Every finding on record at Pioneer Lodge

Based on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when staff failed to use the Hoyer (total body mechanical lift) lift for Resident (R) 1, per her plan of care, resulting in a non-injury fall.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia and anxiety.R1's 07/20/2026 Annual Change Minimum Data Set (MDS) documented that R2 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. R1's MDS documented that she was a total assist for transfers.R1's 07/23/2026 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R1 was dependent on staff to make decisions regarding activities of daily living (ADLs). R1 would be care planned to minimize risks related to cognitive loss/dementia.R1's Care Plan, dated 03/25/2025, instructed staff that R1 was to be transferred with the Hoyer lift.R1's Care Plan, dated 06/24/2025, instructed staff that R1 required two staff for all transfers and they were to use a Hoyer lift only. R1 was non-weight bearing.R1's Incident Note, dated 08/21/2026 at 02:00 PM, documented she was assessed while in her bed and there were no new skin issues.R1's Doctor Visit Note, dated 08/21/2026 at 02:58 PM, documented R1 presented to the clinic with her daughter after a fall sustained on 08/21/2026 around 06:00 AM. It was reported that R1 fell twice when two staff members did not use the mechanical lift when they transferred her Additional information was obtained from the involved staff members, and they acknowledged that they did not use the mechanical lift when they transferred R1 and she slipped and was lowered to the ground and did not hit her knees. The staff members were able to get her into her wheelchair.Review of the facility's Facility Reportable Incident 3173466, dated 08/26/2026, documented that R1 was transferred by Licensed Nurse (LN) G and Certified Nurse Aide (CNA) M without using the mechanical lift that R1 was care planned to be transferred with. The facility was unable to verify if R1 was dropped during the transfer. Corrective actions taken in response to this incident documented that all nursing staff would be educated on the no lift policy and charge nurses were informed to make sure they understood to review resident care plans for appropriate transfer assignments.Review of the facility's Education Review, dated 08/21/2026, documented that as of this date, it was mandatory for all nursing staff who worked for the facility or agencies that were hired by the facility to be trained in the proper techniques for transferring all residents. All employees that fulfilled any shift on or after 08/21/202 were to sign that they had read and understood the memo.Review of Certified Nurse Aide (CNA) S's Witness Statement, dated 08/21/2026 at 08:44 AM, documented that during the first transfer observed, unknown staff initially stated that they were not going to use a lift. Staff proceeded to manually lift the unknown resident to transfer her to a wheelchair. The staff placed a lift sling underneath the resident, but the lift itself was not used for the transfer. After the resident had been transferred, staff realized that something had been forgotten or needed to be put on the resident. Staff then lifted the resident again. The resident was then transferred again, and during that attempt, staff appeared to have to move urgently because the resident was almost dropped onto the floor. It was documented that CNA S questioned the other staff as to why a lift was not used, and they told her that they did not have time for that.Review of Licensed Nurse (LN) G's Witness Statement, dated 08/21/2026 at 03:12 PM, documented that LN G and CNA M, on the morning of 08/21/2026, assisted an unknown resident to a seated position on the side of her bed to assist her to a standing position and transferred her to the chair. The resident had difficulty standing, and her knees started to buckle. Resident's pants were used to get her in her wheelchair. LN G documented that she educated CNA S that the resident used a sling lift to transfer for that reason.Review of CNA M's Witness Statement, dated 08/31/2026 at 03:55 PM, documented that on the morning of 08/21/2026, LNG and CNA M offered to stay over to assist residents up for the morning. LN G and CNA M assisted an unknown resident in a seated position on the side of her bed to assist her to a standing position and transferred her to the chair. The resident had difficulty standing, and her knees started to buckle. The resident's pants were used to get her into her wheelchair. CNA M documented that she educated CNA S that the resident used a sling lift to transfer for that reason.Review of the facility's Education Review, dated 08/31/2026, lacked a documented signature from CNA M, CNA N, CNA O, and Certified Medication Aide (CMA) R.Review of the facility's schedule, dated 08/21/2026 through 08/31/2026, documented the following:CNA M worked on 08/25/2026, 08/28/2026, 08/29/2026, and 08/30/2026 the 06:00 PM - 06:00 AM shifts.CNA N worked on 08/27/2026 the 06:00 AM - 02:00 PM shift.CNA O worked on 08/26/2026 the 11:00 AM - 02:00 PM shift. CMA R worked on 08/24/2026, 08/25/2026, 08/26/2026, 08/27/2026, and 08/28/2026 on the 08:30 AM - 05:00 PM shift.Observed on 08/31/2026 at 10:20 AM, R1 sat in her recliner in her room; her eyes were closed, and her TV was on. R1 had a lift sling underneath her with purple trim, and a mechanical lift was in her room.Observed on 08/31/2026 at 11:10 AM, R1 was transferred into bed with the mechanical lift, assisted by CNA P and CNA Q.Observed on 08/31/2026 at 11:20 AM, CNA P and CNA Q transferred R1 into her wheelchair with the mechanical lift. CNA P pulled on the sling itself, not the sling handles, to guide her into the wheelchair.On 08/31/2026 at 01:01 PM, CNA Q reported she had an orientation day a couple of weeks ago at the facility, and she had worked for the past two days. She reported that she was told to always use a two person assist for all lifts and to follow the care plan.On 08/31/2026 at 01:37 PM, CNA P reported that she received education for the no lift policy and to use the mechanical lift CNA P said she was short and that was why she pulled on the back of the lift sling instead of on the handles on the back of the lift.On 08/31/2026 at 01:40 PM, LN H reported that he assessed R1 after he was told that CNA M and LN G had transferred her without the mechanical lift. He reported that R1 had no injuries. LN H reported that he did receive education after the reported incident.On 08/31/2026 at 02:25 PM, Administrative Staff A reported that all the staff members had not received education about the no lift policy and that included CNA M, who was the other staff member that lifted R1 without the use of the mechanical lift on 08/21/2026. Administrative Staff A reported she expected all the staff members to be educated and realized there were a few other staff members not educated who had worked since the education was provided. Administrative Staff A reported that she should have placed the education at the nurse's station after she scanned the education that had been completed up until 08/24/2026.On 08/31/2026 at 02:45 PM, Administrative Nurse D reported that she had spoken to LN G, who did not follow the care plan and transferred R1 without the mechanical lift. Administrative Nurse D reported it was a verbal conversation and no written documentation or any disciplinary action was documented.The facility's undated No Lift policy documented that all employees involved in the movement of residents would be responsible for knowing which resident required the use of the mechanical lift. The charge nurse on each shift would be responsible for monitoring the use of the mechanical lifts and reporting infractions to the Director of Nursing. The first violation would be a written notification of warning to be given to the employee. The second violation would result in employment being terminated.

The facility reported a census of 23 residents. Based on observation, interview and record review, the facility failed to provide Registered Nurse (RN) coverage for at least eight continuous hours daily. Finding includes:- The facility's Daily Census Report, dated 09/21/25, documented 23 residents resided in the facility.Review of nursing schedules for 04/01/24 through 12/31/24 revealed a lack of RN coverage for eight continuous hours on 04/28/24, 05/11/24, 05/25/24, 06/01/24, 06/22/24, 06/23/24, 07/06/24, 07/07/24, 07/20/24, 07/21/24, 08/03/24, 08/04/24, 08/17/24, 08/18/24, 08/31/24, 09/01/24, 09/14/24, 09/15/24, 10/26/24, 10/27/24, 11/23/24, 11/24/24, and 12/21/24.Review of RN payroll documents for 04/01/24 through 12/31/24 revealed a lack of RN coverage for eight continuous hours on 04/28/24, 05/11/24, 05/25/24, 06/01/24, 06/22/24, 06/23/24, 07/06/24, 07/07/24, 07/20/24, 07/21/24, 08/03/24, 08/04/24, 08/17/24, 08/18/24, 08/31/24, 09/01/24, 09/14/24, 09/15/24, 10/26/24, 10/27/24, 11/23/24, 11/24/24, and 12/21/24.On 09/21/25 at 10:30 AM, observation revealed 23 residents resided in the facility.During an interview on 09/22/2025 at 03:43 PM, Administrative Staff A stated that the facility did not have RN coverage on the days listed. Administrative Staff A stated the facility had identified this issue and had since improved.The facility did not provide a policy for RN coverage.

The facility reported a census of 23 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.Findings included:- Observation of the kitchen and food storage areas on 09/21/25 at 09:20 AM revealed the following areas of concern:Dry Storage Area:Several storage bins filled with a variety of pasta with no date or label.Free-standing freezer:One bag of French toast sticks with no date or label.Several bags of English muffins with no date.One bag of garlic bread with no date or label.One bag of chicken patties, no date or label.One bag of chicken legs with no date or label.Several bags of ground beef and pork sausage, no date.One bag of pepperoni, no date.One bag of unidentified meat, no date or label.Free-Standing refrigerator:Three opened gallons of milk, no date.One opened bottle of tartar sauce, no date.One opened container of Parmesan cheese, no date.Three-bay Refrigerator:Old dried blood on the bottom of the refrigerator.One opened bag of lunch meat with no date.One large bag of opened shredded cheese, no date.One plastic container of tomato sauce, no date or label.One plastic container of red Jello, no date or label.Several unsealed wrinkled black-brown colored tomatoes.Several unsealed wrinkled green peppers.One bag of wilted brown lettuce, no date.Three packaged bags of ground beef in a metal container were observed thawing above the stove, which contained two pans of cut-up potatoes cooking.One packaged bag of ground pork sausage in a metal container, thawing above the stove, that contained two pans of cut-up potatoes cooking.Two packaged bags of ham lunch meat in a metal container, thawing above the stove, that contained two pans of cut-up potatoes cooking. The lunch meat was soft and warm when touched.During an interview on 09/21/25 at 09:40 AM, Dietary Staff CC reported that all food items in the freezer, dry storage, and refrigerator required to be sealed, labeled, and dated when opened. Dietary Staff CC reported that this was how he thawed the meats that were on the menu to be prepared.During an interview on 09/22/25 at 10:36 AM, Dietary Staff BB, Certified Dietary Manager, stated she expected the staff to label, date, and seal all food items. Dietary Staff BB stated she expected the staff to keep all areas of the kitchen clean. Additionally, Dietary Staff BB stated she expected staff to thaw all meats the correct way.During an interview on 09/23/25 at 11:40 AM, Administrative Staff A stated he expected all food items to be stored, sealed, labeled, and dated properly. Administrative Staff A stated she expected the dietary staff to thaw out all meats appropriately.The facility's policy Food Preparation and Handling dated 01/13/2016, states that all food items and products served to elders would be prepared from the central kitchen using methods and techniques designed to preserve maximum nutritive value and be free of injurious organisms and substances. The kitchen equipment would be kept clean. Food items would be checked, dated, and stored properly. Defrosting of food would be completed by placing the frozen item in the refrigerator until thawed or placing it in a cold-water bath for defrosting.

The facility reported a census of 23 residents. Five Certified Nurse Aide (CNA) staff who worked in the facility for more than 12 months were reviewed for the required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff with the required topics and no less than 12 hours per year. Findings included:- Review of CNA personnel files revealed the following:CNA M, who was hired for the facility on 02/26/1997, lacked the total hours calculated for the 12 hours required.CNA N, who was hired 10/24/23, lacked the total hours calculated for the 12 hours required.CNA O, who was hired 08/29/17, lacked Abuse, Neglect, and Exploitation (ANE) and social media training. CNA O's total hours were not calculated for the 12 hours required.During an interview on 09/23/25 at 09:00 AM, Administrative Staff A reported he expected the staff to have the required education and the required 12 hours annually.The facility did not provide a policy for CNA staff required for in-service and annual training hours.

The facility reported a census of 23 residents; the sample included 14 residents. Based on interview and record review, the facility failed to inform Resident (R) 18, R6, R9, R5 and R15 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:- Review of both Electronic Medical Record (EMR) and paper records revealed the following:R18's July 2025 Medication Administration record (MAR) documented an order for escitalopram oxalate (antidepressant medication used to treat mood disorders) five milligrams (mg) daily, dated 07/29/25 (discontinued on 09/08/25). R18's clinical record lacked evidence of informed consent related to the medication.R6's September 2025 MAR documented orders for divalproex sodium (anticonvulsant used for psychotropic properties to address mood and behavior) 125 mg at bedtime for major depressive disorder (major mood disorder that causes persistent feelings of sadness) dated 02/20/25 and Seroquel (antipsychotic medication) 300 mg at bedtime for psychotic disorder (major mental disorder characterized by a gross impairment in reality perception) dated 09/25/24. R6's clinical record lacked evidence of informed consent related to the medications.R9's September 2025 MAR documented orders for alprazolam (antianxiety medication) 0.25 mg each evening for anxiety, dated 04/24/25, and Zoloft (antidepressant) 25 mg, dated 07/23/25. R9's clinical record lacked evidence of informed consent related to the medications.R5's EMR documented an order for risperidone 0.5 mg twice daily for dementia (a progressive mental disorder characterized by failing memory and confusion) dated 03/05/24. R5's clinical record lacked evidence of informed consent related to the medication.R15's EMR documented orders for Seroquel 100 mg at bedtime for borderline personality disorder (a disorder characterized by disturbed and unstable interpersonal relationships and self-image along with impulsive, reckless, and often self-destructive behavior) dated 12/04/23; divalproex sodium 125 mg at bedtime for borderline personality disorder dated 12/04/23; olanzapine (antipsychotic medication) 20 mg at bedtime for borderline personality disorder dated 12/04/23; escitalopram 20 mg for depression dated 12/04/23 and clonazepam (benzodiazepine medication) 0.5 mg twice a day for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) dated 12/04/23. R15's clinical record lacked evidence of informed consent related to the medications.During an interview on 09/22/25 at 03:01 PM, Administrative Nurse D reported that the facility did not complete consents for psychotropic medications unless the resident started a new medication.The facility's policy Psychotropic Medication Use dated 01/09/25, documented that every psychoactive medication will initiate a signed Informed Consent to ensure the physician has reviewed with the resident and/or resident representative the potential adverse effects of the order of any psychoactive medication.

The facility reported a census of 23 residents. Based on observation, and interview, the facility failed to ensure that meals were served at safe and appetizing temperature. This was evident of a one of one meal observation.Findings included:- During an observation on 09/22/25 at 10:42 AM, Dietary Staff DD prepared three servings of pureed sausage, onions, and peppers that had a cooked temperature of 165 degrees Fahrenheit (F). Dietary Staff DD pureed the food, and the temperature after preparation was 127 degrees F. Dietary Staff DD placed the pureed sausage in three separate, divided dishes and covered the dishes with foil. Dietary Staff DD prepared the pureed potatoes that had a cooked temperature of 186 degrees F. Dietary Staff checked the potatoes' temperature after they were pureed at 135 degrees F. Dietary Staff DD uncovered the three divided dishes and placed the pureed potatoes into the dish, and covered the dishes with foil that remained on the counter in the kitchen until 11:00 AM, when Dietary Staff DD placed the three divided dishes of prepared pureed food in the steam table.During an observation on 09/22/25 at 11:30 AM, Dietary Staff DD re-temped the pureed food that was on the steam table. The pureed potatoes' temperature was 115 degrees F., and the pureed sausage temperature was 120 degrees F. Dietary Staff DD served the pureed foods to the residents at those recorded temperatures.During an interview on 09/22/25 at 01:05 PM, Dietary Staff BB stated she expected staff to serve all food items at the required holding temperatures of 135 degrees F. for hot food.During an interview on 09/23/25 at 11:40 AM, Administrative Staff A stated she expected the dietary staff to serve food at the appropriate temperatures.The facility's policy Food Preparation and Handling dated 01/13/2016, states that all food items and products served to elders would be prepared from the central kitchen using methods and techniques designed to preserve maximum nutritive value and be free of injurious organisms and substances. The facility's policy lacked the temperature requirements for cooked and holding food.

