Every finding on record at The Springs Magnolia

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to provide the appropriate treatment with enteral nutrition for one (Resident #11) of one resident reviewed for Medication Administration through a Percutaneous feeding tube (PEG).Based on observations, record review, interviews, and facility policy review, the facility failed to provide the appropriate services and treatment to prevent complications for one (Resident #11) of one resident reviewed for medication administration through a percutaneous endoscopic gastrostomy (PEG) tube. The findings include: During a medication administration observation on 08/27/2025 at 10:10 AM, Licensed Practical Nurse (LPN) #3 prepared medications and a tube feeding for Resident #11. LPN #3 administered the medications followed by the tube feeding, then flushed with water after the administrations. LPN #3 did not flush with water prior to the medication or tube feeding. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/01/2025, revealed Resident #11 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident was cognitively moderately impaired The MDS also indicated Resident #11 had diagnoses which included difficulty with language comprehension and production, interrupted blood flow to the brain, malnutrition, and a feeding tube through the skin directly into the stomach (PEG). A review of Resident #11's Order Summary indicated two active orders related to the PEG as of 08/27/2025 as follow: 1. Flush PEG Tube with 30 milliliters (ml) of water before and after meds 2. Give 60 ml water flush before and after each bolus feeding. During an interview on 08/28/2025 at 11:12 AM, LPN #3 indicated that it was important to perform water flushes before and after medications and feedings, according to the provider's order, to make sure the tube was clear and not clogged. During an interview on 08/28/2025 at 11:35 AM, Nurse Practitioner #4 indicated that it was important to perform the water flushes with medications and feedings, according to the provider's order, to prevent clogging and make sure the tube was working properly. During an interview on 08/28/2025 at 2:41 PM, the Director of Nursing indicated that it was important to perform the water flushes with medications and feedings, according to the provider's order, to make sure the line was clear. A review of a policy titled Administering Mediation through an Enteral Tube with a revision date of November 2018, indicated staff must verify there was a physician's medication order for the procedure. The enteral feeding should be flushed with at least 15 ml of warm purified water, or as ordered, prior to administering mediations. A review of the policy titled Administering Medication with a revision date of April 2019, indicated medications are administered in accordance with prescriber orders.

Based on observation, record review, interviews, and facility policy review, it was determined the facility did not ensure incontinence care was provided in a manner that promoted cleanliness, prevented odor, and/or infections for one (Resident #1) of one resident, observed for incontinence care technique and hygiene care. The findings include: During an observation on 06/17/2025 at 8:30 AM, this surveyor observed Certified Nursing Assistant (CNA) #1 assist Resident #1, who had been incontinent of bladder, onto the toilet. The resident ' s pants and wheelchair were visibly wet. CNA #1 provided incontinence care from behind Resident #1, but did not clean the resident ' s entire perineal area, buttocks, or thighs, prior to application of a new brief. CNA #1 placed Resident #1 back into the visibly wet wheelchair, without cleaning it. A review of Resident #1 ' s admission Minimum Data Set (MDS), with an Assessment Reference Date of 04/08/2025, revealed the resident had a Brief Interview of Mental Status score of 08, which indicated moderate cognitive impairment. The MDS also revealed Resident #1 was frequently incontinent of bowel and bladder, was dependent for toileting and required substantial to maximum assistance for transfers. A review of Resident #1 ' s Care Plan Report, initiated 04/14/2025, revealed the resident had bladder incontinence related to dementia. Interventions included to clean the perineal area with each incontinence episode, establish voiding patterns, and to limit fluids two to three hours prior to bedtime. During a phone interview on 06/16/2025 at 9:55 AM, Resident #1 ' s family member stated the facility was not providing incontinence care in a timely manner, and when they visited Resident #1, the resident was sitting in urine. The family member stated staff did provide care when requested, but felt the resident needed a bath. During an interview on 06/17/2025 at 8:47 AM, CNA #1 stated she did not clean every area on Resident #1 that had been touched by urine. During an interview on 06/18/2025 at 9:02 AM, the Director of Nursing (DON) stated if the resident's pants were wet, the wetness would transfer to the wheelchair and if not cleaned, it would cause an odor. This surveyor showed the DON a picture taken of Resident #1 ' s wet pants. After a review of the picture, the DON stated that the resident's perineal area, buttocks, and thigh should have been cleaned. The DON stated that it was not possible to properly clean the entire genital area from behind the resident. During an interview on 06/18/2025 at 9:28 AM, the Administrator stated proper incontinence care could not be done from behind the resident. A review of policy titled Perineal Care, noted the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.

Based on observation, interview, record review, and facility policy review, it was determined the facility did not ensure proper hand hygiene and infection control procedures were used while incontinence care was being provided to one (Resident #1) of one resident observed for incontinence care technique and hygiene care. The findings include: During an observation on 06/17/2025 at 8:30 AM, this surveyor observed Certified Nursing Assistant (CNA) #1 pushing Resident #1 in a wheelchair to the resident's bathroom to assist with toileting. This surveyor noted CNA #1 did not use hand hygiene prior to or after assisting Resident #1 with toileting. After providing care to Resident #1, CNA #1 retrieved a pair of pants from the resident's closet, without changing gloves or performing hand hygiene. CNA #1 did not like the choice of pants and returned to the closet to get a second pair of pants, still wearing the same dirty gloves. The CNA then removed Resident #1 ' s wet pants and discarded them onto the floor. CNA #1 assisted the resident with dressing, adjusted the resident's jacket, and placed the resident ' s feet on the footrest of the wheelchair, touching the resident's socks with the same contaminated gloves. Resident #1 was offered hand hygiene, which was accepted and performed. A review of Resident #1 ' s admission Minimum Data Set, (MDS)with an Assessment Reference Date of 04/08/2025, revealed the resident had a Brief Interview of Mental Status score of 8, which indicated moderate cognitive impairment. The MDS also revealed Resident #1 was frequently incontinent of bowel and bladder. A review of Resident #1 ' s Care Plan Report, initiated 04/14/2025, revealed the resident had bladder incontinence related to dementia. The care plan indicated that Resident #1 required total assistance of 1 staff with toileting. During an interview on 06/17/2025 at 8:47 AM, CNA #1 confirmed she did not remove her dirty gloves prior to opening the cabinet, removing Resident #1 ' s clothing, placing clothing on the resident, or adjusting the resident's clothing. CNA #1 stated staff were educated to place wet or soiled clothing in trash bags for infection control purposes, as opposed to depositing the items on the floor, but she did not have any trash bags. During an interview on 06/18/2025 at 9:02 AM, the Director of Nursing (DON) stated staff were instructed to use trash bags for soiled or wet clothing, to prevent cross contamination. The DON stated staff should not touch the resident ' s closet doors, resident's clean clothing, their wheelchair, or clothing the residents while wearing dirty gloves, because that would be an infection control issue. During an interview on 06/18/2025 at 9:28 AM, the Administrator stated staff were instructed to place soiled or wet clothing into a trash bag for infection control, to prevent cross contamination and odor. The Administrator stated staff should not touch the resident ' s closet doors, the resident's clean clothing, their wheelchair, or clothing the residents were wearing with dirty gloves, because that would be cross contamination. A review of a policy titled Handwashing/Hand Hygiene, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene should be used in the following situations: Before and after direct contact with residents, after contact with blood or bodily fluids, after contact with objects in the immediate vicinity of the residents, and after removing gloves.

Based on observation, record review, and interview, the facility failed to ensure 2 (Residents #23 and #49) did not have medications stored at the bedside. The findings are: 1. Review of Resident #23's Medical Diagnosis sheet revealed the resident had diagnoses of heart failure, chronic kidney disease, and type II diabetes mellitus. a. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment). b. On 06/17/2024 at 11:12 AM, the Surveyor observed Resident #23 with a 32 ounce open bottle of 0.91% alcohol sitting on the floor, on the left side of the bed. Resident #23 confirmed, I brought the alcohol from home to rub on my knee. c. On 06/17/2024 at 11:30 AM, the Surveyor observed a 32 ounce bottle of 0.91% alcohol was resting on the floor to the right of Resident #23's feet. d. On 06/17/2024 at 12:58 PM, during a concurrent observation and interview, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to Resident #23's room. During an interview, LPN #1 asked if 0.91% alcohol was found in the drawer and the Surveyor pointed out the 32 ounce bottle of alcohol resting on resident's floor near resident's shoes at the edge of the bed. The Surveyor asked if it was standard practice to store alcohol in a resident's room and LPN #1 said no, because anyone could get their hands on it. 2. Review of Resident #49's Medical Diagnosis sheet revealed the resident had diagnoses of heart failure, type 2 diabetes mellitus, and anxiety. a. Review of the Quarterly MDS with an ARD of 05/24/2024 revealed a BIMS score of 12 (8-12 indicates moderate cognitive impairment). b. Review of the Physicians Order (dated, 02/19/2024) revealed an order for Enulose Solution one time a day for constipation. c. Review of the Physicians Order (dated, 03/08/2024) Juven Oral Packet (Nutritional Supplements) one time a day. d. On 06/17/2024 at 11:51 AM, Resident #49 was observed in bed with a clear cup containing about an inch of orange fluid and a straw. The Surveyor noted a powdery substance or film around the inside of the cup of orange fluid and Resident #49 told the Surveyor it was some of the resident's medication. e. On 06/17/2024 at 12:14 PM, during a concurrent observation and interview, Licensed Practical Nurse (LPN) #2 identified a cup of orange drink at Resident #49's bedside as Juven and Lactulose. The Surveyor asked LPN #2 if it is standard practice to leave medications at the bedside. LPN #2 said it is not standard practice, and that she had left to go change out some oxygen. The Surveyor asked if there was any reason she would not want to leave a cup of medication at the bedside. LPN #2 said, Someone else could have gotten it and consumed it. e. On 06/18/2024 at 02:44 PM, the Administrator provided a document confirming the facility does not have any residents with self-administration rights. f. On 06/18/2024 at 02:48 PM, review of a policy provided by the Administrator titled, Storage of Medications documenting, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . g. On 06/18/2024 at 02:48 PM, review of a policy provided by the Administrator titled, Self-Administration Medications documenting .Policy heading Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation . Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. h. On 06/19/2024 at 10:32 AM, during an interview, the Director of Nursing (DON) was asked if it is standard practice for staff to leave medications in resident rooms at the bedside. The DON confirmed medications should not be left at the bedside because anyone could possibly take the medication.

Based on observation, record review and interview, the facility failed to ensure canned goods were dent free and cleaning supplies were not setting on the puree prep table while food was being prepared. The findings are: 1. On 06/17/2024 at 10:33 AM, the Surveyor observed one 7 pound can of vanilla pudding had a dent next to the top seal. 2. On 06/18/2024 at 10:50 AM, the Surveyor observed a red bucket containing greyish colored water with small bubbles on the surface was sitting in the top right corner of the puree prep table. There were food items on the tabletop with the red bucket. Dietary Aide #8 was pureeing food with the red bucket on the tabletop. The Dietary Manager confirmed the bucket contained sanitizer and water for cleaning the tabletops, and the bucket should be on a bottom shelf below food items. 3. On 06/18/2024 at 11:03 AM, during an interview, the Dietary Manager confirmed food items in cans are to be dent free and to be placed on the dented can shelf. 4. On 06/18/2024 at 1:57 PM, review of the policy provided by the Administrator for Safe Storage of Food showed, .9. All packaged and canned food items will be kept clean, dry and properly sealed .Toxic Materials will not be stored with food .

Based on observation, record review and interview, the facility failed to ensure staff provided proper hand hygiene while providing incontinent care to 1 (Resident #61) to prevent the risk of cross contamination. The findings are: 1. On 06/19/2024 at 2:10 PM, the Surveyor observed Certified Nursing Assistant (CNA) #6 performing hand hygiene and putting on gloves. CNA #6 pulled down the front of Resident #61's brief and reached the right hand into the bag of clean wipes and wiped the front of Resident #61's peri area with the right hand. 2. On 06/19/2024 at 2:15 PM, during the observation, Resident #61 was turned onto the left side by CNA #5. CNA #6 changed gloves and performed hand hygiene. CNA #6 then continued to use the right hand to get clean wipes from a clear bag, and wipe stool from the resident using the same right hand. CNA #6 was observed twice reaching into the clean bag of wipes with the left hand, then place the wipe into the right hand and wipe the resident while resting the left hand on Resident #61's right hip without changing gloves or performing hand hygiene. 3. On 06/19/2024 at 2:25 PM, while interviewing CNA #6 on the procedure for maintaining a clean hand and dirty hand while performing peri-care, CNA #6 said the left hand was her clean hand. CNA #6 confirmed the right hand was used to get clean wipes out of a clear bag, and the buttocks and stool was wiped using the right hand. 4. On 06/19/2024 at 2:35 PM, during an interview, the Director of Nursing (DON) was asked if staff was expected to use a clean hand and dirty hand technique when providing peri-care, and why. The DON confirmed staff should not use the same hand to get clean wipes, as the hand used to wipe a resident's buttocks to prevent cross contamination. The DON told the Surveyor the staff had been in-serviced on peri-care. The DON was asked to provide the peri-care policy and the in-services. 5. On 06/19/2024 at 3:00 PM, review of an in-service provided by the DON titled, Pericare (perineal care), UTI's, catheter care, privacy bags, leg bands documented, .proper steps of pericare .Pericare Tips .Infection Control, Cross Contamination and Dignity to Observe while checking off CNAs .Did CNA's remember to change gloves at appropriate times during care? After handling dirty items, before using clean items? . The in-service was signed by CNA #5. Review of the policy titled, Perineal Care documented, .Purpose the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . 6. On 06/19/2024 at 3:37 PM, review of a policy provided by the Administrator titled, Handwashing/Hand Hygiene documented, .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .

Based on observations, interviews, and facility policy review, the facility failed to notify the proper state authority when they became aware of a new diagnosis of mental illness for 1 (Resident #53) sampled Resident. The findings include: Review of the Medical Diagnosis section in the facility computer software system revealed Resident #53 had a diagnosis of bipolar disorder, entered into the system on 06/12/2023, and anxiety disorder. Review of the Quarterly Minimum Data Set with an Assessment Reference Date of 05/28/2024 revealed Resident #53 was unable to complete the Brief Interview of Mental Status and had a diagnosis of bipolar disorder. Review of a Care Plan for Resident #53, revision date 03/05/2024, documented Resident #53 had the potential for nutritional deficits related to vitamin deficiency, diabetes mellitus type 2, bipolar disorder, anxiety, and dementia. On 06/18/2024 at 1:20 PM, the Surveyor was provided Resident #53's Level 1 Preadmission Screen for major mental Conditions/Intellectual Disabilities and Related Conditions dated 07/22/2022 that documented Resident #53 did not have a diagnosis or history of mental illness. On 06/18/2024 at 1:21 PM, during an interview, the Administrator voiced that Resident #53 did not have the diagnosis of bipolar upon admission. On 06/18/2024 at 2:15 PM, during an interview, the Administrator voiced that the proper state authority was not notified that Resident #53 had a new diagnosis of bipolar because the screening process was used, and the Resident did not have a Geri-psych (geriatric psychiatry) stay. On 06/18/2024 at 2:18 PM, the Surveyor called the [State Designated Professional Associates] to get clarification. The [State Designated Professional Associates] informed the Surveyor if the Resident received the diagnosis after October 2023 there was no need to submit a new application, but if the Resident received the diagnosis before October 2023 a new application should have been submitted. On 06/19/2024 at 03:37 PM, the Administrator provided documentation that the facility did not have a policy on Pre-Admission Screening and Resident Review (PASARR).

Based on observation, interviews, and facility policy review, the facility failed to ensure the treatment cart used to store medication was locked when unattended by staff. The findings include: On 06/19/2024 at 3:07 PM, the Surveyor observed an unattended unlocked treatment cart on the secured unit in the facility. On 06/19/2024 at 3:08 PM, during an interview, Licensed Practical Nurse (LPN) #7 voiced the treatment cart did not lock and the medication on the cart could be potentially harmful if a resident gained access to them. On 06/19/2024 at 3:20 PM, the Administrator voiced the treatment cart should be locked to ensure the residents do not get into the cart and get the medications and it was more likely to occur on the secure unit. On 06/19/2024 at 3:37 PM, review of a policy titled, Safety and Supervision of Residents, that documented, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .

Based on observation, interview and record review, the facility failed to follow a Resident ' s care plan concerning transfer, resulting in a fall for one (Resident (R) #1) of three (R #1, #2 and #3) sampled residents. The findings are: R #1 had diagnoses of End stage renal disease and Dependence on dialysis. The Quarterly minimum data set [MDS] with an assessment reference date [ARD] of 01/04/24 documented a brief interview of mental status [BIMS] of 14 (13-15 indicates cognitively intact). The Admission MDS with an ARD of 10/04/2023 documented Resident #1 was dependent on staff for transfers. R#1's care plan initiated 09/28/2023 documented, .Transfers: The resident requires mechanical lift/staff assistance for transfers resident is totally dependent on staff for transfers .Resident requires 2 person assist with transfers. An in-service dated 03/24/2023 which included .Transferring: Gait Belt, Mechanical Lift, Sit to Stand lift was signed by Certified Nursing Assistant (CNA) #1 and CNA #2 as having attended. On 02/13/2024 at 8:55 AM, CNA #1 was interviewed and asked to explain the events that happened 01/29/2023 that led to R#1's fall. She stated, I went and gave (R#1) a bed bath and got resident ready for dialysis, the battery in the (Mechanical) lift was dead and didn't work. I then undressed (doffed PPE (Personal Protective equipment) because resident had Covid at the time). I went to get another battery, [NAME], transport, was coming down the hall and I asked him to come and help me transfer (R #1) to the wheelchair since the battery did not work. When we went to transfer, his leg gave out and then we lowered the resident to the floor. We lifted her (R #1) up in the wheelchair, I finished getting (R #1) ready and went down the hall to report it to the nurse. I didn't see her, I got busy, and it slipped my mind. CNA #1 was then asked if it was normal practice to transfer the resident without using the lift and she confirmed, no it was not normal. CNA #1 was asked if she was familiar with R #1's plan of care, she confirmed that she was, but they were in a hurry that morning because she needed to go to dialysis. On 02/13/2024 at 9:02 AM CNA #2 was interviewed and asked to explain the events that happened on 01/29/2024 that led to R #1's fall. CNA #2 stated, I was getting things together to take two residents to dialysis. I had just finished getting another resident ready and was coming down the hall and CNA #1 said she needed a hand to get (R#1) out of bed and into wheelchair. R #1 was dressed and ready to get up. We sat R #1 up on the side of the bed, went to stand (R #1) up and pivot from bed to wheelchair. My foot slipped and the transfer was not going well so we sat (R #1) on the floor between the bed and wheelchair. When asked if he was familiar with R#1's care plan, he stated I did know she was a lift transfer, but she had stand pivoted in the past. On 02/13/2024 at 9:40 AM, the surveyor asked R #1 to explain what happened the day of the fall. R #1 stated, Instead of getting the lift and using it, (CNA #1 and #2) stood me up and turned me around to get me in my wheelchair. CNA #2's foot slipped, and I went down. They tried to ease me down, and they did part of the way, but then I fell . On 02/13/2024 at 11:50 AM, the Director of Nursing [DON] was asked, How do you ensure staff competencies? She replied, I do frequent check offs, recently did a check off on lift transfers in December. I do check offs on new hires and yearly on staff. She was asked, Do CNA's have access to resident ' s care plans? The DON responded, Yes.

