Every finding on record at The Healthcare Resort of Olathe

The facility reported a census of 57 residents. The sample included 15 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing hours. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - The PBJ provided by CMS for Fiscal Year (FY) 2024 of the fourth quarter (07/01/24 through 09/30/24) indicated the facility was triggered for low weekend staff. The PBJ provided by CMS for Fiscal Year (FY) 2025 of the first quarter (10/01/24 through 12/31/24) indicated the facility was triggered for low weekend staff. A review of the facility's working schedule, time sheets /punches, and posted staffing hours was completed for missed weekend coverages between 07/01/24 to 09/30/24 and 10/01/24 to 12/31/24. The review revealed no missed coverage or gaps. On 04/16/24 at 01:22 PM, Administrative Nurse D stated the facility had no missed licensed nurse shifts and utilized agency staff to fill in the gaps on the schedules. She stated some of the shifts may not have been accurately reported during the PBJ submission hours to reflect agency and administrative nurse shift fill-ins. On 04/16/25 at 01:35 PM, Administrator AA stated the facility had worked hard to cover staffing and believed the triggering was due to an error related to the administrative nurse's hours not being included while filling in the weekend shift. She also stated some agency staff hours may not have been reported. The facility's Payroll Based Journaling policy revised 12/2024 indicated the facility would provide complete and accurate payroll data that could be validated and auditable.

The facility identified a census of 57 residents. The facility identified 17 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store Resident (R) 5, R9, and R37's respiratory equipment in a sanitary manner. The facility additionally failed to store clean linens in a sanitary manner and further failed to ensure R34's Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) remained off the floor. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 04/14/25 at 07:10 AM, a walkthrough of the facility was completed, and noted: An inspection of R5's room revealed oxygen nasal tubing wrapped around a standing oxygen canister handle. No sanitary storage was present. An inspection of R9's room revealed a nebulizer mask laid directly on a bedside table. No sanitary storage was present. An inspection of R37's room revealed her wheelchair's supplemental oxygen tank tubing and nasal cannula rested on the seat of her wheelchair. No sanitary storage bag was present. On 04/14/25 at 08:40 AM, R34 sat in her recliner with her feet elevated. R34's catheter bag contained amber-colored urine in the drainage bag. R34's catheter drainage bag laid directly on the floor. The catheter drainage bag did not have a privacy bag cover. On 04/14/25 at 08:46 AM, clean linens were placed on the EBP cart outside R42's room. On 04/16/25 at 07:15 AM, Licensed Nurse (LN) H stated nebulizer mask and nasal oxygen should be stored in a sanitary bag with the resident's name. He stated linens should not be left outside of a resident's room, and urine catheter bags should never be on the floor. On 04/16/25 at 08:15 AM, Certified Nursing Aide (CNA) M stated oxygen tubing could be wrapped around the canister; staff were to ensure the tubing was not on the floor. She stated linens should be placed in the residents' rooms, not outside the rooms. CNA M stated urine catheters should be off the floor and covered. On 04/16/24 at 01:20 PM, Administrative Nurse D stated nasal tubing should be stored in a sanitary bag when not in use and nebulizers should be rinsed and placed on a barrier to dry. She stated linen should not be placed in the hall, catheters should never be on the floor, and should always have a privacy cover. The facility's Infection Control policy dated 10/24 documented the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The Infection program would be carried out by the facility's infection preventionist. The goal of the facility was to decrease the risk of infection to residents and personnel. The facility would recognize infection control practices while providing care, and Identify and correct problems related to infection control.

The facility reported a census of 57 residents. The facility identified two medication rooms and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure one of four medication carts. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 04/14/25 at 07:26 AM, an inspection of the west wing was completed. The west wing inspection revealed an unsecured medication cart next to the oxygen storage room revealed prescribed medications, ointments, and treatment care supplies accessible without staff supervision. On 04/14/25 at 07:30 AM, Certified Medication Aide (CMA) R came around the corner from the medication storage area and secured the cart. She stated the carts were to be locked when not supervised. On 04/16/25 at 12:33 PM, Licensed Nurse (LN) G stated the medication carts and computers were to be locked while staff were away from them. On 04/16/25 at 01:03 PM, Administrative Nurse D stated staff were expected to lock the medication carts when not in use or unsupervised. The facility's Medication Storage policy revised 12/2024 indicated the facility was to secure all medication in a clean, locked, and organized manner to ensure safe handling and administration.

The facility reported a census of 57 residents. The sample included 15 residents with six 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 record review, interviews, and observations, the facility failed to follow preventative wound care practices related to Residents (R) 29 and R42's low air-loss mattress (specialized mattress used to reduce pressure on the body) settings. The facility additionally failed to float R28 and R37's heels per their wound care interventions. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) noted diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body), major depressive disorder (major mood disorder), and dysphagia (difficulty swallowing). R29's Quarterly Minimum Data Set (MDS) completed 01/13/25 revealed a Brief Interview for Mental Status Score of zero indicating severe cognitive impairment. The MDS indicated he had bilateral upper and lower extremity impairments. The MDS indicated he was dependent on staff assistance for bed mobility, transfers, toileting, bathing, dressing, personal hygiene, and Broda chair (specialized wheelchair with the ability to tilt and recline) mobility. The MDS indicated he was at risk for developing 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). The MDS indicated he had pressure-relieving devices for his bed and chair. The MDS noted he weighed 186 pounds (lbs). R29's Pressure Ulcer Care Area Assessment (CAA) completed 10/07/24 indicated he required total assistance from staff and was at risk for falls, skin breakdown, pressure injury development, and incontinence. The CAA noted he was provided pressure-reducing devices. The CAA noted staff would continue to provide repositioning and care plan interventions were implemented to reduce the risks associated with pressure injuries. R29's Care Plan initiated on 11/28/20 indicated he required assistance with his activities of daily living (ADL). The plan indicated he required assistance from one staff for bathing, dressing, toileting, bed mobility, and transfers. The plan noted he was at risk for pressure ulcer development. The plan indicated he had pressure-reducing devices, preventative skin care, repositioning, and nutritional management in place. The plan noted he had a low air-loss mattress in place and instructed staff to check its function every shift. The plan lacked documentation related to the mattress's setting or care instructions. A review of the manual of low air-loss mattress manufacturers' operation (Drive Model) indicated that the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range and comfort settings. The manual indicated an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. R29's EMR under Vitals indicated he weighed 190.2 lbs. on 04/14/24. On 04/14/25 at 07:57 AM, R29 slept in his bed. His bed was set to a low height with his call light next to him within reach. R29's low air-loss mattress was set to 450 lbs. The mattress pump had fixed weight settings of 250lbs or less, 300lbs, 350lbs, 400lbs, 450lbs, 500lbs, 550lbs, and 600 to 1000lbs. On 04/16/25 at 12:03 PM, Certified Nurse Aide (CNA) M stated the air mattress settings were by the resident's current weight. She stated staff would check if the bed alarms or pump alarms were going off. On 04/16/25 at 12:33 PM, Licensed Nurse (LN) G stated the mattress pumps were set by weight. She stated staff should be checking them each shift to ensure the correct settings were entered. On 04/16/25 at 01:10 PM, Administrative Nurse D stated the mattresses should be set by the resident's weight per the manufacturer's recommendation. She stated staff were also to perform a softness check with their hands to ensure the beds were not too firm. The facility's Skin and Wound Monitoring and Management policy revised 12/2023 indicated the facility was to promote interventions that prevent pressure injury development and heal injuries that were present. The policy identified nutritional monitoring, repositioning, weekly wound assessments, and pressure-reducing devices. - The Medical Diagnosis section within R42's Electronic Medical Records (EMR) noted diagnoses of Dementia (a progressive mental disorder characterized by failing memory and confusion), insomnia (difficulty sleeping), muscle weakness, and cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R42's Quarterly Minimum Data Set (MDS) completed 01/13/25 revealed a Brief Interview for Mental Status (BIMS) score of ten indicating moderate cognitive impairment. The MDS indicated she required substantial to maximal assistance for bed mobility, transfers, toileting, bathing, dressing, personal hygiene, and wheelchair mobility. The MDS indicated she had frequent bowel and bladder incontinence. The MDS noted she was at risk for the development of 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). The MDS indicated she had pressure-reducing devices for her bed and wheelchair in place. The MDS indicated she weighed 136 pounds (lbs.). R42's Functional Abilities Care Area Assessment (CAA) completed 08/30/24 indicated she required assistance from staff related to her impaired mobility, poor cognition, and medical diagnoses. The CAA noted she had generalized weakness and decreased safety awareness. The CAA noted care planned interventions were implemented to address her risks. R42's Pressure Ulcer CAA completed 08/30/24 indicated she was at risk for the development of pressure ulcers. The CAA noted she had incontinence, decreased mobility, cognitive loss, and recurrent urinary tract infections (UTIs) as risk factors for pressure ulcer development. The plan instructed staff to complete weekly skin assessments and provide preventative care. The CAA noted care planned interventions were implemented to address her risks. R42's Care Plan initiated on 06/22/23 indicated was at risk for the development of pressure ulcers due to decreased mobility and her medical diagnoses. The plan noted she required assistance from staff for bed mobility, transfers, toileting, dressing, bathing, and personal hygiene. The plan indicated she had a history of pressure injuries but no current wounds. The plan instructed staff to provide repositioning throughout the day. The plan instructed staff to complete weekly wound assessments. The plan noted she had a pressure-reducing device for her wheelchair and a low air-loss mattress (specialized air mattress used to reduce pressure applied to the body). The plan lacked documentation related to the mattress's setting or care instructions. A review of the manual of low air-loss mattress manufacturers' operation (Drive Model) indicated that the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range and comfort settings. The manual indicated an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. R42's EMR under Vitals noted her weight was 130.4 lbs. on 04/07/25. On 04/14/25 at 07:20 AM, R42 slept in her bed. Her bed was set to a low height with her call light next to her bed within reach. R42's low air-loss mattress was set to 350 lbs. (maximum setting). The mattress pump had fixed weight settings of 50lbs, 100lbs, 150lbs, 170lbs, 200lbs, 250lbs, 300lbs, and 350lbs. Her call light was pinned to her blanket. On 04/15/25 at 07:37 AM, R42 slept in her bed. Her bed remained in a low position. Her mattress pump was set to 350lbs. R42's call light was pinned to a pillow placed on her recliner next to her bed. The call light was out of reach. At 07:40 AM, Administrative Nurse D entered the room moved the call light to R42's bed, and stated staff were expected to ensure the call lights were within reach at all times. She stated the low air-loss settings were set by the manufacturer's recommendation and assessments. On 04/16/25 at 09:21 AM, R42 at her breakfast in bed. Her mattress settings were set to 350lbs. On 04/16/25 at 12:03 PM, Certified Nurse Aide (CNA) M stated the air mattress settings were by the resident's current weight. She stated staff would check if the bed alarms or pump alarms were going off. On 04/16/25 at 12:33 PM, Licensed Nurse (LN) G stated the mattress pumps were set by weight. She stated staff should be checking them each shift to ensure the correct settings were entered. On 04/16/25 at 01:10 PM, Administrative Nurse D stated the mattresses should be set by the resident's weight per the manufacturer's recommendation. She stated staff were also to perform a softness check with their hands to ensure the beds were not too firm. The facility's Skin and Wound Monitoring and Management policy revised on 12/2023 indicated the facility was to promote interventions that prevent pressure injury development and heal injuries that were present. The policy identified nutritional monitoring, repositioning, weekly wound assessments, and pressure-reducing devices. 41037 - R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), muscle weakness, need for assistance with personal care, and pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 required partial to moderate assistance with toileting and mobility. The MDS also documented R28 required substantial to maximum assistance with bathing, lower extremity dressing, and transfers. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R28 was dependent on staff for bathing, transfers, toileting, lower extremity dressing, mobility, repositioning in bed, and personal hygiene. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 received antipsychotic medication, anticoagulant medication, antidepressant medication, antianxiety medication, diuretic medication, antibiotic medication, and opioid medication. R28's Pressure Ulcer Care Area Assessment (CAA) dated 07/01/24 documented she had the potential for the development of pressure ulcers. R28's contributing factors included her impaired mobility, incontinence, and fluid deficit risk. R28's Care Plan dated 12/13/24 documented the staff would educate R28 on causative factors and measures to prevent skin injury. R28's EMR under the Orders tab revealed the following physician orders: Pressure-reducing boots to bilateral lower extremities while in bed dated 08/27/24. On 04/15/25 at 08:06 AM, R28 sat on her bed with the head of the bed elevated. R28's mattress had slid forward and was bending back toward R28. R28's bilateral heels pressed against the bent portion of the mattress, without any pressure-reducing devices. On 04/16/25 at 07:15 AM, Licensed Nurse (LN) H stated the nurse was responsible to floating of heels or applying soft boots to heels. He stated the order was on the Treatment Administrative Report (TAR). He stated the nurse could delegate the task to a Certified Nurse's Aide (CNA), but the nurse should verify the task was performed before signing the TAR. On 04/16/25 at 08:15 AM, CNA M stated the CNAs get a brief overall description of what task should be performed for each resident. CNA M stated if the CNAs were unsure, they could always ask the LN. On 04/16/25 at 01:10 PM, Administrative Nurse D stated specific interventions should be followed, and any resident at risk of pressure ulcers should have their heels floated or soft boots applied to heels. The facility's Skin and Wound Monitoring and Management policy revised on 12/2023 indicated the facility was to promote interventions that prevent pressure injury development and heal injuries that were present. The policy identified nutritional monitoring, repositioning, weekly wound assessments, and pressure-reducing devices. 49634 - R37's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer function adequately), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hyperlipidemia (condition of elevated blood lipid levels), hypertension (high blood pressure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), open wound right foot, acquired absence of right toes, cognitive communication deficit, need for assistance with personal care, muscle weakness difficulty walking, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and respiratory failure with hypoxia (occurs when the lungs cannot adequately exchange oxygen and carbon dioxide in the blood). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R37 had impairment on one side of her lower body. The MDS documented R37 was dependent on staff for toileting and needed substantial to maximal assistance for bathing. The MDS documented R37 had a recent surgery and shortness of breath or trouble breathing. R37's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 01/28/25 triggered secondary to the potential for pressure ulcers. Contributing factors include activities of daily living (ADL), functional, mobility impairment, and incontinence. Risk factors include pain, development of pressure ulcers, and skin condition. The CAA documented a Licensed Nurse (LN) would assess skin each week and put proper interventions in place to prevent skin breakdown. The CAA documented skin was also assessed by caregivers with each bath and each time the resident was dressed. The CAA documented the physician was to be notified of any abnormal findings, and treatment orders were to be obtained. The CAA documented the dietitian would monitor R37's food and fluid intake, and implement dietary interventions, as necessary. The CAA documented R37's plan of care would be initiated to improve current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer and fluid deficit risk. R37s Care Plan dated 01/23/25 documented R37 had a pressure ulcer or potential for pressure ulcer development related to impaired mobility. R37's plan of care documented a pressure ulcer, and the surgical wound showed signs of healing and remained free from infection, and staff were to administer treatments as ordered by the physician. The care plan for R37 documented staff would educate residents, family, and caregivers as to causes of skin breakdown, including transfer and positioning requirements; the importance of taking care during ambulating and mobility, good nutrition, and frequent repositioning. R37's plan of care documented staff would encourage fluid intake and assist in keeping skin hydrated, nursing would be notified of any new areas of skin breakdown. The plan of care documented R37 required a pressure relieving and reducing device on the bed and wheelchair, and nursing staff would perform a head-to-toe weekly head-to-toe assessment. R37's Braden Scale for Prediction Pressure Sore Risk dated 03/26/25 documented a score of 15 indicating a low risk for pressure ulcers. R37s Licensed Nurse (LN) Weekly and as needed (PRN) Skin assessment dated [DATE] documented a surgical incision to the right foot from the amputation of toes, treatment was in the plan. Followed by the wound care provider. R37's EMR under the Orders tab documented the following physician's orders: -Wound treatment: Apply skin-prep (liquid skin protectant) to the right dorsal foot every day shift, every Tuesday, Thursday, and Saturday for wound care dated 04/03/25. -Wound treatment: cleanse right toe amputation site for wound care, apply gauze, abdominal pad (ABD), wrap with kerlix, and apply tub grip, every day shift every Tuesday, Thursday, and Saturday for wound care and PRN for wound care If dressing is removed or soiled dated 04/03/25. -Pressure-reducing device to bilateral extremities while in chair or bed, every shift to offload bilateral extremities, or apply soft boots to bilateral extremities for pressure relief dated 03/24/25. On 04/14/25 at 07:10 AM, R37 laid on the bed, R37's heels laid directly on her mattress. R37's heels were not offloaded, and R37 did not have soft boots applied to her feet. On 04/15/25 at 07:12 AM, R37 laid on her bed. R37's heels laid directly on her mattress. R37's heels were not offloaded, and R37 did not have soft boots applied to her feet. On 04/16/25 at 07:15 AM, LN H stated floating of heels or applying soft boots to heels, would fall on the nurse. He stated the order was on the Treatment Administrative Report (TAR) he stated the nurse could delegate the task to a Certified Nurse's Aide (CNA), but the nurse should verify the task was performed before signing the TAR. On 04/16/25 at 08:15 AM, CNA M stated the CNAs got a brief overall description of what task should be performed for each resident. CNA M stated if the CNAs were unsure, they could always ask the LN. On 04/16/25 at 01:10 PM, Administrative Nurse D stated specific interventions should be followed, and any resident at risk of pressure ulcers should have their heels floated or soft boots applied to heels. The facility's Infection Prevention Control policy revised on 12/23 documented it is the policy of this facility that: a resident who entered the facility without pressure injury does not develop pressure injury unless the resident's clinical condition or other factors demonstrated that a developed pressure injury was unavoidable; and a resident having pressure injury's received necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.

