified R14's diagnosis of depression for the use of the [MEDICATION(S)] was not an appropriate diagnosis. The facility's Medication Monitoring policy, dated 07/27/12 documented each elder is provided only the medications that are clinically indicated, including the dose and duration to meet his/her assessed needs. The policy recorded the effects of medications on elders are monitored to assess the effectiveness of the medication therapy and to minimize the occurrence of adverse events and the nurse or medication aide administering medications evaluated the elder continuously for effectiveness and adverse effects of medications as indicated on the medication care plan. The facility failed to have an appropriate diagnosis for the use of the antipsychotic medication for R14 placing the resident at risk for adverse side effects.

The facility had a census of 70 residents. The sample included one resident reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff identified an injury of unknown origin as an alleged violation potentially involving abuse, neglect or mistreatment. The facility further failed to ensure staff immediately reported the alleged violation (injury of unknown origin) to the facility administrator. On 10/12/21, Certified Medication Aide (CMA) R and Licensed Nurse (G) identified significant bruising to Resident (R) 1's inner thighs. Both staff failed to identify R1's injury as possible abuse and report to Administrative Staff A. On 10/13/21 Certified Nurse Aide M noted the bruising to R1's inner thighs and failed to report it to Administrative Staff. On 10/17/21 LN H identified bruising to R1's inner thighs and bloody urine, but failed to identify and report as possible abuse. On 10/19/21, Consultant Physician GG referred R1 to a local hospital to evaluate for a possible sexual assault. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six indicating severely impaired cognition, inattention that comes and goes, delusions, and physical behavioral symptoms directed toward others for one to three days during the lookback period. The MDS documented the resident rejected cares daily and required supervision of one staff with most activities of daily living (ADLs), except for bathing. The MDS recorded the resident was frequently incontinent of urine, had no skin issues, and did not receive a blood thinner during the look back period. The 08/18/21 Care Plan documented the resident had impaired decision making related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan directed one staff to offer stand by assistance to the bathroom whenever the resident was observed to be awake at night, to offer and provide assistance with perineal cares as the resident would allow, and check her room for soiled linens/briefs as resident would hide soiled items. It further directed staff to offer the bathroom every two hours while the resident was awake. The intervention, dated 10/19/21, directed two staff to assist the resident with all ADLs and supervise the resident when she was in common areas. Review of the Skin Integrity Sheets for R1 revealed the following: 08/02/21 through 09/27/21 - No skin concerns or bruises were identified for the resident. 10/11/21 and 10/14/21 - The resident refused a head to toe assessment. 10/17/21 The resident had unmeasurable purple bruising to her right and left inner thighs with no drainage and no pain noted. 10/19/21 - The resident had unmeasurable dark purple bruising with yellowing around the edges to right and left inner thighs with no drainage or pain noted. The Facility Investigation dated 10/19/21 revealed on 10/12/21 CMA R identified bruising to the resident's inner thighs and reported to LN G sometime between 06:00 - 08:00 PM. LN G assessed R1 and found fairly significant bruises to the resident's inner thighs, did not document anything or notify the family, physician, or DON about the injury of unknown origin as she intended to do it after her medication pass. LN G had a [CONDITION(S)] prior to the end of her shift at 09:30 PM and never made the notifications. On 10/17/21 LN H and an unidentified CMA observed R1's bruising and noted bleeding/blood in the resident's urine during a bath. There was no documentation of notifications to family, physician, administrator or DON. LN H completed a skin sheet and placed it in the skin book at the nurse's station. The Interdisciplinary (ID) Note, dated 10/18/21 at 04:05 PM, documented a telephone call to Consultant Physician GG regarding bleeding and a possible urinary tract infection ([CONDITION(S)]). The ID Note, dated 10/18/21 at 08:29 PM, documented the facility received a fax from Consultant Physician GG instructing staff to start the resident on [MEDICATION(S)] (antibiotic) 500 milligrams (mg twice a day for 7 days for [CONDITION(S)] and collect a urine sample for a urinalysis (evaluation of urine). The ID Note, dated 10/19/21 at 10:06 AM, documented the resident had dark purple bruising to both inner thighs, excessive bleeding from perineal area, and the facility called the physician to schedule an appointment for the resident. The ID Note, dated 10/19/21 at 10:42 AM (7 days after the bruises were originally identified), documented LN I called in to check on the resident as her nurse noted this morning the resident had purple bruising to both thigh areas with yellowing at outer edges. After speaking with another nurse who worked the evening shift it was noted the resident had an incontinent brief twisted around her thighs the night before, while she was seated in common area and staff assisted her to change her undergarment and dress for bed. The late entry ID Note, dated 10/19/21 at 02:35 PM, documented on 10/17/21 an unidentified CMA gave the resident a bath and notified LN H the resident had blood in her urine and purple bruising to the inside of the right and left thighs. The resident could not tell staff how the bruising occurred. The ID Note, dated 10/19/21 at 10:44 PM, documented the resident returned to the facility at 10:15 PM accompanied by family and had new orders to continue antibiotics as ordered, recheck urine in 2-3 days, and if blood continued in urine to have a scan of abdomen and pelvis and see urologist. On 10/25/21 at 03:47 PM, observation revealed R1 seated in her wheelchair with a long-sleeved shirt like dress and white towel covering her thighs. The resident wore non-skid tennis shoes, had a pleasant affect, and no bruises noted on exposed skin on lower legs and hands. R1 smiled, talked freely, and when asked if she had any bruises she lifted up the towel covering her thighs and revealed numerous large and small bruises on both right and left inner thighs with dark purple centers and yellow edges. R1 stated the bruises did not hurt. On 10/25/21 at 11:51 AM, Administrative Nurse D stated the resident was very independent with her cares, rejected a lot of cares, and staff were directed to try different approaches with the resident. Administrative Nurse D stated the resident was incontinent of urine, would place things in her incontinent brief to soak up the moisture, and would refuse bathing. Administrative Nurse D was out of the facility the week of 10/17 to 10/23/21 stated skin checks would be completed at least one time a week and if a resident refused she would expect staff to approach the resident later and reattempt. Administrative Nurse D stated she expected to be notified immediately of any injury of unknown origin including any fractures or any large bruising of unknown origin. She verified the bruising found on 10/12 and 10/17 was not relayed to administrative nursing staff in a timely manner and the bruising she observed in pictures was very concerning to her due to being