Every finding on record at United Presbyterian Home

Based on clinical record review, staff interview, and facility policy the facility failed to review and revise comprehensive care plans in a timely manner for 1 of 1 resident (Resident #6) reviewed for hospice. The Care Plan did not indicate Resident #6 received hospice services. The facility reported a census of 46. Findings include: The Progress Note dated 7/9/25 at 11:35 AM documented Resident #6's admitted to hospice with diagnoses including senile degeneration of the brain (a gradual decline in mental function due to aging) and chronic kidney disease (long-term damage reducing kidney function). Resident #6's Minimum Data Set (MDS) dated [DATE] documented diagnoses including cancer, heart disease, and kidney disease. Staff didn't code the MDS for hospice services. Resident #6's Care Plan revised 7/22/26 didn't include hospice care. On 8/19/26 at 1:25 PM, the Director of Nursing (DON) acknowledged the Care Plan should've included active hospice services. The DON relayed the MDS coordinator took a vacation and the contracted company didn't ensure appropriate updates to Resident #6's clinical record. The Administrator relayed staff would ensure the correction. The policy titled Care Plan Development Process revised May 2025 instructed that the care plan guides the care and treatment provided to each resident. The policy directed the MDS coordinator holds responsibility to ensure staff review and update each portion of the care plan at least quarterly and as necessary when a change in resident condition occurs. The policy further instructed staff to incorporate hospice plans of care with the comprehensive care plan.

Based on clinical record review, staff interview, and facility policy the facility failed to code hospice on the Minimum Data Set (MDS) for 1 of 1 resident reviewed for hospice (Resident #6). The facility reported a census of 46 residents. Findings include:Resident #6's progress note dated 7/9/26 at 11:35 AM documented admission to hospice with diagnoses including senile degeneration of the brain (a gradual decline in mental function due to aging) and chronic kidney disease (long-term damage reducing kidney function). Resident #6's Minimum Data Set (MDS) dated [DATE] documented diagnoses including cancer, heart disease, and kidney disease. Staff didn't code the MDS to include hospice services received by Resident #6. Resident #6's Care Plan with a Targe date of 10/20/26 didn't include hospice care. On 8/19/26 at 1:25 PM, the Director of Nursing (DON) acknowledged staff should've coded the MDS for hospice. The DON relayed the MDS coordinator took a vacation, the contracted company didn't accurately complete the significant change MDS, and staff would submit a correction. The policy titled Resident Assessments revised June 2025 directed guidelines and procedures for federally mandated assessments, including significant change in status assessments. The policy instructed the resident assessment coordinator holds responsibility for ensuring the interdisciplinary team conducts timely and appropriate resident assessments.

Based on clinical records, Pre-admission Screening and Resident Review (PASRR) screening document, interviews and facility policy the facility failed to accurately report a mental health diagnoses to the designated state agency for 1 of 1 resident (Resident #1) diagnosed with Post Traumatic Stress Disorder (PTSD). The facility reported a census of 46 residents. Findings include:Resident #1's Minimum Data Set (MDS) dated [DATE] documented psychiatric diagnoses including depression, anxiety disorder, and post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying event). Resident #1's Brief Interview for Mental Status (BIMS) documented a score of 15, indicating intact cognition. Resident #1's Electronic Health Record (EHR) titled Medical Diagnosis documented diagnoses including anxiety disorder dated 2/25/25, PTSD dated 6/9/23, and major depressive disorder (single episode, unspecified) dated 6/9/23. Resident #1's Notice of Preadmission Screening and Resident Review (PASRR, a federally mandated screening process for individuals with mental illness or intellectual disabilities) Level I Screen Outcome dated 6/8/23 documented mental health diagnoses including major depression and anxiety disorder. The PASRR screen outcome didn't include PTSD. The PASRR screen outcome listed two medications: Ativan (a medication used to treat anxiety) for depressive disorder and Mirtazapine (an antidepressant medication) for anxiety disorder. Resident #1's Medication Administration Record (MAR) dated August 2026 documented the following medication changes:* Duloxetine (an antidepressant medication), 60 milligrams (mg) one time a day for major depressive disorder.* Trazodone (an antidepressant medication), 150 mg one time a day at bedtime for sleep.* Venlafaxine Extended Release (an antidepressant medication), 187.5 mg daily for major depressive disorder.* Buspirone (an anti-anxiety medication), 10 mg twice daily for generalized anxiety disorder.* Lorazepam (a medication used to treat anxiety), 1 mg three times a day for anxiety disorder. On 8/18/26 at 8:39 AM, Resident #1 reported rarely leaving her room and stated she prefers to remain alone. On 8/19/26, during an interview with the Administrator and Staff A, Social Services Designee (SSD) in charge of PASRR submissions, Staff A relayed that the submission process for the PASRR didn't include PTSD as a specific check-box diagnosis. Staff A acknowledged that staff could've added PTSD under the other mental health diagnosis section. The policy titled Resident Assessment, PASRR Prescreening Policy revised April 2024 instructed that the purpose of the PASRR is to ensure individuals with a mental disorder or related condition receive care and services appropriate to their needs.

Based on clinical record review, review of unwitnessed fall reports, facility policy review, family and staff interviews, the facility failed to assess the appropriateness and effectiveness of a cushioned bolster used for fall prevention for 1 of 2 residents (Resident #31) using bolsters. The facility reported a census of 49 residents.Findings include: Review of the the Minimum Data Set (MDS) Assessment for Resident #31, dated 4/18/25, revealed the list of diagnoses included Parkinson's disease and end stage renal disease. The Brief Interview Mental Status (BIMS) score of 5 out of 15, which indicated a severe cognitive impairment. The MDS assessed Resident #31 dependent on staff for activities of daily living which included personal hygiene, mobility, transfers, dressing, toileting and rolling in bed from side to side.A review of the Care Plan, revised on 6/25/25 revealed a Focus area to address I am at risk for falls per Fall Risk Assessment. Fall on 01/29/25; no injury. Fall on 5/22/25; No injury. Fall on 05/30/25; No injury. Fall on 06/03/25; No injury. Fall on 06/23/25; Forehead Abrasion. Interventions included, in part: a. Anticipate and meet my needs. Date initiated: 3/2/23.b. Educate me/my family/caregivers about safety reminders and what to do if a fall occurs. Date initiated: 3/2/23.c. Encourage my participation in activities that promote exercise, physical activity for strengthening and improved mobility such as Restorative Program and/or group exercises. Date initiate: 3/2/23. d. Fall intervention for fall on 05/22/25; Offer resident to use the toilet after each meal. Date initiated: 5/23/25.b. Fall Intervention for fall on 05/30/25; Fall mat provided to be placed on the floor when lying down. Date initiated: 5/30/25.c. Fall Intervention for fall on 06/03/25; Bilateral bolsters placed on the bed. Date initiated: 6/3/25.d. Fall Intervention for fall on 06/23/25; Staff to ensure bolsters are tightly secured as they become loose over time. Date initiated: 6/23/25e. Please make sure my bed bolster is tight after laying me down. Date initiated: 6/23/25Review of documents titled, Unwitnessed Fall, revealed, in part: a. On 5/22/25 at 2:10 PM: Nursing Description: resident was found sitting position resting against the side of the bed as if the resident had slipped out of the bed upon inspection it seemed as though the resident was trying to go to the restroom. Resident is uninjured and acting her normal baseline.Resident Description: Resident unable to give description. Immediate Action Taken: resident assessed for injury, vitals taken all stable, neuro-check completed no deficit from baseline, resident assisted to restroom with 2 assist and hoyer lift. Offer the resident the toilet after each meal. Entered by Staff C, Licensed Practical Nurse (LPN). b. On 5/30/25 at 2:37 PM: Nursing Description: Called to resident room by therapy to observe resident lying on the floor next to her bed on her right side. Resident Description: noneImmediate Action Taken: Resident assessed for injury Resident was noted to be incontinent of urine, changed and assisted off the floor with hoyer and 4 staff.fall mat placed beside bed. Entered by Staff D, Registered Nurse (RN)c. On 6/3/25 at 3:50 AM: Nurse Description: CNA (Certified Nursing Aide) heard res calling out went into room, found res sitting on fall mat legs under bed, near foot of bed. CNA came to this nurse in charting room, reported fall to nurse. When this nurse arrived in res room res lying on R side parallel to bed, head at the HOB (head of bed) on fall mat. Denies pain, stated I slid down. [NAME] (move all extremities) per usual, oriented to self and cite.Hoyer used w/3 staff to get res back in bed, inc (incontinent) of small hard BM (Bowel movement) .Resident Description: see above [referred to Nursing Description]Immediate Action Taken: Place bilat (bilateral) to bedEntered by Staff E, RNd. On 6/23/25 at 1:40 PM: Nursing Description: Nurse was alerted by activities staff that resident was found on the floor. upon entering resident's room nurse found resident lying on her right side directly next to fall mat, upon assessment abrasion found on residents left forehead and Right side of the nasal bridge. resident reported that her face was a little sore. Bed bolster had slid down to the side of the bed. Resident Description: When asked resident reported she was trying to get up to void, and brief was wet. resident stated that her face was a little sore.Immediate Action Taken: residents VS (vital signs) taken, resident assessed for injury and pain, resident assisted back into bed with the CNA staff members.Bed bolster adjusted and tightened.Make sure Bed Bolster is tight after laying resident down. Entered by Staff C, LPNDuring an observation on 7/14/2025 at 1:00 PM, Resident #31 in bed, eyes closed, lying on her back. A Hoyer mechanical lift and reclining, high-backed wheelchair were located in the bathroom. The resident positioned with a large wedge-shaped bolster placed on the left and right side of the bed. The bolsters held in place by a strap fastened to the bed. On the left side, a body pillow positioned between the resident and the bolster. The body pillow went from the residents shoulder to knee in length. During an observation on 7/15/2025 at 8:30 AM, Resident #31 in bed, lying on her back with the bolster placed on the left and right side of the bed. The bolsters fastened to the bed. A mat observed on the floor. A body pillow positioned between the resident and the left bolster, with a sheet tucked in over the resident and the left bolster. During an interview on 7/15/25 at 8:30 AM, Staff A, LPN, reported the staff kept the resident's bed low and put the bolsters in place to prevent the resident from rolling out of bed. Staff A explained they used the bolsters since they couldn't use side rails. Staff A reported that the resident was not capable of getting over the top of the bolsters. Staff A explained the resident was dependent on staff for repositioning and the resident was not able to ambulate.During an interview on 7/15/2025 at 12:02 PM, with Staff F, CNA, and Staff G, CNA, Staff F reported the bolsters for Resident #31 were in place for fall prevention. Staff F reported she had seen the resident kick her leg over the bolster. Staff F reported the resident did get over the bolster a week ago while Staff H, CNA, was working with the resident. Staff F reported the resident did have the ability to lift her leg if she wanted. Staff F reported the bolsters prevented the resident from getting out of bed. Staff F explained that most days the resident was calm, but sometimes the resident would be in a mood. The resident would yell and kick their feet over the bolster. Staff F reported the resident was able to help with repositing, but most days the resident would not help. Staff G confirmed the resident was able to reposition herself if she wanted to. Staff F stated she had seen the resident try to climb over the bolsters, and prior to the placement of the bolsters, the resident would put her legs over the edge of the bed.During an interview on 7/15/25 at 3:31 PM, Resident #31's family member/Power of Attorney (POA) explained the resident's bed was in a low position and there was a fall mat on the floor. The POA reported the bolsters were in place to try to keep the resident from falling out of bed. The POA reported that even with the bolsters on the bed, the resident managed to slide out of the bed and get on the floor. During an observation on 7/16/2025 at 11:15 AM, Staff F, CNA, and Staff G, CNA, transferred Resident #31 from her bed to a wheelchair. Staff F removed the body pillow from the left side of the resident, raised the bed from low to high position, removed the floor mat, and loosened the strap that ran across the top of the bed that was holding the bolsters in place. The staff proceeded to provide personal cares and used a mechanical lift to transfer the resident to her wheelchair. Resident #31 dependent on staff throughout the process.During an interview on 7/16/2025 at 2:42 PM, the MDS Coordinator reported she was responsible for the revisions to the residents' care plans. The MDS Coordinator explained the purpose of the addition of the bolsters for Resident #31 was to help to give the resident a feeling of the edge of the bed. The resident had several falls where she rolled out of bed and needed a boundary. The MDS Coordinator explained the bolsters did not prevent the resident from getting out of bed, because the resident could still put her legs over the bolsters. The MDS Coordinator reported that the resident still had good and bad days, and sometimes the resident could sit herself up and drink by herself. The MDS Coordinator stated that, care wise, she is dependent. The MDS Coordinator reported the fall on 6/23/25 resulted from the bolsters not being appropriately secured to the bed. The MDS Coordinator denied an assessment had been completed to determine if the bolsters were appropriate and safe. During an interview on 7/17/2025 at 8: 43 AM Staff C, LPN, explained Resident #31 had made attempts to get out of bed, and every once in a while the resident forgot that she could not walk. Staff C stated the resident slid out of bed on 5/22/25 while attempting to go to the bathroom. The resident did not have an injury from the fall. Staff C reported that for the fall on 6/23/25, Staff J, Activities Aide, found the resident and notified Staff C. Staff C explained the bed bolster had slid down to the side of the bed. Staff C reported the resident told him she was trying to get up to go to the bathroom. Staff C reported that normally the bolster was on top of the bed, but it looked like the bolster had been pushed to the side. Staff C explained that he did not feel the resident is capable of pushing the bolster out of the way when it is tightened. He stated the bolster was loose at the time of the fall. He explained they added an intervention to tighten the bolster strap after laying the resident down. Staff C explained the bolster deterred a good amount of the resident's attempts to get out of bed. Staff C stated, with the bolsters in general, if you put enough pressure on them, they can be moved. On 7/17/2025 at 9:17AM, Staff J, Activities Aide, reported she was the first person to find the resident after her unwitnessed fall on 6/23/25. Staff J explained the bolster was on the bed, but it looked like the resident had rolled over it since the bolster was off to the side of the bed. Staff J reported that she had observed other times when the resident would put her leg out over the bolster, but she had not seen the resident climbing over the bolster. Staff J explained this usually happened in the afternoon after 2:00 or 2:30 PM when the resident wanted to get up. During an interview on 7/17/25 at 9:37 AM, the Director of Nursing (DON) reported bolters were put in place for Resident #31 as a fall prevention intervention in order for the resident to know her boundaries. The DON explained the resident was able to swing her legs over the bed and did this all of time on second shift. The DON explained the resident did get over the bolster when the resident had her last fall. She explained the bolsters loosen over time from under the mattress, so staff needed to make sure the strap was tight. The DON reported Staff I, CNA, had seen the resident kick her legs over the bolsters, push the bolsters out of the way and loosen the bolsters. The DON reported no assessment completed related to the use of the bolsters. The DON did not think the bolsters were an accident hazard. The DON reported she felt like the resident would be getting out of bed more and hurting herself even worse. On 7/17/2025 at 10:04 AM, Staff H, CNA, reported that sometimes the resident pushed the bolsters out of the way. Staff H explained the staff put the body pillow behind the resident to try to limit her ability to push the bolsters out of the way. Staff H reported being present for the resident's fall on 6/23/25. She explained that on 6/23/25, the bolsters were tight. Staff H reported she was across the hall, and ran to the resident's room, because she heard the resident yelling. Staff H reported the resident had rolled over the bolster and was found on the floor. Staff H reported the bolsters were still in place and the strap tight to the bed. On 7/17/2025 at 1:33 PM, Staff I, CNA reported that yesterday, 7/16/25, at 2:30 PM, the resident had two legs over the left bolster and the body pillow was located at the bottom of the bed. Staff I reported the body pillow frequently ended up on the floor. Staff I reported the resident was able to climb out of the end of the bed and get around the bolsters. Staff I reported 7/16/25 was not the first time she had seen the resident get over or around the bolsters. Review of the facility policy, titled Accidents and Hazards Policy, dated 9/2024, revealed facility staff were responsible for identification of hazards and individual resident risk of an avoidable accident including the need for supervision to reduce individual risk hazards in the environment.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to notify the provider when a resident with a pressure ulcer did not wear his ordered orthotic (referring to externally applied devices, primarily custom-made shoe inserts, designed to support the feet and correct structural and functional issues) shoes for 1 of 2 residents reviewed for pressure ulcers (Resident #10) and failed to notify the provider in a timely manner of a significant weight loss for 1 of 3 residents reviewed for nutrition (Resident #33). The facility reported a census of 49.Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 3/24/25, listed diagnoses for Resident #10 which included cellulitis (inflammation of the tissues) of the right lower limb, pain in the right foot, and non-Alzheimer's dementia. The MDS stated the resident had an infection of the foot and one unhealed pressure ulcer. The MDS did not state the stage of the ulcer. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating moderately impaired cognition. Review of the a 4/6/25 Care Plan entry revealed the resident had a Stage 3 pressure ulcer (characterized by full-thickness tissue loss, where the damage extended through the dermis (second layer of skin) into the fat layer on the right foot due to a foot deformity and directed staff to administer treatments as ordered and monitor for effectiveness. An Order Note, dated 5/6/25 entered by Staff K, Wound Doctor of Nursing Practice(DNP) directed staff to consult with occupational therapy (OT) for off-loading footwear recommendations to promote wound healing. Review of Wound Treatment Plans, written by Staff K revealed the following: a. A 5/27/25 note stated therapy worked on getting a custom shoe. b. A 6/10/25 note stated therapy worked on getting a custom shoe and it had not yet arrived. c. A 6/24/25 note stated the shoes had not arrived and the date of arrival was unknown. d. A 7/1/25 note stated the resident had custom boots. e. A 7/8/25 note stated the resident had custom boots. f. A 7/15/25 note stated the resident had custom boots. During an observation on 7/14/25 at 12:47 p.m., Resident #10 was in his room and wore black slip on shoes. Next to the resident's bed, there was a pair of brown work boots. The boots did not contain any special inserts. No other boots were present in the resident's room During an observation on 7/17/25 at 10:22 a.m., Staff C, Licensed Practical Nurse (LPN) measured a wound on Resident #10's right inner ankle, with the following results: 1.6 centimeters (cm) x 1.3 cm x 0.2 cm (length x width x depth). The wound appeared to have a light yellow wound base and white edges. The work boots sat next to the bed. No other boots were present in the resident's room. Review of the facility policy titled Managing Condition Changes/Physician Notification, reviewed 5/2025, directed staff to report changes to the resident's physician. Review of the facility document titled Pressure Ulcers/Skin Breakdown-Clinical Protocol revealed the physician would order pertinent wound treatments including pressure reduction surfaces. During an interview on 7/17/25 at 11:37 AM, Staff L, Physical Therapy Assistant (PTA) stated the facility received an order for a custom shoe but the resident and his friend decided they would go to a shoe store themselves and figure out what the resident wanted. Staff L stated they went to a shoe store and purchased a regular work boot. Staff L stated he thought Staff K was aware of this as it was communicated through nursing. During an interview on 7/17/25 at 11:48 AM, the Director of Nursing (DON) stated she would want orthotic orders carried out. She stated she would want Staff K to know if the resident did not wear the boots. During a phone interview on 7/17/25 at 2:01 PM, Staff K, Wound DNP stated the resident wore orthotic shoes. She stated she conducted her visits virtually but Staff B, LPN stated the work boots were actually the orthotics. She stated there were orthotic inserts in his boots. During an interview on 7/17/25 at 2:09 PM, Staff B LPN confirmed the boots in the resident's room were just regular boots off the shelf. He stated Staff K interpreted the boots as orthotics but they were not and did not have inserts. Staff B stated he would relate to Staff K that they were not custom shoes. The facility lacked documentation as of 7/17/25 that they notified Staff K the resident did not wear custom boots. 2. The MDS assessment dated [DATE] revealed Resident #33 scored a 6 out of 15 on the BIMS, which indicated cognition severely impaired. The MDS indicated the resident required setup or clean-up assistance with eating. The MDS revealed no known weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months. The MDS indicated medical diagnoses for non-Alzheimer's dementia and Parkinson's disease. The MDS indicated the resident prescribed an diuretic. Review of the Care Plan revealed a Focus area dated 2/26/25 for altered nutritional status related to pneumonia, cardiovascular accident (CVA), Parkinson disease, dementia, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). The interventions dated 2/26/25 directed daily weights unless otherwise noted by physician or dietician and resident's physician would be notified of significant weight changes. Review of the Weight Summary, dated 7/17/25 revealed: a. On 02/21/2025, the resident weighed 175 Lbs. (pounds). On 03/23/2025, the resident weighed 165.5 Lbs. -5.0% change [Comparison Weight 2/21/25 175.0 Lbs, -5.1% (loss), -9.0 Lbs.] b. On 03/09/2025, the resident weighed 173 Lbs. On 04/12/2025, the resident weighed 163.5 Lbs. -5.0% change [Comparison Weight 3/9/25 173.0 Lbs, -5.5% (loss), -9.5 Lbs.]. c. On 02/21/2025, the resident weighed 175 lbs. On 04/28/2025, the resident weighed 158.5 Lbs. -5.0% change [Comparison Weight 3/29/25, 167.0, -5.1%, -8.5LBS]; -7.5% change [Comparison Weight 2/21/25, 175 Lbs, -9.4% (loss), -16.5 Lbs] Review of the electronic health record (EHR) revealed a lack of documentation of provider notified of the significant weight losses. Review of Provider notes dated 3/24/25 and 4/21/25 revealed a lack of documentation of the weight loss reviewed. During an observation on 7/15/25 at 11:50 AM, Resident #33 sat in the dining room and ate his lunch independently. During an interview on 7/16/25 at 3:07 PM, Staff A, LPN queried on who monitored significant weight losses and Staff A stated the Dietician did. Staff A queried if she knew anything about Resident #33 weight loss and Staff A stated no. Staff A explained she had notified the doctor for another resident who had a significant weight loss. During an interview on 7/17/25 at 10:22 AM, Staff B, LPN queried on who monitored weights and Staff B stated the nurses documented in the chart. Staff B stated he was not sure who reviewed the weights for significant weight losses, and confirmed the floor nurses did not review the resident's chart for significant weight losses. Staff B asked if he knew of Resident #33 weight loss and he stated no. Staff B reviewed the computer, and explained he noticed a steady decline in weights. Staff B queried if the provider needed notified with a weight loss of 5% in 30 days and Staff B stated he would notify. During an interview on 7/17/25 at 12:24 PM, the Dietician stated she reviewed Resident #33 notes and the Dietician didn't note a significant weight loss until May. The Dietician stated she didn't look in the EHR at the weights, and stated she went from exactly 30 days and seen if the residents showed a weight loss. The Dietician stated the provider needed to be notified of significant weight changes and in May the provider was notified. During an interview on 7/17/25 at 1:03 PM, the DON queried on Resident #33 weight loss and the DON stated she didn't know of any with him recently. The DON stated the Dietician reviewed the weights weekly and made notes in a binder. The DON reviewed the binder and stated she didn't see any notes concerning Resident #33 in April or May. The DON queried if the provider needed notified for significant weight losses and the DON stated yes, but she wanted to speak to the Assistant Director of Nursing (ADON) to see if the provider expected weight loss. During an interview on 7/17/25 at 2:02 PM, the Assistant Director of Nursing (ADON) queried on Resident #33 weight loss and the ADON stated the Dietician alerted them of weight losses. The ADON reviewed Resident #33 weights and then asked if the provider should be notified of weight loss and the ADON stated yes, but the provider might of wanted the weight loss and would look through the provider notes. During an interview on 7/17/25 at 3:09 PM, the Advanced Registered Nurse (ARNP) queried on who reviewed the significant weight changes and the ARNP stated usually the Dietician worked with the facility and when the ARNP came in, the facility gave her a stack of papers for resident's weights to review. The ARNP stated she signed a paper when notified of weight losses. The ARNP stated when she reviewed the resident's weights she looked at the previous note and compared to the current weight. The ARNP stated if she received a paper with weights for a resident, she reviewed the weights further. The ARNP reviewed Resident #33 weights and confirmed she would of expected notification of a 5% weight loss in 30 days.

