Every finding on record at Rolling Hills Health Center

The facility identified a census of 44 residents. Based on observation, record review, and interviews, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of a lack of assessment and inappropriate care.Findings included:- The facility's April, May, June, July, August, and September 2024 nursing schedule lacked evidence of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 04/06/24, 05/04/24, 06/15/24, 07/04/24, 07/20/24, and 07/27/24. The facility was unable to provide verifiable, auditable evidence of RN coverage.On 07/29/25 at 09:10 AM, Administrative Staff A stated she was unable to provide payroll documentation for RN coverage for those six days. On 07/29/25 at 11:42 AM, Administrative Nurse D stated the facility staff scheduler was responsible to ensure there was RN coverage. Administrative Nurse D stated that the weekends had been the hardest days to have RN coverage. The facility's Competent and Sufficient Staffing policy, dated November 2024, documented that the facility would provide a sufficient number of nursing staff with the skill sets and competency necessary to provide care/services for all residents in accordance with resident care plans and the Facility Assessment. A Registered Nurse provided services for at least eight consecutive hours every 24 hours, seven days a week. RNs may be scheduled more than eight hours, depending on the acuity needs of the residents.

The facility identified a census of 44 residents with one kitchen and dining room. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food storage and equipment cleaning. This deficient practice placed the residents at risk of food-borne illnesses and food safety concerns. Findings included:- On 07/27/25 at 10:00 AM, a walkthrough of the facility's kitchen was completed:An inspection of the food preparation area revealed a microwave oven. The inside of the microwave oven contained a bowl of uncovered green beans. The inside of the microwave oven had old food debris spattered on the walls of the inside surfaces. An inspection of the walk-in refrigerator unit revealed built-up dust and debris covering the blower vents. An inspection of the dry food storage area revealed two unboxed packages of napkins resting directly against the storage room wall without a barrier to keep them clean. An inspection of the dry food storage area revealed multiple syrup-based dessert sauce bottles with syrup residue caked on the lids of the bottles, placed on the dry food storage racks.An inspection of the dry food storage area revealed gnats flying and landing on the bread packages in the dry food storage room. On 07/29/25 at 08:30 AM, a walkthrough with Dietary Staff BB was completed. Dietary Staff BB removed the dessert sauce containers and stated that staff were expected to wipe them down after use. An inspection of the bread area revealed a small number of gnats flying around the bread. Dietary Staff BB stated the facility was working with pest-control services, and most of the gnats were removed the previous day. She stated kitchen staff were expected to clean all surfaces after each meal service to ensure sanitary conditions. The facility's Food Preparation and Service, revised 04/2020, stated the facility was to ensure food service employees handle kitchen food and equipment in a manner that complies with safe handling practices. The policy noted that all food was to be labeled and dated. The policy noted that cooking equipment would be maintained in a sanitary environment and stored in a manner to prevent contamination or soiling.

The facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag was properly hung. The facility failed to ensure R34 and R54's nasal cannula (NC- a hollow tube medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) were properly stored when not in use. This placed R2, R34, and R54 residents at risk of infection development and possible respiratory and/or urinary complications.Findings included: - On 07/27/25 at 10:13 AM, R34 sat on the bed. R34's NC oxygen tubing was hanging over the walker railing, no bag noted.On 07/27/25 at 10:14 AM, R2 slept in her bed. R2's bed was in the low position. Her urinary catheter collection bag lay flat directly on the floor with yellow urine visible in the bag and collection tubing.On 07/27/25 at 11:05 AM, R2's urinary catheter tubing and collection bag were hung on the bed frame with a privacy bag in place. On 07/28/25 at 12:06 PM, R54's NC laid on the floor in her room. Administrative Nurse D picked up the NC from the floor and handed it to R54 to put on. Administrative Nurse D failed to discard the dirty NC and obtain a new one.On 07/29/25 at 08:52 AM, Administrative Nurse D, the facility's infection preventionist, stated that NC should be stored in the provided bag when not in use. Administrative Nurse D stated that catheter bags should never be on the floor, and she would expect staff to change out the bag and ensure that the bag was hung on the side of the bed with the dignity bag covering the bag. Administrative Nurse D stated yesterday that she had realized after the incident with R54's NC that she should have replaced the tubing with a new one and should not have given R54 the NC that had been lying on the floor. The facility's Catheter Drainage Bag policy, dated 11/28/17, documented if the drainage bag or drainage tubing came into contact with the floor, all areas of the bag and tubing must be cleansed with alcohol.The facility's Oxygen Safety and Management policy, dated 03/22/19, documented equipment used for oxygen administration would be replaced every two weeks. The equipment should be marked with the name of the resident and the date it was put into use. Oxygen cannulas and masks should not be allowed to come in contact with the floor or other potentially dirty surfaces. If this occurred, they should be replaced. The cannulas or masks should be stored in plastic bags to prevent contamination.

The facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings included:- A review of the facility's Activity Calendars for May 2024, June 2025, and July 2025 was completed. The activities calendar for each month noted the same scheduled activities for Saturdays and Sundays. The calendar noted movies, games, social hour, puzzles, and a [NAME] game. On 07/28/25 at 11:00 AM, the facility's Resident Council reported weekend activities were often non-existent. The council stated that the activities coordinator sometimes came in and completed activities, but not every weekend. The council reported that the facility's nursing care staff did not complete the scheduled activities when the activity coordinator was not in the facility on the weekend. The council reported staff would put on movies and television shows, but did not complete staff-led activities. The council reported that the residents were often bored on weekends. On 07/29/25 at 11:30 AM, Certified Nurse Aide (CNA) M stated that scheduled weekend activities often did not get completed on weekends. She stated the activities staff were not in the facility on weekends, and staff often were too busy completing resident care. She stated the facility did provide puzzles and games for the residents to complete on their own. On 07/29/25 at 11:55 AM, Licensed Nurse (LN) G stated that weekend activities were not completed. She stated staff would try to provide movies and television for the residents, but direct care staff were not available to provide staff-led activities due to the resident care needs in the building. On 07/29/25 at 12:05 PM, Activities Staff Z stated she worked Monday through Friday but would sometimes come in on weekends to provide weekend activities. She stated that direct care staff were expected to complete the activities on the day she could not come to the facility. She stated the facility also provided coloring pages, puzzles, and games for the residents to complete individually when staff were not available to provide group activities. The facility's Activities Programming policy, revised 04/2018, indicated the facility would provide activities that meet the residents' needs and interests to support their physical, mental, and psychosocial well-being.

The facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment when cleaning chemicals and Sani-wipes (a disposable disinfecting wipe) were not securely stored out of the residents' reach. The facility failed to ensure interventions were put in place after Resident (R) 27 had a fall. This placed the residents at risk for avoidable falls and avoidable injury.Findings included:- On 07/27/25 at 10:15 AM, outside of room [ROOM NUMBER], the Hoyer (total body mechanical lift) lift had a container of Sani-Wipe disposable cloths on it that was easily removed from the lift. On 07/27/25 at 10:22 AM, in the Tuscany room, Sani-wipes above the ice machine were unsecured, and an Alpha HP multi-surface disinfectant spray bottle, with a label that stated: keep out of reach of children, was in an unsecured cabinet underneath the sink. On 07/29/25 at 11:24 AM, Certified Nurse Aide (CNA) M stated the Sani-wipes and cleaners should be stored and locked out of the resident's reach.On 07/29/25 at 11:32 AM, Licensed Nurse (LN) G stated that residents typically did not go to the Tuscany room, but chemicals/cleaners should not be stored in a cabinet that was not locked or anywhere that residents had access to.On 07/29/25 at 11:42 AM, Administrative Nurse D stated that chemicals and the wipes should not be left out where residents had access to them. Administrative Nurse D stated the Sani-wipes had been put on the lifts after COVID-19 (highly contagious respiratory virus), so staff could easily sanitize the lifts after use. Administrative Nurse D stated that the wipes were secured to the lift, but had not realized that the container could be pulled off the lift when the container was close to being empty. The facility policy Chemical and Hazardous Material Storage dated November 2018, documented that all chemicals and hazardous items would be stored in a manner as to protect residents. Ensure that chemicals and hazardous items were stored in a locked area. Ensure that all chemicals and hazardous items are stored in the designated area when not in use by staff.- R27's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance (a range of problematic or disruptive behaviors that deviate from what is considered typical or expected for a given age, situation, or individual), and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition).R27's Significant Change Minimum Data Set (MDS) dated 08/28/24 documented a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. R27 required the use of a wheelchair to assist with mobility. R27 required substantial to dependent from staff for assistance with her activities of daily living (ADL).R27's Falls Care Area Assessment (CAA) dated 09/03/24 documented R27 was at risk for falls related to the medications she received, poor cognition, incontinence, and her need for assistance with transfers and bed mobility. R27 also had poor trunk strength and required a high-back wheelchair. R27 had not had any falls since the prior assessment.R27's Care Plan, last revised on 06/04/25, directed staff that she required one-on-one, extensive assistance for transfers. The Care Plan directed staff that R27 needed staff to reposition her when her bottom got close to the front of the wheelchair cushion or if I am leaning back in my chair for fall prevention. The Care Plan directed staff that R27 did not have wheelchair pedals on her wheelchair because she self-propelled her wheelchair. R27's Care Plan lacked new fall interventions post fall on 03/14/25 and 07/18/25.R27's Quarterly Assessment in the EMR dated 03/16/25 documented R27 was at risk for falls. R27's Quarterly Assessment in the EMR dated 06/09/25 documented she was at risk for falls related to her impaired mobility, incontinence, the medications she received and her impaired cognition. Review of R27's Un-witnessed Fall or Fall with Head Injury #1644 report dated 03/14/25 documented R27 had an unwitnessed fall near the nurse's station around 02:50 PM. R27 was heard yelling for help. Staff immediately responded. R27 had been wheeling herself around the nursing station before the incident. R27 was observed to be on the floor at the head of Hall 1, in front of her wheelchair, with her buttocks on a leg rest and the underside of her right arm on the other leg rest. R27 has severe dementia and was unable to communicate what happened. Review of the facility video revealed that she removed her shoe and then leaned forward to replace the shoe without locking her wheelchair brakes. The wheelchair moved backwards while she leaned forward, causing her to fall. R27 was noted to have bruising to her right hand post-fall. R27 was oriented to person only but was confused with impaired gait balance and impaired memory.R27's Witnessed Fall (no head injury) #1685 report dated 07/18/25 documented the resident was found lying on the floor, in a fetal position, in the main dining room. R27 stated she was just lying on the floor and did not fall. On 07/22/25, after investigation and review of the video, R27 had a fall in the dining room. R27 was seen in her wheelchair, then she stood up, using the table as a support, R27 turned slightly to see where to sit, and while attempting to sit down, R27 missed the wheelchair and fell to the floor. No new fall intervention was put in place post fall.On 07/27/25 at 10:15 AM, R27 sat in her wheelchair, telling staff that she was not going to go back to her room and to leave her alone. R27's wheelchair was noted to have Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) in the seat and no foot pedals on the wheelchair.On 07/29/25 at 11:32 AM, Licensed Nurse (LN) G stated that after a resident had a fall and assessment was completed, and then an investigation was done. LN G stated that management staff worked together after the fall to implement a new intervention to avoid further falls. On 07/29/25 at 11:42 AM, Administrative Nurse D stated that after each fall, the staff would complete an assessment of the resident and then complete witness statements. The management team would then review the fall information and implement a new intervention to avoid future falls. The care plan should be revised with the new intervention upon completion of the fall investigation.The facility's Falls policy dated 04/27/18, documented that individualized care plan interventions would be developed for residents identified through assessment as being at fall risk. Those interventions would be reviewed and updated on a regular basis and if/when a fall occurred.

The facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 27's care plan was revised with new interventions after having falls. This placed R27 at risk for delayed care and possible injuries.Findings included:- R27's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance (a range of problematic or disruptive behaviors that deviate from what is considered typical or expected for a given age, situation, or individual), and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition).R27's Significant Change Minimum Data Set (MDS) dated 08/28/24 documented a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. R27 required the use of a wheelchair to assist with mobility. R27 required substantial to being dependent on staff for assistance with her activities of daily living (ADL).R27's Falls Care Area Assessment (CAA) dated 09/03/24 documented R27 was at risk for falls related to the medications she received, poor cognition, incontinence, and her need for assistance with transfers and bed mobility. R27 also had poor trunk strength and required a high back wheelchair. R27 had not had any falls since the prior assessment.R27's Care Plan last revised on 06/04/25 directed staff that she required one-on-one extensive assistance for transfers. The Care Plan directed staff that R27 needed staff to reposition her when her bottom got close to the front of the wheelchair cushion or if I am leaning back in my chair for fall prevention. The Care Plan directed staff that R27 did not have wheelchair pedals on her wheelchair because she self-propelled her wheelchair. R27's Care Plan lacked new fall interventions post fall on 03/14/25 and 07/18/25.R27's Quarterly Assessment dated 03/16/25 documented R27 was at risk for falls. R27's Quarterly Assessment dated 06/09/25 documented she was at risk for falls related to her impaired mobility, incontinence, the medications she received, and her impaired cognition. Review of R27's Un-witnessed Fall or Fall with Head Injury #1644 report dated 03/14/25 documented R27 had an unwitnessed fall near the nurse's station around 02:50 PM. R27 was heard yelling for help. Staff immediately responded. R27 had been wheeling herself around the nursing station before the incident. R27 was observed to be on the floor at the head of Hall 1, in front of her wheelchair, with her buttocks on a leg rest and the underside of her right arm on the other leg rest. R27 has severe dementia and was unable to communicate what happened. Review of the facility video revealed that she removed her shoe and then leaned forward to replace the shoe without locking her wheelchair brakes. The wheelchair moved backwards while she leaned forward, causing her to fall. R27 was noted to have bruising to her right hand post-fall. R27 was oriented to person only but was confused with impaired gait balance and impaired memory. No new intervention was put in place post-fall.R27's Witnessed Fall (no head injury) #1685 report dated 07/18/25 documented the resident was found lying on the floor, in a fetal position, in the main dining room. R27 stated she was just lying on the floor and did not fall. On 07/22/25 after investigation and review of video, it was noted that the resident had a fall in the dining room. R27 was seen in her wheelchair, then she stood up, using the table as a support. R27 turned slightly to see where to sit, and while attempting to sit down, R27 missed the wheelchair and fell to the floor. No new fall intervention was put in place post-fall.On 07/27/25 at 10:15 AM, R27 sat in her wheelchair, telling staff that she was not going to go back to her room and to leave her alone. R27's wheelchair was noted to have Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) in the seat and no foot pedals on the wheelchair.On 07/29/25 at 11:32 AM, Licensed Nurse (LN) G stated that after a resident had a fall an assessment was completed, and then an investigation was done. LN G stated that management staff worked together after the fall to implement a new intervention to avoid further falls. On 07/29/25 at 11:42 AM, Administrative Nurse D stated that after each fall, the staff would complete an assessment of the resident and then complete witness statements. The management team would then review the fall information and implement a new intervention to avoid future falls. The care plan should be revised with the new intervention upon completion of the fall investigation. The facility's Care Plan policy dated 03/21/24 documented the care plan should be designed to address the resident's preferences and needs to enable discharge. The care plan should be updated on an ongoing basis as the resident achieved goals and progressed towards discharge.