The facility reported a census of 23 residents; the sample included 14 with two residents reviewed for positioning and mobility. Based on observation, interview, and record review, the facility failed to provide a footboard or footrests for Resident (R) 3 and R9. Findings included:- R3's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and pain.R3's 04/14/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of zero, which indicated severely impaired cognition. R3's MDS recorded impairment to one side of R3's lower extremity. The MDS recorded R3 required total dependence of all activities of daily living. The 04/17/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R3 did not answer any questions. R3 was sometimes able to communicate nonverbally.R3's Care Plan instructed staff to provide a high-back wheelchair with anti-tip bars and to propel the wheelchair for the resident, dated 04/09/24. The plan instructed staff to provide total staff assistance for locomotion via a manual high back wheelchair, dated 05/29/25.R3's Progress Note on 07/09/25 at 09:09 PM documented the resident tolerated a restorative program for positioning in a wheelchair.During an observation on 09/22/25 at 08:56 AM, R3 sat in a wheelchair at the nurses' station with no footrests. R3's feet were dangling approximately two inches off the ground.During an observation on 09/22/25 at 09:00 AM, Certified Nurse Aide (CNA) N propelled R3 down the hallway in her wheelchair to the shower room. R3's feet dangled off the ground.During an observation on 09/22/25 at 12:04 PM, R3 was in the dining room in her wheelchair. The tips of R3's toes touched the floor. R3 was unable to place her feet on the ground.During an observation on 09/23/25 at 08:30 AM, R3 sat in a wheelchair with no footrests. R3's feet were dangling approximately two inches off the ground.During an interview on 09/23/25 at 10:15 AM, CNA P reported that R3 did not have foot pedals for her wheelchair and that R3's toes would only touch the ground sometimes. CNA P reported that R3 used to have foot pedals, but they caused her pain when the staff would have to bend her knee to place her feet on the foot pedals. CNA P reported that R3 could not self-propel her wheelchair or adjust herself in the wheelchair.During an interview on 09/23/25 at 11:27 AM, Certified Restorative Aide (CRA) M reported that she believed the facility staff had tried foot pedals on R3's wheelchair in the past, and it would not work as she would cross her feet, and they would fall behind the wheelchair legs. CRA M reported that R3 had a footboard at one time to keep her feet positioned and was unsure why R3 no longer had that footboard. CRA M reported that when she worked with the residents on the restorative program, she would look at how the residents' body was positioned but not their feet.During an interview on 09/23/2025 at 11:46 AM, Licensed Nurse (LN) G reported that she really did not know of any residents who had no foot pedals that could not self-propel.During an interview on 09/23/25 at 12:25 PM, Administrative Nurse D stated she expected that residents who were not able to self-propel independently in their wheelchairs would have footrests. - R9's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain).R9's 01/20/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of two, which indicated severely impaired cognition. R9's MDS recorded R9 required total dependence for most activities of daily living, which included total dependence on staff with transfers and wheelchair mobility.The 01/24/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R9 had dementia, and R9 was alert and generally able to make needs known to staff.R9's Care Plan plan instructed staff to provide total staff assistance for locomotion via a wheelchair, dated 01/22/25.R9's Progress Note on 04/18/25 at 10:25 AM documented the resident required one staff member's assistance for wheelchair mobility.During an observation on 09/21/25 at 12:30 PM, R9 sat in a wheelchair in her room, with no footrests. R9's feet were dangling approximately two inches off the ground.During an observation on 09/22/25 at 12:04 PM, R9 was in the dining room in her wheelchair. The tips of R9's toes touched the floor. R9 was unable to place her feet on the ground.During an interview on 09/23/25 at 10:15 AM, Certified Nurse Aide (CNA) P reported that R9 never had foot pedals for her wheelchair, and CNA P reported that R9's feet dangle all the time when R9 is in her wheelchair. CNA P reported that R9 could not self-propel her wheelchair or adjust herself in the wheelchair.During an interview on 09/23/25 at 11:27 AM, Certified Restorative Aide (CRA) M reported that R9 never had foot pedals on her wheelchair, and she was unaware why. CRA M reported that when she worked with the residents on the restorative program, she would look at how the residents' body was positioned but not their feet.During an interview on 09/23/2025 at 11:46 AM, Licensed Nurse (LN) G reported that she really did not know of any residents who had no foot pedals that could not self-propel.During an interview on 09/23/25 at 12:25 PM, Administrative Nurse D stated she expected that residents who were not able to self-propel independently in their wheelchairs would have footrests.The facility's policy Restorative Plan f-or Wheelchair Mobility dated 01/09/25, documented each elder using a wheelchair as a mobility device must be provided with individualized measurements for appropriate wheelchair size position elder in 90-90-90 position, foot support, do not allow feet to dangle Provide appropriate foot support.

The facility reported a census of 23 residents; 14 residents were sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure two resident's advanced directives were accurately reflected when Resident (R) 2 had a Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) form completed but had an order for a full code. Additionally, R3's DNR lacked a resident/responsible party and witness signature. R14 declined a DNR in 2016, and the facility had a DNR order.Findings included:- Review of R2's Physician Order in the Electronic Medical Record (EMR) recorded an order for Full Code dated [DATE]. R2's Care Plan staff instructed to provide CPR dated [DATE]. Review of R2's EMR revealed a DNR signed by R2 on [DATE] and by a physician on [DATE].R3's Physician Order in the EMR recorded an order for DNR dated [DATE]. R3's DNR documented a physician's signature only, dated [DATE], but lacked a witness, representative, and/or resident signature.R14's Physician Order in the EMR noted an order for DNR dated [DATE]. R14's Care Plan staff instructed that R14 had a signed DNR in her EMR. Review of R14's EMR revealed R14 signed a document stating they do not agree to a DNR on [DATE]. Additionally, the provider did not check off DNR and signed the acknowledgement on [DATE].During an interview on [DATE] at 12:07 PM, Administrative Nurse D stated the Social Service Designee (SSD) X would complete the advanced directive paperwork, and the floor nurse would document the order in EMR. Administrative Nurse D stated she expected all residents would have the correct paperwork completed, care planned, and ordered.The facility did not provide a policy on advance directives.

The facility had a census of 23 residents. The sample included 14 residents with one resident reviewed for nutrition. Based on observation, record review, and interview, the facility failed to notify the representative of changes in weight for Resident (R) 1. Findings included:- R1's Electronic Medical Record (EMR) listed diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), dementia (a progressive mental disorder characterized by failing memory and confusion), and heart disease.R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted R1 weighed 139 pounds, had a mechanically altered diet, and had no chewing or swallowing issues. The MDS noted the resident had a significant weight loss.R1's Care Plan documented R1 had potential nutritional problems related to a history of weight loss, severe cognitive impairment, and dependence on staff for eating and drinking. He consumed a pureed diet with honey-thickened liquids, revised on 01/20/25. It instructed staff to provide R1 with a pureed diet with nectar-thick liquids and to monitor his intake; revised on 05/29/24. Staff were to give R1 a daily Mighty Shake for nutrition supplementation; initiated on 01/09/24 R1's EMR Physician Orders documented R1 was provided a pureed texture diet with honey/moderately thick drinks, related to dementia. R1 was to have a Mighty Shake two times a day. R1's Mini Nutritional Evaluation dated 09/18/25 documented R1 was malnourished. R1 had a weight of 140.2 and had a severe decrease in food intake. R1's clinical record documented a weight of 160 pounds on 03/21/25 and a weight of 140.6 pounds on 09/19/25.R1's Nutrition/Dietary Note documented the Registered Dietitian completed the Quarterly Nutritional Assessment. The score of one indicated malnutrition related to hospitalization for pneumonia (infection of the lungs) and a severe decrease in food intake with severe cognitive impairment. The note documented that staff reported the resident only eats one time a day, and staff offered a Mighty Shakes two times a day. R1's clinical record lacked documentation that R1's representative was notified of the weight loss. On 09/21/25 at 11:48 AM, R1 sat at the table with his eyes closed. Licensed Nurse (LN) H assisted him with lunch. LN H stated that when R1 closes his eyes, he is done with the meal. On 09/23/25 at 01:23 PM, Certified Nurse Aide (CNA) N stated that the CNA staff weighed the residents and recorded the weight on the clipboard. CNA N said the nurse looks at the weights and determines who has lost weight.On 09/23/25 at 01:30 PM, Administrative Nurse D stated R1 had been declining and losing weight. Administrative Nurse D stated the nurse should have notified R1's family of the change. The facility's policy Nurse Notification of Physician, Resident and Representative of Changes dated 01/09/25 documented the Nurse will notify the resident and the resident's representative of all non-immediate changes on the shift that the change occurred unless the physician directed otherwise.

The facility reported a census of 23 residents. The sample included 14 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 1 a written notification of transfer to the resident and/or his representative as soon as practicable. Findings included:- R1's Electronic Medical Record (EMR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's needs) schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and dementia (a progressive mental disorder characterized by failing memory and confusion).R1's EMR documented a Health Status Note dated 08/24/25 at 07:00 AM that documented R1 was barely responsive with rapid breaths. The provider was notified and ordered R1 to be sent to the hospital for evaluation.R1's EMR documented a Health Status Note dated 08/26/25 at 01:40 PM that the bed hold was sent to the guardian.R1's EMR lacked documentation of a written notification to the resident and/or his representative, which explained the reason for the transfer to the hospital.On 09/23/25 at 11:17 AM, Licensed Nurse (LN) G stated she was not aware of who provided the bed hold information and the letter in writing to the DPOA/Guardian.On 09/23/25 at 11:21 AM, Administrative Nurse D stated she provided the Ombudsman notification monthly for all the discharges and transfers out of the facility. Social Service Staff X or Administrative Staff A provided the bed hold to the family. Administrative Nurse D was unaware of the requirement to notify the resident and/or his representative in writing of the reason for transfer to the hospital and confirmed that this was not done for R1's transfer on 07/14/25.On 09/23/25 at 11:23 AM, Administrative Staff A stated that Social Service Staff X or she gave the Bed Hold to the resident's representatives. Administrative Staff A was not aware of the requirement to notify the resident and/or his representative in writing of the reason for transfer to the hospital and confirmed that this was not done for R1's transfer on 08/24/25.The facility did not provide a policy.

The facility reported a census of 23 residents; the sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to implement interventions to prevent further falls after a fall for Resident (R) 7 and 14.Findings included:- R7's Electronic Medical Records (EMR) documented diagnoses that included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hallucination (sensing things while awake that appear to be real, but the mind created), history of falls, and cognitive decline. R7's 07/14/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The MDS documented R7 had two or more falls within the last quarter.R7's Care Plan documented R7 was at high risk for falls related to confusion, incontinence, being unaware of safety needs, vision and hearing problems, and wandering; initiated on 02/02/24. Staff were to place R7's wheelchair by her bed, and anti-roll back brakes were attached on 02/07/24. A bed alarm was placed on 09/01/24. Staff were to frequently check on R7 initiated on 12/10/24, and lower the bed to the lowest position initiated on 06/04/25. R7's Incident Note dated 08/20/25 at 02:30 PM documented the floor alarm sounded, and staff found R7 on the floor beside her bed. R7 had a dime-sized skin tear on her back. R7's Care Plan documented that the intervention was to remind R7 to use the call light, initiated on 08/20/25.On 09/22/25 at 8:52 AM, R7 lay in bed in her room. R7's wheelchair was beside her bed, and the motion sensor was facing her. On 09/23/25 at 4:23 PM, Certified Nurse Aide (CNA) N stated that when a resident fell, she got the nurse, and the nurse assessed the resident, checked vital signs, and started neurological checks. CNA N said the nurse decided on interventions and stated CNA staff were not involved in the process, but sometimes the restorative aide helped. CNA N said the nurse or Administrative Nurse D tells them what the interventions are, and they put it on the report sheet. On 09/23/25 at 4:27 PM, Licensed Nurse (LN) G stated that when a resident fell, she assessed them and started interventions. LN G said she was unsure who came up with the interventions, but assumed that Administrative Nurse D decided on the interventions and told staff. On 09/23/25 at 4:34 PM, Administrative Nurse D stated that the charge nurse was supposed to come up with the intervention at the time of the fall, and then the MDS nurse followed up on it and made sure it was in the computer, and everyone knew about it. Administrative Nurse D said she expected staff to come up with an appropriate intervention for every fall. Administrative Nurse D verified that reminding R7 to use her call light was not an appropriate intervention, as she could not retain the information. - R14's Electronic Medical Records (EMR) documented diagnoses that included bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk).R14's 08/11/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of ten, indicating moderate cognitive impairment. The MDS documented R14 had no falls within the last quarter.R14's Care Plan last updated 04/03/25 documented R14 was at risk for falls. R14 was independent with a walker; dated 03/20/24. R14 was to wear oxygen, dated 01/15/25.R14's Incident Note dated 02/11/25 at 07:15 AM documented R14 was standing as she put in her dentures, and she fell. At the time of the fall, her oxygen saturation (percentage of oxygen in the blood) was 89 percent, and R14 was not wearing oxygen. R14's Care Plan documented no updates were made to the care plan for the 02/11/25 fall. On 09/21/25 at 11:21 AM, R14 was in the bathroom, and her walker was outside the bathroom door. R14 was short of breath and did not have her oxygen on. A staff member entered and assisted her. On 09/23/25 at 4:23 PM, Certified Nurse Aide (CNA) N stated that when a resident fell, she got the nurse, and the nurse assessed the resident, checked vital signs, and started neurological checks. CNA N said the nurse decided on interventions and stated CNA staff were not involved in the process, but sometimes the restorative aide helped. CNA N said the nurse or Administrative Nurse D tells them what the interventions are, and they put them on the report sheet. On 09/23/25 at 4:27 PM, Licensed Nurse (LN) G stated that when a resident fell, she assessed them and started interventions. LN G said she was unsure who came up with the interventions, but assumed that Administrative Nurse D decided on the interventions and told staff. On 09/23/25 at 4:34 PM, Administrative Nurse D stated that the charge nurse was supposed to come up with the intervention at the time of the fall, and then the MDS nurse followed up on it and made sure it was in the computer, and everyone knew about it. Administrative Nurse D said she expected staff to come up with an appropriate intervention for every fall.The facility's policy Fall Follow-up Protocol dated 01/09/25 documents the fall is documented on the care plan with interventions to prevent further falls based on the determined causal factors at the time of the initial fall follow-up. To determine causal factors, a Root Cause Analysis will be conducted.

The facility reported a census of 23 residents. The sample included 14 residents. Based on observation, interview and record review, the facility failed to use adequate hand hygiene when caring for residents. Additionally, staff failed to disinfect the mechanical lift after use. Findings included:- Observation on 09/22/25 at 12:46 PM, Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) P brought the mechanical lift to the room and transferred Resident(R) 9 to the bed. R9 had been incontinent of a large soft stool. CMA R washed R9's buttocks, removed her gloves, and washed her hands, then applied new gloves and gathered more wipes out of the packet. They rolled R9 onto her back, and CNA P performed front peri care; she took her gloves off and applied new gloves without hand hygiene, then applied barrier cream. CNA P then removed her gloves and applied clean gloves again without hand hygiene. CNA P then took a new outfit out of R9's closet, and they dressed R9. Staff removed the lift from R9's room and placed it into R3's room with no sanitation completed on the lift by CMA R or CNA P. On 09/23/25 at 10:15 AM, CNA P reported that the facility does not have sanitation wipes to wipe off the mechanical lift between residents. She also reported that she would normally wash her hands after she removed her gloves before applying new gloves, but she was nervous. On 09/23/25 at 2:16 PM, Administrative Nurse D stated that she expected staff to use appropriate hand hygiene, which included hand hygiene after removing soiled gloves prior to putting on clean gloves. Administrative Nurse D stated that the reusable shared equipment, like the mechanical lifts, should be sanitized after each use.The facility's policy Hand Hygiene dated 01/09/25 documented that staff were to change gloves during resident care when moving from a contaminated site to a clean site and decontaminate their hands after removing gloves by using appropriate hand hygiene.The facility's policy Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment dated 01/09/25 documented that all items routinely shared will be cleaned between uses and will also follow a regular schedule for cleaning and disinfection.