Based on observation, policy review, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 kitchen areas and failed to carry out sanitary food handling for 2 of 2 meals observed. The facility reported a census of 42 residents. Findings include: The initial kitchen tour, conducted on 8/19/24 at 9:51 a.m., revealed a fan near the dishwasher with thick dust particles on the fan covering. The fan blew toward a rack containing clean metal pans. A follow-up tour of the kitchen on 8/20/24 at 9:30 a.m. revealed the following concerns: a. Thick dust particles remained on the fan covering. The fan blew toward a rack which contained two water pitchers, trays, and tongs. b. Dust particles hung from the spigots of the fire suppression system. The particles moved with the airflow of the stove vent and hung directly above onions cooking. c. The Certified Dietary Manager(CDM) had a mustache and did not wear a mustache cover as he prepared food. Observation of the noon meal service on 8/20/24 at 11:20 a.m. in the facility's front kitchenette near the front dining room revealed the following concerns: a. Staff A Kitchen Staff crumpled a paper towel up in his ungloved left hand while he obtained the temperature of creamed corn. Staff A then used the crumpled up paper towel to wipe off the thermometer and was about to insert the thermometer into another pan of food before the surveyor intervened in order to prevent cross contamination of the food item. The surveyor asked him how he sanitized the thermometer and he said that he did not know. He called the CDM on the phone. When the CDM arrived, he instructed him to utilize the sanitizing wipes which were in a bucket. b. Dust particles hung from the fire suppression system pipes which were located directly above the griddle which staff cooked on. c. Staff A had a mustache which extended into his upper lip. He did not wear a mustache cover as he served food. Observation of the noon meal service on 8/21/24 at 11:34 a.m. in the facility's back kitchenette near the back dining room revealed the following concern: a. Staff B Kitchen Staff donned gloves on both hands. With both of his gloved hands, he touched the outside of a bread bag, the outside of wrapped cheese, and the outside of a ham package. With the same gloves, he touched the ham and the bread as he constructed and cut the sandwich. He then served the sandwich to a resident. On 8/22/24 at 11:00 a.m. the CDM stated he had a cleaning schedule and they cleaned the fan and fire suppression spigots monthly. He stated he did not look at the spigots of the fire suppression system this week. He stated they needed cleaned. He stated Staff A knew how to clean the thermometer as he was employed for a while. He stated with regard to gloving, staff should not touch objects and then touch food. He stated he thought as long as mustaches were neatly kept, a hair restraint was not needed. The facility Sanitary Conditions/Food Handling policy, updated 12/23, stated the policy's purpose was to prevent the spread of food borne illness and reduce those practices which resulted in food contamination and compromised food safety in nursing homes. The policy stated sanitary conditions were defined as storing, preparing, distributing, and serving food properly to prevent food borne illness. The facility policy Glove Use in Food Service updated 8/23, directed staff to change gloves whenever the activity changed and to remove gloves and discard when not performing a food contact task. The undated Late General cleaning checklist directed staff to clean the dish room fan. The facility's kitchen cleaning checklists lacked documentation of staff direction to clean the fire suppression systems above the stoves. The undated facility Dietary Personnel Policy, stated hair must be covered.

Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to provide foods at an appetizing temperature for 1 of 1 meals observed. The facility reported a census of 51 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 8/23/23, listed Resident #8's Brief Interview for Mental Status (BIMS) score as 13 out of 15, which indicated intact cognition. On 11/13/23 at 12:27 p.m., Resident #8 stated that in the evenings the soup was not hot. 2. The Quarterly MDS assessment tool, dated 8/30/23, listed Resident #33's BIMS score as 15 out of 15, which indicated intact cognition. On 11/13/23 at 1:13 p.m., Resident #33 stated lunch was cold half the time. 3. The Quarterly MDS assessment tool, dated 8/23/23, listed Resident #19's BIMS score as 15 out of 15, which indicated intact cognition. On 11/13/23 at 12:55 p.m., Resident #19 stated the soup was not hot enough in the evenings. 4. The Quarterly MDS assessment tool, dated 8/23/23, listed Resident #12's BIMS score as 15 out of 15, indicating intact cognition. On 11/13/23 at approximately 2:00 p.m., the resident stated the food in the evenings was cold. On 11/14/23 at 11:31 a.m. Staff A Cook placed food in a Styrofoam container for Resident #44 and placed it on the kitchenette counter. A Certified Nursing Assistant (CNA) stated that the staff member who was going to feed Resident #44 was on her way. The container sat there until 11:42 a.m. when Staff B Cook walked over to the container, placed both hands on the container, and started to pick it up. The surveyor requested that she obtain temperatures on the food prior to taking it and Staff B obtained the following temperatures: Ground meat 117.4 degrees Fahrenheit Mashed potatoes 130.5 degrees Fahrenheit Squash 130.8 degrees Fahrenheit. After the surveyor requested the temperatures, Staff A told Staff B to inform her of the temperatures and if it was cold they would replace the meal. After Staff B informed Staff A of the temperatures, she prepared a new plate of food for the resident. The facility policy Acceptable Hold Temperatures for Foods, reviewed 9/23, listed hot holding temperatures for the following foods as 140 degrees Fahrenheit or higher: eggs, hot cereal, entrees, potatoes, vegetables, soup. On 11/15/23 at 1:31 p.m., Staff C Registered Nurse(RN) stated residents complained about cold food and the evening meal was the struggle. When there was no cook, the food trays arrived already prepared and come from the front so they are colder. On 11/15/23 at 1:44 p.m., Staff E CNA stated residents complained a few months ago about cold food and there was one resident who stated that it was cold every day. On 11/15/23 at 1:47 a.m., Staff D CNA stated a resident complained to her a couple weeks ago that the food was cold and they did not want to eat it. On 11/16/23 at 9:22 a.m., the Certified Dietary Manager(CDM) stated he received complaints of cold food. He stated this occurred mostly when they did not have a cook in the back unit of the facility due to staffing issues. He stated this occurred when they plated the food in advance. He stated in the last month, he would guess there were around 5 times when there was no cook on this unit. He stated he expected hot holding temperatures to be a minimum of 160 degree Fahrenheit.

Based on observation, staff interview and facility policy the facility failed to maintain sanitary surfaces on the counter used for cutting meat to prevent possible cross-contamination of food for 14 of 36 residents served the meat option. The facility reported a census of 51. Findings include: On 11/14/23 at 11:45 AM start of lunch service observation, Cook, Staff F, placed individual resident paper menus on the counter in front of the steam table for review of resident individual choices circled on their menu's. Staff F moved the paper menus and proceeded to retrieve and cut the eight-ounce meat patty option in half on the same counter location the paper menus were placed. Staff repeated this process, looked at the menus and then cut the meat patty for those choosing the meat option. On 11/15/23 at 01:38 PM interview with the Dietary Manager Staff G, relayed had witnessed the cook, Staff F during the meal service on 11/14/23 who used the same counter space for viewing menus and was also used for cutting meat. Staff G relayed had spoke to the cook for an improved sanitary process. Policy titled Sanitary Conditions/Food Handling revised 9/2023 documented purpose to prevent the spread of food borne illness and reduce practices resulting in food contamination. Guidelines included sanitary conditions, included serving food properly to prevent food borne illness.