The facility identified a census of 44 residents. The sample included 12 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, 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) 2's pressure-reducing interventions were implemented correctly when R2's low air-loss mattress (a specialized adjustable air mattress that reduces pressure applied to the body) was not set within her current weight range. This deficient practice placed R2 at risk for complications related to skin breakdown and pressure ulcers.Findings included:- The Medical Diagnosis section within R2's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (major mood disorder), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic kidney disease, and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). R2's Significant Change Minimum Data Set (MDS) completed 06/30/25 noted a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she required substantial to maximal assistance with bathing, toileting, dressing, transfers, and bed mobility. The MDS noted she had a suprapubic urinary catheter (urinary bladder catheter inserted through the abdomen into the bladder). The MDS noted R2 had a stage-one pressure ulcer (pressure wound which appears reddened, does not blanche, and may be painful but is not open). The MDS noted she had pressure-reducing devices for her bed and chair. R2's Pressure Ulcer Care Area Assessment (CAA) completed 06/18/25 indicated she had a suprapubic urinary catheter and instructed staff to monitor her catheter for infections and skin breakdown. The CAA noted she had a history of pressure-related wounds. The CAA noted that interventions were care planned to minimize the risks and complications. The CAA noted she had a potential skin break on her coccyx (area at the base of the spine). The CAA noted she had a low-air-loss mattress and bilateral heel boots to float her feet. R2's Care Plan initiated 02/18/25 indicated she was at risk of skin breakdown, pressure ulcers, falls, and infections related to her suprapubic urinary catheter. The Plan noted she required staff assistance for toileting, dressing, bathing, footwear, transfers, and bed mobility. The plan noted she had a suprapubic urinary catheter. The plan instructed staff to ensure the catheter drainage bag and tubing were secured in a privacy bag and did not to touch the floor. The plan instructed staff to provide catheter care as needed. The plan instructed staff to ensure she was repositioned every two hours, but required staff assistance to shift her weight. The plan noted she had a pressure-reducing cushion for her wheelchair and a low-air-loss mattress for her bed. The plan lacked instructions related to the required weight and comfort settings for R2's low-air-loss mattress. R2's EMR under Physicians Orders revealed an order dated 07/23/25. The order indicated she had a low air-loss mattress and instructed staff to ensure proper functioning every shift. The order lacked an indication of weight or comfort settings related to R2's needs. R2's EMR under Vitals indicated she weighed 117 pounds (lbs.) on 07/09/25. A review of the manual of low air-loss mattress manufacturers' operation (Drive Model) indicated that 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 and comfort settings. The manual indicated that an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. On 07/27/25 at 07:23 AM, R2 sat in her bed. R2 stated her bed was uncomfortable, and staff did not adjust the control panel for comfort. R2's low air-loss mattress control panel was set to 250 lbs. The mattress pump had fixed weight settings of 80lbs, 120lbs, 150lbs, 180lbs, 210lbs, 250lbs, 280lbs, 320lbs, and 350lbs. On 07/29/25 at 10:08 AM, R2 slept in her bed. Her low air-loss mattress pump remained set at 250lbs. On 07/29/25 at 10:10 AM, Licensed Nurse G stated the bed was to be set by weight and verified the mattress was set to 250lbs. She stated staff sometimes increased the weight to ensure it was inflated properly, but normally the mattresses were to be set by the resident's actual weight. On 07/29/25 at 11:45 AM, Certified Nurse's Aide (CNA) M stated the mattresses were set by weight, but the nurses usually checked them every shift. She stated that direct care staff just made sure the mattress was inflated and not flat. On 07/29/25 at 11:50 AM, Administrative Nurse D stated the low air-loss mattresses were to be set by the resident's current weight, and staff were expected to check the setting each shift. The facility's Wound Management policy (revised 11/2017) indicated that the facility would assess each resident's risk related to pressure ulcers and implement preventative interventions. The policy indicated that the effectiveness of the implemented intervention would be evaluated and reviewed.

The facility reported a census of 44 residents. The sample included 12 residents, with two reviewed for urinary catheter care. Based on record review, interviews, and observations, the facility failed to maintain Resident (R) 2's indwelling urinary catheter in a safe and sanitary manner. This deficient practice placed R2 at risk for complications related to urinary tract infections. Findings included:- The Medical Diagnosis section within R2's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (major mood disorder), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic kidney disease, and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). R2's Significant Change Minimum Data Set (MDS) completed 06/30/25, noted a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she required substantial to maximal assistance with bathing, toileting, dressing, transfers, and bed mobility. The MDS noted she had a suprapubic urinary catheter (urinary bladder catheter inserted through the abdomen into the bladder). The MDS noted R2 had a stage-one pressure ulcer (pressure wound which appears reddened, does not blanche, and may be painful but is not open). The MDS noted she had pressure-reducing devices for her bed and chair. R2's Urinary Incontinence Care Area Assessment (CAA) completed 06/18/25 indicated she had a suprapubic urinary catheter and instructed staff to monitor her catheter for infections and skin breakdown. The CAA noted interventions were care planned to minimize the risks and complications associated with her catheter. R2's Care Plan initiated 02/18/25 indicated she was at risk of skin breakdown, pressure ulcers, falls, and infections related to her suprapubic urinary catheter. The plan noted she required staff assistance for toileting, dressing, bathing, footwear, transfers, and bed mobility. The plan noted she had a suprapubic urinary catheter. The plan instructed staff to ensure the catheter drainage bag and tubing were secured in a privacy bag and not to touch the floor. The plan instructed staff to provide catheter care as needed. R2's EMR under Progress Notes revealed an admission Summary completed on 06/03/25 that indicated R2 was readmitted to the facility from an acute medical facility. The note revealed she was diagnosed with acute kidney injury (AKI) and a urinary tract infection (UTI).On 07/27/25 at 07:14 AM, R2 slept in her bed. R2's bed was in the low position. Her urinary catheter collection bag lay flat directly on the floor with yellow urine visible in the bag and collection tubing. On 07/27/25 at 10:24 AM, R2 sat in her bed. R2's urinary catheter collection bag remained on the floor, not hung on her bedframe. Yellow urine was visible in the collection bag and tubing. On 07/27/25 at 11:05 AM, R2's urinary catheter tubing and collection bag were hung on the bed frame with a privacy bag in place. On 07/29/25 at 10:10 AM, Licensed Nurse G stated that urinary catheter tubing and collection bags were to be placed in a privacy bag and not allowed to touch the floor. On 07/29/25 at 11:50 AM, Administrative Nurse D stated the urinary catheter collection bags were to be hung below the level of the bladder in a privacy bag and off the floor. The facility's Indwelling Urinary Catheter Management policy, issued 04/2018, indicated the facility was to ensure standards of practice were followed to ensure safe and sanitary urinary catheter care. The policy indicated staff were to ensure unobstructed urine flow within the catheter by inspecting the tubing for kinks, frequent emptying, and maintaining the catheter collection bag below the level of the resident's bladder. The policy instructed to ensure the catheter system be maintained in a sanitary manner to prevent infections.

The facility identified a census of 44 residents. The sample included 12 residents, with one resident reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 3's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R3 at risk for decreased psychosocial well-being and ineffective treatment.Findings included:- R3's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of PTSD, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) disorder.The Significant Change Minimum Data Set (MDS) dated 07/04/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R3 did not have any behaviors during the observation period.R3's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/15/25 documented her current medication placed her at risk for severe adverse side effects.R3's Care Plan, dated 03/23/22 documented staff would monitor for any behaviors of seeing things that are not real and had any auditory or visual hallucinations. The plan of care documented the staff would document the behaviors or adverse side effects of her medications. The plan of care documented the staff would allow R3 to talk about her feelings when she was upset and provide her with one-on-one talks. The plan of care lacked personalized interventions to assist her with coping with her PTSD.R3‘s EMR under the Assessment tab revealed the following Primary Care PTSD Screen dated 09/20/24 documented R3 had answered yes to having nightmares or thoughts about her PTSD when she did not want to. The PTSD assessment documented R3 had answered yes, she tried hard not to think about it, or went out of her way to avoid situations that reminded her of the trauma.On 07/29/25 at 7:43 AM, R3 laid on her back on the bed and stated she was comfortable. R3's head of her bed was elevated.On 07/29/25 at 11:20 AM, Administrative Nurse F stated that social service staff would be responsible for ensuring a trauma-based assessment was completed and the resident's plan of care was updated. Administrative Nurse F stated the social services staff would be responsible for ensuring the resident with a PTSD diagnosis care plan included the type of trauma and personalized interventions to prevent re-traumatization. On 07/29/25 at 11:25 AM, Certified Nurse Aide (CNA) M stated the charge nurse would notify the nursing staff if a resident had a diagnosis of PTSD. CNA M stated she would refer to the resident information sheets that are printed by the nurses for the resident's Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 07/29/25 at 11:32 AM, Licensed Nurse (LN) G stated staff could look at the resident's EMR under the assessment tab for the PTSD assessment, plan of care, or on the resident's Kardex. LN G stated she was not sure who was responsible for completing the PTSD screening and was not sure if the type of trauma or personalized interventions would be addressed in the resident's plan of care. On 07/29/25 at 11:42 AM, Administrative Nurse D stated she would expect the physicians to determine if a resident's diagnosis of PTSD was active. Administrative Nurse D stated she would expect the nurses to complete the PTSD assessment, and the MDS coordinator would be responsible to add the information to the resident's plan of care. On 07/29/25 at 11:55 AM, Social Service Staff X stated the nurses were responsible for completing the PTSD assessment. She stated she had never completed a PTSD assessment, and the MDS coordinator was responsible for ensuring it was addressed on the resident's plan of care.The facility's Trauma Informed Care policy, last updated 11/09/21, documented the facility would ensure residents who are trauma survivors received culturally competent, trauma-informed care accounting for the resident's experiences and preferences. Trauma-informed care recognized the effects of physical, psychological, and emotional trauma on the overall well-being of residents. Trauma can result from a variety of experiences that may occur at any time throughout the resident's lifetime. A screening would be completed on residents to identify any potential experiences which may impact care needs. The Posttraumatic Stress Disorder (PTSD) Screening would be completed during the lookback period for the admission, significant Change, and Annual MDS.

The facility had a census of 95 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). This placed the residents at risk for impaired care due to unidentified staffing issues.Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year 2024 for Quarter 3 and Quarter 4 indicated the facility triggered for no Registered Nurse (RN) hours for 10 days. The facility provided payroll documentation of RN coverage for 04/27/24, 05/18/24, 05/19/25, and 07/13/24.On 07/29/25 at 09:10 AM, Administrative Staff A stated she was unable to provide payroll documentation for RN coverage for those other six days. The facility's Competent and Sufficient Staffing policy dated November/2024 documented the facility would provide a sufficient number of nursing staff with the skill sets and competency necessary to provide care/services for all residents in accordance with resident care plans and the Facility Assessment. A Registered Nurse provided services for at least eight consecutive hours every 24 hours, seven days a week. RNs may be scheduled more than eight hours, depending on the acuity needs of the residents.

The facility documented a census of 41 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a mechanical lift for safe transfers. As a result, R1 sustained a humerus (upper arm bone) fracture. This deficient practice also placed R1 at risk for pain and impaired independence. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of pleural effusion (abnormal accumulation of fluid in the lungs), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), polyosteoarthritis (joint pain or arthritis that affects five or more joints simultaneously), and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R1 had an Entry Minimum Data Set (MDS) dated [DATE] when R1 admitted to the facility. A Discharge Assessment Return Anticipated MDS dated 10/12/24, documented an unplanned discharge to the hospital. The staff interview for resident cognition revealed R1 had some cognitive difficulty in new situations. The MDS noted R1 used a wheelchair and depended on staff for propelling in the wheelchair at least 50 feet, with the ability to make two turns. The MDS documented R1 was dependent on staff for toileting hygiene. The MDS documented R1 required substantial to maximal assistance for dressing, transfers from seated-to-lying or seated-to-standing positions, and bed-to-chair transfers. The MDS further documented R1 required substantial to maximal assistance for transfers to and from the toilet and shower or tub. R1 had an Entry MDS dated [DATE] when R1 readmitted to the facility, with no BIMS completed. A Discharge Assessment Return Anticipated MDS dated [DATE] (after the incident) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS noted the resident had no rejection of care behaviors. R1's Baseline Care Plan dated 10/10/24, documented R1 required one-person physical assistance for transfers, toileting, dressing, and bathing. The Baseline Care Plan documented R1 used a wheelchair. R1's Care Plan, initiated and created on 10/18/24 after the incident, directed staff R1 could not reposition herself and needed a Hoyer (full-body mechanical lift) lift for transfer though R1 often declined the use of the Hoyer. The plan, dated 10/18/24, directed staff if R1 declined the Hoyer the staff should use two staff and a gait belt. R1's Care Plan Note documented R1 fell at home and had broken ribs and poor endurance due to pain. The note recorded the provider ordered medications to address the pain. The note documented a recommendation to use the sit-to-stand lift or the Hoyer due to rib pain when using the gait belt. An Occupational Therapy Daily Note with a service date of 10/15/24 documented R1 had a shower and was able to demonstrate the ability to wash and dry her hair and body with moderate assistance. R1 was able to stand from the shower bench seat and use a grab bar with moderate to maximal assistance from two staff. The note documented R1 was very fatigued after the showering task. The note further documented R1 completed a stand pivot transfer from the wheelchair to the bed with maximal assistance from two staff but was unable to take steps due to fatigue. The note documented R1 was moved to a Hoyer lift for transfers with staff assistance of two due to fatigue. A Physical Therapy Daily Note with a service date of 10/16/24, documented R1 demonstrated fair tolerance to activities on 10/16/24 with increased time and frequent rests. The note documented a recommendation for the continued use of the total body lift for transfers with nursing staff. R1's 10/16/24 Medicare A Progress Note documented R1 was alert and oriented, had an unsteady gait that required supervision, impaired balance, and weakness. The note recorded R1 required assistance with transfers. R1's Transfer to Hospital Summary note dated 10/17/24, documented staff assisted R1 to the shower with a two-person assist as R1 declined to allow the Certified Nurse Aides (CNA) to use the lift. The note documented R1 stated she had not allowed the CNAs to use a lift. R1 sat on the shower chair and needed scooted back. R1 and the CNAs stated the CNAs placed their arms under R1 ' s shoulders and assisted R1 to scoot back in the shower chair, and they all heard a popping noise and alerted the nurse. The note documented upon the nurse's assessment, R1 cried and stated her pain was rated a 10 (pain rating on a zero to 10 scale, with zero meaning no pain and 10 meaning the worst imaginable) in her right upper arm. The note further documented there appeared to be a bump between R1 ' s shoulder and her elbow and R1 ' s right arm was extremely painful but R1 denied pain anywhere else. The staff stabilized R1 ' s arm so it did not shift, in case there was a fracture. The note documented R1 was adamant she wanted to stand up to transfer and not use a lift. The note documented R1's doctor was on site, assessed R1, and asked for R1 to go to the emergency room for evaluation. R1 agreed to the transfer. The note documented staff notified R1 ' s family and Durable Power of Attorney (DPOA) and R1 was transferred to the emergency room via ambulance. The facility ' s untitled incident report #1593 dated 10/17/24 documented staff assisted R1 with her shower. Once R1 transferred to the shower chair, she needed to be scooted back in the chair so Certified Nurse Aide (CNA) M assisted R1 with scooting. The report documented during the activity, staff heard a popping noise from R1 ' s right arm. The report documented R1 declined to allow the CNAs to use a lift to transfer her and R1 told the CNAs she would stand and transfer. The report documented R1 stated she felt her right upper arm pop and then had severe pain at that time. R1 went to the hospital, and an injury was identified to R1 ' s right upper arm. The report documented the CNAs used their arms under R1 ' s arms in order to boost the resident and when the CNAs lifted R1, they heard a popping noise from R1 ' s right arm. The report documented the CNAs did not use a gait belt for the transfer and the CNAs misplaced their arms in relation to R1 ' s arm. The report documented all staff would be educated on safe transfer techniques of residents. The report further noted the facility educated the two CNAs involved in R1's transfer incident on the safe transferring of residents and the use of a gait belt unless the resident was independent at the time of the incident. CNA M ' s notarized Complaint Investigation Witness Statement dated 10/17/24, documented CNA M and CNA N went to give R1 a shower. The CNAs asked R1 multiple times how she transferred and R1 stated she did not want the full body lift or gait belt, and she could stand and pivot. The statement documented the CNAs assisted R1 to the side of the bed and R1 transferred to the shower chair. The statement noted R1 asked to be scooted back in the chair, so CNA M and CNA N placed their arms under R1 ' s arms and moved R1. They heard a pop and immediately stopped. CNA M documented she went to get the nurse and CNA N stayed with R1. CNA N ' s notarized Complaint Investigation Witness Statement dated 10/17/24, documented CNA N went into R1 ' s room to transfer her into a shower chair. Both CNA M and CNA N asked R1 if she wanted to use the gait belt because R1 refused the full-body lift, and she told the CNAs No and said she could stand and do it. CNA N ' s statement documented R1 stood up and moved into the shower chair but wanted to be moved back into the chair, so CNA N placed her forearm under one of R1's arms and CNA M put hers under the resident's other arm and moved R1 back. CNA N documented that when they moved R1 back, she heard a crack sound in R1 ' s right arm. CNA N noted she held R1 ' s arm in place until Administrative Nurse D came in and made a sling to prop R1 ' s arm up. CNA N documented staff asked R1 if she thought the staff hurt her on purpose and R1 stated no, the staff had tried to help her. Administrative Nurse D ' s notarized Complaint Investigation Witness Statement dated 10/17/24, documented Administrative Nurse D interviewed R1 following the incident. Administrative Nurse D documented R1 reported both CNA M and CNA N offered a lift transfer but R1 told CNA M and CNA N she did not want to use a lift and would stand to transfer from the bed to the wheelchair or shower chair. Administrative Nurse D noted R1 transferred to the shower chair with assistance from CNA M and CNA N with no problem. R1 stated she needed to scoot back in the shower chair and asked the CNAs to help. Administrative Nurse D documented R1 reported the CNAs put their arms under hers, then attempted to lift her, and that was when the resident felt her right arm pop and experienced pain. R1's hospital Discharge Summary dated 11/07/24 documented R1 was admitted on [DATE] with a humerus fracture. The summary noted R1 was boosted under her arms, heard a pop, and had immediate pain. An X-ray confirmed the humeral fracture. The summary noted orthopedic (bone specialists) surgery performed an open reduction and internal fixation (a surgical procedure to repair broken bones) on 10/19/24. On 06/02/25 at 01:40 PM, CNA O stated he received lift and transfer training at the time he was hired CNA O stated if a staff member made a mistake during a transfer, the facility provided education for all staff related to safe transfers as a response. CNA O stated he would never grab a resident by, or under, the arms to transfer or reposition them. CNA O stated grabbing a resident by or under the arms could cause bruising, skin tears, or other injuries. CNA O stated if a resident was supposed to use a lift but refused, he would find another way to reposition them by using a lift sling to slide the resident back into the chair, but not pull on the resident ' s body. CNA O stated staff knew how a resident transferred by viewing the care plan. CNA O also stated staff can use a lift to transfer a resident if they believe transferring the resident without a lift would be unsafe. On 06/02/25 at 02:10 PM, Licensed Nurse (LN) G stated therapy made the determination if a resident required a lift and then communicated that information to staff. LN G stated therapy did a good job of informing staff of how residents need to be transferred. LN G stated residents have (dry erase) boards in their room that also instruct staff on how the residents transfer and the information should also be on the care plan. LN G stated if a resident needed a full-body lift but refused the use of the lift or a gait belt, staff should notify the charge nurse. LN G stated staff should never grab a resident by or under their arms to transfer or reposition the resident and it was inappropriate to do so. LN G stated if staff grabbed a resident by or under their arms, it could cause dislocations, skin tears, or other injuries. On 06/02/25 at 02:43 PM, Administrative Staff A stated Administrative Nurse D was out of the facility and unavailable for an interview. Administrative Staff A said the facility provided lift and transfer training annually and if needed, additional training was provided. Administrative Staff A stated therapy also provided some training with staff when a resident transitioned from a Hoyer use to walking. She stated therapy placed signs in resident rooms with instructions on how the resident transferred. Administrative Staff A stated staff could also find information regarding how a resident transferred by reviewing the resident ' s care plan, and the CNAs also had the information on care cards they carried with them. Administrative Staff A stated that R1 refused for staff to use a gait belt or lift at the time of the occurrence. Administrative Staff A stated R1 asked to be scooted back in the chair as she was too far forward so staff each placed one arm under R1's arms, grabbed R1 ' s pants with their other hand, and attempted to slide R1 back. Administrative Staff A stated she could not confirm this action was appropriate but R1 had refused both the gait belt and Hoyer lift. The facility ' s undated Accidents and Occurrences policy documented it is the policy to ensure that each resident receives adequate supervision and assistive devices to prevent occurrences. Staff shall be trained to provide emergency care in the case of an accident. The policy documented to ensure relevant, individualized interventions have been added to the care plan, if casual factors are determined to have a potential impact on other residents, ensure system-wide interventions are implemented. The facility completed corrective actions by 01/30/25 that included education to staff on safe transfers and using the necessary equipment to facilitate safe transfers prior to the onsite survey therefore the deficient practice was deemed past noncompliance and remained at the scope and severity of a G to represent the actual, but isolated harm to R1.

