Every finding on record at Salem Home

Based on observation and interview, the facility failed to store and prepare food in the main kitchen and kitchenette under sanitary conditions to prevent food borne illnesses. Findings included:- The initial tour of South Kitchen on 06/08/2026 at 08:13 AM with Dietary Staff BB identified the following concerns:The reach-in freezer had built-up frost on three shelves.Two deep freezers had food stuck to the top.The table holding coffee pots and a tea machine had dried-on fluids on the white plastic legs and a buildup of dust on the wooden board behind the table.The side by side two-door refrigerator had food on the bottom and front of the bottom door.There was no trash can by the hand-washing sink.Flour and sugar containers had flour and sugar on top of the lid.The kitchen floor drain had a build-up of an unknown substance. Additionally, the tour of the Kitchenette on 06/08/2026 at 10:04 AM with Dietary Staff BB identified the following concerns:The inside of the microwave had dried food throughout.The trash can had dried food and liquids on the top and sides. On 06/10/2026 at 09:13 AM, Dietary Staff BB confirmed the above findings and reported that the identified areas should be cleaned and food should be stored and prepared in a sanitary condition to prevent foodborne illnesses. The facility policy, Sanitation of Equipment and Supplies, issued 04/2022, documentation included refrigerators shall be cleaned weekly, and freezers shall be cleaned bi-weekly. Kitchen floors shall be sanitized daily at the end of the day.

Based on observation, interview, and record review, the facility failed to provide appropriate activity of daily living (ADL) assistance to Resident (R)3 when staff did not assist him to change his soiled clothing.- R3's Electronic Medical Record (EMR) documented a diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R3's admission Minimum Data Set (MDS), dated [DATE], documented that R3 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. He was dependent on staff for upper-body dressing. R3's Activities of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA), dated 05/13/2026, documented that R3 had limitations in range of motion (ROM) on his left side and required staff assistance with dressing. R3's Care Plan, dated 05/08/2026, instructed staff that he required total staff assistance for dressing. R3's EMR under the Task tab from 05/12/2026 through 06/09/2026 (30 days) revealed R3 required substantial to maximum staff assistance with upper body dressing. On 06/08/2026 at 08:50 AM, Licensed Nurse (LN) G and Certified Medication Aide (CMA) R transferred R3 from his wheelchair to his bed. R3 wore a white T-shirt with food debris and spilled fluids on the front. Staff did not change R3's shirt before leaving the room. On 06/08/2026 at 11:25 AM, the resident sat in the dining room awaiting lunch. He continued to wear the white T-shirt with food debris and dried fluids on the front. On 06/08/2026 at 01:00 PM, CMA R confirmed she had not changed R3's dirty t-shirt before leaving his room and stated staff should change the resident's clothes when they are dirty. On 06/10/2026 at 07:57 AM, Administrative Nurse D stated it was the expectation for staff to change residents' clothes when they became dirty. The facility policy, Activities of Daily Living, reviewed 05/2026, included: The facility shall provide each resident with care and services according to the resident's individualized care plan.

Based on observation, interview, and record review, the facility failed to assess and ensure cognitively impaired Resident (R) 4 ability to safely self-administer medications prior to leaving the medications with the resident to self-administer. Findings included:- R4's Electronic Medical Record (EMR) revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R4's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R4's MDS revealed he was administered an antidepressant (a class of medications used to treat mood disorders) and an opioid (a class of controlled drugs used to treat pain). R4's Cognitive Loss/Dementia, dated 05/27/2026, documented R4's cognition during this lookback period; R4 scored a 10 on his BIMs, indicating moderate impairment. R4's Care Plan, dated 06/03/2025, instructed staff to administer medications as ordered. Monitor/document for side effects and effectiveness. R4's Electronic Medication Administration Record, dated 06/09/2026, documented the following AM medications: Amlodipine (an antihypertensive, a class of medication used to treat high blood pressure) 2.5 milligrams (mg), give 1 tablet by mouth one time a day.Atorvastatin (for atherosclerosis, a buildup of fats, cholesterol, and other substances in and on the artery walls) 20 mg: give 1 tablet by mouth daily. Centrum Adult multivitamin chewable: give 2 gummies by mouth daily. Donepezil 10 mg (for cognition): give 1 tablet by mouth daily. Lexapro 5 mg (an antidepressant): give 1 tablet by mouth daily. Lisinopril 20 mg (antihypertensive): give 1 tablet by mouth daily.Pantoprazole delayed release 40 mg (gastroesophageal reflux {GERD}-backflow of stomach contents to the esophagus), give 1 tablet by mouth daily.Vitamin B12 chewable 1000 micrograms, give 2 gummies, by mouth daily.Calcium carbonate 1000mg chewable (for GERD), give 1 tablet by mouth twice a day. Oxycodone 5 mg (for pain): give 1 tablet by mouth three times a day. Senna oral tablet (for constipation): give 1 tablet by mouth three times a day. Acetaminophen 325 mg tablets (for pain): give 2 tablets by mouth every 6 hours. R4's EMR lacked self-administration of medications.On 06/09/2026 at 08:50 AM, Licensed Nurse (LN) I left two medication cups in R4's room on his stand next to his recliner. LN I reported that R4 did not want her to watch him take his medications and wanted to finish his breakfast. On 06/09/2026 at 08:52 AM, R4 leaned to his right side and picked a pill off the floor as he reported he dropped it and placed the unidentified medication into his mouth. R4 has the chewable medications in one medicine cup and several other medications in the other medication cup. On 06/09/2026 at 09:12 AM, LN I reported that she removed the remainder of R4's medications out of his room as he had not taken them yet and placed them in her medication cart. LN I reported that he had taken himself to the bathroom again as she noted the door was closed. LN I reported that she had left his medications before in his room in the past and had always gone back to make sure he took his medications. She did not feel that R4 was as confused as he used to be. She did not realize that he had dropped a pill and then picked it up and took it. On 06/10/2026 at 01:10 PM, Administrative Nurse D revealed she expected that no medications should be left in residents' rooms that were not care-planned for self-administration. The facility's policy Self-Administration of Medication, dated May 2026, documented that all residents determined to be eligible by their physician, nursing staff, and interdisciplinary team will be offered the option of dispensing their own medication. After eligibility is determined, they will receive full instructions on how to use/take the medications. A licensed nurse will complete the Medication Self-Administration Safety Screen. Partial self-administration will allow resident participation in defined aspects as noted on their care plan. Aspects could include limitations to only certain medications kept at bedside, self-administration of dispensed meds, use of lotions or creams at bedside, etc.

Based on observation, interview, and record review, the facility failed to provide privacy for Residents (R)3 and R5, while staff performed cares in their rooms. Findings included:1. R3's Electronic Medical Record (EMR) documented a diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R3's admission Minimum Data Set (MDS), dated [DATE], documented that R3 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. He was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. R3's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 05/13/2026, documented that R3 required total staff assistance with toileting and transfers. R3's Care Plan instructed staff that he required total assistance with transfers and toileting hygiene. R3's EMR under the Task tab from 05/12/2026 through 06/09/2026 (30 days) revealed R3 was always incontinent of urine and required total assistance of staff for toileting hygiene. On 06/09/2026 at 08:34 AM, Certified Nurse Aide (CNA) N and CNA P performed peri-care (the cleansing of genitals) with R3 as he lay on his bed, naked from the waist down. The blinds to the windows, which looked out over the courtyard, were open during the cares. On 06/09/2026 at 08:34 AM, CNA P stated the staff does not typically close the resident's blinds while performing cares in R3's room. 2. R5's EMR documented a diagnosis of cerebral infarction. R5's admission MDS dated 05/11/2026 documented R5 had a BIMS score of nine, indicating moderately impaired cognition. She was always incontinent of bowel and bladder and required total staff assistance with toileting hygiene. R5's Urinary Incontinence and Indwelling CAA dated 05/11/2026, documented R5 required total staff assistance with toileting hygiene. R5's Care Plan, dated 05/08/2026, instructed staff that R5 was dependent on staff for toileting hygiene. R5's EMR under the Task tab from 05/12/2026 through 06/09/2026 (30 days) revealed R5 was always incontinent of urine and required total assistance of staff for toileting hygiene. On 06/09/2026 at 08:00 AM, CNA N and CNA P performed peri-care with R5 as she lay on her bed, naked from the waist down. CNA P exited R5's room and re-entered the room by opening and closing the door, exposing R5 to staff, other residents, and workmen who were in the hall directly outside the resident's room. Staff did not cover R5 as CNA P exited and re-entered the room. On 06/09/2026 at 08:00 AM, CNA P confirmed she had exited and re-entered R5's room while she lay naked from the waist down on her bed. On 06/10/2026 at 07:51 AM, Licensed Nurse (LN) G stated the staff should cover the residents while giving care in order to prevent exposing them to others in the hall. On 06/10/2026 at 07:57 AM, Administrative Nurse D stated the staff should ensure the resident's privacy was protected by covering them when they exit and re-enter the resident's room. The facility policy Resident Rights, reviewed 01/2026, included: Each resident in the facility shall have the right and shall be afforded the right to a dignified existence.

Based on interviews, observation, and record review, the facility failed to provide Resident (R) 17 with a bilevel positive airway pressure (BiPAP- a noninvasive ventilator that helps breathing) as per physician orders. Findings included:- R17's Electronic Medical Record (EMR) revealed diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations) and Friedreich ataxia (a rare, inherited, progressive neuromuscular disease that damages the nervous system). R17's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. Total severity score of 0, indicating no depression. No behaviors noted. The resident required total staff dependence with bed mobility. R17's MDS documented that he had a non-invasive mechanical ventilator. R17's Functional Care Area Assessment (CAA), dated 08/19/2025, documented: R17 was admitted following a hospitalization for ankle pain and lack of a caregiver at home. R17 does have a diagnosis of Friedreich's ataxia, which is a progressive neurological disorder. The resident requires substantial/maximal to total assistance with all activities of daily living (ADLs). The goal is for R17 to improve independence and ADL abilities through the next review date. R17's Care Plan, dated 08/20/2025, instructed staff to ensure the BiPAP mask fits appropriately and that there are no other devices present underneath the mask. Lift and reposition the mask when able. R17's Care Plan, dated 08/20/2025, instructed staff to assist with applying the BiPAP mask and turning BiPAP on and off. R17's Physician Orders, documented May wear BiPAP at present settings. Staff to assist with applying at bedtime related to obstructive sleep apnea, date ordered 08/06/2025. R17's Progress Note, dated 05/10/2026 at 01:51 AM, documented that R17 voiced his BiPAP was broken tonight and needs it to be looked at, but voiced he has worn it for the last four nights, email sent to human resources. R17's Orders - Administration Note, dated 05/12/2026 at 09:50 PM, documented that R17 reported that the BiPAP equipment fell and broke. R17's Orders - Administration Note, dated 05/15/2026 at 12:06 AM, documented that R17 reported that the BiPAP equipment was broken. R17's Orders - Administration Note, dated 05/15/2026 at 11:42 PM, documented that R17 reported that the BiPAP equipment was broken. R17's Progress Note, dated 05/18/2026 at 04:25 PM, documented that staff spoke with R17 about his BiPAP not working and needing to call to get it fixed. R17 said that he had the number on his phone and that he would call them. R17's Orders - Administration Note, dated 05/18/2026 at 09:58 PM, documented the call number on BiPAP and informed the company that he had dropped/broken his machine. No contact information was found on the machine. R17's Orders - Administration Note, dated 05/22/2026 at 08:37 AM, documented a call to inform them that R17 had dropped/broken his BiPAP. The number to call is [redacted]. This nurse called and left a detailed message with a callback number. R17's Orders - Administration Note, dated 05/23/2026 through 06/09/2026, documented that BiPAP was not working and was waiting for repair.R17's EMR lacked any further documentation to contact the company that supplied the BiPAP. R17's EMR lacked documentation that the provider was updated that R17's BiPAP was not working from 05/10/2026 through 06/09/2026. On 06/10/2026 at 07:53 AM, R17 exited his room in his power chair, heading to the dining room. R17 reported that his BiPAP machine fell to the floor about a month ago, and he had called the number on the machine and was unable to get in contact with anyone. On 06/10/2026 at 07:59 AM, Licensed Nurse (LN) G reported that R17's BiPAP machine had been broken for about a month now. LN G reported that she did call a number and left a message on 05/21/2026 but had not heard back and reported that maybe Administrative Nurse D had heard back. LN G reported she was unsure if the provider was aware that R17's BiPAP was not working. On 06/10/2026 at 09:25 AM, Administrative Nurse D reported that she was aware that R17's BiPAP was not working and that the staff had called the company several times. She revealed the facility had not heard back from them. Administrative Nurse D reported that the provider was probably updated verbally of R17's BiPAP being broken and not able to use. Administrative Nurse D confirmed that the EMR lacked documentation of the company being called several times and that the provider was notified. The facility's policy BiPAP dated 05/2026 documented all use of BiPAP required specific physician orders and the ordered level of air pressure to keep the airway open during sleep may not be changed without consulting the ordering physician with resultant change in settings orders.