Based on observations, clinical record review and staff interviews, the facility failed to provide adequate supervision to prevent hazards when a safety intervention was disarmed by staff. A confused, independently mobile resident came near an elevator, the wanderguard signaled the Elpas screen and a staff member disarmed the screen when the resident was not visualized. The resident then entered the elevator, exited into the basement and approximately 15 minutes later was inadvertently discovered by a staff member. The facility reported a census of 51 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #27 revealed a diagnosis of dementia with behavioral disturbance and daily, displayed continuous inattentive and had disorganized thinking, pacing and rummaging behavior. The MDS did not identify wandering behavior. Resident #27 was identified as needing supervision but was independent with transfers and ambulation, utilizing a walker for a mobility device. Resident #27 Brief Interview for Mental Status (BIMS) score was a 3, which indicated a severely impaired cognitive status. The Care Plan dated 8/16/23 revealed that Resident #27 was an elopement risk and directed staff to distract the resident by offering pleasant diversions, structured activities and Resident #27 had an Elpas wanderguard watch that will lock doors and sound when attempting to leave the health center. Physician order dated 10/30/23 Wanderguard, Elpas wrist bracelet to alert staff when attempting to leave the facility unsupervised. Wanderguard Watch Check one time a day By signing off watch is functioning properly and was on resident. AND every evening shift By signing off, watch was correctly placed on resident. AND every night shift By signing off, watch was correctly placed on resident. The Treatment Administration Record (TAR) dated August 2023 revealed documentation every shift by nursing staff for the Elpas Wanderguard wrist bracelet to alert staff when attempting to leave the facility unsupervised was on and functioning. Progress notes dated 8/16/23, at 1042 am Resident #27 exited the elevator accompanied by staff. Nurse immediately assessed resident with no apparent injuries, denied discomfort at time of assessment. Vitals taken Blood Pressure (BP) 117/53 Pulse (P) 58 Respires (R)18 T 97.6 SPO2 95%. Verified wanderguard working and in place. Facility provided an investigation of the elopement on 8/16/23 which revealed Resident #27 was alerted as missing to nursing staff at 10:30 AM and staff initiated a search. A timeline revealed: a. Resident #27 last seen at 10:20 AM ambulating in the south hallway. b. The Elpas system notified staff that Resident #27 was near the elevator. c. Staff cleared the Elpas screen as Resident #27 was not visualized near elevator. View of Video with Staff H, Maintenance Director, revealed on 8/16/23: a. Lower Level (LL) camera pointed toward Wellness/Therapy area b. 10:27 AM Independent facility residents leave the wellness room and pushed the elevator button. c. 10:28 AM Elevator opens and Resident #27 exits and the 3 Independent Residents enter the elevator. d. Resident #27 ambulates with walker toward child care area then returns to enter bathroom across from the elevator. e. Multiple wellness staff visualized in video, assisting residents into the wellness area, all unaware of Resident #27 in bathroom. f. Staff I, Wellness Staff, received call from wellness center about Resident #27, hung up, got in elevator and looked around, called health center back, all clear. g. 10:31 AM Staff H arrived, had received a call of stuck elevator, pushed elevator button and cleared elevator. h. 10:33 AM Staff J. Independent Center Maintenance walks up to bathroom as Resident #27 exits bathroom. i. 10:33 AM Resident #27 ambulates off camera toward the daycare. j. 10:33 AM Staff I checked in an Independent center Resident to Wellness Center and unaware of Resident #27. k. 10:34 AM Staff J leaves bathroom and walked across the hall to exit stairs. l. 10:39 AM Staff K, Certified Nursing Assistant (CNA) exited elevator looked toward daycare then went to Wellness Center desk, then walked toward Day Care. m. 10:41 AM Staff K returned to elevator, pushed the button. n. 10:42 AM Resident #27 and Staff L, CNA, walked up to elevator and entered Elpas readout revealed: a. the system sounded identifying Resident #27 near the elevator at 10:16 AM, system cleared at 10:17 AM. b. the system sounded at 10:44 AM identifying Resident #27 near elevator and at 10:44 AM cleared. The tour of Elevator and Lower Level revealed: a. Elevator had 1st floor, health center, Ground floor open to an atrium and unalarmed ext door and lower level. a. Lower level view across from elevator was the bathroom, to the left is the Wellness/Therapy area and to the right is a short hall to a ramp. b. Ramp lead to left, switch back to right ramp to an unalarmed exit door. c. To the left was the Day Care area with 4 doors to child care areas. d. The last door at the end of hall to the left has a window to see inside to an area set up with 3 cribs. During an interview on 11/15/23 at 10:46 AM, Staff M, CNA, stated worked the day shift on 8/16/23, the Wanderguard alarm alerted for Resident #27 and assumed she was sitting around the corner from the elevator. Staff M stated she was in the front of the building between east and west hall and did not visualize Resident #27 when she cleared the Elpas alert then went about my duties. Staff M stated about 10:30 AM, a radio message stated, Has anyone seen (Resident #27)? Staff M stated during the search, Staff L radio message was that she found Resident #27. Staff M stated there was a meeting two days later that requested better communication to account for residents before clearing the elevator to be sure they were safe. During an interview on 11/15/23 at 11:10 AM Staff L, CNA stated she went to the daycare center in the basement of the facility to check on her baby approximately 10:30 a.m. on 8/16/23. While in the day care, Resident #27 peered into the daycare window. Staff L stated Resident #27 was unattended and had utilized the radio to notify the health center. Staff L stated there was an immediate meeting that included staff must be with a resident before clearing the wanderguard and the elopement policy. During an interview on 11/15/23 at 1:30 PM, Staff K, Certified Medication Aide (CMA), stated in the morning of 8/16/23, he attempted to locate Resident #27 for a bath and was informed the Elpas system alarmed, new building elevator, but it was cleared. Staff K stated the search included the elevator and the lower level wellness area where Resident #27 was located. Staff K stated the administration conducted a huddle with staff and a formal training two days later. The facility provided an undated document titled Residents with Wanderguards, listed 10 residents to include Resident #27, and identified the listed residents as a high risk for elopement. The Elopement policy dated 6/2023 revealed: a. The nurse should be notified immediately if a resident cannot be found. b. If the resident not found, the nurse will initiate a search and utilize the Elpas system to locate the last location of a resident. c. The charge nurse will notify the Administrator and Director. d. Contact law enforcement if unable to locate. During an interview on 11/15/23 at 10:00 AM, The Director of Healthcare stated they have a video of the incident and the Lower Level does not have Elpas Wanderguard alarmed doors and are unalarmed. The Director stated that all of the aides have tablets which have an alert screen that identifies the resident and the exit door they have alarmed/locked out or elevator door locked out. The Director stated the staff have a purple clicker that will be brought to the resident's wanderguard to deactivate it and the alarm can also be deactivate or cleared by the nurse computers or the main computer in the front office.

