Every finding on record at Topside Manor Inc

Based on observation, interviews, and record review, the facility failed to store and serve food under sanitary conditions and with professional standards of food service safety by failing to document food temperatures for each meal, failing to date open food items, and failing to cover food items transported throughout the facility. Findings included: - Upon the initial tour of the facility's three kitchens, each kitchen revealed several items in each refrigerator that were not dated when opened. These items were as follows: Boxes of orange juice and apple juice Bottles of cranberry juice Gallon jugs of milk Bottles of mustard (different flavors) Bottles of ketchup Bottles of soy sauce Jars of mayonnaise Cans of [NAME]-Whip Salad dressings (several varieties) Review of the food temperature logs for one of the three kitchens revealed the notebook contained breakfast and lunch meal temperatures from July 2026. The following dates had no temperatures documented: 07/01/2026-07/02/2026 breakfast and lunch 07/06/2026-07/10/2026 breakfast and lunch 07/11/2026-07/13/2026 lunch 07/18/2026-07/19/2026 breakfast and lunch The log lacked evidence supper meal temperatures were assessed. During an interview on 07/21/2026 at 11:45 AM, Dietary CC stated she was aware of the food items not being dated upon opening, and the incomplete meal temperature logs. She stated the facility had an ongoing Performance Improvement Plan (PIP) related to the issues. She presented an undated PIP. During an interview on 07/21/2026 at 12:01 PM, Administrative Staff A stated she was aware this issue continued to be ongoing and said she expected to see better results by now. - On 07/21/2026 at 12:05 PM, Dietary Staff (DS) BB prepared the midday meal, plated the food, and put it on a cart for transportation to a resident's room. The cart had two beverages on it also. A different staff member came and took the cart with the uncovered food and drinks to a resident's room. On 07/22/2026 at 08:18 AM, DS BB prepared a breakfast meal, placed it on a cart, along with two cups of liquid. Certified Nurse Aide (CNA) O came and took the food and drinks to a resident's room uncovered. CNA O verified the plate and cups were not covered. DS BB verified the meal should be covered when transporting room tray meals. The facility's undated Food Preparation and Service policy stated food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Food distribution means the processes involved in getting food to the residents. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas are to be distributed, covering food is appropriate, either individually or in a mobile food cart.

Based on observation, interviews, and record review, the facility failed to implement adequate infection control practices when staff failed to wear gloves when administering nasal spray for Resident (R) 34 and did not clean the applicator before and after use. The facility failed to ensure R4's nasal cannula (NC - a thin hollow tube that assists in providing supplemental oxygen) was stored in a sanitary manner when not in use, and continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) equipment for R4, R26 and R12 was cleaned and stored in a sanitary manner when not in use. The facility failed to implement adequate hand hygiene during care for R12. Findings include: 1.On 07/21/2026 at 09:12 AM observation revealed Certified Medical Assistant (CMA) R administered nasal spray into each nostril for R34 without performing hand hygiene or using gloves. CMA R then recapped the nasal spray without cleaning the applicator after use. In an interview on 07/21/2026 at 09:15 AM, CMA R stated gloves are supposed to be worn when administering nasal spray to residents. 2. An observation on 07/21/2026 at 03:56 PM revealed R4 sat in her room in a recliner watching tv. R4's CPAP mask lay next to machine on her nightstand. There was no bag present for sanitary storage. On 07/21/2026 at 03:58 PM, R4 stated she wished staff would clean her CPAP mask or give her a wipe so she could clean it. During an observation on 07/22/2026 at 7:32 AM, R4's CPAP machine was running, and the mask hose was on top of nightstand and oxygen nasal cannula tubing was coiled on the floor. 3. An observation on 07/21/2026 at 07:40 AM revealed resident barely awake in his recliner, wearing nasal cannula for oxygen, and the CPAP mask was on the nightstand. On 07/21/2026 at 07:48 AM, R26 stated he was supposed to be wearing his CPAP mask every night, but he did not think staff cleaned it. On 07/21/26 at 11:36 AM, Licensed Nurse (LN) G stated oxygen tubing and CPAP masks should be contained in a bag when not in use, which should be dated as to when the tubing was last replaced. On 07/22/2026 at 09:14 AM, Administrative Nurse D verified the respiratory equipment should be bagged while not in use. The Facility Assessment dated 08/2025 documented that, as part of an ongoing commitment to maintain the highest standards of care and ensure the safety and well-being of the residents and staff, the facility implemented comprehensive infection control policies and procedures. These measures were designed to prevent and manage infections effectively within the facility. The facility's policy Personal Protective Equipment- Gloves, dated 2025, documented all personnel must wear gloves when exposed to blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin, and when performing device care. No policy for oxygen tubing storage was provided upon request. - On 07/21/2026 at 08:30 AM, Certified Nurse Aide (CNA) M knocked on R12's door and asked R12 if he was ready to get up. R12's wheelchair had an oxygen tank on the back, and the NC and tubing were wrapped around the top of the tank rather than stored in a bag. R12 had NC and tubing that was connected to an oxygen concentrator (a machine that provides supplemental oxygen). Certified Nurse Aide (CNA) M donned a clean gown and gloves and raised R12's bed. CNA M lowered R12's sweatpants and removed the soiled incontinence brief. CNA M provided peri care, put on a new brief, and pulled up the resident's sweatpants with the same soiled gloves. Continued observation revealed CNA M put the mechanical lift (a mobility device used to transfer individuals who cannot bear their own weight) under R12, removed his NC, and dropped it onto a black box that was beside his bed. The CNA attached the sling to the lift and transferred R12 into his wheelchair while wearing the same soiled gloves. R12 asked CNA M to turn off his air conditioner, and CNA M went and turned it off while still wearing the soiled gloves. On 07/21/2026 at 08:45 AM, CNA M stated she should have changed her gloves and washed her hands before she put the new incontinence brief on the resident and asked if it would help if she went back into the room and wiped down the areas she had touched with a Sani wipe (professional grad premoistened disposable wipe primarily used to clean, sanitize, and disinfect hard, non-porous surfaces and medical equipment). On 07/21/2026 at 02:15 AM, Licensed Nurse (LN) G stated that residents who had supplemental oxygen should have a clean bag for the NC and tubing to be stored in when not in use. LN G verified R12's tubing was not in a bag. On 07/22/2026 at 09:25 AM, Administrative Nurse D stated that the CNA should have changed her gloves and sanitized her hands before putting on R12's clean incontinence brief and stated that NC and tubing should be stored in clean bags when not in use. The facility's Personal Protective Equipment-Gloves policy, dated 12/2025, documented that gloves are used only once and discarded after use. Gloves do not replace the need for hand hygiene. Hand hygiene is always performed immediately before donning gloves and immediately after the removal of gloves. Gloves are removed, hand hygiene performed, and clean gloves are applied when moving from a contaminated body site to a clean body site on the same resident and when gloves become heavily soiled, torn, or ripped. The Facility Assessment dated 08/2025 documented that, as part of an ongoing commitment to maintain the highest standards of care and ensure the safety and well-being of our residents and staff, we have implemented comprehensive infection control policies and procedures. These measures are designed to prevent and manage infections effectively within the facility.

Based on observation, interview, and record review, the facility failed to ensure that Resident (R)39 was free from antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality) without an appropriate indication of use or a physician-documented rationale, including risks versus benefits. Findings included:- R39's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion)with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), pain, chronic kidney disease, insomnia (inability to sleep), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and adjustment disorder mixed with anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depressed mood. R39's Significant Change Minimum Data Sheet (MDS), dated [DATE], documented R39 had severe cognitive impairment and required substantial/maximal assistance with functional abilities and mobility. R39 received a scheduled pain medication regimen, an antipsychotic, and an antidepressant (a class of medications used to treat mood disorders). The antipsychotics were received on a routine basis only. A gradual dose reduction (GDR) had been attempted on 04/17/2026. There was no physician documentation that it was clinically contraindicated. The Psychotropic Medication Care Area Assessment (CAA), dated 05/14/2026, documented R39 had unspecified dementia with agitation and behavior disturbance. R39 took Seroquel (an antipsychotic) for dementia with behaviors. R39's Care Plan dated 05/13/2026 documented R39 used Seroquel related to behavior management. The plan directed staff to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least every quarter, monitor for side effects, and occurrence of target behaviors symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, and violence/aggression toward staff and others. The Physician Order dated 03/10/2026 directed staff to administer Paxil (an antidepressant) 40 milligrams (mgs) in the morning for sexual behaviors related to dementia. The Physician Order dated 05/27/2026 directed staff to administer Seroquel 25 mg at bedtime related to dementia. The Consulted Pharmacist (CP) report dated 03/17/2026 reported R39 received Paxil for sexual behaviors and to reevaluate use of Paxil and document a clinical contraindication for a gradual dose reduction (GDR). The physician declined the recommendation due to adjusting other medications. The CP report dated 04/13/2026 documented R39 had a diagnosis of dementia and received Seroquel and to evaluate the continued use. The physician response declined the recommendation and did not want to implement any changes due to decreasing the dose. The Progress Note dated 06/20/2026 at 10:52 AM documented R39 was seen by the contracted psychiatrist, and the plan of care was ongoing. On 07/20/2026 at 02:34 PM, R39 independently wheeled himself to his room, and an audible alarm sounded. Staff ran to check R39 and then encouraged him to participate in a game with another resident in the private dining area of the house. On 07/21/2026 at 11:46 AM, Certified Medication Aide (CMA) R reported R39 exhibited behaviors of being awake for up to 24 hours at a time, attempted to go into other residents' rooms, and at times was difficult to redirect. On 07/22/2026 at 09:20 AM, Administrative Nurse D reported R39 had returned from a geriatric psych unit for behaviors and returned with the Seroquel order for dementia. Administrative Nurse D verified a lack of documentation related to the indication of use or risk versus benefit statement. The facility's Psychotropic Medication Use policy dated 02/2025 documented that residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. If psychotropic medication is prescribed or administered as a substitute or adjunct for psychotropic medication, there is a documented clinical rationale, the medications are monitored and managed as psychotropic medication.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 8, who was at risk for falls and had wounds on her feet, had foot pedals on her wheelchair before staff propelled her out of her room. Findings included:- The Electronic Medical Record (EMR) for R8 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), restlessness and agitation, a history of falls, arterial ulcers (open sores caused by poor circulation and tissue oxygen deprivation), and hereditary spastic paraplegia (a group of rare genetic disorders where upper motor neurons in the brain and spinal cord slowly degenerate).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired cognition. R8 was dependent upon staff for all activities of daily living except for setup assistance for eating. R8 had lower functional impairment on both sides, had one fall, and did not ambulate.R8's 07/16/2026 Care Plan, initiated on 04/02/2026, directed staff to remove wheelchair pedals when the resident was in her room but have them on while pushing her in her wheelchair.On 07/20/2026 at 10:30 AM, Certified Nurse Aide (CNA) Q told R8 to raise her feet so she could push her to the dining room table. R8 lifted her feet, which were barely off the ground, and she was taken to the dining room table.On 07/20/2026 at approximately 01:30 PM, a facility staff member pushed R8 in her wheelchair, without foot pedals, down the hall by the conference room. R8's feet were barely off the floor.On 07/21/2026 at 09:23 AM, CNA M told R8 to lift her feet and wheeled her to the table. R8 stated that her foot hurt and thought they had put her shoe on too tight.On 07/21/2026 at 03:39 PM, CNA N stated that when R8 was in her room, she did not need her foot pedals on her wheelchair because she moves around, but family wanted staff to make sure they put foot pedals on when she was out of her room and staff were pushing her.On 07/22/2026 at 02:15 PM, Licensed Nurse (LN) G stated that R8 was to have her foot pedals on the wheelchair whenever staff pushed her, except when she was in her room.On 07/22/2026 at 09:25 AM, Administrative Nurse D stated foot pedals should always be on the wheelchair when staff were pushing any resident in the facility.The facility's Falls and Fall Risk, Managing policy, dated 03/2018, documented that staff would identify interventions related to specific risks and causes to try to prevent the resident from falling or sustaining injuries.

Based on observation, interview, and record review, the facility failed to store the oxygen nasal cannula and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) treatments in a sanitary manner for Resident (R) 43, who had been treated for respiratory infections. Findings included:- R43's Electronic Medical Record (EMR) documented diagnoses fluid overload, dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) disease, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R43 had moderately impaired cognition. R43 was dependent on staff for functional abilities and mobility, with the exception of partial/moderate assistance with eating. R43 had shortness of breath or trouble breathing when lying flat. The MDS further documented R43 received insulin, anti-anxiety medication, antidepressant medication, anticoagulant (a class of medications used to prevent the blood from clotting), diuretic (a medication to promote the formation and excretion of urine), opioid (a class of controlled drugs used to treat pain), hypoglycemic (a class of medications used to lower blood sugar levels), and anticonvulsant medication. R43 received oxygen therapy. R43's Care Plan dated 06/10/2026 documented R43 had altered respiratory status/difficulty breathing related to COPD. The plan directed staff to administer medications/puffers as ordered and monitor them for effectiveness and side effects; monitor for signs or symptoms of respiratory distress and notify the physician. The plan further documented the oxygen settings via nasal cannula at one to four liters to titrate to about 90 percent throughout the day if needed. The oxygen setting was two liters at all times via nasal prongs/mask. The Physician Orders dated 10/25/2025 directed staff to change nebulizer tubing and supplies every Sunday night for infection control related to COPD. The Physician Order dated 10/25/2025 directed staff to change the oxygen tubing and storage bag every Sunday night shift related to COPD. The Physician Order dated 11/15/2025 directed the staff to titrate oxygen to one to four liters to maintain oxygen saturations above 90% if needed and notify the physician of all changes or initiation of oxygen therapy related to COPD. The Progress Note dated 03/31/2026 at 04:44 PM documented R43 was seen by the provider and had been ordered to administer Azithromycin (an antibiotic) 500 milligrams (mgs) daily for five days and Amoxicillin (an antibiotic) 500 mgs three times a day for ten days with the diagnosis of pneumonia. The Progress Note dated 07/10/2026 at 12:15 PM documented the physician ordered doxycycline (antibiotic) 100 mg twice a day for ten days for an upper respiratory infection. On 07/21/2026 at 08:55 AM, R43 was brought to the dining room in her wheelchair. R43 was dressed and groomed for the day. R43 had a nasal cannula attached to R43's nose. The oxygen flow rate was two liters. On 07/21/2026 at 11:44 AM, R43 sat in her room in a recliner with her feet elevated, eyes closed; she received oxygen per nasal cannula. R43's nebulizer mask and medication dispenser were lying on the bedside stand uncovered and unbagged. On 07/21/2026 at 01:44 PM, R43 sat in her room in her wheelchair with the nebulizer treatment running. R43's oxygen concentrator was sitting next to her with the oxygen nasal cannula coiled on top of the handle, unbagged. Certified Medication Aide (CMA) R reported the licensed nursing staff administered the nebulizer treatments. On 07/21/2026 at 02:15 PM, Licensed Nurse (LN) G stated that oxygen tubing should be bagged when not in use, as well as the other oxygen equipment when not in use. On 07/21/2026 at 03:22 PM, R43 rested in bed with her eyes closed wearing an oxygen cannula. The nebulizer mask and medication dispenser lay unbagged atop the nebulizer machine. On 07/22/2026 at 07:43 AM, staff were in R43's room, dressing and grooming the resident for the day. Certified Nurse Aide (CNA) O left the room, guiding the oxygen concentrator with her right hand, and in her left hand had a bag of trash with the nasal cannula, touching the trash bag. The concentrator did have a clear bag attached to the machine. CNA O deposited the trash bag; she then took the concentrator to the dining room and draped the nasal cannula onto the seat of a chair next to R43's table place. On 07/22/2026 at 09:14 AM, Administrative Nurse D verified the respiratory equipment should be bagged while not in use, including transportation. Administrative Nurse verified R43 had a history of respiratory infections. The Facility Assessment dated 08/2025 documented that, as part of an ongoing commitment to maintain the highest standards of care and ensure the safety and well-being of our residents and staff, we have implemented comprehensive infection control policies and procedures. These measures are designed to prevent and manage infections effectively within the facility.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals adequately for Resident (R) 43 when staff failed to date an insulin when it was opened. Findings included:- On 07/21/2026 at 07:45 AM, Licensed Nurse (LN)G was preparing R43's insulin for administration. Upon review of the Novolog (fast acting insulin) insulin pen, the pen lacked a date when the pen was opened and placed in use. LN G verified the policy of the facility was to date the insulin pens when opened for use. On 07/22/26 at 12:45 PM, Administrative Nurse D verified the insulin should have been dated. Medlineplus.gov directs open, unrefrigerated Novolog, Humalog, and Lantus can be used within 28 days; after that time, they must be discarded. The facility's Medication Labeling and Storage policy, dated 02/2023, documented that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for an open vial.

The facility identified a census of 45 residents. Based on record review and interview, the facility failed to ensure nursing staff possessed current licensure as required. This deficient practice placed all the residents residing in the facility at risk for not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - The Kansas State Board of Nursing License Verification, printed on [DATE], documented Licensed Nurse (LN) G's Licensed Practical Nursing (LPN) license expired on [DATE]. The Facility's Working Schedule for the month of [DATE], documented LN G worked eight days out of twenty-three days as an LPN after LN G's license had expired. LN G was the only Licensed Nurse on the evening shift, 06:00 PM to 06:00 AM, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], LN G was suspended and taken off the schedule until her license was reinstated. On [DATE] at 10:30 AM, Administrative Nurse D stated LN G had come to her on [DATE] to tell her that she had forgotten to renew her nursing license by [DATE] when the nursing license expired. Administrative Nurse D stated LN G was immediately taken off the schedule and she notified Administrative Staff A On [DATE] at 11:00 AM, Administrative Staff A stated she expected licensed nursing staff to be aware of when their nursing license expired and take care of renewing their license. Administrative Staff A stated the facility did not have any system ensuring licensed nursing staff employed by the facility maintained their licensure at the time of the incident. Administrative Staff A stated the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee would be allowed to work in a registered, licensed, or certified position without proof of active license status. The facility's Staffing, Sufficient and Competent Nursing, revised [DATE], documented the facility provided sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements by state law. The facility identified and implemented immediate corrective actions, which were completed on [DATE] and included: the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee will be allowed to work in a registered, licensed, or certified position without proof of active license status. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at an F scope and severity.

The facility identified a census of 45 residents. Based on record review and interview, the facility failed to ensure adequate administrative oversight when the facility failed to monitor and ensure all nurses practicing in the facility maintained active license as required to provide the residents residing in the facility with the care they needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This deficient practice placed the residents residing in the facility at risk for lack of quality nursing care. Findings included: - The Kansas State Board of Nursing License Verification, printed on [DATE], documented Licensed Nurse (LN) G's Licensed Practical Nursing (LPN) license expired on [DATE]. The Facility's Working Schedule for the month of [DATE], documented LN G worked eight days out of twenty-three days as an LPN after LN G's license had expired. LN G was the only Licensed Nurse on the evening shift, 06:00 PM to 06:00 AM, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], LN G was suspended and taken off the schedule until her license was reinstated. On [DATE] at 10:30 AM, Administrative Nurse D stated LN G had come to her on [DATE] to tell her that she had forgotten to renew her nursing license by [DATE] when the nursing license expired. Administrative Nurse D stated LN G was immediately taken off the schedule and she notified Administrative Staff A. On [DATE] at 11:00 AM, Administrative Staff A stated she expected licensed nursing staff to be aware of when their nursing license expired and take care of renewing their license. Administrative Staff A stated the facility did not have any system ensuring licensed nursing staff employed by the facility maintained their licensure at the time of the incident. Administrative Staff A stated the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee would be allowed to work in a registered, licensed, or certified position without proof of active license status. The facility's Staffing, Sufficient and Competent Nursing, revised [DATE], documented the facility provided sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements by state law. The facility identified and implemented immediate corrective actions, which were completed on [DATE] and included: the facility's business office manager will run a monthly report to ensure staff renew their licenses on a timely basis. No employee will be allowed to work in a registered, licensed, or certified position without proof of active license status. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at an F scope and severity.

The facility had a census of 44 residents. Based on observation, interview, and record review the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week, placing all residents who reside at the facility at risk of decreased quality of care. Findings included: - The Payroll Based Journal (PBJ-a required detail of staffing information submitted by nursing homes to the Centers for Medicare and Medicaid Services) documented the facility lacked eight consecutive hours of RN coverage for the following months: April 2023- seven days May 2023- seven days June 2023- six days July 2023- eight days August 2023- six days September 2023- six days October 2023- eight days November 2023- four days December 2023- four days March 2024- four days April 2024- four days May 2024- four days June 2024- eight days July 2024- eight days August 2024- six days On 08/29/24 at 08:27 AM, Administrative Nurse D verified the facility did not have an RN on duty for eight consecutive hours on the dates listed on the PBJ. The facility's Staffing, Sufficient and Competent Nursing policy, dated 09/22, documented the facility provided enough nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled for more than eight (8) hours depending on the acuity needs of the resident. The facility failed to provide RN coverage eight consecutive hours a day, seven days a week, placing all residents who reside at the facility at risk of lack of assessments and inappropriate care.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 44 residents who resided in the facility and received meals from the facility's kitchens. This placed the residents at risk for inadequate nutrition. Findings included: - On 08/27/24 at 11:22 AM, a review of the noon meal consisted of chicken parmesan, buttered penne pasta, asparagus tips, fruit crisp, and garlic toast. On 08/27/24 at 11:30 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 08/26/24 at 08:00 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had enrolled in the classes. On 08/29/24 at 07:15 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Dietitian Policy, revised in November 2022, documented that if a dietitian is not employed full-time (35 or more hours per week) a director of food and nutrition services would be designated. This individual would: Be a certified dietary manager or be a certified food service manager or be nationally certified in food service management and safety; or Had an associate's (or higher) degree in food service management or hospitality, if the course includes food service or restaurant management from an accredited institution; or Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing, receiving; and met any state requirement for food service or dietary managers; and received frequently scheduled consultations from a qualified dietitian or qualified nutrition professional. The facility failed to employ a full-time certified dietary manager for 44 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 44 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 08/26/24 at 11:48 PM observation of the noon meal, in the Sunflower House, revealed the following: Dietary Staff (DS) DD applied gloves and touched the refrigerator, counter, and pans. Then, wearing the same soiled gloves, DS DD touched a resident's roast beef while cutting it up, and then continued to serve residents their plates. Further observation revealed DS DD, with the same soiled gloves, took a baked potato out of the oven, placed it on a resident's plate, and held onto it while cutting it. Further observation revealed DS DD continued the same process, with the same soiled gloves, when plating the other residents' roast beef and baked potatoes. Continued observation revealed DS DD, wearing the same soiled gloves, wiped her right gloved hand across her nose and then served strawberry shortcakes to each resident at the dining room table. After serving the cake, DS DD removed and discarded the gloves. DS DD applied new gloves and touched the cabinets, touched the refrigerator handle, then with the same soiled gloves, used her hands to take two slices of bread out of the toaster and place them on a plate. DS DD touched the refrigerator handle, took mayonnaise out of the refrigerator, touched the jar, and then held one slice of toast at a time in her left hand while she spread mayonnaise on the two slices of toast with her right hand. Continued observation revealed DS DD, with the same soiled gloves, took the roast beef, placed it on one slice of toast, and then placed the other slice of toast on top of the roast beef, placed mayonnaise on the bread, and then placed on a plate and served to a resident. A review of the Cottonwood House kitchenette logs revealed missing documentation on the following dates in August 2024 for the kitchen refrigerator, kitchen freezer, pantry refrigerator, pantry freezer, small juice refrigerator, food, and dishwasher temperatures, and the sanitizer parts per million (PPM) tests for the dishwasher: 08/01/24-pureed diet temp, ground, casserole temp, meat temp, vegetable temp, starch temp dessert temp, dishwasher, and PPM for breakfast and lunch 08/02/24-breakfast, lunch, dinner-all temperatures and PPM tests 08/03/24- breakfast, lunch, -all temperatures and PPM tests 08/04/24-breakfast, dinner-all temperatures and PPM tests 08/05/24-breakfast, lunch, dinner all temperatures, and PPM tests 08/06/24-breakfast, lunch and dinner-all temperatures and PPM tests 08/07/24-breakfast, all lunch food temps missing 08/08/24-breakfast, lunch purred and ground, dinner all temperatures and PPM tests 08/09/24-breakfast, lunch, dinner all temperatures, and PPM tests 08/10/24-breakfast meat, vegetable, starch dessert, dinner all temperatures and PPM tests 08/11/24-breakfast, lunch, dinner -all meals temperatures and PPM tests 08/12/24-breakfast and lunch all temperatures and PPM test, dinner pureed and ground dishwasher temp 08/13/24-breakfast, lunch, and dinner all meals temperatures and PPM test 08/14/24-breakfast and lunch all temperatures and PPM tests 08/15/24-breakfast food items, dishwasher temperatures PPM 08/16/24-breakfast, lunch, and dinner all temperatures and PPM tests 08/17/24-breakfast and lunch, all temperatures and PPM tests 08/18/24-breakfast, lunch, dinner all temperatures, and PPM tests 08/19/24- lunch and dinner all temperatures and PPM tests. 08/20/24-breakfast -pantry refrigerator, pantry freezer, small juice refrigerator, food items temperature, and PPM test, lunch- pantry refrigerator, pantry freeze, small juice refrigerator temperatures and PPM tests and dinner all temperatures and PPM tests 08/21/24-breakfast and lunch, all temperatures and PPM tests 08/22/24- breakfast and lunch, all temperatures and PPM tests On 08/27/24 at 0154 PM, DM BB verified the lack of documentation in the above findings and stated administrative staff had identified the lack of documentation and were working on a new form for staff to document on. On 08/27/24 at 12:13 PM, observation in the Cottonwood House during the preparation of the pureed diets, DS CC retrieved two bowls, placed them on the counter, placed 2(4oz) scoops of noodles into a blender, blended, added 1 (4oz) scoop hot water from the pan the noodles were cooked in, blended to the consistency of mashed potatoes. DS CC left the blender container used to puree the noodles on the blender and the lid upside down on the counter. Further observation revealed at 12:35 PM, DS CC reported the facility had one ground meat diet, placed a chicken breast into the same soiled blender used to puree the noodles, blended to ground consistency, placed the ground chicken on a plate, and served it to a resident. Continued observation revealed at 12:45 PM, DS BB pushed an uncovered food tray cart down the hall to two residents' rooms. At 12:50 PM, DS BB verified she had delivered the uncovered room trays to the residents and stated she was told that staff did not have to cover the trays when delivering them down the hall due to the house being a homelike setting. On 08/28/24 at 10:23 AM, observation in the Meadowlark House dry storage room refrigerator revealed a turkey breast and a package of pork chops thawing in the same pan. The refrigerator lacked thermometers in the refrigerator and freezer. DS EE verified the finding and stated the turkey breast and pork chops should be in separate pans and the refrigerator and freezer should have backup thermometers. Observation revealed DS EE retrieved a new pan and placed the turkey breast in the pan. On 08/28/24 at 01:15 PM, Registered Dietician (RD) HH stated he expected staff to put different food items in a different pan when storing them in the refrigerator. RD HH stated staff, when plating and serving a resident's food items, should have all the items needed for the meal out of the refrigerator and should change gloves and wash hands, then deglove between tasks. RD HH stated staff should cover food items when delivering them down the hall. RD HH stated staff should record the temperatures of all refrigerators and freezers, and check PPM tests daily. The facility's Food Preparation and Service Policy, revised in November 2022, documented Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Food preparation staff should adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The policy documented that when serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (down a hallway, to a different unit or floor). The policy documented that when verifying food temperatures, staff use a thermometer that is clean, sanitized, and calibrated to ensure accuracy. The policy documented that raw meat should be stored separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. The facility's Refrigerators and Freezers Policy, revised in November 2022, documented the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and would observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures. The sheets include time, refrigerator temperature, temperature of potential hazardous food (PHF), and Time/temperature control for safety (TCS) food with initials. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This placed the residents at risk for foodborne illness.

The facility had a census of 44 residents. Based on interviews and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter (Q) 3 indicated no licensed nurse coverage on seven dates. The PBJ report for FY 2023 Q4 recorded no licensed nurse coverage on nine dates. The PBJ report for FY 2024 Q2 recorded no licensed nurse on four dates. A review of the facility licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 08/28/24 at 07:58 AM, Administrative Staff A stated the information for the PBJ was submitted from someone off campus and she did not realize there were submission problems. Administrative Staff A further stated there was always a licensed nurse in the building and they have more registered nurses than they used to, so she was unsure why the PBJ showed they did not have licensed nurses in the building each day. The facility's Reporting Direct Care Staffing information was reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. Staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 44 residents. The sample included 12 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for Resident (R) 22, when staff called R22 Honey multiple times instead of addressing her by her proper name. This placed the resident at risk for undignified care and services. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia with psychotic disturbance, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), agitation (feelings of aggravation or restlessness brought on by a provocation or a medical condition), anxiety ( mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, restlessness (the inability to relax as a result of anxiety), and chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all activities of daily living (ADLs) and had inattention and disorganized thinking. The assessment further documented that R22 had physical and verbal behaviors, and rejected care for 4 to 6 days. R22 received antipsychotic (a class of medication used to treat psychosis and other mental-emotional conditions), and antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication. The Quarterly MDS, dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all ADLs, had disorganized thinking, and altered level of consciousness. The assessment further documented R22 had physical and verbal behaviors for 4 to 6 days and rejection of care for 1 to 3 days. R22 received antipsychotic and antidepressant medication. R22's Care Plan, dated 08/12/24, initiated on 03/14/22 directed staff to reminisce with the resident using photos of family and friends. The update, dated 04/19/22, directed staff to offer her a sucker or chocolate when she was anxious or agitated, encourage her to participate in activities, and if she did not want to attend, sit and talk with her for a bit. The update, dated 04/23/22, documented R22 was physically aggressive, would hit, kick, and attempt to bite during bedtime care and directed staff to give her as many choices as possible about care and activities, engage calmly in conversations, consult a psychiatrist as indicated, administer medications as ordered, answer her questions, and do not touch her until she was ready. The update, dated 06/17/22, documented R22 only tolerated one person at a time, needed personal space, and directed staff to sit her alone at a table during mealtime when she was agitated. The care plan directed staff to modify her environment, adjust the room temperature to a comfortable level, and reduce noise. The update, dated 02/24/23, directed staff to anticipate and meet her needs, provide a program of activities that were of interest, and accommodate her status. The update dated 08/06/23, directed staff to offer her the fidget board. R22's Care Plan lacked evidence the resident preferred to be called Honey. On 08/26/24 at 11:18 AM, observation revealed R22 sat at the dining table and yelled Help! Help! over and over. Certified Nurse Aid (CNA) M went to the table and asked R22 if she needed something, called her Honey multiple times, and offered to take her into the living room area to watch television. CNA M asked R22 if she wanted to watch Little House on the Prairie, and R22 stated Yes. CNA M did not change the channel to the television show R22 wanted to watch, but stated, Oh here's a farm show you would like, can I transfer you into the recliner Honey? R22 continued to yell Help and CNA made a shushing noise towards R22. CNA M stated, Let me know if you want the channel changed and she walked away. Continued observation revealed R22 started to yell, Help! Help! CNA M went to her and stated Did you not like this show Honey R22 stated, NO! CNA M asked R22 if she wanted the channel changed to Little House on the Prairie and R22 stated Yes. On 08/28/24 at 03:45 PM, Licensed Nurse (LN) G stated staff should call the resident by her name unless they have been given permission to call them by something else. On 08/29/24 at 11:30 AM Administrative Nurse D stated staff should not call R22 Honey as that is not very dignified and is unsure if R22 would like to be called Honey. The facility's Dignity policy, dated 02/2021. documented residents were treated with dignity and respect at all times and staff should promptly respond to a resident's request for toileting assistance. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. The facility failed to promote dignity for R22 when staff called R22 Honey multiple times instead of addressing her by her proper name. This placed the resident at risk for undignified care and services.

