Every finding on record at Riverbend Post Acute Rehabilitation

Based on interviews, record review, and observation, the facility failed to ensure a safe, clean home-like environment for the residents. Findings Included:- During an observation on 05/05/26 at 08:10 AM on the second floor of the facility, the ice room revealed a dirty towel underneath the door into the room. A tray of clean cups was next to a tray on the counter with multiple cups, plates, and food from a previous meal, and dirty towels were on the sink next to the tray of clean cups. The bottom of the cabinet underneath the handwashing sink was sunken and had multiple wet & soiled towels and a black substance on the floor of this cabinet. The cabinet doors had water damage at the top of the door. The sink was soiled with food debris. A fan full of dust on the screen and blades was blowing and oscillating and blew directly onto the tray of clean cups on the counter. An ice scoop was lying on a stained & dirty lid of an ice chest. Ice water inside the ice chest had debris floating in the water.An observation on 05/05/26 at 08:30 AM on the second floor of the facility in the soiled utility room revealed nine sharps containers overfilled with syringes, needles, and other used sharps, with one container missing a lid and another container with the lid in the open position. A dirty and rusty file cabinet with a mop in a bucket leaned against in front of the sink. The interior bowl of the hopper was dirty with debris and had a brown & black substance on it. The corner of the floor next to the hopper had a brown substance on it.An observation on 05/05/26 at 0842 AM in the activity room on the second floor of the facility in front of the piano the floor revealed numerous small pieces of small glass pebbles. The window to the left of the piano had a torn screen with sharp metal pieces exposed in two places on the screen. One tear to the middle of the screen was approximately eight inches in length by two inches wide. The other tear to the bottom right corner of the screen in a circular pattern was approximately two inches in circumference. The thermostat in the room had no cover, the inside of the thermostat was exposed. In the dining area of the activity room, there was food debris on the bottom of a cabinet. The floor had a white liquid and food debris on it. A shelf in a cabinet underneath the television in the dining room had a mound of a sawdust substance in the center of the cabinet's bottom shelf.Observation on 05/05/26 at 08:30 AM, next to the vestibule area on the second floor, there was a drinking fountain with a bandage tape lying in it, a glass partially filled with water sat on the drain, and the fountain had black substance in the well. The area was soiled all around and near the drain. In the vestibule, there were three wheelchairs that were visibly soiled with dirt and food. There were three lifts that the base was soiled with debris, food, and dirt. The surface of a red and black crash cart in the cart egress area was visibly soiled; the suction machine was not covered. There were staff personal items located next to the uncovered suction machine.Observation on 05/05/26 at 08:37 AM, in a hallway next to a resident dining/activity/gathering room was a light green cart with the top edge cracked open, exposing sharp edges, the edges pulled away from the tray at the corner. The sink for handwashing in the gathering room had no hot water, the sink was visibly soiled and stained. A shelf on the wall next to the sink had three bowls and a plate sitting on it.Interview on 05/07/26 at 10:50 AM, Administrative Nurse D reported the sharps containers should be filled to the marked fill line in the container, and the lid should be secured to the base. Sharps containers should be stored in the biohazard room in the basement. Interview on 05/07/26 at 11:07 AM, Housekeeping/Laundry Staff V reported that the dining rooms and floors were cleaned after all meals and as needed, and the resident rooms and floors were cleaned daily and as needed.Interview on 05/07/26 at 11:12 AM, Housekeeping Director (HD) W reported housekeeping should clean dining areas thoroughly after each meal, and resident rooms should be swept and mopped daily. HD W said the floor technician was supposed to clean the floors two to three times a week, and any debris or pieces from a broken object should be swept up and properly disposed of. HD W stated all staff had access to cleaners, rags, mops, and brooms that were accessible for use on all shifts.Interview on 05/07/26 at 11:40 AM, Maintenance Staff (MS) U reported the drainage pump became clogged and backed up, and as a result, the cabinet door and floor received water damage. MS U said they would be replaced. He also reported the handle was seized for the hot water in the handwashing sink and said it would be repaired. Staff U reported maintenance was responsible for the fan above the sink and said the fan would be removed. He further reported the torn screens should be replaced and verified it should have been identified during spring cleaning checks. MS U confirmed the screens would be replaced.The facility policy Safe and Homelike Environment dated 02/22, documented it is the policy of the facility to ensure residents are provided the right to a safe, clean, comfortable, and homelike environment.

Based on interviews, record reviews, and observation, the facility staff failed to implement adequate infection control practices related to lack of hand hygiene, cleaning of shared equipment, and sanitary storage of respiratory equipment. Findings included:- Observed on 05/06/26 at 07:40 AM, Certified Medication Aide (CMA) R obtained Resident (R) 6's blood pressure and pulse with the vital machine; CMA R took the vitals machine from the neighboring room. CMA R did not sanitize the vitals machine before taking it into R6's room. Licensed Nurse (LN) G asked for the vitals machine, stated she would bring the vitals machine back. LN G did not sanitize the vitals machine before taking the machine from R6's room, who was on EHB. LN G took the vitals machine down the hall and obtained vitals from a resident sitting next to her medication cart. LN G did not sanitize the vitals machine after obtaining vitals. LN G returned the vitals machine to CMA R. CMA R did not sanitize the vitals machine before taking it to the next resident's room.Observed on 05/05/26 at 08:12 AM, R100's CPAP mask and nebulizer laid on her bedside table; R100's CPAP and nebulizer mask were not stored in a sanitary container. Observed on 05/06/26 at 09:11 AM R 100's CPAP mask and nebulizer mask laid on her bed side table, R100's CPAP mask and nebulizer mask. R100's CPAP mask and nebulizer mask were not in a sanitary container. R100 stated she did not have bags or containers for her CPAP mask and nebulizer mask.Observed on 05/06/2026 at 09:45 AM, Certified Nurse Aide (CNA) SS and CMA S donned gowns and gloves outside of R3's room without handwashing or sanitizer used prior to donning personal protective equipment (PPE). R3 was incontinent of bladder, and her brief was changed in bed. CNA SS removed her PPE to leave the room to obtain the Hoyer lift. No handwashing or hand sanitizer was used after removing her gown and gloves. CMA S removed her gloves and reapplied gloves after providing personal care to R3 but did not use sanitizer or wash her hands. CNA SS returned to the room with the lift and donned new gloves in the room but did not use sanitizer or wash hands.During an interview on 05/07/26 at 08:42 AM, CNA M stated respiratory equipment should be placed in bags when not in use. She stated that it was a nurse's duty.During an interview on 05/07/26 at 08:45 AM, CNA N stated she was unsure when the respiratory equipment should be placed in a bag that was in the rooms. She stated normally the nurse would place the equipment in the bags in the room.During an interview on 05/07/26 at 8:51, LN H stated respiratory equipment not in use should be stored in a clean bag with the date written on the bag. She stated the respiratory equipment could be placed in a drawer after the equipment was cleaned. She stated normally that would be the nurse's duty, but the CNAs or CMAs could also place the respiratory equipment that was not in use. LN H stated the vitals machine was cleaned before each shift. She stated staff should not take the vitals machine into rooms with EHB precautions. She stated she would take a handheld blood pressure cuff into rooms that were EHB precautions. LN H stated she did not think the equipment needed to be cleaned between each resident. During an interview on 05/07/26 at 10:13 AM, Administrative Nurse D stated the nurses were responsible for placing the respiratory equipment in bags after the equipment was cleaned. She stated placing the respiratory equipment in bags was placed on the nursing TAR. Administrative Nurse D stated all equipment should be sanitized between residents, and especially after the equipment was used in an EHB precautions room. She stated all staff have been educated on the sanitation of shared equipment.The facility's Infection Control Policy dated 05/2007 documented it was the policy of this facility to provide supplies and equipment that are adequately cleaned and disinfected.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 76 was assessed for the ability to safely self-administer oral medications before staff left medications in a medication cup in the resident's room. Findings included:- R76's Electronic Medical Record (EMR) documented diagnoses of gastro-esophageal reflux disease (GERD - backflow of stomach contents into the esophagus), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), chronic pain syndrome, seizures (violent involuntary series of contractions of a group of muscles), muscle weakness, dysphagia (swallowing difficulty), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), chronic kidney disease (CKD), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (HTN - elevated blood pressure). R76's Annual Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. She used a walker or a wheelchair for mobility. R76's Care Plan dated 03/23/25 documented R76 had an alteration in self-care related to bowel and bladder incontinence and was at risk for complications due to her decreased functional mobility, pain, seizures, weakness, and dementia. R76 required one staff member to assist her with activities of daily living (ADLs), including bed mobility, dressing, bathing, and personal hygiene. R76's Assessments tab of the EMR lacked evidence the facility assessed R76's ability to safely administer her medications. R76's clinical record lacked a physician's order to keep medications at bedside. On 05/05/26 at 10:12 AM, observation revealed a small plastic cup containing four different medications (two round and two oblong tablets) labeled with R76's first name and last initial sat on R76's breakfast tray. The tray also contained partially eaten breakfast and cups. R76 laid in bed with her eyes closed, facing away from the tray. On 05/07/26 at 09:45 AM, Licensed Nurse (LN) L stated no resident on the second floor of the facility was able to self-administer their medications. LN L said if a resident could self-administer the medications, it would be on the resident's Care Plan. On 05/07/26 at 09:46 AM, Certified Medication Aide (CMA) S stated medications should never be left unattended because it was unknown whether or not the resident would take them or throw them away. On 05/07/26 at 11:50 AM, Administrative Nurse D stated a resident must be assessed to determine whether or not they were permitted to self-administer medications, and that would be documented in their care plan. Administrative Nurse d stated she was not sure which residents were able to self-administer their medications. A policy on Self-Administration of Medications dated 01/2026 documents resident will be assessed to determine if they can safely administer their prescribed medications and will then be documented in the resident's EMR.

Based on observation, interview, and record review, the facility failed to verify the advanced directive (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves) displayed in Resident (R) 16's clinical record accurately reflected her advanced directives for Do Not Resuscitate Directive (DNR- a legal document or order that means the person does not desire resuscitative measures in the event of cardiac arrest). Findings included: - R16's Electronic Health Record (EHR) included diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body), hypertension, anxiety disorder, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).R16's Quarterly Minimum Data Set (MDS), dated [DATE] documented a BIMS of 12, which indicated moderate cognitive impairment. The MDS documented that R16 utilized a wheelchair for mobility. R16 required set-up/clean/up assistance for eating and oral hygiene but was dependent on staff for all other activities of daily living (ADL).R16's Care Plan, dated 01/13/25, did not document R16's advanced directive wishes.R16's EHR, under the scanned documents section, revealed a Do-Not-Resuscitate Directive signed by the resident, with a date of 01/21/25.On 05/05/26 at 01:18 PM, R16's EHR Home tab documented R16's code status (full code or DNR) as full code (indicating full resuscitative measures).R16's EHR had a Physician's Order, dated 02/02/26, that R16 was a full code. This order was discontinued on 05/06/26.R16's EHR had a Physician's Order, with an active date of 05/06/26, that documented R16 was a DNR.On 05/05/26 at 01:18 PM, R16 stated that she was a DNR.On 05/06/26 at 08:28 AM, Certified Medication Aide (CMA) R said that if a resident was a DNR or full code, it showed on the EHR with capital letters. She verified that R16 showed full code. CMA R then verified that R16 had a signed DNR in her EHR.On 05/06/26 at 08:33 AM, Licensed Nurse (LN) G stated that R16's code status showed as full code. She then verified that R16 had a DNR in her EHR that was signed and dated for 01/21/25.On 05/06/26 at 08:41 AM, Administrative Nurse D said that chart audits were performed daily, and the record reviews were performed quarterly, annually and when a significant change occurred. She then verified that R16's chart showed her as full code and that she had an order for Full Code. She then verified that R16 had a signed DNR in the EHR dated 01/21/25.On 05/06/26 at 08:59 AM, Administrative Nurse E said that LN G had notified her earlier that the code status for R16 was wrong. Administrative Nurse E said she then verified that R16 had an order for full code, in conflict with her signed DNR that was in the EHR. She said she then reviewed the EHR and changed R16's code status to DNR to reflect the resident's wishes and DNR documentation. The facility policy Advance Directives, dated 11/2016, documented that a resident's choice about advance directives would be recognized and respected. The policy further documented that the facility recognized and respected the resident's right to choose his/her treatment and make decisions about care received at the end of his/her life.

Based on observation, record review, and interview, the facility failed to ensure that residents were free from all forms of abuse when Resident (R) 132 grabbed R127 by the neck on 04/13/26. Findings included:- R132's Electronic Medical Record (EMR) documented diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), major depressive disorder (MDD - a major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion).R132's Annual Minimum Data Set (MDS), dated 02/11/26, documented he had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented that R132 utilized a walker for mobility.R132's Functional Abilities Care Area Assessment (CAA), dated 02/26/26, documented he was at risk for alterations in self-care related to occasional bowel and bladder incontinence, and required assistance with activities of daily living (ADL) and was at risk for complications as evidenced by decreased functional mobility, MDD, dementia, and bipolar disorder.R132's Care Plan dated 03/04/26, documented that he had verbal behaviors toward staff. R132, when agitated, had verbal or physical altercations and attempted to assist other residents requiring redirection. R132 would insert himself into other resident situations and was easily excitable with loud noise or voices. Staff were directed to intervene when he became agitated before the agitation escalated; staff were to guide him away from the source of distress and engage him calmly in conversation. If R132's response was aggressive, staff were to walk calmly away and approach him later. Staff was directed to assess his understanding of the situation and allow him time to express himself and his feelings toward the situation. The plan further directed staff to document the observed behavior and attempted interventions.A facility report dated 04/13/26, from Administrative Staff A, documented on 04/13/26, at approximately 07:01 PM, R127 was standing at the nurse's station talking with Certified Nurse Aide (CNA) PP. R127 turned to go to her room. As she turned to walk away from the nurse's station, R127 was met by R132 as he walked with his walker out of the dining area toward the nurse's desk. He started to curse aloud stating, This is my walker, this is my walker. R132 then grabbed R127 by her neck and caused a small scratch near her left eye. The residents were immediately separated without incident. Licensed Nurse (LN) G immediately notified R127's representative. The facility provider was notified of the incident; orders were received, and R132 was immediately placed on one-on-one (1-on-1) supervision by facility staff. R132's guardian was notified of the incident. R132 remained on a 1-on-1 for 72 hours without further incident. Speech therapy completed a new BIMS, St. Louis University Mental Status (SLUMS - screening tool used by clinicians to detect mild cognitive impairment and dementia), and a Brief Cognitive Assessment Tool (BCAT - a multi-factorial test used by health professionals to measure cognitive functioning, specifically executive function and contextual memory in older adults) on R132. The results of these assessments indicated significant cognitive impairment and mild stage dementia. A psychiatric assessment was completed on R132, and he stated that he did not recall the event, expressed remorse, and said that if he did act in that manner, he was truly sorry and did not understand why he would have done so. Social services met with R127, who had no recollection of the event and said she was safe and doing well with her peers. Social services completed interviews with three alert residents on the same floor, each resident expressed no concerns, and each felt safe.A witness statement dated 04/13/26 from CNA PP documented that on 04/13/26, while sitting at the nurse's station talking with R127, R132 walked up behind R127 yelling this is my walker and he his hands on R127. CNA PP came from behind the nurse's station and separated the two.A witness statement from LN K, dated 04/13/26, documented she was doing the nighttime insulin (a hormone that lowers the level of glucose in the blood) when she heard staff telling residents to separate from each other. She documented that by the time she got to the incident, the residents were separated, and staff told her what had occurred.A witness statement dated 04/14/26 from CNA QQ documented that on 04/13/26, she was sitting in the sensory room when she heard CNA PP yell hey stop and CNA PP ran around the nurse's desk, and CNA QQ got up and followed CAN PP, and she saw R132 and R127 standing face to face, and CNA QQ observed R132 hands on R127's neck. CNA PP and CNA QQ separated R132 and R127.A Nursing Progress Note dated 04/20/26 at 03:20 PM from Administrative Nurse KK, documented that approximately 01:30 PM, Administrative Nurse KK heard loud yelling in the hallway while standing in the medication room. Administrative Nurse KK then opened the door and ran out of the medication room and saw R132 pushing a female resident down. Administrative Nurse KK redirected R132 and noted that he was bleeding from a scratch to the left side of his face, on his nose. The nurse on duty assisted and then took over assessing the female resident that was on the floor. Administrative Nurse KK helped R132 back to his room, where vitals were taken, and first-aid was applied to the scratch on his face. A staff member was assigned to this resident for 1-on-1. The progress notes then documented the administrator, director of nursing (DON), provider, and resident representative were notified.A Social Services Progress Note in the EMR dated 04/21/26 at 09:15 PM documented R132 had been seen on 04/20/26 by psychiatry services due to his recent behaviors. The progress notes further documented that the assessment had been unable to be completed because the more questions asked, the more agitated the R132 became and he was unable to answer. It was documented that R132's impairment in judgement and decision making was severe and due to cognitive impairment, treatment was unable to be carried forward.A Social Services Progress Note in the EMR dated 04/21/26 at 11:33 AM, documented the psychiatric hospital intake called and advised they had accepted R132. The progress notes further documented that the R132's guardian had been notified that he had been accepted to the psychiatric hospital.On 05/07/26 at 10:52 AM, CNA N stated the facility provides abuse and dementia training often but could not recall when the most recent training had occurred. CNA N further stated that when there was an altercation with residents, they were immediately separated, and staff made sure everyone was safe. The nurse would be notified if they were not present and staff would keep the residents separated.On 05/07/26 at 10:57 AM, LN H stated the residents would immediately be separated, then assessed to check for any injuries if an altercation had occurred between them and taken to safety. The director of nursing, administrator, physician, and resident representatives would have then been notified. LN H said the initiator of the incident would have been placed on 1-on-1 with staff until all necessary assessments had been completed and doctor orders received.On 05/07/26 at 11:39 AM, Administrative Nurse D stated R132 had not had any previous incidents with any residents before the incident on 04/13/26. Administrative Nurse D said R132 was followed by psychiatry and had some adjustments made to his medications, and was not aware that another incident had occurred with him. Administrative Nurse D also said the provider was in the facility six out of seven days of the week. Administrative Nurse D further stated R132 was sent out of the facility on 04/21/26 due to increased behavior and agitation.The facility's Abuse: Prevention of and Prohibition Against policy, revised on 04/2025, documented it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. It was also the policy of the facility to recognize the resident's right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This also included taking, keeping, using, or distributing photographs or video recordings of residents in any manner that would demean or humiliate them, regardless of consent provided or the resident's cognitive status.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 122 received the assistance he needed with eating. Findings Included:- R122's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (HTN-elevated blood pressure, and obesity, need for assistance with personal care, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R122 had an impairment of the extremities on both sides of his body. The MDS documented R122 needed substantial/maximal assistance in eating.R122's Communication Care Area Assessment dated 03/25/26 documented R122 had alteration in communication and was at risk for complications following a CVA. R122 was unable to speak.R122's Care Plan documented:03/19/26-Staff to provide R122 with a regular diet with pureed texture.03/25/26-R122 was provided with a mechanically altered diet, on thickened liquids for weight loss.05/01/26-R122 needed substantial/maximal assistance of one person for oral hygiene.R122 needed substantial/maximal assistance of one person with assistance with eating.On 05/04/26 at 08:34 AM, R122 sat up in his bed. R122's breakfast tray sat on his bedside table. R122 scooped hot cereal from a white divided tray. R122 had white food dripping down his chin, the right side of his mouth, and his neck into his gown. R122 was in his room eating by himself; there were no staff in his room assisting. On 05/05/26 at 08:26 AM, R122 was in bed. R122's breakfast tray sat on his bedside table. R122 was attempting to eat hot cereal from a white, divided plate. R122 dripped the cereal down his chin onto his neck and over his gown. R122 was in his room eating by himself; there were no staff in his room to assist R122.On 05/07/26 at 08:05 AM, Certified Nurse's Aide (CNA) M stated R122 did need staff monitoring while he was eating, and said the staff just know him and know he had problems with swallowing. She stated she would know if a resident needed assistance by looking at the Kardex (nursing tool that gives a brief overview of the care needs of each resident).On 05/07/26 at 9:06 AM, Licensed Nurse (LN)H stated staff have access to the Kardex and the plan of care for each resident. LN H stated staff would look at Kardex and know if a resident needed assistance or monitoring when eating. LN H stated she normally did not work the hall R122 was on, but she would read the residents care plan and let CNAs know they should check him while he was eating.On 05/07/26 at 10:13 AM, Administrative Nurse D stated if a resident needed monitored or needed assistance that would be care planned. She stated all staff have access to the care plans and to Kardex. She stated staff would be able to look at the residents' charts to see how much assistance a resident needed. Administrative Nurse D stated if the residents care plan stated they should have one assistant while eating, the staff should assist that resident.The facility's Quality of Care dated 10/23 documented It was the policy of the facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities.

Based on observation, interview, and record review the facility failed to provide Resident (R) 31 the necessary activities of daily living (ADL) cares including hygiene assistance with cleaning his fingernails. Findings:- Review of the Electronic Health Record (EHR) revealed that R31's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, major depressive disorder (major mood disorder that causes persistent feelings of sadness), seizures (violent involuntary series of contractions of a group of muscles), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).R31's admission Minimum Data Set (MDS), dated 07/17/25, documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognitive impairment. He required a wheelchair for mobility; he was dependent on staff for bathing and hygiene care, and all other ADL.The Functional Abilities Care Area Assessment (CAA), dated 07/17/25, documented R31 required assistance with ADLs and was at risk for complications.R31's Care Plan for ADLs, dated 07/11/225 with latest review date of 04/18/26, instructed staff he was dependent on staff assistance of one for bathing. The plan lacked instructions to staff regarding nail care.R31's EHR, under the Tasks for nails, lacked evidence R31 received nail care from 04/07/26 to 05/07/2026. There were no documented refusals from 04/07/26 to 05/07/26.R31's EHR, under the Progress notes lacked evidence R31 refused nail care.R31s EHR, under Tasks for bathing, documented he received bathing eight times in the month of April 2026 and two times in the month of May 2026.Observation on 05/06/26 at 09:19 AM, R31 had a brown substance on both right and left hands on the fingertips and underneath the fingernails.Observation on 05/07/26 at 08:19 AM, R31 had a brown substance on right and left hands, on the fingertips, and underneath the fingernails.Interviewed on 05/06/26 at 09:55 AM, R31 reported that he would not mind if staff cleaned his fingertips and fingernails. R31 reported that staff did not ask him if he wanted his nails cleaned.Interviewed on 05/06/26 at 11:03 AM, Licensed Nurse (LN) J reported R31's nail care could be provided by the support staff. LN J reported she had not been alerted by staff that R31 had refused nail care. On 05/07/26 at 08:19 AM, with Certified Medication Aid (CMA) S reported R31's nails were dirty with a brown substance that might be food. She stated that activities did nail care. CMA S verified that a resident's nails should never look like R31's nails looked.On 05/06/26 at 10:54 AM, Certified Nursing Assistant (CNA) P stated staff should clean R31's nails if he wanted them cleaned.On 05/07/26 at 08:28 AM, CNA Q stated activities staff would clean R31's nails sometimes, but it should be done during showers as that was the best time to clean nails.On 05/07/26 at 08:35 AM, Activity Staff AA stated staff did nail care for the residents every other Wednesday.On 05/07/26 at 08:40 AM, Activity Director Z stated activities staff normally did spa days every other Wednesday, which included cleaning underneath the nails and soaking nails to remove dirt and debris from underneath the nails. Activity Director Z said no one had reported that R31 needed his nails cleaned.On 05/07/26 at 09:58 AM, Administrative Nurse D stated nail care can be provided with the shower and said staff chart nail care under resident Tasks. The facility policy Nail Care of Finger and Toe, dated 05/2007, documented that it is the policy of this facility to clean the nail bed, keep nails trimmed, and prevent infections.

Based on observation, interview, and record review, the facility failed to provide consistent activities for Resident (R) 10. Findings included: - The Electronic Health Records (EHR) for R10 included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (common motor deficits affecting one side of the body following a cerebral infarction [stroke]), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and aphasia (condition with disordered or absent language function).R10's Annual Minimum Data Set (MDS), dated 09/10/25, documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive impairment. The MDS documented that R10 used a wheelchair for mobility and was dependent on staff for all activities of daily living (ADL). The MDS documented that R10 had an indwelling urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) and a percutaneous endoscopic gastrostomy tube (PEG - a flexible feeding tube placed through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications tube) for feeding. Further MDS documentation revealed that it was very important for R10 to listen to music she liked, not very important to do group activities, and that her primary respondent for daily and activity preferences was family or her significant other.R10's Communication Care Area Assessment (CAA), dated 09/10/25, documented R10 was rarely and never understood when she tried to express ideas and that rarely and never understood verbal expression.R10's Quarterly MDS, dated 03/13/26, documented a BIMS of one, which indicated severe cognitive impairment. The MDS documented that R10 used a wheelchair for mobility and was dependent on staff for all ADL. The MDS documented that R10 had an indwelling urinary catheter and a PEG tube for feeding. R10's Care Plan, dated 04/14/26, documented that R10 was dependent on staff for activities, cognitive stimulation, and social interactions. An intervention, dated 04/21/26, instructed staff that her preferred activities included listening to country music, old rock and roll from the 1980's, being outdoors, parties, getting her nails done, watching television, and pets. An intervention dated 04/21/26 instructed staff to record prior level activity involvement and interests by talking with R10, caregivers, and family on admission and as necessary. Other interventions, dated 04/21/26, instructed staff to provide one to one bedside/in-room visits and activities if R10 was unable to attend out of room events, and staff were to provide a program of activities that was of interest and empowered her by allowing choice, self-expression, and responsibility.The One-to-One lists, dated 04/12/26 to 05/02/26, l R10 was to receive activity three times weekly. It was documented that R10 received activity on 04/14/16, 04/22/26, and 04/29/26. There was no documentation of activity refusal recorded.R10's EHR Activity Progress Note, dated 04/14/26, documented R10 had no changes since the last report and that she was offered one to one room visits for sensory stimulation. The note also documented that R10 would not wake up for visits and did not want to be bothered. The progress notes further documented that R10 enjoyed people-watching at times and observing some group activities when she was awake and out of bed. Observed on 05/05/26 at 09:36 AM, R10 rested in her bed and had the television on. A sign on the wall read that staff were to get R10 up and into her wheelchair three times weekly with the Hoyer lift.Observed on 05/06/26 at 09:10 AM, R10 was lying in bed with her television on, there were no staff present. A bible study activity was performed in the facility common area.Observed on 05/06/26 at 02:37 PM, R10 remained in her room, in bed with the television on.On 05/07/26 at 08:02 AM, Licensed Nurse (LN) I stated that one-to-one activities were provided by the activity staff, and she was unsure when or how often this was provided.On 05/07/26 at 09:17 AM, Activity Z said that the one-to-one residents were assigned an activity person, and those individuals were responsible for performing the one-to-one activity. She then said that the activity person recorded the activity performed on a one-to-one document sheet, if the resident refused an activity that was also to be documented. Activity Z then verified that R10 had been offered activities once weekly, 04/12/26 to 05/02/26, and there was no refusal documented, and she then said that the activity staff had not been documenting refusals. Activity Z then stated that if the resident required a Hoyer lift transfer and wanted to participate in a group activity, then the activity staff would coordinate with the nursing staff to get the resident up for the activity.On 05/07/26 at 09:22 AM, Certified Nurse Aide (CNA) O said that CNAs and activity personnel provided a joint effort when offering and getting Hoyer residents up for activities. She said if it was an activity person, then that person notified the CNA or nurse staff to get the resident up for an activity. CNA O then said that if the resident refused to attend or get up, there was no real way for it to be charted.The facility policy Activities Programming, dated 04/2025, documented that it was the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. The policy also documented that activities may be facility-sponsored group or independent.

The facility census totaled 126 residents. Based on observation, interview, and record review, the facility failed to ensure a safe environment free from accidents and hazards when staff left a cognitively impaired resident by herself in the shower, resulting in a fall with injury. (Resident 127) Findings included:- Review of the Electronic Health Record (EHR) for Resident (R) 127 revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, cognitive communication deficit (an impairment in organization, sequencing, memory and attention, memory, planning, problem-solving and safety awareness), and iron deficiency anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The 03/19/26 Annual admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The Care Plan dated 03/12/26 for R127 revealed due to the alteration in self-care due to her unsteadiness on her feet, and her decrease in functional mobility and dementia, R127 required one staff to assist with Activities of Daily Living (ADLs). The 03/19/26 Falls Care Area Assessment (CAA) documented R127 was a risk for falls related to bowel and bladder incontinence; she also required staff assistance with ADLs and was at risk for complications because of her decreased functional mobility, unsteadiness on her feet, and dementia. The Progress Note on 05/06/26 at 03:17 PM by Administrative Nurse D documented the facility's fall investigation, revealing Certified Nurse Aide (CNA) NN left R127 unattended in the shower on 05/04/26. CNA NN returned from retrieving supplies and found R127 lying face down in the shower. Staff notified the second-floor nurse, who noted R127 had a pulse, blood was noted from the left side of her face, as well as emesis (vomit) from her mouth. The staff called Emergency Medical Services (EMS), and the resident was responsive at the time of EMS' arrival on scene, per documentation by the Fall Committee Interdisciplinary Team (IDT) Progress Note. R127 transferred to a local hospital, where she was evaluated and treated for the fall sustained in the shower. R127 required one stitch to close her lower lip laceration due to the fall. During an interview on 05/07/26 at 10:48 AM, CNA Q stated she did not think any resident on the second floor should be left alone in the shower, but especially not R127. During an interview on 05/07/26 at 11:32 AM, CNA MM stated R127 should not be left alone in the shower. CNA MM stated he gets along with R127 well, and R127 let him assist with the washing processes without any difficulty. R127 was observed walking slowly to the nurse's station at 11:36 AM. She was smiling and had a bruised and swollen lower lip with a stitch visible to the left side of her lip. R127 stated her lip was tender, but she wasn't sure why. During an interview on 05/07/26 at 12:44 PM, Licensed Nurse (LN) J stated R127 was a resident who should not be left alone, even if R127 or any other resident insisted on being left alone for privacy. The facility's Providence Policy revised on 10/2023, documents residents unable to carry out ADLs will receive assistance in good nutrition, grooming, personal, and oral hygiene. - R56's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS document R56 needed set up or cleanup for eating and substantial/maximal assistance with bathing and oral care, and was dependent on staff for toileting. The MDS documented R56 had one fall without injury during the observation period. The Falls Care Area assessment dated [DATE] documented R56 was at risk for falls related to bowel and bladder incontinence and required assistance with activities of daily living (ADLs). The CAA documented R56 was at risk for complications due to decreased functional abilities and Alzheimer's disease. R56's Care Plan documented the following: 06/22/23- Staff was to ensure R56's call light was within her reach and to encourage her to use the call light. 12/01/25- R56 would have nonskid strips on the left side of her bed. 01/07/26- R56 would have a toilet riser. On 05/05/26 at 08:40 AM, R56 laid on her bed on her back. R56 was yelling out for help. R56's call light laid curled up at the bottom of her bed. R56's call light was not within her reach. R56 did not have a toilet riser or non-skid strips to the left side of her bed as care planned On 05/06/26 at 11:10 AM, R56 sat in her wheelchair in front of her bed. R56's call light was behind her bed. R56's call light was not within her reach. R56 did not have a toilet riser and did not have non-skid strips to the left of her bed as care planned. On 05/07/26 at 08:42 AM, Certified Nurse Aide (CNA)M stated call lights should be within the reach of the resident. She stated the call light should not be at the bottom of the bed, out of reach of the resident. CNA M stated she would know what fall interventions were in place for any resident, by looking at the resident's care plan or Kardex (nursing tool that gives a brief overview of the care needs of each resident). She verified the nonskid strips were not in place, and there was not a stool riser anywhere in the resident's room. On 05/07/26 at 09:06 AM, Licensed Nurse (LN) H stated call lights should be within the reach of the resident. LN H stated if the care plan stated a resident should have a stool riser, and skid strips, they should be in place. She stated she was unsure who would get the stool riser, or who would place the skid strips. LN H stated any staff could report to the Director of Nursing to let her know fall interventions were not in place or available. On 05/07/26 at 10:13 AM, Administrative Nurse D stated all nursing staff have access to the resident's care plan. She stated R56 had moved rooms, and her fall interventions were not moved with her. Administrative Nurse D stated it was all nursing staff's responsibility to ensure each resident had what they needed, and what was care planned for each resident. The facility's Falls Management System dated 04/25 documented It was the policy of the facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when staff failed to properly secure a medication cart. Findings included:- Observed 05/06/26 at 08:17 AM on the second floor, a large rolling medication cart sat in the hall, unattended, with the lock partially pushed in. It contained stock bottles of medications, cards of resident-specific medication, and personal drink cups. In an interview on 05/06/26 at 08:19 AM with Licensed Nurse (LN) L, she confirmed she thought the cart was locked and stated the medication cart should always be locked when it is unattended or out of sight. The requested facility policy, Medication Labels and Storage, dated 03/2024, did not address the resident medication carts.

