Every finding on record at Village Shalom Inc

The facility identified a census of 64 residents. The facility had one main kitchen, three kitchenettes, and dining areas. Based on observation and interview the facility failed to ensure that opened packages of frozen foods were stored in a sealed bag with a label and an open date. The facility failed to ensure staff wore a hairnet when in the kitchen food preparation and serving areas. The facility failed to ensure staff delivered plates of food in a sanitary manner. The facility failed to ensure staff performed hand hygiene after serving residents their plates and or drinks. This placed residents at risk of food-borne illnesses. Findings included: - During the initial tour of the main kitchen area on 06/02/25 at 07:08 AM, the following was noted: Dietary Staff CC was noted not to be wearing a hairnet to cover his hair and was not wearing a beard net to cover his facial hair and beard. In the food prep freezer were three opened brown bags of frozen potato products. The bags had not been placed into a sealed bag and the items had no label or open date present. On 06/02/25 at 12:17 PM, on the 700-hall dining/serving area the unidentified dietary server had a hairnet on and had gloves on during the serving of the food. The unidentified dietary server drained the liquid off a bowl of fruit and then continued to place food items on plates of food for the residents. The unidentified dietary server had not changed her gloves during the meal service. On 06/02/25 at 12:23 PM, an unidentified Certified Nurse Aide (CNA) assisted with serving prepared plates of food to the residents. During the serving of resident plates, the unidentified CNA served two plates to a resident with her thumb on top of the lip of the plate. During the service of four residents, the unidentified CNA failed to perform hand hygiene at any point during the serving of the plated food. On 06/03/25 at 08:56 AM, on the 100-hall kitchenette area, the unidentified dietary server wore gloves while serving food but did not have her long ponytailed hair in a hairnet. On 06/03/24 at 10:58 AM, Dietary Services BB stated all staff either in the kitchen or in the unit kitchenettes should be wearing a hairnet whenever in the food prep or serving areas. Dietary BB also stated that any opened bags of food should be placed in a sealed bag with a label and an open date. Dietary BB stated she would talk to staff to reeducate them on appropriate food serving and hand hygiene techniques. The Food Storage- Food Safety & Infection Control policy dated 09/07/22, documented all opened food items returned to storage must be labeled and dated with the opened date or the prepared and a use-by date. All food items must be properly wrapped or placed in a container. The date the item was opened must be written below the date received. All identified food items that are open and not labeled with a use-by date are immediately discarded. The facility lacked a policy for serving meals.

The facility identified a census of 65 residents. The facility identified eleven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to perform hand hygiene before performing glucose checks, and before performing intravenous (IV - administered directly into the bloodstream via a vein) administration. The facility further failed to sanitize the Hoyer (total body mechanical lift) lift between residents. This defiant practice placed residents at risk of infections. Included findings: - On 06/02/25 at 11:44 AM, Licensed Nurse (LN) G performed a blood glucose checks for Resident (R)163. LN G cleaned the glucometer (an instrument used to calculate blood glucose), with alcohol wipes, LN G wiped R163's finger with the same alcohol wipe and then wiped the hub of the insulin pen. LN G did not perform hand hygiene before preparing the glucometer. On 06/02/25 at 12:18 PM, LN G gathered supplies from the nurse cart. LN G knocked on the door of R58's room. LN G did not perform hand hygiene before going into R58's room. LN G placed the IV supplies for R58 on her bed. LN G opened the alcohol wipe and removed the cap from the IV port hub. LN G cleaned the hub with an alcohol wipe and primed the IV medication. LN G did not perform hand hygiene before attaching the IV medication to the hub. On 06/04/25 at 11:22 AM, Certified Nurse's Aide (CNA) M used the Hoyer lift in R1's room. When CNA M was finished with the Hoyer lift, CNA M pushed the Hoyer lift into the hallway and walked away from the Hoyer lift. CNA M did not sanitize the Hoyer lift. On 06/02/25 at 11:30 AM, L N G stated she should have performed hand hygiene prior to the finger stick for R163 and at the end of the task. On 06/02/25 at 12:31 PM, LN G stated hand hygiene should be performed before entering a resident's room, and hand hygiene should be performed going from dirty to clean task when administrating IV medications. On 06/04/25 at 11:20 AM, LN I stated the nursing staff disinfected the sit-to-stand. LNI stated nursing staff do not always sanitize the Hoyer, because the resident does touch the lift. LN I stated the neighborhood keeps the sanitizing wipes in the medication cart, and nursing staff could just ask for those. On 06/04/25 at 11:22 AM, CNA M stated nursing staff are trained to sanitize lifts. CNA M stated sit to stands were always sanitized because the residents touch the lift. CNA M stated she does not clean the Hoyer as often, because the residents were in slings with their arms crossed and are not touching the lift. On 06/05/25 at 01:13 PM Administrative Nurse D stated all shared equipment should be sanitized between resident use. Administrative Nurse D stated staff should perform hand hygiene before entering a resident room and going from dirty to clean tasks. The facility's Hand Hygiene policy revised on 01/05/22 documented that all staff members would comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of heal associated infections (HAIs). When hands were visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. Handwashing may also be used for routine decontamination hands in the following clinical situations, before and after having direct contact with patients. When moving from a contaminated body site to a clean body site during elder care before and after contact with inanimate objects including medical equipment in eh immediate vicinity of the elder and after removing gloves.