The facility had a census of 44 residents. The sample included 12 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the correct CMS Form 10055, Skilled Nursing Facility [SNF] Advanced Beneficiary Notice [ABN] which included the estimated cost to continue services for skilled services to the resident or their representative for three residents: Resident (R) 1, R16, and R145. This placed all three residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare SNF ABN form 10055 informs the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for payment of services. (3) I do not want the listed services. The facility's Medicare ABN form staff provided to R1 (or their representative) was CMS-R-131. The facility's Medicare ABN form staff provided to R16 (or their representative) was from CMS-R-131. The facility's Medicare ABN form staff provided to R145 (or their representative) was from CMS-R-131. On 08/28/24 at 08:00 AM, Social Services X stated he did not realize he had been providing the families with the correct CMS form. The facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy, dated 09/23, documented that residents were informed in advance when changes would occur to their bills, The facility would provide a Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) to residents for initiation, reduction, or termination of Medicare benefits. The facility failed to provide R1, R16, and R145 the correct SNF ABN from CMS 10055 as required. This placed all three residents at risk for uninformed decisions regarding skilled services.

The facility had a census of 44 residents. The sample included 12 residents with three reviewed for hospitalization . Based on record review and interview the facility failed to provide a written notice for a facility-initiated transfer for Resident (R) 5, R11, and R1 or their representatives when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of the discharges. This placed the residents at risk for uninformed care choices. Findings included: - R5's Electronic Medical Record (EMR) documented the resident had diagnoses of pain in the knee and hyponatremia (concentration of sodium in your blood is abnormally low). R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented that R5 required partial, moderate staff assistance with oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, and transfers. R5 required supervision with ambulation. R5's Care Plan, revised 07/21/24, documented R5 received pain medication and was at high risk for falls pertaining to lack of vision. The care plan instructed staff to be sure R5's call light was within reach and encourage him to use it for assistance as needed, provide prompt response to all requests for assistance, and make sure R5 used his assistive device when walking. R5's Progress Notes, dated 02/26/24 at 11:00 AM and 03/18/24 at 07:00 PM documented the resident was transferred to the hospital. R5's clinical record lacked evidence the resident or representative was provided written notice. On 08/27/24 at 08:00 AM, observation revealed R5 sat in a chair at the kitchenette counter On 08/29/24 at 11:30 AM, Administrative Staff D stated she was not aware the appropriate documentation was not provided to the resident or his representative. On 08/28/24 at 07:53 AM, Social Service X stated he was unaware he was required to notify the LTCO when a resident went to the hospital. Social Service X stated he was also unaware of any written notification required to the resident or representative. Social Services X stated he provided the resident's representative with a bed hold notice. On 08/29/24 at 11:30 AM, Administrative Staff D stated she was not aware the appropriate documentation was not provided to the resident or his representative. The facility's Transfer or Discharge Notice Policy, revised March 2024, documented a copy of the notice would be sent to the office of the state Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. The facility failed to provide R5 or his representative written notice regarding R5's transfer to the hospital and failed to notify the office of the LTCO. This placed the resident and/or her representative at risk of uninformed care choices. - R11's Electronic Medical Record (EMR) documented R11 had a diagnosis of heart failure. R11's Quarterly Minimum Data Set (MDS), 07/12/24, documented R11 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R11 had heart failure. R11's Care Plan, revised 07/19/24-, documented R11 had coronary artery disease (a condition that occurs when the heart's blood supply is reduced due to plaque (sticky substance) buildup in the arteries). The care plan instructed staff to administer medications to R11 as the physician ordered, encourage compliance with the treatment regimen, monitor blood pressure and notify the physician of any abnormal readings, monitor R11's cholesterol (a fat-like substance in the body) levels, and report findings to the physician. The Progress Note, dated 01/31/2024 at 12:30 PM, documented R11 was admitted to the hospital. R11's clinical record lacked evidence the resident or representative was provided a written notice when she was transferred to the hospital. On 08/27/24 at 01:00 PM, observation revealed R11 ambulated down the hall with a walker. On 08/28/24 at 07:53 AM, Social Service X stated he was unaware he was required to notify the LTCO when a resident went to the hospital. Social Service X stated he was also unaware of any written notification required to the resident or representative. Social Services X stated he provided the resident's representative with a bed hold notice. On 08/29/24 at 11:30 AM, Administrative Nurse D stated she was not aware the appropriate documentation was not provided to the resident or her representative. The facility's Transfer or Discharge Notice Policy, revised March 2024, documented a copy of the notice would be sent to the office of the state Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. The facility failed to provide R11 or her representative written notice regarding R11's facility-initiated transfer. This placed the resident at risk of uninformed care choices. 32360 - The Electronic Medical Record (EMR) for R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough glucose is made or the body cannot respond to the insulin), edema (excess watery fluid in the tissues of the body), vaginitis (inflammation of the vagina that can result in discharge, itching, and pain), urinary tract infection (UTI-an infection in any part of the urinary system), kidney disease (damage to or disease of a kidney), and a femur fracture (broken thigh bone). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition and was dependent on all activities of daily living (ADLs). R1 was always incontinent of bowel and frequently incontinent of bladder. R1 received an antidepressant (medication used to treat mood disorders and relieve symptoms of depression), a diuretic (medication to promote the formation and excretion of urine), and an anticoagulant (medication that prevents blood clots from forming in the bloodstream) medication. R1's Quarterly MDS, dated [DATE], documented R1 had moderately impaired cognition and was dependent upon staff for toileting and transfers. R1 required substantial assistance with dressing and personal hygiene. R1 was always incontinent of bladder and bowel and received anticoagulant, diuretic, and opioid (narcotic pain medication) medication. R1's Care Plan, dated 06/27/24 and initiated on 03/22/22, documented R1 was dependent upon two staff for toileting and one for personal hygiene. The update, dated 04/01/22 directed staff to administer medications as ordered and monitor for edema. The update dated 04/10/24 documented R1 was a full sling lift. The Progress Note, dated 01/16/24 at 09:52 AM, documented R1 was admitted to the hospital due to increased weight and edema. The Progress Note, dated 03/25/34 at 11:23 AM, documented R1 was admitted to the hospital due to a fall with a fracture. The Progress Note, dated 06/10/24 at 02:23 AM, documented R1 was admitted to the hospital due to abnormal vaginal bleeding. R1's clinical record lacked evidence the resident or her representative was provided a written notice when she was transferred to the hospital on the above dates. On 08/26/24 at 11:56 AM, observation revealed R1 was at the dining table visiting with her family. On 08/28/24 at 07:53 AM, Social Service X stated he was unaware he was required to notify the LTCO when a resident went to the hospital. Social Service X stated he was also unaware of any written notification required to the resident or representative. Social Services X stated he provided the resident's representative with a bed hold notice. On 08/29/24 at 11:30 AM, Administrative Nurse D stated she was not aware the appropriate documentation was not provided to the resident or her representative. The facility's Transfer or Discharge Notice Policy, revised March 2024, documented a copy of the notice would be sent to the office of the state Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. The facility failed to provide R11 or her representative written notice regarding R11's facility-initiated transfer. This placed the resident at risk of uninformed care choices.

The facility had a census of 44 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure staff followed the care plan to prevent accidents when staff failed to place Resident (R) 9's alarm (a device designed to monitor a patient's movements) underneath her when she was in bed per her plan of care resulting in a fall. This also placed R9 at risk for injuries from falls. Findings included: - R9's Electronic Medical Record (EMR) documented R9 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), muscle weakness, unsteadiness on her feet, and a history of falling. R9's Quarterly Minimum Data Assessment, (MDS) revised 07/12/24, documented R9 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R9 used a walker and had a fall with injury during the observation period. R9's Care Plan revised 04/22/24, documented R9 was a high risk for falls, and used a bed and chair alarm. The plan instructed staff to ensure the alarm was on at all times when R9 was in bed or a wheelchair. The Progress Note, dated 08/24/24 at 01:18 AM, documented that Certified Nurse Aide (CNA) N notified the nurse that R9 was on the floor. When the nurse entered the room R9 was against the bathroom door. The nurse noticed R9's bed alarm was in place but the box to the bed alarm was missing. The note documented CNA N stated he left the box in the living room and he was not aware that the box needed to be transferred to her bed alarm. On 08/27/24 at 09:44 AM, observation revealed R9 sat quietly in a wheelchair in the activity room at an exercise activity. On 08/28/24 at 02:05 PM, Licensed Nurse (LN) G stated to prevent R9 from falling staff placed a pressure alarm underneath R9 when she was in bed or a wheelchair to notify staff when R9 tried to get up. On 08/29/24 at 09:23 AM, Administrative Nurse D verified R9 had a fall on 08/24/24 at 01:18 AM from her bed because the staff had not placed the alarm box on the bed alarm as the care plan instructed. Administrative Nurse D stated staff should ensure R9's alarm device was in place at all times when R9 was in her wheelchair or bed. Administrative Nurse D stated R9 now had two separate alarms one for the bed and one for her wheelchair. The facility's Falls-Clinical Protocol Policy, revised in March 2018, documented that if interventions have been successful in fall prevention, the staff would continue with current approaches. If the individual continues to fall, the staff and physician would re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and reconsider the current interventions. The facility staff failed to place an alarm underneath R9 when she was in bed per her plan of care and R9 had a fall. This also placed R9 at risk for injuries from a fall.

The facility had a census of 44 residents. The sample included 12 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Resident (R) 22 when staff did not provide her oxygen during the breakfast meal and failed to store the oxygen tubing and cannula (a medical device that delivers supplemental oxygen to patients through their nose) in a sanitary manner when not in use. This placed R22 at risk for respiratory complications. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia (a progressive mental disorder characterized by failing memory and confusion) with psychotic disturbance, depression (an abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all activities of daily living (ADLs). R22 did not have shortness of breath and received oxygen daily. R22 did not receive a diuretic (treats fluid retention) medication. R22's Care Plan, dated 08/12/24, initiated on 02/28/22, directed staff to monitor her for signs and symptoms of respiratory distress and report to the physician as needed, have continuous oxygen at 2 liters (L) per minute via nasal cannula and titrate (adjust the flow) to keep the oxygen saturation above 90%. The Physician's Order, dated 08/12/24, directed staff to administer continuous oxygen via nasal cannula at 2L to keep saturation above 90%, notify the physician of all changes, and monitor R22's oxygen saturation every shift for COPD. On 08/26/24 at 11:18 AM, observation revealed R22 sat at the dining table and did not have her oxygen concentrator with her at the dining room table. Further observation revealed staff took R22 to the living room area and did not bring her oxygen to her. CNA M stated R22 refused her oxygen earlier, and staff could not force her to wear it, so she did not bring it to the table. Continued observation revealed after being questioned, CNA M brought out R22's oxygen concentrator and stated, You forgot your oxygen Honey, can I put it on? R22 responded Yes. On 08/27/24 at 09:05 AM, observation revealed R22 at the dining table. Staff attempted to fix her oxygen cannula as it was partially out of her nose but R22 did not allow it. Further observation revealed the CNA took the oxygen tubing and laid it over the handles of the wheelchair and the cannula was resting against R22's back. On 08/28/24 at 09:31 AM, CNA Q removed R22's oxygen and placed the tubing in the bag on the concentrator. CNA Q took R22 to her room for care, then brought her back and tried to put R22's oxygen on and R22 would not let her so CNA Q laid the oxygen tubing in R22's lap. On 08/28/24 at 09:30 AM, CNA Q stated she did not know why she did not place the oxygen tubing in the bag as she had previously. On 8/28/24 at 03:45 PM, Licensed Nurse (LN) G stated staff should put the oxygen tubing in the bag that was provided on the concentrator. LN G said staff should have checked R22's oxygen saturation after R22 went without oxygen for that period. On 8/29/24 at 11:30 AM Administrative Nurse D stated there were bags provided to the residents with oxygen for the staff to put the oxygen tubing in if the resident was not wearing it. The facility's Oxygen Administration policy, dated 10/2010, documented the procedure was to provide guidelines for safe oxygen administration, and if a resident refused the oxygen, document the reason why and what interventions were taken. The facility failed to provide adequate respiratory care and services for R22 when staff did not provide her oxygen during the breakfast meal and failed to store the oxygen tubing and cannula in a sanitary manner when not in use. This placed R22 at risk for respiratory complications.

The facility had a census of 44 residents. The sample included 12 residents with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on observation, record review, and interview, the facility failed to provide dementia care and services for Resident (R) 22, who had dementia and behaviors. This placed R22 at risk for abuse and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of moderate dementia with psychotic disturbance, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), agitation (feelings of aggravation or restlessness brought on by a provocation or a medical condition), anxiety ( mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, restlessness (the inability to relax as a result of anxiety), and Chronic Obstructive Pulmonary Disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all activities of daily living (ADLs) and had inattention and disorganized thinking. The assessment further documented R22 had physical and verbal behaviors, and rejected care for 4 to 6 days. R22 received antipsychotic (a class of medication used to treat psychosis and other mental-emotional conditions), and antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication. The Quarterly MDS, dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for all ADLs, had disorganized thinking, and altered level of consciousness. The assessment further documented R22 had physical and verbal behaviors for 4 to 6 days and rejection of care for 1 to 3 days. R22 received antipsychotic and antidepressant medication. R22's Care Plan, dated 08/12/24, initiated on 03/14/22 directed staff to reminisce with the resident using photos of family and friends. The update, dated 04/19/22, directed staff to offer her a sucker or chocolate when she was anxious or agitated, encourage her to participate in activities, and if she did not want to attend, sit and talk with her for a bit. The update, dated 04/23/22, documented R22 was physically aggressive, would hit, kick, and attempt to bite during bedtime care and directed staff to give her as many choices as possible about care and activities, engage calmly in conversations, consult a psychiatrist as indicated, administer medications as ordered, answer her questions, and do not touch her until she was ready. The update, dated 06/17/22, documented R22 only tolerated one person at a time, needed personal space, and directed staff to sit her alone at a table during mealtime when she was agitated. The care plan directed staff to modify her environment, adjust the room temperature to a comfortable level, and reduce noise. The update, dated 02/24/23, directed staff to anticipate and meet her needs, provide a program of activities that were of interest, and accommodate her status. The update dated 08/06/23, directed staff to offer her the fidget board. The Physician's Order, dated 07/19/22, directed staff to administer quetiapine (an antipsychotic medication), 50 milligrams (mg), by mouth, twice per day, for dementia with psychotic disturbance. The Physician's Order, dated 10/21/22, directed staff to administer divalproex sodium (a medication used to prevent seizures and also used for mood and behaviors), 125 mg, by mouth, twice per day, for agitation. The Physician's Order, dated 12/13/23, directed staff to administer vilazodone (an antidepressant medication), 40 mg, by mouth, daily for depression. The Physician's Order, dated 02/06/24, directed staff to administer Remeron (an antidepressant medication), 7.5 mg, by mouth, at bedtime for appetite stimulant. The Physician's Order, dated 08/12/24, directed staff to administer continuous oxygen via nasal cannula at 2 Liters to keep saturation above 90%, notify the physician of all changes, and monitor her saturation every shift for COPD. The Nurse's Note, dated 02/14/24 at 01:46 AM, documented R22 was combative with staff at dinner. She yelled, Help! Help!, spit her food at the Certified Nurse Aide (CNA), and attempted to hit the CNA. R22 was put to bed early but continued to hit both CNAs. The Nurse's Note, dated 07/28/24 at 10:50 PM, documented that R22 was combative when assisted to bed. She bit and pinched the CNA. The Nurse's Note, dated 08/01/24 at 02:12 AM, documented R22 bit, kicked, and pinched staff during care, and received an abrasion (scrape) to her right foot. R22 was placed into bed and offered water; staff put her bed in a low position with a blue mat. The Nurse's Note, dated 08/12/24 at 10:39 PM, documented R22 yelled Help! for hours and started to lose her voice. Staff checked on R22 every 30 minutes as she tried to self-transfer out of bed. The note documented that R22 tried to bite, punch, and dig her nails into staff when she was toileted. The Nurse's Note, dated 08/25/24 at 02:34 AM, documented that R22 yelled most of the day and hit and bit staff members during care. On 08/26/24 at 11:18 AM, observation revealed R22 sat at the dining table and yelled Help! Help! over and over. Certified Nurse Aid (CNA) M went to the table and asked R22 if she needed something, called her Honey multiple times, and offered to take her into the living room area to watch television. CNA M asked R22 if she wanted to watch Little House on the Prairie, and R22 stated Yes. CNA M did not change the channel to the television show R22 wanted to watch, but stated, Oh here's a farm show you would like, can I transfer you into the recliner Honey? R22 continued to yell Help and CNA made a shushing noise towards R22. CNA M stated, Let me know if you want the channel changed and she walked away. Continued observation revealed R22 started to yell, Help! Help! CNA M went to her and stated Did you not like this show Honey R22 stated, NO! CNA M asked R22 if she wanted the channel changed to Little House on the Prairie and R22 stated Yes. CNA M changed the channel to a movie and did not change it to the program R22 wanted to watch. CNA M stated she did not know why she did not change the channel to the program R22 wanted to watch and stated that R22 had refused her oxygen earlier, so she did not bring it to the table. On 08/27/24 at 12:23 PM, the Meadowlark House dining room had residents waiting for the noon meal, and two CNAs present. One CNA cooked the meal, and one assisted the residents. R22 sat at the dining table and yelled Help! I need to go to the bathroom! loudly and as staff did not respond, the level of need in her voice raised as she continued to say she needed to go to the bathroom. Continued observation revealed CNA O looked over at the resident but did not respond to her, went into the kitchen area, and told the second CNA that R22 needed to go to the bathroom but neither CNA responded to R22. Observation revealed at 12:39 PM, R22 continued to request toileting and would often yell Help! Help!. CNA O went over to the resident and placed a blanket around her shoulders but did not offer toileting. Continued observation revealed CNA O fixed herself a plate of food took it into the nurse's room and shut the door. At 01:00 PM, CNA O came out of the room and when questioned stated R22 would be toileted when the residents were done with the meal. CNA O further stated that there were only two CNAs working in the house that day, and R22 required the assistance of two staff. CNA O said that R22 was a check and change and did not sit on the toilet. On 08/27/24 at 09:05 AM, observation revealed R22 at the dining table, yelling Help! Help! over and over. R22 looked over at another table with residents talking, and started to yell, Shut up! shut up! R22 continued to yell Help! and then yelled Shut up if anyone responded to her. The staff did not offer any other alternatives except food and fluids. R22 continued to yell throughout meal service until Consultant GG entered the household and offered to take R22 outside. On 08/28/24 at 09:31 AM, observation revealed R22 at the dining table continuously yelling Help! or Shut up! Staff offered her food but she did not want anything. R22 started to spell out her name, and then say her name out loud and another resident tried to talk to her but R22 told her to Shut up! Observation revealed at 09:30 AM, CNA Q removed R22's oxygen and placed the tubing in the bag on the concentrator. CNA Q took R22 to her room for care, then brought her back and tried to put R22's oxygen on and R22 would not let her so CNA Q laid the oxygen tubing in R22's lap. On 08/28/24 at 09:23 AM, CNA P stated she did not know what interventions to offer R22 when she had behaviors but said she would offer her food and fluids. On 08/28/24 at 09:30 AM, CNA Q stated this was her first day in the house and that she was unsure what interventions to offer R22 when she had behaviors. CNA Q further stated they receive dementia training prior to working and they are given a list of residents and how to care for them when they come on shift. On 8/28/24 at 03:45 PM, Licensed Nurse (LN) G stated staff should have called her to assist R22 with toileting. LN G stated the staff should engage with R22 and talk with her when she gets upset, especially about her farm and cat. On 08/28/24 at 04:00 PM, Certified Medication Aide (CMA) R stated the medication aides help the CNAs if they need anything and said she would assist with R22 if needed. On 8/29/24 at 11:30 AM Administrative Nurse D stated staff should have tried to get the show she wanted on TV and should offer her the activity box they have for her. Administrative Nurse D further stated staff should try to sit down and talk to her. Administrative Nurse D stated all staff gets dementia with behavior training. The facility's Dementia- Clinical Protocol, dated 11/2018, documented individuals with confirmed dementia the staff would identify a resident-centered care plan to maximize remaining function and quality of life. The nursing assistants would receive initial training in the care of residents with dementia and related behaviors and services would be conducted annually thereafter. Interventions and the overall plan would be adjusted depending on the resident's progression of dementia. The facility failed to provide dementia care and services for R22 in order to promote and maintain R22's highest practicable well-being. This placed R22 at risk for abuse and decreased quality of life.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to prepare all the food items on the noon menu while preparing Resident (R) 20 and R22's pureed diet. This placed the residents at risk for impaired nutrition. Findings included: - On 08/27/24 at 11:22 AM, a review of the noon meal consisted of chicken parmesan, buttered penne pasta, asparagus tips, fruit crisp, and garlic toast. On 08/27/24 at 11:22 AM, Dietary Staff (DS) CC reported the Meadowlark Kitchenette had two residents who received a pureed diet. DS CC stated staff only prepared mashed potatoes and gravy for R22 at the noon meal and R20 would receive the full pureed diet. DS CC placed a 4-ounce (oz) piece of chicken parmesan into the blender container, added two (8 oz) ladles of red marinate sauce into the container, and blended it. DS CC reported it was still too thick and added another 8-oz ladle of marinate sauce, then blended to the consistency of mashed potatoes. Further observation revealed DS CC placed an unmeasured amount of hot water into a bowl added an unmeasured amount of boxed potato flakes and stirred with a fork. Continued observation revealed at 12:13 PM, DS CC retrieved two bowls, placed them on the counter, and then placed two (4oz) scoops of cooked noodles into the blender. DS CC blended, then added one (4oz) scoop of hot water from the noodle pan and blended to the consistency of mashed potatoes. When asked about the other food items on the menu, DS CC stated she would not prepare the bread, asparagus, or the fruit crisp for the residents who were on a pureed diet; they would receive protein ice cream as their dessert and a can of V8 juice (a juice made mainly from water and tomato concentrate, and concentrate of eight vegetables, specifically: beets, celery, carrots, lettuce, parsley, watercress, spinach, and tomato). Further observation revealed DS CC retrieved a 5.5 milliliter (ml) can of V8 juice, poured it into a glass, and served it to R20. On 08/27/24 at 12:45 PM, Dietary Manager BB verified DS CC had not prepared all the food items for R20 and R22's pureed diet. On 08/28/24 at 01:15 PM, Registered Dietitian CC stated he expected staff to prepare the same food items on the menu for the residents who received a pureed diet as the other residents, but V8 juice was a good vegetable replacement. Upon request, the facility did not provide a pureed diet recipe. The facility kitchen staff failed to puree all the food items on the noon menu in one of three kitchenettes. This placed R20 and R22 at risk for impaired nutrition.

The facility identified a census of 44 residents. The sample included 12 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination to Resident (R) 9 per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the resident at risk for pneumococcal infection and related complications. Findings included: - R9's Admission Minimum Data Set, dated dated dated [DATE] documented R9 admitted to the facility on [DATE]. The MDS documented R9 received the influenza (flu) vaccine before admitting to the facility. The MDs documented R9's pneumococcal vaccination was not up to date, and was not offered. A review of R9's clinical medical records lacked evidence the facility offered and received the vaccination or of a signed declination for the PCV20 vaccine. On 08/28/24 at 11:48 AM, Administrative Nurse D stated she could not find any documentation that R9 was offered the PCV20 on admission but stated the resident had an influenza vaccine prior to admission. Administrative Nurse D stated the pharmacy keeps track of which immunizations residents are eligible for. The facility's Pneumococcal Vaccine Policy, revised in October 2023, documented all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated are offered the vaccine series within thirty day (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. The facility failed to offer R9 the PCV20 pneumococcal vaccination. This deficient practice placed the resident at risk of acquiring, spreading, and experiencing complications from pneumonia.

The facility identified a census of 40 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from accidents when staff failed to safely operate a mechanical lift resulting in a fall with injury. On 05/22/24 at approximately 05:00 PM, Certified Nurse Aide (CNA) M prepared R1 for a mechanical lift transfer (by use of a ceiling lift) from her bed to her wheelchair. CNA M failed to ensure the lift sling harness loops were attached to the mechanical lift correctly. During the transfer, R1 fell out of the lift sling to the floor and required emergency transfer and evaluation. R1 was then transferred to a higher level of care to treat a right comminuted (a broken bone that has multiple pieces or fragments at the fracture site) distal (away from the farthest point of origin or attachment) femoral (thigh bone) fracture (broken bone) as a result of the incorrect placement of the harness loops and subsequent fall. This deficient practice also placed R1 at risk for unnecessary injury and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of polyneuropathy (a neurological disorder that causes damage to peripheral nerves in similar areas on both sides of the body), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition with low heart output and the body becomes congested with fluid) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R1 had functional limitation in range of motion on both sides of her upper extremities and lower extremities. The MDS documented R1 required a wheelchair for locomotion pushed by staff. The MDS documented R1 was dependent on staff for oral hygiene, toileting hygiene, showering, dressing, bed mobility, and transfer. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/09/24, documented R1 had moderate cognitive impairment and had difficulty communicating some words and thoughts. The CAA documented R1 was at risk for unmet needs, uncontrolled pain, and mood changes. The Functional Abilities CAA, dated 01/09/24, documented R1 was dependent on staff for activities of daily living except for eating. The CAA documented R1 was at risk for skin breakdown and falls and the goal was for R1 to have her needs met and avoid complications from her limited mobility. R1's Care Plan documented R1 was on non-weight bearing status due to weakness and pain in her lower extremities (02/20/23). The care plan documented R1 was totally dependent on one staff for transfers using the ceiling lift or two staff members for the full body lift (02/09/23). The care plan documented for transfers, R1 required a basic high lift sling with a height measurement of 36 inches and width measurements of 1) 18 inches and 2) 32 inches. The care plan documented R1 was at moderate risk for falls and R1 would not sustain serious injury (01/23/24). The Fall Risk Evaluation, dated 04/05/24, documented R1 had a score of 17 and was at risk for falls. The evaluation documented R1 had intermittent confusion, had no falls in the last three months, was chair-bound, and required the use of an assistive device (wheelchair). The Fall Risk Evaluation, dated 05/23/24, documented R1 had a score of 19 and was at risk for falls. The evaluation documented R1 had intermittent confusion, had one to two falls in the past three months, was chair-bound, and required the use of an assistive device (wheelchair). The Progress Note, dated 05/22/24 at 05:54 PM, documented Licensed Nurse (LN) G was in the kitchen when she heard yelling over the radio. LN G and CNA N went to R1's room and noted CNA M in R1's room yelling for help. R1 was noted lying on the floor with her feet facing the window and the lift sling above her. LN G asked CNA M to go get therapy to assist. LN G noted R1 had significant internal rotation to her right leg and R1 was yelling out in pain and complained of pain to her bilateral legs. LN G stepped out of the room and left CNA N and the therapy staff at R1's side. LN G placed a call to 911 and requested the Emergency Medical Service (EMS) at about 05:09 PM and called R1's responsible party. LN G went back to R1's room and R1 complained of pain in her head and left leg. LN G did not note any significant deformities with R1's head. LN G did not note any internal rotation to R1's left leg. EMS arrived and staff directed them to R1's room. EMS assessed R1 and was assisted to the gurney via a slide sheet by EMS staff and LN G. LN G inspected the lift sling and noted CNA M had not hooked up the sling correctly and the sling straps were uneven. LN G had therapy staff look at the sling and they noted the inconsistency as well. The Diagnostic Imaging Report, dated 05/22/24 at 05:49 PM, documented R1 was having pain after being dropped. The findings documented R1 had a right comminuted and displaced distal femoral fracture. The Communication/Visit with Physician Note, dated 05/23/24 at 12:11 AM, documented the local hospital reported R1 had a distal femoral fracture and was admitted to the hospital for pain control after R1 was sedated and the fracture re-set. The At Risk Note, dated 05/23/24 at 02:04 PM, documented R1 had a fall with a major injury. A new Triple Check System would be implemented (make sure the sling is in good shape, verify sling size, and verify all straps on the sling are placed correctly) and all nursing staff would have ceiling lift training. The undated Facility Incident Report, documented on 05/22/24 at 05:00 PM, LN G was called over the radio to R1's room. LN G and CNA N immediately responded to the call. Upon entering R1's room, LN G and CNA M observed CNA M yelling for help. R1 lay on the floor with her feet facing the window and the lift still above her, still connected to the lift. LN G instructed CNA M to request assistance from a therapy staff member and staff paged Certified Medication Aide (CMA) R over the radio to come assist. LN G noted R1 had significant internal rotation of her right leg and R1 yelled and complained of bilateral leg pain. LN G stepped out of R1's room and called 911 at approximately 05:09 PM and then contacted R1's responsible party. When LN G returned to R1's room, R1 voiced complaints of pain in her head and her left leg. EMS arrived and entered R1's room. LN G and Consultant GG remained in the room while EMS assessed R1. R1 was transferred onto the gurney by a slide sheet by two EMS personnel, LN G, and Consultant GG. LN G inspected the lift sling and noted CNA M had not hooked up the sling correctly; the sling straps were uneven at the top hooks. CNA M was placed on suspension pending the investigation. At 12:11 AM, the local hospital reported R1 was admitted to the hospital for a distal femoral fracture and pain control after sedation and resetting the fracture. R1 had not experienced a change of condition within seventy-two hours prior to the incident. CNA M had followed R1's care plan for full-body ceiling lift transfers. CNA M received lift training prior to the incident and was noted to be competent in utilizing the ceiling lifts on 03/25/24. The root cause analysis indicated CNA M had not connected the lift sling correctly. The facility provided education on the ceiling lift policy on 05/23/24 and the lift Triple Check System was initiated; these were placed on all lifts in the facility. The Triple Check System was 1) verify the lift sling is in good working order, 2) verify the sling size, and 3) verify all straps on the sling are placed correctly. R1's Care Plan would be re-evaluated on her return from the hospital. The facility would monitor weekly during At Risk meetings and monthly at the Quality Assurance and Performance Improvement (QAPI) meetings. Consultant GG's Witness Statement, dated 05/23/24, documented that Consultant GG was called by CNA M down the hallway. CNA M stated, You've got to come now. It is an emergency. Consultant GG entered R1's room to find R1 on the floor. R1 was positioned with her head towards the head of the bed and her feet oriented towards the window. R1 showed increased internal rotation of her right lower extremity and extreme plantar flexion of her bilateral ankles though no other visible abnormalities of body alignment were noted. Consultant GG assessed the lift and sling placement as LN G indicated and noted the sling was looped through the green strap on one side and the grey strap on the other. R1 yelled out in pain. R1 was asked to point towards her pain and R1 pointed towards the left femur. LN G requested CNA M to retreat to assist others as needed and document a statement. LN G then requested the occupational therapy assistant and Consultant GG remain with R1 while staff called the emergency team. After one to two minutes, R1 began to complain of posterior head pain. The emergency team arrived, assessed R1, and administered care. R1 was lifted with emergency service members providing leg support on R1's left lateral side, LN G supported R1's head, and Consultant GG on the right lateral side to the gurney. R1 was then escorted to the ambulance. CNA M's Witness Statement, dated 05/28/24, documented at approximately 04:45 PM, CNA M checked and changed R1 and then placed her in her sling to transfer her to her wheelchair for supper. CNA M stated he made sure to cross the legs before picking R1 up on the lift. At approximately 05:00 PM, CNA M lifted R1 up and as he was beginning to lower her to the chair, R1 fell out of the sling. CNA M noted he believed R1 hit her head. CNA M called immediately for LN G. CNA N and LN G came quickly. CNA M was told to get therapy. Upon examining the sling CNA M had just the black loop on the right side. CNA N's Witness Statement, dated 05/28/24, documented CNA N was in the kitchen talking to LN G when they heard unrecognizable crying over the radio and it sounded like the commotion was coming from R1's room. LN G and CNA N went quickly to R1's room and when they opened the door CNA M was coming out. CNA M was crying I don't know how. CNA N went to R1 and tried to reassure R1 but LN G intervened so CNA N sat with R1 while LN G assessed. LN G called EMS and called on the radio for therapy to come and assist. When therapy showed up, the therapy staff and CNA N stayed in the room with R1 while LN G went outside the room. LN G came back shortly and told CNA N to go let EMS staff in when they arrived. CNA N went to the dining room and a couple of minutes later EMS arrived; she let them in and told them what room and pointed them over to her. On 06/03/24 at 10:30 AM, observation revealed signage on the ceiling lifts with the triple-check instructions. On 06/03/23 at 10:45 AM, CNA M stated he was so concerned about R1 complaining of pain in her legs and making sure R1's legs were crossed that he forgot to look to make sure the sling was balanced before he transferred R1. CNA M stated he and the other staff had re-training on the Triple Check System. On 06/03/24 at 11:00 AM, Administrative Nurse D stated the incident happened because CNA M did not make sure the lift sling loops were on the same-colored loop and R1 slid out of the lift sling to the floor. Administrative Nurse D stated all the lifts in the facility now have signage with the Triple Check System to remind staff to check all three components. The facility's Lifting Machine, Using a Mechanical (Guldman Ceiling Lift) Policy, revised May 2024, documented the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. At least one nursing assistant is needed to safely move a resident with a mechanical ceiling lift per Guldman Incorporated. Before using a lifting device, assess the resident's current condition. Measure the resident for proper sling size and purpose according to the manufacturer's guidelines. Select a sling bar that is appropriate for the resident's size and task. Prepare the environment. Make sure the battery is charged. Test the lift controls. Ensure the emergency release feature works. Make sure the lift is stable and locked. Make sure all the necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. Double-check the sling and machine's weight limits against the resident's weight. Place the sling underneath the resident. Visually check the size to make sure it is not too large or too small. Lower the sling bar closer to the resident. Attach the sling straps to the sling bar. Make sure the sling is securely attached to the clips and that it is properly balanced. Check to make sure the resident's head, neck, and back are supported. Before the resident is lifted, double-check the security of the sling attachment. Examine all hooks, clips, or fasteners. Check the stability of the straps. Ensure the sling bar is securely attached and sound. Lift the resident two inches from the surface to check the stability of the attachments, the fit of the sling, and the weight distribution. The facility failed to ensure staff transferred R1 safely during a mechanical lift transfer to prevent a fall with injury This deficient practice placed R1 at risk for unnecessary injury and pain. All corrective actions were completed on 05/23/24 and included: Education on ceiling lift policy and use was given on 05/23/24 and a lift Triple Check System was initiated; these checks were placed on all lifts in the facility. R1's Care Plan will be re-evaluated on her return from the hospital. The facility will monitor weekly during At Risk meetings and monthly at QAPI meetings. Since all corrections were completed before the onsite survey, the citation was deemed past noncompliance at a G scope and severity.