The facility identified a census of 47 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. This placed all residents in the facility at risk for decreased quality of care. Findings included: - RN coverage for 2023 was reviewed and the following dates lacked evidence that the facility had RN coverage for eight consecutive hours for a 24-hour period: 01/08/23, 02/04/23, 02/05/23, 04/01/23,04/08/23, 04/15/23, 05/06/23, 05/07/23, 05/13/23, 05/20/23, 05/28/23, 06/04/23, 06/11/23, 06/18/23, 07/01/23, 07/15/23, 07/16/23, 07/22/23, 07/29/23, 07/30/23, 08/12/23, 08/13/23, 08/19/23, 08/20/23, 08/26/23 08/30/23, 10/29/23, 11/26/23, 12/10/23 and 12/24/23. The facility was unable to provide evidence of eight consecutive hours of RN coverage for the above dates. On 01/11/24 at 02:57 PM, an interview was conducted with Administrative Staff A and Consultant Staff II. Consultant Staff II returned a list of the above dates and stated the facility did not have RN coverage for those dates. Administrative Staff A confirmed that the facility did not have RN coverage for the above-listed dates. The facility did not provide a policy for Registered Nursing services. The facility failed to provide an RN for at least eight consecutive hours, seven days a week. This placed all residents in the facility at risk for decreased quality of care.

The facility had a census of 47 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's performance evaluation records revealed the following: CNA N, hired 01/11/22, no yearly performance evaluations were provided upon request. CNA Q, hired 06/23/20, no yearly performance evaluations were provided upon request. CNA LL, hired 07/12/16, no yearly performance evaluations were provided upon request. CNA MM, hired 11/16/21, no yearly performance evaluations were provided upon request. CNA NN, hired 03/02/22, no yearly performance evaluations were provided upon request. On 01/10/24 at 02:36 PM Administrative Staff A stated the facility did not do yearly performance evaluations for the employees. Administrative Staff A stated if there was an issue with a staff member then it would have been addressed at the time, but they did not otherwise do yearly performance evaluations. The facility did not provide a policy related to yearly performance evaluations. The facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 47 residents. The facility failed to provide the services of a full-time certified dietary manager for the 47 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 01/09/24 at 07:26 AM during the initial tour of the kitchen, Dietary Staff BB stated she completed the test to become a Certified Dietary Manager (CDM) but had not passed the test. On 01/10/24 at 11:19 AM Dietary Staff BB stated the Registered Dietician (RD) came to the facility at least every other week or weekly. On 01/11/24 at 12:09 PM Administrative Staff A stated the facility was without a CDM since August of 2022. Administrative Staff A verified the RD did come at least every other week or weekly to the facility. The facility's The Director of Dining Services Roles and Responsibilities policy dated 04/03/20 documented the Director of Dining Services supervised the day-to-day functions of the dining services department and maintained compliance with state and federal regulations. The Director of Dining Services received scheduled consultation and supervision by a qualified dietitian. The Director of Dining Services was an individual who met one of the following requirements: Was a qualified dietitian. Was a certified dietary manager. A food service manager who has an associate's or higher degree in food service management or hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. The Director of Dining Services was a full-time employee and was responsible for the day-to-day functions of the Dining Services Department. This individual worked closely with a registered dietitian to provide quality nutritional care and dining services for residents. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 47 residents in the facility, placing the residents at risk for inadequate nutrition.

The facility identified a census of 47 residents. The facility had one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to ensure proper transportation of food items from the kitchen to the kitchenette. The facility also failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened, and the food items were not placed in a sealed container/storage bag with the proper labeling and date. This placed all residents who ate food from the facility at risk for food-borne illness. Findings included: - During the initial tour on 01/09/24 at 07:26 AM a package of unlabeled ham and cheese was found in the refrigerator. Observation on 01/10/24 at 11:16 AM Dietary Staff CC wore gloves as she prepared a grilled cheese sandwich. She reached into her pocket with her gloved hands to remove her phone. Dietary Staff CC then placed her phone back into her pocket and continued to prepare the grilled cheese sandwich with her soiled gloves. On 01/10/24 at 11:35 AM, Dietary Staff CC gathered food items into her arms and held the items against her shirt to relocate items to the kitchenette. On 01/10/24 at 11:40 AM Dietary Staff BB stated staff should always have a hairnet on when in the kitchen food preparation area. Dietary Staff BB stated staff should always wash their hands and dispose of their gloves if they touch anything other than food. Dietary Staff BB stated all food opened and removed from its original packaging should always be relabeled with the name of the item and the date it was opened. The facility's Food Storage policy last revised on 04/06/20 documented that food would be stored on shelves in a clean, dry area, free from contaminants. Food would be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Staff would label all food items. The label must include the name of the food and the date it was opened or prepared, or the date it should be sold, consumed, or discarded. The Facility's Guidelines for Dining Services Staff Fundamentals to Prevent Food Borne Illness policy last revised on 04/27/20 documented that dirty hands or gloves spread germs/bacteria. Hands and fingernails should be washed thoroughly using the correct procedure that includes soap and warm water before work, after using the toilet and any time they are soiled, after handling raw foods, between work tasks, and any time the employee leaves and re-enters the kitchen. Gloves are used only one time, are the right size, and are changed anytime they become soiled and between tasks. Gloves are treated like a food contact surface. Gloves are used anytime ready-to-eat foods must be touched by a hand and are changed if they encounter an unclean surface, door, or piece of equipment. A bare hand is never used to touch ready-to-eat foods. Proper handwashing should occur before putting on gloves and after removing gloves. The facility failed to ensure a safe food preparation and servicing area These deficient practices placed residents at risk for contamination and food-borne illness.

The facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure a dignified dining experience for the residents who chose to eat in their rooms when the facility provided plastic silverware with the room trays. This deficient practice placed residents at risk for an undignified and unenjoyable dining experience. Findings included: - Observation during the initial tour on 01/09/24 at 08:34 AM room trays were served with plastic silverware. On 01/10/24 at 08:19 AM Resident (R)29 stated she always received plastic silverware and had never been offered regular silverware with a napkin at meals. Observation revealed she had plastic silverware on her breakfast tray. On 01/10/24 at 11:38 AM Dietary Staff BB stated the decision to send plastic silverware on the room trays was related to the loss of regular silverware, then not having enough silverware available, and the dietary budget. Dietary Staff BB stated the nursing staff offered the residents regular silverware when room trays were delivered. On 01/11/24 at 11:42 AM Certified Nurse Aide (CNA) M stated plastic silverware was the only silverware delivered with the room trays. CNA M stated it was her understanding the facility did not have enough regular silverware at one time. On 01/11/24 at 12:09 PM Administrative Staff A stated she just learned that the residents received plastic silverware on their room trays. The facilities were unable to provide a policy related to dignity. The facility failed to ensure a dignified dining experience for the residents who chose to eat in their rooms by only providing plastic silverware. This deficient practice placed residents at risk for an undignified and unenjoyable dining experience.

The facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings included: - On 01/09/24 at 07:40 AM there was a dirty towel and washcloth draped over the handrail outside of room [ROOM NUMBER]. On 01/09/24 at 07:45 AM, room [ROOM NUMBER] had a large area of the wall (the size of a dinner plate) that was missing paint and was scratched/torn up. On 01/09/24 at 07:47 AM, a strong urine odor was noted from the hall outside of R1's room. Upon walking into R1's room, it was noted her clothing had a strong urine smell as well as the bed linens. On 01/09/24 at 08:00 AM an inspection of the facility's main hall revealed the wall next to the elevator had a large hole (large enough for a fist to fit through), containing exposed wiring, above the elevator's control button. On 01/09/24 at 10:04 AM R32's room had a large discolored and sticky area on the floor next to his bed. There were smashed food particles in the carpet that R32 stated was food, from last night's dinner. On 01/09/24 at 08:43 AM the 211-222 hallway had large brown/black colored water stains on two panels on the ceiling. On 01/09/24 at 08:43 AM down the 211-222 hallway, several small holes were noted in the carpet. On 01/09/24 at 08:58 AM the door and wall above the door in room [ROOM NUMBER] had brown spots that appeared as if something was splashed across the door. On 0/10/24 at 11:23 AM in the main television sitting area, three cloth upholstered armchairs smelled of urine. On 01/11/24 at 11:22 AM Licensed Nurse (LN) H stated that housekeeping cleaned the rooms daily. LN H stated if there was equipment or something in a room that was noted to need repair a work order was sent to maintenance to have it fixed. On 01/11/24 at 11:43 AM Certified Nurse Aide (CNA) M stated a work order would need to be submitted to maintenance when something needed to be repaired. On 01/11/23 at 01:31 PM Administrative Nurse D stated resident rooms did get cleaned daily. Administrative Nurse D stated some of the rooms needed some deep cleaning and those areas would be addressed. Administrative Nurse D stated the facility was awaiting some renovations inside the building soon. On 01/11/24 at 02:57 PM Administrative Staff A stated that the entire building was going to be renovated. Administrative Staff A stated the facility was awaiting the permits and approval for the massive renovations. Administrative Staff A stated the facility had just received an odorizing machine two days ago. Administrative Staff A was aware of the hole in the wall beside the elevator that had since been covered. The Housekeeping and Maintenance Services policy revised 01/13/17 documented: The facility would provide housekeeping and maintenance services to maintain a safe, clean, comfortable, and homelike environment while allowing the resident to use his/her personal belongings to the extent possible. Housekeeping and maintenance services would be provided to maintain a sanitary, orderly, and comfortable interior. This included adequate and comfortable lighting, comfortable and safe temperature levels, comfortable sound levels, and a homelike environment. The facility failed to ensure residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

The facility identified a census of 47 residents. The sample included 14 residents. The facility identified two influenza (highly contagious viral infection) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection prevention standards were followed related to disinfecting shared equipment, urinary catheter care, laundry services, and wound treatment practices. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 01/09/24 at 07:23 AM a bag of soiled linen was on the floor in Resident (R)30's room. On 01/09/24 at 09:09 AM Certified Nurse Aid (CNA) M and CNA O transferred R23 from her Broda chair (specialized wheelchair with the ability to tilt and recline) to her bed via Hoyer lift (total body mechanical lift). While transferring R23 to the bed, staff placed the Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) collection bag directly on her bed with the urine in the tube backflowing into her body as they adjusted R23's positioning in her bed. Staff then placed R23's catheter bag off the side of her bed. Staff failed to complete hand hygiene or change gloves while handling the catheter bag or repositioning R23. On 01/09/24 at 10:04 AM an inspection of R32's room revealed his urinary collection bag on the floor. On 01/11/24 at 07:28 AM Licensed Nurse (LN) G prepped a glucometer before testing R6's blood glucose. LN G failed to put a barrier under the glucometer before it was placed on the medication cart. LN G then utilized the glucometer to test R6's blood glucose without cleaning the equipment. On 01/11/24 at 07:38 AM LN H prepped a glucometer before testing R32's blood glucose. LN H placed the glucometer down on a visibly soiled side table. LN H failed to sanitize the glucometer before testing R32's blood glucose. On 01/11/24 at 09:49 AM Administrative Nurse D removed R10's dressing from her right heel, Administrative Nurse D placed R10's right heel directly on the pressure ankle foot orthotic boot (PRAFO-special boot which keeps the ankle and foot aligned to treat muscle weakness and imbalance). Administrative Nurse D stated R10's right heel had started to drain. Administrative Nurse D lifted R10's right heel from the PRAFO boot for the physician to evaluate the pressure ulcer on the right heel. Administrative Nurse D placed R10's undressed right heel directly back into the PRAFO boot and strapped the PRAFO boot back onto R10's right foot and ankle. On 01/11/24 at 09:58 AM CNA O and CNA P transferred R10 into bed with the assistance of a sit-to-stand lift. CNA P removed R10's PRAFO boot from the right foot and placed R10's right heel directly onto the bed. CNA P covered R10 with a blanket. CNA O pushed the sit-to-stand lift from the room into the hallway. CNA P returned and wiped the handles of the sit-to-stand lift off with a disinfecting wipe but failed to wipe the multiple-use sling with the disinfection wipe. On 01/11/24 at 11:03 AM an inspection of the laundry room revealed no gloves or face shield personal protective equipment available in the laundry room. An inspection of the facility's three clothes dryers revealed heavy lint buildup in the machine's lint traps. Housekeeping Staff U stated the lint traps were changed out daily and staff had to go to the maintenance office for gloves and personal protective equipment (PPE). He stated laundry should be transported covered and nothing should be placed directly on the floor. On 01/11/24 at 11:21 AM, CNA M stated catheter bags should be hung on the bedside or wheelchair. She stated the tubing and equipment should never touch the floor or soiled surfaces to prevent infections. She stated soiled linens and clothing should be placed in bags and taken directly to the laundry room. On 01/11/24 at 12:05 PM, LN H stated that shared equipment should sanitized before and after use on the residents. She stated catheter bags should be hung securely on the bed in a manner to prevent contamination. On 01/11/24 at 01:45 Administrative Nurse D stated she expected staff to handle medical equipment and care for the residents in a sanitary manner that prevents infections. She stated hand hygiene and PPE must be donned to prevent the spread of infections throughout the facility. She stated barriers must be placed to prevent cross-contamination when providing care to residents. A review of the facility's Housekeeping policy revised 04/2018 indicated the facility would provide services in a sanitary, safe, and temperature-controlled environment. The policy indicated linen would be handled and transported in a sanitary manner that prevents contamination of the environment and linen. noted that PPE is to create a barrier between the employee and hazards in the workplace. A review of the Wound Care policy 11/2017 indicated the facility will provide wound care in a manner that promotes healing and prevents infections. The facility's Infection Prevention and Control policy indicated staff must follow sanitary precautions to ensure resident safety during care. The policy indicated staff was to utilize hand hygiene and wear PPE to prevent the spreading of contagious illnesses/infections throughout the care environment. The policy noted medical equipment must be clean and maintained in a manner that reduces exposure to pathogens (infectious agents) and environmental hazards. The facility failed to ensure infection prevention standards were followed related to shared equipment, urinary catheter care, laundry services, and wound treatment practices. This deficient practice placed the residents at risk for infectious diseases.