close to the resident's private area. Administrative Nurse D stated she expected the CMAs on 10/12/21 to relay the bruising information to the nurse who took over for the nurse who had a [CONDITION(S)]. On 10/25/21 at 01:10 PM, Administrative Staff A stated on 10/18/21 he was informed of the blood in the resident's urine, but was not told about any bruising to her thighs during the morning meeting. On 10/19/21 Nurse K observed the thigh bruises and notified Nurse I and he overheard their conversation and started and investigation. The resident liked to do her own ADL cares and was found to have been wearing several briefs at a time. During investigation he found that CNA M and CMA R reported the bruising to LN G on 10/12/21 and LN G assessed the bruising, but did not document the information due to having a [CONDITION(S)]. During interviews with CNA M and CMA R he found they were not aware what LN G did with the assessment information of the resident's bruises. From 10/12 to 10/17 there was nothing documented about the resident's bruises in the skin book or ID notes. On 10/17/21 a staff member convinced the resident to take a shower and the bruises were assessed by LN H. Staff were expected to complete an incident report and notify family and physician, which LN H did not complete. Administrative Staff A stated staff should report any injury of unknown origin to him and/or the Director of Nursing immediately. On 10/19/21 the resident was sent to Consultant Physician GG for bleeding and bruising and sexual assault was suspected so the resident was sent for further evaluation at another hospital. On 10/25/21 at 04:14 PM, LN G stated she worked on 10/12/21 from approximately 04:30 - 09:30 PM. CMA R told her the resident had bruising on inner thighs and needed to be assessed. The resident was seated on the toilet and her thighs were together so very difficult to assess. The resident's bruises were approximately half dollar size, blue gray in color with yellow tint to them, and she did not feel they were new. LN G stated she did not feel the bruises were an emergent situation that needed to be reported immediately and was not able to complete her charting for her shift as she had a [CONDITION(S)]. On 10/25/21 at 04:41 PM, CMA R stated the resident was very private, wanted to be independent with all ADLs and staff attempted to toilet the resident every two hours as the resident would put on several briefs at times and they could all be soiled. CMA R saw R1's bruises on both of her inner thighs for the first time on 10/12/21 between 06:00 and 08:00 PM when she observed the resident seated on the toilet. CMA R immediately asked LN G to come into the bathroom and observe the bruising. CMA R stated the bruises were approximately 2 inches x 4 inches and purple/dark purple in color. The resident was asked if she fell and the resident stated she did not and did not know how she obtained the bruises. CMA R stated at the end of LN G's shift around 09:30 PM, LN G had a [CONDITION(S)]. CMA R stated she had not observed R1's skin again until 10/21/21 when the resident returned from the emergency room and she assisted to give the resident a bath and she had not reported the bruising to any other staff after 10/12/21. On 10/26/21 at 09:18 AM, LN H stated she worked on the resident's hall on 10/17/21 and the resident agreed to let the medication aide give her a bath. The medication aide found bruises and called LN H in to do an assessment. The bruises ran down R1's inner thighs to the back of her legs and not in one solid spot so they were difficult to measure. LN H asked the resident what happened, and the resident said she got those all of the time. LN H stated she documented the bruises on the skin integrity sheet and the sheets went into the skin book at the nurse's station. LN H stated she did not make an ID note in the computer or notify the physician or the family as she had been educated. On 10/26/21 at 09:47 AM, LN K stated she attempted to do a head to toe skin assessment on the resident on 10/11 and 10/14 and the resident refused. LN K stated the resident would often refuse cares and assessments and LN K would ask other staff to approach the resident. LN K stated on 10/19/21 she observed the bruising on the resident's thighs and the resident stated they had been there a long time. LN K checked the skin book and found the documentation from 10/17/21 and notified LN I to observe the bruising. LN K stated she called Consultant Physician GG and reported the blood in the urine and bruises. On 10/26/21 at 11:31 AM, CNA M stated she observed R1's bruises on her inner thighs on 10/12/21, when she assisted CMA R to toilet the resident. CNA M stated the bruises were very dark and very big and LN G came and looked at the bruises while the resident was seated on the toilet. On 10/18/21 when CNA M arrived for her shift the resident was seated in the commons area and had a brief on each of knees. CNA M stated she assisted the resident to the bathroom, found the resident had 3 soiled briefs on, and the bruises were not as dark as before. There were splotchy bruises on the outside of the resident's thighs also. CNA M stated she reported all of the bruises to LN J and CMA S the morning of the 13th at the end of her shift, but no other staff after that day. On 10/26/21 at 11:44 AM, LN J stated on 10/13/21 she did not receive any information about bruises on R1 found on 10/12/21. LN J stated she received report from the previous shift nurse who did not report any bruising to the resident. On 10/26/21 at 11:54 AM, CMA S stated she received report from CNA M on 10/13/21 regarding residents on 10/12/21 and was not told about any bruising on the resident's thighs. CMA S stated the first time she was notified about the resident's bruises was in report on 10/18/21 at 05:00 AM and she never saw the bruises on the 18th as the resident does not allow the staff to assist her to the bathroom very often. The facility's Resident Abuse, Neglect and Exploitation policy, dated 12/11/17, documented in the event of any evidence of cause to believe that a resident has suffered any of the above definitions of abuse, neglect or exploitation, the employee, visitor or family member is requested to report all allegations, suspicions, and/or incidents to the director of nursing, charge nurse, a nurse manager and/or administrator. All injuries will be reported on the skin assessment form to be given to the DON or designee. The incident/accident reports are filled out by all witnesses or persons associated with the incident. The DON and the administrator review all reports and will determine if further evaluation is needed. The facility failed to ensure staff identified an injury of unknown origin on 10/12/21 and 10/17/21 and immediately report as possible abuse to the facility administrator. This deficient practice placed R1 in immediate jeopardy. On 10/21/21, the facility completed the following actions to remove the immediate jeopardy: Educated all employees on Abuse, Neglect and exploitation policy. Re-educated all licensed nursing staff on skin care policy. Educated all nursing staff on investigating injuries of unknown origin and investigating suspected sexual abuse of an elder. Administrator and wound nurse reviewed all resident skin reports from 10/11 - 10/18 to assure not a widespread problem. For the next 4 months the wound/skin nurse/or designee will do weekly random audit with visual check on 3 residents per neighborhood (total of 12 resident audits weekly). From weekly skin assessment done by license nurses to assure proper skin assessments are being conducted correct and accurate. The deficient practice was cited as past noncompliance.