The facility reported a census of 23 residents; the sample included 14. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through monitoring for the appropriate use of antibiotics prescribed for Resident (R) 2 to prevent antibiotic resistance and spread of multidrug resistant organisms within the facility. Findings included:- R2's Electronic Medical Record (EMR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R2's 09/08/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The MDS recorded R2 required moderate assistance from staff to complete toileting hygiene. The MDS recorded R2 was occasionally incontinent of urine, and R2 had a urinary tract infection (UTI-an infection in any part of the urinary system) in the past 30 days.R2's 09/16/25 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 required moderate assistance with toileting hygiene, and R2 was occasionally incontinent of bladder. R2 had a UTI and finished oral antibiotics on 08/16/25. R2 also had a confirmed UTI on 05/15/25. The CAA noted that a care plan would be developed to minimize risks and avoid complications related to urinary incontinence, including prevention of UTIs.R2's Care Plan documented she had a history of UTIs and was at risk for UTIs dated 08/19/25. The plan instructed staff to encourage adequate fluid intake dated 08/12/25. The plan directed staff to monitor, document, and report to the physician for any signs or symptoms of UTI: frequency, urgency, malaise, foul-smelling urine, painful urination, fever, nausea, vomiting, loss of appetite, and or behavioral changes.R2's Progress Note on 02/05/25 at 05:02 PM documented R2 complained of painful urination and upset stomach and reported she felt like she had a UTI. Staff obtained a urine sample and sent it to the lab. The physician ordered to administer Keflex (antibiotic medication) 500 milligrams (mg) twice a day for seven days.R2's Laboratory Report dated 02/07/25 at 08:00 AM, documented a culture and sensitivity (C&S) report of the susceptible (the bacteria causing an infection are likely to be effectively treated with the specific antibiotic being tested) antibiotics to administer for the UTI. Keflex was not on the list of susceptible antibiotics for the infection. The lab report documented it was sent to the provider via modem and faxed to the provider on 02/09/25.R2's Medication Administration Record (MAR) documented R2 was administered Keflex 500 mg, by mouth, two times a day from 02/05/25 through 02/12/25.R2's Progress Note on 08/11/25 at 07:14 PM, documented R2 provided a urine specimen due to complaints of UTI, low back pain, and burning with urination; the urine tested positive for leucocytes (white blood cells), blood, protein, and bilirubin (breakdown of red blood cells). Staff called the provider. R2's Progress Note on 08/11/25 at 07:20 PM, documented staff received new orders from the physician to send urine to the lab for C&S and administer Keflex 500 mg by mouth three times a day for five days.R2's Laboratory Report dated 08/14/25 at 08:00 AM, documented a C&S report of the susceptible antibiotics to administer for the UTI. Keflex was not on the list of susceptible antibiotics for the infection. The provider documented on the lab report on 08/14/25 that there were no orders, and it was noted by Licensed Nurse (LN) H 08/14/25.R2's MAR documented R2 was administered Keflex 500 mg, by mouth, 15 times from 08/11/25 through 08/16/25.During an interview/observation on 09/21/25 at 12:50 PM, R2 was seated in her recliner in her room as she watched television. R2 reported she would get UTIs often and did not know why. She reported she did require some staff assistance in the bathroom, but declined to be observed during the survey.During an interview on 09/23/25 at 10:45 AM, LN G reported that if the physician ordered an antibiotic before the C&S report was received, the nurse would update the physician on the C&S report. LN G said she expected the physician to order one of the susceptible antibiotics on the report.During an interview on 09/23/25 at 02:16 PM, Administrative Nurse D, who was also the facility's Infection Preventionist, stated she expected the physician to follow the C&S report and administer the correct antibiotic. Administrative Nurse D reported she had no documentation from the physician as to why he did not change the Keflex orders in February and August 2025.The facility's policy Antibiotic Stewardship dated 08/2024, documented that it is the facility's policy to implement antibiotic stewardship to promote appropriate use of antibiotics while optimizing the treatment of infections. An antibiotic review process, also known as antibiotic time-out (ATO), is conducted for all antibiotics prescribed in the facility. ATOs prompt clinicians to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available.

The facility reported a census of 23 residents. Based on observation, interview, and record review, the facility failed to ensure the daily staff posting included the actual hours worked by the nursing staff as required. Findings included:- During an observation on 09/21/25 at 11:00 AM, the daily staff posting document lacked documentation of actual hours worked. Furthermore, it was difficult to read the titles of the staff Certified Nurse Aide (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN) above the columns for the shifts.Review of the daily staff posting documents from 09/21/25 to 09/23/25 revealed a lack of documentation of actual hours worked.During an interview on 09/22/25 at 03:50 PM, Administrative Nurse D stated she had never documented the actual hours worked for the posted staff sheet.The facility did not provide a policy for posted nursing staff.

The facility reported a census of 23 residents. Based on interview and record review, the facility failed to electronically submit accurate staffing information through Payroll-Based Journaling (PBJ). Findings included:- The PBJ Staffing Data Report for Fiscal Year (FY) 2024 Quarter 3 (April 1 - June 30) documented the facility had excessively low staffing. FY 2024 Quarter 4 (July 1 - September 30) documented facility failed to have licensed nursing (LN) coverage 24 hours on the following days: 07/05/24, 07/06/24, 07/07/24. 07/10/24/ 07/11/24, 07/19/24, 07/20/24, 08/04/24, 08/08/24, 09/01/24, 09/05/24, 09/27/24, 09/28/24, and 09/29/24. FY 2025 Quarter 2 (January 1 - March 31) documented facility failed to have licensed nursing coverage 24 hours on the following days: 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/18/25, 02/22/25, 03/03/25, 03/17/25, and 03/22/25.Review of the Daily Nurse Staffing Form and Payroll Data Sheets indicated the days listed above were covered with the appropriate staff, with LN coverage 24 hours each day. Additionally, no concerns with low weekend staffing were noted.During an interview on 09/22/25 at 03:43 pm, Administrative Staff A stated the PBJ report was submitted from an outside firm. Additionally, Administrative Staff A stated she expected he report to be completed accurately and realized some concerns with FY Quarter 1 and has started to see an improvement.The facility's policy Payroll Based Journal dated 08/18/25, documents this policy, which outlines the guidelines and procedures for maintaining accurate and timely records of staff employment and payroll information in this facility, in accordance with the Payroll-Based Journal (PBJ) reporting requirements. This policy aims to ensure compliance with Federal regulations and ensure the facility promotes transparency and accountability in workforce management.

The facility reported a census of 23 residents. The facility identified one central kitchen with one dining area. Based on observation, interview, and record review, the facility failed to provide proper sanitary food storage to prevent the spread of food born illness to the residents of the facility. Findings included: - Initial tour of the kitchen on 12/12/23 at 08:10 AM with Dietary Staff G revealed the following concerns: In the upright freezer: 1. One bag of tator tots unsealed and opened to air. 2. One package of hash browns opened and stored in a plastic bag, which lacked an opened date. 3. Two packages of opened french fries, opened to air, with visible freezer burn to both packages of fries. 4. One package of breaded chicken patties stored in a plastic bag with no opened date. 5. One package of breaded shrimp was open and not dated. 6. One package of chicken strips opened to air with visible freezer burn on the meat. 7. One package of chicken cordon bleu opened and undated. 8. Two packages of hot dogs stored in a plastic bag with no opened date. On 12/12/23 at 08:30 AM, dietary staff G reported staff should write an opened date on all food items. On 12/13/23 at 09:50 AM, dietary staff E reported food bags should be closed, labeled and dated. The facility's policy for Safe Food Preparation and Handling, dated 01/13/2016 revealed the facility would maintain a safe, sanitary environment for food storage, food would be covered when stored, and food would not be served from broken packages, swollen or dented cans. The facility failed to provide proper storage of food to prevent the spread of food borne illness to the residents of the facility.

The facility reported a census of 23 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), related to licensed nursing staff coverage 24 hours a day. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for the fiscal year (FY)- Quarter 4, 2022 (July 1- September 30) revealed the lack of Licensed Nursing (LN) coverage 24 hours/ seven days a week 07/10/22, Sunday (SU), 08/02/22, Tuesday (TU), 08/07/22 (SU), 08/11/22, Thursday (TH), 09/03/22 (SA), 09/04/22 (SU), 09/16/22, Friday (FR), 09/24/22, (SA) and 09/25/22, (SU). Review of the PBJ's FY Quarter 1, 2023 (October 1- December 31) revealed the lack of LN coverage 24 hour/ seven days a week for 10/02/22 (SU), 10/08/22 (SA), 10/12/22, Wednesday (WE), 10/16/22 (SU), 10/22/22 (SA), 10/30/22 (SU), 11/06/22 (SU), 11/13/22 (SU), 11/19/22 (SA), 11/24/22 (TH), 11/27/22 (SU), 11/30/22 (WE),12/04/22 (SU), 12/11/22 (SU), 12/25/22, (SU), 12/28/22 (WE), 12/29/22 (TH), and 12/31/22 (SA). Review of the PBJ's FY Quarter 2, 2023 (January 01 - March 31) revealed the lack of LN coverage 24 hour/seven days a week for 01/01/23 (SU), 01/08/23 (SU), 01/15/23 (SU), 01/22/23 (SU) 02/05/23 (SU), 02/12/23 (SU), 02/26/23 (SU), 02/27/23 (MO), 03/11/23 (SA), 03/26/23 (SU),03/27/23 (MO), and 03/30/23 (TH). Review of the PBJ's FY Quarter 3, 2023 (April 1- June 30) revealed the lack of LN coverage 24 hour/seven days a week for 05/16/23 (TU), 05/24/23 (WE), 05/25/23 (TH), 06/11/23 (SU), 06/25/23 (SU), 06/26/23 (MO), and 06/27/23 (TU). Review of the nursing schedule and time sheets for licensed nursing staff on the above dates revealed adequate hours to account for 24- hour nursing coverage, however the facility reported inaccurate staffing data for LN coverage 24 hour/seven days a week for the above quarters Interview on 12/14/23 at 2:00 PM with Administrative Nurse B, reported she always had nursing coverage. It was difficult to find Registered Nurses but with staff and agency Nurses, the facility had licensed staff on duty. Review of the facility's policy dated 02/22/22 for Mandatory Submission of Uniform Format Staffing Information (PBJ) revealed the facility would electronically submit to the Centers of Medicare and Medicaid Services complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to electronically submit to CMS complete and accurate direct care staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS related to licensed nursing coverage 24 hour/ seven days as week, as required.

The facility reported a census of 23 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms, failure to place distilled water jugs on a surface other than the floor and failure of staff to appropriately clean nebulizers (a device which changes liquid medication into a mist easily inhaled into the lungs) after use. This deficient practice has the potential to lead to cross contamination between residents, and to place the residents receiving oxygen and nebulized medications at increased for respiratory infections. Findings include: - On [DATE] at 07:76 AM, Laundry Staff L observed carrying clean resident bed linens against her body from the cart in the hallway to a linen closet and then into a resident room . On [DATE] at 07:50 AM, Laundry Staff L confirmed she carried clean resident bed linens against her body and stated that staff should carry clean resident bed linens away from her body. On [DATE] at 12:32 AM, Administrative Nurse B confirmed staff should not carry linens against their body as this was an infection control concern with the potential for cross contamination. The facility failed to provide a policy related to delivering of resident bed linens as requested on [DATE]. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. - The Electronic Health Records (EHR) documented Resident (R)13 had the following diagnoses that included history of pulmonary emboli (blood clots in the lungs) and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was independent with all cares and received oxygen. The [DATE] Quarterly MDS, documented a BIMS score of 15, which indicated intact cognition. The resident was independent with all cares and received oxygen. The Care Plan documented the following instructions for staff: 1. On [DATE], that R13 was on oxygen therapy and included administration instructions to keep away from sparks and other sources of ignition, but lacked information related to changing of supplies, filling of humidifier or documenting dates on supplies. 2. On [DATE], lacked information related to administration of inhaled (nebulized) medications The EHR Physician Orders documented the following: 1. Oxygen, two to three liters per minute (,d+[DATE] LPM) per nasal cannula every shift related to COPD, dated [DATE]. 2. Ipratropium-Albuterol inhalation solution 0XXX,d+[DATE].5 (3) milligram (mg) per 3 milliters (mL), inhale (nebulize) one vial four times per day related to COPD, dated [DATE]. 3. Nebulizer: tubing and mask change, every night shift on the 15th of every month, dated [DATE]. 4. Oxygen: tubing and humidifier change, every night shift on the 15th of every month, dated [DATE]. The [DATE] to [DATE] Progress Notes reviewed and lacked information related to oxygen delivery or nebulized medication. On [DATE] at 08:30 AM, observation of R13's room included an oxygen concentrator with humidifier, dated [DATE], attached in-line with cannula, nebulizer device stored intact on top of the bedside table, undated, with unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and concentrator, stored on the floor, was an opened and undated jug of distilled water. On [DATE] at 09:40 AM, R13 observed ambulating from the hallway to the resident's room while wearing oxygen with a portable oxygen concentrator. R13 ambulated into her room and switched herself from the portable oxygen concentrator to an oxygen concentrator in her room. The nebulizer device stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. Between the resident's recliner and the concentrator, stored on the floor, the opened and undated jug of distilled water remained. On [DATE] at 08:14 AM, observation of R13's room included an oxygen concentrator with a humidifier, dated [DATE], attached in-line with cannula, the nebulizer device stored intact on top of bedside table, undated with an unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and concentrator, stored directly on the floor, was an opened and undated jug of distilled water. On [DATE] at 01:18 PM, observation of R13's room included an oxygen concentrator with humidifier, dated [DATE], attached in-line with cannula, the nebulizer device stored intact on top of bedside table, undated, with an unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and the concentrator, stored directly on the floor, was an opened and undated jug of distilled water. On [DATE] at 08:30 AM, observation of R13's room included an oxygen concentrator with humidifier, dated [DATE], attached in-line with cannula, the nebulizer device stored intact on top of bedside table, undated with unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and the oxygen concentrator, stored directly on the floor, was an opened and undated jug of distilled water. On [DATE] at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month and filling of humidifiers as needed. Further stated that she washes out, dries with a paper towel and places the nebulizer tubing back into a zipper-style plastic bag after each use, but stated does not know what the policy is for nebulizer cleaning after use. On [DATE] at 12:18 PM, Administrative Nurse B stated that night shift nurses were responsible for changing oxygen tubing and humidifiers. Further stated that the date of [DATE] on R13's humidifier meant that it expired on [DATE] and should have been changed on [DATE]. Additionally stated that her expectation was for nurses to clean nebulizers after each use by being rinsed with water, towel dried , reassembled and immediately put back in a zipper-style bag. Further stated that all bottles of distilled water for the humidifier should be stored on a shelf in the room or in the resident's closet. The facility failed to provide a policy related to filling of humidifiers or care of oxygen delivery equipment. The facility's Nebulizer Treatment policy, dated [DATE] documented that nebulizers were to be cleaned after each use by disassembling mouthpiece (or mask) and t-piece from cup and washing mouthpiece (or mask) and t-piece with mild soap and warm water, then rinsing under strong stream of water for 30 seconds, shake off excess water, dry on a clean cloth or paper towel and store nebulizer in zipper-style plastic bag. Lacked instructions related to cleaning of nebulizer chamber. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean nebulizers after each use as evidenced by unknown clear liquid in nebulizer chamber between uses. This deficient practice had the potential to lead to respiratory infections and/or complications for R13. - Review of the Electronic Health Record (EHR) documented Resident (R)24 had the following diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition in which the heart muscle does not pump as well as it should which causes difficulty breathing), heart disease (disease of the vessels of the heart) and persistent asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The [DATE] Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13 which indicated intact cognition. R24 was independent with all cares and received oxygen. The [DATE] Quarterly MDS documented a BIMS of 14 which indicated intact cognition, and R25 received oxygen. The Care Plan documented the following instructions to staff: 1. On [DATE], R24 was on oxygen at two liters per minute (2 LPM) continuously but lacked interventions related to nebulized medications, changing of oxygen tubing or humidifier preference. The EHR Physician orders documented the following: 1. Oxygen at 2 liters per minute continuous, every shift related to COPD, dated [DATE]. 2. Ipratropium-Albuterol inhalation solution 0XXX,d+[DATE].5 (3) milligram (mg) / 3 milliters (mL), inhale (nebulize) one vial orally four times a day related to COPD, dated [DATE]. On [DATE] at 11:24 AM, R24 sat in the recliner in the bedroom. R24 had on oxygen via oxygen concentrator, and the nebulizer mask stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. On [DATE] at 08:24 AM, R24 sat in the recliner in the bedroom. R24 had on oxygen via oxygen concentrator, and the nebulizer mask stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. On [DATE] at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month and filling of humidifiers as needed. Further stated and demonstrated that she washed the nebulizer chamber out, dried with a paper towel and placed the nebulizer back into a zipper-style plastic bag after each use, but stated did not know what the policy was for nebulizer cleaning after use. On [DATE] at 12:18 PM, Administrative Nurse B stated that her expectation was for nurses to clean nebulizers after each use by being rinsed with water, towel dried, reassembled and immediately put back in a zipper-style bag. The facility's Nebulizer Treatment policy, dated [DATE] documented that nebulizers were to be cleaned after each use by disassembling mouthpiece (or mask) and t-piece from cup and washing mouthpiece (or mask) and t-piece with mild soap and warm water, then rinsing under strong stream of water for 30 seconds, shake off excess water, dry on a clean cloth or paper towel and store nebulizer in zipper-style plastic bag. Lacked instructions related to cleaning of nebulizer chamber. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean nebulizers after each use as evidenced by unknown clear liquid in nebulizer chamber between uses. This deficient practice had the potential to lead to respiratory infections and/or complications for R24. - The Electronic Health Records (EHR) documented Resident (R)7 had the following diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and heart failure (a condition in which the heart muscle does not pump as well as it should which causes difficulty breathing). The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. R7 required limited assistance or supervision with all cares and received oxygen. The [DATE] Quarterly MDS documented a BIMS of seven, which indicated severely impaired cognition. R7 was independent with all cares and received oxygen. The undated Care Plan documented that R7 required oxygen therapy and instructed staff to: 1. Change tubing per protocol. 2. Deliver oxygen at two liters per minute (LPM) via nasal cannula. 3. Give nebulizer treatment four times per day as ordered. The EHR Physician Orders documented the following: 1. Oxygen as needed via nasal cannula to maintain oxygen saturation between ,d+[DATE] per cent (%), every shift, related to COPD, dated [DATE]. 2. Oxygen: tubing and humidifier change, every night shift on the 15th of every month, related to COPD, dated [DATE]. 3. Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 (3) milligrams (mg) /3 milliters (mL), inhale (nebulize) one vial orally four times per day related to COPD, dated [DATE]. On [DATE] at 10:25 AM, observation of R7's room included an oxygen concentrator with attached nasal cannula, nebulizer device stored intact inside a plastic bag that hung from a bookshelf with an unknown clear liquid in the nebulizer chamber. On [DATE] at 08:30 AM, observation of R7's room included an oxygen concentrator with attached nasal cannula, nebulizer device stored intact inside a plastic bag that hung from a bookshelf with an unknown clear liquid in the nebulizer chamber. On [DATE] at 01:14 PM, observation of R7's room included an oxygen concentrator with attached nasal cannula, nebulizer device stored intact inside a plastic bag that hung from a bookshelf with an unknown clear liquid in the nebulizer chamber. On [DATE] at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month and filling of humidifiers as needed. Further stated that staff should wash out the nebulizer chamber, dry the chamber and place the nebulizer back into a zipper-style plastic bag after each use, but stated did not know what the policy was for nebulizer cleaning after use. On [DATE] at 12:18 PM, Administrative Nurse B stated that her expectation was for nurses to clean nebulizers after each use by being rinsed with water, towel dried, reassembled and immediately put back in a zipper-style bag. The facility's Nebulizer Treatment policy, dated [DATE] documented that nebulizers were to be cleaned after each use by disassembling mouthpiece (or mask) and t-piece from cup and washing mouthpiece (or mask) and t-piece with mild soap and warm water, then rinsing under strong stream of water for 30 seconds, shake off excess water, dry on a clean cloth or paper towel and store nebulizer in zipper-style plastic bag. Lacked instructions related to cleaning of nebulizer chamber. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean nebulizers after each use as evidenced by unknown clear liquid in nebulizer chamber between uses. This deficient practice had the potential to lead to respiratory infections and/or complications for R7.