The facility identified a census of 47. The sample included 14 residents with 14 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)30's Care Plan to reflect his needs related to the type of wheelchair needed. The facility failed to revise R32's Care Plan to ensure the interventions listed matched the resident's current needs and goals. The facility failed to ensure R25's Care Plan was revised to address antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use. This deficient practice placed R30, R32, and R25 at risk for impaired care due to uncommunicated care needs. Findings included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness), and dementia (progressive mental disorder characterized by failing memory, confusion). R30's Quarterly Minimum Data Set (MDS) completed 11/01/23 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The MDS indicated he was dependent on staff assistance for transfers, bathing, bed mobility, dressing, and toileting. The MDS indicated he used a wheelchair for mobility. R30's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 05/30/23 indicated he required a Hoyer (full body mechanical lift) lift for transfers and utilized a high-back wheelchair for mobility. The CAA noted he required extensive staff assistance for transfers, bed mobility, toileting, bathing, and dressing. The CAA noted he used a bed cane for bed mobility. R30's Care Plan initiated on 05/30/23 indicated he was at risk for decreased mobility and falls. The plan noted he had a high-back wheelchair. The plan noted he was no longer able to propel himself and required staff assistance for mobility. On 12/18/23, R30's plan noted he had a new high-back wheelchair and was to remain seated upright to improve his trunk strength. A review of an Occupational Therapy Note dated 12/15/23 indicated continued concerns related to R30's posture and continued reclining while in his high-back wheelchair. The note indicated he had poor balance while sitting and encouraged staff to remind him to sit up straight. A review of R30's EMR revealed no documentation showing when his wheelchair was changed. On 01/10/24 at 08:00 AM R30 sat in the dining room and awaited his breakfast. R30 sat in a normal (non-high back) wheelchair at a table. R30 was slouched over in his chair as his meal arrived. R30 fed himself without issue and returned to his room to rest in his bed. R30 reported his wheelchair had been changed a few weeks ago and he preferred his old one. On 01/11/24 at 10:14 AM Certified Nurses Aid (CNA) M stated R30 had a high-back wheelchair, but his chair was changed out right after Christmas due to positioning concerns with pushing himself to the edge of the chair with his upper body. She stated she was not sure why the care plan still indicated he used a high-back wheelchair. On 01/11/24 at 09:34 AM Consultant HH stated R30's wheelchair was recently switched to a low-back wheelchair due to him pushing himself to the edge of his wheelchair by pushing his upper body in the higher backrest of the chair. She stated switching the wheelchairs was a trial to see how well he would adjust to the new chair. A review of the facility's Comprehensive Care Plan policy (undated) indicated the care plan will be updated showing the resident's individualized care needs and the level of assistance required to achieve the highest practicable level of function. The policy noted the facility will provide ongoing assessment and updated interventions to meet the needs of the residents. The facility failed to revise R30's care plan to reflect his needs related to the type of wheelchair needed. This deficient practice placed R30 at risk for impaired care due to uncommunicated care needs. 47834 - The Diagnoses tab of R32's Electronic Medical Record (EMR) documented diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) dated [DATE] documented R32 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS further documented R32 was independent with activities of daily living (ADL). The Falls Care Area Assessment (CAA) dated 10/03/23, documented R32 was at risk for falls and would be care planned to minimize risk for falls. R32's Care Plan with an initiated date of 01/04/24, documented R32 had a mat on the floor next to his bed and he often preferred to lay directly on it rather than his bed because of the cooler temperatures. On 01/11/24 at 07:30 AM R32 laid in his bed and slept. No floor mats were observed next to his bed during observation. On 01/11/24 at 11:21 AM Licensed Nurse H stated R32 was previously in an isolation room due to illness and while in that room, R32 had a mat next to his bed that he could lay on. LN H stated R32 did not need the mat in his current room and that the intervention should have been taken off the care plan since the mat was no longer needed. On 01/11/24 at 12:21 PM Administrative Staff B stated the mat R32 had next to his bed was not put in place as a fall intervention. Administrative Staff B stated R32 had been sick and was moved into an isolation room. Administrative Staff B further stated R32 complained the room was hot and he used the mat next to his bed to lay on as the temperature was cooler on the floor. Administrative Staff B stated the mattress intervention should not have been placed under fall interventions on R32's care plan and should have been placed under ADLs instead. The undated facility Care Plan policy documented the care plan should be updated on an ongoing basis as the resident achieves goals and progresses toward discharge. The facility failed to revise R32's Care Plan to ensure the interventions listed matched the resident's current needs and goals. This placed the resident at risk for inappropriate care related to uncommunicated care needs. 49634 - R25's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), late-onset Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significate Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R25 was dependent on two staff members for assistance with activities of daily living (ADLs). The MDS documented R25 received antipsychotic medication during the observation period. R25's Psychotropic Drug Use Care Area Assessment (CAA) dated 08/11/23 documented R25 received psychotropic medication and was at risk for adverse side effects. R25's Care Plan dated 06/17/22 documented the facility would consult with the pharmacist and physician to consider dose reduction of psychotropic medication when clinically indicated. R25's Psychosocial Care Plan, revised 06/17/22, documented R25 received Risperdal (antipsychotic), Effexor (medication used to treat depression), and Ativan (medication used to treat anxiety) for targeted behavior and instructed staff to watch R25 for side effects of his medication. R25's Care Plan lacked evidence of interventions or monitoring to address the antipsychotic drug use including direction to staff on associated side effects to monitor. The Physician's order dated 10/12/23 ordered give risperidone (Risperdal) one milligram (mg) by mouth one time a day for bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) with psychotic features. On 01/09/24 at 11:30 PM, observation revealed R25 sat in his room in a Broda chair (special wheelchair with tilt and recline capability). R25 did not visit but watched TV while reclined in the Broda chair. On 01/11/24 at 11:32 AM Licensed Nurse (LN) H stated interventions should be care planned, to ensure staff know what interventions should happen before medications were given. On 01/11/24 at 01:31 PM Administrative Nurse D stated she was unsure of what the care plan should read for psychotropic medications, or if psychotropic medications were care planned, as she did not do care plans. The facility's Care Plan Policy, revised 11/28/17 documented a care plan would be developed for each resident that included measurable objectives to meet the resident's medical, nursing, mental, and psychosocial needs. The facility failed to revise R25's comprehensive care plan to include directions to staff regarding R25's antipsychotic medication and associated side effects and risks. This placed R25 at risk for complications related to antipsychotic medication due to uncommunicated care needs.

The facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide the necessary assistive care and services to Resident (R) 29. This deficient practice placed the resident at risk for poor hygiene, decreased self-esteem, and impaired dignity. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis and 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), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R29 was dependent on staff assistance for the dressing of upper and lower extremities. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R29 was dependent on staff assistance for the dressing of upper and lower extremities. The MDS documented R29 had a limited range of motion on one side for both the upper and lower extremities. R29's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/18/23 documented she required the assistance of two staff for dressing. R29's Care Plan dated 10/02/23 documented R29 required extensive assistance from two staff members for dressing. On 01/09/24 at 08:34 AM R29 laid on her back in bed. Oatmeal was observed on R29's right side of her hospital gown and face after staff removed her breakfast tray from her room. On 1/10/24 at 09:04 AM R29 laid in bed. She had cereal, along with the oatmeal stain from the previous day on the right side of her hospital gown after staff removed the breakfast tray from her room. On 01/11/24 at 08:20 AM R29 remained in bed. Observation revealed R29 still had the oatmeal from the previous two days on the right side of her hospital gown. On 01/11/24 at 08:50 AM Certified Nurse Aide (CNA) N stated staff would change R29's hospital gown after her bath. CNA N stated R29 required assistance from staff to change her clothes. On 01/11/24 at 11:22 AM Licensed Nurse (LN) H stated R29's gown should be changed when soiled, at night, and in the morning. LN H stated staff should assist her with changing her hospital gown. On 01/11/24 at 01:31 PM Administrative Nurse D stated staff should assist R29 at least daily with changing her clothes or when soiled. The facility's Activities of Daily Living policy last revised on 04/27/18 documented that the facility would provide the necessary care and services to ensure a resident's abilities in the activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrate such diminution was unavoidable. The facility would provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following activities of daily living: Hygiene - bathing, dressing, grooming, and oral care. Residents who are unable to carry out activities of daily living and are dependent on staff would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to ensure staff assisted R29 with changing her soiled hospital gown. This deficient practice had the risk of poor hygiene, decreased self-esteem, and impaired dignity.

The facility identified a census of 36 residents. The sample included three residents reviewed for falls. Based on record review, interview, and observation, the facility failed to ensure staff followed Resident (R)1's plan of care to have two staff members assist R1 with transfers using a sit to stand lift. On 11/03/22 Certified Nurse Aide (CNA) M transferred R1 using the lift without assistance from a second qualified staff member. During this transfer, R1 became weak, her legs buckled, and she slid to her knees. As a result, R1 sustained a femur (thigh bone) fracture on her left lower extremity. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (muscular weakness of one half of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, and [CONDITION(S)] (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded R1 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. R1 required extensive assist of one staff member for personal hygiene, dressing, and locomotion on and off the unit. The MDS recorded R1 had impairment on one side for upper and lower extremities. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS recorded R1 was dependent upon two staff members for transfers and required extensive assistance of one staff member for personal hygiene, toilet use, dressing, bed mobility, and locomotion on and off the unit. The MDS recorded R1 had impairment on one side for upper and lower extremities. The Activities of Daily Living [ADL] Care Area Assessment (CAA) dated 01/27/21 documented R1 had physical limitation related to [CONDITION(S)] that may affect ADL functional potential. The Falls CAA dated 01/27/21 documented R1 had poor balance with sitting and transfers, [CONDITION(S)] and [CONDITION(S)] that may affect the resident for falls. The Mobility/Falls Care Plan initiated 08/12/19 directed staff R1 required assistance with transfers and two staff members needed to help R1 use the sit to stand lift for transfers. R1's EMR recorded a General Note dated 11/03/21 at 04:42 PM which documented Licensed Nurse (LN) G responded to R1's room. R1 was on the sit to stand lift. R1 was at the side of the bed, and her left knee touched the standing platform of the lift. LN G assisted staff to hold R1 up so the sit to stand could be removed and R1 placed in bed. R1 had no complaint of pain and no visible signs of injuries at that time. R1 complained of pain when LN G touched R1's left foot. Staff informed Consultant GG and ordered an x-ray. In a Witness Statement CNA M stated on 11/03/21 she transferred R1 to the bathroom using the sit to stand lift. R1 wore non-skid socks at the time of the transfer. When R1 finished in the bathroom, CNA M assisted R1 from the toilet into the sit to stand lift. CNA M began to transfer R1 from the bathroom to R1's bed. At approximately three feet from R1's bed, R1 lost strength and her knees shifted to the right. R1's left knee came to rest in the lift's right-knee support and R1's right knee shifted outside of the supports. CNA M went behind R1 to hold her up. CNA M placed her left knee under R1's buttock to relive pressure from R1's left foot. R1's left foot then lifted off the lift platform and slid off onto the floor. R1's left knee came to rest on the platform in the kneeling position, while R1's right foot remained on the platform. CNA M sent a non-certified staff domestic aide to get help. The statement recorded two unidentified staff members arrived, a certified medication aide (CMA) and a LN. The CMA and the LN assisted CNA M to get R1 into bed. Staff repositioned R1 and R1 had no complaints of pain and no visible injury at that time. CNA M further stated around 04:00 PM, CNA M and another unidentified CNA weighed R1 using a total body sling lift and R1 then stated her left leg hurt. CNA M reported R1's complaint of pain to R1's nurse. In a Witness Statement Domestic Aide (DA) N stated on 11/03/21 she witnessed an event at approximately 09:15 AM. DA N wrote she shadowed CNA M while CNA M transferred R1 back to her bed. DA N stated during the transfer, R1's left leg buckled and R1 was unable to bare weight. R1 slowly began to drop to her knee though her right foot remained on the lift platform. DA N stated she ran to get help. DA N documented she notified CMA R that CNA M and R1 needed assistance. LN G also responded to R1's room. CNA M, CMA R, and LN G transferred R1 into her bed. R1 denied pain at that time. The facility investigation Note dated 11/08/21 documented staff assisted R1 to the restroom on 11/03/21 at approximately 09:15 AM with the sit to stand lift. Once R1 completed using the toilet, CNA M assisted R1 off the toilet and took R1 towards R1's bed. CNA M reported R1 held onto the lift when R1's lower extremities became weak and R1 started to slide off the lift. CNA M attempted to hold R1 up to prevent further sliding down without success. DA N went to go to find help to assist with R1. R1 slid further down into a squatting position with R1's left leg coming to a rest on the foot platform of the lift. LN G and CMA R responded and assisted R1 back to bed. LN G initiated a head to toe assessment with no visible injury or pain noted at that time. Around 04:00 PM CNA M and an unidentified nursing staff assisted R1 in obtaining a weight with a Hoyer lift (total body mechanical lift used to transfer residents). At that time, R1 voiced pain to left leg. Staff contacted Consultant GG, who ordered an x-ray. Initial results of the x-ray noted a possible fracture of the left femur. On 03/01/22 at 03:30 PM four sit-to-stand lifts were observed with leg supports but no leg straps. On 03/01/22 at 01:10 PM CNA P stated R1 could participate in the sit-to-stand transfer sometimes and other times, R1 was not able to do it. CNA P stated R1's ability to transfer with the sit to stand lift depended on when staff wanted to get R1 up. On 03/01/22 at 03:45 PM LN H stated that when using the lifts, staff were supposed to use two staff members, but some staff had gotten in to the habit of doing it alone because the facility was short staffed or staff didn't want to wait to get someone to help with the transfer. LN H stated sometimes R1 was not able to hold onto the lift during the sit to stand transfer. On 03/01/22 at 04:08 PM DA N stated that on 11/03/21, she was a hospitality aid and was not allowed to assist with the resident transfers. DA N stated CNA M asked DA N for help, but DA N ran to get help instead, as she was not allowed to assist with the lifts. On 03/01/22 at 04:32 PM CNA O stated that she did not use a sit to stand lift alone because every resident in the facility required two staff for sit to stand lift transfers. CNA O revealed that R1 had days where R1 did okay with the sit to stand and days R1 did not do well. CNA O further revealed that after R1's incident with the sit to stand lift, nursing staff were educated that there was to always be two staff members when the machine was used. On 03/02/22 at 01:08 PM Administrative Nurse D stated that when transferring a resident, staff were to make sure they transferred the resident as indicated in the plan of care and also ensure the resident was alert enough for the transfer. Administrative Nurse D stated that R1 was alert and did not have a lot of limitation with the left side of her body. Administrative Nurse D stated she expected two staff to run the sit to stand lift when transferring the resident. On 03/03/22 Consultant GG was unavailable for interview. The facility's Falls policy recorded a fall was defined as unintentionally coming to rest on the ground, floor, or other lower level but not the result of an overwhelming external force. The policy further directed factors that may result in falls included but were not limited to environmental hazards, lower extremity weakness, balance disorders and functional impairments. The facility failed to ensure two staff assisted R1 with a sit to stand lift transfer as indicated in R1's plan of care. Subsequently, R1 became weak during a transfer and without a second person to assist, R1 slid from the lift which resulted in a broken left femur.