The facility had a census of 70 residents. The sample included one resident. Based on observation, record review, and interview, the facility failed to notify the physician in a timely manner when staff discovered large bruises (injuries of unknown origin) on Resident (R) 1's inner thighs on 10/12/21 and 10/17/21. Findings included: - R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six indicating severely impaired cognition, inattention that comes and goes, delusions, and physical behavioral symptoms directed toward others for one to three days during the lookback period. The MDS documented the resident rejected cares daily and required supervision of one staff with most activities of daily living (ADLs), except for bathing. The MDS recorded the resident was frequently incontinent of urine, had no skin issues, and did not receive a blood thinner during the look back period. The 08/18/21 Care Plan documented the resident had impaired decision making related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan directed one staff to offer stand by assistance to the bathroom whenever the resident was observed to be awake at night, to offer and provide assistance with perineal cares as the resident would allow, and check her room for soiled linens/briefs as resident would hide soiled items. It further directed staff to offer the bathroom every two hours while the resident was awake. Review of the Skin Integrity Sheets for R1 revealed the following: 08/02/21 through 09/27/21 - No skin concerns or bruises were identified for the resident. 10/11/21 and 10/14/21 - The resident refused a head to toe assessment. 10/17/21 The resident had unmeasurable purple bruising to her right and left inner thighs with no drainage and no pain noted. The Facility Investigation dated 10/19/21 revealed on 10/12/21 Certified Medication Aide (CMA) R identified bruising to the resident's inner thighs and reported to Licensed Nurse (LN) G sometime between 06:00 - 08:00 PM. LN G assessed R1 and found fairly significant bruises to the resident's inner thighs, did not document anything or notify the family, physician, or Director of Nursing (DON) about the injury of unknown origin as she intended to do it after her medication pass. LN G had a [CONDITION(S)] prior to the end of her shift at 09:30 PM and never made the notifications. On 10/17/21 LN H and an unidentified CMA observed R1's bruising and noted bleeding/blood in the resident's urine during a bath. There was no documentation of notifications to family, physician, administrator or DON. LN H completed a skin sheet and placed it in the skin book at the nurse's station. The Interdisciplinary (ID) Note, dated 10/18/21 at 04:05 PM, documented a telephone call to Consultant Physician GG regarding bleeding and a possible urinary tract infection ([CONDITION(S)]). The ID Note, dated 10/18/21 at 08:29 PM, documented the facility received a fax from Consultant Physician GG instructing staff to start the resident on [MEDICATION(S)] (antibiotic) 500 milligrams (mg) twice a day for seven days for [CONDITION(S)] and collect a urine sample for a urinalysis (evaluation of urine). The ID Note, dated 10/19/21 at 10:06 AM, documented the resident had dark purple bruising to both inner thighs, excessive bleeding from perineal area, and the facility called the physician to schedule an appointment for the resident. The late entry ID Note, dated 10/19/21 at 02:35 PM, documented on 10/17/21 an unidentified CMA gave the resident a bath and notified LN H the resident had blood in her urine and purple bruising to the inside of the right and left thighs. The resident could not tell staff how the bruising occurred. On 10/25/21 at 03:47 PM, observation revealed R1 seated in her wheelchair with a long-sleeved shirt like dress and white towel covering her thighs. The resident wore non-skid tennis shoes, had a pleasant affect, and no bruises noted on exposed skin on lower legs and hands. R1 smiled, talked freely, and when asked if she had any bruises she lifted up the towel covering her thighs and revealed numerous large and small bruises on both right and left inner thighs with dark purple centers and yellow edges. R1 stated the bruises did not hurt. On 10/25/21 at 11:51 AM, Administrative Nurse D stated skin checks would be completed at least one time a week and if a resident refused she would expect staff to approach the resident later and reattempt. Administrative Nurse D stated she expected to be notified immediately of any injury of unknown origin including any fractures or any large bruising of unknown origin and the physician and family should also be notified. She verified the bruising found on 10/12 and 10/17 was not relayed to administrative nursing staff in a timely manner and the bruising she observed in pictures was very concerning to her due to being close to the resident's private area. Administrative Nurse D stated she expected the CMAs on 10/12/21 to relay the bruising information to the nurse On 10/25/21 at 01:10 PM, Administrative Staff A stated on 10/18/21 he was informed of the blood in the resident's urine, but was not told about any bruising to her thighs during the morning meeting. From 10/12 to 10/17 there was nothing documented about the resident's bruises in the skin book or ID notes. On 10/17/21 a staff member convinced the resident to take a shower and the bruises were assessed by LN H. Staff were expected to complete an incident report and notify family and physician, which LN H did not complete. On 10/19/21 the resident was sent to Consultant Physician GG for bleeding and bruising and sexual assault was suspected so the resident was sent for further evaluation at another hospital. On 10/25/21 at 04:14 PM, LN G stated she worked on 10/12/21 from approximately 04:30 - 09:30 PM. CMA R told her the resident had bruising on inner thighs and needed to be assessed. The resident was seated on the toilet and her thighs were together so very difficult to assess. The resident's bruises were approximately half dollar size, blue gray in color with yellow tint to them, and she did not feel they were new. LN G stated she did not feel the bruises were an emergent situation that needed to be reported immediately and was not able to complete her charting for her shift. On 10/26/21 at 09:18 AM, LN H stated she worked on the resident's hall on 10/17/21 and the resident agreed to let the medication aide give her a bath. The medication aide found bruises and called LN H in to do an assessment. The bruises ran down R1's inner thighs to the back of her legs and not in one solid spot so they were difficult to measure. LN H asked the resident what happened, and the resident said she got those all of the time. LN H stated she documented the bruises on the skin integrity sheet and the sheets went into the skin book at the nurse's station. LN H stated she did not make an ID note in the computer or notify the physician or the family as she had been educated. On 10/26/21 at 09:47 AM, LN K stated she attempted to do a head to toe skin assessment on the resident on 10/11 and 10/14 and the resident refused. LN K stated the resident would often refuse cares and assessments and LN K would ask other staff to approach the resident. LN K stated on 10/19/21 she observed the bruising on the resident's thighs and the resident stated they had been there a long time. LN K checked the skin book and found the documentation from 10/17/21 and notified LN I to observe the bruising. LN K stated she called Consultant Physician GG and reported the blood in the urine and bruises. The facility's Skin Care Protocol policy, dated 06/16/14, documented nurses would document skin assessments in the skin book accordingly. This includes a drawing of any skin variances and a narrative on their general skin condition. The nurse will complete an ID note indicating that the skin assessment was done and to refer to the skin book documentation for details. If a new skin variance is noted the nurse will notify the physician, the family, and the life care specialist, who will notify the Director of Nursing. The facility failed to notify the physician in a timely manner when staff discovered large bruises on R1's inner thighs (injuries of unknown origin) placing the resident at risk for abuse/neglect.

The facility had a census of 63 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards on one of three halls for the 10 cognitively impaired, independently mobile residents who resided in the facility. Findings included: - On 02/25/2020 at 08:17 AM, observation during initial tour of 500 Hall kitchenette and commons area nurse's desk revealed the following: One pair of pipe pliers in an unlocked drawer to right side of sink in the kitchenette One pair of scissors in top drawer of cabinet in the kitchenette One pair of silver scissors in the unlocked middle drawer of the nurse's desk One pair of red handled scissors in unlocked bottom drawer on right side of the nurse's desk On 02/25/2020 at 08:19 AM, Certified Medication Aide (CMA) R stated the pipe pliers and scissors should be in locked drawers. On 02/25/2020 at 08:29 AM, Dietary Staff (DS) BB stated scissors should be stored in a locked drawer. The facility's Environment Safety policy, dated 12/19/2019, documented the facility was committed to providing and maintaining a safe interior and exterior environment for residents, staff, and visitors. Maintenance staff will survey the interior and exterior of the facility on a regular basis for any hazards that may pose a potential threat. The facility failed to provide an environment free of accident hazards on one of three halls for the 10 cognitively impaired, independently mobile residents in the facility, placing the residents at risk for injury.