The facility census totaled 23 residents. Based on interview and record review, the facility failed to maintain an in-service training program for nurses' aides that was appropriate and effective to ensure the continuing competence of nurse aides. The facility identified three Certified Nurse Assistants (CNA's) had been employed over one year. Three of three CNAs lacked the required 12 hours of in-service training to include dementia and abuse training, to ensure the continuing competence of nurse aides and appropriate care and services to all the residents of the facility. Findings included: - Review of a list of Certified Nursing Assistants (CNA) employment dates revealed only three CNAs had been employed for at least 12 months. Of the three employees, only one completed training in abuse, neglect, and exploitation (ANE). None of the three employees had training dealing with dementia residents. On 12/13/23 the training log for CNA J revealed in the last 12 months the employee had 14.25 hours of training including ANE-The Elder Act. However, CNA J lacked training for working with residents with dementia. On 12/13/23 the training log for CNA K had a total of 4.25 hours of training and had no training for ANE or dementia training. On 12/13/23 the training log for CNA L had a total of 2.0 hours with no dementia or ANE training completed. On 12/14/23 at 12:30 PM, CNA J revealed the facility had a computer training for staff and occasionally would have a meeting. CNA J did not know if administrative staff monitored the training, but most of the time, the on-line training was inconvenient. On 12/14/23 at 01:20 PM, CNA D reported she worked on contract at the facility and did not know if she had to do the CNA on-line training. On 12/14/23 at 02:30 PM, Administrative Nurse B reported the facility had online training, but she did not have anyone to oversee to make sure staff watched what they needed/required. She was surprised when she pulled the sheets for the above employees at how little training had been completed. Review of the facility's policy for Required Training and In-Services of Staff dated 02/15/23, revealed the facility developed, implemented, and maintains an effective training program for all new and existing individuals providing services under a contractual arrangement. All direct care staff are required to attend 12 hours of continuing education and demonstrate competency annually including dementia and abuse training. The facility failed to provide three of three CNAs with the required 12 hours of in-service training to include dementia and abuse training.

The facility reported a census of 23 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 10 related to the use of oxygen (O2) therapy, R 4 related to nebulizer treatments, and for R 16, related to no diabetic interventions on the care plan. Findings included: - R10's signed Physician Orders revealed the following diagnosis of vascular dementia (progressive mental disorder characterized by failing memory, confusion) and heart failure (heart not functioning properly). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The resident had delusions and verbal behaviors on one to three days of the look back period. The quarterly MDS dated [DATE] revealed no significant changes other than the addition of oxygen (O2) use. R10's Care Plan dated 06/10/22 revealed the resident required assistance with all daily cares. The care plan lacked use and care of oxygen therapy. Review of the physician's order dated 12/04/22 revealed Oxygen at two liters per minute per nasal cannula (NC), every shift. Observation on 12/13/23 at 08:54 AM revealed R10 reclined in her recliner chair. The resident had O2 applied. On 12/13/23 at 01:52 PM, Certified Nursing Assistant (CNA) D reported the resident was extensive assistance of two staff with most of her care and required O2. On 12/14/23 at 09:45 AM (LN) C reported she did not write the residents' care plans. If there was just a simple update, she would do those but Administrative Nurse B or the MDS person wrote the care plans. LN C verified the resident required O2. On 12/13/23 at 03:00 PM, Administrative nurse B reported the facility was able to find an MDS Coordinator to do the assessments and care plans and would be able to review the care plans. A policy regarding Comprehensive Care Plans requested on 12/14/23 with no policy provided. The facility failed to develop a comprehensive care plan for R10 for the use of continuous O2 therapy. - Resident (R) 16's signed physician orders revealed a diagnosis that included diabetes mellitus type two ( when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received insulin injections daily. The annual MDS dated [DATE] revealed a BIMS of 15. No changes in medications. The care plan dated 03/17/21 lacked guidance related to R16's diabetes. The Physician Orders included the following orders: Accuchecks after meals and at bedtime, every Monday and Thursday, related to diabetes mellitus with hyperglycemia (greater than normal amount of glucose in the blood), ordered 07/26/21. Basaglar Kwik Pen Pen-injector 100 UNIT/Milliliters (ML) (Insulin Glargine), Inject 30 units, subcutaneously (beneath the skin) at bedtime, for type two diabetes mellitus, ordered 11/22/23. Novolog FlexPen injector 100 UNIT/ML (Insulin Aspart), Inject 23 units, subcutaneously, one time a day, in the morning, for diabetes, ordered 11/22/23. Novolog FlexPen injector 100 UNIT/ML (Insulin Aspart), Inject 30 units, subcutaneously, in the evening, for diabetes, ordered 11/22/23. Novolog FlexPen injector 100 UNIT/ML (Insulin Aspart), Inject 14 units, subcutaneously, every 24 hours, for diabetes, ordered 11/23/23. Give daily after noon meal. Observation on 12/13/23 at 12:30 PM, R16 ambulated with LN C out of the dining area for her insulin. On 12/13/23 at 12:30 PM Licensed Nurse (LN) C reported the resident was an insulin dependent diabetic with routine blood sugar monitoring. She was unaware if staff guidance related to R16's diabetes was care planned. On 12/13/23 at 03:00 PM, Administrative Nurse B reported the facility was able to find an MDS Coordinator to do the assessments and care plans and would be able to review the care plans. A policy regarding Comprehensive Care Plans requested on 12/14/23, with no policy provided. The facility failed to develop a comprehensive care plan for the care and treatment of R16's diabetes mellitus. 49590 - Resident (R)4's diagnosis included chronic obstructive pulmonary disease ([COPD] is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing.) The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating interview not able to be conducted due to severely impaired cognition. The physician's order included Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams /3 milliliter per nebulizer (device that changes liquid medication into a mist easily inhaled into the lungs), four times a day, for wheezing, ordered 11/23/23. The care plan, updated 07/10/23 lacked guidance related to R4's nebulizer. The physician's order included to change the nebulizer tubing on the 15th of the month on night shift, dated 11/23/23. On 12/14/23 at 09:45 AM (LN) C reported she did not write the residents' care plans. If there was just a simple update, she would do those but Administrative Nurse B or the MDS person wrote the care plans. LN C verified the resident required O2. On 12/13/23 at 03:00 PM, Administrative nurse B reported the facility was able to find an MDS Coordinator to do the assessments and care plans and would be able to review the care plans. A policy regarding Comprehensive Care Plans requested on 12/14/23 with no policy provided. The facility failed to develop a comprehensive care plan for R4 for the use of a nebulizer treatment.