The facility identified a census of 57 residents. The sample includes 15 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being. Findings included: - A review of the facility's Activity Calendar for February, March, and April 2025 was completed. The review revealed in February 2024 the following weekend activities were scheduled: a movie matinee, and residents' choice. Activities in March revealed the following weekend activities were scheduled: a movie matinee, and residents' choice. Activities for April on each Sunday revealed a movie matinee, residents' choice, on Saturday 04/05/25 an easter egg hunt, and on 04/12/25 a jazz concert. On 04/15/25 at 01:30 PM, Resident Council members reported activities rarely occurred on weekends. The council reported there were movie matinees upstairs on the assisted living floor. The council reported they would like activities on the weekends, with interactive groups The Resident Council stated they would like to have staff lead the activities. On 04/15/25 at 02:25 PM, Activities Staff Z confirmed the facility did not have consistent scheduled activities on the weekends. Activity Staff Z stated she did have an assistant who helped on the weekends, and the facility was working on weekend activities. She stated she was going to start more weekend activities in April. On 04/16/25 at 08:15 AM, Certified Nurses Aid (CNA) M stated she was unsure if there were weekend activities. She stated she did not work many weekends in the facility. The facility's Activities Program policy dated 12/24 documented it was the policy of this facility was to ensure that activities were available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. Activities may be facility-sponsored group or independent. The facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being.

The facility identified a census of 57 residents. The sample includes 15 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 04/14/25 at 7:55 AM, an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 04/15/25 at 01:30 PM, the Resident Council members reported they were not aware if the facility provided a way to complete anonymous grievances. The council reported they must take the grievance to a staff member. The Resident Council stated the staff helped the residents fill out grievances. The Resident Council stated residents could also talk to the social services person. On 04/15/25 at 02:35 PM, Activities Director Z stated there was not an anonymous grievance box. She stated the residents were able to call the facility hotline and leave an anonymous report. On 04/15/25 at 03:04 PM, Administrator Nurse D stated the facility did not have an anonymous reporting box. She stated the residents gave the grievance to a staff member or an administrative person. Administrator D stated the facility had a hotline, and staff could call for the resident if the resident was unable to make the phone call. The facility's Grievance policy dated 12/24 documented that it was the policy of this facility to establish a grievance process that allowed the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances included those concerning care and treatment that has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their facility stay. The facility would make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the residents may have.

The facility identified a census of 57 residents. The sample included 15 residents, with five reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure a safe care environment free from potential hazards related to following Residents (R) 50, R29, and R26's implemented fall interventions. This deficient practice placed the residents at risk for preventable falls and injuries. Findings Included: - The Medical Diagnosis section within R50's Electronic Medical Records (EMR) noted diagnoses of senile degeneration of the brain (a progressive mental disorder characterized by failing memory and confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and overactive bladder. R50's Annual Minimum Data Set (MDS) completed 03/14/25 revealed a Brief Interview for Mental Status Score of three indicating severe cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS indicated she was dependent on staff assistance for bed mobility, transfers, toileting, bathing, dressing, personal hygiene, and wheelchair mobility. The MDS indicated she had two non-injury falls since her last assessment. R50's Falls Care Area Assessment completed 04/14/25 noted she was at high risk for falls related to her weakness and required assistance to complete her activities of daily living (ADL). The CAA noted a care plan was implemented to prevent falls with major injuries. R50's Care Plan initiated on 03/21/24 indicated she was at risk for an ADL deficit and falls related to her impaired cognitive status, impulsiveness, and poor balance. The plan noted she required assistance from staff to complete bathing, transfers, bed mobility, dressing, personal hygiene, and toileting (03/21/24). The plan instructed staff to ensure her call light was within reach and her bed was maintained in the lowest position (03/21/24). The plan indicated she had a non-injury fall on 12/28/24. R50's plan was updated on 01/03/25 to implement the use of a Dycem (non-slip mat used to prevent falls) under the cushion of her wheelchair cushion. The plan noted she had a minor injury fall on 02/24/25. R50's plan was updated on 02/25/25 to implement the use of an anti-rollback device on her wheelchair. On 04/14/25 at 07:35 AM, R50 slept in her bed. Her bed was in the lowest position. Her call light was pinned to her covered within reach. An inspection of R50's wheelchair revealed no anti-rollback device or Dycem mat. On 04/15/25 at 08:00 AM, R50 was in the west dining room for breakfast. R50's ate her entire breakfast without concerns. R50's wheelchair had no anti-rollback device. R50 was taken back to her room. Upon transfer, R50's wheelchair had no Dycem in place. On 04/15/25 at 12:20 PM, R50 sat in the dining room in her wheelchair for lunch. R50's wheelchair had no anti-rollback device or Dycem. On 04/16/25 at 12:03 PM, Certified Nurse Aide (CNA) M stated that R50's chair may have been recently switched out and the equipment may not have been applied to the new chair. She stated staff had access to the care plan to view the fall interventions and would have reported to the nurses if something was not in place. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) G stated that R50's chair should have had the fall interventions implemented. She stated if the interventions were dropped or no longer needed, they should have been removed from the care plan. She stated that R29 was a high fall risk and needed the floor mat in place. On 04/16/25 at 01:10 PM, Administrative Nurse D stated staff were expected to review the implemented fall interventions and ensure they were in place for the residents in their care. The facility's Fall Management System dated 12/2024 indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred. - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) noted diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body), major depressive disorder (major mood disorder), and dysphagia (difficulty swallowing). R29's Quarterly Minimum Data Set (MDS) completed 01/13/25 revealed a Brief Interview for Mental Status Score of zero indicating severe cognitive impairment. The MDS indicated he had bilateral upper and lower extremity impairments. The MDS indicated he was dependent on staff assistance for bed mobility, transfers, toileting, bathing, dressing, personal hygiene, and Broda chair (specialized wheelchair with the ability to tilt and recline) mobility. The MDS indicated no falls since his last assessment. R29's Falls Care Area Assessment (CAA) completed 10/07/24 indicated he required total assistance from staff and was at risk for falls, skin breakdown, pressure injury development, and incontinence. The CAA noted he was a high fall risk. The CAA noted staff would continue to provide safety cues for him and care plan interventions were implemented to reduce the risks associated with falls. R29's Care Plan initiated on 11/28/20 indicated he required assistance with his activities of daily living (ADLs). The plan indicated he required assistance from one staff for bathing, dressing, toileting, bed mobility, and transfers. The plan noted he had a history of non-injury falls. The plan instructed staff to ensure his personal items were left within reach. The plan instructed staff to encourage him to use his call light and provide two-hour repositioning. The plan indicated he was to have a fall mat next to his bed while in bed. On 04/14/25 at 07:24 AM, R29 slept in his bed. His bed was in the lowest position. His call light was within reach. His fall mat was propped up against the wall by his dresser. On 04/14/25 at 0820 AM, R29's fall mat was propped against the wall next to his dresser. R29 slept in his bed. On 04/15/25 at 07:21 AM, R29 slept in his bed. His fall mat was placed on the floor next to his bed. On 04/16/25 at 12:03 PM, Certified Nurse Aide (CNA) M stated direct care staff were expected to ensure fall mats were placed next to the beds after transferring the residents back to bed. She stated R29's ability to move has declined but he was still a fall risk. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) G stated if the interventions were dropped or no longer needed, they should have been removed from the care plan. She stated that R29 was a high fall risk and needed the floor mat in place. On 04/16/25 at 01:10 PM, Administrative Nurse D stated staff were expected to review the implemented fall interventions and ensure they were in place for the residents in their care. The facility's Fall Management System dated 12/2024 indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred. 49634 - R26's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of lymphedema (swelling caused by accumulation of lymph), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, need for assistance with personal care, hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), insomnia (inability to sleep), reduced mobility, dementia (a progressive mental disorder characterized by failing memory and confusion), hyperlipidemia (condition of elevated blood lipid levels), peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), cognitive communication deficit, difficulty walking, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R26 required to set up and clean up by staff for eating and oral hygiene. The MDS documented R26 was dependent on staff for bathing and toileting and was frequently incontinent of bowel and bladder. The MDS documented R26 was at risk for pressure ulcers, and no unhealed pressure ulcers. The MDS documented R26 required a pressure-reducing mattress for her bed and a pressure-reducing cushion for her chair. R26's Falls Care Area assessment dated [DATE] documented staff would continue with the current plan of care to prevent injury. R26's Care Plan dated 02/21/25 documented R26 was at risk for falls related to weakness, medication, and history of falls. R26's plan of care documented therapy would perform an evaluation and treatment per physicians' orders. R26's plan of care dated 02/21/25 documented a non-injury fall, and the intervention was for staff to ensure R26's bed was in the lowest position and the call light was within her reach. R26's plan of care dated 03/14/25 documented a non-injury fall the intervention put in place was to place access furniture placement and environment to mimic her home. On 04/14/25 at 07:23 AM, R26 laid on her bed, R26's bed was elevated approximately three feet. R26's bed was not in a low position. On 04/15/25 at 07:28 AM, R26 laid on her bed, R26's bed was elevated approximately three feet. R26's bed was not in a low position. On 04/16/24 at 07:15 AM, Licensed Nurse (LN) H stated all nursing staff have access to each resident's care plan. He stated CNAs could ask the nurse to ensure the beds were in the correct position. LN H stated that R26's bed should be in a low position. On 04/16/25 at 08:15 AM, Certified Nurses Aide (CNA) M stated the CNA's get a brief overall description of what task should be performed for each resident. CNA M stated if the CNAs were unsure, they could always ask the LN. On 04/16/25 at 01:10 PM, Administrative Nurse D stated all nursing staff have access to the resident's care plan, and specific interventions should be followed for every situation. The facility's Fall Management System policy dated 12/24 documented it was the policy of this facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

The facility identified a census of 57 residents. The sample included 15 residents, with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Residents (R) 37 and R42 had a way to communicate their needs due to their call lights being left out of reach. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 04/14/25 at 07:00 AM, an inspection of R37's (a physically impaired resident unable to self-transfer) room revealed her asleep in her bed. R37's call light was on the floor to the left side of her bed. On 04/15/25 at 07:37 AM, R42 (a cognitively and physically impaired resident unable to self-transfer) slept in her bed. Her bed remained in a low position. R42's call light was pinned to a pillow placed on her recliner across from her bed. The call light was out of reach. At 07:40 AM, Administrative Nurse D entered the room, moved the call light to R42's bed, and stated staff were expected to ensure the call lights remained within reach at all times. On 04/16/25 at 12:03 PM, Certified Nurse Aide (CNA) M stated staff was expected to ensure the call lights were pinned to the residents or placed within the resident's reach. On 04/16/25 at 12:33 PM, Licensed Nurse (LN) G stated call lights needed to be kept within reach of the residents when staff left the room. On 04/16/25 at 01:10 PM, Administrative Nurse D staff were expected to ensure the residents had access to their call lights. She stated the call lights were to be pinned to the residents or their beds within the resident's reach. The facility's Fall Management System dated 12/2024 indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility assessed and provided the appropriate equipment to ensure resident safety. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred. The facility did not provide a policy related to the accommodation of needs as requested on 04/16/25.

The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record review, and interviews, the facility failed to ensure the standard of care was provided for Resident (R) 34 who had a history of urinary tract infection (UTI - an infection in any part of the urinary system) when her catheter drainage bag laid directly on the floor. This deficient practice placed R34 at risk of catheter-related complications and further UTIs. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), urinary tract infection (UTI - an infection in any part of the urinary system), and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R34 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) during the observation period. The MDS documented R34 required substantial to maximum assistance of staff for toileting. The MDS documented R34 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented R34 had an indwelling catheter. The MDS documented that R34 was dependent on assistance for toileting. The MDS documented R34 had received diuretic medication during the observation period. R34's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 08/16/24 documented she required assistance with toileting needs and she had recurrent UTIs. R34's Care Plan, dated 08/28/24 documented she had an indwelling catheter 16 French with a 30-milliliter (ml) bulb. The plan of care documented staff would provide her with catheter care every shift and as needed. R34's EMR under the Orders tab revealed the following physician orders: Indwelling catheter French 16 with a 30 ml to closed drainage system, diagnosis to support use: neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) dated 03/18/25. Ciprofloxacin (antibiotic) hci tablet 250 milligrams (mg) give one tablet by mouth every 12 hours for UTI for seven days dated 08/26/24. Doxycycline hyclate (antibiotic) tablet 100 mg give one tablet by mouth two times a day for UTI for seven days dated 08/29/24. Merrem (antibiotic) intravenous solution reconstituted 500 mg (Meropenem) administer 500 mg intravenously every eight hours for UTI for five days dated 09/25/24. Doxycycline hyclate tablet 100 mg give one tablet by mouth two times a day for UTI, for seven days dated 12/04/24. On 04/14/25 at 08:40 AM, R34 sat in her recliner with her feet elevated. R34's catheter bag with amber-colored urine in the drainage bag that laid directly on the floor under the footrest of her recliner. The catheter drainage bag did not have a privacy bag. On 04/16/25 at 2:03 PM, Certified Nurse Aide (CNA) N stated a resident's catheter should never be placed on the floor. CNA N stated there should be a privacy bag to put the catheter drainage bag in to prevent the bag from touching the floor. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) I stated a resident's catheter bag should never be placed on the. LN I stated the catheter drainage bag should be placed below the resident's bladder and not be placed where it possibly could pull on the catheter tubing. On 04/16/25 at 01:10 PM, Administrative Nurse D stated she would expect a catheter bag to be placed below the bladder, in a privacy bag, and not on the floor. The facility's Indwelling Catheter Care policy documented it was the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, and comfort, and decrease the risk of infection.

The facility identified a census of 57 residents. The sample included 15 residents, with five residents reviewed for unnecessary medications. Based on record review and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 28. This deficient practice placed R28 at risk for unnecessary medication use and physical complications for the affected residents. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic kidney disease, congestive heart failure, muscle weakness, need for assistance with personal care, and pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 required partial to moderate assistance with toileting and mobility. The MDS also documented R28 required substantial to maximum assistance with bathing, lower extremity dressing, and transfers. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 had received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R28 was dependent on staff for bathing, transfers, toileting, lower extremity dressing, mobility, repositioning in bed, and personal hygiene. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 had received antipsychotic medication, anticoagulant medication, antidepressant medication, antianxiety medication, diuretic medication, antibiotic medication, and opioid medication. R28's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/01/24 documented she had generalized weakness, and decreased safety awareness. R28 risk factors included further decline in activities of daily living, falls, incontinence, skin breakdown, and pain. R28's Care Plan dated 07/23/21 documented staff administered medication as ordered by the physician and monitored for side effects or effectiveness. R28's EMR under the Orders tab revealed the following physician orders: Voltaren external gel (anti-inflammatory class of medication used to reduce inflammation) one percent (%) (diclofenac sodium) (topical), apply to knee and shoulder topically every 12 hours as needed for pain dated 04/12/25. The order lacked a dose. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) I stated every medication should have the dosage included in the physician's order. On 04/16/25 at 01:10 PM, Administrative Nurse D stated she would expect the pharmacy to catch any medication that lacked a dosage. Administrative Nurse D stated Voltaren gel should have a dosage included in the order. The facility's undated policy Pharmacy Services/Nursing Services documented it was the policy of this facility that drugs would be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It was the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

The facility identified a census of 57 residents. The sample included 15 residents, with one resident reviewed for a therapeutic diet. Based on observation, record review, and interviews, the facility failed to implement a therapeutic diet as ordered by the physician order for Resident (R) 28, who had a diagnosis of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R28 at risk of adverse side effects from unnecessary medication or complications related to CHF. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic kidney disease, congestive heart failure, muscle weakness, need for assistance with personal care, and pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 required partial to moderate assistance with toileting and mobility. The MDS also documented R28 required substantial to maximum assistance with bathing, lower extremity dressing, and transfers. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 had received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R28 was dependent on staff for bathing, transfers, toileting, lower extremity dressing, mobility, repositioning in bed, and personal hygiene. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 had received antipsychotic medication, anticoagulant medication, antidepressant medication, antianxiety medication, diuretic medication, antibiotic medication, and opioid medication. R28's Nutritional Status Care Area Assessment (CAA) dated 07/01/24 documented a gradual weight loss was highly recommended for her overall health. R28's weight was trending down. R28's Care Plan, dated 05/26/23 documented the facility would provide her diet as ordered by the physician. R28's EMR under the Orders tab revealed the following physician orders: Regular diet with thin liquids consistency, staff would cut her food if needed dated 01/30/25. Two-gram low sodium diet and a two-liter (2000 milliliters) fluid restriction due to CHF dated 02/05/2025. Review of R28's dietary meal ticket listed her diet as regular. On 04/15/25 at 08:06 AM, R28 sat on her bed with the head of the bed elevated. R28's mattress had slid forward and was bending back toward R28 with her bilateral heels pressed against the bent portion of the mattress without any pressure-reducing devices. On 04/16/25 at 11:23 PM, Certified Nurse Aide (CNA) N stated the staff reviewed the diet slip when serving the resident their meal tray. CNA N stated the nurse would print the resident's current diet list. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) I stated when a new diet order or a fluid restriction was received from a physician a copy would be sent to dietary. LN I stated the fluid restriction would be documented on the Treatment Administration Record (TAR). On 04/16/25 at 01:10 PM, Administrative Nurse D stated that R28's new diet and fluid restriction order had been entered into R28's EMR incorrectly and was overlooked. Administrative Nurse D stated once the physician entered a new order, a nurse must confirm the new order, and ensure the correct departments were notified of the new order. Administrative Nurse D stated the fluid restriction would be documented and monitored on the resident's TAR. The facility's Nutritional Status Management dated 12/23 documented it was the policy of this facility to assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and other available data, unless the resident's clinical condition demonstrates that this is not possible.