Based on interviews, observation and record review, the facility failed to implement adequate infection control practices related to respiratory equipment for Resident (R) 17 and hand hygiene during incontinence care for R7. Findings included:1. On 06/08/2026 at 09:49 AM, R17 was in his room in bed. His bilevel positive airway pressure (BiPAP- a noninvasive ventilator that helps breathing) mask lay directly on the floor on the left side of his bed. R17 reported that he has no place to put the BiPAP mask when he takes it off. On 06/09/2026 at 08:20 AM, R17's BIPAP mask was noted on the floor next to his bed. On 06/10/2026 at 07:55 AM, Certified Nurse Aide (CNA) L reported that she does not do anything with the BiPAP machines; the Certified Medication Aides and Licensed Nurses (LN) take care of them. CNA L reported the mask should not be on the floor, though. On 06/10/2026 at 07:59 AM, LN G reported that R17's BiPAP machine had been broken for about a month now. LN G reported that the mask should not be on the floor, that is should be placed in a bag, and reported that since he has not worn the BiPAP, the staff probably have not noticed the mask on the floor. LN G verified there was no bag in his room to place the mask. 2. On 06/09/2026 at 01:07 PM, CNA L provided R7 with incontinent care with the assistance of CNA LL. R7 was assisted with the removal of his soiled brief of urine and bowel movement by CNA L. She removed her gloves, washed her hands, and applied new gloves. CNA LL handed CNA L the cleansing wipes. CNA L wiped the bowel movement off R7's buttocks. CNA L did not perform hand hygiene and used the same gloves to cleanse R7's urinary meatus and groin. On 06/09/2026 at 01:22 PM, CNA L reported that she should have cleansed R7 better on his front private area she then reported that she should have removed her gloves, performed hand hygiene, and applied new gloves after she cleansed the buttocks that had bowel movement them before she cleansed his front. On 06/09/2026 at 01:24 PM, LN I reported that the staff should cleanse the front of the resident's peri area completely before they wash the buttocks, she reported that the staff should remove the gloves and perform hand hygiene before cleansing the peri area after cleansing the bowel movement from a resident. On 06/10/2026 at 09:50 AM, Administrative Nurse E (Infection Preventionist) reported that she expected the staff to remove gloves and wash hands prior to cleansing the resident's peri area after they cleansed the bowel movement from the buttocks. Administrative Nurse E reported that the mask from a BIPAP should be placed in a bag when not in use, and being on the floor was not acceptable. The facility's policy BiPAP dated May 2026 documented in the morning, clean mask or pillows. Perform daily cleaning of the apparatus. Do not clean any parts of the system with alcohol, cleaning solutions containing alcohol, bleach, or any strong sanitization chemicals. Allow masks or pillows to air dry on a clean barrier. The facility's policy Incontinent Care dated May 2026 documented that when a resident is found to be incontinent of urine or bowel, direct care staff will provide incontinence care using standard precautions and cleansing wipes to cleanse the perineal area and replace the incontinence containment product. The facility's policy Infection Control, dated January 2026, documented that all staff have a responsible for following hand hygiene protocols of this facility and are able to demonstrate competency in hand hygiene annually.

Based on interview and record review the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services necessary to care for residents' needs related to provision of enteral tube feeding and medication administration via percutaneous enteral epigastric tube feeding (PEG tube-external device inserted in the abdomen to deliver nutrition, hydration, and/or medication directly to the stomach). Findings included: - Resident (R) 7's undated physician's order (POS) documented diagnoses which included cerebral vascular accident (CVA-stroke due to interrupted blood flow to the brain), hemiplegia (paralysis of one side of the body), dysphagia (impaired ability to swallow), and dementia (decline in mental abilities severe enough to interfere with daily life). R7's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of seven, indicating severe cognitive impairment. The resident was dependent on staff for total assistance with eating. He had a feeding tube for nourishment / hydration and medication administration and received nothing by mouth (NPO). The Feeding Tube Care Area Assessment (CAA) dated 09/22/2025, documentation included R7, had a feeding tube related to the diagnosis of dysphagia following a CVA. His only source of nutrition/hydration was via a PEG tube. The goal is for R7 to remain free from complications. R7's Care Plan documentation initiated 11/30/2021, included guidance to staff as follows:R7 was dependent on a tube for feeding and water flushes.Administer medications via PEG tube.Monitor/document/report symptoms of aspiration, which include fever and/or shortness of breath, tube dislodgement, infection at tube site, removal of tube by resident, tube dysfunction or malfunction, abnormal breath/lung sounds, normal lab values, abdominal pain, distension, tenderness, diarrhea, nausea/vomiting, and dehydration.Provide local care to the PEG site as ordered and monitor for signs and symptoms of infection.R7's Medication Administration Record/Treatment Administration Record (MAR/TAR) for 05/01/2026 through 06/09/2026 was documented on 05/07/2026 at 07:00 AM. Certified Medication Aide (CMA) T administered R7's tube feeding and her medications via PEG. R7's MAR/TAR for 05/01/2026 through 06/09/2026 documented CMA S administered R7's tube feeding and her medications via PEG on 05/08/2026, 06/01/2026 and 06/04/2026 at 08:00 PM. Review of five CMA training/competencies documentation and/or administering tube feedings and/or medications revealed CMA T's most recent annual competency/skill check-off for administering PEG feeding and/or medications via PEG was on 11/05/2024 (seven months overdue). CMA S's most recent annual competency/skill check-off for administering PEG feeding and/or medications via PEG was on 03/04/2025 (three months overdue). On 06/08/2026 at 02:03 PM, Certified Medication Aide (CMA) RR reported that she administers medications and enteral feedings to R7. She reported she had completed a competency check-off but could not remember when. On 06/08/2026 at 01:50 PM, Licensed Nurse (N) G reported that R7 was not due for her tube feeding until 05:00 PM. LN G stated the CMAs administered the tube feeding and medications for R7. On 06/09/2026 at 03:20 PM, Social Service Staff X reviewed the five selected CMA's files for their competencies for administering medications and enteral feeding via PEG. She confirmed that of the five reviewed, CMA T and CMA S lacked annual competency and skills check-off as expected, and confirmed that CMA T and CMA S had administered tube feedings and medications to R7 past the required annual competency requirement. On 06/10/2026 at 09:25 AM, Administrative Nurse D reported she expected the CMAs to have annual competency completed for the delegated tasks assigned to them by the nurse. She reported that they had hired a nurse to complete staff education, but that it did not work out. She confirmed that two of the five CMAs that were reviewed did not have a current competency to administer medications and enteral feeding. The 05/2026 facility policy titled Required Training/In-services and Evaluation of CNAs/CMAs documentation included that all employees directly employed at this facility are required to demonstrate competency to complete work assignments prior to providing care to any resident in the facility. In-service training classes are conducted to provide employees with information concerning their position, methods, and procedures to follow in implementing assigned duties, and to provide up-to-date information that may assist the employee, as well as the organization, in providing quality health care to the residents. The facility Director of Nursing defines the competencies required of the staff providing care, treatment, and services related to techniques, procedures, technology, equipment, and skills required to provide the elders served with care, treatment, and services.

Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuge properly in a closed dumpster to prevent pests and odors, and related contamination. Findings included:- During the initial kitchen tour on 06/10/2026 at 09:13 AM, three dumpsters had piled, bagged trash which prevented the lids from closing and securing the garbage and refuge. On 06/10/2026 at 09:13 AM, Dietary Staff BB confirmed the dumpster lids were open and should be closed to contain trash and debris. The facility policy, titled Dumpster Policy, issued 05/2024, included dumpster lids must be closed after each use to help control pests, odors, and weather-related contamination.

The facility reported a census of 44 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel. Findings included: - Review of the PBJ Staffing Data Report for Fiscal Year (FY) for Quarter 3 - 2023 (April 1 - June 30), the data indicated the facility failed to have Licensed Nursing Coverage 24 hours/Day on the following dates: 04/01/23 Saturday (SA), 04/09/23 Sunday (SU), 04/16/23 (SU), 04/29/23 (SA) and 05/13/23 (SA). Review of the nursing schedule and payroll data sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage. On 08/07/24 at 08:24 AM, Administrative Nurse D reported that payroll data and scheduling data reflected that 24- hour nursing coverage and that nursing staff were scheduled for either eight-hour or 12-hour shifts where no lunch was taken but the PBJ submission deducted a 30-minute period for lunch. The facility's Mandatory Submission of PBJ policy, dated 05/2024, documented that the facility would complete electronic and accurate submission of staffing information based on payroll data as specified in regulatory requirements. The facility failed to submit complete and accurate staffing information to the Federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all nursing personnel.

The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. Findings included: - Observation on 08/06/24 at 10:45 AM, revealed room trays for residents set with beverages. Two trays contained a glass of milk, and one contained a liquid nutritional supplement in a glass. Observation, on 08/06/24 at 11:15 AM, revealed Dietary Staff DD, obtained the temperature a glass of milk on the tray and revealed a temperature of 60 degrees Fahrenheit (F). Dietary Staff DD stated the milk should be served at 41 degrees F, and the supplier delivered the milk earlier and may not have cooled down to 41 degrees F. Dietary Staff DD obtained two new glasses of milk from newly delivered milk from the refrigerator and revealed a temperature of 48 degrees F. Dietary Staff DD obtained the temperature of the nutritional supplement and revealed a temperature of 57 degrees F. Dietary Staff DD obtained a new nutritional supplement which had a temperature of 57 degrees F and stated the temperature should be 41 degrees and obtained a new nutritional supplement from the refrigerator which had a temperature of 42 degrees F. Dietary Staff DD stated the trays were usually set up 30 minutes before serving. Observation, on 08/06/24 at 11:20 AM, revealed Dietary Staff CC prepared to serve the residents their noon meal with dishware that contained worn colors and faded designs. Dietary Staff CC stated the entire service ware which included plates and bowls contained faded designs and worn areas. Observation, on 08/07/24 at 08:45 AM, during the environmental tour of the kitchen revealed the following areas of concern: 1. Three air vents and ceiling above the stove area contained a black substance over multiple areas of various sizes. Interview with Dietary Staff BB, confirmed the areas and stated maintenance was responsible for cleaning the vents and ceiling. Interview with Maintenance staff U, revealed dietary staff was responsible for cleaning the vents and ceiling. Maintenance Staff U scrubbed the black areas and thought the substance may be accumulation of dust and grease. 2. The front surface of a wooden cabinet drawers which contained serving items, contained peeling varnish and a liquid stain. The serving items (four spatulas and two pizza wheels) contained brown/black substance in the surface grooves. The doors of the cabinet also contained areas of worn varnish and the inside shelves, which contained various service items, contained shelves with a black substance in the wood grain and peeling varnish. 3.The shelf beneath the double ovens contained grime and debris. 4. Two omelet pans contained a black substance around the interior sides. 5.The ice machine drain lay directly in the sewer drain in the basement. Maintenance staff U confirmed the drain was for the ice machine and should provide a two-inch air gap for the drain. Interview, on 08/07/24 at 08:45 AM, with Dietary Staff BB, revealed the milk delivered to the facility on [DATE] should be refrigerated immediately and staff should set the milk on the trays just before distribution to ensure a temperature of at 41 degrees F. Dietary Staff BB confirmed the entire set of dishware was worn with faded colors and pattern. Interview, on 08/07/24 at 12:00 PM, with Administrative Staff A, confirmed the worn dishware patterns on the entire set, and confirmed the dishware should be replaced. The facility did not provide a policy for food temperatures prior to serving. The facility policy Sanitation and Safety dated May 2024, instructed staff to maintain acceptable sanitary conditions in storage, preparation, and distribution of foods. The facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents.

The facility census totaled 44 residents on two halls with a commons area where residents gathered for meals and activities. The facility had two medication carts and a nurse treatment cart. Based on observation, interview, and record review, the facility failed to provide a safe environment for nine residents by the failure to ensure a nurse treatment cart that contained insulin (a medication used to treat diabetes [a disease when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin]) remained locked when not in direct line of vision of the nurse. Findings included: - On 08/06/24 at 11:19 AM, a treatment cart on the 200 hall observed unlocked and unattended. On 08/06/24 at 11:20 AM, Licensed Nurse (LN) G confirmed the medication cart was left unattended and unlocked. LN G further confirmed that the cart serviced nine residents and contained insulin and general wound care supplies. LN G revealed that the medication cart should be always locked when unattended and stated that she failed to lock the medication cart before going the nurses' station. LN G identified two self-mobile and confused residents who lived in the 200 hall. On 08/06/24 at 11:25 AM, Administrative Nurse D stated the expectation was for all staff who have access to medication carts to lock the medication carts before walking away. The facility's Medication Administration Policy policy, dated 06/2024, documented that medication carts, including the nurse treatment carts, are to be locked when not in the direct line of sight of medical personnel. The facility failed to provide a safe environment for all residents by the failure to ensure a medication cart used by the facility remained locked when not in direct line of vision of the licensed nurse passing medications from their carts.

The facility reported a census of 44 residents. The facility identified two residents required pureed diets. Based on observation, interview, and record review, the facility failed to ensure pureed foods were prepared to ensure nutritional and flavor compatibility with the menu to enhance the dining experience for these two residents. Findings included: - Observation, on 08/06/24 at 10:45 AM revealed Dietary Staff CC prepared pureed diet for two residents. The menu for the noon meal included beef soft taco with lettuce, cheese, tomato, sour cream, spanish rice, and fiesta corn. Dietary staff CC stated the facility form Mechanically Soft Level Two Diet indicated that staff should avoid corn or regular rice, so she substituted mashed beans (pork and beans) for the corn and mashed potatoes and gravy for the fiesta rice. Dietary staff CC stated she did not have a nutritionally equivalent substitute guide for the spanish rice or fiesta corn for pureed diets. Interview, on 08/07/24 at 09:00 AM, with Dietary Staff BB confirmed that the facility had a computerized program for dietary substitutes but did not routinely use a pureed diet guide other than the posted Mechanically Soft (Level 2) Diet and a regular menu. Interview, on 08/07/24 at 09:30 AM, with Dietary Consultant GG, revealed the substitute for corn included pureed cream corn, and the fiesta rice included cream of rice, and various recipes for pureed rice. Dietary Consultant GG stated if foods are substituted, they should be nutritionally appropriate substitutes for pureed foods, and would provide the facility with the guidelines/menus. The facility guideline 4 Pureed dated January 2019, contained a list of foods to avoid and characteristics to avoid. The guide instructed the reader/staff to consult with a health care professional for specific advice for diet needs and the list was intended for general information only. The facility policy Blended and Pureed Meat Diets dated February 2023, instructed staff to follow the the regular menu and provide the consistency modification as ordered by the physician. The facility failed to provide pureed food substitutes nutritionally and with flavor compatibility with the menu to enhance the dining experience for two residents that required a pureed diet.

