Every finding on record at The Cedars

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to implement interventions for diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or he body cannot respond to the insulin) management for one resident, Resident (R) 2, and failed to implement individualized fall interventions for one resident, R31.Findings included:- The Electronic Medical Record (EMR) for R2 documented a diagnosis of diabetes mellitus.The admission Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status score (BIMS) of 13, which indicated intact cognition. R2 was dependent upon staff for toileting hygiene, mobility, transfers, and did not ambulate. The MDS further documented that R2 received insulin (controls blood sugar by moving glucose from the blood into the cells) daily.R2's Care Plan dated 01/09/26 directed staff to provide R2 a protein snack during the night to keep her blood sugars even. The care plan lacked direction for staff related to her diabetes.The Physician Order dated 12/09/25 directed staff to obtain R2's blood sugars before meals and at bedtime for the diagnosis of diabetes mellitus.Review of the medical record lacked documentation of blood sugar parameters for R2.On 01/21/26 at 08:15 AM, R2 sat in her wheelchair in the dayroom next to her husband.On 01/22/26 at 08:31 AM, Licensed Nurse (LN) H verified R2 did not have blood sugar parameters and would use his nursing judgement to notify the physician if he felt R2's blood sugar was too high. LN H further verified that the Certified Medication Aide (CMA) obtained R2's blood sugars, but the nurse administered the insulin.On 01/22/26 at 08:51 AM, CMA R stated she did not know what the parameters should be for R2's blood sugars. CMA R further stated R2 had blood sugar parameters when they had a different computer program, but with the new system, there were none.On 01/22/26 at 10:59 AM, Administrative Nurse D stated R2 should have physician-ordered blood sugar parameters and that the care plan should provide direction to staff on what to be aware of with R2's diabetes mellitus.The facility's Resident Care Plan policy, dated 10/03/23, documented upon admission each resident would be evaluated by the interdisciplinary team and a care pan would be initiated within 48 hours of admission. The baseline care plan would be revised as needed until the comprehensive care plan was developed. Prior to the comprehensive care plan being completed, the baseline care plan would be shared with the resident and/or resident's representative. The care plan must be reviewed, revised, and documented if a resident's needs [NAME]. The MDS Coordinator was responsible for developing the schedule and advising the other disciplines so all residents can be reviewed according to state and federal standards.- The Electronic Medical Record (EMR) documented R31 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental and emotional reaction characterized by apprehension, uncertainty, and irrational fear), and repeated falls.The admission Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R31 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R31 was dependent on staff assistance for ambulation, toileting hygiene, and lower-body dressing. R31 required substantial staff assistance for mobility and supervision with transfers. R31 was at risk for falls, did not have any functional impairment, and had two or more falls since admission.R31's 12/15/25 Care Plan directed staff to determine and address causative factors of the fall, provide activities that promoted exercise and strength building where possible. The plan of care documented to obtain a physical therapy consultation for strength, mobility, and requested the pharmacist to evaluate medications and share findings with the primary care physician.The care plan lacked further interventions related to R31's falls.The Fall Assessment dated 12/02/25 documented R31 was a high risk for falls.The Fall Investigation dated 12/02/25 at 08:16 PM documented R31 was observed on the floor, positioned in front of the room door, as it appeared she had scooted herself on the floor. R31 was very confused at the time and did not have any signs or symptoms of pain. Staff brought R31 out to the day room. The immediate care plan was to get a fall mat.The Fall Investigation dated 12/10/25 at 01:41 AM documented that at 11:15 PM, staff observed R31 on the floor seated by the entry of her room door and scooted herself closer towards her room door. The fall was unwitnessed, and she did not sustain any injury. The immediate intervention was signs placed in the room to remind her to call for help before she tried to transfer herself.The Fall Investigation dated 12/15/25 at 12:29 PM documented that at 07:30 AM, R31 scooted herself on her room floor. R31 indicated to the staff that she needed to go to the bathroom. The investigator documented that the fall was unwitnessed, and she did not sustain any injuries. The immediate intervention was that signs were placed in the room to remind her to call for help before she tried to transfer herself.The Fall Investigation dated 12/19/25 at 08:50 PM documented R31 scooted herself on the floor in her room. Her bed was in the lowest position, her call light was within reach, and her floor mat was next to the bed. R31 stated she did not know what happened.On 01/21/26 at 10:45 AM, R31 was in bed that was lowered to the floor, and a fall mat was beside the bed. Certified Nurse Aide (CNA) M and CNA N put a gait belt around the resident's waist, CNA M swung her legs off the bed, and she sat on the side of the bed. R31 was able to stand up and hold onto the walker. R31 ambulated to the bathroom; her gait was steady.On 01/21/26 at 10:45 AM, CNA M stated that R31 had numerous falls, so they had her in a low bed and a fall mat by the bed. CNA M further stated R31 had a Wander Guard (a bracelet that helps monitor residents who are at risk of wandering) that went off a lot because when R31 was in her wheelchair, she got close to the doors. The staff tried to put her in a recliner in the dayroom so they could keep an eye on her.On 01/22/26 at 08:31 AM, Licensed Nurse (LN) H stated that R31 had to be out in the dayroom because she had a lot of falls in her room. R31 got very anxious at times and would spend one-on-one time with her.On 01/22/26 at 10:59 AM, Administrative Nurse D stated R31 had a lot of falls in her room that staff should have put interventions into place for those falls. All the incidents in her room were considered falls, even though she scooted herself on the floor.The facility's Resident Care Plan policy, dated 10/03/23, documented upon admission, each resident would be evaluated by the interdisciplinary team, and a care plan would be initiated within 48 hours of admission. The baseline care plan would be revised as needed until the comprehensive care plan was developed. Prior to the comprehensive care plan being completed, the baseline care plan would be shared with the resident and/or the resident's representative. The care plan must be reviewed, revised, and documented if a resident's needs change. The MDS Coordinator was responsible for developing the schedule and advising the other disciplines so all residents could be reviewed according to state and federal standards.

The facility had a census of 33 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain blood sugar parameters from the physician for one resident, Resident (R) 2, who had her blood sugar taken four times per day.Findings included:- The Electronic Medical Record (EMR) for R2 documented diagnosis of diabetes mellitus (DM -when the boy cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The admission 5-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R2 is dependent upon staff for toileting hygiene, mobility, transfers, and does not ambulate. The MDS further documented that R2 received insulin (controls blood sugar by moving glucose from the blood into the cells) daily.R2's Care Plan dated 01/09/26 directed staff to provide R2 a protein snack during the night to keep her blood sugars even. The care plan lacked direction for staff related to her diabetes.The Physician Order dated 12/09/25 directed staff to obtain R2's blood sugars before meals and at bedtime for the diagnosis of diabetes mellitus.Review of the medical record lacked documentation of blood sugar parameters for R2.On 01/21/26 at 08:15 AM, R2 sat in her wheelchair in the dayroom next to her husband.On 01/22/26 at 08:31 AM, Licensed Nurse (LN) H verified R2 did not have blood sugar parameters and would use his nursing judgement to notify the physician if he felt R2's blood sugars were too high. LN H further verified that the Certified Medication Aide (CMA) obtained R2's blood sugars, but the nurse administered the insulin.On 01/22/26 at 08:51 AM, CMA R stated she did not know what the parameters should be for R2's blood sugars. CMA R further stated R2 had blood sugar parameters when they had a different computer program, but with the new system, there were none.On 01/22/26 at 10:59 AM, Administrative Nurse D stated R2 should have physician-ordered blood sugar parameters and that the care plan should provide direction to staff on what to be aware of with R2's diabetes mellitus.Upon request, on 01/22/26, a policy for Blood Sugar Management was not provided by the facility.

The facility had a census of 33. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to provide care for Resident (R) 23 who had a Brief Interview for Mental Status (BIMS) score of eleven, which indicated moderately impaired cognition in a manner that protected and promoted their dignity.Findings included: - On 01/21/26 at 07:55 AM, observation revealed R23 sat at the dining room table. Licensed Nurse (LN) G obtained R23's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R23's right index finger. LN G stated, Your blood sugar reading is high. We probably need to contact your doctor and see if he wants to start you on insulin. Continued observation revealed five residents seated in the dining room awaiting breakfast to be served, while other staff and a visitor were in the dining room as well.On 01/22/26 at 10:00 AM, Administrative Nurse D stated staff should not check a resident's blood sugar reading in the dining room. Administrative Nurse D stated staff should take the resident to their room or to a private area.The facility's admission Agreement packet contained the Your Rights and Protection as a Nursing Home Resident policy, dated 04/21/25, which documented a nursing home resident had the right to be treated with dignity and respect.

The facility has a census of 33 residents. The sample included 12 residents, with three reviewed for Beneficiary Notices. Based on interview and record review, the facility failed to provide two sampled residents, Resident R9 and R28 (or their representative), with the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123, Centers for Medicare and Medicaid Services (CMS).Findings include:- The facility lacked the documentation staff provided R9, or his representative, form 10123, which included a detailed explanation of non-coverage and explained the appeal process. The resident's skilled services ended on 11/20/25.The facility lacked the documentation staff provided R28, or his representative, form 10123, which included a detailed explanation of non-coverage and explained the appeal process. The resident's skilled services ended on 01/13/26.On 01/23/26 at 01:40 PM, Administrative Staff A verified that Form 10123 was not provided to the two residents and should have been given to the resident or the representative.The Medicare form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy. The form included detailed explanations of non-coverage and explained the appeal process.Upon request, on 01/23/26, a policy for Beneficiary Notices was not provided by the facility.

The facility had a census of 33 residents. The sample included 12 residents, with one reviewed for discharge. Based on the interview and record review, the facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of Resident (R) 49's stay.Findings included:- The Electronic Medical Record (EMR) for R49 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acute blood loss anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to the body tissues), and lower gastrointestinal bleed (bleeding into the stomach and/or digestive tract).The admission 5-Day Medicare Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R49 required partial staff assistance with toileting hygiene, showers, dressing, personal hygiene, and transfers.R49's Care Plan dated 10/14/25 documented R49 was to be discharged from the facility. The care plan directed staff to encourage verbalizations of fears and concerns, and to clarify any misconceptions. The care plan directed staff to provide her and her family with an opportunity to attend care plan conferences, discharge planning, and offer alternative care options.The Nurse's Note dated 10/06/25 at 12:54 PM documented R49 was admitted to the facility with the diagnosis of lower gastrointestinal bleed and anemia.The Nurse's Note dated 11/05/25 at 03:03 PM documented R49 was discharged with her husband to go home.R49's clinical record lacked a completed recapitulation of R49's stay in the facility.On 01/22/26 at 10:59 AM, Administrative Nurse D verified that a recapitulation upon discharge was not completed when R49 discharged from the facility.The facility's Discharge Planning policy, dated 04/25/25, documented that discharge planning was the process of creating an individualized discharge care plan, which was part of the comprehensive care plan. It involved the interdisciplinary teams working with the resident and resident representative to develop interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition from the facility to the post-discharge setting. All discharge planning activities are documented in the resident's clinical record.

The facility had a census of 33 residents. The sample included 12 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attends to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 23.Findings included:- R23's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), metabolic encephalopathy (when the brain has trouble functioning because of a chemical, or metabolic problem in the body), diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), atrial fibrillation (rapid, irregular heartbeat), and chronic pain.R23's Significant Change Minimum Data Set (MDS) dated [DATE] recorded R23 had a Brief Interview for Mental Status (BIMS) score of eleven, which indicated moderately impaired cognition. The MDS recorded she required extensive staff assistance with toilet hygiene and supervision with oral hygiene, personal hygiene, and activities of daily living (ADL). The MDS documented R23 received hospice services.R23's Activities of Daily Living (ADL) Care Plan dated 12/15/25 recorded R23 had declined in her ability to care for herself after a fall in assisted living. R23 care plan documented R23 exhibited increased confusion, sustained several falls, and required increased staff assistance with most ADL care.Review of R23's clinical record revealed the resident was admitted to hospice care on 11/14/25 with a diagnosis of senile degeneration of the brain. Review of R23's care plan lacked information the resident was on hospice services. On 01/21/26 at 07:55 AM, R23 was dressed in street clothes, seated at the dining room table, eating breakfast.On 01/21/26 at 12:35 PM, Administrative Nurse D verified the facility lacked any information on the facility care plan that the resident received hospice services. Administrative Nurse D verified R11 had been on hospice since 11/14/25 and stated the facility should coordinate with the hospice care plan and the facility care plan.The facility's End Of Life policy, dated 06/03/25, documented the facility's goal was to provide comfort care when the, resident and/or family decides is time to move from a treatment mode to addressing symptoms that cause discomfort, at the time the decide, the physician would be consulted regarding offering the option to use their Hospice benefits if they qualify. The goals of care are to assess and treat pain and symptoms that cause the resident discomfort in the final stages of life. All areas are assessed: the physical, emotional/social, and spiritual. Care is given through an interdisciplinary approach. End of life care does not prolong or hasten death; rather, it lets the natural course of events occur while assuring that the resident is as comfortable as possible. Each resident would receive individualized care that respects his or her goals, likes and choices. Consideration for weight loss and associated sequelae shall be included in end-of-life orders and or care plan. A care plan is developed by the interdisciplinary team that addresses actual and potential problems.