The facility had a census of 65 residents. The sample included 16 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the 11 cognitively impaired independently mobile residents. The facility additionally failed to provide Resident (R) 19 with consistent supervision during her meals and ensure her call light remained within reach. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings included: - On 06/05/25 at 07:10 AM, an inspection of an unlocked supply closet in the dining area of the 700 hall revealed 13 fully pressurized supplemental oxygen cylinders stored in floor racks. An inspection of a storage closet next to the supply closet revealed unsecured cleaning chemicals. The containers contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 06/05/25 at 07:16 AM, Licensed Nurse (LN) K stated the rooms should be always locked and secured the doors. She stated sometimes staff forget to pull them fully closed. On 06/04/25 at 12:44 PM, Administrative Nurse D stated all utility closets containing chemicals or oxygen were expected to be locked and not accessible to the residents. The facility's Oxygen Storage policy revised 10/2024 indicated oxygen cylinders were to be stored in a manner that ensured proper ventilation, and safety, and secured away from potential combustible elements. The facility's Control of Hazardous Chemicals policy revised 10/2023 indicated the facility was to ensure an environment free from potentially hazardous materials, chemicals, and equipment. - The Medical Diagnosis section within R19's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), anxiety (cognitive or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and speech/language deficits. R19's Quarterly Minimum Data Set (MDS) completed 04/02/25 noted a Brief Interview for Mental Status (BIMS) of zero, indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS indicated she required substantial to maximal assistance from staff to eat her meals. The MDS indicated she was at risk for skin breakdown and pressure ulcers but had no wounds. The MDS indicated she had pressure-reducing devices for her bed and wheelchair. The MDS noted she had a repositioning program and nutritional interventions to prevent pressure ulcers. The MDS noted she weighed 122 pounds (lbs.). R19's Functional Ability Care Area Assessment (CAA) completed 01/09/25 indicated she required assistance from staff for her Activities of Daily Living (ADL) related to her medical diagnoses. The CAA noted she had confusion due to a decline in her cognition. The CAA noted she required maximum assistance from one to two staff for bed mobility. The CAA noted she was not always able to express her needs. The CAA noted she was at risk for falls related to her limited mobility and declining ADLs. R19's Care Plan initiated on 01/22/25 indicated she was at risk for impaired decision-making, ADL deficits falls, and weight loss related to her cognitive impairments and medical diagnoses. The plan noted she required extensive assistance from staff for bed mobility, transfers, bathing, dressing, toileting, and wheelchair mobility. The plan noted that R19 required assistance from one staff while eating her meals. The plan instructed staff to encourage her to have meals in the dining room so she had supervision and cues to eat food during meals. The plan instructed staff to provide feeding assistance by mimicking actions to help her with self-feeding during meals. The plan indicated she was not to be left in her room alone while eating. The plan indicated she had a pressure-reducing low air-loss mattress on her bed. The plan instructed staff to keep her call light within reach while in her bed or chair. R19's EMR under Physician's Orders revealed an order (dated 02/10/22) that instructed staff to administer one carton of Ensure (supplemental nutrition to prevent weight loss) by mouth 30 minutes after each meal for protein-calorie malnutrition. R19's EMR under Assessments revealed a Nutrition Risk Assessment completed 05/29/25. The assessment indicated that R19 required supervision during meals. The assessment noted she required partial to maximal assistance during mealtimes with feeding. The assessment revealed she was provided Ensure supplementation three times daily. On 06/02/25 at 09:30 AM, R19's rested in her bed. R19's bedside table was positioned over her chest. R19 lay flat on her back with the shoulders and neck propped upward to her bedside table. R19's breakfast meal was uncovered and untouched. R19's Ensure supplement was left with her breakfast meal. On 06/02/25 at 09:56 AM, R19 remained asleep in the same position but her Ensure supplement bottle was empty and rested downward in her lap. R19's push-button call light rested on the bed underneath her bed next to the wall. R19's breakfast meal remained untouched. R19's low air-loss mattress control panel was set to 200 lbs. On 06/03/25 at 09:20 AM, R19's rested in her bed. R19's bedside table was positioned over her chest. R19 lay flat on her back with the shoulders and neck propped upward to her bedside table. R19's food was untouched and uncovered. R19's Ensure supplement was served with her meal. On 06/03/25 at 09:32 AM, R19 lay in her bed and ate her breakfast meal in her room. Staff were not present as she consumed her breakfast meal. R19 call light was under her bed near the back wall. On 06/04/25 at 09:37 AM, R19's breakfast was served to her in her room. R19'sEnsure supplement was given to her with her breakfast. Staff stayed in the room as she ate her meal and consumed her Ensure during her meal. On 06/04/25 at 11:25 AM, Licensed Nurse (LN) J stated R19 only used the call light attached to her wall. She stated R19 had communication deficits and staff were expected to either move her out to the common area or ensure her call light was in reach while she was in her room. She stated staff were expected to monitor her during meals and provide encouragement. She stated R19 often was confused and needed cueing. She stated staff were never to allow her to eat alone in her room. On 06/04/25 at 12:24 PM, Certified Nurses Aide (CNA) N stated staff were expected to follow the care plan. She stated if resident chose to eat in their room and required assistance, staff were to stay with them during the meal and aid them. She stated call lights were to remain within the resident's reach while in bed. On 06/04/25 at 01:13 PM, Administrative Nurse D stated staff were expected to supervise and provide assistance to residents based on their care planned needs. She stated resident with cognitive impairment should not be left alone in their rooms to eat during mealtimes. She stated staff were expected to encourage them to eat in the dining area or sit with them during mealtimes in their rooms. She stated call lights were to remain within the resident's reach while in bed. The facility's Fall Management Policy policy revised 02/2025 indicated the facility was to assess each resident to identify potential accident risks and hazards. The policy indicated implementing interventions would be in place.to minimize the risks. The facility's Call Light Policy policy revised 11/2023 indicated the resident were to have access to a call system for communication. The policy indicated staff were expected to ensure the call light remained within reach of the residents.