The facility had a census of 42 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide adequate supervision for Resident (R) 4 who was independent with ambulation and required staff supervision for safety due to a diagnosis of schizoaffective (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations [perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there] or delusions [altered reality that is persistently held despite evidence or agreement to the contrary], and mood disorder symptoms, such as depression [persistent feeling of sadness and loss of interest] or mania [abnormally elevated, extreme changes in your mood or emotions, energy level or activity level]) disorder, intellectual disabilities, and a personal history of physical, sexual, and psychological trauma. The resident's care plan directed R4 should not be allowed to leave the facility without supervision and was to be protected from any interaction with specific individuals. On 08/15/22 at 09:30 PM staff observed R4 in the common area of the facility. At approximately 10:06 PM the county Sheriff's Office notified facility staff that R4 was in police custody. R4 left the facility without staff awareness and supervision and walked nine blocks through town to the gas station. R4 called 911 and reported she left the facility without telling anyone. Police returned R4 to the facility. R4's face was flushed and R4 was upset. R4 reported she punched the code in the door and since no one saw her, she kept walking. Facility staff failed to provide adequate supervision to prevent an elopement (when a resident leaves the facility without staff knowledge and/or supervision) and failed to identify the resident was not in the facility until reported by law enforcement. This placed R4 in Immediate Jeopardy. Findings included: - R4's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder bipolar (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), intellectual disabilities, and a personal history of physical and psychological trauma. R4's Annual Minimum Data Set (MDS) dated [DATE] recorded R4 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS recorded R4 admitted to the facility on [DATE] from a psychiatric hospital. The MDS recorded R4 had no behaviors or wandering during the look back period. She required supervision with set up help from staff for locomotion on and off the unit, supervision with assistance of one staff for personal hygiene; she required supervision with no physical assistance for all other activities of daily living (ADL). The MDS recorded R4 had medically complex conditions and referenced her diagnosis of schizoaffective disorder. The MDS documented R4 had psychiatric /mood disorders of anxiety and schizophrenia (e.g., schizoaffective) disorder. The MDS recorded the resident received scheduled pain medication and was a current tobacco user. The MDS recorded no falls. R4 received antipsychotic medications (medications for psychotic disorder) daily during the look back period. The MDS documented R4 had no active plan to discharge into the community. Review of R4's 'Wandering/Elopement Risk Assessment revealed on 01/26/22 R4 received a score of nine which indicated she was at risk for wandering/elopement. The assessment indicated that a score between zero and eight indicated low risk for wandering/elopement. R4 assessment revealed a low risk for wandering/elopement on 03/12/22 (4), 03/30/22 (2), 06/30/22 (4) and again after the elopement event on 08/16/22 (8). R4's Care Plan dated 07/01/21 recorded R4 had a past traumatic event or experience of abuse (sexual), severe human suffering (pregnancy through sexual assault with subsequent adoption of child that was conceived), and sexual assault (sex trafficking by her father). The care plan directed staff R4 should have no contact with her father an dR4 should not leave the facility with any family without the guardian's consent. The care plan further directed staff to redirect R4 if she reached out to others in an inappropriate way (wanting to cuddle or offering sex or to show them her body. It further directed staff that due to R4's sexual trauma, R4 may reach out in a sexual way and desire that kind of attention from others; the care plan directed staff to remind R4 to respect her body and to also respect other's bodies. R4's Care Plan revised on 10/05/21 documented R4 had a diagnosis of schizoaffective disorder and anxiety. She enjoyed visiting with staff and sought desired staff members for 1:1. The care plan directed staff R4's physician and guardian felt it was in R4's best interest not to have visits or phone calls from her father due to allegation for sex trafficking. The care plan directed staff to monitor and record occurrences of pacing, wandering, disrobing, inappropriate response to verbal communications, and violence and/or aggression towards staff or others. R4's Care Plan dated 11/20/21 (and revised only after the event on 08/16/22) documented R4 was at risk for elopement. It directed staff to perform frequent visual checks to verify R4's location and safety. It further instructed R4 had a Wanderguard (a device that is used to alert staff when a resident is near an exit door) on her right wrist. Interventions were added on 08/16/22 after the elopement which directed staff to perform hourly visual checks for two weeks and remind R4 not to leave the facility without supervision and to remind R4 she was not to leave the facility without supervision. On 11/20/2021 at 04:50 PM a Plan of Care Note Late Entry recorded R4 approached the nurse and stated she (R4) was leaving to go walk around town and find a job. R4 had her coat on, and her book bag. Staff informed R4 that the businesses were not open on Saturdays and that she cannot leave facility on her own. R4 then returned to her room. Staff applied a Wanderguard to R4 at that time and placed R4 on 30-minute visual checks as well. On 03/12/22 at 05:56 PM the Nurses Notes documented R4 cut off her Wanderguard bracelet. R4 stated to staff the bracelet smelled bad. Staff noted the metal clasp on the bracelet had irritated the back of R4's right hand, Staff reassessed R4 and noted R4 was no longer at risk to wander as she had not wandered in the previous six months and did not try to leave without assistance. On 08/15/22 at 10:21 PM the Nurses Notes documented the County Sheriff called the facility on the phone and stated they had R4 in their custody. R4 had called 911 from the convenience store and informed them she had left the facility without anyone knowing. The County [NAME] reported to the facility they were in route back to the facility. Staff notified the (unidentified)on-call nurse who came to the facility and provided one to one supervision for R4. On 8/15/2022 at 10:54 PM a Health Status Note documented R4 was last seen by the Certified Medication Aid at 09:30 when the CMA gave R4 water from the kitchenette that R4 requested. The note further recorded the (unidentified) CMA and Certified Nurse Aid (CNA) were putting a resident to bed. The police officer was just leaving at that time. R4 sat on the recliner, sweating and her face was red. R4 wore a long sleeve shirt, long pants, and purple tennis shoes. R4 was upset and stated she left because no one wanted her at the facility and people were blaming her for everything. Staff told R4 that staff wanted to keep R4 safe and asked R4 if she was safe when she left. The note recorded R4 stated she did not feel safe and was scared and asked the police officer to bring her back to the facility. R4 stated that she punched the code in the door to get out and no one saw her, so she left and kept walking. The note documented R4 did not have a wanderguard on; R4 stated that she had taken it off at some point. R4 stated the staff member was her friend and she knew staff wanted her to stay; R4 stated that she was sorry and knew she should not have left. R4 stated that she would not leave again. Staff placed a Wanderguard on R4's wrist and dated it. The charge nurse assessed R4's vital signs and R4 had calmed down, stopped sweating, and her face went back to normal color. R4 rested in bed with a Wanderguard in place. The note recorded the CNAs were educated to do frequent visual checks along with the charge nurse. Staff notified the director of nursing, the physician and Administrative Staff A was notified by Administrative Nurse D. The note further recorded R4 had no new issues, no injuries and had no interactions other than with the employee at the convenience store and the police officer that brought her back to the facility. On 08/16/2022 01:59 PM a Health Status Note Late Entry recorded R4 was educated that she may not leave the facility without supervision. She verbalized understanding. The note further recorded R4 was placed on frequent visual checksR4's Conservator asked if R4 could ride along with the transportation driver one day a week as that might help R4 with her continued feeling of needing to leave the facility. On 08/16/2022 at 04:35 PM a Psychosocial Note Late Entry recorded Social Services X spoke to R4 about R4's elopement. R4 stated that a family member of another resident kept telling her to leave; the note also noted Social Services X was unable to confirm or deny this. The note documented R4 stated that she knew that she should not have done that. The note further recorded Social Services X asked R4 if she realized that bad things could have happened to her and R4 said yes and that she will not be leaving by herself anymore. A Witness Statement dated 08/18/22 from CNA P noted the last time CNA P saw R4 on 08/15/22 was at 08:00 PM when R4 sat in the chairs in the nursing place. The statement recorded CNA P left the facility at 09:00 PM on Monday. A Witness Statement dated 08/19/22 from CNA Q recorded CNA Q saw R4 at 09:00 PM outside smoking and then again at 09:30 PM in the sitting area. A Witness Statement dated 08/19/22 from CNA M recorded CNA M saw R4 in bed reading a book at 09:10 PM. A Witness Statement dated 08/18/22 from CNA N recorded on 08/15/22 around 09:00 PM CNA Q, CMA R and CNA N went outside to the courtyard to smoke and took R4 out with them to smoke. Around 09:15 PM, the staff members went back inside and Licensed Nurse (LN) H came outside and smoked and sat with R4. Around 09:25 PM both R4 and LN H went inside. CNA N sat by the nurse's station and charted. CNA N noted at 09:35 PM she last saw R4 in a recliner by the nurse's station. A Witness Statement dated 08/19/22 from CMA R recorded CMA R saw R4 at 09:30 PM when R4 asked CMA R for fresh water. CMA R filled R4's cup and R4 left the area. CMA R saw R4 again when R4 reentered the building around 10:00 PM. On 12/07/22 at 10:30AM, observation revealed R4 laid on her bed in her room. On 12/08/22 at 07:00 AM observation revealed the convenience store R4 walked to was nine blocks away from the facility. There area did have sidewalks. There was a four way stop with a flashing red light on the way to the convenience store from the facility. On 12/08/22 at 09:00 AM review of Wunderground.com revealed the temperature on 08/15/22 between 09:30 and 10:00 PM was 87 degrees Fahrenheit. On 12/8/22 9:30AM, Administrative Staff A verified R4 does require frequent one on one from staff and is an elopement risk. Administrative Staff A reported the door code was posted at the door as required by the state Fire Marshall. Administrative Staff A reported that R4 was assessed and found not to be at risk for elopement, so her Wanderguard had been removed. He stated that staff were unable to watch the residnet 24 hours a day. The facility's Elopement policy, dated 12/2021, states to ensure the safety of those residents who have been identified as being at risk for elopement. It is the policy of this facility to identify those residents at risk for elopement and take precautions to ensure their safety and well-being. A Wanderguard door locking system is provided. Upon admit each resident is assessed for the potential for elopement risk. Consideration will be given to the residents prior to history of wandering, impaired decision making or impaired cognition. All other residents will be accounted for at least every two hours. All exit doors are alarmed with audible alerts, In the case of a door alarm sounding, staff will immediately go to the door indicated on the enunciator system and check both inside and outside the door to determine who/why the door alarm sounded. Facility staff failed to provide adequate supervision to prevent an elopement and failed to identify the residnet was not in the facility until reported by law enforcement. This placed R4 in Immediate Jeopardy. 1. On 08/16/22 the facility completed the following corrections: 2. Staff reassessed R4 as a low risk for elopement and placed a Wanderguard on R4. 3. CNA and nurse staff were educated to do frequent visual checks on R4; R4 placed on hourly checks. 4. Wanderguard devices on all elopement risk residents were assessed for function. All residents were reassessed for risk for wander and appropriate actions were implemented. 5. Staff received education on Elopement policy and procedures. 6. The door code was changed and posted higher in effort to prevent R4 from reading and exiting again. 7. Facility staff coordinated so R4 could ride along with the transportation CNA one time weekly to assist R4 with her continued feeling of need to leave the facility. The deficient practice was cited as past non-compliance.

The facility had a census of 42 residents. The sample included 13 residents of which one reviewed for dignity. Based on observation, record review and interviews, the facility failed to ensure Resident (R)21 was treated with respect and dignity and cared for in a manner that promotes quality of life. This placed R21 at risk for impaired psychosocial well-being. Findings included: - R21's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition and received daily insulin (a medication used for high blood sugar given by an injection). On 12/08/22 at 11:25AM, observation revealed R21 sat in his wheelchair at the dining table. Further observation revealed 23 other facility residents also sat in the dining room. R21 lifted up his shirt and exposed his abdomen and his right side and Licensed Nurse (LN) G administered a Novolog (insulin medication) injection at the table. On 12/08/22 at 11:35AM, LN G stated she always gave R21 his insulin in the dining room at the table. LN G then stated I guess I could have taken him to a more private area to administer the insulin. On 12/13/22 at 9:20AM, Administrative Nurse (AN) D verified administering R21's insulin at the dining table was inappropriate and R21 should have been taken to a private area to administer the insulin. The facility's undated Resident Rights policy stated each resident in the facility is to be treated with respect and dignity. The facility failed to provide dignity for R21, placing the resident at risk for an undignified experience.