The facility had a resident census of 33. The sample included 12 residents, of whom seven were reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow the plan of care for one resident, Resident (R) 9, who had falls in his room and a fall with injury because his shoes were too big. The facility failed to provide a safe environment for R43, who had two falls involving the sit-to-stand lift (which helps transfer residents from one seated surface to another) and did not follow the plan of care.Findings included:- The Electronic Medical Record (EMR) documented R9 had diagnoses of Dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R9 had a Brief Interview for Mental Status Score (BIMS) of 14, which indicated intact cognition. R9 required partial staff assistance for toileting hygiene, showers, dressing, personal hygiene, and supervision for transfers and ambulation. R9 was independent with mobility, had no functional impairment, and had two or more non-injury falls since the prior assessment.The Quarterly MDS dated 11/20/25 documented R9 had a BIMS score of 15, which indicated intact cognition. R9 was dependent upon staff assistance for toileting hygiene and substantial staff assistance for mobility, transfers, putting on shoes, dressing, showers, and personal hygiene. R9 required partial staff assistance for ambulation, was at risk for falls, and had two or more non-injury falls since the prior assessment.R9's Fall Risk Assessments dated 10/23/25 and 01/14/26 documented R9 was a high risk for falls.R9's 11/24/25 Care Plan included the following interventions:05/08/25 - Directed staff to place call light within reach, place personal items and frequently used items within reach, and obtain a physical and occupational therapy consultation.06/11/25 - Educate R9 to use the call light for assistance when transferring.07/23/25 - Directed staff to place a winged mattress on the bed.10/19/25 - Directed staff to put slipper socks on at bedtime, put a night light on in the bathroom.10/23/25 - Directed staff to offer R9 a urinal every two hours.10/27/25 - Directed staff to assist R9 to a recliner in the dayroom when restless at night.11/16/25 - Directed staff to offer R9 to sit in the dayroom when the family is not there.11/21/25 - Directed staff to encourage the use of the dayroom when he is restless, and family is not with him.12/22/25 - Documented R9's family was called to bring in shoes that fit correctly.The Fall Investigation dated 11/16/25 at 09:20 AM documented that the nurse heard a crash from R9's room and he was found on the floor next to his recliner. R9 did not obtain any injury, and R9 stated his legs gave out.The Nurse's Note dated 11/20/25 at 02:04 PM documented that the nurse heard a sound from R9's room. R9 was observed to the side of his recliner under the side table. R9 stated he tried to get out of his recliner. Staff took R9 out to the dayroom so that he could be visualized in high traffic area. The EMR lacked documentation of the fall, which was investigated.The Fall Investigation dated 11/21/25 at 06:45 PM documented R9 was in the recliner, and the nurse heard a loud crash. The nurse found R9 on the floor next to his air conditioner heater unit. R9 stated he tried to get his bed ready. R9 did not sustain any injury.The Fall Investigation dated 12/22/25 at 7:33 AM documented that staff had a gait belt on R9 and had his walker. While staff walked with him, he tripped over his feet and fell onto his left side. The investigation stated that he sustained skin tears, lacerations, a hematoma, and a split fingernail. The investigation stated R9's shoes were too big.The Nurse's Note dated 12/22/25 at 07:33 AM documented R9 was sent to the emergency room for evaluation as he sustained the following injuries from his fall. A laceration (cut) to the left side of the eyebrow, which measured 0.2 centimeters (cm) by 1 cm by 0.2 cm. He sustained a hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) that measured 4 cm by 3 cm. He sustained a skin tear to the left elbow, which measured 3 cm by 3 cm.The Nurse's Note dated 12/22/25 at 10:36 AM documented R9 had a computed tomography (CT scan- a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels), which was negative for abnormalities. The laceration was closed with Dermabond (a sterile, liquid, topical skin adhesive that acts as a surgical glue to hold closed, easily approximated skin edges of wounds from trauma-induced lacerations), and instructions for wound care were given.On 01/22/25 at 07:52 AM, R9 had a gait belt around his waist. Certified Medication Aide (CMA) R assisted him to stand, and he started to walk with the use of his walker. R9's gait was steady, and CMA R gave him verbal cues on where to go.On 01/21/26 at 01:21 PM, Certified Nurse Aide (CNA) M stated R9 was a one staff assistance with ambulation and that he was in the dayroom for staff visualization, and his wife sits beside him.On 01/22/26 at 08:31 AM, Licensed Nurse (LN) H stated R9 had to sit out in the dayroom because he was not to be left alone in his room except to use the bathroom and to sleep at night due to his falls.On 01/22/26 at 10:59 AM, Administrative Nurse D stated that R9's shoes were too big and that contributed to his fall in December. Administrative Nurse D further stated that staff should have followed the intervention in the care plan for falls.The facility's Falls-Accident Reporting Policy & Procedure, dated 10/03/23, documented that fall interventions would be initiated with documentation on the care plan. Following any fall, a Fall Report would be completed by the licensed nurse to be reviewed by the Quality Assurance Coordinator for further investigation.The facility's Resident Fall Checklist policy, dated 11/13/25, directed staff to have a licensed nurse perform a head-to-toe assessment before being assisted off the floor. Notify the durable power of attorney of the incident and document it in the progress note. Notify the physician, determine the most appropriate intervention to prevent further falls, and update the care plan. Obtain witness statements for all falls with injury or possible injury. Immediately notify the Director of Nursing or designee for all falls with injury, and the Risk Manager for all falls with major injury. Licensed staff would document the progress notes every shift for three days and would notify therapy.- The Electronic Medical Record (EMR) documented R43 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), macular degeneration (progressive deterioration of the retina), repeated falls, and weakness.The Quarterly Minimum Data Set (MDS) 07/08/25 documented R43 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R43 required substantial staff assistance with transfers, toileting hygiene, and mobility, and R43 did not ambulate. The MDS further documented R43 had lower functional impairment on both sides and did not have any falls.The Annual MDS dated 10/08/25 documented R43 had a BIMS score of four, which indicated severely impaired cognition. R43 required substantial staff assistance with showers, toileting hygiene, transfers, and did not ambulate. The MDS further documented R43 had no functional impairment and had one non-injury fall.The Fall Assessments dated 04/09/25, 07/10/25, and 10/08/25 documented R43 was a high risk for falls.R43's 11/05/25 Care Plan included the following interventions:02/20/25 - Directed staff to place a fall mat beside the bed.08/11/25 - Documented education to staff about proper sling placement.11/05/25 - Directed staff to anticipate R43's needs and know her routine, reinforce the use of her call light if she was able to remember to use it, and keep the call light within easy reach. The care plan further directed staff to put the bed in a low position at night and personal items within reach.11/17/25 - Documented R43 required two staff with the use of a sit-to-stand lift (which helps transfer residents from one seated surface to another) for safety.The Fall Investigation dated 08/11/25 at 02:30 PM documented that during a sit-to-stand transfer, R43's knees gave out. She slid out of the sling and slid off the toilet onto the floor. R43 did not have any injury. The immediate care plan was to make sure the sling was on securely and correctly.The Nurses Note dated 08/11/25 at 03:08 PM documented that R43 slid out of the sling and was on the floor. R43 sat on the bathroom floor with her legs extended towards the door, with her back against the toilet. Staff reported that when R43 was being transferred back to her wheelchair using the sit-to-stand lift, R43 slid out of the sling and slid down the toilet and onto the floor.The Fall Investigation dated 11/17/25 at 03:55 PM documented that during a sit-to-stand transfer to the toilet, R43 let go of the lift, slid through the belt on the sling, and went down onto her bottom. R43 did not have any injuries. The immediate plan of care was to make sure the proper sling was in the room.On 01/21/26 at 11:10 AM, Certified Nurse Aide (CNA) M placed a gait belt around R43's waist. CNA M and CNA N transferred R43 from the recliner to the wheelchair. CNA M stated she was unaware of any falls during transfer with the sit-to-stand lift. CNA M further stated R43 was a one-to-two-person transfer but could use the sit-to-stand lift if needed. CNA M stated R43 sat in the dayroom so staff could keep an eye on her, and she liked to watch television.On 01/22/26 at 07:41 AM, CNA M placed a gait belt around R43's waist, and Licensed Nurse (LN) H transferred her from the recliner to the wheelchair.On 01/22/26 at 08:31 AM, LN H stated that staff transferred R43 with two people and tried to keep her in the dayroom so that staff could watch her. LN H further stated that he was unaware of any falls during the use of the sit-to-stand lift with R43.On 01/22/26 at 10:59 AM, Administrative Nurse D stated when R43 slid through the sling, the staff had not put on the sling correctly, and stated that the second fall with the lift, there was only one staff person with the resident, and was unable to catch her before she slid out. Administrative Nurse D further stated that staff use a two-person transfer except while toileting, then they use the sit-to-stand. Administrative Nurse D stated the care plan should have been updated to reflect that.The facility's Falls-Accident Reporting Policy & Procedure, dated 10/03/23, documented that fall interventions would be initiated with documentation on the care plan. Following any/all, a Fall Report would be completed by the licensed nurse for review by the Quality Assurance coordinator for further investigation.The facility's Resident Fall Checklist policy, dated 11/13/25, directed staff to have a licensed nurse perform a head-to-toe assessment before being assisted off the floor. The policy documented to notify the durable power of attorney of the incident and to document it in the progress note. Notify the physician, determine the most appropriate intervention to prevent further falls, and update the care plan. Obtain witness statements for all falls with injury or possible injury. Immediately notify the Director of Nursing or designee for all falls with injury, and the Risk Manager for all falls with major injury. Licensed staff would document the progress notes every shift for three days and would notify therapy.

The facility had a census of 33 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R) 11's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. The facility further failed to ensure R5 and R31's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date.Findings Included: - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and encephalopathy (a broad term for any brain disease that alters brain function or structure). R11's admission Minimum Data Set (MDS) dated [DATE] recorded R11 had severely impaired cognition. The MDS recorded R11 required staff assistance with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The Cognitive loss/Dementia Care Area Assessment (CAA) dated 12/30/25 recorded R11 had been admitted to the facility post-hospitalization for encephalopathy and dementia. The CAA documented R11 received antipsychotic medication twice a day and antidepressant medication once daily. The CAA documented R11 would go back and forth between being cooperative and being non-compliant, refusing care, and rejecting care. R11's Care Plan dated 12/29/25 recorded R11 received antipsychotic medication for the diagnosis of dementia, and staff monitored for side effects and effectiveness every shift. The care plan documented staff monitored for adverse reactions to the medication, such as falls, unsteady gait, refusal to eat, difficulty swallowing, depression, and suicidal ideation. The Physician's Order dated 12/23/25 directed staff to administer Seroquel (antipsychotic) 25 milligrams (mg), twice daily for a diagnosis of dementia with agitation. R11's EMR lacked a documented physician rationale, which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. On 01/21/26 at 08:25 AM, observation revealed R11 sat at the dining room table drinking coffee and eating breakfast. R11 told staff she was agitated, she had to sit at the table with other residents, and would prefer to eat alone. On 01/21/26 at 07:45 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of dementia, which was an inappropriate indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis, and the consultant pharmacist identified the need for the correct diagnosis. The facility's Antipsychotic Medication Administration policy, dated 08/05/25, documented guidelines for use of antipsychotic medications are based on a comprehensive assessment of each resident, interdisciplinary team would ensure: A resident who has not used antipsychotics are not given an antipsychotic drug unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. Any resident who uses an antipsychotic drug receives routine dose reduction and behavioral interventions unless clinically contraindicated, in an effort to discontinue these drugs to ensure the resident does not receive unnecessary medications, and at the lowest possible dose is administered for the shortest amount of time. All physician orders for antipsychotic medications will be clear and accurate and will include a diagnosis, condition, or indication for use: Tourette's (a condition of the nervous system causing uncontrollable repetitive movements or unwanted sounds) Huntington's (a rare, hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder) Schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) Affective Disorder (mental health conditions characterized by significant, persistent disturbances in emotional state) Psychotic disorder with delusions and/or hallucinations (a mental health condition characterized by a loss of contact with reality, where individuals experience severe, abnormal perceptions or fixed, false beliefs) Refractory Severe Depression (treatment resistant depression, occurs when a major depressive episode does not improve after at least two different antidepressant trials at adequate doses) Delusional Disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) Psychosis in the absence of dementia (any major mental disorder characterized by a gross impairment in reality perception) Hallucinations (sensing things while awake that appear to be real, but the mind created) Bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) Manic episode (mood characterized by an unstable, expansive emotional state, extreme excitement, hyperactivities) Medical illnesses with psychosis behavior (any major mental disorder characterized by a gross impairment in reality perception) The DON/Designee and the consultant pharmacist would review the appropriateness of all antipsychotic medication orders. - The Electronic Medical Record (EMR) for R5 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by falling memory and confusion), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R5's Significant Change Minimum Data Set (MDS) dated [DATE] documented R5 had a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. R5 required substantial staff assistance for toileting hygiene, dressing, personal hygiene, mobility, and transfers. The MDS further documented R5 received an antianxiety medication. R5's Care Plan dated 11/05/25 directed staff to administer antianxiety medications as ordered by the physician, educate the resident and family about the risks, benefits, and side effects of antianxiety medication, report as needed any adverse reactions to antianxiety therapy, and watch for targeted behavior symptoms and document per facility protocol. The Physician's Order dated 11/05/25 directed staff to administer alprazolam (antianxiety medication), 0.5 milligrams (mg), by mouth, every eight hours, PRN, for anxiety. The order lacked a stop date. R5's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN alprazolam. On 01/21/26 at 10:00 AM, R5 was in bed and received her medication without issue. R5 was calm and cooperative with the staff. On 01/21/26 at 10:00 AM, Certified Medication Aide (CMA) R stated R5 got anxious and hollered out a lot, and staff sat with her a lot. CMA R further stated that she received PRN medications as well as scheduled medication for her anxiety. On 01/22/26 at 08:31 AM, Licensed Nurse (LN) H verified that the PRN alprazolam did not have a stop date, and the nurse was supposed to ensure there was a 14-day stop date. LN H further stated that the physician should reassess the resident to make sure she still needed the medication. On 01/22/26 at 10:59 AM, Administrative Nurse D stated that the old computer program would automatically put in a 14-day stop date, but with the new program, it did not do that, and there should be a 14-day stop date for the alprazolam medication. The facility's Psychotropic Medication Use policy, dated 04/07/25, documented that all psychotropic medication would be initiated by the facility only after informed consent related to the drug with the resident and/or the responsible party/family has been obtained. For PRN orders, the ordering practitioner would assess the resident's response to the PRN medication and would document a risk-benefit rationale statement for continued use of the medication and indicate the duration of the PRN order. If the assessment indicated continued use of the medication, a specific duration would be included in the reorder of the medication. - The Electronic Medical Record (EMR) documented R31 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental and emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). The admission Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R31 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R31 was dependent on staff assistance for ambulation, toileting hygiene, and lower-body dressing. R31 required substantial staff assistance for mobility and supervision with transfers. R31 received antianxiety and antidepressant medications (a class of medications used to treat mood disorders) daily. R31's Care Plan dated 12/15/25 directed staff to administer medications as ordered by the physician, report as needed adverse reactions to the anti-anxiety therapy, and watch for the occurrence of target behavior symptoms. The Physician's Order dated 12/21/25 directed staff to administer lorazepam (antianxiety medication) 0.5 milligrams (mg), by mouth, PRN every four hours, for the diagnosis of anxiety. The order lacked a stop date. R31's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam. On 01/21/26 at 03:00 PM, R31 propelled herself around the dayroom in her wheelchair. As R31 got close to the front door, the wander guard (a bracelet that helps monitor residents who are at risk of wandering) alarm kept going off, and staff would redirect her. On 01/21/26 at 10:00 AM, Certified Medication Aide (CMA) R stated R31 got anxious and did not like to sit in the recliner for very long. CMA R further stated that she received PRN for her anxiety. On 01/22/26 at 08:31 AM, Licensed Nurse (LN) H verified that the PRN lorazepam did not have a stop date, and the nurse was supposed to ensure there was a 14-day stop date. LN H further stated that the physician should reassess the resident to make sure she still needed the medication. On 01/22/26 at 10:59 AM, Administrative Nurse D stated that the old computer program would automatically put in a 14-day stop date, but with the new program, it did not do that, and there should be a 14-day stop date for the lorazepam medication. The facility's Psychotropic Medication Use policy, dated 04/07/25, documented that all psychotropic medication would be initiated by the facility only after an informed consent related to the drug with the resident and/or responsible party/family has been obtained. For PRN orders, the ordering practitioner would assess the resident's response to the PRN medication and would document a risk-benefit rationale statement for continued use of the medication and indicate the duration of the PRN order. If the assessment indicated continued use of the medication, a specific duration would be included in the reorder of the medication.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 33 residents who resided in the facility and received their meals from the kitchen. Findings included:- On 01/20/26 at 09:00 AM, observation revealed that dietary staff in the kitchen prepared the lunch meal. On 01/20/26 at 09:30 AM, Dietary Staff BB verified she was not a certified dietary manager, stated she was taking the course to become certified, and would need to take the test to become certified. Dietary Staff BB stated the facility had two residents with a pureed (smooth, moist, pudding-like food that requires no chewing, designed for residents with severe swallowing or chewing difficulties) diet and three with a minced and moist (soft, moist foods that are easy to swallow and require minimal chewing) diet. On 01/22/26 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified.The facility's Personnel policy, dated 03/26/24, documented the food and nutrition services department would be staffed to ensure that sufficient competent, supportive personnel carry out the functions of the department.

The facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to initiate protective measures and fully investigate an allegation of abuse for Resident (R) 1. This placed the resident at risk for ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), personal history of malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the breast, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set, dated dated dated [DATE], documented R1 had severe cognitive impairment. R1 had verbal behaviors directed toward others and rejected care for one to three days of the observation period. R1 was dependent on staff for oral, personal, and toileting hygiene, and dressing. The MDS further documented R1 was always incontinent of bladder and bowel. The resident received scheduled pain medication, an antianxiety medication (a class of medications that calm and relax people), and an antidepressant (a class of medications used to treat mood disorders). The Behavioral Symptoms Care Area Assessment (CAA), dated 09/13/24, documented a care plan would be developed related to the resident having verbal behaviors due to dementia, HTN, and depression. The CAA further documented R1 had a risk for increased confusion, falls, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and injury. R1's Care Plan dated 03/11/24, directed one to two staff members to assist R1 with bed mobility, transfers, walking, toileting, grooming, personal hygiene, and bathing. The plan further documented R1 would refuse care, become combative, and yell at staff. The plan directed staff to ensure resident safety, then leave R1 with her call light in reach and try to reapproach and attempt talking again later. The Physician Orders dated 07/27/24, directed staff to administer Ativan (an antianxiety) one milligram (mg) twice weekly before showers and one to two mg every two hours as needed for mild to moderate anxiety or agitation for generalized anxiety disorder. The Skin Evaluation dated 10/22/24 and 10/29/24, documented no issues. The Interdisciplinary Note (ID) dated 10/25/24 at 09:04 PM, documented R1 hollered out with care, however, R1 was fine after lying down in bed. On 11/12/24 at 12:45 PM, observation revealed CMA S and CMA R wheel R1 back to her room in a wheelchair. CMA S and CMA R explained to R1 that they were going to assist R1 onto the mechanical lift and take her to the bathroom. The staff proceeded to provide incontinent care; R1 yelled Ouch and Stop. CMA S and CMA R reported it was common for R1 to yell out especially when cares involved something wet like wipes and showers. On 11/12/24 Administrative Nurse D was unavailable for an interview. On 11/12/24 at 10:44 AM, Administrative Staff A reported she was informed by Certified Medication Aide (CMA) R on 11/05/24 of an occurrence with R1 and CMA T that took place on 10/25/24. Administrative Staff A stated CMA R reported to her that Certified Nurse Aide (CNA) M saw CMA T place her hand on R1's arm while R1 was being assisted for transfer and care prior to supper and reported that CMA T had potentially handled R1 roughly. Administrative Staff A confirmed that CMA T was suspended on 11/07/24 pending an investigation of alleged physical abuse. Administrative Staff A stated Administrative Nurse D was aware of the allegation on 10/25/24 and should have informed her of the 10/25/24 allegation of possible physical abuse to R1. On 11/12/24 at 01:55 PM, CMA R stated she was told by CNA M she had witnessed CMA T squeezing R1's arm while R1 was yelling out and being assisted with a lift transfer. CMA R further stated when she had inquired about the status of the investigation regarding the 10/25/24 occurrence, Administrative Nurse D stated it had been taken care of. CMA R further reported that on 11/05/24 she called Administrative Staff A and reported the alleged physical abuse of R1 by CMA T, and Administrative Staff A told CMA R she had no knowledge of the incident. CMA R said that since then, Administrative Staff A has called her several times inquiring about the 10/25/24 situation. On 11/12/24 at 03:05 PM, CNA M stated on 10/25/24 prior to the evening meal, she heard R1 yelling out and went to see if CMA T needed assistance with R1. CNA M stated when she had entered R1's room, CMA T had her hand on R1's left arm. CNA M then proceeded to assist CMA T in providing incontinent care and transfers for the evening meal. CNA M reported after the meal she had noticed R1's left arm was red. CNA M reported the redness on R1's left arm to Licensed Nurse (LN) G and said that CMA T may have handled R1 roughly prior to the evening meal. On 11/12/24 at 01:30 PM, Administrative Staff A provided an email sent to Administrative Nurse D on 10/25/24 at 08:31 PM by LN G which stated at about 05:55 PM on 10/25/24 CNA M reported a concern she witnessed prior to the evening meal of CMA T being more rough than necessary and CNA M felt she should bring it to the nurses' attention. The email continued to state when LN H came on duty, both nurses took R1 into her room and examined her. LN G stated R1 had bruising to her arms, typical per her normal and none stood out, R1 was pleasant and cooperative, and there was no new bruising. LN G stated she and LN H had a conversation with CMA T in the email regarding CMA T asking for help when necessary and what to expect when caring for R1. The facility's Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 05/2023, documented the facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law, and take all necessary corrective actions depending on the results of the investigation. The facility ' s Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 05/2023, documented the facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law, and take all necessary corrective actions depending on the results of the investigation. For protection, as soon as it is reported that there was alleged abuse of a resident by an employee, the employee is to be immediately suspended pending the outcome of the investigation and asked to leave the premises until they are called in for review of the findings upon completion of the investigation. The facility failed to fully investigate and initiate protective measures for R1 after an allegation of abuse. This placed the resident at risk for continued abuse.

The facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure staff identified an allegation of rough care as potential abuse and reported immediately to the Licensed Nursing Home Administrator (LNHA). The facility further failed to report the allegation of abuse to the State Agency (SA) as required. This placed the resident at risk for ongoing abuse and mistreatment. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), personal history of malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the breast, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set, dated dated dated [DATE], documented R1 had severe cognitive impairment. R1 had verbal behaviors directed toward others and rejected care for one to three days of the observation period. R1 was dependent on staff for oral, personal, and toileting hygiene, and dressing. The MDS further documented R1 was always incontinent of bladder and bowel. The resident received scheduled pain medication, an antianxiety medication (a class of medications that calm and relax people), and an antidepressant (a class of medications used to treat mood disorders). The Behavioral Symptoms Care Area Assessment (CAA), dated 09/13/24, documented a care plan would be developed related to the resident having verbal behaviors due to dementia, HTN, and depression. The CAA further documented R1 had a risk for increased confusion, falls, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and injury. R1's Care Plan dated 03/11/24, directed one to two staff members to assist R1 with bed mobility, transfers, walking, toileting, grooming, personal hygiene, and bathing. The plan further documented R1 would refuse care, become combative, and yell at staff. The plan directed staff to ensure resident safety, then leave R1 with her call light in reach and try to reapproach and attempt talking again later. The Physician Orders dated 07/27/24, directed staff to administer Ativan (an antianxiety) one milligram (mg) twice weekly before showers and one to two mg every two hours as needed for mild to moderate anxiety or agitation for generalized anxiety disorder. The Skin Evaluation dated 10/22/24 and 10/29/24, documented no issues. The Interdisciplinary Note (ID) dated 10/25/24 at 09:04 PM, documented R1 hollered out with care, however, R1 was fine after lying down in bed. On 11/12/24 at 12:45 PM, observation revealed CMA S and CMA R wheel R1 back to her room in a wheelchair. CMA S and CMA R explained to R1 that they were going to assist R1 onto the mechanical lift and take her to the bathroom. The staff proceeded to provide incontinent care; R1 yelled Ouch and Stop. CMA S and CMA R reported it was common for R1 to yell out especially when cares involved something wet like wipes and showers. On 11/12/24 Administrative Nurse D was unavailable for an interview. On 11/12/24 at 10:44 AM, Administrative Staff A reported she was informed by Certified Medication Aide (CMA) R on 11/05/24 of an occurrence with R1 and CMA T that took place on 10/25/24. Administrative Staff A stated CMA R reported to her that Certified Nurse Aide (CNA) M saw CMA T place her hand on R1's arm while R1 was being assisted for transfer and care prior to supper and reported that CMA T had potentially handled R1 roughly. Administrative Staff A confirmed that CMA T was suspended on 11/07/24 pending an investigation of alleged physical abuse. Administrative Staff A stated Administrative Nurse D was aware of the allegation on 10/25/24 and should have informed her of the 10/25/24 allegation of possible physical abuse to R1. On 11/12/24 at 01:55 PM, CMA R stated she was told by CNA M she had witnessed CMA T squeezing R1's arm while R1 was yelling out and being assisted with a lift transfer. CMA R further stated when she had inquired about the status of the investigation regarding the 10/25/24 occurrence, Administrative Nurse D stated it had been taken care of. CMA R further reported that on 11/05/24 she called Administrative Staff A and reported the alleged physical abuse of R1 by CMA T, and Administrative Staff A told CMA R she had no knowledge of the incident. CMA R said that since then, Administrative Staff A has called her several times inquiring about the 10/25/24 situation. On 11/12/24 at 03:05 PM, CNA M stated on 10/25/24 prior to the evening meal, she heard R1 yelling out and went to see if CMA T needed assistance with R1. CNA M stated when she had entered R1's room, CMA T had her hand on R1's left arm. CNA M then proceeded to assist CMA T in providing incontinent care and transfers for the evening meal. CNA M reported after the meal she had noticed R1's left arm was red. CNA M reported the redness on R1's left arm to Licensed Nurse (LN) G and said that CMA T may have handled R1 roughly prior to the evening meal. On 11/12/24 at 01:30 PM, Administrative Staff A provided an email sent to Administrative Nurse D on 10/25/24 at 08:31 PM by LN G which stated at about 05:55 PM on 10/25/24 CNA M reported a concern she witnessed prior to the evening meal of CMA T being more rough than necessary and CNA M felt she should bring it to the nurses' attention. The email continued to state when LN H came on duty, both nurses took R1 into her room and examined her. LN G stated R1 had bruising to her arms, typical per her normal and none stood out, R1 was pleasant and cooperative, and there was no new bruising. LN G stated she and LN H had a conversation with CMA T in the email regarding CMA T asking for help when necessary and what to expect when caring for R1. The facility's Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 05/2023, documented the facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law, and take all necessary corrective actions depending on the results of the investigation. The facility failed to ensure staff identified an allegation of rough care as potential abuse and reported it immediately to the LNHA. The facility further failed to report the allegation of abuse to the SA as required. This placed the resident at risk for ongoing abuse and mistreatment.

The facility had a census of 37 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 2 indicated the facility did not have a Registered Nurse (RN) on 5 dates, FY 2023 Quarter 3 indicated no RN for on 91 dates and FY 2023 Quarter 4 for 26 dates. The PBJ also indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days in FY 2023: Quarter 3 for 91 dates and Quarter 4 for 31 dates. The PBJ further indicated Fiscal YR 2024 Quarter 1 did not have an RN for 26 days and did not have a licensed nurse coverage 24 hours a day, seven days a week for 46 dates. A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed an RN for eight consecutive hours daily and a licensed nurse on duty for 24 hours a day seven days a week. On 03/06/24 at 09:30 AM, observation revealed an RN and a licensed practical nurse on duty in the facility. On 03/11/24 at 11:15 AM, Administrative Nurse D stated the facility staff were not sure how to submit the PBJ information and knew that they had submitted it incorrectly. Administrative Nurse D further stated that the facility administration would contact the appropriate people to make sure it was done correctly. Upon request a policy for PBJ was not provided by the facility. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 37 residents. The facility had one main kitchen and three kitchenettes. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchens when staff stored unlabeled, undated food in the refrigerators. Staff did not sanitize the thermometer between food items when checking food temperatures and failed to ensure clean and sanitary preparation areas. This placed the 37 residents at risk for foodborne illness. Findings included: - On 03/05/24 at 08:05 AM, observation in the kitchen revealed the following: An updated, unlabeled plastic bag with liquid coffee. 12 uncovered, undated, and unlabeled slices of cheese. An undated, unlabeled plastic container of barbeque sauce. On 03/05/24 at 08:05 AM, Dietary Staff (DS) BB verified the above finding and stated food items placed in the refrigerator should be labeled, dated, and completely covered. DS BB disposed of the food items in the trash. On 03/06/24 at 09:55 AM, observation in the kitchen revealed DS BB checked the food temperatures of the noon food items without cleansing or disinfecting the thermometer between different food items. DS BB stated he should have cleaned the thermometer between the different food items. On 03/06/24 at 10:00 AM, observation in the kitchen revealed the following: Two unlabeled, undated flour containers. Three ceiling vents had four inches of a gray-colored substance around them. A three-quarter full 5-gallon bucket filled with a black greasy substance on the floor by the three-well sink in the dishwashing area. The floor underneath the three-well sink had an area of brown substance approximately six inches by three feet long. On 03/06/24 at 10:15 AM, DS DD verified the above findings and stated maintenance staff were responsible for cleaning the ceiling vents. DS DD said she would put in a requisition to have them cleaned. DS DD stated staff should not store the bucket of fryer grease in the kitchen, staff should take it outside every time they empty grease into the bucket after it cooled down. DS DD stated the dietary staff had a daily cleaning schedule and the floor should be clean underneath the sinks. On 03/06/24 at 10:41 AM, observation in the 100-House kitchenette refrigerator revealed the following: Two undated chocolate Mighty shakes. Eight undated strawberry Mighty shakes. One undated fast-food chocolate shake and one fast-food chocolate and vanilla shake. An undated plastic bag with four ice cream sandwiches and another one with seven ice cream sandwiches. An undated, unlabeled one-quarter-full bag of shredded cheddar cheese. An undated, nine-ounce (oz) plastic container of black forest ham. An undated package (pkg) of ham slices. An undated, unlabeled one-quarter-full plastic bag of bacon toppings. Two undated pkg of sliced yellow cheese. One undated pkg of mozzarella cheese slices. An unlabeled, undated bowl of shredded turkey. An unlabeled, undated bowl of orange slices. An unlabeled, undated pkg of cherry tomatoes. On 03/06/24 at 10:412 AM, DS CC verified the above findings in the 100-House kitchenette and stated dietary staff should label and date food when they receive it from the kitchen. DS CC discarded all food items listed above in the trash. On 03/07/24 at 11:50 AM, Administrative Staff A stated staff should not keep a bucket of grease in the kitchen. Administrative Staff A said staff should take the bucket out and pour it into the container by the dumpster. Administrative Staff A stated the closing dietary staff were supposed to check for outdated and unlabeled food in the refrigerators daily. Administrative Staff A stated when staff obtained food items from the kitchen, they should label and date them before placing them in the refrigerator. The facility's Food Storage Chart Policy, revised 07/2013, documented that food must be stored in a way in which quality is preserved and in a way that ensures proper rotation. This means that food must be sealed to reduce the growth of bacteria and date marked to ensure that the oldest items are used first. The facility's Cleaning of Work Surfaces, Utensils, and Equipment Policy revised 04/2013 documented utensils and equipment would be cleaned routinely to help prevent cross-contamination and food-borne illnesses. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchen and one of three kitchenettes. This placed the 37 residents at risk for foodborne illness.

The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 32 with sanitary indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care and treatment which placed the resident at risk for urinary tract infections (UTI). Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia or hypoxia (inadequate supply of oxygen), dementia (a progressive mental disorder characterized by failing memory, and confusion), constipation (difficulty passing stools), retention of urine, delirium (sudden severe confusion, disorientation and restlessness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid, pain, and encephalopathy (broad term for any brain disease that alters brain function or structure). The Admission Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition, disorganized thinking which fluctuated, other behavioral symptoms not directed to others which occurred daily that significantly disrupted care or living environment, required set up and clean up assistance with eating and partial to moderate assistance with toileting, upper and lower body dressing, personal hygiene and mobility. The MDS further documented R32 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was always continent of bowel, had shortness of breath or trouble breathing with exertion and sitting at rest. R32 weighed 164 pounds, had a weight loss of five percent (%) or more in the last month or 10 % in six months, and was not on a physician-prescribed weight loss regimen. R32 took a diuretic (medication to promote the formation and excretion of urine) during the observation period. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 02/09/24, documented the facility would care plan for the indwelling catheter to reduce risk for injury and infection. R32's Care Plan, dated 02/15/24, documented R32 had an indwelling catheter due to bladder outlet obstruction. The care plan directed staff to provide catheter care twice a day (BID) and as needed (PRN), ensure tubing is secure to reduce pulling, monitor for symptoms of UTI, and notify the provider of symptoms. The Physician Order, dated 02/07/24, directed staff to provide R32 peri catheter care, to pull back the foreskin, and clean thoroughly BID for disorder of the skin and subcutaneous (beneath the skin) tissue. The Physician Order, dated 02/16/24, directed staff to apply a small amount of Nystatin (antifungal) topical cream at the end of the penis three times a day for tinea cruris (fungal infection in the skin of genitals, inner thigh, and buttocks). On 02/16/24 at 06:14 PM an Interdisciplinary (ID) Note documented that staff communicated with the physician regarding R32's penis lesions that were bleeding and got worse since the order of Nystatin. The physician ordered to send R32 to the emergency room . On 02/18/24 at 03:46 PM an ID Note documented R32's physician ordered the resident to be sent to the emergency room due to the resident not eating, moaning, and unable to communicate what he needed or feeling. On 02/19/24 at 12:49 AM an ID Note documented R32 had returned to the facility from the emergency room with a prescription for an antibiotic for a UTI. On 03/06/24 at 07:41 AM observation revealed Licensed Nurse (LN) H provided catheter care by cleansing the catheter insertion site with disposable wipes. LN H then applied the prescribed ointment without changing gloves. On 03/11/24 at 10:43 AM, Administrative Nurse D stated LN H should have changed gloves after cleansing the catheter and before applying the medicated ointment. The facility's Medication Administration policy, dated 05/2020, documented that if your hands have become soiled, i.e., touching a resident's mouth, contacting saliva, if you touch their spoon or glass, you must use alcohol gel or wash your hands. The facility failed to provide R32 with sanitary indwelling catheter care and treatment, which placed the resident at risk for continued complications of UTIs and fungal skin conditions.

The facility had a census of 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accident hazards for Resident (R) 7, who spilled her hot tea onto her lap twice in one week. This placed the resident at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, macular degeneration (progressive deterioration of the retina), epilepsy (brain disorder characterized by repeated seizures), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), falls, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had severely impaired cognition. R7 was dependent on staff for toileting and required substantial/maximum assistance for dressing and bathing. R7 required partial/moderate assistance for mobility and transfers and set-up assistance for eating. R7's Hot Liquid Assessment, dated 01/28/24, documented R7 was cognitively impaired but was deemed safe to handle and ingest hot liquids. R7's Care Plan dated 02/07/24, initiated on 09/27/23 documented R7 had impaired decision-making skills and directed staff to offer R7 simple choices and monitor for changes in her behavior, appetite, and health needs. The care plan directed staff to monitor for fatigue, weakness, altered muscle tone or strength, involuntary movements, and contractions of muscles or muscle groups related to her seizure disorder. The care plan directed staff to cut up R7's meat into bite-size pieces, provide a regular diet, and use an insulated cup. The Nurse's Note, dated 03/03/24 at 11:39 AM, documented R7 spilled hot tea on her lap at lunch. The note documented R7 used a Kennedy cup (an adaptable drinking cup designed to prevent spills) with a lid, but the resident removed the lid. The note further documented R7's pants were removed immediately and there was no sign of erythema (redness) or burns. The Nurse's Note, dated 03/07/24 at 03:02 PM, documented R7 was steeping her hot tea and she reported it was on the edge of the table and tipped onto her lap. The note documented R7 pulled at her pants to keep the warmth off her thighs and the nurse used a towel to get some of the hot water off her. A skin assessment was performed and the area to the inner right thigh was light red but blanchable (when the skin becomes white or pale in appearance). The staff applied a cool washcloth to the area. R7's EMR lacked documentation R7 was assessed for safety with hot liquids after she spilled her hot tea on 03/03/24 and 03/07/24 and lacked evidence of interventions to address the hot liquid spills. On 03/11/24 at 07:45 AM, observation revealed R7 sat at the dining room table with a regular coffee cup and no lid. R7 was able to drink the coffee without incident. On 03/06/24 at 11:06 AM, Certified Nurse Aide (CNA) N stated she was unaware of any problems with R7 drinking and said she did not know of any accidents with R7 and hot liquids. On 03/11/24 at 09:29 AM, Administrative Nurse E stated she had not completed another hot liquid assessment and did not update R7's Care Plan because R7 did not receive any injury with the recent hot tea incident. Administrative Nurse E further stated the cup was on the edge of the table when it fell on to R7's lap; the area on R7's inner thigh was pink and blanchable at first and ultimately had no injury. On 03/11/24 at 11:15 AM, Administrative Nurse D stated staff should make sure R7's cup was away from the edge of the table. Administrative Nurse D said she expected staff to complete a new hot liquid assessment and care plan interventions to prevent further incidents for R7. The facility's Skin and Wound Prevention Management policy, dated 01/21, documented that skin integrity would be maintained at the optimum level for the duration of the resident's stay. The care plan would be reviewed and revised as needed to manage treatment and identify prevention approaches. The facility's Accident and Incident Reporting policy, dated 09/18, documented, that the facility strived to have the best quality of life for the residents to prevent accidents and incidents and any accident or incident would be reviewed and investigated timely. If an accident or incident that resulted in no apparent injury, or minor injury would be investigated, and the report would be reviewed with the administrator and risk team within seven calendar days. The facility failed to ensure an environment free from preventable accident hazards for R7. This placed the resident at risk for preventable injury.