The facility identified a census of 65 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 50 and R1, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. This deficient practice placed R50 and R1 at risk for ineffective treatment, unnecessary medication use, and unwarranted side effects. Findings included: - R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), tachycardia (rapid heartbeat greater than 100 beats per minute), hypotension, hemiplegia (paralysis of one side of the body), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) The Annual Minimum Data Set (MDS) dated 12/25/24 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R50 had received antidepressant (a class of medications used to treat mood disorders) and antipsychotic medication during the observation period. The Quarterly MDS dated 03/12/25 documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R50 had received antipsychotic medication and antidepressant medication during the observation period. R50's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/03/25 documented he was at risk for adverse side effects of psychotropic medications. R50's Care Plan, dated 04/16/24, documented staff provided medication and treatments per the physician's orders. The plan of care documented the staff would monitor for side effects of his medications and notify the physician. R50's EMR under the Orders tab revealed the following physician orders: Olanzapine (antipsychotic) five mg, give one tablet by mouth daily for psychosis (any major mental disorder characterized by a gross impairment in reality perception), dated 03/13/25. Review of the Monthly Medication Review (MMR) reviewed from May 2024 to April 2025 revealed the CP had identified and reported the irregularities related to the non-approved indication for the use of antipsychotic medication Olanzapine for R50 who had a diagnosis of dementia and Alzheimer's disease. The facility was unable to provide physician documentation for risk versus benefits upon request. On 06/04/25 at 08:46 AM, R50 sat upright on the side of his bed as he watched TV in his room. On 06/04/25 at 11:20 AM, Licensed Nurse (LN) I stated he was unsure what the appropriate indications should be for antipsychotic medications. LN I stated the facility documented R50's behaviors. On 06/04/25 at 01:13 PM, Administrative Nurse D stated only CMS-approved indications should be used for antipsychotic medications. She stated psychosis was not an appropriate indication for Olanzapine. Administrative Nurse D stated she was unsure if the physician had documented a risk vs benefit for R50's Olanzapine. The facility's Psychotropic Medication Use policy revised on 02/07/22 documented the resident's need for the psychotropic medication would be monitored, as well as when the resident received optimal benefits from the medication and when the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of as-needed (PRN) orders for psychotropic drugs to manage behaviors. - The Diagnosis tab of R1's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, encounter for palliative care (a specialized form of care that focuses on improving the quality of life for people living with serious illnesses when the resident was nearing the end of life or not), dependence on wheelchair, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated 03/19/25, documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R1 was rarely or never understood. The MDS documented R1 had behaviors that fluctuated in severity. The MDS documented R1 was dependent on staff for toileting and bathing. The MDS documented R1 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) during the observation period. R1's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 documented R1 triggered for this CAA due to the use of antipsychotic medication. The CAA documented the factors that place residents at risk for a problem including the potential for side effects from psychoactive medication. The CAA documented R1 had no recent falls that were attributed to the use of the medication. The CAA documented R1 had not demonstrated any apparent side effects or adverse consequences from the current medication regimen that contains Black Box Warning (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). R1's Care Plan dated 04/30/24 documented the facility would work with the physician for a reduction in dosing when target behaviors are absent and or easily altered for specified periods, but no less than quarterly. R1's plan of care documented the facility would consider pharmacological interventions using medications other than antipsychotics, such as pain medication, by observing for lessening behavior and collaborating with the interdisciplinary team. The plan of care for R1 documented nursing was to administer a medication regimen as prescribed by the physician and notify the physician and psychiatrist for increased sedation, an increase in behavioral symptoms, unresponsiveness to environmental interventions, or an increase in side effects. R1's plan of care documented the facility would attempt gradual dose reduction (GDR) for antipsychotic medications per physician orders as recommended by the pharmacy consultant. R1's plan of care documented a GDR was being attempted, and staff will provide physical activities for R1 to participate in and help control the number of stimuli in her immediate environment. R1's EMR under Orders documented the following physician's order: Quetiapine fumarate (antipsychotic) 25 milligrams (mg) oral tablet, give 0.5 tablet by mouth every evening for severe dementia with agitation, dated 07/24/24. A review of R1's EMR revealed no physician-documented rationale for the continued use of quetiapine fumarate for dementia-related behaviors. The facility when asked was unable to provide a risk vs benefit for R1's continued use of Quetiapine. On 06/04/25 at 09:32 AM, R1 sat at the dining room table, visiting with peers. On 06/04/25 at 11:20 AM, Licensed Nurse (LN) I stated he was unsure what the appropriate indications should be for antipsychotic medications. LN I stated the facility documented R1's behaviors. On 06/04/25 at 01:13 PM, Administrative Nurse D stated only CMS-approved indications should be used for antipsychotic medications. She stated dementia was not an appropriate indication for quetiapine. Administrative Nurse D stated she was unsure if the physician had documented a risk vs benefit for R1's quetiapine. The facility's Psychotropic Medication Use policy revised on 02/07/22 documented the resident's need for the psychotropic medication would be monitored, as well as when the resident received optimal benefits from the medication and when the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of as-needed (PRN) orders for psychotropic drugs to manage behaviors.