Based on observation, record review, and interviews, the facility failed to ensure a functional call light system for Resident (R) 111 while he was on or in bed, in order to convey his needs to staff. Findings included:- R111's Electronic Medical Record (EMR) showed a diagnosis of generalized muscle weakness, difficulty walking, and unsteadiness on feet.R111's Care Plan dated 08/25/2025 stated R111 was at risk for falls related to occasional bladder incontinence and he required assistance with activities of daily living (ADL)s He was at risk for complications as evidenced by decreased functional mobility and dementia (decline in cognitive functioning The plan directed staff to be sure the call light was within reach and encourage the resident to use it to call for assistance as needed.Observed on 05/05/2026 at 10:25 AM, R111's call light was at the head of his bed. R111 sat on the edge of the bed. R111 stated he was trying to get some help, but no one was coming. A check of the call light within reach of R111's bed revealed the light did not come on at the door or at the monitor where staff watch for call lights when the button was activated. Observed on 05/06/2026 at 08:19 AM, R111 self-propelled his wheelchair to the dining area for breakfast. His call light laid on the bed, but upon further check, the call light still did not alert at the monitor or above the room door.Observed on 05/06/2026 at 01:44 PM, R111 laid in bed awake. When asked if he used the call light to summon staff, R111 picked up the call light next to his bed and pushed it. The call light still did not alert at the monitor or above the room door. During an interview on 05/06/2026 at 02:54 PM, Certified Nurse Aide (CNA)P stated that she was not aware R111's call light was not working or how long it had been like that as he did not use it very often. She said she would inform the nurse, as that is the facility protocol.During an interview on 05/06/2026 at 03:07 PM, CNA RR stated that anyone could place a work order in the computer if they needed something fixed. CNA RR placed the work order since the nurse was at lunch. During an interview on 05/06/2026 at 04:05 PM, Maintenance U stated that after a staff member placed a work order in the system, it would show up on his phone and alert him. He stated he had a work order in his system that showed up for the call light not working in R111 room. The facility did not provide a policy for a functional call light system.

Based on interviews, record reviews, and observation, the facility staff failed to ensure a safe, sanitary, and functional environment on one of the stairwells. Findings included:- Observed on 05/07/2026 at 08:30 AM, one of the stairwells had a white, wet, organic type substance on the walls with a strong musty odor. There was dusty debris, which appeared to be flaked plaster, on the handrail and the floor at the back wall of the stairwell. There were stains which appeared to be water damage on the ceiling inside the stairwell.Interviewed on 05/07/2026 at 08:37 AM, Housekeeping Staff stated that housekeeping staff were responsible for cleaning the floors and handrails in the stairwell, but not the walls and ceilingsInterviewed on 05/07/2026 at 08:40 AM, Maintenance Staff U stated the maintenance department would be responsible for cleaning the walls of the stairwell. He said he would get a plan in place to spray the white substance on the walls with bleach to clean it.During an interview on 05/07/2026 at 08:40 AM, Administrative Staff A stated the white substance on the wall developed due to increased moisture from a leak in the roof, which had not yet been fixed. She stated that maintenance was responsible for cleaning the walls and said she submitted an order for it to be repaired. She reported she would follow up and see what is going on with the bid. During an interview on 05/07/2026 at 09:15 AM, Administrative A verified there would be someone there at noon that day to look at it around noon and get a plan of action in place. The facility's policy [NAME] 25 Safe and Homelike Environment dated 02/2022 stated it was the policy to ensure that resident's that reside here are provided the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility identified a census of 123 residents. The sample included 25 residents, with seven reviewed for reasonable accommodation of needs related to call lights and wheelchair foot pedals. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 84 had a call light he could functionally activate for staff assistance and ensure R96, R47, and R81 had foot pedals on their wheelchairs while being pushed. The facility additionally failed to provide R10's sensory hand item.Findings Included:- On 11/18/25 at 08:55 AM, R84 (severely cognitively impaired resident) sat in his bed with his bedside table over him. He stated he was done with his breakfast tray and needed staff to assist him. R84's call light was placed inside the dresser next to his bed and out of his reach. R84's low air-loss mattress was set to 200 pounds (lbs). On 11/18/25 at 09:00 AM, R96 (severely cognitively impaired resident) was pushed into the dining room in his wheelchair. His feet slid on the floor as he was pushed from his room to the dining room table. His wheelchair had no foot pedals attached. On 11/18/25 at 01:02 PM, R96, R47 (severely cognitively impaired resident), and R81 (severely cognitively impaired resident) were pushed from their rooms to the dining room table without foot pedals. Their feet slid on the ground as staff pushed them in their wheelchair. On 11/19/25 at 09:55 AM, Certified Nurse's Aide (CNA) M stated staff should use the foot pedals while pushing the residents in their wheelchairs. On 11/19/25 at 10:00 AM, Licensed Nurse (LN) G stated all residents had foot pedals for their wheelchairs and staff were expected to use them while pushing the residents. On 11/19/25 at 12:05 PM, Administrative Nurse D stated staff were never to allow the residents' feet to drag while being pushed in their wheelchairs. The facility's Fall Management System, dated 06/2018, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated that the facility assessed and provided the appropriate equipment to ensure resident safety. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred. - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA: stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing, need for assistance), and dysphagia (swallowing difficulty, and contracture- abnormal permanent fixation of a joint). The Annual Minimum Data Set (MDS) for R10, dated 08/16/25 recorded a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R10 had an impairment in his upper and lower extremities on one side of his body. The MDS documented R10 required staff assistance for all activities of daily living (ADL). The MDS documented that R10 had a tracheostomy (an opening through the neck into the trachea, through which an indwelling tube may be inserted) and a tube feeding (the administration of nutritionally balanced, liquefied foods or nutrients through a tube). R10's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/16/25 documented R10 had an alteration in cognition related to dementia (progressive mental disorder characterized by failing memory and confusion). The CAA documented R10 was at risk for complications due to restricted mobility and being unable to communicate. R10's Care Plan, revised on 08/29/25, documented the following: - R10 had a self-care performance deficit related to bowel and bladder incontinence and required assistance with ADLs and decreased functional mobility. - R10's would maintain his current level of function in total dependence on staff with ADLs. - R10's plan of care dated 01/02/24 documented staff were to ensure R10 had one of his sensory objects in his right hand while in bed. - R10 would pull on his tracheostomy; and pull out the feeding tube and swing it around. - R10's wife preferred the flashlight be placed in R10's right hand. On 11/17/25 at 07:55 AM, R10 laid in his bed on his back with his eyes closed. R10's sign on his wall stated, Place sensory object in R10's hand, while he was in bed. R10 did not have a sensory object in his right hand. R10's right hand was placed on his abdomen. On 11/18/25 at 08:19 AM, R10 laid in his bed on his back with his eyes open. R10's head was turned to his room door. R10's hand was under his sheet. R10 did not have a sensory object in his right hand. On 11/19/25 at 11:48 AM, Certified Nurse's Aide (CNA) stated any staff walking into R10's room should notice he did not have a sensory object in his right hand and place an object in his hand. She stated all staff were responsible for putting a sensory object in R10's hand. On 11/19/25 at 11:58 AM, Licensed Nurse (LN) K stated all facility staff can put an object in R10's hand. She stated there was a sign on his wall to apply a sensory object while he was in his bed. LN K stated it was the nurse's duty working R10's hall to ensure all tasks were completed for each resident. On 11/19/25 at 12:04 PM, Administrative Nurse D stated all staff can read the sign and ensure there was a sensory object placed in R10's right hand. She stated it was ultimately the nurses' responsibility to ensure tasks were done. The facility's Accommodation of Needs policy, reviewed 08/2024, documented it was the policy of the facility to ensure that a resident had the right to reside and receive services in the facility with reasonable accommodation for individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

The facility had a census of 123 residents. The sample included 25 residents, with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. The facility additionally failed to follow Resident (R) 61 and R67's implemented fall interventions per their care plans.Findings Included: - On 11/17/25 at 07:10 AM, a walkthrough was completed in the facility's secured 2nd floor, and the following was observed: An inspection of an unsecured linen closet next to the nurse's station next to the elevator, revealed a container of purple disinfectant wipes on top of the room's counter. An inspection of the dining area revealed a cabinet next to the seating area with a container of purple wipes stored in the upper cabinet. An inspection of an unsecured soiled utility closet next to the rear nurse's station revealed two overfilled Sharps containers with syringes. An inspection of an unsecured shower room next to the rear nurse's station revealed a spray bottle of disinfectant. On 11/17/25 at 07:50 AM, Licensed Nurse (LN) G secured the doors and stated the rooms with potentially hazardous chemicals were supposed to be secured. She stated the residents were not to have access to secured areas. On 11/19/25 at 12:05 PM, Administrative Nurse D stated staff were expected to ensure hazardous chemicals were locked up and not accessible to the residents. The facility's Fall Management System policy, dated 06/2018, documented the facility was committed to promoting resident autonomy by providing an environment that remained as free of accident hazards as possible. Each resident was assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. The facility provides each resident with appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. The resident's care plan would be updated. - R61's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R61's Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R61 needed staff setup or clean up assistance for eating, was dependent on staff for toileting and bathing, and needed partial/moderate assistance by staff for dressing, chair to bed transfer, and toilet transfers. The MDS documented R61 had no falls since admission/entry. R61's Falls Care Area Assessment (CAA) dated 08/25/25 had bowel/bladder incontinence and required assistance with ADLs and was at risk for complications due to dementia, severe cognitive impairment, decreased functional mobility, and anxiety. R61's Care Plan documented the following fall interventions: 11/21/24 - Staff to ensure the call light was within reach and encourage R61 to use it to call for assistance. 03/10/25 - Change Dycem (a non-slip material used for sliding in chairs) to a one-way slide. On 11/18/25 at 01:49 PM, R61 laid on her bed on her back, R61's fall mat was in place, and the bed was in a low position. R61's call light laid at the top of her bed under her pillow. R61's call light was out of her reach. R61's wheelchair was on her right side next to her bed. R61 did not have a Dycem in her wheelchair. On 11/19/25 11:48 AM, Certified Nurse's Aide (CNA) N stated call lights should always be within a resident's reach. She stated therapy took care of all the Dycem and ensured that Dycem was in each resident's wheelchair as ordered. On 11/19/25 at 11:58 AM, Licensed Nurse (LN) K stated therapy was responsible for putting the Dycem in the resident's chair; she was unsure who was responsible for ensuring the Dycem remained in the resident's chair. LN K stated that a resident's call light should always be within a resident's reach. On 11/19/25 at 12:04 PM, Administrative Nurse D stated it was the therapy department that put the Dycem in the wheelchair. She stated it would be any staff member's responsibility that put R61 in her wheelchair to check that the Dycem was in the chair. Administrative Nurse D stated the call light should be placed where the resident could reach it to use it. The facility's Fall Management System policy, dated 06/2018, documented that the facility was committed to promoting resident autonomy by providing an environment that remained as free of accident hazards as possible. Each resident was assisted in attaining or maintaining their highest practicable level of function through providing the resident with adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. The facility provides each resident with appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. The resident's care plan would be updated. - The Electronic Medical Record (EMR) for R67 documented diagnoses of unsteadiness, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), history of falls, and muscle weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented R67 had intact cognition. R67 required supervision from staff for showers, dressing, mobility, transfers, and did not ambulate. The assessment documented R67 had no functional impairment and had no falls. R67's Quarterly MDS dated 10/21/25 documented R67 had intact cognition. R67 required supervision with showers, dressing, mobility, transfers, and ambulation. The assessment documented R67 had no functional impairment and had one fall with injury. R67's 10/15/25 Care Plan included the following fall interventions: 01/12/24 – Supervision assistance with transfers. Be sure her call light was within reach and encourage her to use it to call for assistance as needed. 01/29/24 – Staff educated that R67 was not allowed to be in the shower room alone. 05/03/24 - Supervision assistance with her front-wheeled walker. 09/29/25 – Staff educated to assist R67 with placing her oxygen tank in proper bags on her wheelchair or walker for ambulation purposes. R67's Fall Assessments dated 07/11/25 documented R67 was a medium risk for falls. The Fall Investigation dated 09/29/25 documented on 09/29/25 at 07:23 PM, R67 had a witnessed fall while coming back into the facility from a smoke break. R67 pushed her walker and oxygen tank. When the tank tipped, she fell. R67 complained of neck and right knee pain. R67 sustained an abrasion (scrape) to her right knee. The investigation documented R67 had a gait imbalance and was educated to ask for assistance and for her oxygen tank to be placed in the bag on her walker. The investigation further documented that staff were educated to assist R67 with placing the oxygen tank into the proper bag on her walker or wheelchair. On 11/18/25 at 11:00 AM, R67 ambulated down the hall with unidentified therapy staff. R67 used a walker and had a small oxygen tank in a pouch on the front of her walker. On 11/18/25 at 02:30 PM, Certified Nurse Aide (CNA) M stated R67 was independent with ambulation except when going to the shower, and staff are to supervise her. CNA M further stated that she was unaware of any falls that R67 might have had. On 11/18/25 at 08:30 AM, Licensed Nurse (LN) J stated R67 used a walker and supervised when she ambulated. LN J further stated that she was unaware of any falls for the resident. On 11/19/25 at 09:45 AM, Administrative Nurse D stated staff should make sure R67's oxygen tank was in the pouch of the walker and supervise her when ambulating. The facility's Fall Management System policy, dated 06/2018, documented the facility was committed to promoting resident autonomy by providing an environment that remained as free of accident hazards as possible. Each resident was assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. The facility provides each resident with appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. The resident's care plan would be updated.

The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 67 had a physician's order and was assessed for the ability to safely self-administer an inhaler medication.Findings included:- The Electronic Medical Record (EMR) for R67 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute and chronic respiratory failure with hypercapnia (when the body can't effectively get rid of carbon dioxide because of persistent lung disease).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R67 had intact cognition. R67 required supervision with showers, dressing, mobility, transfers, and ambulation. The assessment documented R67 received an antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), and hypoglycemic (a medication to treat low blood sugars) medication.R67's 10/16/25 Care Plan included the following interventions for COPD:01/12/24 - Administer nebulizer treatments as ordered, give oxygen therapy as ordered by the physician, and monitor for signs and symptoms of acute respiratory insufficiency.06/16/25 - Administer inhalers as ordered.The Physician's Order dated 07/11/25 directed staff to administer fluticasone-umeclidinium-vilant (used to help control the symptoms of asthma and improve lung function) 100-62.5-25 micrograms (mcg)/act, one inhalation, orally, daily for COPD. The EMR documented that the inhaler was scheduled for 07:00 AM daily.On 11/18/25 at 08:10 AM, Licensed Nurse (LN) I handed R67 the inhaler, did not provide instructions on how to use it, turned and went out to the cart to get applesauce to mix into R67's medication. R67 tried to inhale and found that the inhaler was empty. LN I came back into the room, and R67 handed her the inhaler and stated it was empty. LN I had R67's medication for her breathing treatment and told R67 that she was going to put the medication in the nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) and to make sure that she took it after she ate. As LN, I started to put the medication into the nebulizer machine, she asked me if it was ok that she leave it. This surveyor told her that I did not know and asked what the facility policy was. LN I stated, she would return after R67 finished her meal to administer her breathing treatment. On 11/18/25 at 08:20 AM, LN I stated that she would contact the physician to tell her that R67 had not received her inhaler as scheduled. LN I stated staff should have seen that the inhaler was almost empty and should have reordered it. LN I stated that she was not sure if R67 had an assessment to make sure she was able to administer her inhaler independently, but felt she could since R67 was cognitively intact. LN I further stated that they leave her breathing treatment medication at her bedside all the time, and she always took it.On 11/19/25 at 09:43 AM, Administrative Nurse D stated staff should have reordered the inhaler, and she would not have missed her scheduled dose. Administrative Nurse D verified that R67 did not have an assessment for self-administration of medications and should not have been given the inhaler to self-medicate.The facility's Self-Medication of Medications policy, dated 01/2025, documented the clinician would provide an opportunity for the patient to administer his/her own medications. The medications listed at the time of admission and recertification would be considered part of the plan of care. Staff assess the patient's ability to self-administer medications correctly and document the patient's response and understanding to teaching.

The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed, due to her posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), to provide only female caregivers that were requested, for Resident (R) 82. Findings included:- The Electronic Medical Record (EMR) for R82 documented diagnoses of PTSD and insomnia (inability to sleep).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R82 had intact cognition. R82 was independent with dressing, personal hygiene, mobility, transfers, and ambulation. The assessment documented R82 had no behaviors and did not receive psychotropic medications.R82's Care Plan dated 09/27/25, initiated on 06/27/25, documented social services to provide psychosocial support as needed. The care plan lacked documentation R82 requested no male caregivers.The Social Services Assessment dated 07/06/25 documented R82 had a diagnosis of PTSD and had been abused by her ex-husband, and stated the abuse was primarily emotional, mental, and financial. The assessment documented R82 preferred no male caregivers, and her trigger was loud noises. The assessment documented R82 refused psychiatric services at that time.The Social Services Assessment dated 10/06/25 documented R82's trauma had been identified in the previous assessment and had not changed, and to refer to her care plan. The assessment documented R82 understood the importance of having social interaction, and no new needs were identified. The assessment lacked documentation R82 was offered psychiatric services.On 11/18/25 at 07:45 AM, R82 in bed working on her computer. R82 stated she did not have concerns with her care and liked to be in her room on her computer.On 11/18/25 at 01:00 PM, Licensed Nurse (LN) J stated she was unaware R82 had PTSD or of any residents on the first floor that had PTSD. LN J further stated she was unaware that R82 preferred not to have male caregivers.On 11/18/25 at 03:30 PM, Social Service X stated she had been unaware that the resident's request for no male caregivers was not on the care plan. On 11/19/25 at 08:20 AM, CNA O stated he had just been made aware R82 did not want any male caregivers and had assisted her many times in the past.On 11/18/25 at 03:45 PM, Administrative Nurse E stated that R82's request for no male caregivers should be on the care plan, and verified it was not.On 11/19/25 at 09:45 AM, Administrative Nurse D stated R82's PTSD and triggers should have been on the care plan before yesterday. Staff should have been made aware that the resident had PTSD and that she preferred female caregivers. The facility's Resident Rights policy, dated 10/04/23, documented that as a resident of the nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident had the right to exercise their rights without interference, coercion, discrimination, or reprisal from the facility. The resident had the right to be treated with respect and dignity and receive services in the facility with reasonable accommodation of the need and preferences, except when to do so would endanger the resident or other residents.

The facility identified a census of 123 residents. The sample included 25 residents, with one resident reviewed for the discharge process. Based on record review and interviews, the facility failed to provide a final summary of Resident (R) 128's status at discharge. Findings included:- R128s Electronic Medical Records (EMR) documented diagnoses of unsteadiness on feet, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), dependence on renal dialysis (a procedure where impurities or wastes are removed from the blood), acquired absence of left great toe, blindness right eye muscle, and dysphagia (swallowing difficulty).R128's Entry Minimum Data Set (MDS) completed 09/18/25.R128's Care Plan dated 09/18/25 documented:- R128 wanted to be discharged home after his skilled stay in the facility. - R128's plan of care dated 10/03/25 documented a pre-discharge plan would be held with the resident, family caregivers, to evaluate progress and revise the discharge plan as needed.R128's EMR under the Assessment tab for the Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitionR128's EMR under Fall Committee Interdisciplinary Team (IDT) dated 09/22/25 documented post-fall investigation for the fall that occurred on 09/21/25. R128 fell out of bed. R128 was sent to the emergency room (ER) due to being on Heparin (blood thinner) for evaluation and treatment post fall. Staff would provide a falling star outside of R128's room for intervention.R128's EMR under Social Services dated 0/22/25 documented R128's spouse declined a bed hold. R128's spouse stated he would not be coming back to the facility because bed rails were not allowed.On 11/19/25 at 11:58 AM, Licensed Nurse (LN) K stated she was unsure whose responsibility it would be to do a discharge summary for a resident who was an unplanned discharge.On 11/19/25 at 12:04 PM, Administrative Nurse D stated that for an unplanned discharge, the social services did a portion of the discharge summary. Administrative Nurse D stated the remainder of the unplanned discharge would be her responsibility. On 11/19/25 at 10:44 AM, Administrative Staff A stated the facility was unable to locate a discharge summary or recompilation of R128's care as requested.The facility's Admission, Transfer, and Discharge policy dated 11/16 documented that it was the policy of the facility that each resident would remain in the facility and not be transferred or discharged unless the discharge or transfer was appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility would ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider.

The facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 67 for smoking, and for R82 for posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). Findings included:- The Electronic Medical Record (EMR) for R67 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute and chronic respiratory failure with hypercapnia (when the body can't effectively get rid of carbon dioxide because of persistent lung disease).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R67 had intact cognition. R67 required R67 supervision with showers, dressing, mobility, transfers, and ambulation. The assessment documented R67 received oxygen therapy.R67's 10/15/25 Care Plan lacked documentation a care plan for smoking was developed.The Smoking Assessment dated 04/25/25 documented R67 had no visual deficits, no cognitive loss, and no falls. The assessment documented R67 smoked zero times per day, could light her own cigarette, and used oxygen. The assessment further documented R67 had been educated on safe smoking practices and education of the risks of smoking.On 11/19/25 at 09:30 AM, R67 sat in a wheelchair outside smoking.On 11/18/25 at 02:45 PM, Certified Nurse Aide (CNA) M stated R67 went outside several times a day with supervision to smoke.On 11/18/25 at 08:30 AM, Licensed Nurse (LN) J stated R67 smoked and was able to go outside with staff assistance.On 11/19/25 at 09:40 AM, Administrative Nurse D verified there was not a smoking care plan for R67, and she should have one.The facility's Care Plans-Initial/Baseline and Comprehensive policy, dated 02/22, documented the facility's development and implementation of a baseline or initial, and a comprehensive care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. The care plan must meet professional standards of quality care, Care. Treatment and services are planned to ensure that they are appropriate to the residents' needs and provide an individualized, interdisciplinary plan of care for residents that is appropriate to the residents' needs, strengths, limitations, and goals.- The Electronic Medical Record (EMR) for F82 documented diagnoses of PTSD and insomnia (inability to sleep).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R82 had intact cognition. R82 was independent with dressing, personal hygiene, mobility, transfers, and ambulation. The assessment documented R82 had no behaviors and did not receive psychotropic medications.R82's Care Plan dated 09/27/25 initiated on 06/27/25, documented social services to provide psychosocial support as needed. The EMR lacked documentation of a care plan for R82's PTSD that was developed.The Social Services Assessment dated 07/06/25 documented R82 had a diagnosis of PTSD and had been abused by her ex-husband, and stated the abuse was primarily emotional, mental, and financial. The assessment documented R82 preferred no male caregivers, and her trigger was loud noises. The assessment documented R82 refused psychiatric services at that time.The Social Services Assessment dated 10/06/25 documented R82's trauma had been identified in the previous assessment, had not changed, and to refer to her care plan. The assessment documented R82 understood the importance of having social interaction, and no new needs were identified. The assessment lacked documentation. R82 was offered psychiatric services.On 11/18/25 at 07:45 AM, R82 in bed working on her computer. R82 stated she did not have concerns with her care and liked to be in her room on her computer.On 11/18/25 at 02:45 PM, Certified Nurse Aide (CNA) M stated she was not aware R82 had a diagnosis of PTSD and did not know what her triggers would be.On 11/18/25 at 01:00 PM, Licensed Nurse (LN) J stated she was unaware R82 had PTSD or of any residents on the first floor that had PTSD. LN J further stated she was unaware that R82 preferred not to have male caregivers.On 11/18/25 at 03:30 PM, Social Service X stated she was unaware that there was no care plan for staff to provide the PTSD triggers when providing care for R82. Social Service X further stated she did not talk to R82 about her past trauma because she did not want to bring up past trauma and upset her. On 11/18/25 at 03:45 PM, Administrative Nurse E stated that she had just put a PTSD care plan in place for R82 and verified that it should have been on the care plan after the PTSD assessment was completed. On 11/19/25 at 09:45 AM, Administrative Nurse D stated R82's PTSD and triggers should have been on the care plan before yesterday. Staff should have been made aware that the resident had PTSD and that she preferred female caregivers. The facility's Care Plans-Initial/Baseline and Comprehensive policy, dated 02/2022, documented the facility's development and implementation of a baseline or initial, and a comprehensive care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. The care plan must meet professional standards of quality care, Care. Treatment and services are planned to ensure that they are appropriate to the residents' needs and provide an individualized, interdisciplinary plan of care for residents that is appropriate to the residents' needs, strengths, limitations, and goals.

The facility identified a census of 123 residents. The sample included 25 residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 10 with showers as scheduled. Findings Included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA: stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing, need for assistance), dysphagia (swallowing difficulty), and contracture (abnormal permanent fixation of a joint).R10's Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R10 had an impairment in his upper and lower extremities on one side of his body. The MDS documented R10 required staff assistance for all ADLs.R10's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/16/25 documented R10 had an alteration in cognition related to dementia (a progressive mental disorder characterized by failing memory and confusion). The CAA documented R10 was at risk for complications due to restricted mobility and being unable to communicate.R10's Care Plan revised 09/02/25 documented:- R10 would maintain his current level of function. - R10 was in total dependence on staff with activities of daily living (ADL), bed mobility, transfers, eating, dressing, grooming, and toilet use.R10's EMR under Progress Notes documented the following note by social services on 11/04/25. A care plan meeting was held with R10's spouse, and the assistant director of nursing stated she was monitoring that showers were being given. R10's spouse stated she would like full showers, not bed baths, and had requested showers be moved to the evening shift. The assistant director of nursing stated R10's chart had been updated with the new request for R10.R10's EMR under Task documented R10 received a shower on 11/01/25, 11/04/25, a sponge bath on 11/10/25, a shower on 11/13/25, and a shower on 11/17/25.On 11/17/25 at 07:55, R10 laid in his bed on his back with his eyes closed. R10's hair appeared greasy.On 11/19/25 08:35 AM, Administrative Nurse F stated she oversaw ensuring all residents received their showers or baths, whichever the resident requested. Administrative Nurse F stated she picked up shower sheets daily. If a resident did not get a shower as scheduled, she talked to the Certified Nurse's Aides (CNA), and the process was that the resident would get a shower the next day. Administrative Nurse F stated it was the request of R10's spouse that he received a full shower and not a bed bath.On 11/19/25 at 11:48 AM, CNA N stated it was the CNA who was responsible for ensuring R10 received his shower. She stated CNAs have a bath schedule every day they are responsible for. She stated bath sheets were filled out every day, and if a resident did not get his bath that day, it was expected that staff would pass that information on to the next shift to do. On 11/19/25 at 12:04 PM, Administrative Nurse D stated that all CNAs have a shower schedule for each day. She stated it was expected that the showers would be done on the day they were scheduled. Administrative Nurse D stated that Administrative Nurse F was responsible for following up with the staff if a resident did not get their shower as scheduled.The facility's Quality of Care policy dated 10/2023 documented that it was the policy of the facility that residents were given the appropriate treatment and services to improve his or her abilities. Residents who were unable to carry out ADLs would receive necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene.