Based on an interview and record review, the facility failed to thoroughly investigate for misappropriation of funds for 6 (Residents #1, #5, #6, #7, #8 and #9) of 6 case mix residents after the facility's Business Office Manager was identified as stealing funds from resident accounts. The findings are: 1. On 09/13/23 at 1:39 PM, the Regional Business Office Manager stated the facility had identified that the facility Business Office Manager was using the residents debit cards and getting cash and buying items online. This affected two residents and a report was completed on both and was sent to the Office of Long Term Care. The police have an ongoing investigation. 2. On 09/14/23 at 11:34 AM, the Surveyor asked the Administrator if a complete audit was done after the misappropriation of funds was identified. She stated she was told a complete audit was done by the Regional Business Office Manager and that she audited the credit card users, and trust funds. 3. On 09/14/23 at 11:43 AM, the Regional Business Office Manager stated that after the incident they did a review for each transaction that was put into the computer. We used the documents we could find in the office. She stated there were only a few receipts. She had no documentation of a thorough investigation of the trust fund. 4. On 09/14/23 at 12:20 PM, the administrator stated she could not say what the money was spent on. She was unable to produce receipts to show who spent the money and what it was spent on. 5. On 09/14/23 at 11:36 AM, Resident #1's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #1 spent $220.00 on 06/06/23, $75.00 on 06/09/23, $150.00 on 06/20/23, $150.00 on 07/14/23, $200.00 on 07/14/23, $50.00 on 08/02/23 (Total $845.00) on Personal Needs Items. No receipts were available for the above withdrawals. 6. On 09/14/23 at 11:40 AM, Resident 5's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #5 spent $150.00 on 06/06/23, $70.00 on 06/20/23, $75.00 on 06/23/23, $100.00 on 07/03/23, and $100.00 on 07/14/23 (Total of $495.00) on Personal Needs Items. No receipts were available for the above withdrawals. 7. On 09/14/23 at 11:50 A.M. Resident 6's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #6 spent $75.00 on 06/09/23, $70.00 on 06/16/23, $100.00 on 07/11/23, $200.00 on 07/14/23, $250.00 on 07/18/23 and $100.00 on 07/21/23 (Total of $795.00) for Personal Needs Items. No receipts were available for the above withdrawals. 8. On 09/14/23 at 12:38 PM, Resident #7's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #7 spent $700.00 on 06/27/23, $250.00 on 06/30/23, $1500.00 on 07/06/23 and $250.00 on 07/17/23 (Total $2700.00) on Personal Needs Items. No receipts were available for the above withdrawals. 9. On 09/14/23 at 12:45 PM, Resident #8's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #8 spent $250.00 on 06/27/23 and $100.00 on 07/11/23 (Total S350.00) for Personal Needs Items. No receipts were available for the above withdrawals. 10. On 09/14/23 at 1:00 PM, Resident #9's Quarterly Trust Fund Statement for June 2023 to September 2023 noted on 07/11/23 Resident #9 spent $100.00 on Personal Needs Items. No receipts were available for the above withdrawal. 11. The facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, provided by the Administrator on 09/14/23 at 2:35 PM documented, Policy Statement: All report of resident abuse ., neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies . and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations . 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation . 7. The individual conducting the investigation as a minimum: . l. documents the investigation completely and thoroughly .

Based on interview and record review, the facility failed to ensure receipts were filed for charges imposed by the facility for 6 (Residents #1, #5, #6, #7, #8 and #9) of 6 case mix residents. The findings are: 1. On 09/14/23 at 11:36 AM, Resident #1's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #1 spent $220.00 on 06/06/23, $75.00 on 06/09/23, $150.00 on 06/20/23, $150.00 on 07/14/23, $200.00 on 07/14/23, $50.00 on 08/02/23 (Total $845.00) on Personal Needs Items. No receipts were available for the above withdrawals. 2. On 09/14/23 at 11:40 AM, Resident 5's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #5 spent $150.00 on 06/06/23, $70.00 on 06/20/23, $75.00 on 06/23/23, $100.00 on 07/03/23, and $100.00 on 07/14/23 (Total of $495.00) on Personal Needs Items. No receipts were available for the above withdrawals. 3. On 09/14/23 at 11:50 A.M. Resident #6's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #6 spent $75.00 on 06/09/23, $70.00 on 06/16/23, $100.00 on 07/11/23, $200.00 on 07/14/23, $250.00 on 07/18/23 and $100.00 on 07/21/23 (Total of $795.00) for Personal Needs Items. No receipts were available for the above withdrawals. 4. On 09/14/23 at 12:38 PM, Resident #7's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #7 spent $700.00 on 06/27/23, $250.00 on 06/30/23, $1500.00 on 07/06/23 and $250.00 on 07/17/23 (Total $2700.00) on Personal Needs Items. No receipts were available for the above withdrawals. 5. On 09/14/23 at 12:45 PM, Resident #8's Quarterly Trust Fund Statement for June 2023 to September 2023 noted Resident #8 spent $250.00 on 06/27/23 and $100.00 on 07/11/23 (Total $350.00) for Personal Needs Items. No receipts were available for the above withdrawals. 6. On 09/14/23 at 1:00 PM, Resident #9's Quarterly Trust Fund Statement for June 2023 to September 2023 noted on 07/11/23 Resident #9 spent $100.00 on Personal Needs Items. No receipts were available for the above withdrawal. 7. On 09/14/23 at 12:20 PM, the Administrator was unable to produce receipts for the Personal Needs Items and stated she could not say what the money was spent on for Residents #1, #5, #6, #7, #8 and #9. 8. The facility policy titled, Accounting and Records of Resident Funds, provided by the Administrator on 09/14/23 at 2:33 PM documented, Policy Statement Our facility maintains accounting records of resident funds on deposit with the facility. Policy Interpretation and Implementation .2. Individual accounting ledgers are maintained in accordance with generally accepted accounting principles and include: .d. the date and amount of each deposit and withdrawal; e. the name of the person who accepted or withdrew funds; f. the balance after each transaction; g. receipts for charges imposed by the facility .

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered and dated, dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, 2 of 2 ice machine were maintained in a clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 71 residents who received meals from the kitchen (total census: 72) as documented on a list provided by the Dietary Supervisor on 06/06/23 at 8:00 AM. The findings are: 1. On 06/05/23 at 9:34 AM, an opened box of sausage was stored on a shelf in the walk-in refrigerator with no open date on the box. 2. On 06/05/23 at 9:40 AM, the following food items were stored on a shelf in the walk-in freezer with no open dates. a. A box of mixed vegetables b. A box of biscuits c. A box of pancakes d. A box of beef patties e. There were 9 glasses of water on the tray without lids on them. 3. On 06/05/23 at 9:45 AM, a pan of baked chicken covered in foil dated 05/19/23 was on the shelf in the walk-in refrigerator. The Surveyor asked the Dietary Supervisor, What was in the pan? The Dietary Supervisor stated, It was leftover baked chicken from 05/19/23. The Surveyor asked how long leftover food should be kept in the refrigerator. The Dietary Supervisor stated, About 5 to 7 days. 4. On 06/05/23 at 9:54 AM, the top panels of the 2 of 2 ice machines in a room between the Dining Room and the Dietary Supervisor's office had a wet black/brown residue on them. The Surveyor asked the Dietary Supervisor to wipe off the black/brown residue on the panel with a paper towel. She did so, and the black/brown substance easily transferred to the paper towel. The Dietary Employee Supervisor stated, It had black/brown residue. The Surveyor asked, Who used the ice from the ice machine and how often do you clean ice machine? She The Dietary Supervisor stated, We use it to fill beverages served to the residents at meals. The CNAs also use it for the water pitchers in the residents' rooms. We clean it once a week. 5. On 06/05/23 at 9:58 AM, the following spices were stored on a shelf above the food preparation counter with no open dates on them. a. Two containers of garlic salt. b. A container of black pepper. c. A container of lemon pepper. d. A container of cinnamon. e. A container of ground oregano. f. A container of beef base and a container of seasoning salt. 6. On 06/05/23 at 10:06 AM, a 13-ounce bag of lightly salted restaurant style chips was on a shelf in the Storage Room and had an expiration date of 05/22/23. 7. On 06/05/23 at 10:16 AM, Dietary Employee (DE) #1 turned on the hand washing sink faucet and washed her hands. After washing her hands, she turned off the sink faucet with her hands, contaminating them. She picked up a clean pan from under the counter, placed it on the counter, and touched the inside of it. DE #1 transferred the baked chicken into the pan and placed it in the oven to be served to the residents for lunch. At 10:22 AM, she turned on the stove. Without washing her hands, she picked up a pan from under the counter and placed it on the counter with her fingers inside it. She then placed the hamburger patties in the pan and placed them in the oven to be served to the residents who did not like chicken for lunch. 8. On 06/05/23 at 10:34 AM, DE #1 turned on the sink faucet and obtained water in a container. After obtaining the water, she turned the water faucet off with her bare hands. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. She placed 3 fried chicken tenders into a blender with a tong. At 10:36 AM, she placed the gloves on her hands, contaminating them. She deboned 5 servings of baked chicken, placed them into a blender, removed the gloves and threw them away. DE #1 untied a bag of bread that was on the counter, contaminating her hands. Without washing her hands, she removed 4 slices of bread from the bag, placed them into a blender, added cream soup to chicken and pureed them. On 06/05/23 10:48 AM, DE #1 turned on the sink faucet and washed her hands. After washing her hands, she turned off the faucet with her hands, contaminating them. She picked a clean pan from under the steam table and placed it on the counter with her fingers touching the inside of it. She poured the pureed chicken into a pan and placed it in the oven to be served to the residents who received pureed diets. The Surveyor asked DE #1, What should you have done after touching dirt object and before handling clean equipment? DE #1 stated, Washed my hands. 9. On 06/05/23 at 11:08 AM, DE #1 was wearing gloves on her hands when she went into the walk-in refrigerator. At 11:10 AM, she walked out of the walk-in refrigerator with a slice of cheese in her gloved hand. She placed the slice of cheese on top of the mashed potatoes in a pan on the counter. As she was about to mix it in with the mashed potatoes, the Surveyor immediately stopped her and asked, Should you have used the same glove that you wore when you went into the refrigerator to remove cheese? DE #1 stated, I should have changed gloves. 10. The facility policy titled, Hand washing, provided by the Dietary Supervisor documented, Wash your hands as often as possible. It is important to wash your hands. Before starting to work with food, utensils, or equipment. Before putting on gloves. As often as needed during food preparation and when changing tasks.

Based on observation and interview, the facility failed to ensure the pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 6 residents who received pureed diets as documented on the list provided by the Food Service Supervisor on 06/06/23. The findings are: 1. On 06/05/23 at 10:36 AM, Dietary Employee (DE) #1 pureed the chicken tenders and the baked chicken to be served to the residents on pureed diets. At 10:48 AM, the consistency of the pureed chicken was lumpy. 2. On 06/05/23 at 11:49 AM, DE #3 pureed the hamburger patties from the grill with a temperature of 133 degrees Fahrenheit. The consistency of the pureed hamburger patties was runny and lumpy, with pieces of meat visible in the mixture. 3. On 06/05/23 at 11:55 AM, the pureed bread was served to the residents on pureed diets. The consistency of the pureed bread was lumpy. The Surveyor asked DE #3 to describe the consistency of the pureed hamburger patties and the pureed bread. DE #3 stated, They are supposed to be smooth and not lumpy. 4. On 06/05/23 at 12:21 PM, Certified Nursing Assistant (CNA) #1 was assisting the residents in the unit Dining Room. The Surveyor asked CNA #1 to describe the consistency of the pureed diets served to the residents. CNA #1 stated, Pureed foods are supposed to be like baby food, smooth and not lumpy. The pureed bread was lumpy with unidentified strings in it. Those black things in the pureed cut green beans look like black pepper.

Based on observation, record review, and interview, the facility failed to ensure that the call light system on the 200 Hall was functioning properly for 1 resident (Resident #54) of 3 (#6, #54 and #62) sampled residents who were able to use a call light indicated by a list provided by the Administrator on 06/08/23 at 9:14 AM. This failed practice had the potential to affect 14 residents who reside in 200 Hall. The findings are: a. On 06/05/23 at 2:52 PM, the Surveyor entered Resident #54's room. He asked the Surveyor to get him something to drink. The Surveyor instructed him to push his call light. Resident #54 stated, I've been pushing it. He pushed the call light in front of the Surveyor, and it did not work. Certified Nurse Assistant (CNA) #2 was alerted. She went into the room and attempted to get the call light to work and stated, It's not working, I'll fix it. b. On 06/06/23 at 8:08 AM, the Surveyor entered Resident #54's room. The Surveyor asked Resident #54 to push the call light and it did not work. CNA #2 was notified, and she moved the non-working light to the other bed in the room. c. On 06/06/23 at 9:11 AM, the call light in Resident #54's room on the other bed, was still not working. The Surveyor asked CNA #2 if she had left the non-working call light in the room she stated, Yes. The Surveyor asked how she could make sure that the non-working call light would not be put back on Residents #54's side for him to use. CNA #2 stated, When I'm here I'll check it often. The Surveyor asked how she could ensure it didn't get switched when she wasn't working or that a resident got moved to the other bed. CNA #2 stated, Before I get off, I'll let the nurse know to watch it. The Surveyor asked if there was anyone else who could be notified to get it fixed. CNA #2 stated, I can put it on a piece of paper like a Maintenance slip. The Surveyor asked if she turned in a Maintenance slip on 06/05/23 when she was alerted that the call light did not work. CNA #2 stated, No. d. On 06/06/23 at 9:30 AM, Maintenance Employee #1 entered Resident #54's room and attempted to fix the non-working light. At 9:45 AM, he replaced the non-working call light with a new call light. e. On 06/07/23 at 12:56 PM, the Surveyor asked the Director of Nursing (DON) what she expected the staff to do if there was a call light not working. The DON stated, Do 15-minute checks. The Surveyor asked if 15-minute checks were forever, The DON stated, I'll tell Maintenance Employee # by the Maintenance Logbook. The DON stated, We keep a sheet of the 15-minute checks. The Surveyor asked if she was aware of the call light not functioning on 200 Hall on 06/06/23 and 06/07/23 and if so, could she provide the 15-minute checks. The DON stated, I was not aware. f. The facility policy titled, Answering the Call Light, provided by the Administrator on 06/08/23 at 9:14 AM documented, Purpose: The purpose of the procedure is to ensure timely responses to the resident's requests and needs . .General Guidelines: #7. Report all defective call lights to the nurse supervisor promptly .

Based on observation, interview, and record review, the facility failed to ensure water was accessible and provided based on physician orders for 1 (Resident #10) of 2 (#10 and #63) sampled residents. This failed practice had the potential to affect 2 residents who are on Therapeutic Orders for hydration according to a list provided by the Administrator on 06/08/23 at 9:14 AM. The findings are: 1. Resident #10 Minimum Data Set with an Assessment Reference Date of 3/15/23 documented no issues with swallowing. 2. The Care Plan with an initiation date of 06/15/22 documented, Offer water routinely as directed and PRN [as needed] during care, btw [between] meals and at night while awake. 3. The Physician Order with a start date of 04/21/23 documented, Encourage fluid intake q [every] hour due to increased BUN [Blood Urea Nitrogen]. 4. On 06/05/23 at 10:59 AM, Resident #10 was lying in his bed. There was no water pitcher at his bedside. 5. On 06/05/23 at 2:45 PM, Resident #10 was lying in his bed. There was no water pitcher at his bedside. 6. On 06/06/23 at 8:01 AM, there was no water pitcher at Resident #10's bedside. 7. On 06/07/23 at 8:10 AM, Resident #10 was sitting on the side of the bed eating his breakfast. There was no water pitcher in his room or water on his tray. 8. On 06/07/23 at 10:11 AM, the Surveyor asked Certified Nurse Assistant (CNA) #2, Why Resident #10 did not have a water pitcher in his room? CNA #2 stated, Because when we put one in his room, the resident will throw it against the wall or pour the water out. The Surveyor asked, How often was water offered? CNA #2 stated When we pass ice. The Surveyor asked how often they passed ice. CNA #2 stated, Every 2 hours. The Surveyor asked if she was aware that the resident was supposed to be offered water every hour. CNA #2 said Yes. The Surveyor asked, So you know the resident was supposed to be offered water every hour, but you only offer water when passing ice. CNA #2 stated, Well if the resident is standing up. The Surveyor asked what the outcome was of not getting enough water. CNA #2 stated, Dehydration. 9. There was no documentation of Resident #10 pouring out water or refusing a water pitcher. 10. On 06/07/23 at 10:16 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Why Resident #10 did not have a water pitcher in his room? LPN #2 stated, I'm not aware he doesn't have one. LPN #2 accompanied the surveyor to Resident 10's room to locate the water pitcher. LPN #2 stated, He doesn't have one in here. The Surveyor asked how often Resident #10 was supposed to be offered water. LPN #2 stated, Every hour. The Surveyor asked if she had made sure he got water every hour. LPN #2 stated, I try to give him something. The Surveyor asked why she was supposed to give him water every hour. LPN #2 stated, His creatine. The Surveyor asked, What could happen if Resident #10 did not receive water as ordered? LPN #2 stated, Kidney failure. 11. On 06/07/23 at 12:50 PM, the Surveyor asked the Director of Nursing (DON) what Offer water routinely as directed (from the care plan) meant. The DON stated, To follow MD [Medical Doctor] Orders. The Surveyor asked if she expected the nurses to follow the Physicians Orders. The DON stated, Yes. The Surveyor asked, How often do the staff pass water? The DON stated, Once every 8 hours. The Surveyor asked, What could happen to a resident whose BUN was 82 and did not receive water per Physicians Orders? The DON stated, Dehydration. 12. The facility policy titled, Hydration-Clinical Protocol, provided the Administrator on 06/08/23 at 9:14 AM documented, . Treatment/Management 2. The staff will provide supportive measures such as supplemental fluids .

Based on observation, record review, and interview, the facility failed to ensure posting of cautionary and safety signs for resident rooms indicating the use of oxygen in the facility for 2 (Residents #3 and #33) of 4 (#3, #33, #38 and #60) sampled residents who use oxygen, as documented on lists provided by the Director of Nursing (DON) on 06/07/23 at 3:26 PM. The findings are: 1. Resident #3 was readmitted on [DATE] and had a diagnosis of Fracture of the left femur. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/18/23 documented the resident scored 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. The Physician Order with a start date of 01/20/23 documented, Oxygen two liters per minute every 1 hour as needed for Shortness of Breath Oxygen @ [at] 2 Liters PRN [as needed] may remove per self for ADL's [Activities of Daily Living] . b. On 06/05/23 at 10:11 AM, Resident #3 was lying in her bed alert and awake, with her oxygen on per nasal canula and the setting was one and half liters per minute. The Surveyor was unable to locate Oxygen in Use signage on the doorway or in the entrance to her room. c. On 06/06/23 at 11:00 AM, the Surveyor observed the front entrance to the nursing facility, and was unable to locate a no Smoking, Non-Smoking Facility, or No Smoking Oxygen in use signage on the front door entrance. The Surveyor observed the doorway entrance coming into the facility from the smoking area and was unable to locate a No Smoking in facility sign on the doorway entrance doors. d. On 06/07/23 at 8:10 AM, Resident #3 was in her room lying in bed with her oxygen on per nasal canula. The Signage that said, No Smoking, Oxygen in Use was not located on doorway. 2. Resident #33 with an admitted [DATE] had a diagnosis of Alzheimer's early onset. The Quarterly MDS with an ARD of 05/09/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS and required supervision/setup assist with eating and toileting. a. The Physician Order with an order date of 05/30/23 documented, .O2 @ 2 LPM via n/c [nasal canula] at bedtime for supplemental . b. The Medication Administration Record documented Resident #33 using oxygen on June 2nd [second], 3rd [third], and 6th [sixth] 2023. c. On 06/07/23 at 2:00 PM, the Surveyor Resident #33 in his room sitting in his chair. The Surveyor asked, Do you use your oxygen? Resident stated, I used it a few nights, but it didn't really help. d. On 06/07/23 at 2:10 PM, the Surveyor asked Licensed Practical Nurse (LPN)#1, Who is responsible for oxygen setup in the nursing facility? LPN #1 replied, The nurses are, we get the concentrator and set it up for the resident when we get the orders. The Surveyor asked, Does the nursing facility have any no smoking signs at the entrances of the facility or stating Oxygen in use in the nursing facility? LPN #1 replied, No, not that I know of, I really have not ever noticed any. The Surveyor asked, Should there always be a sign stating Oxygen in Use on the door to the resident's room, if the resident is using Oxygen? LPN #1 replied, Yes, there should. e. On 06/07/23 at 2:20 PM, the Surveyor asked the Director of Nursing (DON), Who is responsible for oxygen setup in the nursing facility? The DON stated, The nurses. The Surveyor asked, Does that include the signage for the door showing Oxygen in use? The DON stated, Yes. The Surveyor asked, Does the nursing facility have any no smoking signs at the entrances of the facility or signs stating oxygen in use? The DON stated, No. The Surveyor asked, Should there always be a sign stating Oxygen in use on the door to the resident's room, if the resident is using Oxygen? The DON stated, Yes. f. The facility policy titled Oxygen Administration, provided by the DON on 06/07/23 at 3:26 PM, documented, .Steps in the procedure . and . #2. Place an Oxygen in Use sign on the outside of the room entrance door .