The facility had a census of 37 residents. The sample included 15 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 29 with dignity when staff checked his blood glucose level at the dining room table with two other residents able to view the procedure. This placed the resident at risk for an undignified experience. Findings included: - On 03/05/24 at 10:57 AM, observation revealed in the 300-House dining room, Certified Medication Aide (CMA) R used a glucometer (an instrument used to calculate blood glucose) to check R29's blood glucose level at the dining room table during the meal service and dining. There were two other residents present and able to view the procedure. On 03/11/24 at 10:46 AM, Administrative Nurse D stated she expected staff to take R29 to his room or a private area when they checked his blood glucose level. The facility's Supporting the Resident's Right to Privacy and Confidentiality Policy, revised 02/2009, documented it was the responsibility of each employee of the community to ensure that the privacy and confidentiality of each resident was protected. The facility staff failed to treat R29 with dignity when staff checked his blood glucose level at the 300-House dining room table during meals. This placed the resident at risk for an undignified experience.

The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to assess and treat Resident (R) 32's alteration in bowel movements, which placed the resident at risk of ongoing constipation and possible fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) complications. Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia or hypoxia (inadequate supply of oxygen), dementia (a progressive mental disorder characterized by failing memory, and confusion), and constipation. The Admission Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition, disorganized thinking which fluctuated, and other behavioral symptoms not directed to others which occurred daily that significantly disrupted care or living environment. R32 required set-up and clean-up assistance with eating and partial to moderate assistance with toileting, upper and lower body dressing, personal hygiene, and mobility. The MDS further documented R32 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was always continent of bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 02/09/24, documented the facility would care plan for an indwelling catheter to reduce the risk for injury and infection. R32's Care Plan, dated 02/15/24, documented R32 did not have continence issues and had an indwelling catheter due to bladder outlet obstruction. The care plan directed staff to monitor R32's bowel movements and treat for constipation per provider orders. The Physician Order, dated 01/30/24, directed staff to administer polyethylene (medication used to treat constipation) 17 grams by mouth once daily for other functional intestinal disorders. The Physician Order, dated 02/04/24, directed staff to administer Milk of Magnesia (MOM) 1200 mg, 30 cubic centimeters (cc) by mouth as needed (PRN) every 12 hours, with a maximum of two doses in 24 hours for constipation. The Physician Order, dated 02/29/24, directed staff to administer bisacodyl suppository 10 milligrams (mg) rectally PRN daily for constipation, if no bowel movement for three days. On 01/30/24 at 02:31 PM the Interdisciplinary Note documented R32 was admitted to the facility from a hospital. The note further documented R32's last bowel movement on 01/28/24. On 02/04/24 at 04:18 PM, the Interdisciplinary Note documented R32's abdomen was soft, non-tender with active bowel sounds in four quadrants. R32 had a bowel movement that morning and was on the three-day no bowel movement list so MOM was administered. On 02/07/24 the Physician Note documented R32 required enemas (introduction of a solution into the rectum for cleansing or therapeutic purposes) for constipation while hospitalized from 01/19/24 to 01/30/24. On 02/07/24 at 01:50 AM, the Interdisciplinary Note documented R32's abdomen was soft, non-tender with active bowel sounds in four quadrants. R32 had no bowel movement and was on the bowel movement list for day two. On 02/10/24 at 01:38 PM, the Interdisciplinary Note documented R32's normal active bowel sounds and R32 had no bowel movement that evening. On 02/11/24 at 06:58 PM, the Interdisciplinary Note documented R32 had normal active bowel sounds and had no bowel movement. The EMR lacked further documentation of bowel movement or treatment. R32's February 2024 Bowel Movement Record revealed R32 did not have a bowel movement on February 5-9 (five days), 11-17 (seven days), 19-22 (four days), and 24-28 (five days). R32's EMR revealed MOM had been administered on the following dates: 02/04/24 02/09/24 After five days with no bowel movement. 02/15/24 After four days with no bowel movement and again on 02/17/24 with now seven days with no bowel movement. 02/23/24 After four days with no bowel movement. On 03/11/24 at 10:43 AM, Administrative Nurse D reported that R32 continued to decline and that the staff should utilize the use of bowel protocols and PRN medication and treatments to manage R32's bowels. The facility's Constipation Standing Protocols-PRN Medication and Treatment orders reviewed 01/03/24, documented the use of: Milk of magnesium 30 cc by mouth every 12 hours PRN, no more than two doses in 24 hours. Senna (bowel stimulant) 8.6 one or two tablets by mouth twice a day as needed. Bisacodyl suppository per rectum if no stool for three days. Fleets enema for distention or hard stool, repeat one time if no results. Fiber stat 15 to 30 cc as directed per nurse judgment. The facility's Bowel Management policy, dated 08/01/11, documented bowel monitoring, and management will be followed to minimize any bowel problems such as constipation or fecal impaction by actively employing all preventative options possible. The facility failed to treat R32's lack of bowel movements which placed the resident at risk of ongoing constipation and fecal impaction complications.

The facility had a census of 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent avoidable accidents. This placed the resident at risk for further accidents due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, macular degeneration (progressive deterioration of the retina), epilepsy (brain disorder characterized by repeated seizures), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), falls, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had severely impaired cognition. R7 was dependent on staff for toileting and required substantial/maximum assistance for dressing and bathing. R7 required partial/moderate assistance for mobility and transfers and set-up assistance for eating. R7's Hot Liquid Assessment, dated 01/28/24, documented R7 was cognitively impaired but was deemed safe to handle and ingest hot liquids. R7's Care Plan dated 02/07/24, initiated on 09/27/23 documented R7 had impaired decision-making skills and directed staff to offer R7 simple choices and monitor for changes in her behavior, appetite, and health needs. The care plan directed staff to monitor for fatigue, weakness, altered muscle tone or strength, involuntary movements, and contractions of muscles or muscle groups related to her seizure disorder. The care plan directed staff to cut up R7's meat into bite-size pieces, provide a regular diet, and use an insulated cup. The Nurse's Note, dated 03/03/24 at 11:39 AM, documented R7 spilled hot tea on her lap at lunch. The note documented R7 used a Kennedy cup (an adaptable drinking cup designed to prevent spills) with a lid, but the resident removed the lid. The note further documented R7's pants were removed immediately and there was no sign of erythema (redness) or burns. The Nurse's Note, dated 03/07/24 at 03:02 PM, documented R7 was steeping her hot tea and she reported it was on the edge of the table and tipped onto her lap. The note documented R7 pulled at her pants to keep the warmth off her thighs and the nurse used a towel to get some of the hot water off her. A skin assessment was performed and the area to the inner right thigh was light red but blanchable (when the skin becomes white or pale in appearance). The staff applied a cool washcloth to the area. R7's EMR lacked documentation R7 was assessed for safety with hot liquids after she spilled her hot tea on 03/03/24 and 03/07/24 and lacked evidence of interventions to address the hot liquid spills. On 03/11/24 at 07:45 AM, observation revealed R7 at the dining room table with a regular coffee cup and no lid and R7 was able to drink the coffee without incident. On 03/06/24 at 11:06 AM, Certified Nurse Aide (CNA) N stated she was unaware of any problems with R7 drinking and said she did not know of any accidents with R7 and hot liquids. On 03/11/24 at 09:29 AM, Administrative Nurse E stated she had not completed another hot liquid assessment and did not update R7's Care Plan because R7 did not receive any injury with the recent hot tea incident. Administrative Nurse E further stated the cup was on the edge of the table when it fell on to R7's lap; the area on R7's inner thigh was pink and blanchable. On 03/11/24 at 11:15 AM, Administrative Nurse D stated staff should make sure R7's cup was away from the edge of the table. Administrative Nurse D said she expected staff to complete a new hot liquid assessment and care plan interventions to prevent further incidents for R7. The facility's Skin and Wound Prevention Management policy, dated 01/21, documented that skin integrity would be maintained at the optimum level for the duration of the resident's stay. The care plan would be reviewed and revised as needed to manage treatment and identify prevention approaches. The facility failed to revise R7's care plan with interventions to prevent further accidents with her hot beverages. This placed the resident at risk for further injury due to uncommunicated care needs.

The facility had a census of 37 residents. The sample included 15 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 16, R17, and R190 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay for skilled services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) receive the specified skilled services listed, and bill Medicare for an official decision on payment. The recipient understands if Medicare does not pay, the recipient is responsible for payment but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, the recipient is responsible for payment for services. (3) the recipient does not want the listed therapy services. The Center of Medicare (CMS)-10055 form provided to R16 when the skilled services ended on 01/16/24, lacked the estimated costs of services. The Center of Medicare (CMS)-10055 form provided to R17 when the skilled services ended on 10/13/23 lacked the estimated costs of services. The Center of Medicare (CMS)-10055 form provided to R19 when the skilled services ended on 03/01/24 lacked the estimated costs of services. On 03/12/24 at 10:50 AM, Administrative Nurse D and Social Services X verified there was no estimated cost of continued services on the CMS-10055. The facility's Medicare Coverage policy, dated 12/2000, documented Medicare will cover 100 percent (%) of service from one to 29 days of the resident's stay in the Skilled Nursing Unit. The resident is responsible for covering the cost of the co-pay for skilled nursing care for days 21 to 100. The amount varies from year to year. If the resident disagrees with the determination, the resident can ask for a Demand Bill. The facility failed to provide the resident (or their representative) the completed CMS-10055 form when discharged from skilled services for R16, R17, and R190 which included the estimated cost of continued services. This placed the residents at risk of making uninformed decisions for their skilled services.

The facility had a census of 37 residents. The sample included 15 residents, with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement nutritional interventions to promote healing for one resident, Resident (R) 11, after development of a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer. This placed the resident at risk for complications from pressure injuries and delayed healing. Findings included: - The Electronic Medical Record (EMR for R11 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), pressure ulcer, and nutritional deficiency (severely reduced levels of one or more nutrients). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition and required extensive assistance from one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS documented R11 was at risk for pressure ulcers and had pressure-relieving devices for his bed and chair. The MDS documented R11 had no skin breakdown. R11's Quarterly MDS, dated [DATE], documented R11 had intact cognition and was dependent on staff for toileting and transfers. R11 required substantial/maximum assistance for mobility. R11 had frequent bladder incontinence. R11 was at risk for pressure ulcers and had pressure-relieving devices for his bed and chair. R11 had two Stage 2 pressure ulcers and received pressure ulcer care. The Braden Scale Assessment, (a formal assessment for predicting pressure ulcer risk) dated 06/26/23, 09/21/23, and 12/21/23, documented R11 was at high risk for pressure ulcers. R11's Care Plan, dated 02/01/24, initiated on 12/31/20, directed staff to remind R11 to lie down to get off his bottom and to change positions every two hours. The plan directed R11 should wear heel protectors at night and take off his incontinence pull-up at night. The update, dated 06/25/22, directed staff to make sure his cushion was moved from chair to chair. The update, dated 09/27/23, documented R11 had two Stage 2 pressure ulcers on his right and left buttocks. The plan directed staff to assess R11's skin weekly and ensure R11 had a pressure-reducing mattress on his bed. The update dated 02/29/24 directed staff to encourage R11 to use a rolled-up towel under his hips to offload pressure, alternating sides. The Skin Evaluation Record, dated 09/13/23, documented R11 had an open sore on his left buttock which measured 0.4 centimeters (cm) x 0.8 cm x 0.2. The Physician's Order, dated 09/20/23, directed staff to apply Triad wound dressing paste (a paste that covers moist, weeping wounds), apply a small amount to the wound as needed, and leave it open to air. The Skin Evaluation Record, dated 10/23/23, documented R11 had a Stage 2 pressure ulcer on his left buttock that measured 0.4 cm x 0.8 cm x 0.2 cm. The note documented the pressure ulcer was macerated (prolonged exposure to moisture) and directed staff to bandage after showers. The Nutritional Assessment, dated 10/31/23, documented R11 had skin breakdown on his left buttock. The note documented the Registered Dietician (RD) recommended Vitamin C 500 milligrams (mg) twice per day, a multivitamin daily, and Arginaide (supplement to aid in wound healing) twice per day. The EMR lacked evidence R11 was provided the recommendations from the RD and lacked evidence the physician was presented with the recommendations and /or declined the recommendations. The Skin Evaluation Record, dated 11/15/23, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 1.4 cm x 0.5 cm x 0.2 cm. The Physician's Order, dated 11/30/23, directed staff to apply Fibracol Plus Collagen (absorbent dressing with protein) and alginate (promotes wound healing) to the wound bed. Cover with a bandage and change every other day or sooner if soiled. The Skin Evaluation Record, dated 12/21/23, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 0.4 cm x 0.3 cm x 0.2 cm, and a new pressure ulcer on his right gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) which measured 0.7 cm x 0.7 cm. The evaluation documented that Fibracol Plus was applied to both wounds. The Skin Evaluation Record, dated 01/05/24, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 0.5 cm x 0.4 cm x 0.2 cm, and a Stage 2 pressure ulcer on his right gluteal fold which measured 0/7 cm x 0.5 cm. The Skin Evaluation Record, dated 01/25/24, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 0.8 cm x 1.3 cm x 0.2 cm, and a Stage 2 pressure ulcer on his right gluteal fold which measured 1.0 cm x 0.8 cm x 0.2 cm. The Nutritional Assessment, dated 01/29/24, documented R11 had skin breakdown on his left buttock and right gluteal fold and recommended Vitamin C 500 mg twice per day, a multivitamin daily, and Arginaide twice per day. The Physician's Order, dated 02/02/24, directed staff to administer Vitamin C 500 mg by mouth twice per day, a multivitamin daily, and Arginaide, one serving daily for wound healing. On 03/06/24 at 07:30 AM, R11 stated he had pressure ulcers off and on. R11 stated the wounds would heal but after the treatment was finished, nothing was done to it to protect it, and it would open again. R11 further stated that he had staff place a sign on the wall to remind them to move the cushion from his wheelchair to the recliner because it was often forgotten. R11 stated he usually slept in his recliner except for on shower days, then he would lie down in bed. On 03/06/24 at 09:30 AM, observation revealed Consultant GG and her assistant, Consultant HH, were in R11's room to provide wound care. Consultant HH sanitized her hands, gloved and cleansed the pressure ulcer with wound cleanser, and measured the wound at 1.6 cm x 1.3 cm. Further observation revealed Consultant GG changed places with Consultant HH to look at the wound and to measure the depth of the wound, which was 0.2 cm. Consultant HH stated the wound had improved and said it was much smaller. Consultant HH applied the antibiotic ointment, placed a foam dressing on top of the wound, and placed a bandage over the top. On 03/06/23 at 09:45 AM Consultant GG stated the wound was avoidable and that R11 needed to make sure he was offloading several times per day. On 03/06/24 at 10:15 AM, Certified Nurse Aide (CNA) N stated staff reminded R11 to reposition often and tried to encourage him to sit in his recliner. On 03/11/24 at 09:31 AM, Administrative Nurse E stated she was unsure why the facility did not implement the recommendations from the RD on 10/31/23 and said it may have been overlooked. On 03/11/24 at 11:15 AM, Administrative Nurse D stated she did not receive the email regarding the RD recommendations on 10/31/23. Administrative Nurse D said if she had the recommendations would have been implemented. The facility's Skin and Wound Prevention Management policy, dated 01/21, documented that skin integrity would be maintained at the optimum level for the duration of the resident's stay. A comprehensive prevention plan would be initiated for all residents who had intact skin and were at risk. The dietician would be notified and a follow-up on any recommendations made when there was a development of skin injury. The facility's Pressure Injury Prevention and Management policy, dated 01/20, documented the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries, The facility should establish and utilize a systemic approach for pressure injury prevention and management including prompt assessment and treatment, intervening to stabilize, reduce or remove the underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. The facility failed to implement nutritional interventions to promote healing for R11's pressure injuries. This placed the resident at risk for complications related to pressure injuries and delayed healing.