The facility identified a census of 43 residents. The sample included three residents with three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse when the facility failed to prevent Resident(R)1 from inappropriately touching his roommate, R2, in an unwanted sexual nature. On 12/09/21 Activity Staff Y observed R1 seated next to R2's bed and R1 had his hand under R2's shirt on his chest. Activity Staff Y did not report this occurrence to the residents' nurse or Administrative Staff A. Subsequently, on 12/10/21 between 04:30 to 05:00 AM, R2 was awakened by R1, who was performing a sexual act on R2. R2 did not consent to this activity. This failure placed R2 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS recorded R1 felt down, depressed or hopeless one or less days during the look back period. The MDS recorded R1 felt bad about himself or felt that he was a failure seven to ten days during the look back period and had thoughts he was better off dead or hurting himself two to six days during the look back period. R1 had no behaviors documented. R1 was independent with no set up or physical help from staff for activities of daily living (ADL). The Cognitive Loss Care Area Assessment (CAA) dated 09/20/21 documented R1 had difficulty communicating needs and wants at times, and verbalized understanding of others. The Mood CAA dated 09/20/21 documented R1 had anxiety, depression, and dementia that could impact mood. The Psychotic Drug Care Plan initiated 09/13/21 directed staff that R1 took [MEDICATION(S)] (anti-depressant) to help control his behaviors and staff needed to give it to him as doctor ordered. The ADL Care Plan initiated 09/13/21 documented R1 ambulated independently with the assistance of a four-wheel walker. The Tasks tab directed staff to monitor R1 for the target behavior (reason) R1 received the psychoactive (affecting mind or mood) medication [MEDICATION(S)] and listed the reason as tearfulness. It also directed staff to monitor for restlessness for which R1 received [MEDICATION(S)] (psychoactive medication used to treat nerve pain and depression). The Progress Notes tab in R1's EMR recorded a Communication Note dated 12/13/21 at 12:44 PM that Social Services U was informed about a report that was made on 12/10/21 regarding R1 and R2. Social Services U interviewed R1 and R1 was unable to recall the event. Social Services U referred R1 to Social Services W for follow up. Review of the undated Witness Statement, provided by Social Services W documented R2 stated that on 12/03/21 R1 sat on his bed and started to rub R2's leg and private parts. R2 stated that it happened again on 12/05/21, 12/07/21, and the last time before he told staff was on 12/09/21. R2 stated that he felt he should have said something before but didn't want to say anything because he felt like R1 manipulated him. R2 revealed that he did not want to be R1's roommate anymore. Review of the undated Witness Statement, provided by Activity Staff Y documented that when Activity Staff Y delivered room trays for the evening meal around 05:30 PM, she entered R1 and R2's room and observed R1 sitting on R2's bed. R2 had his shirt halfway up and R1 had his hand up R2's shirt and it looked like R1 was touching R2's chest area. R1 did not pull his hand away. Neither R1 or R2 looked embarrassed or quit when Activity Staff Y was there. Activity Staff Y wrote R1 prompted Activity Staff Y to bring food for R2. Activity Staff Y asked R2 if he wanted food and R2 responded yes. Activity Staff Y left the room to get the tray for R2 and when she returned R1 was back in his recliner. Review of the undated Witness Statement, provided by Administrative Staff A documented that R2 stated he was embarrassed to tell anyone, but R2 was now telling because R2 wanted R1 to stop. On 12/16/21 at 10:45 AM R1 sat in the chair in his room. He appeared calm. Certified Nurse Aide (CNA) M sat outside R1's room within line of sight of R1. On 12/16/21 at 11:10 AM R2 stated that R1 had taken advantage of him four different times. R2 revealed that he was the one that told the nurse what happened. R2 stated he didn't like getting woken up and being taken advantage of. R2 continued to state that he didn't want R1 to touch his privates or perform sexual acts on him. R2 said on the day he told the nurse, 12/10/21, R1 had performed a sexual act on him that same morning. R2 revealed that Activity Staff Y walked in on everything on 12/09/21. R2 further stated he never wanted that to happen, he was shy, and he wanted R1 to pay for what he did to R2. R2 said he was embarrassed and as R2 stated what occurred with R1, R2 stood up and moved his coat off his shoulders and wrapped it around his waist. Once R2's jacket was around his waist and covering his bottom he sat back down into his wheelchair and tucked the arms of his jacket in between his legs and covered his groin. R2 avoided eye contact through the interview. He appeared withdrawn, hesitant, and he stated that he didn't want to talk about it any more at the end of the interview. On 12/16/21 at 11:53 AM Activity Staff Y stated on 12/09/21 she served supper trays to R1's room. The door was open, and she observed R1 seated beside R2 on R2's bed. R2's shirt was pulled halfway up and R1 had his hand up R2's shirt. Activity Staff Y stated when she brought in R1's tray, he got up and moved to his recliner on his side of the room. Activity Staff Y stated that she didn't separate them but left the room to get R2's room tray. Activity Staff Y stated that neither R1 or R2 seemed embarrassed and she assumed they were ok with the relationship. Activity Staff Y stated she did not tell anyone about it that evening, but did let her supervisor, Activity Staff Z, know the following morning. Activity Staff Y stated that Activity Staff Z said it was weird and that Activity Staff Z had never walked in on anything like that before. On 12/16/21 at 12:05 PM Activity Staff Z stated he could not recall if Activity Staff Y informed him about Activity Staff Y's observation of R1 and R2. Activity Staff Z stated he thought Activity Staff Y said R1 and R2 did something, but Activity Staff Y did not seem upset or anything. Activity Staff Z further stated that he did not catch everything that Activity Staff Y stated, but he could not recall Activity Staff Y having any stress or concern in her voice, just surprise. Activity Staff Z stated, in hindsight he misunderstood Activity Staff Y. Activity Staff Z stated he would have asked further about what Activity Y witnessed and instructed Activity Staff Y to separate R1 and R2 and report it immediately to Administrative Staff A Activity Staff Z stated Activity Staff Y did not relay enough information about the situation and what she observed. On 12/16/21 at 01:05 PM Licensed Nurse (LN) G stated R2 approached her and told her that R2 hated to be woken up with R1 engaging him in a sexual nature (described to LN G by R2) LN G said she confirmed to R2 what R2 told her by restating what R2 said, which R2 said was correct. LN G stated R2 approached her on 12/10/21 and she immediately thought to separate the residents, so she had R2 stay in the living room within staffs' line of sight, and reported what was told to her to Administrative Staff A. On 12/16/21 at 03:00 PM Administrative Staff A stated staff notified her of the event on 12/10/21 and came to the building to make sure that R1 and R2 had a room change and were separated. Administrative Staff A revealed that she contacted the police department and reported the event. Administrative Staff A stated when she heard from Activity Staff Y what had been witnessed the night before it was already too late. The facility policy's Abuse, Neglect and Exploitation revised 11/28/17 documented the resident had a right to be free from verbal, sexual, physical and mental abuse. Sexual abuse included non-consensual sexual contact of any type with a resident and included, but not limited to, sexual harassment, sexual coercion, or sexual assault. The facility failed to ensure residents remained free from abuse when the facility failed to prevent Resident(R)1 from inappropriately touching his roommate, R2, in an unwanted sexual nature. This placed R2 in immediate jeopardy. The immediate jeopardy was corrected on 12/15/21 when the facility completed the following actions: R2 was moved to a different room. R1 was placed on constant observations by staff to ensure no inappropriate behaviors. Staff were reeducated on identification and prevention of abuse. Due to the fact the corrective actions were completed prior to the survey on 12/16/21, this deficient practice was cited as past noncompliance.

The facility identified a census of 43 residents. The sample included three residents with three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified a situation of inappropriate touching as a possible incident of abuse. The facility further failed to ensure staff immediately reported the incident to the facility administrator. On 12/09/21 Activity Staff Y observed Resident (R)1 seated next to R2's bed and R1 had his hand under R2's shirt. Activity Staff Y did not report this occurrence to the residents' nurse or Administrative Staff A. Activity Staff Y did alert Activity Staff Z the next morning of her observation and Activity Staff Z did not follow up with the resident, the residents' nurse, or Administrative Staff A. This allegation was not reported until the resident reported it to a trusted nurse on the evening of 12/10/21. This deficient practice placed R2 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS recorded R1 felt down, depressed or hopeless one or less days during the look back period. The MDS recorded R1 felt bad about himself or felt that he was a failure seven to ten days during the look back period and had thoughts he was better off dead or hurting himself two to six days during the look back period. R1 had no behaviors documented. R1 was independent with no set up or physical help from staff for activities of daily living (ADL). The Cognitive Loss Care Area Assessment (CAA) dated 09/20/21 documented R1 had difficulty communicating needs and wants at times, and verbalized understanding of others. The Mood CAA dated 09/20/21 documented R1 had anxiety, depression, and dementia that could impact mood. The Psychotic Drug Care Plan initiated 09/13/21 directed staff that R1 took [MEDICATION(S)] (anti-depressant) to help control his behaviors and staff needed to give it to him as doctor ordered. The ADL Care Plan initiated 09/13/21 documented R1 ambulated independently with the assistance of a four-wheel walker. The Tasks tab directed staff to monitor R1 for the target behavior (reason) R1 received the psychoactive (affecting mind or mood) medication [MEDICATION(S)] and listed the reason as tearfulness. It also directed staff to monitor for restlessness for which R1 received [MEDICATION(S)] (psychoactive medication used to treat nerve pain and depression). The Progress Notes tab in R1's EMR recorded a Communication Note dated 12/13/21 at 12:44 PM that Social Services U was informed about a report that was made on 12/10/21 regarding R1 and R2. Social Services U interviewed R1 and R1 was unable to recall the event. Social Services U referred R1 to Social Services W for follow up . Review of the undated Witness Statement, provided by Activity Staff Y documented that when Activity Staff Y delivered room trays for the evening meal around 05:30 PM, she entered R1 and R2's room and observed R1 sitting on R2's bed. R2 had his shirt halfway up and R1 had his hand up R2's shirt and it looked like R1 was touching R2's chest area. R1 did not pull his hand away. Neither R1 or R2 looked embarrassed or quit when Activity Staff Y was there. Activity Staff Y wrote R1 prompted Activity Staff Y to bring food for R2. Activity Staff Y asked R2 if he wanted food and R2 responded yes. Activity Staff Y left the room to get the tray for R2 and when she returned R1 was back in his recliner. Review of the undated Witness Statement, provided by Administrative Staff A documented that R2 stated he was embarrassed to tell anyone, but R2 was now telling because R2 wanted R1 to stop. On 12/16/21 at 10:45 AM R1 sat in the chair in his room. He appeared calm. Certified Nurse Aide (CNA) M sat outside R1's room within line of sight of R1. On 12/16/21 at 11:10 AM R2 stated that R1 took advantage of him four different times. R2 revealed that he was the one that told the nurse what happened. R2 stated he didn't like getting woken up and being taken advantage of. R2 continued to state that he didn't want R1 to touch his privates or perform sexual acts on him. R2 said on the day he told the nurse, 12/10/21, R1 had performed a sexual act on him that same morning. R2 revealed that Activity Staff Y walked in on everything on 12/09/21. R2 further stated he never wanted that to happen, he was shy, and he wanted R1 to pay for what he did to R2. R2 said he was embarrassed and as R2 stated what occurred with R1, R2 stood up and moved his coat off his shoulders and wrapped it around his waist. Once R2's jacket was around his waist and covering his bottom he sat back down into his wheelchair and tucked the arms of his jacket in between his legs and covered his groin. R2 avoided eye contact through the interview. He appeared withdrawn, hesitant, and he stated that he didn't want to talk about it any more at the end of the interview. On 12/16/21 at 11:53 AM Activity Staff Y stated on 12/09/21 she served supper trays to R1's room. The door was open, and she observed R1 seated beside R2 on R2's bed. R2's shirt was pulled halfway up and R1 had his hand up R2's shirt. Activity Staff Y stated when she brought in R1's tray, he got up and moved to his recliner on his side of the room. Activity Staff Y stated that she didn't separate them, but left the room to get R2's room tray. Activity Staff Y stated that neither R1 or R2 seemed embarrassed and she assumed they were ok with the relationship. Activity Staff Y stated she did not tell anyone about it that evening, but did let her supervisor, Activity Staff Z, know the following morning. Activity Staff Y stated that Activity Staff Z said it was weird and that Activity Staff Z never walked in on anything like that before. On 12/16/21 at 12:05 PM Activity Staff Z stated he could not recall if Activity Staff Y informed him about Activity Staff Y's observation of R1 and R2. Activity Staff Z stated he thought Activity Staff Y said R1 and R2 did something, but Activity Staff Y did not seem upset or anything. Activity Staff Z further stated that he did not catch everything that Activity Staff Y stated, but he could not recall Activity Staff Y having any stress or concern in her voice, just surprise. Activity Staff Z stated, in hindsight he misunderstood Activity Staff Y. Activity Staff Z stated he would have asked further about what Activity Y witnessed and instructed Activity Staff Y to separate R1 and R2 and report it immediately to Administrative Staff A Activity Staff Z stated Activity Staff Y did not relay enough information about the situation and what she observed. On 12/16/21 at 01:05 PM Licensed Nurse (LN) G stated R2 approached her and told her that R2 hated to be woken up with R1 engaging him in a sexual nature (described to LN G by R2). LN G said she confirmed to R2 what R2 told her by restating what R2 said, which R2 said was correct. LN G stated R2 approached her on 12/10/21 and she immediately thought to separate the residents, so she had R2 stay in the living room within staffs' line of sight, and reported what was told to her to Administrative Staff A. On 12/16/21 at 03:00 PM Administrative Staff A stated staff notified her of the event on 12/10/21 and came to the building to make sure that R1 and R2 had a room change and were separated. Administrative Staff A revealed that she contacted the police department and reported the event. Administrative Staff A stated when she heard from Activity Staff Y what had been witnessed the night before it was already too late. The facility policy's Abuse, Neglect and Exploitation revised 11/28/17 documented the resident had a right to be free from verbal, sexual, physical and mental abuse. Sexual abuse included non-consensual sexual contact of any type with a resident and included, but not limited to, sexual harassment, sexual coercion, or sexual assault . The policy documented the facility would ensure all alleged violations involving abuse, or mistreatment were reported immediately by the individual who identified it to the administrator, director of nursing and charge nurse. The policy also recorded any allegation of abuse must be immediately reported to a supervisor and/or the administrator. If reported to a supervisor, the supervisor must immediately report such to the administrator. The facility failed to ensure staff identified a situation of inappropriate touching as a possible violation involving abuse. The facility further failed to ensure staff immediately reported the potential (alleged) violation to the facility administrator. This placed R2 in immediate jeopardy. The immediate jeopardy was corrected on 12/15/21 when the facility completed the following actions: R2 was moved to a different room. R1 was placed on constant observations by staff to ensure no inappropriate behaviors. Staff were reeducated on identification of possible abuse and reporting immediately any allegation involving any form of abuse to the facility administrator. Due to the fact the corrective actions were completed prior to the survey on 12/16/21, this deficient practice was cited as past noncompliance.