Based on observation and interview, the facility failed to ensure the narcotics that had been discontinued were properly stored and locked in a permanently affixed compartment prior to being sent back to the state for destruction. The failed practice has the potential to affect all ambulatory residents in the facility. a. On 06/08/23 the Surveyor asked the Director of Nursing (DON), Where do you store the discontinued narcotics before returning them to the State? She reached under her desk and pulled a paste board box out and handed it to the Surveyor. Inside the box was a bottle of clear liquid labeled Hydrocodone 7.5mg/325mg (milligrams) with a resident's name on it. There were 5 ounces of liquid in the bottle. The Surveyor asked, Do you have a cabinet, safe or file cabinet to store the narcotics in before they are sent in? The DON stated, No. The Surveyor asked, Do you know where the previous DON stored the narcotics? The DON stated, No, I don't. The Surveyor asked, How many keys are there to this office? The DON stated, I'm not sure the Administrator has one. The Surveyor asked, Does Maintenance have a master key? The DON stated, I'm not sure. b. Review of the policy titled, Storage of Medications, last revised in November 2020 revealed, scheduled drugs are stored in separately locked, permanently affixed compartments.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 12 residents who received mechanical soft diets, and 6 residents who received pureed diets from the kitchen according to a list provided by the Dietary Supervisor on 06/06/23. The findings are: a. The facility menu for lunch l provided by the Dietary Supervisor on 06/06/23 at 8:00 AM, documented that each resident who received mechanical soft diets were to receive a #10 scoop (3 ounces) of herb roasted chicken and the residents who received pureed diets received 4 ounces (1/2 cup) of creamy garlic noodles. b. On 06/05/22 at 10:29 AM, Dietary Employee (DE) #1 placed 11 servings of fried chicken tenders into a blender instead of 24 chicken tenders. She grounded them, poured them into a pan and placed the pan in the oven. At 11:58 AM, DE #1 used a #10 scoop (3 ounce) and served a half (1/2) a portion of ground chicken tenders, but not the full 3-ounce portion per the menu. c. On 06/05/23 at 11:05 AM, DE #2 used a #8 scoop placed 4 servings of peach halves into a blender and pureed them. She poured the pureed peach halves into 6 bowls. d. During the noon meal preparation on 06/05/23, there were no noodles prepared for the residents that were on pureed diets. At 11:55 AM, the residents on the pureed diets were served mashed potatoes. The Surveyor asked the Dietary Supervisor the reason why the residents on pureed diets were not served noodles. The Dietary Supervisor stated, It's hard to puree noodles. e. The Manufacture Specification on the box of chicken tenders Nutrition Facts, provided by the Dietary Supervisor on 06/06/23 at 8:00 AM documented, Serving size: 2 Pieces.

Based on record review and interview, the facility failed to ensure advanced directive information was accurately documented in the medical record to ensure the resident's wishes would be carried out in the event of cardiopulmonary arrest for 1 resident (Resident #30) of 3 (#30, #31 and #224) sampled residents that were admitted in the last 3 months and had signed a document stating Do Not Resuscitate (DNR). This failed practice had the potential to affect all 6 residents in the facility as documented on list provided by Director of Nursing (DON) on [DATE] at 3:26 PM. The findings are: 1. Resident #30 was admitted on [DATE] and had diagnoses of Heart Failure, Depression and Diabetes Mellitus. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented a score of 15 (,d+[DATE] indicates cognitively Intact) on the Brief Interview for Mental Status (BIMS). a. Resident #30's Resuscitation Designation Order dated [DATE] documented, I do not want CPR [Cardiopulmonary Resuscitation]. Signed by the resident's family and the Physician. b. The Physicians Order dated [DATE] documented, CPR. c. On [DATE] at 2:20 PM, the Surveyor asked the DON, Should the resident choice for CPR/code status per the signed residents document match the residents EHR profile area and Care Plan, and that the Physicians Order? DON stated, Yes the resident's profile should match the orders and the document the resident has signed in regard to their wishes for DNR/CPR. The Surveyor asked, Why should they match? The DON stated, If they don't match that could cause issues, if the resident is not breathing, we would start CPR. The Surveyor asked, If the resident has signed a form stating DNR in April, should the profile and order reflect that on [DATE]? The DON stated, Yes it should. The Surveyor asked, Does the facility have any other system they use for the staff to be aware of the resident's choice regarding full code or a DNR status? The DON replied, No we do not, just the Care Plan and the record. d. The facility policy titled, Advance Directives, provided by the DON on [DATE] at 3:26 PM, documented, .Advance directives will be respected in accordance with state law and facility policy . and .#10. The Plan of Care for the resident will be consistent with his or her documented treatment preferences and/or advance directive .

Based on observation, record review, and interview the facility failed to ensure that the Residents' fingernails and toenails were groomed and clipped to promote good hygiene for 1 (Resident #3) of 5 sample residents (R #1, R #2, R #3, R #4, and R #5) who were dependent for nail care according to the list presented by the Administrator on 11/17/2022 at 4:07 PM. The findings are: 1. Resident # 3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set [MDS] with a Brief Interview Mental Status [BIMS] documented a score of 11 (Indicated Moderately Impaired Cognition), was independent in Activities of Daily Living self-performance skills. 2. The Plan of Care dated 06/14/22 documented, Nail Care, check nail length and clean, and trim as necessary. a. On 11/14/22 at 12:35 PM, The Resident was sitting in his room, alert and oriented. He wore sandals with bare feet. His toenails were extremely long, the great toenail on the left foot was greater than 1/4 inches long and pointed. The Surveyor asked, Do you need those cut? He stated, Yes, and I need these cut too, holding his hands out for the fingernails to be seen. The fingernails were long, greater than 1/4 inch over the end of the nails. The Surveyor asked, Have you asked someone to cut them? He stated, Yes, one of the workers back here. The Resident resided on the Secure Unit. 3. On 11/16/22 at 10:30 AM, The Surveyor asked the Direct Care workers, How often should a resident's fingernails and toenails be cut?: a. At 10 :30 AM, Certified Nursing Assistant (CNA)#1 stated, When needed, especially on bath or shower days. b. At 10:40 AM, CNA #2 stated, On bath days and whenever they need it. c. At 11:10 AM, CNA #3 stated, Whenever they need to be cut, look at them every day. d. At 11:30 AM, CNA #4 stated, When they get their baths, but if they are diabetic, the nurses have to cut them 4. On 11/16/22 at 12:30 PM, The Resident was sitting in his room and walked in the hall with the Surveyor. The fingernails and toenails still had not been cut. 5. On 11/17/22 at 8:40 AM, The Resident's fingernails nor toenails had been cut nor trimmed. The Administrator was shown the Resident's nails. 6. On 11/18/22 at 4:07 PM, The Care of Toenails and Fingernails Policy given by the Administrator documented, The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infection. Nail care includes daily cleaning and regular trimming.