The facility identified a census of 123 residents. The sample included 25 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 84's pressure-reducing interventions were implemented correctly when R84's low air-loss mattress (specialized air mattress used to prevent pressure related wounds) was not set within his current weight range. The facility additionally failed to float R10's heels as directed by wound treatment. heelsFindings included:- R84's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), heart disease, and a stage-three (full-thickness pressure injury extending through the skin into the tissue below) pressure injury. R84's admission Minimum Data Set (MDS) dated 10/26/25 noted a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS noted he had no upper or lower extremity mobility impairments. The MDS noted he was dependent on staff assistance for bathing, dressing, personal hygiene, and oral hygiene. The MDS noted he required substantial to maximal assistance for bed mobility and transfers. The MDS noted he had one stage-three pressure ulcer and was at risk for further pressure ulcer development. The MDS noted he had pressure-reducing devices for his bed and wheelchair. R84's Care Area Assessment (CAA) within his MDS triggered for functional abilities on 10/28/25. The CAA noted he required staff assistance for his activities of daily living (ADL). The CAA noted his care plan was implemented to minimize the risks related to his ADL decline. R84's CAA triggered for pressure ulcers on 10/28/25. The CAA noted he admitted to the facility with a stage-three pressure injury. The CAA noted his care plan was implemented to minimize the risks related to pressure ulcers. R84's Care Plan initiated 10/20/25 indicated the following interventions: 10/20/25- He was dependent on staff assistance for bathing, toileting, oral hygiene, and dressing. 10/20/25- He required substantial assistance from staff for transfers and bed mobility. 10/20/25- He was at risk for pressure ulcers and had an air mattress. The intervention instructed staff to check the placement and function of the mattress. The plan lacked instructions related to the low-air-loss mattress settings. R84's EMR under Assessments indicated he admitted to the facility on [DATE] with a stage-two pressure injury on his left heel. The EMR indicated no decline or further development of new wounds during his stay at the facility. R84's EMR under Vitals indicated he weighed 132.1 pounds (lbs.) on 11/07/25. R84's EMR under Physician Orders dated 10/20/25 indicated he had a low-air-loss mattress and instructed staff to check placement and functioning. A review of the low-air-loss mattress manufacturer's operation (Drive) manual indicated the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range selected. The manual revealed that using the mattress while deflated puts the resident at risk for injuries. On 11/17/25 at 07:57 AM, R84 lay in his bed. R84's low-air-loss mattress was set to 200 lbs. The mattress pump had fixed weight settings of 50lbs, 75lbs, 125lbs, 150lbs, 175lbs, 200lbs, 250lbs, 275lbs, 300lbs, and 350lbs. On 11/18/25 at 08:55 AM, R84 sat in his bed with his bedside table over him. He stated he was done with his breakfast tray and needed staff to assist him. R84's call light was placed inside the dresser next to his bed and out of his reach. R84's low-air-loss mattress was set to 200lbs. On 11/19/25 at 10:00 AM, Licensed Nurse (LN) G stated the low-air-loss mattress was set based on what the care plan indicated. She stated the bed was set by the resident's current weight. On 11/19/25 at 12:05 PM, Administrative Nurse D stated staff were expected to check the bed settings each shift. She stated the bed was to be set by the weight of the residents. She stated the care plans were to identify the correct settings of each mattress. The facility's Skin and Wound Monitoring and Management policy, reviewed 04/2025, indicated the facility would provide preventative wound management practices to include skin assessments, pressure-reducing devices, wound care services to management, and prevent wounds. - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA: stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing, need for assistance, dysphagia- swallowing difficulty), and contracture (abnormal permanent fixation of a joint). The Annual Minimum Data Set (MDS) for R10 dated 08/16/25 recorded a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R10 was at risk for pressure injury. The MDS documented R10 had a pressure-reducing device in his wheelchair and a pressure-reducing device in his chair. The MDS documented R10 had a turning/repositioning program and nutrition or hydration interventions. The MDS documented R10 had no pressure wounds. R10's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 08/16/25 documented R10 was at risk for skin/pressure injury related to bowel and bladder incontinence. The CAA documented R10 required assistance with activities of daily living (ADL). R10's Care Plan dated 08/06/25 documented the following: - R10 required a low air loss mattress to bed, and a pressure reducing cushion to wheelchair, nursing staff were to monitor for functioning and settings. - R10's plan of care documented nursing was to do a head-to-toe skin assessment weekly. - R10's plan of care documented R10 was at risk for skin/pressure injury related to bowel and bladder incontinence and requires assistance with ADLs. R10's Braden Scale for Prediction Pressure Sore Risk dated 10/06/2025 documented a score of 11, indicating a high risk for pressure ulcers. R10's Weekly Wound Assessment dated 11/14/25 documented no new skin issues. R10's EMR under the Orders tab revealed the following physician orders: Offload heels while in bed as the resident tolerates every shift, dated 10/01/25. On 11/17/25 at 07:55 AM, R10 laid in his bed on his back with his eyes closed. R10 heels laid directly on the mattress. On 11/17/25 at 01:30 PM, R10 laid on his back in his bed. R10 had a hand towel laid on his shoulder, around his neck. R10's heels laid directly on the mattress. On 11/19/25 at 11:48 AM, Certified Nurse's Aide (CNA) N stated it was anyone who went into R10's room's responsibility that ensure that his heels were not floated, to ensure they were elevated off the mattress. On 11/19/25 at 11:58 AM, Licensed Nurse (LN) K stated it was the nurse's job to sign off that heels were floated. She stated any staff member who had worked with R10 was responsible for ensuring heels were floated when they leave his room. On 11/19/25 at 12:04 PM, Administrative Nurse D stated it was the responsibility of all nursing staff and therapy to ensure R10's heels were floated before leaving his room. She stated the nurse does sign off that heels were floated while the nurse was in the room doing cares. The facility's Skin and Wound Monitoring and Management policy reviewed 04/25 documented it was the policy of the facility that a resident who enters the facility without pressure injury does not develop pressure injury unless the individuals clinical condition or other factors demonstrates that a developed pressure injury was unavoidable and a resident having pressure injury receives necessary treatment and services to promoted healing, prevent infection , and prevent new, avoidable pressure injury from developing.

The facility identified a census of 112 residents. The sample included three residents reviewed for neglect. The facility failed to ensure Resident (R) 1 remained free from neglect when staff failed to ensure R1 received adequate care and services required to prevent harm or injury to her physical and psychosocial wellbeing. R1, who had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) and an indwelling urinary catheter (a flexible tube inserted through into the bladder to drain urine), was legally blind and dependent on staff for hygiene was outside without staff for extended periods of time with no brief or underwear, and with urinary catheter tubing exposed. On 05/28/24 R1 complained of a burning sensation to her genital area and the staff took R1 to her room for assessment and discovered maggots in R1's genital area and vagina. R1 was sent to the hospital for evaluation of the infestation of her genital area. The facility's failure to identify risks associated with resident behaviors and activity and implement interventions or strategies to mitigate risks as well as the failure to provide adequate hygiene and catheter care to prevent a maggot infestation placed R1 in Immediate Jeopardy. Findings included: - R1's Electric Medical Record (EMR), under the Diagnosis tab documented diagnoses of neuromuscular dysfunction of bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), weakness, muscle weakness, colostomy, bilateral amputations of the right and left legs, type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) without complications, and dependence on wheelchair. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required substantial to maximal assistance from staff where staff provided more than half the effort for toileting hygiene, shower and or bathing self, upper body dressing, lower body dressing, and personal hygiene. R1 had a colostomy and an indwelling catheter. R1's vision is severely impaired with no vision or sees only light colors or shapes; R1's eyes did not appear to follow objects. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 01/14/24 documented R1 had alteration in selfcare related to a Foley catheter (tube inserted into the bladder to drain urine into a collection bag), colostomy, and required assistance with ADLs. The Urinary Incontinence and Indwelling Catheter CAA dated 01/14/24 documented R1 had an indwelling Foley catheter and colostomy bag and required assistance with ADLs and was at risk for complications related to her neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Pressure Ulcer CAA dated 01/14/24 documented R1 was at risk for skin and or pressure injury related to her Foley catheter, colostomy and required assistance with ADLs and was at risk for complications related to decreased functional mobility, alteration in vision, right below the knee amputation, and left above the knee amputation. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. R1 required substantial to maximal assistance from staff where staff provided more than half the effort for toileting hygiene, shower and or bathing self, upper body dressing, lower body dressing, and personal hygiene. R1 had a colostomy and an indwelling catheter. R1's vision is severely impaired with no vision or sees only light colors or shapes; R1's eyes did not appear to follow objects. R1's Care Plan revised 10/12/23 documented R1 had the potential for injury related to smoking and was at risk for complications as she was legally blind. The plan directed staff that R1 was alert and oriented knew the risks versus benefits related to smoking. R1 was able to smoke without being supervised. An intervention dated 09/16/23 directed staff to report non-compliance or unsafe smoking habits to R1's physician and responsible party. R1's Care Plan initiated on 01/07/23 directed staff to monitor, record, and report to the medical director signs and symptoms of a urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, four smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. R1's Care Plan revised on 01/13/23 directed staff that R1 had an indwelling catheter and staff were to provide catheter care every shift and as needed. R1's revised interventions dated 03/30/24 directed staff that R1 required substantial to maximal assistance with toileting hygiene. R1's Care Plan dated 04/28/24 documented R1 was at risk for complications because she often refused wound care and would rather sit outside and vape or smoke. The plan directed staff to negotiate a time for ADL so that the resident could participate in the decision-making process, staff were to return at the agreed upon time. The plan directed staff if the resident resisted with ADL, to reassure the resident, leave and return five to 10 minutes later to try again. R1's Care Plan lacked any interventions relating to R1 refusing to allow care to be provided related to her changing her clothing, preference to not wear a brief or underwear, or refusal of catheter and perineal care specifically. R1's Weekly Skin Evaluation located under the Assessments tab, dated 05/20/24 at 09:22 AM documented R1 continued Skin-prep (liquid skin protectant) treatments to sacrum (large triangular bone/area between the two hip bones) and left buttock. R1 continued to have bruising and scabbing to her bilateral upper extremities, bruising to abdominal area. The assessment recorded redness and irritation noted to R1's vaginal area. R1's Weekly Skin Evaluation located under the Assessments tab, dated 05/27/24 at 09:39 AM documented no edema was noted. Staff applied Skin-prep. R1 continued with wound care to her sacrum and under the left buttock. R1 had redness under her right buttock and continued to have bruising and scabbing noted to her bilateral upper extremities. R1's Document Survey Report documented R1 had a shower on 05/14/24, 05/17/24, 05/21/24 and 05/24/24; she was not available for a shower on 05/28/24. Review of the report revealed R1 did not have documented bathing refusals. R1's 30 Day Lookback Period lacked documentation for behavior symptoms. Review of Lab Results collected 05/27/24 for a urinalysis documented greater than three organisms isolated which indicated probable contamination. The lab recommended a recollection and reorder if clinically indicated. The Nursing Note dated 05/28/24 at 01:26 PM documented R1 returned from dialysis very upset and crying. R1 stated that she was hurting in the peri area and felt like she had a urinary tract infection. R1 had already had a urinalysis obtained and awaiting results. Unidentified Certified Nurse Aides (CNA) reported R1 refused peri care, to lay down throughout the day and to change clothing. Administrative Nurse F aware of complaints and aware of the refusals of care. Licensed Nurse (LN) H discussed this with R1 and R1 agreed to allow cares and to get on a routine that would allow rest, and cleaning and changing of clothes as needed and on a routine basis. The Nursing Note dated 05/28/24 at 03:22 PM documented an unidentified CNA reported to LN I that R1 needed her colostomy bag changed which nurse changed and reported that R1 was crying since R1 had returned from dialysis. LN I checked on R1 and R1 stated that her bottom and peri area was hurting and R1 felt a burning sensation. R1 was getting ready to take a bath and or shower and after R1 transferred into bed, an unidentified CNA reported to LN I that R1 appeared to have maggots in her pants, around her buttock, and peri area. Administrative Nurse F and Administrative Nurse D were notified and R1 was sent to the hospital. The Nursing Note dated 05/28/24 at 07:35 PM documented LN J was notified by an unidentified CNA that R1 complained of a burning sensation to her vaginal area. R1 was taken to her room and assessed. Upon assessment, R1 appeared to have maggots in her vaginal area. The staff cleaned R1's peri area and removed her catheter. The staff contacted the physician and the physician ordered R1 to be sent to the hospital. LN J received a call LN K and was informed R1 was cleaned up while in the emergency room , and maggots were removed from R1's vagina. LN K reported R1 was stable and being sent back. LN K reported R1 needed to be washed with soap and water. The Nursing Note dated 05/28/24 at 08:03 PM documented R1 returned to the facility at 07:50 PM and was taken to R1's room and transferred into bed. R1 was informed she would be showered to which R1 agreed to and received a shower immediately upon arrival back to the facility. The staff washed R1 with soap and water, provided peri care, applied barrier cream to R1's peri area, and applied a brief to R1. R1's room was cleaned and disinfected. The Progress Notes from 03/01/24 through 05/27/24 lacked documentation that R1 refused catheter and/or perineal cares. R1's Treatment Administration Record for May 2024 documented an order for indwelling catheter care every shift, dated 10/23/23. The TAR was signed to indicate staff provided catheter care three times each day including all three shifts on 05/27/24, and the morning shift of 05/28/24. There were no refusals prior to 05/28/24 documented on the TAR. Review of the hospital's ED Provider Notes documented the resident presented to the emergency department after her nursing home found maggots in her vaginal area. The resident reported she had itchiness in the area the last couple days and had ben treated for a yeast infection recently. The resident reported she felt safe and wanted to return to the facility. The note documented a diagnosis of maggot infestation and directed the facility to keep the area clean and dry. The note recorded a report would be made regarding the facility due to concerns for cleanliness. During an observation on 06/03/24 at 12:35 PM R1 was seated in her high back wheelchair with clean clothing on and appeared well groomed. R1 stated staff had started to provide peri care and catheter care since R1 had went out to the hospital after They (indicating maggots) were found. R1 stated that prior to this happening she received no peri care and no catheter care. R1 stated her genitals had hurt for so long and R1 had thought it was another urinary tract infection. R1 revealed staff finally got a urinalysis collected the day before staff found the maggots. R1 stated when staff collected the urinalysis it was performed by clamping off her catheter tubing and drawing the urine from the port access. R1 stated her pants were never removed and she was not assessed related to the discomfort she felt in her genital area. R1 stated when the staff found the maggots R1 was embarrassed at first, but now R1 stated she is just in pain. R1 described the pain in her genital area as burning and kind of itchy, but the burning was what hurt the most. R1 stated she never refused cares. R1 revealed she may have refused to change her clothes but if staff had informed R1 that R1 had clothing on for more than a day or two and staff wanted to help her change and provide cares, R1 would have absolutely allowed that. R1 rocked back and forth on her bottom during the interview. R1 revealed that she rocked to help with the burning and itching in her private area. During an interview on 06/03/24 at 10:53 AM, Administrative Nurse D stated R1 liked to sit outside. Administrative Nurse D stated R1 would not put any underwear, brief, or anything on other than pants or shorts. Administrative Nurse D stated that R1 continued to refuse cares. Administrative Nurse D stated she had recently gone through and done training that staff needed to be providing catheter cares and peri care. During an interview on 06/03/24 at 12:33 PM, Certified Medication Aide (CMA) R stated R1 allowed staff to provide peri care and catheter care and rarely refused. CMA R stated if R1 refused CMA R reported it to the charge nurse and documented the refusal into point of care charting. CMA R stated she provided R1 cares but not that often. CMA R stated it had been quite a while since she had received catheter care training and stated it was roughly a year. On 06/03/24 at 12:52 PM LN G stated that the CNAs knew to do catheter cares for the residents because it was a required task. LN G stated that R1 did not like having her clothes changed and she would not let the staff change her clothes. LN G stated that R1 sometimes refused to allow catheter care and when R1 refused, LN G made a progress note of R1's refusal. On 06/03/24 at 12:41 PM Administrative Nurse E stated that catheter cares did not show up on point of care charting for the CNAs but it was on the nurses Treatment Administration Record (TAR). On 06/03/24 at 03:29 PM CNA M stated he had not received training for catheter or perineal care since starting work at the facility. On 06/03/24 at 04:10 PM CNA N stated she could not recall the last time she had received catheter and perineal care training. The facility's Indwelling Urinary Catheter Care: Quality of Care policy revised December 2023 documented it was the policy of the facility that each resident with an indwelling catheter would receive catheter care daily and as needed to promote hygiene, comfort, and decrease the risk of infection. The facility's Abuse: Prevention and Prohibition Against: Freedom From Abuse, Neglect Exploitation revised December 2023 documented the facility would provide oversight and monitoring to ensure that its staff, who are agents of the Facility, delivered care and services in a way that promoted and respected the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy. Neglect is documented as the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurred when the facility is aware of, or should have been aware of, goods or services that a resident(s) required but the facility failed to provide them to the resident(s), that resulted in or may have resulted in physical harm, pain, mental anguish, or emotional distress. Neglect included cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. On 06/03/24 at 03:15 PM Administrative Staff A, Administrative Nurse D, Administrative Nurse E, and Consultant GG were provided the IJ template and notified the facility failed to ensure staff provided the necessary cares and services to ensure R1 remained free from harm or injury and failed to provide adequate care to prevent a maggot infestation. Other psychosocial considerations include the likelihood for fear and humiliation due to R1 having maggots in her genital area. The facility provided an acceptable immediacy removal plan on 06/03/24 at 04:41 PM which included the following corrective actions to be completed by 06/03/24 by 08:00 PM. 1. The staff cleaned the resident and the resident room completely on 05/28/24. 2. The facility in-serviced the nursing staff for notification of resident refusals, changes in resident preferences, refusal of resident cares, refusal of peri-care, residents who go outside without wearing a brief. The staff were signing that care was completed when the resident refused or did not want to come in from being outside. Staff were inserviced on what to do in the event a resident refused care and to notify the nurse and then reattempt to go and render the care as necessary. 3. The facility would provide on-going nursing in-services to staff regarding documenting only the cares that are completed and charting refusals as refusals. The facility will in-service on thorough and complete catheter and peri-care for all nursing staff. Inservice staff on how neglecting this practice is both harmful to the resident psychologically and physically and that it is neglectful treatment. All nursing staff will be inserviced now and any staff who come to work will be inserviced prior to starting their shift. 4. The Director of Nursing (DON) provided education to the resident on the importance of always wearing a brief. Especially the need to wear a brief is she was spending most of her day outside. Educated on necessity of sanitary care of peri area and catheter care given to resident. 5. The DON and ADON would complete frequent checks on the resident weekly to ensure care was provided and there was no reoccurrence of the issue. 6. The facility conducted an audit of all residents who were potentially affected to ensure appropriate peri-care and catheter care. 7. The facility will conduct ongoing audits on appropriate pericare, catheter care and monitoring for correct documentation by nursing staff, and complete nursing in-services recompleted quarterly to ensure correct peri care and catheter care per doctor's orders. 8. The facility would monitor to ensure on-going compliance by following up monthly in QAPI for three months, with review of all audits completed and changes made as needed. ED to ensure that ANE is discussed in the next three all staff meetings. The surveyor verified the corrective action while onsite on 06/04/24 at 11:30 AM. The deficient practice remained at a G scope and severity, following removal of the immediacy.

The facility identified a census of 98 residents. The sample included eight residents with one reviewed for discharge. Based on interviews and record review, the facility failed to allow Resident (R)1 to return to the facility after the facility non-emergently transferred him to the Emergency Department (ED) for a psychiatric evaluation, on 06/27/22. The facility further failed to allow R1 to return to the facility pending and during the appeals process as required. As a result of this failure, R1 remained in an inpatient hospital setting since the transfer on 06/27/22, greater than four months, as the hospital could not find alternative placement. Due to these failures, cognitively impaired R1, who was unable to make decisions, remained homeless. R1, with history of depression (persistent feeling of sadness and loss of interest) and anxiety, was unable to attend activities, deprived of a homelike environment, socially isolated from peers, and unable to leave the acute hospital for therapeutic leave to spend time with his family due to his inpatient status. Findings Included: - The Entry Tracking Record documented R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety, Wernicke's encephalopathy (degenerative brain disorder caused by the lack of vitamin B1), and schizoaffective disorder (combination of symptoms of schizophrenia [a serious mental disorder in which people interpret reality abnormally] and mood disorder, such as depression). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R1 had Brief Interview for Mental Status score of nine, which indicated moderately impaired cognition and no signs of acute mental status changes. The MDS recorded R1 had no behaviors in the look back period. R1 was independent with transfers, locomotion on and off the unit, and toileting. He required supervision and assistance from one staff with walking and required limited assistance of one staff member for personal hygiene. He was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS recorded R1 had no pain and received no pain medication. R1 received an antidepressant (medication used to treat depression) and an antipsychotic (medication used to treat mental disorder such as schizophrenia) for all seven of the look-back days. The MDS recorded the resident did not want to discuss the possibility of leaving the facility and returning to the community to live. The Discharge Assessment-Return Not Anticipated documented R1 discharged on [DATE] to an acute care facility (psychiatric hospital option was present but not selected). The assessment recorded staff identified R1 had a memory problem and moderately impaired decision making; R1 required supervision and cues with decisions. The assessment documented R1 had disorganized thinking continuously without fluctuation. The staff interview for mood was not completed. The assessment recorded R1 did not have psychosis (mental disorder characterized by a disconnection from reality) but did have physical behaviors and verbal behaviors directed towards others one to three days of the look back period. The impact of the behaviors on other residents, and on R1, was not answered on the assessment. The section regarding a change in behavior or other symptoms was left blank. The assessment recorded R1 required supervision with bed mobility, transfers, dressing, toileting and personal hygiene. R1 was independent with walking on and off the unit, locomotion on and off the unit, and eating. R1 received an antidepressant and antipsychotic medication for all seven of the look back days. The assessment documented there was an active discharge plan for the resident to return to the community. The questions regarding who participated in the planning were left blank. The assessment recorded a referral was made to the local contact agency. R1's Care Plan recorded a focus revised on 10/02/20 which directed R1 wished to remain long term care. A Nursing notes under the Progress Notes tab in R1's EMR recorded on 06/24/2022 at 01:30 PM, Social Services X, Administrative Nurse D, and the nurse called R1's guardian to discuss an incident the previous night. R1's representative was shocked and stated R1 had not shown physical aggression towards anyone in his life. The note recorded staff discussed the facility was looking at sending R1 to an acute inpatient psychiatric hospital that day and informed R1's representative that R1 was served a misdemeanor summons by the police. R1's representative stated that he shared power of attorney and he would relay all of the information to R1's other representative. A Nursing note dated 06/26/22 at 03:21 PM documented admission was notified the acute inpatient psychiatric hospital was unable to accept R1 due to staffing shortage. The facility was looking at other options. The record lacked evidence this information was provided to R1's representative. Review of the non-emergency medical transportation service invoice revealed R1 was sent non- emergently to the hospital via the transportation service on 06/27/22. A Nursing note dated 06/28/22 at 04:54 PM recorded the hospital notified the facility three psychiatric evaluations were completed on R1 and none indicated anything wrong. The note recorded the hospital stated they were sending R1 back to the facility. The note recorded the facility stated it was not an appropriate place to handle that type of resident due to the lack of experienced staff for the behaviors. The note recorded the hospital admission person said there was nowhere else to send R1. The note recorded R1's representative did not want him to return to the facility and the facility awaited an answer from the hospital regarding what the hospital was doing with R1's admission. R1's clinical record lacked evidence or documentation R1's representative would not allow R1 to return to the facility. The hospital Social Work Services assessment dated [DATE] recorded R1 had mental illness, and homelessness. The note documented R1 was formerly at a long-term care (LTC) facility but was kicked out due to assaulting a roommate. The LTC facility later recanted the severity of the assault (stabbing down to scratching) and would take R1 back for an additional $15.00 a day for a private room. The LTC facility then changed their mind and asked for $30.00 a day. R1's legal guardians contacted Medicaid. A court hearing was scheduled in October. New placement was sought, and multiple referrals sent, but no facilities accepted R1. The hospital Length of Stay Note dated 09/02/22 recorded the case manager spoke with R1's representative regarding discharge planning. The social worker made mass referrals to Kansas facilities, but R1 was likely to return to [the former nursing home] after a hearing on 10/11/22. The note recorded R1's discharge plan was a facility; anticipated discharge date was greater than seven days. The note recorded the medical reason for the hospitalization was NA and recorded specialty consults were also NA. The hospital Social Work Free Text Note dated 09/06/22 recorded the social worker received a call from facility staff Administrative Staff E. Administrative Staff E reported Social Services X was no longer at the facility so Administrative Staff E would assist. The note recorded the facility did want R1 to return but believed the court would make the facility take R1 back after the hearing in October. Administrative Staff E hoped to find placement before that but needed the hospital to complete a Kansas Level II Pre-Admission Screening and Resident Review (PASARR). Review of the Notice of Proposed Transfer/discharge date d 10/18/22 (113 days after the transfer/discharge on 06/27/22) documented the discharge location as the acute hospital. The notice recorded the reason for the discharge notice was the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident [R1] and further cited the reason the safety of others in the facility was endangered was due to the 06/24/22 incident; R1 broke the handle off a hospital cup and used the jagged edge to attack his roommate. R1's roommate was found with multiple cuts and scratches all over his body, including long, bleeding scratches on his bilateral legs. The notice directed if R1 and/or his representative believed the transfer/discharge was inappropriate and involuntary they had the right to appeal. The appeal could be filed in writing to, or by calling, the listed agencies. The notice listed KDADS and the physical address as well as the main phone number. The notice further identified the State Long Term Care Ombudsman (LTCO) and a street address and phone number. The notice lacked information regarding how to file an appeal, or who would be available to assist the resident/representative in filing an appeal. The notice lacked information on how to contact the Office of Administrative Hearing (OAH). The notice lacked instruction on how to contact all appropriate agencies electronically and lacked information, including the phone number, on how to file a formal complaint with the appropriate state agency. The notice lacked information (was left blank) regarding the State Advocacy Agency for Persons with Mental Health Disorders (despite R1's diagnosis of schizoaffective disorder). The notice recorded it was sent to the OAH Judge, both R1's representatives and the LTCO. The notice lacked evidence it was provided to the facility listed as discharge location. R1's clinical record lacked evidence the facility evaluated R1's status at the time the discharge notice was issued. The facility was unable to provide any documentation or evidence of evaluations of R1's status at the time the discharge notice was issued and only referred to the 06/24/22 event. An Inpatient Social Work Referral Note dated 10/21/22 recorded mass referrals were sent to approximately 150 Kansas facilities, and denials were received. Review of R1's acute hospitalization notes lacked documentation of behavioral events, physical aggression, or the need for inpatient psychiatric services. On 10/26/22 the facility was unable to provide documentation of assessment of R1's current status as related to returning to the facility. The facility was further unable to provide evidence of attempted placement in other facilities. A statement from Administrative Staff A written and provided on 10/26/22 noted there was no written correspondence between the facility and the hospital regarding the transfer of R1 back to the facility. There were a series of phone calls from an [unidentified] hospital staff member in the psych department. The conversations were regarding the status and psychological wellbeing of R1 and his decreased need to be admitted to a psychiatric facility. The statement noted that Consultant GG and Administrative Staff A stated the facility was not capable of caring for R1 due to the nature of the incident that occurred between R1 and his roommate. The statement recorded Consultant GG and Administrative Staff A asked the [unidentified] hospital staff member for a psychological evaluation for R1 and the hospital staff member hung up on them. The statement recorded later phone calls were made to R1's representative regarding R1's status and the conversations were regarding R1 and his current needs at that time. The statement recorded the facility and R1's representative had still not to come to an agreement at the time of the statement and continued to work through the process. On 10/26/22 at 03:34 PM, Administrative Staff E stated the facility started to try to find placement for R1 immediately after the event on 06/24/22. R1 was placed in a private room with a one to one sitter and staff tried to get multiple places to accept R1. Administrative Staff E stated the hospital was able to take R1, so he was sent non-emergent EMS for a psych evaluation through the hospital ED. She said she spoke with the hospital and the hospital (unable to identify the hospital staff) said just send R1 through the ED, and he can admit through the ED. She said that hospital was the only place that would accept R1 that day due to the train wreck [derailment] on 06/27/22. She further reported the hospital tried to find a place for R1. She stated the facility worked on finding placement for R1. Administrative Staff E stated she was pretty sure R1 was still at the hospital. She stated she tried to call the hospital about a week after R1 transferred but the hospital had no information for her. She stated she assumed R1 was in the psychiatric unit. She further revealed the facility had not received a referral or updated packet from the hospital regarding R1's status. On 10/27/22 at 10:50 AM in a telephone interview, Social Work Consultant II confirmed R1 was dropped off at the acute hospital ED due to a behavioral episode reported by the facility. consultant II stated R1 was evaluated and was found to have no need for inpatient psychiatric health services. Consultant II confirmed that during R1's stay at the acute hospital, which was currently over months and ongoing, R1 had no behaviors, no aggression and no actions which warranted an inpatient psychiatric stay and had not been admitted for psychiatric or behavioral health reasons. Consultant II confirmed the facility refused to allow R1 to return to the facility and based on the facility's initial allegation that r1 tried to stab his roommate, which was later downgraded to scratching, no other facility would accept R1. She stated R1 remained on the medical/surgical unit, awaiting placement. Consultant II reported the hospital continued to try to find placement for R1 and worked with R1's representative to find a safe discharge for R1. Consultant II reported the hospital was unaware the facility issued an involuntary discharge notice on 10/18/22 as it was discussed the facility would allow R1 to return if a payment for a private room could be arranged. On 11/07/22 at 08:54 AM, R1's representative state he learned of the transfer on 12:35 AM on 06/28/22 from the ED. He stated he had not spoken with anyone from the facility at that point regarding the transfer on 06/27/22. R1's representative stated he knew about the incident that occurred on 06/24/22 and was shocked to learn of it because R1 had no history of been physically aggressive with other residents in the facility. R1's representative stated R1 was currently in the hospital. He said R1 did not do much of anything except sleep all day. R1 did like to watch television but because R1 had impaired memory it was hard for R1 to remember what he liked. R1's representative stated when R1 was in the facility, R1's family could come and take R1 out to the lake and out to enjoy R1's favorite foods which always made R1 happy. The current situation, with R1 inpatient at the hospital, did not allow R1 and the family to go on family outings. R1's representative stated he tried to get to the hospital as much as possible to try to visit with R1, but it was more difficult and R1's mother was unable to visit as much as desired. R1's representative stated he hoped R1 could return to the facility and resume his normal activities. R1's representative did express some concern that the facility may retaliate or not provide supportive cares for R1 due to extended battle and court proceedings. R1's representative stated he was unsure how the situation had impacted R1 because R1's mental illness made it difficult for R1 to express how he was feeling and R1 reacted to things differently due to the mental illness and his impaired memory. The facility policy Discharge or Transfer revised 01/2022 documented for planned discharges to other healthcare facilities, the facility would obtain orders for discharge from the physician, keep the resident/family involved with all the discharge planning, complete the transfer/discharge form. The facility would document the entire process in the nursing notes. The policy directed the facility would provide a safe, organized, structured transfer and/or discharge to hospital, other healthcare facility, or home that would meet the residents highest practical level of medical, physical, and psychosocial wellbeing. The facility failed to allow R1 to return to the facility after he was transferred non emergently on 06/27/22 to the Emergency Department (ED) for a psychiatric evaluation. The facility further failed to allow R1 to return to the facility pending and during the appeals process as required. As a result of this failure, R1 remains in an inpatient hospital setting since the transfer on 06/27/22, greater than four months, as the hospital was unable to find alternative placement. R1 is now homeless, unable to attend activities, deprived of a homelike environment, and socially isolated from peers in his inpatient status. R1 is unable to leave the acute hospital for therapeutic leave to spend time with his family due to his inpatient status. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R1's mental illness and inability to self-identify and express his feelings.