The facility reported a census of 41, including three residents reviewed for accidents. Based on observations, interviews, and record review, the facility failed to ensure the safety of one Resident (R)1, of the three sampled residents when Certified Nurse Aide (CNA) M failed to supervise the resident while in the whirlpool room by turning around to gather supplies and staff further failed to use the safety belt while giving R1 a whirlpool bath. These failures resulted in R1 falling out of the whirlpool chair, onto the floor, and as a result of the fall the resident sustained a left [CONDITION(S)]. Findings included: - The Physician Order Sheet (POS), dated 05/19/22, revealed R1 with a diagnosis of [CONDITION(S)] with behavior disturbance (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The resident required two-person extensive assistance for bed mobility and toileting. The resident required total dependence on staff for transfers and total dependence for bathing. The resident was not steady without staff assistance. The Cognitive Loss/Dementia Loss Care Area Assessment (CAA), dated 08/31/21, documented the contributing factors of [CONDITION(S)] and inability to make her needs known. The Fall CAA dated 08/31/21, documented the resident required assistance with Activities of Daily Living (ADLs) for transfers. The resident used a wheelchair for mobility. The Quarterly MDS dated [DATE], documented the resident had a BIMS score of 0. The resident required two-person extensive assistance for transfers. The resident required one-person total dependence on staff for bathing. The resident's balance was not steady without staff assistance. The Cognition Care Plan, dated 02/11/22, documented the resident was alert and oriented to person only. She required one-person total assistance with bathing twice a week and required two-person extensive assist with transfers. The Safety Care Plan, dated 01/26/22, guided staff that the resident was at risk for falls, had impaired mobility, had impaired cognition, required medications, had comorbid conditions, and a history of falls. Staff should ensure the resident wore appropriate footwear (gripper socks or shoes) while transferring. The resident required two-staff with cares. One Certified Nurse Aide should stay with the resident while the other Certified Nurse Aide gathered supplies. On 02/09/22, the [NAME] Fall Risk Assessment scored 13, which indicated a high risk for falls. On 04/20/22, the [NAME] Fall Risk Assessment scored 13, which indicated high risk for falls. Review of nurses notes on 04/07/22 at 08:00 PM, revealed Certified Nurse Aide (CNA) M gave R1 a whirlpool bath and transferred the resident out of the whirlpool with the whirlpool chair. CNA M turned around to get the body lotion behind her when R1 leaned forward in the whirlpool chair and fell forward out of the whirlpool chair. CNA M failed to secure the whirlpool seatbelt. The assessment revealed the resident had a two-inch bruise on her left hip. Three staff assisted the resident with a mechanical lift and transferred the resident to her bed. The resident complained of pain and burning in the left hip with the transfer. The resident transferred to the hospital. On 04/08/22 review of R1's Hospital Operative Report revealed a diagnosis of a left [CONDITION(S)]. On 06/14/22 at 03:01 PM, the resident was lying in her bed on her right side with two pillows off-loading her hips and between her knees. On 06/22/22 at 10:29 AM, CMA N and CNA O, transferred R1 with the mechanical lift from the bed to the resident's wheelchair. On 06/14/22 at 12:15 PM, CNA P reported staff should use the whirlpool seat belt when providing residents with whirlpool bathing. On 06/22/22 at 10:13 AM, CNA Q reported staff should use the whirlpool seatbelt during the whirlpool bathing process. On 06/22/22 at 01:10 PM, CNA MM reported staff should apply the seat belt to the resident when in the whirlpool seat. Staff should have all the supplies ready for the resident prior to bathing due to safety concerns. On 06/22/22 at 02:44 PM, Licensed Nurse (LN) I reported R1 required two-staff for assistance with her Activities of Daily Living. The whirlpool lift chair always required a seatbelt to be used. She reported the use of seat belts for the whirlpool chair was the facility policy. After R1's fall, all staff were re-educated on the whirlpool policy. On 06/22/22 at 03:00 PM, Administrative Nurse D reported the staff member did not place the seat belt on R1 during the whirlpool bath. It was facility policy for residents to wear the seat belt for safety during whirlpool baths. The CNA turned around to get the lotion, which was on the counter directly behind the staff member, two feet away from the resident. The facility revised Bath-Whirlpool-Tub, dated 04/2022, included that staff members ensure the use of the whirlpool belt for the safety of the residents. The facility failed to ensure the safety of this residents when staff turned away from the resident while she was unsecured in the whirlpool chair, and the resident fell to the floor and sustained a left [CONDITION(S)]. This citation was considered past non-compliance, when the facility corrected the deficient practice, with implementation and completion of the nursing staff education on Bath-Whirlpool-Tub Policy on 04/14/22 at 06:00 AM.

The facility reported a census of 38 residents with three selected for review for pressure ulcers/injuries. Based on interview and record review, the facility failed to inspect/assess one of the three resident's skin, Resident (R)7, under a CAM (controlled ankle motion) boot (a boot designed for the lower extremity that provides support, protection, and immobilization of the ankle after injury) between 12/13/21 and 12/31/21 (17 days) during the scheduled weekly skin assessment. During this time the resident developed a pressure ulcer/injury (a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure in combination with shear) identified as unstageable upon discovery due to the presence of slough (non-viable yellow, tan, gray, green, or brown tissue, usually moist and may be adherent to the base of a wound) tissue, measuring seven centimeters (cm) in length by five cm in width to her left ankle. The facility's failure to assess R7's skin under the CAM boot resulted in serious injury to the R7's skin, which placed this resident in immediate jeopardy. Findings included: - The Order Summary Report, dated 10/29/21 for Resident (R)7 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, (MDS), dated [DATE], assessed R7 with a Brief Interview of Mental Status score of 12, indicating moderately impaired cognition. She did not reject care, required limited assist of one for bed mobility, and required supervision and one person assist with dressing. R7 did not have any pressure ulcers/injuries, was not at risk for developing pressure ulcers/injuries, had a pressure reducing device to her bed and was not on a turning/repositioning program. The Significant Change MDS, dated [DATE], assessed R7 with a BIMS score of 99, indicating she was unable to complete the interview. The staff assessment of her mental status revealed a short-term and a long-term memory problem and severely impaired decision making. She required limited assist of two or more staff for dressing and extensive assist of two or more staff for bed mobility. R7 had a range of motion limitation to one side of her upper and lower extremities. She was at risk for developing pressure ulcers/injuries, had no pressure ulcers/injuries present, had no skin issues to her feet, had a pressure relieving device to her bed, and was on a turning/repositioning program. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 12/20/21, revealed that R7 was free of any skin breakdown or pressure injuries and was at increased risk to develop pressure injuries related to her impaired cognition, a [CONDITION(S)] ([CONDITION(S)]-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and comorbid conditions. The goal was for her to remain free of pressure injuries/skin breakdown through the next review date. The Care Plan, dated 11/13/19, included a new problem, dated 11/03/21, of a left distal fibula fracture from a fall which lacked interventions regarding the use of the new CAM boot, however it included instructions to follow the medical doctor orders for weight bearing status. The care plan included a revised problem, dated 11/16/21, of self-care deficit with activities of daily living (ADLs) related to a [CONDITION(S)] and left ankle fracture. She required extensive assistance of two staff for making major changes while in bed, for dressing and undressing, and total assist of one for bathing. The care plan included for a licensed nurse to conduct a weekly skin assessment and a Certified Nurse Aide (CNA) to inspect the resident's skin during bathing and cares, and to report any abnormalities to the charge nurse. An intervention added to the care plan, dated 11/16/21, included during skin assessments the staff were to inspect areas under the CAM boot on her left foot for signs and symptoms of pressure injury. On 12/20/21, an intervention in the care plan under the hospice section for hospice staff to assist the facility in monitoring the resident's skin integrity. The Progress Notes, dated 11/03/21, revealed at 09:05 AM, a CNA alerted the nurse that R7 was sitting on the floor in the bathroom with her left leg and foot under her bottom, and with shoes in place. R7 stated that her left foot got tangled with her right foot and she started to sit down and slid off the toilet, sat on the floor, and said her left foot was squished and hurting. Staff observed R7's ankle as swollen. The staff notified the doctor, who ordered an x-ray. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note, dated 11/03/21 at 01:33 PM, revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The undated Facility Investigation, revealed the staff applied the CAM boot on 11/09/21. The Physician's Progress Notes, dated 11/29/21, revealed left distal fibula fracture, non-weight bearing to her left lower extremity, CAM boot, and follow up in one month. The note lacked instructions if the boot could be removed/opened for cleaning and inspection of skin. The hospice Visit Note, dated 12/13/21, revealed R7 had a boot on and discussed with family possibly taking it off or providing something else with her as family felt the boot was causing pain, and the hospice nurse advised she would discuss with the physician. The visit note lacked assessment of the skin under the boot. A facility Witness Statement, dated 01/04/22, by CNA O, revealed on 12/13/21, she took the resident's CAM boot off for a whirlpool bath and did not observe any wounds. The hospice Visit Note, dated 12/17/21, revealed R7's left lower extremity was in a plastic boot due to possible fracture. The note lacked if the staff inspected the skin under the boot. The Weekly Skin Observation assessment, dated 12/17/21 and 12/24/21, revealed the skin was clean, dry, and intact other than healing bruises present to her right arm on the 12/17/21 assessment. The hospice Visit Note, dated 12/28/21, revealed R7 had a boot to left foot up calf and lacked any documentation if the hospice staff assessed the skin under the boot. On 12/29/21, CNA P gave R7 a bath, and did not take the boot off because she had been told since it was on, not to remove the boot, per the facility Witness Statement, dated 01/04/22. The Progress Note, dated 12/31/21 at 01:09 PM, revealed that the CNAs removed R7's CAM boot and sock and observed a pressure wound to the left outer ankle. The wound was red on the outside and in the middle was a cream-colored slough, bone was felt underneath the wound, and the wound was painful to touch. Staff documented the measurements of the wound under the skin assessment. The hospice Visit Note, dated 12/31/21, revealed care coordinated with Licensed Nurse (LN) G, whom reported she found a stage four ulcer under the ankle cast and the last time that it was removed was on 12/13/21 for a whirlpool bath, which revealed there was not any ulcers there at that time. The family insisted that the cast be removed today, which was on the schedule to be taken off on 01/04/22. The Weekly Skin Observation assessment, dated 12/31/21, revealed R7 had a pressure ulcer to the left ankle measuring seven cm in length by five cm in width with an unknown depth. The staff staged the wound as a suspected deep tissue injury. On 01/25/22 at 10:27 AM, CNA M stated she was not allowed to take the boot off because it had to be done by the orthopedic doctor, so she did not observe the skin under the boot. On 01/25/22 at 12:13 PM, LN G stated she completed the skin assessment for R7 on 12/24/21 and did not remove or open the CAM boot to inspect the skin underneath as she was told not to remove the boot. LN G stated she tried to open the boot once and was told by Administrative Nurse E not to mess with it and not to take if off for showers. On 12/31/21 when the CNA staff removed the boot on her left outer ankle, the area was red around the outside with slough to the open area and the sock the staff removed under the boot, was white with a yellowish color to where it had been against the wound. On 01/25/22 at 12:52 PM, Administrative Nurse E stated that the order for R7 that she knew about was to leave the CAM boot on, and as far as she knew, the staff were not to open the boot up to look at her skin underneath. On 01/25/22 at 01:22 PM, an unidentified family member stated on 12/31/21 that she was at the facility and told the staff to take the CAM boot off because it was bothering R7 and had been for the past several weeks. The family member stated that she was out of the room when the staff first took the boot off, and then the nurse told her R7 had the worst pressure ulcer she had ever seen. The room had a smell of the ulcer as well. The family member stated he/she photographed the ulcer. On 01/25/22 at 04:19 PM, Administrative Nurse D stated she expected the staff to assess R7's skin under her boot during the weekly skin assessments and R7 had on her care plan instructions to do so. On 01/26/22 at 11:04 AM, LN G stated that she completed the skin assessment on 12/17/21 and did not remove the boot to assess the skin under it on that date. She verified the that R7's ulcer appeared as shown in a submitted photograph of the wound. On 01/26/22 at 11:44 AM, telephone contact with Consultant GG was unsuccessful. On 01/26/22 at 01:17 PM, CNA N stated she was on duty on 12/31/21 when the staff removed the CAM boot and R7's ankle wound appeared like it did in the submitted photograph of the wound. CNA N recalled staff, none specifically, saying not to remove the CAM boot since her ankle was broken. The facility policy Skin Assessment, issued 01/2016 and updated January 2022, instructed staff to assess skin and mucous membranes for integrity, turgor, general appearance. Assess skin for color and venous pattern, pruritis, dryness, bruises and color. Assess risk for and/or presence of pressure sores and/or ulcers. The Licensed Nurse was to complete skin assessment weekly. The facility failed to inspect/assess R7's skin under the CAM boot for 17 days during the scheduled weekly skin assessment resulting in serious injury, a pressure ulcer/injury, to her skin under the CAM boot. This deficient practice placed the resident in immediate jeopardy. On 01/26/22 at 04:03 PM, Administrative Nurse D was informed the resident was in immediate jeopardy status and provide the Immediate Jeopardy Template for failure to assess R7's skin under the CAM boot between 12/13/21 and 12/31/21 (17 days) which resulted in serious injury to her skin. The facility provided an acceptable plan of removal of the immediate jeopardy on 01/26/22 at 05:05 PM. The plan included: 1. Training with CNA's and CMA's began on 01/04/22 for all residents who wore a removable device, such as a boot, need to have their skin visualized every shift to ensure there is no evidence of skin breakdown, as these boots place resident's at high risk for skin breakdown. All residents with a removeable device. 2. All residents with a removeable device, such as a CAM boot or brace, were assessed by the charge nurse on 01/26/22 for evidence of skin breakdown and documented in the nurse's notes. 3. All nurses began training on 01/11/22 regarding proper skin assessments; any residents with a removeable device such as a CAM walker needs this area assessed at least weekly by the charge nurse. The skin assessment policy reviewed and signed. 4. All nursing staff members not trained on proper skin assessments will not be allowed to return to work until they have completed the required training on the skin assessment policy. 5. All residents with a CAM boot or removeable device, such as a brace, will be assessed every shift for evidence of skin breakdown and will be documented on the treatment administration record. 6. This will be monitored weekly during the Risk Management meeting and monthly during facility Quality Assurance and Performance Improvement meeting. 7. Effective 01/26/22, the facility wound nurse will assess any resident with a removeable device, such as a CAM walker or a brace, for evidence of skin breakdown underneath the device at least weekly. 8. The bath sheets will continue to be audited weekly by the wound nurse. 9. Compliance date as of 01/26/22, all nursing staff will be trained on proper skin assessments, those not yet trained will be required to complete training before returning to work and the Director of Nursing will monitor for compliance. The survey team validated the immediate jeopardy was removed on 01/26/22 at 04:30 PM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was lowered to a G (actual harm that is not immediate jeopardy) following the removal of the immediate jeopardy.