Based on observation, record review and interview, the facility failed to ensure nutritional interventions ordered by the physician or recommended by the Registered Dietitian (RD) were promptly evaluated by the Interdisciplinary Team for appropriateness, developed and initiated, and the RD was promptly consulted for further nutritional recommendations when the resident's weight continued to decline from month to month, in order to minimize further weight loss and maintain nutritional status to the extent possible for 2 (Resident #62 and #64) of 28 (Resident #1, #3, #7, #11, #14, #18, #20, #22, #23, #25, #28, #36, #37, #41, #43, #47, #49, #51, #52, #62, #63, #64, #67, #74, #129, #234, #235, and #239) sampled resident who had experienced a severe weight loss over the last 6 months and failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failed practices resulted in a pattern of actual harm for Resident #62 who experienced a severe weight loss of 12.32% in a 6-month period and Resident #64 who experienced a severe weight loss of 13.01% in a 6-month period, and had the potential to cause more than minimal harm for 37 residents who had experienced significant weight losses, according to a list provided by the Administrator on 3/21/22 at 11:00 a.m. The findings are: 1. Resident #62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/22 documented the resident scored 6 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and was independent with eating requiring set up only. The MDS documented the resident had no difficulty with swallowing and no significant weight loss. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The RD recommendation report dated 11/29/21 2:46 pm, in the electronic record documented, . Resident reviewed due to weight and readmit. NKFA (No Know Food Allergies). Dx [diagnoses] of significance Pleural Effusion, [CONDITION(S)], Idiopathic Aseptic Necrosis of L [left] femur, unspec (unspecified) [CONDITION(S)] not due to a substance or known physiological condition, CHF, [Congestive Heart Failure] Gastrointestinal Hemorrhage, Post Cholecystectomy, Major Depressive Disorder, [CONDITION(S)], [CONDITION(S)] [Hypertension], Dementia without behavioral disturbance, Personal hx [History] of Pulmonary Embolism, [CONDITION(S)] . Meds [Medication] of significance are [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] XL, [MEDICATION(S)], Potassium Cl, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], vit [Vitamin] E, [MEDICATION(S)], Ocular vitamins, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] HCl, and [MEDICATION(S)]. Resident is on a regular diet. Current wt. (weight) 196.2 lbs [pounds] 11/22/21, down 3.2 lbs in 1 week (1.63%), down 11.4 lbs in 1 mo (5.49%), down 12.6 lbs in 3 mo (6.03%), down 10.2 lbs since admit (4.94%). No significant wt changes x [times] 1 week, 3 mo [month], admit, but significant wt loss x 1 mo. Ht [height] 64.5 in. BMI [body mass index] 33.2. Labs 10/27/21 Hgb [hemoglobin] 8.4 low, Hct [hematocrit] 30.5 low, Co2 [carbon [MEDICATION(S)]] 31 high, Ca [Calcium] 8.4 low. Resident noted to have a bruise to R [right] outer forearm per weekly wound note. Unintended wt loss related to increased energy needs AEB (as evidenced by) significant wt loss. Goals: 1) Maintain wt. 2) No significant wt changes. 3) PO [by mouth] intake 50-75 or greater. 4) Maintain skin integrity. Rec [Recommendation] 1) Consider starting ice cream with meals BID [two times daily] unless weight loss is desired by resident with goal weight . B Nursing Recommendations B. Nursing Response RD recommendations have been reviewed and considered? 1. Yes 2. Physician/Clinician notified of recommendation 1. Yes 3. Date and time of notification: 12/31/2021 at 10:00 [a.m.] .6. Family/significant other notification (Blank) 7. Response or action to recommendation: start ice cream bid unless patient attempting to lose weight . C. Dietary Response: 1. RD recommendations have been reviewed and considered? 3. NA [not applicable] . e-SIGNED] Signed Date 02/09/2022 . c. The RD Recommendations report dated 12/30/21 at 3:04 p.m., in the electronic record documented, . Resident reviewed due to weight. Meds [medications] of significance are the same from 11/29/21 date. Resident is on a regular diet. No skin issues per weekly skin check form. No new labs available for review at this time. Current wt. 197.2 lbs 12/27/21, up 2 lbs in 1 week (1.02%), down 6 lbs in 1 mo (2.95%), down 16.2 lbs in 3 mo (7.59%), down 9.2 lbs since admit (4.46%). No significant wt. changes x 1 week, 1 mo, admit, but significant wt loss x 3 mo. Goals 1) Maintain wt. 2) No significant wt changes 3) PO intake 50-75% or greater 4) Maintain skin integrity. Rec 1) Consider starting 2.0 calorie supplement 90 ml BID . d. On 12/30/2021 at 8:21 p.m., the RD Assessment and Recommendation Report in the Electronic record documented, . 5 RD Assessment and Recommendations .rec 1) Consider starting 2.0 calorie supplement 90 ml BID ----please see progress note for complete details . B. Nursing Recommendations B. Nursing Response 1. RD recommendations have been reviewed and considered? 3. NA 2. Physician/Clinician notified of recommendations? 3. NA . C. Dietary Response 1. RD recommendations have been reviewed and considered? 3. NA . Director of Nursing [e-SIGNED] Signed Date 03/09/2022 . e. The RD Recommendation dated 1/26/22 at 10:12 a.m., in the electronic record documented, . Resident reviewed due to quarterly, weight, and recent dx [diagnosis]. NKFA [no know food allergies]. Recent dx of COVID 19, so wt loss and decreased appetite may occur. Meds of significance are unchanged. Resident is on a regular diet. Current wt 194.8 lb 1/5/22, down 2.4 lb in 1 week (1.22%), no wt change x 1 mo, down 18.6 lb in 3 mo (8.72%), down 11.6 lb since admit (5.62%). No significant wt changes x 1 week, 1 mo, admit, but significant wt loss x 3 mo. Ht 64.5 in. BMI 32.9. No new labs available for review at this time. No skin issues per weekly skin check form. Unintended wt loss related to increased energy needs AEB significant wt loss. Goals 1) Maintain wt 2) No significant wt changes 3) PO intake 50-75% or greater 4) Maintain skin integrity. Rec 1) consider starting snacks BID or super donut with one meal daily . f. The RD Assessment and Recommendation dated 1/26/22 at 2:14 p.m., in the Electronic record documented, . 5 RD Assessment and Recommendations .rec 1) consider starting snacks BID or super donut with one meal daily ----please see progress note for complete details . B. Nursing Recommendations B. Nursing Response 1. RD recommendations have been reviewed and considered? 3. NA 2. Physician/Clinician notified of recommendations? 3. NA . C. Dietary Response 1. RD recommendations have been reviewed and considered? 3. NA . Director of Nursing [e-SIGNED] Signed Date 03/09/2022 . g. A CMP (Complete Metabolic Profile) and a CBC with Diff (Complete Blood Count with Differential) dated 1/28/22 in the resident's electronic record documented, . [MEDICATION(S)] 3.3 (normal 3.5 -5.2) . Total Protein 5.5 (normal 6.4 -8.3), . Hemoglobin 7.4 (normal 11.2 15.7) . Hematocrit 27.9 (normal 34.1 - 44.9) . h. The Care Plan revised on 2/15/22 documented, .Resident has potential for nutritional deficits . Goal: Resident will receive adequate nutrition as evidenced by weight stable . Interventions: RD [Registered Dietician] to evaluate and make diet change recommendations PRN [as needed] . i. The RD Recommendation Report dated 2/28/22 at 11:38 a.m., documented, .Resident reviewed due to weight. Meds of significance added was [MEDICATION(S)] Sulfate. Resident is on a regular diet. No skin issues per weekly skin check form. Labs 2/14/22 Hgb 7.3 low, Hct 27.7 low, iron 14 low; 1/28/22 vit D 28.4 low, Alb [[MEDICATION(S)]] 3.3 low, Cl [Chloride] 108 high, T. pro [total protein] 5.5 low, Na [Sodium] 147 high, HDL [high density lipoprotein (cholesterol)] 34 low. Current wt. 188 lb 2/2/22, down 6.8 lbs in 1 mo (3.49%), down 11.6 lbs in 3 mo (5.81%), down 19 lbs in 6 mo (9.18%). No significant wt. changes x 1, 3, 6 mo. Wt trending down x 1, 6 mo. Goals 1) Maintain wt 2) No significant wt changes 3) PO intake 50-75% or greater 4) Maintain skin integrity. Rec 1) Consider starting Medpass 90 ml BID or house shake with one meal daily . j. The RD Assessment and Recommendation Report dated 2/28/22 at 3:35 p.m., in the electronic record documented, . 5. RD Assessment and Recommendations .Rec 1) Consider starting Medpass 90 ml BID or house shake with one meal daily ----please see progress note for complete details . B. Nursing Recommendations B. Nursing Response 1. RD recommendations have been reviewed and considered? 1. Yes 2. Physician/Clinician notified of recommendations? 1. Yes . 3. Date and time of Physician/clinician notification of recommendations: 3:14:22 00:00 [12:00 a.m.] 4. Name of Physician/clinician notified: agree with recommendations 5. Date and time of family notification: 3/14/2022 00:00 6. Family/significant other notified: spoke with son 7. Response to action: Agree with recommendation C. Dietary Response 1. RD recommendations have been reviewed and considered? 1. Yes . 2. Response and Action to RD recommendation: agree . Director of Nursing [e-SIGNED] Signed Date 03/14/2022 . k. On 03/04/2022, the resident weighed 185 pounds. The weight on 09/06/2021, was 211.0 lbs. This was a 12.32% loss in 6 months. Total loss of 26 lbs. l. On 3/15/22 at 8:45 AM, Resident #62 was sitting up in her room with oxygen in use at 2 liters per nasal cannula. The resident had eaten her breakfast of eggs, grits, juice, toast, bacon, and water. The resident ate approximately 50% of the meal served. There were no supplements on the tray. m. On 03/16/22 at 09:29 AM, the weight record in the chart documented the resident was being weighted weekly until 1/5/22. After that date, weights were documented monthly. According to the monthly weights the resident continued to have weight loss after 1/5/22. The monthly weights for Resident #62 for the past 6 months in the medical record documented, . 9/6/21- 211 lbs, 10/05/21- 213.4 lbs, 11/8/21- 199.6 lbs, 12/6/21- 194.8 lbs, 1/5/22- 194.8 lbs, 2/2/22- 188.0 lbs, 3/4/22- 185 lbs . n. On 03/17/22 at 08:57 AM, Certified Nursing Assistant (CNA) #5 was asked, Are you familiar with [Resident #62]'s care? CNA #5 stated, Yes. CNA #5 was asked, How is [Resident #62's] appetite? CNA #5 stated, She eats 25% -50% of her meals. We encourage her, but she will only eat what she wants. CNA #5 was asked, Does she have any kind of supplements with her meals? CNA #5 stated, No. CNA #5 was asked, Does she have any particular foods that she likes? CNA #5 stated, She eats a variety of foods. CNA #5 was asked, If the resident does not like the meal that is served what do you do? CNA #5 stated, I get her something else. There is always an alternate and we can get other things besides the alternate. She usually does not want anything else though. CNA #5 was asked, Does the resident get snacks in between meals? CNA #5 stated She gets offered snacks but does not want them. Her son brings her snacks such as candy and cookies, cheese bits and she will eat some of those. o. On 3/17/22 at 9:25 AM, the tray card for R #62 provided by the Dietary Manager (DM) documented, . Regular diet . There were no special instructions or supplements listed on the card. p. On 3/17/22 at 9:27 AM, the Dietary Manager (DM) was asked, Has [Resident #62] lost weight recently? The DM stated, Not in the last couple of months. The DM was asked, has [R#62] had an overall weight loss? The DM stated, Yes she has. I think she was in the hospital with COVID in January. The DM was asked, How do you know what interventions to put in place if a resident has weight loss? The DM stated, The RD makes recommendations. Dietary provides the fortified foods and Ensure with the meals. The DM was asked, Was the Registered Dietitians recommendation for 11/29/21 to consider starting ice cream bid for [Resident #62] carried out? The DM stated, No it was not. I am normally on top of that. The DM was asked, Was the Registered Dietitians recommendation for 2 Cal Supplement 90 ml BID in 12/30/21 carried out? The DM stated, That would be a nursing recommendation. The Dietary Manager was asked, Was the RD recommendation on 1/26/22 to consider starting snacks BID or Super Donut carried out? The DM stated, Let me look and make sure. The DM was asked, How are the residents' weights monitored? The DM stated, We have a weekly meeting and discuss weight loss. The DM was asked, Who attends the meetings? The DM stated, Therapy, nursing, dietary and the MDS coordinator attend the meetings. The DM was asked, Do you notify the residents family of weight loss? The DM stated, Yes we let the family know. q. On 3/17/22 at 10:05 AM, the DM returned and stated, The orders for the RD recommendations were not put into PCC (electronic medical record software program), so they were not carried out. The DM was asked, Who is responsible for putting the orders in the electronic record? The DM stated, Nursing is responsible for putting them in. The Director of Nursing would put them into PCC and then it is passed on to me. r. On 03/17/22 at 11:20 AM, the Director of Nursing (DON) was asked, How are residents weights monitored? The DON stated, The residents get monthly weights. There are some that get weekly or biweekly weights depending if they are skilled, new admissions or on their condition. The DON was asked, Who is involved in monitoring resident's weights? The DON stated, Our clinical management team which consists of restorative aide who get the weights, myself, the MDS Coordinator, Speech Therapy, ADON (Assistant Director of Nursing), Treatment Nurse, and DM. The DON was asked, Do you have routine meetings to discuss changes in resident's weights? The DON stated, We try to meet weekly on Wednesdays or Thursdays. The DON was asked, Who is responsible for following up on the RD recommendations? The DON stated, Nursing is responsible for following up. The DON was asked, Has [Resident #62] lost weight? The DON stated, Yes. The DON was asked Has she lost a significant amount of weight? The DON stated Yes. The DON was asked, When [Resident #62] had COVID in January, did she go to the hospital? The DON stated, She stayed in the facility when she had COVID. The DON was asked, Why was the RD recommendation in November to add ice cream with meals BID not implemented? The DON stated, I do not know why it was not carried out. The Nurse Consultant stated, We went from paper assessments to electronic assessment in November [2021]. Let me look and I will tell you the exact date. It was on 11/11/21 and that resulted in nursing having a problem keeping up with the RD recommendations because there was no alert that a dietary recommendation had been made and were in the record. Prior to this the Dietitian handed the facility a paper report. The Nurse consultant was asked, When did you first discover this was a problem? The Nurse Consultant stated, We thought when we first made the change it might cause some problems, but we identified the full extent of the problem about a month ago. and we did a PIP (Performance Improvement Plan) then. The Nurse Consultant was asked to provide me a copy of this plan. The DON was asked why the recommendation was made on 2/28/22 by the RD to implement Med Pass 90ML BID or house shakes with one meal not implemented until 3/15/22. The Nurse Consultant stated, When we discovered that we had a problem with not addressing the recommendations, we asked the RD to re-evaluate the residents needs and make new recommendations. We did not want to put too many interventions in place at once. The DON was asked, Did you document that you discussed this with the RD? The DON stated, No I did not document that. The DON was asked How quickly should the RD recommendation be followed up on? She stated, I am trying to monitor everyday now for any recommendations. The Nurse consultant stated, We try to have them addressed with the doctor within 48-72 hours and the order should be in place within a week of when we receive the consolidated report. s. On 3/17/22 at 12:52 PM, Resident #62 was weighed by the Restorative Aide and her weight was 181 lbs. This showed an additional 4lb weight loss in 13 days and a 14.22% weight loss since 9/5/21, identifying an overall weight loss of 30 lbs. t. On 3/18/22 at 10:55 AM, the Restorative Aide was asked, Do you do the residents' weights? The Restorative Aide stated, Yes, Ma'am. The Restorative Aide was asked, Who do you give weights to when you have finished doing them? The Restorative Aide stated, I give to the nurses on each hall the weekly and daily weights. I do [CONDITION(S)] residents' weights every day and I do the weekly weights on Monday. The Restorative Aide was asked, Who do you give the monthly weights to? The Restorative Aide stated, I give them to the DON. The Restorative Aide was asked, Do you re-weigh the resident if you have a big difference in the previous weight? The Restorative Aide stated, Yes. The Restorative Aide was asked, Who enters the weights into the medical record? The Restorative Aide stated, I put the weights into the computer. The DON will enter them sometimes if I am busy. The DON will then call me to the office and tell me if we need to add anyone to the weekly weights. The Restorative Aide was asked, Do you have group meetings to talk about the resident's weights? The Restorative Aide stated, Yes. We usually have the meetings on Wednesdays. The Restorative Aide was asked, Who attends the meetings? The Restorative Aide stated, Me, the DON, Therapy and MDS. The Restorative Aide was asked, What do you discuss at the meeting? The Restorative Aide stated, We look at the weights from previous weeks. We may change to monthly, but if still down we keep weekly. The Restorative Aide was asked, Do you ever get told to add people to weekly weights at that meeting? She stated, Yes. The Restorative Aide was asked Have you noticed any residents has been losing weight? The Restorative Aide stated [Resident #62]'s weight did go down. It was weekly for a while. When it came up, we changed it back to monthly. 2. Resident #64 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was independent with eating and required set up assistance only, had no documented swallowing difficulty and no documented weight loss. a. The Care Plan revised on 2/15/22 documented, Resident is at risk for altered nutritional status r/t [related to] her disease process REGULAR DIET . The resident will maintain present weight +/- [plus or minus] 5 lbs . b. The Physicians Order dated 3/14/22 documented, . REGULAR diet, REGULAR texture, REGULAR consistency, . ice cream with lunch and dinner . c. The monthly weights in the resident's electronic record documented . 9/1/21- 316.8 lbs, 10/5/21- 320.4 lbs, 11/8/21- 334.0 lbs, 12/3/21- 293.3 lbs, 1/5/22- 280.4 lbs, 2/2/22- 282.4 lbs, 3/4/22- 275.6 lbs, and 3/1722- 272.9 lbs. On 03/04/2022, the resident weighed 275.6 pounds. On 09/01/2021, the resident weighed 316.8 lbs. which is a -13.01% Loss in 6 months. Loss of 41.2 lbs in 6 months. d. The RD Recommendation Note dated 12/30/21 at 3:15 pm, in the electronic record documented, . Resident reviewed due to weight. Meds of significance are [MEDICATION(S)] (SS) (Sliding Scale), [MEDICATION(S)] HCl, [MEDICATION(S)], [MEDICATION(S)], MVI-minerals, [MEDICATION(S)], Culturelle, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] sodium, [MEDICATION(S)], Vit D3, [MEDICATION(S)] calcium, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Calcium+D. Resident is on a regular diet. Also receives HS (Hour of Sleep) snack. Current wt (weight) 293.2 lbs 12/3/21, down 40.8 lbs in 1 mo (month) (12.22%), down 23.6 lbs in 3 mo (7.45%), down 14.4 lbs in 6 mo (4.68%). No significant wt changes x 3, 6 mo, but significant wt loss x 1 mo. Wt trending down x 3 mo. No new labs available for review at this time. No skin issues per weekly skin check form. Goals 1) Maintain wt 2) No significant wt changes 3) PO intake 50-75% or greater 4) Maintain skin integrity. Rec 1) Consider starting 2.0 calorie supplement 90 ml BID or house shake with one meal daily . e. The RD Assessment and Recommendation Note dated 12/30/21 at 9:55 p.m. documented, . 5. RD Assessment and Recommendations: Rec 1) Consider starting 2.0 calorie supplement 90 ml BID or house shake with one meal daily ----please see progress note for complete details . B. Nursing Recommendations B. Nursing Response 1. RD recommendations have been reviewed and considered? 3. NA . 2. Physician/Clinician has been notified of recommendations? 3.NA C. Dietary Response 1. RD recommendations have been reviewed and considered? 3. NA . Director of Nursing [e-SIGNED] Signed Date 03/09/2022 . f. The RD Recommendation Note dated 1/26/22 at 9:59 a.m., in the electronic record documented, . Resident reviewed due to quarterly and monthly weight. NKFA (No Known Food Allergies). Dx (Diagnosis) of significance are Type 2 DM, [Diabetes Mellitus] [CONDITION(S)], [CONDITION(S)] Disorder, age-related [CONDITION(S)], Vit B12 deficiency [CONDITION(S)], [CONDITION(S)], Constipation, [CONDITION(S)], CKD [Chronic Kidney Disease] stage 3, and GERD [Gastroesophageal Reflex Disease]. Meds of significance are the same from 12/30/21. Resident is on a regular diet. Also receives HS snack. Current wt 280.4 lb 1/5/22, down 12.8 lb in 1 mo (4.37%), down 40 lb in 3 mo (12.48%), down 29.8 lb in 6 mo (9.61%). No significant wt changes x 1, 6 mo, but significant wt loss x 3 mo. Wt trending down x 1, 6 mo. Ht 69 in. BMI (Body Mass Index) 41.4. No new labs available for review at this time except for [MEDICATION(S)] level. No skin issues per weekly skin check form. Unintended wt loss related to increased energy needs AEB (As Evidenced By) significant wt loss, wt trending down. Goals 1) Maintain wt 2) No significant wt changes 3) PO intake 50-75% or greater 4) Maintain skin integrity. Rec 1) Consider starting ice cream with meals BID . g. On 1/26/22 at 12:53 p.m., an RD Assessment and Recommendation note documented, . 5. RD Assessment and Recommendation: Rec 1) Consider starting ice cream with meals BID ----please see progress note for complete details .B. Nursing Recommendation B. Nursing Response 1. RD recommendations have been reviewed and considered? 3. NA . 2. Physician/Clinician notified of recommendations? . 3. NA . C. Dietary Response 1. RD recommendations have been reviewed and considered? . 3. NA . Director of Nursing [e-SIGNED] Signed Date 03/09/2022 . h. On 2/28/22 at 11:57, the RD Recommendation Note in the electronic record documented, .Resident reviewed due to weight. Meds of significance are the same as 12/30/21. Resident is on a regular diet. Also receives HS snack. Current wt 282.4 lbs 2/2/22, up 2 lbs in 1 mo (0.71%), down 51.6 lbs in 3 mo (15.45%), down 24.6 lbs in 6 mo (8.01%). No significant wt changes x 1, 6 mo, but significant wt loss x 3 mo. Wt trending down x 6 mo. No new labs available for review at this time. No skin issues per weekly skin check form. Goals: 1) Maintain wt 2) No significant wt changes 3) PO intake 50-75% or greater 4) Maintain skin integrity. Rec 1) determine if resident is wanting/trying to lose weight 2) If not trying to lose weight consider starting ice cream with meals BID and super donut once daily . i. The RD Assessment and Recommendation Note dated 2/28/22 at 3:53 pm, in the electronic record documented, . 5. RD Assessment and Recommendations: Rec 1) determine if resident is wanting/trying to lose weight 2) If not trying to lose weight consider starting ice cream with meals BID and super donut once daily -----please see progress note for complete details . B. Nursing Recommendations B. Nursing Response 1. RD recommendations have been reviewed and considered? .1. Yes . 2. Physician. /Clinician notified of recommendations. 1. Yes . 3. Date and time of clinician notification: 03/14/2022 00:00 .5. Date and time of family notification: 03/14/2022 00:00 . 6. Family/Significant other notified: Resident is own person .7. Response or actions to recommendations: Clarify if wanting to lose weight, if not agree with recommendations (Advanced Practice Nurse Practitioner) only starting on ice cream with meals BID . Director of Nursing [e-SIGNED] Signed Date 03/14/2022 . j. On 03/15/22 at 08:56 AM, Resident #64 was sitting up in the bed eating breakfast of fried egg, grits, juice, toast, bacon, water. Resident ate only few bits, drank about 60 ml apple juice, and drank 240ml water. k. On 03/15/22 at 1:44 PM, Resident #64 was lying in the bed. Her lunch tray was on the bedside table. It had chicken leg, corn bread, greens and pinto beans, water, and tea. The resident had eaten about 10% of diet served. There was no ice cream on the tray. The resident was asked, Why did you eat so little of your lunch. Do you not like what was served? The resident stated, I just do not have much appetite. The resident was asked, Have you lost any weight? The resident stated, Yes. I think I have lost weight recently. l. On 3/17/22 the resident was weighted by the Restorative Aide and weighted 272.9. This was an additional weight loss of 2.7 lbs in 13 days. Total Loss of 43.9 lbs since 9/1/21. m. On 03/18/22 at 9:05AM, the resident was lying in the bed. Her breakfast tray was on her bed side table. She had grits, scrambled eggs, sausage, toast, jelly, coffee, and apple juice. She had eaten approximately 1/2 of sausage patty, few bites of eggs, few bites of toast and approximately 30ml of the apple juice. [Resident #64] was asked, Are you trying to lose weight? [Resident #64] stated, No. I just do not have any appetite. [Resident #64] was asked, How long have you not had any appetite? [Resident #64] stated, For a good little while. n. On 03/18/22 at 09:35 AM, Resident #64 was asked, Would you eat a donut if they gave it to you? [Resident #64] stated, Yes I like donuts. [Resident #64] was asked, Would you eat ice cream if they gave it to you? Ms. Smith [Resident #64] stated, Yes. [Resident #64] was asked, Have they given you any ice cream to eat recently? [Resident #64] stated, No they have not given me any ice cream recently . o. On 3/18/22 at 10:08 AM, the tray card provided by the Dietary Manager (DM) for Resident #64 documented, . Regular diet . Lunch . Ice Cream Vanilla . Dinner *MIGHTY SHAKE, . Van (Vanilla) Ice Cream . Special Instructions .Lunch: Double portions per resident . Dinner: Double portions per resident . p. On 3/18/22 at 10:55 AM, the Restorative Aide was asked, has [Resident #64] been losing weight? The Restorative Aide stated, Yes her weight has been going down. She has been made a weekly weight now. q. On 3/18/22 at 12:25 PM, the DM was asked, When did you receive the orders for ice cream and Might Shake on [Resident #64]? The DM stated, I received orders on 3/18/22 on [R#64] for ice cream bid and mighty shake . r. On 3/21/22 at 3:25 PM, the Medical Director was asked, Were you aware that [R#64] had a significant weight loss over the last 6 months? He stated, No, ma'am. He was asked, Should the facility notify you when a resident has a significant weight loss? He stated, Yes, ma'am. s. On 3/21/22 at 3:40 PM, the Registered Dietician was asked, Were you aware that [R#64] had a significant weight loss over the last 6 months? She stated, Yes ma'am. In December [2021] she went down from 334 lbs to 292 lbs. I recommended 2.0 cal or house shake twice daily on December 30, 2021. In January [2022] she continued to lose weight and I recommended ice cream with meals and if not trying to lose weight add super donut and ice cream twice a day. On 3/18/22 I recommended an appetite stimulant. She was asked, What should the facility do when you recommend nutritional recommendations? She stated, Tell the physician and he gives the orders. 3. Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/2021 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance for eating with one-person physical assist and had no documented swallowing disorder. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. A Registered Dietician Note dated 2/28/22 documented, .Resident reviewed due to skin issues. NKA. [No known allergies] Dx of significance are: COVID 19, [CONDITION(S)], Heart Failure, [Unspecified] Protein-Calorie Malnutrition, [CONDITION(S)], Dementia with Behavioral Disturbance, Constipation, Alcohol use, Vitamin Deficiency, Catatonic Disorder, Seizures, GERD, Recurrent Depressive Disorder, [CONDITION(S)], [Unspecified] [CONDITION(S)] not due to a substance or known physiological condition. Resident is on a regular diet. Also receives 2.0 calorie supplement BID (started 3/14/22), double portions with meals. Meds [medication] of significance are Vitamin C (started 3/15/22), MVI [Multivitamin] (started 3/15/22), [MEDICATION(S)], Protonic, [MEDICATION(S)], [MEDICATION(S)], Vit D3, [MEDICATION(S)], [MEDICATION(S)] HCl, [MEDICATION(S)], Folic Acid, [MEDICATION(S)] HCl, [MEDICATION(S)] Sodium. Resident noted to have a DTI [Deep Tissue Injury] to R [right] heel deteriorated, skin tear to L [left] shin, stage 1 to lateral R foot identified 3/15/22, DTI to dorsum R foot no change, DTI to R foot 5th digit, skin tear to R trochanter with Tx [treatment] in place per weekly wound note. Meal intake average ~ [about] 57% per task reports. No new labs available for review at this time except for [MEDICATION(S)] level. Current wt. [weight] 150.4 lbs. 3/17/22, up 2.7 lbs. in 2 weeks (1.83%), down 26.8 lbs. in 3 mo. (15.12%), down 41.4 lbs. in 6 mo. (21.58%). No significant wt. change x [times] 2 weeks, but significant wt. loss x 3, 6 mo. Ht [height] 75 in. BMI [body mass index] 18.8. Estimated needs: 1915-2257 kcal (28-33 kcal/kg [kilocalorie per kilogram]), 68-82 g (1.0-1.2 g/kg) [grams per kilogram], 1915-2257 ml (28-33 ml/kg). [milliliter per kilogram] Unintended wt. loss related to increased energy needs AEB [as evidence by] significant wt. loss, pressure ulcers. Goals: 1) Maintain wt. 2) No significant wt. changes 3) PO intake 50-75% or greater 4) Improved skin integrity. Receives vit C, MVI, double portions to assist with healing. Rec: 1) Consider starting an appetite stimulant and protein supplement 30 ml BID . c. A Care Plan dated of 3/10/2022 documented, DIET: Regular diet with double portions all meals. 2.0 calorie supplement 2 times a day per physician orders. Obtain food preferences, likes / dislikes. Offer super cereal at breakfast. Provide diet per MD [Medical Doctor] order. RD [Registered Dietitian] to evaluate and make diet change recommendations. Resident has potential for nutritional deficits and/or changes in weight r/t [related to] Dx [diagnoses] of Malnutrition, [CONDITION(S)] and Vitamin Deficiency, Unspecified and Dementia with ETOH [alcohol] abuse and skin wounds. d. On 3/16/2 [TRUN