The facility reported a census of 21 residents with 11 in the sample and 2 residents reviewed for accidents. Based on observation, interview and record review the facility failed to identify causal factors for falls and failed to place appropriate interventions to prevent further falls for cognitively impaired resident #5, who experienced 17 falls in 9 months, one which resulted in a fracture of his/her right wrist on 1/26/19. Findings included: - Review of resident #5's pertinent [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) of 6, indicating severely impaired cognition. The resident had no rejection of care identified on the assessment. The resident transferred and walked in his/her room and corridor with limited assistance of one staff. The resident mobilized on the unit independently, with the use of a wheelchair. The resident required extensive assistance of one staff member for toileting. The resident was not steady and required human assistance to turn. The resident had frequent bladder/bowel incontinence, was not on a urinary training program and had a bowel training program at the time of the assessment. The resident had one non-injury fall and one injury fall since the last MDS. Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had a BIMS of 6, indicating severely impaired cognition. The resident had no rejection of care identified on the assessment. The resident walked in his/her room/corridor with limited assistance of one staff. The resident had no change in mobility on the unit. The resident required extensive assistance with one staff for toileting and transfers. The resident had no changes in bowel and bladder continence. The resident had two or more non-injury falls, two or more injury falls, and one fall with major injury since last MDS. Review of the fall care area assessment (CAA) dated 4/1/19 revealed the resident was at risk for falls due to altered gait pattern with a [DIAGNOSES REDACTED]. heart). The resident fatigued with extended walking and used a wheelchair for general mobility, but he/she walked, and staff provided assistance as needed. The resident had a shuffling gait, took small steps and became tired at times where he/she stopped to rest, sat in a chair or stood holding onto grab bars in the hallways. The resident had several falls during the observation period for the assessment. The resident had a fall in the hallway, two falls in his/her room on the floor next to his/her bed, two falls in the bathroom and one fall in his/her room. The resident had a fall on 1/26/19 with injury (a fractured right wrist) which required surgical repair. The resident had frequent incontinence of urine, and he/she relayed when he/she needed to urinate. The resident could ask staff for direction to the bathroom or find a bathroom on his/her own. The resident had periods of the day when he/she had little to no incontinence noted. Review of care plan dated 4/3/19 revealed the following undated interventions: The resident had a risk for self-care deficit with potential for falls and injury. The resident used a wheelchair for mobility and the wheelchair had anti-roll back brakes for safety. The resident walked with staff assistance for safety. The resident had a slow shuffling gait, balance difficulties and required a restorative nursing program, which the physical therapist reviewed every three months and PRN (as needed). The resident had cardiac problems and would become tired and weak especially if he/she walked too far. Staff would encourage him/her to rest between tasks and activities. The resident would walk down the hall, forget where he/she was going, tire out and hold onto the rail (for support). The resident had poor decision-making skills, forgot he/she was weak and had poor balance. Staff would respond to the resident quickly if observed to be up without assistance. Staff were to ensure the resident had shoes on when out of bed. He/she had glasses that he/she wears at his/her choosing. Staff to provide night light or leave cubby light on at night. Staff to check resident and assist him/her to the restroom for toileting at 1:00AM and 5:00AM, and if resident was restless during the night, staff to assist him/her to the bathroom. The resident had episodes of urinary incontinence and wore pull-ups for dignity and protection. The resident took himself/herself to the bathroom at times. Staff would provide cues or question needs to void and assist the resident as needed. The resident's care plan lacked the number of staff required to assist the resident with toileting, transfers, walking, and further failed to specify times for toileting. Review of the fall risk assessments dated (MONTH) (YEAR)-April 2019 revealed the resident was a high risk for falls. Review of the monthly restorative nursing sheets, from 7/15/18-3/15/19, revealed staff reviewed the resident's scheduled toileting and indicated the need to toilet resident before/after meals with no other times indicated. Review of Certified Nurse's Aide (CNA) bowel/bladder logs dated (MONTH) (YEAR)-March 2019 revealed the resident consistently had urinary incontinence up to 3 times a shift. The bowel and bladder logs further revealed multiple areas of missing documentation. The logs did not indicate the time direct care staff would toilet the resident. Review of chart for bowel/bladder assessments revealed the facility did not complete bowel/bladder assessments for this resident, and no bowel/bladder voiding trial noted on chart. Review of the fall investigation dated 6/13/18 at 4:00 AM revealed the resident had an unwitnessed, non-injury fall in his/her room due to resident wanting water. The investigation revealed a change of medication in the prior week that caused dry mouth. The facility identified the root cause as the resident continued to not know to ask for assistance due to cognitive impairment and the resident wanted to remain independent and ambulatory. The root cause lacked evidence the resident had an unmet need and wanted water. The investigation indicated the resident's care plan was not updated. Review of fall investigation dated 6/13/18 at 9:00 AM revealed an incomplete post fall risk assessment. The incident investigation for the fall revealed the resident had an unwitnessed fall in the lobby due to self-transferring to/from chair or wheelchair. The investigation lacked identification of a root cause, had incomplete staff witness statements, and lacked an updated care planned intervention. Review of fall investigation dated 7/3/18 at 8:01 AM revealed the resident had an unwitnessed, non-injury fall in the restorative restroom due to the resident sat down too hard, breaking the toilet seat. The facility identified the root cause of the fall as the resident sat down too hard and the care plan addendum included staff to remind the resident to sit softly, and not to plop down on the toilet. Review of fall investigation dated 7/8/18 at 9:10 PM revealed the resident had an unwitnessed, non-injury fall in the dining room due to resident eating a snack and attempted to clear the table. The facility identified the root cause of the fall and the care plan addendum included staff were to check on the resident often if he/she had dishes and staff would remind the resident the staff would clear the dishes. Review of fall investigation dated 8/3/18 at 2:22 PM revealed the resident had an unwitnessed, non-injury fall in his/her bathroom after an incontinent episode due to the resident self-toileted and slipped on urine on the floor. The investigation noted the root cause as the resident toileted him/herself, was incontinent of bowel/bladder and his/her pants were around his/her ankles. The investigation noted staff last toileted the resident at lunch, with no time listed. Review of the fall intervention/care plan addendum dated 8/3/18 revealed staff would be re-educated to know the resident needed to be toileted after each meal and at 2:00 PM shift change, immediately after report. Review of fall investigation dated 8/16/18 at 11:45 PM revealed the resident had an unwitnessed, non-injury fall in his/her room due to walking to his/her restroom unattended. The investigation noted the resident as not able to be re-educated on safety issues, staff would monitor the resident hourly, the resident did not call for assistance, he/she had multiple falls and was last toileted at 8:30 PM (3 hours and 15 minutes prior to the fall). The facility added a care planned addendum dated 8/16/19, which instructed staff to follow up when they heard a noise from the resident's room. The intervention lacked any direction related to the resident attempting to go to the bathroom by him/herself. Review of fall investigation dated 11/9/18 at 1:05 PM revealed the resident had an unwitnessed, non-injury fall in his/her bathroom. The investigation identified the root cause of the resident's fall as follows: continue toilet schedules and monitor for noise from the resident's room. The investigation lacked the last time staff toileted the resident, completed staff statements and/or any care plan updates. Review of fall investigation dated 12/13/18 at 7:15 PM revealed resident had a witnessed, non-injury fall in the dining room due to the resident tried to stand up from his/her wheelchair unassisted. Review of fall intervention care plan addendum dated 12/13/18 revealed staff were to check the resident's anti-rollback brakes when resident got into his/her wheelchair. Review of fall investigation dated 1/2/19 at 9:20 PM revealed the resident had an unwitnessed, non-injury fall in the his/her room after he/she reached for an object and rolled out of bed. Review of fall intervention care plan addendum dated 1/2/19 revealed staff were to keep snacks in reach of the resident. Review of fall investigation dated 1/8/19 at 11:20 AM revealed an incomplete post fall risk assessment. The fall investigation revealed the resident had an unwitnessed, non-injury fall in the lobby because he/she reached for an object and fell . The investigation lacked any causal factors related to the fall and/or any care planned interventions. Review of fall investigation dated 1/20/19 at 1:15 AM revealed the resident had an unwitnessed, injury fall in his/her room when he/she attempted to walk to the bathroom without assistance. The investigation lacked any causal factors or the last time (specific) staff toileted the resident. The faxed physician communication revealed the resident had injuries noted to his/her right forearm, right/left knee abrasions, and the resident complained of right wrist/hand pain. Review of the care plan addendum dated 1/20/19 revealed staff would check on noises heard from the resident's room; intervention already noted for prior fall. Review of resident's hourly visual check log dated 1/20/19 revealed no documentation of resident checks between the hours of 12:00 AM and 5:00 AM (5 hours). Review of the nurse's note dated 1/20/19 1:15AM to 1:20 AM revealed staff heard a noise and the registered nurse (RN) went to check on the resident. He/she found the resident on the floor with his/her feet in the hallway, but resting on his/her left back/side laying up against his/her closet. The resident complained of right wrist/hand pain, but moved the hand on his/her own. The nurse noted an abrasion to the resident's right lower forearm and revealed a few visible specks of blood. The nurse had the resident move to sitting position and he/she moved his/her legs and arms on his/her own with no problems noted. The nurse assisted the resident to stand and then had him/her sit in his/her wheelchair. The nurse assessed the resident's skin, where he/she noted a left knee abrasion with some denuded (rubbed off) skin and a previous scab pulled open. The resident's right knee was red in color and had no other areas of injury noted. The nurse assisted the resident to the bathroom and the resident voided. The resident returned to his/her bed via his/her wheelchair. The nurse instructed the resident to use the call light to call for help if he/she needed to get up. Review of nurse's notes dated 1/26/19 at 10:00 AM revealed the resident called for help and direct care staff F found the resident lying on the floor next to his/her bed on his/her right side. Direct care staff F called for other staff assistance, where the writer noted an abrasion to resident's right forehead, right knee scratches, scratches to his/her left ankle and his/her right hand/wrist appeared to be displaced (out of normal position). Four unidentified staff members assisted the resident into his/her wheelchair. Review of fall investigation dated 1/26/19 at 10:00 AM revealed the resident had an unwitnessed fall with major injury (right wrist fracture) in his/her room when he/she walked unassisted. The investigation lacked identification of causal factors for the fall. The investigation stated the staff last toileted the resident at 6:30 AM (3.5 hours before the fall). Review of the care plan addendum dated 1/26/19 revealed staff would leave the resident's door open for better visibility when he/she was in his/her room. Review of x-ray (a photographic or digital image of the internal composition of something, especially a part of the body) dated 1/26/19 at 10:24 AM revealed an acute comminuted impacted [MEDICAL CONDITION] radius with intra-articular extension of the right wrist (Intra-articular fractures are wrist fractures that affect the wrist joint. Comminuted fractures involve multiple breaks of the distal radius. The radius is the larger of the two bones of the forearm. The end toward the wrist is called the distal end. A [MEDICAL CONDITION] radius occurs when the area of the radius near the wrist breaks). There was no dislocation present (No dislocation means the bones may not move out of place initially) and soft tissue (tissue around bones) swelling was present surrounding the wrist. Review of nurse's note dated 1/26/19 at 12:00 PM revealed the resident returned to the facility with a [DIAGNOSES REDACTED]. The follow-up appointment was scheduled with the orthopedic doctor for 1/30/19 at 11:00 AM. The resident was not to eat or be without oral intake (also known as being NPO) the night of 1/29/19 in case he/she required surgical intervention. The staff were to ensure the resident kept his/her right arm elevated and in the sling at all times. The doctor initiated a standing order for Tylenol and ice as needed (PRN) and to notify him/her of any trouble the resident had with the splint. Review of fall investigation dated 1/28/19 at 3:10 PM the resident had an unwitnessed, injury fall in the resident's room due to the resident got out of bed unassisted. The root cause was not noted, and the resident was last toileted after lunch. The resident sustained [REDACTED]. Review of orthopedist documentation of visit dated 1/30/19 revealed the had a cast placed on his/her right wrist with no surgical intervention needed. Review of fall investigation dated 3/2/19 at 1:35 PM revealed the resident had an unwitnessed, non-injury fall in the resident's bathroom. The resident fell attempting to propel in his/her wheelchair to the bathroom for toileting, due to the resident's need for incontinence care. The root cause was not noted and staff last toileted the resident at 1:20 PM. Review of fall intervention care plan addendum dated 3/2/19 revealed staff were to toilet the resident frequently in the afternoon and have the resident in staff view when he/she was in the wheelchair. Review of fall investigation dated 3/11/19 at 1:00 PM revealed the resident had an unwitnessed, non-injury fall in resident's bathroom due to the resident going to bathroom unassisted. The resident was last toileted at 12:25 PM. Review of the fall intervention care plan addendum dated 3/11/19 revealed the resident was toileted often, and staff were to check on the resident every 30 minutes between 1:00pm and 2:00pm, and bowel toileting at regular time. Review of fall investigation dated 3/13/19 at 4:30 PM revealed the resident had an unwitnessed, non-injury fall in the resident's room due to the resident stood up unassisted and then tried to sit, and the wheelchair was not behind him/her. The root cause was not noted, and the resident was last toileted at 4:00 PM. Review of fall intervention care plan addendum dated 3/13/19 revealed the staff to remind the resident not to stand unassisted. Review of a signed physician communication dated 4/14/18 at 11:59 PM revealed the resident fell when he/she got up unassisted and lost his/her balance while attempting to get to the bathroom and fell on to his/her left side sustaining an abrasion measuring 2 centimeters (cm) x 2 cm to his/her left forehead and an abrasion to his/her left knee measuring 1.5 cm x 1 cm. The associated fall investigation was incomplete. Review of fall investigation dated 4/18/19 at 5:40 AM revealed the resident had an unwitnessed, non-injury fall in the resident's room due to the resident ambulated unassisted towards the window and fell . The staff last toileted the resident at 4:02 AM. Review of fall intervention care plan addendum dated 4/18/19 revealed the resident's wheelchair needed to be kept near his/her bed for ease of access. Review of resident hourly check log dated 5/30/18-4/26/19 revealed missing documentation on 5/31/18, 6/2/18, 7/13/18, 8/2/18, 9/13/18, 11/25/18, 1/1/19, 1/20/19. Review of CNA shift assignment sheets documentation dated (MONTH) 2019- (MONTH) 2019 for 1 to 2-hour resident toileting revealed there was no documentation as to when or how often staff toileted the resident or asked if he/she needed the toilet. Observation on 4/30/19 at 11:20 AM revealed direct care staff F and direct care staff J assisted the resident to the bathroom. The resident required assistance with peri-care and brief placement/pull up. Staff F and J used a gait-belt (belt used to help transfer a person from one place to another) to assist the resident to transfer from the toilet to his/her wheelchair. Observation on 5/1/19 at 8:25 AM revealed direct care staff F and direct care staff B asked the resident if he/she needed to go to the bathroom. The resident responded to the direct care staff by saying maybe. Both staff assisted the resident from the bed to his/her wheelchair with the use of a gait-belt, and assisted the resident with toileting. Interview with direct care staff H on 4/29/19 at 12:18 PM revealed the resident fractured his/her right wrist at least 2 months ago. He/she had a shuffled gait and staff were to remind him/her to pick his/her feet up when he/she walked. When the resident broke his/her wrist, he/she walked to the bathroom unassisted and on the way back to bed, he/she fell . The resident was supposed to have one to two staff assistance with toileting. The interventions put in place after the fall included changing what time the staff toileted the resident, due to the fact that he/she would not push his/her call light, forgets and then thinks he/she can do things on his/her own. The care plan book was at the nurse's station and staff look to the care plan for providing care to the resident. Staff H reported the resident fell about 5 to 10 times in the past year. Interview with direct care staff F on 4/30/19 at 11:41 AM indicated the resident was on a toileting schedule and staff kept the resident's wheelchair close to his/her bed. The resident required one to two staff assistance with toileting and transfers. The resident was on scheduled hourly checks and staff checked on the resident every 30 minutes between 1:00 PM and 2:00 PM daily, but there was not a place to log the checks. The resident's scheduled toileting was at 8:30 AM, 12:45 PM, 2:30 PM and 4:00 PM. The hourly check log was used to check on where the resident was and what he/she was doing. Staff used the shift assignment sheets to document when staff asked the resident if he/she needed to be toileted. The resident had an unwitnessed fall a couple of months ago and he/she broke his/her right wrist when he/she attempted to get out of bed on his/her own. Direct care staff F indicated he/she usually checked on the resident about every 30 minutes, but he/she was an hourly check as well. Staff F stated the resident had been on the toileting schedule for over a year and reported that after falls the care plan was updated, but the interventions are not dated. Staff stated the resident forgets to call for help and thinks he/she can do things by himself/herself. Interview with administrative licensed nursing staff G on 4/30/19 at 11:46 AM revealed the resident's risk factors for falls included unsteady gait, balance problems, memory issues, and he/she could be impulsive. Staff G said interventions or assistance needed for the resident to prevent falls would be updated and on the care plan with every new fall and a new care plan had been written, but he/she did not date the new interventions. Staff G stated the care plan revisions should be dated so the facility could track past and future interventions. He/she said the resident fell recently and broken his/her right wrist in (MONTH) of 2019. Staff G was unsure of the circumstances of the fall, but the resident was found on the floor. Staff G said the resident tended to attempt to get up on his/her own, and if he/she was up walking the staff would walk with him/her or get him/her to sit down. The resident was on hourly visual checks as well. The nurse that completed the initial fall paperwork updated the care plan and there was a fall flowsheet to fill out. He/she indicated that some interventions that were in place before the accident were on the care plan, but that he/she did not put dates on revisions. He/she reported the staff identified needed interventions based on the resident's cognitive status, family input, and abilities. The staff try to think ahead and anticipate what the resident would do. The resident could be resistive to care and had to be re-approached if he/she refused care, but would eventually be receptive. Administrative staff monitored direct care staff by watching for care that was on the care plan. At 12:03 PM staff G revealed staff did not complete the bowel/bladder assessments for resident #5, and he/she could not locate a voiding diary that had been completed since the resident came to the facility. Staff G just figured out the resident needed toileted in the morning and afternoon more. He/she stated that he/she guessed it was a good idea to talk with the direct care staff to review the resident's incontinence and find a way to better track the resident's incontinence. Interview with administrative staff D on 4/30/19 at 12:03 PM revealed the resident's risk factors for having a fall included cognitive impairment, [MEDICAL CONDITION], pacemaker, mobility issues, and medications. Staff D did not mention incontinence and stated staff completed monthly bowel/bladder assessments. He/she stated interventions or assistance needed to prevent falls were on the resident's care plan and staff G must keep the care plans up to date from the fall investigations. Staff D stated updates were also on the daily communication log. Staff D said the resident had 17 falls since (MONTH) of (YEAR). He/she had an injury fall on (MONTH) 26th, 2019 where he/she fell and broke his/her right wrist. The interventions in place before the fall included the wheelchair was to be placed near the resident, he/she was on a toileting schedule, and his/her bed was in the low position. The facility tried a fall mat years ago, but it hindered the resident more. Interventions that were implemented after a fall included leaving the resident's door open for visibility. The care plan should be updated for every fall and the interventions should be dated when placed on the care plan. The facility identified the interventions suitable for the resident based on the situation that caused the fall. He/she said fall investigations included the fall investigation form, fall risk assessment form, witness statements, correct root cause analysis, updated care plan, and new interventions. Interview with physician C on 5/2/19 at 8:13 AM revealed if a confused resident was getting up without assistance to go to the restroom and there was documentation on multiple fall investigations in which the resident had been frequently incontinent or seeking the restroom, toileting the resident more often than what was already occurring was a reasonable and logical updated intervention to combat future falls for that resident. Review of the fall follow-up policy with a revision date of 1/2019 revealed each resident residing at the facility would be provided services that ensured the resident's environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents. Every resident would be assessed for the causal factors for falling at the time of admission, upon return from a healthcare facility and after every fall in the facility. Each resident of the facility who experienced a fall would be treated and assessed to adequately treat any current injuries, either physical or psychosocial, and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. Staff were to document circumstances, notification of medical director of findings from the assessment of the clinical record. The fall would be documented on the care plan with interventions to prevent further falls based on the determined causal factors at the time of the initial fall follow-up. To determine causal factors, an investigation would be conducted initially by the nursing staff and complete an incident report. Incident reports and clinical record documentation would include assessment, fall prevention interventions implemented at the time of the incident including care provided during shift of occurrence and the last time the resident was toileted, root cause analysis to determine the cause of the incident, and new fall prevention interventions that were implemented to prevent further falls based on the root cause analysis of incident. The facility failed to identify causal factors for falls and failed to have dated care planned interventions as appropriate to prevent further falls for cognitively impaired resident #5, who experienced 17 falls in 9 months, one which resulted in a fracture of his/her right wrist on 1/26/19.