Based on clinical record review, staff interview, resident interview, and facility policy review the facility failed to protect residents from resident to resident altercations which included sexual gestures, physical touching, grabbing, and attempted hitting by Resident #51 for four of five residents reviewed for abuse (Resident #1, Resident #4, Resident #17, Resident #37), and also unidentified residents. The facility reported a census of 49 residents. Findings include: The Admission Minimum Data Set (MDS) assessment for Resident #51 dated 11/12/21 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had severely impaired cognition. Per this assessment, Resident #51 displayed delusions, other behavioral symptoms not directed towards others, and wandered which significantly intruded on the privacy or activities of others. The MDS for Resident #51 dated 5/4/22 documented the resident again scored 3 out of 15 on a BIMS exam. Per this assessment, the resident required limited assistance of one person to walk in their room and in the corridor, and had fluctuating behaviors of inattention and disorganized thinking. It had also been documented per the assessment that Resident #51 had delusions, displayed physical behaviors directed towards others, verbal behaviors directed towards others, and other behavioral symptoms not directed towards others. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 5/17/22 documented, I have a behavior problem wandering, refusal of cares, physically aggressive, verbally aggressive, and inappropriate advances r/t (related to) Dementia with Behavioral disturbances. Interventions, all dated 5/17/22, included the following: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Anticipate and meet my needs. c. Assist in developing more appropriate methods of coping and interacting. Encourage me to express my feelings appropriately. d. Caregivers to provided opportunity for positive interaction/attention. Speak/stop/talk with me as passing by. e. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. f. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. g. Praise any indication of The resident's progress/improvement in behavior. The Wandering Risk assessment dated [DATE] identified Resident #51 at moderate risk for wandering. The Incident Note dated 11/7/2021 at 11:30 PM documented, Resident had wandered into [Resident #1's] room and had been told to leave room by her. He would not until two staff members redirected him back to his room. He had only a brief and gripper socks on. The CNA (Certified Nursing Assistant) Note dated 11/8/2021 at 3:43 AM authored by Staff P, Certified Nursing Assistant (CNA) documented, Resident had wondered <sic> into female residents room. When found was sitting on bed with female resident in only a brief and was trying to touch female resident. Female resident had asked multiple times for him to leave her room and he didn't comply. (The resident mentioned in this note had been later identified by Staff P as Resident #1. The Nurses Note for Resident #1, dated 11/10/21 at 6:43 AM, stated the resident called staff to her room and asked if that man next door was in the dining area. The staff member informed her he was and the resident stated she was frightened of him and hardly slept the previous night because she worried he would come back into her room. The Nurses Note for Resident #2 dated 11/16/2021 at 7:49 PM documented, Resident complains that male resident across the hall continues to enter her room and not leave. Resident expresses concern that fell ow resident has entered into the hall in his shorts and is afraid that he will enter her room dressed in only shorts. Resident states can you not just make him stay out of our rooms? He frightens us and we are not able to sleep from worrying about him coming in our rooms while we are sleeping. The CNA Note dated 11/17/2021 at 3:47 AM (in Resident #51's record) documented, Resident up wondering <sic> in room and outside room since 0200 (2:00 AM). Going in room [Room Number where Resident #2 resided] and resident scared of him going in in the middle of the night. Reported to nurse. Review of a Psychosocial Note for Resident #2 dated 11/24/2021 at 11:28 AM documented, in part, Nursing reviewed recent medication changes. Mild improvement with the increase in her Buspar; however, [Resident #2] voiced anxiety secondary to new male resident coming into her room and the room next to her. She denies being scared but states she does not like that he awakens her at night generally from the noise he is causing and she feels bad for the staff. She voiced that she plans to go visit family for Thanksgiving but is concerned what I will come back to. The [Hospital Name] note for Telemedicine, encounter date 12/7/21, revealed, in part, the following: a. He [Resident #51] was found wandering naked in the hallway the first night at the facility. He was awake most of the night .He slept after wandering into a female peers room just wearing underwear and gripper socks. He was told to leave the room by the peer, but would not leave until 2 staff members redirected him back to his room. He again wandered into a female residents room the next night and was found sitting on her bed in his brief, and was trying to touch her and would not leave despite her asking him to do so. b. The next day and the next night [Resident #51] again entered the room of a female peer. He was not easily redirected on one of these occasions. c. [Resident #51] went into female peers room during the night 11/17/21 who was afraid of him. He wandered all second shift that day, looking for a phone and a way out. d. [Resident #51] needed to be redirected from the rooms of 2 female residents 3 different times on 11/19/21 day shift. e. On 11/20, he was in another resident's room who is a fall risk trying to assist the resident and then he was trying to get in the med room and told a female resident they were getting married and she was terrified. On 11/22 night he was wandering the halls in his underwear trying to enter other rooms. f. On 11/30 pm he was wandering in other rooms in his underwear. g. On 12/4, he was again going in other rooms and putting himself on the floor .He was later on the floor naked with his hands on his penis in front of 2 female resident's rooms. The CNA Note dated 12/5/2021 at 3:01 PM documented, aide ask me to help her get him dress an off the floor. he was lying on floor naked and had his hands on his penis. in front of 2 female resident rooms. their doors was open. assist him in dressing assist to bed. The Behavior Note dated 12/14/2021 at 8:38 AM documented, This staff member was on my way to the [section of facility] charting room to file papers. At this time I witnessed [Resident Initials] standing in the hall between his room and 2 other female resident rooms with his pants and brief pulled down. Facility nurse was with him trying to help pull up his brief and take him to his room. The CNA note dated 12/14/21 at 8:12 PM documented, Resident would not stop trying to get into other residents rooms. Resident kept saying open the son of a [expletive] resident was hitting staff, punching, kicking, and biting. The Behavior Note dated 12/21/2021 at 9:00 AM documented, While making rounds Nurse noticed that resident was walking in another female's resident room without any clothing on. Female resident was upset stating, I'm sick and tired of this. This has been an ongoing situation, and something needs to be done about it! Nurse grabbed a blanket to wrap around the naked resident and redirected him back to his room. The Behavior Note authored by the Activities Director dated 12/28/21 at 3:05 PM documented, This staff was in the [NAME] Center to put a move on for resident's there. This staff observed resident [Resident #51] lifting up [Resident #4's] Leg. Referring to her as [Name Redacted]. Staff did move [Resident #4] to the counter area to have a snack. Staff just reminded resident [Resident #51] not to touch other's. [Resident #4] was moved several times so that they were not in the same area. This resident also put his hands on [Resident #37's].) wheelchair handles. He then took his right hand just inside her top. (Resident #37) grabbed his hand and shoved it away and stated he is evil. This staff removed [Resident #37] from that area. (Identities of residents involved had later been confirmed during interview with the Activities Director). The Nurses Note dated 12/28/2021 at 3:36 PM documented, Return call rec'd from ARNP (Advanced Registered Nurse Practitioner) office et spoke with [Name Redacted] who states message from [NP] states that she would need to see the frequency of behaviors before a PRN (as needed) would be given et suggested calling daughter [Name Redacted] to sit with resident. This RN (Registered Nurse) reiterated that resident had placed hand down a female resident's blouse et that had been grabbing another female resident's leg et (and) that this would be considered inappropriate sexual contact. [Name Redacted] states she will message ARNP back et that ARNP would likely phone facility. This RN passed information onto floor nurse, [Initials]. The CNA Note dated 12/28/2021 at 9:08 PM documented, Resident has been touching female residents inappropriately <sic>, they touched a female residents breast area, put his hand in their bra, female resident yanked his hand out of their. Resident has also been rubbing the legs near the crotch area and arms of a different female resident. Staff moved the female resident many times, he just followed. Resident has been trying to get into other residents rooms in his depend, resident grabbed a female residents hand and tried to hit them. Resident was kicking, biting, hitting staff. Review of documentation for a Facility Reported Incident for Resident #51 dated 12/28/21, not signed, documented, This nurse received a report the evening of 12/28/2021 that the resident had had an increase in behaviors and staff was finding it difficult to redirect him. Staff reported that resident was propelling himself in his walker and was looking for his wife. Resident was calling out, [Name Redacted] his wife's name. This resident then approached a female resident and put his hand down her shirt. Resident was approached by staff told that the behavior was inappropriate yet he continued to seek out his wife. He then approached another female resident who was in a wheelchair and began rubbing her leg. Resident was again asked to stop and told that behavior was inappropriate. Resident continued to seek out female residents but did not touch any other residents. This nurse was at the building from approximately 1700-1745 (5:00 PM-5:45 PM) and at that time the resident was sitting on his walker seat in the dining area away from other residents and was being monitored closely by staff. While this nurse was present this resident attempted to go into another resident room and was easily redirected back to his room. At the time this nurse left the facility resident was in his room. This nurse received a call later that evening from facility staff stating that resident had grabbed the wrist of a female resident and swung at her. Staff intervened and the female resident was not injured. The Behavior Note dated 12/29/2021 at 6:30 AM documented, This nurse received report from nursing staff that resident was being combative and had blocked himself in another resident's room and he was naked. Prior to blocking himself in a room he was combative with staff, striking them and scratching them. At this time staff has been unable to redirect resident. The Behavior Note for Resident #51 dated 12/29/2021 at 7:25 AM documented, This RN (Registered Nurse) went down to [Specific Part of facility) after being told resident was naked in a female resident's room et she was reporting being scared. This RN approached resident who was naked in female resident's bathroom. This RN attempted to redirect resident et discuss his need to exit her room et go into his room to use bathroom as well as the need to get dressed et not walk around facility naked. Resident was raising voice at this RN, stating that he would not leave the room like this. The [Hospital Name] note for Telemedicine, encounter date 1/4/22, revealed, He [Resident #51] has been taking his medications. His aggressive behaviors continued and escalated 12/29/21 with some new behaviors of trying to touch staff and female residents inappropriately. He was taken to the local ER (emergency room ) on 12/29 with hopes of transfer to [Hospital], nut there were no beds available. Behaviors continued 12/30. He sleeps in the nude and always has, He was naked in a female resident's room [ROOM NUMBER]/30 night, and could not be redirected. He would not let go of the walker and it hit him in the face and he struck a staff member in the face. The Nurses Note dated 5/29/22 at 7:47 PM documented the Nurse heard female resident confined to bed yelling and entered room to find this resident in female residents room, and [staff] convinced resident to sit on seat of walker and rolled resident out of female resident's room. The Nurses Note dated 5/30/22 at 9:23 PM documented, Resident was found coming out of female resident [Initials Redacted] room and going into her neighbors [Initials Redacted] room. Resident was redirected to his room and nurse assisted resident with taking his shoes off and laying in his bed. Resident asked nurse to turn out the light so he could rest. The Nurses Note dated 5/31/22 at 8:56 PM documented, Resident opened door and entered female residents, [Initials Redacted], room. Resident [Initials Redacted] was very upset and stated that she is scared of him and that this is not fair. She should be able to lay down and sleep at night without being frightened that a man will enter her room. Resident was redirected and allowed nurse to escort him to his room and get him ready for bed. Once in bed resident told the nurse goodnight and asked that his light be turned off. The Nurses Note dated 5/31/2022 at 9:05 for Resident #25, who's initials matched those of the resident in the note dated 5/31/22 at 8:56 PM, documented, Male resident, [Initials matching Resident #51] entered resident's room while she was in bed. Resident was very upset and stated that she is scared of him and that this is not fair. She should be able to lay down and sleep at night without being frightened that a man will enter her room. Male resident was redirected and removed from resident's room. Resident calmed down some when nurse assured her that he would not be back in her room tonight and that nurse would watch over him for the remainder of this shift and make certain that he does not leave his room again. The Incident Report authored by Staff H, Licensed Practical Nurse (LPN) dated 6/16/22 at 7:28PM documented per the Incident Description, This nurse heard female resident yelling and went to see what was happening. Resident had female residents [later identified as Resident #17's] walker and when she tried to get her walker back he grabbed her by the front of her shirt and twisted pulling her to him. This nurse was able to get resident to let go of female resident and release her walker. Resident became very angry with nurse and started trying to bite and hit nurse. Review of the Witness Statement portion of the form documented Resident #19 had witnessed the incident, and the statement documented, He just come in and snatched her walker from her, and then he grabbed her by the shirt and I started yelling. Resident asked what they, all of us ladies, are supposed to do if he tries to hurt us. We are all really scared of him. He beats on you girls all the time. The Nurses Note for Resident #17 dated 6/16/2022 at 6:28 PM documented, This nurse heard female resident yelling and went to see what was happening. Male resident had female residents walker and when she tried to get her walker back he grabbed her by the front of her shirt and twisted pulling her to him. This nurse was able to get male resident to let go of female resident and release her walker. Resident was very angry with male resident and stated what would happen if I rared back and punched him as hard as I could? We should not have to put up with him behaving that way. On 7/7/22 at 3:22 PM, when queried if Resident #51 had been physically aggressive to staff and residents,Staff H, LPN, explained Resident #51 had been physically aggressive with one the week before he had been transferred. Per Staff H, he had taken [Resident #17's] walker, grabbed her by the shirt, and had yanked her up to him. Staff H reported there was no doubt if they had not gotten there faster he would have hit her. Staff H acknowledged there had been need to get the resident out of many female resident rooms at night. When queried if the resident walked, Staff H responded sort of, yeah, and said the resident could move quickly. When she [Resident #17] had tried to take her walker back, Resident #51 had grabbed her by the shirt, twisted her shirt pulling her to him, and the other resident [Resident #19] had been screaming. Per Staff H, that night the resident had been looking for his keys, had wanted his wife to bring his keys, and wanted to get out of the facility. Per Staff H, it was something different each time, and they knew that certain things triggered the resident. Staff H explained she knew residents were scared of Resident #51 because they would see him beat on the staff. On 7/12/22 at 12:21 PM, when queried about Resident #51's behaviors, the Social Worker explained mostly recently the resident's behaviors had been discussed because the resident had gone into a female resident room across the hall, both female residents had been spoken with and one had said they were afraid of Resident #51 because he kept coming in, and the other said they were ready to bop him. Per the Social Worker, the resident had been going in other people's rooms and did grab [Resident #17] by the collar and didn't hurt her. The Social Worker further explained Resident #51 had gone across the hall, and it sounded like he had been looking for a walker. Resident #17 had been outside of Resident #19's room, and from what Resident #17 told the Social Worker, Resident #51 continued to approach her, she said don't come in this room, and Resident #51 had kept coming towards her. Resident #19 had yelled for help and someone came down, and by that time Resident #51 had Resident #17's collar. The Social Worker explained she had spoken with Resident #17 the next day, and Resident #17 had been mad. Resident #19, who was in her chair, asked what would have happened if I would have kicked him? Per the Social Worker, Resident #19 could not get out of her chair, and it was scary for her. The Social Worker explained when Resident #51 had first come, he had been going into rooms around his room and had wandering behaviors, described by the Social Worker as kind of off and on. At times, the resident would get medication and be better and sleep a lot .When the resident's [MEDICATION(S)] (antipsychotic) medication had been adjusted the resident had experienced more and more behaviors. Per the Social Worker, discussion had occurred with the resident's family, staff, and departments head and it had been determined another placement was needed. When queried if the resident had displayed sexual behaviors, the Social Worker explained the only thing they had been aware of had been what was charted, described by the Social Worker as trying to put his hands down someone's shirt or grab. When queried about non-medical interventions that had been implemented for Resident #51, the Social Worker explained that when the resident had been in a specific part of the facility, stop signs had been put on doors or something outside the resident's room so he know where his room was located. The Social Worker also explained that the resident's family member frequently visited, and per the Social Worker it seemed like later in the day when those things had been happening. The Social Worker explained the resident liked ice cream and that was something that had been tried, the resident had been taken in to the bathroom, and Resident #51 liked to tinker with things, however the resident's attention span had been short and it was difficult to find things to engage the resident for longer periods of time. When queried about increased monitoring, the Social Worker explained she did not remember anything that was care planned, and the other thing done most recently was an alarm to the resident's door so if he went out it would ring like a doorbell. The Social Worker explained they believed when the resident had been in a different part of the facility this had been tried also, and when the resident opened their door a tab would be set off so they would go check on him. The Social Worker did not recall careplanning anything about increased checks for the resident, however stated this could have occurred and they did not recall. Per the Social Worker, the resident generally understood what had been said, had been somewhat hard of hearing, always did things his way, had moderate cognitive deficit, and could not follow cues really easily. On 7/12/22 at 12:42 PM, when queried about Resident #51's behaviors, Staff I, Certified Medication Aide (CMA) explained the resident hit, pinched, and cussed at staff. When queried about behaviors towards residents, Staff I explained she had never seen this but had heard. Staff I acknowledged the resident wandered, went into resident rooms, and was not always able to be redirected. When queried where they would look to know how to address behaviors, Staff I responded as a CMA the only thing she could see was in the nurses notes section in the POS, then she could read the notes other people had put in. When queried if CNAs could access the Care Plan, Staff I responded they could see it on their tablets. When queried if Resident #51 had been ambulatory, Staff I explained the resident did walk, and also acknowledged the resident had been cognitively impaired. On 7/12/22 at 3:07 PM, Staff J,CMA, had been queried about Resident #51, and explained he would do sexual things to some of the residents. Per Staff J, she thought it had been [Name Redacted], and the resident had his hands in her shirt. Staff J explained the resident had been in one part of the facility then moved to South Hall. Staff J explained the resident had been ambulatory and the ladies back (in the back part of the facility) in the corner had been afraid of him. Per Staff J, Resident #51 had been back in that corner and would go in and out of their rooms and they were scared. Staff J explained Resident #19 had been scared of him. When queried if Resident #51 had been able to be redirected, Staff J explained sometimes. Staff J acknowledged the resident wandered, and acknowledged the resident wandered around without clothing. Per Staff J, alarms had been put on his door so they knew when he came out. When queried if there had been enough staff to respond to it, Staff J explained not always and they would find the resident in others rooms, or they would turn their lights on, or would just holler out to get help. On 7/12/22 at 3:18 PM, Staff N, CNA, explained about two weeks before the resident left the facility she had been down the East Hall, had come out of the room to get supplies, and had heard someone screaming. Per Staff N, this had been Resident #19. Resident #51 had been sitting on her (Resident #19's) toilet and had bowel movement all over the floor, Staff N explained the resident had been crying and screaming. Per Staff N, other residents had been scared of Resident #51. Staff N further explained Resident #51 had been sexually inappropriate with other residents, so he was moved up front, and that may have helped for a little bit. Per Staff N, the resident should not have been at the facility as the facility was not the place for him, and per Staff N the facility could not handle him. On 7/12/22 at 3:44 PM, when queried about Resident #51, Staff O, CNA explained when the resident was first back (towards back of the facility) they had dealt with the resident. Staff O explained he had grabbed a resident's (later identified as Resident #37's) breast and had gone into the bra. Staff O explained she had reported it. Per Staff O, [Resident #51] would always go into Resident #1 and Resident #2's rooms. Per Staff O, Resident #51 had gone into Resident #31's room naked, and would also be very combative with staff. Staff O explained she did not think the facility was the place for him, and also explained the resident had been terrified of him. Per Staff O, the resident had wandered, and would wander into everybody's room. Per Staff O, she had witnessed the incident with Resident #37, and also with Resident #17. Staff O reported Resident #17 had wanted to hit the resident because she had been scared. Staff O further explained some kind of tape barrier had been put on Resident #1's and Resident #2's doors, but that did not help as Resident #51 had gotten under it. When queried about increased supervision for the resident, Staff O explained the resident got a fall mat once and a bed alarm, may have had checks, and did not have one to one supervision. On 7/13/22 at 8:00 AM, when queried if residents had come into her room, Resident #19 explained Resident #51 lived across the hall and down one. Per Resident #19, Resident #51 would come in and she would yell at him that this was not his room and he needed to leave. Per Resident #19, he did not, said he needed to pee, and went into the bathroom. Resident #19 further explained they had started yelling for nurses and had pushed the button too and it had been the middle of the night. When queried how this had made the resident feel, Resident #19 explained it had made them feel kind of frightened, and they didn't know what to expect. Per Resident #19, the were frightened and angry at the same time, and explained the question of what was he [Resident #51] going to do and why's he coming in here. Per Resident #19, Resident #51 used to try to go into another resident's room across the hall and whenever she would see the resident doing that, she would call a nurse aide as he had no business being in there. Per Resident #19, she felt Resident #19 didn't know where he was or what he was doing. When queried if she had ever seen Resident #51 push, pull, or grab others, Resident #19 acknowledged a nurse had been trying to keep the resident out of another resident's room and Resident #51 had kept hitting at their arm. Resident #19 denied the resident acting in that manner towards other residents, and stated she felt the resident should be in a place other than the facility because they could not watch [Resident #51] all the time. Per Resident #19, she had spoken with facility staff about how she felt, and further explained we spend big bucks to stay here and would like to feel safe. On 7/13/22 at 4:00 PM, when queried about Resident #51's behaviors, Staff P, CNA, explained the resident could be combative and sometimes really sweet. Per Staff P, the resident would wander the halls, would go in other resident rooms, and use other resident's bathroom. When queried about documentation she had written that Resident #51 had touched another resident, Staff P identified the resident as Resident #1. When queried where Resident #51 had been trying to touch the resident [Resident #1], Staff P explained Resident #1 had reported Resident #51 had been trying to touch her, and she had just saw him on the bed. When queried if the resident had been accepting of redirection, Staff P reported sometimes the resident would accept redirection, and that day he did. On 7/14/22 at 8:45 AM, the Activities Director explained Resident #51 would roam around on his wheeled walker. When queried about the events she had documented in the progress note on 12/28/21 at 3:05 PM, the Activities Director explained she thought they were either getting people or bringing people back from the activity, Resident #4 had been sitting, and Resident #51 had the resident's leg up. Per the Activities Director, you could just tell on Resident #4's face that the resident did not like that. The Activities Director explained Resident #51 had been moved, she had gone to get Resident #4 some pop, and when she went back Resident #51 had been over with Resident #37 and had his hand really close to the resident's breast. The Activities Director explained Resident #37 had told the resident to get out, and the resident's hand had been over the Resident #37's shirt really close to the resident's breast. Per the Activities Director, Resident #37 had told him to stop and the resident had been removed. On 7/14/22 at 1:36 PM, the Infection Preventionist explained they had been the facility's Director of Nursing (DON) until January or February of 2022. When queried if the resident had displayed any physical behaviors towards residents, the Infection Preventionist explained Resident #51 had touched or put his hand down the shirt of one of the female residents, identified as Resident #37. Per the Infection Preventionist, Resident #51 had been rubbing the leg of Resident #4, and most recently she had been made aware of an issue with Resident #17 when she had been in Resident #19's room. When queried about the documentation of resident to resident touching in November, the Infection Preventionist explained she had known the resident had gone into a few female resident rooms in a brief, and had not been aware that he had been trying to touch her. When queried as to what actions staff were to have taken if this type of incident occurred, the Infection Preventionist explained if it had been a CNA they were to tell the charge nurse, and the information next would be reported to the DON to see how they needed to proceed. The Infection Preventionist explained they could not remember if they had been notified about the touching, and she did not recall that Resident #51 had tried to touch another resident. Per the Infection Preventionist, Resident #51 had walked, had wandered, and explained the following interventions had been attempted: one to one with staff, activities offered, changed medications, and eventually the resident's room had been moved to another hallway. Per the Infection Preventionist, stop signs had been placed in front of doors to keep the resident from going into the two closest rooms to where the resident had been located. The Infection Preventionist acknowledged most of the interventions had been unsuccessful, explained the one to one had not been a formal arrangement, and people would just spend a lot of time sitting with the resident in his room, talked to him, and made sure they had their eyes on him. The Infection Preventionist explained the following about the Facility Reported Incident: The Infection Preventionist remembered it had been reported Resident #51 had put his hand down Resident #37's shirt and had groped/touched her breast, and had gone up to Resident #4 when she had been at the table and had been rubbing her leg. The Infection Preventionist further reported that the resident often time would come out without clothes, slept without clothes, and a couple of times did lay on the floor or stand and touched himself inappropriately. When asked if this behavior had ever taken place within view of other residents, the Infection Preventionist responded she believed it had, by Residents #1 and Resident #2. Per the Infection Preventionist, a lot of nights on second shift the resident had an informal one to one because the resident's behaviors escalated in the evening, and the more you approached the resident, he became aggressive with staff as well. When queried about alarms for Resident #51, the Infection Preventi[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene and glove use when staff moved between resident rooms, collected trays, passed water, and during an observation of a catheter dressing change for one of one resident observed for a dressing change (Resident #34).The facility reported a census of 49 residents. Findings include: 1. On 7/07/22 at 8:27 AM, observation revealed Staff C, Housekeeper, while wearing blue gloves, moved down the hallway. At 8:28 AM, Staff C moved the housekeeping cart down the hallway with their gloves applied. At 8:29 AM, Staff C entered a resident room, exited the resident's room with blue gloves applied, and put the tray on a rack in the hallway. At 8:29 AM, the staff member opened a door in the hallway, and at 8:31 AM Staff C closed the housekeeping door in the hallway while they wore the same blue gloves, then she entered a resident room, and went back down the hallway with gloves applied. Next Staff C entered another resident room, exited the room with a tray, and put it on a rack in the hallway with blue gloves applied. On 7/13/22 at 11:17 AM, when asked if staff went into a room with gloves on if they should have been doffed when they came out, the Director of Nursing (DON) acknowledged this should occur. The facility policy for Hand Washing, last reviewed 2/22, directed the following in the Times Hand Washing Is Important section: 1. Before feeding residents-during feeding if soiled or contamination occurs 3. Before and after caring for a resident .5. After handling resident articles, dressings, or equipment that may be soiled. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 recorded a Brief Interview for Mental Status (BIMS) score of 2 or severe cognitive impairment. The MDS showed Resident #34 required extensive assistance from 2 staff members for bed mobility, transfers, ambulation and most activities of daily living. The resident had an indwelling catheter. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan reviewed on 6/2/22 identified that Resident #34 had a suprapubic catheter (urinary catheter that drains from the abdomen). An intervention directed to clean around the suprapubic site daily and apply a 4 x 4 (dressing) to the stoma. An order dated 6/25/22 at 6:00 AM instructed to clean around the suprapubic catheter stoma site daily and apply a 4 x 4 daily to stoma, assess for any changes, signs/symptoms of infection/urine leakage every day shift. An order dated 6/23/22 at 2:00 PM directed to apply Triad Hydrophilic Wound Dressing Paste to an open area topically every day and evening shift. During observation 7/11/22 at 1:15 PM Staff K, LPN (Licensed Practical Nurse), did a suprapubic catheter dressing change for Resident #34. The nurse gathered and placed the equipment on the bedside tray. Staff K did not place a barrier down or clean the tray first. She washed her hands and applied gloves, positioned the resident and removed the old dressing and put it in the trash. Staff K did not remove her soiled gloves, but then picked up a gauze pad and applied normal saline to it. Staff K cleansed the catheter insertion site, then cleansed the area again and along with 2-3 inches down the tubing with a second gauze pad. Staff K picked up a pair of scissors, made a split in a gauze pad and placed it on the site. She dated the dressing and taped it in place and then removed her gloves. As she cleaned up the equipment, Staff K placed the scissors and tape in her pocket. She washed her hands, lowered the resident's bed, covered him and left the room. During observation on 7/12/22 at 10:00 AM Staff L, LPN, did wound care for Resident # 34. The nurse placed the tube of Triad Cream on the bedside tray without a barrier on it or cleaning the tray. Staff L washed her hands and applied gloves. She helped the resident reposition and removed part of his brief to give her access to his coccyx area. Staff L used soap and water to clean the site with a towel. Staff L then changed her gloves but did not wash her hands. Staff L applied Triad Cream to the wound site. Staff L removed her gloves and washed her hands, put the resident's back in a low position and returned supplies to the cart. In an interview on 7/13/22 at 8:20 AM, the DON stated she expects that staff will place a barrier on the tray before placing equipment on it. The DON also expected staff to remove dirty gloves and wash their hands after touching or removing a dirty dressing. The facility's procedure on Dressings Dry Sterile, reviewed 2/22, instructed to place the soiled dressings in a waterproof bag. Remove disposable gloves and discard these in the waterproof bag also. The policy lacked direction to wash hands or put a barrier down to place equipment on. The facility's Handwashing policy, reviewed 2/22, did not instruct that staffs' hands need to be washed after removing gloves. The Centers for Disease Control (CDC) website titled Hand Hygiene in Health Care Settings reviewed on 1/8/21 contained the recommendations that hand hygiene should be performed immediately after removing gloves. That gloves need changed when moving from work at a soiled body site to a clean body site on the same patient. 3. During an observation on 7/7/22 at 10:29 a.m., Staff D, Resident Assistant, wore blue gloves and entered room [ROOM NUMBER] and then exited into the hall. Staff D then picked up a water pitcher from a cart in the hall and entered room [ROOM NUMBER]. She exited room [ROOM NUMBER] with a dirty water pitcher and placed it on the bottom shelf of the cart. Staff D then entered room [ROOM NUMBER] with a clean water pitcher and exited the room with a dirty water pitcher. She then brought a new water pitcher into room [ROOM NUMBER] and exited the room with the old water pitcher. Staff D wore the same pair of gloves when entering and exiting the rooms. The facility's policy on Use of Ice Scoop(s), reviewed 3/20, directed staff to utilize proper hand washing before using a scoop to distribute ice to glasses and to wear gloves when passing ice water. During in interview on 7/13/22 at 8:16 a.m., the Infection Preventionist and former DON stated when staff distributed ice water, they would wash their hands and change gloves in between rooms.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure no more than 14 hours elapsed between a substantial evening meal and breakfast the next morning. The facility reported a census of 49 residents. Findings include: During an observation on 7/6/22, staff served Resident #37 her evening meal at 4:23 p.m. and served Resident #45 his evening meal at 4:26 p.m. During an observation on 7/7/22 at 8:04 a.m., staff served Resident #37 her breakfast. As of 8:04 a.m., Resident #45 did not have his breakfast. At 8:25 a.m. observation revealed Resident #45 eating his breakfast. Upon request, the facility lacked documentation staff offered residents a substantial evening snack. The undated facility document for Dining Services listed the following meal times: a. Breakfast 7:00 a.m.-9:00 a.m. b. Lunch 11:00 a.m. Monday-Saturday and 11:30 a.m. Sunday. c. Supper 4:30 p.m.-6:30 p.m. The facility's undated Snack Cart Policy directed that Resident Assistants would distribute snacks between 5:30 p.m.-6:45 p.m. and the facility did not require documentation of selections or intake. During an interview on 7/12/22 at 2:54 p.m., Staff J CMA (Certified Medication Assistant) stated the facility did not have bedtime snacks like they used to. Staff J stated staff just passed ice at bedtime. During in interview on 7/13/22 at 8:16 a.m., the Infection Preventionist and former DON (Director of Nursing) stated the evening meal started at 4:30 p.m. so there was not an extended time between meals. She stated staff should pass an evening snack but they did not have any documentation of evening snacks. During an interview on 7/13/22 at 9:10 a.m., the Dietary Manager (DM) stated the CNAs (Certified Nursing Assistants) were in charge of the snacks. The DM stated they had items like chips, cookies, and donuts. Staff also had access to the refrigerator if residents wanted something additional. The DM stated 14 hours was the maximum amount of time which should elapse between the evening meal and breakfast. The DM stated she informed staff residents should not eat prior to 4:30 p.m. and breakfast was at 7:00 a.m.