The facility identified a census of 43 residents. The sample included three residents with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to ensure resident safety and provide protection when the facility failed to implement interventions and take immediate measures to protect Resident(R)2 from resident to resident sexual abuse. On 12/09/21 Activity Staff Y observed R1 seated next to R2's bed and R1 had his hand under R2's shirt. Activity Staff Y did not report this occurrence to the residents' nurse or Administrative Staff A. Because no immediate action was taken, R2 was awakened on 12/10/21 by R1, who was performing a nonconsensual sexual act on R2. This deficient practice placed R2 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS recorded R1 felt down, depressed or hopeless one or less days during the look back period. The MDS recorded R1 felt bad about himself or felt that he was a failure seven to ten days during the look back period and had thoughts he was better off dead or hurting himself two to six days during the look back period. R1 had no behaviors documented. R1 was independent with no set up or physical help from staff for activities of daily living (ADL). The Cognitive Loss Care Area Assessment (CAA) dated 09/20/21 documented R1 had difficulty communicating needs and wants at times, and verbalized understanding of others. The Mood CAA dated 09/20/21 documented R1 had anxiety, depression, and dementia that could impact mood. The Psychotic Drug Care Plan initiated 09/13/21 directed staff that R1 took [MEDICATION(S)] (anti-depressant) to help control his behaviors and staff needed to give it to him as doctor ordered. The ADL Care Plan initiated 09/13/21 documented R1 ambulated independently with the assistance of a four-wheel walker. The Care Plan recorded an intervention on 12/13/21 which indicated R1 moved to a private room and had one on one supervision which would continue indefinitely. The Tasks tab directed staff to monitor R1 for the target behavior (reason) R1 received the psychoactive (affecting mind or mood) medication [MEDICATION(S)] and listed the reason as tearfulness. It also directed staff to monitor for restlessness for which R1 received [MEDICATION(S)] (psychoactive medication used to treat nerve pain and depression). The Progress Notes tab in R1's EMR recorded a Communication Note dated 12/13/21 at 12:44 PM that Social Services U was informed about a report that was made on 12/10/21 regarding R1 and R2. Social Services U interviewed R1 and R1 was unable to recall the event. Social Services U referred R1 to Social Services W for follow up. R1's clinical record lacked documentation that R1 had one to one staff supervision until 12/13/21 when a General Note dated at 02:41 PM recorded R1 was up per his normal routine and he continued to have 1:1. The Progress Notes tab of R2's EMR recorded a Communication Note on 12/13/21 at 01:43 PM which recorded Social Services U was informed about a report that was made by R2 regarding his roommate on 12/10/21. Social Services U met with R2 regarding the situation and completed an interview. Staff moved R2 to a new room. R2 agreed to see a licensed clinical social worker weekly. Social Services U would continue to follow up with R2. Review of the undated Witness Statement, provided by Social Services W documented R2 stated that on 12/03/21 R1 sat on his bed and started to rub R2's leg and private parts. R2 stated that it happened again on 12/05/21, 12/07/21, and the last time before he told staff was on 12/09/21. R2 stated that he felt he should have said something before but didn't want to say anything because he felt like R1 manipulated him. R2 revealed that he did not want to be R1's roommate anymore. Review of the undated Witness Statement, provided by Activity Staff Y documented that when Activity Staff Y delivered room trays for the evening meal around 05:30 PM, she entered R1 and R2's room and observed R1 sitting on R2's bed. R2 had his shirt halfway up and R1 had his hand up R2's shirt and it looked like R1 was touching R2's chest area. R1 did not pull his hand away. Neither R1 or R2 looked embarrassed or quit when Activity Staff Y was there. Activity Staff Y wrote R1 prompted Activity Staff Y to bring food for R2. Activity Staff Y asked R2 if he wanted food and R2 responded yes. Activity Staff Y left the room to get the tray for R2 and when she returned R1 was back in his recliner. Review of the undated Witness Statement, provided by Administrative Staff A documented that R2 stated he was embarrassed to tell anyone, but R2 was now telling because R2 wanted R1 to stop. On 12/16/21 at 10:45 AM R1 sat in the chair in his room. He appeared calm. Certified Nurse Aide (CNA) M sat outside R1's room within line of sight of R1. On 12/16/21 at 11:10 AM R2 stated that R1 had taken advantage of him four different times. R2 revealed that he was the one that told the nurse what happened. R2 stated he did not like getting woken up and being taken advantage of. R2 continued to state that he didn't want R1 to touch his privates or perform sexual acts on him. R2 said on the day he told the nurse, 12/10/21, R1 had performed a sexual act on him that same morning. R2 revealed that Activity Staff Y walked in on everything on 12/09/21. R2 further stated he never wanted that to happen, he was shy, and he wanted R1 to pay for what he did to R2. R2 said he was embarrassed and as R2 stated what occurred with R1, R2 stood up and moved his coat off his shoulders and wrapped it around his waist. Once R2's jacket was around his waist and covering his bottom he sat back down into his wheelchair and tucked the arms of his jacket in between his legs and covered his groin. R2 avoided eye contact through the interview. He appeared withdrawn, hesitant, and he stated that he did not want to talk about it anymore at the end of the interview. On 12/16/21 at 11:53 AM Activity Staff Y stated on 12/09/21 she served supper trays to R1's room. The door was open, and she observed R1 seated beside R2 on R2's bed. R2's shirt was pulled halfway up and R1 had his hand up R2's shirt. Activity Staff Y stated when she brought in R1's tray, he got up and moved to his recliner on his side of the room. Activity Staff Y stated that she didn't separate them but left the room to get R2's room tray. Activity Staff Y stated that neither R1 or R2 seemed embarrassed and she assumed they were ok with the relationship. Activity Staff Y stated she did not tell anyone about it that evening, but did let her supervisor, Activity Staff Z, know the following morning. Activity Staff Y stated that Activity Staff Z said it was weird and that Activity Staff Z had never walked in on anything like that before. On 12/16/21 at 12:05 PM Activity Staff Z stated he could not recall if Activity Staff Y informed him about Activity Staff Y's observation of R1 and R2. Activity Staff Z stated he thought Activity Staff Y said R1 and R2 did something, but Activity Staff Y did not seem upset or anything. Activity Staff Z further stated that he did not catch everything that Activity Staff Y stated, but he could not recall Activity Staff Y having any stress or concern in her voice, just surprise. Activity Staff Z stated, in hindsight he misunderstood Activity Staff Y. Activity Staff Z stated he would have asked further about what Activity Y witnessed and instructed Activity Staff Y to separate R1 and R2 and report it immediately to Administrative Staff A Activity Staff Z stated Activity Staff Y did not relay enough information about the situation and what she observed. On 12/16/21 at 01:05 PM Licensed Nurse (LN) G stated R2 approached her and told her that R2 hated to be woken up with R1 engaging him in a sexual nature (described to LN G by R2). LN G said she confirmed to R2 what R2 told her by restating what R2 said, which R2 said was correct. LN G stated R2 approached her on 12/10/21 and she immediately thought to separate the residents, so she had R2 stay in the living room within staffs' line of sight, and reported what was told to her to Administrative Staff A. On 12/16/21 at 03:00 PM Administrative Staff A stated staff notified her of the event on 12/10/21 and came to the building to make sure that R1 and R2 had a room change and were separated. Administrative Staff A revealed that she contacted the police department and reported the event. Administrative Staff A stated when she heard from Activity Staff Y what had been witnessed the night before it was already too late. The facility policy's Abuse, Neglect and Exploitation revised 11/28/17 documented the resident had a right to be free from verbal, sexual, physical and mental abuse. Sexual abuse included non-consensual sexual contact of any type with a resident and included, but not limited to, sexual harassment, sexual coercion, or sexual assault. The policy documented the facility would ensure all alleged violations involving abuse, or mistreatment were reported immediately by the individual who identified it to the administrator, director of nursing and charge nurse. The policy documented the facility would take immediate actions to protect the resident and involved and all other residents. The facility failed to ensure resident safety and provide protection when the facility failed to implement interventions and take immediate measures to protect Resident(R)2 from resident to resident sexual abuse. This placed R2 in immediate jeopardy. The immediate jeopardy was corrected on 12/15/21 when the facility completed the following actions: R2 was moved to a different room. Referral was made for clinical psychosocial support. R1 was placed on constant observations by staff to ensure no inappropriate behaviors. Staff were reeducated on identification, prevention, reporting and protecting residents from abuse. Due to the fact the corrective actions were completed prior to the survey on 12/16/21, this deficient practice was cited as past noncompliance.

The facility reported a census of 86 residents. The sample included five residents. Based on record review, observations, and interviews, the facility failed to ensure Resident (R)1 received adequate supervision and assistance with eating and drinking, resulting in R1 spilling coffee on herself, sustaining [MEDICAL CONDITION] her chest and abdomen. Findings included: - The Electronic Medical Record (EMR) documented R1 had [DIAGNOSES REDACTED]. The Entry Minimum Data Set (MDS) documented R1 entered the facility on [DATE]. The resident's Admission Assessment created on [DATE] and signed on [DATE] by Licensed Nurse (LN ) I documented the resident was alert to person, was totally dependent on staff for all Activities of Daily Living (ADLs) including eating, had a swallowing problem and received a mechanically altered diet. The Look Back MDS Assessment V.5 created on [DATE] and signed on [DATE] documented the resident was alert and oriented to person, required total assistance of two staff with most ADLs including meals and eating. The Baseline Care Plan-V1 dated [DATE] and signed on [DATE] recorded R1 was alert, but cognitively impaired. R1's Baseline Care Plan V1recorded the resident required one-person physical assistance with eating, received a mechanically altered diet, ate in the dining room, and was at risk for weight loss, swallowing, and chewing problems. The Baseline Care Plan V1 under the Safety Risks section documented the resident had a history of [REDACTED]. The Facility Investigation documented on Thursday [DATE] at approximately 11:50 AM an unidentified dietary staff member served R1 coffee while she sat in the dining room. R1 picked up the cup, drank the coffee independently until 11:55 AM, when she spilled the coffee on her chest and abdomen. The investigation recorded the resident called out ouch. Certified Nurse Aid (CNA) N, who was serving a meal tray to another resident at the table responded to the resident and called for staff assistance. CNA O assisted CNA N in moving R1 from the dining room to the nurse's station for further evaluation. The investigation further recorded LN G assessed R1 within minutes of the incident and noted no injuries. Staff assisted the resident into a clean, dry shirt and brought her back to the dining room. R1 then received assistance with the noon meal. The facility investigation recorded on Friday [DATE] CNA O gave R1 a bed bath and during the bath, noted R1's skin was peeling. CNA O notified Administrative Nurse [NAME] and LN [MI] Administrative Nurse [NAME] and LN L assessed R1 and noted an open blister on R1's mid-abdomen 30 centimeters (cm) by 3 cm, reddened areas to R1's lower abdomen 32 cm x 11 cm, and another area 9 cm x 1.5 cm. A notarized Witness Statement by CNA N, signed on [DATE] documented on [DATE] at approximately 12:30 PM CNA N was taking a resident's plate to the resident at the table. At that time, CNA N heard R1 state ouch, ouch, ouch. CNA N looked over at R1 and observed R1 holding an empty coffee cup and R1 had coffee all over the front of her. CNA N documented she called CNA O, told CNA O what happened. CNA O immediately took R1 back to her room and changed her clothes. A notarized Witness Statement by CNA O, signed on [DATE], documented on [DATE] CNA N told CNA O R1 spilled hot coffee on the front of herself. CNA O took R1 to the nurse's station and had LN G assess R1. LN G assessed R1 and did not see anything. CNA O changed R1's shirt and pushed her back to the dining room. Review of the INTERACT Change in Condition Evaluation V5.1 form, dated [DATE] at 11:54 [NAME]M. documented the resident had a change in condition: resident slipped (sic) coffee on self-,[DATE] blister from spill noticed ,[DATE]. The form documented a burn and listed the location as chest and abdomen. During an interview on [DATE] at 10:00 AM, CNA O stated on [DATE] during lunch she was notified by LN G that RI had spilled coffee. CNA O and LN G took R1 to the shower room and changed R1's shirt. CNA O stated at that time, R1 had slight redness to her abdominal area. CNA O stated the next day she went to give R1 a bed bath and noticed R1's skin was peeling back around the burn area with two new blistered areas on R1's abdomen. She informed LN L and Administrative Nurse [NAME] who came in and dressed the wound. CNA O stated she filled out a witness report on [DATE] and [DATE] regarding the incident. CNA O stated she knew from her own assessment that the resident required assistance with eating. CNA O could not say if staff assisted R1 at lunch on [DATE]. CNA O stated no staff seemed to know how the incident occurred. In an interview on [DATE] at 2:47 PM R1's responsible party/family member stated she met with social services and the hospice team members when R1 admitted to the facility. The family member reported that at that time, she informed the facility R1 could not feed herself. She also said the facility had R1's hospital paperwork which indicated R1 required assistance with eating and drinking. The family member said R1 got the burn on her from coffee on Thursday ([DATE]). She was at the facility with R1 and then received a call from R1's previous nursing home that she could come and pick up R1's belongings. The family member stated she was in the facility on Friday [DATE] two different times and she spoke with hospice and was never told anything about this burn. The family member said she was in the facility several times on [DATE], but the facility staff did not discuss [MEDICAL CONDITION] her. She said she learned about [MEDICAL CONDITION] another family member who visited R1. When she asked the facility staff about the incident, staff informed her that the resident spilled her coffee a few days prior, but at that time staff did not think it was a problem. Interviewed on [DATE] at 3:30 PM, LN H stated she was not aware of the blisters until Monday, [DATE]. She said she found out because staff asked her to administer R1 pain medication due to R1's burns. She stated she was surprised because R1 did not have [MEDICAL CONDITION] to her arriving at the facility. LN H stated R1 was able to tell facility staff what she wanted and R1 liked to have coffee and drinks, but LN H did not know who left R1 unassisted with the coffee. Interview on [DATE] at 4:15 PM, Social Services (SS) X stated when R1 admitted , SS X was present and R1's family member was upset about R1's most [MEDICAL CONDITION] diagnosis. SS X stated R1 mumbled and responded to her daughter's voice with a few words and answered a few yes/no questions. Interview on [DATE] at 4:25 PM SS Y stated she met with R1 and R1's family member at admission and scheduled a care plan meeting for that week, but R1 expired before the meeting took place. SS Y stated every department including dietary performed their own assessment at the time of admission. SS Y stated she learned of the incident about the coffee spill on Monday [DATE] during morning meeting. SS Y stated Administrative Nurse D said the resident was drinking coffee and spilled the coffee on herself. SS Y said she asked if R1's family was aware and was told that nursing staff notified R1's family. SS Y stated she had no knowledge about the incident other than there was a grievance about it. In an interview on [DATE] 10:13 A,M. LN G stated on [DATE], around lunch, a CNA reported to her R1 spilled hot coffee on herself. LN G looked at R1's skin. She said at that time here was no indication of redness and R1 did not report any pain. LN G said she and CNA O went ahead and washed the area and then put fresh clothes on R1. LN G stated she was not in the dining room at the time of the incident. LN G stated R1 required total assistance with all ADLs. She said R1 would reach out for things and would move her limbs but required staff to assist with everything. LN G stated nurses were aware of R1's care needs and restricted movements from the information in the admission assessment and from verbal nurse to nurse reports. She stated the nurses also reviewed the hospital notes to know what cares the resident needed. She reported staff knew which residents needed assistance with eating and drinking by looking at the care plan. She said it was also on the dietary sheets. LN G said the dietary sheets had a code to indicate if the resident required limited or total assistance, and/or supervision. LN G said that one of the nurses should be present in the dining room during meals, but that was very difficult to accomplish. LN G said that on the day in question, [DATE], the nurse who should have been in the dining room for the lunchtime meal was not there because she was new and did not know she should be in the dining room. In an interview on [DATE] at 11:25 AM, Consultant Nurse Practitioner GG reported she assessed R1 on [DATE] in response to a nurse report [MEDICAL CONDITION] pain for R1. Consultant GG stated her assessment findings of R1 revealed a large softball sized blister to R1's chest which appeared to be a second-degree burn. Consultant GG reported R1 was unable to speak at that time. She further stated the facility staff did not mention or report [MEDICAL CONDITION] blisters to R1's abdomen during that assessment. Interview on [DATE] 12:00 PM Dietary BB stated she was not here the day R1 spilled coffee, but she was told of the incident by a staff member. She reported she also received an electronic mail (Email) from administration that someone gave coffee to the resident, the resident took several drinks, and the last time she spilled the coffee on her chest. Dietary BB said she was told there was an aide in the dining room who responded to the situation. Dietary BB reported that dietary staff were made aware of which residents required assistance with eating or drinking via notification forms from nursing. She reported that the dietary department then annotated the level of assistance on the resident's diet card. She said the purpose for this was to ensure no residents who required assistance with eating or drinking would be served food or drink by the dietary department unless a staff member was with the resident to assist. Dietary BB stated she could not remember if R1's diet card indicated R1 required assistance. She further stated she could not find the diet communication slip nursing would have sent to the dietary department for R1 when R1 admitted . Interview on [DATE] at 12:21 PM Administrative Nurse D stated that R1 spilled the coffee on [DATE], but she was not notified until the next day by Administrative Nurse E. Administrative Nurse D stated that when R1 spilled the coffee it, CNA N witnessed the incident while assisting a different resident across the table. She said when CNA N heard R1 cry out ouch CNA N stopped assisting the unidentified resident and went to R1 and called for an additional CNA to assist with removing R1 from the dining room. LN G assessed R1, took her shirt off, and assessed her skin. LN G did not notice any areas of injury and put a clean shirt on R1, and staff assisted R1 back to the dining room. Administrative Nurse D stated that the staff involved had not notified anyone and that she expected staff to alert facility administration, family, and the physician of this type of incident. Administrative Nurse D stated that the CNA seated across the table from R1 was a supervision level of assistance and not limited or extensive assistance of one staff person. Administrative Nurse D confirmed the documentation in R1's clinical record indicated R1 was dependent on staff for cares, including eating and drinking. The facility's Activities of Daily Living policy received (MONTH) 27, (YEAR) recorded: The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following activities of daily living: dining, eating including meals and snacks. For residents who are unable to carryout activities of daily living and are dependent on staff they will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, The facility failed to ensure staff provided the required assistance with eating and drinking to R1, who was dependent on staff. This deficient practice resulted in an accident in which R1 received second [MEDICAL CONDITION] her chest and abdomen.