The facility reported a census of 38 residents with three residents selected for review for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 did not cause repeat abuse attempts to Resident (R)2, when staff assigned to constantly monitor R1 left her alone, allowing her to hit at R2 for a second time. Findings included: - R1's Progress Notes, dated 09/11/21 at 05:36 PM, revealed R1 had verbal exchange of words with a male resident (R2) this afternoon before she was assisted from the commons area. She would continue to make derogatory remarks or call staff or other residents names. Staff offered food and fluids, which helped for a short period of time. A staff member conducted one to one monitoring of R1 at supper to keep her from going in and out of other resident rooms. She continued to use foul language, yelling it out loudly at times, but was in her room eating supper quietly at this time in front of her television in her room. R1's Progress Note, dated 09/11/21 at 10:51 PM, revealed that R1 had been quite active during the evening. She had been up ad lib in her wheelchair, would get up to walk around, found at the front door trying to get it open and trying the keypad. She would curse at the nurse when the nurse made attempts to get her away from the door and into her wheelchair. R1 finally agreed, after encouragement to move away from the door, to go check on her baby. R1 was content for a short time and laid down with her baby which was short lived and then she was up and back at the front door again trying to exit. She could not be redirected; she was set on leaving the facility. A CMA was able to redirect her, made her a milkshake, and provided her an as needed ordered [MEDICATION(S)] (antianxiety medication), which took some time to calm her, then she rested in bed. R1's Progress Note, dated 09/12/21 at 04:33 PM, revealed that around 03:45 PM, R1 started going in and out of rooms and the staff redirected her. R1 was okay with that for awhile before becoming angry when she saw someone in room [ROOM NUMBER]. Staff had to intervene with the confrontation with the resident that currently resided there. R1 then became agitated and began calling staff and other residents that passed (very foul curse names). R1 tried hitting and kicking anyone who happened to be close to her. The staff administered [MEDICATION(S)], assisted her to the bathroom with using lots of peanut butter cups. R1 was then good and smiling and laughing for the moment. R1's Progress Notes, dated 09/12/21 at 11:40 PM, revealed that around 08:21 PM, R1 had a verbal altercation with R2. R1 initiated contact with R2 by bending over in her wheelchair and grabbing R2's foot. R2 started to kick at R1 and her hand became caught between the wheelchair and the bottom of his foot which resulted in hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the back of R1's hand. The staff separated the two residents, removed R1 from the area, and encouraged her to go down the south hall. A Certified Nurse Aide (CNA) was assigned to provide one to one monitoring with R1 to keep her separated from the other residents. The facility Witness Statement, dated 09/13/21 for the altercation that occurred on 09/12/21 around 08:21 PM, between R1 and R2 by Certified Medication Aide (CMA) T, revealed that she was passing medications down the south hall when she heard R1 and R2 arguing with each other. R2 was telling R1 to go away and started kicking at her. R1 was in her wheelchair and R2 was in a recliner near the nurse's station. CMA T immediately moved to separate them. R2 was sideways in the recliner kicking at R1 and R1's hand became caught between her wheelchair and the bottom of his foot. A hematoma was forming on the back of R1's right hand. CNA T immediately removed R1 to take her to the nurse. The facility Complaint Investigation Report, dated 09/15/21, revealed that the facility was actively pursuing geri-psych placement for R1 for management of her behaviors. This was evident upon review of the Progress Notes, dated 09/13/22 and 09/14/22 for R1. R1's Progress Note, dated 09/15/21 at 01:21 PM, revealed R1 went to the chapel where other residents waited for Bingo. R1 began calling other residents (foul names) and when they pointed at her she yelled back that she was the (foul name). R1 was crying and upset when a CNA removed her from the chapel. R1 was taken to the living area with staff and had her baby doll and was drinking a Pepsi. R1 had stated that she was worried she would go to jail. R1's Progress Note, dated 09/15/21 at 07:13 PM, revealed R1 was in a verbal argument that resulted in fist blows with R2. It resulted in a small abrasion to R1's left hand that bled. The staff failed to provide the intervention of one to one monitoring with R1 at that time. The facility Witness Statement, dated 09/16/21 for the incident occurring on 09/15/21, written by CMA OO revealed when she was on the south hall around the corner, she heard yelling and ran over to the north hall by the shower room. CMA OO observed R2 holding on to R1's arm while R1 was punching R2. CMA OO grabbed arms of both residents, stood between them, told them to stop, and asked R2 to let go. R2 said he did not hit R1. The facility Complaint Investigation Report, dated 09/20/21, revealed that the facility did not follow R1's care plan as she was to have one to one with staff when up in the wheelchair and staff should redirect her when approaching R2. This failure allowed R1 to again attempt abuse to R2. The Order Summary Report, dated 11/04/21, for R1 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS, dated [DATE], revealed no changes to memory recall or decision making. She had inattention that fluctuated, physical behavior symptoms that occurred one to three days, verbal behavior symptoms that occurred four to six days, and other behavior symptoms not directed towards others that occurred one to three days. The behaviors did not put the resident at significant risk for physical illness or injury but significantly interfered with her care and participation in activities or social interactions. The behaviors did put others at significant risk of physical injury, intruded on the privacy or activity of others, and significantly disrupted the care or living environment. R1 rejected care for one to three days and wandered daily. Her behaviors worsened since the prior assessment. She required limited assist of one staff for walking, transfers, and locomotion. She continued to use a walker and a wheelchair for mobility. R1 received an antipsychotic medication seven days and an antidepressant five days. A bed alarm, chair alarm, and wander/elopement alarm were used daily. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/28/21, revealed R1 had severe memory impairment and displayed confusion, forgetfulness, and impaired safety awareness. She had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavior CAA, dated 09/28/21, revealed R1 had a recent increase in behaviors, both physical and verbal altercations had occurred, and she was at increased risk for those events to occur related to her multiple comorbidity conditions. The Care Plan, dated 07/14/21, included a problem for mood and behavior and revealed that sometimes R1 had thoughts and delusions that staff were against her, did not like her, or were thinking of ways to harm her. She received [CONDITION(S)] medications, a psychiatric consult as ordered/indicated, refer her to social service designee for one to one as needed, and assist to develop a program of activities that were meaningful and of interest to her. The activity portion of the care plan included that R1 enjoyed reading, listening to music and had a radio in her room, participate in church, had a baby doll that she enjoyed taking of care of, and to invite her to scheduled activities. Additional interventions added to the care plan included: 1. On 08/08/21, when R1 became agitated or cursing/yelling, the staff were to attempt to redirect her. Offer her a snack (she liked chocolate and Pepsi) and offer her the baby doll as that often calmed her. 2. On 08/27/21, instructed the staff to monitor her whereabouts frequently and to ensure she was not left unattended with other residents who she would become agitated with. 3. On 09/04/21, instructed the staff to redirect her if she goes near the resident who resided in room [ROOM NUMBER] as she did not like that resident. The care plan lacked the one to one intervention on the care plan, initiated following the resident to resident altercation on 09/12/21 at 08:21 PM. The facility Complaint Investigation Report, dated 09/15/21, included the intervention that R1 would be one to one with staff when she was up on her wheelchair until placement at geri-psych could be found. The Order Summary Report, dated 12/06/21, for R2 (the victim), included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS, dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R2 had occurrence of physical behavior symptoms that occurred one to three days and verbal behavior symptoms that occurred four to six days. The behavior symptoms significantly interfered with resident care and participation in activities or social interactions. R2 rejected cares one to three days and had no change in his behavior symptoms since the prior assessment. He required extensive assistance of two or more staff for transfers and supervision, one staff for physical assistance for locomotion, and used a wheelchair for mobility. R2 did not receive any [CONDITION(S)] medications. The Cognitive Loss/Dementia CAA, dated 09/10/21, indicated that R2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavioral Symptoms CAA, dated 09/10/21, revealed that R2 had physical and verbal aggression/behaviors and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 would also become agitated in response to other residents who would curse or holler. The Quarterly MDS, dated [DATE], assessed R2 with a BIMS score of nine, indicating moderate cognitive impairment. He had physical and verbal behavior symptoms that occurred one to three days and he did not reject care or wander. R2 did not have any changes to his transfer ability or locomotion since the prior MDS assessment and continued to use a wheelchair for mobility. He did not receive any [CONDITION(S)] medications and continued to require the use of an alarm to alert staff to movement. The Care Plan, intervention, for R2, dated 09/04/21 and revised on 09/09/21, directed the staff to keep R1 from getting too close to him, as R1 did not like him and her cursing would tend to upset him. On 01/24/22 at 11:04 AM, R2 was sitting in his wheelchair, propelling himself in the hallway and to the chapel, then he exited the room towards the sitting area outside of the chapel. On 01/25/22 at 10:23 AM, R2 was in his wheelchair self-propelling it with his feet. He responded back to staff in a pleasant manner when they would pass and speak to him. On 01/27/22 at 02:49 PM, Administrative Nurse D stated that the staff informed CNA P to be the one assigned to do one to one monitoring with R1, on her shift, on 09/15/21. She had left R1 unsupervised in her wheelchair to go do another task and did not find another staff to replace her to provide the one to one monitoring. Administrative Nurse D stated she expected the staff to provide one to one monitoring with R1, and if another task needed done, then the assigned staff member should find another staff member to take over and not to leave the one to one resident unsupervised. The facility policy for Prevention of Abuse, Neglect, and Exploitation of Residents, issued 09/2016 and revised 11/2021, revealed that the residents of the facility would be free from abuse, and residents identified as having personal histories rendering them at risk for abusing other residents would be observed, and intervention strategies would be developed to prevent occurrences. The facility failed to ensure R1 did not cause repeated abuse attemps to Resident (R)2, when staff assigned to constantly monitor R1 left her alone, allowing her to again hit at R2.