The facility identified a census of 43 residents with three residents reviewed for falls and accidents. Based on record review and interview, the facility failed to ensure Resident (R) 1's safety during a transfer when Certified Nurse Aide (CNA) M used the ceiling-mounted full body lift to transfer R1 from her bed to her wheelchair. During the transfer, R1 slid out of the lift sling onto the floor. As a result, R1 sustained a left femoral (thigh bone) fracture and a left fibular (one of the two bones in the lower leg) fracture. This deficient practice also placed R1 at risk for pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), obesity (excessive body fat) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R1 was dependent on staff assistance for all activities of daily living except eating which required set-up assistance. The MDS documented R1 required the use of a mechanical lift and manual wheelchair. R1 had impairment to her bilateral lower extremities. The MDS documented R1 weighed 267 pounds. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/29/24, documented R1 had severe cognitive impairment which placed R1 at risk for behaviors, communication deficits, and activities of daily living (ADLs) functional decline. The Functional Abilities CAA, dated 01/29/24 documented R1 required set-up assistance for eating and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfer, and was non-ambulatory with the use of a wheelchair for mobility pushed by staff. The CAA documented R1 was at risk for skin breakdown, falls, and ADL decline. R1's Care Plan, dated 06/17/22 documented staff would be educated on the proper use of the lift and directed staff to use two persons with the stand-aid. An intervention dated 01/08/24 directed staff to use a full body lift for transfers at all times but did not indicate how many staff. The Fall Risk Evaluation, dated 01/29/24, documented R1 had a fall risk score of 11.0 which indicated R1 was at risk for falls. The Health Status Note, dated 03/23/24, documented CNA M called Licensed Nurse (LN) G to R1's room at 08:18 AM. LN G entered the room in under a minute, and upon entering R1's room, LN G saw R1 sitting on the floor with her legs partially under her bed and CNA M was kneeling behind R1, keeping R1 in a sitting position. R1 was holding on to the edge of the bed. R1 was yelling out in pain and stated the pain was centralized in her left knee. LN G asked CNA M what happened and CNA M stated she was transferring R1 to her wheelchair from the bed with the ceiling lift and R1 slipped out of the sling. LN G performed a full body assessment and noted no internal or external rotation to the upper extremities or the right leg. LN G noted R1's left thigh was curved outward the kneecap was on the outside of the knee, and the calf was internally rotated with the foot slightly externally rotated. R1's left leg was out of alignment with her hip. LN G tried to perform a complete assessment of R1's left hip but was unable to find the hip joint due to R1 sitting on the floor and crying out in pain. R1 answered LN G's questions per her baseline. R1 was unable to state what happened but was able to answer questions regarding pain, and location, and described the pain clearly to LN G. LN G called CNA N into the room to assist with keeping R1 in a seated position. Staff assessed R1's vital signs and LN G asked CNA M to call emergency medical personnel (EMS) for emergency transport at 08:27 AM while LN G continued to assess R1; LN G kept R1 in position to keep her from further injury. When CNA M came back into R1's room, LN G left R1's room to print paperwork and notify the family and the emergency room of the transfer. LN G called R1's family member at 08:31 AM. The ER was notified at 08:37 AM. The EMS entered the building at 08:40 AM. At 10:50 AM, LN G contacted the ER for an update and was told R1 had fractures from her left knee to her ankle and was being transferred to a higher level of care. The Health Status Note, dated 03/23/24, documented LN G inspected the lift sling that was used on R1 at the time of the fall. The full-body sling was a size extra-large, the seams were intact, and there were no rips or holes in the sling. The Diagnostic Imaging Report, dated 03/23/24, documented R1 sustained a displaced and comminuted (a bone that has been broken in three or more places) distal (farther away) femoral shaft fracture and a proximal (closer to the body) fibular fracture. CNA M's Witness Statement, dated 03/29/24, documented CNA M retrieved an extra-large sling. CNA M stated she inspected the sling and did not see any tears. CNA M went to R1's room to get R1 ready for breakfast. CNA M changed and dressed R1. CNA M put the lift sling on R1 and hooked up the lift sling. CNA M stated she made sure the lift sling was put on properly. CNA M stated she lifted R1 partially and then checked again to ensure the lift sling was secure. CNA M stated when she started to move R1 away from the bed, R1 slipped out of the lift sling. CNA M asked R1 if she was okay and immediately called LN G. LN G's Witness Statement, dated 03/29/24, documented CNA M called LN G to R1's room stat at 08:18 AM. LN G entered the room in under a minute. Upon entering R1's room, LN G saw R1 sitting on the floor with her legs partially under her bed and CNA M kneeling behind R1, keeping R1 in a sitting position. R1 was holding on to the edge of the bed. R1 was yelling out in pain and stated the pain was centralized in her left knee. LN G asked CNA M what happened, and CNA M stated she was transferring R1 to her wheelchair from the bed with the ceiling lift and R1 slipped out of the sling. LN G stated she inspected the lift sling that was used to transfer R1 at the time of the fall. The lift sling was a size extra-large, seemed intact, and no rips or holes were noted in the lift sling. CNA N's Witness Statement, dated 03/29/24, documented at 08:20 AM LN G called CNA N over the radio for extra assistance in R1's room. CNA N got to R1's room at 08:21 AM. LN G and CNA M were in R1's room and R1 was sitting on the floor. LN G asked CNA N to obtain the vitals machine. CNA N got the vitals machine and LN G obtained R1's vital signs. CNA N sat behind R1 so R1 could lean against her. CNA M called EMS and LN G got paperwork ready and CNA N stayed with R1. The Facility Incident Report, dated 03/29/24, documented CNA M called LN G to R1's room stat at 08:18 AM. LN G entered the room in under a minute. Upon entering R1's room, LN G saw R1 sitting on the floor with her legs partially under her bed and CNA M was kneeling behind R1 keeping R1 in a sitting position. R1 was holding on to the edge of the bed. R1 was yelling out in pain and stated the pain was centralized in her left knee. LN G asked CNA M what had happened. CNA M stated she was transferring R1 to her wheelchair from the bed with the ceiling lift and R1 slipped out of the sling. The root cause analysis was identified as being the lift sling size. The lift sling was intact and correctly attached to the lift, the technique used for R1's transfer was deemed sufficient per the manufacturer's recommendation. The report recorded an intervention that R1 would be measured and fit for the lift sling upon her return from the hospital to ensure appropriate lift sling is used. Mandatory lift transfer evaluations would occur for all nursing staff before their next shift to ensure staff understanding and competence in safely using the ceiling lift equipment. An all-staff meeting was scheduled for 04/03/24 and 04/04/24 focusing on the appropriate use, facility standards of use, and patient positioning, transfer, and care techniques. Size assessments for all patients requiring the full body lift will be conducted to match them with the correct lift sling size per the manufacturer's specifications. The size of the lift sling will also be documented for clarity and ease of identification in patient rooms. Implementation of a monthly rolling schedule for lift sling inspection and patient assessments to ensure all equipment is appropriate and in good condition for the patient's current needs. R1 was unavailable for observation or interview. On 04/01/24 at 11:30 AM, Administrative Nurse D stated the incident with R1 should have never happened. CNA M went and got a different-sized lift sling to transfer R1 from her bed to her wheelchair because CNA M didn't think the lift sling in R1's room was big enough and R1 fell through the lift sling. Administrative Nurse D stated all residents who required the full lift were going to be evaluated by the physical therapy team to measure the residents and ensure the correct size of lift sling would be used for the residents. Administrative Nurse D stated all staff meetings would take place on 04/03/24 and 04/04/24 regarding education on the proper use of the ceiling lift sling. The facility's Lifting Machine, using a Mechanical Policy, revised in July 2017, documented the purpose of the policy is to establish the general principles of safe lifting using a mechanical lifting device. At least, two nursing assistants are needed to safely move a resident with a mechanical lift. Measure the resident for proper sling size and purpose. Select a sling bar that is appropriate for the resident's size and the task. Clear an unobstructed path. Ensure there is enough room to pivot. Position the lift near the receiving surface. Place the lift at the correct height. Make sure all the necessary equipment (sling, hooks, chains, straps, and supports) is on hand and in good condition. The facility failed to ensure R1 remained free from preventable accidents involving the use of a full-body lift. This deficient practice resulted in a fractured femur and fibula for R1 and placed R1 at risk for pain.

The facility identified a census of 44 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to identify fall risk and initiate fall interventions for Resident (R) 1 on 11/08/23 when he admitted to the facility with a diagnosis of frequent falls. On 11/09/23 at 10:10 PM staff found R1 in his room on the floor. R1 complained of severe pain in his back and was transported to the local hospital where he was diagnosed with fourth and fifth rib fractures on his right side. This deficient practice also placed R1 at risk for falls, injury, and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), history of falling, and weakness. The Discharge Return Anticipated Minimum Data Set (MDS), dated [DATE], documented R1 required moderate to substantial assistance with all activities of daily living (ADL). The MDS documented R1 had falls in the last month prior to admission, had falls two to six months prior to admission, and had one fall with major injury since admission to the facility. R1's baseline Care Plan, dated 11/08/23, failed to have any fall interventions in place. On 11/10/23, after R1's fall, the care plan was updated with interventions of a fall mat placed at R1's bedside, a pressure alarm placed in R1's bed, and physical therapy to consult for strength and mobility. The Admission Data Collection Form, dated 11/08/23, documented R1 was admitted to the facility due to frequent falls at home. The form recorded R1 had a history of dizziness and vertigo (sensation of spinning, dizziness), had generalized weakness, had impairment on both sides of his upper and lower extremities, and was not consistent or reliable in bearing weight. The facility did not perform the Fall Risk Assessment upon R1's admission. The Fall Risk Assessment performed after R1's fall, dated 11/10/23, documented R1 had a fall risk score of fifteen which indicated R1 was at risk for falls. The Medication Drug Review Potential Significant Issues (MDRSI), dated 11/09/23, documented R1 was on fluoxetine (anti-depressant medication) and directed nursing staff to monitor R1 for falls, fatigue, unsteadiness, and confusion. R1's admission paperwork which included a Health and Physical (H & P) Admission Document, dated 10/30/23, documented R1 admitted to the hospital with asthenia (weakness), dementia, and falls. The H & P documented R1's wife stated R1 exceeded her ability to care for him andR1 had lost function over the past few days to weeks and fell several times. R1's wife felt R1 lost cognitive abilities and noted he walked with a walker at home but fell despite that. R1's admission paperwork included a Hospital Progress Note, dated 11/02/23, which documented R1 worked with therapies and walked with a walker. R1 felt off balance most of the time and had unpredictable spells of feeling like he was falling to the right. R1's admission paperwork included a Hospital Progress Note, dated 11/08/23, which documented R1's asthenia had slightly improved, but he continued to be a fall risk and was not safe for discharge home; he would be discharged to the nursing facility that day. R1's EMR under the Notes tab recorded a Health Status Note, dated 11/09/23 at 10:10 PM, which documented Licensed Nurse (LN) G was called to R1's room by Certified Nurse's Aide (CNA) M. R1's door was locked. LN G unlocked R1's door and CNA M walked into R1's room and noted R1 laying on his left side next to the wheelchair and bed. CNA M noted R1's pants were halfway down, with a clean brief on the top of his pants. R1 awoke to verbal stimuli. R1 started moaning and stated he was in pain. R1 stated he had back pain. R1 was oriented to himself with confusion. R1 was not moved due to his complaints of severe pain with movement. R1 stated he did not want to go to the hospital. Staff called R1's representative, and she came to the facility. R1 went to the local hospital emergency room by emergency medical service (EMS). The note documented R1's pain was 10 on a 0-10 scale (zero being no pain and 10 the worst pain imaginable). A Health Status Note, dated 11/10/23 at 01:29 AM, documented LN G received report from the local hospital emergency room regarding R1 admitted to the hospital for pain control due to fourth and fifth rib fractures. A Fall Huddle Worksheet, dated 11/09/23 documented R1 was found in his room next to his bed and wheelchair. R1 was not wearing his glasses and lost strength. R1 had bare feet when found. The last person to have contact with R1 was CMA N, at approximately 09:00 PM during check and change. R1 was found on the floor in his room at 10:00 PM. R1 received an anti-depressant medication within the last eight hours prior to fall. R1 was oriented to person but confused. The fall occurred next to a transfer surface. R1 had back pain with movement. The worksheet documented the root cause was self-transfer and fall interventions put in place included a bed alarm and fall mat. CNA M's Witness Statement, dated 11/10/23, documented CNA M went to check on R1 at 10:08 PM and noted R1's door was locked. CNA M texted LN G to ask her to come to the living unit to unlock R1's door. At 10:10 PM, LN G unlocked R1's door and CNA M opened his door and saw R1 on the floor with his foot moving. CNA M notified LN G of the fall and LN G grabbed the vitals machine while CNA M stayed in R1's room. R1 responded to verbal stimuli. R1 was on his left side with his pants down to mid-thigh and his brief was over his pants. R1 was shirtless. R1's wheelchair was behind him. LN G and CNA M had R1 roll onto his back while his vital signs were obtained and R1 was assessed. R1 complained of his back hurting and rolled back to his left side. LN G went to call R1's wife and CNA M stayed with R1 on the floor until EMS arrived and took over. LN G's Witness Statement, dated 11/10/23, documented LN G was called to R1's room by CNA M. LN G noted R1's door was locked and unlocked the door. CNA M walked into R1's room and noted R1 on the floor laying on his left side next to his wheelchair and bed. R1's pants were halfway down with clean briefs on top of his sweatpants. R1 awoke to verbal stimuli. R1 started moaning and stated he was having back pain. R1 was oriented to self with confusion. R1 was sent out by EMS to the local hospital. CNA N's Witness Statement, dated 11/16/23, documented R1 was incontinent of urine after supper around 06:00 PM to 06:30 PM and R1 was changed. CNA N stated he did final rounds around 08:30 PM to 09:00 PM and R1 was dry and other cares were performed so CNA N told R1 to have a good night. On 11/28/23 at 10:57 AM, R1's representative stated she told the nursing staff at the facility that R1 was a fall risk, had multiple falls at home, and needed assistance with ambulation and toileting. R1's representative stated she asked for side rails and a bed alarm but was told the facility could not place those interventions because they were against the rules. R1's representative stated they were now taking care of R1 at home. She stated R1 told her he fell in the bathroom at the nursing facility. On 11/28/23 at 11:05 AM, CNA N stated he took R1 back to R1's room after supper between 06:00 PM and 06:30 PM and R1 was incontinent. CNA N stated he put R1 in bed after changing R1. CNA N stated he went and checked on R1 during final rounds between 08:30 PM and 09:00 PM and R1 was dry and said he did not want to go to the bathroom. CNA N stated he wished R1 a good night and left the room. CNA N stated there were no fall interventions in place for R1. On 11/28/23 at 11:15 AM, CNA M stated she went to check on R1 and found his door locked so she called LN G to come and unlock his door. CNA M stated when she opened R1's door he was laying on the floor on his left side. CNA N stated R1 did not have a shirt on, did not have socks on, and his pants were halfway down his legs with a clean brief on over the top of his pants. CNA M stated it looked like R1 was walking back to bed from the bathroom when he fell . CNA M stated there were no fall interventions in place for R1. On 11/28/23 at 01:00 PM, Administrative Nurse D stated a fall risk assessment was not completed on admission for R1 and there were no fall interventions put in place for R1 upon admission. Administrative Nurse D stated she had not read R1's hospital paperwork. On 11/28/23 at 01:15 PM, Administrative Nurse E stated the facility needed to update the admission checklist to ensure a fall risk assessment was completed on day one of admission and fall interventions put in place. The facility's Fall Risk Assessment Policy, revised March of 2018, documented the nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The facility failed to identify R1's risk for falls and failed to initiate fall interventions upon admission to the facility. R1 fell which resulted in two rib fractures and severe pain. This deficient practice also placed R1 at risk for falls, injury, and pain.

The facility had a census of 41 residents. The sample included 13, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement preventative interventions for Resident (R)23 who had a current pressure area on her buttocks and had a decline in health. As a result, R23 developed an unstageable (pressure injury where tissue loss and actual depth of the ulcer is completely obscured) pressure ulcer on her left heel. The facility further failed to ensure the resident received interventions, which included offloading pressure to the resident's heels to promote healing and prevent further pressure injuries. This deficient practiced placed R23 at risk for further breakdown. Findings included: - The Electronic Medical Recorded (EMR) for R23 documented diagnoses of multiple sclerosis (a potentially disabling disease of the pain and spinal cord), pressure ulcers, vitamin deficiency, protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), osteomyelitis (inflammation of one or bone marrow usually due to infection), and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented R23 had moderately impaired cognition, and was dependent upon one staff member for transfers, and toileting. R23 required extensive assistance of two staff for bed mobility and extensive assistance of one staff for dressing and personal hygiene. The assessment further documented R23 was at risk for pressure ulcers, had a stage four pressure ulcer (a deep crater-like wound that extends down to the bone), received pressure ulcer care, had a pressure device for her bed and chair, a turning and repositioning program, and non-surgical dressings other than to her feet. R23's Quarterly MDS, dated [DATE], documented R23 had intact cognition and was dependent upon two staff for bed mobility, transfers, toileting. R23 required extensive assistance of two staff for dressing, and dependent upon one staff for personal hygiene. The assessment further documented R23 was at risk for pressure ulcers (PU), had one stage four PU, one unstageable PU, and received pressure ulcer care. R23 had a pressure device for her bed and chair, a turning and repositioning program, and non-surgical dressings other than to her feet. The Braden Scale Assessment, (formal assessment for predicting pressure ulcer risk) dated 07/29/23, documented a score of 16, indicating R23 was at risk for pressure ulcer development. The Care Plan, revised 07/06/23, originally dated 07/15/21, revealed staff were to complete weekly treatment documentation, which included measurement of each area of skin breakdown. R23 required supplemental protein, amino acids, vitamins, and minerals as ordered to promote wound healing. The plan directed staff to teach the resident the importance of changing positions to prevent pressure ulcers and staff would monitor labs. The plan recorded R23 required the use of an air mattress to reduce pressure, and a Roho cushion (a cushion that decreases the amount of pressure on the sitting area) in place in tilt-in-space wheelchair. The update, dated 08/14/23, directed staff to change R23's position at least every hour. The care plan lacked documentation R23 had an unstageable pressure ulcer of the left heel and further lacked interventions to prevent heel pressure injuries or to promote healing for the left heel pressure ulcer such as offloading. The Physician's Order, dated 07/15/21, directed staff to administer protein liquid, 30 millimeters (ml), in the afternoon, for wound healing. The Physician's Order, dated 12/03/21, directed staff to administer vitamin C, 500 milligrams (mg), one tablet, in the morning for skin integrity. The Physician's Order, dated 03/22/23, directed staff to administer a house supplement, four times daily for skin integrity. The Physician's Order, dated 05/06/23, directed staff to administer Arginaid (a nonprescription nutritional drink that supplies the amino acid L-arginine along with vitamin C and E), 1 packet, twice a day, for wound healing. The Physician's Order, dated 08/10/23, directed staff to ensure R23 changed positions hourly. The Physician's Order, dated 08/10/23, directed staff to cleanse the left heel, apply hydrogel (a gel that gently increases the moisture level within the wound, encouraging moist wound healing through autolytic debridement), and cover with Telfa (nonstick gauze) secure with stretch gauze, every 3 days. The Physician's Order, dated 08/25/23, directed staff to apply Betadine (an antiseptic [prevents the growth of disease -causing microorganisms] used for skin disinfection) swab-stick to the left heel at bedtime for the unstageable pressure ulcer of the left heel. The Dietician Annual Assessment, dated 05/03/23, documented R23 received supplements, Arginaid, and liquid protein; R23 had a wound. The Skin Monitoring Comprehensive Nurse Aide Shower Review, date 08/03/23, documented R23 had a sore on her left heel. The Skin Observation Tool, dated 08/03/23, documented R23 had a left heel wound, unstageable, and staff would monitor. The Wound Data Collection Tool, dated 08/10/23, documented R23 had a facility acquired, unstageable pressure ulcer on her left heel that measured 4 centimeters (cm) x 3.5 cm x 0.1 cm, had 100 percent necrotic (the death of body tissues from injury), tissue, minimum drainage, no tunneling, educated staff to elevate R23's heel. The Wound Data Collection Tool, dated 08/24/23, documented R23 had a facility acquired, unstageable pressure ulcer on her left heel that measured 4.1 cm x 3.2 cm x 0.1 cm, had 100 percent epithelial tissue (the tissue that forms the covering on all internal and external surfaces of the body), light pink tissue that migrates inward from the wound margins or appears as small islands over the surface of the wound, no drainage, intact wound margins, no tunneling, physician and family notified, paint with betadine, and educate the staff to float R23's heels. The Wound Data Collection Tool, dated 08/29/23, documented R23 had a facility acquired, unstageable pressure ulcer on her left heel that measured 1.8 cm x 5.0 cm, worsening, as previous documentation did not have a new area of discoloration, 100 percent of necrotic (dead) tissue, dry, thick, leathery tissue, wound margins and surrounding skin was intact, no tunneling, pain or infection. The tool further documented the physician was updated with wound information, and staff were educated to float R23's heel and for R23 to wear boots. The Nurse's Note, dated 08/28/23 at 11:32 PM, documented R23's dressing was intact, open to air, being treated with betadine and R23 wore booties. On 08/29/23 at 11:10 AM, observation revealed R23, in her wheelchair, with no heel protectors on. Her left foot was off of the wheelchair pedal, with the back of her heel resting on the edge of the pedal. Her right heel rested on the foot pedal. On 08/29/23 at 01:30 PM, observation revealed Administrative Nurse D washed her hands, gloved, and removed R23's sock and 4 x 4 gauze dressing. Administrative Nurse D measured the wound, provided wound care, putR23's sock back on, and applied a green left heel protector. On 08/30/23 at 09:41 AM, observation revealed R23, in her wheelchair. R23 wore Prevelon boots (cushioned boots that float the heel off the surface of the mattress and stays on for continuous pressure relief) on both of her feet. On 08/29/23 at 01:30 PM, Administrative Nurse D stated staff did not float R23's heels for a couple of nights and the resident acquired the pressure ulcer on her heel. Administrative Nurse D stated staff were to make sure R23's heels were floated, and she make sure she had heel protectors on. Administrative Nurse D further stated R23 should have the heel protectors on in and out of bed and verified the care plan lacked documentation R23 had a pressure ulcer on her left heel or any interventions to prevent breakdown on R23's heels including direction to staff to float the resident's heels. On 08/31/23 at 09:14 AM, Licensed Nurse (LN) H stated staff were to float R23's heel and that she did not start wearing the heel protector until R23 obtained the pressure ulcer. On 08/31/23 at 11:30 AM, Certified Nurse Aide (CNA) N stated R23 was repositioned every hour and needed to wear the new Prevelon boots at all times. The facility's Prevention of Pressure Injuries policy, dated 04/20, documented staff review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The risk assessment document the risk factors, and the resident's skin is inspected on a daily basis when performing or assisting with personal care, inspect pressure points, and reposition residents as indicated on the care plan. The policy further documented to reposition all resident with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care plan team, teach residents who can change positions independently the importance of repositioning and provide support devices and assistance as needed, and remind and encourage residents to change positions. Staff are to monitor regularly for comfort and signs of pressure-related injury, evaluate, report and document potential changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis. The facility failed to implement preventative interventions to prevent pressure injuries on R23's left heel. As a result of this deficient practice, R23 developed an unstageable pressure ulcer on her left heel. The facility further failed to ensure offloading measures were implemented which placed R23 at risk for delayed healing and further pressure related injuries.