The facility identified a census of 38 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to use safe methods when transferring and ambulating Resident (R) 1, placing her at risk for falling, injury, and pain. On 06/04/23 at 06:45 AM, Certified Medication Aide (CMA) R ambulated R1 from her room to the scale, to weigh R1. CMA R did not place a gait belt on R1. CMA R got R1 close to the scale and then CMA R turned her back to R1 to turn the scale on. During this time, R1 reached for her phone in the basket of her walker and in doing so, lost balance and fell to the floor on her left side. She landed on her left hip/upper thigh. Staff assessed R1 for injury and noted no deformity or bruising. A nurse and CMA R attempted to stand R1, but R1 could not stand so staff sat R1 on the seat of her four-wheeled walker. Staff obtained a wheelchair and pivot transferred R1 to the wheelchair and took R1 to the dining room table for breakfast. Approximately fifteen minutes later, R1 grimaced and held her left leg and stated it hurt a lot. Staff took R1 to her room for further assessment. When moving R1's leg off the wheelchair leg rest, R1 yelled out in pain. The facility transferred R1 to the hospital, where they performed an x-ray showing a mildly displaced intertrochanteric left femoral (a broken left hip) fracture and R1 required a cephalomedullary (surgical treatment for unstable fractures) fixation on 06/04/23. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), atrial fibrillation (rapid, irregular heartbeat), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid) The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. TMDSMDS documented R1 required limited to extensive assistance of one to two staff for bed mobility, transfer, ambulation, locomotion, toileting, personal hygiene, and bathingMDShe MDS documented R1 had two or more non-injury falls during the look back period and was not stable during transitions and walking and required staff for stabilization. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/06/23, directed staff to proceed to care plan to support R1's moderate cognitive impairment and best quality of life. The Activities of Daily Living CAA, dated 02/06/23, directed staff to proceed to care plan with the amount of assistance needed with activities of daily living and persona cares. The Falls CAA, dated 02/06/23, directed staff to proceed to care plan with interventions for prevention of falls. The Fall Care Plan, revised 06/04/23, directed staff to assist R1 up after 06:00 AM rounds, keep R1's walker out of sight while she was in bed, and perform frequent visual checks. The plan directed staff to ensure R1 wore shoes when ambulating (no slippers), place a fall mat beside her bed on floor, and to provide a soft touch call light, not to turn away from R1 when walking to the weight scale. New interventions were added to address the 06/04/23 fall which directed staff not to leave R1's cell phone on her walker seat, keep bed in lowest position, and take R1 for a walk when R1 seemed anxious. The Fall Assessment, dated 01/30/23, documented a fall risk score of fourteen which indicated R1 was a high fall risk. The Fall Assessment documented R1 was disoriented, R1 had three or more falls in the last three months, R1 had balance problems while standing and walking, and was jerky and unstable when making turns. The Facility Incident Report, dated 06/08/23, documented CMA R assisted R1 out of bed to get ready for the day. R1's level of function prior to the fall included use of a four-wheeled walker with one staff assist. When CMA R walked R1 out to breakfast, they stopped at the scale due to obtain R1's weight. CMA R turned to activate the scale and R1 reached over to get her cell phone out of her walker basket, to put it on the top of her walker seat. Upon reaching into the basket, R1 lost her balance and fell to the floor landing on her left hip/upper left thigh. The staff notified the nurse on duty. The nurse entered the room and found R1 seated on the floor with CMA R standing behind her, as a backrest. The nurse assessed R1 and R1's vital signs were within normal limits and the left thigh assessment was normal. R1 stated her leg was sore though she had no deformity or pain with palpation. R1 wanted to get off the floor, but could not stand and staff assisted her to a sitting position on her four-wheeled walker seat. Staff obtained a wheelchair and pivot-transferred R1 to the wheelchair. R1 reported again that her leg was just sore. Staff assisted R1 to the dining room table. Approximately fifteen minutes later, R1 was grimacing and holding her left leg. R1 stated her leg hurt a lot. The staff took R1 to her room for further assessment. When the staff moved R1's leg off the wheelchair leg rest, R1 yelled out in pain. With assistance, R1 stood with her weight on her right leg so the left leg could be further assessed. The staff noted no bruising or deformity to the left leg. Due to increased pain in R1's left leg with movement and at rest, the staff notified R1's primary care physician and obtained an order to send R1 to the emergency room . The emergency medical service transferred R1 to the hospital. The facility implemented corrective actions including the staff would ensure they assisted R1 to a seated position on her walker, prior to staff needing to turn away for any reason. On 06/27/23 at 10:30 AM, observation revealed R1 laid back in a recliner in the commons area visiting with physical therapy staff. R1's right leg was bent at the knee and she swayed it back and forth. On 06/27/23 at 10:45 AM, CNA M stated prior to R1's fall and fracture she was very unstable when she stood and walked, and she required one staff assistance with a gait belt for safety. On 06/27/23 at 11:00 AM, Physical Therapy Assistant GG stated prior to her broken hip, R1 was not stable with standing or ambulation, and staff should always use a gait belt should always. On 06/27/23 at 11:15 AM, Physical Therapist HH stated R1 had recently come off therapy and therapy recommended R1 required one staff assistance with a gait belt for all transfers and ambulation. Physical Therapist HH stated R1 was unstable and unable to stabilize without assistance with standing and ambulation, prior to her fall with fracture. On 06/27/23 at 12:00 PM, CMA R stated she did not use a gait belt when she transferred and ambulated R1 the day R1 fell and broke her left hip. CMA R stated there was no gait belt in R1's room and since everyone was busy that morning, she ambulated R1 to the scale without a gait belt. CMA R stated she should have put on R1's call light and waited for someone to come so they could get her a gait belt to use with R1, prior to ambulating R1. On 06/27/23 at 12:10 PM, Administrative Nurse D stated all the nursing staff should know to use a gait belt when transferring and ambulating any of the residents. Administrative Nurse D verified the facilities second day of training covered gait belt use. Administrative Nurse D stated the facilities gait belt policy was vague and needed reviewed. The facility's Gait Belt Policy, dated August 2018, documented the rationale for gait belts was to prevent undo injury to the employee or the resident when moving the resident. Staff were directed to obtain a gait belt from the resident's room, explain to the resident what was being done, apply the belt around the resident's waist over their clothing to allow enough room between the belt and the residents clothing to allow a flat hand to be inserted, after procedure remove the belt and return it to its location in residents' room. The Fall Management Policy, revised July 2022, documented the facility recognized that falls have the potential of being a devastating event for the residents. Because of this, the facility will systematically assess residents and evaluate fall situations and potential situations with the goal of identifying common fall risks, factors and developing care plan interventions to mitigate potential harm. The facility failed to use safe methods when transferring and ambulating R1, to include lack of gait belt use and adequate supervision, which resulted in a fall and fractured left hip for R1 and required surgical repair.

The facility identified a census of 50 residents. The sample included three residents reviewed for quality of life/quality of care. Based on record review and interview, the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to act immediately upon changes in Resident (R) 1's health status when Licensed Nurse (LN) G failed to ensure R1's physician received the notification regarding R1's respiratory difficulty and changes in R1's mentation. On 04/03/22 at 05:15 AM LN G documented R1 had decreased oxygen saturation at 90 percent (%) (the amount of oxygen present in blood, normal is 95 to 100 %) and confusion. Administrative Nurse E faxed Consultant GG at 06:40 AM on 04/03/22 (Sunday) and reported R1 had noisy, labored breathing which worsened when R1 slept and hallucinations. Facility nursing staff failed to follow up with Consultant GG when no response was received to the fax sent on 04/03/22. On 04/04/22 at 04:51 AM LN G documented R1 was restless, confused, and was difficult to understand. R1 continued to have labored breathing and periods of not breathing for up to 10 seconds followed by gasping breaths. LN G failed to notify R1's physician of the findings. On 04/04/22 at 06:15 AM, LN H observed R1 gasping for air, coughing, and gurgling. LN H called Consultant GG and received a verbal order to send R1 to the hospital. Subsequently, R1 required intubation (insertion of a tube into the lungs to assist with breathing) and was diagnosed with pneumonia (inflammation of the lungs), [CONDITION(S)] (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of [CONDITION(S)] can lead to the medical emergency, septic shock) and respiratory failure. These failures placed R1 in Immediate Jeopardy. Findings included: - R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Entry Minimum Data Set recorded R1 admitted to the facility on [DATE]. The Admission Nurses Note, dated 03/30/22, documented R1 admitted from the hospital after a traumatic injury. R1 presented with sutures (a row of stitches holding together the edges of a wound) to his left eyebrow. The number of sutures was unknown due to the amount of swelling, dried drainage and multiple bruises to R1's face, arms, and neck. R1 experienced double vision due to trauma to his left eye. R1 was alert and oriented to person, place, and time. R1's lung sounds were clear to auscultation (the action of listening to the lungs with a stethoscope), with no cough or congestion noted. The Activities of Daily Living Care Plan, dated 03/30/22, directed staff that R1 required one staff assist for bed mobility, transfer, ambulation with front wheeled walker, dressing, and bathing. The Baseline Care Plan, dated 03/30/22, documented R1's care needs would be met, R1 was alert and oriented to person, place, and time, R1 answered questions readily, had clear speech, and was talkative. The Mood/Behavior Note, dated 04/01/22, documented R1 had been restless at intervals, had removed his neck brace repeatedly, and tried to get up multiple times by himself. R1 stated he was dreaming he was taking off the neck brace. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse also reported to Consultant GG R1's continuous oxygen usage as R1's oxygen saturation was 95-96% at all times on room air. Consultant GG ordered [MEDICATION(S)] (anti-depressant that aids with sleep) 25 milligrams (mg) to be given daily at bedtime and oxygen as needed. The Skilled Nurses Note, dated 04/01/22, documented R1 was alert and oriented to person, place and time with intermittent confusion. R1's lung sounds were clear in all lobes and he continued to have continuous oxygen delivered per nasal canula (tube that delivers oxygen through the nares). The left side of R1's head was swollen. R1 was restless and up and down. The Skilled Nurses Note, dated 04/02/22, documented R1 was alert and oriented to person, place and time, lung sounds were clear to auscultation, and R1 was pleasant with nursing staff and other residents. The Behavior/Mood Note, dated 04/03/22 at 05:15 AM by LN G documented R1 had been very restless and anxious and was found on his roommates' side of the room. When redirected, R1 became angry and said he was going outside. R1 tried to walk past staff several times to get outside. The note recorded R1 was hallucinating. R1 believed he had a piece of string that needed to be tied and tried to hand the imaginary string to the nurse. LN G assessed R1's oxygen saturation and R1's oxygen saturation was 90%. LN G applied oxygen and notified Administrative Nurse E. The note lacked evidence LN G assessed and recorded R1's lung sounds. The Status Note, dated 04/03/22 at 06:40 AM (Sunday), documented Administrative Nurse E reported to Consultant GG via fax that R1 had noisy, labored breathing which worsened when R1 slept and reported R1 hallucinated. The facility documentation and R1's clinical record lacked evidence of follow up with Consultant GG when no response was received to the fax sent on 04/03/22 at 06:40 AM. The Behavior/Mood Note, by LN G dated 04/04/22 at 04:51 AM, twenty-three hours later, documented R1 was restless, confused, and was difficult to understand. R1 continued to have labored breathing and periods of not breathing for up to 10 seconds followed by gasping breaths. R1's clinical record lacked evidence nursing staff notified R1's physician of the findings and lacked evidence LN G assessed R1's lung sounds and oxygenation status. In an ER [emergency room ] Visit Note, dated 04/04/22 at 06:15 AM, LN H documented R1 gasped for air, coughed, and was gurgling. LN H documented R1 was unable to speak due to shortness of breath. R1's oxygen saturation was 83-88% on 3 liters of oxygen. LN H called Consultant GG and received a verbal order to send R1 to the hospital. The emergency room Documentation, dated 04/04/02 at 07:07 AM, documented R1 had audible stridor (a harsh vibrating noise when breathing). R1's upper airway required suctioning (using suction to clear mucous) and revealed a fair amount of discolored slightly bloody discharge. The emergency room 's assessment of R1 revealed pneumonia, respiratory failure, and [CONDITION(S)]. The emergency room doctors intubated R1 and transferred him to another hospital with a higher level of care. On 05/04/22 at 11:30 AM, Administrative Staff A stated she reviewed the documentation regarding R1. Administrative Staff A stated the nurses failed to perform a skilled nursing assessment twice a shift for R1 and when the changes started happening, they did not notify the primary care physician or family. Administrative Staff A stated nursing can pick up the phone any time and call for emergency services to take a resident to the hospital. On 05/04/22 at 01:00 PM, Certified Nurse Aide (CNA) M, stated when she came to work on 04/04/22 R1 was really struggling to breath and he appeared very anxious and panicked. On 05/04/22 at 01:15 PM, Certified Medication Aide (CMA) R, stated that she worked the whole weekend with R1, and he was anxious and restless all the time. CMA R stated nursing staff tried to make him comfortable but were unsuccessful. On 05/04/22 at 01:30 PM, Administrative Nurse D stated that if a resident was having difficulty breathing and hallucinating, she would expect the nurses to call the physician so the resident could be seen in the emergency room immediately. On 05/04/22 at 02:00 PM R1's representative stated R1 hallucinated and seemed to be having difficulty breathing on 04/03/22 during a visit. R1's representative stated the observations were relayed to facility nursing staff though no actions appeared to be taken at that time On 05/04/22 at 15:11 PM, Consultant GG stated if a resident was having difficulty breathing, difficulty with maintaining adequate oxygenation, and/or hallucinating she expected the facility nurses to call her, or the doctor on call, to report their findings. On 05/04/22 at 04:00 PM, LN G stated R1 had difficulty with breathing since his admission. LN G stated she was able to identify when a resident needed to go to the hospital, and she did not feel that R1 needed to go to the hospital when she cared for him on 04/03/22 through the morning of 04/04/22. The facility's Notification of Attending Physician policy, revised April 2018, documented the attending physician and legal representative would be notified promptly of any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by the resident. The facility's inability to obtain or administer prompt and timely drugs, equipment, supplies, or services as prescribed under conditions which present a risk to the health, safety, or security to the resident. The facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to act immediately upon changes in R1's health status when nursing staff failed to ensure R1's physician received the notification regarding R1's respiratory difficulty and changes in R1's mentation. Facility nursing staff failed to follow up with Consultant GG when no response was received to a fax communication. Subsequently, R1 was sent to the hospital on 04/04/22, required intubation and was diagnosed with pneumonia, [CONDITION(S)] and respiratory failure. These failures placed R1 in Immediate Jeopardy. On 05/04/22 the facility submitted a plan to remove the immediacy and implemented the following: Involved nursing staff received education and disciplinary action related to the lack of assessments and failure to identify and/or report a change in resident status. All licensed nursing staff received education on change of condition and physician notification requirements (both regulator and facility policy and procedure). All nursing assistants received education on change of condition and communication of resident status and/or changes to licensed nurses. The deficient practice remained at a scope and severity of a G