The facility had a census of 69 residents. The sample included three residents sampled for abuse. Based on observation, interview, and record review, the facility failed to provide a safe environment and protect residents from alleged abuse, when staff found Resident (R) 1 lying on her bed with no brief on, feet flat on the bed, knees bent up, and her legs spread apart. Certified Nurse Aide (CNA) M, was observed standing in front of R1, between her legs, with his pants unzipped, and down around his hips, placing R1 in immediate jeopardy. This deficient practice had the potential to affect the other 68 residents in the facility. Findings include: - R1's quarterly Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS documented the resident required extensive assistance of one staff for bed mobility, transfers, walking in her room, dressing, toileting, personal hygiene, and bathing. The MDS documented R1 used a walker and wheelchair for mobility. The care plan, dated 08/10/19, directed staff to provide the resident a whirlpool bath in the mornings, twice a week. The care plan documented the resident preferred to get out of bed between 05:30 AM and 09:00 AM, and after grooming and getting dressed, had breakfast in the dining room. The care plan documented R1 liked female care givers, but she liked and would work with CNA M. Review of the facility's investigation documented on 08/27/19 at 04:50 AM, Licensed Nurse (LN) G notified Administrative Nurse D of concerns of abuse toward R1 by CNA M. LN G reported CNA N called LN H to R1's room. CNA N reported she entered R1's room and observed CNA M standing and facing R1's bed with his pants unzipped. CNA N reported R1's incontinent brief was on the floor next to her bed and her nightgown was up around her waist. CNA N yelled out What are you doing? and CNA M's pants fell to the floor. CNA N called for LN H to come immediately and she told CNA M to get out of the room. LN H sent CNA M to the nurse's desk, away from all residents, and staff stayed with R1 to ensure her safety. Staff assisted R1 to the bathroom at her request. LN G contacted law enforcement at 05:13 AM and they arrived at the facility at approximately 05:30 AM. On 08/28/19 at 02:15 PM, observation revealed R1 in her bed, covered with a blanket, and her eyes closed. On 08/29/19 at 08:40 AM, Administrative Nurse D stated staff notified her on 08/27/19 at approximately 05:12 AM of a potential abuse situation involving R1 and CNA M. Administrative Nurse D stated she instructed LN G to call the police and Administrative Nurse D came to the facility immediately. On 08/29/19 at 10:36 AM, CNA N stated on 08/27/19 at approximately 04:50 AM, CNA M said he would give R1 a bed bath. CNA N offered to help and told CNA M to turn R1's call light on when he was ready for her to come to R1's room. CNA N said the call light never sounded, so she knocked on the door and entered R1's room. CNA N observed R1 on the lower part of her bed, without a brief on, knees bent, feet flat on the bed, and her legs spread apart. CNA N stated she observed CNA M facing R1, positioned between her legs, with his pants unzipped and holding on to them with one hand. CNA N stated she asked what he was doing, and he fumbled for words and stated, It's not what it looks like and his pants fell to the floor. CNA N stated R1's bed had been raised and was even with CNA M's hips. On 08/29/19 at 12:39 PM, LN H verified she observed CNA N at the door of R1's room, and CNA Aide N screamed at her to come to R1's room. LN H stated she entered the room and observed R1 at the bottom of her bed with her legs dangling off the bed, her night gown up to her waist, no incontinent brief on, and her genital area exposed. LN H verified she observed CNA M with his pants unzipped. On 08/29/19 at 02:54 PM, LN G stated she received a call from LN H and was told she needed help with a situation. LN G stated she called Administrative Nurse D at 05:12 AM to report the situation, and Administrative Nurse D instructed her to call the police. LN G stated she called the police at 05:13 AM, and they arrived at the facility at approximately 05:30 AM. The facility's Abuse, Neglect and Exploitation policy, dated 12/11/17, documented the purpose of the policy was to ensure residents were free from verbal, physical, sexual, and mental abuse. The policy documented the definition of sexual abuse as the non-consensual sexual contact of any type with a resident, but is not limited to sexual harassment, sexual coercion, or sexual assault. The facility failed to ensure residents were protected from abuse, when CNA M allegedly abused R1. On 08/29/19 at 06:20 PM, Administrative Staff A and Administrative Nurse D were provided a copy of the IJ Template and notified that the facility failed to ensure R1 was protected from alleged abuse and this constituted immediate jeopardy at F600. The immediate jeopardy was determined to begin on 08/27/19, when the facility discovered CNA M allegedly abused R1. The deficient practice was identified as Past Non-Compliance and corrected on 8/27/19 when the facility staff immediately removed the staff member from the resident's room, notified the Director of Nursing, Administrator, and Police Department. The resident was assessed by nursing staff and placed on one on one. The facility was placed on lock down and implemented abuse training with all staff on shift and will train oncoming staff prior to working.