The facility had a census of 41 residents. The sample included 13 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to complete a root cause analysis to identify causative factors and failed to implement meaningful, resident centered interventions for Resident (R) 31, who subsequently fell and sustained a nondisplaced intertrochanteric fracture (broken) of the right femur. The facility failed to investigate two falls for R31 and failed to follow R31's plan of care, which resulted in a fall. The facility also failed to complete a root cause analysis to identify causative factors and failed to implement meaningful, resident centered interventions for R34. The facility failed to prevent R27 from exiting the facility in 20-degree weather. This placed the residents at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of history of falls, lack of coordination, diastolic heart failure (a condition in which the hearts main pumping chamber becomes still and unable to fill properly), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented R31 had severely impaired cognition and required supervision and one staff for bed mobility, ambulation, dressing, toileting, and personal hygiene. The assessment further documented R31 had unsteady balance, no functional impairment, and had no falls. The Fall Care Area Assessment [CAA]. dated 09/06/22, documented R31 had severe cognitive impairment, had unsteady balance but was able to stabilize without staff assistance and without any assistive devices, and had no functional limited range of motion. The Quarterly MDS, dated [DATE], documented R31 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and ambulation occurred once or twice. The MDS further documented R31 had unsteady balance, upper functional assessment on both sides, and lower functional impairment on one side. The Fall Risk Assessments, dated 08/31/22, 09/14/22, 09/17/22, 11/17/22, 02/13/23, 05/13/23, 05/26/23, 06/23/23, 07/20/23, 07/30/23, 08/22/23, and 08/30/23 documented the resident had a high risk for falls. The Care Plan, dated 06/01/23, initiated on 09/01/22, directed staff to make sure R31's call light was within reach and encourage R31 to use it for assistance as needed. R31 would be supervised while ambulating outside of his room and had a restorative ambulation program to assist with strengthening. The update, dated 11/17/22, directed staff to toilet R31 after meals. The update, dated 05/25/23, directed staff to make sure his walker was by his bedside, place a pressure alarm on his bed, remove the air mattress from his bed, and replace it with a regular mattress. The update, dated 06/05/23, directed staff to keep R31's bed in the low position at night. The update, dated 06/22/23, directed staff to have R31 wear non-slid socks when in bed. The update, dated 07/19/23, directed staff to place a body pillow beside him when he was lying in bed. The update, dated 07/30/23, directed staff to not leave R31 unsupervised when seated in his wheelchair. The update, dated 08/21/23, directs staff to start a 3-day toileting diary to establish a toileting schedule. The update, dated 08/31/23, directed staff to put gripper socks on over his regular socks. The Fall Investigation, dated 09/14/22 at 02:33 AM, documented R31 had an unwitnessed fall in his shower. The investigation documented R31 was found in the bathroom shower, the floor was wet, and R31 sustained a skin tear to his right elbow. The investigation documented R31 was educated to ask for assistance when he wanted to take a shower. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall in order to implement interventions to prevent further falls. The Fall Investigation, dated 09/17/22, untimed, documented R31 went to the nurse's station to talk to staff. When he turned around to go back to his room, R31's walker got caught in the door frame, and he fell . The investigation further documented R31 sustained skin tears to his knuckles on the left hand which measured 0.5 centimeters (cm) x 2.5 cm, the edges were approximated, and steri-strips (adhesive wound closures) were applied and covered with a band aide. The left had also had two skin tears, which the first measured 0.5 cm x 1.5 cm and the second measured 0.5 cm x 1.8 cm, the edges were unable to be approximated. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall in order to implement interventions to prevent further falls. The Fall Investigation, dated 09/18/23 at 12:37 AM, documented R31 had an unwitnessed fall in his room next to his nightstand. The investigation further documented R31 sustained a skin tear to the back of his head and R31 was educated to use his call light for assistance. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall in order to implement interventions to prevent further falls. The Fall Investigation, dated 11/17/22 at 06:04 PM, documented R31 was found by staff on the floor in his bathroom as he ambulated without assistance and sustained a skin tear on his right palm. The investigation further documented staff were educated to provide activities that promoted exercise and strength building when possible. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Nurse's Note, dated 03/15/23 at 03:30 AM, documented staff found R31 squatting at his bedside with his walker within reach of his left hand. The note further documented staff assisted R31 to lie down and his call light was within reach. The Nurse's Note, dated 03/16/23 at 06:20 AM, documented R31 had an unwitnessed fall on 03/15/23 and had no complaint of injury. The EMR lacked documentation staff completed an investigation for the 03/15/23 fall. The Nurse's Note, dated 05/08/23 at 05:30 PM, documented R31 got tangled up in his walker and fell to his knees and sustained a bruise to his right knee. The EMR lacked documentation an investigation was completed for the fall. The Nurse's Note, dated 05/25/23 at 11:15 PM, documented R31 was found on the floor in his room with his feet facing the top of the bed and his head facing the foot of the bed lying on his right side. R31 was unable to tell staff what he had been trying to do. R31 had two new skin tears to his right arm, one on the elbow that measured 4.5 cm x 1 cm, and the other was on his wrist and measured 1 cm x 1 cm. The investigation documented no external or internal rotation was noted and R31 denied pain. The nurse and the nurse aide stood R31 up and he complained of pain in one of his legs. The nurse performed range of motion on his lower extremities and R31 complained of severe pain in his right leg. The nurse called emergency medical services to transport R31 to the hospital for observation. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Nurse's Note, date 05/30/23 at 05:32 PM documented R31 readmitted to the facility after surgery for a nondisplaced intertrochanteric fracture of the right femur. A bed alarm was placed on his bed per family request, and R31 was weight bearing as tolerated. R31 self-transferred to his bed without staff present and he was educated on the need to use his call light. The Physician's Order, dated 05/31/23 at 01:47 PM, directed staff to monitor the dressing for drainage and not to remove the dressing until 06/09/23. The Nurse's Note, dated 06/09/23 at 01:10 PM, documented 10 staples were removed from R31's lower right hip and 9 staples were removed from R31's upper right hip and steri-strips were put into place. The Fall Investigation, dated 06/22/23 at 09:15 PM, documented R31 fell out of bed onto his back. The investigation further documented R31 was soiled at time of discovery, was assessed for injury, complained of bilateral hip pain, did hit the back of his head but did not want to be transported to the emergency room to be evaluated. The investigation documented staff had not followed R31's care plan and staff were educated to keep the resident's bed in the lowest position, and he was wearing white socks with no grip. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Fall Investigation, dated 07/30/23, documented R31 tried to stand up alone in the dining room and walk back to his room while staff answered call lights, lost his balance and fell . Staff were directed to not let R31 be left unsupervised in his wheelchair. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Fall Investigation, dated 08/21/23, untimed, documented staff heard the resident's bed alarm sounding, went to his room, and he was attempting to self-transfer and fell . The investigation further documented R31 sustained a skin tear to his right inner arm noted his incontinence brief was soiled with bowel movement and staff thought he was attempting to get to the bathroom. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. The Fall Investigation, dated 08/30/23 at 06:55 PM, documented R31 fell in his room when he tried to get out of his bed. The investigation documented staff found R31 on the floor with his feet toward the head of the bed and his feet toward the head of his bed and noted he was not wearing gripper socks due to refusal to wear them after his shower. The EMR lacked documentation that a root cause analysis was completed after the fall to determine causative factors of the fall. On 08/29/23 at 01:07 PM, observation revealed R31 lying in bed. R31 did not have a body pillow and he wore regular white socks on his feet. Further observation revealed Certified Nurse Aide (CNA) M placed a gait belt around R31's waist and R31 stood up, pivoted, and CNA M sat him down in his wheelchair. On 08/29/23 at 01:10 PM, CNA M stated R31 was impulsive and would try to transfer himself so staff were directed to make sure his bed was always in low position. On 08/30/23 at 11:45 AM, Licensed Nurse (LN) G stated R31 often tried to get up on his own and would fall. LN G further stated, R31 had a bed alarm and a fall matt, and if he fell on his fall matt, it was not considered a fall. This Surveyor never observed a fall matt in R31's room. On 08/31/23 at 12:48 PM, Administrative Nurse D stated staff did not follow the care plan for one of R31's falls and verified there were two falls that were not investigated at all. She stated she had not completed root cause analysis for the falls but was in process of starting to do those. LN G stated interventions were put into place for R31's falls after he had an injury with a fall. The facility's Falls and Fall Risk, Managing policy, dated 03/2018, documented staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility's Falls-Clinical Protocol, dated 03/2018, documented staff and practitioner would review each resident's risk factors for falling and document in the medical record. The staff would evaluate, and document falls that occur while the individual was in the facility. If the interventions have been successful in fall prevention, the staff would continue with current approaches and would discuss periodically with the physician whether these measures are still needed and if the resident continued to fall, the staff and physician would re-evaluate and reconsider possible reasons for the resident's falling, and as needed after an appropriately thorough review, the physician would document any uncorrectable risk factors and underlying causes. The facility failed to complete root cause analysis to identify causative factors for falls and failed to implement meaningful, resident centered interventions for R31, who had multiple falls, one which resulted in a nondisplaced intertrochanteric fracture of the right femur. This placed the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) for R34 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), unsteadiness on feet, history of falling, lack of coordination, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), need for continuous supervision, and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition and required limited assistance of one staff for bed mobility, transfers, ambulation, toileting and personal hygiene. The MDS further documented R34 had unsteady balance, upper functional impairment on one side, had no alarms, and no falls since admission. R34's Quarterly MDS, dated [DATE], documented R34 had moderately impaired cognition and was independent with bed mobility, transfers, ambulation, dressing, and toileting. The MDS further documented R34 had steady balance, no functional impairment, and no falls during the lookback period. The Fall Risk Assessment, dated 10/20/22, 11/11/22, 11/16/22,12/29/22, 01/10/23, 02/27/23, 03/08/23, 06/05/23, 07/11/23, documented R34 was a high risk for falls. The Fall Care Plan, dated 06/22/23, initiated on 11/11/22, directed staff to make sure R34's call light was within reach when sitting in the recliner. The update, dated 11/26/22, directed staff to provide activities that promoted exercise and strength building where possible. The update, dated 12/29/22, directed staff to make sure any assistive devices were within reach when sitting in the recliner. The update, dated 01/09/23, directed staff to ensure her shoes were the proper fit if her shoe caught the carpet or flooring. The update, dated 07/11/23, directed staff to evaluate the stability of her recliner and reinforce to ensure no sliding when attempting to get out of the recliner. R34's EMR documented falls on these dates: 11/11/22, 11/25/22, 12/29/22, 07/11/23. R34's clinical record lacked evidence of a root cause analysis to identify causative factors for her falls. On 08/29/23 at 12:56 PM, observation revealed R34 independently ambulated with her walker to the dining room. Further observation revealed her shoes squeaked as she walked due to her not picking her feet up when she walked. On 08/31/23 at 09:50 AM, observation revealed R34 had two recliners in her room. There was no carpet. R34 stated she liked to sit in the recliner closest to the window but she had to pull it away from the wall so that it did not scratch the wall. R34 further stated she never had any falls in the facility and that no one fixed her recliner so that it did not slide across the floor. On 08/30/23 at 03:00 PM, Licensed Nurse (LN) G stated R34 was independent with ambulation, and had a manual recliner. LN G did not know about hR34's falls. On 08/31/23 at 09:32 AM, Certified Nurse Aide (CNA) O stated R34 had a few falls out of her recliner and required stand by assistance when she ambulated. On 08/31/23 at 12:48 PM, Administrative Nurse D stated the interventions for R34 did not really address the safety factors related to her falls and verified she had not completed any root cause analysis for R34's falls. The facility's Falls-Clinical Protocol, dated 03/2018, documented staff and practitioner would review each resident's risk factors for falling and document in the medical record. The staff would evaluate, and document falls that occur while the individual was in the facility. If the interventions have been successful in fall prevention, the staff would continue with current approaches and would discuss periodically with the physician whether these measures are still needed and if the resident continued to fall, the staff and physician would re-evaluate and reconsider possible reasons for the resident's falling, and as needed after an appropriately thorough review, the physician would document any uncorrectable risk factors and underlying causes. The facility failed to complete root cause analysis to identify causative factors for falls and failed to implement meaningful, resident centered interventions for R34. This placed the resident at risk for further falls and injury. 37450 - The Electronic Medical Record (EMR) documented R27 had diagnoses of restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal cares, adjustment disorder with depressed mood, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormalities of gait and mobility, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R27 had severe cognitive impairment, had inattention and disorganized thinking behavior which fluctuated, was independent with no set up or physical help from staff with activities of daily living, and no alarms or restraint use. The MDS further documented R27 had received an antianxiety medication four days out of seven days of the look back period and an antibiotic (medication used to treat infection) seven days of seven day look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/22/22, documented R27 had severe cognitive impairment. The Elopement Risk/Wanderer Care Plan, initiated on 04/29/22, documented R27 was disoriented to place and had dementia. The interventions were resolved the same date 04/29/22, which directed to to assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. To identify pattern of wandering, monitor for fatigue and weight loss, and use of wander guard. The only active intervention dated 09/19/22 directed staff to provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The Progress Note, dated 11/07/22 at 03:22 PM, documented R27 tested positive for Covid-19 (a highly contagious respiratory disease), and the family and physician were notified. The note further documented R27 would eat in her room and remain on isolation until cleared to participate in social settings. The Progress Note, dated 11/07/22 at 08:33 PM, recorded the physician ordered buspirone (medication used to treat anxiety disorder) twice a day. The Progress Note, dated 11/12/22 at 08:50 AM, recorded R27 was found by a certified nurse aid with tweezers down her throat at 07:50 AM, R27 was alert and oriented after the tweezers were removed and her oxygen saturation was 98 percent. R27 did not answer questions as to why she did that. The tweezers were taken, and the resident was left in the room eating breakfast as if nothing happened. R27's representatives and the assistant director of nursing were notified. R27's clinical record lacked evidence of further assessment of R27's condition related to tweezers or other items of safety found or removed. The Progress Note, dated 11/15/22 at 02:14 AM, documented R27 was found outside in the fenced patio area at 01:00 AM with another resident. Both residents did not have coats on and the temperature outside at the time was aground 20 degrees Fahrenheit (F.), however both residents had blankets with them. R27 was supposed to be in quarantine for Covid-19. After the certified nurse aide found her outside, R27 was taken to her room and was angry and began to slam her doors and hitting the wall with her feet and dresser. R27's clinical record lacked evidence of immediate physical assessment due to inclement weather and attempts at self-harm and lacked notification to family, physician or facility administration. On 08/30/23 at 08:42 AM, observation revealed R27 left her room with her husband, and walked independently with a walker. The facility's Wandering and Elopements policy, dated 03/2019, documented the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will indicate strategies and interventions to maintain the resident's safety. The facility failed to provide R27 with adequate supervision to prevent accidents which resulted in an elopement. This placed the resident at risk for injuries related to preventable accident or hazards.

The facility identified a census of 43 residents. Three residents were reviewed for abuse, neglect, and exploitation. Based on record review and interview, the facility failed to prevent the neglect of Resident (R)1, who had a history of aspiration pneumonia, choking, and swallowing difficulties, when staff did not follow up on a speech therapy evaluation and treatment request for the resident, after a choking episode. On 02/23/23, R1 choked on cottage cheese, and transferred to the emergency room (ER). The ER suctioned a good amount of cottage cheese from R1's lungs and the ER ordered antibiotics for R1's aspiration pneumonia (swelling and infection of the lungs or large airways which occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) on 02/23/23. The facility documented they sent a fax to R1's physician for speech therapy to evaluate and treat R1 but did not follow up or request a change in diet order for R1. Then, on 04/09/23 at 05:40 PM (at shift change), R1 started choking and coughing at the supper table, and coughed out undigested food. Licensed Nurse (LN) G came in and assessed R1 and noted frothy phlegm (thicker than normal mucus due to illness or irritation, coughed up from the respiratory tract) coming out of R1's mouth, and rhonchi (continuous gurgling or bubbling sounds typically heard during both inhalation and expiration) lungs sounds. LN G noted R1 talked to her, and she did not appear to be struggling to breathe. R1 stated she needed a drink because she felt like it had not all come up. LN G left the unit, and told the Certified Nurse Aides (CNAs) to stay with R1 in the dining room. LN gave report to LN H, called R1's Durable Power of Attorney (DPOA) to obtain permission to send R1 to the ER, and then notified the ER of R1's emergency transfer for possible aspiration. Meanwhile, CNA M and CNA N propelled R1 to her room as they felt the other residents were staring at R1. CNA M stated R1's breathing was shallow. CNA N stated after they took R1 into her room she was not talking, her color went really pale, and her head slumped forward. The CNAs tried to page LN G and LN H to come to the room immediately, however, LN G stated there was so much radio usage at the time, that the communication was garbled between all three units, and she did not hear/understand the CNAs call to R1's room until she was headed back to the Sunflower living unit. It was then she heard the CNAs call for LN H. The CNAs asked for LN G to come immediately. When LN G arrived in R1's room at 06:09 PM on 04/09/23, R1 was cyanotic (bluish -purple hue to the skin), without respirations or heartbeat; staff did not perform emergency procedures since R1 was a Do Not Resuscitate (DNR). The facility failed to obtain the speech therapy services needed to adequately address R1's aspiration and failed to respond and provide care in an adequate time to during an acute change of condition related to an aspiration event. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1's had diagnoses of atrial fibrillation (fast irregular heartbeat), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required extensive assistance to totally dependent of one to two staff for most activities of daily living (ADL), and required supervision of one staff with eating. The MDS documented R1 had signs and symptoms of a swallowing disorders as R1 was documented as holding food in her mouth/cheeks or residual food in her mouth after meals and R1 exhibited coughing or choking during meals or when swallowing medications. The Nutritional Status Care Area Assessment (CAA), dated 03/03/23, documented R1 was on a low sodium (low salt) diet. The CAA documented R1 exhibited holding food in her mouth/cheeks or residual food in mouth after her meals, coughing, and choking during meals or when swallowing medications; R1 gagged when eating or drinking. The CAA documented it was the facilitiy's goal to meet R1's nutritional needs without significant weight changes and to avoid complications from R1's swallowing difficulties and avoidance of any further aspiration issues. The Activity of Daily Living (ADL) CAA, dated 03/03/23, documented R1 ate with supervision, due to her recent aspiration of food. The Nutritional Care Plan, dated 10/22/20, with revision dated 02/23/2, documented R1 had recent aspiration pneumonia with cottage cheese and exhibited holding of food in her mouth/cheeks or residual food in her mouth after meals, coughing or choking during meals or when swallowing medications. R1 gagged when eating or drinking. The Care Plan directed staff to monitor/document/report any signs and symptoms of dysphagia (swallowing difficulty) such as pocketing food, choking, coughing, drooling, holding food in her mouth, several attempts at swallowing, refusal to eat, or anxiety during meals. The Care Plan directed staff to provide and serve R1's diet as ordered. The Health Status Note, dated 02/23/23, documented R1 had complained of difficulty swallowing. R1 claimed the cottage cheese was stuck in her throat. The staff noted R1 was coughing up cottage cheese and mucus, had regular consistency saliva, and did not appear to be silently aspirating. The facility sent a fax to R1's primary care provider requesting speech therapy to evaluate and treat. The EMR lacked evidence R1's primary care physician received a fax and lacked evidence the facility followed up on the lack of response to the request. The Health Status Note, dated 02/23/23, documented R1 complained of difficulty breathing. R1's pulse oximetry (a noninvasive method for monitoring a person's blood oxygen percentage) was 80% on five liters of oxygen. The emergency medical system was called. R1 was noted to have gurgling sounds with breathing. R1 stated it was hard to breathe and was unable to speak without taking a breath between words. The Health Status Note, dated 02/23/23, documented the facility received a call from the local hospital emergency room with report. The emergency room staff stated R1 had been deep suctioned and the ER removed a good amount of cottage cheese from R1's lungs and trachea (a large tube that conveys air to and from the lungs). The emergency room staff stated they would start R1 on an antibiotic (medication for bacterial infections) for prevention of aspiration pneumonia. The emergency room staff told the facility staff to watch out for R1 having a fever over the next two days and informed the facility staff R1 would continue to have gurgling breath sounds. R1 was dismissed back to the facility. The facility staff called and notified the facility administrator, director of nursing, and assistant director of nursing. The Resident Dining Data Collection, dated 02/28/23, documented R1 exhibited holding food in her mouth/cheeks or residual food in her mouth after meals, coughing or choking during meals or when swallowing medications; she gagged when eating or drinking, had symptoms such as reddened face and watery eyes that may have indicated Silent aspiration problems, had difficulty sitting upright, and there had been no change in R1's diet consistency (texture) in the last thirty days. Between 02/28/23 and 04/09/23, R1's EMR lacked evidence of speech therapy evaluation or treatment or change in diet order for R1. The Health Status Note, dated 04/09/23 at 06:50 PM, documented at 05:40 PM staff called LN G and told LN G R1 appeared to be choking on her dinner, a possible aspiration. LN G went to the living unit and noted R1 was coughing and LN G heard audible gurgling. LN G auscultated R1's lung sounds and noted rhonchi in R1's lower lung lobes. R1's vital signs included a blood pressure of 198/99 millimeters of mercury (mmHg), blood oxygen level of 92% on two liters (L) of oxygen, and a pulse of 78 beats per minute. R1 verbalized she did not feel like it all came up and asked the CNA for another drink. LN G directed R1 to tilt her chin to her chest to assist her in swallowing and R1 stated she could not do that. LN G left the living unit to inform R1's DPOA of the findings of her assessment and ask permission to send R1 to the emergency room . R1's DPOA was agreeable. LN G then called the emergency room to inform them she would send R1 to the ER for further evaluation. LN G arranged transport for R1 to the emergency room . LN G gave report to the oncoming nurse and printed R1's paperwork for transport. LN G was on the way back to the living unit when she received a call on the radio that she was needed in R1's room immediately. LN G arrived in R1's room and noted R1 had cyanosis of the lips, R1's head was down, and R1 had no rise and fall of the chest. LN G auscultated R1's apical (heart) pulse and found no heart rhythm at 06:09 PM. LN G called to LN H over the radio to come to R1's room for verification of absent heart rhythm. On 05/08/23 at 10:00 AM, CNA O stated R1 had difficulty swallowing and chewing at meals and CNA O would almost grind up her food so she could eat, and he would thicken her fluids because it was easier for her to drink. On 05/08/23 at 10:15 AM, CNA P stated R1 had difficulty swallowing and chewing and the CNAs on the living unit would cut up her food really small so she could eat it. On 05/08/23 at 10:30 AM, CNA M stated on 04/09/23 she helped R1 eat because R1 was struggling to feed herself, and then R1 started coughing. CNA M stated she stopped feeding R1and she called CNA N over to assist her, and they started giving R1 gentle back blows and massaging R1's back. R1 continued to cough and CNA M paged LN G over the radio to come right away. R1 started to cough up undigested food. LN G came to the living unit and assessed R1. CNA M stated she went to answer a call light and when she came back to R1, R1 had shallow breathing. CNA M and CNA N wheeled R1 back to her room and paged LN G twice to come to R1's room immediately. On 05/08/23 at 10:45 AM, CNA N stated she and CNA M wheeled R1 back to her room because the other residents at the supper table were staring at R1. When R1 got back to her room, R1 stopped talking and turned pale and then the CNAs noticed R1 was not breathing. CNA N stated she and CNA M called on the radio for the nurse to come right away. On 05/08/23 at 11:00 AM, LN G stated she was radioed to come to the living unit because R1 was choking. When LN G got to the living unit, R1 was coughing but LN G did not note any undigested food on her clothing protector. LN G stated she did note R1 had frothy clear sputum coming up when she coughed. LN G stated she assessed R1 and noted R1 had rhonchi lung sounds. LN G stated she assessed R1's vital signs and R1's blood pressure was elevated but LN G thought that was due to R1 coughing. R1's pulse oximetry was 92% on two L of oxygen. LN G stated R1 said she needed a drink of water because R1 felt like she did not get it all up. LN G stated R1 had an episode like this a couple of months ago, so LN G felt it was the right course of action to send R1 to the emergency room for evaluation. LN G stated she left the dining room on the living unit. and told the CNAs to stay with R1 in the dining room and to not leave her and not to lay her down. LN G stated she left to prepare R1's transfer and let the on-coming nurse, LN H, know what was going on. LN G stated she did not give R1 an as needed breathing treatment for congestions or continuously monitor R1's pulse oximetry because R1 presented as stable, as R1 was talking and breathing when LN G left her. LN G stated there was so much radio usage at the time that the communication on the radio was garbled between all three living units and she did not hear/understand the CNAs when they called her to R1's room. LN G stated she was heading back to the living unit with R1's paperwork when she heard the CNA's call for LN H. LN G stated that she responded to the CNA's that she was on her way to the unit with the paperwork. The CNA's called back to her to come immediately. LN G stated that when she arrived to R1's room at 06:09 PM, R1 was cyanotic without breathing or heartbeat and determined R1 had no heartbeat. On 05/08/23 at 11:45 AM, Administrative Nurse D stated speech therapy had been requested via fax in February when R1 had another choking episode, but speech therapy had not been ordered by R1's primary care physician and no one at the facility had followed up with the doctor to obtain an order for speech therapy. Administrative Nurse D stated the CNAs on the living unit were probably changing the consistency of R1's low sodium diet because they saw her having difficulty swallowing and wanted to make it easier for her to eat. Administrative Nurse D verified R1's primary care physician had not received a fax regarding speech therapy to evaluate and treat as the fax had not been sent correctly and no follow up done, regarding R1's difficulty swallowing and chewing. Administrative Nurse D verified the CNAs did not have orders to change the consistency of R1's food. The facility's Abuse and Neglect Policy, revised July 2017, documented neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify findings. Along with other staff and management, the physician will help identify situations that constitute or could be construed as neglect. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of neglect. The facility's Dysphagia Policy, revised July 2017, documented the staff and physician will identify individuals with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food. Based on information collected and correlated by various disciplines, the staff and practitioner, in conjunction with speech therapy will define the situation carefully (for example: differentiate coughing, choking, wheezing, and aspirating; identify circumstances, details and frequency and severity of any episodes, and other related information) and whether the situation needs additional evaluation and clarification. The facility failed to prevent neglect of R1, when staff failed to follow up on a speech therapy evaluation and consultation for R1, who was at risk for choking and aspirating, which placed R1 in immediate jeopardy. The facility provided and acceptable plan for removal on 05/09/23 at 10:57 AM which included the following actions: On 5/8/23 education will be provided to all CNAs on a Dysphagia-Clinical protocol. They will be educated on the protocol's requirement for aides to report all signs of elder aspiration, coughing, clear nasal drainage, or gurgling sounds to the charge nurse immediately. They will also be educated on following dietary orders and not altering diets (changing consistency, thickening liquids, etc.) without the direction of new dietary orders. On 5/8/23 all licensed nursing staff will be educated on a Dysphagia-Clinical protocol which includes notifying the physician and requesting orders for a speech therapy evaluation when an elder is displaying signs of aspiration or experiences an episode of aspiration. A PIP will be put in place for the Dysphagia-Clinical protocol and reviewed monthly during our QAPI meetings for the next 6 months and quarterly thereafter to ensure the aspiration protocol is being done and followed. The surveyor verified the implementation of all corrective actions onsite on 05/09/23 and the deficiency remained at a G scope and severity.

The facility identified a census of 43 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 remained free from preventable accidents resulting in a closed fibula/tibia (bones in the lower leg) fracture (broken bone) of her right lower leg. On 04/03/23 Certified Nurse Aide (CNA) M pivot transferred R2 with one staff assistance from R2's wheelchair to the bed. R2 was care planned to be transferred by two staff assist using the full lift. After CNA M transferred R2 to bed, R2 cried out in pain and pointed to her right leg. CNA M started to undress R2 and noted blood on R2's right lower leg. CNA M called Licensed Nurse (LN) I on the radio to come to R2's room. After LN I arrived to R2's room, CNA M told LN I she pivot-transferred R2 from her chair to the bed and did not know how R2's skin tore, due to not witnessing R2 strike any surrounding objects with her right leg. LN I noted R2 laid supine (lying face up) on her bed, alert and awake, with no visible tearfulness but did grimace and guard her leg as LN I attempted to remove R2's pant leg, in order to visualize the area of complaint. LN I noted a large gaping area to the lateral (outside) of R2's leg above her ankle, scant (small) amount of blood present on R2's clothing, edema (swelling) and discoloration to the right leg below the skin opening, which extended down into R2's right foot. LN I noted R2 had no pedal (foot) pulse upon palpation and R2's skin appeared dark purple and bright red. R2 was sent via emergency medical service to the local emergency room where they determined R2 sustained a fibula/tibia fracture and then transferred to a higher level of care for treatment. This deficient practice placed R2 at risk for wound complications, delayed healing, pain, and infection. Findings included: - The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), type 2 diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R2 required extensive assistance of one staff for all activities of daily living (ADL), moving from a seated to standing position did not occur, and walking did not occur during the observation period. The MDS documented R2 did not have any open areas to her skin. The Activities of Daily Living Care Area Assessment (CAA), dated 01/06/23, did not trigger for further review. The Pressure Ulcer/Injury CAA, dated 01/06/23, documented R2 was non-ambulatory and had unsteady balance; she was only able to stabilize with staff assistance. The Activities of Daily Living Care Plan, dated 06/10/22, documented R2 could no longer stand and directed staff to transfer R2 with two staff members and a full body lift. The Incident Note, dated 04/03/23 at 09:25 PM, documented staff called LN I to R2's room and CNA M stated R2 cried out in pain and had a skin tear on her right leg. CNA M stated she transferred R2 with one assist pivot-transfer from her wheelchair to her bed and was unsure how R2's skin tore. LN I noted R2 was supine on her bed, awake, and alert, with no visible tearfulness, but did grimace and guard her right leg as LN I attempted to remove her pant leg in order to visualize the area of complaint. LN I noted a large gaping open area to R2's right later leg above the ankle that was swollen and had discoloration from the open area on R2's leg extending down to her foot, and no pedal pulse noted to her right extremity. R2's skin below the open area to her right leg was dark purple and bright red. LN I lightly placed a clean dry dressing over the injured area. R2 transferred via emergency medical service to the local emergency room for evaluation. The Diagnostic Imaging Report, dated 04/03/23, documented R2 sustained acute mildly angulated fractures of the distal tibial and fibular shafts. R2 transferred to a higher level of care due to the fractures. The History and Physical Documentation, dated 04/04/23, documented R2 presented to the higher level of care hospital with right distal tibia/fibula fracture after being transferred from a wheelchair to a bed. R2 presented with obvious pain to her right lower extremity, a right ankle wound with visible tendon, edema, and ecchymosis (bruising), with skin tearing. The course of action was to not operate on the fractures, cast R2's right leg leaving a window in the cast so dressing changes could be performed to the right lower leg wound, and pain control. The Discharge Instructions, dated 04/07/23, documented R2 was to be non-weightbearing to her right lower extremity, staff were to perform dressing changes every two days to the open area to R2's right lower leg with Aquacel ag (dressing with silver), gauze and replace cast window. The Re-Admission Note, dated 04/07/23, documented three nursing home staff and ambulance staff assisted R2 to bed. R2 denied pain or discomfort and was alert and oriented per her baseline. R2's wound dressing was changed and noted a large skin tear that measured 6 centimeters (cm) under cast window. Staff redressed the would per orders. The note revealed R2 had multiple areas of bruising to her bilateral arms and slight redness to her coccyx (tail bone). The Wound Data Collection, dated 04/10/23, documented a traumatic skin tear to R2's right shin that measured 3.5 cm in length and 2.7 cm in width. The wound bed had 10% epithelial (skin) tissue and 90% granulation (tissue formed during wound healing) tissue. R2's wound had minimal sanguineous (bloody) drainage and the wound was painful to R2 most of the time. The Wound Data Collection, dated 04/20/23, documented a traumatic skin tear to R2's right shin that measured 6 cm in length and 2 cm in width. The wound bed had 10% epithelial tissue and 90% granulation tissue. The wound had moderate amount of sanguineous drainage and R2 only had pain during treatment. The Facility Investigation Report, dated 04/25/23, documented CNA M admitted she did not follow R2's care plan when transferring her on 04/03/23. The incident report documented CNA M told LN I that R2 called out in pain during the transfer. The facility findings stated it was likely that R2 sustained the laceration and fractures while being transferred by CNA M. The Wound Data Collection, dated 04/27/23, documented a traumatic skin tear to R2's right shin that measured 4.2 cm in length and 1cm in width. The wound bed had 10% epithelial tissue and 90% granulation tissue. The wound had moderate amount of drainage and was moist. R2 only had pain during treatment. The Wound Data Collection, dated 05/04/23, documented a traumatic skin tear to R2's right shin that measured 3.8 cm in length and 1.5 cm in width. The wound bed had 10% epithelial tissue and 90% granulation tissue. The wound had moderate amount of serosanguineous (clear and bloody) drainage. R2 only had pain during treatment. Observation on 05/08/23 at 01:40 PM, revealed R2 laid in bed with a cast to her right lower leg. The middle of her cast was wrapped with an ace wrap and secured with tape. On 05/08/23 at 10:30 AM, CNA M stated she had not followed R2's care plan when transferring her. CNA M stated she asked another CNA on the floor how R2 transferred and transferred R2 based on what the other CNA told her. On 05/08/23 at 01:40 PM, the surveyor asked R2 in Spanish if she was having pain to her right lower leg. R2 stated Si (yes). On 05/08/23 at 02:00 PM, CNA Q stated staff were to transfer R2 with a full lift and two staff assistance at all times. On 05/08/23 at 02:30 PM, Administrative Nurse D stated CNA M did not transfer R2 as directed in her care plan. Administrative Nurse D stated she expected all staff to follow the residents care plan regarding cares and access the care plan via the Kardex (quick reference guide to plan of care). Administrative Nurse D stated she educated CNA M on how to reference the Kardex to determine the correct plan of care for residents and further provided education to all of the CNAs on following residents plans of care. The facility's Safe Lifting and Movement of Residents Policy, dated July 2017, documented in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical conditions will incorporate into goals and decisions regarding the safe lifting and moving of residents. The facility failed to prevent R2 from sustaining a closed fibula/tibia fracture of her right lower leg when staff did not follow R2's care plan during a transfer in which CNA M provided one staff assistance pivot transfer instead of the two staff assistance and full lift transfer, as care planned This deficient practice placed R2 at risk for wound complications, delayed healing, pain, and infection. All corrective actions including education to staff regarding following the residents plan of care was completed by 05/01/23, prior to the surveyor entrance, therefore the deficient practice was cited as past noncompliance at a G (isolated, actual harm), scope and severity.