The facility reported a census of 38 residents with two of those residents identified at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision- making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to provide adequate supervision of Resident (R)4 when he exited the facility out the front door and ambulated approximately two blocks away when he asked a community member for help, which then notified the facility and brought him back. Additionally, the facility failed to provide adequate supervision to R5 when he exited the facility out the front door and was ambulating around the facility and staff found at the back of the facility on the facility grounds. Findings included: - The Order Summary Report, dated 10/29/21, for Resident (R)4, included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), injury of head, pedal cyclist injured in unspecified traffic accident, and repeated falls. The Admission Minimum Data Set (MDS), dated [DATE], assessed R4 with a Brief Interview of Mental Status, (BIMS) score of 10, indicating moderate cognitive impairment. R4 did not wander, required supervision and setup for locomotion on/off the unit and walking in the corridor. He used a walker for mobility, balance was steady, and a wander/elopement alarm was not used. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/05/21, revealed R4 had a diagnosis of dementia and his BIMS score of 10 indicated moderately impaired cognition. The Activities of Daily Living [ADL] CAA, dated 11/05/21, revealed R4 required limited assistance/supervision with most ADL's. The Baseline Care Plan, dated 10/27/21, revealed his discharge plan was to return to the community and R4 was not an elopement risk. The comprehensive Care Plan, dated 11/10/21, revealed R4 had a discharge plan to return home when therapy goals were reached and when he ambulated with his front wheeled walker independently for both long and short distances. He had a BIMS score of 10 but was alert and oriented to person, place, time, and situation. On 11/20/21, staff added an additional problem for elopement risk that included a Wander guard (bracelet that sets off an alarm when residents wearing one and attempt to exit the building without an escort) to his right wrist, staff were to check the signal daily and replace it as needed, and staff were to perform frequent visual checks at least every 30 minutes to verify location and safety. The Wandering/Elopement Risk, assessment, dated 10/27/21, revealed a score of seven, indicating low risk to wander. He had no reported episodes of wandering in the past six months. The Progress Note, dated 10/27/21 at 05:00 PM, revealed therapy staff reported to the nurse that he was unsteady and unplugged his recliner and he said he would walk out if he had to ask for help. The Progress Note, dated 11/11/21 at 10:08 AM, revealed Physical Therapy services continued and he was given a single point cane to assist with balance while ambulating. Speech Therapy continued to work with him on recall of safety information. The Progress Note, dated 11/17/21 at 08:06 AM, revealed resident was alert and oriented to two of the four options (person, place, time, situation) and used a cane for locomotion. The Progress Note, dated 11/18/21 at 09:04 AM, revealed that R4 walks with the single point cane but does not remember sequencing and will often carry the cane between steps or for short distances. He had met highest practical level at this time and will be discontinued from Physical Therapy on this date. Speech therapy indicated he talked about doing a home visit and going home, however he needed to continue to work on executive functioning skills and should continue therapy especially if his is going home. The Physician Progress Notes, dated 11/18/21, revealed R4 though he was ready to go home and revealed confusion versus dementia and may be residual traumatic brain injury from his head trauma. He was oriented with prompting and probably not able to be home quite yet. The facility Witness Statement, dated 11/20/21, for Licensed Nurse (LN) H, revealed she saw R4 last at 02:30 PM in his room when she took his vital signs. The facility Witness Statement, dated 11/20/21, Certified Medication Aide (CMA), revealed at 03:30 PM, R4 asked her to get him some milk and cookies from the kitchenette, then 10 minutes later he asked another aide for more. Review of Wunderground.com, for 11/20/21 at 03:53 PM, revealed the temperature was 56 degrees Fahrenheit and calm wind at 0 mph. The Progress Note, dated 11/20/21 at 04:42 PM, revealed the facility received a phone call at 04:09 PM, from a gentleman who did not identify himself, and said that R4 was out roaming around town. The gentleman, who turned out to be R4's home neighbor, returned him to the facility. Resident stated he just wanted to go for a walk, and he got lost. The staff placed a Wander Guard on him. The Progress Note, dated 11/20/21 at 04:51 PM, revealed staff assessed R4 who was without injury and his vital signs were within normal limits. The resident had no complaints and was wearing a coat and had his hood up while out of facility. When resident was asked why he left resident stated that he just wanted to go for a walk. The facility Complaint Investigation Report, dated 11/23/21, revealed R4 was two blocks away at his home, without staff knowledge, when the community member, his neighbor, called the facility and brought him back. R4 stated he wanted to go for a walk and pushed the code into the keypad by the front door. He left the facility, make it to his house, then got lost and asked the neighbor for help. On 01/26/22 at 12:48 PM, CMA R stated she worked the day that R4 exited the facility. Before he exited the facility without staff knowing on 11/20/21, he had asked her for milk and cookies, she gave them to him, then he was gone. It was about 20-30 minutes later when the staff realized he was gone after someone called the facility to report him outside. On 01/26/22 at 01:07 PM, Certified Nurse Aide (CNA) N, stated that when talking to R4 he was a little confused, he would say he wanted to go home but did not try to leave the facility. He did walk a lot in the facility. On 01/26/22 at 02:56 PM, CNA Q stated that on 11/20/21, R4 was in his room after 02:00 PM, as she would always see him after clocking in. He was sitting in his recliner watching television. We would stay with him out in the courtyard if he ever wanted to go outside because he was a fall risk. The facility policy for Elopement, issued 04/2016 and last reviewed 11/2021, indicated the policy of the facility was to identify those at risk for elopement and take precautions to ensure their safety and well-being. The facility failed to ensure R4, who had impaired cognition, did not exit the facility and walk two blocks away, without staff awareness, until a neighbor called the facility to report R4 being outside. - The Order Summary Report, dated 12/30/21, for Resident (R)5, included diagnoses of need for assistance with personal care, cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), [CONDITION(S)] disorder (major mental illness that caused people to have episodes of severe high and low moods), disorientation, and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set, (MDS), dated [DATE], assessed R5 with a Brief Interview of Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. He was independent with his activities of daily living (ADL's), did not use any devices for mobility, and did not use a wander/elopement alarm. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/28/21, revealed R5 had moderate cognitive impairment as indicated by a BIMS score of 9. He exhibited impaired decision making and impulsivity. The ADL Functional/Rehabilitation Potential CAA, dated 12/28/21, revealed R5 required minimal to no assist with his ADL's. He was at risk for needing more assistance with ADL's related to his cognition and multiple comorbid conditions. The Baseline Care Plan, dated 12/17/21, included R5's initial discharge goals were to return to the community. He had impaired cognition, ambulated in the corridor with one person assist, did not use any assistive devices, no alarms required, was not at risk for elopement, and did not smoke. The comprehensive Care Plan, dated 01/05/22, included an additional problem for elopement risk, dated 12/31/21. The staff revised this problem on 01/05/22, due to his desire not to be in a long-term care facility and desire to come and go as he pleased. R5 could read and follow instructions putting him at risk for reading the code to the exit doors and entering the code himself, as well as he was watchful of others. The interventions placed on the care plan on 12/31/21 included: Wander Guard to his wrist, check the signal on the Wander Guard daily and replace as needed, and frequent visual checks to verify his location and safety. On 01/05/22, interventions included the Wander Guard to his wrist-resident may ask, but please do not cut this off. R5 enjoyed spending time outside and staff instructions included to encourage to go in the enclosed courtyard. Staff presented alternative placement options to his DPOA (durable power of attorney), who did not want him to come and go as he pleased, but R5's desire to do so as well as cognitive impairments may mean that he needed transferred to a locked/secured unit. Additionally, on 01/05/22, included an intervention that R5 could articulate how/why/where he wanted to go but was not familiar with the town and he frequently would seek cigarettes. He was unable to smoke due to requiring supervision/assistance with smoking. The Wandering/Elopement Risk assessment dated [DATE] and locked on 12/31/21 at 02:16 PM, revealed a score of nine indicating R5 was at risk to wander. The Admission Assessment-Nursing, dated 12/17/21, revealed that he was alert to person only, confused, had a short-term memory problem, was a past smoker and required assistance of staff for walking. The assessment did not include if the resident was at risk for elopement. The Progress Note, dated 12/29/21 at 09:53 PM, indicated that R5 was alert, pleasantly forgetful, up ad lib, and cooperative with cares. The Progress Notes, dated 12/30/21 at 09:17 AM, revealed that Physical Therapy was working with R5 and he exhibited difficulty following directions for more than a few repetitions and did not demonstrate any carryover yet of instruction. Speech Therapy was working with him for cognition and he had no retention or carryover of treatment. The Progress Note, dated 12/30/21 at 08:37 PM, revealed R5 was alert and oriented, ambulated independently, and hoped to go home soon. The Progress Notes dated 12/31/21 at 06:56 AM, revealed R5 walked independently with supervision. Review of weather history at Wunderground.com, for on 12/31/21 at 01:53 PM, revealed the temperature of 45 degrees Fahrenheit and wind from the north at 18 miles per hour. The Progress Note, dated 12/31/21 at 02:15 PM, revealed Licensed Nurse (LN) G received a call at the facility from Consultant staff HH, that he seen resident walking outside behind the facility. R5 was last seen in the facility getting coffee at 01:50 PM and headed back to his room. The staff found him outside at 02:10 PM. R5 stated he went out the front door and went behind the facility looking for a cigarette. R5 had no injuries, he had on pants, socks, tennis shoes, shirt, and a jacket. The staff applied a Wander Guard bracelet to his wrist after testing for proper functioning. On 12/31/21, consultant staff HH, per the facility Witness Statement, dated 01/05/22, revealed that at approximately 02:00 PM he was leaving the facility and saw a person walking east along the north side of the facility, and thought he recognized the person as R5, so he immediately called the facility and spoke with LN G to see if R5 was inside or outside or if he was to be outside. The charge nurse started calling upon the CNA's present to search and then hung up the phone. The Progress Note, dated 12/31/21 at 02:56 PM, revealed the facility had a policy that a resident that required assistance to smoke would not be permitted to smoke at this facility, and R5 required assistance to smoke. The Progress Note, dated 12/31/21 at 02:58 PM, revealed that R5 was exit seeking again and reported to staff he was going to find a cigarette. The Progress Note, dated 01/01/22 at 05:33 AM, revealed R5 was actively seeking a cigarette in the smoking area, a CNA had followed him out where another resident was smoking and R5 had asked that resident for a cigarette. The nurse re-enforced to R5 that he had not been cleared to smoke here, and he responded, I will get a cigarette if I leave and no one can stop me! The Progress Note, dated 01/01/22 at 08:30 AM, revealed R5 was looking for cigarettes and his Wander Guard sounded the alarms off at the courtyard exit door. He asked a kitchen staff member for a cigarette, who responded they did not have one, then he went back inside with staff. The Progress Note, dated 01/01/22 at 08:48 PM, revealed R5 was confused to time and place, forgetful, and was getting upset when looking for a cigarette and would be told he could not get one from another resident. He stated to staff he could smoke if he wanted to. R5 watched other residents going out to smoke and tried to follow them out which made the system alarm. The Progress Note, dated 01/26/22 at 05:44 PM, revealed that R5's Wander Guard bracelet was not working properly and when asked if it could be switched out he stated if this one is coming off, I will not be putting another one on. Review of the Treatment Administration Record (TAR), and the Medication Administration Record (MAR), dated 01/2022, lacked instructions for facility staff to check the signal of the Wander Guard bracelet and when to change the bracelet, until 01/27/22 (27 days after the application of the Wander Guard). On 01/24/22 at 02:27 PM, R5 stated he had been at the facility for six weeks or so and was ready to leave. He had left the facility without notifying staff and they came running out and stopped him and had him come back. R5 stated he was in the back yard and did not know he could not leave. He explained he was going to town to buy smokes. R5 stated he had this thing on his wrist (and pointed to the Wander Guard on his left wrist) and if he wanted to go outside he goes to the smoking area (the enclosed courtyard) and the staff tell him he cannot go out by himself. R5 stated, It is b . s . that I am here and cannot leave, I have thought about leaving five or six times. On 01/25/22 at 08:27 AM, observed R5 outside in smoking area with staff supervising. On 01/25/22 at 12:31 PM, LN G stated she was on duty when R5 exited the facility on 12/31/21. CNA O had seen someone by the front door as she was driving and did not know until questioned that it was R5. LN G believed R5 went out the front door and walked around the building and that Consultant Staff HH had seen him outside. Three CNAs went out the side door when he called and he was behind the facility heading towards another building. The CNAs were able to get him to come inside, it all happened in about 10-20 minutes. The staff applied a Wanderguard bracelet and he wanted the staff to take it off. He had actively been exit seeking since that day. The resident will try to push the door codes, but not to the front door that LN G was aware of. On 01/26/22 at 12:48 PM, CMA R stated she had not seen R5 go out to the smoking area before 12/31/21 but did see him go out there yesterday, he was wanting a cigarette. On 01/26/22 at 01:07 PM, CNA N stated that R5 was an elopement risk, but did not hear that he wanted to leave or ask for a cigarette before 12/31/21. CNA N stated she had worked on 12/31/21 and had seen him at 12:30 PM with a coffee sitting in the television room. On 01/26/22 at 02:14 PM, Certified Medication Aide (CMA) S stated there was a device on the medication cart to check the Wander Guard bracelets to make sure that it was working, and the battery was not dead. CMA S thought that was done on each shift, or at least daily and in the past, it would be documented on the MAR, but it was not currently on the MAR for R5. CMA S stated that she was on duty when R5 exited the facility on 12/31/21, and he headed in the direction of a facility behind this one. Before he exited, he was wanting to know where cigarettes were at and that he wanted to go outside. R5 would linger at the courtyard door and set the Wander Guard alarm off at least daily. The staff go out with him and let him sit or walk around. He was not to be out there by himself. On 01/26/22 at 04:17 PM, CMA T stated that she did not know when the staff were to change the resident's Wander Guard bracelet and she had not checked any of the Wander Guards herself. CMA T stated that R5 did ask her for cigarettes. On 01/27/22 at 08:35 AM, LN I stated that the CMAs have the device to test the signal of the Wander Guard and did not know if the staff had put a new Wander Guard device on the resident since 01/26/22. On 01/27/22 at 08:41 AM, CMA S tested the signal of the device per the surveyor request and the device was functioning. CMA S checked for a date on the device or band for when staff activated it and they lacked a date. CMA S checked the device for the stamped date into the actual device and she confirmed the date to activate the device by was 12/07/21. On 01/27/22 at 08:45 AM, LN I stated that she would think the device or band should be labeled with a date when the staff applied the device. On 01/27/22 at 08:54 AM, Administrative Nurse G stated that if a Wander Guard did not work then staff should replace it and if the resident did not allow that then they would need to be on 15 minute checks and was aware that R5's bracelet was not working. When the staff apply the Wander Guard device they should add the date activated, and it should be on the TAR to check for functioning and when to replace it. On 01/27/22 at 10:12 AM, Consultant Staff HH stated he was parked at the back of the facility on 12/31/21 and around 02:00 PM when he was driving on the north side of the facility he saw someone walking in the grass between the two parking lots on the north side of the building and he called the facility. He was not sure if it was R5 or not. LN G was on the phone and she told the staff to go to R5's room to see if he was there or not and she hung up the phone. On 01/27/22 at 10:42 AM, Administrative Nurse D stated the Wander/Elopement assessment dated on 12/17/21 and locked on 12/31/21 was completed. Based on his history and what the hospital had reported, the staff did not feel like he needed any interventions for elopement risk. The facility policy for Elopement, issued 04/2016, and last reviewed 11/2021, revealed it was the policy of the facility to identify those at risk for elopement and take precautions to ensure their safety and well-being. The facility policy for Wander Guard, updated 05/2020, revealed if a resident scored nine or above, a Wander Guard shall be placed on the resident. When placing a Wander Guard, date the band. Every day a trained staff member will test the signaling devices with a Signaling Device Tester and record it on the Treatment record. The facility failed to ensure R5, who had impaired cognition, did not exit the facility without staff awareness, until a consultant staff driving by the facility noticed him outside. Additionally, the facility failed to date the band when they applied the Wander Guard, test the device daily, and document the testing on the TAR, which increased the risk for the resident to elope should the device malfunction.

The facility reported a census of 39 residents with 16 selected for review, which included three residents selected for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure staff provided dressing changes to one resident (R) 7's pressure ulcers in a sanitary manner to promote wound healing and potential wound contamination. Findings included: - Review of R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status score (BIMS) of 15 indicating normal cognitive status. The resident required extensive assistance of two persons for bed mobility, transfer, and toilet use. The resident had no impairment in upper and lower extremities and utilized a wheelchair for mobility. The resident was frequently incontinent of urine, and always continent of bowel. The resident had diabetic ulcers and moisture associated skin damage (MASD) and no unhealed pressure ulcers. The resident was as at risk for pressure ulcers and had a pressure reducing device for her bed and chair. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 08/13/20, assessed the resident had self-care deficits related to physical limitations of her wounds, weakness obesity and mood disorder. The resident required extensive assistance with ADL. The Pressure Ulcer CAA, dated 08/13/20, assessed the resident was at risk for pressure ulcer development related to MASD (moisture associated skin damage usually from incontinence or excessive sweating), impaired mobility incontinence medications diabetes chronic kidney disease. The care plan, revised 02/11/21, instructed staff to float heels when in bed, ensure a pressure relieving mattress on the resident's bed and chair . Staff instructed to educate the resident regarding the need to offload buttocks and change positions frequently. The resident required use of a mechanical lift for transfers. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff instructed to cut and fit calcium alginate to the wound bed and cover with a bordered foam or composite dressing and change daily for stage two wound. Interview, on 04/22/21 at 02:43 PM, with Certified Nurse Aide (CNA)M revealed the resident has a pressure sore on her buttocks, but the resident prefers to spend most of her day up in her wheelchair or in her recliner. Interview on 04/26/21 at 10:00 AM with the resident seated in her wheelchair in her room doing crafts. The resident stated she likes to sit up in her chair to do crafts, states she toilets quiet often due to water pill. States she always keeps the blue boots on to protect her feet. States she has a cushion in her wheelchair to help her bottom sore, states she prefers to sit up instead of laying in bed. States she can turn herself from side to side when in bed. Observation on 04/26/21 at 2:34 PM revealed the resident position in her bed on her back following a shower. Licensed Nurse (LN) G brought a container with wound care supplies into the resident's room and placed it on her nightstand on top of her personal items. LN G washed her hands and donned gloves, and placed a container of spray saline on the residents bed. The resident turned onto her right side and observation reveald of the right buttocks area revealed an area of beefy red color approximately four centimeters (cm) and an area approximately 0.25 cm by 0.5 cm of white tissue.on the resident's right buttock. LN G cleaned the area with the spray saline (which was directly on the resident's bed) and returned it to the wound supply box. LN G used a gauze pad to pat the area dry, then applied the collagen powder with same gloved hands and patted it into the wound. LN G then removed her gloves and washed her hands, touched her mask with the gloved hand and found the calcium alginate in the supply box and placed a square over the entire wound bed. LN G placed a folded ABD pad over the wound and secured it with paper tape. Interview, at that time with LN G revealed she should perform hand hygiene and wear clean gloves when going from a dirty area to a clean area and confirmed cleansing a wound would lead to dirty gloves and gloves should be removed and hand hygiene performed before applying medicated dressings/creams to the wound bed. Interview, on 04/27/21 a 10:36 AM, with Administrative Nurse D revealed the resident admitted to the facility in August 2020, with the diabetic ulcers to her feet. The resident was non-compliant with diet and had widely fluctuating blood sugars. The resident also was non-compliant with positioning and preferred to sit up in her wheelchair during the day. Staff provided education and offered opportunities for position changes throughout the day. The resident had a BIMS score of 15, indicating she could make her own decisions. The resident developed a pressure area to her buttocks inspite of interventions. Administrative nurse D confirmed she would expect staff to remove gloves and perform hand hygiene when going from a dirty area to a clean area or when contaminated during dressing changes. Administrative nurse D stated the resident should have a composite dressing to her right buttock instead of the ABD pad used during the treatment observed on 4/26/21. The facility policy Dressing Change: Non Sterile, dated August 2019, instructed staff to remove a dirty dressing and place in a plastic bag, then remove gloves and place in a plastic bag, wash hands and set up a clean field to prepare supplies. Staff instructed to put on gloves to clean they would from the inner edge out and then perform treatment according to orders and apply the dressing. The facility failed to provide a dressing change to this resident's stage two pressure area on her buttocks in a sanitary manner to promote wound healing and prevent potential contamination and the development of infection.