The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 26 with cutting her whiskers per her preference. This deficient practice placed R26 at risk for impaired dignity and decreased psychosocial well-being. Findings Included: - R26's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of lymphedema (swelling caused by accumulation of lymph), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, need for assistance with personal care, hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), insomnia (inability to sleep), reduced mobility, dementia (a progressive mental disorder characterized by failing memory and confusion), hyperlipidemia (condition of elevated blood lipid levels), peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), cognitive communication deficit, difficulty walking, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R26 required set up and clean up by staff for eating and oral hygiene. The MDS documented R26 was dependent on staff for bathing and toileting and was frequently incontinent of bowel and bladder. R26's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) completed 12/26/24 documented the activities of daily living (ADL) function CAA triggered secondary to R26 requiring assistance with ADLs, impaired balance and transition during transfers, and functional impairment in activity. The contributing factors include generalized weakness and decreased safety awareness. Risk factors include further ADL decline, falls, incontinence, skin breakdown, and pain. R26's plan of care would be reviewed to maintain current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk. R26's Care Plan revised on 03/29/23 documented ADL self-care performance deficit related to a left fourth toe amputation, staff were to encourage R26 to fully participate possible with each interaction. R26's plan of care documented bathing would be provided on Thursday and Sunday and R26 required the assistance of one staff. R26's plan of care dated 06/07/23 documented resistance to care related to adjustment to a nursing home, anxiety, and dementia. At times R26 declines assistance with care: medications, toileting assistance, repositioning wound care, and bathing. The plan documented R26 would be allowed time to make decisions about the treatment regime, to provide a sense of control. Staff were to try and negotiate a time for ADLs to ensure the resident participated in the decision-making process. On 04/14/25 at 07:22 AM, R26 laid in her bed, R26 had long grey hairs on her chin. On 04/15/25 at 08:17 AM, R26 sat in her wheelchair, R26 had long grey hairs on her chin. On 04/14/25 at 07:22 AM, R26 stated she does not like her chin to have long whiskers. R26 stated when she got a shower, the staff always cut her hair. R26 stated she could cut the whiskers herself if the staff helped her. On 04/16/25 at 07:15 AM, Licensed Nurse (LN) H stated shaving a lady's chin could be part of bathing, or any staff member could ask if a resident was uncomfortable having long chin hairs. LN H stated it was all the nursing staff's duties to ensure the residents were well groomed. LN H was unsure if a lady's chin hair needed to be cut should be in the care plan. On 04/16/25 at 08:15 AM, Certified Nurse Aide (CNA) M stated she was unsure what was care planned for each resident. She stated she would ask her nurse if she was unsure of a resident's preference. CNA M stated when she gave baths, she would ask the residents what their preferences were. On 04/16/25 at 01:10 PM, Administrative Nurse D stated she did not believe a lady who required shaving of her chin would need to be care planned. She stated staff should have a keen eye and ask the residents about their preferences, and that could be done during bathing. The facility's Dignity and Respect policy revised on 10/15 documented all residents be treated with kindness, dignity, and respect. The staff would display respect for residents when speaking with, caring for, or talking about them, as a constant affirmation of their individuality and dignity as human beings. Schedules of daily activities allowed maximum flexibility for residents to exercise choices about what they would do and when they would do it. The resident's individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainment were elicited and respected by the facility. Residents would be appropriately dressed in clean clothes arranged comfortably on their persons and be well groomed.

The facility identified a census of 57 residents. The sample included 15 residents with three reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to implement a physician's order for a fluid restriction for Resident (R) 28. The facility also failed to ensure the physician's order was followed for a daily weight for R34 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). The facility failed to ensure the physician's order was followed to wrap R26's bilateral lower extremities. These deficient practices placed these residents at risk of delayed treatment and untreated illness. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic kidney disease, congestive heart failure, muscle weakness, need for assistance with personal care, and pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 required partial to moderate assistance with toileting and mobility. The MDS also documented R28 required substantial to maximum assistance with bathing, lower extremity dressing, and transfers. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. The MDS documented R28 had received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R28 was dependent on staff for bathing, transfers, toileting, lower extremity dressing, mobility, repositioning in bed, and personal hygiene. The MDS documented R28 was at risk for the development of pressure ulcers. The MDS documented R28 had pressure-reducing devices on her bed and in her chair. The MDS documented R28 had received antipsychotic medication, anticoagulant medication, antidepressant medication, antianxiety medication, diuretic medication, antibiotic medication, and opioid medication. R28's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/01/24 documented she had generalized weakness and decreased safety awareness. R28's risk factors included further decline in activities of daily living, falls, incontinence, skin breakdown, and pain. R28's Care Plan dated 07/23/21 documented staff would administer medication as ordered by the physician and monitor for side effects or effectiveness. R28's EMR under the Orders tab revealed the following physician orders: Two-gram low sodium diet and a two-liter (2000 milliliters) fluid restriction due to CHF dated 02/05/2025. Review of R28's EMR lacked documentation or monitoring of her fluid restriction. On 04/15/25 at 08:06 AM, R28 sat on her bed with the head of the bed elevated. R28's mattress had slid forward and was bending back toward R28. R28's bilateral heels pressed against the bent portion of the mattress without any pressure-reducing devices. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) I stated when a new diet order or a fluid restriction was received from a physician a copy would be sent to dietary. LN I stated the fluid restriction would be documented on the Treatment Administration Record (TAR). On 04/16/25 at 01:10 PM, Administrative Nurse D stated R28's new diet and fluid restriction order had been entered into R28's EMR incorrectly and was overlooked. Administrative Nurse D stated once the physician entered a new order a nurse must confirm the new order and ensure the correct departments were notified of the new order. Administrative Nurse D stated the fluid restriction would be documented and monitored on the resident's TAR. The facility's Provision of Quality Care policy last reviewed on 01/25/25 documented that based on comprehensive assessments, the facility would ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, comprehensive person-centered care plans, and the residents' choices. - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), urinary tract infection (UTI - an infection in any part of the urinary system) and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R34 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) during the observation period. The MDS documented R34 required substantial to maximum assistance of staff for toileting. The MDS documented R34 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented R34 had an indwelling catheter. The MDS documented that R34 was dependent on assistance for toileting. The MDS documented R34 had received diuretic medication during the observation period. R34's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 08/16/24 documented she had generalized weakness and decreased safety awareness. R34's risk factors were a possible decline in her ability to perform activities of daily living, falls, pain, or skin breakdown. R34's Care Plan, dated 09/02/24 documented weight fluctuations were expected related to her diuretic medication. R34's EMR under the Orders tab revealed the following physician orders: Daily weight. Call physician if a three-pound gain in one day or five-pound weight in one week dated 08/05/24. Spironolactone (diuretic) oral tablet 25 milligrams (mg) give one tablet by mouth daily for CHF dated 08/05/24. Lasix (furosemide - diuretic) tablet 20 mg give 0.5 tablet by mouth daily for CHF dated 11/28/24. Review of R34's Medication Administration Record (MAR), Treatment Administration Record (TAR), and under the Vital Signs reviewed from 01/01/25 to 04/14/25 (103 days) lacked evidence staff measured and recorded R34's weight on following 18 dates: 01/05/25, 01/25/25, 01/29/25, 02/07/25, 02/08/25, 02/14/25, 02/18/25, 02/20/25, 02/24/25, 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/17/25, 03/18/25, 03/27/25, 03/29/25, and 04/12/25. R34 refused on the following 10 dates: 01/06/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25, 01/15/25, 01/17/25, 01/26/25, 02/17/25, and 03/16/25. The clinical record lacked evidence of physician notification the daily weights were not obtained or refused. On 04/14/25 at 08:40 AM, R34 sat in her recliner with her feet elevated. R34's catheter bag with amber-colored urine in the drainage bag laid directly on the floor under the footrest of her recliner. The catheter drainage bag did not have a privacy bag. On 04/16/25 at 02:03 PM, Certified Nurse Aide (CNA) N stated everyone works together to get the daily weights and report the weight to the charge nurse. CNA N stated that R34 never refused to be weighed. On 04/16/25 at 12:32 PM, Licensed Nurse (LN) I stated everyone would be responsible for ensuring daily weights were obtained as ordered. LN I stated the physician should be notified if a daily weight was refused frequently. LN I stated the physician notification was documented under the progress notes. On 04/16/25 at 01:10 PM, Administrative Nurse D stated she expected all staff to ensure daily weights were obtained as ordered. Administrative Nurse D stated she expected the physician to be notified if a resident refused frequently and the notification would be documented under the progress notes. The facility's Provision of Quality Care policy last reviewed on 01/25/25 documented based on comprehensive assessments, the facility would ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, comprehensive person-centered care plans, and the residents' choices. - R26's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of lymphedema (swelling caused by accumulation of lymph), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, need for assistance with personal care, hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), insomnia (inability to sleep), reduced mobility, dementia (a progressive mental disorder characterized by failing memory and confusion), hyperlipidemia (condition of elevated blood lipid levels), peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), cognitive communication deficit, difficulty walking, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R26 required set up and clean up by staff for eating and oral hygiene. The MDS documented R26 was dependent on staff for bathing and toileting and was frequently incontinent of bowel and bladder. The MDS documented R26 was at risk for pressure ulcers, and no unhealed pressure ulcers. The MDS documented R26 required a pressure-reducing mattress for her bed, and a pressure-reducing cushion for her chair. R26's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 12/26/24 documented Pressure Ulcers CAA triggered secondary to potential for pressure ulcers. Contributing factors include activities of daily living (ADL), functional mobility impairment, and incontinence. Risk factors include pain, development of pressure ulcers, skin conditions, and fluid deficit risk. A Licensed Nurse (LN) assessed R26's skin each week and put proper interventions in place to prevent skin breakdown. Skin was also assessed by caregivers with each bath and each time the resident was dressed. The physician was to be notified of any abnormal findings and treatment orders were to be obtained. The dietitian was monitoring R26's food and fluid intake, and implementing dietary interventions, as necessary. R26's plan of care would be initiated to improve current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer, and fluid deficit risk. R26's Care Plan revised 06/24/24 documented R26 had an actual skin impairment related to a history of venous ulcers, lymphedema, itchy skin, psoriasis (a chronic skin disorder characterized by red patches covered by thick, dry silvery adherent scales), and bilateral lymphedema. R26's plan of care dated 03/20/23 documented nursing staff would apply lymphedema pumps to bilateral extremities as ordered. R26 was to avoid scratching and keep hands and body parts from excessive moisture, staff were directed to keep R26's fingernails short. R26's plan of care dated 02/15/24 documented staff were to evaluate and offload or float heels while in bed or wheelchair, and staff were to always apply soft boots. Staff were to encourage good nutrition and hydration to promote healthier skin. R26's plan of care dated 02/14/24 documented staff were to encourage R26 to allow pumps and treatments to be completed. at times. R26's Braden Scale for Prediction Pressure Sore Risk dated 02/05/25 documented a score of 16 indicating a low risk for pressure ulcers. R26's Skin Evaluation dated 04/13/25 documented R26 was without new or existing compromise of skin integrity to bilateral lower extremities, with dryness and lymphedema to bilateral lower extremities. R26's physician's orders under the Orders tab revealed the following orders: Heel protector boots should be always worn when in the wheelchair or in bed every shift, dated 05/24/24. Pressure-reducing device to bilateral extremities while in chair or bed, every shift to offload bilateral extremities, float heels, or apply soft boots to bilateral extremities for pressure relief, dated 05/04/24. Pressure-reducing cushion in wheelchair every shift, dated 05/04/24. Pressure-reducing mattress every shift, dated 05/04/24. Apply Skin-prep (liquid skin protectant) to bilateral heels every shift for wound prevention, dated 05/04/24. Apply barrier cream to buttocks and coccyx reddened areas every shift for wound prevention, dated 05/04/24. No ace wraps to bilateral extremities per vascular, dated 12/04/24. Use compression socks, or tub grips on legs, wash legs every day with soap and water, pat dry apply Eucerin (moisturizing lotion) or lotion on the legs daily, and apply tub grips. Every day shift for lymphedema management, dated 04/04/25. On 04/15/25 R26 at 07:22 AM, R26 sat in her wheelchair, R26 bilateral lower extremities were wrapped with ace wraps, and she did not have tubi grips applied to her bilateral lower extremities. On 04/15/25 at 12:50 PM, Licensed Nurse (LN) G stated R26 did have an order for Kerlix (wound dressing) and ace wraps, for bilateral lower extremities, when her legs were weeping. She stated R26's vascular physician stated no ace wraps to bilateral lower extremities. LN G stated the nurse on duty would have applied the ace wraps to R26's legs, and it should have been tubi grips and boots. On 04/16/25 at 01:20 PM, Administrative Nurse D stated all physician's orders should be followed. The facility's Infection Prevention Control policy revised 12/23 documented it is the policy of this facility that: a resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and a resident having pressure injury's receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.

The facility identified a census of 59 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from neglect. On 01/15/25 between 08:00 PM and 09:00 PM, R1 propelled himself in his wheelchair to the bathroom. He reached for the grab bar beside the toilet and the momentum of that action caused him to slip from his wheelchair and fall to the right, into the walk-in shower. R1 laid on the floor, unable to move or reach the call light beside the toilet. R1 remained on the floor until Licensed Nurse (LN) G discovered him on 01/16/25 at approximately 05:10 AM when she entered his room to empty his catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag. R1 told LN G he hit his head and he complained of right rib pain. The facility sent R1 to the hospital for evaluation where the hospital found no acute injuries. Upon investigation, the facility discovered Certified Nurse Aide (CNA) M failed to complete two-hour rounding on her assigned residents. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of contracture (abnormal permanent fixation of a joint or muscle) of the right and left hand, lack of coordination, repeated falls, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R1 required partial to moderate assistance with toileting, upper and lower body dressing, bed mobility, and chair transfers. R1 required substantial to maximal assistance with sit-to-standing, toilet transfers, and bathing transfers. R1 had an indwelling catheter and was occasionally incontinent of bowel movements. R1 had no falls since the last assessment. The Quarterly MDS dated [DATE], documented a BIMS score of 13. R1 required partial to moderate assistance with toileting hygiene, rolling left to right, toilet transfers, and bathing transfers. R1 required substantial to maximal assistance with upper body dressing, from sitting to standing, and chair/bed to chair transfers. R1 required staff dependence with lower body dressing. R1 had no falls since the last assessment. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/09/24, documented R1 needed assistance with activities of daily living (ADL). R1's Care Plan dated 10/25/21, documented R1 had an ADL self-care performance deficit related to back pain and falls and R1 required assistance of one staff with toileting and transfers. R1's Care Plan documented R1 was at risk for falls related to required assistance with ADL, cognitive loss, medication side effects, and a history of falls. The Care Plan included R1 needed a safe environment including a working and reachable call light. The facility's 01/21/25 Investigation documented on 01/16/25 at approximately 05:10 AM LN G found R1 on his bathroom floor. R1's care plan included he needed one staff assistance for toilet transfers, however, R1 attempted to transfer himself without calling staff for help. R1 stated he fell on [DATE] at approximately 09:00 PM and could not reach the call light for help. During the post-fall assessment completed by LN G, R1 stated he hit his head. LN G notified Administrative Nurse E, the provider, and R1's family with a decision made at that time to send R1 to the hospital for further evaluation. The hospital found no major injuries. The investigation concluded CNA M did not complete her two-hour rounds on the residents in her care. LN G received a final written warning to ensure CNAs completed their two-hour rounding. R1's EMR revealed the following: A Nursing note on 01/16/25 at 06:52 AM documented LN G entered R1's room to empty his catheter bag at the end of the shift on 01/16/25 at approximately 05:05 AM. Upon entering R1's room, LN G found R1 lying on the bathroom floor on his back with the upper half of his body in the shower. R1 used his jacket as a pillow behind his head. LN G asked R1 what happened and R1 stated he tried to go to the bathroom last night before bed at approximately 09:30 PM and he slipped out of his wheelchair onto the floor. R1 stated he hit his head and had some pain in his right-sided ribs, and he complained of soreness from lying on the bathroom floor. R1 stated he was okay, and he just wanted to get off the floor. LN G took R1's vital signs before picking him up off the floor. LN G asked R1 if he tried to scream for help and R1 stated what was the point, you guys would not have heard me. LN G sent R1 to the hospital for evaluation and treatment and notified the provider and Administrative Nurse E. A Fall Committee Interdisciplinary Team (IDT) note on 01/16/25 at 03:10 PM documented the Fall Committee met to discuss R1's fall in his bathroom last night at approximately 09:00 PM. R1 was at the hospital in the emergency room (ER) after he voiced he laid on the floor after his fall, for an extended period of time. When LN G found R1, he voiced he fell and hit his head. R1 complained of head pain and LN G immediately sent him to the hospital. R1 was unable to pull his bathroom call light as it was wrapped around the bar, and he had hand contractures. A Computed Tomography (CT scan- a test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan on 01/16/25 at 07:36 AM documented no acute intracranial (within the skull) process and no acute fracture noted in the cervical (neck), thoracic (middle back), or lumbar (low back) spine. In a witness statement on 01/17/25, LN G stated she went to give R1 his medications at approximately 06:45 PM to 07:00 PM and he was in the bathroom. She stated she went back to give him his medications and he refused his eye drops and neck cream. LN G stated CNA M entered R1's room a couple of minutes later and emptied R1's trash. She stated she did not go back into R1's room and she did not know that he needed help to bed. She stated she saw R1 again a little before 05:00 AM on 01/16/25 when she went to empty his catheter bag and found him on the floor. On 01/23/25 at 01:21 PM, R1 sat in his wheelchair in his room. He had a pendant call light around his neck. On 01/23/25 at 01:53 PM, R1's bathroom had a call light cord beside the toilet. The shower had a small lip on the floor to separate from the bathroom floor. On 01/23/25 at 01:21 PM, R1 stated on 01/15/25 he tried to get on the toilet and made the mistake of sitting on the edge of the cushion and the momentum of going forward caused him to slide off and fall onto the floor in the shower. He stated he fell on to the shower floor with his head under the shower seat and only his feet were not in the shower. R1 stated his hands and feet were useless so he could not crawl out of the shower to reach the call light for help. He stated when he laid on the floor, he prayed a lot, sang songs to himself, thought over things, went stir-crazy, and was thirsty. R1 stated the doors were thick so he did not scream for help because staff would not have been able to hear him. He stated he thought he was dying while he laid on the floor, he was cold and did not have a pillow. R1 stated his family almost lost him due to negligence. On 01/23/25 at 02:14 PM, CNA N stated not checking on residents, leaving them soiled, not providing cares that needed done, and not doing rounds were neglect. She stated she completed two-hour checks and for fall risk residents, she checked on them every time she walked past their room. CNA N stated she made sure every resident was where they needed to be and hopefully not on the floor. On 01/23/25 at 02:39 PM, LN H stated not feeding a resident, not changing someone, not giving medications, and not doing rounds were neglect. She stated staff completed rounds every two hours and laid eyes on the residents. LN H stated agency staff read through the agency book policies with the facility staff. On 01/23/25 at 02:45 PM, Administrative Nurse D stated not answering call lights timely, not turning/repositioning, not following treatment orders, and not completing rounds appropriately and timely were neglect. She stated she expected staff to do rounds every two hours, even if the resident was sleeping to make sure their needs were met. She expected facility staff to go over the agency book with the agency staff and the CNA received report. Administrative Nurse D stated the report did state that R1 would pop his head out when he wanted to go to bed. On 01/23/25 at 02:56 PM, Administrative Staff A stated not answering call lights, not checking on residents, and not changing residents were neglect. She stated she expected staff to do two-hour rounds and put eyes on the residents. She stated before agency staff touched a resident, they reviewed the agency book with facility staff, signed it, and then received report. Administrative Staff A stated on 01/16/25, LN G found R1 on the floor and sent him to the hospital. She stated R1 reported he fell around 08:00 PM to 09:00 PM on 01/15/25. She stated she started the investigation, and they determined the root cause analysis was CNA M failed to complete two-hour rounding. On 01/29/25 at 09:00 AM, CNA M stated on 01/15/25 she last saw R1 when she emptied his trash and asked if he needed anything which he did not, but she was unable to recall the time. She stated she received report that R1 would call when he wanted to go to bed. CNA M stated she found it strange that he never called to go to bed, but she did her best to trust what was told in report. She stated she completed rounds every two hours but could not remember going into his room again. On 01/29/25 at 09:04 AM, LN G was unavailable for interview. The facility's Abuse: Prevention and Prohibition Against policy, last revised December 2023, directed each resident had the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The policy defined neglect as the failure of the facility to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to ensure R1 remained free from neglect. On 01/15/25 between 08:00 PM and 09:00 PM, R1 fell on to the bathroom floor and remained there until LN G found him on 01/16/25 at approximately 05:10 AM. The facility sent R1 to the hospital for evaluation where the hospital found no acute injuries. Upon investigation, the facility discovered CNA M failed to complete two-hour rounding on her assigned residents. This deficient practice placed R1 in immediate jeopardy. On 01/29/25 at 04:08 PM, Administrative Staff A was provided a copy of the IJ template and notified of the facility's failure to ensure R1 remained from neglect which placed him in immediate jeopardy. The facility identified and implemented the following corrective measures, completed by 01/20/25: The facility placed CNA M on the do not return list on 01/16/25. LN G received a final written warning for not completing rounding on 01/17/25. The facility started two-hour rounding check sheets at night on 01/16/25. The facility started two-hour rounding check sheets all day on 01/18/25 The facility updated R1's care plan to include a call-light pendant on 01/20/25. The facility completed staff education on rounding, agency education, and abuse/neglect/exploitation by 01/20/25. The surveyor verified the implemented corrective actions on 01/29/25 at 04:14 PM. Due to the facility's corrective actions completed prior to the surveyor's arrival onsite, the deficient practice was deemed past non-compliance at a J scope and severity.