The facility identified a census of 87 residents. The sampled included 3 residents. Based on interview and record review, the facility failed to follow policy for bowel monitoring, monitor the effectiveness of administration of multiple laxatives, and follow physician orders [REDACTED].#1) identified with constipation (difficulty passing stools). The facility failed to provide ongoing assessments to resident#1 who experienced a change in condition with signs and symptoms after going 5 days without having a bowel movement. This deficient practice placed this resident with a history of constipation in Immediate Jeopardy. Findings included: - The facility admitted resident #1 on [DATE] with the [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set Assessment ((MDS) dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) of 15 which indicated the resident was alert and oriented and independent with decision-making skills. The MDS documented the resident required extensive assistance with activities of daily living (ADLs) except with eating, was frequently incontinent of bowel and bladder, on a toileting plan, and received scheduled pain medications. Review of the Care Area Assessment for activities of daily living dated [DATE], recorded the resident had functional mobility deficits, was morbidly obese, and required extensive assistance from staff with most activities of daily living. Review of the resident's activities of daily living plan of care dated [DATE] directed staff to report to the nurse and physician right away with changes in ability to concentrate, make decisions, or changes in normal mood. The resident may be getting sick or have other changes in condition that could be identified and treated. The resident's plan of care lacked interventions for the [DIAGNOSES REDACTED]. Record review of the [DATE] through [DATE] Medication Administration History (MAH) documented the resident received [MEDICATION NAME] HCL ([MEDICATION NAME]) 5 milligrams (mg) one tablet every 4 hours as needed (PRN) for pain, dated [DATE], given 34 times. The resident received 4 doses during the month of [DATE], between the 1st and 10th. The resident received [MEDICATION NAME] on [DATE] at 12:25 PM. According to the Lexicomp's Drug Information Handbook for Nursing, 13th Edition, page 914, appropriate laxatives should be administered, with use of [MEDICATION NAME], to avoid the associated constipating side effects. Record review of the [DATE] MAH recorded physician orders [REDACTED]. [MEDICATION NAME] 17 gram dose powder once daily, [DATE]. [MEDICATION NAME] 100 milligrams (mg) daily, [DATE]. Natural [MEDICATION NAME] Fiber, 3.4 grams mixed with juice three times daily, [DATE]. The [DATE] to 9 /30 /14 MAH documented, the resident received the doses. The resident received doses of scheduled medications from [DATE] to [DATE], except he/she refused one dose of Natural [MEDICATION NAME] Fiber on [DATE] at 11:42 A.M. The primary care physician's standing orders dated [DATE] directed: Milk of Magnesia 30 ml po daily PRN for constipation, if no stool for 3 days. [MEDICATION NAME] one suppository per rectum daily every 3 days PRN, if no bowel movement in 3 days and if Milk of Magnesia was ineffective. Soap Suds enema rectally PRN for constipation, if Milk of Magnesia and rectal suppository were not effective. Review of the ADL Verification Worksheet for bowel monitoring from [DATE] to [DATE] recorded the following dates without BMs: ,[DATE], ,[DATE] and ,[DATE]- 3 days, no bowel movement (BM) ,[DATE], ,[DATE], ,[DATE]- 3 days, no BM ,[DATE], ,[DATE], ,[DATE]- 3 days, no BM ,[DATE], ,[DATE], ,[DATE] and ,[DATE]- 4 days, no BM ,[DATE], ,[DATE] and ,[DATE]- 3 days, no BM ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]- 5 days, no BM until the resident expired. The clinical record lacked evidence the staff assessed and monitored the resident's bowel sounds during the above time frames. The [DATE] MAH documented the physician order [REDACTED]. Review of the [DATE] MAH revealed staff failed to administer the Milk of Magnesia in September five times when the resident went longer than 3 days between bowel movements. The facility provided two different sets of documentation regarding MOM administered to the resident. The times do not match on the two documents and record the following: Review of the [DATE] MAH revealed staff administered the Milk of Magnesia on [DATE] at 1:10 P.M. and again at 9:29 P.M., against the physician's orders [REDACTED]. Review of the Administration entry provided by the facility documented the resident received MOM on [DATE] at 5:16 P.M. then signed and locked it as administered on [DATE] at 9:29 P.M. (given after the resident died ) The Administration entry also recorded the resident had relief from the MOM at 4:22 P.M., however, the BM records and nurses notes do not support this. Nursing note dated [DATE] timed 10:24 A.M. documented the resident complained of lightheaded feeling, skin cool and clammy, feeling nauseous with a small amount of emesis (vomit), and blood pressure of ,[DATE]. Nursing staff notified the primary care physician. The clinical record lacked documentation of what staff reported to the physician. Per interview with consultant physician HH on [DATE] at 1:08 P.M., the facility staff did notify him/her the resident had nausea but failed to notify him/her the resident had been constipated and without a BM for five days, and if he/she had been notified of that, he/she would have given additional orders and instruction. The clinical record lacked evidence on [DATE] at 10:24 A.M. the facility followed the physician's orders [REDACTED]. Nursing note dated [DATE] timed 12:06 P.M. recorded the resident continued cool to the touch and clammy, no further emesis at this time, temperature 97 degrees Fahrenheit, pulse 60, respirations 16, and blood pressure ,[DATE]. The clinical record lacked evidence the facility notified the physician of the resident's continued symptoms. Nursing note dated [DATE] timed 1:21 P.M. recorded the resident complained of feeling constipated and staff administered the physician ordered PRN Milk of Magnesia (MOM). The clinical record lacked evidence the facility notified the physician. Nursing note dated [DATE] documented at 4:25 P.M. the nursing staff administered a rectal suppository for constipation as requested by the resident. This note was signed at 10:05 PM by nursing staff. Nursing note dated [DATE] timed 9:31 P.M. recorded at 5:16 P.M. the staff provided and the resident drank some prune juice. Nursing note dated [DATE] timed 9:22 P.M. recorded at 7:17 P.M. direct care staff called licensed nursing staff to the unresponsive resident's room and initiated cardiopulmonary resuscitation. Nursing note dated [DATE] timed 8:37 P.M. documented the emergency room physician by phone called the resident's time of death [DATE] at 7:47 P.M. in the facility. During an interview on [DATE] at 12:15 P.M. licensed nursing staff H reported he/she printed out the bowel monitoring sheets, provided them to the nurses, and when a resident does not have a bowel movement by the 3rd day, staff administered a PRN laxative ordered by the physician. On [DATE] at 12:30 P.M. licensed nursing staff L revealed nursing staff followed up on the bowel list that night shift printed. Nursing staff looked to make sure the resident was having bowel movements at least every 3 days. Licensed nursing staff L reported staff followed physician orders [REDACTED]. On [DATE] at 12:55 P.M. direct care staff O revealed staff monitored for resident's bowel movements and recorded the BM's in the computer Kiosk (a small, stand-alone device providing information for staff on a computer screen and was often used for entering services provided). On [DATE] at 1:10 P.M. direct care staff P reported on [DATE] after breakfast around 9:30 A.M., the resident complained of not feeling well and not did have a BM during the day shift on [DATE]. Staff monitored BMs and recorded in the computer each shift. On [DATE] at 2:30 P.M. direct care staff Q reported nursing staff recorded resident's bowel movements in the computer and the licensed nurses told direct care staff about a change or giving a laxative to watch for bowel movements. Direct care staff Q reported at approximately 7:15 P.M. the resident looked gray, was not moving, and he/she called for another staff member to assess the resident. On [DATE] at 4:44 P.M. licensed nursing staff J reported on [DATE] about 10:26 A.M., the resident was weak, sweaty, blood pressure was low, and the resident complained of aching all over. Licensed nursing staff J reported he/she notified the physician of the resident's change of condition and received orders to continue to monitor and if the resident did not improve to call the physician back. Licensed nursing staff J reported he/she administered pain medication for the resident's complaint of lower back and all-over pain at approximately 12:25 P.M. Licensed nursing staff J revealed he/she reported the resident's condition to the director of nursing, who said it looked like a stomach virus. Licensed nursing staff revealed he she received the BM monitoring sheet about 1:15 P.M. that recorded the resident had not had a BM in 5 days and administered PRN Milk of Magnesia to the resident. Licensed nursing staff J revealed he/she gave shift report to the director of nursing and documented on the shift report, as well as giving an oral report to the oncoming licensed nursing staff that the resident had no results from the PRN laxative by 3:00 P.M., staff needed to notify the physician. On [DATE] at 7:30 A.M. licensed nursing staff K reported the resident was on a routine bowel regimen and received PRN pain medication. The resident's primary physician had standing orders for Milk of Magnesia and a rectal suppository. The night shift nurse either wrote a list or prints out a list for resident's with no BMs for 3 days. If resident has a PRN laxative, nursing staff give that with morning meds and then nurses have to chart in computer for follow up in 1 hour. Usually there are no results and nurses chart "results not expected". When staff administered a laxative with the morning medications, expectations were results by 2 P.M., and to notify the resident's physician with no results. On [DATE] at 9:45 A.M. licensed nursing staff I reported the nurse-to-nurse report advised the resident had not had results from the administration of a PRN laxative. Licensed nursing staff I revealed before 5 P.M., he/she administered a rectal suppository for constipation and then shortly after 5 P.M. the resident agreed to drink some warm prune juice with [MEDICATION NAME], which the resident had ordered PRN, and some Milk of Magnesia. Licensed nursing staff I revealed he/she did not document the medication administrations in the MAR and staff had to enter PRN medications on physician standing orders to the EMAR. Licensed nursing staff I revealed he/she did not call the resident's physician. Review of the [DATE] electronic MAH revealed staff administered the physician ordered [MEDICATION NAME] scheduled daily at 7:38 A.M. and was not a PRN order. On [DATE] at 10:22 A.M. direct care staff R reported after breakfast on [DATE], the resident was drenched in sweat, nauseous and did not feel well. The charge nurse reported the resident received Milk of Magnesia and to report if the resident had a bowel movement. On [DATE] at 1:15 P.M. direct care staff U reported on [DATE] after 4 P.M. the charge nurse directed him/her to give the resident prune juice with a scoop of [MEDICATION NAME] and 30 mls of Milk of Magnesia. The charge nurse assisted with administering a rectal suppository for the resident's constipation. Direct care staff U reported at approximately 7 P.M. direct care staff found the resident unresponsive, sitting upright in bed. On [DATE] at 2:45 P.M. direct care staff S reported after the evening meal on [DATE], he/she assisted direct care staff U to position the resident for administration of a suppository laxative. The resident did not have a bowel movement. On [DATE] at 4:25 P.M. direct care staff T reported during the afternoon on [DATE] the resident appeared pale and in pain. The resident asked him/her to tell the nurse he/she had pain in the stomach and wanted to know what the doctor said about the pain in his/her stomach. Direct care staff T revealed he/she reported to the charge nurse and approximately 30 minutes later the nurse reported the resident needed a suppository or enema and the resident agreed. On [DATE] at 3:30 P.M. administrative nursing staff E revealed an oral PRN laxative usually provided results in 35 to 40 minutes and if the medication failed to provide results, staff followed physician standing orders, located at the nursing station. If the PRN medication did not work, staff notified the physician. On [DATE] at 3:30 P.M. consultant physician HH revealed licensed nursing staff notified him/her on [DATE] at approximately 9:00 A.M. the resident had nausea and a gastrointestinal illness was prevalent in the facility. Consultant physician HH revealed he/she instructed nursing staff to call back if the resident did not improve and he/she did not receive any further calls about the resident on [DATE]. Consultant physician HH revealed he/she signed an on-line death certificate request by the corner with the diagnosis "acute abdomen, probable intestinal obstruction." Consultant physician HH reported the resident had several medical conditions, but relatively healthy and he/she would have expected the nursing staff to contact him/her again that afternoon about the resident's status if he/she continued to worsen and did not seem any better. On [DATE] at 3:45 P.M. administrative nursing staff D reported licensed nursing staff record in the MAH immediately when giving medications and assessed PRN laxatives. The nurses had access to the physician standing orders and add the orders to the electronic MAH as needed. Licensed nursing staff reported to the physician for laxative orders and report resident's complaint. Administrative nursing staff D reported he/she assessed the resident after breakfast. Early in the afternoon on [DATE], licensed nursing staff reported the resident had no BM for 5 days and he/she administered Milk of Magnesia. Administrative nursing staff D directed the staff to call the physician and get an order for [REDACTED]. On [DATE] at 1:08 P.M. consultant physician HH stated the staff nurse contacted him/her the resident had nausea and he/she instructed staff to call him/her back if things changed and to keep an eye on the resident. The nurse never told him/her the resident's constipation. The nurse later told physician HH that he/she did not know at the time of the notification that the resident was constipated and had not had a BM for 5 days, but later looked in the record and that's when he/she told the oncoming nurse to give the resident something for constipation before she left. The staff never called physician HH back. The facility provided policy Electronic Medical Record: Bowel Movement Monitoring Report dated [DATE] recorded staff documented bowel movements in the electronic medical record reports, which were generated and printed for use by physicians or caregivers, as necessary. Nurses were expected to monitor the occurrence, or lack thereof, of bowel movements on a daily basis. The facility provided undated policy Bowel Movement Recording documented the policy was to ensure that resident's bowel elimination was monitored and recorded to prevent complications associated with constipation and impactions. The certified nurses aide responsible for providing care for the resident was to record all bowel movements (BM) on the BM Record before the end of his/her shift. Each day, after midnight, the night nurse would review the BM Record for the residents to determine who had not had a bowel movement in the last three (3) days. Based on this review a list of residents was generated who were in need of bowel management interventions per physician order. The facility policy Medication Administration- General Guidelines dated ,[DATE] documented medications were administered in accordance with written orders from the attending physician. The facility policy Documentation for Medication Administration dated ,[DATE] recorded the individual administering the medication doses record the administration of medications before reporting off-duty. The facility provided undated policy Notification of Change recorded the policy of the facility to inform the physician when there was a change in the resident's condition, a significant change, and a need to alter treatment significantly, or commence a new form of treatment. The facility's policy titled Interact Change in Condition: When to report to the MD/NP/PA directed staff to provide immediate notification for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change (i/e/more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. The facility failed to monitor the effectiveness of multiple laxative administrations for this resident and failed to follow the facility policy for bowel monitoring, physician orders [REDACTED]. The facility also failed to assess the resident and notify the physician regarding change in condition and constipation for 5 days. This deficient practice placed the resident in Immediate Jeopardy. The facility abated the immediate jeopardy on [DATE] at 4:00 P.M., when they revised the policy for bowel monitoring to include that the director of nursing will review the bowel monitoring report daily to ensure compliance with policy and provide ongoing education as needed and provided in-service education to all nursing staff on the bowel monitoring policy and the interact change in condition policy. This deficient practice remains at the scope and severity of a G.