The facility census totaled 23 residents. The facility identified 3 residents at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without staff knowledge). The sample included 3 residents at risk for elopement. Based on observation, interview and record review the facility failed to ensure supervision to prevent 1 of 3 sampled residents (#1) from leaving the facility without staff knowledge. This failure placed resident #1 in immediate jeopardy on 3-13-18 at 7:39 p.m. when the resident left the facility without staff knowledge, a door alarm sounded and staff looked outside the door but did not determine who left or entered the facility. The resident left via the west door (front door) which opened to a large parking lot surrounded on one side by a deep drainage ditch with steep embankments. Findings included: - Review of resident #1's physician orders [REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 4 (severely impaired cognition). The resident used a hearing aid and had adequate vision with glasses. The MDS indicated the resident wandered 4 to 6 days in the assessment look back period and the wandering placed him/her at risk of danger. The resident required limited assistance of one staff member for transfers and was independently mobile on and off the unit. Review of the cognitive care area assessment (CAA) dated 7/11/17 revealed the resident had memory impairment and he/she occasionally wanted to leave the building to see the horses or take care of them. The resident was very impatient with poor impulse control. He/she did not redirect easily at times. Review of the behavioral CAA dated 7/11/17 revealed the resident believed he/she needed to take care of the horses or go to a horse sale. Review of the fall CAA dated 7/11/17 revealed the resident had shuffling gait with small steps. He/she became tired at times and stopped to rest by sitting in a chair. The resident used a wheelchair for temporary mobility. The resident had 4 falls since the last assessment. Review of resident #1's quarterly minimum data set (MDS dated [DATE] revealed a BIMS score of 5 (severe cognitive impairment). The resident's hearing was intact and he/she had adequate vision with corrective lenses. The MDS indicated the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbally abusive behaviors towards the staff and no history of wandering. He/she required limited assistance of one staff member for transfers, and walking in his/her room and the corridor. The resident was independently mobile on and off the unit with a wheelchair as his/her primary mode of locomotion.Review of the care plan initiated on 11/17/15 revealed the following: the resident had short and long-term memory loss with inappropriate behaviors directed at the staff and wandering. Review of the elopement risk assessment dated [DATE] revealed a score of 20 (high risk for elopement). Review of the nurse's progress notes dated 3/13/18 at 7:00 p.m. revealed the licensed nurse was in the dining room to watch residents finishing supper when he/she heard the south door exit alarm go off. Both Certified nursing assistants were down the hallway putting residents to bed. The licensed nurse could not see who went out, or came in the front door. Approximately 3.5 minutes later the licensed nurse walked out to the Nurses' Station to see the resident coming in the West exit door in his/her wheelchair as he/she propelled him/herself through the door. The resident had zero signs and symptoms of injury and voiced no pain or discomfort upon examination. The resident stated, I was just looking around. Review of the facility investigation dated 3/13/18 revealed the facility determined the resident exited the facility via the west door (front door) of the facility in his/her wheelchair at 7:39 p.m. and re-entered the facility via the south door of the facility at 7:45 p.m. per the door alarm record. The facility determined the front door alarm sounded and licensed nurse A failed to complete a thorough check of the front of the facility, failed to identify resident #1 exited the facility and silenced the alarm leaving the resident outside unattended by staff. Review of the door alarm record dated 3/13/18 confirmed the door alarmed at 7:39 p.m. and again at 7:45 p.m. Review of wunderground.com revealed the temperature on 3/13/17 at 7:39 p.m. was 50 degrees Fahrenheit with 5 miles per hour winds and no precipitation. Observation on 3/19/18 at 4:12 p.m. of the route the facility determined the resident traveled, unattended after he/she eloped from the facility, revealed the front door of the facility opened to a large parking lot of a side street with low traffic. The parking lot was surrounded on one side by a deep drainage ditch with steep embankments. The building had a side walk from the front door to the south door the resident re-entered the facility. The route the resident took measure 284 feet from the front door to the south door of the facility. The side walk was in good repair, flat and free from hazards. The south side of the facility had 3 blue wooden chairs next to the south door the resident re-entered. One of the chairs was overturned and broken with jagged wood edges. Review of the witness statement by licensed nurse A dated 3/13/18 revealed staff A heard the alarm system sound at 7:39 p.m., he/she glanced out the door, did not see anyone, and reset the alarm. He/she did not realize the resident eloped from the facility until he/she heard the alarm system sounding at 7:45 p.m. and witnessed resident #1 re-entering the facility via the south door. During an Interview on 3/19/18 at 2:36 p.m. with licensed nurse C, revealed the expectation was for staff to check the door that alarmed to ensure a resident had not left the facility. Staff C revealed all staff were trained upon hire on the proper use of the alarm system and monitoring of the door to ensure a resident did not exit the building. Interview on 3/19/18 at 2:58 p.m. with administrative nurse B revealed licensed nurse A failed to complete a thorough observation of the front of the facility and parking lot after the alarm alerted staff the front door of the facility opened. He/she shut the alarm off, leaving the resident outside unattended from 7:39 p.m. to 7:45 p.m. when the resident opened the south door of the facility to re-enter the building. Staff B revealed the facility policy directed all staff to do a thorough check of the building and area outside the building after an alarm was activated prior to resetting the alarm to ensure the safety of the residents. Staff B revealed all staff received training on the door alarm system on hire and the training was reviewed periodically throughout the year. Review of the facility's undated Elopement Policy revealed if an elder is identified as having wandering behavior on admission, specific interventions will be implemented and documented on the care plan. Elders who develop wandering behavior after admission will be reassessed and appropriate interventions will be implemented and documented on the care plan. The interventions will address specific behavioral patterns of the elder that put the elder at risk for elopement. All residents will have their whereabouts checked least every hour day and night and elders who are assessed at risk for elopement will have their clothing marked with their name in each article of clothing and a photograph taken on admission and updated as necessary. The facility failed to determine if a resident entered or exited the facility when a door alarm sounded, to ensure he/she did not exit the building without staff's knowledge. Resident #1, a resident with dementia, a fall risk with physical limitations, remained unattended outside of the facility from 7:39 p.m. to 7:45 p.m. which placed resident # 1 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 3/15/17 at 4:00 p.m. when the facility completed staff education on the policy and procedure for elopement and completion of training on the alarm monitoring protocol on all shifts.

The facility reported a census of 23 residents, with a sample of 2 reviewed for abuse. The facility failed to provide evidence staff thoroughly investigated an abuse allegation when resident #1 alleged a staff member slapped him/her in the stomach. The facility failed to interview all potential witnesses, assess the resident for injury, and initiate a thorough investigation in a timely manner. The facility failed to prevent further abuse and ensure appropriate corrective actions by failure to remove the alleged perpetrator from working with residents in the facility and ensure the alleged perpetrator had further training, per their corrective action before he/she returned to work with residents. This failure had the potential to impact all residents who lived in the facility. This deficient practice placed resident all residents in immediate jeopardy. Findings included: - Review of resident #1's significant change minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 6, which indicated severe cognitive impairment. The resident had no hearing, speech or vision problems. The resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and verbal behavioral symptoms directed toward others that occurred 1-3 days of the 7-day observation period. The resident required extensive assistance of 1 staff for most activities of daily living (ADLs). Review of the ADL care area assessment (CAA) summary dated 12/11/17 revealed the resident required extensive assistance of one staff member for transfers, locomotion, toileting and bathing. The resident required total assistance of one staff to dress and he/she did not put on his/her own pants, socks, or shoes. Review of the 10/31/17 care plan, revised on 12/19/17 revealed the resident had short and long-term memory problems, with delusional thoughts and episodes of anger and tearfulness and included the following interventions: Staff would know the resident needed assistance to complete ADLs. The resident required assistance from staff to get from a lying to a sitting position in bed and assistance getting his/her feet out of bed. The resident required 1 staff assistance for grooming, dressing, toileting and bathing. The nurse would assess the resident's skin weekly and as needed (PRN). The resident had clear speech and could make his/her own needs known. Review of the facility investigation report form signed 3/1/18 revealed an incident, which occurred 2/23/18. The facility identified the resident involved in the incident as resident #1. The report revealed direct care staff A and direct care staff B assisted resident #1 to get up and ready for breakfast. Staff B left the resident's room and he/she reported to staff A, that staff B did not like him/her and slapped him/her. The investigation report lacked the time staff B slapped him/her. The report then stated staff reported the incident to licensed nurse G and administrative nurse C, although the report did not identify the time staff reported the allegation to either staff G or staff C. During an interview with resident #1 at 12:30 PM, the resident reported a staff member slapped him/her on the stomach and he/she did not know the staff member's name. The facility showed the resident their employee photo book, where he/she identified staff B as the alleged perpetrator. The facility reported they examined the resident to have no redness, bruising or changes noted, although did not provide a time or date they examined the resident. The corrective action listed in response to the incident revealed administration suspended staff B at 1:45 PM on 2/23/18 (1 hour and 15 minutes after staff interviewed the resident) and he/she returned to work on 2/27/18, when staff completed the investigation. The facility would re-educate residents and direct care staff on the reporting of abuse, neglect, exploitation and resident safety. The facility reported to law enforcement on 3/1/18 at 3:00 PM, 6 days after the resident's initial allegation and 2 days after the alleged perpetrator returned to work. Review of the facility's Potential Resident Abuse Incident Report filed by direct care staff A on 2/23/18 revealed at around 7:15 AM, resident #1 informed him/her of an allegation that occurred with direct care staff B. The resident reported staff B slapped him/her once. Review of the signed/notarized witness statement dated 3/6/18 at 10:33 AM direct care staff A reported around 7:15 AM on 2/23/18 he/she and direct care staff B went to get the resident up for breakfast. After both direct care staff assisted the resident up and in his/her wheelchair staff B walked out of the room. While staff A finished getting the resident ready for the day, the resident stated, I don't like (staff B). The resident then stated, Did you know (staff B) slapped me once? Staff A told the resident he/she would report the allegation. The resident then stated, I don't want (staff B) taking care of me. After staff A took the resident to the dining room, he/she reported the allegation to the licensed nurse G, and decided they would talk to administrative nurse C when he/she arrived at the facility. Administrative staff C arrived at around 10:00 AM, but staff A was busy taking care of residents. Whenever staff A had to take care of the resident he/she took another direct care staff with him/her. Staff G and staff A then spoke with administrative staff C around 11:15 AM in his/her office, 4 hours after resident #1 made the initial allegation. Staff A then assisted residents with lunch and after lunch administrative staff C gave staff A a paper (Potential Resident Abuse Incident Report) to fill out and he/she finished the form around 1:30 PM. Review of the facility Elder Abuse Investigation report signed 3/1/18 revealed resident #1 reported an incident on 2/23/18, which involved physical abuse and mistreatment. The findings stated staff examined the resident and did not identify bruises or marks on the resident's chest. Although the resident originally reported he/she had been slapped in the stomach, the note failed to mention any assessment other than the resident's chest. Review of the facility investigation lacked evidence of a notarized witness statement for direct care staff A, although the resident initially reported the allegation to him/her. Review of the facility investigation lacked evidence licensed nurse staff G completed a witness statement after staff A reported resident #1's allegation to him/her. Review of the facility investigation lacked evidence direct care staff B gave a statement or signed a notarized witness statement until 3/1/18, 2 days after he/she returned to work and 6 days after the original allegation by resident #1. Review of the nurse's notes for resident #1 from 2/23/18 through 2/26/18 lacked evidence of the allegation direct care staff B slapped him/her, assessment of the resident related to the allegation or any follow up on the resident's emotional status related to the allegation by resident #1. Review of the resident's skin assessments lacked any assessment of the resident's skin on 2/23/18. Review of the facility investigation and nurse's notes lacked evidence the facility notified the resident's representative of the allegation prior to 2/26/18, 3 days after the resident reported he/she was slapped by direct care staff B. Review of the facility alert and oriented resident interviews related to the allegation, and included in the facility investigation dated 2/26/18, revealed the facility asked resident #2 if he/she had any staff member that he/she was afraid of and it was noted resident #2's facial expression changed. The interviewer asked the resident if any staff member had been abrupt, mean or cranky and he/she responded he/she felt staff were abrupt and probably didn't like him/her. The resident did not know staff member names, but identified direct care staff B and direct care staff F as being mean and rough talking. Review of the facility investigation lacked evidence resident #2's allegation was followed up with staff B or staff F. Review of the Elder Abuse Investigation report signed 3/1/18 revealed based on interview of other residents who lived in the facility, administration could not confirm other incidents (allegations of abuse) at this time, although resident #2 stated staff B had been mean and talked rough during his/her interview on 2/26/18. Review of the Elder Abuse Investigation report signed 3/1/18 revealed direct care staff B returned to work on 2/27/18 with one-on-one education. The report identified abuse, neglect and exploitation education, stress management techniques and computerized training courses were provided to staff B. The investigation report lacked evidence staff B completed the training before he/she returned to work on 2/27/18 or that he/she started the training prior to 3/6/18. Review of the facility provided information regarding updated courses identified as part of the corrective actions assigned to direct care staff B revealed the following courses: Customer service strategies, Elder Justice Act, Environmental Safety: Maintaining a safe Environment in a Healthcare Facility and Emergency Preparedness, Fire safety, Hand Hygiene, Module 1: Understanding the world of Dementia, What is abuse?, Being with a person with dementia: Listening and speaking, Being with a person with dementia: Actions and reactions, Preventing abuse, Being with a person with dementia: making a difference, Hand in hand quiz, respecting patient rights, rights on target: Respecting Resident Rights, Telephone Etiquette, and Vulnerable Adult. There were 16 modules not attempted or not completed as of 3/6/18 by direct care staff B. Review of direct care staff B's signed, notarized witness statement dated 3/6/18 revealed on 3/1/18 administrative nursing staff C and administrative staff D talked to him/her, typed up his/her statement and assigned computerized training classes. Staff B did not start or complete the assigned training 11 days after resident #1 reported he/she slapped him/her, resident #2 reported he/she had been mean/rough talking, and 8 days after he/she returned to work. During an interview with direct care staff B on 3/6/18 at 10:57 AM revealed he/she worked shifts through the facility by covering for other direct care staffs' days off. Staff B reported he/she provided cares for resident #1, when he/she worked his/her area and when other direct care staff working the resident's area needed help. He/she reported he/she had abuse, neglect, exploitation training, but could not think of the date or what the training covered. Staff B stated he/she received a report that resident #1 stated he/she hit him/her in the stomach. He/she found out about the allegation on the day of the reported incident (2/23/18) about 1:50 PM and stated no one from facility management talked to him/her before that time. Staff B stated they told him/her about the allegation at 1:50 PM and sent him/her home (approximately 6 hours and 35 minutes after the initial allegation). Staff B reported he/she was off work and returned to work the following Tuesday 2/27/18. On 3/1/18 administrative staff D typed up his/her statement and had it notarized. Staff B reported the 1st statement the facility received from him/her was 3/1/18. When staff B returned to work he/she reported the facility initially did no additional training with him/her and assigned him/her extra computer based training. Staff B stated he/she had not started the extra academy training. When staff B returned to work on 2/27/18 the resident was in the hospital and the facility did not educate staff B about anything related to caring for resident #1 when he/she returned to the facility. During interview with direct care staff A on 3/6/18 at 10:33 AM revealed on 2/23/18 resident #1 caught him/her off guard when he/she made an allegation about direct care staff B. Staff A and staff B were on the resident's hall and he/she told staff A I don't like (staff B) and then said, did you know (staff B) slapped me. Staff A stated he/she finished taking care of the resident and reported the allegation to licensed staff G. Staff A reported they waited until administrative staff C arrived at the facility that day and did not have people in the office, which was about 11:15 AM, 4 hours after the initial report by resident #1, to report the allegation to administrative staff G. Staff A stated the facility had an in-service related to abuse just before the incident with resident #1, but could not remember exactly when it occurred. Staff A reported he/she had training on what to report and when to report related to abuse. Staff A further reported he/she would report physical abuse within 24 hours. Staff A completed a witness statement on 2/23/18 and reported the witness statement was never notarized. During an interview with administrative staff C on 3/6/18 at 2:16 PM regarding the incident when resident #1 reported an allegation of abuse to direct care staff A at around 7:30 AM. Direct care staff A filled out the potential resident abuse incident form and did not talk to administrative staff C about it until 11:30 AM (4 hours after the initial allegation). Staff C expected the person who reported the allegation to fill out the potential resident abuse incident report. Staff C used the potential resident abuse incident form as his/her witness statement for the person reporting the incident and did not get it notarized. Staff A reported the allegation to the charge nurse (licensed staff G) at 7:30 AM and they went together at 11:30 AM to staff C's office. Staff C reported he/she had no witness statement from the licensed staff G because they went to him/her and staff A gave the report. Staff C stated staff G did not chart anything related to the allegation in the resident's record and he/she expected the allegation to be charted in the nurse's notes, including a physical head-to-toe assessment for markings and bruising. Staff C stated the resident already started lunch when he/she heard about the allegation and he/she interviewed him/her at approximately 12:30 PM. He/she reported he/she did not record the resident's statement anywhere. Staff C stated the resident could not tell him/her a name or date, but identified direct care staff B in the facility employee picture book. Staff C reported direct care staff B did not leave the building until 1:45 PM because he/she was on his/her break, then he/she had staff B chart at approximately 1:20 PM. Staff C did not give staff B details of the allegation at the time of the suspension. Staff C stated he/she talked to the resident representative about the allegation on 2/23/18, but did not document the notification anywhere. Staff C verified the allegation was initially reported at 7:30 AM to direct care staff A, reported to him/her at around 11:30 AM (4 hours after the initial allegation), and the alleged perpetrator left the building at around 1:45 PM (6 hours and 15 minutes after the allegation). He/she reported administrative staff D interviewed alert and oriented residents, staff members, and he/she had no other issues reported from other residents so they could not substantiate resident #1's allegation. Regarding resident #2's allegation of staff being mean and rough talking, no staff had any further training or follow up related to the allegation. Staff C stated staff D probably should have investigated the allegations of staff being mean/rough talking further. Staff C stated he/she did not report the allegation to law enforcement until 3/1/18, 6 days after the initial allegation and 2 days after staff B returned to work. He/she verified staff B did not compete a witness statement until 3/1/18, but stated he/she talked to staff B about the allegation on 2/27/18 when he/she returned to work. During further interview with administrative staff C on 3/6/18 at 3:12 PM revealed direct care staff B was assigned online training, but had not started or completed it yet. During an interview with the administrative staff D on 3/7/18 at 8:27 AM revealed staff reported the incident to him/her on 2/23/18 about lunchtime. The residents were eating their lunch and staff C was going to talk to the reporting resident after he/she ate his/her lunch. After staff C talked with the resident he/she sent the alleged perpetrator home and started his/her investigation. Staff D believed the allegation occurred right before lunch as the direct care staff were getting the resident up. Staff D stated he/she did not know about the allegation until later in the morning, about lunchtime and denied knowing the resident reported the incident at approximately 7:15 - 7:30 AM. Staff D stated direct care staff should report allegations to administration shortly after they arrived at the facility or by phone. Staff D thought direct care staff should tell the charge nurse immediately about any allegation and then the charge nurse should tell administration. Staff D stated the licensed nurse should contact management in a timely manner after an allegation of abuse was reported. Licensed staff G talked to him/her, staff C, and talked to the resident (the facility investigation lacked documentation from staff G). Staff D reported he/she interviewed alert and oriented residents and staff members on Monday 2/26/18. When asked about the interview with resident #2 and his/her facial expression change he/she stated the resident got kind of a sad face. He/she stated they went through the picture book (the resident and staff D) and he/she identified 2 staff as mean/rough talking. Staff D stated rough talking was what resident #2 meant when he/she said staff were mean. Staff D stated rough talk included statements like, it's time to get up now and not giving the resident a choice to get up. Staff D left resident #2's statement as part of the investigation and talked with staff C about the findings of the investigation, but did not investigate resident #2's statements further. Staff D stated administration talked to direct care staff B about his/her tone with residents before he/she returned to work (the investigation lacked documentation of training about tone of voice for staff B). Staff D stated there was no follow up after resident #2 reported staff were mean/rough talking. Staff D stated he/she should have put more documentation about his/her conversation with resident #2. Staff D stated direct care staff B was sent home on 2/23/18 right after lunch, but was informed to finish charting around 1-1:30 PM. Staff B finished his/her charting at the nurse's station alone and did not have anyone watching him/her until he/she left the building. Staff D reported the facility had a policy to send alleged perpetrators home after an allegation was made. Staff B returned to work on 2/27/18 and the facility notified law enforcement on 3/1/18. Staff D stated law enforcement should have been notified of the allegation on 2/23/18 and the alleged perpetrator should not have returned to work before law enforcement had been called. Staff D stated the facility concluded its investigation on Monday afternoon (2/26/18) and staff B returned to work on 2/27/18. Staff D and staff C felt the corrective action should have been education regarding staff B's tone and they felt it was safe for him/her to return to work. The facility determined the allegation was unsubstantiated because the resident could not tell them the date the incident occurred and staff C checked the resident and identified no bruising. Staff D expected to have a skin assessment completed on 2/23/18, the date of the allegation. Staff D stated staff B was assigned computerized training and he/she would have expected him/her to have training complete before he/she returned to work. Staff D stated he/she typed up witness statements after taking short notes during the witness's statement. Review of the facility policy Abuse, Neglect and Exploitation dated 11/10/17 revealed: All staff would be trained during new employee orientation and annually that any suspicion of abuse, neglect, exploitation and/or mistreatment would be reported immediately to the health services administrator or his/her designee and a report would be filed by administrative staff with state department of aging and disability services, immediately (within 24 hours of the incident). The administrator would contact the Kansas Department of Aging and Disability Services (KDADS) abuse hotline with in 24 actual hours of the incident and would proceed with the investigation after KDADS notification. If there were any evidence the incident met the definition of assault and battery, major financial theft or rape local law enforcement would be notified by the administrator or designee immediately. The elder's legal representative or designated family member would be informed of the investigation. A list would be compiled of all witnesses and other persons who had knowledge of the event. The following individuals would be interviewed: the person making the report, individuals alleged to have been involved in the incident, the elder, team members on duty in the neighborhood during the time of the alleged incident, team members that may have had contact with the elder before or after the period of the alleged incident, the elder's roommate, the elder's family, visitors and other elders who received care and services from the individual or individuals alleged to have committed the abuse. Following each interview, the individual interviewed would complete a witness statement summarizing the events related to the incident. It would be emphasized to each person that they are to write the statement in their own words. Each individual would sign and date their witness statement in front of a notary public. If there was evidence to suspect that an individual may have abused or neglected an elder that individual would not be allowed to work or be present in the facility or allowed access to the facility until the outcome of the investigation was known. Any alleged perpetrator would be immediately suspended from working in the facility or being present on the property of the facility unless continuously supervised by a management staff member for investigatory purposes. Any alleged perpetrator would be asked to complete a witness statement prior to leaving the property. All witness statements obtained would be filed with the investigation report. Within 5 days of the incident the administrator would review the information and prepare a written report that included: a list of findings, summary and conclusions of the investigation, recommendations to the neighborhood council for changes in policy and procedure that could prevent a similar event from occurring and recommendations for employee education when the employee did not follow of exhibited a lack of knowledge of the policies and procedures of this organization. The facility investigation would take the form of physical assessment of the elder, clinical record review, staff interview, collection of elder statement and/or other investigative techniques. Facility staff were charged with the responsibility to protect elders from abusive staff members, family members and from other elders who might be acting in an aggressive manner. Any alleged perpetrator who was an employee of the facility and accused or alleged of abuse, neglect and exploitation would be immediately suspended from employment, would leave the employment property and not return to the property until the investigation by the facility and law enforcement was complete and the incident was resolved. The alleged perpetrator could return to the property prior to resolution if constantly supervised by the administrator during and investigatory interview. The facility failed to provide evidence staff thoroughly investigated an abuse allegation by the failure to interview all potential witnesses, assess the resident for injury, and failed to initiate a thorough investigation in a timely manner when resident #1 alleged a staff member slapped him/her in the stomach. The facility also failed to prevent further abuse and ensure appropriate corrective actions by the failure to remove the alleged perpetrator from working with all residents in the facility and ensure the alleged perpetrator had further training, per their corrective action before he/she returned to working with residents. The immediate jeopardy was abated on 3/7/18 at 5:40 PM by immediately educating all employees on reporting and protection of abuse as outlined in the abatement plan. The facility completed the education with employees and posted a sign with reporting procedures in the facility break room in addition to signs already posted in the public areas. The facility will provide follow up monitoring by interviewing staff randomly about reporting abuse, neglect, exploitation and the protection of residents. The administrator and director of nursing will do follow up monitoring of ten employees a week for four weeks, then five employees a week for four weeks, then thereafter as needed. The deficient practice remained at a scope and severity of a F.