The facility identified a census of 62 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate staff response to door alarms to prevent cognitively impaired and independently mobile Resident (R)1 from eloping from the facility. On 09/11/24 at 07:26 AM R1 pressed the release bar on the northwest emergency exit door for 15 seconds, opened the door, and exited the facility. The door alarm sounded but no staff responded, therefore, staff were unaware R1 exited the facility. R1 wheeled herself down the sidewalk of the rear parking lot. Therapy Consultant GG arrived for work around 07:32 AM and observed R1 outside near the facility dumpsters on the northwest side of the building and alerted facility staff. Staff assisted R1 back inside the facility and assessed for injuries though none were noted. The failure of facility staff to respond to the door alarms in order to ensure R1's safety and prevent cognitively impaired R1 from exiting the facility without staff supervision or knowledge, placed R1 in immediate jeopardy. Findings Included: - R1's Electronic Medical Record (EMR) documented diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), altered mental status, dementia (progressive mental disorder characterized by failing memory, confusion), generalized muscle weakness, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and a need for assistance with personal care. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair and was independently mobile. The MDS further documented R1 was independent for most activities of daily living (ADL). The MDS documented R1 had no wandering behaviors. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 09/30/23, documented R1 triggered the CAA due to a BIMS score of less than 13 and disorganized thinking. The ADL Functional / Rehabilitation Potential CAA, dated 09/30/23, documented R1 had both self-care and mobility deficits. The CAA further documented R1 had problems with balance and cognition. The CAA documented nursing provided ADL, mobility, and transfer assistance for R1. R1's Care Plan with an initiated date of 10/25/21, documented R1 was at risk for impaired cognitive function, dementia, or impaired thought process related to psychotropic (alters mood or thought) drug use and dementia. An intervention dated 11/05/21 directed staff to monitor, document, and report to the physician (MD) any changes in cognitive function, specifically changes in decision-making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Interventions dated 10/28/21 documented R1 was independent with wheelchair propulsion and required assistance of one staff member for transfers. R1's plan of care did not address elopement potential. R1's EMR recorded a Nursing note dated 09/11/24 at 10:00 AM that documented staff placed a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1's right wrist. A Social Services note dated 09/11/24 at 10:01 AM documented staff contacted R1's representative to discuss recent exit seeking behaviors. The director of nursing (DON) communicated a Wander Guard was placed on R1. The note documented R1's representative expressed that she had noticed increased a decline in R1's cognition in the last month. The note further documented staff discussed with R1's representative the possibility of exploring memory care facilities if R1's exit seeking behaviors continued. R1's EMR lacked any further documentation related to R1's elopement on 09/11/24. An investigation document provided by the facility titled [R1] Investigation dated 09/11/24 documented a timeline of events related to R1's elopement. The document recorded the following: On 09/11/24 at 07:15 AM to 07:20 AM Certified Nurse Aide (CNA) M entered R1's room and woke her up, ensured R1 had what she needed, and oversaw the transfer from R1's bed to her wheelchair. On 09/11/24 at 07:26 AM facility camera footage revealed R1 left her room and went straight to the northwest exit door, where R1 exited the building. On 09/11/24 at 07:32 AM R1 was seen at the back door with staff as they brought R1 back inside the building. On 09/11/24 at 07:33 AM staff contacted the Assistant Directors of Nursing (ADON) and made them aware. On 09/11/24 at 07:36 AM staff contacted Administrative Nurse D and made him aware. Administrative Nurse D requested a head-to-toe assessment on R1 and a head count of the entire unit. On 09/11/24 at 07:37 AM Administrative Nurse D called Administrative Staff A. The investigation document further recorded R1 did make it outside of the building for six minutes. The document recorded when R1 was at the northwest door, R1 did press on the door for 15 seconds before the door released. The door was checked by the Administrative Staff A, Administrative Nurse D, and the maintenance director. The documented further recorded the door alarm was working and functioned properly; however, they all felt as though the door alarm could have been louder to draw more attention to the door being opened. An electronic communication from Social Services X to Administrative Nurse D and Administrative Staff A dated 09/11/24 at 08:42 AM documented Social Services X reviewed camera footage for 09/11/24 from 07:00 AM to 07:45 AM. The documented recorded R1 wheeled herself to the northwest end of the hallway. R1 then pushed the door open on her own at 07:26 AM and wheeled herself outside. R1 was then brought back in at 07:32 AM via a therapist and nursing staff. An undated and unnotarized interview with CNA M conducted by Administrative Nurse D and titled [R1] Investigation documented CNA M got R1 up between 07:15 AM and 07:20 AM. CNA M informed R1 it was time for breakfast and supervised R1's transfer from her bed to her wheelchair. CNA M informed R1 she could go to the dining room when she was ready. CNA M then left R1's room between 07:25 AM and 07:30 AM to get the next resident up for the day. CNA M reported they were still helping another resident when they were made aware R1 had left the unit and it had been within five to ten minutes of leaving R1. CNA M reported that he was informed R1 was brought in from the parking lot. An undated and unnotarized interview with Licensed Nurse (LN) G conducted by Administrative Nurse D and titled [R1] Investigation documented LN G was getting medications ready for residents at 07:33 AM when Consultant GG and Certified Medication Aide (CMA) R came up to LN G and stated they found R1 in the rear parking lot and brought her in. LN G reported they asked CNA M when he got R1 up and CNA M reported about 10 minutes before. LN G reported they contacted the ADONs at 07:36 AM and informed Administrative Nurse E that R1 got out of the building. LN G reported they did a head to toe assessment, R1's vitals were in normal limits and no new skin issues were found. LN G reported they checked the door alarm when they were on the phone with Administrative Nurse E and the alarm was working, but the alarm did not go off when R1 got out. Consultant GG's untitled and undated statement, provided by the facility, documented R1 was found in the parking lot around 07:30 AM when Consultant GG pulled into the parking lot that morning. The statement documented R1 appeared okay and reported she had used the back door to get out. Consultant GG documented she took R1 inside. CNA M's untitled statement dated 09/11/24, provided by the facility, documented CNA M woke R1 up and waited for her to sit in her wheelchair at 07:15 AM. CNA M documented he went to assist another resident and staff found R1 outside with Consultant GG. LN G's untitled statement dated 09/11/24, provided by the facility, documented Consultant GG and CMA R approached her with R1. The statement documented Consultant GG stated R1 was found in the back parking lot. CNA M came over and stated that he had gotten R1 up and dressed for the day 10 minutes prior. LN G documented they contacted the ADON and then assessed R1's skin and took R1's vital signs. LN G documented R1 had no new skin issues and R1's vital signs were within normal limits. LN G documented staff performed a head count of residents on the west side. On 09/16/24 at 01:38 PM observation of the facility rear parking lot, and surrounding area, revealed the northwest door opened to a sidewalk with one on and off ramp on the east side of the sidewalk. The area surrounding the sidewalk had a tall curb that connected to the parking lot. The sidewalk near the northwest door was close to the facility's dumpsters. The edges of the rear parking lot had tall curbs that surrounded the entire perimeter. The east side of the parking lot had one entrance and exit for vehicles and connected to a road that ran north and south and had a posted speed limit of 10 miles per hour (mph). The road on the east side of the building connected to a busy road toward the front of the building with two lanes of traffic that ran each direction and posted speeds of 45 miles per hour. On 09/16/24 at 02:22 PM R1 sat in her wheelchair, in her room. R1 had a WanderGuard bracelet to her right wrist . On 09/16/24 at 01:43 PM CNA M stated he got R1 up six to seven minutes prior to R1 being found outside. CNA M stated R1 got out of the back door and he wasn't sure how she got through the door. CNA M stated he thought perhaps staff had taken the trash outside and the door may not have shut all the way, and she may have been able to get out because of that. CNA M stated he heard the door beep one time when R1 went out. CNA M stated he did not hear a door alarm, only the single beep. CNA M stated he believed R1 had only been outside for about 10 minutes at the longest and had no distress when she was brought inside. CNA M stated staff placed a Wander Guard on R1 and checked it daily. On 09/16/24 at 01:26 PM Consultant GG stated she found R1 around 07:30 AM when she pulled into the parking lot. Consultant GG stated she was not sure of the exact date when she found R1 outside, but stated it was recent and within the last week. Consultant GG stated she asked R1 how she got outside and felt R1's skin and hands to see if R1 was cold. Consultant GG stated R1's hands and skin felt okay and R1 was not cold. Consultant GG stated she took R1 to the back door, knocked on it, and staff opened it to let them inside. Consultant GG stated she reported to the nurse what had happened, and the nurse took R1 and assessed her. Consultant GG stated R1 did not appear to be in distress at the time. On 09/16/24 at 01:38 PM Consultant GG walked out to the rear parking lot and pointed out the area R1 was found in. Consultant GG stated R1 was found in a section of the rear parking lot, on the northwest side of the building, near the facility's dumpsters. Consultant GG stated R1 had made it down from the sidewalk and into the actual parking lot when she found R1. On 09/17/24 at 01:25 PM CNA N stated staff can hear the door alarms on either end of the hallway even if they are on the opposite end of the hallway. CNA N stated all staff are supposed to respond to the doors when the alarms are going off. CNA N stated the facility recently provided door alarm and elopement education for staff. On 09/17/24 at 01:18 PM LN H stated there were no issues with the door alarms that she was aware of. LN H stated the door alarms could be heard at either end of the hallway, even if staff stood at the end of the opposite hall from where the alarm was sounding. LN H stated if a resident exhibited exit seeking behavior staff would notify the DON and the resident's doctor about the behavior and request a WanderGuard from maintenance. LN H stated she would have documented a note if she witnessed exit seeking behaviors, and who was notified, in the resident's progress notes or under risk assessments. LN H stated the facility provided elopement education, what to do and who to contact as well as education on door alarms after R1's elopement. On 09/17/24 at 01:34 PM Maintenance U stated they check the door alarms weekly and then perform a more extensive inspection monthly. Maintenance U stated there were no issues with the door R1 went out on 09/1/24 and that everything was working as intended. Maintenance U further stated the facility placed a louder alarm on the door because they felt it could be louder. On 09/17/24 at 12:09 PM in a joint interview with Administrative Staff A and Administrative Nurse D, Administrative Staff A and Administrative Nurse D stated they were not aware of any exit seeking behaviors prior to R1's elopement. They reported R1 had some confusion but was at baseline. Administrative Nurse D stated R1 started out in the assisted living (AL) and he was not aware of any exit seeking behaviors while there. Administrative Staff A and Administrative Nurse D stated R1 had never left or attempted to leave the facility, and never vocalized that she wanted to leave the facility that they were aware of. Administrative Staff A and Administrative Nurse D stated they expected staff to document if they witnessed exit seeking behaviors from any of the residents. They expected nurses to document a skin assessment, complete vitals, and have the social worker notify family in this incident. Administrative Nurse D stated because there was no fall, or medical related issues, there was no expectation for nurses to document anything other than the assessment and a statement for their soft file. Administrative Nurse D stated the notification for the family was documented by the social worker as there was no injury or medical related issues resulting from the elopement. Administrative Nurse D stated he expected staff to notify family and facility leadership. Administrative Nurse D stated they reviewed the camera footage, interviewed staff and created a timeline of events related to the incident. Administrative Nurse D stated CNA M helped R1 out of bed, R1 was seen in the hallway while CNA M went into another resident room to assist them. He stated R1 then went to the right down the hall, pressed the door for 15 seconds, the door opened, and R1 went outside. Administrative Nurse D stated there were no other staff in the hallway within camera view at the time, and staff were either in the dining room or in other resident rooms. Administrative Nurse D stated the door alarms were working, and staff reported they could hear them, but the facility felt the door alarms were not as loud as they could be. Administrative Nurse D stated maintenance installed new speakers so the alarm could be louder. Administrative Nurse D and Administrative Staff A stated they believe staff may have been complacent in responding to the alarm, and that perhaps they thought someone else would get the alarm, as they were busy helping other residents. Administrative Nurse D stated staff were educated that everyone will respond to a door alarm regardless moving forward. Administrative Nurse D and Administrative Staff A stated the facility have conducted door alarm drills to test staff after education was provided and will have an all staff Inservice over elopements tomorrow. Administrative Nurse D stated R1's care plan was updated to reflect the new behavior, a WanderGuard was placed, and R1's representative was notified. Administrative Nurse D stated if R1's exit seeking behaviors worsen, the facility may look at locked unit placement for R1 and this was discussed with the family. Administrative Nurse D stated for now, the interventions were working, and it hasn't come to that. Administrative Nurse D stated he felt staff responded well in notifying leadership and getting the resident back inside the building. The facility's Elopement/Unsafe Wandering policy with an original date of 06/2018 documented it is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. The facility will notify the appropriate State Agency in accordance with state requirements: [SPECIFY REQUIREMENTS HERE]. Notification to the appropriate State Agency will be made within twenty-four (24) hours of the serious accident/incident. A narrative summary of each incident/accident will be forwarded to the appropriate State Agency within five (5) days. On 9/17/24 at 03:31 PM, the facility received the Immediate Jeopardy [IJ] Template and was informed that the facility failure to respond to door alarms in order to prevent cognitively impaired R1 from exiting the facility without staff supervision or knowledge and entering an unsafe location placed R1 in IJ. The facility submitted an acceptable plan of corrective actions for removal on 09/17/24. The plan included the following actions: R1's Care Plan was updated to include the current status of R1's exit seeking. Staff placed a Wander Guard on R1. A full in-service was given to [nursing] staff to discuss R1 and the procedure for answering door alarms, The maintenance director assessed the door, door alarms, and added a louder door alarm for the northwest door. Nursing staff were educated on answering alarms immediately. Any resident suspected of exit seeking would be assessed by the interdisciplinary team (IDT) and protective action taken immediately. An all-staff in-service on elopement prevention and response to door alarms was scheduled for 09/18/24. Implementation of the corrective actions and removal of the immediacy was verified during the onsite survey on 09/17/24 at 04:14 PM. The deficient practice remained at a scope and severity of D.