The facility identified a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 50 was free from a significant medication error by not following the physician-ordered parameter for the administration of Midodrine (hypotensive medication used to treat low blood pressure). This deficient practice placed R50 at risk for increased complications, untreated complications, and falls with possible injuries. Findings included: - R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), tachycardia (rapid heartbeat greater than 100 beats per minute), hypotension (low blood pressure), hemiplegia (paralysis of one side of the body), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) The Annual Minimum Data Set (MDS) dated 12/25/24 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R50 had received antidepressant (a class of medications used to treat mood disorders) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Quarterly MDS dated 03/12/25 documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R50 had received antipsychotic medication and antidepressant medication during the observation period. R50's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/03/25 documented he was at risk for adverse side effects of psychotropic medications. R50's Care Plan, dated 04/16/24, documented staff provided medication and treatments per the physician's orders. The plan of care documented the staff would monitor for side effects of his medications and notify the physician. R50's EMR under the Orders tab revealed the following physician orders: Midodrine (hypotensive medication) five milligrams (mg) tablet, give one tablet by mouth three times a day for hypotension as needed. Administer for systolic blood pressure (SBP - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less than (<) 130 millimeters (mm) of mercury (Hg) or diastolic blood pressure (DBP - minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 60 mmHg, not to exceed three times a day as needed, ordered on 02/11/25 and discontinued on 05/06/25. Review of EMR under the Vitals tab revealed from 03/01/25 to 05/06/25 (67 days) documented blood pressure was within the physician-ordered parameters for administration of Midodrine on the following dates (50 opportunities): 03/01/25, 03/02/25, 03/05/25, 03/07/25, 03/09/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25, 03/17/25, 03/18/25, 03/19/25, 03/20/25, 03/21/25, 03/24/25, 03/25/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 04/01/25, 04/02/25, 04/03/25, 04/04/25, 04/05/25, 04/08/25, 04/09/25, 04/10/25, 04/13/25, 04/14/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, 04/20/25, 04/21/25, 04/22/25, 04/23/25, 04/24/25, 04/25/25, 04/28/25, 04/29/25, 04/30/25, 05/01/25, 05/02/25, 05/03/25, 05/04/25, 05/05/25, and 05/06/25. The clinical record lacked documentation the physician was notified. Review of R50's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 03/01/25 to 05/06/25 revealed Midodrine was administered on 03/30/25. On 06/04/25 at 08:46 AM, R50 sat upright on the side of his bed as he watched TV in his room. On 06/04/25 at 01:00 PM, Licensed Nurse (LN) H stated the nurse or the certified nurse aide (CMA) would obtain the blood pressure and the pulse before administering any medication that required vital signs. LN H stated the nurse was responsible to ensure the medication was given as ordered by the physician. LN H stated the CMA would notify the nurse if a resident's vital signs were outside the normal or physician-ordered parameters. LN H stated the physician should be notified if that was ordered and the notification would be documented in the interdisciplinary (ID) notes, along with the physician's response. On 06/04/25 at 01:13 PM, Administrative Nurse D stated she expected the physician's orders to be followed. Administrative Nurse D stated the physician should be notified if a physician order was not followed, and that notification would be documented in the resident's interdisciplinary notes. The facility's Physician Orders for Medication and Treatments policy dated 10/20/23 documented all medications would be administered as ordered by a healthcare professional authorized by the state to order medications.

The facility identified a census of 65 residents. The sample included 16 residents, with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Center for Medicare/Medicaid Services (CMS) form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the CMS form-10123 Notice of Medicare Non-Coverage (NOMNC) form was provided to Resident (R) 165. This placed R165 at risk of uninformed treatment decisions and unexpected costs. Findings included: - Review of R165 ' s Electronic Medical Record (EMR) noted an Interdisciplinary Team (IDT) Progress Note dated 02/03/25 at 04:41 PM documented staff met with R165's daughter and contacted the physician. Staff spoke to R165 regarding the last day covered and discharge to long-term care (LTC) on 02/07/25. Staff discussed with the NOMNC and the right to appeal. Staff discussed a room for the resident in the neighborhood of preference and would coordinate a transition date. The SNF Beneficiary Notification Review form (CMS-20052) completed by social services, documented R165 ' s Medicare Part A episode would end on 02/06/25. R165 remained in the facility for long-term care (LTC). Upon request from Social Services staff, R165 ' s SNF ABN form 10055 and NOMNC form 10123 was not provided. On 06/03/54 at 10:52 AM, Social Services X stated there had been a changeover in staff recently and it had been discovered that the ABN and NOMNC forms had not been issued to residents as they should have been. Social Services X stated she had recently taken over the responsibility of providing the ABN and NOMNC and residents would now receive the forms as required. The facility policy Medicare Denial Notices revised on 01/24/25 documented this facility will inform each resident before, or at the time of admission, and periodically during the resident ' s stay of services available in the facility and charges for those services including any charges for services not covered under Medicare by the facility ' s per diem rate. The facility would provide each resident with a written description of legal rights which included a description of the manner of protecting personal funds. This facility would provide written notification to residents with the necessary information to decide whether to appeal a decision to terminate Medicare care and services at least three days prior to the planned change in payor status or discharge.