The facility reported a census of 39 residents with 16 selected for review, which included one resident selected for skin issues (diabetic foot ulcers.) Based on observation, interview and record review, the facility failed to ensure staff provided dressing changes to one resident (R) 7's diabetic foot ulcers in a sanitary manner to promote wound healing and potential wound contamination. Findings included: - Review of R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status score (BIMS) of 15 indicating normal cognitive status. The resident required extensive assistance of two persons for bed mobility, transfer, and toilet use. The resident had no impairment in upper and lower extremities and utilized a wheelchair for mobility. The resident was frequently incontinent of urine, and always continent of bowel. The resident had diabetic ulcers and moisture associated skin damage (a condition caused by incontinence of excessive sweating/moisture) and no unhealed pressure ulcers. The resident was as at risk for pressure ulcers and had a pressure reducing device for her bed and chair. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 08/13/20, assessed the resident had self-care deficits related to physical limitations of her wounds, weakness obesity and mood disorder. The resident required extensive assistance with ADL. The Pressure Ulcer CAA, dated 08/13/20, assessed the resident was at risk for pressure ulcer development related to MASD (moisture associated skin damage usually from incontinence or excessive sweating), impaired mobility incontinence medications diabetes chronic kidney disease. The care plan, revised 02/11/21, instructed staff to float heels when in bed, ensure a pressure relieving mattress on the resident's bed and chair . Staff instructed to educate the resident regarding the need to offload buttocks and change positions frequently. The resident required use of a mechanical lift for transfers. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff instructed to apply skin prep (a protective solution often in the form of a small towelette) to the peri wound (skin surrounding the wound). Staff instructed to apply topical Santyl (a medicated ointment use to help remove dead tissue) nickel thick, to the wound bed and apply calcium alginate (a substance that absorbs wound drainage) and cover the wound with a super absorbent dressing and secure with bulky gauze and tape. Observation, on 04/22/21 at 07:13 AM, revealed the resident positioned in bed on her back with her feet offloaded with a pillow. Licensed Nurse (LN) G washed her hands and donned gloves. LN G removed the gauze wrap from the resident's right foot and revealed the heel contained an area of eschar (dead tissue) approximately six centimeters by five centimeters. LN G cleaned the heel with saline and gauze pads and applied skin prep to the peri wound (skin surrounding the wound). LN G picked up a trash can and took it to the foot of the resident's bed. At that time, surveyor GG advised LN G to remove her gloves and wash her hands. LN G complied and obtained a tube of Santyl and applied it directly to the wound with the tube and smeared the ointment around the wound with the tube tip then placed the cap back on the tube and placed it in the supply basket. LN G removed her gloves, washed her hands, and donned clean gloves, and applied calcium alginate to the wound bed. LN applied an ABD (multilayers gauze dressing) pad, [MEDICATION(S)] (a thick elastic type gauze wrap) and a self-adherent wrap. Interview, on 04/22/21 at 02:43 PM with Certified Nurse Aide (CNA)M revealed the resident has a pressure sore on her buttocks but the resident prefers to spend most of her day up in her wheelchair or in her recliner. CNA M stated the resident also had ulcers on her feet and keeps the blue booties on at all times. Interview on 04/26/21 at 10:00 AM with the resident seated in her wheelchair in her room doing crafts. The resident stated she likes to sit up in her chair to do crafts, states she toilets quiet often due to water pill. States she always keeps the blue boots on to protect her feet. States she has a cushion in her wheelchair to help her bottom sore, states she prefers to sit up instead of laying in bed. States she can turn herself from side to side when in bed. Observation on 04 /26/21 at 2:34 PM revealed the resident positioned in her bed on her back, following a shower. Licensed Nurse (LN) G brought a container with wound care supplies into the resident's room and placed it on her nightstand on top of her personal items. LN G washed her hands and donned gloves and found the spray saline and placed it in on the resident's bed near her foot and sprayed the right heel wound with the saline spray and patted it dry. LN G with the same gloved hands obtained the skin prep in the supply box and proceeded to wipe the peri wound area with the skin prep. LN removed her gloves and donned clean gloves and found the tube of Santyl and applied it directly with the gloved hands. LN G removed her gloves, washed her hands, and donned clean gloves, found the calcium alginate, and placed a square in the wound bed, and applied an ABD dressing and [MEDICATION(S)] and secured with a self-adherent wrap. Interview, on 04/27/21 a 10:36 AM, with Administrative Nurse D revealed the resident admitted to the facility in August 2020, with the diabetic ulcers to her feet. The resident was non-compliant with diet and had widely fluctuating blood sugars. The resident also was non-compliant with positioning and preferred to sit up in her wheelchair during the day. Staff provided education and offered opportunities for position changes throughout the day. The resident had a BIMS score of 15, indicating she could make her own decisions. Administrative nurse D confirmed she would expect staff to remove gloves and perform hand hygiene when going from a dirty area to a clean area or when contaminated during dressing changes. The facility policy Dressing Change: Non Sterile, dated August 2019, instructed staff to remove a dirty dressing and place in a plastic bag, then remove gloves and place in a plastic bag, wash hands and set up a clean field to prepare supplies. Staff instructed to put on gloves to clean they would from the inner edge out and then perform treatment according to orders and apply the dressing. The facility failed to provide a dressing change to this resident's diabetic heel wounds in a sanitary manner to promote wound healing and prevent potential contamination and the development of infection.

The facility reported a census of 38 residents with 3 selected for sample review of accidents. Based on interview and record review, the facility failed to ensure 1 resident (#1) of the 3 reviewed, received adequate supervision or assistive devices while in the facility van to prevent an accident, when staff failed to connect the safety straps to the wheelchair before leaving the resident unattended in the back of the van. The resident, who was agitated at the time the staff placed the resident in the van, tipped over in the wheelchair, striking his/her head on the metal floor grate of the lift and sustained 2 cervical fractures (C1 and C2), a large hematoma and laceration to the head, which required ER (emergency room ) treatment and hospitalization . Findings included: - Resident #1's [DIAGNOSES REDACTED]. A significant change MDS (minimum data set), dated 8/10/18, included a BIMS (brief interview of mental status) score of 1/15, which indicated severe impairment of cognition. The assessment further identified the resident experienced worsened delusional thoughts and hallucinations and rejected care. The staff identified the resident required extensive assistance to total dependence for ADLs (activities of daily living), including mobility. A quarterly MDS, dated [DATE], identified the resident scored 2/15, which indicated severe impairment of cognition, exhibited inattention, expressed little interest in doing things, felt down/depressed, experienced delusions, exhibited verbal behavioral symptoms and rejection of care. The resident continued to require total dependence to extensive assistance of staff for ADLs. The CAA (care area assessment), dated 8/15/18, for behaviors included, the resident exhibited severe cognitive impairment with periods of difficulty concentrating and trouble focusing. He/she was easily distracted at times and refused cares and medications, on a daily basis. The resident's care plan, last reviewed 11/15/18, lacked any directions to staff regarding safe transportation for the resident. Review of the nursing notes, from 11/2/18 to 12/1/18, evidenced the resident with agitation. A nursing note, on 12/3/18 at 3:46 PM, evidenced the resident was sent to the hospital with fractures of the C1 (cervical spine first vertebrae) and C2 (cervical spine second vertebrae). On 12/11/18 at 9:45 AM, upon entrance to the facility, the resident remained hospitalized , from the 12/3/18 incident. The facility conducted investigation, identified staff C transported the resident to a doctor appointment, on 12/3/18, in the facility handicapped accessible van. After completion of the physician appointment, staff C brought the resident back to the van, in the wheelchair, and placed the resident, who was agitated at that time, into the back of the van. Because of the cold, staff C loaded the resident inside, through the back doors, using the lift, did not secure the wheelchair safety straps so the wheelchair would not move, then got out of the van and closed the doors. Staff C then returned inside the van, through a side door, and found the resident with his/her wheelchair partially tipped backwards, resting against the floor grate of the lift and the resident's head was actively bleeding. Staff C reported he/she then secured the resident with the safety straps from to the wheelchair and to the floor of the van, placed the seatbelt across the resident, and transported the resident to the emergency room (ER). The examination at the ER (emergency room ) revealed the resident, upon x-ray, to have cervical (neck) fractures. Staff C returned to the facility, completed an incident/accident report, and then transported another resident to another appointment. Around 5:30 PM the facility received a call from the hospital requesting transportation for the second resident at the hospital, to return to the facility. Staff of the facility then checked the parking lot and determined that staff C returned the van to the facility parking lot, left the keys and the transportation cell phone in the unlocked van and had left the premises. Per the investigation notes, the employee did not return to work. Review of hospital x-ray reports, dated 12/3/18, identified an acute [MEDICAL CONDITION] vertebral body and facet joints (joints of the spine which allow bending and twisting). Also, a tiny [MEDICAL CONDITION] arch of the C1 vertebral body. Additionally, a large hematoma measuring 6.8 by 5.4 by 2.1 cm (centimeter) over the posterior inferior scalp with soft tissue swelling and a laceration. Interviews conducted, on 12/11/18 at various times with 5 other interviewable residents, who utilized the services of the facility van all denied any concerns. However, one resident, reported staff C's driving skills were not what he/she liked but that the employee always connected the seatbelt and secured the wheelchair with the use of the straps. On 12/11/18 at 2:20 PM, maintenance staff E reported being the safety director and provided training to direct care staff C at the time he/she began providing services as the transportation driver. Staff E verified that staff C was fully aware of the proper restraint system required for maintaining safety measures for the residents during transportation. On 12/11/18 at 3:20 PM, administrative licensed nursing staff D reported he/she spoke to direct care staff C, on 12/3/18, when the staff member returned to the facility after the accident with the resident. Physician assistant E, on 12/11/18 at 3:40 PM, reported that the extent of the resident's injuries would require that a good deal of force or momentum occurred prior to the impact for the fractures and the extent of the hematoma. The interviewee indicated that leaning back and bumping his/her head against the grate would not have resulted in such an injury. On 12/11/18 at 3:45 PM, administrative nursing staff B and administrative staff A reported they both believed that the investigation conducted lacked evidence of wrong doing, except for the extent of the resident's injury. On 12/12/18 at 9:10 AM, direct care staff C reported on 12/3/18 he/she transported the resident to an appointment to the clinic downtown. After completion of the doctor visit, staff C propelled the resident in the wheelchair outside to the facility handicapped van for transport back to the facility. The resident became agitated when finding out the spouse who met the resident at the appointment was not returning to the facility with him/her. Staff C reported it was a windy and cold day and upon getting out into the cold the resident became more agitated and complained about the cold. Therefore, the staff reported he/she placed the resident inside the van, locked the brakes on the wheelchair, and then exited the van to close the lift and the back entrance door to keep out the cold air. Staff C verified he/she did not place the safety straps on the resident's wheelchiar. When staff C re-entered the van from the front door, staff C indicated the resident had tipped the wheelchair backwards and was leaned against the grate floor of the lift, causing a bump to the head. The staff reported the resident complained his/her head hurt and because the resident's head was bleeding staff member C immediately strapped the resident's wheelchair in and drove the resident to the ER. Staff C reported the resident lacked foot pedals on the wheelchair. The facility policy and procedure on transportation, dated 12/15, lacked direction to staff on proper safety measures of utilization of the safety harnesses and seat belts. The facility failed to ensure the safe transportation of the resident in the facility van when staff failed to connect the safety straps to the wheelchair before leaving the resident unattended in the back of the van. The resident, who was agitated at the time the staff placed the resident in the van, tipped over in the wheelchair, striking his/her head on the metal floor grate of the lift and sustained 2 cervical fractures (C1 and C2), a large hematoma and laceration to the head, which required ER treatment and hospitalization .