The facility had a census of 70 residents. The sample included 18 residents of which 5 were reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure the resident environment remained as free of accident hazards for 3 of 5 sampled residents. Resident #22 had multiple falls with injuries, Resident #60, had multiple falls with no new preventative measures implemented, and Resident #16 received a reddened area which developed into a blister, then an open area from a hot pack. Findings included: - Resident #16's (POS) physician order [REDACTED]. The annual (MDS) Minimum Data Set Assessment, dated 12/3/16, documented the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment documented the resident was at risk for skin breakdown and did not have any open areas. The quarterly MDS, dated [DATE], documented the resident had a BIMS of 15, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment further documented the resident was at risk for skin breakdown and did not have any open areas or treatments. The 12/3/16 (CAA) Care Area Assessment summary for (ADL's) Activities of Daily Living documented the resident had pressure redistribution interventions in place to prevent skin breakdown and limited mobility. The 9/14/17 care plan directed staff to monitor the resident's skin for redness during dressing, and documented the resident had an air mattress on the bed, and a pressure reducing cushion to his/her chair. The care plan lacked documentation the resident used rice hot packs for pain management and comfort, and no direction to the staff on length of time to heat the packs in the microwave and when to remove the hot pack from the resident's skin. The 10/17/17 skin variance sheet documented the resident had a reddened area on his/her right outer hip, which measured 4 (cm) centimeters x 3 cm, due to a hot pack. The skin variance sheet documented the staff received teachable moment education on warm packs. The 10/18/17 facility investigation documented the resident stated the reddened area observed was due to a heat pack that was too warm. Upon assessment, a small red area was noted and the resident reported he/she asked staff to heat his/her rice bag. The resident was unable to pinpoint when the incident happened, possibly sometime during the prior week. The area measured 2 cm x 3 cm, with intact skin and the resident denied pain upon palpation (examination with the hands). The investigation documented staff provided the resident with a new heat pack with specific time parameters by the manufacturer and instructions not to sit on the heat pack, but to place it on the affected area to continue with pain management. The 10/19/17 fax to the physician documented the resident had a reddened area on his/her right hip and staff applied A & D ointment (a skin protectant that aids in healing) to the area. The physician directed staff to continue current care and update him/her if it worsened. The 10/20/17 fax to the physician documented a blister approximately 1cm x 1 cm with redness around it, which measured 5 cm x 3 cm. The fax documented staff continued use A & D ointment on the area. The physician directed staff to apply double antibiotic ointment (a combination of antibiotics used to treat certain types of infections caused by bacteria), twice a day, for 10 days. The 10/23/17 skin variance sheet for the right hip measured a 2 cm x 2 cm blister surrounded by 2 cm reddened area, and painful. The 10/26/17 physician visit documented he/she evaluated the resident for irritation of a [MEDICAL CONDITION] on the resident's right hip from a rice bag. The physician directed staff to administer Keflex (an antibiotic), 500 (mg) milligrams, by mouth, twice a day, for 7 days for the [DIAGNOSES REDACTED]. The 11/2/17 fax to the physician documented the area remained red, warm and tender to the touch. The area measured 7 cm x 6 cm with a white area in the center and had a small amount of clear drainage. The physician directed staff to apply a dry dressing of [MEDICATION NAME] (an absorbent, foam dressing) to the right hip, change daily and as needed, and to discontinue the double antibiotic ointment. The 11/6/17 skin variance sheet documented the wound measured 7 cm x 6 cm, reddened area, with a 1 cm x 0.5 cm white center, and no drainage present. The 11/10/17 fax to the physician documented the wound measured 4 cm x 5 cm, blanchable (loses all redness when pressed) with a 1 cm x 0.5 cm white center. The physician directed staff to administer [MEDICATION NAME] (an antibiotic), 100 mg, by mouth, twice a day, for 7 days for the [DIAGNOSES REDACTED]. The 11/14/17 skin variance sheet documented the wound measured 1.7 cm x 1.2 cm brown with slough (dead tissue) to the center of the area and scant serosanguinous (containing blood and fluid) drainage. The 11/16/17 physician order [REDACTED]. The 11/21/17 skin variance sheet documented the open area measured 1.2 cm x 1.2 cm with a 0.7 cm x 0.5 cm dark center. The 11/28/17 skin variance sheet documented the open area measured 1.2 cm x 1.2 cm surrounded by 1.0 cm x 0.5cm pink area. The center of the open area was pink and had a scant amount of serosanguinous drainage. On 12/4/17 at 9:27 AM, observation revealed the resident sat in his/her recliner, positioned slightly on his/her left hip. Licensed Nurse D donned clean gloves and pulled the dressing partially from the area. The wound measured approximately 1.2 cm surrounded by 1 cm dark red area, without drainage. Licensed Nurse D placed the dressing back over the area. On 11/28/17 at 10:43 AM, the resident stated he/she received a burn from a rice pack. The resident stated it happened a couple months ago and he/she received treatment. On 12/4/17 at 9:32 AM, Licensed Nurse D stated the resident received a burn from his/her own personal rice pack and the wound turned into [MEDICAL CONDITION] and he/she was unsure how long the staff heated the warm pack in the microwave. Licensed Nurse D further stated, now there was a sign on the therapy room microwave to direct staff how long to heat the heat pack but did not know if the sign was in place prior to the incident. On 12/4/17 at 2:36 PM, Nurse Aide E stated the resident received a burn from his/her own personal rice pack and the facility provided the resident a new warm pack with instructions for the hot pack on the microwave in the therapy room. On 12/4/17 at 2:46 PM Administrative Nurse A stated the resident brought in his/her homemade rice pack and was particular on how long to heat it in the microwave, and always asked for the rice pack to be hotter. Administrative Nurse A further stated the facility purchased warm packs from a manufacturer which gave specific heating instructions and verified the facility had no instructions for staff guidance on heating instructions prior to the resident's burn. On 12/6/17 at 10:44 AM, Administrative Nurse A stated there was not a policy in place prior to the incident, just guidance on the microwave posted in the therapy room. Administrative Nurse A further stated the resident had a hip replacement in 2010 to that area and had questioned the physician if the internal hardware might be causing pressure, but the physician did not respond. Administrative Nurse A stated the irritation to the skin resolved, now it is an open area that measured approximately 1 cm x 0.7 cm. The 10/18/17 facility Heat Pack Policy documented any heat packs used by residents must be from a manufacturer and not homemade. Heat packs should only be heated for as long as manufacturer recommendations and be inspected prior to use and discarded if any signs of burns, rips, or tear, and the resident should not lay or sit on heat packs. After heating the pack, staff should check for hot spots, by gently massaging the heat packs to move the contents around to ensure heat was distributed. Staff should never place a heat pack directly on a resident's skin, use a cloth or towel to ensure there was a barrier between the resident's skin and the heat pack. The facility failed to ensure Resident #16 remained as free of accident hazards as possible and to provide guidance to staff on appropriate guidelines to prevent accidents for heating a homemade rice pack, resulting in an avoidable facility acquired skin injury (burn) which required multiple physician ordered treatments and oral antibiotics to treat [MEDICAL CONDITION]. The facility provided additional education to nursing staff, including nurses, certified nurse aides and certified medication aides prior to staff returning to work. The additional education included information from the facility's 10/18/17 Heat Pack Policy and documented staff signatures and the date the education was provided. Documentation was provided by the facility that staff members received the education prior to the state agency entering the facility for the annual resurvey. - Resident #60's (POS) physician order [REDACTED]. The annual (MDS) Minimum Data Set Assessment, dated 2/4/17, documented the resident had long and short term memory problems with moderately impaired decision making skills. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 staff for locomotion on and off the unit, toileting, dressing and personal hygiene. The assessment further revealed the resident had unsteady balance, upper extremity impairment on both sides, always incontinent of bladder and bowel, and had no falls. The quarterly MDS, dated [DATE], documented the resident had long and short term memory problems with moderately impaired decision making skills and required extensive assistance of 1 staff for bed mobility, transfers, toileting, dressing, and locomotion on and off the unit. The assessment further documented the resident had unsteady balance, upper extremity impairment on both sides, frequently incontinent of bladder and bowel, and had 2 or more falls without injury. The 2/4/17 (CAA) Care Area Assessment for falls documented the resident had a history of [REDACTED]. The 2/23/17 care plan directed staff to do visual checks on the resident when he/she was alone in his/her room, toileting program for fall prevention and incontinence management, fall risk assessments quarterly, 2 person pivot transfer or 1-2 person assist with stand-up lift for all transfers. The 6/30/17 care plan update directed staff to place a motion sensor alarm when the resident was lying in bed. The 8/23/17 care plan update documented staff were re-educated on the proper placement of the motion detector, and to keep all other fall interventions in place. The 10/3/17 care plan update directed staff to do visual checks on the resident when he/she was in his/her rock and go wheelchair (a wheelchair designed to ease agitation in Alzheimer's and dementia patients). The 10/15/17 care plan update directed staff to continue current interventions. The 10/22/17 care plan update directed staff to turn the motion detector on when the resident was alone in his/her room. The 11/29/17 care plan update directed staff to do visual checks on the resident, and encourage the resident to move to his/her recliner when in his/her room. The 8/1/17 and 11/1/17 fall assessment, documented the resident was at risk for falls. The 3/17/17 at 8:30 AM, incident report documented the resident had an unwitnessed fall from his/her lowered bed to the floor mat, landing on his/her knees and elbows. The report documented the resident received a 1 (cm) centimeter x 1 cm scratch on his/her right upper arm. Review of the care plan lacked further interventions to prevent falls. The 6/5/17 at 3:10 PM, incident report documented staff found the resident lying on the floor in front of his/her lift chair that was in the highest position. The report documented the resident had lifted the chair into the highest position and had slid out onto the floor. The report documented the resident did not receive any injuries from the falls. Review of the care plan lacked further interventions to prevent falls. The 6/14/17 at 1:30 AM, incident report documented the resident yelled for help and staff found the resident lying on his/her right side on the mat beside his/her bed. The incident report documented the resident stated he/she had to go to the bathroom. Review of the care plan lacked further interventions to prevent falls. The 6/23/17 at 8:00 PM, incident report documented the resident was seated on the floor in front of his/her wheelchair, arms rested on the wheelchair leg pedals. The resident denied pain or discomfort and stated he/she was getting more money. Review of the care plan lacked further interventions to prevent falls. The 6/28/17 at 4:30 AM, incident report documented staff found the resident on the floor at the end of his/her bed and he/she had no injury. Review of the care plan, dated 6/30/17, revealed interventions implemented were to have a motion detector in place when the resident was lying down in bed. The 7/1/17 at 3:45 AM, incident report documented the resident had his/her legs hanging out of the bed. As the staff assisted the resident to put his/her legs back into bed, he/she slid out of bed onto the cushioned floor. The incident report documented the resident removed his/her incontinent brief and urinated on the cushioned floor mat. The resident was cleaned up and assisted back into bed. Review of the care plan directed staff to continue current interventions. The 8/23/17 at 1:45 AM, incident report documented the resident yelled for help and staff found him/her lying on the floor on the mat by the bed. Review of the care plan documented staff were educated on proper placement of the motion detector and to continue current interventions. The 10/3/17 at 9:00 PM, incident report documented the resident yelled for help and staff found him/her lying on his/her left side in front of his/her wheelchair facing towards the wall. The incident report further documented the resident was going to the bathroom. Review of the care plan directed staff to do visual checks on the resident when he/she was in his/her rock and go wheelchair, but did not specify how frequent to do the visual checks. The 10/15/17 at 3:30 PM, incident report documented staff found the resident beside the bed in front of his/her rock and go wheelchair. The resident was assessed and did not have any injury. Review of the care plan directed staff to continue current interventions. The 10/21/17 at 7:52 PM, incident report documented the resident slid out of his/her rock and go wheelchair. Review of the care plan directed staff to place the motion detector on when the resident was in his/her room alone. The 10/25/17 at 8:50 PM, incident report documented staff found the resident seated in an upright position with his/her back leaning against his/her wheelchair. The resident stated he/she was trying to get out of there. Review of the care plan lacked further interventions to prevent falls. The 11/29/17 at 9:40 PM, incident report documented the resident was seated on the floor in front of his/ her rock and go wheelchair. Review of the care plan directed staff to do frequent visual checks on the resident when he/she was in his/her rock and go wheelchair in the room and to encourage the resident to move to his/her recliner. On 12/4/17 at 11:14 PM, observation revealed Nurse Aide E and Nurse Aide M in the resident's room to assist with a transfer. Nurse Aide E sat the resident on the side of his/her bed and placed the sit to stand lift sling around the resident. Nurse Aide M raised the resident to a standing position and transported him/her to the bathroom. Nurse Aide E removed the resident's incontinent brief and lowered the lift enabling the resident to sit on the toilet. Nurse Aide E performed pericare, placed a clean brief and pants on the resident then stood the resident and sat him/her into his/her wheelchair. On 12/4/17 at 11:15 AM, Nurse Aide M stated the resident had a lot of falls and had to have the motion detector on at all times. Nurse Aide M further stated the resident liked to push the wheelchair up against the wall and stand up, and he/she would fall. On 12/4/17 at 1:30 PM, Administrative Nurse A stated staff toileted the resident during the night at midnight and 4:00 AM, and staff had difficulty with interventions for the resident, because the resident still felt like he/she could walk. Administrative Nurse A stated the facility had not completed a formal root cause analysis but discussed the resident's falls and try to implement new interventions after each fall. On 12/5/17 at 11:25 AM, Licensed Nurse D stated he/she updated the care plan when the resident had falls and would use past and current interventions on the care plan. Licensed Nurse D further stated the facility has fall risk team meetings to discuss interventions for the resident and would discuss root cause analysis. The facility's 5/14/14 Falls Management Policy documented all residents would be evaluated for fall risk upon admission, after 7 days, after 14 days, with quarterly reviews, and with significant changes. Appropriate interventions would be implemented to decrease the risk for falls. The facility would discuss residents with falls daily and any observations of potential falls would be acted upon when observed. The facility would have high