The facility identified a census of 100. The sample included 27 residents with 12 residents reviewed for abuse. The facility identified the Kensington unit as the dementia unit, with a census of 37 residents. Based on record review, observation, and interviews the facility failed to ensure the residents were free from abuse and neglect. Resident (R) 84, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On another occasion, R84 acted aggressively, then punched R47. Approximately two hours later, R84 hit R71. R21, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to prevent abuse by R84 and R21 placed those residents on the dementia unit in immediate jeopardy. Further, the facility failed to ensure residents were free from neglect when the facility failed to provide the necessary care as defined in the comprehensive plan for care for R148. R148, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide the hourly check and during the time unattended, R148 obtained injuries consistent with a fall which included an acetabular fracture (pelvis fracture involving the hip joint). The injury necessitated an emergent transfer to an acute care setting where she required a surgical intervention to treat the fracture. Findings include: - R84's diagnoses, listed under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R84's Admission Minimum Data Set (MDS) on 04/12/21 recorded R84 had a Brief Interview for Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS recorded he wandered one to three days of the look back period which improved from his prior assessment. The 04/12/21 Behaviors Symptoms Care Area Assessment indicated R84's behaviors would be addressed in the plan of care. The Quarterly MDS dated [DATE] recorded R84's BIMS remained four. The MDS recorded R84 received limited assistance of one staff for locomotion on the unit in a wheelchair. The MDS documented R84 had behaviors, which included physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for one to three days of the look back period. R84 had verbal behavioral symptoms directed at others (e.g. threatening, screaming, cursing) for one to three days of the look back period. Sections 0500 and 0600 of the MDS which addressed the impact R84's behaviors had on himself and other residents was incomplete. R84's Care Plan, in the EMR under the Care Plan tab documented a focus dated 10/20/20 and revised on 07/14/21, which recorded R84 had actual physical behaviors (yelling, hitting) due to his dementia, [CONDITION(S)], [CONDITION(S)] disorder, anger, depression, and poor impulse control. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan interventions dated 10/21/20 directed staff to analyze key times, places, and triggers as well as what de-escalated the behaviors and document. It directed staff to assess and address for contributing sensory deficits, assess and anticipate the resident's needs: food, thirst, toileting needs, comfort level, body positioning, and pain. The Care Plan directed staff to document observed behavior, attempted interventions, and further directed staff to guide R84 away from sources of distress, engage him calmly in conversation. The Care Plan directed staff to walk calmly away, and approach later if R84's response to staff was aggressive. The Care Plan also documented the following interventions dated 10/21/21: Resident to resident 10/20/20. Resident [R84] went into another resident's room and hit [the] resident in the eye. Resident [R84] redirected back to his room and given snacks. Resident to resident 10/21/20. Resident [R84] went into another resident's room and started hitting [the] resident. Resident [R84] redirected to common area. Resident [R84] sitting with a one on one and plan to send resident [R84] to [hospital] for evaluation. Another intervention, dated 07/13/21 recorded Resident to resident 7/13/2021: Psychiatrist gave order for UA [urinalysis] and referral to [psychiatric hospital] for potential admission and change of condition for increased behaviors, aggressiveness towards other staff. The Progress Notes tab in R84's EMR recorded the following notes: A Nursing Note dated 10/20/20 at 02:06 PM recorded an unidentified Certified Medication Aid (CMA) and Social Worker alerted License Nurse (LN) G that R84 went into another unidentified resident's room and hit him the eye. LN G documented staff observed R84 wandering approximately 10 minutes prior to the incident but demonstrated no aggressive behaviors. A IDT [interdisciplinary] Note dated 10/21/20 at 07:00AM authored by Administrative Nurse D recorded the IDT team met to discuss the altercation. CMA and social worker notified LN G R84 went to another resident's room and hit him, R84 wandered in the common area approximately 10 minutes prior to the incident. R84 had no aggression noted after the incident. Staff easily redirected R84 to his room and offered snacks and supervision to ensure he stayed in his room. The note recorded an intervention of resident redirected to room and offered supervision with no signs of aggression or agitation noted. A Social Service Summary dated 10/21/20 at 09:00 AM authored by Social Services X documented R84 was a pleasant male with Lewy body dementia, admitted to the facility for long term care following a hospitalization . The note recorded R84 was previously at a long-term care facility, but he became agitated and combative with another resident and could not return there. A Nursing Note dated 10/21/20 at 03:50 PM authored by LN G documented R84 sat in the common area when he began to wander off the unit. Staff attempted to redirect R84 and he got upset and made repetitive aggressive statements. R84 then went into R56's room and began to hit R56 in his face while he laid in bed. R56 yelled out NO repeatedly. R84 then left R56's room with the unidentified social worker and sat in the common area. Staff contacted R84's representative and gave permission for R84 to be sent to the hospital if necessary. Staff notified the (unidentified) physician and the physician gave the order to transfer as needed. R84 was one to one observation. An IDT Note dated 10/21/20 at 04:37 PM authored by Administrative Nurse D recorded the IDT met to discuss the incident that occurred on 10/21/21. R84 sat in the common area where he began to wander on the unit. Staff attempted to redirect him, he became upset, and made aggressive statements. He then entered R56's room and began to hit R56 in the face while R56 laid in bed. R84 exited R56's room with a (unidentified) social worker and staff redirected the resident to sit in the common area. The note documented an intervention of R84 to be one to one observation and sent to the hospital for evaluation. A Nursing Note on 10/21/20 at 06:33 PM recorded R84 transferred to the hospital. A Nursing Note dated 10/22/20 at 02:15 AM recorded R84 returned to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Report dated 10/22/20 revealed the following account of the 10/21/20 incident: on 10/21/2020 at 03:45 PM a resident to resident altercation occurred between R84, who had a BIMS of 99 (unable to complete interview) and R56 who had a BIMS of six (severe cognitive impairment). Both residents resided on the locked memory care unit. On 10/21/20, R84 began wandering on the unit. Staff members attempted to redirect R84 and he became upset and made aggressive repetitive statements. R84 then went into R56 ' s room and began to hit R56 in his face while R56 was lying in bed. R56 was yelling out No, no, No. The social worker witnessed the incident and attempted to redirect R84. R56 attempted to defend himself by putting his left arm over his face. R84 then came out of the room with the social worker. Staff redirected R84 to the common area where he appeared calm with no agitation or aggression. Staff immediately initiated 1:1 constant supervision of R84. Staff notified Consultant HH and received orders to transfer to the hospital of choice for evaluation. Staff notified R84's durable power of attorney (DPOA) and they agreed with sending the resident to the emergency department for evaluation. R56 had two small scratches noted to his left forearm with no bruising or discoloration to the face at this time. R84 was unable to give a statement of why he struck R56. R84 did not answer any questions related to incident . Further review of Progress Notes tab in R84's EMR revealed the following: A Nursing Note dated 10/27/20 at 10:00 PM authored by LN H recorded R84 wandered and talked to himself. Staff closely monitored him and when they attempted to redirect him. R84 became agitated and swung at staff. LN L attempted to redirect R84 three times with the same result. R84 went into another resident's room and laid in that resident's bed. When staff attempted to assist R84 to his room, R84 screamed and threatened staff. Staff notified Consultant HH and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff administered an injection of [MEDICATION(S)] to R84. LN L obtained a (unidentified) male nurse to assist R84 to his room. A Nursing Note dated 07/13/21 at 03:00 PM authored by LN K recorded R84 sat in the common area when another (unidentified) male resident attempted to pass by. R84 told the other resident R84 was going to kill him. Both residents yelled at each other. R84 made a fist and lifted his hand to hit the other resident. LN K intervened and quickly moved the other resident. Both residents were angry. LN K explained to both residents that their behavior was inappropriate. R84 responded with cold, cold it's cold. R84 was alert, but oriented to his name only. At approximately 06:00 PM LN K heard R84, in the hallway coming back from the dining room, threaten someone. LN K ran over to see what was going on and saw R84 threaten a (unidentified) female resident. He attempted to hit her and missed. LN K again removed R84 from area and placed him in front of his room. At 06:05 PM R84 propelled himself to the common area and hit another (unidentified) resident in the face and chest with his fist. LN K again removed R84 and contacted the psych nurse NP [nurse practitioner] who gave new orders. The note documented staff notified Administrative Nurse E immediately after each incident. A Nursing Note dated 07/13/21 at 04:09 PM authored by LN K recorded the following At 4pm this writer observed resident [R84] sitting in his w/c [wheelchair] next to this writer when resident reached over and socked a female resident who was sitting in a chair next to him asleep, he hit her with his fist saying do you want to die. this writer removed the resident with a 1:1 in a room without anyone else. he became calm and he stayed in the dining room being fed and removed as soon as he was finished being fed. Review of the Facility Report dated 07/14/21 revealed the following account of the 07/13/21 incident: A resident to resident altercation on 07/13/21 at 04:30 PM and 06:05 PM which involved R84, with a BIMS of four, R47 with a BIMS of six and R71 with a BIMS of six. The report documented on 07/13/21 at approximately 04:30 PM R84 sat in the common area. He went over to R47 and punched her in her side. Witnesses stated R84 was not showing signs of agitation and R47 was sleeping in her chair at that time. Staff separated the residents and redirected R84 to his room. Staff assessed R47 for injuries after the altercation with no injuries found or reported. Staff placed her on 72-hour monitoring for bruising. The report recorded R84 could walk on his own. The report further recorded on 07/13/21 at approximately 06:05 PM R84 was in the dining room for dinner, went over to R71 and started hitting her in the face and chest. R84 was immediately redirected back to his room. Staff assessed R71 for injury with no pain or injury noted. R84 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/02/21 at 07:20 AM R84 sat in his wheelchair, in the 200 hallway of Kensington unit, in front the dining area. On 08/03/21 at 07:24 AM R84 sat in his wheelchair in the common area by the nurse's station on the Kensington unit. There were six female residents also seated in the same area. No staff were present, the closest staff member was down the middle hall passing medications, out of the line of sight to view R84. On 08/03/21 at 7:31 AM R84 continued to sit in his wheelchair at the nurse's station with six other female residents. An unidentified staff member pushed another female resident to the common area in a wheelchair, parked the chair, applied the brakes, and walked away. On 08/03/21 at 09:05 AM R84 sat in his wheelchair in the common area by the nurse's station. He lifted his feet in an alternating repetitive motion as if walking. No staff were present in the common area at that time though four other female residents were in the common area with R84. On 08/04/21 at 07:50 AM R84 was in his new room at the end of the hall on the Serenity unit ( a unit adjacent to Kensington unit) with a staff member seated in a chair directly outside his room. On 08/04/21 at 10:02 AM R84 sat in his wheelchair in the dining area on Serenity unit , dressed and covered with a blanket. An unidentified staff member sat with him. On 08/03/21 at 11:20 AM Certified Nurse Aid (CNA) M stated she always worked on the dementia unit. CNA M stated when the CNA knew which residents were at risk for or actually had behaviors by receiving a verbal report during walking rounds at the beginning and end of each shift. The CNA reported to each other any changes, new behaviors, or ongoing concerns. She stated they also checked the Kardex (electronic tool which lists specific cares required by the resident as directed on the care plan or resident task list). She stated the Kardex should tell them everything they need to know to provide care for the residents. CNA M stated she received training when she was hired regarding direct care as well as training on abuse and neglect. She stated abuse, neglect and exploitation was covered frequently in the monthly trainings. CNA M stated that she knew if residents had behaviors, staff should try to figure out the cause of the behaviors. In the event of a resident to resident altercation, they should try to separate the residents and see if the resident could be redirected by coloring books, changing the climate or atmosphere, and adjusting the noise levels. She stated the CNA was to report to the charge nurse if any resident to resident altercation or any new behaviors were identified. She stated some residents would need to be kept separate and staff would know those residents by looking in their Kardex. CNA M said R84 could be combative at times. He typically self-propelled in his wheelchair. She further stated that because R84 had a tendency to use his feet to get himself forward other residents might mistake that for agitation and become afraid. CNA M stated they occasionally had to redirect R84 away from other residents and they would typically use activities or chocolates. CNA stated she could not remember if R84 ever struck another resident, but she was aware staff were to make sure he is not in a certain amount of space of other residents. On 08/03/21 at 11:30 AM CNA N stated she typically worked on the dementia unit. She stated there were many residents on the unit with varying stages of dementia, some were more with it than others. CNA N stated the CNAs learn how to provide care for the residents by looking in their chart. She stated the resident's chart and the Kardex told the CNA everything they need to know to care for the resident including how they transferred, toileted, and if the resident had any behaviors the CNA was to monitor for, and it would also be on the Kardex. She stated any behaviors they observed were reported to the charge nurse. If it was a really big behavior the CNA could put in a new alert in the point of care (POC) documentation which would go to the Director of Nursing (DON), and Assistant Director of Nursing (ADON). She stated if there was a new, big behavior she would definitely chart a new alert for it, but not for their routine, normal behaviors. If they were having a routine behavior CNA N would try to separate the residents, get them in their rooms, and figure out the cause of the behavior. If that did not work, she stated she would get a nurse. She stated she received training on abuse, neglect, and exploitation via the computer training and in-services. CNA N recalled R84 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA N stated R84 had a habit of thumping his chest and one resident thought he was swinging at her, but he was not. The resident just misunderstood. At that time, staff just removed the other resident and explained to her that R84 was not trying to hit her. CNA N stated she did not think R84 hit anybody though she said he kicked at staff when he was in bed. CNA N stated staff had no specific actions or interventions regarding R84's behaviors that she knew about. She then said if she saw a resident strike another resident she would intervene immediately and then report to the nurse. On 08/02/21 at 12:00 PM LN H stated there were a lot of behaviors on the dementia unit. She said in the event of resident to resident abuse, she would make sure the area was safe and render any first aid if needed. She said she would make sure both residents were safe, by separating them, and placing them in their rooms or trying redirection. She said if there were specific interventions, it would be listed on the MAR [Medication Administration Record]. LN H said if the situation was significant, she would alert the DON and Administrator. LN H stated R84 had not any recent behaviors that she was aware of. She said she did know he had been physically aggressive towards the staff and other residents at times. LN H stated nursing staff had no special instruction or interventions related to R84's aggressive behaviors. She said any new interventions or changes would be listed in his chart. On 08/02/21 at 02:18 PM Administrative Nurse D stated abuse training had been provided to facility staff frequently this year, at least two or three times, both in-person and via computer training. Administrative Nurse D said R84 had some resident to resident altercations. She stated in those type of situations, she expected staff would separate the residents, assess them for injuries, and look for any identifiable causes. She said after that, staff should keep the involved residents separate from each other and monitor. She further stated the IDT team would review, nursing would make a progress note in the resident's chart each shift and continue to monitor for behaviors. She stated that in the October incident with R84, he was wandering. She stated staff did not generally intervene with wandering for residents on the dementia unit since it was a locked unit. She said if staff noted he had any aggressive behaviors, they would have redirected him back to his room. Administrative Staff D stated R84 became agitated and over-stimulated. Being in his room helped him de-escalate. She stated staff placed him in his room for that purpose, but R84 was able to self-propel himself back to the common areas. Administrative Nurse D said she believed that occurred in July, when the resident struck two other residents. She stated staff placed him in his room, but he brought himself back out, or staff may have brought him out to the dining room since he required assistance with eating. Administrative Nurse D stated she was unable to speculate if any of the resident to resident abuse events could have been prevented although she stated it appeared the interventions and actions taken to prevent abuse in the two instances (October and July) were not entirely effective. The facility policy Abuse: Prevention of and Prohibition Against revised 01/2021 recorded it was the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility would provide oversight and monitoring to ensure that it's staff, who were agents of the facility, delivered care and services in a way that promoted and respected the rights of the residents to be free from abuse and neglect. The policy documented the facility would train staff to understand behavioral symptoms of the residents which increased the risk of abuse which included aggressive reactions of the residents, wandering type behaviors, resistance to care, and outbursts or yelling out. The policy further recorded the facility would [MEDICATION(S)] to protect and prevent abuse and neglect from occurring within the facility. The facility failed to prevent multiple episodes of resident to resident abuse when R84, who had a documented history of aggressive behavior and physical altercation with another resident entered R56's room on 10/21/20 and struck him in the face several times. On 07/13/21, R84 made verbal and physical threats towards another resident and then punched R47 and R71. This deficient practice placed the 37 residents on Kensington, the dementia unit, in immediate jeopardy. The facility removed the immediacy at 10:40 AM on 08/03/21 by completing the following actions: Move R84 to Serenity Unit. 1:1 with this resident during waking hours with 15 Minute checks during sleeping hours Inpatient referral to be completed on August 4th to find a more appropriate placement for this type of resident with behaviors. IDT completed full audit of all residents on the second floor on August 3, 2021 to determine what residents have the potential to be aggressive and potentially hurt other residents. All residents determined to have the potential to be aggressive or harm residents will have care plan updated, staff informed via jot sheets and the shift change report. Behavioral monitoring audit to be added to the daily clinical meeting. Immediate intervention from staff if there is a resident to resident altercation. Any interaction will need to be reported to DON/ED immediately. All staff will be re-in serviced on this process immediately to be completed by 4:30 pm on Wednesday, August 4th, 2021. Staff will be educated on notifying administration immediately when a resident begins to get upset so that aggression can be avoided, and interventions put in place. - The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R21 had a Brief Interview for Mental Status (BIMS) score of six. BIMS scores under seven indicated severe cognitive impairment. R21 had no behaviors during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/14/21 documented R21 was unable to correctly answer questions during the BIMS interview. The Care Plan dated 01/27/17 documented R21 had dementia and directed staff to administer medications as ordered and monitor/document/report to the medical doctor (MD) any changes in cognitive function. The Care Plan dated 03/19/20, resolved 05/18/21, documented R21 had the potential for lashing out if others got in his space and directed staff to help R21 to maintain safe distance from other residents in common area and to monitor, record, report increased episodes of agitation. The Care Plan dated 03/18/21 documented R21 had the potential to demonstrate physical behaviors related to anger, dementia, and poor impulse control. The Care Plan documented on 03/17/21, R21 grabbed another resident by the left shoulder and bent her forward. The Care Plan directed staff to analyze key times, places, circumstances, triggers, and what escalated behaviors and document. It further directed staff documented observed behavior and attempted interventions, and monitor/document/report to the MD of danger to self and others. The Care Plan directed when R21 became agitated, staff should guide him away from the source of distress and engage R21 calmly in conversation. If his response was aggressive then staff were to walk away calmly and approach later. The Notes tab of R21's EMR revealed a Nursing Note on 03/17/21 at 03:28 PM that documented R21 was in the common area by the nurses' desk. R21 grabbed an unidentified resident by her left shoulder and bent her forward. R21 yelled that she was stealing and stated, if that [expletive] keeps stealing, I'll keep ripping her head off. R21 went to his room and the residents were to stay separated throughout the night. The Notes tab of R15's EMR revealed a Nursing Note on 03/17/21 at 03:31 PM that documented R15 sat in a chair by nurses' desk. Another resident grabbed her by the shoulder and bent her forward. Staff separated the residents and assessed R15's skin. R15 had small amount of redness to the back of the left shoulder. Staffs continued to separate the residents throughout the shift. The Notes tab of R15's EMR revealed a Nursing Note on 03/17/21 at 03:32 PM that documented R15 was involved in resident-to-resident altercation. Another resident grabbed R15 when she took a snack off the other resident's tray and the other resident cussed her out per staff. R15 denied pain upon interview and staff examined her skin. Floor staff educated to keep the residents away from each other. The Notes tab of R21's EMR revealed an Interdisciplinary (IDT) Note on 03/18/21 at 09:57 AM that documented IDT met to discuss an incident of resident to resident altercation on the previous date. R21 grabbed an unidentified resident by the left shoulder and bent her forward. Staff separated the residents. R21 was upset the resident took snacks off his cart. R21 went to his room. Staff were to keep residents separated and if one resident went into the common area, the staff were to redirect the other resident to a separate area. Staff were to monitor the residents at that time. A review of the Facility Report dated 03/20/21 revealed the following account of the 03/17/21 incident: A resident-to-resident altercation on 03/17/21 that involved R21 with a BIMS of five and R15 with a BIMS of three. The report documented R21 was in the common area eating his lunch when R21 came and grabbed his fudge round cookie off his tray. When R15 took the cookie, this made R21 mad, so he grabbed R21 by the shoulder and held her. Staff heard the commotion and removed R21 from the scene. R21 was angry R15 stole the cookie off his tray. Staff redirected R21 to his room. Initial assessment revealed R15 had some light pink fingernail marks from where R21 grabbed her. An order was put in to monitor R21 for behavioral changes. Staff were notified of the situation and advised to redirect R21 back to his room, so the two residents were not near each other. Corrective actions taken in response to the incident included R21 was moved to first floor to keep him separate from residents who wander. A focus in R21's Comprehensive Plan of Care, recorded that on 03/28/21, R21 grabbed another resident by the wrist and started bending her finger backwards. The clinical record lacked further documentation of this resident to resident occurrence on 03/28/21. The facility was unable to provide an investigation for the occurrence on 03/28/21. The Orders tab of R15's EMR documented a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for R15 lacked documentation for the resident-to-resident altercation on 03/28/21. On 08/04/21 at 07:30 AM, R21 laid in bed with his eyes closed. He appeared comfortable and without signs or symptoms of distress or discomfort. No behaviors noted. On 08/05/21 at 01:15 PM, R15 sat in a chair in the day room beside another resident. The other resident rested comfortably with her eyes closed in a reclining wheelchair, a weighted blanket laid on top of her lower body. R15 attempted to pull the weighted blanket off the other resident and onto herself. Certified Medication Aide (CMA) R told R15 no and called her a name in Spanish. R15 stopped pulling the blanket off the other resident. R15 appeared comfortable and without signs of distress. 08/03/21 at 11:11 AM, Certified Nurse Aide (CNA) M stated she always worked on the dementia unit. CNA M stated when the CNA knew which residents were at risk for or actually had behaviors by receiving a verbal report during walking rounds at the beginning and end of each shift. The CNA reported to each other any changes, new behaviors, or ongoing concerns. She stated they also checked the Kardex (electronic tool which lists specific cares required by the resident as directed on the care plan or resident task list). She stated the Kardex should tell them everything they need to know to provide care for the residents. CNA M stated she received training when she was hired regarding direct care as well as training on abuse and neglect. She stated abuse, neglect and exploitation was covered frequently in the monthly trainings. CNA M stated that she knew if residents were having behaviors, staff tried to figure out the cause of the behaviors. In the event of a resident to resident altercation, they should try to separate the residents and see if the resident could be redirected by coloring books, changing the climate or atmosphere, and adjusting the noise levels. She stated the CNA was to report to the charge nurse if any resident to resident altercation or any new behaviors were identified. She stated some residents would need to be kept separate and staff would know those residents by looking in their Kardex. She stated a female resident grabbed R21's cookie and he got upset, but she could not recall any other incidents. On 08/03/21 at 11:30 AM CNA N stated she typically worked on the dementia unit. She stated there were many residents on the unit with varying stages of dementia, some were more with it than others. CNA N stated the CNAs learn how to provide care for the residents by looking in their chart. She stated the resident's chart and the Kardex told the CNA everything they need to know on how to care for the resident including how they transferred, toileted, and if the resident had any behaviors. She stated any behaviors they observed were reported to the charge nurse. If it was a really big behavior the CNA could put in a new alert in the point of care (POC) documentation which would go to the Director of Nursing (DON), and Assistant Director of Nursing (ADON). She stated if there was a new, big behavior she would definitely chart a new alert for it, but not for their routine, normal behaviors. If they were having a routine behavior CNA N would try to separate the residents, g [TRUNCATED]