Based on observation, staff interviews, and facility record review, facility staff failed to handle food and beverages in a sanitary manner showing an extended use of gloves in two of three dining rooms at the facility. The facility reported a census of 49 residents. Findings include: 1. Observation on 7/06/22 at 4:05 PM revealed Staff B, Resident Assistant, assisted with preparation of drinks in the front dining room. Staff B touched touched her hair and mask with her blue gloves, then touched her glasses. Staff B adjusted the glasses and then touched a large silver drink dispenser. Staff B then adjusted her clothing and hair while wearing the same gloves, touched a cart, her safety glasses, and a mug. Staff B then prepared drinks with the same gloves applied, then touched her hair again. Staff B then prepared drinks without hand hygiene or a change of gloves. During interview on 7/13/22 at 11:15 AM, the Director of Nursing (DON) acknowledged with each person staff were supposed to be changing gloves, and perform hand washing or sanitizer. The DON acknowledged staff were supposed to be changing gloves if they touched equipment or their person. 2. Observation of the noon meal service in the back dining room on 7/5/22 at 11:45 a.m. revealed Staff A, Cook wore gloves and with her right gloved hand touched items such as a spoon handle and with her left gloved hand she touched the outside of small bowls. With the same gloves, she touched a grilled cheese sandwich while cutting it. She then served the sandwich to a resident. Staff A Cook wore new gloves and with her left gloved hand she touched the refrigerator handle and with her right hand touched utensils in a drawer. Without changing gloves, Staff A then plated a pink frosted dessert and touched several of the desserts while placing them from the dessert pan onto the plate. Frosting was visible on the Staff C's gloves. She then served the dessert to residents. Staff A donned new gloves and with her right gloved hand touched small bowls, tong handles, and a knife and with her left gloved hand, she touched a plastic lid. She then used both her right and left gloved hands to move meat onto a plate. Staff A then served the food to residents. 3. Observation of the noon meal service in the back dining room on 07/06/22 at 11:26 a.m. revealed Staff A wore gloves and with her right gloved hand she touched a ladle, a plate, and hot dog tongs and with her left hand she touched a plate and tongs. With the same gloves, Staff A touched meat with both hands. She then placed the meat on a resident's plate. Staff A donned new gloves and with her right gloved hand, she touched a piece of paper on the counter and with the left gloved hand she touched small bowls. Staff A then touched a bun with her right and left gloved hands which she then served to a resident. The facility's undated policy on Sanitary Conditions stated the facility would prevent the spread of food borne illness and reduce practices which contaminated and compromised food safety. The policy directed staff to complete hand hygiene prior to preparing, serving, and distributing food. The policy did not address glove use. During an interview on 7/13/22 at 9:10 a.m., the Dietary Manager stated staff used gloves for ready-to-eat food. She stated between tasks, staff should reglove and also used tongs and forks. The Dietary Manager stated she would conduct an in-service regarding glove use.

Based on review of clinical record, the facility assessment, call light logs, resident council meeting minutes and facility policy, and staff interview, the facility failed to assure sufficient staff available at all times to provide nursing and related services to meet the residents' needs for 2 of 24 residents reviewed (Residents #38 and #45). The facility reported a census of 49 residents. Findings. 1. The MDS (Minimum Data Set) Assessment tool, dated 5/11/22 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident required limited assistance of 1 staff for personal hygiene, and extensive assistance of 1 staff for bathing. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 2 out of 15, indicating severely impaired cognition. The untitled call light log for Resident #38 for the period of 7/4/22-7/11/22, revealed a call light response time on 7/4/22 at 3:29 p.m. of 27 minutes. A Care Plan entry, revised 3/26/21, stated the resident had a bath on Wednesdays and Saturdays. The June 2022 Documentation Survey Report V2 lacked documentation Resident #38 received assistance with a bath during the period of 6/15/22-6/19/22. 2. The MDS assessment tool, dated 6/1/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident required extensive assistance of 1 staff for dressing and personal hygiene and extensive assistance of 2 staff for bed mobility, transfers, toilet use and bathing. The MDS listed the resident's BIMS score as 11 out of 15, indicating moderately impaired cognition. The untitled call light logs for Resident #45 for the period of 7/4/22-7/11/22, revealed the following call light response times which exceeded 15 minutes: a. 7/4/22 27 minutes at 3:29 p.m. b. 7/5/22 21 minutes at 9:22 a.m., 18 minutes at 10:41 a.m., 24 minutes at 11:57 a.m., 20 minutes at 7:54 a.m. c. 7/6/22 19 minutes at 6:32 p.m. d. 7/9/22 24 minutes at 10:40 a.m. An untitled document provided to the survey team which listed staffing for 7/4/22 listed for the day shift worked with 4 CNAs (Certified Nursing Assistants), 2 RAs (Resident Assistants), and 2 Nurses. The facility schedule for 7/5/22 listed for the day shift of 7/5/22 4 CNAs and 2 nurses. The undated facility policy on Tub Baths recorded a bath's purpose was to cleanse, refresh and comfort the resident, to stimulate circulation a, and to observe the condition of the skin. The facility policy on Call Lights, updated 10/21 directed CNAs to monitor call lights and answer the light promptly. The policy stated the DON (Director of Nursing) would receive notification of call lights exceeding 15 minutes. During an interview on 7/12/22 at 12:46 p.m., Staff I CMA (Certified Medication Aide) stated the facility did not have enough staffing and there were times due to this that staff did not complete baths. She stated there were times when they could not answer call lights within 15 minutes and it could exceed 20 minutes. Staff I stated recently residents complained to her about this. During an interview on 7/12/22 at 2:47 p.m., Staff L LPN (Licensed Practical Nurse) stated she worked at the facility off and on for a year and CNA staffing had been an issue since she started, but the last couple of months it was evident. Staff L stated there were days when there were not enough staff to give baths. During an interview on 7/12/22 at 2:54 p.m., Staff J CMA stated it was tough to answer call lights within 15 minutes and she saw the call light response time exceed 20-25 minutes. During an interview on 7/12/22 at 3:12 p.m., Staff N CNA stated facility staffing was not good. She stated call light response times definitely exceeded 15 minutes and had extended at least 40 minutes. Staff N stated residents complained about it. Staff N stated that due to staffing, there were times when residents were wet and staff could not assist them with changing. During an interview on 7/12/22 at 3:36 p.m., Staff O CNA stated staffing on the first shift was horrible. She stated there were times when they could not get to baths and saw call lights exceed 25 minutes. During an interview on 7/13/22 at 11:04 a.m., the DON stated she felt like call light response time was a common complaint. She stated there was no sound to alert staff of call lights and they had to look at their tablets to see if a call light alerted. The DON offered that staff should answer call lights within 15 minutes. Review of the Resident Council Meeting Minutes for May 2022 and June 2022 documented, in part, the following: a. 5/26/22: When a resident used their call light it seems like it takes a while for them to answer the light. Staff will check with administration. b. 6/27/22: When a resident used their call light, it took a while for them to answer the light. Staff did check with administration it looks like there was some wait but not long wait times. Staff told residents that if this happens or if they feel like it takes a while just let staff know. Review of the Facility Assessment Tool, last updated 5/16/22, for its general staffing plan for direct care staff documented: Direct Care RNs (Registered Nurses)/LPNs: Day shift range 1 - 3, Afternoon shift range 1 - 2, and Night shift range 1 - 2. CNAs were documented: Day shift range 5 - 6, Evening shift range 5 - 6, and Night shift range 2 - 3. On 7/7/22 at 3:29 PM, when asked about staffing at the facility, Staff H, LPN stated the CNAs were overworked, and understaffed all the time. Staff H stated there had been complaints from resident and families about staffing. Staff H acknowledged there was not enough time to do all the cares, feed residents, make sure they don't choke, and residents could get a shower later. Per Staff H, there had been many days lately that they had to make that a priority, and if there were only 2 or 3 people they asked if some of the showers could be done tomorrow. A list would be given of who did not get done to know where to start in the morning, and normally people pitched in and helped. On 7/11/22 at 11:08 AM, asked about staffing on the weekends, Staff F, RN stated it depended on the weekend, and it was usually low with not much CNA help. Per Staff F, a lot of the time there were 2 nurses. Staff F also acknowledged that sometimes the CNAs did not do showers and stuff, depending on how much staffing they had and if they had the time.

Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure a resident received medications per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 49 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented the resident scored three out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan dated 10/5/20 documented she had a [CONDITION(S)]. The intervention dated 10/5/20 documented to give medications as ordered and monitor/document for effectiveness and side effects. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give after [CONDITION(S)] activity. The Nurses Note, authored by Staff F, Registered Nurse (RN), dated 6/25/22 at 5:53 PM documented the resident starting seizing while CNAs (Certified Nursing Assistants) were taking her to the bathroom. Resident #3 was sitting on the toilet when she suddenly slumped over to the right side, he arms and head were shaky and she went unresponsive for about 5 minutes. The resident's blood pressure and pulse measured within normal limits and her O2 (oxygen) saturation measured 85%. Resident #3 opened her eyes when spoken to after about 2 minutes from the time Staff F entered the room. After [CONDITION(S)] was finished, staff transferred the resident back to bed and applied oxygen. Resident #3 currently rested in bed still but said she felt good and was alert and orientated. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3 following the resident's [CONDITION(S)] on 6/25/22. The Nurses Note dated 7/8/22 at 10:01 AM documented Resident #3 began seizing at breakfast beginning at 7:13 AM. The episode lasted for 7 minutes, the resident drooled and was unresponsive throughout. Staff took the resident back to her room, laid her down, and applied O2 (oxygen). The resident's SpO2 (oxygen saturation) measured 92% at 2.5 L (Liters) and her heart rate and blood pressure measured within normal limits. Staff called the Nurse Practitioner following the incident and received a nursing order for a [MEDICATION(S)] (an antiseizure medication) lab draw for the resident. Review of the MAR for July 2022 lacked documentation that staff administered [MEDICATION(S)] to Resident #3 following the resident's [CONDITION(S)] on 7/8/22. On 7/11/22 at 11:04 AM, when asked if they had worked with Resident #3 when the resident had experienced a [CONDITION(S)], Staff F acknowledged this had happened once. When asked if she knew if the resident had a medication to give following [CONDITION(S)], Staff F responded no. On 7/13/22 at 11:12 AM, when asked about administration of medication following a [CONDITION(S)] for Resident #3, the Director of Nursing (DON) acknowledged she thought the resident had an [MEDICATION(S)] order until 12/22. The lack of documentation of administration of the medication for 6/25/22 and 7/18/22 was communicated to the DON at this time, and a copy of the proof of use/narcotic record for the medication requested. Email correspondence from the DON dated 7/13/22 at 12:54 PM revealed the facility did not have a proof of record for [MEDICATION(S)], the order had been written, but a script never got sent to the pharmacy resulting in no card getting delivered. The RN Staff Nurse Job Description, undated, documented, in part: The staff nurse is a professional RN responsible for the implementation of the nursing process for the total nursing care of all residents in Health Center and for the supervision if all nursing personnel assigned to assist them in providing nursing care. The RN is responsible for assessing, planning, implementing and evaluating the care of all residents. The Charge Nurse/LPN (Licensed Practical Nurse) Job Description last revised 6/19 documented, in part: The charge nurse will perform direct nursing services to residents, as identified in the individual plans of care and physician orders.

Based on clinical record review, observation, staff interview and facility policy review, the facility failed to treat the resident with dignity and respect by not keeping his urinary catheter bag covered for 1 of 3 residents (Resident #16). The facility reported a census of 49. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 documented a Brief Interview for Mental Status (BIMS) score of 8, or moderately impaired cognition. The MDS revealed the resident needed extensive assistance of 2 staff members for toilet use and 1 staff member for personal hygiene. He required an indwelling urinary catheter. The MDS revealed Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, revised on 7/13/22, for Resident #15 identified the resident had an indwelling urinary catheter. The care plan did not contain direction to use a cover bag/dignity bag. In an observation on 07/06/22 at 2:30 PM Resident #16 had a urinary catheter bag hanging on his walker, off to the side of the recliner. The catheter bag and urine within could be seen from the doorway. The resident had a cloth cover bag/dignity bag attached to his walker but it was not in use. In an observation on 07/07/22 at 2:00 PM Resident #16 had an urinary catheter bag without a cover bag/dignity bag. The bag with urine could be seen from the door. During observation on 07/12/22 at 09:11 AM Resident #16 had a urinary catheter bag not covered with a cover bag/dignity bag hanging on the walker next to his recliner. The bag and urine could be seen from the door. An observation on 07/12/22 at 2:11 PM revealed Resident #16 had an uncovered urinary catheter bag hanging from his walker and urine in the bag could be seen from the door. In an interview on 07/12/22 at 03:08 Staff J CMA (Certified Medication Aide) stated the staff had been informed they will not use leg bags any more due to infection issues. They now put cover bags/dignity bags over a resident's urine bag. In an interview on 7/13/22 at 8:20 AM the DON (Director of Nursing) stated she doesn't know any residents that would like a leg bag. She expected that staff place a catheter urine bag in a dignity bag. The facility's undated Catheter Care policy recorded the procedure for perineal cleansing of a resident with a urinary catheter. The policy contained no information on using a cover bag/dignity bag over a catheter drainage bag.