risk meetings weekly for those who have fallen in the past week and for those that are high risk are reviewed, and all interventions should be individualized. The facility failed to provide adequate supervision and lacked new preventative measures for Resident #60, who had multiple falls, placing the resident at risk for injury. - Resident #22's physician order [REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 9/13/17, documented the resident's (BIMS) Brief Interview for Mental Status score of 9, indicating moderately impaired decision making ability. The MDS further documented the resident required extensive assistance of 1 staff for (ADLs) Activities of Daily Living, balance was unsteady, although he/she was able to rebalance on his/her own. The MDS documented the resident used a walker and wheelchair, had 1 fall with no injury, 2 or more falls with injury between 8/29/17 and 9/13/17, and was on a restorative nursing program for walking and eating. The MDS documented the resident received (PT) Physical Therapy and (OT) Occupational Therapy. The revised fall (CAA) Care Area Assessment, dated 9/15/17, documented staff provided visual checks of the resident and reminded the resident to use the call light for staff assistance. The CAA further documented staff monitored the resident for a decline in his/her ADLs, directed staff to provide fall interventions: a low bed, toileting program, safety reminders, and a motion sensor in his/her room. The discharge MDS, dated [DATE], documented the resident had a short term memory deficit, with moderately impaired decision making ability, which required supervision and cues. The MDS further documented the resident rejected care, required extensive assistance of 1 staff for his/her (ADLs) Activities of Daily Living, had shortness of breath with movement, sitting at rest, and lying flat. The MDS documented the resident had 2 or more falls with no injury and 2 or more falls with injury since the prior assessment reference date on 9/13/17, and received an antibiotic for 4 days. The 11/18/17 revised fall care plan, for readmission from the hospital, directed staff to provide the following interventions, which included interventions prior to hospitalization : 6/1/17 intervention repeated on 10/18/17 - Staff performed visual checks for safety, day and night, assure the resident's call light and important objects remain in reach. 6/1/17 - The resident had intermittent confusion and a history of delusions, notify the nurse and document the delusions and hallucinations, wandergard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on the left wrist, and checked the device weekly. 6/1/17 intervention repeated on 10/18/17 - Assist with supervision of 1 staff for ADLs. 6/1/17 intervention repeated on 9/17/17 - Encourage the resident to wear appropriate footwear with ambulation. (MONTH) use gripper socks at night. 6/5/17 - Provide a restorative therapy program to maintain the resident's highest level of function, which included sitting and standing exercises, walk to dine program, with a wheeled walker and stand by assistance. 8/30/17 - Provide a toileting program - assist to the bathroom upon waking, before and after meals, bedtime, midnight and 4:00 AM with resident checks. The program directed staff to increase visual checks to an hourly basis when the resident slept, assist to the bathroom when awake. 9/5/17- intervention repeated on 9/18/17 - Provide a low bed, with a soft mat on the floor beside the bed. 9/5/17- intervention repeated on 11/18/17 - (PT) Physical Therapy and (OT) Occupational Therapy to evaluate and treat after a fall. 9/6/17 - Provide a motion sensor and frequent visual checks. 11/2/17 - Staff administered Bactrim DS (antibiotic medication) for 7 days to treat a urinary tract infection. 11/6/17 - The resident had an unwitnessed fall and staff placed a different motion sensor. 11/7/17 - The resident had an unwitnessed fall with injury, and 2 rib fractures on the right side. Staff to apply an ice pack for 10-15 minutes, 3 times a day, for 2 days, warm pack 10-15 minutes, 3 times per day as needed, and administer Tylenol (pain relieving medication) 500 (mg) milligrams, by mouth, 3 times per day for 7 days (This is an appropriate intervention for an acute injury, but would not assist with future fall prevention). 11/20/17 - Physical Therapy and Occupational Therapy each started a program to treat for 5 days each week, for 30 days. 11/21/17 - The restorative program was reviewed and discontinued, because the program was no longer appropriate for the resident. 11/22/17- [DIAGNOSES REDACTED]. The 8/28/17 at 9:10 PM, nurse's note documented staff found the resident on the floor in his/her room, with no call light on. The resident reported he/she fell walking from the bathroom into his/her room. The note documented the physician and the responsible party were notified. The note did not include root cause analysis or an updated care plan intervention on 8/28/17 for fall prevention on that date. The 8/29/17 at 1:05 AM, nurse's note documented staff found the resident on the floor in front of the bathroom door, with blood under his/her head, and a laceration on the back of the left side. The note further documented the resident was transported by ambulance to the emergency room for evaluation of the raised area on his/her head. The note documented the resident's responsible party was notified and the care plan updated, to include a toileting program, dated 8/30/17 (The facility did not complete a voiding diary or incontinence assessment to assist with development of an effective toileting program). The 9/5/17 at 1:30 PM, nurse's note documented staff found the resident on the floor in front of his/her bed and observed a 1(cm) centimeter by 1 cm laceration to the right forehead. The note further documented the resident was unable to state what happened, the motion detector was on, but did not signal staff. The note documented the nurse applied Steri-Strips to the laceration, notified the resident's responsible party, updated the care plan to include a low bed, soft mat on the floor beside the bed, and PT and OT screened the resident. The 9/6/17 at 1:30 AM, nurse's note documented staff found the resident lying on the mat beside the bed and observed a skin tear to his/her right elbow, which measured 1 cm x 0.5 cm. The note further documented the resident was unable to state what happened, staff notified the physician and resident's responsible party, and directed staff to continue the interventions documented on 9/5/17. The 9/17/17 at 8:00 PM, nurse's note documented staff responded to the resident's call light and found the resident lying on the ground in his/her room. The note documented the physician and resident's responsible party were notified, and the care plan updated to include gripper socks at night (although he/she had gripper socks in place since 6/1/17). The 9/18/17 at 4:05 AM, nurse's note documented staff responded to the motion sensor and found the resident in a kneeling position on the mat on the floor, facing the low positioned bed. The note documented the resident stated he/she tried to get up from bed, had no injury, the physician and responsible party were notified, and the care plan updated. The nurse documented staff were directed to place a motion sensor on the floor, with a soft floor mat next to the bed in the low position (although he/she had a motion sensor in place since 9/5/17). The 9/21/17 Interdisciplinary team meeting documented the resident had dementia and lacked insight into his/her cognitive and physical limitations resulting in safety concerns. The note further documented the resident worked with PT and OT to address the resident's physical limitations. The therapists reported the resident was inconsistent in progress and remained a high fall risk due to poor safety awareness. The 11/5/17 at 8:52 AM, nurse's note documented staff administered, Bactrim DS (an antibiotic medication) for 7 days for a urinary tract infection. The note documented the resident reported he/she felt dizzy when he/she stood from the bed. The 11/6/17 at 10:28 PM, nurse's note documented staff found the resident on the floor. The note further documented the resident reported he/she fell as he/she walked from the bathroom. The note documented the motion sensor was in place, and on, however staff determined the resident partially opened the bathroom to avoid having the motion sensor detect his/her movement. The note documented the resident complained of pelvic pain and right hip pain on assessment. The note documented the physician