The facility identified a census of 62 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to identify an elopement for Resident (R) 1 as potential neglect and report to the State Agency (SA) as required. This placed R1 at risk for unidentified and ongoing neglect. Findings Included: - R1's Electronic Medical Record (EMR) documented diagnosis of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), altered mental status, dementia (progressive mental disorder characterized by failing memory, confusion), generalized muscle weakness, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and a need for assistance with personal care. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair and was independently mobile. The MDS further documented R1 was independent for most activities of daily living (ADL). The MDS documented R1 had no wandering behaviors. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 09/30/23, documented R1 triggered for the Cognitive Loss / Dementia CAA due to a BIMS score of less than 13 and disorganized thinking. The Functional / Rehabilitation Potential CAA, dated 09/30/23, documented R1 had both self-care and mobility deficits. The CAA further documented R1 had problems with balance and cognition. The CAA documented nursing provided ADL, mobility, and transfer assistance for R1. R1's Care Plan with an initiated date of 10/25/21, documented R1 was at risk for impaired cognitive function, dementia, or impaired thought process related to psychotropic (alters mood or thought) drug use and dementia. An intervention with an initiated date of 11/05/21 directed staff to monitor, document and report to the physician (MD) any changes in cognitive function, specifically changes in decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Interventions with an initiated date of 10/28/21 documented R1 was independent with wheelchair propulsion and required assistance of one staff member for transfers. R1's plan of care did not address elopement potential. An investigation document provided by the facility titled [R1] Investigation dated 09/11/24 documented a timeline of events related to R1's elopement. The document recorded the following: On 09/11/24 at 07:15 AM to 07:20 AM Certified Nurse Aide (CNA) M entered R1's room and woke her up, ensured R1 had what she needed, and oversaw the transfer from R1's bed to her wheelchair. On 09/11/24 at 07:26 AM facility camera footage revealed R1 left her room and went straight to the northwest exit door, where R1 exited the building. On 09/11/24 at 07:32 AM R1 was seen at the back door with staff as they brought R1 back inside the building. On 09/11/24 at 07:33 AM staff contacted the Assistant Directors of Nursing (ADON) and made them aware. On 09/11/24 at 07:36 AM staff contacted Administrative Nurse D and made him aware. Administrative Nurse D requested a head-to-toe assessment on R1 and a head count of the entire unit. On 09/11/24 at 07:37 AM Administrative Nurse D called Administrative Staff A The investigation document further recorded R1 did make it outside of the building for six minutes. The document recorded when R1 was at the northwest door, R1 did press on the door for 15 seconds before the door released. The door was checked by the Administrative Staff A, Administrative Nurse D, and the maintenance director. The documented further recorded the door alarm was working and functioned properly; however, they all felt as though the door alarm could have been louder to draw more attention to the door being opened. An undated and unnotarized interview with CNA M conducted by Administrative Nurse D and titled [R1] Investigation documented CNA M got R1 up between 07:15 AM and 07:20 AM. CNA M informed R1 it was time for breakfast and supervised R1's transfer from her bed to her wheelchair. CNA M informed R1 she could go to the dining room when she was ready. CNA M then left R1's room between 07:25 AM and 07:30 AM to get the next resident up for the day. CNA M reported they were still helping another resident when they were made aware R1 had left the unit and it had been within five to ten minutes of leaving R1. CNA M reported that he was informed R1 was brought in from the parking lot. Consultant GG's untitled and undated statement, provided by the facility, documented R1 was found in the parking lot around 07:30 AM when Consultant GG pulled into the parking lot that morning. The statement documented R1 appeared okay and reported she had used the back door to get out. Consultant GG documented she took R1 inside. On 09/16/24 at 01:38 PM observation of the facility rear parking lot, and surrounding area, revealed the northwest door opened to a sidewalk with one on and off ramp on the east side of the sidewalk. The area surrounding the sidewalk had a tall curb that connected to the parking lot. The sidewalk near the northwest door was close to the facility's dumpsters. The edges of the rear parking lot had tall curbs that surrounded the entire perimeter. The east side of the parking lot had one entrance and exit for vehicles and connected to a road that ran north and south and had a posted speed limit of 10 miles per hour (mph). The road on the east side of the building connected to a busy road toward the front of the building with two lanes of traffic that ran each direction and posted speeds of 45 miles per hour. On 09/16/24 at 02:22 PM R1 sat in her wheelchair, in her room. R1 had a Wander Guard bracelet to her right wrist. On 09/17/24 at 12:09 PM in a joint interview with Administrative Staff A and Administrative Nurse D, Administrative Staff A and Administrative Nurse D stated they believe staff may have been complacent in responding to the alarm, and that perhaps they thought someone else would get the alarm as they were busy helping other residents. Administrative Nurse D stated elopements would be reported to the SA on a case-by-case basis. Administrative Nurse D stated he had spoken with the regional staff about the elopement and said if R1 had been at risk for elopement or if there would have been harm or an injury then it would have been reported to the SA. Administrative Nurse D stated it happened so quick; the facility didn't report it. Administrative Nurse D stated they wanted to make sure they got interventions in place and discussed it with the regionals. He further stated the facility made the final decisions on whether it was reported, but took the advice from the regionals, and their advice was no, that it did not need to be reported because of how quick it was and there was no harm. Administrative Nurse D stated the facility was on top of it with interventions and education, and if it would have been a bigger thing then it would have been reported. The facility's Elopement/Unsafe Wandering policy with an original date of 06/2018 documented it is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. The facility will notify the appropriate State Agency in accordance with state requirements: [SPECIFY REQUIREMENTS HERE]. Notification to the appropriate State Agency will be made within twenty-four (24) hours of the serious accident/incident. A narrative summary of each incident/accident will be forwarded to the appropriate State Agency within five (5) days . The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy with an original date of 11/2017, documented in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: the administrator, the State Survey Agency, and Adult Protective Services (as appropriate). The facility failed to identify an elopement for R1 as potential neglect and report to the SA as required. This placed R1 at risk for unidentified and ongoing neglect.

The facility identified a census of 69 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect. On 07/22/24, R1, who was cognitively intact but diabetic (individual with a chronic disease that results in too much glucose in the blood), legally blind, and had bilateral lower extremity amputations (surgical removal of a limb), wheeled himself outside around 08:00 PM without letting staff know and without his cell phone. R1 tipped over in his wheelchair and was unable to get up or contact staff for assistance. R1 laid on the ground and called out for staff to assist him though no one came to help. R1 remained outside on the ground from around 08:00 PM on 07/22/24 until early the next morning. On the morning of 07/23/24, another resident's family member observed R1 on the ground outside, alerted the staff, and the staff then went outside and assisted R1 back inside. The facility neglected to provide the standard of care and follow R1's Care Plan to check on R1 overnight every two to three hours. As a result, R1 laid outside in the tall grass on the ground overnight, for at least 10 hours while the weather ranged from 77 degrees Fahrenheit (F) to 65 degrees F . The facility's neglect in providing the necessary care for R1, placed R1 in immediate jeopardy. Findings Included: - R1's Electronic Medical Record (EMR) documented diagnosis of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), absence of right leg below knee, absence of left leg above knee, legal blindness, neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), visuospatial deficit (difficulties with processing information about 3D objects, which can affect a person's spatial awareness and ability to judge distances), a need for assistance with personal care, and weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 used a wheelchair and had limb prosthesis (artificial body part). The MDS further documented R1 as independent for oral, personal, and toileting hygiene, and changing from lying to seated position on side of the bed. The MDS document R1 required set up or clean up assistance for eating, upper body dressing, change from a sit to lying position, and chair to bed, or bed to chair transfers. The MDS documented R1 required substantial, maximal assistance for bathing, lower body dressing, and shower or tub transfers. The ADL [Activities of Daily Living] Functional / Rehabilitation Potential Care Area Assessment (CAA), dated 09/23/23, documented R1 needed help with ADL and mobility. The CAA documented contributing factors of neuromuscular dysfunction of bladder, right below knee amputation, and left above knee amputation. Risk factors that impacted ADLs were legal blindness, balance deficits during transfers, and potential for further decline in ADLS and mobility. The Visual Function CAA dated 09/23/23, documented R1 was legally blind, had diabetes mellitus with retinopathy (noninflammatory disorders that damage the retina, the light-sensitive tissue at the back of the eye that senses light) and cerebrovascular accident (stroke) with left side vision loss. R1's Care Plan with an initiated date of 09/16/22, documented R1 had an ADL self-care performance deficit. R1's Care Plan with an initiated date of 10/12/22, documented R1 had impaired visual function related to legal blindness, diabetes mellitus with and cerebrovascular accident with left side vision loss and neglect. An intervention with an initiated date of 10/12/22 directed staff to arrange items in R1's room in order to promote independence. An intervention with an initiated date of 11/17/22, documented R1 used an assistive device, right bed assist bar, and staff were to reposition and turn in bed. R1's Care Plan with an initiated date of 10/12/22 documented R1 had bowel and bladder incontinence related to mobility impairment and neuromuscular dysfunction of bowel and bladder. R1's Care Plan intervention with an initiated date of 10/12/22 (revised and resolved date on 08/02/24, after the incident) documented R1 was incontinent and directed staff to check as required for incontinence. An intervention with an initiated date of 09/12/23 (revised and resolved on 08/02/24) directed staff to offer upon R1 rising, before and after meals, at bedtime, and every two to three hours as needed. R1's Care Plan lacked interventions related to R1's ability to go outside without staff assistance or supervision until after the occurrence. The plan was updated on 07/23/24 to direct the resident should have his cell phone on him when he goes outside. An Encounter note dated 07/23/24 documented R1 exited the building during the previous evening and went with his wheelchair off the sidewalk into a field next to the building. The note documented R1 was blind, got lost and turned around, and R1's wheelchair tipped backwards into the long grass. The note documented R1 was unable to get himself off the ground and was outside of the building overnight. The note further documented the morning of 07/23/24, R1 was seen in the field and brought inside. A Nursing note dated 07/23/24 documented a witness saw R1 as he sat outside by his wheelchair around 06:30 AM. The note documented day shift staff approached R1 as he sat next to his wheelchair, and R1 was alert, oriented and he stated he had gone outside for fresh air and went off the sidewalk path. The note further documented R1 stated his wheelchair started to tip backwards slowly and he landed on his backside. A Nursing note dated 07/23/24 documented a witness found R1 outside in the grass with his wheelchair behind him and a nurse and two Certified Nurse Aides (CNA) assisted R1 from the ground to his wheelchair and brought him back inside. The note documented R1 stated he went outside to get fresh air, got turned around, and got lost. The note further documented R1 stated while he attempted to find his way back, his wheelchair slowly fell backwards, and he fell on to the ground. An Encounter note dated 07/30/24 documented R1 sustained a fall during the previous week in the middle of the night, from his wheelchair. The note documented R1 was outside the building overnight. An untitled document, provided by the facility, documented the dates and times R1 accessed the facility doors and elevators. The document noted R1 accessed the main entrance on 07/22/24 at 08:15 PM. The document lacked evidence of R1 accessed any facility doors after 08:15 PM. An untitled document provided by the facility recorded a timeline of events related to R1 on 07/22/24. The document recorded the following: 07/22/24 at 07:27 PM R1 depressed his call light. 07/22/24 at 07:30 PM staff answered and silenced the call light. 07/22/24 at 08:15 PM R1 punched his room number at the front door keypad to exit the building. 07/22/24 at 08:16 PM Licensed Nurse (LN) I saw resident outside in front of the building, LN I approached R1 and let him know the clouds were dark and it may rain. The document recorded R1 stated he wanted to catch a breath of fresh air and then he would be back in. LN I approached R1's nurse on duty, LN G, and let her know R1 was out front. LN G stated R1 was fine to be outside by himself, as he always did that, and he would be alright. 07/23/24 at 06:30 AM a visiting family member alerted staff that there was someone outside sitting in the grass next to his wheelchair. 07/23/24 at 06:30 AM staff exited the building and went to where R1 was at. The documented recorded at that time R1 stated he got off his normal path, then it got too dark, and he could not see anything. R1 stated his wheelchair got stuck and he tried to get it unstuck and it slowly tipped backwards, and he landed on his back in the tall grass. The document further recorded R1 stated he did not lose consciousness at any point. R1 stated he did not normally go out after dark and stated it was later than he usually went out. R1 stated he wheeled around the building and tried to find the door but was unable to. The documented recorded R1 stated he did not take his cellphone with him and that he usually took it out with him. R1 denied pain. 07/23/24 at 06:35 AM R1 was brought into the building and taken to his room where he was transferred into bed and a nurse assessed R1's skin. R1's skin was intact with a slight rash to his backside. The document recorded R1 did not have any pain or itching to the rash and R1 thought it was due to the grass. 07/23/24 at 06:57 AM R1 depressed call light and staff responded and silenced call light at 07:01 AM. 07/23/24 at 07:00 AM the nurse practitioner was onsite and assessed the resident and new orders were obtained. 07/23/24 at 08:49 AM the lab company arrived to draw stat (immediate) labs. 07/23/24 at 09:24 AM the lab results finalized in their computer. 07/23/24 at 12:30 PM an order was received to start intravenous (IV-administered directly into the blood stream via a vein) fluids times one bag total . LN I's untitled, undated, statement documented that on 07/22/24 at around 08:15 PM, LN I heard the front door alarm going off. LN I went and found R1 had opened the doors to get outside and the doors had not closed properly, which set the alarm off. The document recorded R1 sat in his wheelchair right outside the main doors. LN I asked R1 if he was okay to be out there, and R1 responded he was okay, he wanted some fresh air, and he would be back in after a while. LN I documented he went and asked R1's nurse if R1 was okay to be out there, and R1's nurse verbalized that R1 was okay adding that R1 always went out and came back. LN G's untitled statement provided by the facility, dated 07/23/24, documented LN G gave R1 his medications and insulin (hormone used to lower blood glucose levels) at approximately 07:00 PM. LN G documented she saw R1 about 08:30 PM to 09:00 PM going down the hallway. The statement further documented shortly after, LN I asked LN G if R1 was okay to be outside and LN G told LN I Yes and that R1 sometimes went outside for fresh air. The statement further documented CNA M told LN G she gave R1 some Sprite and ice at about 12:30 AM. The statement documented R1 normally slept through with one to two bathroom stops and put his call light on for assistance back to his bed from the toilet. The statement further documented LN G reported she spoke with R1 and R1 told her he went outside a second time without letting anyone know. CNA M's untitled statement, provided by the facility and dated 07/23/24, documented CNA M saw R1 around 08:30 PM or 09:00 PM in a hallway. CNA M documented LN I came and asked LN G if it was okay to let R1 outside. The statement further documented R1 asked CNA M for a diet Shasta and ice and the statement recorded CNA M gave them to R1 around 12:30 AM. The statement documented R1 usually put on his call light when he needed something, or when he needed help in the bathroom. The statement further documented R1 went back out without saying anything to staff. LN H's untitled statement, provided by the facility and dated 07/23/24, documented that around 06:30 AM, LN H was notified R1 was found outside. LN H documented she assessed R1's skin, assessed his vital signs and blood glucose, and R1 denied any pain or discomfort. The statement further documented R1 stated he went outside at 10:00 PM on 07/22/24 and fell backwards out of their wheelchair. The statement documented R1 denied he hit his head, R1 was alert and oriented, had no new skin issues and his range of motion was within normal limits. Staff initiated neurological checks and the nurse practitioner was onsite and assessed R1. Certified Medication Aide (CMA) R's untitled statement, provided by the facility and dated 07/23/24, documented night shift was giving report when another resident's daughter-in -law came out into the hallway to notify staff that there was a resident in the field next to his wheelchair. CMA R documented CNA M, and LN G ran out the dining room door and found R1 on the far corner of the field as he sat next to his wheelchair and yelled for help. The statement further documented as staff approached R1, they asked if he was okay and how long he had sat outside. R1 stated he was okay and said he wanted to get back inside. CMA R documented staff transferred R1 into his wheelchair and brought him back inside and then a nurse began to assess him. According to Wunderground.com the temperature at 08:00 PM on 07/22/24 was 77 degrees F. and the temperatures dropped to a low of 65 degrees F. at 06:00 AM on 07/23/24. On 08/19/24 at 12:04 PM R1 sat on a bed in his room. He had a right leg below the knee amputation and left leg above the knee amputation. R1 stated that he was unable to see out of his right eye and was only able to see about 10 feet in front of him out of his left eye as long as there was light. R1 stated if the area was too dark, he would be unable to see anything at all. R1 stated that he went outside, through the main door, around 08:00 PM on 07/22/24. R1 stated he liked to go out around sunset to relax and said that he believed the staff were unaware he went outside initially. R1 stated he did not intend to be outside for long; however, as it got dark, he found it difficult to see. He became disoriented and was unable to find his way back to the main entrance to the facility. R1 further stated he managed to stay on the sidewalk for part of the evening and propelled himself up and down the sidewalk yelling for help as he searched for a way back inside. R1 stated he expected someone to come look for him eventually, but no one did. R1 stated as the night went on, one of the wheels on his wheelchair went off the edge of the sidewalk. He stated he attempted to use his one prosthetic leg to push himself back onto the sidewalk; however, his wheelchair went backwards off the sidewalk, and he ended up tipping over, on his back, in a small field on the left side of the building. R1 stated he laid on his back, in the tall grass, and was unable to get himself off the ground and back into his wheelchair. R1 further stated that he was scared and believed it may have been over for him as he laid on the ground. He stated he was unsure where he was and was not sure anyone would ever find him. R1 stated he was also afraid that his blood glucose may drop overnight, due to his diabetes, and that he may not have made it if someone did not find him. R1 stated he did not have his cell phone with him at that time and was unable to call the facility for help. R1 stated staff found him in the early morning and that he had been outside all evening. He stated CMA R was the staff member that found him; however, he stated there were other staff that came out to assist. R1 stated one of the staff members asked him what time he had gone outside, and after he told them, he heard one of the staff stated, you have been outside for almost 12 hours. On 08/19/24 at 12:54 PM Administrative Nurse D stated if a resident was care planned for scheduled checks, such as a check and change for incontinence, then the expectation was that staff would check the resident and pass that information on to other staff. Administrative Nurse D stated he did not believe there was documentation of when staff checked on the residents; however, the expectation was that information would have been passed on verbally during report. On 08/19/24 at 03:24 PM CMA R stated she was one of the staff that found the resident outside. CMA R stated she was in report and another resident's family member told staff a resident was outside on the ground in the grass. CMA R stated she went outside with the two-night shift staff, LN G and CNA M, to get R1 and found him in the small field, on the left side of the facility, near the base of a small hill in the tall grass. CMA R stated the resident was facing the toward the street and was hollering for help. She stated R1 was a little confused at the time and that R1 stated it was too dark for him to see during the night and he got turned around and went down the hill near the sidewalk before he tipped over into the grass. CMA R stated facility administration viewed the camera footage and R1 had gone outside around 08:00 PM the night before and had not come back inside. CMA R stated the grassy area was bumpy and she did not believe the resident could have got back into his wheelchair or made it back to the facility on his own once he went out into the grass. CMA R stated LN H held the door open for staff to bring R1 back into the facility but did not go out to assist that morning. CMA R stated LN G and CNA M were the two staff that worked during the night shift with R1 and were let go due to the incident. CMA R stated she believed R1 was likely scared out there all night and staff would sometimes see coyotes or other animals out in that field during the early morning hours. On 08/19/24 at 03:46 PM LN H was unavailable for interview. On 08/19/24 at 04:04 PM Administrative Staff A stated she got a call at 07:00 AM, the morning R1 was found, informing her the resident was outside. Administrative Staff A stated her understanding was R1 had lowered his wheelchair to the ground outside and he was spotted through a window waving to staff. Administrative Staff A stated the previous Director of Nursing (DON) spoke to LN G and CNA M about the incident and the two staff no longer worked at the facility. Administrative Staff A stated at first, staff believed R1 went out that morning and lowered himself to the ground during the early morning hours; however, she stated after the facility completed a full investigation, and spoke with R1, they realized R1 was outside overnight. Administrative Staff A stated the facility staff reviewed video footage and saw R1 had went out that evening and used his own code to exit the building through the main entrance. Administrative Staff A further stated the facility did not report the incident as neglect due to the resident had a BIMS of 15, R1 wanted to go outside, it was his right to go outside and R1 did not suffer any injuries. She further stated LN G and CNA M reported that they had checked on the resident and brought him things during the night. Administrative Staff A stated the resident does not like people in his space and would use his call light if he wanted or needed something, and that may have been why LN G and CNA M did not check on him during the night. Administrative Staff A stated staff not checking on the resident was not part of the focus, and they were more concerned to find out if R1 had been outside all night. She further stated she believed it was a quick incident at first and it was discussed with the previous DON, and the regionals, and it was decided the facility would not report the incident. Administrative Staff A stated the reasons discussed for not reporting the incident were related to R1's high BIMS score, the fact R1 wanted to go outside and that he did not have any harm. Administrative Staff A stated it was fair to assume if staff would have checked on R1, during the night, they would have known he was not in the building. Administrative Staff A stated LN G and CNA M did tell her they checked on R1 during the night and brought him items he requested; however, the facility realized this was not true after they reviewed video footage and door access records for that evening. The facility's Abuse: Prevention of and Prohibition Against policy with an original date of 11/2017, documented it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them to the resident that has resulted in or mat result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, anguish, or emotional distress. On 08/19/24 at 06:09 PM, the facility received the Immediate Jeopardy [IJ] Template and was informed that the facility failure to ensure R1 remained free from neglect placed R1 in IJ. On 08/07/24 the facility completed corrective actions which included an all-staff in-service on preventing abuse, neglect, and exploitation, elopement policy and procedure, Quality Assurance and Performance Improvement, and various other care areas. The facility provided staff training on resident rounding every two hours, locating residents not noted upon two-hour checks, and the resident sign out policy. The facility Interdisciplinary team (IDT) reviewed all residents to determine other residents at risk and reviewed and updated the care plans as needed. The facility provided a lanyard for R1's phone when he goes outside and provided education to R1 on the process and use of the lanyard. The facility implemented an intervention for staff to check on R1 every 30 minutes when R1 was outside. The corrective actions were completed prior to the onsite survey therefore the deficient practice was cited as past noncompliance and remained at a scope and severity of J.