The facility identified a census of 100. The sample included 27 residents with 12 residents reviewed for abuse. Based on record review, observation, and interviews, the facility failed to protect 37 residents on the Kensington unit (secured dementia unit) from abuse and neglect while investigating episodes and/or allegations of abuse and neglect. The facility further failed to fully investigate, identify, and implement interventions in response to instances of resident to resident abuse. Resident (R) 84, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On another occasion, R84 acted aggressively. Staff failed to implement an immediate intervention, subsequently R84 punched R47. Again, staff failed to implement measures aimed to protect residents and approximately two hours later, R84 hit R71. The facility further failed to implement protective interventions when R21, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to protect residents from resident to resident abuse placed residents on the dementia unit in immediate jeopardy. Further, the facility failed to fully investigate and identify an episode of neglect when the facility failed to complete a thorough investigation and identify the facility's failure to provide the necessary care as defined in the comprehensive plan for care for R148. R148, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide the hourly check and during the time unattended, R148 obtained injuries consistent with a fall which included an acetabular fracture (pelvis fracture involving the hip joint). The facility reviewed the occurrence, placed interventions for a fall but did not address the neglect which occurred when staff failed to provide the necessary hourly checks for R148. This placed R148 at risk for continued neglect . Findings include: - R84's diagnoses, listed under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R84's Admission Minimum Data Set (MDS) on 04/12/21 recorded R84 had a Brief Interview for Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS recorded he wandered one to three days of the look back period, which was improved from his prior assessment. The 04/12/21 Behaviors Symptoms Care Area Assessment indicated R84's behaviors would be addressed in the plan of care. The Quarterly MDS dated [DATE] recorded R84's BIMS remained four. The MDS recorded R84 received limited assistance of one staff for locomotion on the unit in a wheelchair. The MDS documented R84 had behaviors which included physical behavioral symptoms directed towards other (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for one to three days of the look back period. R84 had verbal behavioral symptoms directed at others (e.g. threatening, screaming, cursing) for one to three days of the look back period. Sections 0500 and 0600 of the MDS which addressed the impact R84's behaviors had on himself and other residents was not completed. R84's Care Plan, in the EMR under the Care Plan tab, documented a focus dated 10/20/20 and revised on 07/14/21 which recorded R84 had actual physical behaviors (yelling, hitting) due to his dementia, [CONDITION(S)], [CONDITION(S)] disorder, anger, depression, and poor impulse control. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan interventions dated 10/21/20 directed staff to analyze key times, places and triggers as well as what de-escalated the behaviors and document. It directed staff to assess and address for contributing sensory deficits, assess and anticipate the resident's needs: food, thirst, toileting needs, comfort level, body positioning, and pain. The Care Plan directed to document observed behavior and attempted interventions and directed staff to guide R84 away from sources of distress, engage him calmly in conversation. The Care Plan directed staff to walk calmly away, and approach later if R84's response to staff was aggressive. The Care Plan and clinical record lacked specific interventions or evidence measures were implemented and communicated to staff after the 10/20/20 incident. The Care Plan also documented the following interventions dated 10/21/21: Resident to resident 10/20/20. Resident [R84] went into another resident's room and hit [the] resident in the eye. Resident [R84] redirected back to his room and given snacks. Resident to resident 10/21/20. Resident [R84] went into another resident's room and started hitting [the] resident. Resident [R84] redirected to common area. Resident [R84] sitting with a one on one and plan to send resident [R84] to [hospital] for evaluation. Other interventions dated 07/13/21 recorded Resident to resident 7/13/2021: Psychiatrist gave order for UA [urinalysis] and referral to [psychiatric hospital] for potential admission and change of condition for increased behaviors, aggressiveness towards other staff. The Care Plan and clinical record lacked evidence resident-specific interventions were implemented and communicated to staff to prevent further episodes of abuse. The Progress Notes tab in R84's EMR recorded the following notes: A Nursing Note dated 10/20/20 at 02:06 PM which recorded an unidentified Certified Medication Aid (CMA) and social worker alerted License Nurse (LN) G R84 went into another unidentified resident's room and hit him the eye. LN G documented R84 was observed wandering approximately 10 minutes prior to the incident but had demonstrated no aggressive behaviors. A IDT (interdisciplinary) Note dated 10/21/20 at 07:00AM authored by Administrative Nurse D recorded the IDT team met to discuss the altercation. CMA and social worker notified LNG R84 went to another resident's room and hit him, R84 was noted wandering in the common area approximately 10 minutes prior to the incident. R84 had no aggression noted after the incident. R84 was easily redirected to his room and offered snacks and supervision to ensure he stayed in his room. The note recorded an intervention of resident redirected to room and offered supervision with no signs of aggression or agitation noted. A Social Service Summary dated 10/21/20 at 09:00 AM authored by Social Services X documented R84 was a pleasant male with Lewy body dementia, admitted to the facility for long term care following a hospitalization . The note recorded R84 was previously at a long-term care facility, but he became agitated nad combative with another resident and could not return there. A Nursing Note dated 10/21/20 at 03:50 PM authored by LN G documented R84 sat in the common area when he began to wander off the unit. Staff attempted to redirect R84 and he got upset and made repetitive aggressive statement. R84 then went into [R56's] room and began to hit R56 in his face while he laid in bed. R56 yelled out NO repeatedly. R84 then left R56's room with the unidentified social worker and sat in the common area. R84's representative was contacted and gave permission for R84 to be sent to the hospital in necessary. The (unidentified) physician was notified and the physician gave the order to transfer as needed. R84 was one to one observation. An IDT Note dated 10/21/20 at 04:37 PM authored by Administrative Nurse D recorded the IDT met to discuss the incident that occurred on 10/21/21. R84 sat in the common area where he began to wander on the unit. Staff attempted to redirect him, and he became upset, and made aggressive statements. He then entered [R56's] room and began to hit R56 in the face while R56 laid in bed. R84 exited R56's room with a (unidentified) social worker and was redirected to sit in the common area. The note documented an intervention of R84 to be one to one observation and sent to the hospital for evaluation. A Nursing Note on 10/21/20 at 06:33 PM recorded R84 was transferred to the hospital. A Nursing Note dated 10/22/20 at 02:15 AM recorded R84 returned to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Report dated 10/22/20 revealed the following account of the 10/21/20 incident: on 10/21/2020 at 03:45 PM a resident to resident altercation occurred between R84, who had aa BIMS of 99 ( unable to complete interview) and R56 who had a BIMS of six ( severe cognitive impairment). Both residents resided on the locked memory care unit. On 10/21/20, R84 was observed beginning to wander on the unit. Staff members attempted to redirect R84 and he began to get upset, made aggressive repetitive statements. R84 then went into R56 ' s room and began to hit R56 in his face while R56 was lying in bed. R56 was yelling out No, no, No. The incident was witnessed by the social worker who was attempting to redirect R84. R56 did attempt to defend himself by putting his left arm over his face. R84 then came out of the room with the social worker. R84 was redirected to the common area where he appeared calm with no agitation or aggression noted. Staff immediately initiated 1:1 constant supervision of R84. Consultant HH was notified and orders given to transfer to the hospital of choice for evaluation. R84's durable power of attorney (DPOA) was notified and in agreement with sending to emergency department for evaluation. R56 had two small scratches noted to his left forearm. No bruising or discoloration to face currently. R84 was unable to give a statement of why he struck R56. R84 did not answer any questions related to incident. Further review of Progress Notes tab in R84's EMR revealed the following: A Nursing Note dated 10/27/20 at 10:00 PM authored by LN H recorded R84 wandered and talked to himself. Staff closely monitored him and when attempted to redirect him. R84 became agitated and swung at staff. LN L attempted to redirect R84 three times with the same result. R84 went into another resident's room and laid in that resident's bed. When staff attempted to assist R84 to his room, R84 screamed and threatened staff. Staff notified Consultant HH and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An injection of [MEDICATION(S)] was administered to R84. LN L obtained a (unidentified) male nurse to assist R84 to his room. A Nursing Note' dated 07/13/21 at 03:00 PM authored by LN K recorded R84 sat in the common area when another (unidentified) male resident attempted to pass by. R84 told the other resident R84 was going to kill him. Both residents yelled at each other. R84 made a fist and lifted his hand to hit the other resident. LN K intervened and quickly moved the other resident. Both residents were angry. LN K explained to both residents that their behavior was inappropriate. R84 responded with cold, cold it's cold. R84 was alert but oriented to his name only. At approximately 06:00 PM LN K heard R84, in the hallway coming back from the dining room, threaten someone. LN K ran over to see what was going on and saw R84 threaten a (unidentified) female resident. He attempted to hit her and missed. LN K again removed R84 from area and placed him in front of his room. At 06:05 PM R84 propelled himself to the common area and hit another (unidentified) resident in the face and chest with his fist. LN K again removed R84 and contacted the psych nurse NP [nurse practitioner] who gave new orders. The note documented Administrative Nurse E was notified after immediately after each incident. A Nursing Note dated 07/13/21 at 04:09 PM authored by LNK recorded the following At 4pm this writer observed resident [R84]sitting in his w/c [wheelchair] next to this writer when resident reached over and socked a female resident who was sitting in a chair next to him asleep, he hit her with his fist saying do you want to die. this writer removed the resident with a 1:1 in a room without anyone else. he became calm and he stayed in the dining room being fed and removed as soon as he was finished being fed. A Nursing Note dated 07/14/21 at 04:21 PM authored by LN K repeated the same note as documented by LN K on 07/13/21 at 03:00PM. Review of the Facility Report dated 07/14/21 revealed the following account of the 07/13/21 incident: A resident to resident altercation on 07/13/21 at 04:30 PM and 06:05 PM which involved R84, with a BIMS of four, R47 with a BIMS of six and R71 with a BIMS of six. The report documented on 07/13/21 at approximately 04:30 PM R84 sat in the common area. He went over to R47 and punched her in her side. Witnesses stated R84 was not showing signs of agitation and R47 was sleeping in her chair at that time. The residents were separated, and R84 was redirected to his room. R47 was assessed for injuries after the altercation with no injuries found or reported. She was placed on 72-hour monitoring for bruising. The report recorded R84 could walk on his own. The report further recorded on 07/13/21 at approximately 06:05 PM R84 was in the dining room for dinner, went over to R71 and started hitting her in the face and chest. R84 was immediately redirected back to his room. R71 was assessed for injury with no pain or injury noted. R84 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/02/21 at 07:20 AM R84 sat in his wheelchair, in the 200 hallway of Kensington unit, in front the dining area. On 08/03/21 at 07:24 AM R84 sat in his wheelchair in the common area by the nurse's station on the Kensington unit. There were six female residents also seated in the same area. No staff were present, the closest staff member was down the middle hall passing medications, out of the line of sight to view R84. On 08/03/21 at 7:31 AM R84 continued to sit in his wheelchair at the nurse's station on the Kensington unit with six other female residents. An unidentified staff member pushed another female resident to the common area in a wheelchair, parked the chair, applied the brakes and walked away. On 08/03/21 at 09:05 AM R84 sat in his wheelchair in the common area by the nurse's station on Kensington unit. He lifted his feet in an alternating repetitive motion as if walking. No staff were present in the common area at that time though four other female residents were in the common area with R84. On 08/04/21 at 07:50 AM R84 was in his new room at the end of the hall on the Serenity unit (another unit in the facility adjacent to Kensington unit) with a staff member seated in a chair directly outside his room. On 08/04/21 at 10:02 AM R84 sat in his wheelchair in the dining area on Serenity unit , dressed and covered with a blanket. An unidentified staff member sat with him. On 08/03/21 at 11:20 AM Certified Nurse Aid (CNA) M stated the CNA knew which residents were at risk for or actually had behaviors by receiving a verbal report during walking rounds at the beginning and end of each shift. The CNA reported to each other any changes, new behaviors or ongoing concerns. She stated they also check the Kardex (electronic tool which lists specific cares required by the resident as directed on the care plan or resident task list). She stated the Kardex should tell them everything they need to know to provide care for the residents. CNA M stated that she was knew if resident were having behaviors, staff should try to figure out what the cause of the behaviors was. In the event of a resident to resident altercation, they should try to separate the residents and see if the resident could be redirected by coloring books, changing the climate or atmosphere and adjusting the noise levels. She stated the CNA was to report to the charge nurse if any resident to resident altercation or any new behaviors were identified. She stated some residents would need to be kept separate and staff would know those residents by looking in their Kardex. CNA M said R84 could be combative at time. He typically self-propelled in his wheelchair. She further stated that because R84 had a tendency to use his feet to get himself forward other residents might mistake that for agitation and become afraid. CNA M stated they occasionally had to redirect R84 away from other residents and they would typically use activities, or chocolates. CNa stated she could not remember if R84 had ever struck another resident, but she was aware staff were to make sure he is not in a certain amount of space of other residents. On 08/03/21 at 11:30 AM CNA N there were many residents on the unit with varying stages of dementia, some were more with it than others. CNA N stated the CNAs learn how to provide care for the appropriate cares to the residents by looking in their chart. She stated the resident's chart, the Kardex, told the CNA everything they need to know on how to care for the resident including how they transferred and toileted and if the resident had any behaviors the CNA was to monitor for, it would also be on the Kardex. CNA N tried to separate the residents, get them in their rooms, and figure out the cause of the behavior. If that did not work, she stated she would get a nurse. She stated she had received training on abuse, neglect and exploitation via the computer training and in-services. CNA N recalled R84 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA N stated R84 had a habit of thumping his chest and one resident thought he was swinging at her but he was not. The resident just misunderstood. At that time, staff just removed the other resident and explained to her that R84 was not trying to hit her. CNA N stated she did not think R84 had hit anybody though she said he had kicked at staff when he was in bed. CNA N stated staff had no specific actions or interventions regarding R84's behaviors that she knew about. He then said if she saw a resident strike another resident she would intervene immediately and then report to the nurse. On 08/02/21 at 12:00 PM LN H stated there were a lot of behaviors on the dementia unit. She said in the event of resident to resident abuse, she would make sure the area was safe and render any first aid if needed. She said she would make sure both residents were safe, by separating them and placing them in their rooms or trying redirection. She said if there were specific interventions nursing was required to do, it would be listed on the MAR [Medication Administration Record]. LN H said if the situation was significant, she would alert the DON and Administrator. LN H stated R84 had not any recent behaviors that she was aware of. She said she did know he had been very physically aggressive towards the staff and other residents at times. LN H stated nursing staff had no special instruction or interventions related to R84's aggressive behaviors. She said any new interventions or changes would be listed in his chart. On 08/02/21 at 02:18 PM Administrative Nurse D stated abuse training had been provided to facility staff frequently this year, at least two or three times, both in-person and via computer training. Administrative Nurse D said R84 had some resident to resident altercations. She stated in those type of situations, she expected staff would separate the residents and assess them for injury and look for any identifiable causes. She said after that, staff should keep the involved residents separate from each other and monitor. She further stated the IDT team would review, nursing would make a progress note in the resident's chart each shift and continue to monitor for behaviors. She stated that in the October incident with R84, he had been noted wandering. She stated staff did not generally intervene with wandering for residents on the dementia unit since it was a locked unit. She said if staff had noted him with any aggressive behaviors, they would have redirected him back to his room. Administrative Staff D stated R84 gets agitated and over-stimulated and being in his room helped him de-escalate. She stated staff placed him in his room for that purpose but R84 was able to self-propel himself back to the common areas. Administrative Nurse D said she believed this is what occurred in July, when the resident struck two other residents. She stated staff had placed him in his room, but he brought himself back out, or staff may have brought him out to the dining room since he required assistance with eating. Administrative Nurse D stated she was unable to speculate if any of the resident to resident abuse events could have been prevented although she stated it appeared the interventions and actions taken to prevent abuse in the two instances ( October and July) were not entirely effective . The facility policy Abuse: Prevention of and Prohibition Against revised 01/2021 recorded it was the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility would provide oversight and monitoring to ensure that it's staff, who were agents of the facility, delivered care and services in a way that promoted and respected the rights of the residents to be free from abuse and neglect. The policy documented the facility would train staff to understand behavioral symptoms of the residents which increased the risk of abuse which included aggressive reactions of the residents, wandering type behaviors, resistance to care, and outbursts or yelling out. The policy further recorded the facility would [MEDICATION(S)] to protect and prevent abuse and neglect from occurring within the facility. The facility failed to protect residents from abuse and neglect while investigating episodes and/or allegations of abuse and neglect. The facility further failed to fully investigate, identify, and implement interventions in response to instances of resident to resident abuse. Resident (R) 84, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On another occasion, at a later date, R84 acted aggressively. Staff failed to implement an immediate intervention, subsequently R84 punched R47. Again, staff failed to implement measures aimed to protect residents and approximately two hours later, R84 hit R71. This deficient practice placed the residents in immediate jeopardy. The facility removed the immediacy at 10:40 AM on 08/03/21 by completing the following actions: Move R84 to Serenity Unit. 1:1 with this resident during waking hours with 15 Minute checks during sleeping hours Inpatient referral to be completed on August 4th to find a more appropriate placement for this type of resident with behaviors. IDT completed full audit of all residents on the second floor on August 3, 2021 to determine what residents have the potential to be aggressive and potentially hurt other residents. All residents determined to have the potential to be aggressive or harm residents will have care plan updated, staff informed via jot sheets and the shift change report. Behavioral monitoring audit to be added to the daily clinical meeting. Immediate intervention from staff if there is a resident to resident altercation. Any interaction will need to be reported to DON/ED immediately. All staff will be re-in serviced on this process immediately to be completed by 4:30 pm on Wednesday, August 4th, 2021. Staff will be educated on notifying administration immediately when a resident begins to get upset so that aggression can be avoided, and interventions put in place. - The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R21 had a Brief Interview for Mental Status (BIMS) score of six which indicated severe cognitive impairment. R21 had no behaviors during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/14/21 documented R21 was unable to correctly answer questions during the BIMS interview. The Care Plan dated 01/27/17 documented R21 had dementia and directed staff to administer medications as ordered and monitor/document/report to the medical doctor (MD) any changes in cognitive function. The Care Plan dated 03/19/20, resolved 05/18/21, documented R21 had the potential for lashing out if others got in his space and directed staff to help R21 to maintain safe distance from other residents in common area and to monitor, record, report increased episodes of agitation. The Care Plan dated 03/18/21 documented R21 had the potential to demonstrate physical behaviors related to anger, dementia, and poor impulse control. The Care Plan documented on 03/17/21, R21 grabbed another resident by the left shoulder and bent her forward. The Care Plan directed staff analyzed key times, places, circumstances, triggers, and what escalated behavior and documented. It further directed staff documented observed behavior and attempted interventions and monitored/documented/reported to the MD of danger to self and others. The Care Plan directed when R21 became agitated, staff guided him away from source of distress and engaged R21 calmly in conversation, if his response was aggressive then staff were to walk away calmly and approach later. A focus in R21's comprehensive plan of care, recorded that on 03/28/21, R21 grabbed another resident by the wrist and started bending her finger backwards with an intervention on 03/28/21 that R21 moved to another unit. The Notes tab of R21's EMR revealed a Nursing Note on 03/17/21 at 03:28 PM that documented R21 was in the common area by nurses' desk. R21 grabbed an unidentified resident by her left shoulder and bent her forward. R21 yelled that she was stealing and stated, if that [OBSCENITY] keeps stealing, I'll keep ripping her head off. R21 went to his room and the residents were to stay separated throughout the night. The Notes tab of R15's EMR revealed a Nursing Note on 03/17/21 at 03:31 PM that documented R15 sat in chair by nurses' desk. Another resident grabbed her by the shoulder and bent her forward. Staff separated the residents and R15's skin was assessed. R15 had small amount of redness to back of left shoulder. Residents continued to be separated throughout the shift. The Notes tab of R15's EMR revealed a Nursing Note on 03/17/21 at 03:32 PM that documented R15 was involved in resident-to-resident altercation. R15 was grabbed when she took a snack off another resident's tray and was cussed out by the other resident per staff. R15 denied pain upon interview, skin was examined where she was grabbed. Floor staff educated to keep residents away from each other. The Notes tab of R21's EMR revealed a Interdisciplinary (IDT) Note on 03/18/21 at 09:57 AM that documented IDT met to discuss an incident or resident to resident altercation on the previous date. R21 grabbed an unidentified resident by the left shoulder and bent her forward. Staff separated the residents. R21 was upset the resident was taking snacks off his cart. R21 went to his room. Staff was educated to keep residents separated and if one resident went into the common area, the staff were to redirect the other resident to a separate area. Staff were to monitor the residents at that time. The Notes tab of R21's EMR revealed a Nursing Note on 03/19/21 at 05:31 AM that documented R21 was kept away from the female resident, no grabbing was noted. The writer overheard a female resident ask R21 Who are you? R21 replied to the female resident he was a woman killer. The writer intervened and directed R21 not to use that kind of wording to the other resident and directed him to go to his room. The Notes tab of R21's EMR revealed a Nursing Note on 03/20/21 at 05:46 AM that documented R21 was alert and oriented, able to voice needs. Staff continued to monitor R21's behavior towards other residents, no behaviors all shift. The Notes tab of R21's EMR revealed a Nursing Note on 03/20/21 at 02:34 PM that documented R21 had no aggressive or physical outbursts with staff or other residents. The Notes tab of R21's EMR revealed a Nursing Note on 03/26/21 at 02:39 AM that documented R21 had one episode of aggressive behavior in common area where he was verbally threatening female residents. The writer separated R21 and educated him on his inappropriate behavior. R21 was told he would have to go to his room if he continued to be aggressive, R21 calmed down then later went back to his room. The Notes tab of R21's EMR revealed a Nursing Note on 03/29/21 at 03:05 AM that R21 did not have any abnormal aggressive behavior noted at that time and was in his bedroom, staff continued to redirect resident away from other resident. The Notes tab of R21's EMR revealed a Nursing Note on 03/30/21 at 05:05 AM that R21 did not have any aggressive behavior towards any resident that shift. The Notes tab of R21's EMR revealed a Social Services Note on 03/30/21 at 10:16 AM that documented facility left a message for R21's guardian that he moved from second floor to first floor due to increased behaviors. The clinical record lacked further documentation of this resident to resident occurrence on 03/28/21. A review of the Facility Report dated 03/20/21 revealed the following account of the 03/17/21 incident: A resident-to-resident altercation on 03/17/21 that involved R21 with a BIMS of five and R15 with a BIMS of three. The report documented R21 was in the common area eating his lunch when R21 came and grabbed his fudge round cookie off his tray. When R15 took the cookie, this made R21 mad, so he grabbed R21 by the shoulder and held her. Staff heard the commotion and removed R21 from the scene. R21 was angry R15 stole the cookie off his tray. Staff redirected R21 to his room. Initial assessment revealed R15 had some light pink fingernail marks from where R21 grabbed her. An order was put in to monitor R21 for behavioral changes. Staff were notified of the situation and advised to redirect R21 back to his room, so the two residents were not near each other. Corrective actions taken in response to the incident included R21 was moved to first floor to keep him separate from residents who wander. Upon request, the facility was unable to provide a Facility Report for the resident-to-resident altercation on 03/28/21. The Orders tab of R15's EMR documented an order with a start date of 03/28/21 to monitor wrist and finger for bruising for any signs/symptoms of injury and to notify primary care provider as soon as possible for any bruising or any change of condition. The clinical record for R15 lacked documentation for the resident-to-resident altercation on 03/28/21. On 08/04/21 at 07:30 AM, R21 laid in bed with his eyes closed. He appeared comfortable and without signs or symptoms of distress or discomfort. No behaviors noted. On 08/05/21 at 01:15 PM, R15 sat in a chair in the day room beside another resident. The other resident rested comfortably with her eyes closed in a reclining wheelchair, a weighted blanket laid on top of her lower body. R15 attempted to pull the weighted blanket off the other resident and onto herself. Certified Medication Aide (CMA) R told R15 no and called he [TRUNCATED]