Based on clinical record review, observation, interview, and facility policy review, the facility failed to notify the physician in a timely manner following a resident who experienced a [CONDITION(S)] and after a resident fell and sustained a hematoma to the forehead and multiple skin tears for two of four residents reviewed for notification of changes (Residents #3 and #11). The facility reported a census of 49 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 recorded the resident scored three out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 10/5/2020 documented, she had a [CONDITION(S)] disorder. The Nurses Note, authored by Staff F, Registered Nurse (RN), dated 6/25/22 at 5:53 PM documented the resident starting seizing while CNAs (Certified Nursing Assistants) were taking her to the bathroom. Resident #3 was sitting on the toilet when she suddenly slumped over to the right side, he arms and head were shaky and she went unresponsive for about 5 minutes. The resident's blood pressure and pulse measured within normal limits and her O2 (oxygen) saturation measured 85%. Resident #3 opened her eyes when spoken to after about 2 minutes from the time Staff F entered the room. After [CONDITION(S)] was finished, staff transferred the resident back to bed and applied oxygen. Resident #3 currently rested in bed still but said she felt good and was alert and orientated. On 7/11/22 at 11:04 AM, when asked if she had worked with Resident #3 when the resident had experienced a [CONDITION(S)], Staff F acknowledged this had occurred once. When asked who she would notify of a [CONDITION(S)], Staff F responded with names of specific staff, and also mentioned the family. When queried where notifications would be documented, Staff F acknowledged this information would be in the note. The Nurses Note above lacked documentation of completion of notifications. On 7/13/22 at 11:08 AM, when asked about notification to the doctor about seizures, the facility's Director of Nursing (DON) stated staff should call the doctor if a resident had a [CONDITION(S)], with how long it lasted, symptoms of their [CONDITION(S)], and acknowledged notification should be in the progress note. Per the DON, at that time of day the Nurse Practitioner (NP) would not have been present at the facility, and the facility did not have a [CONDITION(S)] log book. The DON stated she had never received notification of a [CONDITION(S)], and acknowledged staff also did not call her about resident falls and should be doing so. 2. The quarterly MDS assessment for Resident #11 dated 6/22/22 revealed the resident scored 5 out of 15 on a BIMS exam, which indicated the resident had severely impaired cognition. The assessment documented Resident #11 fell on ce with an injury (except major) since admission or the prior assessment. The resident's Care Plan dated 12/8/14, last revised 7/5/22, documented a moderate risk for falls per the Fall Assessment Fall 5/29. An intervention dated 12/8/14 instructed staff to follow facility fall protocol. Review of an Incident Report authored by Staff G, RN for Resident #11 one 5/29/22 at 12:50 AM for an unwitnessed event documented the following Incident Description: The nurse heard the resident talking louder, went to check, and found the resident on the floor between her bed and her roommates' bed with her head at the foot of bed, lying on R (right) side. Resident #11 could not state what happened. VSS (vital signs stable), BP (blood pressure) low, talking, inc (incontinent) of urine per usual, with no rotation or size differences to legs. Neurological (neuro) checks were WNL (within normal limits) for the resident. The bed bolster had been knocked over, previously in upright in proper position, the bed in low position, she had no slipper socks on. Earlier tonight Resident #11 talked while sleeping in bed. Staff G noted several skin tears, and cleansed and dressed them. The resident had a hematoma to her R forehead and Staff G applied ice. Two staff assisted the resident to stand with a gait belt, then pivot to bed. The resident moved all her extremities per her usual. The Injuries Observed at Time of Incident section of the form documented a hematoma to the resident's face, and skin tears to the back of the right hand, right wrist, right elbow, and front of the left lower leg. The Agencies/People Notified section of the report was not completed. Review of the Fall/Injury Monitor-Suspected Head Injury form dated 5/29/22 at 12:50 AM revealed the resident was found the floor, received anticoagulant medication, and had an injury, had slight bruising, and had a soft tissue injury. The Comments section of the form documented: physician and family to be notified in the am since no serious injury or change in LOC (level of consciousness). The Incident Note dated 5/29/2022 at 10:29 AM documented staff notified on-call, doctor of the resident's fall, who directed to observe her for changes in behavior and to do neuro checks 2 times daily for 7 days. The LPN (Licensed Practical Nurse) also notified the resident's son/POA (Power of Attorney) and daughter. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/07/22 at 8:22 AM, observation revealed Resident #11 present in the dining room in their wheelchair and eating breakfast. On 7/11/22 at 11:05 AM, when asked about physician notification following a fall, Staff F stated if they had an injury the physician would be notified, and if not injured then she would continue doing neuros, assessments, follow the protocol, and notify family members. On 7/11/22 at 3:48 PM, when queried about notification to the doctor pertaining to falls, Staff G indicated the policy was if the fall was at night and the resident had their completely normal level of consciousness and the resident acted just like always, then the doctor would not be called unless the resident needed to be seen imminently. Per Staff G, what she did was write in the communication book that the resident fell , and that family and the physician needed to be notified the next day. Staff G explained the Nurse Practitioner would come in on Monday, and stated the person who worked day shift would make the notification. On 7/13/22 at 11:04 AM, when asked about notification for the doctor regarding falls, the DON stated in the facility if they felt the resident needed to be sent out they would call the on-call provider. If there was nothing of concern where the resident needed to be sent out or seen immediately, the the fall report would be printed out and put in the Nurse Practitioner's folder to see it the next time reviewed. Per the DON, the Nurse Practitioner came on Mondays and Thursdays, and would sign them. When asked if the resident had a hematoma to the head and received an anticoagulant, the DON acknowledged staff needed to call. The DON spoke of Resident #11, and explained she felt like the resident should have been sent out, especially when she saw the size of the hematoma. The nurse didn't feel that way. The DON further explained the resident's neuro check would be hard because the resident did not cooperate with that, and she should have at least been evaluated. The facility's policy on Falls, dated 3/21, documented, 6. Notify the physician and family promptly. The facility's policy on Managing Condition Changes/Physician Notification, reviewed 6/22, documented the following: Condition change is defined as a not usual/alteration from normal status. A significant change in resident status refers to observed changes in the resident's condition which warrant immediate Licensed Nurse assessment, intervention and appropriate follow-up. Clinical record documentation, assessment and follow-up is necessary. The policy also documented: 2. Reporting: A. The Licensed Nurse will notify: a. The attending physician. b. The hospital/x-ray/lab (if ordered by the physician). c. The family (or responsible party). d. The DON, if not in the facility.

Based on clinical record review, facility policy review, and staff interview, the facility failed to provide a bed hold notice at the time of transfer for 1 of 2 residents reviewed for hospitalization s (Resident #4). The facility reported a census of 49 residents. Findings: 1. The MDS (Minimum Data Set) assessment, dated 9/8/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 11/5/21 Nurses Note recorded the resident transferred to the emergency room for evaluation and treatment. An 11/7/21 Nurses Note documented the resident returned from the hospital Saturday (11/6/21). The facility lacked documentation they notified the Ombudsman of the resident's transfer. The facility policy on Transfer Notice, dated September 2019, instructed the facility would notify the Long Term Care Ombudsman of all discharges on a monthly basis. During a phone interview on 7/11/22 at 2:21 p.m., the Social Worker stated residents who went to the hospital for observation did not show up on the list of resident discharges the facility faxed to the Ombudsman. She stated she would find a way to fix this.

Based on clinical record review, facility policy review, and staff interview, the facility failed to provide a bed hold notice at the time of transfer for 1 of 2 residents reviewed for hospitalization s(Resident #4). The facility reported a census of 49 residents. Findings: 1. The MDS (Minimum Data Set) assessment, dated 9/8/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 11/5/21 Nurses Note documented Resident #4 transferred to the emergency room for evaluation and treatment. An 11/7/21 Nurses Note recorded the resident returned from the hospital Saturday (11/6/21). The facility lacked documentation of a bed hold notice provided to the resident or resident's representative at the time of transfer. In an email sent by the DON (Director of Nursing) on 7/13/22 at 12:54 p.m., she stated the facility did not have a bed hold notice for the resident. The facility's policy for Bed-Hold Notice, dated September 2019, instructed the facility would hold the resident's bed upon hospitalization for a maximum of 10 calendar days. During an interview on 7/14/22 at 2:32 p.m., the Administrator stated nurses should ask resident representatives about bed hold upon transfer and document this.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to incorporate the recommendations from a PASRR determination into the resident's plan of care for 1 of 1 residents reviewed for PASRR(Resident #2). The facility reported a census of 49 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated [DATE], listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 9 out of 15, indicating moderately impaired memory and cognition. The PASRR Short-Term Nursing Facility Approval, dated [DATE], recorded the approval expired [DATE] and the resident required specialized services including psychiatric services, individual therapy, and a Crisis Intervention/Safety Plan. The approval stated as a result of the resident's recent self-directed violent thoughts, she would benefit from the creation of a Crisis Intervention Plan with the medical staff in the event she had a self-directed violent thought. The approval stated the plan should include her triggers for self-directed violent thoughts as well as ways to de-escalate her behavior. The Notice of PASRR Level 1 Screen Outcome, dated [DATE], documented a PASRR Level 2 evaluation was not required and stated the services identified in the previous PASRR remained appropriate and the facility should continue to deliver them. The resident's Care Plan did not included a Crisis Intervention Plan specifically related to self-directed violent thoughts, their triggers, and ways to de-escalate the resident's behavior. A [DATE] ARNP (Advanced Registered Nurse Practitioner) note stated the resident had a great deal of difficulty meeting new people and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's policy for Preadmission Screening for MI/MR (Mental Illness/Mental [CONDITION(S)]), reviewed ,d+[DATE], instructed the screening process must be accurate and correspond to the resident's functional level including the presence of diagnoses. The purpose of screening was to determine if those with mental illness required specialized services. During an interview on [DATE] at 2:32 p.m., the Administrator stated the resident and the resident's medical provider developed a Crisis Safety Plan in their sessions and they could retrieve this from the provider if needed.

Based on record review and staff interviews, the facility failed to provide comprehensive assessments and intervene in a timely manner following a fall for 1 of 4 sampled (Resident #1). The lack of assessment delayed the treatment of [REDACTED]. The facility reported census of 53. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had moderate cognitive impairments. Resident #1 required limited assistance supervision with ambulation, limited assistance with transfers and extensive assistance with dressing, toilet use and personal hygiene needs. Resident #1had [DIAGNOSES REDACTED]. The Care Plan revealed Resident #1 ambulated independently with a walker and independently used the bathroom. According to the Fall/Injury Monitor - Suspected Head Injury sheet dated 9/13/19 at 10:05 p.m. the staff heard Resident #1 yelling out, Oh, I fell , I fell . Staff A (Licensed Practical Nurse) documented on the sheet. Resident #1 complained of right elbow pain, although flailing her arm about. Resident #1 complained of right hip pain, but able to move right leg without expressing pain or yelling out. Resident #1 assisted to stand with assistance of three staff to her bed. The sheet revealed noted no pain, injury, bruising or impaired mobility related to the fall. The sheet revealed follow up neurological checks at 11:10 p.m., 12:10 a.m., 1:10 a.m. and 2:10 a.m. The neurological checks noted no change in condition and range of motion as before. During an interview on 1/13/20 at 4:22 p.m., Staff H (Nurse Aide) stated around 10:05 p.m. on 9/13/19 she heard Resident #1 scream for help from across the hall. Staff H summoned Staff A (Licensed Practical Nurse) who assessed Resident #1. Three staff lifted Resident #1 off the floor and placed her in bed. Resident #1 screamed out, but Staff H did not know whether it was her anxiety or pain related. During an interview on 1/9/20 at 5:00 p.m., Staff I (Nurse Aide) stated she worked 9/13/19 on the evening shift. Staff I passed by Resident #1's room and observed Resident #1 on the floor with Staff A and Staff H present. Staff I reported Resident #1 did not seem to be in pain and moved her legs. However, Resident #1 could not move her arm. The three staff picked Resident #1 up and placed her in a chair. Resident #1 could not bear weight. Staff I could not recall if Resident #1 had pain or not. During an interview on 1/14/20 at 11:40 a.m. Staff A (Licensed Practical Nurse) reported she assessed Resident #1 and she was fine, kicking her legs and moving her arms. Resident #1 stated she had no more than the usual amount of pain. Staff A stated they lifted Resident #1 to her feet and she ambulated back to bed using her walker. Staff A stated she never noticed anything unusual and Resident #1 was not yelling out in pain. Staff A stated she completed additional assessments per protocol and did not notice any abnormalities. Staff A stated Resident #1 was able to move her legs and arms as before which meant as she could prior to her fall. Resident #1 squeezed Staff A's hands, but noted her arms are normally stiff anyway and have limited movement. Staff A denied the overnight aide reported Resident #1 had pain or of anything unusual. During an interview on 1/13/20 at 11:25 a.m., Staff B (Nurse Aide) stated she worked overnight on 9/13/19. The evening aide reported to Staff B that Resident #1 had a fall earlier, Staff A responded and Staff A later reported everything was fine. Staff B stated she cared for Resident #1 that night and every time she was in the room providing cares Resident #1 moaned in pain. Staff B reported to Staff A that Resident #1 had pain, but Staff A stated Resident #1 was fine. During an interview on 1/14/20 at 12:59 p.m., Staff C (Licensed Practical Nurse) reported she worked from 6:00 a.m. to 10:00 p.m. on 9/14/19. At 6:00 a.m., the nurse reported Resident #1 had a fall and hit her right arm. Staff C assessed Resident #1 and Resident #1 could move her arms and legs freely without any indication of pain. Resident #1 did not want to get out of bed and Staff C instructed the Aides to allow Resident #1 to stay in bed. Staff C stated she passed Resident #1's medications and did not notice anything unusual. Staff C primarily focused on Resident #1's right side, as told in report. Resident #1 remained in bed through lunch and took her noon pills without incident. Staff C stated no one reported to her anything unusual. Resident #1 could move her arm and legs and squeeze her fingers upon request. Staff C admitted she did not do any passive range of motion on Resident #1's arms and legs. According to a Fall Follow-up report dated 9/14/19 at 11:00 a.m., Staff C documented Resident #1 had no injury, impaired mobility and normal range of motion. Resident #1 denied pain and reported she did not feel well, sick at her stomach, and wanted to stay in bed. During an interview on 1/13/20 at 11:40 a.m., Staff D (Nurse Aide) stated she worked the day shift on 9/14/19. Staff D reported Resident #1 had pain all day and screamed out when moved. Resident #1 complained of left arm pain. Staff D stated she told the Staff C (Nurse) a couple of times that day and Staff C told her not to get Resident #1 up. Resident #1 stated, I'm going to die, I'm going to die. Staff D stated the nurse checked on her, but really did not do anything. During an interview on 1/9/20 at 4:36 p.m., Staff [NAME] (Nurse Aide) stated she worked the day shift on 9/14/19 with Staff D. Staff [NAME] stated Staff D informed her that Resident #1 refused to get up and complained of pain. Staff [NAME] instructed Staff D to report her observations to Staff C (Nurse) and get a room tray. After breakfast, Staff D assisted Resident #1. Staff [NAME] heard Resident #1 yelling. Staff [NAME] entered Resident #1's room and observed Resident #1 sitting at the edge of the bed vomiting. Resident #1 stated she hurt. Staff C (Nurse) entered the room and Staff [NAME] left. Staff C later stated, Resident #1 was yelling because she did not have her medications or food yet. Staff [NAME] stated later when she checked on Resident #1, she screamed out when touched. Staff [NAME] reported this to Staff C (Nurse). Staff [NAME] stated later Staff D and Staff F provided cares and Resident #1 still had pain. Staff [NAME] reported Resident #1 did not get out of bed that day, which was unusual. The Progress Notes dated 9/14/19 at 5:40 p.m., Staff C documented a Nurse Aide reported Resident #1 had pain and not want to eat her soup. Resident #1 complained she felt sick. Resident #1 had pain with range of motion to her lower extremities. Resident #1 voiced discomfort when the left hip and thigh palpated. Resident #1 assisted to sit on the edge of the bed. Resident #1 held on with both hands while changing position. Resident #1 stated she hurt and did not want to get up. When asked where she hurt, Resident #1 responded her head and then pointed at her stomach and left side. Review of the (MONTH) 2019 Medication Record sheets revealed Resident #1 had an order for [REDACTED].#1 had no Tylenol administered on 9/13/19 or 9/14/19. During an interview on 1/13/20 at 2:45 p.m., Staff F (Nurse Aide) stated she worked from 10:00 a.m. to 10:00 p.m. on 9/14/19. At 1:00 p.m., she assisted Staff D with Resident #1. Resident #1 yelled and screamed in pain when moved. Staff F stated she attempted to tell Staff D (Nurse) but Staff D responded Resident #1 exaggerates. Staff F observed Resident #1 was anxious, would not get out of bed, and she knew something was wrong. Staff F stated she checked on Resident #1 about every hour. At 5:00 p.m., Staff F entered Resident #1's room. Staff F removed the pajamas, Resident #1 had on all day. When Staff F removed the long sleeved pajama top, Resident #1 cried out in pain. Staff F noticed Resident #1's left arm had swelling and a huge bruise. Staff F stated she knew it was broken and had never seen anything like it. Staff F stated she left the room and had Staff G (Nurse) assessed Resident #1. Resident #1 transferred to the Emergency Department. During an interview on 1/13/20 at 11:05 a.m., Staff G (Licensed Practical Nurse) stated he worked the evening shift on 9/14/19. At 7:40 p.m., the staff informed Staff F that Resident #1 had an injury. Staff G assessed Resident #1 immediately and noticed a large bruise on her left elbow, swelling in her left arm, pain with movement of the left arm, and diminished range of motion in left leg. Staff G had knowledge of the fall the evening before, but to that point, had not been involved with her care. Staff G stated he suspected an injury right away, contacted the physician, and had her transported to the hospital. The Radiology Consultation Report dated 9/14/19 revealed Resident #1 had a displaced [MEDICAL CONDITION] ulna and displaced fractures of the left superior and inferior pubic rami.