The facility had a census of 63 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure a safe and hazard free environment for one of three sampled residents. Resident (R) 1, a severely cognitively impaired resident, spilled a cup of hot coffee on herself after served by staff and left the resident unattended. The hot coffee caused second degree [CONDITION(S)] (when the first layer and some of the second layer of skin are burned) to the resident's left breast, abdomen, and bilateral thighs, and she required treatment at the emergency room . Findings included: - The Physicians Orders, dated 12/14/20, documented R1 had diagnoses of depression, kyphoscoliosis (abnormal curve of the spine), general muscle weakness, pain, abnormalities of gait and mobility, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R1's Quarterly Minimum Data Set, (MDS), dated [DATE], documented the resident had short and long-term memory problems and severely impaired cognition. The MDS documented R1 required supervision after staff set-up for meals. R1's Activities of Daily Living (ADL) Care Plan, dated 02/05/21, documented R1 received thin liquids. R1's Nutrition Care Plan, dated 02/05/21, documented staff provided necessary assistance at and between meals. The Nurse's Note, dated 03/25/21 at 12:27 PM, documented R1 spilled a cup of hot coffee on her left breast, stomach, and legs. The note documented the areas were red with peeling skin noted to the left of R1's navel, and the resident complained of discomfort and pain. The note documented staff notified R1's physician who ordered to send the resident to the emergency room for evaluation. Staff transported the resident to the hospital at 12:35 PM. The Nurse's Note, dated 03/25/21 at 06:20 PM, documented R1 returned from the emergency room with the following new orders: administer [MEDICATION(S)] (medication used to treat moderate to severe pain) 5/325 milligrams (mg), (already prescribed for pain as needed), change dressings on the [CONDITION(S)] daily, apply a layer of topical antibiotic cream, cover with a non-stick dressing, followed by a gauze dressing. The orders directed staff to schedule a follow up appointment with the resident's physician in five to seven days to ensure the [CONDITION(S)] were healing properly and return to her physician or the emergency room immediately if there were any signs of infection. R1's Skin Evaluation, dated 03/25/21, documented the following [CONDITION(S)]: Right thigh: 4.5 centimeters (cm) by 11 cm, fluid filled blister Left thigh: 4 cm by 14 cm and 2 cm by 1.5 cm fluid filled blisters Abdomen: 12 cm x 15 cm, fluid filled blister Left breast: 2 cm x 2 cm, small, scattered fluid filled blisters The Facility Investigation, dated 03/26/21, documented on 03/25/21 at 12:09 PM, Licensed Nurse (LN) G served R1 a cup of coffee at the dining room table, the resident dropped the cup, and spilled the hot coffee on the top of her body. LN G responded immediately, assisted R1 to her room, removed her saturated clothing, applied a cold washcloth to the [CONDITION(S)], and dressed R1 in dry clothes. The report documented staff notified R1's physician at 12:20 PM who ordered to send the resident to the emergency room for evaluation and treatment of the [CONDITION(S)]. The report documented staff checked the temperature of the coffee staff served R1 and recorded a temperature of 175 degrees Fahrenheit (F). On 04/01/21 at 11:00 AM, LN G stated she served R1 the hot coffee in a cup without a lid. LN G stated she turned around, heard R1 scream, and noted the resident dropped the cup of hot coffee down the front of her body. LN G verified she did not know how hot the coffee was or if the dietary aide checked the temperature of the coffee. LN G stated she assisted R1 to her room, removed her clothing, applied cold washcloths, and dressed R1 in dry clothes. LN G stated staff notified R1's physician who ordered R1 to come to the emergency room to be evaluated for the [CONDITION(S)]. On 04/01/21 at 01:25 PM, Dietary Staff (DS) BB verified dietary staff did not check the temperature of coffee before it was served to residents and stated 175 degrees F was too hot to serve cognitively impaired residents. DS BB stated the coffee pots were set to dispense coffee at 155-175 degrees F. On 04/05/21 at 10:45 AM, Administrative Nurse E stated on 03/25/21 at approximately 12:10 PM, staff called her to R1's room. Administrative Nurse E stated staff served R1 hot coffee, she spilled it on herself, received [CONDITION(S)] to her upper body, and staff transported R1 to the emergency room for treatment. Administrative Nurse E verified there was no lid on the coffee cup. On 04/05/21 at 12:00 PM, Administrative Nurse D verified R1 was cognitively impaired, could eat and drink independently after staff set up her meal, and required staff supervision. Administrative Nurse D verified the facility had not completed hot liquid assessments on residents, and staff used their good judgement and observation to know if a resident required assistance with eating and drinking. Administrative Nurse D verified lids were available for coffee cups, but there was no lid on R1's cup when she spilled the hot coffee on herself. On 04/05/21 at 12:35 PM, Administrative Staff A verified R1 was cognitively impaired, but could eat and drink after staff set up her meal and required staff supervision. Administrative Staff A verified on 03/25/21 staff served R1 hot coffee and she spilled it down the front of her body. Administrative Staff A stated lids were available for coffee cups, did not believe there was a lid on her cup that day as she had not had any problems before. Administrative Staff A verified the facility did not assess residents for safety with hot liquids. The facility's undated Safe Serving of Coffee and Other Hot Liquids policy documented coffee and other hot beverages should be consumed at 155-175 degrees F for most residents and noted this temperature could results in [CONDITION(S)] if the beverage contacted the skin or mucous membranes. The policy documented hot beverages would not be left unattended without accessibility of the hot beverage in carafes or carriers with secure covers to reduce the risk of accidental dispensing. The facility failed to ensure a safe and hazard free environment for R1 when staff served her hot coffee in a cup, spilled it on herself, and received second degree [CONDITION(S)] on her breast, abdomen and thighs.

The facility had a census of 87 residents. The sample included 3 residents, reviewed for falls. Based on record review and interview, the facility failed to provide an environment that was free of accident hazards as possible, when 1 of 3 residents fell and sustained a [MEDICAL CONDITION]. (#1) Findings included: - Resident #1's annual (MDS) Minimum Data Set assessment, dated 11/14/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 7, which indicated he/she had severe cognitive impairment, and had inattention and altered level of consciousness. The MDS documented the resident required extensive assistance of 1 staff for bed mobility, dressing, toileting, personal hygiene, bathing, locomotion on and off the unit, and extensive assistance of 2 staff for transfers. The MDS documented the resident's balance was unsteady, he/she could only stabilize with staff assistance, used a walker or wheelchair for mobility, and had two falls with no injury since his/her last assessment. The (CAA) Care Area Assessment for falls, dated 11/14/17, documented the resident was at risk for falls due to his/her dementia (progressive mental disorder characterized by failing memory, confusion), and he/she often got up without staff assistance, did not use his/her walker, and had 2 non-injury falls since his/her last assessment. The interventions to prevent falls included the resident should remain in the living room area after meals, encouraged to sit in a recliner, be accompanied to his/her room by staff only, and assisted to the bathroom. The 12/30/17 care plan directed staff to provide a high/low bed, a fall mat on the floor beside the bed, anti-lock brakes on his/her wheelchair, encourage the resident to stay in the living room area in a recliner after meals, and accompany the resident to his/her room by staff only. The care plan directed staff to close the door to his/her room when taking the resident to the dining room, and divert him/her from going back to his/her room unaccompanied after meals. The 1/11/18 at 4:37 AM, nurse's note documented the resident was in his/her room after supper on 1/10/18 (no time specified), declined use of the bathroom, and refused to transfer from his/her wheelchair to his/her recliner for Nurse G. The note documented the resident wanted to remain in his/her wheelchair. Nurse G then left the resident's room to go to another unit. At approximately 7:20 PM, Nurse Aide M got Nurse G, and reported Nurse Aide N found the resident on the floor in his/her bathroom. The ambulance transported the resident to the hospital for his/her injuries. The 1/11/18 at 4:37 AM, nurse's note documented staff received a call from the hospital stating the resident admitted to the hospital with [REDACTED]. The 1/10/18 at 8:50 PM, hospital emergency record documented the resident presented with a fall, when he/she fell in his/her bathroom that day, had some rotation to the left leg, and the resident complained of left hip pain. The 1/10/18 at 9:29 PM, hip with pelvis radiology report documented the resident had a [MEDICAL CONDITION] proximal (nearer to a point of reference, the hip) femur (thigh bone). On 2/12/18 at 1:27 PM, Nurse H stated the resident had been assessed as a fall risk and would try to get himself/herself up to use the bathroom, without calling for assistance from staff. Nurse H verified staff were to keep the door to the resident's room closed, to prevent him/her from going into the room alone. Nurse H stated staff were to keep the resident in the living room after meals, and the resident should only go to his/her room with staff. On 2/12/18 at 2:05 PM, Administrative Nurse D stated after supper on 1/10/18, the resident did not want to get out of his/her wheelchair to sit in his/her recliner, and he/she did not want to be in the living room area, so Nurse G took the resident to his/her room and offered to help him/her to use the bathroom, but the resident declined. Administrative Nurse D verified Nurse G left the unit and left the resident in his/her room. Nurse G told Nurse Aide M and Nurse Aide N to check on the resident every 5-10 minutes. Administrative Nurse D stated the resident fell in his/her bathroom. Administrative Nurse D verified the resident's care plan included a fall intervention that stated after meals the resident should remain in the living room area, and be accompanied to his/her room by staff only, and assisted to the bathroom. On 2/12/18 at 3:45 PM, Nurse Aide N stated the resident was in his/her room alone, but staff checked on him/her frequently, at least one time, every 30 minutes. Nurse Aide N stated he/she was standing by the medication cart, when he/she heard a loud groaning coming from the resident's room. Nurse Aide N stated he/she found the resident on the floor of his/her bathroom. On 2/12/18 at 4:07 PM, Nurse G stated he/she took the resident to his/her room after supper on 1/10/18 because the resident did not want to stay in the living room, or sit in a recliner. Nurse G stated he/she offered to take the resident to the bathroom, but the resident declined. Nurse G stated he/she sat at the nurse's desk and could view the wheels of the resident's wheelchair from the desk. Nurse G stated he/she went to another unit, and told Nurse Aide M and Nurse Aide N to check on the resident. Nurse G stated Nurse Aide M reported Nurse Aide N found the resident on the floor of his/her bathroom. On 2/12/18 at 4:30 PM, Nurse Aide M stated the resident was very restless after supper on 1/10/18, and he/she did not want to sit in the living room, but wanted to stay in his/her wheelchair in his/her room. Nurse Aide M stated he/she was aware the resident should not be left alone in his/her room, but staff checked on the resident often. Nurse Aide M stated he/she heard a loud noise coming from the resident's room, and Nurse Aid N found the resident on the floor of his/her bathroom. Nurse Aide M stated he/she notified Nurse G. On 2/12/18 at 4:50 PM, Administrative Staff A stated the resident had a history of [REDACTED]. Administrative Staff A verified the resident's care plan directed staff to keep the resident in the living room after meals, and the resident should only go to his/her room with staff. The facility's fall management policy, dated (MONTH) (YEAR), documented the interdisciplinary team would develop an individualized plan of care for residents determined to have a potential for fall, and all staff who worked directly with the resident would be responsible for knowing and following the care plan. The facility failed to provide adequate supervision for Resident #1, when he/she was left in his/her room, got up from his/her wheelchair on his/her own, fell , and sustained a [MEDICAL CONDITION].

The facility had a census of 93 residents. The sample included 3 residents. Based on observation, record review and interview the facility failed to thoroughly investigate and report an incident of verbal abuse for Resident #1 who had moderately impaired cognition, Resident #4 who had an allegation of staff being rough with treatment, and to protect the 50 residents in the houses at the facility. This deficient practice placed the residents in the houses in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 5/23/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment with fluctuating disorganized thinking, and a mood severity score 7 indicating mild depression, with no behaviors. The MDS recorded the resident required total dependence of 2 staff for transfers, locomotion on unit, dressing, toilet use, personal hygiene, bathing, total dependence of one staff for locomotion off unit, extensive assistance of 2 staff for bed mobility, and independent with eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, functional limitation in (ROM) Range of Motion on one side in upper extremities, used a wheelchair for mobility, always incontinent of bladder, and frequently incontinent of bowel. The MDS recorded the resident received scheduled and (PRN) as needed pain medication, almost constantly had pain rating 10 (scale 0-10), with a condition or chronic disease that may result in life expectancy of less than 6 months. The MDS recorded the resident received oxygen therapy, and hospice care. The Behavioral Symptoms (CAA) Care Area Assessment, dated 2/27/17, recorded the resident had actual behavioral symptoms with risk factors that included un-met needs and a decline in status. The CAA recorded the resident sometimes refused to take his/her scheduled medications. The CAA recorded the resident had chronic pain, was on a scheduled [MEDICATION NAME] (narcotic pain patch), was admitted to hospice services that assessment period, and was monitored daily for behavioral symptoms. The 7/27/17 care plan recorded the resident had impaired behavior related to a [DIAGNOSES REDACTED]. The care plan instructed staff to validate the resident's experiences as expressed, with reality orientation as appropriate. The facility's abuse investigation recorded the investigation began on 7/24/17 when suspected abuse was reported to the nurse management team. The investigation recorded on July 5, 2017, during evening cares with Resident #1, the resident became resistive and pinched Nurse A's breast. Nurse A stated to Resident #1 you don't pinch my t**! Do you want me to call the cops? Do you want to go to jail? The facility's investigation recorded on the night of 7/22/17, Nurse B reported to Administrative staff C, suspected abuse involving Nurse A and Resident #1. Nurse B stated the abuse had been reported to him/her by Nurse Aide D, and had been witnessed by Nurse Aide C and Nurse Aide D. Review of Nurse A's July 2017 time card documented the nurse worked on the following days: 7/5/17 at 5:15 PM - 7/617 at 6:07 AM 7/6/17 at 5:43 PM - 7/7/17 at 6:19 PM 7/17/17 at 5:53 PM - 7/18/17 at 6:25 AM 7/19/17 at 5:44 PM - 7/20/17 at 6:33 AM 7/21/17 at 1:32 PM - 7/22/17 at 6:17 AM 7/2217 a 5:39 PM - 7/23/17 at 6:24 AM 7/23/17 at 1:57 PM - 7/24/17 at 6:29 AM On 8/1/17 at 5:49 PM, observation revealed the resident seated in his/her wheelchair in the dining room for supper. Observation revealed the resident required assistance from facility staff to eat his/her meal. Observation revealed the resident refused to eat or drink any of his/her supper meal, but was smiling when staff talked to him/her, with no behaviors. On 8/1/17 at 3:25 PM, Administrative staff C stated the incident was reported to him/her on 7/22/17 in a casual conversation, more like gossip, while doing overnight rounds. Administrative staff C stated after hearing about the incident, he/she thought about it and started to ask questions and investigate things the next day. Nurse A had kind of a gruff personality, so comments he/she made could have easily been misinterpreted. Administrative staff C stated when the 2 Nurse Aides who reported it were interviewed, they said they really didn't think to much about it and simply just forgot that they should have said something. On 8/2/17 at 6:33 AM, Nurse Aide D stated on July 5 around 8-8:30 PM, Resident #1 and Nurse A were involved in an incident. Nurse Aide D stated Resident #1 was agitated and wasn't wanting to take his/her medication, but Nurse A talked to him/her and was able to get him/her to take it. Nurse Aide D stated he/she and Nurse Aide E assisted the resident with a shower, at which time the resident was very agitated at which time the resident was refusing to get dressed. Nurse Aide D stated he/she tried to calm the resident but was unable to calm the resident, so Nurse A was called for assistance. Nurse Aide D stated when Nurse A was asked for assistance, he/she did not want to help, stating if we could not get the resident to cooperate, that he/she probably could not do it either. Nurse Aide D stated Nurse A came into the resident's room and started to talk to Resident #1 in a nice way to try to get him/her into bed. Resident #1 started to relax and allowed staff to dress him/her. Nurse Aide D stated then something happened and Resident #1 pinched Nurse A's breast causing Nurse A to become agitated and began yelling at her, you don't pinch me in the boob, you want me to call the cops on you, I could have you arrested. Pinching me is assault, you can't pinch people in the boob, I'm going to have you thrown in jail. Nurse Aide D stated Nurse A repeated this over and over for a minute or so. Resident #1 just stared at Nurse A, and said no. Nurse Aide D stated Nurse A then left the room and staff assisted the resident to bed. Nurse Aide G stated he/she did not know what to do, so he/she did not report it right away. Nurse Aide D stated he/she was just scared to report it, and was scared of Nurse A finding out and being mad at him/her. Nurse Aide D stated after he/she reported the incident (on July 20, 2 weeks after the incident occurred), he/she was scared he/she was going to have to work with Nurse A. Nurse Aide D stated staff are supposed to report anything they view as abuse. Nurse Aide D stated he/she should have talked to somebody sooner about the incident involving Resident #1. Nurse Aide D stated if he/she saw physical abuse he/she would have reported it immediately, but in his/her mind, he/she was trying to justify what happened that Nurse A didn't physically hurt Resident #1. On 8/2/17 at 8:35 AM, Administrative Nurse F stated he/she first found out about the incident on 7/24/17 from the Administrative Staff C, who said it was kind of hearsay. Nurse A was suspended on 7/26/17 at 4 PM. Administrative Nurse F stated he/she would have expected staff to report the incident to him/her immediately and said something to Nurse A that his/her behavior was inappropriate. Staff did not follow the facility's policy on reporting abuse, neglect, exploitation. On 8/2/17 at 8:55 AM, Nurse Aide E stated the incident happened on July 5, 2017 between 8 and 8:30 PM. Nurse Aide E stated he/she did not report the incident to anyone after it happened, because it was just so unexpected. Nurse Aide E stated the resident changed so much and got calmer after the incident, that he/she did not think about reporting it. On 8/2/17 at 9:12 AM, Nurse B stated the incident was reported to him/her after the fact, on July 20, 2017 by Nurse Aide D. Nurse B stated he/she asked Nurse Aide D if he/she had reported the incident to anybody, Nurse Aide D said that he/she had mentioned it to somebody else but couldn't remember who it was, and had not made an official report. Nurse B stated after he/she heard about the incident, he/she reported it to Administrative Staff C the next day, Administrative Staff C made him/her fill out a witness statement and told him/her it would be taken care of. Nurse B stated on 7/22/17 he/she was assisting a facility nurse aide with Resident #4 when the resident stated Nurse A was mean to him/her all the time. (Resident #4 received injections in his/her stomach) Resident #4 stated Nurse A would just jab the needle in when giving the injection. Nurse B stated the resident pulled up his/her shirt, showing Nurse B a small amount of blood on his/her abdomen when the injection had occurred. Nurse B stated that he/she had not reported this to anyone, but had not heard anything since then. On 8/2/17 at 10:33 AM, Administrative Staff C stated he/she would have expected staff to report the incident immediately and tell administration any concerns they may have, the facility has a no tolerance policy with abuse. Administrative Staff C stated Nurse A was not in the facility when the incident was reported to him/her, if he/she would have been, Administrative Staff C stated he/she would have talked to him/her. Administrative staff C stated the staff could have done a better job, with the delay in reporting and the way of hearing about it, the incident should have been reported in more of an official manner and sooner than it was. On 8/2/17 at 11:42 AM, Resident #4 stated Nurse A was very sarcastic with him/her. Resident #4 stated when Nurse A would administer his/her injections, Nurse A would just jab it in, and it hurt a lot. On 8/2/17 at 12:17 PM, Administrative Staff C stated the incident with Resident #4 had not been reported to him/her. The facility's Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 6/17, states staff will be trained to respond to potential abuse by 1.) protecting the resident, and 2.) immediately reporting it to their supervisor or nearest staff in charge. Notice will be posted notifying employees that they may file a complaint with the Kansas State Agency against the facility if they are retaliated against for reporting suspected abuse, neglect and/or exploitation. The facility failed to thoroughly investigate and report an incident of verbal abuse for Resident #1 who was verbally abused by staff and went unreported for 15 days, failed to report and investigate an allegation of abuse for Resident #4, and failed to protect the residents who reside in the houses at the facility, when Nurse A continued to work after the allegations of abuse, placing the 50 residents at risk for further abuse and mental distress. This deficient practice placed the residents in the houses (50) in immediate jeopardy. The facility abated the immediate jeopardy on 8/3/17, when they completed the following: staff education and training of the updated abuse policy and expectation of reporting were immediately initiated, online training of abuse will be increased to a quarterly mandated course, update of the policy on abuse, neglect, exploitation and reporting expectations will be highlighted in new hire training, staff huddles, and online education. The deficient practice remained at a scope and severity of (H)