Based on observation, record review, and interview, the facility failed to ensure a newly admitted resident was closely supervised after exhibiting exit-seeking behaviors and verbalizing an intent to leave the facility, to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who were at risk for elopement. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who exited the facility undetected by staff and was found approximately 0.7 miles from facility walking by the side of a busy highway, and had the potential to cause more than minimal harm to 15 residents who were at risk for elopement, as documented on a list provided by the Administrator on 02/17/22 at 9:50 AM. The Administrator was notified of the past Immediate Jeopardy situation on 2/15/22 at 4:50 PM. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance and Anxiety Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 2/10/22 was in progress as of the survey date. a. The hospital Discharge Instructions dated 2/4/22 at 13:38 (1:38 PM), which were available for review in the resident's medical record, documented, .Reason for Admission: Pt [Patient] was getting lost, had drove his car to Oklahoma and could not find his way home. Pt. had went [sic] to the lake and was staying in his car with [CONDITION(S)] son and four dogs because he thought he was being evicted from his house . Problem / Potential Prob. [Problem] and Intervention: Patient resistant to 'losing my freedom.' Does not recognize that he needs assistance due to poor insight. Pt believes he is 'going to move to Tennessee' . Mental Status at Discharge: Alert and orientated x [times] 2, confused . Activity Order / Restrictions: Pt ambulatory ad lib [at will]. Pt door checks at times .Patient Safety Plan - Triggers / Warning Signs: Making threats and door checks . b A General Nurses Note dated 2/4/22 at 19:33 (7:33 PM) documented, . [Employee] from [Regional Hospital] called 3:20 pm and gave report on [Resident #1], resident .is an adult protective referral, . resident is still confused and exit seeking . aps [Adult Protective Service] custody . full ambulatory . resident is placed in [room number on 200 Hall], bed b . c. The Elopement assessment dated [DATE] at 18:49 (6:49 PM) documented, .Score 5 . b. Scoring: A score of 0-6 = LOW [risk] . B. Checklist . 3. Ambulation: Able to ambulate independently with or without assistive device . 5. History of wandering prior to nursing home placement: a) Yes . C. Care Plan 1. Care plan initiated and updated a. Yes . d. The Care Plan dated as initiated 2/4/22 documented, .Focus: I am an elopement risk / wanderer r/t [related to] Impaired safety awareness, dementia with behaviors and new admission to LTC [Long Term Care]. Goal: I will not leave facility unattended . Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 02/04/2022 .Evaluate for placement on a secure unit, if indicated Date Initiated: 02/04/2022 .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Intervene as appropriate. Date Initiated: 02/04/2022 . Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated 02/04/2022 . e. A Nurses General Note dated 2/5/22 at 9:10 AM documented, .Patient walked out of the facility and was noted walking on the side of Hwy [Highway] 79 in front of [local restaurant] . 1.) The Office of Long-Term Care (OLTC) Witness Statement dated 2/5/22 at 10:59 AM and signed by Certified Nursing Assistant (CNA) #2 documented, .Around 7-7:30 AM R [Resident] wandered down 100 hall. Me and 2 other aides was on hall passing trays R stopped and asked could we let him out. We stated that we were unable to. R then followed me to the dining room then followed a 400 hall CNA to their hall. Haven't seen resident since . 2.) Weather Underground's weather history report at https://www.wunderground.com/history/daily/us/ar/magnolia/KELD/date/2022-2-5 documented the temperature in Magnolia, Arkansas on the morning of 2/5/2022 was 29 degrees Fahrenheit (F.) at 8:53 AM and 34 degrees F. at 9:53 AM. f. On 2/14/22 at 12:30 PM, the surveyor was making rounds on the secure memory unit. Resident #1 asked to talk with the surveyor. The surveyor went with Resident #1 into his room. Resident #1 stated I do not belong here. Before I came here, I was put in a home and kept a prisoner for 30 days. I think it was the state that did it. After that I was let go and I tried to go home and look for my son, but he was not there, so I went looking for him. They said that I did not have any food and no water at my home. There was plenty of water and I had money on my card for food. Resident #1 was asked, Where do you live? Resident #1 stated, I think I was living in Oklahoma. Resident #1 was asked, Where were you before you came here? Resident #1 stated, I think it was [NAME], but I brought myself here, no one brought me here. I lived with my son. I do not understand why I cannot leave. I have a car. At first, I parked it over in the wooded area, and then I moved it to the parking lot. The Aide (unidentified) who was with the resident at this time showed the surveyor some papers and stated that the resident was 1 on 1 at this time for observation. The surveyor informed the resident that she would check into this for him and get back with him tomorrow. g. On 2/14/22 at 3:00 PM, Door Sitter #1 was asked, What shift do you work? Door Sitter #1 stated, I work the evening shift. Door Sitter #1 was asked, Do they have someone screening the door on all shifts? Door Sitter #1 stated, Yes they do. Door Sitter #1 was asked, Is the door to the main building kept locked at all times? Door Sitter #1 stated, Yes, it is kept locked. Door Sitter #1 was asked, Do the staff know the codes to get in and out through the door? Door Sitter #1 stated, Yes the staff know the codes. Door Sitter #1 was asked, Do the residents know the code to the door? Door Sitter #1 stated, The residents do not know the code. h. On 2/14/22 at 2:40 PM, the surveyor drove the route that Resident #1 took when he exited the building on 2/5/22. The road from the facility ends at the junction of Highway 82 and Highway 79. The resident would have turned left at this point onto Highway 79. There was a sign on the highway showing the speed limit had reduced to 45 miles per hour. The local restaurant, where the Weekend Registered Nurse (RN) documented she saw Resident #1, was 0.7 miles from the facility. Resident #1 must have crossed Highway 79 at some point on his journey to be on the side of the highway where the local restaurant was located. i. On 2/15/22 at 10:00 AM, the Weekend RN Supervisor was interviewed via telephone and was asked, What hours did you work on 2/5/22? The Weekend RN Supervisor stated, I came in early that morning. I believe it was about 6 AM. The Weekend RN Supervisor was asked, What time did you first see [Resident #1] that morning? The Weekend RN Supervisor stated, It was before 7 AM but after 6 AM. I saw him at the desk. He seemed to be confused, stating he wanted to get out of the facility. He was carrying 2 white bags and wearing a coat. The 11-7 [11:00 PM to 7:00 AM] Aide was talking to him; that's how I know it was before 7 AM. The Weekend House Supervisor was asked, What time did you leave the facility that morning when you saw the resident was outside the facility? The Weekend RN Supervisor stated, I left at about 9 AM because it was about 9:05 AM when I saw him. The Weekend RN Supervisor was asked, When you left the building, was there a screener at the door? The Weekend RN Supervisor stated, Yes. The Weekend RN Supervisor was asked, Is there always a screener at the front door? The Weekend RN Supervisor Stated, Yes ma'am, there is. The Weekend RN Supervisor was asked, Where did you see the resident? The Weekend RN Supervisor stated, I saw him by the side of the highway in front of [Local Restaurant]. I recognized him because he was wearing the same coat and carrying the two white bags. The Weekend RN Supervisor was asked, When you asked the resident to get into the car, did he come willingly? The Weekend RN Supervisor stated, Yes. The Weekend RN Supervisor was asked, Did you ask the resident where he was going? The Weekend RN Supervisor stated, Yes I did, and he stated he was going home. When he got in the car, he stated that we were going the wrong way. I told him we had some business to take care of back at the facility and he came back willingly with me. The Weekend RN Supervisor was asked, What did you do when you got him back into the building? The Weekend RN Supervisor stated, I took him back to his room on the quarantine unit. The Weekend RN Supervisor was asked, Did you notify anyone? The Weekend RN Supervisor stated, I notified the DON [Director of Nursing] when I saw him by the highway. The Weekend RN Supervisor was asked, Can you just open the double doors that go to the quarantine hall? The Weekend RN Supervisor stated, Yes you can just open them. The Weekend RN Supervisor was asked, Had [Resident #1] been staying in his room since he was supposed to be on quarantine? The Weekend RN Supervisor stated, No, he had not been staying in his room. The Weekend RN Supervisor was asked, What did the DON tell you to do once [Resident #1] was back in the facility? The Weekend RN Supervisor stated, She told me to put [Resident #1] on 1 on 1, which I did. The Weekend RN Supervisor was asked. Did [Resident #1] go back to the secure unit that day? The Weekend RN Supervisor stated, No, because he was on quarantine. The Weekend RN Supervisor was asked, Was there a dedicated staff member working the quarantine unit that morning prior to the resident leaving? The Weekend RN Supervisor stated, No. I believe the aide who had the first part of 100 hall also had the quarantine unit. The Weekend RN Supervisor was asked, Did you ask staff how the resident got out of the building? The Weekend RN Supervisor stated, Yes. The lady at the front door said no-one came through the front door except some women. The Weekend RN Supervisor was asked, Do you have any idea how [Resident #1] might have gotten out? The Weekend RN Supervisor stated, The exit door off the quarantine unit will open if you push on it. An alarm will go off if that happens, but it can be hard to hear if there is a lot going on. I did ask the resident and he stated he did not remember getting out. I walked with him to the side door, and he stated no when I asked him if that was how he got out. I walked him to the front door, and he looked at the door and pointed. The Weekend RN Supervisor was asked, Did he say he got out the front door? The Weekend RN Supervisor stated, No he did not actually say that; he did he just pointed. The Weekend RN Supervisor was asked, Did you talk to the other staff that were working? The Weekend RN Supervisor stated, I did an elopement in-service and I talked to staff. The Weekend RN Supervisor was asked, Did any of the staff state that they saw the resident leaving the building? The Weekend RN Supervisor stated, No. All the staff stated they were on the halls passing trays or giving showers. The Weekend RN Supervisor was asked, When was the resident last seen in the building prior to being found outside? The Weekend RN Supervisor stated, The Medication Nurse stated she saw him about 8:40 AM when she was giving him his medications. She remembered because at that time all he would take was his vitamin. He took his other medications when he got back to the facility. The Weekend RN Supervisor was asked, Did you check to make sure all the residents were in the building? The Weekend RN Supervisor stated, Yes we did a head count. The Weekend RN Supervisor was asked, Did someone check to make sure all the doors were functioning correctly? The Weekend RN Supervisor stated, [Human Resources employee] came in and checked all the doors. The Weekend RN Supervisor was asked, Do you know when [Resident #1] was placed on the secure unit? The Weekend RN Supervisor stated, I am not sure. I do know he was kept 1 on 1. j. On 2/15/22 at 11:10 AM, Door Sitter #2 was interviewed via telephone and was asked, What hours do you work? Door Sitter #2 stated, I work 7 AM -7 PM on the weekend. Door Sitter #2 was asked, Did you see a male leave the facility on 2/5/21 after your shift started up to 9 AM? Door Sitter #2 stated, No. I only saw females leave. Door Sitter #2 was asked, Did you sit at the front door your entire shift? Door Sitter #2 stated, Yes, except when I took my break, and I took it at 3:20 PM to 3:50 PM that day. Door Sitter #2 was asked, Did you have to take a bathroom break during your shift? Door Sitter #2 stated, No, I did not have to leave to go to the bathroom. Door Sitter #2 was asked, Who knows the code to the door to the main facility? Door Sitter #2 stated, Administration staff know it, I know it, and the regular staff know it. Door Sitter #2 was asked, Do any of the visitors know the code to the door? Door Sitter #2 stated, Some of the visitors that have had family here a long time may know the code, but most do not know the code. I did not have any visitors that day until 11 AM, though. Door Sitter #2 was asked, When did you first see the resident that left the building? Door Sitter #2 stated, When he came back in the building with the nurse. Door Sitter #2 was asked, Prior to that, did he come to the door trying to get out? Door Sitter #2 stated, No. Door Sitter #2 was asked, Are you aware of any other resident ever exiting through the front door unsupervised? Door Sitter #2 stated, No ma'am, I am not. k. On 2/15/22 at 11:33AM, Licensed Practical Nurse (LPN) #1 was interviewed via telephone and was asked, On 2/5/22, what units were you responsible for? LPN #1 stated, I had the 200 hall that includes the quarantine unit and the secure unit, and I had the COVID hall. LPN #1 was asked, How many residents were on the quarantine hall? LPN #1 stated, I believe there were 4 on the quarantine unit. The COVID hall had 2-3, I believe, and there are about 14 on the secure unit that is located behind the quarantine unit. LPN #1 was asked, Did you see [Resident #1] prior to giving him his morning medications? LPN #1 stated, I made walking rounds with the night nurse, and he was not in his room at that time. After I made rounds, I started my medications on the secure unit, then I went to the quarantine hall. LPN#1 was asked, What time did you give [Resident #1] his morning medications? LPN #1 stated, I cannot say the exact time, but it was between 8:30 AM and 8:45 AM. I know it was not as late as 9 AM. LPN #1 was asked, Did [Resident #1] talk about wanting to leave when you were giving him his medications? LPN #1 stated, He said he was not a resident, and that no doctor had prescribed any medications for him. He did not talk about wanting to leave. I explained to him who his doctor was and what medications he had ordered. He took the vitamin at that time. He took the other medications when he got back to the facility. LPN #1 was asked, How was the resident acting when he got back to the facility after leaving? LPN #1 stated, He was trying to exit, but we had him on 1 on 1 from when he got back. LPN #1 was asked, Do you have any idea how he might have been able to get out of the facility? LPN #1 stated, No, I have no idea how he got out. According to the information I had, he had got to the facility the night before. He was not talking about leaving. If he had been talking about leaving, I would have been proactive about making sure that did not happen. LPN #1 was asked, When you got report from the night nurse, did she say anything about [Resident #1] trying to leave? LPN #1 stated, No ma'am, she did not. l. On 2/15/22 at 1:15 PM, LPN #2 was interviewed via telephone and was asked, Did you work on 2/4/22 when [Resident #1] was admitted to the facility? LPN #2 stated, Yes, I did work from 7 AM to 7 PM that day. LPN #2 was asked, What areas were you responsible for on your shift? LPN #2 stated, I was responsible for 200 hall and the COVID hall [300 hall]. LPN #2 was asked, Was the resident cooperative when he admitted to the facility? LPN #2 stated, Yes he was. LPN #2 was asked, What area was [Resident #1] admitted to? LPN #2 stated, He was admitted to the quarantine area on the front of 200 hall. LPN #2 was asked, After [Resident #1] was admitted , did he stay in his room? LPN #2 stated, He was coming out of the room and wanted to see his son, but he could be re-directed, and I explained they would help him check on that in the morning. LPN #2 was asked, Did [Resident #1] attempt to exit seek while you were caring for him that evening? LPN #2 stated, No he did not go towards any exits while I was there. Another nurse came at 7 PM to relieve me. LPN #2 was asked, Who made [Resident #1's] room assignment? LPN #2 stated, The DON gave me the room number . LPN #2 was asked, Did you receive a report from the facility that [Resident #1] was transferred from? LPN #2 stated, Yes. LPN #2 was asked, Did the transferring facility tell you that [Resident #1] was exit seeking? LPN #2 stated, Yes they said that he was confused and exit seeking and that he would need to be placed on a secure unit. LPN #2 was asked, Did you tell the DON that the facility said the resident was exit seeking? LPN #2 stated, No ma'am, I don't think that I did. I did think that she had already had report on him. m. On 2/15/22 at 1:25 PM, Certified Nursing Assistant (CNA) #1 was asked, Were you working the day [Resident #1] eloped from the facility? CNA #1 stated, I was working on the 100 hall. CNA #1 was asked, What time did you first see [Resident #1] that morning? CNA #1 stated, I saw him about 7:15 AM just after I first came into work. I knew we were getting a new admission. At that time, he was standing in front of the nurses' station. CNA #1 was asked, When did you next see the resident? CNA #1 stated, I had the breakfast trays on 100 hall and me and two other aides were passing out the trays. The resident approached us and asked me to help him get out. He had two hospital bags. He looked more like a family member, but because I had seen him earlier, I told my co-workers he was a resident. [CNA #2] walked him back up the hall trying to re-direct him. The next time I saw him, the RN Supervisor was bringing him back in the facility. CNA #1 was asked, Do you have any idea how [Resident #1] got out of the facility? CNA #1 stated, I think he must have gone out the front door. If he had gone out of any other door the door the alarm would have gone off and I did not hear any alarms going off before he was brought back to the facility. n. On 2/15/22 at 1:55 PM, the Director of Nursing (DON) was asked, Where did [Resident #1] admit from? The DON stated, He admitted from the psychiatric part of [Regional Hospital]. The DON was asked, Do you know why he was admitted to the hospital? The DON stated, According to the notes from the hospital, he was pulled over by the police. He was confused and appeared to be lost. His son, who was in his 50s and has [CONDITION(S)], was in the car with him. They were both taken to the hospital in [NAME]. APS got involved and his son was found placement. The DON was asked, How did you decide where to place the resident in the facility? The DON stated, He was not vaccinated, and no-one knew if he had recently had COVID, so he was placed on the quarantine hall. The DON was asked, Did you see the resident on the day that he admitted ? The DON stated, No it was after I had already left for the day. The DON was asked, Were you concerned that he would attempt to elope? The DON stated, No I did not have any reason based on the referral paperwork that I had received? The DON was asked, Did you get a report on the patient on the day that he admitted ? The DON stated, The report was called to the floor nurse. The DON was asked, Did you see the paperwork that is in the electronic record from the hospital prior to the resident admitting? The DON stated, No. I believe that paperwork came with the resident. The paperwork I saw was the referral and that was dated prior to when he was ready for discharge to the facility. They were still working on getting him ready to be discharged . The DON was asked, Did the charge nurse that was there when the resident admitted tell you that the resident was an elopement risk? The DON stated, No she did not tell me. I did text her about the resident and she told me he was in his room and doing well. The DON was asked, Who notified you the morning that the resident eloped? The DON stated, [Staff member name], the Weekend RN Supervisor called me from her car and told me she had picked him up. The DON was asked, What did you instruct the Weekend RN Supervisor to do? The DON stated, I instructed her to take him back to the facility and have someone stay one on one with him. I called the Administrator to start the elopement process. The DON was asked, How did you go about determining how the resident had gotten out of the facility? The DON stated, The Weekend Supervisor reported that none of the doors at the facility had been alarming at the time that he left the facility. She checked every door to make sure that the alarm worked if the door was opened, and all the alarms worked. When the resident was asked, he stated he went out the front door, but he said no-one let him out. The front door has to be open with the code, but it has a 30-second delay locking system. We are not sure if he followed someone out. The DON was asked, Do you always have someone at the door screening as people enter and leave? The DON stated, Yes, we have someone on every shift. The DON was asked, Did you ask the person who was at the door that day doing the screening if they saw the resident go out? The DON stated, Yes we asked her, and she said she did not leave the door and she did not see any males leaving the facility. The DON was asked, When did you put the resident on the secure unit? The DON stated, We put him on that day with someone still staying one on one with him. The DON was asked, When visitors are in the facility, how do they get out? The DON stated, They knock on the door and the Door Sitter lets them out. o. On 2/15/22 at 2:40 PM, LPN #3 was interviewed via telephone and was asked, Did you care for [Resident #1] on 2/4/22 on the 7 PM to 7 AM shift? LPN #3 stated, Yes he was admitted right before I came in that evening to work. LPN #3 was asked, What areas were you responsible for on your shift? LPN #3 stated, I was responsible for the quarantine unit, the secure unit on 200 hall and the COVID unit. LPN #3 was asked, How did [Resident #1] behave during your shift? LPN #3 stated, He was sitting in a chair in his room when I first came to work. During the shift he was sleeping most of the time. LPN #3 was asked, Did you have to give him any medications during your shift? LPN #3 stated, No. I do not believe his medications had come in from the pharmacy, but I did not have to give him any medications. LPN #3 was asked, Did [Resident #1] attempt to leave at any time? LPN #3 stated, He did not try to leave. He was asleep most of the night. p. The policy report titled, Elopement Prevention and Management, dated as revised 06/21 documented, POLICY: The facility strives to prevent resident/patient elopement . The facility defines elopement as follows: when a cognitively impaired resident/patient leave the physical structure of the facility unattended and without staff knowledge . PURPOSE: 1. To identify residents/patients at risk for unsafe wandering and exit seeking behavior. 2. To develop individualized prevention and management interventions based on exit seeking/Elopement Evaluation . Procedure: 1. Complete admission evaluations including, but not limited to, the following: Telephone Referral and Preadmission Evaluation, Nursing Comprehensive Admission and Quarterly Evaluations (Including Exit Seeking/Elopement Risk Evaluation . q. The facility removed the immediate jeopardy and corrected the failed practices on 02/05/2022, prior to the survey, as evidenced by the following: 1.) The corrective plan of action for resident elopement, provided by the DON on 2/15/2022 at 4:40 PM documented: Step #1 Corrective Action On 02/05/22 immediately upon notification of resident elopement: A. DON/Designee completed elopement risk assessment on all residents. B. DON/Designee updated the elopement binder and placed elopement binder in front lobby. C. Maintenance/Designee completed elopement drills for all shifts. Step #2 Identification of others with the potential for being affected: On 2/5/2022 Administrator verified with the census that 15 residents had the potential of being affected that were at risk for elopement Step #3 To ensure deficient practice does not recur: On 02/05/2022: A. DON/Designee ensured interventions were implemented for all residents who are at risk for elopement B. DON/Designee in-serviced all staff on the location of the elopement binder C. Maintenance/Designee educated staff on elopement drill policies and procedures. Step #4 Monitoring A. DON/Designee will monitor all residents and new admissions for elopement risk assessments for 6 weeks. B. DON/Designee will update the elopement binder and place in front lobby weekly for 6 weeks and as needed. C. Maintenance/Designee will monitor elopement drill on every shift immediately after incident and randomly on shifts weekly for 6 weeks. 2.) An In-service dated 2/5/22 on the 7:00 AM to 3:00 PM shift and with the Elopement Prevention and Management Policy attached documented, .Topic Elopement Procedure . Elopement Drill - All responded - No issues . 3.) An In-service dated 2/5/22 on the 3:00 PM to 11:00 PM shift and with the Elopement Prevention and Management Policy attached documented, .Topic Elopement Procedure . Elopement Drill - All responded - No issues . 4.) An In-service dated 2/5/22 on the 11:00 PM to 7:00 AM shift with the Elopement Prevention and Management Policy attached documented, .Topic Elopement Procedure . Elopement Drill - All responded - No issues . 5.) On 2/15/22 at 1:55 PM, the DON was asked, What else did you do after the elopement occurred? The DON stated, We immediately updated all the residents' elopement assessments. We updated the elopement binder. We put the binder at the front desk with the door sitter so that whoever was working the door would be aware of all the residents that are at risk for elopement. The DON was asked, Does the binder have pictures of the residents? The DON stated, Yes it does. All the staff including the door sitters were in-serviced regarding elopement, and this included that the binder had been updated and was now located at the front door. We also did elopement drills on all three shifts. The DON was asked, Do you have any residents that are not on the secure unit that are exit seeking? The DON stated, No. Some are in the elopement book as based on our assessment, they have the potential, but anyone who is actually exit seeking, would be reassessed, placed one on one and moved to the unit if a male. Our unit is all males. Females would remain one on one until appropriate placement could be found for them.