The facility identified a census of 89 residents. The sample included six residents with three residents reviewed for weight loss Based on interviews, observations, and record reviews the facility failed to identify and act to prevent avoidable weight loss for Resident (R) 1 who had a significant loss of 18.36 percent in 90 days. This placed R1 at risk for decreased nutritional status and health complications related to malnutrition. Findings included: - R1's electronic medical record (EMR) under the Med [DIAGNOSES REDACTED]. The Admission Minimum data set ((MDS) dated [DATE] recorded R1 had a Brief Interview for mental status (BIMS) score of three, which indicated severe cognitive impairment. He had no behaviors per the MDS. He required supervision with set up assistance of one staff for eating. The MDS recorded R1 had no issues swallowing, weighed 288 pounds (lbs.) and no or unknown weight loss at that time. The Nutritional Status Care Area Assessment (CAA) recorded R1 triggered due to a body mass index (BMI) which was too high or low. The CAA documented the Care Plan addressed nutrition and directed to see dietary assessments, progress notes, and care plan. The CAA lacked further analysis of the resident's nutritional status. The Cognitive Loss CAA dated 09/11/20 recorded R1 had difficulty concentrating and seemed confused. The CAA documented the Care Plan addressed R1's nutrition. The Quarterly MDS dated [DATE] documented a staff assessment which indicated R1 had severe cognitive impairment. He had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected cares for four to six of the look back days. He also had wandering behaviors for four to six of the look back days. The MDS recorded R1 was independent with bed mobility, transfers, and walking. He was independent after set-up assistance for eating. The MDS recorded R1 weighed 252 lbs. and had no or unknown weight loss at that time. The Care Plan dated 09/08/20 documented R1 was at risk for nutrition due to his dementia. The Care Plan recorded a goal, created on 09/26/20 and revised on 12/22/20 which directed R1 would comply with recommended diet for weight reduction daily. Interventions dated 09/08/20 directed staff to administer medications as ordered, honor R1's dietary preferences and allow R1 to eat in the dining room. An intervention dated 09/10/20 directed staff to monitor and report to the physician as needed signs and symptoms of: decreased appetite, nausea, vomiting, unexpected weight loss, or stomach pain. Another intervention dated 09/10/20 and revised on 10/09/20 directed staff to provide and serve R1's diet as ordered (regular, regular texture, thin liquids with snacks twice daily (BID)). The Care Plan lacked reference to R1's dietary preferences and lacked further resident centered interventions regarding weight loss and nutrition orders. The Care Plan lacked reference to a diet associated with weight loss and lacked physician ordered goals for acceptable loss. R1's EMR, in the Assessments tab, recorded a Nutrition / Hydration Risk Evaluation dated 09/07/20 which recorded R1 had excellent intake, fed himself, and was low risk with a score of four. R1's EMR, in the Assessments tab, recorded a Nutrition-Admission Evaluations dated 09/10/20 documented R1 received a regular diet, and had a desired or ideal weight of 287 lbs. plus or minus three percent (%). It recorded R1 had no issues chewing or swallowing. He ate 25-100 % of meals, varying. He was a potential nutrition /hydration risk due to his BMI suggested he was overweight. Recommendation was to continue regular diet, monitor intake since it varied and add interventions as needed. The goal was to maintain weight +-3%. A Nutrition Note under the Progress Notes' tab dated 10/09/20 and entered by Registered Dietician (RD) II documented R1 was on a regular diet and ate 25-100 % of meals, varying. He had Alzheimer's, was restless, and wandered per nursing. His weight was 276 lbs. on 10/01/20 which indicated a 5.5% loss in 30 days. His BMI, 43.2, indicated he was overweight/obese. R1 had weight loss in regard to inconsistent meal intake as evidenced by a significant loss in 30 days. RD HH recommended R1 continue regular diet, staff reweighed resident to validate the loss, and weekly weights for four weeks or until stable X 4 or until stable. She further recommended to add snacks BID and listed a goal for R1 to maintain his weight +-3%. An Interdisciplinary (IDT) Note in the Progress Notes section dated 11/11/20 recorded R1 was being followed for risk of weight loss. His current weight was 257.0 lbs. on 11/10/2020. R1 ate 25-100% of all meals. R1 needed to be fed by staff at times. R1 got distracted while eating. Fortified cereal would be added to breakfast. Staff would assist R1 more with meals. A Nutrition Note under the Progress Notes' tab dated 11/11/20 and entered by Registered Dietician (RD) HH documented R1 had a current body weight of 257 lbs. with a BMI of 40.2(obese). This reflected a 19 lb. (6.8%) loss in 90 days; 35 lb. (11.9%) loss since 9/4/20 admission weight. RD HH recorded she discussed R1's weight loss with the IDT. R1 was on a regular diet and ate 25-100% of meals, varying. He may need more assistance with meals as he could get distracted. R1 had weight loss related to inconsistent meal intake as evidenced by a significant loss in 30 days. RD HHrecommended to continue regular diet, add weekly weights and change hot cereal to fortified cereal for increased calories. RD HHlisted a goal for R1 to maintain weight +-3%. R1's EMR, in the Assessments tab, recorded a Nutrition-Quarterly Evaluations dated 12/04/20 documented R1 received a regular diet. The most recent weight was 234.8 lbs. on 12/04/20. The assessment lacked documentation of a usual weight or desired/ideal weight. The assessment recorded R1 required limited assistance with dining. It recorded No to New Requests and also lacked an entry under Identified Dietary Needs for Dietary Interventions. R1's EMR, in the Assessments tab, recorded a Nutrition / Hydration Risk Evaluation dated 12/07/20 recorded R1 was at medium risk with a score of six. It documented R1 fed himself with verbal cue, had stable weight for three months, and good intake (ate 50-75% of meals). The Orders tab of R1's EMR recorded a physician's orders [REDACTED]. A physician order [REDACTED]. The Orders tab of R1's EMR recorded a physician's orders [REDACTED]. The tab also recorded a physician's orders [REDACTED]. The Orders tab of R1's EMR lacked evidence of a physician ordered weight loss regimen or a specialized weight reduction diet. The Weights and Vitals tab of R1's EMR recorded the following weights: 9/4/2020 17:40 287.6 Lbs. (Admission weight) 10/14/2020 07:58 267.8 Lbs. (6.88% loss in 40 days) 11/10/2020 10:45 257.0 Lbs. (10.64% loss in 67 days) 12/4/2020 06:07 234.8 Lbs. (18.36% loss in 90 days) R1's EMR under the Tasks tab documented the percentages of meals eaten from 11/24/20 through 12/18/20 as: 0-25 percent (%) intake for 23 meals, 26-50% intake for 11 meals, 51-75% meal intake for 15 meals, and 76-100% meal intake for ten meals. The clinical record for R1 including scanned documents, progress notes and physician docuemntation lacked evidence of a phsyisian ordered weight reduction program. The scanned document Discharge Summary dated 12/21/20 under the Misc tab in R1's EMR documented the resident admitted to the acute care hospital on [DATE] and was discharged on [DATE]. The Discharge Summary listed a [DIAGNOSES REDACTED]. 4 month weight loss and minimal p.o. (by mouth) intake which was present on R1's admission to the acute care hospital. On 12/22/20 at 04:17 PM R1 rested in his bed on the COVID unit. His body posturing was relaxed with no signs of pain or anxiety. On 12/22/20 at 11:55 AM Licensed Nurse G stated staff obtained residents' weights monthly unless there was a weight loss of greater the six percent in a month. The weights were then obtained weekly and nutritional supplements would most likely be ordered. On 12/22/20 at 03:08 PM Administrative Nurse E stated R1 had been on a weight loss program due to obesity. He was placed on interventions for weight loss due to a [DIAGNOSES REDACTED]. On 12/22/20 03:26 PM Administrative Nurse D stated staff obtained residents' weights monthly unless there was a weight problem, then staff weighed weekly. Staff documented weights in the residents' EMR and the computer program highlighted significant changes. The dietician reviewed residents' weights remotely and the Administrative Team reviewed weights with the dietician to coordinate interventions needed. Administrative Nurse D was unsure why R1 had been on a weight loss program in the first place, but the staff noticed his loss of appetite in recent days. R1 was to receive nutritional supplements for recently diagnosed protein/calorie malnutrition. On 12/22/20 at 03:30 PM RD II was unavailable for interview. On 12/23/20 at 12:30 PM RD HH was unavailable for interview. The facility's Nutrition policy dated August 2020 documented any resident weight that varied from the previous reporting period by five percent in 30 days, 7.5% in 90 days, and ten percent in 180 days were evaluated by the IDT to determine the cause of weight loss/gain and interventions required. The facility failed to identify and act to prevent unintended and avoidable weight loss for Resident (R) 1 who had a significant loss of 18.36 percent in 90 days. This resulted in a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to protect all residents in the facility by not following acceptable infection control practice recommendations for COVID-19 from the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). These failures had the likelihood to expose all residents in the facility to COVID-19 resulting in serious harm or death. The facility census was 87. I. The facility failed to conduct staff screenings for signs and symptoms of COVID-19, follow up on staff documented signs and symptoms of COVID-19 prior to staff providing care to residents, and allowed staff who had tested positive for COVID-19 to return to work and care for residents. As a result of the noncompliance, an Immediate Jeopardy (IJ) was identified on [DATE]. These facility failures to appropriately screen staff, restrict sick employees from providing care to the residents, and preventing staff from returning to work too soon after experiencing COVID-19 signs/symptoms and/or positive COVID-19 test results were found to have started on [DATE]. On [DATE] the IJ remained ongoing after surveyors determined continued noncompliance for the facility's failure to assess staff for signs and symptoms of COVID-19 and failure to follow up on staff documented signs and symptoms of COVID-19 prior to staff providing care to the residents on [DATE]. A determination was made that the facility's noncompliance placed all residents in immediate jeopardy. Findings include: Review of a facility provided document titled Riverbend Post Acute COVID-19 Timeline, completed and provided by the Director of Nursing (DON), showed the following: -[DATE], the facility initiated an employee log for tracking symptoms and monitoring the temperature of staff entering the facility. Any abnormal responses were to be reported to the Director of Nursing, Assistant Director of Nursing, Infection Control Nurse, House Supervisor or Weekend Supervisor. -[DATE]: Continuing to screen all employees as they come to work. During an interview on [DATE] at 10:00am, the Administrator stated that 25 employees had tested positive for COVID-19. The facility's employee screening logs were provided by the Administrator on [DATE]. On [DATE], review of the facility's employee COVID-19 screening logs from [DATE]-[DATE] showed the following: -[DATE]: Nurse Aide 8 (NA8), documented cough. -[DATE]: 10pm-6am shift, 10 employees had temperatures assessed and documented, but no screenings documented for any signs or symptoms of COVID-19. -,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]: NA6 documented cough. -[DATE] and [DATE]: NA2 documented cough. -[DATE]: No temperature assessed for dietary aide 1 (DA1). -[DATE]: No temperature assessed for NA3. -[DATE]: No temperature assessed for Speech Therapist 1 (SP1). -[DATE]: NA4 documented had had contact with someone with or under investigation for COVID-19. -[DATE]: NA5 No documentation of being screened. Name only. -[DATE]: No temperature assessed or documented for Licensed Practical Nurse 6 (LPN6). -[DATE]: Physical Therapy Assistant 4 (PTA4) documented cough. -[DATE]: No temperature assessed or documented for DA2. -,[DATE], ,[DATE], and [DATE]: Maintenance Supervisor documented cough. -[DATE] and [DATE]: LPN7 documented cough. -[DATE]: No temperature assessed or documented for Social Worker (SW). -[DATE]: Housekeeping 2 (HK2) documented cough. -,[DATE], ,[DATE], and [DATE]: DA3 documented cough. -[DATE]: DA4 documented cough. -,[DATE] and [DATE]: Maintenance Supervisor documented shortness of breath. The facility failed to follow up on employee reported signs/symptoms of COVID-19 and allowed staff to work and provide care for residents from [DATE]-[DATE]. Review of employee screening logs for [DATE] showed no documentation of any staff having their temperature assessed or being screened for signs/symptoms of COVID-19 on this date. Review of facility employee time clock records for [DATE] showed 46 employees (RNs, LPNs and NAs) worked on [DATE] and provided care to the residents. Review of employee screening sheets for Physical Therapy Aide (PTA1), showed she had documented had contact with someone with or under investigation for COVID-19 on [DATE], cough and had contact with someone with or under investigation for COVID-19 on [DATE] and cough on [DATE]. During an interview on [DATE], PTA1 stated she provided therapy services to residents who resided on the 3rd floor. She stated she was screened before providing care to the residents and reported having a cough on ,[DATE] and [DATE] and all of that week. She stated at first she thought it was just seasonal allergies [REDACTED]. She stated she became ill with a temperature of 101 degrees and loss of smell and taste on [DATE]. She stated she tested positive for COVID-19 on [DATE]. Review of PTA1's time clock records showed she worked and provided care to the residents on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. The facility failed to follow up on reported signs and symptoms of COVID-19 on ,[DATE], ,[DATE] and [DATE] and allowed PTA1 to work and provide care to the residents. Review of the employee screening sheets for NA8 showed she documented cough on [DATE]. Review of NA8's time clock records showed she worked and provided care to residents on [DATE] on the 10pm. to 6am shift. She clocked in at 10:06pm on [DATE] and clocked out at 7:07am on [DATE]. Additionally, she worked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. NA8 was not on the list of staff who had positive or negative test results documented for COVID-19. Her COVID-19 status was an unknown to the facility. Review of the employee screening sheets for Registered Nurse (RN3), showed she documented cough on [DATE]. Review of RN3's time clock records showed she worked and provided care to residents on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Review of a list of employees who were tested for COVID-19, provided by the DON on [DATE], showed RN3 tested positive for COVID-19 on [DATE]. The facility failed to follow up on reported signs and symptoms of COVID-19 on [DATE] and allowed RN3 to work and provide care to the residents. Review of employee screening sheets for Occupational Therapy Assistant 2 (OTA2), showed she documented cough and had contact with someone with or being investigated for COVID-19 on [DATE]. Review of OTA2's time clock record for [DATE] showed she worked and provided care to residents from 8:19am until 4:32pm. During an interview on [DATE] at 9:55am, OTA2 stated she worked with residents who resided on the 3rd floor, which was the short term rehabilitation floor, and also with long term care residents who resided on the other floors of the facility. She stated she began having symptoms on [DATE] which included a bad headache, body aches and a fever. Review of a list of employees who had been tested for COVID-19, provided by the DON on [DATE], showed OTA2 tested positive for COVID-19 on [DATE]. The facility failed to follow up on reported signs and symptoms of COVID-19 on [DATE] and allowed OTA2 to work and provide care to the residents. Review of employee screening sheets for PTA2 showed she documented cough on ,[DATE], ,[DATE] and on [DATE]. Review of PTA2's time clock records showed she worked and provided care to residents on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Review of a list of employees who had been tested for COVID-19, provided by the DON on [DATE], showed PTA2 tested positive for COVID-19 on [DATE]. The facility failed to follow up on reported signs and symptoms of COVID-19 on ,[DATE], ,[DATE] and [DATE] and allowed PTA2 to work and provide care to the residents. Review of the employee screening sheets for the Assistant Business Office Manager (ABOM) showed she documented shortness of breath, cough and sore throat on [DATE]. Review of time clock records for the ABOM showed she worked on [DATE]. Review of a list of employees who had been tested for COVID-19, provided by the DON on [DATE], showed the ABOM tested positive for COVID-19 on [DATE]. During an interview on [DATE] at 11:50am, the ABOM stated her boss was sick about a week or two before she became sick. She stated the facility allowed her boss to come to work with a cough and a sore throat. She stated she went to work on [DATE] and left around noon because she didn't feel well. She stated she thought the policy was that if you didn't have a temperature or more than a few symptoms, you were supposed to report to work. The facility failed to follow up on reported signs and symptoms of COVID-19 on [DATE] and allowed ABOM to enter the facility and work. During an interview on [DATE] at 10:30am, LPN3 stated she began to have symptoms of headache and feeling weak on [DATE]. She stated that she had missed the cut off time to call in sick to work so she took some Tylenol before going to work on [DATE]. She stated she didn't have a fever or symptoms when she completed the screening form, but she just did not feel well. She stated she went to the Human Resources (HR) office after clocking in and let them know she was not feeling well. She said HR found a replacement for her and she clocked out and went home. She stated she was tested on [DATE] and was notified on [DATE] she was positive for COVID-19. She stated she had no other symptoms and returned to work on [DATE]. Review of LPN3's time clock records for [DATE] showed she clocked in at 6:20am and clocked out at 7:04am. Review of a list of employees who had been tested for COVID-19, provided by the DON on [DATE], showed LPN3 had tested positive for COVID-19 on [DATE]. Review of LPN3's time clock records showed she worked and provided care to the residents on ,[DATE], ,[DATE] and ,[DATE] after testing positive for COVID-19 on [DATE]. Review of the Riverbend Post Acute COVID-19 Timeline, provided by the Director of Nursing (DON), showed NA7 had stated late in the morning that she was not feeling well. She was sent home when she told the nursing supervisor that she was unwell. During an interview on [DATE] at 1:04pm, NA7 stated on [DATE] she was at work and had to go outside multiple times due to it being hot in the facility and not being able to breathe. She stated she went to work at 2:30pm on [DATE] and stated she was not feeling well and noticed she had a metallic taste in her mouth after eating a sandwich on her way to work. She stated she was not able to finish her shift and left the facility around 8:00pm that evening. She stated she tested positive for COVID-19 on [DATE]. She stated prior to her becoming sick she had cared for residents who were sick with symptoms of COVID-19, but she had not been instructed to wear PPE when caring for them. She stated she was told by the DON that a mask was not needed when caring for these residents. Review of the employee screening sheets for signs and symptoms of COVID-19 showed no documentation of NA7 being screened on [DATE] for signs and symptoms of COVID-19 prior to allowing NA7 to work, providing care to the residents. Review of a list of employees who had been tested for COVID-19, provided by the DON, on [DATE], showed Certified Medication Assistant 1 (CMA1) tested positive for COVID-19 on [DATE]. Review of time clock records showed CMA1 worked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Review of employee screening logs showed no documentation of CMA1 being screened for signs and symptoms of COVID-19 on [DATE]. Review of staff time clock records showed CMA2, CMA3, NA11 and NA12, worked on [DATE]. Review of staff screening log for [DATE] showed no screening for signs or symptoms of COVID-19 and no temperature assessed for CMA2, CMA3, NA11 and NA12. Review of the employee screening sheets dated [DATE] showed the following: -Office Services employee documented headache. -DA5 documented cough. -NA9, no temperature assessed. -LPN8 documented cough. -NA10, no temperature assessed. -CMA2, no documentation of a screening for signs or symptoms of COVID-19 for [DATE]. The facility failed to screen staff and follow up on staff documented signs and symptoms of COVID-19 prior to providing care to the residents. During interview on [DATE] at 3:30pm, the Administrator stated all staff were screened by a staff person upon entering the front of the building. If there were any concerns regarding the information obtained on the screening sheet, a nurse was notified to review the form. The night shift nurse would come in about 15 minutes early and conduct the employee screenings for the employees who were working the night shift. If there were any concerns regarding the screenings, a supervisor was notified. The facility failed to provide any documentation of follow up from staff reported signs and symptoms of COVID-19 prior to working and providing care to the residents. During an interview on [DATE] at 4:00pm, the DON stated they did not have any staff that worked while having symptoms of COVID-19. She stated that after a staff tested positive for COVID-19, they had to be 3 days without a fever and 7 days without any symptoms before returning to work. Review of CMS QSO Memo ,[DATE]-NH, dated [DATE], provided guidance to long term care facilities which included screening all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough and sore throat. If they are ill, have them self-isolate at home. Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated [DATE], showed the following: -Screen all healthcare professionals (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. -Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. -Fever is either measured temperature >100.0 degrees Fahrenheit or subjective fever. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath, and sore throat. Review of a policy titled Riverbend Post Acute Rehabilitation Policy/Procedure for Staffing during Emergency, dated [DATE], documented the following: -If staff are ill, have a fever, cough or upper respiratory compromise, or have other symptoms consistent with a contagious process, they should not present to the facility for regular or emergency duty, unless it is in response to a pandemic outbreak involving the facility itself (such as COVID-19). In that case, if the facility has confirmed cases of COVID-19, staff who have confirmed or suspected COVID-19 or have mild to moderate symptoms, will report to duty to work with only COVID-19 positive residents who are segregated from other residents and staff. II. The facility failed to ensure COVID-19 positive residents remained in their rooms and failed to ensure staff and residents wore personal protective equipment (PPE) appropriately in an attempt to prevent the spread of COVID-19. As a result of the identified non-compliance, the facility was notified on [DATE] of Immediate Jeopardy related to the facility's failure to follow the guidance and recommendations from the CDC for COVID-19 by not restricting COVID-19 positive residents to their rooms, by not ensuring staff and residents wore the appropriate PPE to prevent the spread of COVID-19, and failed to have an area designated to care for residents with suspected or confirmed COVID-19. The IJ cited on [DATE] was removed on [DATE] after surveyors verified implementation of an acceptable removal plan. Findings include: During an interview on [DATE] at 9:15am, the Administrator reported the facility was deemed a COVID-19 Positive Facility meaning (most all residents had tested positive for COVID-19 after respiratory tract specimens were taken and the qualitative detection procedures were performed). The facility Administrator indicated he suspected the COVID-19 death number was higher than 32 since many residents died with symptoms for COVID-19, but were not confirmed as COVID-19 positive prior to their death, but more residents had died with COVID-19 symptoms that had not been tested . During an interview on [DATE] at 10:12am, the Director of Nursing (DON) and the Infection Control Nurse (ICN) both reported in an effort to conserve personal protective equipment (PPE) and to decrease resident cohorting, residents were no longer required to wear masks or stay in their rooms regardless of if a resident tested positive or negative or showed signs or symptoms of COVID-19. The facility had consulted with the local health department and made a decision on [DATE] to discontinue those efforts to decrease the spread of [MEDICAL CONDITION] because all residents in the facility were now considered positive for COVID-19. The DON further indicated the facility was aware of the CDC and CMS regulatory guidance related to infection control and COVID-19. The CDC Coronavirus Disease 2019 (COVID-19) guidance, located at www.cdc.gov, entitled Preparing for COVID-19: Long-term Care Facilities, Nursing Homes provided guidance that indicated all recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gowns. The CDC provided further guidance located at www.cdcgov/coronavirus/2019 and contained an update dated [DATE] entitled,Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings and provided the following guidance: Cancel communal dining and all group activities, such as internal and external activities. Remind residents to practice social distancing and perform frequent hand hygiene. Have residents wear a cloth face covering or facemask whenever they leave their room, including for procedures outside of the facility. During a tour of the facility on [DATE], the following observations were made at the following times: - 9:30am, therapy staff wore masks but did not wear eye protection, gowns or gloves while providing therapy to four residents (R2, R3, R4 and R5 all tested positive for COVID-19 during the month of April, 2020) in the therapy room. -12:12pm, Registered Nurse 1 (RN1) stood within two to three feet from R6 who tested positive for COVID-19 on [DATE], who was coughing in the common area and not wearing a mask. RN1 was not wearing appropriate PPE such as gloves or goggles/face shield. RN1 stated, I don't know if he is positive for COVID, but he is sick with respiratory symptoms, has decreased oxygen saturation, fever and is lethargic. RN1 said she chose not to wear goggles or a face shield because they fog up but she did not state a reason for not wearing gloves. -12:20pm, observation of the first floor dining room revealed R8, R1, R9, R10, R11, R12, R13 and R14 sat eating together and not [MEDICATION NAME] social distancing, some were fed by staff. Occupational Therapy Aide 1 (OTA1) and Licensed Practical Nurse 4 (LPN4) sat approximately two feet away from R1 and R14 while they assisted them to eat. OTA1 and LPN4 were not wearing appropriate PPE such as goggles or a face shield. RN2 sat at the nursing station near and in view of the dining room and reported she was the Charge Nurse who cared for eight of the residents who were eating in the dining room. She was not sure which residents in the dining room were positive for COVID-19, but she was able to look up the information in the computer. She further reported all eight of her residents had tested positive for COVID-19 and one resident assigned to her tested negative. She also stated the resident who tested negative did not have any symptoms of COVID-19, mostly stayed in his room, but was able to come out and eat in the dining room if he chose to do so. Staff did not treat the resident who tested negative for [MEDICAL CONDITION] differently from the residents who tested positive and did not attempt to separate the residents from each other. -12:50pm, observation of the second floor dining room revealed six residents ate in the dining room, three of those residents sat close together at a dining room table. NA1 assisted residents to eat in the dining room and did not wear gloves or any type of PPE for her eyes. NA1 was within two feet of the residents that she assisted. LPN7 sat at the nursing station near and in view of the dining room and was not wearing PPE for her eyes. LPN7 stated she provided supervision for NA1 and the residents who were in the dining room, but did not instruct NA1 to wear gloves or PPE for her eyes. LPN7 said the goggles hurt her eyes and so she preferred not to wear them. LPN7 reported all of the residents on the second floor were positive for COVID-19 except two residents who tested negative and did not have any symptoms of [MEDICAL CONDITION]. She explained all of the residents are considered as positive for COVID-19, even those residents who tested negative so staff did not have to change PPE when caring for residents, only glove changes and hand washing were done. Negative and positive COVID-19 residents were all able to use the common areas of the second floor. -1:05pm, observation on the second floor revealed Housekeeper 1 (HK1) cleaned a room wearing gloves and a mask, wiped down the bathroom, cleaned the floors and took out the trash. When she exited the room she removed her gloves and put on new gloves without sanitizing her hands. HK1 said she did not know which resident rooms were COVID-19 positive residents. She said she cleaned all of the rooms the same way and it did not matter what residents were positive or negative for [MEDICAL CONDITION]. She chose to only wear gloves and not the rest of the PPE the facility had provided to her because it made her hot and sweat. HK2 worked with HK1 on cleaning the rooms. He said this was the second day he worked at the facility and he was being trained by HK1 since he was new to the job. He was told to wear goggles when he worked, but the facility did not provide him with any PPE except gloves. -1:32pm, observation on the first floor revealed OTA1 walked next to R12, identified by RN2 as a positive COVID-19 resident. The resident pulled herself holding onto the hand rail with her right hand while propelling in the wheelchair. R12 was not wearing a mask or gloves and OTA1 was not wearing full PPE, only a mask and gown. RN1 was in this same area and was wearing a gown and mask, but did not wear gloves or eye protection. She stood in the hall holding onto the hand rail with her right hand. She said possibly two residents who lived on the first floor were negative for COVID-19, but she was not sure. She stated the facility directed staff to treat all residents as if they were positive for COVID-19 and to wear the same PPE when going from caring for one resident to the next. During a tour of the facility on [DATE], the following interviews were obtained at the following times: -12:35pm, RN1 reported residents who tested negative and did not have symptoms of COVID-19 should be on reverse isolation and staff needed to change out the N95 mask for a surgical mask when they entered those resident rooms. - 1:03pm, RN2 reported she did not wear goggles or a face shield, but did wear the same gown and mask for the entire shift and did not change PPE after caring for the COVID-19 positive residents and prior to caring for the COVID-19 negative and asymptomatic residents. -1:10pm, LPN2 stated she took care of R15 on the second floor who had tested COVID-19 negative and who did not have any symptoms of the disease. That resident was a Loner, preferred to stay in her room, but was not in isolation or kept away from the other residents. She said the resident came out of her room and down the hall for showers and staff should give her a mask to wear when she is in the hall. I wash my hands prior to going into her room, but I wear the same PPE when I go in there, I don't change PPE. LPN2 further stated she wore the same PPE with both positive and negative COVID-19 residents and did not change between going from a positive tested resident to care for a negative tested and symptom free resident. LPN2 indicated she wore the same mask for five days and wore the same gown for one day before she discarded the worn mask and gown and donned clean PPE. -1:30pm, LPN3 reported she provided cares to R16, R17, R18 and R19 who tested negative for COVID-19. She said she wore the same PPE in all resident rooms irrespective of their positive or negative COVID-19 tested status. She said one of the four residents, R16, did have symptoms of [MEDICAL CONDITION] and had fevers, but tested negative. That resident was a roommate to a resident who tested negative, R17 and did not have symptoms of [MEDICAL CONDITION]. She said staff treat both residents in the room the same as far as using the vitals tower (mobile medical equipment used to assess vital signs that is placed in contact with a resident's body), pulse oximeter and thermometer, which was cleaned between resident uses. (Review of the clinical records and the Differential Testing for Isolation Residents report showed the report indicated R16 and R17 shared a room together and were not isolated in their own spaces. R16 tested negative for COVID-19 on [DATE]. R17 tested positive for COVID-19 on [DATE]. R16 was retested for COVID-19 on [DATE] and the result was positive.) LPN3 further stated she wore the same PPE when caring for both residents in the shared room space. LPN3 wore her goggles up on her forehead instead over her eyes and her mask covered her chin and not her mouth or nose. She said the facility had instructed her to wear the mask at all times, but it was easier to talk when the mask was not covering her mouth. Observation on [DATE] at 1:29pm, showed PTA3 walking down the hallway on the second floor of the facility with R2. PTA3 was holding hands with R2, and neither were wearing gloves. During an interview on [DATE] at 2:00pm, PTA3 stated it was not a facility policy but rather his own policy not to wear gloves while in the hallways of the facility. Review of R2's electronic medical record (EMR) showed she tested positive for COVID-19 on [DATE]. During an interview on [DATE] at 9:27am, PTA3 stated he began experiencing symptoms of chills and then a fever of 102 degrees and tested positive for COVID-19 on [DATE]. - 4:30pm, the Administrator and Director of Nursing reported 21 residents who reside in the facility had tested negative for COVID-19 on [DATE], but since a large number of residents had tested positive, staff were directed to consider all residents as positive for [MEDICAL CONDITION] and there was no longer any need to keep the residents separated. The facility reported they had plenty of PPE available currently for all staff and training was conducted with all staff on the use of PPE. Staff were instructed to wear the same gown between caring for all residents along with eye protection and masks. Staff cleaned the eye protection at the end of the shift and used it again. During an interview on [DATE] at 4:45pm, the Administrator indicated the facility recently tested for COVID-19 and out of those 21 residents who had previously tested negative on [DATE], nine residents remained negative for COVID-19 and remain symptom free. The CDC guidance, dated [DATE], entitled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings indicated the following: HCP (Healthcare Professionals) (see Section 5 for measures for non-HCP visitors) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The CDC Coronavirus/2019 guidance entitled Preparing for COVID-19:Long-term Care Facilities, Nursing Homes directs the following guidance: Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them.

The facility identified a census of 121 residents. The sample included three residents for elopement risk. Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (#1). The resident eloped from the facility on 5/13/17, and was found at an intersection approximately 0.13 miles from the facility. Staff O shut off the Wanderguard alarm after the resident exited the facility and staff DD observed the resident off facility property and failed to immediately stop and protect the resident. This deficient practice placed cognitively impaired resident #1 in immediate jeopardy. Findings included: The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status Score of 7, which indicated severely impaired cognition. The resident used a walker for mobility, had impairment on one side of a lower extremity, and required limited assistance with the assist of one staff for locomotion on and off the unit. The resident did not exhibit wandering behavior. The Care Area Assessment (CAA) dated 2/28/17 for Cognitive Loss and Dementia documented the resident had dementia, was alert with confusion, and had severely impaired decision making abilities. The CAA dated 2/28/17 for Activities of Daily Living (ADLs) documented the resident required supervision to limited assistance with all ADLs. The care plan dated 2/28/17 documented the resident had a potential for injury related to his/her history of wandering and directed staff to place a Wanderguard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) as ordered by the physician. On 5/14/17, a revision to the care plan documented the resident resided on a secured, locked unit since 5/13/17 and directed staff to check the placement and function of the Wanderguard each shift. The admission Elopement/Wandering Evaluation dated 2/22/17 documented the resident was high risk for elopement. A physician order [REDACTED]. of elopement. Review of the Treatment Administration Record for February 2017 through May 2017 documented the resident's Wanderguard was in place on the right arm and staff checked the function each shift. A progress note dated 2/25/17 at 6:28 P.M. by licensed nursing staff H documented the resident was confused and occasionally forget to use his/her walker. A therapist brought the resident back to the nursing station and stated staff found the resident standing next to the main door without his/her walker and when asked where it was, he/she did not know. Staff placed a Wanderguard on the resident due to risk of elopement. A progress note dated 3/2/17 at 10:58 A.M. by licensed nursing staff I documented the resident had short term memory impairment, impaired safety awareness, and staff should focus on safety awareness. Staff scheduled a care conference to discuss the possible need to move the resident to the secured unit. The clinical record lacked evidence this move occurred. Review of progress notes from 4/7/17 through 5/13/17 documented staff observed the resident wandering the halls and into other resident rooms. A progress note dated 5/13/17 at 11:36 A.M. by licensed nursing staff J documented he/she received a phone call from staff at the front desk who stated the resident got out of the building, he/she was going to the gazebo, but was seen in the community. Staff retrieved the resident on 78th Street and assisted the resident back into the building. Staff used the tool for testing the Wanderguard to ensure it was working properly, he/she was placed on one-on-one staff observation, and a physician order [REDACTED]. A progress note dated 5/15/17 at 10:19 A.M. by consultant staff KK documented the resident eloped from the facility on 5/13/17 and was found on a sidewalk in front of the facility. Staff returned the resident to the facility without injuries. He/she was pleasantly confused and denied recollection of the incident. Staff moved the resident to the secured unit for safety. Review of the facility investigation dated 5/15/17 documented on 5/13/17 at approximately 8:45 A.M., the resident was in the front lobby and stated to staff O that he/she wanted to get some fresh air. When staff O looked up, the resident was no longer in the lobby. Approximately 10 to 15 minutes later, dietary staff DD was reporting to work and informed staff O the resident was walking toward 78th Street. Staff O reported the elopement to a charge nurse and staff retrieved the resident without injury. Review of the facility provided notarized witness statement dated 5/13/17 by dietary staff DD documented on 5/13/17 he/she turned the corner onto the street in front of the facility as he/she was arriving to work and he/she observed the resident walking toward 78th Street. Staff DD told staff O about the resident being outside and staff O reported the incident immediately to a charge nurse. Staff O stated the resident had asked to go out and sit in the gazebo and staff DD stated, No, he/she is on 78th Street. Review of the facility provided notarized witness statement dated 5/13/17 by staff O documented on 5/13/17 at or around 8:45 AM, he/she saw the resident hanging around the front lobby area. Staff O heard the resident state he/she was going to get some air. When staff O looked up again, the resident was no longer in the lobby. Staff O did not hear an alarm sound when the resident left the building. At or about 10 to 15 minutes later, dietary staff DD entered the building and stated he/she had observed the resident walking down 78th Street toward Parallel Parkway. Staff O called the nursing station to report the elopement and several nursing staff left to retrieve the resident. Review of the facility provided undated notarized witness statement by licensed nursing staff J documented at around 9:15 A.M., he/she received a call from the front desk staff who stated the resident was out of the building and was going to go to the gazebo, then it was reported that he/she was off facility property. Direct care staff P ran to get the resident and staff called a code to alert staff of the elopement. Licensed nursing staff J drove his/her vehicle to pick the resident up and assisted him/her back into the facility. Staff tested the Wanderguard and it worked properly. The resident had no injury, staff placed the resident on one-to-one observation, and staff received a physician order [REDACTED]. Review of the facility provided undated notarized witness statement by licensed nursing staff K documented at the time of the code, he/she was in the secured unit. When licensed nursing staff K heard the code announcement, he/she looked up the resident's picture in the electronic health record and went to the first floor to look for the resident. Another staff member told him/her that someone saw the resident on 78th Street by the stop sign. He/she started to walk toward the entrance when other staff members walked the resident in. As the resident walked through the entrance, the resident's Wanderguard alarmed. Another nurse and licensed nursing staff K assessed the resident for injuries. Since the incident, the resident was placed on one-to-one observation with licensed nursing staff K. Review of the Weekly Wander Guard Inspection Log documented all exit doors and stairwells were most recently tested on [DATE], 5/3/17, 4/26/17, 4/18/17, 4/13/, and 4/3/17. Review of the Daily Egress and Oxygen Room Inspection for May 2017 documented staff completed a daily visual inspection of the Wanderguard system every Monday through Friday to ensure each exit was active for the monitoring system. Review of the In-Service Attendance Record dated 4/27/17 documented facility staff received education on the elopement policy and procedure. Review of the Elopement Drill Logbook documented the facility conducted a drill on 5/11/17 and conducted monthly drills from 1/26/16 through May 2017. On 5/16/17 at 1:30 P.M., observation of the speed limit on Freeman Avenue was 20 miles per hour (MPH) and on 78th Street was 30 MPH. In a two-minute timeframe, 5 cars passed by on 78th Street. On 5/16/7 at 10:33 A.M., the resident sat in a chair on the outside patio of the secured unit. A Wanderguard was in place on his/her right wrist. The resident appeared confused, brushed her hair with her hands, and stated she enjoyed being outside. On 5/16/16 at 10:52 A.M., licensed nursing staff L tested the function of the resident's Wanderguard. The Wanderguard was in place on the resident's right wrist and active. On 5/16/17 at 3:02 P.M., maintenance staff Y tested the Wanderguard system. As the survey team approached the main entrance with a Wanderguard, the door immediately locked. As a visitor exited the building, the survey team followed the visitor through the door with the Wanderguard and an alarm immediately sounded. At 3:05 P.M., maintenance staff Y entered the security code into the keypad, the survey team exited through the door with the Wanderguard bracelet, and the alarm did not sound until the survey team came back through the door. At that time, maintenance staff Y stated when the security code was entered into the keypad, there was a 15 to 20 second delay which allowed someone to exit the building without the alarm sounding. He/she stated the cameras in the facility were live feed only and did not record any data. He/she did not know how the resident got out without the door alarming because both the door and Wanderguard were functional. On 5/16/17 at 3:35 P.M., observation revealed from the front entrance of the facility to the corner of Freeman Avenue and 78th Street, was a distance of 0.13 miles. On 5/15/17 at 8:01 A.M., visitor BB reported to the state agency that on 5/13/17 between 9:00 A.M. and 9:15 A.M., an elderly person in pajamas with long white hair was walking on Freeman Avenue with his/her walker toward 78th Street and Parallel Parkway. Visitor BB reported there was a lot of traffic and the resident had no safety awareness as he/she walked in front of his/her car. Visitor BB proceeded to the facility and as he/she entered the building, staff O announced a code orange and he/she asked staff O what that meant. Staff O informed visitor BB the code meant a resident was missing. Visitor BB informed staff O of the location he/she had seen the resident and when staff returned the resident to the facility, it was the same person he/she had observed walking on the street. Visitor BB reported that staff O told him/her the resident had asked to go outside and staff O had let the resident out. Visitor BB reported that direct care staff P went outside to get the resident. On 5/15/17 at 1:53 P.M., visitor AA reported to the state agency that on 5/13/17, he/she was talking to staff O when another visitor entered the facility and stated he/she had seen a resident outside that he/she knew was a resident of the facility because he/she had seen the resident when he/she visited his/her family member. Visitor AA stated as he/she drove to the facility, he/she observed a person walking in his/her pajamas with a walker but did not know it was a resident at the time. Visitor AA reported that staff O told him/her the resident had asked to go outside and staff O let him/her out. On 5/16/17 at 8:09 A.M., dietary staff DD stated he/she heard the resident went out of the building the past weekend. He/she stated if a Wanderguard was in place, it would alarm if the resident went out of the building. On 5/16/17 at 9:18 A.M., staff O stated he/she was working at the receptionist desk on 5/13/17 and saw the resident in the lobby when he/she entered the building. At approximately 8:30 A.M. or 8:45 A.M., staff O went around the corner of the reception area to use the copier and when he/she returned to the desk, the resident was not in the lobby. Staff O stated he/she did not hear an alarm. Approximately 10 minutes later, dietary staff DD entered the building and told him/her that the resident was outside. Staff O did not know if the resident had a Wanderguard on at the time but later found out he/she did have one in place. Staff O stated the key pad on the door was about 5 minutes different than his/her desk phone and he/she did not know if turning the phones over to the ring setting might have triggered the alarm not to work. On 5/16/17 at 11:40 A.M., administrative staff A stated the facility had a camera system in the hallways and the front entrance but it did not record any data. Staff notified administrative staff A of the resident's elopement on 5/13/17 and stated the Director of Nursing (DON) came into the facility to start the investigation. He/she stated when the DON interviewed staff O, his/her statement never changed. Staff O reported that the resident was in the lobby and stated he/she wanted to go outside. When staff O looked up, the resident was gone. Administrative staff A stated dietary staff DD told staff O the resident was walking toward 78th Street and had not yet reached the stop sign when staff reached the resident. Administrative staff A stated no other residents or visitors had reported the elopement or stated they had witnessed the resident on the street. On 5/16/17 at 11:58 A.M., maintenance staff X stated he/she performed daily checks on Monday through Friday on all the egress doors to visually inspect that the door light was active for the Wanderguard system. He/she also performed a weekly check by using a Wanderguard bracelet and testing kit provided by the manufacturer to ensure each egress door and stairwell was locked and alarmed. Maintenance staff X stated the facility completed monthly elopement drills. He/she last inspected and tested the function of the door alarm on 5/9/17, and the last facility elopement drill was completed on 5/11/17. Maintenance staff X stated when a resident with a Wanderguard approached the door, the door would automatically lock and not allow anyone to exit. He/she stated if a staff or visitor entered the security code into the keypad, and a resident with a Wanderguard walked through the door, an alarm would sound once the resident passed the threshold. On 5/16/17 at 12:00 P.M., administrative staff A stated the main entrance remained locked from 5:00 P.M. until about 8:35 A.M. He/she stated between 8:30 A.M. to 5:00 P.M., a receptionist was present at the desk. When the receptionist was on break or needed to leave the desk, another staff member should monitor the desk and front lobby. On 5/16/17 at 12:03 P.M., administrative nursing staff D stated licensed nursing staff J notified him/her on 5/13/17 that the resident had been out of the building but was returned without injury. The nurse had placed the resident on one-on-one observation, checked the placement and function of the Wanderguard and had obtained a physician order [REDACTED]. Administrative staff D stated he/she came to the facility to start the investigation and staff had reported the alarm sounded when the resident returned to the building but had not alarmed when he/she exited. Administrative staff D stated the facility could not figure out how the resident actually got out of the building since the Wanderguard and door were functional. On 5/16/17 at 12:20 P.M., staff O stated on 5/13/17, he/she did not hear an alarm sound, nor was he/she aware of hearing the door lock. Staff O stated the resident was not in the lobby when he/she returned from the copy machine to the desk and he/she assumed the resident had walked back toward his/her unit. Staff O stated he/she was alone at the reception desk when dietary staff DD entered the facility and reported the resident was outside. Staff O stated he/she was not aware of any staff or visitors that allowed the resident to exit the building and no visitors had reported seeing the resident off the facility property. On 5/16/17 at 12:48 P.M., dietary staff DD stated on 5/13/17, he/she had been at work and clocked out to run a personal errand. At approximately 9:20 A.M., as he/she returned to the facility to work, dietary staff DD observed the resident on the sidewalk on 78th street with his/her walker. Dietary staff DD stated the resident did not appear to be in distress so he/she continued to the facility, entered the building, and immediately reported the resident's location to staff O. Dietary staff DD stated that staff O said, No, he/she wanted to go to the gazebo. Dietary staff DD reiterated to staff O that the resident was on the sidewalk on 78th Street. Dietary staff DD stated the DON and charge nurse had asked him/her why he/she did not stop when he/she observed the resident off the facility property. Dietary staff DD stated he/she did not know he/she was allowed to stop and stay with the resident, but did know he/she should immediately notify staff and get help. On 5/16/17, dietary staff DD provided a notarized witness statement to the state agency that was consistent with his/her interview dated 5/16/17 at 12:48 P.M. On 5/16/17 at 1:45 P.M., administrative nursing staff D stated when staff observed a resident off facility property, the staff should immediately attend to the resident and use their cell phone to call the community for assistance. He/she stated staff should never leave the resident unattended. On 5/16/17 at 2:00 P.M., staff O stated he/she worked on 5/13/17 and arrived to the facility at approximately 8:30 A.M. At approximately 8:35 A.M., he/she manually unlocked the main entrance so staff and visitors would be free to come and go. Staff O stated he/she was familiar with the Wanderguard system and knew that if a resident wore a Wanderguard and approached an exit door, it would lock the door. Staff O stated between 8:45 A.M. to 9:00 A.M., he/she observed the resident in the lobby and heard the resident state he/she wanted fresh air. Staff O stated he/she was not familiar with the resident and did not remember seeing a Wanderguard in place at that time. Staff O stated he/she went around the corner to use the copier and when he/she returned to the desk, the resident was not in the lobby. Staff O stated he/she did not hear the resident talk about the gazebo or that he/she wanted to go outside to the gazebo. Approximately 10 minutes later, dietary staff DD entered the facility and informed him/her the resident was on the sidewalk on 78th Street walking north toward Parallel Parkway. Staff O stated he/she called the nursing station, reported the code for elopement, and nursing staff returned the resident to the facility. Staff O stated he/she observed visitor AA enter the facility after staff announced the code. Staff O stated that direct care staff Q reported to him/her that visitor AA told nursing staff on the second floor that he/she had observed the resident on the sidewalk off facility property. On 5/16/17, staff O provided a notarized witness statement to the state agency that was consistent with his/her interview dated 5/16/17 at 2:00 P.M. but conflicted with the interview and witness statement from dietary staff O. On 5/16/17 at 3:30 P.M., administrative staff A and administrative nursing staff D stated the resident was not moved to the secured unit prior to his/her elopement because he/she did not have any actual exit-seeking behavior and was easily redirected by staff. Administrative staff A stated prior to the elopement on 5/13/17, staff were to rely on the elopement risk assessment and placement of a Wanderguard to know which residents were at risk. He/she stated the facility could not speculate as to how the resident exited the building because both the alarm and Wanderguard were functional. Administrative staff A and administrative nursing staff D stated when staff O left the desk to make copies, he/she thought the resident was safe because even if he/she did not know the resident's elopement risk, the Wanderguard was in place and would have locked down the door. On 5/17/17 at 11:50 A.M., direct care staff Q stated on 5/13/17, after the staff had been notified of the elopement, visitor AA stated he/she had seen the resident outside. On 5/17/17 at 3:14 P.M., direct care staff R stated he/she worked on 5/13/17 and had observed visitor and family member AA in the common area. He/she heard visitor AA tell nursing staff that as he/she drove to the facility, he/she had observed the resident out of the facility on the street. On 5/17/17 at 6:15 P.M., maintenance staff Y reviewed the facility provided Bracelet Events log with the survey team. He/she confirmed the log lacked documentation of the Wanderguard alarm on 5/13/17 at the time the resident eloped from the facility and stated if a visitor or staff entered the security code, the alarm would not show up on the report. On 5/18/17 at 2:34 P.M., administrative staff A provided an e-mail with two notarized witness statements from staff S and staff O dated 5/18/17. Review of the facility provided notarized witness statement from staff S dated 5/18/17 documented after staff initiated the elopement code, he/she went to the front desk as staff returned the resident to the facility. When the resident entered the building, the door alarm went off and was reset by staff. He/she asked staff O what had happened and staff O indicated the resident was walking toward the door while other guests were leaving at the same time. Staff O then stated the resident had indicated he/she was going to the gazebo to get some fresh air. Staff O told staff S the alarm did not go off when the resident exited the building. Staff O indicated he/she was not aware the resident was an elopement risk. Review of the facility provided notarized witness statement from staff O dated 5/18/17 documented on 5/13/17 after he/she made copies, he/she heard the alarm on the front door beeping. Staff O stopped the alarm. The notarized witness statement dated 5/18/17 from staff O conflicted with the original interviews and notarized witness statements he/she provided to the facility and state agency. Review of the facility provided Elopement policy dated 11/2016 documented the facility provided a safe and secure atmosphere for all residents in the facility and that exit doors were properly alarmed and secured. Residents who were assessed as high risk for elopement in the electronic charting system would have an assessment completed by a licensed nurse for validity of assessment and need for interventions. The facility failed to provide adequate supervision to this cognitively impaired resident who eloped from the facility on 5/13/17, after staff heard him/her make statements of wanting to exit. Further, staff heard the alarm, shut it off without actively searching for the resident, and another staff observed the resident outside and failed to stop and immediately protect the resident. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 5/17/17 at 6:00 P.M. by initiating the following: Resident Specific: Resident #1 on 5/13/17, upon entrance to the community, the resident was immediately put on 1:1 supervision, an immediate skin evaluation was completed by the licensed nurse and no injuries were noted. A licensed nurse performed an elopement assessment on the resident. The Director of Nursing, Executive Director, physician, and the resident's durable power of attorney (DPOA) (a power of attorney that becomes irrevocable if and when the person becomes incapacitated) were immediately notified of the incident. Maintenance staff arrived after the notification, audited the sensory on the Wanderguard system, and audited all the doors in the facility; no issues were identified. The resident remained on 1:1 supervision until he/she moved to the secured unit at 11:53 A.M. on 5/13/2017. The Director of Nursing reported to the community on 5/13/17 and initiated an investigation. All licensed staff on first floor interviewed by Director of nursing on 5/13/17. Staff education took place on 5/13/17 by the Director of Nursing during staff interviews. Identification of Others: The Director of Nursing performed an audit of residents triggering high risk for elopement on 5/13/17 in-house, excluding residents located on the secured unit. Residents on the secured unit were excluded from re-evaluation due to the residents already pre-determined to be an elopement risk/exit seeking, thus the justification for secured unit placement. All residents residing on the secured unit had a Wanderguard in place. Systems and Measures: The facility initiated an elopement book, with residents who were high risk for elopement. The initial book was placed at front desk on 5/13/17. Additional elopement books were placed at nursing stations on 5/15/17. All departments received additional elopement books on 5/16/17; the elopement books have pictures and residents' information located in them. The elopement book will be maintained and updated as needed by the Activity Director or designee under the direction of the Nursing Leadership. In-Service education was initiated for all staff in regards to procedure to follow for unknown alarms, placement of elopement binders, procedure for staff when residents were observed outside of the building, and implementation of 1:1 supervision for residents who eloped. If a true elopement occurred, nursing would conduct assessments on the eloped resident. Nursing would do appropriate party notification, and overview of entire elopement policy and procedure. The education was provided by the Director of Nursing or designee. Education was to be completed by 5/17/17 at 5:00 P.M. Staff members that were unable to participate in training, by 5:00 P.M. on 5/17/17, would not be scheduled to work until the necessary education was completed. The face-to-face education would be provided by the Director of Nursing or designee. The facility initiated hourly checks of alarmed doors on 5/16/17 at 5:00 P.M. Staff performed hourly checks until all staff education was completed on 5/17/17 by 5:00 P.M. The facility initiated hourly checks of all residents and Wanderguards for placement and functioning until all staff were educated on 5/17/17 by 5:00 P.M. The facility initiated a staff member to stay at front desk on 5/16/17 from 5:30 P.M. until all staff education was completed on 5/17/17 by 5:00. The Executive Director educated the front desk employee and the weekend manager on duty by 5/17/17 at 2:00 P.M. The education included: the employee remained at front desk between 8:30 A.M. to 5:00 P.M., and employees would not leave the front desk unattended without proper relief in place for supervision of the main entrance. All new-hire employees would be trained on the elopement procedure prior to working the floor. The education would be completed by the Maintenance Director or designee. Monitoring: The Maintenance Director/designee would audit the Wanderguard system weekly on an ongoing basis. The Maintenance Director/designee would conduct daily on an ongoing basis visual inspection of each Wanderguard door. Maintenance Director/designee would continue with random monthly elopement drills. The Director of Nursing/designee would monitor the placement and function of Wanderguards each shift. The Director of Nursing and/or designee would evaluate all residents upon admission, quarterly, annually, and with change of condition for elopement risk to ensure proper interventions in place. Any issues identified would be brought to the next QAPI meeting which was scheduled for May 19th, 2017 for the purpose of quality improvement. Ongoing compliance with the facility's Elopement Policy and Procedure would be discussed during the monthly QAPI meeting for further review and evaluation. The deficient practice remained at a scope and severity of D.