The facility identified a census of 59 residents. The sample included three residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 received the required assistance with activities of daily living (ADL). This placed R1 at risk for skin breakdown, poor hygiene, and impaired psychosocial well-being. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, reduced mobility, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 had impairment on one side for the upper and lower extremities. R1 required supervision or touching assistance with eating and oral hygiene. R1 was dependent for toileting hygiene and required staff to complete the activity. R1 was dependent on staff for bed mobility and transfers. R1 had no behaviors. The ADL Care Area Assessment (CAA) dated 03/22/24 documented R1 needed assistance with transfers and ADLs related to weakness associated with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Pressure Ulcer CAA dated 03/22/24 documented R1 needed assistance with bed mobility and weakness. R1 triggered 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) due to R1's ADL and mobility impairment and incontinence. R1's Care Plan revised 03/28/24 directed staff that R1 required assistance to use the toilet. R1 required substantial to maximum assistance with rolling left and right, sitting to lying, and lying to sitting. R1's Care Plan directed staff that he was dependent for toileting hygiene. R1 required staff supervision or touching assistance with eating. The Progress Notes from 03/01/24 through 05/21/24 lacked any documentation regarding the refusal of staff assistance with toileting hygiene and /or eating. On 05/21/24 at 10:50 AM R1 laid in his bed on his back. R1 was covered with a blanket from his legs to his lower abdomen. R1 had a folded washcloth laid on his chest with 11 various-sized brown crumbs from breakfast on the washcloth. R1 wore a hospital gown with a brown clump on it which appeared to be food on the right upper chest area. R1's room had a distinct foul odor present. On 05/21/24 at 02:35 PM, R1 lay in bed, in the same position as previously seen but with his blanket pulled down to his mid-thighs. R1 had the soiled washcloth from that morning still in place. The cloth had additional food including taco salad spilled on it, and to the left of the washcloth on R1's bare chest. R1 stated he was waiting for staff assistance to be cleaned up. R1 had a brownish-black smear on his brief and left upper thigh. R1 stated he had been waiting for assistance since breakfast. R1 indicated he was not too worried about the food on him, but he was concerned by his soiled brief. R1 verified he had asked for staff assistance at breakfast time and was told he had to wait. R1 appeared distressed and upset with having to wait for assistance from staff. On 05/21/24 at 02:38 PM, Certified Nurses Aid (CNA) O verified she needed to get down to R1's room to help him. CNA O stated R1 had asked to get up after breakfast, but CNA O needed two other staff members to get him up. CNA O further stated she knew R1 needed to be cleaned up, but after breakfast, the staff were so busy running around. CNA O revealed that an unidentified CNA was on lunch break, and upon that CNAs return, R1 would hopefully be assisted. CNA O confirmed R1 had been waiting a while but said she had also taken her lunch break due to being hungry. On 05/21/24 at 02:41 PM Administrative Staff A stated that R1 should not have waited since breakfast to be assisted. Administrative Staff A verified it was unacceptable for a resident to sit in a soiled brief for any extended period. Administrative Staff A verified R1 had food on his chest and needed staff assistance. On 05/21/24 at 02:42 PM Administrative Nurse D stated that he expected staff to provide care to the residents promptly. On 05/21/24 at 02:47 PM Licensed Nurse (LN) G stated that if there were not enough staff available when a resident needed assistance, she would alert the staff that upon completion of their current task, the staff needed to attend to the other resident in need. LN G stated she would help provide ADL care so the resident received care in a timely manner. LN G stated a resident should not have to wait as long as R1 had that day. LN G stated it should never have happened. The facility's Quality of Care: ADL, Services to Carry Out policy revised in January 2024 documented it was the policy of the facility that residents were given the appropriate treatment and services to maintain or improve his or her abilities. The policy directed residents who were unable to carry out ADLS to receive the necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene. The facility failed to ensure R1 received ADL assistance as required. This deficient practice placed R1 at risk for skin breakdown, a decreased quality of life, and impaired psychosocial well-being.

The facility identified a census of 59 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified an incident as verbal abuse and reported the incident to the Administrator immediately. This deficient practice created the risk of unidentified and ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, reduced mobility, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 had impairment on one side for the upper and lower extremities. R1 required supervision or touching assistance with eating and oral hygiene. R1 was dependent for toileting hygiene and required staff to complete the activity. R1 was dependent on staff for bed mobility and transfers. R1 had no behaviors. The ADL Care Area Assessment (CAA) dated 03/22/24 documented R1 needed assistance with transfers and ADLs related to weakness associated with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Pressure Ulcer CAA dated 03/22/24 documented R1 needed assistance with bed mobility and weakness. R1 triggered 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) due to R1's ADL and mobility impairment and incontinence. The Urinary CAA dated 03/22/24 documented R1 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). R1's Care Plan revised 03/28/24 directed staff that R1 required assistance to use the toilet. R1 required substantial to maximum assistance with rolling left and right, sitting to lying, and lying to sitting. R1's Care Plan directed staff that he was dependent for toileting hygiene. R1 required staff supervision or touching assistance with eating. R1's care plan documented R1 had excessive worry. A review of the undated Facility Investigation documented CNA M told R1 that R1 had a small penis while providing peri-care on 05/15/24. CNA N reported the incident on 05/16/24. Staff spoke with R1 about the event but R1 did not want to discuss the incident. R1 confirmed that the staff said something inappropriate while giving R1 care. R1 was embarrassed. R1 refused to share who made the inappropriate comment but confirmed CNA M, CNA N, and CNA P were in R1's room providing care. On 05/21/24 at 01:25 PM Administrative Nurse D stated he expected staff to report an incident like this right away and not wait. Administrative Nurse D stated they had received training related to reporting timely. On 05/21/24 at 01:39 PM, CNA N stated that R1 required three staff members in there to change him. CNA N stated that when CNA M was cleaning R1's catheter, she said something about R1's penis being small and not being able to see it. CNA N noticed that this upset R1 because R1 started to say that it was not always that small and began to describe it as it was. CNA N stated that the statement made him very uncomfortable and he later pulled CNA M aside and informed her that what she said to R1 was inappropriate. CNA N stated he was not sure how to approach what happened in R1's room as he was so upset with himself over it. CNA N again reiterated that he felt very uncomfortable when CNA M said that to R1, and he approached Administrative Nurse D about it. CNA N said he realized he should have reported it sooner, but he was unsure what to do. On 05/21/24 at 02:47 PM Licensed Nurse (LN) G stated that if there was a concern of abuse or neglect, she would report it to a manager immediately and investigate to see what needed to happen for the resident. LN G stated she would remove the staff member from the situation and follow up with the resident to see that the resident was ok. On 05/21/24 at 03:00 PM Administrative Staff A stated staff were expected to report all allegations or events of abuse immediately. The facility's Abuse: Prevention and Prohibition Against Freedom From Abuse, Neglect Exploitation revised December 2023 documented that all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. The facility failed to ensure staff identified an incident as verbal abuse and reported the incident to the Administrator immediately. This deficient practice created the risk of unidentified and ongoing abuse.

The facility identified a census of 59 residents. The sample included three residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 remained free from verbal abuse when staff made inappropriate statements to R1. On 05/16/24 Certified Nurse Aide (CNA) M became irritated with R1 and made disparaging remarks about the size of R1's genitals. This placed R1 at risk for impaired psychosocial well-being including humiliation and degradation. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, reduced mobility, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 had impairment on one side for the upper and lower extremities. R1 required supervision or touching assistance with eating and oral hygiene. R1 was dependent for toileting hygiene and required staff to complete the activity. R1 was dependent on staff for bed mobility and transfers. R1 had no behaviors. The Activities of Daily Living [ADL] Care Area Assessment (CAA) dated 03/22/24 documented R1 needed assistance with transfers and ADLs related to weakness associated with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Pressure Ulcer CAA dated 03/22/24 documented R1 needed assistance with bed mobility and weakness. R1 triggered for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) due to R1's ADL and mobility impairment and incontinence. The Urinary CAA dated 03/22/24 documented R1 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) The Mood CAA and Behavior CAA did not trigger. R1's Care Plan revised 03/28/24 directed staff that R1 required assistance to use the toilet. R1 required substantial to maximum assistance with rolling left and right, sitting to lying, and lying to sitting. R1's Care Plan directed staff that he was dependent for toileting hygiene. R1 required staff supervision or touching assistance with eating. R1's care plan documented R1 had excessive worry. A review of the undated Facility Investigation documented CNA M told R1 that R1 had a small penis while providing peri-care on 05/15/24. CNA N reported the incident on 05/16/24. Staff spoke with R1 about the event but R1 did not want to discuss the incident. R1 confirmed that the staff said something inappropriate while giving R1 care. R1 was embarrassed. R1 refused to share who made the inappropriate comment but confirmed CNA M, CNA N, and CNA P were in R1's room providing care. The Facility Investigation lacked witness statements from CNA N and CNA P. A review of CNA M's typed statement documented CNA M cleaned R1's penis and testicles. CNA M documented she tried to pull back R1's foreskin and CNA N stated she should pull the foreskin back further. CNA M documented she told CNA N that she could not see any more skin to pull back. CNA M documented R1 made a statement regarding the size of his penis that she felt it was inappropriate but she said nothing. On 05/21/24 at 10:46 AM R2 stated that there were times that staff would be rude to the residents but nothing more than that, not heavy abuse in his opinion, but staff did get upset with R1 because R1 pushed his call light too much. On 05/21/24 at 10:50 AM R1 stated he felt terrible when CNA M talked about his genitals. R1 stated that is not how staff should operate. R1 further stated that he was afraid to say too much because he was concerned the direct care staff would punish him. On 05/21/24 at 01:39 PM, CNA N stated that R1 required three staff members in there to change him. CNA N stated that when CNA M was cleaning R1's catheter, she said something about R1's penis being small and not being able to see it. CNA N noticed that this upset R1 because R1 started to say that it was not always that small and began to describe it as it was. CNA N stated that the statement made him very uncomfortable and he later pulled CNA M aside and informed her that what she said to R1 was inappropriate. CNA N stated he was not sure how to approach what happened in R1's room as he was so upset with himself over it. CNA N again reiterated that he felt very uncomfortable when CNA M said that to R1, and he approached Administrative Nurse D about it. CNA N said he realized he should have reported it sooner, but he was unsure what to do. On 05/21/24 at 01:47 PM CNA P was unavailable for interview. On 05/21/24 at 01:51 PM, CNA M stated that when she was assisting CNA N in getting R1 up, she did say something about R1's genitals, but it was due to not being able to see them anymore with R1's catheter. CNA M stated she did not know if R1 or CNA N interpreted her meaning correctly. CNA M stated that R1 then commented on the size his genitals used to be. On 05/21/24 at 02:47 PM Licensed Nurse (LN) G stated that if there was a concern of verbal abuse, she would report it to a manager immediately and investigate to see what needed to happen for the resident. LN G stated she would remove the staff member from the situation and follow up with the resident to see that the resident was ok. On 05/21/24 at 03:05 PM Administrative Nurse D stated that during the investigation he could not find out what exactly was said. Administrative Nurse D stated because he was unable to find out what exactly was said to R1, he could not substantiate that any abuse happened to R1. Administrative Nurse D stated he spoke with all three staff members but only had CNA M write anything out. On 05/21/24 at 03:09 PM Administrative Staff A asked if R1 reported exactly what was said to him. Administrative Staff A stated R1 would only say that it embarrassed him. Administrative Staff A stated the facility could not substantiate any abuse without knowing what exactly was said to R1. Administrative Staff A stated that CNA N, CNA M, and CNA P were verbally interviewed but CNA M and CNA P were not asked by the facility to write a witness statement. The facility's Abuse: Prevention and Prohibition Against Freedom from Abuse, Neglect Exploitation revised December 2023 documented each resident had the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The facility would provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Mental abuse included, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Verbal abuse included the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The facility failed to ensure R1 remained free from verbal abuse. This placed R1 at risk for impaired psychosocial well-being including humiliation and degradation.