Complaint # (AR 722) was substantiated, all or in part with these findings. Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to promote healing and prevent infection for 2 (Residents #4 and #5) of 3 (Residents #3, #4 and #5) case mix residents who had pressure sores, as evidenced by failure to consistently conduct and document wound assessments and promptly identify and address deterioration of a pressure ulcer for Resident #4 after he developed a Stage 3 decubitus; and failure to obtain a treatment order and regularly monitor a wound for Resident #5 after he developed a wound on his toe. The failed practices resulted in a pattern of actual harm for Residents #4, who experienced a significant weight loss and wound deterioration, resulting in hospitalization [MEDICAL CONDITION] and wound debridement, and Resident #5, who was identified with a small toe wound which was then covered with a Band-aid and provided with no further treatment for [REDACTED]. The failed practices also had the potential to cause more than minimal harm to 14 residents who had pressure sores, according to a list provided by the Registered Nurse (RN) Consultant on 10/31/19 at 10:26 a.m. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/31/19 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance from 2 people for bed mobility, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers but had no pressure ulcers. a. The Plan of Care documented, Date initiated: 1/24/19. The resident has potential impairment to skin integrity related to b/b (bowel and bladder) incontinence and impaired mobility. b. The Weight Summary dated 7/1/19 documented, 177.2 lbs (pounds). c. The Weight Summary dated 8/2/19 documented, 172.8 lbs. d. The Skin Observation Tool dated 8/13/19 documented, Groin redness. No new skin issues at this time. e. A Physician order [REDACTED]. There was no documentation of a wound assessment, with measurements, until 8/20/19. f. The Skin Observation Tool dated 8/20/19 documented, Site: Sacrum. Type: Pressure. 5 cm (centimeters) x (by) 3 cm x 0.2 cm. Stage: 3. Continue treatment as ordered. There was no documentation of a description of the wound, presence or absence of odor or drainage, and condition of the surrounding tissue. g. The Skin Observation Tool dated 8/27/19 documented, Site: Sacrum. Type: Pressure. 3.4 cm x 2.8 cm x 0.2 cm. Stage: 3. No new skin issues. There was no documentation of a description of the wound, presence or absence of odor or drainage, or the condition of the surrounding tissue. h. The Skin Observation Tool dated 9/3/19 documented, Site: Coccyx. Type: Pressure. 4.8 cm x 3.0 cm x 0.2 cm. Stage: 3. There was no documentation of a description of the wound, presence or absence of odor or drainage, or the condition of the surrounding tissue. i. The Weight Summary dated 9/5/19 documented, 158.1 lbs. According to the documented weight on 8/2/19 of 172.8 pounds, this was an 8.5% weight loss in one month. j. The Weight Summary dated 9/10/19 documented, 159.9 lbs. k. The Skin Observation Tool dated 9/10/19 documented, Site: Coccyx. Type: Pressure. Stage: 2. Continue treatment plan. There was no documentation of a description of the wound, presence or absence of odor or drainage, or the condition of the surrounding tissue. l. A Nurse's Note dated 9/16/19 at 1:31 p.m. documented, Resident has the stomach virus. MD (Medical Doctor) notified. MD stated [MEDICAL CONDITION] has to run its course and encourage fluids and Gatorade. If resident's N/V (nausea and vomiting) gets worse, notify MD . m. The Weight Summary dated 9/17/19 documented, 150.3 lbs. n. The Skin Observation Tool dated 9/17/19 documented, Coccyx. Type: Pressure. Stage: 2. Continue treatment plan. There was no documentation of a description of the wound, presence or absence of odor or drainage, or the condition of the surrounding tissue. o. A Nurse's Note dated 10/1/19 documented, Resident noted to have Stage 3 pressure ulcer to sacrum 9 cm x 12.3 cm x 0.2 cm. No odor noted. 40% slough, 60% granulation tissue. Hyper granulation tissue noted. Scant serous drainage noted. New order obtained for plan of treatment. Resident noted to be on low air loss mattress at this time. Will continue to observe and note any changes and address any needs. p. A Weekly Wound Note dated 10/15/19 and signed by RN #1 documented, Site: Coccyx. Description: 25% granulation tissue, 25% [MEDICATION NAME] tissue, 50% slough. Pressure. Stage 3. 7 cm x 8 cm x 0.2 cm. Small amount of exudate. No odor. Surrounding skin color: Normal for skin. No tunneling. No undermining. No signs of infection. q. A Nurse's Note dated 10/19/19 at 2:52 p.m. documented, 7:45 a.m., V/S (vital signs) reported to (physician). Also, manual BP (blood pressure) was retaken at 9:00 a.m. and resident BP (blood pressure)124/76 . 10:48 a.m. (physician) was notified by this nurse that family wanting to send out resident to hospital. Orders were given to this nurse to send to (hospital) for evaluation . r. A hospital Progress Note dated 10/21/19 documented, .Since the source of the septic episode is the severely infected pressure ulcer, an aggressive debridement is recommended . s. A hospital Progress Note dated 10/22/19 documented, IMPRESSION AND PLAN: .admitted for UTI (urinary tract infection) on [MEDICATION NAME] 1 g (Gram) Q24H (every 24 hours) . wound care consulted for decubitus ulcer . Pt (patient) will be taken for surgical debridement tomorrow morning .[MEDICAL CONDITION] secondary to decubitus sacral ulcer . wound cx (culture) prelim (preliminary) proteus and e.coli (Escherichia coli) . t. A Nurse's Note dated 10/24/19 at 8:16 p.m. documented, Resident readmitted from hospital . Pressure ulcer of sacral region Stage 3 . Weight 168.7 lbs . Resident returned to facility with debridement to his sacral decubitus ulcer being done at (hospital) . u. The Weight Summary dated 10/27/19 documented, 168.7 lbs. v. As of 10/28/19 at 4:30 p.m., five days after the resident's return to the facility, there was no documentation of an assessment of the pressure ulcer to the sacrum / coccyx upon readmission, to provide the nursing staff with a baseline assessment of the measurements and condition of the pressure ulcer upon the resident's return from the hospital. w. On 10/29/19 at 11:25 a.m., the resident was observed in bed. Registered Nurse #1 was observed performing the treatment on the resident's sacral wound. Certified Nurse Assistant (CNA) #1 was assisting with the positioning of the resident. The resident had just been showered. The wound measured 12 cm x 6.5 cm x 1.0 cm. There was undermining from 12 o'clock to 12 o'clock. There was a 5 cm tunnel at 12 o'clock, a 3 cm tunnel at 7 o'clock, a 6.5 cm tunnel at 9 o'clock and a 6 cm tunnel at 11 o'clock. The wound bed was 80% slough and 20% granulation. Sutures were present at 2 different locations of the outer edges of the wound. There was a moderate amount of serosanguinous drainage. No odor was noted. The treatment nurse stated the wound had declined. The surveyor took a photograph of the pressure ulcer at this time. x. On 10/29/19 at 8:14 p.m., Licensed Practical Nurse (LPN) #1 was asked to explain her recent role at the facility, including treatment nurse. She stated, I was trying to do treatments, the ADON (Assistant Director of Nursing) duties, working the floor and doing the scheduling for the CNAs. She was asked to talk about Resident #4. She stated, He went from having a raw spot on his genital area to having breakdown on his bottom. She was asked about only having measurements on his pressure sore and not a better description of the wound from the time it was identified until 10/1/19. She stated, They kept telling me they would send someone down to train me for doing treatments, but no one came. She was asked about the lack of documented wound assessments between 9/17/19 - 10/1/19 and 10/1/19 - 10/15/19. She stated, During that time, I was working the floor, and the floor nurses were supposed to be doing their own. I couldn't do that plus everything else I was supposed to be doing. y. On 10/30/19 at 10:25 a.m., RN #1 was asked if she saw a decline in the resident's wound from 10/14/19 until he went to the hospital 10/19/19. She stated, No, I didn't. I didn't really have much to go on because there was not an assessment the previous week, so I didn't know what the wound looked like recently. But I went back to the assessment on 10/1 and that made me think the wound had improved some, so I stuck with the same treatment. I was going to give that treatment a week and see how he did, then change it if there was no improvement. But he went to the hospital before the week was up. z. On 10/31/19 at 10:04 a.m., the Dietary Manager was asked why there were no dietary interventions promptly after the resident's weight loss was identified on 9/5/19? She stated, I can't just go and add stuff like mighty shakes. I have to have an order from the nurses. I can do ice cream and stuff like that, but supplements I have to have an order. She was asked if she called the Registered Dietician (RD). She stated, No, I didn't. The RD we did have . I would message her and would never get a response, so I didn't know who else I could call. We just got a new RD this month. She was asked if she went to the Director of Nursing (DON) to try and get an order for [REDACTED]. But restorative lets me know when someone has a weight loss. I put them on cheesy eggs, super cereal and stuff. The restorative person told me on 9/17/19 about this weight loss and I started him on cheesy eggs, super cereal and ice cream, lunch and supper. We were without an RD for about a month. I kept trying to contact her, but she wouldn't call me back. aa. On 10/31/19 at 10:52 a.m., the DON was asked if there were any documented wound assessments between 9/17 - 10/1/19 and 10/1 - 10/15/19. She stated, No, I don't know of any. 2. Resident #5 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 7/26/19 documented the resident scored 9 (8-12 indicates moderately impaired) on the BIMS, required extensive assistance from 2 people for bed mobility, had no pressure sores or foot problems but was at risk for pressure ulcers. a. The Plan of Care dated 9/4/19 documented, The resident has Diabetes Mellitus Interventions .Check all body for breaks in skin and treat promptly as ordered by doctor. b. A Weekly Wound Note dated 10/17/19 and signed by RN #1 documented, Description: Left 3rd and 4th toe 100% slough noted. Pressure. Unstageable due to slough/eschar. 4 cm x 3 cm x 0.2 cm. Moderate, purulent exudate. Odor present. Surrounding skin color: bright red. Signs of infection. 3rd toe is covered in 100% slough. 4th toe is slightly broken down. 5th toe is swollen and inflamed. (Physician #1) notified. (Physician #2) notified, will see resident 10/18/19 at 10:30 a.m. Will await wound care orders. c. A Nurse's Note dated 10/17/19 at 5:51 p.m. and signed by LPN #2 documented, Notified by treatment nurse and DON that res (resident) had a band-aid that had been left on his left foot for a while and on the 3rd toe, the bone was showing. 4th and 5th toes have [MEDICAL CONDITION]. N.O. (New order) to start Keflex 500 mg (milligrams) BID (twice daily) for infection and treatment to treat as ordered . d. A physician progress notes [REDACTED].He has necrosis on the left 3rd toe, wound measures pre 1.5 x 0.7 x 0.2, post 2 x 1 x 0.25 with bone prominent. It was cleaned and then covered with Iodosorb gel and a dressing. He is scheduled for an amputation of the toe on 11/12/19 . e. The Physician order [REDACTED]. f. On 10/29/19 at 11:07 a.m., the resident was in a wheelchair in his room. The Treatment Nurse was present and performed the resident's treatment to his foot (left 3rd toe). The area measured 2cm x 2cm x 0.3 with 40% stable eschar, 30% [MEDICATION NAME] and 30% granulation tissue. A mild odor was noted. There was a small amount of serosanguinous drainage. The area was cleaned with a 4x4. Collagen with silver was placed on the wound, a non-adhesive pad placed over that and then the foot was wrapped with kling and secured with tape. The RN stated, It looks so much better than when I first saw it on the 17th. I'm hoping the doctor decides to not do the amputation because it has improved so much. A picture was taken of the area on the resident's toe by the surveyor at this time. There was no bone visible during this observation. g. On 10/30/19 at 1:18 p.m., CNA #2 was asked to explain what happened with Resident #5 when he got the band-aid put on his toe. She stated, I gave him a shower and I noticed his toe was bleeding. After the shower I dried him off and took him to his room. I reported it to (LPN #2). She put a band-aid on it. Then his next shower day, I noticed the same band-aid was still on there, so I went and reported it to the Treatment (Tx) nurse. I didn't want to pull it off. All I know is that they took him to the doctor, and he came back upset because the doctor has to cut his toe off. h. On 10/30/19 at 2:29 p.m., LPN #2 was asked about her role involving Resident #5. She stated, He had what looked like a scab that had been knocked off. So, I put a band-aid on it. I told (Consultant) that I probably got busy and just forgot about it. I think they found it like 5 days later. It's my fault. I should have done an I/A (Incident and Accident Report). He had just had two [MEDICAL CONDITION] a couple of days before so it might have happened then . 3. On 10/31/19 at 10:00 a.m., the Registered Nurse Consultant provided documentation of in-services that had been conducted since 10/17/19. They included in-services on I/As, body audits, wounds and obtaining treatment orders. She provided a Disciplinary Action Report dated 10/17/19 for LPN #2 that documented, Report and make incident report of all incidents. (Resident #5) had a cut on his toe which caused necrotic tissue. She provided an In-service Training Report dated 10/17/19 for LPN #2 that documented, Body audit on all admissions, remove dressings to assess areas, document. Complete I/A for any incident requiring investigation and affecting a resident. Suggestions - use a note pad to write reminders and check at close of shifts . The Consultant stated a new treatment nurse was hired on 10/14/19 and will be responsible for doing all body audits and wound assessment documentation, and a corporate nurse comes to the facility weekly to monitor her and make sure the body audits are being done weekly. 4. The facility's Wound Care Monitoring Policy provided by Registered Nurse #2 on 10/29/19 documented, To promote healing, prevent infections, and prevent new pressure ulcers from developing . A licensed nurse will assess the pressure ulcer weekly and keep the physician informed of progress with prescribed treatments . The Wound Care Coordinator or licensed nurse that is responsible for the wound care will examine wounds weekly to assess and document findings. The Wound Care Coordinator or licensed nurse will complete a weekly wound description in the resident's health record. Documentation will reflect if dressing is intact, drainage noted, pain associated with the wound, any odor and condition of surrounding skin which is visual around dressing.