The facility identified a census of 125 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one (#1) of three residents who required hospitalization for a change in level of consciousness, lack of blood flow in his/her right lower extremity, septic shock, and gangrene. The facility further failed to perform weekly skin assessments for three (#1, #2, #3) of three residents and to monitor the daily weight of two (#1, #2) of three residents with [MEDICAL CONDITIONS] (a condition with low heart output and the body becomes congested with fluid). These deficient practices placed resident #1 in Immediate Jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition and he/she had intact skin. The 30-Day MDS dated [DATE] documented the resident had a BIMS of 14, which indicated intact cognition and he/she had intact skin. The Care Area Assessment for Pressure Ulcers dated [DATE] documented the resident at risk for pressure ulcer development due to his/her disease processes, but his/her skin was currently intact. The care plan dated [DATE] documented the resident on anticoagulant (a medication used to prevent blood clot formation) therapy and directed staff to perform a daily skin inspection, report abnormalities to the nurse, and to monitor, document, and report signs and symptoms of anticoagulant complications including lethargy, bruising, shortness of breath, sudden changes in mental status, and significant or sudden changes in vital signs. The care plan revised [DATE] documented the resident had a potential for pressure ulcer development and directed staff to notify the nurse of any new areas of skin breakdown, including redness, blisters, bruising, and discoloration. The care plan further documented the resident had [MEDICAL CONDITION] and directed staff to obtain a daily weight and to monitor, document, and report to the physician signs and symptoms of [MEDICAL CONDITION], including dependent [MEDICAL CONDITION] (an abnormal accumulation of fluid in the lower extremity) of the legs and feet, shortness of breath, cool skin, weakness and fatigue (extreme tiredness), [MEDICAL CONDITION](increased heart rate), lethargy (deep unresponsiveness or inactivity), and disorientation. The care plan revised [DATE] documented the resident had a urinary tract infection and directed staff to administer an antibiotic as prescribed and to monitor, document, and report to the physician signs and symptoms of a urinary tract infection, including malaise (a general feeling of discomfort, illness, or uneasiness), altered mental status, and behavioral changes. A physician order [REDACTED]. Review of the clinical record from [DATE] through [DATE] lacked documentation of daily weights for 15 days in [DATE] days in [DATE], and 1 day in [DATE]. According to the Agency for Healthcare Research and Quality (a division of the U.S. Department of Health and Human Services), the national recommendation dated [DATE] for management of [MEDICAL CONDITION] documented daily weights were critical for managing heart failure and early detection of increases in fluid retention. A progress note dated [DATE] at 1:16 P.M. by licensed nursing staff G documented the resident had bilateral pedal pulses (the pulse taken on the top and inner side of the foot) and [MEDICAL CONDITION] (an abnormal accumulation of fluid in the lower extremity with persisting indentation). A progress note dated [DATE] at 11:56 P.M. by licensed nursing staff H documented the resident began to act out of character and staff obtained a physician order [REDACTED]. A progress note dated [DATE] at 2:02 P.M. by licensed nursing staff G documented the resident had increased weeping and [MEDICAL CONDITION] to his/her bilateral lower extremities. A Fax Form for Non-Immediate Communication dated [DATE] completed by therapist X documented the resident had moderate to maximum [MEDICAL CONDITION] in his/her legs, irrational behavior, and required cueing. A weekly skin evaluation dated [DATE] documented the resident had bilateral lower leg [MEDICAL CONDITION] and a blister on top of his/her right foot. A physician order [REDACTED]. Review of the [DATE] and [DATE] Treatment Administration Record (TAR) documented the gauze wraps were in place on [DATE] through [DATE]. The [DATE] TAR lacked documentation for [DATE]. The clinical record lacked documentation the gauze wraps were removed and/or changed daily to inspect and monitor the bilateral lower extremity swelling. A progress note dated [DATE] at 12:15 A.M. by licensed nursing staff H documented the resident's blood pressure was ,[DATE] (a normal top number should be between 90 to 120 and a normal bottom number should be between 60 to 80). The resident was lethargic, forgetful, confused, and had delusions. Licensed nursing staff H documented the resident was clearly not him/herself and suffered from severe level of altered mental status and his/her vital signs were extremely low. The resident had decreased grasps of the bilateral upper extremities, unclear speech, clear skin, and positive bilateral pedal pulses. A physician order [REDACTED]. Review of the hospital emergency room report dated [DATE] documented the resident's lower extremities had wraps in place for [MEDICAL CONDITION] and the wraps were removed to reveal mottling, discoloration, and blistering that appeared chronic in nature. The resident's blood pressure was ,[DATE], heart rate 104 (normal range 60 to 100), and oxygen saturation was 88% (a normal saturation is greater than 90%). The resident was severely hypotensive (extremely low blood pressure), had over-diuresis (increased formation and secretion of urine), fluid loss, [MEDICAL CONDITION] (a life-threatening complication of an infection). Review of the hospital laboratory studies dated [DATE] at 11:15 A.M. documented an INR of 3.4 (normal range 0XXX,[DATE].1) (international normalized ratio, a test used to measure how long it takes for blood to clot), a potassium level of 5.8 (normal range 3XXX,[DATE].1), BUN 65 (normal range ,[DATE]) (blood urea nitrogen used to evaluate kidney function), Creatinine of 1.9 (normal range 0XXX,[DATE].3) (a waste product from the breakdown of muscle tissue and a test of kidney function), and a lactic acid of 7.1 (normal range 0XXX,[DATE].0) (an elevated lactic acid indicates severe infection). Review of the hospital history and physical dated [DATE] documented the resident had swelling in his/her lower extremities, the right leg was cold, purple in color and had moderate [MEDICAL CONDITION], and the left leg was cold and [MEDICAL CONDITION]. The resident was diagnosed with [REDACTED]. The resident was placed in the intensive care unit with a guarded prognosis. Review of the hospital vascular consult dated [DATE] documented the resident's family reported he/she had complained of pain in the right foot on Monday ([DATE]). The resident's right lower leg was dark blue and purple in color from just below the knee down through the foot, swollen with large blisters, and had the beginning signs of gangrene (dead tissue caused by an infection or lack of blood flow). The vascular physician was unable to obtain doppler (ultrasonography used to evaluate the direction and pattern of blood flow) blood flow in the right foot and the left foot pulse was weak with the doppler. The right leg had an occlusion of the right mid superficial femoral artery (the large artery in the thigh and the main arterial supply to the lower limb) and no blood flow below that level. The left leg had an occlusion (the blockage or closing of a blood vessel) of the left mid superficial femoral artery with minimal flow in the lower leg. The vascular consult documented the resident's right lower extremity had ischemia with cyanosis (bluish discoloration of skin) of the calf, ankle, and foot, blistering, and signs of early gangrene causing septic shock. Review of the hospital nurse's note dated [DATE] at 9:30 P.M. documented the resident expired. Observation of the resident was not available as the resident was deceased . On [DATE] at 5:15 P.M., therapy staff Y stated he/she noticed the resident's legs were reddened, and the swelling made the skin of the legs appear stretched, tight, and shiny in appearance. Therapy staff Y reviewed his/her notes in the clinical record and stated he/she had notified the physician of his/her concerns regarding the resident's lower extremities on [DATE]. Therapy staff Y was present in the resident's room when the physician examined the resident's legs. The legs appeared significantly swollen with heavy weeping. On [DATE] at 5:33 P.M., consultant staff KK stated he/she performed wound care for residents with venous stasis ulcers and pressure ulcers that were not healing. Consultant staff KK reviewed the clinical record and stated he/she had not been consulted regarding this resident's legs. On [DATE] at 5:38 P.M., administrative nursing staff D stated the resident had bilateral lower extremity [MEDICAL CONDITION] that staff wrapped with gauze but he/she was not aware of any discoloration of the resident's skin. Administrative nursing staff D stated he/she was aware the resident had a blister on his/her right foot and it was not monitored further on wound sheets because the blister was caused by the [MEDICAL CONDITION] and was not considered a wound. On [DATE] at 6:00 P.M., a family member stated he/she saw the resident at the facility on [DATE] and the resident told him/her that his/her right foot hurt. Another family member had visited on [DATE] and noticed the resident's legs were wrapped in gauze but staff had not informed either family member about a change in condition or the purpose of the gauze. On [DATE] at approximately 10:30 A.M., the family member was notified by the facility that the resident had transferred to the hospital due to a mental status change. The family member stated he/she was never informed by the facility about the resident's critically low blood pressure, or the swelling, discoloration, blisters, and lack of blood flow to the right foot. On [DATE] at 11:17 A.M., licensed nursing staff G stated the resident had severe [MEDICAL CONDITION] and blisters but he/she could not remember if the resident's lower extremities were wrapped in gauze. Licensed nursing staff G stated when a blister developed, it should be documented on a weekly skin evaluation and progress note and the unit manager and director of nursing should be notified so the wound nurse could be consulted for further evaluation and monitoring. Licensed nursing staff G stated he/she worked on [DATE] and did not remember a change of condition for this resident that day. Licensed nursing staff G stated this resident had [MEDICAL CONDITION] and his/her weight should have been monitored daily. He/she stated if the resident did not have an order for [REDACTED]. On [DATE] at 3:25 P.M., administrative nursing staff E stated the resident had weeping [MEDICAL CONDITION] and the day or two before he/she transferred to the hospital, staff documented a blister. He/she stated the resident had an order for [REDACTED]. He/she stated residents with [MEDICAL CONDITION] should have daily weights. On [DATE] at 4:00 P.M., administrative nursing staff D stated this resident should have had daily weights started on admission and acknowledged staff did not obtain an order for [REDACTED]. Review of the facility provided Weights policy dated ,[DATE] documented the facility was responsible for obtaining correct weights and keeping accurate records. Weights would be monitored weekly for four weeks following admission to the facility, and then monthly thereafter unless otherwise indicated. Review of the facility provided Monitoring for Significant Change in Condition policy dated ,[DATE] documented each resident received quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in according with the comprehensive assessment and plan of care. The policy directed staff to notify the nurse supervisor of change in behavior, change in weight and intake and to attempt to identify the cause of the decline. The facility failed to obtain daily weights on this resident with [MEDICAL CONDITION]. The facility further failed to monitor the resident's lower extremities, which had the early signs of gangrene, lacked blood flow, which resulted in septic shock and the expiration of this resident. This deficient practice placed resident #1 in Immediate Jeopardy. The facility abated the Immediate Jeopardy on [DATE] at 11:30 P.M. by initiating the following: the resident was deceased and no longer resided at the community. Licensed nursing staff completed head-to-toe evaluations on current residents and any change of condition was reported to the physician and responsible party. Current residents with a physician order [REDACTED]. The director of nursing or designee conducted a daily review of treatment orders, TAR documentation, and progress notes. The deficient practice remained at a scope and severity of a G. - Review of the clinical record documented resident #2 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition, had one venous/arterial ulcer, and he/she received a diuretic for 7 days of the lookback period. The Quarterly MDS dated [DATE] documented the resident had a BIMS score of 7, which indicated severely impaired cognition, had one venous/arterial ulcer, and he/she received a diuretic for 7 days of the lookback period. The Care Area Assessment for Pressure Ulcers dated [DATE] documented the resident had a venous ulcer on the right lower extremity. The care plan dated [DATE] documented the resident received an antibiotic for treatment of [REDACTED]. A revision on [DATE] documented the resident had a venous stasis ulcer related to [MEDICAL CONDITIONS] and directed staff to cleanse the left lower extremity with wound cleanser or normal saline, pat dry, apply skin preparation around the edges of the opening, and cover with a foam dressing. The venous ulcer on the right lower extremity had healed. A physician order [REDACTED]. A physician order [REDACTED]. Review of the clinical record from [DATE] through [DATE] lacked documentation staff had obtained an order for [REDACTED]. Review of the clinical record from [DATE] through [DATE] lacked documentation of daily weights for 7 days in [DATE] and 2 days in February 2017. Review of the clinical record on [DATE] recorded a weight of 203 pounds. The clinical record lacked a recorded weight on [DATE]. On [DATE], the resident's recorded weight was 222 pounds, a gain of 19 pounds in two days. The clinical record lacked documentation the physician had been notified of the weight gain. Review of the clinical record on [DATE] recorded a weight of 223 pounds. On [DATE], the recorded weight was 213 pounds, a loss of 10 pounds in one day. The clinical record lacked documentation the physician had been notified of the weight loss. According to the Agency for Healthcare Research and Quality (a division of the U.S. Department of Health and Human Services), the national recommendation dated [DATE] for management of [MEDICAL CONDITION] documented daily weights were critical for managing heart failure and early detection of increases in fluid retention. A physician order [REDACTED]. Review of the clinical record lacked documentation of weekly skin assessments for the weeks of [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 10:48 A.M., the resident's lower extremities were visualized with licensed nursing staff G. The venous ulcer on the right leg had healed. Licensed nursing staff G changed the dressing of the left venous ulcer according to the physician's orders [REDACTED]. On [DATE] at 5:38 P.M., consultant staff KK stated he/she performed wound care for residents with venous stasis ulcers and pressure ulcers that were not healing. Consultant staff KK stated he/she monitored the specific wounds and did not complete a head-to-toe skin assessment. On [DATE] at 11:00 A.M., licensed nursing staff G stated staff completed skin assessments weekly on each resident and documented on the Weekly Skin Evaluation form. Licensed nursing staff G stated this resident had [MEDICAL CONDITION] and had an order for [REDACTED]. On [DATE] at 3:25 P.M., administrative nursing staff E stated he/she expected staff to follow physician orders [REDACTED]. Administrative nursing staff E stated he/she expected staff to complete a weekly skin assessment on each resident and clarified that the wound nurse's assessment did not replace their weekly skin evaluation because the wound nurse did not complete a head-to-toe assessment. On [DATE] at 4:00 P.M., administrative nursing staff D stated this resident should have had daily weights started on admission on [DATE] and acknowledged staff did not obtain an order for [REDACTED].>Review of the facility provided Weights policy dated ,[DATE] documented the facility was responsible for obtaining correct weights and keeping accurate records. Weights would be monitored weekly for four weeks following admission to the facility, and then monthly thereafter unless otherwise indicated. Review of the undated facility provided Wound Management policy lacked documentation regarding frequency and documentation of skin assessments. The facility failed to obtain daily weights on this resident with [MEDICAL CONDITION]. The facility further failed to obtain weekly skin assessments of this cognitively impaired and dependent resident. - Review of the clinical record documented resident #3 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 15, which indicated intact cognition. The resident had a stage II pressure ulcer present on admission and was on hospice services. The Care Area Assessment for Pressure Ulcers dated [DATE] documented the resident had [MEDICAL CONDITION] that had metastasized to the bone and a stage II pressure ulcer. Staff were to perform weekly wound inspections and use a pressure reducing device for the bed. The care plan dated [DATE] documented the resident had actual impairment of skin integrity and directed staff to monitor and document the skin injury. Review of the clinical record lacked documentation of weekly skin assessments for the weeks of [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 1:19 P.M., the resident's right ankle wound and left heel wound were visualized with licensed nursing staff F. The right ankle wound was approximately quarter size and had a moist, pink wound bed. The skin of the left heel was intact and was dark purple in color. The dressing change was completed according to the physician's orders [REDACTED].>On [DATE] at 1:30 P.M., the resident stated his/her wounds were present prior to admission and he/she was followed by the wound nurse weekly. On [DATE] at 5:38 P.M., consultant staff KK stated he/she performed wound care for residents with venous stasis ulcers and pressure ulcers that were not healing. Consultant staff KK stated he/she monitored the specific wounds and did not complete a head-to-toe skin assessment. On [DATE] at 11:00 A.M., licensed nursing staff G stated staff completed skin assessments weekly on each resident and documented on the Weekly Skin Evaluation form. On [DATE] at 3:25 P.M., administrative nursing staff E stated he/she expected staff to complete a weekly skin assessment on each resident and clarified that the wound nurse's assessment did not replace their weekly skin evaluation because the wound nurse did not complete a head-to-toe assessment. Review of the undated facility provided Wound Management policy lacked documentation regarding frequency and documentation of skin assessments. The facility failed to obtain weekly skin assessments of this cognitively impaired and dependent resident.

The facility identified a census of 87 residents and 3 residents were included in the sample. Based on observation, record review and staff interview the facility failed to implement interventions as planned regarding transfer status to prevent accidents which resulted in a fracture (broken bone) for one (#1) of three residents sampled for accidents. The resident fractured his/her fibula (bone of the lower leg/ankle) during an unsafe transfer. Findings included: - A review of the physician's orders [REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment for daily decision making. The resident required extensive assist of two staff for bed mobility, transfers, dressing, and toileting, used a wheelchair for mobility and required staff assistance with locomotion on and off the unit. Review of the cognitive CAA (Care Area Assessment) dated 01/13/2016 identified resident required assist of 1-2 staff related to self-care deficit and dementia with physical deficits. The resident was at risk for falls due to decreased cognition and poor safety awareness. The Care Plan dated 05/14/2015 documented the resident had impaired mobility and self-care deficit due to dementia and physical deficits and staff were directed to use 2 staff and a Stand-up Lift (a mechanical lift to aid to assist to transfer residents). Staff revised the care plan on 04/28/2016 and directed staff the resident had a recent fracture of his/her left fibula, was non-weight bearing on the left leg, and required 2 staff to transfer him/her using a Hoyer Lift (total body lift used to transfer residents). Review of the Interdisciplinary Notes dated 04/28/2016 at 9:55 A.M. documented direct care staff reported the resident complained of severe left leg pain during a transfer on a stand up lift. Nursing assessed the resident and noted the resident was in severe pain during the assessment. Staff contacted the doctor and he/she ordered an X-ray of the knee, ankle and foot. The resident was sent to the emergency room at 2:39 P.M. and returned to the facility with a confirmed fracture where the tibia and fibula meet the ankle. ER staff applied a splint to the resident's ankle and administered a narcotic for pain. The resident was non-weight bearing on his/her lower left extremity and staff were to use the Hoyer lift for transfers. The Radiology Report dated 04/28/2016 documented the evaluation today in the ER was consistent with a fracture and staff placed a splint today in the emergency room . During an observation on 5/11/2016 at 9:20 A.M. the resident was in bed. The resident had a splint in place on the left ankle/lower leg and observation revealed the leg/foot remained elevated on a pillow. An observation on 06/08/2016 at 12:50 P.M. revealed staff entered the room and with the use of the Hoyer lift transferred the resident into his/her wheel chair and propelled the resident to the dining room for lunch. The splint remained on the left ankle/leg and both feet were elevated on the foot rest of the chair. During an interview with direct care staff O on 06/08/2016 at 12:22 P.M. he/she stated the resident sat in the hall when he/she arrived at work on the evening shift on 04/27/2016 around 2:30 P.M. and the resident wanted to go to bed. Staff O said none of the lifts were operating because the batteries were not charged. Staff O said he/she and direct care staff P assisted transferring the resident into his/her bed using gait belts, and after the nurse checked the resident for pain, staff transferred him/her into the wheel chair using the gait belts as well. Staff O said the resident should be transferred using a stand up lift and two staff, but that was not how the transfers were done that day. During an interview on 06/08/2016 at 2:51 P.M. direct care staff P stated that he/she came into work around 3:30 P.M. on 04/27/2016 and the resident was in the hall and wanted to go to have his/her brief changed. Direct care staff P and direct care staff O transferred the resident into bed with a gait belt as there were problems with the batteries on the lift. The resident was normally transferred with a stand up lift. Staff P said the transfer went pretty smooth with the gait belts and the resident did complain of his/her leg hurting. Staff O reported the leg hurting to the nurse. Later that shift, direct care staff P and O assisted the resident up and into the wheel chair using the gait belts to transfer him/her again. During an interview on 06/08/2016 at 11:46 A.M. licensed staff H stated that he/she was on duty when the incident happened and direct care staff O reported the resident's foot twisted with the transfer to bed. Staff H said he/she went to the room and assessed the resident's foot and leg with no concerns at the time. Staff H said he/she knew the resident should be transferred using the stand up lift. Staff H said when he/she returned the next day the resident was complaining of knee pain with transferring to his/her wheel chair and staff reported the resident complained of a lot of pain. After nursing assessed the resident, staff called the doctor and received an order for [REDACTED]. The resident returned the same evening and had a splint to the left lower leg/ankle, was non-weight bearing and was changed from a stand up lift to a Hoyer lift for transfers. During an interview with administrative nursing staff D on 06/08/2016 at 4:40 P.M. he/she stated he/she expected staff to follow the care plan and two staff were to be used with both the stand-up lift and the Hoyer lift. Staff D said he/she expected all the equipment to function, and if the battery did not work the staff should notify maintenance. Staff D said he/she was informed the lifts had new batteries, the lifts functioned, and staff charged batteries overnight and replaced. Staff D expected batteries always be available and the equipment to be functioning. The Facility Policy Lifting and Transferring Residents up-dated December 2008 revealed residents are lifted and transferred safely in all instances. Mechanical lift procedures are used on any resident who is semi-weight bearing and requires some lifting to perform the activities of daily living. The facility failed to implement interventions as care planned for safe transfers, which resulted in a broken leg/ankle for this cognitively impaired, dependent resident.