The facility identified a census of 69 residents. The sample included three residents reviewed for falls. Based on observations, record review, and interviews, the facility failed to follow fall interventions to prevent a fall with major injury for Resident (R) 1. On 09/16/23, Certified Nurse Aide (CNA) M forgot to place the fall mat on the floor, next to R1's bed. R1 was subsequently found on the floor with a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma), skin tear, and a right thumb fracture. The injuries resulting from the deficient practice also placed R1 at increased risk for pain. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of encephalopathy (damage or disease that affects the brain), need for assistance with personal care, generalized muscle weakness, and dementia (progressive mental disorder characterized by failing memory, confusion) with other behavioral disturbance. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. R1 required extensive assistance with two staff for bed mobility, transfers, dressing, and toileting and extensive assistance with one staff for personal hygiene. R1 had no falls since admission. The Cognitive Loss/Dementia Care Area Assessment (CAA) date 08/30/23, documented R1 had a BIMS score of 10, with cognitive communication deficits as the problem. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 08/30/23, documented R1 needed help with ADLs and mobility. R1's Care Plan dated 08/14/23, documented R1 was at risk for falls related to frequent falls, weakness, medication side effects, and impulsivity. The Care Plan documented an intervention, dated 08/27/23, that directed R1 had a minor injury fall and a fall mat was placed next to the bed. The Notes tab of R1's EMR revealed the following: A Nursing Note on 09/17/23 at 04:10 AM documented R1 left on a stretcher to the hospital due to the development of a hematoma on the back of his head and swelling, bruising, and pain on his right thumb related to falls. A Nursing Note on 09/17/23 at 06:17 AM documented R1 was found sitting on the floor next to his bed. He had a skin tear on his forehead above the left eye and no other injuries were noted at that time. Staff assisted R1 off the floor. Staff cleaned the skin tear and applied a band-aid. The note documented the unidentified CNA that assisted R1 to bed forgot to place the floor mat next to R1's bed. The CNA was reminded to always place mat next to R1's bed in order to prevent falls and the CNA voiced understanding. During a follow-up skin assessment, a quarter-sized hematoma was noticed at the back of R1's head and some bruising and swelling were noticed to his right hand and thumb area. R1 voiced pain and tenderness with touch. Staff notified the physician of the changes and received an order to send R1 to hospital for x-ray of the right hand and a computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) of the head. A Nursing Note on 09/17/23 at 04:06 PM documented R1 returned from hospital on 09/17/23 at 06:30 AM. He came back with a contusion (bruise), a fracture to his right hand, and a head injury. R1 was to follow-up with orthopedics and had a splint in place. The note documented an intervention, staff were to get R1 in bed between 08:00 PM and 09:00 PM with a fall mat in place by the bed. R1 sat comfortably in wheelchair in sight of nurse and the CNAs were aware of updated interventions. A Nursing Note on 09/18/23 at 12:15 PM documented the Interdisciplinary Team (IDT) met to review R1 related to second fall from 09/16/23. The note documented R1 was found lying on the floor next to his bed with a small skin tear above the left eye and he had been checked on approximately 15 to 20 minutes prior to the fall and was resting in bed comfortably. The note documented an intervention for R1 to have a parameter overlay applied to his bed to help him establish the edge of the bed during bed mobility. A Nursing Note on 09/18/23 at 12:18 PM documented IDT met to review R1 related to his incidents from 09/16/23 and 09/17/23. The note documented R1 had two falls and sustained small skin tears to the forehead at his hairline and above his eye. The note documented R1 started exhibiting pain to his right hand, had bruising to his right hand, and was sent to the hospital for evaluation and treatment. R1 returned on 09/17/23 with a right hand/thumb fracture. The note documented R1 had a splint in place to his right hand but continued to remove it despite redirection. Upon request, the facility provided the x-ray report from 09/17/23. The x-ray report documented R1 had an acute traumatic fracture at the base of the first metacarpal (thumb). The facility's investigative report, dated 09/25/23, documented on 09/16/23 at approximately 11:03 PM, R1 fell and was noted to have a small hematoma and pain to his right hand. The facility sent R1 to the hospital for evaluation and treatment and family and medical doctor were notified at the time of the fall. Staff checked on R1 approximately 15 to 30 minutes prior to the fall due to R1 was being on increased monitoring related to fall precautions. R1 had a fracture to his right hand and a laceration (cut) to the left side of his forehead. R1 returned to the facility on [DATE] at approximately 06:30 AM with a splint in place and a follow-up appointment scheduled with orthopedics. Certified Nurse Aide (CNA) M from the shift was educated on the importance of completing fall interventions and ensuring the fall mat was in place. On 10/17/23 at 12:24 PM, R1 sat in his wheelchair in the dining room. He attempted to stand up from his wheelchair and staff quickly attended to him. He stated he wanted to go to the restroom and staff assisted him to the shower room for toileting. He wore splints on both hands/wrists. On 10/17/23 at 03:28 PM, CNA N stated the Kardex (nursing tool that gives a brief overview of the care needs of each resident) told staff how to care for residents including how to transfer and how many staff were needed for assistance. She stated R1's fall preventions included a fall mat on the floor when the resident was in bed and a perimeter mattress. CNA N stated she did not open the Kardex unless she was not 100 percent sure about how to take care of someone. CNA N said if there was a new intervention, then the nurse or therapy staff told the CNA. On 10/17/23 at 03:49 PM, Licensed Nurse (LN) G stated staff knew how to care for residents by looking at the care plan which was updated between nursing and therapy staff. She stated the CNAs had access to the Kardex which told them how a resident transferred, what staff assistance with ADLs were required, and any fall interventions such as a fall mat. LN G stated falls were prevented with R1 by keeping him entertained including giving him a snack, giving him coffee, having him do the fidget board or activities, and bringing him to the dining room; if R1 was in his bed, he had a fall mat placed beside the bed and was on frequent checks. On 10/17/23 at 04:15 PM, Administrative Nurse D stated the Kardex told staff how to care for a resident as well as the Tasks tab of the EMR. The Kardex told staff transfer status, diet type, fall interventions, and any assistance needed with meals. Administrative Nurse D stated fall interventions for R1 included the bed in low position, toileting schedule, fall mat, and bolsters on the mattress to show R1 the edge of the bed. CNA M was unavailable for interview on 10/23/23 at 07:17 PM. The facility's Fall Management System policy, last revised June 2023, directed residents with high risk factors identified on the Fall Risk Evaluation had an individualized care plan developed that included measurable objectives and timeframes. The care plan interventions were developed to prevent falls by addressing the risk factors and considered the particular elements of the evaluation that put the resident at risk. The facility failed to follow fall interventions to prevent a fall with major injury for R1. This deficient practice resulted in R1 suffered a right thumb fracture. The facility implemented the following corrections by 09/29/23: R1's care plan was updated on 09/16/23. CNA M received education on fall precautions and interventions on 09/18/23. CNA M received counseling on inadequate implementation of fall interventions on 09/18/23. Staff were educated on falls during monthly in-service on 09/29/23. This deficient practice was cited at past noncompliance. The scope and severity remained at a G.

The facility identified a census of 53 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 remained free of significant medication errors. On [DATE] at approximately 09:00 AM, Licensed Nurse (LN) G administered R2's medications to R1, which included three antihypertensive (medication used to treat hypertension [high blood pressure]) medications, one antianxiety (medication used to treat anxiety [mental or emotional reaction characterized by apprehension, uncertainty and irrational fear]) medication, one antidepressant (medication used to treat depression [major mood disorder]) medication, one narcotic (medication used to treat pain) medication, and eight other medications. LN G did not verify R1's name before she gave R1 the medications. When LN G identified the error, she called Consultant GG who gave orders to monitor R1 and ordered a medication to help increase R1's blood pressures. At 09:30 to 09:50 PM, R1's blood pressure was ,d+[DATE] millimeters per mercury (mmHg) with a pulse of 49 beats per minute (bpm). About two hours later, R1's oxygen saturation began declining. LN H notified the on-call provider on [DATE] at 12:35 AM and received an order to send R1 to the hospital. When Emergency Medical Services (EMS) arrived, R1 was unresponsive, and EMS began cardiopulmonary resuscitation (CPR- emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, et cetera) until confirmation of her do not resuscitate (DNR) status. R1 passed away in the facility on [DATE] at 01:26 AM. The facility failure to ensure R1 remained free from significant mediation errors placed R1 in immediate jeopardy. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. R1 required extensive assistance with one staff for bed mobility; extensive assistance with two staff for transfers and toileting; supervision with one staff for locomotion, eating, and personal hygiene; and limited assistance with one staff for dressing. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated [DATE], documented R1 had a BIMS score of 11. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated [DATE], documented R1 needed help with ADLs and mobility. The Care Plan dated [DATE] and last revised on [DATE], documented R1 had an ADL self-care performance deficit and directed staff to explain all procedures/tasks before starting. The facility's Investigation dated [DATE], documented on [DATE] at approximately 09:00 AM, LN G administered R2's medications to R1. The medications given to R1 were carvedilol (antihypertensive medication) 25 milligrams (mg), losartan potassium (antihypertensive medication) 50 mg, metoprolol tartrate (antihypertensive medication) 50 mg, gabapentin (medication used to treat seizures and neuropathy [nerve pain]) 100 mg, guaifenesin (expectorant- medication used to thin mucus in the air passages to make it easier to cough and clear the airways) 400 mg, Tylenol (pain medication) 650 mg, buspirone (antianxiety medication) hydrochloride (HCl) 5 mg, cholecalciferol (vitamin) 1000 Units, Claritin (allergy medication) 10 mg, duloxetine HCl (antidepressant medication), levothyroxine (medication used to treat hypothyroidism [condition characterized by decreased activity of the thyroid gland]) 25 micrograms (mcg), multivitamin, omeprazole (medication used to treat acid reflux [backflow of stomach contents to the esophagus]), and oxycodone (narcotic pain medication) 5 mg. LN G discovered her error within 10 minutes and immediately called Consultant GG. She received orders to monitor R1's condition and blood pressure and to administer midodrine (medication used to increase blood pressure) five mg with meals for one day. Consultant GG assessed R1 within a couple of hours and R1 was stable at that time. There were orders to continue to monitor R1's condition and to take her blood pressure every four hours. Throughout the afternoon and evening, R1 was stable without any changes in her blood pressure. At 09:30 PM, LN H noted R1's blood pressure dropped to ,d+[DATE] mmHg. LN H administered extra oral fluids and oxygen as her oxygen saturations were dropping, as well. She called the provider since R1 was not responding to the interventions and was told to send her to the hospital. When EMS arrived, they found R1 unresponsive and R1 was a DNR. R1 passed away shortly after EMS arrival. In a Witness Statement on [DATE], LN G stated on [DATE], she passed morning medications. She asked LN H if it was R1 or R2 sitting at the table. She stated she heard LN H say it was R2 sitting at the table, so she got R2's medications ready. LN G stated she checked the resident's blood pressure and then gave her the medications. She continued to pass medications down the hallway and when she got to R1's room, she saw she had already labeled a cup to put her medications in. She then realized R1 received the wrong medications, and she went in to check on her and got a full set of vitals with assessment. LN G stated she called the on-call number and was advised to call the on-call nurse practitioner. She stated she called Consultant GG and did what she told her to do. LN G stated Consultant GG came by later to check on R1. She stated Consultant GG put orders in to check R1's blood pressure at designated intervals which she stated she did. LN G stated at the end of her shift, R1 was stable, and she reported to the oncoming shift about the new orders and the medication error. In a Witness Statement on [DATE], LN H stated she was asked by LN G which resident was in the dining room. She explained the resident in the dining room was R1 and that R2 usually stayed in her room for meals. About an hour and a half later, LN G stated she thought she had given the wrong medications to the wrong resident. LN H stated she advised LN G to call the staffing number to get instructions on what to do next. She stated she was instructed to help LN G fill out the risk assessment form. LN H stated that was all the involvement she had in the situation, and she never saw or evaluated R1. In a Witness Statement on [DATE], LN I stated she reported for her scheduled night shift on [DATE]. She received report from LN G and was told that a medication error was made involving R1, who was given the wrong medications. LN I stated she was told that an order for midodrine two doses had been administered before 05:00 PM and that R1's blood pressures did come up. She stated frequent blood pressures were to be done. LN I stated when she saw R1 at approximately 06:30 PM, R1 was lethargic and almost asleep. She asked R1 if she was going to eat her dinner and R1 stated, no she did not want it. LN I stated she gave R1 her bedtime medications and left the room. At approximately 09:30 PM, she took R1's blood pressure and pulse which were ,d+[DATE] mmHg and 49 bpm. R1 was still lethargic but continued to converse and answer questions. Two Certified Nurse Aides (CNAs) assisted with making R1 comfortable and blood pressures were taken many times with systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) ranging from 85 to 78 mmHg and pulses in the 50's, 40's, and 30's bpm. LN I stated at that time, her blood oxygen level was noted to be in the high 70's to middle 80's, she then placed R1 on oxygen. She stated R1 remained conversant and answered questions until approximately 12:00 AM. She called the on-call provider and received an order to send R1 to the hospital then called 911. LN I stated R1 had coded in her room and paramedics were working on her. EMS did chest compressions until they were told to stop by EMS direction, as R1 had a DNR order. R1's time of death was 01:26 AM. On [DATE] at 11:03 AM, Administrative Nurse D stated on [DATE], LN G was passing morning medications and asked LN H if a resident was R1 or R2. LN G thought she heard LN H say it was R2. He stated when LN G got to R2's room, she saw R2 was in her room and realized she made a medication error. Administrative Nurse D stated LN G notified Consultant GG, who saw R1. He stated R1's blood pressure and heart rate dropped, and staff administered two doses of midodrine and R1 stabilized until later that night. Around 10:00 PM to 12:00 AM, LN I noted R1 was more lethargic, and LN I encouraged fluids, as her blood pressure and pulse were low, and R1's blood oxygen level was dropping, so LN I placed R1 on oxygen. LN I notified the provider and received an order to send R1 to the hospital. Administrative Nurse D stated when EMS arrived, they found R1 unresponsive and started compressions but stopped when they confirmed R1's DNR status. On [DATE] at 12:26 PM, LN I stated she was told in report on [DATE] that R1 received R2's medications. She stated when she saw R1, R1 was more tired but carried on a conversation. She went to give R1 her medications around 06:30 PM because R1 liked to go to bed early and noticed something was not quite right with R1. LN I stated she took R1's blood pressure around 09:00 PM, not knowing she had scheduled hourly blood pressures, and R1's blood pressure kept dropping along with her blood oxygen level. She stated R1 was drinking fluids and carried on a conversation. LN I stated she notified the provider around 11:30 PM to 12:00 AM. On [DATE] at 04:11 PM, Consultant GG stated on [DATE] around 09:00 to 09:30 AM, she received a call about R1's medication error. She stated she gave a stat (immediate) order to administer midodrine and to call her back in 15 minutes with a full set of vitals. Consultant GG stated she was on her way to the facility and saw R1, who was alert and oriented. She stated she put an order in for scheduled midodrine because she was given antihypertensive medications and an order to check BP and pulse with a directive to call the provider if R1's SBP was less than 90 mmHg, or her pulse was less than 50 bpm. On [DATE] at 07:03 PM, LN G stated on [DATE] she started labeling medication cups and reviewed the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for what she had to do. She stated around breakfast, she was passing medications to residents in the dining room first and saw a resident in the dining room. She asked a coworker if the resident was R1 or R2 and the coworker said the wrong name. LN G stated she gave the resident medications and continued down the hallway. When she got to R1's room some time after breakfast, saw her in her room, saw she still had a medication cup labeled with R1's room number, and realized she had given R1 the wrong medications earlier in the dining room. LN G stated she notified Consultant GG who gave an order for midodrine and blood pressure monitoring every 15 minutes then every four hours. She stated R1 was stable the rest of her shift. She stated R1 had an order to monitor blood pressure and pulse with parameters to call the provider if they were below a certain number. LN G stated she passed the order on in report. The facility's Six Rights of Medication Administration dated [DATE] directed the facility administered medications in accordance with care and practice and while typically five rights of medication were commonly acknowledged, the policy included an additional protocol for consideration of administration of medications. The policy directed the six rights of medication administration as right medication, right dose, right route, right time, right resident, and right documentation. The policy directed staff checked resident photo and addressed resident by their name. The facility failed to ensure R1 remained free of significant medication errors on [DATE] at approximately 09:00 AM, when LN G administered R1's morning medications to R2. This deficient practice resulted in R1 becoming hypotensive and placed R1 in immediate jeopardy. The facility implemented the following corrective action, which were completed by [DATE]: LN G was suspended pending investigation, was counseled, and received education [DATE]. She was assigned computer training and observation and performance of skills training before she worked by herself again in the facility. Inservice with all Certified Medication Aides (CMAs) and nurses on the Six Rights of Medication Administration on [DATE]. An emergency Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] with a Root Cause Analysis (RCA) and Performance Improvement Plan (PIP) identified and put into place. Name alerts for residents with similar names were placed in the EMR on [DATE]. Name plates outside of residents' rooms were updated with first and last names on [DATE]. Medication administration observations were initiated on [DATE] with a plan to be completed for five residents daily for five days then five residents weekly for five weeks. Completion of the corrective actions were verified onsite and therefore the deficient practice was deemed past noncompliance and remained at the scope and severity of J.