The facility reported a census of 32 residents. The sample of 6 residents included 3 reviewed for accidents. Based on interview and record review, the facility failed to implement interventions to prevent a fall for resident (#1) and repeated falls for (#3), of the 3 residents reviewed for accidents. The facility failed to implement appropriate interventions for confused resident (#3) with a recent history of multiple falls, to prevent further falls. The resident experienced a fall which resulted in a [MEDICAL CONDITION] and fractured C1 (The cervical spine, composed of a stack of bones called vertebrae. The C1 vertebra is the top one, closest to the skull). Findings included: - Resident #3's POS (physician order [REDACTED]. The admission MDS (minimum data set), dated 7/26/18, documented the resident admitted on [DATE], with a BIMS (brief interview for mental status) score of 8, indicating moderate intact cognition. The resident required limited assistance for most ADLs (activities of daily living) needs, including bed mobility, transfers and walking. The resident was not steady with walking and was only able to stabilize with staff assistance, including turning around. The resident used a walker and a wheelchair. The assessment further indicated the resident had a fall history in the month prior to admission, within the 2 to 6 months prior to admit without fractures and had no falls since admission. A significant change in condition MDS, dated [DATE], included the resident was not understood for interview of the BIMS and staff identified the resident as severely impaired of cognition. The CAA (care area assessment), for cognition, dated 7/27/18, included the resident's BIMS score indicated cognitive impairment although he/she did not have a [DIAGNOSES REDACTED]. The CAA, for falls, dated 7/27/18, included on admission the resident stated he/she had not had a history of [REDACTED]. The resident does have impaired mental status and a BIMS completed on 7/25/18, was a score of 8, which indicated moderate cognitive impairment. At the time of admission, he/she used a wheelchair but had also brought a 4-wheeled walker which ended up being his/her primary mode of mobility. He/she is at high risk for falls. A Morse Fall Assessment, completed on admission, 7/20/18, identified the resident with a score of 80 being a high risk for falls. The baseline care plan, dated 7/20/18, included the resident was cognitively impaired; transferred, ambulated, and toileted with assistance. The resident used an assistive device for ambulation. The care plan failed to address the resident's risk for falls. Nurses' notes, dated 7/21/18 at 1:19 PM, documented the resident continued with skilled therapy due to pneumonia. The resident attempted to get up on his/her own a few times this AM. The resident reported he/she had fallen several times in the past. The resident was weak at times when walking. Physical therapy evaluation, dated 7/23/18, documented the resident needed skilled PT (physical therapy) services with bed mobility, transfers, ambulation and functional act in standing. The deficits were a result of the resident's impaired strength and balance. The resident was not aware of diagnosis, when explained the resident asked the same questions and gave the same information within minutes. The resident had deficits in memory and safety awareness. Nurses' notes, dated 7/25/18 at 3:25 PM, documented the resident continued on antibiotics for the pneumonia, did continue to get up on his/her own without assistance, and required assistance with most all ADLs. Nurses' notes, dated 7/26/18 at 6:40 AM, documented as a late entry, that at around 6:40 AM, staff found the resident on the floor, where he/she had hit the back of his/her head causing a laceration with a large amount of blood. The resident was unable to say what happened and stated, I don't know I just wanted to get up out of bed. Staff assessed the resident while on the floor and found a small 4 cm (centimeter) deep and 1 cm long laceration to the left back side of the head, also the left elbow was very swollen, with blood all over the floor. Staff assessed range of motion to all extremities and the resident reported his/her head hurt, the left elbow also hurt, and the left hip was a little sore. The staff notified the resident's family member and physician. The staff assisted the resident to shower to evaluate the [MEDICAL CONDITION] closer before being sent by ambulance to the hospital. The CT cervical spine results, dated 7/26/18 at 9:27 AM, documented the findings included: Vertical minimally displaced fractured the left lateral mass of C1. Nurses' notes, dated 7/26/18 at 2:31 PM, documented the staff talked with the resident's family member who reported the family was currently making the decision to go on hospice services and/or possible surgery, related to a fractured C1. Nurses' notes, dated 7/26/18 at 3:50 PM, documented the resident returned to the facility with a C1 fracture, in a neck brace, in a lot of pain, moaning out to, help me, and with admission for hospice services. Nurses' notes, dated 7/27/18 at 4:46 AM, documented the resident's attempts to verbalize were unclear and garbled. The staff provided routine repositioning using a turn sheet/log roll. The staff had the bed in the low position and with a functioning pressure pad alarm in place on the bed. On 8/28/18 at 11:30 AM, administrative licensed nurse staff A explained the resident was in the facility such a short time, the staff did not really determine the resident's habits, but the plan was that staff would be checking on the resident often to ensure his/her needs were met. He/she was not to ambulate independently but did not always call for assistance when needed and staff determined that he/she needed more help than he/she had been getting. On 8/28/18 at 5:09 PM, direct care staff B explained the morning of the accident, the resident was yelling around 5:35 AM at the doorway and was very agitated, at that time. Staff B tried to calm the resident and he/she did go back to bed. The staff heard and found the resident on the floor between 6:15 and 6:30 AM, the same morning. On 8/30/18 at 3:00 PM, phone interview with the resident's physician, revealed the staff provided appropriate care and services to the resident following the fall, and the shower the staff provided to the resident prior to going to the hospital did not change the resident's outcome from the incident. The facility failed to implement appropriate interventions for this cognitively impaired resident, who repeatedly got up without assistance, fell and experienced a laceration to the head and a fractured C1. This deficient practice also affected resident #1, with the facility failure to maintain/provide the implemented interventions for staff to transfer the resident with the use of a gait belt, and the resident experienced a fall.

The facility had a census of 34 residents. The sample included 12 residents of which 5 residents were reviewed for accidents. Based on observation, record review, and interview the facility failed to develop and implement appropriate interventions to prevent accidents for 2 of the 5 sampled residents. (#48 and #16) Resident #48 fell from the whirlpool bathtub chair when staff failed to use a seatbelt, and he/she sustained fractures of the nose. Resident #16 for inappropriate use of a sit to stand lift. The facility failed to maintain a safe environment on the interior and exterior of the building for the residents who reside in the facility. Findings included: - Resident #48's [DIAGNOSES REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 1/19/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 6 which indicated severely impaired cognition. The assessment revealed the resident required limited assistance with 1-2 staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The assessment further revealed the resident required extensive assistance with 2 staff for walking and total assistance of 1 staff for bathing. The assessment revealed the resident did not have steady balance, but was able to stabilize without staff assistance, and had 2 or more non-injury falls since the prior assessment. The falls (CAA) Care Area Assessment, dated 2/1/16, indicated the resident had a history of [REDACTED]. The CAA further stated the resident remained a high fall risk and the goal was for him/her to be free from injurious falls. The 1/18/16 care plan directed staff to provide a safe environment including: call light within reach, adequate low glare light, bed in lowest position with the wheels locked, and indicated the resident needed extensive assistance of 1 staff for bathing/showering. The care plan update on 1/27/16 directed staff to make sure the whirlpool belt secured the resident in the whirlpool chair at all times during bathing. The Fall Risk Assessments, dated 1/18/16 and 2/2/16, indicated the resident was a high risk for falls. Review of the fall investigation revealed the resident had an injury fall on 1/27/16 at 3:15 PM, witnessed by a staff member. The investigation stated the CNA assisted the resident with the whirlpool bath, had opened the door to the whirlpool and turned the whirlpool chair around to assist the resident with placing his/her feet outside of the whirlpool. The report further stated the resident fell forward bumping his/her head and face on the wall and floor. The investigation report further revealed there was not a belt attached to the whirlpool chair and the resident was not wearing a belt while receiving a whirlpool bath. The 1/27/16 at 3:45 PM nurse's note revealed the physician assistant came to the facility to assess the resident at 3:45 PM, approximately 30 minutes after the fall, ordered a (CT scan) computed tomography, (a test that uses x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) of the resident's head and nose. The note further stated a licensed staff member took the resident to the hospital at 4:15 PM to receive the CT scan. The 1/27/16 untimed physician's orders [REDACTED]. The physician further directed nursing staff to cleanse the resident's skin tears with saline and apply dressings to the resident's right hand and left knee. The 1/27/16 at 7:00 PM nurse's note revealed the resident's nose was swollen with an abrasion to the left side and he/she remained confused. On 1/28/16 at 12:21 PM, the facility received the CT scan results which revealed the resident had fractures involving both nasal bones, the bridge of the nose, and the anterior superior nasal septum (the top, front portion of the bone that seperates the nasal cavities). The 1/28/16 at 12:23 PM nurse's note revealed the staff administered Tylenol to the resident for complaints of pain all over his/her body. The 1/30/16 at 6:00 PM nurse's note revealed the resident had bruising to his/her eyes, and dressings intact to the abrasions on the resident's nose, head, left knee, and both shoulder areas. On 2/2/16 at 4:19 PM, observation revealed the resident in his/her room, walking from the bed to the recliner, using his/her walker without any staff assistance. Further observation revealed the resident sat in his/her recliner, stood up, and placed the gait belt around his/her own waist. Continued observation revealed Licensed Nurse Q went into the resident's room, asked what he/she could do to help him/her, then walked with the resident down the hallway to the living room area. Observation revealed the resident's face with purple bruising below both eyes and the bridge of the nose, with an intact scab on the bridge of the nose. On 2/3/16 at 11:25 AM, observation revealed the whirlpool bathtub had a belt in place to the chair. On 2/3/16 at 3:06 PM, Nurse Aide J stated he/she had asked for a belt for the whirlpool seat while in orientation and staff told him/her the facility does not use a belt for the whirlpool chair. Nurse Aide J further stated after the resident fell , the staff found the belt to the whirlpool chair in a basket in the whirlpool room. On 2/3/16 at 3:45 PM, Nurse Aide L stated there was a belt for the whirlpool chair and staff found the belt in a closet or a basket in the whirlpool room the same day the resident fell . Nurse Aide L further stated prior to the fall, the whirlpool chair belt had been missing for a couple of months. On 2/3/16 at 1:35 PM, Administrative Nurse A stated at the time of the resident's fall, there was not a belt in place in the whirlpool chair. He/she further stated after the fall, the facility ordered a new whirlpool chair belt and two whirlpool belts were found the same day, after the fall occurred. At 4:19 PM, Administrative Nurse A stated that he/she was unsure how long the whirlpool chair belt had been missing or was not in use. On 2/4/16 at 3:57 PM, Physician O stated the resident was medically stable two months ago and has had a significant decline that progressed rapidly. Physician O further stated he/she thought the staff may not have recognized the resident's decline as quickly as they could have and if the decline was recognized then the fall may have been preventable. The facility's 2/2016 Bath-Whirlpool-Tub Policy instructed staff to assist the resident into the whirlpool chair and once the resident is in a comfortable position, place the belt around resident's waist and fasten. The policy further instructs staff to immediately notify the charge nurse if the resident refused to wear the belt. The facility failed to ensure the resident's environment remained free of accident hazards for cognitively impaired Resident #48, who received multiple nasal fractures from a fall out of the whirlpool chair, without a seat belt. - On 2/1/16 at 10:00 AM, during the initial tour, observation revealed the following: The side walk, outside the front entrance to the facility, had areas of missing concrete with the following measurements: Approximately 3 feet long by 6 inches wide Approximately 2 feet long by 3-4 inches wide Approximately 1 foot long by 3-4 inches wide The resident sit to stand lifts and full lifts were left in the hallway, outside residents' rooms, in both halls, when not in use. On 2/3/16 at 8:05 AM, during the environmental tour, Environmental Services Staff I verified the above findings. The facility's November 2015 Maintenance Upkeep Policy stated staff would check the floor/steps and observe for cracks, chips, uneven surfaces, broken moldings, torn carpets, and etc. The facility failed to maintain a safe environment on the interior and exterior of the building, for the residents who reside in the facility. - Resident #16's quarterly (MDS) Minimum Data Set assessment, dated 12/29/15, indicated the resident had short and long term memory problems with severely impaired decision making skills. The assessment revealed the resident was dependent upon staff for toileting and required extensive assistance of 2 staff for bed mobility and transfers. The assessment further revealed the resident had unsteady balance, only able to stabilize with staff assistance, and had bilateral upper and lower extremity impairment. The 10/6/15 (CAA) Care Area Assessment for falls stated the resident at risk for falls and had not had not had any falls during the assessment period. The CAA further stated the resident remained at risk due to medication use, poor cognition, decision making, and the inability to stand or walk. The 1/6/16 care plan directed staff to transfer the resident with a full or sit to stand lift and 1-2 staff assistance. The 12/28/15 and the 10/6/15 Morse Fall Scale documented the resident had a score of 30 which indicates a moderate risk for falling. On 2/2/16 at 4:19 PM, observation revealed Nurse Aides V and W assisted the resident to a sitting position on the side of the bed and brought the sit to stand lift to the bed. Further observation revealed Nurse Aide W placed both of the resident's knees in the left side of the foot platform, fastened the sling around the resident's waist, but did not tighten the belt to keep it from riding up under the resident's armpits. Nurse Aide W fastened the strap around the resident's ankles and started to raise the resident to a standing position. Continued observation revealed as the staff lifted the resident, the sling slid up under his/her armpits and the resident lifted his/her right foot. The resident dangled from the lift and his/her right foot drug along the floor. Observation revealed Nurse Aide V and Nurse Aide W lowered the lift back down and tried to reposition the resident by placing one of the resident's knees on each side of the foot platform and placed his/her feet back on the platform. Nurse Aide V started to raise the resident again into a standing positron, the resident's head rested on the cushion on the back of the lift, and his/her arms were brought up and away from the resident's body. Nurse Aide V lowered the resident into a broda chair (a positioning chair), and unstrapped the sling from the resident. On 2/3/16 at 4:30 PM, Nurse Aide D stated the staff provide total care to the resident, and he/she is unable to ambulate. Nurse Aide D further stated the care plan directs staff to use either the full or sit to stand lift but staff use the sit to stand because it is easier to use. On 2/4/16 at 8:42 AM observation revealed Nurse Aide P and an assistant aide entered the resident's room to transfer the resident with a sit to stand lift. Further observation revealed staff placed the residents's feet on the foot platform, fastened the sling around the resident's waist, but did not tighten the belt to keep it from riding up under the resident's armpits. Continued observation revealed, as the lift raised the resident to a standing position, the resident was unable to hold on or bear weight with both legs, his/her elbows were brought up and away from his/her body, causing the resident to dangle from the belt with his/her ars bent and ebows up and tpointed away from his/her body. Observation revealed staff transferred the resident to his/her bed, positioned him/her on his/her right side, and placed a pillow between his/her knees. On 2/2/16 at 4:22 PM, Nurse Aide V stated the resident needs to be re-evaluated because he/she is no longer able to stand. On 2/4/16 at 11:02 AM, Nursing Staff N stated the resident required the use of a lift for transfers and should be reassessed to make sure the proper lift is being used. On 2/3/16 at 3:19 PM Occupational Therapist X stated the facility, along with therapy, decide which lift is appropriate for the resident. On 2/4/16 at 10:20 AM Administrative Nurse A stated when a resident was care planned for both lifts, the staff determine which to use by how the resident was acting at the time. Administrative Nurse A further verified a resident who can nt bear weight or stand to stand should not be using a sit to stand lift. The facility's May 2015 Lift Policy and Sit to Stand Lift-if the strap slips upward under arms, let the resident back down, reposition, and adjust the strap as needed. The facility's July 2015 Positioning of Residents stated that if a resident is not able to stand without assistance then a mechanical lift will be used. The policy further stated a resident who was not able to stand at all, a full mechanical lift would be used. The facility failed to ensure the staff appropriately assessed Resident #16 for the safe use of a sit to stand lift for transfers.