The facility had a census of 23 residents, with 16 selected for sample. The sample included review of weight loss for 3 residents. Based on observation, interview and record review, the facility failed to ensure that 1 of 3 residents did not experience avoidable weight loss. One resident (#12) experienced a severe weight loss of 10.6% in 180 days, and the facility failed to identify weight loss as a problem, evaluate for the cause of the weight loss, develop/implement appropriate strategies to address the weight loss, and failed to implement the registered dietician's recommended diet for a period of more than 4 months. Findings included: - Review of resident #12's signed physician orders [REDACTED]. Review of the annual MDS (minimum data set) dated 3/17/14 revealed a BIMS (brief interview for mental status) score of 3 indicating severe cognitive impairment. The resident required set up and supervision with eating. The resident had no eating problems and weighed 157 pounds with no weight loss reported. Review of the nutritional CAA (care area assessment) dated 3/17/14 revealed the resident had lethargic (the resident was not alert) episodes and would leave food uneaten. The resident had hallucinations and delusions. The resident fed him/herself, though required cueing and moved to the assisted side of the dining room for one to one cueing. The resident received a nutritional supplement BID (twice a day). Review of the quarterly MDS dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. The resident required set up and supervision with eating. The assessment revealed a weight of 145 pounds with no weight loss reported. Review of the care plan with a date of 7/24/12 included interventions to offer the resident food substitutions if the resident refused to eat. Dietician was to evaluate resident's nutritional status. The undated care plan revision revealed the resident was to receive house supplement at 3:00 p.m. and at HS (bedtime). The care plan lacked evidence of review/revision in the time period since 7/24/12 other than the addition of supplements twice a day. Review of the physician orders [REDACTED]. Review of the resident's weights revealed a severe weight loss of 10.6% over the last 180 days. The clinical record lacked evidence the facility notified the physician or implemented interventions to prevent further weight loss after staff obtained the following weights: 3/1/14- 156.6 pounds 3/30/14-154.6 pounds 5/1/14-147.2 pounds 7/1/14-142.8 pounds 8/1/14- 144 pounds 9/1/14- 140 pounds 10/1/14-140 pounds Review of the dietary progress notes signed by the registered dietician, dated 5/7/14 revealed a current weight of 147.2 pounds. The resident had no significant weight loss documented on the assessment. The resident was not on a weight reduction program. The resident received a regular diet, although the registered dietician recommended a change to a mechanical soft diet. Staff were to monitor the resident for mouth pain since the resident currently received an antibiotic for a tooth ache. Review of the dietary progress notes signed by the registered dietician, dated 9/3/14 weight monitoring revealed a current weight of 140 pounds, down 4.8 pounds in 30 days (3.3%) down 4.6 pounds in 90 days for (3.2 %) weight loss and 16.6 pounds in last 180 days (10.6%). Discussed intake with the charge nurse who reported the resident was still taking supplements as ordered. The charge nurse reported the resident had a toothache the facility was trying to get the resident into a dentist. The resident still received a regular diet with the registered dietician recommending soft foods. Observation on 9/30/14 at 12:02 p.m. staff assisted the resident through the cafeteria line for the choice of meal. The resident had a plate of 3 fish sticks, a serving of macaroni and cheese, bowl of cherry tomatoes, a bowl of fruit. Further observation at 12:34 p.m. revealed the resident ate all the meal except the cherry tomatoes. No additional food was offered and the resident was taken from the dining room. Observation on 10/1/14 at 7:50 a.m. the resident sat at the dining table in a wheelchair. The resident had scrambled eggs and a cut up piece of ham with a blueberry muffin. The resident was eating well without assistance. Further observation at 8:12 a.m. revealed the resident ate the eggs, 1/2 the ham and toast but did not eat the muffin. No additional food was offered and the resident was taken from the dining room. During an interview on 9/30/14 at 1:35 p.m. direct care staff G, reported the resident had a very poor appetite and needed staff to sit with him/her during meals and assist and coax him/her to eat. Staff thought the resident had a recent weight loss and received a health shake or some other liquid supplement at 3 and at 8 during passing of snacks. On 10/1/14 at 4:40 p.m. direct care staff E reported the resident needed much encouragement to eat meals. The resident had no appetite so it was difficult to eat meals. The resident received a nutritional supplement 2 times on the evening shift. The resident liked the supplements and took them. The resident did not like the food. The residents had their choice of what they wanted. During an interview on 10/1/14 at 5:00 p.m. licensed staff H reported the resident took on average about 50% of his/her meals. It depended on a day to day basis and his/her mood what and if he/she ate. The resident had the same weight for a couple of month so nurse H thought the resident's weight had stabilized. On 10/2/14 at 9:30 a.m. administrative nurse A acknowledged the resident had a significant weight loss. The resident was on a supplement since January of 2013. Nurse A reported the dietician recommended the resident have a mechanical soft diet in May 2014 but the nurses failed to follow up on the request. The dietician recommended the same diet change on 9/3/14 with the resident continuing to lose weight. That diet change also had no follow up. No recommendation was made for a different supplement, fortified foods or anything that would raise the caloric intake for the resident. Nurse A reported the resident had some dental issues in the last 6 months and that was why the dietician recommended the diet change. On 10/2/14 at 1:40 p.m., dietary supervisor C reported the registered dietician would come in and review resident weights and wrote a report with recommendations. That report went to administrative nurse A to make changes. During an interview on 10/2/14 at 1:35 p.m., Dietary Consultant D reported changing the resident's diet to mechanical soft as per the 5/7/14 and 9/3/14 recommendations may have positively affected resident #12's weight loss. Interview with administrative nurse A on 10-15-14 at 10:38 a.m. revealed the registered dietician made a recommendation on 5-7-14 to consider a mechanical soft diet because the resident had a broken tooth pulled and started an antibiotic on 4-8-14. On 5-14-14, Physician Consultant L signed the recommendation, but did not change the resident's diet because the extraction site healed. On 9-3-14, the registered dietician noted the resident had a weight decrease of 10.6%. He/she also had a newly identified toothache, and the facility staff were in the process of making an appointment with the dentist. Administrative nurse A said a physician extender saw the resident and did not change the diet to mechanical soft. Administrative nurse A said the physician saw the resident on 12-11-13 and noted the resident had a weight gain, but also had [MEDICAL CONDITION]. The physician put the resident on a diuretic, but the physician discontinued the diuretic in December of 2013. Administrative nurse A said a certified nurse aide or a certified medication aide weighed the residents. He/she said if a resident had a weight loss or gain of 5 pounds, the staff weighed the resident 3 days in a row and if the weights substantiated a weight gain or loss the charge nurse notified the physician. The nurse also put the resident's name on a list for the registered Dietician to review when he/she came next. He/she said staff normally started a resident with a 5 pound loss or gain on weekly weights and moved to an area to receive more assistance with dining. He/she said notes for the 6/24/14 care plan meeting for the resident indicated the staff discussed a move to more assistance with dining at that time. During an interview on 10/2/14 at 2:00 p.m., Physician Consultant L denied previous knowledge of the extent of resident #12's weight loss (10.6% in 180 days). According to Physician L, he/she would expect the facility to follow the registered dietician's recommendations to change the diet to a mechanical soft. Review of the undated facility policy Monitoring Weights revealed: All elders of the facility would be evaluated for weight loss stabilization for timely identification of weight loss, and treatment would be provided when possible and accepted by the elder and/or surrogate decision maker to prevent weight loss unless the physician has indicated a planned weight loss program. The facility failed to ensure that 1 of 3 residents did not experience avoidable weight loss. Resident #12 experienced a severe weight loss of 10.6% in 180 days, and the facility failed to identify weight loss as a problem, evaluate for the cause of the weight loss, develop/implement appropriate strategies to address the weight loss, and failed to implement the registered dietician's diet for a period of more than 4 months.