The facility identified a census of 43 residents with three residents reviewed for accidents. Based on record review, observation, and interview the facility failed to evaluate Resident (R) 1 for safety when operating an electric lift chair/recliner, which placed R1 at risk for avoidable falls and injury. On 03/09/23 Certified Nurse's Aide (CNA) M found R1 on the floor in front of her electric lift chair/recliner in the farthest up position. R1 was lying on top of the bedside table and the bedside table legs were underneath the recliner. R1 stated she pushed the wrong button on her remote. R1 had a notable rotation to her right leg. R1 was sent to the hospital for evaluation. The hospital sent R1 back to the nursing facility stating R1 had no broken bones. R1 continued to have extreme pain through the next day so the facility sent R1 to an appointment with her primary care physician. R1's primary care physician admitted R1 into the hospital for pain control and performed a Magnetic Resonance Imaging (MRI - an imaging technique that uses a magnetic field and computer-generated waves to create images). The MRI showed R1 had sustained a right femur (large upper leg bone) fracture (broken bone). R1 was sent to a higher level of care for surgical repair of her right femur. The facility failed to ensure R1's safety when operating an electric lift chair/recliner by not performing timely evaluations to ensure R1 was capable of safely operating the electronic lift chair/recliner in her room, which resulted in a fall with major injury for R1 Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of fourteen which indicated intact cognition. The MDS documented R1 required limited assistance of one staff with bed mobility, transfer, dressing, toileting, ambulation, locomotion, and personal hygiene. R1 was totally dependent on one staff for bathing. The Significant Change MDS, dated [DATE], documented R1 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of two staff for bed mobility, dressing, locomotion on unit, and personal hygiene. The MDS documented R1 was totally dependent on two staff for toileting and transfer. The MDS documented R1 had pain frequently, rated at an eight on a scale of 0-10, and the pain made it hard for R1 to sleep at night and perform her activities of daily living. The Activities of Daily Living Care Area Assessment (CAA), dated 03/20/23, documented R1 had a recent fall and sustained a fracture of her right femur and has limited range of motion with her upper and lower extremity on one side. R1 required extensive assistance for bed mobility, dependent for transfers, extensive assistance for locomotion, extensive dependence for dressing, dependent for toileting and was incontinent of urine. The Cognitive Loss/Dementia CAA, dated 03/20/23, documented R1 had a BIMS score of 10, which indicated R1 had moderate cognitive impairment and had behaviors of rejection of care. The Mood State CAA, dated 03/20/23, documented R1 had depressive symptoms and R1 reported she felt down, bad about herself, and had trouble concentrating. The Fall CAA, dated 03/20/23, documented R1 had a recent fall resulting in a fracture of her right femur that required surgical repair after falling out of her recliner. R1 was documented as being at risk from injuries from falls and activities of daily living decline due to her injuries. The Pain CAA, dated 03/20/23, documented R1 reported having frequent sharp pain to her right him that had limited her activities of daily living and limited her sleep. R1 is at risk for activity of daily living decline, rejection of cares, and depressive symptoms due to having pain. The Fall Care Plan, dated 10/11/13, directed staff to educate R1 about safety reminders, educate R1 regarding safe use of assistive devices, and monitor R1 for changes in gait, mobility, positioning devices, standing/sitting balance, and lower extremity joint function. The intervention on 03/09/23 after the fall was for the facility to perform a recliner chair evaluation. The Recliner/Chair Evaluation, dated 07/10/20, documented R1 wanted to use an electric recliner, R1 was able to safely and independently retrieve and operate the controls of the electric recliner, R1 was able to safely and independently recline the electric recliner using the controls, R1 was able to safely and independently raise the chair with the controls, and R1 was able to safely and independently lower the electric chair with the controls. R1 was documented as not being able to transfer in safely and independently and out of the electric chair. The EMR lacked any other Recliner/Chair Evaluation. The Fall Risk Evaluation, dated 02/13/23, documented R1 was a moderate risk for falls. The Incident Note, dated 03/09/23 at 06:32 PM, documented R1 was found on the floor laying on top of the bedside table with her recliner in the up position and the bedside table legs under the recliner. R1 complained of pain in both of her legs and R1's right foot was rotated out. R1 was sent out via Emergency Medical Services (EMS). The Progress Note, dated 03/09/23 at 07:54 PM, documented the hospital called report to the facility andR1 was discharged back to the facility with no broken bones. The Progress Note, dated 03/09/23 at 08:22 PM, documented R1 was returned to the facility and complained of soreness to her right lower extremity. Pain medications given per as needed orders. R1 was awake, alert, and verbal upon return. R1 was transferred to bed by two staff assistance. The Health Status Note, dated 03/10/23, documented R1 was seen at the clinic at 09:15 AM and then R1 was admitted to the hospital at 10:00 AM for pain control and an MRI. The Readmission Note, dated 03/13/23, documented R1 was readmitted to the facility at 02:43 PM after having surgical repair performed to R1's distal right femur fracture. R1 was non-weight bearing to her right leg, two staff pivot transfer with gait belt only, right immobilizer to stay in place at all times except to shower. Dressing over staples to stay in place until one week follow up. On 04/05/23 at 10:30 AM, observation revealed R1 laid in bed with her house coat on and her head of the bed elevated. Certified Medication Aide (CMA) R administered medications to R1. R1 had difficulty swallowing the medications. R1 had a weak persistent cough. The CMA had R1 perform incentive spirometry (exercise to promote deep breathing and to prevent pneumonia). R1 had a leg brace on from her right groin to her right ankle. On 04/05/23 at 10:30 AM, R1 stated she did not remember how she fell and broke her leg. R1 refused to continue to talk or answer questions. On 04/05/23 at 10:40 AM, CMA R statedR1 had declined in her ability to perform activities of daily living. CMA R stated R1 was isolating in her room and rarely wanted to get out of bed. On 04/05/23 at 10:50 AM, CNA N stated R1 had decline a lot since she had sustained the right femur fracture. CNA N stated R1 was depressed and did not want to do anything because she was in so much pain. On 04/05/23 at 11:30 AM, Administrative Nurse D stated that she was not aware of how often the Recliner/Chair Evaluation was to be completed because the MDS nurse performed the evaluations. Administrative Nurse D stated she called the MDS nurse and asked her about how often the Recliner Chair Evaluation was performed. The MDS nurse told Administrative Nurse D whatever the policy says. Administrative Nurse D stated that the policy was very vague and did not have a frequency for the Recliner/Chair Evaluation to be done. Administrative Nurse D stated she expected the evaluation to be performed on admission and at least yearly if not quarterly since residents BIMS changed so frequently. Administrative Nurse D stated the policy would have to be re-written. The facility's Accommodation of Needs Policy, revised March 2021, documented the facility's environment and staff behaviors were directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents could be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an on-going basis. The facility's Fall and Fall Risk Policy, revised March 2018, documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. The facility failed to ensure R1's safety when operating an electric lift chair/recliner by not performing timely evaluations to ensure R1 was capable of operating the electronic lift chair/recliner in her room. This deficient practice resulted in a fall with major injury for R1.

The facility had a census of 34 residents. The sample included 12 residents, with two reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent the development of two facility acquired pressure ulcers for Resident (R) 1, who acquired a Stage 4 pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone) and R20, who acquired a Stage 2 pressure ulcer (shallow with a reddish base and have a break in the top two layers of skin). The facility failed to implement interventions which included wound assessments to evaluate for effectiveness of treatments, nutritional consults to promote optimal healing, and preventative measures to promote healing and prevent worsening for R1. This deficient practice resulted in a facility acquired Stage 4 pressure ulcer which caused pain and placed R1 at increased risk due to wound infection. The facility further failed to implement interventions to prevent the development of a facility acquired Stage 2 pressure ulcer and nutritional consults to promote optimal healing for R20. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS documented R1 had functional impairment in range of motion on both sides, was at risk for pressure ulcers, had no skin issues, no turning or repositioning program, and no pressure relieving device for her bed or chair. The Pressure Ulcer Care Area Assessment (CAA), dated 12/22/21, documented the resident required extensive assistance for bed mobility, transfers, dressing, and toileting with frequent bowel and bladder incontinence. The CAA further documented R1 did not have skin impairment, but remained at risk for the development of pressure ulcers. The Braden Scale Assessment, (assessment for predicting pressure ulcer risk), dated 01/19/22, documented a score of 17, indicating at risk for pressure ulcer development. The Braden Scale Assessment, dated 03/14/22, documented a score of 15, indicating at risk for pressure ulcer development. The Pressure Ulcer Care Plan, revised 01/06/22, originally dated 10/22/20, directed staff to educate the resident, family, and caregivers to the causes of skin breakdown including transfers, good nutrition, and frequent positioning. An intervention, dated 02/27/22 directed staff to document weekly the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Observation Tool, dated 02/08/22, documented R1's left buttock had a shearing (the separation of skin layers caused by friction or trauma) wound which measured 2 centimeters (cm) x 1.1 cm. The Fax Communication to the physician, dated 02/08/22, documented R1 had several areas of bruising and potential skin shearing thought to be caused by improper removal of the lift sling. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The physician discontinued the order on 02/25/22.) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Observation Tool, dated 02/17/22 documented R1 had a left buttock wound covered with [MEDICATION(S)]. The tool lacked measurements and observations of the wound bed as well as evaluation of the effectiveness of the treatment in place. The clinical record lacked any other evaluation of the wound between 02/08/22 and 02/17/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Observation Tool, dated 02/24/22 documented R1 had a previous wound to her buttock. The tool lacked measurements and observations of the wound bed as well as evaluation of the effectiveness of the treatment in place. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The physician discontinued the order on 02/28/22.) A Wound Data Collection Tool, dated 02/27/22 documented an unstageable (full thickness tissue loss) pressure injury on R1's left buttock (the rear pelvic area on a person's body) which measured 3.5 cm x 3.5 cm, with 90 percent (%) slough (a mass of dead tissue separating from an ulcer) and 10% necrotic tissue (pertaining to the death of tissue in response to disease or injury). The wound had heavy serosanguineous (discharge that contains both blood and a clear yellow liquid known as blood serum) drainage with 90 percent slough and 10% necrotic tissue. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The physician discontinued the order on 03/10/22.) The Wound Data Collection Tool, dated 03/08/22, documented the wound was a Stage 3 (partial thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer, measured 4 cm x 4.5 cm x 5.5 cm and was worsening. The tool documented the wound had 10% epithelial tissue (thin tissue that cover all exposed surfaces of the body), 30% granulation (the part of the healing process in which lumpy, pink tissue containing new connective tissue that formed around the edge of the wound), 50% slough, 10% necrosis, moderate serosanguineous draining, had undermining tunneling, odor and had pain most of the time. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Final Culture Laboratory Report, dated 03/08/22, documented the resident had gram stain positive rods with some gram-negative rods. The Fax Communication to the physician dated 03/08/22 documented R1 continued to have a worsening pressure ulcer and had an appointment to see a wound specialist on 03/11/22 for wound debridement (removal of dead, damaged, or infected tissue to improve the healing potential) and possible wound vac placement. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1s Clinical Record lacked evidence a Registered Dietician reviewed R1's nutritional status after the wound development in order to promote wound healing. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 at 08:30 AM, observation revealed R1 sat on a shower chair, in a sling, attached to the full body lift, naked from the waist down. As R1 was raised, blood dripped from her buttocks. On the shower chair, a thin gel cushion had slipped off to the front of the shower chair and there was smeared blood on the seat of the shower chair. As staff placed R1 in bed using the sling and lift, R1 began to have a bowel movement. Certified Nurse Aide (CNA) O rolled R1 to her right side, so CNA MM could provide personal care. During this roll, R1 moaned. CNA MM finished care and as both CNAs rolled the resident onto her back, R1 moaned again. R1 was left lying on the bed without an incontinence brief, uncovered, as the CNAs waited for the nurse to come to the room to do R1's daily wound care. At 08:40 AM, Administrative Nurse D washed her hands, donned clean gloves, and both CNAs went to the right side of the bed to roll R1 onto her right side while Administrative Nurse D performed wound care. As staff rolled R1, her body tensed, and her face and right shoulder were pressed against the bed rail. As Administrative Nurse D removed the calcium alginate packing from R1's wound, R1 stated, ouch. Upon inquiry, Administrative Nurse D stated R1 had scheduled pain medication. Administrative Nurse D changed her gloves, flushed the wound with normal saline, repacked the wound with calcium alginate and placed a foam dressing over the wound. On 03/16/22 at 09:40 AM, observation revealed Licensed Nurse (LN) G washed her hands and donned clean gloves. R1 laid on her right side, and as CNA N raised the bed, R1 moaned. LN G sprayed wound cleanser on a gauze pad and wiped the inside of the wound and took another gauze pad and dried the wound. R1's body tensed, and she said ouch. CNA MM placed her hands on the R1's buttocks and pulled R1 closer to her which caused the wound to stretch and R1 said ouch again. LN G measured the wound as 4 cm x 4 cm. LN G then took a cotton swab inside the wound and at the 11 o'clock angle, measured 3.6 cm of tunneling, at the 5 o'clock angle 2.8 cm of tunneling, and straight into the wound measured a depth of 2.9 cm. LN G changed her gloves and packed the wound with the calcium alginate. R1 continued to say ow, ow during this process, but LN G never asked the resident what her pain level was during the procedure. LN G wiped the outside of the wound with skin prep (forms a protective film or barrier) and placed a foam dressing over the wound. On 03/15/22 at 08:30 AM, CNA O stated staff repositioned the resident every two hours and make sure not to leave the sling under the resident. On 03/15/22 at 08:40 AM, Administrative Nurse D stated the wound started as shearing from the sling of the lift and it worsened. Administrative Nurse D further stated R1 used to sleep in her recliner all the time and did not have a bed in her room. The staff were not to leave the sling under the resident when she was in bed or in her recliner anymore and the facility placed the air mattress on 02/18/22 after R1 obtained the wound. Administrative Nurse D stated R1 had a thin gel cushion in her recliner at the time she obtained the shearing wound which the facility then replaced with a thicker pad. On 03/16/22 at 09:40 AM, LN G stated the resident's wound started as shearing from the resident sleeping in her recliner all the time. On 03/16/22 at 11:21 AM, Administrative Nurse D verified the Registered Dietician had not been notified of the resident's skin breakdown and that the resident was not on any vitamins or supplements to assist with wound healing. Administrative Nurse D stated Nurse Consultant II saw the wound, but R1's physician had not observed the wound yet. On 03/16/22 at 11:30 AM, LN H stated R1 had an appointment to see the wound specialist on 03/11/22, but due to inclement weather, the appointment was canceled. LN H stated the only physician who evaluated R1's wound was Nurse Consultant II, who assisted the facility with wounds. Nurse Consultant II evaluated R1's wound on 03/08/22 and gave recommendations for treatment. On 03/16/22 at 01:05 PM, Dietary Consultant GG stated he had not been notified R1 had any skin breakdown. Dietary Consultant GG stated upon knowledge of the wound, he would make recommendations to the facility to promote wound healing. On 03/18/22 and 03/21/22 the Physician Consultant HH was unavailable for interview. The facility's Prevention of Pressure Injuries policy, dated April 2020, documented the facility would review the care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable for pressure ulcers. The staff would inspect the skin daily when performing or assisting with personal care, reposition residents as indicated on the care plan, conduct a nutritional screening for residents at risk, conduct a comprehensive nutritional assessment for any residents at risk of pressure injury, and monitor the resident's weight loss and intake of food and fluids. The policy further documented the facility would include nutritional supplements in the resident's diet to increase calories and protein as indicated in the care plan, reposition all residents with or at risk of pressure injuries on an individualized schedule as determined by the care team. The facility failed to implement interventions which included wound assessments to evaluate for effectiveness of treatments, nutritional consults to promote optimal healing, and preventative measures to promote healing and prevent worsening for R1. This deficient practice resulted in a facility acquired Stage 4 pressure ulcer which caused the resident pain and placed R1 at increased risk due to a wound infection. - The Electronic Medical Record (EMR) for R20 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS further documented the resident had lower functional impairment on both sides, at risk for skin break down, no skin issues, no turning and repositioning program, and no pressure relieving device for his bed and chair. The Pressure Ulcer Care Area Assessment (CAA), dated 04/10/21, documented R20 required staff assistance with bed mobility and transfers and was incontinent of bowel. The CAA further documented the resident was at risk for skin breakdown. The Pressure Ulcer Care Plan, revised 01/13/22, originally dated 05/29/21, documented the resident was at risk for pressure injury due to limited mobility and incontinence. An intervention, dated 06/15/21, directed staff to teach the resident the importance of changing positions, the causes of skin breakdown, required a pressure relieving device, and to document weekly treatments. The Care Plan lacked documentation the resident had a facility acquired pressure ulcer and further interventions to prevent skin breakdown. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Braden Scale Assessment, (assessment for predicting pressure ulcer risk), dated 10/04/21, documented a score of 13, indicating at risk for pressure ulcer development. The Braden Scale Assessment, dated 01/03/22, documented a score of 14, indicating a moderate risk for pressure ulcer development. The Skin Observation Tool, dated 02/25/22, documented the resident had a wound on his right gluteal fold (a prominent fold on the back of the upper thigh that marks the upper limit of the thigh from the lower limit of the buttock), and staff would continue to monitor. The Skin Observation Tool, dated 02/27/22, documented the resident had a wound on his right gluteal fold from friction and documented the physician was aware and to continue to monitor. The Fax Communication to the physician, dated 03/08/22, documented R20 had an open sore on his right-side buttocks, measured 4 centimeters (cm) x 3.5 cm, with eschar (dry, dark scab or falling away of dead skin) and purulent (containing pus) drainage. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Data Collection Tool, dated 03/14/22, documented a Stage 2 (partial thickness loss) on the right gluteal fold, measured 5 cm x 4.2 cm x 0.1 cm, with 60 percent (%) granulation (the part of the healing process in which lumpy, pink tissue containing new connective tissue that formed around the edge of the wound), moderate serosanguineous (discharge that contains both blood and clear yellow liquid known as blood serum), the wound margins were macerated (skin that had been exposed to moisture for too long), with wet, white, waterlogged tissue, and had no odor or suspected infection. The tool further documented staff were educated to offload and keep R20 out of the wheelchair. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/16/22 at 10:00 AM, observation revealed R20 lying on his left side, Licensed Nurse (LN) G donned clean gloves, and cleansed the wound with wound cleanser. Further observation revealed LN G, donned clean gloves, took a clear plastic grid to measure the wound and found the wound measured 4.5 cm x 4 cm. Continued observation revealed LN G used skin prep (forms a protective film or barrier) around the outside of the wound, placed the [MEDICATION(S)] dressing on the wound, and covered it with a padded foam dressing. On 03/15/22 at 09:20 AM, Certified Nurse Aide (CNA) N stated she was unsure how R20 received the wound and staff repositioned the resident every two hours. On 03/15/22 at 09:30 AM, Administrative Nurse D stated R20 had obtained the wound as a shearing wound from the sling when staff used the sling lift. On 03/16/22 at 10:00 AM, LN G stated R20 received the wound from shearing when being offloaded and wound care was provided daily. On 03/16/22 at 11:20 AM, Administrative Nurse D verified the registered dietician had not been notified of R20's skin breakdown but R20 was on supplements and vitamins for previous skin breakdown. On 03/16/22 at 01:05, Dietary Consultant GG stated he had not been notified R20 had any skin breakdown. Dietary Consultant GG stated upon knowledge of the wound, he would make recommendations to the facility for wound healing. The facility's Prevention of Pressure Injuries policy, dated April 2020, documented the facility would review the care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable for pressure ulcers. The staff would inspect the skin daily when performing or assisting with personal care, reposition residents as indicated on the care plan, conduct a nutritional screening for residents at risk, conduct a comprehensive nutritional assessment for any residents at risk of pressure injury, and monitor the resident's weight loss and intake of food and fluids. The policy further documented the facility would include nutritional supplements in the resident's diet to increase calories and protein as indicated in the care plan, reposition all residents with or at risk of pressure injuries on an individualized schedule as determined by the care team. The facility failed to implement interventions to prevent the development of a facility acquired Stage 2 pressure ulcer and nutritional consults to promote optimal healing for R20. This placed the resident at risk for further breakdown.

The facility had a census of 34 residents. The sample included 12 residents with one reviewed for pain. Based on observation, record review, and interview, the facility failed to administer physician ordered pain medication in a timely manner for R1, who had pain during wound care of her Stage 4 pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone) placing the resident at risk for further pain and discomfort. The facility further failed to assess R1's pain levels during wound cares and adjust treatment or administer the available as-needed pain medication for breakthrough pain. As a result, R1 reported severe unrelieved pain, rated higher than her habitual pain, in her wound area and back. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status score of 14 indicating intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS documented R1 had functional limitations in range of motion on both sides of the lower extremities, was at risk for pressure ulcers, had no skin issues, no turning or repositioning program, and no pressure relieving device for her bed or chair. The MDS recorded R1 received opioid (class of medication used to treat pain) seven of the look back days, had scheduled pain medication, and was frequently in pain. The Pain Care Area Assessment (CAA), dated 12/22/21, documented R1 had frequent upper back and elbow pain that interfered with her day to day activities with the highest rating of pain being a seven (on a scale of 0 - 10 with 10 being the most severe pain). The Pain Care Plan, dated 01/06/22, directed staff to monitor and document the probable cause of each pain episode, monitor for side effects of pain medication, monitor and report to the nurse any signs and symptoms of non-verbal and vocalization of pain, monitor and report to the nurse R1's complaints of pain or request for pain treatment, and notify the physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain. The Pain Interview, dated 01/04/22, documented R1 had pain almost constantly, which effected R1's sleep and was rated at an eight. The document recorded the resident received [MEDICATION(S)] (a narcotic medication to treat moderate to severe pain) and [MEDICATION(S)] (a narcotic medication to treat moderate to moderately severe pain) and directed staff to reposition R1 to alleviate her pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 at 08:30 AM, observation revealed R1 sat on a shower chair, in a sling, attached to the full body lift, naked from the waist down. As R1 was raised, blood dripped from her buttocks. On the shower chair, a thin gel cushion had slipped off to the front of the shower chair and there was smeared blood on the seat of the shower chair. As staff placed R1 in bed using the sling and lift, R1 began to have a bowel movement. Certified Nurse Aide (CNA) O rolled R1 to her right side, so CNA MM could provide personal care. During this roll, R1 moaned. CNA MM finished care and as both CNAs rolled the resident onto her back, R1 moaned again. R1 was left lying on the bed without an incontinence brief, uncovered, as the CNAs waited for the nurse to come to the room to do R1's daily wound care. At 08:40 AM, Administrative Nurse D washed her hands, donned clean gloves, and both CNAs went to the right side of the bed to roll R1 onto her right side while Administrative Nurse D performed wound care. As staff rolled R1, her body tensed, and her face and right shoulder pressed against the bed rail. As Administrative Nurse D removed the calcium alginate packing from R1's wound, R1 stated, ouch. Upon inquiry, Administrative Nurse D stated R1 had scheduled pain medication. Continued observation revealed Administrative Nurse D changed her gloves, flushed the wound with normal saline, repacked the wound with calcium alginate and placed a foam dressing over the wound. On 03/15/22 at 03:15 PM, observation revealed Administrative Nurse D placed the lift sling underneath R1. Administrative Nurse D stood in front of R1 and stated, This is gonna hurt and proceeded to pull on the left lift sling leg strap. R1 grimaced (to distort one's face in an expression usually of pain) and replied Ow! as Administrative Nurse D pulled on the strap. On 03/16/22 at 09:40 AM, observation revealed Licensed Nurse (LN) G washed her hands and donned clean gloves. R1 laid on her right side, and as CNA N raised the bed, R1 moaned. LN G sprayed wound cleanser on a gauze pad and wiped the inside of the wound and took another gauze pad and dried the wound. R1's body tensed, and she said ouch. CNA MM placed her hands on the R1's buttocks and pulled R1 closer to her which caused the wound to stretch and R1 said ouch again. LN G took a clear plastic grid to measure the wound and found the wound measured 4 cm x 4 cm. LN then took a cotton swab inside the wound and at the 11 o'clock angle, measured 3.6 cm tunneling, at the 5 o'clock angle 2.8 cm tunneling, and straight into the wound 2.9 cm depth. LN G changed her gloves and packed the wound with the calcium alginate. R1 continued to say Ow, Ow during this process, but LN G never asked the resident what her pain level was during the procedure. On 03/15/22 at 08:50 AM, R1 stated she had not received any pain medication since the middle of the night and was experiencing severe pain in the wound area and in her back.R1 stated she does have pain daily. She said there was no specific time scheduled for the wound care, it just occurred whenever the staff were able to do it despite when she last received her pain medication. R1 reported she was scheduled to receive [MEDICATION(S)] at 08:00 AM and [MEDICATION(S)] scheduled every eight hours but the nurse did the wound care whenever they could. R1 stated it was always very painful when staff completed wound cares. On 03/15/22 at 08:55 AM, after the dressing change was completed, Certified Medication Aide (CMA) R stated R1 had pain medication scheduled at 08:00 AM, but the resident was in the shower, so R1 did not receive any pain medication yet. On 03/15/22 at 03:00 PM, R1 stated she had just returned after receiving her antibiotic and was having pain. R1 stated her pain level was an eight and stated she was unaware she had extra pain medication ordered and available if she requested. On 03/15/22 at 04:00 PM, CMA R stated the only time she asked R1's pain level was when she administered R1's pain medication. On 03/16/22 at 09:40 AM, LN G stated she liked to give the resident her pain medication then wait for it to take effect prior to wound care. On 03/16/22 at 11:21 AM, Administrative Nurse D stated R1 was aware she could get as needed pain medication, but at times R1 had confusion and may forget. Administrative Nurse D further stated the nurse providing wound care should ask the resident if she had pain during wound care and the level of pain she experienced. The facility Pain Assessment and Management policy, dated March 2020, documented staff identify pain in the resident and develop interventions that are consistent with the resident's goals, needs, and address the underlying causes of pain. Pain Management is a multidisciplinary care process that included assessing the potential for pain, recognizing the presence of pain, identifying characteristics of pain, addressing the underlying cause of pain, and developing and implementing approaches to pain management by using strategies for different levels and sources of pain. The policy documented acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief was obtained for stable chronic pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to administer physician ordered pain medication in a timely manner for R1, who had pain during wound care placing the resident at risk for further pain and discomfort. The facility further failed to assess R1's pain levels during wound cares and adjust treatment or administer the available as-needed pain medication for breakthrough pain. As a result. R1 reported severe unrelieved pain, rated higher than her habitual pain, in her wound area and back.