The facility had a census of 93 residents. The sample included 3 residents. Based on observation, record review and interview the facility failed to provide an environment free from verbal abuse for 1 of 3 sampled residents, Resident #1 who was verbally abused by facility staff while the incident went unreported for 15 days and the staff member continued to work at the facility, placing Resident #1 in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 5/23/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment with fluctuating disorganized thinking, and a mood severity of 7 indicating mild depression, with no behaviors. The MDS recorded the resident required total dependence of 2 staff for transfers, locomotion on unit, dressing, toilet use, personal hygiene, bathing, total dependence of one staff for locomotion off unit, extensive assistance of 2 staff for bed mobility, and independent with eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, functional limitation in (ROM) Range of Motion on one side in upper extremities, used a wheelchair for mobility, always incontinent of bladder, and frequently incontinent of bowel. The MDS recorded the resident received scheduled and (PRN) as needed pain medication, almost constantly had pain rating 10 (scale 0-10), with a condition or chronic disease that may result in life expectancy of less than 6 months. The MDS recorded the resident received oxygen therapy, and hospice care. The Behavioral Symptoms (CAA) Care Area Assessment, dated 2/27/17, recorded the resident had actual behavioral symptoms with risk factors that included un-met needs and a decline in status. The CAA recorded the resident sometimes refused to take his/her scheduled medications. The CAA recorded the resident had chronic pain, was on a scheduled [MEDICATION NAME] (narcotic pain patch), was admitted to hospice services that assessment period, and was monitored daily for behavioral symptoms. The 7/27/17 care plan recorded the resident had impaired behavior related to a [DIAGNOSES REDACTED]. The care plan instructed staff to validate the resident's experiences as expressed, with reality orientation as appropriate. The facility's abuse investigation recorded the investigation began on 7/24/17 when suspected abuse was reported to the nurse management team. The investigation recorded on July 5, 2017, during evening cares with Resident #1, the resident became resistive and pinched Nurse A's breast. Nurse A stated to Resident #1 you don't pinch my t**! Do you want me to call the cops? Do you want to go to jail? The facility's investigation recorded on the night of 7/22/17 (17 days after the incident), Nurse B reported to Administrative staff C, suspected abuse involving Nurse A and Resident #1. Nurse B stated the abuse had been reported to him/her by Nurse Aide D, and had been witnessed by Nurse Aide C and Nurse Aide D. Nurse Aide D's notorized witness statement stated the resident had become agitated after his/her shower and Nurse Aides D and E were having difficulty dressing the resident for bed, so they called for Nurse A's assistance. The witness statement further stated Nurse A was able to calm Resident #1 for a little while and then the resident pinched Nurse A's breast. Nurse A started yelling at the resident saying, Do you want to go to jail? I'm going to call the cops on you. You don't pinch my t**, that's assault. I'm going to have you arrested! Nurse Aide D stated Nurse A repeated this statement over a few times until Resident #1 said, No. Nurse A then left the room while Nurse Aides D and E assisted the resident to bed. The facility's investigation substantiated the allegations of abuse. Review of Nurse A's July 2017 time card documented the nurse worked on the following days: 7/5/17 at 5:15 PM - 7/617 at 6:07 AM 7/6/17 at 5:43 PM - 7/7/17 at 6:19 PM 7/17/17 at 5:53 PM - 7/18/17 at 6:25 AM 7/19/17 at 5:44 PM - 7/20/17 at 6:33 AM 7/21/17 at 1:32 PM - 7/22/17 at 6:17 AM 7/2217 a 5:39 PM - 7/23/17 at 6:24 AM 7/23/17 at 1:57 PM - 7/24/17 at 6:29 AM On 8/1/17 at 5:49 PM, observation revealed the resident seated in his/her wheelchair in the dining room for supper. Observation revealed the resident required assistance from facility staff to eat his/her meal. Observation revealed the resident refused to eat or drink any of his/her supper meal, but was smiling when staff talked to him/her, with no behaviors. On 8/1/17 at 3:25 PM, Administrative Staff C stated the incident was reported to him/her on 7/22/17 in a casual conversation, more like gossip, while doing overnight rounds. Administrative Staff C stated after hearing about the incident, he/she thought about it and started to ask questions and investigate things the next day (7/23/17). He/she further stated Nurse A had kind of a gruff personality, so comments he/she made could have easily been misinterpreted. Administrative Staff C stated when the 2 Nurse Aides who reported it were interviewed, they said they really didn't think to much about it and simply just forgot that they should have said something. On 8/1/17 at 3:25 PM, Administrative Nurse F stated the incident should have been reported immediately, and verified once the staff and residents were interviewed, Nurse A was terminated from employment. On 8/2/17 at 6:33 AM, Nurse Aide D stated on July 5, 2017 around 8-8:30 PM, Resident #1 and Nurse A were involved in an incident. Nurse Aide D stated Resident #1 was agitated and wasn't wanting to take his/her medication, but Nurse A talked to the resident and was able to get him/her to take it. Nurse Aide D stated he/she and Nurse Aide E assisted the resident with a shower, at which time the resident was very agitated and the resident refused to get dressed. Nurse Aide D stated he/she tried to calm the resident but was unable to calm the resident, so Nurse A was called for assistance. Nurse Aide D stated when Nurse A was asked for assistance, he/she did not want to help, stating if Nurse Aides D and E could not get the resident to cooperate, that he/she probably could not do it either. Nurse Aide D stated Nurse A came into the resident's room and started to talk to Resident #1 in a nice way to try to get him/her into bed. Resident #1 started to relax and allowed staff to dress him/her. Nurse Aide D stated then something happened and Resident #1 pinched Nurse A's breast causing Nurse A to become agitated and began yelling at the resident, you don't pinch me in the boob, you want me to call the cops on you, I could have you arrested. Pinching me is assault, you can't pinch people in the boob, I'm going to have you thrown in jail. Nurse Aide D stated Nurse A repeated this over and over for a minute or so. Resident #1 was just staring at Nurse A, and said no. Nurse Aide D stated Nurse A then left the room and staff assisted the resident to bed. On 8/2/17 at 8:35 AM, Administrative Nurse F stated Nurse A was suspended on 7/26/17 at 4:00 PM because he/she was supposed to work that night. Administrative Nurse F stated Nurse A did work on July 6, 2017, the day after the incident, was sick from 7/7/17-7/16/17, and returned to work on 7/17/17. Administrative Nurse F stated administration had no knowledge of the incident during the 5 days Nurse A worked after his/her illness. On 8/2/17 at 2:11 PM, Nurse A stated on July 5, 2017 another nurse and (CMA) certified medication aide or (CNA) certified nurse aide (Nurse A was unable to state who the staff person was) called him/her to give Resident #1 his/her medications because he/she was refusing to take them. Nurse A stated he/she was working in a different house that night, but came over to help. Nurse A stated when he/she was giving Resident #1 his/her medication, the resident grabbed Nurse A's breast so Nurse A told the resident not to pinch(NAME)and(NAME)(referring to his/her breasts). Nurse A stated an aide heard him/her make this statement and asked Nurse A what he/she was talking about, Nurse A stated he/she told the aide that he/she did not say boob, but referred to his/her breasts at(NAME)and(NAME) the aide said it was cool. Nurse A stated he/she made a joking comment to the aide that saying(NAME)and(NAME)was better than telling the resident that he/she was going to call the cops. Nurse A stated that was the end of the conversation. Nurse A denied any form of abuse or neglect. The facility's Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 6/17, defined verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility failed to provide an environment free from abuse for Resident #1, who was verbally abused by staff, placing Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 8/3/17, when they completed the following: staff education and training of the updated abuse policy and expectation of reporting were immediately initiated, online training of abuse will be increased to a quarterly mandated course, update of the policy on abuse, neglect, exploitation and reporting expectations will be highlighted in new hire training, staff huddles, and online education. The deficient practice remained at a scope and severity of (G)

The facility had a census of 101 residents with 13 selected for sample and 1 reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident sampled with pressure ulcers received necessary treatment and services to prevent the development of a new pressure ulcer. Staff failed to implement interventions to reduce heel pressure for a resident with decreased physical mobility, and the resident developed a facility acquired unstageable pressure ulcer. (#136) Findings included: - Resident# 136's 11/25/14 physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 12/2/14, revealed the resident had long and short term memory problems, moderately impaired decision making skills, and required extensive assistance of 2 staff for bed mobility, transfers, ambulation, toileting, hygiene, dressing, and bathing. He/she received a scheduled pain medication, was at risk for development of pressure ulcers, and had a pressure reducing mattress and device in the chair. The MDS did not indicate the resident was on a turning/repositioning program or rejected care. The 12/8/14 (ADLs) Activity of Daily Living (CAA) Care Area Assessment revealed the resident required assistance of 1 to 2 staff for daily care and was occasionally incontinent of urine and bowel. The 12/8/14 pressure ulcer CAA revealed a risk for developing a pressure area related to his/her decreased mobility. The 12/8/14 care plan revealed the resident required assistance from 2 staff for bed mobility, transfer, ambulation, and dressing. He/she needed assistance of 1 staff for toileting, hygiene, and bathing. The care plan lacked instructions for the staff to reposition the resident, did not include provision for a pressure reducing mattress, or a pressure reducing device for his/her feet. The 1/14/15 care plan revision revealed the resident had an unstageable pressure area to the right heel found on 12/29/14, with the following interventions: a gel mattress overlay placed on the bed, and directed staff to place a pillow underneath the resident's lower legs to prevent his/her heels from resting on the bed. The care plan revealed an order for [REDACTED]. The 1/28/15 care plan revision stated interventions for a risk for skin breakdown and to apply black boots to reduce pressure. The 11/26/14 Admission Physician order [REDACTED]. The 11/26/14 Braden Scale revealed a score of 21, no risk for developing a pressure ulcer. On 11/27/14 the resident was evaluated by a physician in the hospital emergency room and diagnosed with [REDACTED]. The 12/5/14 at 2:09 PM, Nutrition Risk Assessment stated the resident received a consistent carbohydrate diet, medium portions, and a protein snack at bedtime. He/she ate independently, with an intake of 50-75 percent. The medical record revealed no recent blood laboratory values. The 9/4/14 labs revealed a metabolic panel with a glucose of 285 (normal from 80 - 105) and an [MEDICATION NAME] of 4.0 (normal from 3.4 - 5.4 grams per deciliter). An elevated blood glucose level and a low [MEDICATION NAME] delay wound healing. The Daily Intake Record for a supplement during the month of December and January revealed an intake of 100 percent, except for 9 days in January when the resident refused the supplement. The 12/23/14 at 8:20 PM, nurse's note stated the resident complained of pain, but was unable to rate the pain level. The resident tolerated the pain as he/she lay on the bed, verbalized an increase in pain as staff attempted to move him/her on the bed or when he/she walked. The 12/24/14 at 6:31 AM, nurse's note revealed the resident asked for a narcotic pain medication. Staff administered [MEDICATION NAME] (a narcotic pain medication) to the resident. He/she received a bed bath with no further complaints of pain verbalized. The 12/29/14 at 10:09 PM, nurse's note stated the nurse and the medication aide assisted the resident to the bathroom and noted an intact, purple area on the back if the right heel that measured 2.5 (cm) centimeters X 1.4 cm. The nurse placed sheepskin under the resident's heels and elevated his/her feet to relieve pressure. The note stated the nurse notified the physician and the Physical Therapist would be contacted with a request made to obtain a pair of black pressure reduction boots. The 12/31/14 at 5:34 AM, Skin Condition Assessment stated a pillow elevated the resident's feet to relieve pressure, skin intact, hard around the edges, with a softer purple center. The 1/2/15 at 12:04 AM, nurse's note stated the staff notified the resident's durable power of attorney regarding the resident continued to refuse to get out of bed, use the bathroom, or eat meals, and experienced increased pain due to the lumbar compression fracture. The 1/4/15 at 3:14 PM, nurse's note revealed the resident wore the black protective boots on his/her feet, as he/she rested. The 1/6/15 at 7:14 PM, nurse's note stated the resident walked a few steps, grimaced and verbalized pain. He/she declined a medication for pain relief. The 1/7/14 at 12:02 AM, Skin Condition Assessment stated the pressure ulcer measurements as 3.0 cm x 1.5 cm with skin intact, hard around the edges, with a softer purple center. (An increase in size ten days after discovered by staff.) The 1/9/15 at 7:21 PM, Skin Condition Assessment stated the pressure ulcer measurement as 3.0 cm x 1.5 cm skin intact, hard around the edges, with a softer purple center. The 1/14/15 at 12:00 PM, Registered Dietician's note stated the resident needed 69-77 grams of protein per day for a stage 2 healing ulcer. He/she had a stable weight at 120.6 pounds and a meal intake of 75 to 85 percent. Staff encouraged the resident to accept a no added sugar health shake. The 1/14/15 at 12:00 PM, Skin Condition Assessment stated the pressure ulcer measurements as 3.0 cm x 2.1 cm with skin intact, hard around the edges, with a softer purple center. The 1/20/15 at 12:44 PM, Skin Condition Assessment stated the wound measurement as 3.0 cm x 2.1 cm with skin intact, hard around the edges, with a softer purple center. The 1/27/15 5:09 PM, Skin Condition Assessment stated the wound measurement as 2.8 cm x 2.0 cm, with intact skin and an odd shape. The resident had black boots on with his/her feet elevated, and a gel pad on the mattress. The 1/28/15 at 6:06 PM, Skin Condition Assessment stated the wound measurement as 2.8 cm x 2.0 cm. On 1/27/15 at 3:31 PM, observation revealed the resident, seated in a recliner with the footrest elevated, black socks on his/her feet, and rubber soled terrycloth slippers. The resident rested the back side of his/her heels directly on the recliner footrest and removed his/her right sock. The wound on the right outer aspect of the heel, was a non-circular shape, with a large intact scab, approximately ? in X ? in and pink flesh toned skin surrounding the site. The heel in the resident's walking shoes had no rough edges or areas that appeared worn from rubbing/friction. On 2/3/15 at 8:26 PM, observation revealed the resident asleep in bed on his/her right side, legs drawn up, bent at the knees with the right outer aspect of the heel against the top of the sheepskin. Observation revealed the the black boots were on the floor next to the bed. On 2/3/15 at 8:47 AM observation revealed the resident walking independently into the bathroom with a front wheeled walker. He/she had on white socks and no shoes or slippers. Observation of the bed revealed a sheepskin that covered the lower third of a scoop mattress, with a blanket tri-folded on top of the sheepskin in the area where the resident ' s lower legs would lay. The black pressure reducing boots remained on the floor next to the end of the bed. On 2/3/15 at 7:56 AM, Nurse Aide L stated the resident was not on a turning program, although staff attempted to reposition him/her frequently. Staff changed the resident's incontinent pads in bed and the resident did not always allow a pillow to be placed under his/her legs. The aide explained the resident wore a pair of black boots during the night, which staff initiated after the sore developed on his/her heel. On 2/3/15 at 8:03 AM, Nurse M stated the resident experienced severe pelvic pain and did not want to get out of bed or reposition. The nurse stated after the resident's heel began to get soft, staff initiated interventions to reduce pressure to the area and stated staff repositioned the resident every 2 hours. On 2/3/15 at 2:54 PM, Nurse Aide D stated at the time of the compression fracture to his/her back, the resident did not have a turning program, was depressed, and had to have the incontinent products changed while he/she lay in bed. The resident yelled at staff as they attempted to reposition him/her. Nurse Aide D stated the resident did not move his/her feet in bed and did not like the pillow under his/her legs. Nurse Aide D verified the black boots were on the floor next to the bed. On 2/3/15 at 3:48 PM, Nurse A verified staff implemented the interventions - a gel overlay for the mattress, sheepskin, pillow under the legs, and black boots were initiated after discovery of the unstageable pressure ulcer. Nurse A verified the resident's refusal to wear the black pressure reducing boots and refusal to leave the bed following the compression fracture were not communicated to the management team. Nurse A acknowledged the resident experienced increased pain from the compression fracture, mobility decreased, the resident remained in bed or the recliner for longer periods, and required extensive assistance from staff. On 2/9/15 at 12:25, Physician P stated on 12/23/14, the resident was seen by his/her physician assistant at the clinic. At that time the resident was ambulating well, without concern, he/she did complain of some hip pain, but nothing that would keep him/her from ambulating. On 12/27/14 the resident was diagnosed with [REDACTED]. During that 2-3 day time frame is when the resident developed the area on his/her heel. Physician P stated the facility may have implemented interventions for prevention over that 2-3 day time span, and it may have been prevented. Once the resident was no longer ambulating, he/she was at risk. Physician P stated the resident was ambulating on the 23rd, stopped ambulating on the 27th, and the heel area developed on the 29th . Upon request, the facility was unable to provide a policy and procedure for pressure ulcer prevention. The facility failed to provide necessary services and interventions to prevent the development of an unstageable pressure ulcer, after Resident #136 had fractures, increased pain, decreased mobility, and spent his/her time in the recliner or bed.