The facility identified a census of 87 residents. The sampled included 3 residents. Based on interview and record review, the facility failed to notify the physician in a timely manner for 1 of 3 residents included in the sample (#1) when he/she had increasing signs and symptoms of constipation and pain after not having a bowel movement for 5 days. Findings included: - The facility admitted resident #1 on [DATE] with the [DIAGNOSES REDACTED]. The resident's plan of care lacked interventions for the [DIAGNOSES REDACTED]. Review of the ADL Verification Worksheet for bowel monitoring from [DATE] to [DATE] recorded the following: ,[DATE], ,[DATE] and ,[DATE]- 3 days, no bowel movement (BM) ,[DATE], ,[DATE], ,[DATE]- 3 days, no BM ,[DATE], ,[DATE], ,[DATE]- 3 days, no BM ,[DATE], ,[DATE], ,[DATE] and ,[DATE]- 4 days, no BM ,[DATE], ,[DATE] and ,[DATE]- 3 days, no BM ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]- 5 days, no BM until the resident expired The clinical record lacked evidence the staff monitored the resident's bowel sounds during the above time frames. The [DATE] MAH documented the physician order [REDACTED]. Review of the [DATE] MAH revealed staff failed to administer the Milk of Magnesia in September five times when the resident went longer than 3 days between bowel movements. Review of the [DATE] MAH revealed staff administered the Milk of Magnesia on [DATE] at 1:10 P.M. and again at 5:16 P.M., documented at 9:29 P.M. (against the physician's orders [REDACTED]. Nursing note dated [DATE] timed 10:24 A.M. documented the resident complained of lightheaded feeling, skin cool and clammy, feeling nauseous with a small amount of emesis (vomit), and blood pressure of ,[DATE]. Nursing staff notified the primary care physician. The clinical record lacked documentation that staff notified the physician of the resident's constipation and lack of bowel movement for 5 days. Per interview with consultant physician HH on [DATE] at 1:08 P.M., the facility staff did notify him/her the resident had nausea but failed to notify him/her the resident had been constipated and without a BM for five days, and if he/she had been notified of that, he/she would have given additional orders and instruction. The clinical record lacked evidence on [DATE] at 10:24 A.M. the facility followed the physician's orders [REDACTED]. Nursing note dated [DATE] timed 12:06 P.M. recorded the resident continued cool to the touch and clammy, no further emesis at this time, temperature 97 degrees Fahrenheit, pulse 60, respirations 16, and blood pressure ,[DATE]. The clinical record lacked evidence the facility notified the physician of the resident's continued symptoms. Nursing note dated [DATE] timed 1:21 P.M. recorded the resident complained of feeling constipated and staff administered the physician ordered PRN Milk of Magnesia. The clinical record lacked evidence the facility notified the physician. Nursing note dated [DATE] timed 10:05 P.M. documented at 4:25 P.M. the nursing staff administered a rectal suppository for constipation as requested by the resident. The clinical record lacked evidence the facility notified the physician. Nursing note dated [DATE] timed 9:31 P.M. recorded at 5:16 P.M. the staff provided and the resident drank some prune juice. Nursing note dated [DATE] timed 9:22 P.M. recorded at 7:17 P.M. direct care staff called licensed nursing staff to the unresponsive resident's room and initiated cardiopulmonary resuscitation. Nursing note dated [DATE] timed 8:37 P.M. documented the emergency room physician by phone called the resident's time of death [DATE] at 7:47 P.M. in the facility. On [DATE] at 4:44 P.M. licensed nursing staff J reported on [DATE] about 10:26 A.M., the resident was weak, sweaty, blood pressure was low, and the resident complained of aching all over. Licensed nursing staff J reported he/she notified the physician of the resident's change of condition and received orders to continue to monitor and if the resident did not improve to call the physician back. Licensed nursing staff J reported he/she administered pain medication for the resident's complaint of lower back and all-over pain at approximately 12:25 P.M. Licensed nursing staff J revealed he/she gave shift report to the director of nursing and documented on the shift report, as well as giving an oral report to the oncoming licensed nursing staff that the resident had no results from the PRN laxative by 3:00 P.M., staff needed to notify the physician. On [DATE] at 7:30 A.M. licensed nursing staff K reported when staff administered a laxative with the morning medications, expectations were results by 2 P.M., and to notify the resident's physician with no results. On [DATE] at 9:45 A.M. licensed nursing staff I reported the nurse-to-nurse report advised the resident had not had results from the administration of a PRN laxative. Licensed nursing staff I revealed before 5 P.M., he/she administered a rectal suppository for constipation and then shortly after 5 P.M. the resident agreed to drink some warm prune juice with [MEDICATION NAME], which the Physician had ordered PRN, and some Milk of Magnesia. Licensed nursing staff I revealed he/she did not document the medication administrations in the MAH and staff had to enter PRN medications on physician standing orders to the EMAR. Licensed nursing staff I revealed he/she did not call the resident's physician. On [DATE] at 10:22 A.M. direct care staff R reported after breakfast on [DATE], the resident was drenched in sweat, nauseous and did not feel well. The charge nurse reported the resident received Milk of Magnesia and to report if the resident had a bowel movement. On [DATE] at 1:15 P.M. direct care staff U reported on [DATE] after 4 P.M. the charge nurse directed him/her to give the resident prune juice with a scoop of [MEDICATION NAME] and 30 mls of Milk of Magnesia. The charge nurse assisted with administering a rectal suppository for the resident's constipation. Direct care staff U reported at approximately 7 P.M. direct care staff found the resident unresponsive, sitting upright in bed. On [DATE] at 4:25 P.M. direct care staff T reported during the afternoon on [DATE] the resident appeared pale and in pain. The resident asked him/her to tell the nurse he/she had pain in the stomach and wanted to know what the doctor said about the pain in his/her stomach. Direct care staff T revealed he/she reported to the charge nurse and approximately 30 minutes later the nurse reported the resident needed a suppository or enema and the resident agreed. On [DATE] at 3:30 P.M. administrative nursing staff E revealed an oral PRN laxative usually provided results in 35 to 40 minutes and if the medication failed to provide results, staff followed physician standing orders, located at the nursing station. If the PRN medication did not work, staff notified the physician. On [DATE] at 3:30 P.M. consultant physician HH revealed he/she instructed nursing staff to call back if the resident did not improve and he/she did not receive any further calls about the resident on [DATE]. Consultant physician HH reported he/she would have expected the nursing staff to contact him/her again that afternoon about the resident's status if he/she continued to worsen and did not seem any better. On [DATE] at 3:45 P.M. administrative nursing staff D reported licensed nursing staff reported to the physician for laxative orders and report resident's complaint. Administrative nursing staff D directed the staff to call the physician and get an order for [REDACTED]. On [DATE] at 1:08 P.M. consultant physician HH stated the staff nurse contacted him/her the resident had nausea and he/she instructed staff to call him/her back if things changed and to keep an eye on the resident. The nurse never told him/her the resident's constipation. The nurse later told physician HH that he/she did not know at the time of the notification that the resident was constipated and had not had a BM for 5 days, but later looked in the record and that's when he/she told the oncoming nurse to give the resident something for constipation before she left. The staff never called physician HH back. The facility provided undated policy Notification of Change recorded the policy of the facility to inform the physician when there was a change in the resident's condition, a significant change, and a need to alter treatment significantly, or commence a new form of treatment. The facility's policy titled Interact Change in Condition: When to report to the MD/NP/PA directed staff to provide immediate notification for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change (i/e/more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. The facility failed to notify the physician of the resident's continued worsening of symptoms, increased pain and complaint of constipation and no BM for 5 days, after staff administered PRN medications.

The facility identified a census of 87 residents. The sampled included 3 residents who wore monitoring alert devices. Based on observation, record review, and staff interview, the facility failed to provide supervision to prevent 1(#1) resident, of the three sample, from leaving the facility unsupervised. This failure placed the resident in immediate jeopardy. Findings included: - The physician's orders [REDACTED]. The physician progress notes [REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident had short and long term memory impairment and had modified independence with decision making. He/she was independent with Activities of Daily Living (ADL) except needed supervision with dressing and personal hygiene. He/she had Range of Motion (ROM) limitations on both side of his/her legs and feet with a partial loss of voluntary movement. The resident had an unsteady gait, fell in the last 31-180 days, and received Active Range of Motion (AROM) three times weekly. The annual MDS dated [DATE] said the resident used a cane/walker/crutch for assistance with ambulation. The Resident Assessment Protocol (RAP) for cognitive loss dated 11/16/09 said he/she had a [DIAGNOSES REDACTED]. He/she participated in various activities. The Mini Mental assessment dated [DATE] recorded the resident score of 15 out of 30. An interview with licensed staff C on 9/30/10 at 2:20 P.M. said that a score of 27 or greater indicated normal cognition, he/she said a score of 15 indicated there was dementia and a significant cognitive loss. The Elopement Risk assessment dated [DATE] said the resident scored 4. A score of less than less than 8 indicated the resident was not at risk for elopement. The care plan for falls dated 7/22/10 said the resident was at risk for falls due to an unsteady gait, altered mental status and urinary tract infections. Staff assisted the resident with Activities of Daily Living (ADL) as needed, encouraged him/her to ask staff for assistance, kept room free of clutter, redirected the resident as needed and reminded him/her to use the walker. Staff encouraged exercise class five times weekly. The resident received restorative nursing program which included AROM bilaterally to the lower extremities with 1-2 pound weights and Nustep 1-2 times a week for 3-10 minutes each time. Review of the Risk Assessment Record (RAR) noted the resident had two falls in June, 2010. On 6/10/10 the resident stepped backwards and tripped over his/her shoe and fell . No injuries reported. On 6/22/10, the resident reported he/she fell after he/she tripped on the carpet in the resident's room. The resident had two small raised areas to the head. Review of the nurses notes dated 8/15/10 at 3:00 P.M. recorded a Certified Nursing Assistant ( CNA) reported to the nurse the transit bus driver assisted the resident out the front door. The CNA notified the transit driver the resident could not leave the facility unattended. Staff escorted the resident back into the facility without difficulty. The resident told staff he/she wanted a ride to the police station because his/her spouse was there. Staff started 15 minute visual checks on the resident's whereabouts. An interview on 9/28/10 with licensed staff A at 3:30 P.M. said on 8/15/10 the resident left the facility with the transit bus driver. He/she said he/she did not work at the facility that day and did not know if the alarms sounded or not. The resident came back in the facility without problems and staff informed the bus driver that this resident was not to leave the inside of the facility without staff accompaniment. Staff initiated the monitoring system and the 15 minutes visual checks after the incident. According to the Treatment Administration Record (TAR) on on 8/15/10, staff placed a monitoring device on the resident. Staff checked it twice daily for placement and function. The nurses notes dated 9/11/10 at 8:30 P.M. said the Certified Mediation Aide (CMA) called the nurse to the facility front lobby, where a resident, staff and and person stood. The citizen said the resident was wandering on Urish road with his/her walker and was very close to traffic. Fifteen minute checks were implemented at this time. A late entry in the nurses notes said the resident entered the facility at 8:35 P.M. with assistance of staff and the use of his/her walker. No injuries noted. The resident said he/she was looking for his/her sister. The resident was dressed in black short sleeved T-shirt, pink pajama bottoms and house slippers. The clothing was in place with no visible tears or soiling. The monitoring device remained in place. The resident's blood pressure was 138/86 , pulse 92, respirations 24 , temperature 98.9 degrees Farenheit (F) and oxygen saturation was 94% on room air. An interview on 9/28/10 at 12:26 P.M. with the citizen said he/she and spouse traveled south in their automobile on September 11, 2010 at approximately 8:25 P.M.-8:30 P.M., it was dark outside. He/she said a car veered into their lane, they then saw a person walking with a walker north on street that the driver of the car avoided hitting. The citizen said the resident was on street the facility was located on but approximately 10 feet north, if a straight line was drawn from the main door of the facility to the resident. He/she said the resident was on the side of the street because there were no shoulders. They stopped their car to help the resident. The resident told the citizen he/she was scared. The citizen said he/she walked the resident through the grass, down the embankment, to the parking lot and to the facility. He/she said the resident did not come through on the grass because it was difficult to get him/her back to the facility going through the grass with the walker. He/she said the resident must have walked out the door, south on the driveway to the stop sign, then west, and then turned and walked north. He/she said the resident was not injured but was frightened. He/she went in and told staff a resident was outside. Staff came and assisted the resident to the front door but the door remained locked and they were not able to enter until the resident stepped back and then the door opened and they assisted the resident into the facility. He/she said staff was not aware the resident left the facility. An interview with administrative staff D on 9/28/10 at 1:50 P.M. said He/she thought the citizen said the resident was 50 feet from the southwest entry door. He/she said the resident probably traveled at least 300 yards to get to where the citizen said they found him/her. An interview on 9/28/10 at 3:05 P.M. revealed direct care staff A said he/she had assisted a coworker on Hall 1, the hall the resident resided, then walked down the hallway toward the north end of the facility, a person approached him/her and told him/her that they found an elderly resident in pajamas, pushing a walker north on the street the facility was located. Direct care staff A said his/her pager never alerted and he/she was not aware the resident left the facility. He/she said it was dark outside when they assisted the resident back into facility, but the front door would not open until the resident stepped back from the door and then the door opened and staff assisted him/her to the living room. An interview on 9/28/10 at 3:10 P.M. with direct care staff B said he/she worked on the 300 hall and did not know a resident was missing until staff ran to the front door and brought the resident down the hallway. An observation on 9/28/10 revealed the speed limit of the street where the resident was found was 45 miles per hour. The updated care plan dated 9/13/10 said the resident was at risk for elopement due to confusion and agitation. Staff ensured the wanderguard was in place and worked properly every shift. The resident wore the wanderguard to his/her left ankle. Staff monitored his/her position in the facility frequently and when he/she attempted to leave, staff approached the resident in a calm manner and attempted to redirect him/her. Staff observed for signs of increased agitation, such as looking for his/her sister. An observation on 9/28/10 at 9:40 A.M. revealed the resident ambulated in the hallway at a steady pace with the assistance of his/her walker. The monitoring alert device was on the resident's left ankle. Observation on 9/28/10 between 10:30 A.M. through 12:00 P.M. the resident sat in the south living room and watched a movie. On 9/28/10 at 2:00 P.M. the resident sat in the main dining room, petting the animals, smiling and talking to volunteers. An interview with the resident on 9/28/10 at 2:10 P.M. revealed his/her speech rapid and difficult to understand at times due to his/her accent. The resident said he/she was born in Tokyo. He/she said he/she moved into the facility recently and liked it here. The resident said he/she left the facility every day to get clothes and to see his/her sister. Review of the facility investigation received 9/17/10 said that the video tape showed resident #1 approaching the front door and pushing the blue automatic door opener for the disabled. It did not appear his/her wanderguard activated the alarm system, after about 15 seconds the door opened and resident #1 quickly slipped out of the building. An interview with administrative staff B on 9/29/10 at 11:25 A.M. revealed he/she was aware a resident with a monitoring alert device could exit the front door if the resident pushed the blue button for the disabled. He/she said this did not occur with the electrical storm of 9/10/10 but had been this way for "sometime, but not sure how long." He/she said the pager alarm system still worked until he/she thought the door was struck by lightening. Administrative staff B said he/she did not know when the alarm system to the pagers quit working properly but assumed it was because of the recent storm. He/she said the facility normally checked the door alarms/locks with the monitoring alert device weekly but did not check it the week of the elopement and possibly the week before that. He /she also said when he/she checked the door alarms, he/she just pushed the door until they sounded and opened, he/she did not use the pagers to check the doors nor did he check the panel. According to the Administrative B work history report revealed the last time he/she checked the operation of the door monitors and the patient wandering system was 8/26/10. An interview with direct care staff A on 9/29/10 at 2:30 P.M. said that he/she did not know a resident could exit the building without alerting staff simply by pushing on the blue button for the disabled. The facility did not notify nursing staff that the wanderguard did not work properly at the front door, and a resident could exit if the blue handicapped button was pushed which released the magnetic lock. The weather report for Topeka on 9/10/10 at 8:30 P.M. from the National Weather Bureau was temperature of 67 degrees, winds calm, and sunset was at 7:37 P.M. The speed limit on Urish was 45 miles per hour (mph). An interview on 9/28/10 at with direct care staff B said Urish had a lot of traffic and no shoulders. The facility failed to provide supervision for this cognitively impaired, independently mobile resident who left the building without staff's knowledge. The facility staff said the last time anyone reported seeing the resident was about 8:05 P.M. The facility video reported the resident pushed on the handicapped button and exited the building unaccompanied at 8:26 P.M. and returned with the citizens who found him/her at 8:34 P.M. The facility staff was not aware the resident was gone from the building until he/she returned. Review of the corrective action plan, submitted by the facility on 9/29/10 at 4:15 P.M. to the regional office, revealed the following plan of correction: "The inner door leading to the front foyer now requires a security code to enter. Door is alarmed and this establishes two alarmed security doors to exit the front of the building. All residents determined to be an elopement risk will be provided a wanderguard alarm and their picture is placed at each nurse's station and at the front desk. Wanderguard alarms will be tested by nursing staff for each shift and removed from service and replaced on their expiration date. If a resident wearing a wanderguard alarm activates the door alarm system, staff from the north and south nurse's station will immediately respond by reporting to the location designated on the alarm panel/monitor/pager. They will deactivate the alarm and perform a thorough search of the outside area to assure no residents have exited the building. The following inservice training was completed on 9/13/10-by the Director of Nursing (DON), an Elopement Drill was conducted by the DON on 9/17/10, 9/21/10-Inservice training for all staff conducted by Administrator and Assistant Director of Nursing (ADON). Door alarm check system was immediately put in place that required nurses on each shift to check all doors daily to make sure they are properly activated. The Maintenance Director would perform a wanderguard alarm check on the front door and the elevator on Monday and Fridays of each week and after a storm activity around our facility." The facility corrected the immediate jeopardy on 9/21/10 with the implementation of the alarm to the second door to the foyer, the repair to the alarm system, increased monitoring of the doors and alarm system and the education of the staff. The immediate jeopardy was abated on 9/21/10. The scope and severity remained at a "D"level.