The facility identified a census of 64 residents. The sample included 16 residents, with three reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide Resident (R) 19 with consistent assistance and supervision during mealtime. This deficient practice placed R19 at risk for potential risk related to impaired nutrition and weight loss. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), anxiety (cognitive or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and speech/language deficits. R19's Quarterly Minimum Data Set (MDS) completed 04/02/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS indicated she required substantial to maximal assistance from staff to eat her meals. The MDS indicated she was at risk for skin breakdown and pressure ulcers but had no wounds. The MDS indicated she had pressure-reducing devices for her bed and wheelchair. The MDS noted she had a repositioning program and nutritional interventions to prevent pressure ulcers. The MDS noted she weighed 122 pounds (lbs.). R19's Functional Ability Care Area Assessment (CAA) completed 01/09/25 indicated she required assistance from staff for her Activities of Daily Living (ADL) related to her medical diagnoses. The CAA noted she had confusion due to a decline in her cognition. The CAA noted she required maximum assistance from one to two staff for bed mobility. The CAA noted she was not always able to express her needs. R19's Nutrition CAA completed 01/09/25 indicated she was at risk for malnutrition and weight loss due to her medical diagnosis. The CAA indicated that the facility was to provide her with a diet as prescribed and implemented interventions to reduce the risk. R19's Care Plan initiated on 01/22/25 indicated she was at risk for impaired decision-making, ADL deficits, falls, and weight loss related to her cognitive impairments and medical diagnoses. The plan noted she required extensive assistance from staff for bed mobility, transfers, bathing, dressing, toileting, and wheelchair mobility. The plan noted that R19 required assistance from one staff while eating her meals. The plan instructed staff to encourage her to have meals in the dining room so R19 had supervision and cues to eat food during meals. The plan instructed staff to provide feeding assistance by mimicking actions to help her with self-feeding during meals. The plan indicated she was not to be left in her room alone while eating. The plan indicated she had a pressure-reducing low air-loss mattress on her bed. R19's EMR under Physician's Orders revealed an order (dated 02/10/22) instructing staff to administer one carton of Ensure (supplemental nutrition to prevent weight loss) by mouth 30 minutes after each meal for protein-calorie malnutrition. R19's EMR under Assessments revealed a Nutrition Risk Assessment completed 05/29/25. The assessment indicated that R19 required supervision during meals. The assessment noted she required partial to maximal assistance during mealtimes with feeding. The assessment revealed she was provided Ensure supplementation three times daily. On 06/02/25 at 09:30 AM, R19 rested in her bed. R19's bedside table was positioned over her chest. R19 lay flat on her back with the shoulders and neck propped upward to her bedside table. R19's breakfast meal was uncovered and untouched. R19's Ensure supplement was left with her breakfast meal. On 06/02/25 at 09:56 AM, R19 remained asleep in the same position but her Ensure supplement bottle was empty and rested downward in her lap. R19's push-button call light rested on the bed underneath her bed next to the wall. R19's breakfast meal remained untouched. R19's low air-loss mattress control panel was set to 200 lbs. On 06/03/25 at 09:20 AM, R19 rested in her bed. R19's bedside table was positioned over her chest. R19 lay flat on her back with the shoulders and neck propped upward to her bedside table. R19's food was untouched and uncovered. R19's Ensure supplement was served with her meal. On 06/03/25 at 09:32 AM, R19 lay in her bed and ate her breakfast meal in her room. Staff were not present as she consumed her breakfast meal. R19's call light was under her bed near the back wall. On 06/04/25 at 09:37 AM, R19's breakfast was served to her in her room. R19's Ensure supplement was given to her with her breakfast. Staff stayed in the room as R19 ate her meal and consumed her Ensure during her meal. On 06/04/25 at 11:25 AM, Licensed Nurse (LN) J stated that R19 only used the call light attached to her wall. She stated R19 had communication deficits and staff were expected to either move her out to the common area or ensure her call light was in reach while she was in her room. She stated staff were expected to monitor her during meals and provide encouragement. She stated that R19 often was confused and needed cueing. She stated staff were never to allow her to eat alone in her room. On 06/04/25 at 12:24 PM, Certified Nurses Aide (CNA) N stated staff were expected to follow the care plan. She stated if a resident chose to eat in their room and required assistance staff were to stay with them during the meal and aid them. On 06/04/25 at 01:13 PM, Administrative Nurse D stated staff were expected to supervise and provide assistance for residents based on their care planned needs. She stated resident with cognitive impairment should not be left alone in their rooms to eat during mealtimes. She stated staff were expected to encourage them to eat in the dining area or sit with them during mealtimes in their rooms. The facility's Activities of Daily Living policy revised 12/2021 stated the facility was to provide each resident with assistance to complete their daily activities and maintain their abilities.