directed staff to transfer the resident to the hospital. The responsible party was notified and an intervention was added to the care plan, which directed staff to replace the motion sensor and continue the current interventions (although he/she had a motion sensor in place since 9/6/17). Review of the motion sensor print out for 11/6/17, revealed the motion the sensor alarmed at 9:23 PM and was reset at 9:25 PM. The resident set off the motion sensor 24 times on 11/6/17, prior to the time of the fall. The resident had 3 falls going to or returning from the bathroom. Review of the medical record revealed a voiding diary was not completed assist with development of an effective toileting program. The 11/6/17 at 11:48 PM, nurse's note documented the hospital staff called and reported to the nurse, the resident had 2 posterior (in back of or behind) fractured ribs. The 11/7/17 at 12:27 AM, nurse's note documented the resident was transported back to the facility with new MEDICATION ORDERS FOR [REDACTED]. The note documented the X-ray revealed minimal displacement of the posterior 9th and 10th rib. The note further directed staff to provide ice packs to the ribs 3 times a day for 2 days and a warm pack for 10 -15 minutes 3 times a day as needed. The 11/11/17 at 10:55 AM, nurse's note documented staff responded to the motion sensor, found the resident lying on his/her right side, in his/her room, next to the dresser, which had the lower drawer pulled out. The note documented the resident had a laceration on the right side of his/her head, which required sutures (thread like material used to sew tissue together), and an abrasion and bruising on the left medial upper thigh. The nurse applied an ice pack to the back of the resident's head, transferred the resident to the emergency room for evaluation and treatment, updated the care plan with the fall information, and directed staff to continue the same interventions. On 11/30/17 at 10:29 AM, observation revealed the resident lying in bed, with the head of the bed down, bed in the low position, call light in reach, mat on the floor, motion sensor in front of the resident. The resident was awake and began speaking to Nurse Aide G. Nurse Aide G raised the head of the bed 30 degrees and asked the resident if he/she was ready to get up. On 12/4/17 at 4:00 PM, observation revealed the resident frequently attempted to move from a lying to sitting position on the bed and presented confused. The resident moved in bed, but did not swing his/her legs off the bed far enough to trigger the motion sensor. On 11/30/17 at 10:30 AM, Nurse Aide G stated the resident slept in some mornings, was confused upon rising and had difficulty finding the correct words to express his/her thoughts. Nurse Aide G stated the facility used a motion sensor in the resident's room to notify staff if the resident stood up or moved around and provided frequent visual checks of the resident. Nurse Aide G lacked knowledge of the manner the motion sensors were checked. Nurse Aide G stated at times, the motion sensors just quit working, and the staff needed to replace the sensors frequently. Nurse G stated the motion sensors functioned off of batteries and stated if a resident's motion sensor did not sound for several hours, he/she checked to make sure the resident was ok and that the sensor worked correctly. On 12/4/17 at 4:13 PM, Nurse H stated the resident walked with a gait belt, wheeled walker, and assistance of 1 staff and was recently readmitted from the hospital for pneumonia. Nurse H further stated the resident was very weak upon readmission to the facility, confused when waking up, lethargic (slowness), and did not attempt to get up on his/her own as frequently. Nurse H reported staff used a motion sensor, low bed, place a styrofoam tube under the (TRUNCATED)

The facility had a census of 70 residents. The sample included 18 residents. Based on observation and interview the facility failed to prepare, distribute, and serve food under sanitary conditions in 1 of 1 main kitchen. Findings included: - On 11/28/17 at 8:47 AM, observation during the initial main kitchen tour, revealed 2-3 inch strands of hair protruded from under Dietary Staff N's hairnet at the nape of the neck. Tour of the kitchen revealed numerous serving platters, face up, stacked under a counter. Observation further revealed a large metal colander, face up, under the counter, next to the serving platters. On 12/4/17 at 10:30 AM, observation revealed the plate stand was not in use and contained stacked plates, which did not have a protective cover and were not inverted (upside down to protect the eating surface of the dishware). Observation also revealed the saucer/bowl stand was not in use and contained stacked bowls, which did not have a protective cover and were not inverted. The stands remained uncovered, with staff passing by frequently and food preparation completed in the kitchen area. Observation revealed the colander, and serving platters remained uncovered, and the clean mixer bowl sat next to the commercial mixer, on the counter top, face up, and uncovered. The mixer bowl remained uncovered during the observation from 10:30 AM to 1:00 PM, and was not in use. On 12/4/17 at 11:05 AM, observation revealed Dietary Staff O and Dietary Staff Q prepared food items for the noon meal. Dietary Staff N walked throughout the food preparation area, and all 3 staff had 2-3 inch strands of hair which protruded from under the hairnet at the nape of the neck. On 12/4/17 at 10:30 AM, Dietary Staff O verified approximately 2-3 inches of loose hair strands protruded from under the hairnet at the nape of his/her neck. Dietary Staff O stated he/she attempted to use hairspray to hold the hair strands down. On 12/5/17 at 2:10 PM, Dietary Staff N verified dietary staff's hair protruded from underneath the hairnets and stated all hair should be contained under a hairnet. Dietary Staff N further verified the serving platters and colander should not be stored face up. Dietary Staff N stated he/she was not aware the dishware should be covered or inverted when not in use. Dietary Staff N reported staff used the electric mixer earlier in the morning, and once cleaned, the bowl should have been covered. The facility's 12/16/13 Dress Code for Dining Service Staff informed staff a hair restraint was mandatory for food service staff who worked in the kitchen, dish room, and dining room. The procedure documented the facility provided the hair restraints. Upon request, the facility did not provide a policy and procedure for storage of dishware, cookware, and/or serviceware. The facility failed to prepare and serve food under sanitary conditions for the 70 residents who resided in the facility and received meals from the facility kitchen.

The facility had a census of 70 residents. Based on observation, record review and interview the facility failed to ensure stock medications had not expired on 2 of the 4 medication carts. Findings included: - On [DATE] at 8:45 AM, observation during the initial tour revealed the following: Applewood medication cart, 1 bottle of Thera-Tablets M 100 count, approximately ,[DATE] full, with an expiration date of ,[DATE]. Sunflower medication cart, 1 bottle of Mucus relief tablets 60 count, approximately ,[DATE] full, with an expiration date of ,[DATE]. On [DATE] at 8:45 AM, Certified Medication Aide B verified the Thera-Tablet M tablets had expired on ,[DATE]. On [DATE] at 9:15 AM, Certified Medication Aide C verified the Mucus relief tablets had expired on ,[DATE]. On [DATE] at 10:30 AM, Administrative Nurse A verified the weekend nurse manager would make rounds to remove medications when outdated, and the nursing staff were responsible to check the expiration dates on the medication before administration to the residents. The (MONTH) 2006 facility policy for Labeling and Storage of Biologicals revealed the facility would: 1) Label the medications with the name of the drug or biological and its strength. 2) The name of the resident and the physician do not have to be on the label of the package however, they must be identified with the package to assure that the drug is administered to the right resident. 3) All drugs approved by the FDA must have expiration dates on the manufacture's container. 4) All drugs and biological must be stored in locked compartments under proper temperature controls. 5) Only authorized personnel to have access to the keys. The facility failed to ensure stock medications were not expired, which placed residents at risk for not receiving the medication effectiveness.