The following information relates to the investigation on self-report # and # . Based on record review, observations and interviews, the facility failed to provide adequate supervision to prevent 2 residents from elopement. The facility did not implement safety provisions to address two (2) exit doors to ensure the safety of residents placing residents health and safety at an immediate jeopardy. Resident #1 eloped from the front door of the facility without staff's knowledge on 12/2/17. The facility staff were not aware Resident #1 had been outside for 7-10 minutes; with a nearby highway approximately 70 feet away. The facility had 4 independently mobile and cognitively impaired residents putting other residents at risk. The facility failed to ensure an audible alarm functioned for Resident #2. Resident #2 Wanderguard's system did not alarm when she exited the nursing home and staff did not know she had been in the independent living section of the building. The facility reported a census of 50 residents. Finding Include: 1. The Independently Mobile and Cognitively Impaired resident list received on 1/25/18 revealed the facility had 4 residents independently mobile and cognitively impaired. a. According to the Admission Record dated 1/18/18 Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairments and no wandering behaviors. The Wandering Risk assessment dated [DATE] revealed Resident #1 had no known wandering or history of wandering, no elopement attempts. The resident required stand by assist with a gait belt and front wheel walker. The Plan of Care revised on 9/27/17 directed the staff to provide contact guard assist of one with ambulation with a walker and pull tab alarm while in bed and chair to alert staff when needs assistance. The Progress Notes dated 12/2/17 at 6:10 p.m. revealed a visitor found Resident #1 wandering in the parking lot between the overhang and parked cars. Staff A assisted Resident #1 inside. Resident #1 had clothing on but no coat. The entry revealed it was 50 degrees Fahrenheit outside. The staff informed the Director of Nurses. The Late Entry dated 12/2/17 at 6:10 p.m. revealed Staff A alerted a person outside walking in the parking lot with a walker. Staff A (Licensed Practical Nurse) approached the person and noted it was Resident #1. Staff A located Resident #1 directly north of the awning, in the parking lot, to the south of the vehicles. Staff A escorted Resident #1 back inside. Resident #1 reported he/she was going home. Staff A notified Staff B (Nurse in Charge) of what happened. The Late Entry dated 12/2/17 at 6:45 p.m. revealed Staff B notified Staff C (Maintenance) of what happened and a Wanderguard placed on Resident #1 at 6:45 p.m. to prevent from leaving the facility. The Late Entry dated 12/2/17 at 7:00 p.m. revealed Staff B completed an assessment of Resident #1 with no abnormal findings. Resident #1 reported he/she just wanted to go home. The Late Entry dated 12/2/17 at 10:40 p.m. revealed Staff B notified the Physician of Resident #1 wandering in the parking lot for 10 minutes and requested an order for [REDACTED].>The facility investigation revealed on 12/2/17 at approximately 5:50 p.m., Resident #1 had been assisted to a chair by the nurse's station; and by 6:05 p.m., a family visitor informed staff Resident #1 was outside by the north front door approximately 50 feet. Resident #1 reported she was going home (when staff brought her back inside). Resident #1 had been fully dressed and wearing shoes. The staff contacted the maintenance staff. Resident #1's Elpas bracelet was replaced with a bracelet that would (now) alarm and lock exit doors and the facility reported the system was working correctly, in that the north exit was approached by any resident and it sent an alert to the central monitoring system; however the facility identified the message alerts were not being sent to the pagers of staff CNAs. The facility reported due to Resident #1's assessment the facility had only received an Elpas watch which would not secure the doors but rather ring to staff pagers. On 12/4/17 the facility documented they had problems with the dead zones and notification didn't always ring to the staff pagers and they had addressed the issued multiple times in the past. The facility identified the original company currently no longer active had not properly wired the facility. The facility documented Resident #1 did not try to exit seek, there was no reason to anticipate this incident. An onsite observation showed 25 steps from the front door to the other side of the awing; and 67 steps to the sidewalk; 70 steps to the street. The facility is located nearby a heavily traveled 4 lane highway (Highway 92). An interview on 1/24/18 at 12:44 p.m. Staff D (Nurse Aide) reported he/she assisted Resident #1 from the dining room to a chair near the Nurse's Station. Staff D reported he/she left Resident #1 in the chair without the chair alarm. Staff D reported he/she knew Resident #1 had a chair alarm. Staff D reported Resident #1 did not have the alarm at the dining room table. Staff D reported he/she did not go look for the alarm. An interview on 1/24/18 at 10:00 a.m. Staff B reported he/she arrived to work at 5:50 p.m. and received report. Staff B reported Staff A informed him/her that Resident #1 was found outside. Staff A asked Staff B why the door alarm did not sound. Staff B told Staff A that Resident #1 did not have a Wanderguard device. Staff B reported he/she went to look for the chair alarm and found it tucked in the cushions of the recliner in Resident #1's room. The Facility Investigation (Social Worker) notes revealed Staff D assisted Resident #1 to sit in a chair by the Nurse's Station around 5:50 p.m. At 6:05 p.m., a visitor informed Staff A that Resident #1 was outside the front door 50 feet away. An interview on 1/24/18 at 3:38 p.m. the Director of Nurses reported Staff D received education for leaving Resident #1 in the chair without an alarm. Resident #1's Plan of Care Updated 12/2/17 revealed the facility added a Wanderguard watch to alert staff if she attempted to leave without assistance. b. Observation on 1/24/18 at 3:58 p.m. revealed when exiting/entering the Front Door of the facility no alarm sounded. When approaching the front door with a Wanderguard device the front door locked down with a 15 second egress delay. An interview on 1/24/18 at 12:28 p.m. the Administrator reported the AL Ramp door and the Front Entrance door do not alarm unless the resident has a Wanderguard device in place to activate the alarm. 2. The Residents with Wanderguard list received on 1/25/18 revealed the facility had 10 residents with Wanderguard devices. a. According to the Admission Record dated 1/18/18, Resident #2 had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairments. The MDS revealed Resident #2 had wandering behaviors. The MDS revealed Resident #2 required supervision with locomotion. The Wander Risk assessment dated [DATE] revealed Resident #2 had forgetfulness, short attention span and early dementia. The assessment revealed Resident #2 a low risk for wandering. The Plan of Care dated 6/8/17 revealed Resident #2 had a wireless monitoring watch to alert staff if Resident #2 exited the facility and to ensure someone accompanies Resident #2 out of the facility. The monitoring watch would lock the door when Resident #2 got close to the door and staff would ensure Resident #2 did not leave unattended. Resident #2 walks (ambulates) by herself and was able to transfer herself without an assistive device. The Progress Notes dated 12/26/17 at 3:55 p.m. revealed the staff received a call from an Independent Living tenant reporting Resident #2 was in the Independent Living unit. The Elpas system recorded Resident #2 at the AL ramp at 3:24 p.m. The staff went to the Independent Living Unit and assisted Resident #2 back to the nursing facility. The staff assessed Resident #2 and found no abnormalities. The staff notified the family who reported they visited earlier and left Resident #2 resting in bed when they left. The Progress Notes dated 12/26/17 at 5:54 p.m. revealed an Independent Living tenant leaving the nursing facility (AL ramp door) reported there was a man who exited the door at the same time as the Independent Living tenant. The Independent Living tenant did not see Resident #2. However, the Independent Living tenant felt that someone was behind him/her. The facility investigation of the incident revealed, a Independent Living tenant asked Resident #2 to accompany her back to the nursing facility on 12/26/17; and Resident #2 did not verbalize an acknowledgment of where she was or where she was going. Upon returning to the nursing home, Resident #2's nurse approached them. Resident #2 had been dressed and wearing a pair of slacks, long sleeve shirt with sweater, and non-skid shoes. Resident #2's had a history of [REDACTED]. The facility noted staff were made aware of Resident #2's was by the East door per the Elpas pagers, but the audible alarm did not sound and they were unaware that she had exited the building (nursing building). The Maintenance staff member may have disabled the audible alarm to the east door when they upgraded the system in September (2017). An interview on 1/19/18 at 12:22 p.m. revealed the Director of Nurses (DON) reported she completed some of the nursing daily door checks. The DON reported she checked the AL Ramp door with a Wanderguard watch. The DON checked to ensure the door locked down when approached. The DON reported she did not push the handicap accessible button to open the door and then walk through the door with the Wanderguard watch to test the audible alarm. The DON reported the facility had a new server installed. When the server was installed the AL Ramp door audible alarm was not programmed into the new server. The audible alarm did not function when Resident #2 went through the AL Ramp door. When a resident goes through the door an audible alarm sounds and a page goes out to the staff that the resident exited the facility. The DON reported the AL Door and the Front door are both alarmed in the same manner. The DON and Maintenance are the only staff authorized to reset the AL Ramp door and the Front Entrance alarm. The DON reported she provided in-service training after Resident #2's elopement on how to properly complete the daily door checks. An interview on 1/19/18 at 9:38 a.m. Staff C (Maintenance) reported on 12/27/17 he/she programmed the AL Ramp door audible alarm in the server. Staff C reported the facility hired a company to install the new server. The new server was installed 9/19/17 to 9/22/17. Staff C reported Staff were alerted she was by the door but did not think Resident #2 went through the door. The Alerts Results reported on 12/26/17 at 3:46 p.m. revealed the staff received an alert Resident #2 at the AL Ramp for 14 seconds. An alert was sent to staff again at 3:58 p.m. for the AL Ramp door. The facility Elpas Nurse Call & Elopement Management system documented each resident wears a pendant and the pendant serves three main purposes - call button for assistance, real-time location and Wanderguard. The facility identified their building is equipped throughout with a variety of readers which can tell where a resident is located anywhere in the premises. The elopement management piece of Elpas for residents with a propensity to wander, a locking wrist band is provided and can only be removed with a special key. When they move into the field of a door reader, the door locks and will not unlock until they leave the door reader's field or after holding the door for 15 seconds. If the resident holds the door for 15 seconds or if they move into the door reader's field when the door is open, a message is sent to the staff handheld devices and staff computers and an alarm will sound alerting staff that the resident is at an open door. On 1/24/18 at 4:33 p.m., the Administrator reviewed the door alarms and reported all door will alarm except for the front door and door to the Independent Living area. The Administrator reported the front doors have 2 Radio Shack magnetic alarms and obtained a key to turn the alarms On. The Administrator then left these alarms turned On and called the maintenance to see what could be placed on the Independent Living door and reported she would have staff stationed by the door to watch for exiting residents. After 10 p.m., the Administrator reported she would then turn back On the Radio Shack alarms and will call the company to see what can be done. On 1/24/18, the facility abated the IJ when they turned On the Radio Shack alarms at the two doors not alarmed and temporarily added a staff to observe residents. On 1/26/18 the facility door management system (Elpas Nurse Call & Elopement Management system) was updated for residents who are not a wander risk, specifically a message is sent to the staff handheld devices and staff computers when they move into a door reader's field. The door will not lock, but if they open the door, a message is sent to the staff handheld devices and staff computers and an alarm will sound alerting staff that the resident is at an open door. Residents are continually monitored for changes in mental status, and if the staff notices a change or an increased propensity to wander, they will be moved into the wander group and provided a locking band to ensure they do not remove their pendant. The facility in-serviced staff on 1/24/18 on this new system. These findings lowered the IJ from a K severity level to a E with ongoing monitoring to ensure residents safety.

Based on observation, record review, and interview, the facility failed to provide appropriate care and treatment to prevent new sores from developing 1 of 2 residents reviewed with pressure ulcers (Resident #4). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/20/16, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene, extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use, and depended totally on 2 staff for bathing. The MDS stated the resident was at risk of developing pressure ulcers and had 1 unstageable pressure ulcer with suspected deep tissue injury. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The resident's Admission Record listed an admitted [DATE] with admission [DIAGNOSES REDACTED]. The Skin Risk Assessment, dated 12/13/16 (the resident's admitted ), revealed the resident had a chronic ulcer under the right great toe and listed the resident's skin risk as low. The document contained no other information related to additional skin concerns upon admission. Skilled charting for 12/14/16 documented the resident had no open skin areas on the left or right foot/toes, protecting area on left outer metatarsal (top middle portion of the foot). a. A Skin Observation Tool, dated 12/20/16, revealed staff noted a blood blister on the left heel, blister intact, [MEDICATION NAME](a transparent film dressing) applied for protection, heels floated in bed, staff informed to avoid all pressure, including shoes and socks and to float heels at all times. Measurements (in length x width x depth) = 2 cm (centimeters) x 3.4 cm x unmeas. The stage was listed as suspected deep tissue injury defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A Skilled Charting entry, dated 12/20/16, documented the resident's heels were flat on the bed, blood blister noted to left heel 2 cm x 3.4 cm, heels floated at this time. The resident's January MAR (Medication Administration Record) displayed a 12/21/16 order for [MEDICATION NAME] for protection to blister on left heel, check every shift for placement. A Skin Observation Tool, dated 12/27/16, listed the left heel measurements as 3.3 cm x 4.8 cm x unease. A Skin Observation Tool, dated 1/3/17, listed 2 measurements for the left heel: 1.6 cm x 1.6 cm x unmeas and 2.8 cm x 3.6 cm x 0.1 cm. The document stated the left heel blister was broken and the top skin came off, no inflammation or drainage, center of blistered area darkened, not black at this time, floating heels and no shoes when in recliner/room. A Skilled Charting entry, dated 1/4/17, identified the dark area on the left heel was larger and the resident had no dressing covering the wound. A Skin Observation Tool, dated 1/4/17, listed measurements for the center of the left heel as 2.6 cm x 1.8 cm x unmeas and described the center as black. The document listed the left heel measurement as 3 cm x 2 cm x 0.1 cm. The document stated the center of the left heel changed since 1/3/17, area black and firm. A 1/4/17 physician's orders [REDACTED]. a. Strict pressure precautions b. Blue boot cushion or similar c. Pad foot of recliner d. Egg crate to bed e. No shoes, daily dressing changes to left foot f. Keep wound clean and dry The MDS assessment tool, dated 1/10/17, revealed the resident was at risk of developing pressure ulcers and had 2 unstageable pressure ulcers with suspected deep tissue injury. A Skin Observation Tool, dated 1/11/17 listed measurements for the black center of the left heel as 3 cm x 2.5 cm x unmeas and listed the left heel measurements as 4 cm x 3 cm x unmeas. A 1/13/17 physician's orders [REDACTED]. A Skin Observation Tool, dated 1/18/17, listed 1 set of measurements for the left heel described as black eschar (dead tissue): 2.2 cm x 3 cm x unmeas. The document stated the left heel pressure round center was blackened, dry, and firm. A Skin Observation Tool, dated 1/25/17, listed measurements for the left heel as 2.2 cm x 3 cm x unmeas. During an observation on 1/31/17 at 10:40 a.m., Staff H, Licensed Practical Nurse (LPN) measured an area of black eschar on the resident's heel at 3 cm x 2 cm. The surveyor noted an odor coming from the wound. The facility lacked any documentation of the odor coming from the wound during the surveyor observation. b. A Skin Observation Tool, dated 12/27/16, identified the facility noted a small scratch to the top of the left great toe measuring 0.2 cm x 0.4 cm x 0.1 cm and listed the stage as N/A(Not available). A Skin Observation Tool, dated 1/3/17, described the area to the top left great toe as a scratch/pressure and categorized the area as a Stage 2 described as partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed. The document listed the measurements as 0.2 cm x 0.2 cm x 0.1 cm. A Skin Observation Tool, dated 1/4/17, listed measurements for the top left great toe as 0.2 cm x 0.2 cm x 0.1 cm. A Skin Observation Tool, dated 1/11/17, listed measurements for the top left great toe as 0.3 cm x 0.3 cm x unmeas. A Skin Observation Tool, dated 1/18/17, listed measurements for the top left great toe as 0 cm x 0 cm x 0 cm and described the area as a dry open scab with slight indentation. A Skin Observation Tool, dated 1/25/17, stated the pressure area on the left great toe resolved, dry flaky skin present. During an observation on 1/31/17 at 10:40 a.m., Staff H LPN measured a pink/red area on the resident's left great toe at 3 cm x 2 cm. The facility lacked documentation of the wound worsening between the 1/25/17 note stating the wound had resolved and the surveyor observation on 1/31/17 with measurements of 3 cm x 2 cm. The initial resident care plan, dated 12/13/16, directed staff to reposition the resident every 2 hours and provide treatment per physician's orders [REDACTED]. A care plan entry, dated 12/23/16, stated the resident had actual impairment to skin integrity of the left heel related to suspected deep tissue injury. Care plan entries, dated 1/2/17 stated the resident required the following interventions: a. Assistance of staff to turn and reposition in bed every 2 hours and as necessary. b. Skin inspection during bathing and as needed, observe for redness, open areas, scratches, cuts, bruises, report changes to the nurse. Care plan entries, dated 1/3/17, stated the resident required the following interventions: a. A pressure relieving/reducing mattress on the bed to protect the skin while in bed b. Float heels while in bed Care plan entries, dated 1/4/17, stated the resident required the following interventions: a. Provide 1 ounce liquid protein twice per day b. Resident is not to wear shoes at this time c. Pressure reducing boots while in bed A care plan entry, dated 1/31/17, stated the resident required an air flow pressure reduction mattress. The care plan lacked documentation of interventions implemented related to the prevention and treatment of [REDACTED]. The care plan did not identify any problems related to the resident's refusing to wear the boot or refusing to float heels. During an interview on 2/1/17 at 10:30 a.m., the Assistant Director of Nursing stated she found the blister on the resident's heel. She stated when she found the blister the resident had his/her heel dug into the mattress. She said it looked like his/her heel was floated but he/she pushed the pillow away. During an interview on 2/1/17 at 4:20 p.m. the Director of Nursing stated the resident was absolutely at risk for skin breakdown upon admission. She stated staff were to float the resident's heels but is questioning whether that was done consistently. She stated she would have expected interventions on the care plan prior to 1/3/17 and stated in the future, she would assign the staff members to the same residents for the purpose of consistency of care.