The facility identified a census of 65 residents. The sample included 16 residents, with one reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure a dignified care environment for Residents (R) 31. This deficient practice placed R31 at risk for impaired dignity and unmet care needs. Findings included: - The Medical Diagnosis section within R31's Electronic Medical Record (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), major depressive disorder (major mood disorder), muscle weakness, overactive bladder, and need for assistance with personal cares. R31's Significant Change Minimum Data Set (MDS) completed 04/06/25 indicated a Brief Interview for Mental Status (BIMS) of zero, indicating severe cognitive impairment. The MDS noted he exhibited wandering and rejection of care behaviors one to three days a week. The MDS indicated he was dependent on staff assistance for dressing, personal hygiene, bed mobility, toileting, and bathing. The MDS indicated he had one-sided lower extremity impairment and used a wheelchair for mobility. R31's Functional Abilities Care Area Assessment (CAA) completed 04/15/25 indicated he required assistance with self-cares and mobility. The CAA noted R31 exhibited poor judgment and safety awareness. The CAA noted he was at risk for falls, skin breakdown, pressure ulcers, weight loss, and a cognitive decline. The CAA noted he had poor memory recall. R31's Behavioral CAA completed 04/15/25 indicated he had behaviors related to refusing cares offered by staff. The CAA noted the behaviors had the potential to place himself at risk due to his poor safety awareness. The CAA noted his right to decline care needs. The CAA noted a care plan was implemented to minimize the risks associated with his potential behaviors. R31's Care Plan initiated 04/16/25 indicated he was at risk for cognitive loss, communication deficits, declined activities of daily living (ADL), bowel and bladder incontinence, and falls related to his cognitive impairment and medical diagnoses. The plan indicated he had behavioral challenges related to refusal of his ADLs, restorative care, medications, and meals. The plan encouraged staff to speak to him calmly, provide redirections, and ensure his environment was safe during agitation. The plan noted he enjoyed shopping trips, music, and special events. The plan lacked interventions related to his preferences or behaviors related to undressing. R31's EMR under ID Notes revealed a Nursing Note completed 06/01/25. The note revealed R31 was found standing in his restroom with no clothes on next to the toilet. The note revealed staff toileted him and assisted with his cares. R31's EMR under ID Notes revealed a Nursing Note completed 05/27/25. The note revealed R31 removed his clothing for the entire night and refused to allow staff to provide cares for him. R31's EMR under ID Notes revealed a Nursing Note completed 06/01/25. The note revealed R31 was found naked in his bed with no sheets or blanket covering him. The note revealed R31 refused to allow staff to dress him or provide cares. On 06/02/25 at 07:03 AM, R31 slept in his bed. R31 was wearing no clothing and was exposed as he slept in his bed. R31's bed was viewable from the hallway. The exterior windows in R31's room were viewable from the outside area. On 06/02/25 at 07:34 AM, R31 was still asleep on his bed. R31 was still naked with nothing covering his body and visible from the hallway. On 06/02/25 at 07:38 AM, Certified Nurse's Aide (CNA) O entered R31's room to provide care. She stated that R31 sometimes preferred to sleep without clothing. She stated staff would still supervise and attempt to cover him up to prevent other residents from seeing him. On 06/04/25 at 11:32 AM, Licensed Nurse (LN) J stated R31 would often take his clothing off at night and refuse to wear them. She stated as long as he remained in his room it was his choice to do so. She stated he often was difficult to redirect or convince to redress or allow care to be given. On 06/05/25 at 12:45 PM, Administrative Nurse D stated residents had the right to choose to wear what they wanted, and staff were expected to make attempts to have the residents dressed. She stated the care plan should indicate a resident's choice or preferences to undress and be naked in their room. She stated staff should attempt to prevent other residents from seeing into the room or ensuring the resident was covered up. The facility's Dignity policy revised 11/2024 stated the facility was to ensure an environment that maintained and enhanced each resident's dignity and respect in full recognition of each resident's individuality.