Based on observation, record review and interview the facility failed to ensure their abuse prohibition policies and procedures were promptly and thoroughly implemented, as evidenced by failure to ensure an allegation of physical abuse was immediately reported to the Administrator and thoroughly investigated and that protective measures were continued until a thorough investigation could be completed, to prevent further potential abuse or injury after a cognitively impaired resident with a visible injury verbalized an allegation of abuse; failure to ensure staff postponed direct care during a period of agitation and combative behavior to prevent injury to the resident; and failure to ensure a subsequent incident of bruising of unknown origin was thoroughly investigated to rule out possible abuse or neglect for 1 of 1 (Resident #21) cognitively impaired case mix resident who verbalized an allegation of abuse. The failed practices resulted in Immediate Jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #21, who voiced an allegation of physical abuse after being discovered with an injury, and had the potential to affect 40 residents who were cognitively impaired, according to a list provided by the Director of Nursing (DON) on 6/24/16. The facility was informed of the immediate jeopardy situation on 6/23/16 at 6:05 p.m. The findings are: 1. The facility's Abuse Prohibition Policy and Procedure, provided by the Administrator on 6/20/16 at 1:12 p.m., documented, .Policy: It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations), are reported immediately to the Administrator of the facility. Such violations will also be reported to state agencies in accordance with existing state law. The Administrator or his/her designee will direct a thorough investigation of each such alleged violation. The administrator or his/her designee is responsible to report the results of all investigations to the state agencies as required by state and federal law . Identification: Immediate reporting of suspected violations is the responsibility of and shall be required by all staff. Protection: If the circumstances require it, the DNS (Director of Nursing Services) or his/her designee shall remove a resident suspected of being the subject of an alleged violations to an environment where the resident's safety can be protected . If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigatory suspension while completing the investigation . When the circumstances of the alleged violation warrants, the DNS or his/her designee shall initiate a physical and mental assessment of the resident and document the findings . Investigation: All investigations shall be conducted by the Administrator or DNS. In the event an alleged violation occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure. The investigation shall include interviews of employees, visitors or residents who may have knowledge of the alleged incident. Factual information only should have documented, not assumptions or speculation. Written statements from involved parties should be requested, utilizing the required Staff Witness form . Corrective Action: The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The DNS or his/her designee shall initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures and should be documented . 2. Resident #21 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 4/11/16 documented the resident scored 6 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, had inattention and disorganized thinking continuously present, required extensive assistance of one person for dressing, toileting and personal hygiene, was frequently incontinent of bladder and bowel, exhibited verbal behavioral symptoms directed towards others on 1 to 3 days of the 7-day assessment period and wandering behaviors daily, but did not exhibit physical behavioral symptoms directed toward others or rejection of care. a. The Care Plan dated 1/11/16 and reviewed/ revised 4/11/16 documented, . I display physically aggressive behavior at times . Approaches . Do not argue with me . Identify causes for my behavior and reduce factors that provoke me . Resident screams + (and) curses at times . 1/30/16 Skin tear to left elbow (with) bruise. PRN (as needed) med (medication) administered as ordered for agitation . 2/22/16 Bruise top left hand. Side rail padded . 4/1/16 two small bruises to left inner forearm . Resident is ambulatory ad lib per self + noted to swing arms when ambulating, frequently bumping into chairs + other objects. Staff WCTM (will continue to monitor) + redirect as needed . There was no documentation on the Care Plan to indicate that the resident had any history of making abuse allegations related to these injuries. b. Departmental Notes dated 3/3/16 through 4/3/16 documented no incidents of physically aggressive or combative behavior and no documentation the resident made any allegations of abuse against staff, visitors or other residents. c. A Departmental Note dated 4/4/16 at 12:14 p.m. and signed by the Activity Director documented, Quarterly Note. Resident is alert, able to make some needs known, with continual confusion. Resident is able to ambulate independently. Resident enjoys people watching, snack and TV time, donut socials . Resident does have behavior issues at times he is combative . d. A Departmental Note dated 4/7/16 at 6:31 a.m. documented, CNA (Certified Nursing Assistant) came and got nurse to assist with resident due to very agitated during care. Had large BM (bowel movement) with incontinent care being given per staff. Resident began hitting staff, cursing at staff, hollering at staff and kicked LPN (Licensed Practical Nurse) in stomach. AM (morning) care given per staff after much encouragement. Resident has refused to get up out of bed, left in bed per staff due to agitation. Will continue to monitor. e. A Departmental Note dated 4/7/16 at 2:09 p.m. and signed by LPN #1 documented, Earlier this a.m., staff notified this nurse that prior to performing care to resident he had a patient gown on and when the CNAs were attempting to remove the gown, an open area and reddened area noted to left arm. CNA notified this nurse I was needed in room to assess resident, once this nurse entered the room bruise and skin tear noted to left upper-outer arm because the left sleeve of the gown was raised and this nurse was able to see the area from the door and once carefully examining the area was able to note the above findings, CNAs also says that resident being very combative with them and seems to be very upset once resident was cleaned and dressed he was assisted up to dining area and he was very anxious at this time and he began to swing his arms all about and this nurse asked him what was wrong and he says 'they hit me, and they said it is my fault' this nurse reassured resident that nothing is his fault notified DON (Director of Nursing) of this statement and resident being monitored closely near nurse's station notified APN (Advanced Practice Nurse) of incident with new order noted to clean skin tear to left upper-outer arm with Saf Cleans, pat dry and apply steri strips, monitor daily for s/s (signs/symptoms) of infection until healed also inservice all unit staff concerning this matter which says if resident becomes anxious prior to or during care to notify nurse and give him a while to settle before attempting to complete care notified RP (responsible party) . of incident and investigation of incident . 1.) A Witness Statement dated 4/7/16 (no time) documented, .Narrative of incident: I, (CNA #2) was in (Resident #21's) room with (CNA #3) assisting getting (Resident #21) cleaned up. (CNA #3) was remove (Resident #21's) gown she noticed a skin tear and I went and got the nurse immediately. 2.) A Witness Statement dated 4/7/16 (no time) and signed by CNA #18 documented, I went in the room, ran the bathroom sink so water can get warm. I got his clothes and shoes together. 'Morning Mr. (name) time to get up for breakfast.' He just nod. I asked him to turn on his back which he didn't. 'wake up Mr. (name) time to get up'. Pull sheets back, resident had BM on himself. 'Mr. (name) you need to get up so I can clean you, you're dirty'. Patient said no. 'Come on Mr. (name) don't you want that mess off of you.' He wouldn't move. Got his legs to turn him toward edge of bed. He started kicking. 'Mr. (name) don't be kicking now I gotta get you up so you can get clean.' I grab his hand and tried to pull him up he started swinging. I went and got my nurse. She tried to talk to him, he kicked or swung at her. She told me to let him stay in bed clean him in bed. I went and gather clean linen. He was laying on side so I started from bed and got him halfway clean. 'Mr. (name) will you turn for me.' He wouldn't move. I tried to move him he started swinging. 'Mr. (name) the sooner you do right the easier /faster it would be and I promise you I'll leave you alone.' So I went to other side of bed and tried to turn him he started kicking and swinging I left and got the nurse again. She tried to talk to him but he still kicking. She had to help me finish putting the diaper on him we covered him back up we both left. 3.) A Witness Statement dated 4/7/16 (no time) and signed by CNA #3 documented, I (CNA #3) was in (Resident #21's) room assisting (CNA #2) in getting (Resident #21) cleaned up. (Resident #21's) gown was being removed and I noticed a skin tear with dried up blood on his left arm. the nurse was told immediately. 4.) A Witness Statement dated 4/7/16 at 6:15 a.m. and signed by LPN #6 documented, .6:15 a.m. the CNA (CNA #18) came to resident's door and asked if I could come and help her clean and change resident because he was fighting her and he needed to be cleaned up because he had BM (bowel movement) on him. I entered room with CNA and walked over to his bed; both of us on same side. We attempted to talk with resident and explain we needed to clean him up. As soon as we began to turn resident over to finish cleaning him and change his brief he began hitting staff, swinging his arm about bumping numerous things. I leaned over to try and talk with resident while during care to assist and clean resident without success. As soon as I leaned over he kicked me in the stomach. I stepped back and told the CNA to wait a bit before doing anything else. She left room to go and get another brief due to BM had gotten on clean one while he was moving around and fighting us in bed. When the CNA came back in with the clean brief I walked to other side of bed. LPN on one side and CNA on other side. I touched resident on shoulder and explained we needed to turn him over from side to side to put clean brief on. As soon as we touched resident and started turning him over, he began to holler and started hitting and thrashing arms and legs again. We got brief on as good as we could. Put side rail back down on bed. Put clean sheet and spread on resident, picked up soiled linens/brief and left room. No further Witness Statements were included in the facility's written investigation. 5.) On 6/23/16 at 3:20 p.m., the DON was asked, If a resident has injuries and states, 'they hit me and said it is my fault', what should you do? The DON stated, Report it to CEO (Chief Executive Officer) so investigation can be started. She was asked, Then what would you do? She stated, Start an investigation, do an inservice on Abuse/Neglect. The DON was asked, Once it has been reported, what do you do? The DON stated, Ask them to get statements of who is working at the time. Go to the prior shift and ask questions. The DON was asked, What do you do for the resident? The DON stated, I interview them ask, 'has anyone harmed you or are you afraid?' If they say 'yes', person named is suspended; if no person is named, get statements / interviews with staff members. See if the resident can describe the person. The DON was asked, What do you do about protecting the resident? The DON stated, I ask them if they are afraid, 'has anyone hurt you? If they say no, I continue with the investigation. If they say yes, they are placed on 1:1 (one on one) monitoring until the investigation is complete. The DON was asked, Did you investigate the allegation of abuse verbalized by (Resident #21) on 4/7/16? The DON stated, I went down and talked to him. I asked him about who hit him and he just kept saying, 'I don't know'. 6.) On 6/23/16 at 4:45 p.m., the DON was asked, When (Resident #21) made this allegation, how long did staff monitor him? The DON stated, He was still up at lunch time. He was walking the halls a lot. The DON was asked, What did you do once (the allegation) was reported to you? The DON stated, I went down and interviewed him and he said, 'I don't know, I don't know', when I asked him if someone hit him. I made sure they contacted the 11 to 7 (11:00 p.m. to 7:00 a.m.) shift to get statements. I think the ADON (Assistant Director of Nursing) did this; she was the Treatment Nurse at the time. At that point in time, he could not tell me anyone hit him, so I ceased the investigation, because we had talked to the nurse and aides on the phone to get their statements and it wasn't an injury of unknown origin. The DON was asked, How was it not an injury of unknown origin? The DON stated, Because they did not change his gown during care, because he was fighting; they didn't see any injury. The DON was asked, Would you normally cease an investigation once a resident couldn't tell you what happened? The DON stated, Not anymore, I won't. 7.) On 6/24/16 at 8:27 a.m., LPN #1 was asked, How long did you monitor the resident after he told you, 'they hit me and said it is my fault'? The LPN stated, The whole day. When asked how the resident was monitored, the LPN stated, We had staff with him, we asked again and he changed his statement. The LPN was asked, Had he ever made allegations like this before? The LPN stated, I don't know. Departmental Notes dated 4/7/16 at 10:35 p.m. documented the resident was up and down out of his chair, walking the halls and talking, and there was no documentation of 1 on 1 supervision or ensuring that 2 or more staff members were present at all times when the resident required personal care. f. An Incident Report dated 6/23/16 at 8:00 a.m. and signed by LPN #8 documented, .Incident type: Other, Type of Injury: Bruise, Location: Resident Room . Narrative of incident and description of injuries: (LPN #3) stated I walked into room to assess resident for daily body audit. Upon entering room saw resident laying (sic) in bed on back no s/sx (signs or symptoms) of pain looked at right arm noticed a 3 x (by) 0.8 cm (centimeter) bruise to right upper arm. Resident unable to explain what happened. Upon investigating, bruise shaped identical to call light. Bruise to right upper arm . Post Incident Actions: .Immediate Post Incident Action: Staff inservice when turning resident in bed be cautious of placement of call light . No further investigation was documented and no witness statements were attached to the form. g. The immediate jeopardy was removed and the scope and severity was reduced to E on 6/23/16 , when the facility initiated the following Plan of Removal: 1. Two staff must go into the resident's room at any time ADL (Activities of Daily Living) care is provided. 2. The facility staff will receive inservice training regarding the need for two staff to be present when providing care to (Resident #21). This inservice began last night (6/23/16) with those staff on duty and will be ongoing until all staff have been trained. All employees will be required to receive this inservice prior to returning to work. 3. All of the interventions put into place for (Resident #21) are noted in his care plan. 4. Future I&A's (incidents and accidents) will be monitored by the DON or designee to ensure they are handled properly. 5. An investigation has been initiated regarding the incident where the resident stated, they hit me and the incident has been reported to OLTC (Office of Long Term Care). All other I&As for this resident related to bruising will be investigated by the Administrator, DON or designee. 6. All facility staff will receive inservice training regarding prevention of abuse and neglect and protecting a resident when an allegation of abuse or neglect has been made. This inservice began last night with those staff on duty and will be ongoing until all staff have been trained. All employees will be required to receive this inservice training from the Staffing coordinator or designee prior to returning to work.

Based on observation, record review and interview the facility failed to ensure an allegation of physical abuse was immediately reported to the Administrator and thoroughly investigated and that protective measures were continued until a thorough investigation could be completed, to prevent further potential abuse or injury after a cognitively impaired resident with a visible injury verbalized an allegation of abuse; failed to ensure staff postponed direct care during a period of agitation and combative behavior to prevent injury to the resident; and failed to ensure a subsequent incident of bruising of unknown origin was thoroughly investigated to rule out possible abuse or neglect for 1 of 1 (Resident #21) cognitively impaired case mix resident who verbalized an allegation of abuse. The failed practices resulted in Immediate Jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #21, who voiced an allegation of physical abuse after being discovered with an injury, and had the potential to affect 40 residents who were cognitively impaired, according to a list provided by the Director of Nursing (DON) on 6/24/16. The facility was informed of the immediate jeopardy situation on 6/23/16 at 6:04 p.m. The findings are: Resident #21 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 4/11/16 documented the resident scored 6 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, had inattention and disorganized thinking continuously present, required extensive assistance of one person for dressing, toileting and personal hygiene, was frequently incontinent of bladder and bowel, exhibited verbal behavioral symptoms directed towards others on 1 to 3 days of the 7-day assessment period and wandering behaviors daily, but did not exhibit physical behavioral symptoms directed toward others or rejection of care. a. The Care Plan dated 1/11/16 and reviewed/ revised 4/11/16 documented, . I display physically aggressive behavior at times . Approaches . Do not argue with me . Identify causes for my behavior and reduce factors that provoke me . Resident screams + (and) curses at times . 1/30/16 Skin tear to left elbow (with) bruise. PRN (as needed) med (medication) administered as ordered for agitation . 2/22/16 Bruise top left hand. Side rail padded . 4/1/16 Two small bruises to left inner forearm . Resident is ambulatory ad lib per self + noted to swing arms when ambulating, frequently bumping into chairs + other objects. Staff WCTM (will continue to monitor) + redirect as needed . There was no documentation on the Care Plan to indicate that the resident had any history of making abuse allegations related to these injuries. b. Departmental Notes dated 3/3/16 through 4/3/16 documented no incidents of physically aggressive or combative behavior and no documentation the resident made any allegations of abuse against staff, visitors or other residents. c. A Departmental Note dated 4/4/16 at 12:14 p.m. and signed by the Activity Director documented, Quarterly Note. Resident is alert, able to make some needs known, with continual confusion. Resident is able to ambulate independently. Resident enjoys people watching, snack and TV time, donut socials . Resident does have behavior issues at times he is combative . d. A Departmental Note dated 4/7/16 at 6:31 a.m. documented, CNA (Certified Nursing Assistant) came and got nurse to assist with resident due to very agitated during care. Had large BM (bowel movement) with incontinent care being given per staff. Resident began hitting staff, cursing at staff, hollering at staff and kicked LPN (Licensed Practical Nurse) in stomach. AM (morning) care given per staff after much encouragement. Resident has refused to get up out of bed, left in bed per staff due to agitation. Will continue to monitor. e. A Departmental Note dated 4/7/16 at 2:09 p.m. and signed by LPN #1 documented, Earlier this a.m., staff notified this nurse that prior to performing care to resident he had a patient gown on and when the CNAs were attempting to remove the gown, an open area and reddened area noted to left arm. CNA notified this nurse I was needed in room to assess resident, once this nurse entered the room bruise and skin tear noted to left upper-outer arm because the left sleeve of the gown was raised and this nurse was able to see the area from the door and once carefully examining the area was able to note the above findings, CNAs also says that resident being very combative with them and seems to be very upset once resident was cleaned and dressed he was assisted up to dining area and he was very anxious at this time and he began to swing his arms all about and this nurse asked him what was wrong and he says 'they hit me, and they said it is my fault' this nurse reassured resident that nothing is his fault notified DON (Director of Nursing) of this statement and resident being monitored closely near nurse's station notified APN (Advanced Practice Nurse) of incident with new order noted to clean skin tear to left upper-outer arm with Saf Cleans, pat dry and apply steri strips, monitor daily for s/s (signs/symptoms) of infection until healed also inservice all unit staff concerning this matter which says if resident becomes anxious prior to or during care to notify nurse and give him a while to settle before attempting to complete care notified RP (responsible party) . of incident and investigation of incident . 1.) A Witness Statement dated 4/7/16 (no time) documented, .Narrative of incident: I, (CNA #2) was in (Resident #21's) room with (CNA #3) assisting getting (Resident #21) cleaned up. (CNA #3) was remove (Resident #21's) gown she noticed a skin tear and I went and got the nurse immediately. 2.) A Witness Statement dated 4/7/16 (no time) and signed by CNA #18 documented, I went in the room, ran the bathroom sink so water can get warm. I got his clothes and shoes together. 'Morning Mr. (name) time to get up for breakfast.' He just nod. I asked him to turn on his back which he didn't. 'wake up Mr. (name) time to get up'. Pull sheets back, resident had BM on himself. 'Mr. (name) you need to get up so I can clean you, you're dirty'. Patient said no. 'Come on Mr. (name) don't you want that mess off of you.' He wouldn't move. Got his legs to turn him toward edge of bed. He started kicking. 'Mr. (name) don't be kicking now I gotta get you up so you can get clean.' I grab his hand and tried to pull him up he started swinging. I went and got my nurse. She tried to talk to him, he kicked or swung at her. She told me to let him stay in bed clean him in bed. I went and gather clean linen. He was laying on side so I started from bed and got him halfway clean. 'Mr. (name) will you turn for me.' He wouldn't move. I tried to move him he started swinging. 'Mr. (name) the sooner you do right the easier /faster it would be and I promise you I'll leave you alone.' So I went to other side of bed and tried to turn him he started kicking and swinging I left and got the nurse again. She tried to talk to him but he still kicking. She had to help me finish putting the diaper on him we covered him back up we both left. 3.) A Witness Statement dated 4/7/16 (no time) and signed by CNA #3 documented, I (CNA #3) was in (Resident #21's) room assisting (CNA #2) in getting (Resident #21) cleaned up. (Resident #21's) gown was being removed and I noticed a skin tear with dried up blood on his left arm. the nurse was told immediately. 4.) A Witness Statement dated 4/7/16 at 6:15 a.m. and signed by LPN #6 documented, .6:15 a.m. the CNA (CNA #18) came to resident's door and asked if I could come and help her clean and change resident because he was fighting her and he needed to be cleaned up because he had BM (bowel movement) on him. I entered room with CNA and walked over to his bed; both of us on same side. We attempted to talk with resident and explain we needed to clean him up. As soon as we began to turn resident over to finish cleaning him and change his brief he began hitting staff, swinging his arm about bumping numerous things. I leaned over to try and talk with resident while during care to assist and clean resident without success. As soon as I leaned over he kicked me in the stomach. I stepped back and told the CNA to wait a bit before doing anything else. She left room to go and get another brief due to BM had gotten on clean one while he was moving around and fighting us in bed. When the CNA came back in with the clean brief I walked to other side of bed. LPN on one side and CNA on other side. I touched resident on shoulder and explained we needed to turn him over from side to side to put clean brief on. As soon as we touched resident and started turning him over, he began to holler and started hitting and thrashing arms and legs again. We got brief on as good as we could. Put side rail back down on bed. Put clean sheet and spread on resident, picked up soiled linens/brief and left room. No further Witness Statements were included in the facility's written investigation. 5.) On 6/23/16 at 3:20 p.m., the DON was asked, If a resident has injuries and states, 'they hit me and said it is my fault', what should you do? The DON stated, Report it to CEO (Chief Executive Officer) so investigation can be started. She was asked, Then what would you do? She stated, Start an investigation, do an inservice on Abuse/Neglect. The DON was asked, Once it has been reported, what do you do? The DON stated, Ask them to get statements of who is working at the time. Go to the prior shift and ask questions. The DON was asked, What do you do for the resident? The DON stated, I interview them ask, 'has anyone harmed you or are you afraid?' If they say 'yes', person named is suspended; if no person is named, get statements / interviews with staff members. See if the resident can describe the person. The DON was asked, What do you do about protecting the resident? The DON stated, I ask them if they are afraid, 'has anyone hurt you? If they say no, I continue with the investigation. If they say yes, they are placed on 1:1 (one on one) monitoring until the investigation is complete. The DON was asked, Did you investigate the allegation of abuse verbalized by (Resident #21) on 4/7/16? The DON stated, I went down and talked to him. I asked him about who hit him and he just kept saying, 'I don't know'. 6.) On 6/23/16 at 4:45 p.m., the DON was asked, When (Resident #21) made this allegation, how long did staff monitor him? The DON stated, He was still up at lunch time. He was walking the halls a lot. The DON was asked, What did you do once (the allegation) was reported to you? The DON stated, I went down and interviewed him and he said, 'I don't know, I don't know', when I asked him if someone hit him. I made sure they contacted the 11 to 7 (11:00 p.m. to 7:00 a.m.) shift to get statements. I think the ADON (Assistant Director of Nursing) did this; she was the Treatment Nurse at the time. At that point in time, he could not tell me anyone hit him, so I ceased the investigation, because we had talked to the nurse and aides on the phone to get their statements and it wasn't an injury of unknown origin. The DON was asked, How was it not an injury of unknown origin? The DON stated, Because they did not change his gown during care, because he was fighting; they didn't see any injury. The DON was asked, Would you normally cease an investigation once a resident couldn't tell you what happened? The DON stated, Not anymore, I won't. 7.) On 6/24/16 at 8:27 a.m., LPN #1 was asked, How long did you monitor the resident after he told you, 'they hit me and said it is my fault'? The LPN stated, The whole day. When asked how the resident was monitored, the LPN stated, We had staff with him, we asked again and he changed his statement. The LPN was asked, Had he ever made allegations like this before? The LPN stated, I don't know. Departmental Notes dated 4/7/16 at 10:35 p.m. documented the resident was up and down out of his chair, walking the halls and talking, and there was no documentation of 1 on 1 supervision or ensuring that 2 or more staff members were present at all times when the resident required personal care. f. An Incident Report dated 6/23/16 at 8:00 a.m. and signed by LPN #8 documented, .Incident type: Other, Type of Injury: Bruise, Location: Resident Room . Narrative of incident and description of injuries: (LPN #3) stated I walked into room to assess resident for daily body audit. Upon entering room saw resident laying (sic) in bed on back no s/sx (signs or symptoms) of pain looked at right arm noticed a 3 x (by) 0.8 cm (centimeter) bruise to right upper arm. Resident unable to explain what happened. Upon investigating, bruise shaped identical to call light. Bruise to right upper arm . Post Incident Actions: .Immediate Post Incident Action: Staff inservice when turning resident in bed be cautious of placement of call light . No further investigation was documented and no witness statements were attached to the form. g. The immediate jeopardy was removed and the scope and severity was reduced to E on 6/23/16 , when the facility initiated the following Plan of Removal: 1. Two staff must go into the resident's room at any time ADL (Activities of Daily Living) care is provided. 2. The facility staff will receive inservice training regarding the need for two staff to be present when providing care to (Resident #21). This inservice began last night (6/23/16) with those staff on duty and will be ongoing until all staff have been trained. All employees will be required to receive this inservice prior to returning to work. 3. All of the interventions put into place for (Resident #21) are noted in his care plan. 4. Future I&A's (incidents and accidents) will be monitored by the DON or designee to ensure they are handled properly. 5. An investigation has been initiated regarding the incident where the resident stated, they hit me and the incident has been reported to OLTC (Office of Long Term Care). All other I&As for this resident related to bruising will be investigated by the Administrator, DON or designee. 6. All facility staff will receive inservice training regarding prevention of abuse and neglect and protecting a resident when an allegation of abuse or neglect has been made. This inservice began last night with those staff on duty and will be ongoing until all staff have been trained. All employees will be required to receive this inservice training from the Staffing coordinator or designee prior to returning to work.