The facility had a census of 37 residents. The sample included 3 residents, of which 1 was reviewed for elopement risk. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent accidents for Resident #1, who eloped (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff) from the facility and was found outside of the facility on separate occasions (7/30/18, 7/31/18, 8/4/18). This placed the resident in immediate jeopardy. Findings included: The resident was admitted to the facility on [DATE]. The 7/9/18 signed physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 7/15/18, documented the resident had a (BIMS) Brief Interview for Mental Status of 4, which indicated he/she had severe cognitive impairment. The MDS documented the resident showed continuous inattention and disorganized thinking, and wandered daily, which placed the resident at significant risk of getting into potentially dangerous places, and intruded on the privacy of others. The MDS documented the resident required staff supervision with toileting, extensive staff assistance with bathing, and was independent with all other activities of daily living, which included walking in his/her room and corridor, without use of mobility devices. The MDS documented the resident received antianxiety medication and wore a wanderguard device (safety system that tracks a person using a wrist or ankle band that alarms if a person goes outside a defined area without the being accompanied by an authorized person) daily. The 7/15/18 admission (CAA) Care Area Assessment for cognition documented the resident had a BIMS of 4, short and long term memory loss, wandered daily, and verbalized he/she wanted to go home. The 7/9/18 elopement assessment documented the resident had been hospitalized from [DATE]-7/9/19, and had escaped from the hospital. The assessment documented the resident lived at home with his/her spouse, who was unable to keep track of him/her. The assessment documented the resident had a history of [REDACTED]. The 7/9/18 admission care plan documented the resident had impaired cognition, and directed staff to redirect and reassure the resident as needed, cue, reorient and supervise as needed, and attempt non-pharmacological interventions such as music, eating, dusting, and wiping down dining room tables. The 8/5/18 revised care plan documented staff would provide one on one supervision due to an elopement on 8/4/18, and the resident would wear a wanderguard alarm to alert staff to the resident's movement, and assist staff in monitoring his/her movement. The 7/30/18 at 3:30 PM (late entry), nurse's note documented the resident was seen outside of the facility by a visitor, and he/she had followed a visitor through the front door, without staff knowing. The note documented staff brought the resident back into the facility, and there was no injury to the resident. The facility's investigation report documented on 7/30/18, at 3:30 PM, some areas of the facility were without power during the time an electrician replaced breaker boxes. The report documented staff thought the door alarms were functioning, when Social Service Staff X, entered the door code to let two visitors out of the front door, was not aware the resident was in the area, and left to go deliver mail to other residents. The resident followed the visitors out the door. The report documented another visitor alerted staff the resident was outside, and staff found the resident outside, approximately 100 yards from the facility, an assessment found no injuries to the resident. The report documented staff discovered the wander guard alarm had been disabled when the electrician turned off power. The report documented one staff member was assigned to stay with the resident at all times, until power was restored. The 7/31/18 at 7:46 PM (late entry) nurse's note documented the resident eloped and left the premises. The note documented a staff member and a visitor were able to redirect the resident and bring him/her safely back into the facility. The facility's investigation report documented on 7/31/18 at 6:00 PM, the resident was walking around the facility after supper, and the charge nurse who was seated at the nurses station did not see the resident go down hallway two. The charge nurse heard the alarm sound, and as he/she left the nurse's station, a visitor told staff the resident walked out the door at the end of hallway two. The report documented the resident was found walking on the lawn, a few yards from the door, and was easily re-directed back inside the facility, with no injuries noted. The report documented the resident wore a long sleeve shirt, blue jeans, socks, and shoes. The temperature outside was 80 degrees Fahrenheit with wind from the south at 7 mph. The report documented staff would meet with the resident's family to discuss placement in a secure memory unit, the family was notified of the resident's elopement. The 8/4/18 at 2:25 PM, nurse's note documented Licensed Nurse H returned from lunch and noted a high pitched sound coming from hallway two. Licensed Nurse H took the key and ran down hallway two while he/she asked other staff if they had seen the resident. The note documented when Licensed Nurse H looked outside, he/she saw the resident down the street, called the resident's name, but the resident continued to walk away from Licensed Nurse H and Direct Care Staff M. The note documented staff was able to redirect the resident back inside the facility and the resident stated we should have stayed inside, it is hot out here. The facility's investigation report documented on 8/4/18 at 2:45 PM, the resident eloped out of the facility, and staff redirected the resident back inside the facility. The report documented the resident wore a long sleeve shirt, jeans, and tennis shoes, and the temperature outside was 95 degree Fahrenheit. The resident was assessed and there were no injuries noted. The physician and family were notified of the elopement. The report documented medications were reviewed with the resident's physician and no changes were made. The report documented the following interventions were added to the care plan: staff will provide one on one supervision until the resident's behavior subsides. The report docucmented Maintenance Staff U checked all the alarms for proper functioning, and set the alarm zone at 20 feet, all nursing staff was educated on the Elopement Policy and Procedure, Behaviors, Causes, and Interventions policy, and a test for acknowledgement was completed, along with all nursing staff educated and trained on how to reset the alarm. The administrator, social worker, and director of nursing had a meeting with the resident's family regarding elopement, behavior and possible placement to a special care unit on in-patient psychiatric evaluation. On 8/7/18 at 8:30 AM, observation revealed the resident in his/her room, with staff member supervising the resident, and a wanderguard in place on the resident's ankle. Further observation revealed different staff were assigned to supervise the resident while he/she continuously walked up and down the halls of the facility, stopping at times to sit and visit briefly with staff and other residents. On 8/8/18 at 8:40 AM, observation revealed the resident walking up and down the halls with staff member, and supervised by several different staff members. At 12:20 PM, observation revealed the resident leaving the dining room accompanied by his/her family. At 4:55 PM, observation revealed the resident walking down hallway two with staff and stated he/she wanted to go home. At 5:20 PM, observation revealed the resident stated he/she is not going to the dining room to eat supper, because his/her grandmother, who lives down the street, had made supper for him/her. Throughout the day, there were numerous observations of the resident and a staff member walking up and down the halls, and he/she stopped at times to peer outside the exit door on hallway two. On 8/7/18 at 8:30 AM, Administrative Nursing Staff D stated the facility admitted the resident on 7/9/19, and was aware that he/she had a history of [REDACTED]. On 8/7/18 at 8:45 AM, Social Service Staff X stated on 7/30/18, at approximately 3:30 PM, he/she assisted two visitors who wanted to leave the facility, by entering the door code for them. Social Service Staff X stated after he/she assisted the visitors, he/she left the area to deliver mail to residents, and was not aware the resident was in the commons area, and the resident followed the visitors out the front door. Social Service Staff X stated as he/she came up the hall, a visitor alerted him/her the resident went outside the facility, approximately 100 yards away, but remained on the facility property, and he/she was easily redirected back inside the facility. Social Service Staff X stated he/she was not aware the wander guard alarm had been disabled by the electrician. On 8/7/18 at 12:45 PM, Maintenance Staff U stated door alarms are checked weekly. Maintenance Staff U stated on 7/30/18 an electrician turned the power off to install new breaker boxes, and staff was not aware the wander guard alarm had been disabled. Maintenance Staff U stated since the last elopement on 8/4/18, he/she now checks the door alarms two times a day. Maintenance Staff U verified the wander guard alarm on the doors did not sound. On 8/7/18 at 3:35 PM, Licensed Nursing Staff H stated on 8/4/18 at approximately 2:30 PM, he/she returned to the facility from lunch, observed the resident in the commons area, when he/she heard a faint alarm from the door. Licensed Nursing Staff H stated the resident was no longer in the commons area, and he/she got the key, and radioed staff to see if anyone had seen the resident, and some one stated the resident was on hallway two. Licensed Nursing Staff H stated when he/she opened the exit door on hallway two, he/she observed the resident down the street, and Direct Care Staff M ran outside after the resident. Licensed Nursing Staff H stated he/she assessed the resident and there were no injuries. Licensed Nursing Staff H stated the resident was wearing a wander guard, had a history of [REDACTED]. On 8/7/18 at 4:00 PM, Administrative Nursing Staff D stated staff should be aware and watch when assisting any one out of the facility, to be sure there are no residents that follow them out. Administrative Nursing Staff D stated the facility should have initiated one on one supervision for the resident sooner than they did to be sure the resident was safe. On 8/8/18 at 12:30 PM, Licensed Nursing Staff I stated the resident wanders all over the facility for most of the day, wears a wander guard, and staff provide one on one supervision. Licensed Nursing Staff I stated the facility has not had an elopement risk resident for sometime, and he/she is now more aware of the resident and his/her whereabouts since the elopements. On 8/8/18 at 1:45 PM, Direct Care Staff M stated on 8/4/18, he/she had finished his/her shift and was leaving the facility, when he/she was told the resident had gone out the door at the end of hallway two. Direct Care Staff M stated he/she went out the door, observed the resident across the street, in the next block, as he/she walked close to the houses in the neighborhood. Direct Care Staff M stated he/she called the resident's name, but the resident did not stop, so he/she ran closer, and the resident stopped. Direct Care Staff M stated the resident walked back to the facility with him/her, and stated he/she was going to his/her grandmother's house. Direct Care Staff M stated the resident had prior elopements, wore a wander guard, always wandered around the facility, and walks and moves very quickly. On 8/918 at 8:30 AM, Administrative Staff A stated on 7/30/18, an electrician was replacing breaker boxes in the facility, and power was shut off to some areas of the facility. Administrative Staff A stated the door key pads were working, and staff did not realize the wander guard alarm had been disabled. Administrative Staff A stated the resident followed some visitors out the front door at approximately 3:30 PM, after Social Worker Staff X had entered the door code, and Social Worker Staff X did not see the resident follow the visitors out. On 7/31/18, the electrician turned the power off from approximately 9:00 AM to 4:00 PM, and during that time, staff placed the resident on one on one supervision. Administrative Staff A verified the resident had not been one on one prior to 9:00 AM and after 4:00 PM. Administrative Staff A stated staff should have started one on one supervision with the resident immediately after he/she eloped on 7/30/18 to be sure the resident was safe, and verified staff had not completed the facility's Elopement Check list for any of the resident's elopements. On 8/9/18 at 9:00 AM, Licensed Nursing Staff G stated the resident had wandering and exit seeking behaviors all day, every day, walked very fast, and was always on the go. Licensed Nursing Staff G stated he/she witnessed the resident go to the exit doors and try to open them many times. Licensed Nursing Staff G stated the resident wore a wander guard since he/she was admitted , and staff is one on one with the resident. Licensed Nursing Staff G stated on 7/31/18, during shift change, at approximately 6:00 PM, a visitor alerted staff the resident had exited the door at the end of hallway two. Licensed Nursing Staff G stated the resident was escorted back inside the facility, and there were no injuries noted. On 8/13/18 at 2:20 PM, Consultant GG stated he/was aware of the residents elopements, and the facility was made aware of his/her behavior before they accepted the resident. Consultant GG stated he/she expected the facility to provide better supervision and interventions to prevent the resident from elopement, and he/she expected his/her residents to be safe, secure and not placed in danger. The facility's 4/2016 Elopement Policy documented when an elopement occurs, immediate efforts to locate the resident will be taken, all occupancies will be documented, and all follow-up required by state and federal regulations will occur. The policy documented all exit doors would be checked weekly to determine if they are in working order, and wander alert bracelets are to be checked daily by the rehabilitation department or nursing, to determine if they are in working order. The policy documented in the event of an elopement, staff should notify the administrator, charge nurse, or their designees, immediately, mobilize staff to begin a search, with at least one person from each unit on the search, and the charge nurse should stay in the building. The policy documented family should be notified in all cases, as well as the physician, and other agencies as required by state and/or federal regulation. The policy documented when an elopement occurs, staff should use the elopement check list worksheet to ensure all steps were completed. The facility failed to provide adequate supervision for Resident #1, who eloped from the facility three times, and was found outside the facility, which placed the resident at risk for harm and injury. The facility abated the immediate jeopardy on 8/9/18 when all staff were educated on the Elopement Policy and Procedure, the Behaviors, Causes, and Intervention policy, including a test for acknowledgement, and education and training on how to reset door alarms. The scope and severity remains at a G.

The facility had a census of 42 residents. The sample included 16 residents, of which 3 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to implement effective interventions to prevent the development of pressure ulcers for 1 of 3 sampled residents. Resident #18 was admitted to the facility with a deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin) on his/her right heel and required extensive to dependent staff assistance with (ADLs) Activities of Daily Living, and developed a facility acquired deep tissue injury to his/her left heel and ankle. Findings included: - Resident #18's (POS) physician order [REDACTED]. pressure, or pressure in combination with shear and/or friction), and unspecified open wound of the left great toe. The admission (MDS) Minimum Data Set assessment, dated 8/14/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, toileting and he/she dependent upon 2 staff for toileting. The assessment further recorded the resident was at risk for pressure ulcers, had 1 unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue), had (MASD) moisture associated skin damage (inflammation or skin erosion caused by prolonged exposure to a source of moisture), pressure relieving device for bed and chair, turning and repositioning program, and pressure ulcer care. The 30 day MDS, dated [DATE], recorded the resident had a BIMS of 15. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, toileting and he/she dependent upon 2 staff for toileting. The assessment further recorded the resident had 2 stage 2 pressure ulcers (partial thickness loss of presenting as a shallow open ulcer), 1 which was present upon admission, pressure relieving device for bed and chair, turning and repositioning program, and pressure ulcer care. The 8/14/17 (CAA) Care Area Assessment for pressure ulcer documented the facility admitted the resident with a suspected deep tissue injury on his/her right heel. The area was measured at 4.5 (cm) centimeters x 5.5 cm, unopened and no drainage. The 8/7/17 initial care plan recorded the resident had a (UTD) unable to determine pressure ulcer on his/her right heel and directed staff to provide education to the family and resident as to the causes of skin breakdown, provide an air mattress for the resident's bed and pressure relieving cushion for the resident's wheelchair, notify the nurse of any new areas of skin breakdown, and turn the resident side to side. (Review of the care plan lacked documentation of interventions to prevent further breakdown or new breakdown for the resident's heels). The care plan, dated 8/17/17, documented the resident had an air mattress and pressure relieving device in his/her wheelchair. The care plan directed staff to monitor the air pressure in the resident's Roho cushion (a specialized pressure reducing cushion that prevents skin injury and can assist healing of pressure ulcers). The 8/7,8/14, 8/21, and 8/28/17 documented a Braden scale score of 18, which indicated the resident was at risk for pressure ulcers. The 8/7/17 wound assessment documented the resident was admitted to the facility with a pressure ulcer on his/her right heel, which measured 4. 5 (cm) centimeters x 5.5 cm and left great toe, which measured 1.2 cm x 1.0 cm. The assessment documented the resident's heels were off loaded and the resident wore a right heel protector. The 8/15/17 physician order [REDACTED]. (In regards to the resident's pressure ulcer to his/her right foot) The 8/24/17 Dietician Assessment documented the resident was on a consistent carbohydrate diet (keeps a consistent intake level of carbohydrates) and ate 51-75% of his/her meals. The assessment further documented the resident required additional calories and protein to promote healing of the pressure areas. The 8/25/17 physician order [REDACTED]. The Laboratory Report, dated 8/31/17, documented the residents [MEDICATION NAME] level (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) of 1.8 (normal is 3.4 - 5.0) and Total Protein Level of 7.5 (normal is 6.4 - 8.2). The 9/4/17 Wound RN Assessment documented a newly suspected deep tissue injury on the resident's left lateral side (outer side), left heel (the back part of the foot below the ankle), and left lateral malleolus (bony prominence on each side of the ankle) of the resident's left foot. The 9/4/17 fax to the physician documented the resident's left heel had a wound which appeared blistered, with dark areas around the edges and measured 4 cm x 3 cm, without drainage. The fax documented staff placed a heel protector on the resident's left foot and floated the heel. The 9/4/17 physician order [REDACTED]. The 9/10/17 physician's orders [REDACTED]. The 9/11/17 wound assessment documented the resident's the left lateral side of the foot was unchanged, left heel had a soft blistered area, filling in with a dark color, the left malleolus had full thickness loss with more eschar (a dry, dark scab or falling away of dead skin). The 9/18/17 physician order [REDACTED]. The 9/21/17 physician's orders [REDACTED]. The 9/25/17 wound assessment for the lateral side of the foot measured 1.2 cm x 1 cm and covered 100% with eschar, the left heel measured 4 cm x 2.6 cm and covered 100% with eschar, and the left lateral malleolus measured 1.3 cm x 1.4 cm and covered 10% with eschar. The 10/2/17 wound assessment for the left side of the foot measured 1.0 cm x 1.0 cm and covered with 100% eschar, left heel documented the wound as 3.8 cm x 2.9 cm and covered 100% with eschar and a small bridge forming across the middle of the wound, and the left lateral malleolus measured 1.6 cm x 1.2 cm and covered 100% with eschar. The 10/10/17 physician's orders [REDACTED]. The 10/21/17 physician order [REDACTED]. The 10/23/17 wound assessment documented the left lateral foot measured 0.7 cm x 0.5 cm and covered with 100% eschar, the left heel measured 3.4 cm x 0.8 cm, and the left lateral malleolus measured 1.5 cm x .3 cm with 90% slough (dead tissue) and 10% granulation (new tissue). The 10/27/17 wound assessment documented, the left lateral foot measured 1.0 cm x 1.0 cm and covered 100% eschar, the left heel measured 3.8 cm x 1.9 cm and covered with 100% eschar, and the left lateral malleolus measured 1.6 cm x 1.2 cm and covered with 100% eschar. The 10/31/17 wound assessment documented the left lateral foot measured at 0.7 cm x 0.5 cm and covered with 100% eschar, the left heel measured 3.4 cm x 0.8 cm and covered with 100% eschar, and left lateral malleolus measured 1.5 cm x 1.3 cm and covered with 90% sough and 10% granulation. The Laboratory Report, dated 10/31/17, documented the resident's [MEDICATION NAME] level of 2.2, indicating low [MEDICATION NAME], and Total Protein Level of 7, indicating normal Total Protein. The 11/6/17 wound assessment documented the left lateral foot measured 0.5 cm x 0.5 cm and covered with 100% eschar, the left heel measured at 3.4 cm x 0.8 cm and covered with 100% moist necrotic tissue, and left lateral malleolous measured 1.5 cm x 1.3 cm. The (MONTH) and (MONTH) (YEAR) meal intake record recorded the resident ate 50-75% of his/her meals. On 11/15/17 at 2:40 PM, Resident #18 stated he/she had skin breakdown on his/her right foot when he/he was admitted to the facility and had acquired the skin breakdown on his/her left foot after he/she was admitted . The resident was unable to remember what interventions were in place prior to him/her acquiring skin breakdown. Resident #18 stated, he/she does not have a good appetite, never has, and gets his/her supplement at mealtime. On 11/16/17 at 9:30 AM, observation revealed the resident seated in his/her recliner, feet elevated, with bilateral heel protectors and heels floated. On 11/16/17 at 10:38 AM, observation revealed Licensed Nurse F removed the old dressings from the resident's left foot and measured the left lateral side wound of his/her foot at 1.0 cm x 0.6 cm, the left heel wound at 3.2 cm x 0.8 cm and left ankle wound at 1.1 cm x 0.7 cm. Licensed Nurse F wiped skin prep to the periwound, applied Santyl and covered with a nonbordered dressing. On 11/16/17 at 10:45 AM, Licensed Nurse F stated staff changed the resident's dressing during the evening when the resident was in bed and staff floated the resident's heels. Licensed Nurse F further stated staff floated the resident's heels when he/she was admitted to the facility. Licensed Nurse F stated staff take the resident to the wound clinic weekly and the physician would make changes to the treatments for the wounds. On 11/16/17 11:30 AM, Licensed Nurse B stated the resident did not have the pressure ulcers on his/her left foot upon admission and only had a heel protector on his/her right foot. Licensed Nurse B further stated the resident's heels were floated and the resident goes to the wound clinic weekly. Licensed Nurse B stated the resident had been going to the wound clinic after the resident was admitted to the facility. On 11/16/17 at 2:03 PM, Nurse Aide M stated the resident's heels had always been offloaded and he/she wore heel protectors all the time but did not know when the resident first started wearing the left heel protector. Nurse Aide M further stated the resident had a pressure relieving mattress on the bed prior to when he/she was admitted to the facility On 11/16/17 at 2:39 PM, Administrative Nurse A stated the resident had breakdown to the right foot upon admission to the facility and staff should have initiated preventative measures in place to prevent breakdown to the resident's left foot. 11/16/17 at 5:00 PM, Physician I stated the resident had poor circulation and did not move around much. On 11/21/17 at 10:40 AM, Dietician P stated the resident did not have a good appetite when he/she was admitted to the facility. Staff provide house supplements daily for the resident and increased his/her protein. The resident was able to make choices of what he/she wants to eat and drink. The (MONTH) (YEAR) facility Skin Assessment, Pressure Ulcer Prevention and Documentation Requirement Procedure documented all residents were identified as at risk of developing pressure ulcers on admission/readmission by a registered nurse using the Braden Scale for Predicting Pressure Sore Risk. Those residents determined to be at risk will have the Braden Scale completed weekly for the first 4 weeks following admission. A systematic skin inspection will be made daily by the nurse assistance assigned to those residents at risk for skin breakdown. The nursing assistance responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. If a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The registered nurse should record the type of wound and the degree of tissue damage on the wound assessment sheet. Notify the physician of the ulcer and resident's condition to obtain orders for treatment. Notify the resident, and/or family of the pressure ulcer, orders and planned interventions. The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment Sheet. The facility failed to implement proactive and effective interventions to prevent the development of a facility acquired pressure ulcers on dependent Resident #18's left lateral side of the foot, left heel, and left lateral malleolus.

The facility had a census of 37 residents. The sample included 4 residents. Based on observation, record review, and interview, the facility failed to protect the 37 residents from potential abuse, when a staff member took photos of 4 of 4 sampled residents in April 2017, placed them on snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will live for between 1 and 10 seconds), and continued providing resident care until the abuse was reported to the facility on [DATE]. ( #1, #2, #3, and #4) Findings included: - Resident #1's annual (MDS) Minimum Data Set assessment, dated 4/28/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 2, which indicated severe cognitive impairment. The MDS documented the resident required extensive staff assistance with dressing and eating, and total staff assistance with bed mobility, transfers, locomotion on and off unit, toilet use, bathing, and personal hygiene. The MDS documented the resident had lower extremity impairment on both sides and used a wheelchair for mobility. The 4/28/17 Cognitive loss/Dementia (progressive mental disorder characterized by failing memory, confusion) (CAA) Care Area Assessment documented the resident had impaired long term memory and short term memory with a BIMS of 2. The CAA documented staff used reality orientation with reassurance, as needed, for all interactions with the resident. The care plan, dated 1/27/17 revised on 5/15/17, instructed staff to reminisce with the resident, reduce any distractions when communicating with the resident, provide the resident with necessary cues, stop and return if agitated, ask yes/no questions in order to determine resident's needs, present just one thought, idea, question or command at a time, and break tasks into one step at a time. The care plan documented the resident required staff assistance with bathing, bed mobility, dressing, oral care, personal hygiene, and instructed staff to use a sit to stand lift with a small harness and 2 assist for transfers, and check and change the resident at night. The care plan instructed staff to provide opportunities for positive interaction, attention, and offer reassurance and or explanation with each task. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #1 sitting on a bath chair, unclothed, in the whirlpool room. The report documented Nurse Aide C (a former employee of the facility) and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After an interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. Review of the facilities employee record revealed Nurse Aide C worked for the facility from 8/2/16 to 6/29/17 and Nurse Aide D worked for the facility form 2/21/17 to 6/29/17. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone. Administrative Nurse A directed him/her to bring proof of the photos to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C took pictures of him/her, Resident #1, and another resident. Nurse Aide D also took pictures of himself/herself with Resident #1 and 3 other residents sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C had taken, and felt there was no harm done, and had not reported the nurse aides. On 7/3/17 at 2:50 PM, observation revealed staff transferred Resident #1, using a sling lift to his/her bed. Observation revealed staff conversed with the resident in a dignified manner. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect policy documented if there is an allegation of employee (s) to resident abuse, the employee (s) will be removed from providing direct care to all residents. The facility failed to protect the 37 residents from potential abuse, when a staff member took photos of 4 of 4 sampled residents in April 2017, placed them on snap chat social media, and continued providing resident care until the abuse was reported to facility on 6/28/17, placing the residents in the facility in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aide D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what tod if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell hone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly. - Resident #2's annual (MDS) Minimum Data Set assessment, dated 5/5/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 11, which indicated moderately impaired cognition. The MDS documented the resident required extensive assistance of 1-2 staff with (ADLs) Activities of Daily Living, except supervision with eating and total staff dependence with bathing. The 5/16/17 Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) (CAA) Care Area Assessment documented the Resident had a BIMS of 11, the resident had trouble with short term memory recall, and nursing staff worked with him/her to become as independent as possible. The 5/16/17 ADL functional/Rehabilitation Potential CAA documented the resident required supervision to total 1-2 staff assistance with ADLs, had right sided weakness due to [MEDICAL CONDITION], and was unable to safely sit on the toilet, so staff check and change him/her with repositioning, and staff used a total lift with medium sling when transferring the resident. The CAA documented the resident was able to eat independently with set up assistance and supervision. The revised 5/16/17 care plan instructed staff to discuss concerns about confusion, disease process and nursing home placement with the resident, and reminisce with the resident about the past. The care plan documented the resident understood consistent, simple, direct sentences, and instructed staff to speak clearly and slowly, and ask yes/no questions in order to determine the resident's needs. The care plan documented the resident required staff assistance with bed mobility, dressing, personal hygiene, and transferring. The care plan instructed staff to approach the resident in a calm manner, deliver attention, provide opportunities for positive interaction, and offer reassurance, if the resident was agitated, by talking with him/her. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #2 lying in bed, clothed, with nurse aide beside him/her. The report documented Nurse Aide C and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After an interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. Review of the facilities employee record revealed Nurse Aide C worked for the facility from 8/2/16 to 6/29/17 and Nurse Aide D worked for the facility form 2/21/17 to 6/29/17. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone. Administrative Nurse A directed him/her to bring proof of the photos to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C and Nurse Aide D took photos of Resident #3 and 1 other resident, Nurse Aide C took other resident photos sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C took, and felt there was no harm done, and had not reported the nurse aides. On 7/10/17 at 2:40 PM, observation revealed staff passed water to the resident and conversed with the resident in a dignified manner. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect policy documented if there is an allegation of employee (s) to resident abuse, the employee (s) will be removed from providing direct care to all residents. The facility failed to protect the 37 residents from potential abuse, when a staff member took photos of 4 of 4 sampled residents in April 2017, placed them on snap chat social media, and continued providing resident care until the abuse was reported to facility on 6/27/17, placing the residents in the facility in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aides D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what tod if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell hone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly. - Resident #3's annual (MDS) Minimum Data Set assessment, dated 1/20/17, documented the resident had a (BIMS) Brief Interview of Mental Status score of 3, which indicated severe cognitive impairment. The MDS documented the resident required extensive 1-2 staff assistance with (ADLs) Activities of daily living, had upper and lower extremity impairment on one side, and used no mobility devices. The 1/20/17 Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) (CAA) Care Area Assessment documented the resident had impaired short and long term memory with a BIMS score of 3, condition was stable for the present time, and he/she received medications as treatment. The 6/28/17 care plan documented the resident needed supervision with all decision making, understood consistent, simple, direct sentences, and directed staff to provide consistent care routines. The care plan documented the resident required weight bearing support by staff and a gait belt when ambulating, assistance from staff with bathing, bed mobility,personal hygiene, toilet use and transferring. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #3 sitting on the toilet in one picture and in another picture was in the whirlpool tub taking a bath. The report documented Nurse Aide C (a former employee of the facility) and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. Review of the facilities employee record revealed Nurse Aide C worked for the facility from 8/2/16 to 6/29/17 and Nurse Aide D worked for the facility form 2/21/17 to 6/29/17. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone, and Administrative Nurse A directed him/her to bring proof to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C took pictures of 3 other residents and Nurse Aide D also took pictures of Resident #3 and another resident sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C took, and felt there was no harm done, and had not reported the nurse aides. On 7/3/17 at 3:00 PM, observation revealed the resident resting quietly in a recliner with his/her eyes closed in the commons area across from the nurse's station. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect policy documented if there is an allegation of employee (s) to resident abuse, the employee (s) will be removed from providing direct care to all residents. The facility failed to protect the 37 residents from potential abuse, when a staff member took photos of 4 of 4 sampled residents in April 2017, placed them on snap chat social media, and continued providing resident care until the abuse was reported to facility on 6/28/17, placing the residents in the facility in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aide D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what to do if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell phone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly. - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 12/30/16, documented the resident had a (BIMS) Brief Interview of Mental Status score of 3, which indicated severe cognitive impairment. The MDS documented the resident required supervision with eating, extensive 1-2 staff assistance with bed mobility, transfers, toilet use and personal hygiene, and total dependent on staff with bathing. The MDS documented the resident had lower extremity impairment on one side and used a wheelchair for mobility. The 12/30/16 Cognitive Loss/Dementia (CAA) Care Area Assessment documented the resident had short and long term memory problems, and received Hospice (an outside service providing care for the sick, especially the terminally ill.) services. The quarterly MDS, dated [DATE], documented the resident had a BIMS of 3, which indicated severe cognitive impairment. The MDS documented the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), required limited staff assistance with eating and toilet use, extensive 1-2 staff assistance with bed mobility, transfers, dressing and personal hygiene, and was totally dependent on staff with bathing. The MDS documented the resident had lower extremity impairment on one side and used a wheelchair for mobility. The 3/31/17 care plan documented the resident had impaired cognition and understood consistent simple, direct sentences. The care plan instructed staff to reminisce with the resident, reduce any distractions when communicating, provide necessary cues, ask yes/no questions in order to determine resident's needs, present just one thought idea, question or command at a time, and break tasks into one step at a time. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #4 sitting on a bath chair in the whirlpool room. The report documented Nurse Aide C (a former employee of the facility) and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After an interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. Review of the facilities employee record revealed Nurse Aide C worked for the facility from 8/2/16 to 6/29/17 and Nurse Aide D worked for the facility form 2/21/17 to 6/29/17. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone. Administrative Nurse A directed him/her to bring proof of photos to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C took photos of 3 residents and Nurse Aide D also took photos of Resident #4 and 2 other residents sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C had taken, and felt there was no harm done, and had not reported the nurse aides. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect policy documented if there is an allegation of employee (s) to resident abuse, the employee (s) will be removed from providing direct care to all residents. The facility failed to protect the 37 residents from potential abuse, when a staff member took photos of 4 of 4 sampled residents in April 2017, placed them on snap chat social media, and continued providing resident care until the abuse was reported to facility on 6/28/17, placing the residents in the facility in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aide D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what to do if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell phone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly.