The facility identified a census of 65 residents. The sample included 12 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) for Resident (R) 50. This deficient practice placed R50 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R17's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), retention of urine, kidney disease, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid, restlessness, and cerebral ischemia (a condition characterized by insufficient blood flow to the brain, leading to lack of oxygen and essential nutrients). The Annual Minimum Data Set (MDS) dated 08/28/24 documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R17 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. The Quarterly MDS dated 02/26/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R17 had received diuretic medication during the observation period. R17's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 02/26/25 documented R17 was noted to be frequently incontinent of bladder and needed extensive assistance with toileting needs including peri care. The CAA documented R17 was continent of bowel, and this increases the risk for skin breakdown and urinary tract infection (UTI). The CAA documented nursing staff would continue to assist R17, as needed, for him to have his needs met and continue his current level of functioning. R17's Care Plan dated 03/15/24 documented R17 was at risk for weight loss related to pain, diabetes, edema, medications, and a mechanically altered diet texture. R17's plan of care documented R17 wished to lose weight by one to two pounds a week. R17's plan of care documented R17 would be served a low carbohydrate diet of his choice with sugar-free beverages. R17's plan of care documented he would be encouraged to eat in the dining room. The plan of care documented R17 would be provided a carbohydrate-controlled diet, as ordered by the physician, and staff would weigh R17 daily as ordered by the physician. R17's EMR under the Orders tab revealed the following physician orders: Daily weight before breakfast, notify the physician with a weight gain of more than two pounds in one day or five pounds in one week, dated 07/15/24. Furosemide (diuretic) 40 milligrams (mg) tablet give one tablet by mouth daily for edema, dated 09/21/24. Review of R17's EMR under the Vitals tab, the Medication Administration Record (MAR), and Treatment Administration Record (TAR) from 03/01/25 to 05/08/25 (69 days) lacked evidence staff measured and recorded R17's weight on following nine dates: 03/04/25, 03/07/25, 03/08/25, 03/12/25, 03/14/25, 03/16/25, 04/04/25, 05/03/25, and 05/08/25. The TAR documented R17 had refused on 05/16/25. The clinical record lacked documentation of physician notification of daily weight was not obtained. On 06/04/25 at 08:38 AM, R17 sat in his wheelchair in his room. R17 sat at the bedside table and ate his breakfast. On 06/04/25 at 12:52 PM, Certified Nurse Aide (CNA) N stated all the staff assisted with obtaining the resident's daily weight if ordered. CNA N stated the nurse would notify the staff who was to be weighed daily. CNA N stated she would notify the nurse of the resident's weight. On 06/04/25 at 01:00 PM, Licensed Nurse (LN) H stated the nurse was responsible for ensuring a resident's daily weight was obtained and recorded. LN H stated the nurse would review the weight and notify the physician if needed and documented the notification and the physician's response in the resident's EMR. On 06/04/25 at 01:13 PM, Administrative Nurse D stated she expected the physician's orders to be followed. Administrative Nurse D stated the physician should be notified if a physician order was not followed, and that notification would be documented in the resident's interdisciplinary notes. The facility's Physician Orders for Medication and Treatments policy dated 10/20/23 documented all medications would be administered as ordered by a healthcare professional authorized by the state to order medications.

The facility identified a census of 64 residents. The sample included 16 residents, with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 19's pressure-reducing interventions were implemented correctly when R19's low air-loss mattress pumps were not set within her current weight range. This deficient practice placed R19 at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), anxiety (cognitive or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and speech/language deficits. R19's Quarterly Minimum Data Set (MDS) completed 04/02/25 noted a Brief Interview for Mental Status (BIMS) of zero, indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS indicated she required substantial to maximal assistance from staff to eat her meals. The MDS indicated she was at risk for skin breakdown and pressure ulcers but had no wounds. The MDS indicated she had pressure-reducing devices for her bed and wheelchair. The MDS noted she had a repositioning program and nutritional interventions to prevent pressure ulcers. The MDS noted she weighed 122 pounds (lbs.). R19's Functional Ability Care Area Assessment (CAA)) completed 01/09/25 indicated she required assistance from staff for her Activities of Daily Living (ADL)related to her medical diagnoses. The CAA noted she had confusion due to a decline in her cognition. The CAA noted she required maximum assistance from one to two staff for bed mobility. The CAA noted she was not always able to express her needs. R19's Pressure Ulcer CAA completed 01/09/25 indicated she was at risk for skin breakdown and pressure ulcers. The CAA noted she had no current skin breakdown but had pressure-relieving devices in place. The CAA noted care plan interventions were implemented to minimize the risks related to skin breakdown. R19's Care Plan initiated on 01/22/25 indicated she was at risk for impaired decision-making, ADL deficits falls, and weight loss related to her cognitive impairments and medical diagnoses. The plan noted she required extensive assistance from staff for bed mobility, transfers, bathing, dressing, toileting, and wheelchair mobility. The plan noted that R19 required assistance from one staff member while eating her meals. The plan instructed staff to encourage her to have meals in the dining room so she had supervision and cues to eat food during meals. The plan instructed staff to provide feeding assistance by mimicking actions to help her with self-feeding during meals. The plan indicated she was not to be left in her room alone while eating. The plan indicated she had a pressure-reducing low air-loss mattress (specialized air mattress used to reduce pressure on the body) on her bed. The plan lacked guidance or instructions related to her low air-loss mattress settings. R19's EMR under Assessments revealed a Nutrition Risk Assessment completed 05/29/25. The assessment indicated that R19 required supervision during meals. The assessment noted she required partial to maximal assistance during mealtimes with feeding. The assessment revealed she was provided Ensure supplementation three times daily. The Assessment revealed she had a Braden score (assessment used to predict pressure ulcer development) of 14 indicating she was at risk for developing pressure ulcers. A review of the manual of low air-loss mattress manufacturers' operation (Meridian Medical) indicated that the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range and comfort settings. The manual indicated an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. On 06/02/25 at 09:56 AM, R19 remained asleep in the same position but her Ensure supplement bottle was empty and rested downward in her lap. R19's push-button call light rested on the bed underneath her bed next to the wall. R19's breakfast meal remained untouched. R19's low air-loss mattress control panel was set to 200 lbs. The mattress pump had fixed weight settings of 80lbs, 110lbs, 140lbs, 170lbs, 200lbs, 230lbs, 290lbs, 320lbs, and 350lbs. On 06/02/25 at 02:01 PM, R19 slept in her bed. R19's low air-loss mattress was set to 200 lbs. On 06/03/25 at 08:22 AM, R19 rested in her bed. R19's low air-loss mattress was set to 200 lbs. On 06/04/25 at 11:25 AM, Licensed Nurse (LN) J stated that R19's mattress was set by her current weight. She stated she noticed the bed setting was too high and just changed it to her current weight. She stated staff were expected to check the bed settings each shift. On 06/04/25 at 01:13 PM, Administrative Nurse D stated the staff were to check the low air-loss mattresses were set to the resident's current weight or within the weight range. She stated staff were expected to check the bed's settings each shift. The facility's Wound Management policy revised 09/2024 indicated the facility will assess each resident's risk related to pressure ulcers and implement preventative interventions. The policy indicated the effectiveness of the implemented intervention will be evaluated and reviewed.