The facility had a census of 98 residents. The sample included 3 residents. Based on observation, record review and interview the facility failed to provide supervision and assistance with ambulation, as care planned, for 1 of 3 sampled residents, which resulted in a fall with a skull fracture and subdural hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma. (#1) Findings included: - Resident # 1's annual (MDS) Minimum Data Set 3.0 assessment, dated 10/29/13, indicated short and long term memory loss with moderately impaired decision making skill and the resident required limited assistance of 1 staff for bed mobility, transfers, walking and locomotion; and extensive assistance with dressing, toileting and hygiene. The MDS indicated the resident's balance was unsteady and he/she was only able to stabilize with staff assistance, The resident had no (ROM) Range of Motion impairment, used a walker and had 1 non-injury and 2 minor injury falls since the prior MDS. The 1/28/14 quarterly MDS indicated the same except no falls. The10/29/13 (CAAS) Care Area Assessment for falls recorded: the resident had falls; factors included dementia (progressive mental disorder characterized by failing memory, confusion), poor balance, and inability to remember that he/she required staff assistance for transfers and ambulation. Risk factors included possible decline in status and he/she had a pressure pad alarm in his/her bed and a floor alarm. The 1/30/14 care plan for falls directed the staff to perform 30 minute visual checks, cue the resident to wear glasses when out of bed, keep the resident ' s bed clear and provide the assistance of 1 staff and a walker for ambulation. The care plan directed the staff to provide a bed alarm, perform weekly alarm checks, for the resident to only sit in dining room chairs with arms and offer toileting at 12 AM and 3 AM. The ADL care plan directed the staff not to use a gait belt because it caused behaviors and he/she hit at staff when they tried to apply the gait belt. The 3/25/14 physician's visit note indicated the staff noticed an increase in behaviors and indicated the resident's dementia was pretty progressive at this point. The physician's orders [REDACTED]. The 3/27/14 at 5:11 AM, nurse's note indicated the resident was up, hollering and wandering around. The CMA (Certified Medication Aide) reported he/she fed the resident apple sauce, pudding and a health shake and the resident returned to his/her bed and slept. The 4/1/14 at 12:00 PM, nurse's note indicated the resident sat in a recliner and mumbled incoherently most of the shift and kept repeating " I feel so bad " . The note indicated the staff asked the resident if he/she was in pain and the resident just repeated the same thing. The note indicated the staff assisted the resident to his/her room to get dressed for the day. Further review of the nurse's notes revealed no further assessment of the resident ' s status from 4/1/14 at 12:00 PM, until the resident experienced a fall with serious injury on 4/2/14 at 11:36 AM, and admitted to the hospital. The 4/2/14 at 1:27 PM, nurse's note stated as the resident was getting out of a lounge chair for lunch, with the assistance of staff, he/she fell to the right and hit his/her head on the ledge of the entertainment center. The note indicated the nurse contacted the physician who ordered the staff to send the resident to the (ER) emergency room . The note further indicated the resident was talking, and stated his/her head hurt, but no open areas or blood noted. The 4/2/14 at 4:02 PM, nurse ' s note indicated the resident transferred to a hospital with the [DIAGNOSES REDACTED]. The 4/2/14 Fall Communication to the physician stated the fall occurred at 11:36 AM and stated the resident was getting out of a lounge chair with a (CMA) Certified Medication Aide standing by. The form indicated the resident lost his/her balance and fell to the right side, hitting the back of his/her head on the edge of the entertainment center. The form indicated the resident ' s vital signs were: temperature 95.3 (normal temperature is 98.6), blood pressure 118/68 (within normal range), pulse 71 (within normal range), and respirations 36 (normal is 12-20) and he/she complained of head pain. The 4/2/14 Post Fall Investigation indicated the resident slept in the chair at 11:00 AM. The investigation indicated the resident required stand by assistance for transfers/ambulation prior to the accident and able to cooperate with cares, but resisted at times, and used a walker for mobility. The report indicated the staff last assisted the resident with toileting between 8:00 and 9:00 AM, the resident wore glasses and shoes. The conclusion of the investigation stated staff were to assist the resident when getting out of chairs and the intervention stated the staff were to walk behind the resident when walking with the walker or getting out of chairs. The 4/2/14 witness statement by the (CMA) Certified Medication Aide who assisted the resident out of the chair included the following: The CMA woke the resident who was sleeping in the recliner. The resident responded and started getting up from the recliner with the assistance of the CMA. The CMA directed the resident to walk to the dining table and walked ahead of Resident #1. The CMA turned around and saw the resident lose his/her balance, fall to the right side and backwards with his/her walker and hit his/her head first on the entertainment center. The 4/2/14 at 5:00PM, Neurosurgery (H & P) History and Physical indicated the resident fell from a standing position, backwards and hit his/her head without loss of consciousness. The report further indicated the resident had a subcutaneous hematoma (bruising that could cause inward pressure on the brain) so the resident transferred to the local ER where they found a non-displaced fracture as well as a small hemorrhage (bleeding) so the resident transferred to a larger hospital for neurosurgical evaluation. The report indicated the resident was awake, alert and oriented to person only, which is his/her baseline. The 4/4/14 hospital discharge summary stated the resident admitted for a skull fracture and subdural hematoma and did not have a neurological recovery to baseline. The 4/4/14 at 4:40 PM, nurse ' s note indicated the resident readmitted to the facility per ambulance with a [DIAGNOSES REDACTED]. The resident moved his/her arms and moaned, but did not open his/her eyes. Hospice staff admitted the resident to Hospice care. On 4/28/14 at 5:10 PM, Nurse A demonstrated what happened when resident #1 fell , on 4/2/14, in the living room. Nurse A reported the CMA assisted the resident to stand up, out of the recliner which was approximately 12 feet in front of the entertainment center, and cued the resident to use his/her walker to ambulate to the dining room. Nurse A stated the CMA was in front of the resident, and when he/she looked back and the resident was falling to one side. Nurse A stated the resident was falling toward the fireplace/entertainment center, hanging onto his/her walker, and his/her head hit the bottom of the entertainment center or the floor. Nurse A verified the staff were to walk beside or behind the Resident #1 with ambulation. On 4/30/14 at 8:00 AM, Nurse C stated the staff were to use standby assistance, walking behind or at least beside the resident as he/she occasionally wobbled to either side and his/her balance was poor. On 4/30/14 at 9:30 AM, Nurse Aide F stated the resident walked pretty well normally, but he/she was asleep and had just been woken up. Nurse Aide F stated the staff did not use a gait belt with the resident because he/she would get very upset and start hitting. He/She stated the staff are supposed to walk beside or behind the resident. On 4/30/14 at 9:40 AM, Nurse Aide H stated the resident used a walker and staff were to provide standby assistance with ambulation, which meant walking beside the resident and to the back a little, just in case he/she was unsteady. On 4/30/14 at 9:54 AM, Restorative Aide D stated when staff were hired he/she did actual hands on training with them and yearly re-training education for transfers. He/She stated the resident was care planned for standby assistance. Restorative Aide D stated the staff were to walk beside the resident when ambulating and the resident was unsteady at times, so he/she was a high fall risk. On 4/30/14 at 10:02 AM, Medication Aide E stated, on 4/2/14, he/she had awakened the resident and watched while he/she stood up and took a step or two. Medication Aide E stated, when the resident stood and started walking, he/she went around and was in front of the resident. Medication Aide stated he/she was at least 2-3 feet ahead of the resident when the resident fell . On 4/30/14 at 12:24PM, Administrative staff J verified the staff who provided standby assistance with ambulation for the resident had not been standing beside the resident when he/she fell . On 5/2/14 at 8:20 AM, Administrative Nurse B verified the staff should have been next to the resident when he/she ambulated. The (FDA) Federal Drug Administration website indicated healthcare providers should pay particular attention to a resident's changes in behavior and mood when Remeron is started. The FDA further stated potential side effects included sleepiness, dizziness and may affect ability to act quickly. The facility ' s 12/13 Fall Management policy stated the interdisciplinary team would develop an individualized plan of care for residents with a potential for falls. The policy further stated all staff who worked directly with the resident were responsible for knowing and following the plan of care. The facility ' s 1/13 Abuse, Neglect, Exploitation policy stated neglect was the failure to provide goods or services which were necessary to ensure the safety and well-being and to avoid physical or mental harm or illness. The facility failed to provide appropriate supervision and assistance with ambulation, as care planned, for Resident #1, who fell and sustained a skull fracture and subdural hematoma.

The facility had a census of 98 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to implement a care plan and follow physician's orders [REDACTED]. (#82) Findings included: - Review of the medical record revealed the facility readmitted Resident #82 on 04/28/12. The 04/28/12 Braden Scale indicated the resident had a total score of 15 related to the resident's decreased mobility due to his/her recent [MEDICAL CONDITION] (total score of 16 or less indicated high risk for pressure ulcer development). The significant change (MDS) Minimum Data Set 3.0 assessment, dated 05/04/12, indicated the resident's (BIMS) Brief Interview for Mental Status score was 11(moderately impaired). The MDS also indicated the resident required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. The MDS further indicated the resident was a risk for pressure ulcers but had no skin issues. The Medicare 30-day (MDS) Minimum Data Set 3.0 assessment, dated 05/30/12, indicated the resident had short and long term memory problems and modified independent decision making skills. The MDS indicated the resident required extensive assistance with be mobility, transfers, toilet use and personal hygiene. The MDS further indicated the resident was high risk for pressure ulcers and had a Stage II pressure ulcer. The 05/13/12 at 1:53 PM, nurse's note indicated the resident transferred with a full body sling lift and 2 staff assistance and was incontinent of bowel and urine. The nurse's note also indicated "moisture barrier continues to be applied to his/her buttocks due to ruptured blister to his/her buttocks." The 05/31/12 care plan revision (no previous care plan in place for skin impairment risk/pressure ulcers) indicated the resident had a Stage II pressure ulcer on his/her buttock due to impaired mobility, increased incontinence and poor meal intake (18 days after the staff had assessed skin issues on the resident's buttocks). The care plan directed the staff to provide the resident's skin treatments as ordered by the physician and to reposition the resident every 2 hours. The 06/28/12 care plan revision indicated the facility had placed an air mattress on the resident's bed (46 days after the staff had assessed skin issues on the resident's buttocks). The 05/25/12 physician's orders [REDACTED]. The 2012 May (MAR) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. review of the resident's medical record revealed [REDACTED]. The 2012 June (TAR) Treatment Administration Record directed the staff to apply Allevyn to the resident's open areas on his/her buttocks every 72 hours and/or as needed. Review of the 2012 June TAR revealed the physician's wound treatment order had been changed from every 24 hours to every 72 hours. review of the resident's medical record revealed [REDACTED]. The 06/05/12 Skin Assessments indicated the resident had skin breakdown on the following areas: 1) left inner buttock - 1.4 (cm) centimeter by 1.5 cm, Stage II, open area (red/raw with some bleeding at the edges) 2) right inner buttock - 2.5 cm by 2.4 cm, Stage II, open area (red/raw) 3) coccyx - 1.5 cm by 1.6 cm by, Stage II, open area (red/raw) The 06/06/12 at 11:21 PM, nurse's note indicated the resident "has received cushion for chair to relieve buttock pressure." The 06/14/12 Skin Assessments indicated the resident had skin breakdown on the following areas: 1) left inner buttock - 1.5 (cm) centimeter by 1.5 cm Stage II open area (red/raw with bleeding) 2) right inner buttock - 2.0 cm by 2.3 cm Stage II open area (red/raw) 3) coccyx - 1.9 cm by 1.5 cm by Stage II open area (red/raw with bleeding) The 06/26/12 Skin Assessments indicated the resident had skin breakdown on the following areas: 1) left buttock - 3.0 cm by 1.5 cm unstageable open area with slough (dead tissue), bloody drainage and wound edge maceration (moist, [MEDICAL CONDITION] tissue) as assessed with [REDACTED]. 2) right buttock - 1.0 cm by 1.0 cm, Stage III, open area with slough as assessed with [REDACTED]. The 06/27/12 physician's orders [REDACTED]. On 06/28/12 at 8:56 AM, observation revealed the resident resting quietly in bed. Continued observation revealed Aides N and P moved the resident's extremities to turn and reposition the resident. Continued observation revealed the resident had not attempted to participate in his/her cares and was incontinent of urine. Continued observation revealed the resident had an intact Allevyn dressing, dated 06/26/12, with an approximate 4.0 cm by 4.0 cm reddish drainage stain on the dressing (physician ordered Hydrogel dressing, dated 06/27/12, not initiated). Continued observation revealed an approximate 3.0 cm by 1.5 cm open area with slough on the resident's left inner buttock, an approximate 1.5 cm by 1.5 cm open area with reddish drainage on the resident's right inner buttock and an approximate 1.0 cm by 1.5 cm open area with reddish drainage on the resident's coccyx. Continued observation revealed Nurse C cleansed the resident's open areas and applied an Allevyn dressing (again, on the 06/27/12 the physician ordered Hydrogel dressing not initiated). On 06/28/12 at 8:58 AM, Nurse C stated the resident required extensive to total assistance with bed mobility, transfers, toilet use and personal hygiene and was incontinent of bowel and urine. Nurse C also stated the staff provided wound cares and dressing changes every 3 days. On 06/28/12 at 8:50 AM, Nurse B stated the facility had assessed the resident as a high risk for pressure ulcers and should of had a care plan in place prior to the development of the resident's pressure ulcers. Nurse B also stated the facility should follow the physician's orders [REDACTED]. The May 2012 Skin and Wound Management Policy directed the staff to assess residents for skin breakdown risks and develop a care plan to identify preventative interventions and/or manage wound treatment. The policy also directed the facility to educate and inform the staff regarding changes in wound treatment and/or care plan interventions. The policy further directed the staff to assess new or worsening skin conditions every day. The facility failed to implement a care plan, including preventative measures for a resident at high risk for developing pressure ulcers and to follow physician's orders [REDACTED].#82.