Based on record review and staff interviews, the facility failed to provide adequate nursing supervision to protect against hazards from self. others or hazards in the environment for 1 of 3 residents reviewed who experienced falls (Resident #11). The resident sustained [REDACTED]. The facility reported a census of 52 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 1/11/17, Resident #11 had [DIAGNOSES REDACTED]. other fracture. and Parkinson's disease. It also identified the resident displayed severe cognitive impairment and required staff assistance with all Activities of Daily Living (ADLs). The resident's care plan initiated on 1/10/16 identified the resident experienced impaired cognitive function and thought processes related to impaired decision making with a goal that indicated the resident would remain oriented to self and spouse. The care plan also identified the resident displayed an Activities of Daily Living (ADL) deficit and was at risk for falls. The care plan directed staff: a. Anticipate and meet the resident's needs. b. Resident #11 utilized a walker for ambulation (walking). c. Provide standby assist of one staff with use of walker for ambulation when he/she is seen up. d. Provide standby assist of one staff for transfers when seen up. e. Provide extensive assist of one staff for toilet use. f. Cue, reorient and supervise as needed. g. Present just one thought, idea, question, or command at a time. h. Be sure the call light is in reach and encourage the resident to use it. i. Apply bed alarm at bedtime and throughout the night to alert staff when he/she is up so staff may check on and assist the resident (added 1/22/16) j. Falls are expected as Resident #11 is not aware of his/her deficits. The resident is able to get down on the floor and he/she often does this to clean floors, baseboards, organize closets and pick up items from the floor. (revised 2/11/16) A Fall/Injury Monitor- Suspected Head Injury form dated 12/31/16 at 6:05p.m. revealed the resident's roommate called for help. Staff entered the room and found the resident on the floor on the roommate's side of the room in front of the roommate's recliner with the left side of his/her face against the floor and the rest of the body in the prone position. The resident's feet pointed toward the head of the bed and the rest of his/her body angled toward the doorway of the room. Staff documented the resident's right lower leg lay over the bottom of the resident's tray table with water from the cup on the tray on the floor. The nurse called the resident's name with no response. Vitals signs as follows: Temperature 97.5, P 63. Respirations 16. Blood Pressure 160/100 and Oxygen Saturation 95% on room air. The staff documented the resident began to open their eyes and was able to provide the nurse with their daughter's name. The resident sustained [REDACTED]. Another staff member had been directed to notify the physician and the writer of the report stayed with Resident #11 until the ambulance arrived. At that time, the resident's roommate reported the resident stood on the bed to hang a picture and fell and hit his/her head. Progress Notes dated 12/31/16 at 6:08a.m. revealed staff documented they notified the physician of the resident's fall and obtained an order to transfer. Progress Notes dated 1/4/17 at 2:11 p.m., revealed the resident returned from an admission to the hospital where he/she had been since 12/31/16 after sustaining a fall with loss of consciousness. The resident sustained [REDACTED]. Resident #11 had an order for [REDACTED]. Staff documented the resident transferred from the wheelchair to the toilet with the assist of one staff. A review of the discharge summary revealed the resident was admitted to the emergency department on 12/31/16, admitted to the local hospital, later transferred to the university hospital and discharged on [DATE] with the reason for admission - trauma and principal [DIAGNOSES REDACTED]. The hospital course included orthopedic and neurosurgery consults. The care plan with the target date of 2/8/17 failed to contain any information related to the resident's fall which occurred on 12/31/16, the Miami J collar, or the need for physical and occupational therapy services. The Progress Notes contained the following entries: a. On 1/10/17 at 9:30p.m. staff found the resident crawling out of bed. Staff assisted him/her to the wheelchair, took the resident to the dining room and gave him/her a snack. b. On 1/15/17 at 12:25 a.m. the Resident #11 stood up from his/her low bed and walked into neighbor's room where staff provided care. The alarm did not sound. Staff documented the resident walked with no problems and staff escorted the resident back to his/her own room. Staff then took the resident to the bathroom. c. On 1/15/17 at 2:21 p.m., the CNA found the resident standing in his her room with the chair alarm in the recliner with his/her lunch tray. The staff attempted to remove the lunch tray and the resident grabbed the tray and would not let go. The RN documented the CNA called for help and RN responded and witnessed the resident with one hand on the tray and water pitcher and another on the walker. The resident poured water on the tray and floor and staff assisted him/her to the recliner and cleaned up the water. Staff then assisted Resident #11 to the wheelchair with the chair alarm alarm and took him/her to the common area by the nurse's station. d. On 1/16/17 at 5:45a.m., Staff found the resident's alarm sounding without the resident in the room. They found the resident under the table in main dining room wiping the floor. Staff brought the resident his/her walker and the resident stood up without help, returned to his/her room and went to sleep. f. On 1/20/17 at 5:17a.m., Staff documented they found the resident under the table in main dining room. The resident stood up alone with the walker and staff assisted him/her back to bed. g. On 1/21/17 at 12:15 a.m. the resident sat at the nurse's station in the wheelchair eating a snack and reading the paper. The resident stood up and began to walk without his/her walker. Staff attempted to assist the resident to their room, but the resident was non¿compliant and resisted. Staff attempted 3 more times and the resident went back to bed. A review of an incident report (fall/injury monitor) revealed the resident fell again on 1/17/17 at 6:15p.m. which resulted in a 3 centimeter hematoma to the left posterior part of the resident's head. In an interview on 2/1/17 at 3:14p.m., Staff G, CNA reported on 12/31/16 the resident's roommate called out for help and reported the resident had attempted to hang a picture on the wall while standing on the bed and fell on the floor. Prior to the fall, the resident had a bed alarm at night and could be up ad lib in the room, however, if out in the hallway required standby assistance. The resident had been found on the floor, unresponsive, sent to the hospital by ambulance and in the hospital for a few days. Staff G reported the resident fell a few more times after returning from the hospital and required the assistance of one person for transfers and ambulation, low bed and now a chair alarm. During an interview on 2/1/17 at 3:26 p.m., Staff I, RN reported prior to the fall on 12/31/16 the resident required the assistance of one staff member with walker when the resident had been seen up. On 12/31/16, staff found the resident on the floor with a small amount of blood noted to the back of the head and unresponsive. Staff sent the resident to the hospital by ambulance. When the resident returned to the facility he/she received skilled services and continued to do so. Staff I stated now the resident is care planned to transfer with assist of one with gait belt and walker and has a bed and a chair alarm. The resident had some falls after he/she returned from the hospital. As a result of one of the falls, Resident #11 sustained a hematoma to the back of the head. Staff G reported the resident now required a lot of one-on-one assistance. A review of the undated facility policy titled: fall prevention directed staff to: a. Interview the resident and family upon admission to determine if there is a history of falls. Attempt to identify times, locations and what the resident was attempting to do when they fell . b. Establish interventions based on the RAP information to eliminate or decrease the resident's risk and/or causative factors. Identify these on the resident's plan of care and the CNA care guide. c. After each fall, complete the falls assessment record. Look for trending. Identify the possible reason for the fall and make appropriate changes to the plan of care.

Based on observation, record review and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for one of five residents reviewed with accidents. Staff K ambulated Resident #5 by using and walker and hands on assistance. Resident #5's requested to use a Kleenex so they stopped at the nurse ' s station for a tissue. At that time, Staff K let go of the resident to get the tissue and change the alarm she was holding from one hand to the other. Also at that time, staff was distracted by the nurse who was asking her a question. When staff turned to respond to the nurse, the resident fell to the floor sustaining skin tears, a head injury that required staples and a fractured hip. The resident has difficulty maintaining balance according to her assessment. Facility census was fifty-two (52) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 5/4/11 assessed Resident #5 with a brief interview for mental status (BIMS) score of 11 (moderate cognitive impairment). The MDS identified the resident to require extensive assistance of one staff with ambulation in room and limited assistance of one staff with ambulation in corridor. MDS section titled "balance during transitions and walking" identified the resident as unsteady and only able to stabilize with human assistance when doing the following activity: moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfers. The resident utilized a mobility device of walker. The resident had [DIAGNOSES REDACTED]. A current care plan, dated 5/12/11 identified the resident with a problem of "risk of injury related to falls". The care plan directed staff to use 1 to 2 staff for transfers and ambulation. The care plan identified the resident used a walker and at times, staff used a Hoyer (mechanical) lift for transfers. An approach listed under a problem of" activities of daily living/rehab potential" directed staff to use a bed/chair alarm to alert staff of attempts to get up without assistance. A physician order [REDACTED]. A restorative/maintenance program form dated 5/13/11 and signed by the Director of Nursing (Staff J) and restorative aide (Staff G), stated staff should ambulate the resident in room with walker and staff assist. The program report stated, "Resident ambulated with walker and one or two assist". Nurses notes dated 5/29/11 at 4 p.m. stated the resident ambulated with a wheeled walker and staff assistance from lobby to the assisted dining area. The resident lost balance and fell to the floor on the right side. The resident received several skin tears and hit his/her head. The resident sustained [REDACTED].) by 0.2 cm., right thumb 1 cm. by 1 cm. , right thigh 6 cm. by 3 cm.. Right knee 2 cm. by 0.2 cm., right ankle 1 cm. by 1 cm. The resident complained of pain in the right hip/pelvic area. The facility notified the physician and the resident transported to the emergency room for evaluation. The resident returned to the facility at 6:45 p.m. with 4 staples to the right posterior head. The physician read the x-ray and determined no fracture present. Nurses notes, dated 5/30/11 at 10:50 a.m. identified with resident with continued complaints of pain. The resident stated "That leg does not move well". Staff administered Tylenol (analgesic) for the pain. Nurses notes dated 5/31/11 at 8:15 a.m. identified the resident with increased right hip pain. Staff administered Tylenol. At 9 a.m. the physician called and stated the radiologist read the x-ray and determined the resident had an impacted fracture of the right hip. At 12:41 p.m., the resident transported to the hospital. The facility investigation indicated the resident underwent [REDACTED]. The resident was at the hospital during the investigation, having just undergone surgery and therefore could not be interviewed. According to an interview that the social worker conducted with the resident on 5/31/11 at noon. Resident #5 reported that she took her hands off of the walker to blow nose and fell . Staff Interviews: On 5/31/11 at 3:08 p.m., Staff K identified self as ambulating the resident with the walker down the hall from the resident's room. They stopped at the nurses station because the resident's nose was running and the resident needed a Kleenex. Staff K stated she let go of the walker to put the resident's alarm in one hand and get the Kleenex with the other hand. Following that, Staff K stated she did not grab back onto the resident. Someone distracted her and when Staff K turned away the resident fell down. Staff K stated she did not use a gait belt for the resident. After the fall, the resident sustained [REDACTED]. On 5/31/11 at 3:20 p.m., Staff L identified self as the nurse on duty when the resident fell . Staff L stated the nurse aide (Staff K) did not pay attention and did not use a gait belt. Staff L stated normally staff either used a gait belt when ambulating the resident or held onto the resident's pants. She stated Staff K stood with the alarm in one hand and then glanced away and did not have a hold of the resident and the resident fell . When asked, on 6/1/11 at 9:18 a.m., what expectations were of the staff when ambulating the resident, the Director of Nursing (Staff J) stated she did not expect staff to hold onto the resident during ambulation. She stated the resident only required standby assistance. She stated the facility did not require staff to use gait belts but they are available if staff wants to use them. Gait belts are only used if physical therapy recommends it or the physician orders [REDACTED]. Review of the disciplinary action form confirmed, on 5/29/11, Staff L and Staff C staff ambulated the resident with a walker and did not use a gait belt or hold onto the resident and the resident fell and a disciplinary action was issued. When asked on 6/1/11 at 12:25 p.m. what she meant by "staff assistance" on the care plan, Staff A (care plan nurse) stated staff assistance means the resident needs to have someone with them. The amount of assistance needed varies day to day. Some days the resident needs hands on versus stand by assistance. It varies on time of day as well. A staff has to be there. They can be hands on or no hands on. On 6/1/11 at 1:52 p.m., Staff B stated she always held onto the back of the resident's pants when ambulating the resident. On 6/1/11 at 1:05 p.m., Staff C (Registered Nurse) stated staff always used a walker and one person hanging onto the resident because the resident "has an alarm". On 6/1/11 at 12:27 p.m., Staff D stated the resident needed help to get up and once up, staff would hold onto the resident's arm while the resident ambulated. On 6/1/11 at 12:12 p.m., Staff E stated when she ambulated the resident she held the resident's upper arm, and walked the resident with a walker and one or two staff assisting On 6/1/11 at 11:47 a.m., Staff F stated the resident used hands on assistance while ambulating and did very well. The resident also used a walker. When asked how staff knows what to do, Staff F stated by the care plan, verbal communication and staff has been employed at the facility for a long time. On 6/1/11 at 10:20 a.m., restorative aide Staff G stated the resident required stand by assistance with verbal cues. Staff G stated the physical therapist had not seen the resident before for ambulation needs. On 6/1/11 at 9:50 a.m., Staff H stated she ambulated the resident with one assist with hands on arm and one hand by "britches" in case the resident got unsteady. Staff H identified the resident as "pretty steady" but "make sure you keep hands on resident and don't let go". On 6/1/11 at 9:57 a.m. Staff I stated when she ambulated the resident, she would have one hand on the walker and one hand on the seat of the resident's pants to keep the resident focused. Staff I stated the resident's knees would give out at times and sometimes while ambulating she would get halfway from room to dining room and would want to sit down. Some days staff would ambulate the resident by having another staff following with a wheelchair. On 6/1/11 at 11:10 a.m., Staff Q stated she always had hands on the resident while ambulating and never left the resident's side. The resident could get unsteady without warning.