Based on observation, record review and interview, the facility failed to ensure falls were consistently evaluated for causative factors; failed to ensure new interventions to prevent further falls or minimize fall-related injuries were developed based on those causative factors; failed to ensure a planned intervention to provide extensive assistance with all ambulation was consistently implemented for 1 (Resident #4) of 21 (Residents #1 through #21) case mix residents who were at risk for falls. The failed practices resulted in actual harm to Resident #4, who sustained a Left Subcapital Femoral NeckFracture, and had the potential to cause more than minimal harm to 126 residents who were at risk for falls, according to a list provided by the Director of Nursing (DON) on [DATE]. The facility failed to ensure a skin tear was evaluated for causative factors and interventions were developed to prevent further potential skin tears for 1 (Resident #11) of 13 (Residents #,[DATE], #13,#14, and #15 ) case mix residents who were at risk for skin tears. This failed practice had the potential to affect 23 residents who resided on the 300 hall that were at risk for skin tears , as identified by a list provided by the Director of Nurses on [DATE]. The facility also failed to ensure planned fall-prevention interventions were consistently implemented to minimize the potential for falls for 4of 4 (Residents #6, #11, #14 and #21) case mix residents who were care planned or had physician orders [REDACTED]. The failed practice had the potential to cause more than minimal harm for 11residents who were care planned or had physician orders [REDACTED]. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and documented the resident scored 6 (,[DATE] indicated cognitively impaired) on the brief interview for mental status, required limited assistance of 1 person for bed mobility, transfers, dressing and toilet use, two person extensive assistance for personal hygiene, required supervision with set up for locomotion on and off the unit and was always continent of bowel and bladder. a. A Care Plan with a problem onset date of [DATE] documented, I am at risk for falls/Poor safety awareness. Assist me with ex (extensive) assist for all ambulation. Keep walker within my reach at all times. Remind me to ask for assist for all ambulation. I use a tab alarm while in bed. Refer me for PT (physical therapy) evaluation prn (as needed). Monitor for changes in my condition that may warrant increased supervision / assistance and notify the physician . b. A Resident Incident Report dated [DATE] at 7:12 p.m. documented, This nurse was called to the entrance of room 213B where resident (Resident #4) was sitting up on the floor with her walker with wheels beside her. Resident stated 'I fell can you help me up.' CNA (Certified Nurse Assistant) (Name) and myself walked resident to her own room . Vitals taken, neuro checks started and body assessment done. Upon further investigation, I discovered Resident her shoes on during meal service in the dining room. She ambulated with walker to her room after meal service and took shoes off. Reddened abrasions on last three knuckles on right hand and left hand. Left buttock slightly pink, no bruising at this time . Immediate Actions Taken: Vitals taken, Neuro checks started, Body assessment obtained . 1.) A form titled Post -Incident Actions dated [DATE] at 7:12 p.m. documented, Immediate post-Incident Actions: Put resident's shoes on . 2.) A form titled Resident Incident Follow up documented. .Additional Follow-Ups: [DATE] .staff inserviced to ensure resident has shoes on when ambulating . 3.) A handwritten Care Plan update dated [DATE] documented, .Unwitness(ed) fall . Staff inserviced to ensure resident is wearing shoes when ambulating . c. A Resident Incident Report dated [DATE] at 4:30 a.m. documented, Notified by Residents roommate that resident needed help. When I entered the room I found resident on the left side of her bed on the floor on her bottom sitting up. I asked resident what happened? She stated 'I don't know', I then asked resident 'How did you fall?' and resident stated, 'I don ' t think I fell ', Resident's roommate was asked what happened and she stated, 'I don ' t know I just saw her going over the side and I came and got y'all for help.' Resident assessed for injuries, body audit performed. Left forearm 1x1x1 (1 centimeter (cm) by 1 cm by 1 cm) reddish purple bruise, left forearm 1x1.5x1 reddish purple bruise, Right forearm .5x1x1 reddish purple bruise . Immediate Action Taken: Assessed for injuries, Neuro checks began, WNL (within normal limits), Body Audit performed, Orthostatic BPs (blood pressures) taken, DON (Director of Nursing) notified, Family notified, (Physician) .Resident placed on 3 day bowel and bladder program q (every) 2 hr (hour) while awake (and) before and after meals, Bed alarm replace and now working properly . A handwritten Care Plan update dated [DATE] documented, [DATE] .3 small bruises to left forearm. One bruise to (right) forearm; Body audit (and) neuro check began . Bed alarm replace . it looks ok, but not going off . The 3-day bowel and bladder program was not added to the Care Plan, nor were any new interventions documented to prevent further falls after the 3-day period expired. A handwritten Care Plan update dated [DATE] documented, [DATE] Bruise to left rear upper arm increased in size . d. A Resident Incident Report dated [DATE] at 9:15 p.m. documented, Res (resident) wandering excessively lately with all staff trying to keep up with her. CNA came out of a room and saw this res sitting on the floor with back against linen cart at end of hall. Walker and glasses found in nearby res room. Resident denied pain, had full ROM (range of motion) and no new bruises, skin tears or deformities. Assisted to feet and amb (ambulated) with walker, to her room. Initially, res had 3 cm (centimeter) reddened area on L (left) back / shoulder blade from leaning against linen cart but this disappeared in a few mins (minutes) . Immediate Actions Taken: Assisted to room, toileted and dressed for bed. Orthostatic BP done with insignificant results . 1.) A form titled Resident Incident Follow Up dated [DATE] at 9:15 p.m. documented, Addition Follow-ups [DATE] Body audit (and) neuro checks per protocol. Orthostatic blood pressures obtained. Staff will continue to monitor (and) redirect resident while wandering . No additional interventions were documented. 2.) A handwritten Care Plan update dated [DATE] documented, .Fall (without) injury. Unwitnessed found sitting on floor in hall with back against lunch cart. Increased wandering noted . continue to monitor (and) redirect as needed . There was no documentation of any new intervention to prevent further falls . 3.) On [DATE] at 9:05 a.m., the Director of Nursing (DON) was asked if any interventions were developed to prevent further falls after the resident fell on [DATE]. The DON reviewed the incident report and stated, We did orthostatic blood pressures. The DON was then asked, What did you do to prevent another fall? She stated, We did the blood pressures and called the doctor. The DON was asked, What interventions did you implement (to prevent further falls) and did the doctor change any of the resident's medications or give you any new orders? The DON stated, Well this (the incident report) states they (the blood pressures) were not significant. The DON looked at the Nurses Notes on the computer for [DATE] and stated, .Resident was toileted and dressed for bed, the doctor was called. I don't know any more information, but if I find some, I'll let you know. As of [DATE] at 2:00 p.m. , no evidence was provided to indicate any fall prevention interventions were developed, related to the resident's fall on [DATE]. e. A Resident Incident Report dated [DATE] at 9:00 p.m. documented, Summoned to (a non-case-mix resident's room) by CNA. Upon entering the room observed (Resident #4) in sitting position at the foot of the bed. Resident denies c/o (complaint of) pain. Able to move all extremities. Assessed resident no s/s (sign or symptoms) of new injuries fading bruising noted to left upper arm and left hip from previous incidents. Resident assisted off the floor into standing position. Resident ambulated with walker down hallway. Later assisted to bed . Immediate Actions Taken: Assessed for injury. 1.) A post - Incident Action dated [DATE] at 9:00 p.m. documented, Immediate Post Incident Actions: Have APN (Advanced Practice Nurse) review medication. 2.) A handwritten Care Plan update dated [DATE] documented, .Fall with injury unwitness found in sitting position at the foot of bed. Assisted off the floor into standing position ambulated with walker down hallway. X-ray of R&L (right and left) knee done. X-ray of left hip performed out to (Hospital) for repair of left hip . 3.) A form titled Resident Incident Follow Up documented, XXX[DATE] Post body assessment completed [DATE] c/o left hip pain. X-ray of left hip performed. Shows evidence of left subcapital femoral neck facture with varus deformity. X-ray to left and right knee on [DATE] no acute findings. [DATE] Resident transferred to (Hospital) for repair of left hip. (A Final Radiology Report dated [DATE] documented, Left subcapital femoral neck fracture with varus deformity.) [DATE] Resident readmitted to facility Skilled Left Subcapital Femoral Neck fx (fracture). Ongoing treatment with therapy and wound care. There was no documentation any new fall prevention interventions were implemented upon the resident's return from the hospital and no new entries were documented on the Care Plan until [DATE], four days after the resident returned to the facility. 4.) A handwritten Care Plan update dated [DATE] documented, .chair alarm in w/c (wheelchair) to alert staff of unsafe transfers. Nurse to check proper placement (and) functioning q (every) shift. 5.) On [DATE] at 10:30 a.m., CNA #1 was asked if she remembered Resident #4's fall and how the resident acted after this fall. She stated, Yes ma'am, (the resident) couldn't stand up like usual, and she wasn't doing the walking like usual, and she was whining a lot and that wasn't in her nature. I reported it to the nurse . On [DATE] at 11:00 a.m., Licensed Practical Nurse (LPN) #1 was asked if the resident had had a fall prior to the fall on [DATE] and stated Yes, she had fallen a few days before that. The LPN was asked what interventions were in place prior to the resident's fall on [DATE]. The LPN stated, Kept an eye on her when she was up. She could transfer by herself. The LPN was asked if the resident had an alarm in place to alert staff when she got up. The LPN stated, I don't recall. f. The MDS with an ARD of [DATE] (seven days after the resident returned to the facility from the hospital) documented the resident required extensive assistance of two or more persons for bed mobility, transfers, bathing and toilet use and required the use of a wheelchair for mobility. The MDS also documented the resident had a history of [REDACTED]. g. A Resident Incident Report dated [DATE] at 12:00 p.m. documented, .hospice CNA states 'I looked around and seen (Resident #4) on the floor next to her wheelchair' .chair alarm sounding . Immediate Actions Taken: Resident assess alert moves all extremities. No s/s (signs/symptoms) of pain noted. Assisted per staff from floor into her wheelchair. New order. Onsite x-ray of left hip pelvis post fall and recent repair of left hip . Additional Follow Ups . [DATE] Therapy to eval (evaluate) resident for a positioning device. [DATE] Pommel cushion was ordered and was put into place yesterday . h. On [DATE] at 10:20 a.m., the resident was in bed with half side rails up on both sides at the head of the bed. A bed alarm was in place. 2. Resident #14 had [DIAGNOSES REDACTED]. The MDS with an ARD of [DATE] documented the resident had severely impaired cognitive skills for daily decision making per a staff Assessment of Mental Status (SAMS), required extensive assistance from staff for transfers and had a history of [REDACTED]. a. Physician orders [REDACTED]. [DATE] Nurse to check proper placement and functioning of bed alarm every shift. b. The Plan of Care dated as revised on [DATE] documented, I am at risk for falls . There was not intervention for alarm mentioned in the care plan. c. A Resident Incident Report dated [DATE] at 2:30 p.m. documented, .(Resident) was face down on floor between bed and air conditioning unit. Resident transfers self from bed without assistance from staff. 1.) The Resident Incident Follow-up form dated [DATE] at 2:30 p.m. documented, .Mats placed on floor on both sides of bed due to resident frequently attempts to get out of bed unassisted & (and) bed alarm in place already. 2.) A Care Plan update dated [DATE] documented, Fall with injury, unwitnessed . Approaches: Mats placed on both sides of bed. Low bed / mats on floor. Resident will climb out of bed and sit on the floor unassisted. d. A Resident Incident Report dated [DATE] at 8:45 a.m. documented, .(Resident) fell out of her wheelchair . seat belt was not in place and chair alarm was not on. e. The Fall Risk Evaluation dated [DATE] documented the resident scored 11, with a score greater than 10 indicating, .resident is at risk for falls - Follow Fall Prevention Protocol. f. On [DATE] at 10:12 a.m. and 11:12 a.m., the resident was in bed with padded quarter side rails on both sides of the bed. There was an alarm on the right side of the bed and a mat on the floor on the left side of the bed. The bed was approximately 24 inches above the floor and approximately 12 inches from the air conditioning unit. There was no mat on the floor between the bed and the air conditioning unit. g. On [DATE] at 1:28 p.m., the DON was asked if the planned fall prevention interventions were being consistently implemented at the time of the resident's fall on [DATE]. She stated, I don't know. She requested the assistance of the Assistant DON (ADON). At 2:05 p.m., the ADON entered the DON's office and made the following statement regarding the fall on [DATE]: The CNA's intention was to get the resident up in the chair to prevent falls. She was called away (from the resident) and forgot to put the alarm and seat belt on (the resident). h. On [DATE] at 3:47 p.m., the resident was in bed with padded quarter side rails up on both sides of the bed. The bed was elevated approximately 32 inches off the floor and there was a mat on only one side of the bed. The alarm was attached to the bed frame on the side of the bed next to the air conditioning unit. One floor mat was folded and leaning between the closet and the wall, instead of on the floor at the side of the bed. i. On [DATE] at 12:12 p.m., the DON was asked about low beds and the proper height for a low bed. The DON stated, A bed that goes all the way to the floor or one that is low to the floor, approximately 12 inches from the floor. 3. Resident #21 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 6 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance bed mobility and personal hygiene and was frequently incontinent of bladder and bowel. a. An Incident and Accident Report (I&A) dated [DATE] at 4:45 p.m. on the Unit Hallway documented the resident fell , after which a bed alarm was put in place. A physician order [REDACTED]. b. An I&A dated [DATE] at 9:31 a.m., in the residents room documented the resident fell , and a chair alarm was implemented. A physician order [REDACTED]. Check every shift for proper placement and functioning . c. The Plan of Care dated [DATE] documented, .I am at risk for falls . may be up in geri chair as tolerated, 2 person assist with gait belt for transfers, [DATE] Fall with no injury unwitnessed, chair alarm placed on chair in room, urinalysis ordered per APN (Advanced Practice Nurse) for c/o (complaint of) dysuria. Hospice MD (Medical Doctor) notified of increased sensitivity noted due to medication increase meds adjusted as ordered . d. An I&A dated [DATE] at 4:00 p.m. in the residents room documented the resident fell . The intervention documented to put a chair alarm into place. No new interventions were documented. A Care Plan update dated [DATE] documented, .Fall with no injury unwitnessed. Found lying on floor in room. Current treatment for [REDACTED]. Door to resident's room kept propped open for closer monitoring. [DATE] Orthostatic BPs (Blood Pressures) obtained. e. An I&A dated [DATE] at 9:30 a.m. in the residents room documented the resident fell . The planned intervention at this time was a floor mat at the bedside. A Care Plan update dated [DATE] documented, .Fall with injury. Witnessed superficial laceration to top L (left) hand. Two puncture type wounds to L outer wrist. Tx (Treatment) as ordered and monitor qd (every day) until healed. Rehab referral screen. Mat placed on floor next to bed . f. On [DATE] at 12:29 p.m. during the initial tour of the facility, the resident was sitting in a geri-chair with an alarm attached to the geri-chair, but the sensor was unplugged from the alarm box and hanging towards the floor. g. On [DATE] at 2:40 p.m., the resident was lying in bed. The bed alarm was in place on the bed frame, but the green power light was not illuminated, indicating the alarm was not turned on. At 2:42 p.m., Certified Nursing Assistant (CNA) # 10 was asked, How do you know if the bed alarm is on and working? The CNA stated, There will be a green light on. The CNA was asked, How long has the resident been in bed? The CNA stated, We put him in bed right after lunch; we forgot to turn it (alarm) on. 4. Resident #6 had [DIAGNOSES REDACTED]. The MDS with an ARD of [DATE] documented the resident had severely impaired cognitive skills for daily decision-making per a staff assessment for mental status, required total assistance with bed mobility, required extensive assistance with transfers and had no history of falls. a. A Care Plan dated [DATE] documented, Do not leave unattended when up in w/c (wheelchair). b. An Incident Report dated [DATE] at 7:43 p.m. documented, .Staff reported blood around resident mouth . 1.) A witness report dated [DATE] and signed by Licensed Practical Nurse #4 documented, I was called to the 300 hall to look at another resident after leaving that room I was notified that this resident had blood around her mouth .There was a small irregular shaped cut . on the right side of her tongue . CNAs .on day shift said that resident fell on day shift today. I asked the charge nurse about it and she said she was not told anything about it in report . Resident roommate told CNAs and Charge nurse that resident fell out of her wheelchair today before lunch was served . I interviewed the roommate first and she told me that the resident was in her wheelchair on the other side of the bed and she had 'taken that box thing off and the next thing I knew she was in the floor'. I asked her who helped resident up off the floor and she said, 'Now I can't tell you that. I know her but I don't know what her name is. If I saw her I could tell you'.I asked roommate if one person helped resident up or more than one. She said, 'No it was just one girl' . 2.) A witness statement dated [DATE] and signed by the ADON documented, .Reported by roommate that resident had a fall . Interviewed resident (and) CNAs involved, resident was not on floor. She was slumped in chair (and) was adjusted in chair after investigation according to staff . 3.) A witness statement dated [DATE] and signed by the ADON documented, .Resident did demonstrate that she can bend over in chair . Laceration to tongue appeared to have come from hardened area to upper gum. c. Based on the facility's witness statements, the resident was unattended while in a wheelchair. Per the Care Plan dated [DATE], the resident was not to be left unattended in the wheelchair. 5. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 6 (,[DATE] indicates severely impaired) on the brief interview for mental status and required extensive assistance with transfers and bed mobility. a. An Incident Report dated [DATE] at 7:00 a.m. documented, .during body audit noticed dried blood to the top of resident's socks 2 x 2 x 0.1 (cm) skin tear below right knee .Immediate Actions Taken: Started Treatment and applied dressing . Additional Follow-Ups [DATE] Monitor socks for tightness. Elevate legs to reduce edema. Resident has a hx (history) of venous stasis ulcer . b. Nurses Notes dated [DATE] 3:10 p.m. documented, Skin Tear / Right Knee . No skin intact, but skin present small amount of bleeding and serous drainage that looks like resident had a blister . c. On [DATE] at 10:20 a.m., the resident was in wheel chair. Wound care was being provided to the skin tear below the resident's right knee by Licensed Practical Nurse #5. The skin tear measured approximately 2 by 2 centimeters and had a small triangular shaped flap of of skin that remained intact. Resident # 11 was asked, What happened to your leg? The resident stated, I don't know and I can't feel it. d. As of [DATE] at 10:45 a.m., the care plan did not address skin tears. d. On [DATE] at 11:00 a.m., the ADON was asked who investigated to determine the cause of the resident's skin tear on [DATE]. The ADON stated, The Treatment Nurse (Licensed Practical Nurse (LPN) #5). e. On [DATE] at 11:45 a.m., LPN #5 was asked what caused the skin tear to the resident's right leg and stated, I think her socks rubbed her leg. The LPN was asked, When did you notice it? The LPN stated, Monday morning ([DATE]). LPN #5 was asked if anyone had reported a blister on the resident's leg prior to identification of the skin tear and stated, No.