The facility census totaled 23 residents with 16 included in the sample. Based on observation, interview and record review the facility failed to ensure 2 of 3 residents sampled for pressure ulcers did not develop unstageable, avoidable facility acquired pressure ulcers after admission. (#13, #18) Findings included: - Review of resident #18's admission MDS (minimum data set) dated 6/15/14 revealed a BIMS (brief interview for mental status) score of 9, indicating moderate cognitive impairment. The resident required extensive assist of two staff for transfers and toilet use. The resident did not reject care. The resident was occasionally incontinent of urine and always continent of bowel. He/she was at risk for developing a pressure ulcer and had a pressure reducing device for the chair and bed. The resident was not on a current turning or repositioning program. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. The resident had clear speech and was understood by others. The resident did not have any behaviors, including the rejection of care. The resident required extensive assist with two staff for transfers and toilet use. The MDS revealed the resident was occasionally incontinent of urine and always continent of bowel. He/she was at risk for developing pressure ulcers and had a pressure reducing device for the chair and bed. The resident was not on a turning or reposition program. Review of Pressure Ulcer CAA (care area assessment) dated 6/15/14 revealed the resident had a pressure reducing mattress and pad in his/her wheelchair. Resident #18 had no history of pressure ulcers, but was at risk due to his/her immobility. Review of the resident's care plan signed on 6/30/14 revealed the resident was at risk for pressure ulcers related to his/her immobility, incontinence, and medications. Staff were instructed to place a pressure reducing cushion on all seating surfaces, encourage him/her to weight shift while sitting up in a chair, use pressure reduction mattress, assess skin weekly, and perform a monthly Braden Score. Staff revised the care plan on 9/2/14 and revealed treatment to pressure areas to right and left heels per physician orders. Nursing staff was to discontinue putting TED hose (specialized compression stocking designed to help manage excess fluid in the feet/legs) on the resident. The resident was to have his/her feet elevated with a pillow when up in a recliner and to wear heel protectors at all times. On 9/15/14 staff documented the pressure ulcer to the heel resolved. The care plan revealed the resident required staff to assist with his/her ADLs and assist with mobility. He/she required two staff with a lift for transfers. Review of the Braden Scale completed on 8/15/14 and 9/15/14 was 15, indicating the resident was at risk for pressure ulcers. Review of a general weekly skin check assessment dated [DATE] revealed the resident's skin was intact. The same log, next line, dated 9/10, revealed the resident's skin was intact. On 9/17/14 the resident's skin was impaired to the right heel; he/she had a rash on the right thigh. On 9/24/14 the resident's skin was impaired to the right leg with scabs and scratches to the thigh with red marks on the left side and back, with nothing new. The facility failed to assess the resident's skin for 21 days. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the nursing note dated 9/2/14 at 4:50 p.m. revealed direct care staff J called the charge nurse to resident #18's room. The Charge nurse documented a pressure ulcer on the left heel 0.75 cm (centimeters) in diameter, a dark spot with white around the edge. Upon inspection, the resident had another pressure ulcer on the right heel 2 cm in diameter, dark spot with white around the edge. Staff removed the resident's TED hose and put heel protectors on. Staff called the physician and a message was left. A nursing note dated 9/15/14 (untimed) revealed a dressing change was done to the heels by the charge nurse. Staff documented the measurement to the right heel on the skin sheet and documented the left heel was resolved. The resident rated his/her worst pain a 4/10 on the 0/10 pain scale and denied any pain with the dressing change and the only time it hurt was when someone bumped into it. The treatment orders were continued as ordered. Nursing note dated 9/18/14 (untimed) revealed Nursing staff did a dressing change to the wound on right heel and the resident was sitting up in his/her wheelchair. Nursing note dated 9/26/14 (untimed) revealed the resident went to see PA (physician assistant) and to continue current treatment to heel. Per the physician order [REDACTED]. The wound assessment dated [DATE] (untimed) revealed the original wound on the right heel was 2 cm (centimeters) round and left heel 0.75 cm round, unstageable. The wounds had eschar (dead tissue) covering it. Staff notified the physician on 9/2/14 of the pressure ulcers on the right and left heels. The resident rated his/her pain at a 4/10 on the 0/10 pain scale. The wound assessment dated [DATE] ( untimed) the nurse charted the wounds were now a stage 1 with the right heel measuring 2x2 cm and left heel just a pin point. The wound assessment dated [DATE] (untimed) revealed the right heel wound measure 1.8 x 2.3 cm, had eschar, and was unstageable. The wound assessment dated [DATE] (untimed) revealed the right heel wound measured 2 x 1.5 cm, had eschar, and was unstageable. The wound assessment dated [DATE] (untimed) revealed the right heel wound measured 2 x 2 cm, had eschar, and was unstageable. The wound assessment dated [DATE] (untimed) revealed the right heel wound measured 2 x 2 cm, had eschar, and was unstageable. Observation on 9/30/14 at 10:15 a.m., revealed the resident resting in his/her recliner with his/her feet elevated under two pillows, blue booties on his/her feet floating over the two pillows. An observation on 9/30/14 at 3:30 p.m. revealed licensed nursing staff N came in to perform the dressing change. He/she put diabetic socks on the resident after applying the [MEDICATION NAME] and covering with tape, then applied heel protectors and propped two pillows under the feet. An observation on 10/1/14 at 8:30 a.m. revealed the resident sat in his/her wheelchair in the dining room. The resident had blue boot on both of his/her feet and had consumed 100% of his/her breakfast. An interview with direct care staff G on 10/1/14 at 7:46 a.m. revealed the resident always had worn tennis shoes during the day before he/she developed the pressure ulcers on the heels. He/she also reported the resident now required special boots, repositioned every two hours, and for his/her heels to be floated at all times. Staff G reported he/she had revealed the resident had a good appetite. Staff G reported he/she would even ask for seconds at meal times. Interview with direct care staff E on 10/1/14 at 4:35 p.m. revealed the staff had not changed the resident's care since he/she got the pressure ulcers. He/she reported direct care staff had tried to move the resident around as often as he/she would allow. Staff E reported the resident had a water pad for his/her chair or recliner. The evening staff removed the residents TED hose, but would never inspect the resident's heels after removing the TED hose. Direct care staff E stated one day the resident reported pain to his/her feet and now he/she required heel pads due to the pressure ulcers. An interview on 10/2/14 at 7:25 a.m. with direct care staff I revealed the resident was to wear heel protectors and blue booties at all times, to use two pillows when in bed or in the recliner to float his/her heels, diabetic socks, and no more TED hose. He/she also stated staff repositioned the resident every two hours and he/she used a bed side commode with a sit to stand lift for transfers. Interview on 10/2/14 at 9:23 a.m. with direct care staff J revealed he/she was the direct care staff working with the resident when he/she reported the pain to his/her feet. Staff J reported this was the first time he/she had reported the pain to him/her. Staff J took off the resident's slippers and TED hose and discovered a black colored mark with red around it on the left heel. He/she then went and got the charge nurse who discovered the second pressure ulcer on the right heel. Staff J revealed the resident no longer wore TED hose, and now required a pressure relief boot and blue boot on the other foot. Staff were to keep his/her feet elevated when in bed and in the recliner. Staff J also reported the resident now used foot pedals with wheel chair. An interview with licensed nursing staff H on 10/1/14 at 4:59 p.m. revealed resident #18 required blue boots on at all times along with the treatment for [REDACTED]. An interview on 10/01/14 at 12:55 p.m. with administrative nursing staff A revealed the night nurse was to do a weekly skin assessment and document the finding in the skin assessment book. Nurse A reported the night charge nurse did miss weekly skin assessments during the time frame when the resident developed two pressure ulcers. He/she revealed the resident was at risk for pressure ulcers from his/her admission and had in place a pressure relieving mattress and cushion on his/her wheel chair. He/she reported the facility failed to have any protection for resident #18's feet from pressure reduction prior to development of the pressure ulcers. Staff A also reported he/she was responsible for coding the first wound assessment and he/she should not have marked the pressure ulcer as unstageable or with the black eschar and did not properly identify the proper staging of the pressure ulcers for the resident. Staff A reported staff should reposition the resident every two hours. Staff A also should have care planned for repositioning and for the resident to wear diabetic socks. An interview on 10/3/14 at 10:25 a.m. with physician K revealed he/she examined the wound to the resident's heel and he/she diagnosed it as a pressure ulcer. Staff K revealed he/she expected the facility to perform weekly skin assessments and to call him/her immediately with any changes in condition. Staff K reported he/she expected the facility follow the procedures for preventing pressure ulcers from worsening by making sure staff repositioned the resident every two hours, and his/her protective blue boots along with the floating those heels with the two pillows as ordered. Review of the facility skin assessment policy dated 2/10, revealed the goal was to protect and to maintain the resident's skin integrity and to quickly identify problem areas. The policy also noted staff were to do a weekly skin assessment on each resident and then document the assessment. Review of the Pressure Ulcer Protocol dated 7/2013, revealed that all residents who enter the facility without a pressure ulcer do not develop pressure ulcers. Wounds that occurred in house will be viewed as a sentinel event with a root cause analysis for the cause. The facility failed to ensure this cognitively impaired, dependent resident who entered the facility without pressure ulcers did not develop 2 unstageable, facility acquired avoidable pressure ulcers after admission. - Review of the admission assessment dated [DATE] revealed resident #13 had a BIMS(brief interview for mental status) score of 4 indicating severe cognitive impairment. The resident required minimal assist with bed mobility, mobility in the halls, extensive assistance of one with transfers and toileting. The resident was at risk for pressure ulcers and had one stage 1 pressure ulcer and one stage 2 pressure ulcer with granulation tissue present in the wound bed. The resident had a pressure reducing device on the bed and in the chair. The resident was on a repositioning/turning program. Review of resident #13's significant change in status MDS (minimum data set) dated 7/20/14 revealed a BIMS (brief interview for mental status) score of 10 indicating moderate cognitive impairment. The resident required minimum assistance of one with bed mobility and transfers and supervision and setup with eating. The resident was always incontinent of urine. The resident had no pressure ulcers identified on the assessment with the resident being a risk for pressure ulcers. The resident had a pressure reducing device on the bed and in the chair. The resident was on a repositioning/turning program. The pressure ulcer CAA (care area assessment) dated 7/20/14 revealed the resident was at risk for breakdown related to decline in ADLs (activities of daily living). The clinical record included a care plan with a date of 7/20/14 that revealed the resident was at risk for impaired skin integrity. The care plan instructed staff to: encourage the resident to shift weight while sitting up in a chair, encourage good nutritional intake, avoid use of restrictive clothing. complete weekly skin assessments, and provide a pressure reducing mattress and chair cushion. An update to the care plan on 9/17/14 included a pressure ulcer to the left heel. Nurses were instructed to treat heel per orders. Heel lift boot to left heel at all times. Review of the most recent Braden scale dated 8/15/14 revealed a score of 16 which indicated the resident had mild risk for skin breakdown. Review of the nurses notes dated 8/19/14 at 6:30 a.m. revealed the direct care staff reported 2 open areas on the residents buttocks. The left buttock measured 1.0 centimeter (cm) in diameter. The right buttock had a superficial open area with no measurements noted. The nurse wrote he/she would report to the day nurse for him/her to contact physician. The clinical record revealed no evidence the facility contacted the physician regarding the resident's two newly acquired pressure ulcers. Review of the clinical record revealed no evidence of daily/weekly assessments of the open areas in the time period between 8/19/14 and 9/28/14. Review of the nurses notes dated 9/17/14 revealed the documentation of an unstageable pressure ulcer identified on the left heel on 9/17/14. Review of the nurse's notes dated 9/28/14 at 8:00 p.m. revealed a 3 cm open area to the buttock as opposed to the previous measurement of 1 cm when last documented/measured on 8/19/14, a deterioration/worsening of the pressure ulcer. The nurse tried to place a [MEDICATION NAME] dressing to the wound but the dressing would not adhere to the area due to [MEDICATION NAME] on the area. The clinical record revealed no evidence staff notified resident #13's physician of the worsening of the pressure ulcer on the buttock. Review of the weekly skin reports (a sheet where the nurse documents the location of skin issues with no detail of the condition of the wound) from 8/2/14 to 9/13/14 failed to identify pressure ulcers to the buttocks. Review of the weekly skin assessment dated [DATE] revealed an area to the left heel though lacked documentation of pressure areas to the buttocks. Review of the weekly skin assessment dated [DATE] revealed an area to the right scalp, left heel and left buttock. Review of the lab work (blood work) dated 9/16/14 revealed a low [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) level of 3.0 with normal range of 3.5 to 5.00 g/dl, and low total protein (amount of protein in the blood needed to maintain skin integrity) of 6.2 with normal range of 6.3 to 8.2 g/dl. Review of the physician orders [REDACTED]. Observation on 9/30/14 at 2:00 p.m., the resident sat in his/her recliner. The resident stated he/she sure had a sore bottom and it hurt sitting. The resident did not know if he/she had a sore on his/her buttock but it was sore. Observation on 10/1/14 at 11:10 a.m. revealed two direct care staff assisted the resident to stand and removed the resident's brief and pants to reveal a pressure ulcer on the left buttock measuring 1.5 cm (centimeters) x 1 cm, and the right buttock had a pressure area measuring 0.6 cm x 0.7 cm. Licensed nurse H reported being unaware of these areas and applied [MEDICATION NAME] to the areas until he/she could get another order. The resident then sat in his/her wheelchair. Nurse H then removed the boot and dressing from the left heel. The area had black eschar (dead tissue) with a pink ring around the area. The area measured 3.1 cm x 3.9 cm. The nurse changed gloves following removal of the dressing and cleaned the area with normal saline and a gauze pad to pat the wound dry. Licensed nurse H changed gloves, applied a [MEDICATION NAME] dressing, a sock and the off load boot. The resident had a cushion in the wheelchair. During an interview on 9/30/14 at 1:30 p.m., direct care staff G reported the resident had an open area on one heel and they were treating the other heel to prevent it from breaking down. The staff had to use a foam wedge to keep the resident off his/her bottom so the area could heal. On 9/30/14 at 3:45 p.m., direct care staff E reported the resident had skin breakdown but did not know where and how many areas the resident had. Direct care staff E reported the resident used to propel around the facility in his/her chair with no foot protection on. On 10/1/14 at 11:15 a.m., licensed nurse H reported not knowing about the area on the resident's buttocks. Nurse H reported that the physician should to be notified of the new pressure areas for a treatment for [REDACTED]. On 10/1/14 at 1:30 p.m. administrative nurse A, reported resident #13 developed multiple pressure ulcers on the buttock and an unstageable pressure ulcer on the heel after admission to the facility. Nurse A reported his/her expectation was that the physician be notified of any pressure ulcers and a treatment ordered. Nurse A also reported the clinical record lacked evidence of adequate assessment of the skin both before and after development of the pressure ulcers, and then assessment of the wounds themselves after they developed. Further interview with Administrative Nurse A on 10-15-14 at 10:27 a.m. revealed the resident admitted to the facility with a pressure ulcer to the left buttocks and a dressing intact at that time. Administrative nurse A said the resident had a pressure relief mattress and a cushion in the chair on 9-17-14 when staff identified the resident had a pressure ulcer to the left heel. Administrative nurse A said the documentation showed the pressure ulcer was initially 3.0 centimeters in diameter and covered with eschar (black dead tissue). Staff notified the physician on 9-17-14 and he/she gave an order for [REDACTED]. Administrative nurse A said at the time the staff identified a pressure ulcer on the left heel, staff initiated the use of heel protectors and floating of the heels to relieve the pressure. On 10-8-14 the pressure ulcer on the left heel had increased to 3.4 by 3.8 centimeters. Administrative nurse A said the dietary staff implemented 4 ounces of cranberry or orange juice each morning. Administrative nurse A said his/her expectation was for the nurse to notify the physician immediately of a pressure sore. Administrative Nurse A said the resident never had a pressure ulcer to the left heel, staff documented incorrectly. Attempts to discuss the facility acquired pressure ulcers with resident #13's physician via telephone were unsuccessful on 10/3/14 at 8:30 a.m. and 10/13/14 at 8:32 a.m. Review of the facility skin assessment policy dated 2/2010, revealed the goal is to protect and to maintain the resident's skin integrity and to quickly identify problem areas. The policy goes on to ensure the residents will have a weekly skin assessment completed and will be document on the form. Review of the Pressure Ulcer Protocol dated 7/2013, revealed that all residents who enter the facility without a pressure ulcer do not develop pressure ulcers. Wounds that occurred in house will be viewed as a sentinel event with a root cause analysis for the cause. The facility failed to ensure resident #13 received treatment and services to prevent the development of 3 avoidable pressure ulcers developed in the facility, including 1 unstageable pressure ulcer.