The facility identified a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to monitor hot liquid temperatures and failed to properly assess and ensure resident (R)9 was able to independently handle and drink hot liquids safely, which resulted in R9 receiving second degree [CONDITION(S)] when she spilled hot tea on herself. Findings included: - The Electronic Medical Record (EMR) for R9 documented diagnoses of [CONDITION(S)] (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), [CONDITION(S)] (a condition that causes weakness, numbness, and pain from nerve damage), and [CONDITION(S)] (inflammation of the spinal cord causing dysfunction in motor and sensory tracts). The Admission Minimum Data Set (MDS) dated [DATE] documented R9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. She required extensive assistance of one staff for activities of daily living (ADLs) The MDS documented R9 was totally dependent on assistance from one staff for eating. She had functional limitation in range of motion of both upper extremities and required the use of a wheelchair for mobility. The Quarterly MDS dated [DATE] documented R9 had a BIMS of 15, which indicated intact cognition. She required extensive assistance of one staff with eating. She had functional limitation in range of motion of both upper extremities and required the use of a wheelchair for mobility. The ADLs Care Area Assessment (CAA) dated 07/21/21 documented R9 required extensive assistance of one staff with eating due to limited range of motion in arms. She used a wheelchair for mobility that she was able to propel herself short distances. Occupational therapy worked with the resident to improve her abilities and worked on being more independent. Under the Assessment tab of the EMR was an Interdisciplinary Team (IDT) Review of Resident Functional Abilities dated 10/07/21 that documented R9 had the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before resident. Her performance was independent. The ADLs Care Plan initiated 07/02/21 and revised 07/20/21 documented R9 required assistance of one with eating. The Impaired Skin Integrity Care Plan revised on 12/08/21 documented R9 spilled hot tea on her chest and left hip and thigh on 12/02/21 and was to use a cup with a lid and a straw for beverages. Under the Progress Notes tab in the EMR was a note dated 12/02/21 at 07:21 PM that documented R9 spilled a hot cup of tea on her chest and left hip. The physician had been notified. Under the Progress Notes tab in the EMR was a note dated 12/02/21 at 07:30 PM that documented R9 was given a cup of tea and while attempting to drink the tea, she spilled the coffee on her chest and left thigh. R9 told staff that she spilled the tea on herself. She was assessed and noted with redness to her upper torso and left upper thigh. Blisters appeared to her chest area and left thigh. Under the Progress Notes tab in the EMR on 12/03/21 at 10:44 AM was an IDT note that documented the IDT met to review an incident that occurred on 12/02/21 at 07:30 PM. R9 reportedly was given a cup of tea and while attempting to drink the tea, she spilled the tea on her chest and left thigh. Blisters appeared to her chest area and left thigh. The physician was notified at the time of the accident. Orders for [MEDICATION(S)] cream 1% (a topical medicated antibiotic cream used to treat partial thickness [CONDITION(S)]) had been ordered to be applied twice daily to burn sites. R9s call light was not on at the time of the incident. R9 told staff the drink was placed near her. The cup was hot and did not have a lid. New interventions placed included R9 educated to use call light and ask for assistance as needed, cups were to have a lid and straw. An order was placed for wound care doctor to follow weekly. A Hot Liquid Safety Assessment was done on R9 on 12/03/21 with results that showed that R9 was not able to manage a coffee cup. She required the use of a lid with a cup and had experienced a burn from a spill. The assessment outcome indicated R9 required staff set up for drinking hot liquids with a lid. Under the Assessment tab was a Licensed Nurse Skin Non-Ulcer Pressure Weekly assessment done on 12/08/21 that documented R9's [CONDITION(S)] to abdomen measured 4.5 centimeters (cm) by 2.2 cm, with a depth of 0.1cm, full thickness; left hip burn measured 13.0 cm by 4.3 cm, with a depth of 0.1cm, full thickness; treatment with [MEDICATION(S)] cream, a single layer of xeroform (a dressing made of fine absorbent mesh gauze that contains petroleum jelly used for wound care), and cover with dry dressing twice daily and as needed. On 12/27/21 at 12:15 PM R9 sat in her wheelchair in her room, bedside table in front of her, with her lunch tray on the table. There were several cold drinks on the tray with her meal, none of which had a lid or a straw, other than her own personal mug/cup she drank from. On 12/28/21 at 10:25 AM the water temperatures of the hot liquids from the coffee/hot water machine measured 157 degrees Fahrenheit (F) on the east unit and 161 degrees F on the west unit. On 12/28/2021 at 11:05 AM R9 sat in her room and watched television. She had a drinking cup with a straw for ice water. She reported she had not ordered hot liquids since the incident and the facility did not provide a special cup for tea since the incident. R9 said she did not use a special cup the day she was burned by the tea. Staff brought the hot tea in and set it down on the bedside table. R9 stated when she tried to reach for it, the cup spilled. In an interview with R9 on 12/28/21 at 12:14 PM R9 stated she did not have lids with her drinks, but did get a straw prior to the incident. When the incident occurred on 12/02/21 the cup of hot tea was a good arm's length away from her. R9he put her hand over the top of the cup to try to pull it towards her, which caused the cup to tip over and spill on her chest and thigh. She did not turn on her call light because the aide was right next door, so she yelled for help and the aide came right away. In an interview with Certified Nurse Aide (CNA) M on 12/28/21 at 09:10 AM stated that drinks were prepared in the kitchen area usually before food service and then they delivered the drinks to the residents. She stated facility staff did not use lids over mugs, staff put plastic wrap over the top when cups were transported. The therapy department let staff know about the special requirements for drinks, and staff also checked the service ticket. Staff did not check the temperatures of (hot) drinks before serving to residents. An interview with Dietary Manager BB on 12/28/21 at 09:00AM stated that each resident had a service ticket that identified the resident's diet and drink preferences and required equipment. Hot drinks were made by the aides and nurses and the kitchen staff prepared the plates of food. Hot drinks were served in a mug and transported with plastic wrap over the top of them. The kitchen staff did not check the drinks or temperatures of the drinks before serving them. On 12/28/21 at 11:22 AM Dietary Manager BB further stated that dietary staff checked the brewing temperatures of the coffee, but not daily. Dietary Manager BB said the coffee/hot water machine temperature was set at 170 F. The temperature of the hot liquid dropped when it was poured into the carafe pots. She stated maintenance completed daily checks of the hot water going into the line to the coffee/hot water machine, but dietary staff did not do a daily check on the temperature of the liquid coming out of the machine. On 12/28/21 at 10:45AM Administrative Nurse D stated the spill occurred after dinner time. The resident was in her room and staff brought her hot tea in a cup that she usually did not use. R9 struggled using the cup and spilled the hot tea. The nurse immediately came into her room, assessed her, and helped her change clothes. Orders were received for [MEDICATION(S)] cream. R9 never had issues with eating before and would only spill food sometimes. At the time of the incident, R9 was on antibiotic therapy and Administrative Nurse D believed that made R9 more unsteady. He stated for most meals R9 just required set-up assistance. R9 had a special cup with a straw/lid that she would normally use. Staff would get drinks from the kitchenette, but dietary was responsible for testing the temperatures. Administrative Nurse D said according to R9's care plan, she required eating assistance of one staff as of 07/20/21 and the use of a cup with a lid and straw for beverages was added with the revision on 12/23/21. On 12/30/21 at 10:08 AM Consultant HH stated therapy assessed R9 over the time she had been in the facility. She was seen twice weekly for physical therapy. Physical Therapy had never done a hot liquid assessment prior to the one completed 12/03/21. Physical Therapy staff were completing hot liquid assessments for all residents this last week. Consultant GG stated R9 would get hot tea most mornings and never had a problem drinking hot tea until the day of the incident. On 12/28/21 at 12:02 PM Administrative Staff A stated the IDT just added a performance improvement plan to add a daily temperature reading of the hot liquid/coffee/water to the food temperature log. The liquid hits the cup at a temperature of 170 degrees F. The Precautions for Hot Beverages Policy dated 2020, documented: The temperature for brewing and serving hot beverages will be based on the manufacturer recommendations for the beverage equipment utilized in each facility. It is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing, anticipated to be between 160 to170 degrees F. The serving temperature should be approximately 10 to 15 degrees less than the brewing temperature. It is suggested that brewing and serving temperatures of beverages are monitored on a monthly or quarterly basis to assure proper functioning of equipment. Additional precautions may be implemented based on the needs of each resident and may include: Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages; Ensuring staff monitors the identified high risk resident during meal times and/or when hot beverages are served; Utilizing specialized spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning; and Assessing those individuals who request beverages served hotter than the guidelines outlines above for the ability to consume hot beverages independently and safely. The facility failed to properly assess R9's the ability of safe handling of hot liquids unassisted to prevent an avoidable accident from occurring and failed to monitor the temperatures of hot liquids from the coffee/hot water machine, which resulted in a second degree burn for R9 to her chest and left hip and thigh, after spilling hot tea on herself.

The facility identified a census of 62 residents. The sample included 7 residents with 3 residents reviewed for medication review. Based on interview, record review and observation, the facility failed to accurately administer scheduled medications to the correct resident for 3 residents (#1, #2 and #3), which resulted in resident #1 being admitted to the hospital for low blood pressure, #2 not receiving the correct medication and #3 noted to have shortness of breath and [MEDICAL CONDITION]. Findings included: - Resident #1's electronic medical record documented the following Diagnoses: [REDACTED]. in breathing). The Quarterly Minimum Data Set (MDS) assessment, dated 11/23/18, documented a Brief Interview Mental Status (BIMS) score of 15 which indicated intact cognition and he/she received anticoagulants (blood thinners) 7 out of 7 days during the look back period. The Annual MDS assessment, dated 2/8/19, documented a BIMS score of 13 which indicated intact cognition and he/she received anticoagulants 1 out of 7 days during the look back period. The care plan dated 2/14/18, documented black box warnings for the following medications: [REDACTED]. Review of the physician orders [REDACTED]. 2/1/18: [MEDICATION NAME] sulfate extended release tablet 160 mg, give one tablet by mouth twice a day. 2/1/18: Magnesium oxide tablet 400mg, give one tablet by mouth twice a day. 2/1/18: [MEDICATION NAME] 1 gram, give 1 tablet by mouth twice a day. 2/2/18: Cranberry tablet 500 milligrams (mg), give 1 tab by mouth daily. 2/2/18: [MEDICATION NAME] capsule 0.4 mg, give one tablet by mouth daily. 2/2/18: Multiple minerals vitamin, give one tablet by mouth daily. 2/2/18: Vitamin B12 tablet extended release 1000 microgram (mcg), give 1 tablet by mouth daily. 2/19/18: Accucheck in the morning, every Monday for diabetes malleates type 2. 12/5/18: [MEDICATION NAME] 10 mg, give 2 tablets by mouth twice a day. 1/4/19: [MEDICATION NAME] HCl tablet 150 mg, give one tablet by mouth daily. 11/29/18: [MEDICATION NAME] HCl tablet 0.1mg, give 1 tablet by mouth every 12 hours as needed for hypertension. Give all the scheduled blood pressure medications and recheck blood pressure in one hour before administering [MEDICATION NAME], give for systolic blood pressure greater than 160 mmHg (millimeters of mercury) at recheck. 7/27/18: Check blood pressure daily in the morning. 11/20/18: Please take blood pressure 45-60 minutes after scheduled antihypertensives. For systolic blood pressures over 180mmHg, please give as needed [MEDICATION NAME] one time daily. Review of the Medication Administration Record [REDACTED]. Review of resident #1's finger stick blood sugar on the Treatment Administration Record (TAR) from 1/7/19 to 2/25/19 revealed a finger stick blood sugar reading of between 98 millimoles per liter (mmol/L) and 124 mmol/L. The progress note dated 2/27/19 at 12:00 PM directed staff to send resident #1 to the emergency room for chest pain and low blood pressure. The physician progress notes [REDACTED]. Further documentation revealed that the resident's blood pressure normally ran 120-150/60-80s mmHg with a heart rate in the 60-70 bpm. The resident was pale with a weak and thready pulse, as well as diaphoretic (sweating heavily) and unable to follow commands related to lethargy (a state of sleepiness or deep unresponsiveness and inactivity). Review of the electronic medical record indicated that the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the hospital discharge summary dated 2/27/19, documented patient believed that he/she received more medication than usual that morning. Blood pressure performed at the hospital noted 83/52 mmHg, finger stick blood sugar was 66 mmol/L, which was below normal range for resident #1; and white blood cell count of 7.99 thousand per unit liter which was noted to be within normal limits. On 3/20/19 at 11:30 AM, resident #1 stated that 'once I got the wrong medicine. That is what caused me to go out to the hospital.' On 3/20/19 at 11:35 AM, resident #2 (BIMS of 15, which indicated intact cognition) stated 'I told the CMA that the medications do not look like my medicine as I do not have enough pills. There was a big black pill and pills that had writing that I know I do not take, and there were not enough pills in the medication cup. I know I take around 20 pills and there was only 9.' On 3/20/19 at 12:42 PM, licensed nursing staff G stated, I noted that (resident #2's) medication had been popped, but he/she didn't have the right medication in the medication cup. Licensed nursing staff G further revealed that he/she was asked to write out a statement on the day that this occurred and then later on told to not worry about it. On 3/21/19 9:25 AM, resident #1 sat next to the medication cart taking her morning medication. He/she had a large black pill in the cup. On 3/21/19 at 3:30 PM, direct care staff M stated he/she went to take care of resident #1 and noted that resident #1 was very pale and sweaty. He/she noted the licensed nursing staff J remarked to direct care staff M the resident was fine before he/she took his/her medications. On 3/21/19 at 3:45 PM, administrative nursing staff E stated that resident #1's family member came to the facility while resident #1 was in the hospital and revealed that the hospital suspected the resident received too much blood pressure medication. On 3/21/19 at 4:51 PM, consultant GG reported that if resident #1 remained in the facility on the day of the incident, it might have resulted in low oxygen to the brain which could have resulted in [MEDICAL CONDITION] or worse. The resident needed to go out to the emergency room . On 3/21/19 at 5:35 PM administrative nursing staff D stated that resident #1 was not questioned in regard to receiving the wrong medication upon returning to the facility. The facility policy Medication Errors and Adverse Reactions dated 08/2007 directed staff to report medication errors and adverse drug reactions to the resident's attending physician. It further directed staff to write a detailed account of the incident in an incident report and that clinically relevant information about follow-up of the resident should be recorded in the chart. The facility failed to accurately administer medications to resident #1 which resulted in a hospital stay due to low blood sugar and low blood pressure. - Resident #2's electronic medical record documented the following Diagnoses: [REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 10/2/18, documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition, and received insulin (medication to keep you blood sugar from getting to high) injections, antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression(abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness)), diuretic (medication to promote the formation and excretion of urine), and opioid (medications used for pain relief) for 7 days during the look back period. The Quarterly MDS assessment dated [DATE] recorded the same information as the Annual MDS. The physician orders [REDACTED].#2: 12/23/16: Cinnamon Tablet 500 milligrams (mg) give two tablets by mouth twice a day. 12/23/16: [MEDICATION NAME] HCl 10 mg give 1 tablet by mouth four times a day. 12/24/16: [MEDICATION NAME] tablet 100 micrograms (mcg), give one tablet by mouth daily. 12/24/16: [MEDICATION NAME] HCL tablet 50 milligrams (mg) give one tablet by mouth daily. 12/24/16: [MEDICATION NAME]-[MEDICATION NAME] tablet 500-400 mg give one capsule by mouth daily. 12/24/16: [MEDICATION NAME] tablet 1000 unit give 1 tablet by mouth three times a day. 12/24/16: [MEDICATION NAME] sulfate tablet 325 mg give one tablet by mouth three times a day. 12/24/16: Multivitamin with minerals give 1 tablet by mouth daily. 12/24/16: Potassium Chloride extended release 20 milliequivalent per grams (mcg) give one tablet by mouth daily. 12/24/16: Vitamin E-400 capsule give one capsule by mouth daily. 12/27/16: [MEDICATION NAME] tablet 40 mg give one tablet by mouth twice a day, hold for blood pressure less than 110 mmHG (millimeters of mercury). 12/28/16: [MEDICATION NAME] tablet 10 mg give 1 tablet by mouth daily, hold for systolic blood pressure less than 110 mmHG. 1/6/17: Carvedilol tablet 25 mg give 1.5 tablet by mouth twice a day, hold for systolic blood pressure less than 110 mmHG and heart rate less than 60 beats per minute. 1/7/17 [MEDICATION NAME] tablet 40 mg give 1 tablet by mouth in the morning and one tablet in the afternoon. 1/12/17: Garlic tablet give one table by mouth daily. 9/7/17: Glimepiride tablet 4 mg give one tablet by mouth daily. 11/4/17: [MEDICATION NAME] Monoitrate tablet give 120 mg by mouth daily, hold for systolic blood pressure less than 110 mmHG. 2/7/18: [MEDICATION NAME] acid 500 mg tablet give one tablet by mouth daily. 2/28/18: [MEDICATION NAME] Magnesium Capsule delayed release 20 mg give 1 capsule by mouth daily. 4/25/18: Calcium Vitamin D tablet 600-400 mg-unit give 1 tablet by mouth daily. 9/20/18: Tylenol Extra Strength 500 mg give 1 tablet by mouth four times a day. 9/20/18: [MEDICATION NAME] HCl 50 mg give 1 tablet by mouth four times a day. On 3/20/19 at 11:35 AM, resident #2 stated I told the CMA (certified medication aide) that the medications do not look like my medicine as I do not have enough pills. There was a big black pill and pills that had writing that I know I do not take, and there were not enough pills in the medication cup. I know I take around 20 pills and there was only 9. I talked with (administrative nursing staff D) and was told that if he/she did not see it then it did not happen. I was asked if I had told anyone, to which I had and the staff that I told took the medication cup and checked it. On 3/20/19 at 12:42 PM, licensed nursing staff G stated, I noted that (resident #2's) medication had been popped, but he/she didn't have the right medication in the medication cup. Licensed nursing staff G further revealed that he/she was asked to write out a statement on the day that this occurred and then later on told to not worry about it. On 3/21/19 at 3:30 PM, direct care staff M stated he/she responded to the call light of resident #2. The resident reported that his/her medications brought to his/her room weren't correct. Direct care staff M then took the medications to the nurse to review. The facility policy Medication Errors and Adverse Reactions dated 08/2007 directed staff to report medication errors and adverse drug reactions to the resident's attending physician. It further directed staff to write a detailed account of the incident in an incident report and that clinically relevant information about follow-up of the resident should be recorded in the chart. The facility failed to accurately administer medication to resident #2 which resulted in a medication error.