The facility had a census of 37 residents. The sample included 4 residents. Based on observation, record review and interview the facility failed to provide a safe environment for 4 of 4 sampled residents, to keep them free from abuse and exploitation, when staff took photos of the residents and placed them on social media. This deficient practice placed Residents #1, #2, #3, and #4 in immediate jeopardy. Findings included: - Resident #1's annual (MDS) Minimum Data Set assessment, dated 4/28/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 2, which indicated severe cognitive impairment. The MDS documented the resident required extensive staff assistance with dressing and eating, and total staff assistance with bed mobility, transfers, locomotion on and off unit, toilet use, bathing, and personal hygiene. The MDS documented the resident had lower extremity impairment on both sides and used a wheelchair for mobility. The 4/28/17 Cognitive loss/Dementia (progressive mental disorder characterized by failing memory, confusion) (CAA) Care Area Assessment documented the resident had impaired long term memory and short term memory with a BIMS of 2. The CAA documented staff used reality orientation with reassurance, as needed, for all interactions with the resident. The care plan, dated 1/27/17 revised on 5/15/17, instructed staff to reminisce with the resident, reduce any distractions when communicating with the resident, provide the resident with necessary cues, stop and return if agitated, ask yes/no questions in order to determine resident's needs, present just one thought, idea, question or command at a time, and break tasks into one step at a time. The care plan documented the resident required staff assistance with bathing, bed mobility, dressing, oral care, personal hygiene, and instructed staff to use a sit to stand lift with a small harness and 2 assist for transfers, and check and change the resident at night. The care plan instructed staff to provide opportunities for positive interaction, attention, and offer reassurance and or explanation with each task. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #1 sitting on a bath chair, unclothed, in the whirlpool room. The report documented Nurse Aide C (a former employee of the facility) and Nurse Aide D were in the photos. The report documented at 7:30 AM, the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D, and after an interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone. Administrative Nurse A directed him/her to bring proof of the photos to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C took pictures of him/her, Resident # 1, and another resident. Nurse Aide D also took pictures of himself/herself with Resident #1 and 3 other residents sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C had taken, and felt there was no harm done, and had not reported the nurse aides. On 7/3/17 at 2:50 PM, observation revealed staff transferred Resident #1, using a sling lift to his/her bed. Observation revealed staff conversed with the resident in a dignified manner. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents' baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect Policy documented the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility's February 2013 Resident Dignity policy instructed staff to refrain from taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment, e.g., cameras, smart phones and other electronic devices, and/or keeping or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks. The facility failed to ensure Resident #1 was free from abuse and exploitation by taking photos of the resident sitting on a bath chair in the whirlpool room, and placed the photo on snap chat for others to see, placing the resident in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aide D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what tod if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell hone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly. - Resident #2's annual (MDS) Minimum Data Set assessment, dated 5/5/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 11, which indicated moderately impaired cognition. The MDS documented the resident required extensive assistance of 1-2 staff with (ADLs) Activities of Daily Living, except supervision with eating and total staff dependence with bathing. The 5/16/17 Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) (CAA) Care Area Assessment documented the Resident had a BIMS of 11, the resident had trouble with short term memory recall, and nursing staff worked with him/her to become as independent as possible. The 5/16/17 ADL functional/Rehabilitation Potential CAA documented the resident required supervision to total 1-2 staff assistance with ADLs, had right sided weakness due to [MEDICAL CONDITION], and was unable to safely sit on the toilet, so staff check and change him/her with repositioning, and staff used a total lift with medium sling when transferring the resident. The CAA documented the resident was able to eat independently with set up assistance and supervision. The revised 5/16/17 care plan instructed staff to discuss concerns about confusion, disease process and nursing home placement with the resident, and reminisce with the resident about the past. The care plan documented the resident understood consistent, simple, direct sentences, and instructed staff to speak clearly and slowly, and ask yes/no questions in order to determine the resident's needs. The care plan documented the resident required staff assistance with bed mobility, dressing, personal hygiene, and transferring. The care plan instructed staff to approach the resident in a calm manner, deliver attention, provide opportunities for positive interaction, and offer reassurance, if the resident was agitated, by talking with him/her. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #2 lying in bed, clothed, with nurse aide beside him/her. The report documented Nurse Aide C and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After an interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone. Administrative Nurse A directed him/her to bring proof of the photos to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C and Nurse Aide D took photos of Resident #3 and 1 other resident, Nurse Aide C took other resident photos sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C took, and felt there was no harm done, and had not reported the nurse aides. On 7/10/17 at 2:40 PM, observation revealed staff passed water to the resident and conversed with the resident in a dignified manner. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect Policy documented the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility's February 2013 Resident Dignity policy instructed staff to refrain from taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment, e.g., cameras, smart phones and other electronic devices, and/or keeping or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks. The facility failed to ensure Resident #2 was free from abuse and exploitation from staff by taking photos of Nurse Aide D lying in bed next to the resident, and placed the photos on snap chat for others to see, placing the resident in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aides D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what tod if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell hone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly. - Resident #3's annual (MDS) Minimum Data Set assessment, dated 1/20/17, documented the resident had a (BIMS) Brief Interview of Mental Status score of 3, which indicated severe cognitive impairment. The MDS documented the resident required extensive 1-2 staff assistance with (ADLs) Activities of daily living, had upper and lower extremity impairment on one side, and used no mobility devices. The 1/20/17 Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) (CAA) Care Area Assessment documented the resident had impaired short and long term memory with a BIMS score of 3, condition was stable for the present time, and he/she received medications as treatment. The 6/28/17 care plan documented the resident needed supervision with all decision making, understood consistent, simple, direct sentences, and directed staff to provide consistent care routines. The care plan documented the resident required weight bearing support by staff and a gait belt when ambulating, assistance from staff with bathing, bed mobility,personal hygiene, toilet use and transferring. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #3 sitting on the toilet in one picture and in another picture was in the whirlpool tub taking a bath. The report documented Nurse Aide C (a former employee of the facility) and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone, and Administrative Nurse A directed him/her to bring proof to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C took pictures of 3 other residents and Nurse Aide D also took pictures of Resident #3 and another resident sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C took, and felt there was no harm done, and had not reported the nurse aides. On 7/3/17 at 3:00 PM, observation revealed the resident resting quietly in a recliner with his/her eyes closed in the commons area across from the nurse's station. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect Policy documented the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility's Abuse and Neglect policy did not include a mandated policy for prohibiting mental abuse related to photograph and audio/video recordings. The facility's February 2013 Resident Dignity policy instructed staff to refrain from taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment, e.g., cameras, smart phones and other electronic devices, and/or keeping or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks. The facility failed to ensure Resident #3 was free from abuse and exploitation by taking photos of the resident sitting on the toilet and in the whirlpool , and placed the photos on snap chat for others to see, placing the resident in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aide D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what to do if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell phone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly. - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 12/30/16, documented the resident had a (BIMS) Brief Interview of Mental Status score of 3, which indicated severe cognitive impairment. The MDS documented the resident required supervision with eating, extensive 1-2 staff assistance with bed mobility, transfers, toilet use and personal hygiene, and total dependent on staff with bathing. The MDS documented the resident had lower extremity impairment on one side and used a wheelchair for mobility. The 12/30/16 Cognitive Loss/Dementia (CAA) Care Area Assessment documented the resident had short and long term memory problems, and received Hospice (an outside service providing care for the sick, especially the terminally ill.) services. The quarterly MDS, dated [DATE], documented the resident had a BIMS of 3, which indicated severe cognitive impairment. The MDS documented the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), required limited staff assistance with eating and toilet use, extensive 1-2 staff assistance with bed mobility, transfers, dressing and personal hygiene, and was totally dependent on staff with bathing. The MDS documented the resident had lower extremity impairment on one side and used a wheelchair for mobility. The 3/31/17 care plan documented the resident had impaired cognition and understood consistent simple, direct sentences. The care plan instructed staff to reminisce with the resident, reduce any distractions when communicating, provide necessary cues, ask yes/no questions in order to determine resident's needs, present just one thought idea, question or command at a time, and break tasks into one step at a time. The 6/29/17 at 7:45 AM, nurse's note documented staff exploited the resident through snap chat social media (the mobile application that allows users to capture videos and pictures that self destruct after a few seconds. When a user sends a message they get to decide whether it will be saved for between 1 and 10 seconds). The 6/29/17 incident report documented on 6/29/17 at 7:15 AM a staff member showed Administrative Nurse A pictures on his/her cell phone of Resident #4 sitting on a bath chair in the whirlpool room. The report documented Nurse Aide C (a former employee of the facility) and Nurse Aide D were in the photos. The report documented at 7:30 AM the facility notified the police and the police arrived at the facility at 7:45 AM, to investigate the incident. The report documented the facility suspended Nurse Aide D. After an interview with Nurse Aide D, who admitted to the exploitation, the facility terminated him/her. The report documented the facility interviewed Nurse Aide E who admitted having knowledge of the photos, and failed to report the abuse to administration. The 6/29/17 facility's witness statement, from Nurse Aide F, documented around 8:00 PM on 6/28/17, he/she became aware of the photos and notified Administrative Nurse A at 8:10 PM by phone. Administrative Nurse A directed him/her to bring proof of photos to the facility in the morning. The 6/29/17 facility's witness statement, from Nurse Aide D, documented Nurse Aide C took photos of 3 residents and Nurse Aide D also took photos of Resident #4 and 2 other residents sometime around April, 2017. The 6/29/17 facility's witness statement, from Nurse Aide E documented he/she viewed a video of a resident in the whirlpool a few months ago, which Nurse Aide D and Nurse Aide C had taken, and felt there was no harm done, and had not reported the nurse aides. On 7/3/17 at 2:12 PM, Dietary Aide G stated he/she found out about the photos on 6/28/17 and reported to his/her supervisor on 6/29/17. Dietary Aide G stated common friends of Nurse Aide D and him/herself told him/her about the photos, but he/she never viewed the photos. On 7/6/17 at 1:31 PM, Nurse Aide F stated he/she found out on 6/28/17 around 8:00 PM about Nurse Aide C and D taking photos, when he/she was at a friend's house and the friend's family member showed him/her the photos. Nurse Aide F stated he/she immediately called Administrative Nurse A and was told to bring proof to the facility the next morning. On 7/3/17 at 2:30 PM, Administrative Nurse A stated Nurse Aide D worked mostly on hall 2, and gave the residents baths, when the incident occurred. On 7/10/17 at 3:22 PM, Administrative Nurse A stated Nurse Aide D had access to all residents residing in the facility, when the incident occurred. The facility's February 2013 Abuse and Neglect Policy documented the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility's Abuse and Neglect policy did not include a mandated policy for prohibiting mental abuse related to photograph and audio/video recordings. The facility's February 2013 Resident Dignity policy instructed staff to refrain from taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment, e.g., cameras, smart phones and other electronic devices, and/or keeping or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks. The facility failed to ensure Resident #4 was free from abuse and exploitation by taking photos of the resident sitting on a bath chair in the whirlpool room, and placed the photos on snap chat for others to see, placing the resident in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility terminated Nurse Aide D and E and provided in-service training to all staff on abuse, neglect and exploitation, and reviewed examples of social media on 6/29, 6/30, and 7/2/17. The administrator and director of nursing will conduct audits on staff to ensure staff know what to do if they identify or suspect abuse, neglect, and exploitation. Will audit 4 staff members a week on alternating shifts for 1 month and then 4 residents a month on-going. On 6/30/17 the administrator developed a cell phone addendum to the employee handbook. Staff will read and sign by 7/7/17. The facility's (QAPI) Quality Assurance Performance Improvement coordinator will audit 4 staff members weekly x 1 month to ensure staff withhold and know the cell phone policy. Starting 6/30/17 the (LSBW) Licensed Social Bachelor Worker will discuss the involved residents weekly at his behavioral committee meeting with front line staff to identify any new or worsening behaviors. The At Risk committee will audit the weekly Behavioral Committee Meeting outcomes and follow upon any findings weekly.

The facility had a census of 44 residents. The sample included 9 residents, with 3 reviewed for nutrition. Based on observation, record review and interview the facility failed to provide adequate nutritional interventions and monitor snack and supplement intake for 1 of 3 sampled residents (#1), who had a 19.4 pound (14.0%) significant weight loss in 48 days. Findings included: - Resident #1's physician's orders [REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 12/12/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 3 (severe cognitive impairment) with inattention, disorganized thinking and resistive behaviors. The MDS also indicated the resident required extensive staff assistance with dressing/grooming, transfers and personal hygiene, and supervision with eating. The MDS further indicated the resident weighed 136 pounds with no recent weight loss or therapeutic diet (diet ordered by a physician or Registered Dietician to treat a medical condition). The 12/12/16 significant change (CAA) Care Area Assessment indicated nutrition had not triggered to indicate whether staff should revise the resident's care plan to address the resident's nutritional status. The 12/22/16 care plan indicated the resident had nutritional problems related to his/her dementia (progressive mental disorder characterized by failing memory and increased confusion). The care plan indicated the resident had a poor appetite and directed staff to encourage food intake at meals and snacks. The care plan lacked documention the resident recieved nutritional supplements for abnormal weight loss. review of the resident's medical record revealed [REDACTED]. 12/07/16 - 137.6 lbs (pounds) (readmit from hospital after fall with [MEDICAL CONDITION] on 11/29/16) 12/16/16 - 133.4 lbs 12/21/16 - 125.2 lbs 01/07/17 - 125.0 lbs (12.6 lbs or 9.16% in 30 days) 01/11/17 - 123.0 lbs 01/18/17 - 120.0 lbs 01/23/17 - 118.2 lbs (19.4 lb or 14% significant change weight loss in 48 days) The 12/06/16 physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. The 12/08/16 Nutritional Status and (RD) Registered Dietician Assessment indicated the resident was readmitted from the hospital on [DATE], current weight 137.6 lbs, and a gradual 7% weight loss in the past 180 days. The RD assessment indicated the resident's average meal intake was 0 to 25% and the resident needed an increase in protein and calories to promote healing after a fracture and surgery. The RD assessment indicated he/she would continue to monitor the resident for nutritional and weight problems. review of the resident's medical record revealed [REDACTED]. The facility's meal intake record, from 12/25/16 to 01/24/17 (30 days), indicated the resident's meal intake was 0 to 25% for 61 out of 90 meals. The facility's HS (bedtime) snack report, from 12/25/16 to 01/24/17 (30 days), indicated the resident received a bedtime snack 6 out of 30 nights. Continued review of the HS snack report indicated staff did not monitor the resident's snack intake. review of the resident's medical record revealed [REDACTED]. The 01/12/17 physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 01/25/17 at 7:29 AM, observation revealed the resident sat in a wheelchair, at a dining room table, while staff served breakfast and encouraged the resident to eat and drink. Continued observation revealed the resident rolled his/her wheelchair back and forth and made no attempts to eat or drink. At 7:45 AM, observation revealed staff moved the resident and his/her meal to another table and staff again encouraged the resident to eat and drink. Continued observation revealed the resident ate a few small bites and refused to stay at the table. On 01/25/17 at 10:17 AM, observation revealed the resident, sat in a wheelchair, in the hall near the nurse's station. Continued observation revealed Nurse D gave a house supplement to the resident and encouraged the resident to drink. Continued observation revealed the resident refused to drink and held the supplement on his/her lap. At 10:41 AM, observation revealed the resident handed the supplement to Nurse Aide B, who disposed of the supplement in the nutrition kitchen. Nurse Aide B verified the supplement container was full. On 01/25/17 at 8:50 AM, Dietary Manager C stated dietary staff monitor and record the resident's meal intake and the resident's usual intake was 0 to 25%. Dietary Manager C stated the resident did not have care plan interventions in place to direct staff to provide nutritional interventions, if the resident did not eat at meals. Dietary Manager C stated dietary staff provided all the residents morning and afternoon snacks and do not monitor the snack intake. Dietary Manager C further stated the facility had not notified the Registered Dietician of the resident's continued weight loss. On 01/25/17 at 9:22 AM, Nurse D stated nursing staff provided the resident's HS snack (dietary staff provided the morning and afternoon snacks) and nutritional supplements. Nurse D further stated staff did not monitor the intake of the HS snack or nutritional supplement. Nurse D stated the resident received nutritional supplements two times a day as ordered by the physician for continued abnormal weight loss. On 01/25/17 at 10:17 AM, Nurse E stated the confused resident had a poor appetite, refused staff assistance with eating and drinking, and usually ate only a few bites at meals. Nurse E stated the resident did not have care plan interventions to provide nutritional interventions when the resident did not eat at meals. Nurse E stated the nursing staff provided nutritional supplements and HS snacks to the resident and did not monitor the intake. Nurse E further stated the physician recently increased the resident's nutritional supplement to two times a day, due to the resident's continued weight loss. On 01/25/17 at 10:20 AM, Nurse Aide A stated the resident was confused with occasional behaviors, ate and drank independently, and refused staff assistance at meals. Nurse Aide A stated staff encouraged the resident to increase meal intake, but the resident usually ate only a few bites. Nurse Aide A further stated the resident frequently only drank a little or none of his/her nutritional supplement. On 01/25/16 at 11:43 AM, Nurse Aide B stated the resident refused to allow staff to assist him/her at meals and usually only ate a few bites. Nurse Aide B stated the resident frequently left his/her unfinished nutritional supplement sitting somewhere or hands the supplement to the staff. Nurse Aide B stated he/she had reported to the nurse several times concerning the resident's unfinished nutritional supplement. On 01/25/17 at 1:42 PM, Administrative Nurse E stated the resident had poor intake at meals, refused staff assistance, and continued with weight loss. Administrative Nurse E stated staff do not monitor the resident's nutritional supplement or snack intake and had not notified the Registered Dietician of the resident's continued weight loss. On 01/30/17 at 10:51 AM, Registered Dietician G stated he/she consulted at the facility two times a month and staff had not notified him/her of the resident's continued weight loss. Registered Dietician G stated, due to the resident's poor meal intake, staff should monitor intake of between meal snacks and nutritional supplements. The facility's Nutrition Policy, dated 02/2016, directed staff to notify the Registered Dietician, if a resident had nutritional impairment and/or weight loss. The policy directed staff to offer the resident alternate food preferences, fortified or high calorie snacks or finger foods to address the resident's poor nutritional intake. The policy further directed staff to monitor snack and nutritional supplement intake, when the resident had continued weight loss. The facility failed to provide adequate nutritional interventions and to monitor snack and supplement intake for cognitively impaired Resident #1, who experienced a significant 14% weight loss in 48 days.

The facility had a census of 48 residents. The sample included 6 residents, 4 of which were reviewed for medications. Based on observation, record review, and interview, the facility failed to ensure staff monitored for side effects of medications for 1 of the 4 sampled residents. Resident #3 had 2 [MEDICATION NAME] (a powerful opiate [MEDICATION NAME]) pain patches on at the same became unresponsive and required evaluation and treatment of [REDACTED]. Findings included: - Resident #3's 5 day Medicare (MDS) Minimum Data Set assessment, dated 6/18/15, indicated the resident had short and long term memory loss, and moderately impaired cognition. The MDS also indicated the resident required extensive staff assistance for all (ADLs) activities of daily living, used a wheelchair for mobility, and received scheduled pain medications. The 6/17/15 signed physician's orders [REDACTED]. disorder characterized by failing memory, and confusion), [MEDICAL CONDITIONS] (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pain, hypopotassemia (low level of potassium in the blood), paranoid state, delusional disorder, [MEDICAL CONDITION] reflux, and under socialized conduct due to aggression. The 6/18/15 care plan informed the staff the resident received [MEDICATION NAME]es that were to be changed by staff every 72 hours. The care plan stated the staff should check on the resident frequently, monitor his/her mental status, and use a wheelchair for mobility. The 6/17/15 at 4:07 PM, nursing admission data collection stated the resident transferred from another facility. The assessment revealed the resident had visual hallucinations(sensing things while awake that appear to be real, but the mind created) with behavior disturbances), and he/she received antipsychotic medications. The assessment also stated the resident was lethargic (feeling sluggish or having little energy), had unclear speech, alert but not oriented to person, place or time. The assessment had no documentation that the resident had a [MEDICATION NAME] on, at the time of admission. The assessment stated the resident's oxygen saturation was 90% on 4 liters of oxygen. The patient transfer form (no time specified), dated 6/17/15, indicated the resident had a [MEDICATION NAME], 25 (mcg) micrograms per hour, to be changed every 72 hours. The form indicated the patch was to be changed on 6/19/15. Review of the resident's Medication Administration Record [REDACTED]. The 6/17/15 at 11:17 PM, nurse's notes stated the resident was lethargic, but alert when he/she was spoken to, had hallucinations, delusions, and denied pain. The note stated the resident's skin was intact with no abnormalities, and no mention the resident had a [MEDICATION NAME] on at that time. The 6/18/15 at 11:00 AM, daily skilled nursing notes stated the resident was very lethargic, drowsy and difficult to arouse. The 6/18/15 at 11:15 AM nurse's note stated the staff notified the resident's family of his/her condition. The 6/18/15 at 11:30 AM nurse's notes stated the resident's bed alarm sounded at 10:15 AM, and the staff found the resident lying on the floor of his/her room. The note stated the staff used a full body lift to transfer the resident to his/her wheelchair The note stated the resident had been very lethargic and hard to arouse. The 6/18/15 at 1:00 PM nurse's note stated the resident's family transported him/her, in his/her wheelchair, to the physician's office across the street from the facility, for his/her scheduled appointment with the physician at 11:30 AM. The resident's oxygen saturation at that time was 90% on 2 liters of oxygen. (normal range is 95-100%, under 90% is considered low). The resident was admitted to the hospital on [DATE] after his/her appointment in the physician's office. The 6/18/15 (no time specified),hospital history and physical examination [REDACTED]. The note stated the resident received [MEDICATION NAME]es for pain. The note stated the resident had fallen out of bed at the facility, was lethargic, with oxygen saturations in the 60's, which improved with oxygen per nasal cannula, however, the resident continued to remain lethargic until approximately 11:30 AM, when the family assisted the resident to the clinic for his/her appointment. The note stated the resident was somnolent (feeling sleepy and drowsy) and slumped over in his/her chair, with minimal response to painful stimuli or sternal rub, but grimaced when the physician tried to open his/her eyelids. The note further stated during the skin evaluation, it was discovered the resident had two [MEDICATION NAME]es, 25 mcg each, on the right side of his/her body, one on the side of the stomach and the second on the left upper shoulder. The assessment plan stated the resident had altered mental status, likely due to narcotic overdose with multiple [MEDICATION NAME]es. The resident responded to [MEDICATION NAME] (a medication that can reverse an opioid overdose), and all narcotics and mind altering medications were held to see how the resident would respond. The resident was hospitalized and once the resident's mental status improved and he/she was more stable, he/she would return to the facility. The 6/22/15 at 11:00 AM nurse's note stated the resident was readmitted to the facility from the hospital, and would be on Hospice. The hospital discharge summary, dated 6/22/15, stated the hospital discharged the resident to the facility in stable condition, with likelihood of demise, with 6 months or less, and more likely less than 2 weeks, due to co-morbidities (two or more diseases exiting at the same time in the body) The resident's medications on discharge included [MEDICATION NAME], 12 mcg, 1 patch [MEDICATION NAME], every 72 hours as needed for pain. In a signed witness statement, dated 6/18/15, Medication Aide A, stated he/she applied a [MEDICATION NAME] to the resident at 7:30 PM, on 6/17/15 and he/she looked, but could not find an old patch to remove on the resident. On 7/8/15 at 10:20 AM, Nurse Aide B stated he/she was working when the staff found the resident on the floor. Nurse Aide B stated the incident happened before lunch, and thought it was close to 11:00 AM. Nurse Aide B verified the resident was on the floor, lying on his/her stomach, and using his/her elbows to try and push himself/herself up. Nurse Aide B verified the staff used the full body lift to transfer the resident from the floor, to his/her wheelchair. Nurse Aide B verified the resident was responsive at that time, but he/she helped hold the resident's head up while staff assisted him/her into the wheelchair. Nurse Aide B stated the family took the resident to the physician's office in the wheelchair. On 7/8/15 at 4:30 AM, Nurse C verified on the night the facility admitted the resident, he/she checked on the resident frequently, approximately every hour, during the shift, and the resident appeared to be fine. Nurse C stated he/she had no knowledge how 2 patches were on the resident, and verified the admitting nurse should have noticed the initial patch during the admission assessment. On 7/8/15 at 8:17 AM, Nurse D verified he/she completed the admission assessment when the facility admitted the resident. Nurse D stated he/she saw a [MEDICATION NAME] on the resident's side at that time, but he/she did not document it on the admission report, and did not relay this information to the medication aide who was working at that time. Nurse C verified he/she saw the papers from the transferring facility, and thought the physician order [REDACTED]. Nurse D verified the facility called him/her on 6/18/15 at 11:00 AM, and reported the resident had low oxygen saturations, had fallen from his/her bed and was unresponsive. Nurse D verified he/she took the resident in his/her wheelchair, to the physician's office located across the street from the facility. On 7/8/15 at 3:10 PM, Administrative Nurse E verified the facility admitted the resident at 4:07 PM on 6/17/15, from another facility, and the admitting nurse was Nurse D. Administrative Nurse E stated the resident had a [MEDICATION NAME] on at that time, but Nurse D did not document that information on the admission assessment, nor inform the medication aide. Administrative Nurse E verified he/she saw the date on the patch at the hospital, and it was dated 6/16/15, which indicated the patch should be changed on 6/19/15. Administrative Nurse E verified the staff found the resident on the floor on 6/18/15 at 10:15-10:30 AM, and he/she was alert but sleepy, drowsy, and hard to wake up. Administrative Nurse E verified the resident's family member transferred the resident to the physician's office by wheelchair, for his/her scheduled appointment. Administrative Nurse E verified the admitting nurse and/or the medication aide should have identified the [MEDICATION NAME] on the resident at the time of admission. On 7/15/15 at 11:30 AM, Physician F stated the resident came from the facility to his/her office for a scheduled appointment. Physician F verified the resident was lethargic and had altered mental status. Physician F verified the resident had two [MEDICATION NAME]es on, and his condition was likely due to a narcotic overdose from the [MEDICATION NAME]es. Physician F verified the resident was given [MEDICATION NAME] (a medication used to counter the effects of opioids, especially in an overdose) and had improved mental status. The facility's September 2012, Admission Documentation procedure policy, stated the Nursing Admit/Re-admit Data Collection should be completed within the shift the facility admitted the resident, and staff should record information on any medication brought in by the resident. The facility failed to ensure staff monitored resident #3 for medication side effects, when he/she was lethargic, had altered mental status, and was found to have 2 [MEDICATION NAME]es on at the same time, which required hospitalization .

The facility had a census of 50 residents with 3 residents selected for sample. Based on observation, interview and record review the facility failed to provide 1 of 3 sampled residents with the necessary care and services (monitoring bowel function, assessment and timely treatment of [REDACTED]. Resident #2 experienced repeated episodes of constipation/fecal impaction which required manual removal of stool. Findings included: - Resident #2's clinical record included physician's orders [REDACTED]. The 7/19/13 Quarterly MDS (Minimum Data Set) identified resident #2 with severe cognitive impairment, the need for extensive staff assistance with transfers and toileting, an inability to ambulate, and use of a wheelchair for mobility. CAAs (Care Area Assessments) dated 5/14/13 lacked any assessments or documentation related to resident #2's bowel function and/or constipation. The 7/31/13 Care Plan noted resident #2's use of a wheelchair for mobility and the need for extensive staff assistance with most ADLs (activities of daily living). The Care Plan lacked identification of problems related to constipation/history of fecal impaction, measurable goals related to bowel function, and appropriate individualized interventions to prevent constipation and/or fecal impaction. A "Bowel Assessment" completed on 11/15/12 noted resident #2's infrequent bowel incontinence and no particular pattern to the time of the resident's bowel movements. Most of the bowel assessment form remained entirely blank, including the area used to note history of constipation/impactions, contributing factors, bowel sounds, usual 24 hour intake, medication/elimination assist, and exercise patterns. physician's orders [REDACTED]. Resident #2's orders included no other orders for laxatives and/or stool softeners. Review of "BM (bowel movement) reports" from July 1, 2013 - August 8, 2013 revealed staff documented the presence of "hard" stools three times during the five week time period. Additionally, the BM reports noted resident #2 had a total of 12 bowel movements during the entire month of July (31 days), with no bowel movements noted from July 10th - July 14th (4 days), July 27th - August 1st (5 days), August 1st - August 6th (5 days). MARs (medication administration records) for July 2013 included no evidence staff administered stool softeners and/or laxatives to resident #2 during the month even though the resident experienced "hard stools" three times during the month. August 2013 MARs documented staff administered MOM on 8/4/13 for "No BM X 3 days." According to documentation on the back of the August MAR, the resident had "no results" from the 8/4/13 dose of MOM. The MAR indicated [REDACTED]. Review of "Interdisciplinary Notes" from July 1, 2013 - August 7, 2013 revealed no documentation related to constipation or fecal impactions. On 8/8/13, a licensed nurse wrote, "Manually removed hard stool and resident then passed soft stool. Order received for [MEDICATION NAME] q (every) day." [MEDICATION NAME] is classified as a stool softener. During an observation on 8/8/13 at 1:00 p.m., Direct Care Staff I and J transferred resident #2 to the toilet via a sit to stand mechanical lift. The resident sat on the toilet, fidgeting continuously and moaning, crying, stating, "I can't push. I can't push." Staff raised the resident to a standing position and Staff I prepared to clean the resident's bottom. While cleaning the bottom, Staff I said, "Oh, (he/she's) got a huge BM there that (he/she) can't push out. I need to call the nurse." Direct Care Staff I summoned Licensed Nurse C to the room via radio communication. Upon arrival in resident #2's room, Nurse C used a gloved hand to remove hard stool from the resident's rectum while the resident stood in the lift in front of the toilet. After removing hard stool, staff placed the resident back onto the toilet and he/she had a soft, formed bowel movement. During an interview on 8/8/13 at 1:00 p.m., Direct Care Staff J reported resident #2 "sometimes needs to have a BM but (he/she) can't do it so the nurse has to dig it out. That happens sometimes. This isn't the first time." During an interview on 8/8/13 at 1:12 p.m., Administrative Nurse B reported nurses are supposed to monitor for residents that haven't had a bowel movement in three days and then give them something for the constipation. According to Nurse B, the computer prints out a "BM alert" that tells nurses who hasn't had recent bowel movements. Nurse B also reported the facility does not have standing orders for medications used to treat constipation and nurses need to call the physicians to get those orders when the need arises. During an interview on 8/8/13 at 4:20 p.m., Licensed Nurse C confirmed he/she removed "lots of small hard balls" of stool from resident #2's rectum during the previously described observation. According to Nurse C, resident #2 requires "manual disimpaction" about "every three to four weeks." Nurse C confirmed the clinical record included no documentation related to previous impactions and stated, "I'm sure they just didn't get charted." Nurse C also reported he/she administered MOM to resident #2 in the past "but not on a frequent basis." Attempts to contact resident #2's physician by telephone were unsuccessful on 8/9/13, 8/14/13 and 8/16/13. According to the facility's "Impaction" procedure dated January 2000 with a revision date of February 2005, "Impaction is the presence of hard stool upon digital rectal exam." The procedure directs staff to obtain a physician's orders [REDACTED]. The procedure also directs staff to "record and describe results of impaction removal on the Interdisciplinary Progress Notes." Although requested of Administrative Nurse B, the facility failed to provide a policy/procedure related to expected treatment of [REDACTED]. The facility failed to provide resident #2 with the necessary care and services (monitoring bowel function, assessment and timely treatment of [REDACTED]. Resident #2 experienced repeated episodes of constipation/fecal impaction which required manual removal of stool.

The facility had a census of 50 residents, with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 2 of 3 sampled residents with the necessary care and services (monitoring of bowel movements, timely treatment of [REDACTED]. (Residents #102 and #104) Findings included: - Resident #102's clinical record included a 7/19/13 Quarterly MDS (Minimum Data Set) which identified the resident with severe cognitive impairment, the need for extensive assistance of two staff for toileting and transfer, and no bowel incontinence during the observation period. CAAs (Care Area Assessments) completed after the 5/3/13 Annual MDS did not include any further assessments related to bowel continence/incontinence or constipation. Resident #102's 7/31/13 care plan noted a need for staff assistance with all ADLS. The care plan did not include interventions related to the presence of constipation, monitoring of bowel movements, and/or treatment of [REDACTED]. physician's orders [REDACTED]. o [MEDICATION NAME] 100 mg. (milligrams) twice daily for treatment of [REDACTED]. o Milk of Magnesia 30 cc (cubic centimeters) daily as needed for constipation (7/26/13 order) o [MEDICATION NAME] 17 grams mixed with 8 ounces of water daily as needed for constipation Bowel Records from 9/20/13 - 10/23/13 revealed the following: o Resident #102 failed to have a bowel movement on 9/21, 9/22, 9/23, 9/24 and 9/25. o Resident #102 failed to have a bowel movement on 10/2, 10/3, 10/4 and 10/5 Review of MARs (Medication Administration Records) for September and October 2013 revealed no evidence staff administered Milk of Magnesia or [MEDICATION NAME] when resident #102 failed to have a bowel movement for a time period of 5 days in one time span and 4 days in another. During an observation on 10.23.13 at 10:45 a.m., staff transferred resident #102 from the wheelchair to the toilet with a mechanical lift. The resident exhibited significant cognitive impairment as well as total dependence on staff for the transfer. During an interview on 10/23/13 at 2:20 p.m., Administrative Nurse A reported nurses should print out a "Bowel Report" each shift and then implement interventions for any residents that have not had bowel movements for three days. According to Nurse A, the facility does not have "standing orders" for bowel medications but most residents have orders for medications used to treat constipation, and if the nurse identified a resident with no bowel movement for 3 days, that nurse should give those medications. In the event the resident with constipation lacked orders for medication to treat constipation, the nurse should contact the physician for orders. Upon review of bowel records and MARs for resident #102, Nurse A confirmed nurses failed to administer medications to the resident when he/she failed to have a bowel movement for more than three days on two separate occasions. Nurse A also reported the facility policy lacks specific directive about administering medications after no bowel movements for three days, and explained a corporate consultant advised him/her to follow the resident's care plan related to implementation of interventions to treat constipation. Nurse A confirmed resident #102's care plan lacked specific interventions related to constipation, bowel monitoring, or treatment of [REDACTED]. During an interview on 10/24/13 at 7:51 p.m., Licensed Nurse B reported nurses print off bowel reports every shift. Nurse B denied knowledge of the need to administer medications for treatment of [REDACTED]." The facility failed to have a system in place to ensure adequate monitoring of resident #102's bowel movements and then timely administration of medications for treatment of [REDACTED]. - Resident #104's clinical record included a 9/20/13 Significant change MDS (Minimum Data Set) that identified the resident with moderate cognitive impairment, the need for extensive assistance of two staff for transfers and toileing, and occasional bowel incontinence. CAAs (Care Area Assessments) completed on 9/29/13 for ADLs (activities of daily living) noted resident #104's need for extensive assistance of staff for all ADLs. Resident #104's 10/2/13 care plan directed staff to transfer the resident with assistance of two staff and a sit to stand mechanical lift. The care plan did not include interventions related to the presence of constipation, monitoring of bowel movements, and/or treatment of [REDACTED]. physician's orders [REDACTED]. o [MEDICATION NAME] 17 grams daily as needed for treatment of [REDACTED]. Bowel Records from 9/20/13 - 10/23/13 revealed the following: o Resident #104 failed to have a bowel movement on 9/27, 9/28, 9/29, 9/30 and 10/1, a time period of 5 days. o Resident #104 failed to have a bowel movement on 10/15, 10/16, 10/17, 10/18 and 10/19, a time period of 5 days. Review of MARs (Medication Administration Records) for September and October 2013 revealed no evidence staff administered [MEDICATION NAME] when resident #104 failed to have a bowel movement for a time period of 5 days on two occasions. During an observation on 10/23/13 at 1:00 p.m., staff assisted resident #104 to transfer from his/her motorized scooter to the toilet via a sit to stand mechanical lift. The resident had significant hearing deficients and responded appropriately to staff questions/instructions. During an interview on 10/23/13 at 2:20 p.m., Administrative Nurse A reported nurses should print out a "Bowel Report" each shift and then implement interventions for any residents that have not had bowel movements for three days. According to Nurse A, the facility does not have "standing orders" for bowel medications but most residents have orders for medications used to treat constipation, and if the nurse identified a resident with no bowel movement for 3 days, that nurse should give those medications. In the event the resident with constipation lacked orders for medication to treat constipation, the nurse should contact the physician for orders. Upon review of bowel records and MARs for resident #104, Nurse A confirmed nurses failed to administer medications to the resident when he/she failed to have a bowel movement for more than three days on two separate occasions. Nurse A also reported the facility policy lacks specific directive about administering medications after no bowel movements for three days, and explained a corporate consultant advised him/her to follow the resident's care plan related to implementation of interventions to treat constipation. Nurse A confirmed resident #104's care plan lacked specific interventions related to constipation, bowel monitoring, or treatment of [REDACTED]. During an interview on 10/24/13 at 7:51 p.m., Licensed Nurse B reported nurses print off bowel reports every shift. Nurse B denied knowledge of the need to administer medications for treatment of [REDACTED]." The facility failed to have a system in place to ensure adequate monitoring of resident #104's bowel movements and then timely administration of medications for treatment of [REDACTED].