The facility's census totaled 121 residents with 3 residents sampled for falls. Based on observation, interview and record review, the facility failed to provide timely and effective interventions to prevent falls for 2 of 3 sampled residents(#1 and #2), and failed to maintain an environment free of accident hazards on the secured unit. Findings included: - The closed record for resident #1 contained a physician's orders [REDACTED]. The admission Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident's cognitive status was moderately impaired. The MDS further documented the resident required limited assistance of 1 staff with bed mobility, transfer, dressing, toilet use, and personal hygiene and required supervision with set up help only with ambulation and eating. The MDS further documented the resident had no fall history. The Activities of Daily Living Care Area Assessment (CAA) dated 6/20/13 documented the resident usually dressed him/herself, the resident was on a toileting plan for bowel incontinence, was ambulatory per a roller walker with a steady gait and had no range of motion limitation. The CAA related to falls dated 6/20/13 documented the resident had no history of any falls prior to admission and none since arrival to this facility. The revised care plan dated 6/24/13 documented the resident was at risk for falls due to the use of anti-anxiety medications. The approaches included: skilled physical therapy/occupational therapy/speech therapy evaluation as needed, ensure the call light was within reach and remind the resident to use the call light to call for assistance, encourage activity participation for cognitive stimulation, encourage and assist the resident to wear nonskid socks or shoes. Review of the clinical record related to falls revealed the following: 1) On 7/1/13 at 6:00 A.M. the resident was found on the floor by certified nurse assistant (CNA). The resident said " I just sat down". When this writer entered the resident's room, the resident was sitting on his/her buttocks next to the bed. The resident stated he/she was trying to go to the bathroom and slid on the floor. The resident's walker was in the bathroom and was not in reach. The resident stated he/she could not find the call light. The resident rested in bed at this time with the call light in reach. Staff reminded the resident to use the call light for assistance and staff applied nonskid socks on the resident. The care plan intervention dated 7/1/13 noted for staff to encourage this cognitively impaired resident to keep the walker by the bedside when he/she was in bed. 2) On 7/11/13 at 10:50 A.M. the resident was found on the floor by a CNA. The resident laid in a supine (lying down with the face up) position on the floor next to his/her bed. The bedroom light was on and the call light was not activated. The resident was not wearing non-skid socks or shoes and the walker was near the head of bed when staff asked resident what happened, he/she said " I was standing to go to the bathroom and slid down, I'm fine, get me up". There was no apparent injury noted with the exception of small area of [DIAGNOSES REDACTED] (redness), measuring approximately 3 centimeters (cm) by (x) 0 cm on the left flank (area on the part of the body between the lowest rib and the hip bone). Staff encouraged the resident to ambulate wearing the non-skid socks or shoes. The care plan intervention dated 7/11/13 noted staff applied non-skid strips to the floor in the bathroom and beside the bed. The care plan intervention documented the resident was non-compliant with wearing the non-skid socks. 3) On 7/13/13 at 9:00 A.M. staff reported the resident was on the floor. The resident sat in front of his/her bed, call light within easy reach but not activated, and non-skid socks and shoes were on. The resident stated " I slid out of my bed ". The staff encouraged the cognitively impaired resident to use the call light and wait for assistance. Care plan intervention dated 7/13/13 ordered physical therapy to evaluate the resident for positioning rails. 4) On 7/22/13 at 12:20 A.M. staff found the resident on the floor beside his/her bed. He/she said he/she slipped on the covers as he/she tried to get up to use the bathroom. He/she had non-skid socks on and non-skid strips were beside his/her bed. He/she was not injured. The care plan dated 7/22/13 noted staff were to remind this resident who had moderate cognitive impairment to use the call light and ensure the resident knew where the call light was located. The resident would receive a pendent call light. 5) On 7/25/13 at 11:20 P.M. staff found the resident on the floor. He/she said he/she slipped out of the bed while trying to get up to use the restroom. Resident had the call pendant on him/her and the call light was within the resident's reach, walker was beside the bed, and non-skid socks were on his/her feet. The cognitively impaired resident was reminded the resident to use the call light and/or pendant. The care plan intervention dated 7/26/13 documented for staff to leave the light on in the bathroom and the resident's room during the night. 6) On 7/27/13 at 9:00 A.M. staff reported the resident was on the floor next to his/her bed. The resident had non-skid socks on his/her feet, the call light and pendant were within easy reach and was not activated, and the walker was next to the bed but not being used. The care plan intervention dated 7/27/13 noted for staff to encourage and remind this cognitively impaired resident to use the call light, the pendent call light, the walker and the positioning rail. Staff were to offer assistance to the resident to toilet after meals and before he/she laid down. 7) On 7/28/13 at 1:21 P.M. the resident attempted to get out of bed and staff was checking on another resident nearby when the staff heard the resident's walker moving. The staff caught the resident as he/ she was sliding off the bed. The staff assisted the resident to the common area and noted he/she ambulated with a slow and unsteady gait. No new care plan interventions documented on this date. 8) On 7/29/13 at 6:15 A.M. staff heard the resident hollering out for help. The resident sat on the floor next to the bed with both legs underneath him/her. The staff found no injury. The care plan intervention dated 7/29/13 documented staff would check the resident's blood sugar during the night and offer the resident a snack at bedtime. Staff to set up an appointment for the resident with an audiologist (a person who assessed hearing and balance). 9) On 7/31/13 at 3:40 P.M. staff found the resident on the floor in the bathroom doorway. The resident stated he/she thought the door was closed and it opened. The resident was laid on his/her left side, wore non-skid socks, and the roller walker was behind him/her. The resident could move all limbs while on the floor and did not express any pain at this time. After staff assisted the resident from the floor to a standing position, the nurse noted the resident guarded his/her left leg and did not bear any weight on it. The left leg appeared slightly shorter than the right leg. The nurse called the doctor and received an order for [REDACTED]. The x-ray was taken at 5:00 P.M. The facility received notice at 6:10 P.M. the resident fractured (broken) femur (thigh bone). The resident was transferred to the hospital at 7:30 P.M. The care plan dated 7/31/13 noted a door stop was activated to the bathroom door, prevented the door from moving in both directions. The fall screen assessment dated [DATE] scored 1 which indicated the resident was not at risk for falls. The fall screen assessment dated [DATE] scored 14 indicated the resident was a high risk for falls. On 11/22/13 at 2:48 P.M. licensed nursing staff H revealed that if a resident was a high risk for falls then all staff should be made aware of it. The staff always reinforced for the resident to use the call light whenever they needed anything and staff made sure the call light was within the resident's reach. Staff kept the bed in a low position. If a resident was confused, staff checked on the resident more frequently like every 30 minutes and it could be more often depending on how the resident was acted. On 11/22/13 at 3:15 P.M. staff D revealed when a resident had a fall, the interventions were discussed at the Quality Assurance meeting. The December 1, 1996, the facility Fall policy documented the residents will be identified for risk of falls and interventions implemented to reduce risk. The facility failed to develop and implement appropriate interventions to prevent fall for this high fall risk, cognitively impaired resident to prevent multiple falls which ultimately resulted in a fracture. - Resident #2's physician's orders [REDACTED]. The annual Minimum Data Set Assessment 3.0 ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive deficits. The MDS further documented the resident was independent with bed mobility, transfers, walking, and toilet use, and independent with set up help only with dressing. The resident's balance was steady at all times and had no impairment with his/her functional range of motion. The resident required the use of a walker. The MDS further documented the resident had no falls. The fall Care Area Assessment (CAA) dated 3/10/13 documented the resident did not have any falls in the last 180 days. The resident was ambulatory per his/her roller walker and had a steady gait. The revised care plan dated 11/4/13 identified the resident with a potential for falls and documented the following approaches: ensure call light was within reach and remind the resident to use the call light when he/she needed assistance, encourage to wear non-skid socks or shoes, ensure the environment was hazard and clutter free, and ensure the resident wore non-skid socks at bedtime. Interventions added on 3/14/13 included to have nonskid strips on the far side of the bed and to have a pendant call light. The 2 fall assessments dated 10/26/13 scored 4 and 5 which revealed the resident was not at risk for falls. The nurse's notes dated 11/6/13 at 6:45 A.M. documented the resident was on the floor, bare footed, and received no apparent injury. On 11/22/13 at 8:45 A.M. the resident revealed he/she slid off of the bed and the facility said they would provide him/her with a pendant alarm because when he/she slid off the bed, he/she could not reach the call light. The resident stated he/she was told this on the first of the month and still he/she did not have the pendant alarm. Review of the fall investigation revealed the administrator and director of nurses signed on 11/14/13 the resident received a call pendant alarm. On 11/22/13 at 9:30 A.M. administrative nursing staff E placed a work order for the call pendant alarm on 11/7/13 but did not follow up to make sure resident received the pendant. On 11/22/13 at 3:15 P.M. administrative nursing staff D revealed he/she thought the resident received the call pendant alarm. He/she said the interventions for this resident were written on 11/6/13 not 3/14/13 as documented in the care plan but the call pendant alarm was not made available to the resident until 11/22/13. The December 1, 1996, facility fall policy documented the residents were identified for risk of falls and interventions implemented to reduce risk. The facility failed to provide an assistive device in a timely manner as planned for this resident after a fall. - During the tour of the facility on 11/22/13 at 9:00 A.M., observation revealed an uneven torn spot in the linoleum in the secured unit in the middle of the dining room. The edges were sharp and with one's foot, the loose piece of linoleum was raised easily . Some residents in the secured unit wore non-skid socks and no shoes. On 11/22/12 at 9:30 A.M. administrative staff A was notified about the torn linoleum and he/she stated "it would be taken care of ". On 11/22/13 at 5:15 P.M. administrative staff A revealed the linoleum in the secured unit was not fixed. The facility failed to secure the torn linoleum on the secured unit where 20 cognitively impaired mobile residents lived.

The facility identified a census of 126 residents. The sample included 24 residents. Based on observation, interview and record review the facility failed to provide timely registered dietician follow up and timely nutrition interventions for 1 (#130) of 3 residents sampled with significant weight loss. Findings included: - Resident #130's quarterly Minimum Data Set (MDS) 3.0 dated 2/16/13 recorded the resident had a Brief Interview for Mental Status score of 9, which indicated the resident with moderately impaired cognition. The resident required supervision for eating, had no swallowing problems and received a mechanical soft diet. The resident was 60 inches tall and weighed 116 pounds. The resident did not have significant weight loss. The Care Area Assessment for nutrition dated 6/6/12 documented the resident was edentulous and on 6/6/12, his/her diet changed to mechanical soft to aid in swallowing. The resident's appetite decreased and he/she refused to eat much at meals. He/She enjoyed between meal snacks of graham crackers and milk encouraged snacks. The resident weighed 123 pounds. The nutrition care plan dated 6/8/12 directed staff to provide a mechanical soft no added salt diet, set up assistance with eating, weekly weights and double portions with breakfast. If the resident refused breakfast and preferred to sleep then staff would ensure the resident went to lunch. The resident liked graham crackers, milk, and hamburgers for lunch with a coke. The care plan did not indicate the resident received any nutritional supplements. Review of the weight history revealed the resident's weight on 11/08/12 was 121.20 pounds. On 12/12/12 the resident's weight was 120.20 pounds. On 2/11/13 staff recorded the resident weighed 116.40 pounds which indicated a 4 percent weight loss in 3 months. On 3/8/13 the resident weighed 107.40 pounds which indicated a significant weight loss of 13.8 pounds or 11.4 percent weight loss in 4 months. On 4/26/13 staff documented the resident weighed 103 pounds which indicated a weight loss of 15% in less than 6 months. Dietary Note dated 10/8/12 documented the resident did not have significant weight changes, chewing difficulty or dental problems and received a mechanical soft diet with double portions at breakfast. Dietary Note dated 3/12/13, 3 months following staff's recorded continued weight loss for the resident, documented the resident experienced a weight loss of 11 pounds over a 3 month period. He/She ate very little breakfast and staff encouraged the resident to eat. The dietitian recommended staff initiate shake supplements with meals and monitor the resident's weight weekly. Review of the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The April 2013 MAR indicated [REDACTED]. Review of the clinical record on 4/30/13 revealed lack of documentation that the staff notified the dietician of the resident's continued weight loss and refusal to drink the supplement after the 3/13/13 dietary review by the dietician. Review of the clinical record on 4/30/13 at 11:06 A.M. revealed a lack of documentation of a completed assessment by the registered dietician of the resident's caloric and protein needs or the Basal Metabolic Index. Review of the meal percentages for April 2013 documented by staff revealed the resident usually consumed 25% of meals and refused 12 meals for the month. Review of the clinical record on 4/30/13 revealed lack of documentation that staff offered the resident between meal snacks. Observation on 4/25/13 at 8:30 A.M. revealed direct care staff S brought the resident a room tray with ground sausage, scrambled eggs, 2 pieces of toast, cereal, fruit and milk with a carton of Mighty shake supplement and 2 doughnuts. The resident laid in bed with his/her eyes open told staff he/she did not want to eat. Staff encouraged the resident to eat the doughnuts which staff reported buying themselves. The resident told staff to take the tray away. Staff took the breakfast tray with the supplement and left the room. Observation on 4/25/13 at 1:00 P.M. staff served the resident ground meat, peas, 2 types of potatoes, roll, Shasta pop, 1 carton of Mighty Shake supplement, 1 carton of milk and pie. Staff opened the Mighty Shake carton and cued the resident to eat and then left the resident to eat at the dining table. The resident took a couple of bites of the ground meat then pushed the food away toward the center of the table and began drinking the soda pop. Observation on 4/25/13 at 1:14 P.M. staff encouraged the resident to eat some of the meal. The resident told staff he/she did not like what was served and wanted Rice Crispy Cereal. Staff returned with a bowl of cereal and milk and added 2 packages of sugar. The resident picked up the spoon and began eating the cereal. Observation on 4/25/13 at 1:25 P.M. revealed the resident consumed 100% of the cereal then took the straw from the Mighty Shake and put in the milk carton and drank 100% of the milk, then put the straw in the glass of soda pop and drank the pop. He/She then picked up the bowl and drank the remaining milk from the cereal bowl. The resident then requested staff take him/her back to bed. The resident did not drink any of the strawberry flavored Mighty Shake supplement. Staff pushed the resident back to his/her room in the wheelchair. On 4/25/13 at 8:30 A.M. direct care S reported the resident had a poor appetite. Staff reported the resident did not eat much for dinner the night before and refused breakfast that morning. The resident did not drink the Mighty Shake supplement. On 4/25/13 at 1:25 P.M. the resident reported he/she did not drink the Mighty Shake because he/she did not like the shake and it made him/her feel sick when he/she tried it in the past. On 4/29/13 at 4:24 P.M. direct care staff R reported the resident did not eat well and was a very picky eater and refused meals. He/She mostly drank coke and ate cereal. Staff gave the resident shakes with meals and a sandwich snack at night, but he/she did not drink the shakes or eat the sandwich. Staff did not document the percent of the shake or the snack consumed by the resident. Staff thought the nurse might document the supplement consumption, but did not know for sure. On 4/29/13 at 4:48 P.M. licensed nurse K reported the resident had a very poor appetite. He/ She preferred to eat cereal. If he/she refused to eat a meal then staff gave the resident cereal. Staff should notify the physician and dietician if a resident showed weight loss. Staff was aware this resident had weight loss and staff monitored the resident's weight weekly. Licensed nurse K stated the staff did not document the percentage of the supplement consumed by the resident and the resident did not drink the supplement that was ordered. He/She acknowledged staff should notifiy the dietician of the resident's refusals to drink the supplement. On 4/30/13 at 11:06 A.M. dietary consultant staff DD reported the resident did have weight loss and was started on the Mighty Shake supplement. The dietician reported staff did not inform him/her of the weight loss timely and would expect to assess the resident within 1-2 weeks of when the resident began to lose weight. He/She reported staff informed him/her today that the resident refused to drink the ordered supplement and he/she had no prior knowledge of the resident's refusals to drink the supplement. Dietary consultant staff DD expected staff to notify him/her sooner of the resident's continued weight loss and refusals to drink the supplement, so he/she could recommend staff try a different supplement that the resident might drink. He/She acknowledged the resident experienced a significant weight loss. On 4/30/13 at 12:22 P.M. administrative nursing staff D reported staff discussed resident weight loss of 3 percent or more in staff meetings and risk meetings and did not know why the resident's weight loss progressed to the degree it did before staff started a supplement. Staff should not have continued to give the supplement to the resident who refused to drink it and should have tried different alternative supplements for the resident. The facility did not provide the registered dietician's assessment of this resident's caloric and protein needs upon request. The facility provided a policy entitled Supplements/Nourishments dated revised 2/08 which instructed nursing to document the amount of supplement consumed in the MAR. The food service director to monitor the resident's acceptance and tolerance of the supplement and make adjustments as necessary according to tolerance. Intolerance, refusal, or poor consumption was communicated to the consultant dietician. Residents requiring supplements due to nutritional risk were reviewed weekly at nutritional risk meetings or it's equivalent. The facility also provided a policy entitled Nutritional Supplement Medication Pass revised January 1, 2004 indicated staff would initiate a supplement after assessment of weight loss by nursing, dietary and the primary care provider if the resident met criteria. One of those criteria listed was unplanned, progressive weight loss or loss of appetite or significant reduced dietary intake and assessed need. Nursing was responsible for monitoring weights and notifying the appropriate personnel to begin the protocol. The facility failed to timely reassess and provide timely interventions for the presence of a significant weight loss in this cognitively dependent resident.

The facility identified a census of 127 residents. The sample included 4 residents. Based on observation, record review, and interview the facility failed to provide care and services to maintain the highest level of well-being for 1 of 3 residents sampled for medication review (#2). Findings included: - The February 2012 Physician order [REDACTED]. The quarterly Minimum Data Set (MDS) with an assessment reference date of 1/25/12 documented the resident with a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS recorded the resident required limited assistance of one staff with most activities of daily living. Record Review revealed, on 1/15/12 at 8:05 A.M., resident #2 received another resident's medications. These medications were [MEDICATION NAME] (an anti-hypertensive medication), [MEDICATION NAME] (an anti-depressant medication), and [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication). Review of the February 2012 POS revealed resident #2 routinely received a different anti-hypertensive medication, however did not receive anti-depressant or anti-[MEDICAL CONDITION] medications. The facility's self report dated 1/17/12 recorded, staff notified the resident's physician "promptly" and "quick" of the medication error and the physician issued, "no new orders" but "advised staff to monitor the resident." Review of the interdisciplinary (ID) notes dated 1/15/12 timed 7:31 P.M. (11.5 hours after the incident) recorded: "This writer was notified that at the A.M. med pass resident inadvertently received [MEDICATION NAME], and [MEDICATION NAME]. {Nurse} called the physician on call and resident's responsible party (RP)." This note lacked documentation of the resident's vital signs including blood pressure and that the physician had advised staff to monitor the resident. Review of the February 2012 POS and telephone orders also lacked documentation for staff to monitor the resident as stated in the facility investigation. Another entry in the ID notes dated 1/15/12 timed 7:37 P.M. summarized the event as follows: "At approximately 1300, (1:00 P.M.) resident's (RP) was here visiting and stated (resident) was feeling dizzy when attempted to get out of bed after laying down for a nap. Vitals were assessed and resident was noted to have a BP (blood pressure) of SBP (systolic blood pressure) 90-100 mm/hgb (millimeters of mercury) and DBP (diastolic blood pressure) 60-50, mm/hgb resident was noted to be dehydrated as evidence by tenting skin on upper arms, resident had an episode of nausea with vomiting and was incontinent of stool at that time, on call physician gave orders for resident to be sent out for an emergency room evaluation. The ID notes further recorded the resident's return to the facility on [DATE] timed 8:38 P.M. Review of the computerized charting recorded staff assessed resident #2's blood pressure on 1/15/12 at 7:56 A.M. before the medication error (BP 169/77 mm/hgb) and at 8:53 A.M. after the medication error (BP 115/56 mm/hgb). Record review revealed the facility report lacked a Flow sheet or documentation that staff monitored the resident's vital signs from 8:53 A.M. to 1:00 P.M. after the medication error. Review of the patient/EMS (Emergency Medical Services) report revealed the resident's blood pressure was 96/60 mm/hgb, respirations 16 and pulse 86. Review of the Emergency Physician record dated 1/15/12 documented the resident had two episodes of diarrhea and two episodes of vomiting this A.M. At 2:00 P.M. the resident's blood pressure was 116/81 mm/hgb. The record documented the resident received the wrong medications at the nursing home. According to Lexi-Comps Drug information Handbook for Nursing 12th edition 2011, the medication, [MEDICATION NAME] contained U.S. Boxed Warning information. A U.S. Boxed warning= a government (FDA) issued warning regarding the potentially severe, sometimes fatal side effects of some medications. This same reference advised: monitor patient very closely with first dose, (severe reactions can occur with first dose example given, [MEDICAL CONDITION], that may potentially affect the airway or intestine, hypoxemia, postural [MEDICAL CONDITION] (low blood pressure with position change) and anaphylactic reaction. Observation on 2/21/12 at 9:45 A.M. revealed the resident seated in the television viewing area in no apparent distress. On 2/22/12 at 11:50 A.M. direct care staff A stated, he/she was just distracted and made a mistake with the resident's medications, and that I ran to tell the nurse what I did, and then the nurse continued to monitor him/her. On 2/22/12 at 12:45 P.M. licensed nurse C stated, "The moment I was made aware of the situation I called the physician and the resident's RP. I took (his/her) vital signs and (his/her) blood pressure was a little low but we did everything the way it's supposed to. As far as the I D notes, (licensed nurse C) stated the weekend nurse supervisor does that charting. " 0n 2/22/12 at 11:30 A.M. Administrative nurse A stated he/she would consider continued monitoring of a resident when stated by the physician to be an order but I can understand why a telephone order may not have been written as it is not a specific order like to obtain labs etcetera, but I would at least expect nurses to check the resident's vital signs every shift after an incidence of a resident receiving the wrong medications. The facility failed to monitor and document changes in vital signs and maintain resident #2's state of wellbeing after he/she received the wrong medications.

The facility documented a census of 136 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of the sampled residents (#1). Findings included: - Resident ' s #1 physician order [REDACTED]. The quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident with short term memory problems. The resident continuously presented with inattention, disorganized thinking altered level of consciousness and psychomotor retardation. The MDS documented the resident required limited assistance of 1 staff with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, dressing, and toilet use, required extensive assist of 1 staff with personal hygiene, and required supervision of 1 staff with eating. The MDS documented the resident's balance during transitions and walking was not steady, only able to stabilize with human assistance. The resident required a walker and a wheelchair for mobility devices. The MDS documented the resident had 2 falls since prior assessment - 2 with no injury and 1 with major injury. The resident weighed 166 and no documented weight loss. The resident received hospice care. The Care Area Assessment Summary (CAAS) dated 1/24/2011 documented that the resident triggered for falls due to balance problems. The resident had no falls in the last 180 days. The fall screening score of 1 indicated the resident was at low risk for falls. The resident experienced episodes of dizziness and was unable to maintain good balance at times. The resident had a walker that he/she is to use when he/she felt unsteady and medication was available as needed. The fall risk assessment dated [DATE] and 4/13/11 documented a score of 4 which indicated the resident not at risk for falls. The care plan reviewed 4/26/11 documented the resident had a potential for falls due to history of falls, unsteady gait, end-stage diagnosis, psychotropic usage, episodes of confusion, agitation, weakness due to cancer, pain, and decreased vision in right eye. The care plan instructed the staff to ensure the resident used adaptive/positioning devices such as wheelchair and walker. The resident ambulates with staff assistance, although he/she did try to get up unassisted. The care plan recorded the resident used a Broda chair most times for mobility and comfort. The care plan recorded an intervention for the resident to sit at the nurses ' station in Broda chair when out of bed for increased observation. An intervention added on 3/3/11 instructed the staff should be sure my bed is in the low position. Review of the fall investigation flow sheets revealed the resident had falls on 2/21/11, 3/2/11, 3/7/11, 4/3/11, 4/5/11 and 4/19/11. Review of the care plan revealed no additional interventions put in place for the falls on 2/21/11, 3/7/11, and 4/5/11. The resident also had a fall on 4/3/11 which resulted in a fracture and the care plan did not address any changes related to this fracture. The clinical record lacked evidence the staff reassessed or added new interventions to prevent further falls. Review of the nurses notes documented the following: 2/17/11 Resident seems to be confused and unstable gait today more than usual, multiple times staff had to a assist with walking. 2/18/11 Resident alert to person only. 2/28/11 Conference call to brother and sister related to decline in cognition. 3/1/11 Resident became very upset and combative with the hospice staff, he/she was yelling for the police and tried to break a window with a cup. The security was called to the floor so that the resident could see that the staff did call the police. 3/2/11 A blood sugar obtained with a finger stick resulted with 436. The staff tried to give the resident insulin as the physician ordered and the resident became combative, snatched the insulin from the nurse, took the cap off of the syringe and tried to stick the staff with the needle. The resident then placed a chair against the door into his/her to keep people out. The nursing supervisor was able to get in room and calm the resident. Family phone conference- family voiced concerns related to resident diet but voiced understanding that resident may choose to eat as she wishes at this point of her life, 3/2/11 at 1:35 P.M. the resident was found on the floor stated he/she was trying to go to the restroom and fell . The resident revealed that he/she had hit his/her head. The resident did not use the call light, the call light was on the bedside within reach. The resident was very confused, agitated and combative. 3/7/11 at 9:15 P.M. the resident was noted to be sitting on the floor in his/her room next to the door, no injury observed. 3/9/11 at 9:24 A.M. nursing went into the resident's room to check his/her blood sugar. The resident was yelling, refused cares, the finger stick, refused medications, the breakfast meal and requested to talk to his/her social worker or call the police. The resident stated " I want to go home you are holding me against my will. " Nursing called the social worker and he/she later came up to discuss resident's care. The resident has been yelling, cursing, refusing care, crying often, and then smiling. The resident later ate breakfast after much consoling from the staff and accepted morning medications. 4/3/11 the resident had an unwitnessed fall in his/her room at 6:30 A.M. The resident was lying on the floor with an overturned chair next to him/her. The resident was moaning with some blood on his/her lips and had apparently bit his/her tongue. The resident complained of pain on his/her left side and left arm pain, very guarded and wincing. The resident sent by ambulance to the hospital. 11:51 A.M. the hospital called the facility and reported the resident had fractured left wrist and that the resident was to wear a splint. 4/4/11 the resident is noncompliant with the sling to the left arm by continuously removing. 4/5/11 at 6:22 A.M. the resident found sitting on the floor by the television with no injury noted. 4/5/11 at 3:30 P.M. the resident did not want anyone to touch him/her. The resident refused to sit in his/her chair. 4/14/11 the resident using a Broda chair and continuous reminders provided to the resident to sit back down. 4/19/11 the resident laid down at 7:00 P.M. and at 8:15 P.M. the resident came out of room and fell in the hallway. The resident obtained no injuries. 4/20/11 the resident did not sleep all night. The resident sat in a Broda chair at the nurses' station and was agitated, emotionally crying at times, and talking. 4/23/11 on the night the resident was crying profusely repeating " I ' ve got to get home I need to go " . He/ she also requested the police to be called, the security came up and talked with her. 5/1/11 the resident was alert and oriented x 1-2 with some confusion noted this shift but agitation was to minimum. 5/2/11 the resident was screaming and crying, yelling out that staff is keeping her here against her will. Staff is trying to keep her away from her family. 5/5/11 The resident ambulating with stand by assistance. The resident's gait was steady. On 6/7/11 at 8:30 A.M. observation revealed the resident ambulating unassisted to his/her room with a roller walker, sat on the edge of his/her bed, (bed in low position with no mats at bedside) took off his/ her shoes and then laid down on the bed. On 6/7/11 at 10:35 A.M. observation revealed the resident walking unassisted into the dining room with a roller walker. The resident's gait steady. The resident obtained a glass of water from the sink and started to walk back out of the dining room pushing his/her walker with one hand and carrying glass of water with the other hand. The resident noted to be ambulatory with roller walker and occasionally he/she would walk without assistive devices. The resident gait steady. On 6/8/11 at 10:35 A.M. licensed nursing staff B revealed that during a daily morning meeting that resident falls are discussed. The care plan is updated with interventions to prevent further accidents. The facility failed to reassess the resident after a fall and failed to put prompt and effective interventions in place to prevent further falls. This resident fell and sustained a fracture.

The facility documented a census of 144 residents. The sample included 3 residents. Based on observation, record review and staff interviews, the facility failed to provide supervision to prevent falls for 1 of 3 sampled residents reviewed for falls (#1). Findings included: - Resident #1 ' s Physician order [REDACTED]. vascular disease, and generalized osteoarthrosis unspecified. The discharge Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident required limited assistance of 1 staff member with transfers and ambulation. The MDS further documented the resident ' s balance not steady and only able to stabilize with human assistance. The resident had functional limitation on one side of his/her lower extremity and uses walker/wheelchair for mobility. The fall risk assessment dated [DATE] documented a score of 2 which indicated the resident not at risk for falls. Review of the restorative nursing assessment dated [DATE] revealed that the resident required an assistive device of a four wheeled walker and stand by assistance with ambulation. The admission care plan dated 4/11/2011 (printed 4/13/2011) documented self care deficit with the resident requiring assist of 1 staff with ambulation/locomotion and transfers. The care plan further documented the resident at risk for falls related to impaired activities of daily living and his/her disease process. The nursing staff should educate the resident on safety measures to reduce falls, provide appropriate activity daily living assistance, assistive devices in place and cueing with safety measures. On 4/28/2011 at 12:17 P.M., interview with licensed nursing staff C revealed that the admitting nursing staff failed to initiate a care plan into the electronic system or provide a hand written care plan related to resident #1 potential for falls. The resident profile detail report (that the nursing staff utilizes for daily cares) documented that the resident ' s mobility required a 4 wheeled walker and stand by assistance and/or contact guard assistance. Review of the nurses notes dated 4/10/2011 documented at 6:20 P.M. that the licensed nursing staff A received report from direct care staff A that the resident had fallen while ambulating unattended in the hallway from the dining room. Licensed nursing staff A assessed the resident in his/her bed and noted limited range of motion in the right lower extremity and mild to moderate pain. The staff called the resident ' s physician and the licensed nursing staff A received an order for [REDACTED]. The revised 2/08 facility policy " Falls " documented that the residents will be identified for risk of falls and interventions implemented to reduce risk. Residents with unwitnessed fall shall be considered to have hit their head unless they are a reliable historian and can definitely say they did not hit their head. Baseline neurological checks will be done on residents that are observed on the floor or have unwitnessed falls. The revised 7/07 facility policy " Occurrence Summary Report for Care Tracker " documented that this report is completed for accidents or incidents where there is injury. The staff with direct observation or first on the scene enters observation in the Care Tracker (electronic system). On 4/27/2011 at 3:30 P.M., an interview with licensed nursing staff B revealed that resident #1 left the independent dining room with several others residents. The resident ' s gait observed to be steady with his/her walker. Licensed nursing staff B and direct care staff A heard a resident, from the hallway, say that someone had fallen. Licensed nursing staff B revealed that he/she had been assigned to the dining room and unable to leave the dining room. Licensed nursing staff B stated that direct care staff A and direct care staff B left the dining room to see what was going on. Licensed nursing staff B stated that he/she was not responsible for the resident that had fallen since the resident was off another hall. On 4/27/2011 at 4:00 P.M., an interview with licensed nursing staff A revealed that direct care staff A and direct care staff B assisted the resident off of the hallway floor, sat the resident on the 4 wheeled walker and pushed the resident to his/her room. Licensed nursing staff A was in the nursing supervisor ' s office, which is located across the hall from the resident ' s room, and observed the staff taking the resident into his/her room per walker. The licensed nursing staff A stated that this was when he/she was first notified that this resident had fallen. On 4/27/2011 at 5:00 P.M., interview with licensed nursing staff C revealed that the nurse should have left the dining room to check on the resident that had fallen. Licensed nursing staff C revealed that a nurse should assess a resident after a fall and before the resident is moved. The facility failed to ensure that resident #1 received stand by assistance or contact guard assistance when ambulating which resulted in a fall with a fractured hip.