The facility had a census of 50 residents with 3 residents selected for sample that either had current pressure ulcers or recently healed pressure ulcers. Based on observation, interview and record review, the facility failed to provide 1 of 3 sampled residents with a pressure ulcer with the necessary treatment and services (develop and implement interventions to prevent the development of a pressure ulcer, complete daily assessments of an unstageable pressure ulcer and/or thorough assessments of an unstageable pressure ulcer with each dressing change) to prevent development of pressure ulcers, promote healing of the existing pressure ulcer and prevent infection. The resident subsequently required hospitalization for treatment of [REDACTED]. (Residents #2 and #3) Findings included: - Resident #1's clinical record included a Face Sheet which noted admission to the facility on [DATE] with multiple medical diagnoses, including "non-displaced femur fracture" (a break of the long bone of the upper leg). The 6/10/13 Admission MDS (Minimum Data Set) identified resident #1 with no cognitive impairment, the need for extensive assistance of two staff for transfers and bed mobility, an inability to ambulate, functional limitations in range of motion in one side of the lower extremities, use of a wheelchair for mobility, no pressure ulcers or recently healed pressure ulcers, a risk for pressure ulcer development, a turning and repositioning program, and nutrition/hydration interventions to manage skin problems. CAAs (Care Area Assessment summaries) completed on 6/13/13 for ADLs (activities of daily living) described resident #1's femur fracture and his/her decision to not have the fracture repaired surgically and therefore the need for non-weight bearing status. The CAA for pressure ulcers noted the resident's risk for pressure ulcers due to frequent bowel incontinence and needing assistance with bed mobility. The CAA noted completion of skin assessments weekly by the charge nurse. The CAAs did not mention use of a full leg immobilizer. The 6/3/13 initial care plan for resident #1 directed staff to use a mechanical lift for transfers, a wheelchair for mobility, change the resident's position every 2 hours, and use of a pressure relieving cushion in the wheelchair as well as an air mattress for the bed. The initial care plan did not mention use of a full leg immobilizer. The 6/19/13 Care Plan noted resident #1's use of a right leg long leg immobilizer to be "on at all times." On 7/22/13, staff added a care plan documentation noting the presence of an "open area on right lower shin." On 7/23/13, staff added care plan documentation noting the change from use of the long leg immobilizer at all times to use only during ambulation. The care plan lacked interventions related to assessments of resident #1's right leg wound. Neither the initial 6/3/13 care plan or the 6/19/13 comprehensive care plan included interventions related to monitoring the condition of the skin beneath the right leg immobilizer. A physicians' order dated 6/3/13, the date of admission, directed staff to use a right long leg immobilizer for resident #1. Braden Scale skin assessments completed on 6/10/13, 6/17/13 and 7/1/13 identified resident #1 as "mild risk" for skin breakdown. The clinical record included "Wound Flow Sheets" completed weekly by licensed nursing staff. According to the weekly assessments, resident #1 had no skin breakdown from admission until 7/22/13. Documentation on 7/22/13 included a description of an area of blackened skin on the "right outer shin" which measured 1.5 cm (centimeters) by 1.5 cm with a 4 cm by 4 cm reddened area surrounding the blackened area and a "moderate amount" of drainage from the wound. According to this entry, "Area appears to be caused from the immobilizer. Immobilizer is only used now during transfers." physician's orders [REDACTED]. Review of TARs (treatment records) for July 2013 included evidence staff completed dressing changes to resident #1's right leg wound every two days as ordered. The TARs and other clinical record documents included no evidence of thorough assessment of the wound at the time of each dressing change. A "Wound Flow Sheet" dated 7/28/13 noted worsening of the right leg wound which now measured 1.5 cm by 1.9 cm, and a moderate amount of purulent (producing or containing pus) drainage. A "Wound Flow Sheet Attachment" dated 7/28/13 also documented worsening of the right leg wound and "unable to determine depth" of wound. This documentation described spontaneous removal of part of the blackened area on the wound and then staff removal of the remaining blackened skin with "thorough cleaning." Review of the clinical record revealed no evidence of thorough nursing assessments of resident #1's right leg unstageable pressure ulcer in the 6 day time period from 7/22/13 to 7/28/13. The wound deteriorated during that time period. The clinical record also included no evidence staff notified resident #1's physician of the changes/worsening of the pressure ulcer as noted on 7/28/13 and the presence of purulent drainage. The clinical record lacked evidence of assessments of the pressure ulcer after 7/28/13 until the resident's hospitalization on [DATE]. On 7/31/13, resident #1's physician ordered admission to the hospital. According to the History and Physical from that admission, resident #1 had a "full thickness decubitus ulcer noted on the right lower lateral (side) leg with some surround [DIAGNOSES REDACTED] (redness or inflammation of the skin) consistent with [MEDICAL CONDITION] (skin infection caused by bacteria that is characterized by heat, redness and swelling).....will admit to hospital for IV (intravenous) antibiotics...." At the time of the onsite revisit (8/7/13, 8/8/13 and 8/9/13), resident #1 remained in the hospital for treatment of [REDACTED]. During an interview on 8/9/13 at 10:00 a.m., Administrative Nurse B reported resident #1 came to the facility on [DATE] with orders for a right long leg splint which he/she wore 24 hours a day. According to Nurse B, resident #1 frequently had [MEDICAL CONDITION] (swelling) of both legs. Nurse B reported the physician changed the orders for the immobilizer within a few weeks of the resident's admission. Nurse B reported resident #1 developed an unstageable pressure ulcer above the right outer ankle after admission to the facility. Nurse B also reported the care plan lacked interventions related to monitoring the resident's skin beneath the immobilizer, particularly in light of the resident's problems with [MEDICAL CONDITION] of the legs which would cause increased pressure on skin that rubbed against the immobilizer. Additionally, Nurse B reported resident #1's right leg ulcer worsened over time and the record included no evidence of thorough nursing assessments of the wound daily or with each scheduled dressing change. Attempts to speak directly with resident #1's physician were unsuccessful on 8/9/13 and 8/15/13. On 8/16/13 at 10:00 a.m. a staff person from resident #1's physicians' office reported the doctor verbalized he/she expected staff to assess resident #1's wound daily after discovery of the unstageable wound on 7/22/13. According to the facility's "Pressure Ulcer Practice Guidelines" policy dated May 2001 with the most recent revision on 03/08, "The center should have a system in place for daily observation of pressure ulcers/wounds which should include: * An evaluation of the ulcer if no dressing is present. * An evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking.) * The status of the area surrounding the ulcer (that can be observed without removing the dressing) * The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound) and The policy also included, "It is recommended that the nursing progress notes reflect the nurse's observation and management of wounds from a shift to shift perspective and with each dressing change...." The facility failed to provide resident #1 with the necessary treatment and services to prevent development of this avoidable, facility acquired pressure ulcer and, after development of the ulcer, failed to notify the physician of deterioration/worsening of the pressure ulcer. The facility also failed to provide thorough wound assessments daily or with each dressing change. - Resident #2's clinical record included a 7/19/13 Quarterly MDS (Minimum Data Set) which identified the resident with severe cognitive impairment, the need for extensive staff assistance with bed mobility and transfers, an inability to ambulate, use of a wheelchair, at risk for development of pressure ulcers, no current pressure ulcers, use of pressure reducing devices for the chair and bed, and a turning and repositioning program. CAAs (Care Area Assessment summaries) dated 5/14/13 for Pressure Ulcers noted resident #2's risk for development of pressure ulcers due to the need for staff assistance with bed mobility and repositioning, history of pressure ulcers, and frequent incontinence. The 7/31/13 Care Plan directed staff to assist resident #2 with position changes every 1-2 hours. A 7/22/13 Braden Scale skin assessment identified resident #2 as "mild risk" for development of skin breakdown. During an observation on 8/8/13 at 7:10 a.m., resident #2 sat in a wheelchair at the dining room table awaiting breakfast. At 7:45 a.m. the resident remained in the wheelchair in the dining room. At 9:30 a.m., resident #2 remained in the wheelchair in a large group activity in the chapel. At 10:37 a.m., the resident remained seated in the wheelchair in the front lobby area. Observations during the 3 1/2 hour time period from 7:10 a.m. - 10:37 a.m. revealed staff failed to reposition the resident as directed by the care plan. On 8/8/13 at 10:45 a.m., Direct Care Staff I and J transferred resident #2 from the wheelchair to the toilet. At that time the resident's buttocks were dark pink and blancheable, with no open areas noted. During an interview on 8/8/13 at 10:50 a.m., Direct Care Staff I confirmed staff did not reposition resident #2 in the 3 1/2 hour time period earlier that morning from 7:10 a.m.- 10:45 a.m..According to Staff I, all staff were busy with other residents and lacked time to reposition the resident. The facility failed to provide resident #2 with the necessary treatment and services (timely repositioning) to prevent development of pressure ulcers. - Resident #3's clinical record included a 7/5/13 Quarterly MDS (Minimum Data Set) which identified the resident with severe cognitive impairment, the need for extensive staff assistance with transfers and bed mobility, at risk for development of pressure ulcers, pressure ulcers present on the previous MDS assessment (Stage 4), pressure reducing devices for the chair and bed and a turning/repositioning program. CAAs (Care Area Assessment summaries) for Pressure Ulcers dated 11/19/12 noted resident #3's risk for development of pressure ulcers due to cognitive impairment, bowel and bladder incontinence, impaired circulation and dependence on staff for bed mobility, transfers and changes of position. The 7/17/13 Care Plan directed staff to use a cushion in bed to float resident #3's heels off the mattress. A 7/8/13 Braden Scale skin assessment identified resident #3 as "mild risk" for skin breakdown. "Wound Flow Sheets" dated 4/3/13 noted the presence of a pressure ulcer on the right heel which was unstageable. Additional notes in the clinical record noted healing of the wound on 4/23/13. During an observation on 8/8/13 at 7:05 a.m., resident #3 lay in bed, asleep, with his/her legs and feet uncovered. The resident did not have a cushion beneath the heels as directed by the care plan and there was no cushion present on the bed on which the feet might have been resting previously. The resident did not wear a heal protector to the right foot at the time of the observation. During an interview on 8/8/13 at 12:50 p.m., Direct Care Staff G reported resident #3 always wears a soft boot/heel protector on the right foot and when staff put the resident to bed they are supposed to also "float" both heels off the bed by placing a cushion under the resident's feet. Staff G denied knowledge of why resident #3's feet were not "floated" or a heel protector to the right foot in place at the time of the 8/8/13 observation at 7:05 a.m., stating, "Night shift just must not have done it." The facility failed to provide resident #3 with the necessary treatment and services (placement of a heel protector and/or floating of heels when in bed) to prevent development of pressure ulcers.

The facility had a census of 56 residents. Seven residents received anticoagulant (blood thinning) medication. Based on observation, interview and record review, the facility failed to ensure 1 of 7 sampled residents remained free of significant medication errors. The facility failed to transcribe an order for [REDACTED]. Facility failure to have systems in place to ensure transcription of physician/mid-level orders correctly, failure to ensure discontinuation of medications (anticoagulants) as ordered, and failure to clarify orders for accuracy placed resident #1 in immediate jeopardy. Findings included: - Resident #1's clinical record included physician's orders [REDACTED]. The 7/22/11 Admission MDS (Minimum Data Set) identified resident #! with cognitive impairment, a need for extensive staff assistance with most ADLs (activities of daily living), and no use of anticoagulant therapy. Transfer forms from an area hospital noted resident #1's return to the facility on [DATE] with a physician's orders [REDACTED]. According to the 2011 Lexi-Comp Geriatric Dosage Handbook, page 1873, [MEDICATION NAME] ([MEDICATION NAME]) is classified as an anticoagulant which has a heightened risk of causing significant patient harm when used in error. Adverse effects listed in this reference include bleeding from "virtually any site." an order written [REDACTED]. (milligrams) per kg (kilogram) daily INR above 2. Recheck INR Saturday. Change [MEDICATION NAME] to 4 q (every) day." Like [MEDICATION NAME] is classified as an anticoagulant which alters the bloods ability to clot. Adverse effects of [MEDICATION NAME] include unintentional bleeding caused by the blood's inability to clot. INR, or International Normalized Ratio, measures the time it takes for blood to clot. [MEDICATION NAME] times measures the amount of time it takes for the liquid portion of blood to clot. MARs (medication administration records) documented staff administration of [MEDICATION NAME] to resident #1 beginning on 10/27/11. According to the MARs, the resident also received [MEDICATION NAME] 4 mg. daily as ordered by the practitioner. Laboratory results from 10/31/11 indicated resident #1 had a [MEDICATION NAME] time of 18.3 (normal range of 9.7 - 12.5) and an INR of 1.7 (normal range of 0.88 - 1.13). After reviewing the lab results, the practitioner wrote an order on 10/31/11 which directed staff to obtain another [MEDICATION NAME] Time and INR in two days. According to laboratory results, staff collected another blood sample on 11/2/11. The results from that lab work documented a [MEDICATION NAME] time of 24.6 (normal range of 9.7 - 12.5) and an INR of 2.33 (normal range of 0.88 - 1.13). Review of the clinical record revealed no evidence staff discontinued the [MEDICATION NAME] injections when the INR reached 2, as ordered by the practitioner on 10/27/11. Resident #1 received [MEDICATION NAME] injections until 11/10/11, eight days after the INR reached 2. On 11/2/11, the mid-level practitioner faxed an order to, "Continue same dose and recheck in 2 weeks." Licensed Nurse C transcribed the order onto the physician's orders [REDACTED]." Although Nurse C added the word, "[MEDICATION NAME]" to the order when transcribing it, the clinical record contained no evidence Nurse C spoke with the practitioner to clarify the original order which did not clearly identify which medication should be continued. During an interview on 11/15/11 at 10:45 a.m., Administrative Nurse B reported the mid-level practitioner had no idea the resident was on [MEDICATION NAME] as well as [MEDICATION NAME] when she wrote the 11/2/11 order to "continue same dose and recheck in 2 weeks." According to Nurse B, Licensed Nurse C should have called the practitioner for a clarification order prior to transcribing the order into the clinical record. Nurse B confirmed resident #1 continued to receive [MEDICATION NAME] injections for eight days after staff should have discontinued it, and resident 1 received [MEDICATION NAME] 4 mg. daily also during that time period. During an interview on 11/16/11 at 4:20 p.m., Mid-level Practitioner F confirmed he/she wrote an order to "continue same dose" on 11/2/11 without knowing staff were still administering [MEDICATION NAME] injections as well as the [MEDICATION NAME]. According to Practitioner F, staff should have discontinued the [MEDICATION NAME] injections when the INR reached 2, as per the 10/27/11 order. Daily Skilled Nursing Notes written by Licensed Nurse D on 11/11/11 at 1:00 p.m. included, "....L (left) eye red in color throughout white area.....denies pain or change in vision....will monitor." The clinical record included no evidence Nurse D notified the resident's physician of resident #1's "red left eye", which might been an indication of bleeding into the eye. The clinical record also included no additional assessments or monitoring of the condition. According to the November MAR, staff administered a dose of [MEDICATION NAME] 4 mg. and an injection of [MEDICATION NAME] on 11/11/11 after Licensed Nurse D noted resident #1's red left eye. During an interview on 11/15/11 at 3:10 p.m., Direct Care Staff E reported resident #1, "didn't act right" on 11/11/11, complaining of increased pain and discomfort throughout the shift. According to Staff E, resident #1 moaned and complained of pain even when no one touched him/her. Staff E considered this unusual behavior for resident #1. Then, after lunch, Staff E noticed one of resident #1's eyes, "was all red", and he/she immediately told Licensed Nurse D about the eye. During an interview on 11/16/11 at 8:40 a.m., Licensed Nurse D confirmed resident #1 had a red eye on 11/11/11 after lunch. According to Nurse D, he/she did not notify the physician of this change in the resident's condition. Nurse D confirmed staff administered an additional dose of [MEDICATION NAME] and [MEDICATION NAME] on 11/11/11 after staff noted the redness in the resident #1's eye. An 11/12/11 Daily Skilled Nursing Note at 7:30 p.m., 29 hours after staff first noticed resident #1's red eye, included, "This nurse was called down to resident's room. Resident had some bloody mucus from nose and rectal vaginal bleeding. Note L (left) eye white completely red. Resident on [MEDICATION NAME] and [MEDICATION NAME].Resident taken to ER (emergency room ) by wheelchair. The 11/12/11 Admission History and Physical from the local hospital noted admission due to rectal and/or vaginal bleeding. Laboratory results from the hospital noted critical laboratory values of a [MEDICATION NAME] time of 141.7 (normal range of 9.7 - 12.5 ) and an INR of 14.64 (normal range of 0.88 - 1.13). During an interview on 11/15/11 at 10:45 a.m., Administrative Nurse B reported resident #1 was in "critical condition" at the time of admission to the hospital due to hypocoagulation. According to Nurse B, the facility didn't have systems in place to prevent medication errors such as the error described in previous paragraphs, but were working on getting such systems in to place immediately. As of 11/16/11, resident #1 remained hospitalized due to hypocoagulation. The facility failed to have systems in place to prevent a significant medication error for resident #1 as related to use of two anticoagulant medications. Due to system failures, resident #1 became over-coagulated and required admission to the hospital in critical condition. Facility failure to have adequate systems in place to prevent significant medication errors placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 11/16/11 by implementing the following measures: o Educated all facility nurses on 11/15/11 about anticoagulant use, noting and transcribing physician orders, monitoring of lab values related to anticoagulant use, obtaining clarification orders from physicians and mid-levels practitioners for orders when orders do not clearly identify the medication, dose, route, etc. o Implemented an "Anti-Coagulation Therapy" audit tool to ensure all current residents on anticoagulant therapy had evidence of adequate monitoring of lab values, clearly defined physician orders [REDACTED]. o Changed the facility policy for anticoagulant use to include automatic stop orders for all anticoagulants. o Educated all direct care staff about residents on anticoagulant therapy as well as the symptoms of adverse effects of anticoagulant therapy. Direct care staff now have a list of residents on anticoagulant therapy on their hand held devices which ensures access to that information at all times. o Implemented a double check system to ensure all physician orders [REDACTED]. After abatement of the immediate jeopardy, a deficient practice remained at a scope/severity of "G."

The facility reported a census of 51 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to provide interventions to prevent a significant (12.6%) weight loss for one of three residents reviewed for weight loss. (68) Findings included: - A face sheet showed the facility admitted resident 68 on 3/16/11. A 3/23/11 admission MDS showed resident 68 had severe cognitive impairment and had experienced a significant weight loss prior to admission. The MDS showed the resident weighed 106 pounds. A Weight Record provided by the facility showed the following: 3/16/11 - 105.8 pounds 3/21/11 - 104 pounds 3/28/11 -- 97.5 pounds 4/4/ 11 -- 96.9 pounds 4/11/11 -- 96.4 pounds A 4/11/11 registered dietician noted stated, " Resident has also been placed on hospice as of 4/7/11 due to Alzheimer ' s and failure to thrive. Appetite and intake are poor and resident was offered mighty shakes ice cream which (the resident) would only sip them. " A 4/15/11 significant change assessment showed the resident required limited assistance of one staff for eating, weighed 97 pounds, and had a significant weight loss. A 4/27/11 care plan included the interventions to serve diet per order, offer a snack three times a day and document the intake, and provide a mighty shake with each meal or an ice cream cup. A Dining Record showed for the month of April, the facility offered the resident a supplement 12 times in 30 days and a snack 7 times in 30 days. The resident consumed an average of 75% of the supplement when offered and 61% of the snacks. In the month of May the facility offered supplement 0 times and a snack 4 times. The resident consumed an average of 75% of the snack when offered. The Weight Record continued with the following weights: 4/18/11 -- 91.8 pounds 4/25/11 -- 96.4 pounds 5/3/11 -- 94 pounds 5/9/11 -- 96.4 pounds 5/17/11 -- 91.4 pounds 5/23/11 -- 95.4 pounds 5/30/11 -- 94.6 pounds 6/6/11 -- 92.4 pounds (a 12.6% weight loss in 3 months) Observations of the resident during the morning meal on 6/8/11 at 7:29 am MDT showed the resident sat at the table with a large glass of apple juice, large glass of milk; two sausage links, a bowl of oatmeal, a pancake and a small bowl of pistachio pudding. Dietary staff R cut up the pancake into large pieces after putting butter on it. The staff left the syrup on the table. The resident had difficulty eating the large pieces of pancake and picked at the other food. The resident consumed small portions of the pancake and one of the sausage links. The resident paused frequently for long periods of time. At 8:03 am, the resident removed the clothing protector, placed it on the plate and began making preparations to leave the table. At no time between 7:29 am and 8:03 am did staff members encourage the resident to eat more. Dietary staff R reported on 6/8/11 at 7:54 am that the resident did not receive a supplement with meals. On 6/8/11 at 11:21 am, the dietary manager C confirmed the resident had not received mighty shakes or ice cream as care planned with meals. On 6/8/11 at 11:46 am, the resident received a pork chop, mashed potatoes with gravy, green beans and applesauce. The resident also received milk, 240 cc of supplement and juice. The resident again picked at the food. From 11:46 am through 12:12 pm, when the resident began to leave the table, the resident again received no encouragement to eat. At 12:12 pm, nursing staff N encouraged the resident to eat more and drink the supplement. The resident did not eat any more food but did drink 100% of the supplement. On 6/8/11 at 3:28 pm, staff had given the resident a container of pudding as a snack. The resident ate 100% of the pudding. On 6/8/11 at 9:22 am, nurse aide K reported staff had to stay with the resident while he/she ate to keep encouraging the resident to take bites . On 6/8/11 at 3:15 pm administrative nurse B reported the facility lacked a system to ensure residents received snacks and supplements as care planned. In summary, the facility failed to have a system in place to ensure resident 68 received snacks and supplements as care planned. The resident did not receive the snacks and supplements as care planned, the resident lost 12.6% of his/her total body weight in 3 months.

The facility had a census of 48 residents, two of whom currently had pressure ulcers. The sample included the two residents with pressure ulcers as well as one other resident. Based on observation, interview and record review, the facility failed to provide two of two sampled residents with current pressure ulcers with the necessary treatment and services to promote healing and prevent new sores from developing. Resident #1 entered the facility in February 2010 with a total of 7 pressure ulcers. Although all but one pressure ulcer healed within a few months of admission, the facility failed to provide weekly skin assessments as directed by the care plan, failed to develop a repositioning program based on the resident's individual needs, failed to notify the physician of a newly developed pressure ulcer, and failed to assess and treat a newly developed pressure ulcer in a timely manner. The resident developed a Stage 3 pressure ulcer. (Resident #1, #2) Findings included: - Resident #1's clinical record included a face sheet which noted admission to the facility on [DATE]. The 3/5/10 Admission MDS (Minimum Data Set) identified resident #1 as dependent on staff for extensive assistance with bed mobility and transfers, frequent bowel and bladder incontinence, and the presence of four Stage 2 pressure ulcers and one Stage 4 pressure ulcer. A 3/5/10 RAP (resident assessment protocol) note related to pressure ulcers included, "resident did come to nursing home with 4 Stage 2 ulcers to buttocks and one unstageable ulcer on left heel...." A 6/16/10, "Positioning Assessment and Evaluation" determined staff should reposition resident #1 every 3 hours and prn with heels floated at all times. According to the, "Positioning Assessment and Evaluation" policy/procedure (GSS #198, Number III-C.198), staff should position the resident in either a sitting or lying position and then observe the condition of skin over bony prominences in 1 hour. If staff did not note redness or discomfort after 1 hour, they should continue to assess by increasing the time without repositioning in 1/2 hour increments, and should, "continue to increase the time between observations in 1/2 hour intervals until the appropriate repositioning frequency has been determined. You are observing for the maximum amount of time a resident is able to tolerate between repositioning." This policy directed staff to stop observations if a bony prominence remained red. If the redness resolved in one hour, the repositioning interval, "was appropriate." If the area remained red, initiate the appropriate wound treatment guideline documentation for Stage 1 ulcers and decrease the repositioning time by 1/2 increments until appropriate repositioning interval is determined. The "Positioning Assessment and Evaluation" tool did not take into consideration resident #1's history of pressure sores to the buttocks, current pressure sore on the heel, and frequent bowel and bladder incontinence. An 8/2/10 Braden Skin assessment identified resident #1 as, "moderate risk" for skin breakdown. The most recent MDS, an 8/9/10 Quarterly, identified resident #1 with total dependence on staff for bed mobility and transfers, frequent urinary incontinence, and the presence of one Stage 2 pressure ulcer. The 8/11/10 Care Plan identified resident #1 with, "Impaired Skin Integrity" and the presence of an unstageable ulcer on the left heel, and included the following interventions: o Weekly skin observation will be done by nurse, observe for redness, swelling of the area, drainage or heat and notify physician if area is not showing signs of healing in 2 weeks o Wound treatment as per protocol and physician order, barrier salve after each incontinent episode o Reposition every 3 hours and prn During an interview on 9/15/10 at 4:00 p.m., Administrative Nurse A reported all weekly skin assessments should be documented by the nurse in the Interdisciplinary Progress Notes. Additionally, wound assessments should be documented on "wound flow sheets." Interdisciplinary Progress Notes for resident #1 revealed no evidence of consistent weekly skin assessments/observations as directed by the care plan and Administrative Nurse A. Progress Notes included the following: o During the month of June 2010, licensed nursing staff documented adequate head to to toe skin assessments in the Interdisciplinary Progress Notes on 6/10/10, 6/17/10, and 6/24/10. o During the month of July 2010, staff documented a partial skin assessment in the progress notes on 7/8/10, with the remainder of the documentation referring only to the presence of an ulcer on the left heel. o August 2010 Interdisciplinary Progress Notes included a thorough skin assessment on 8/5/10, with other documentation throughout the month referring only to the left heel ulcer or, "warm, pink and dry" skin. Interdisciplinary Progress Notes for September 2010 included: o 9/2/10: "Skin pink, warm dry with left heel 1.5 cm (centimeter) X 1 cm open area..." o 9/9/10 at 9:00 p.m.: "Skin pink, warm and dry. Abraded area to right inner buttock pink and almost intact. No drainage of discomfort." Although this Interdisciplinary Progress Note noted the presence of an open, "almost intact" area to the buttock, the treatment record for September did not include any treatments/assessments related to that wound. The clinical record also did not include evidence of physician notification of the presence of the buttock wound until 9/15/10 after survey staff C and Administrative Nurse A observed the wound The only documentation in the clinical record related to the buttock wound was found on a, "Wound Flow Sheet" which staff started on 9/4/10 for the newly developed area of breakdown on the right coccyx. According to that flow sheet, the wound measured 2 cm. X 0.5 cm on 9/4/10, and had worsened to 2.2 cm by 1 cm on 9/7/10. The wound flow sheet included no evidence of assessment/treatment of [REDACTED]. During an observation on 9/15/10 at 2:55 p.m., Administrative Nurse A observed while direct care staff turned resident #1 and provided incontinence care. At that time, resident #1 had a dressing on the right inner gluteal fold. Nurse A removed the dressing and found a large open wound beneath. The wound had some depth to it, with a total loss of the top layer of skin and exposure of subcutaneous tissue. According to Nurse A, she did not know the wound to the area was so bad. On 9/16/10 at 8:45 a.m., Nurse A reported she measured resident #1's previously described open area to the right inner gluteal fold, and obtained measurements of 2.2 cm. X 0.9 cm., with a depth of 0.1 cm. Nurse A confirmed the wound should be classified as a Stage 3 pressure ulcer. According to the Merck Manual Online Medical Library website <www.merck.com>, pressure sores occur in people of any age who are bedbound, chairbound or unable to reposition themselves, and are more common among older people. According to this reference, "People who cannot move themselves should be repositioned every 2 hours if they are in bed and every hour if they are in a chair - more often if possible." During a 9/16/10 interview at 8:45 a.m., Administrative Nurse A confirmed licensed nurses failed to adequately assess and document skin assessments weekly as directed by the care plan, failed to adequately assess and document the open area to the right buttock when first discovered on 9/4/10, failed to notify the physician of the open area in a timely manner, and failed to implement appropriate interventions to promote healing of the wound and prevent new sores from developing. Nurse A also confirmed it might not be in resident #1's best interests to have him/her on an every 3 hour repositioning program when the resident has a known history of multiple areas of skin breakdown, has frequent urinary incontinence, and has an existing long term pressure sore on the heel. During observations on 9/15/10 and 9/16/10, resident #1 required extensive staff assistance with transfers and bed mobility. When in bed, the resident lay in the same position until staff repositioned him/her. The resident also experienced bowel and bladder incontinence. The resident had a large open wound to the left heel which required daily dressing changes and special pressure reduction devices. In summary, the facility failed to provide resident #1 with the necessary care and services to prevent development of new pressure ulcers. Staff failed to complete weekly skin assessments as directed by the care plan, failed to reposition the resident based on the resident's specific needs, failed to notify the physician of a new area of breakdown, and failed to implement appropriate treatment of [REDACTED]. The resident developed a Stage 3 pressure ulcer. - This deficient practice of facility failure to provide residents with the appropriate care and services to promote healing of existing wounds and prevent development of new wounds also affected resident #2 as related to lack of documentation of weekly skin assessments and failure to develop a repositioning program based on the resident's specific needs.