The facility identified a census of 65 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to address the Consultant Pharmacist (CP) recommendations for Resident (R) 50's Midodrine (hypotension (low blood pressure) medication). The facility also failed to ensure the physician had documented the rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of a non-approved indication use of an antipsychotic (class of medications used to treat a mental disorder characterized by a gross impairment in reality testing) medication for R50 and R1 with a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). This deficient practice placed R50 and R1 at risk for unnecessary psychotropic medication and related complications. Findings included: - R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia, tachycardia (rapid heartbeat greater than 100 beats per minute), hypotension, hemiplegia (paralysis of one side of the body), and Alzheimer's disease. The Annual Minimum Data Set (MDS) dated 12/25/24 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R50 had received antidepressant (a class of medications used to treat mood disorders) and antipsychotic medication during the observation period. The Quarterly MDS dated 03/12/25 documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R50 had received antipsychotic medication and antidepressant medication during the observation period. R50's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/03/25 documented he was at risk for adverse side effects of psychotropic medications. R50's Care Plan, dated 04/16/24, documented staff provided medication and treatments per the physician's orders. The plan of care documented the staff would monitor for side effects of his medications and notify the physician. R50's EMR under the Orders tab revealed the following physician orders: Midodrine five milligrams (mg) tablet give one tablet by mouth, three times a day for hypotension as needed. Administer for systolic blood pressure (SBP - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less than (<) 130 millimeters (mm) of mercury (Hg) or diastolic blood pressure (DBP - minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 60 mmHg, not to exceed three times a day as needed ordered on 02/11/25 and discontinued on 05/06/25. Review of EMR under the Vitals tab revealed from 03/01/25 to 05/06/25 (67 days) documented blood pressure was within the physician-ordered parameters for administration of Midodrine on the following dates (50 opportunities): 03/01/25, 03/02/25, 03/05/25, 03/07/25, 03/09/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25, 03/17/25, 03/18/25, 03/19/25, 03/20/25, 03/21/25, 03/24/25, 03/25/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 04/01/25, 04/02/25, 04/03/25, 04/04/25, 04/05/25, 04/08/25, 04/09/25, 04/10/25, 04/13/25, 04/14/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, 04/20/25, 04/21/25, 04/22/25, 04/23/25, 04/24/25, 04/25/25, 04/28/25, 04/29/25, 04/30/25, 05/01/25, 05/02/25, 05/03/25, 05/04/25, 05/05/25, and 05/06/25. The clinical record lacked documentation the physician was notified. Review of R50's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 03/01/25 to 05/06/25 revealed Midodrine was administered on 03/30/25. Review of the Monthly Medication Review (MMR) from May 2024 to April 2025 revealed the CP had identified and reported the irregularities related to the lack of administration of R50's as needed Midodrine as ordered. The CP had reported R50's blood pressure had been within the physician-ordered parameter to be administered on the following dates: 06/17/24, 07/19/24, 01/28/25, 09/01/24, 02/26/25, and 04/20/25. R50's EMR under the Orders tab revealed the following physician orders: Olanzapine five mg, give one tablet by mouth daily for psychosis (any major mental disorder characterized by a gross impairment in reality perception), dated 03/13/25. Review of the Monthly Medication Review (MMR) reviewed from May 2024 to April 2025 revealed the CP had identified and reported the irregularities related to the non-approved indication for the use of antipsychotic medication Olanzapine for R50 who had a diagnosis of dementia and Alzheimer's disease. The facility was unable to provide physician documentation for risk versus benefits upon request. On 06/04/25 at 08:46 AM, R50 sat upright on the side of his bed as he watched TV in his room. On 06/04/25 at 11:20 AM, Licensed Nurse (LN) I stated he was unsure what an appropriate indication for an antipsychotic medication was. LN I stated he did know there needed to be an indication from the physician for the use of the medication. LN H stated the nurse, or the certified nurse aide (CMA) would obtain the blood pressure and the pulse before administering any medication that required vital signs. LN H stated the nurse was responsible to ensure the medication was given as ordered by the physician. LN H stated the CMA would notify the nurse if a resident's vital signs were outside the normal or physician-ordered parameters. LN H stated the physician should be notified if that was ordered and the notification would be documented in the interdisciplinary (ID) notes, along with the physician's response. On 06/04/25 at 01:13 PM, Administrative Nurse D stated she was unsure what all the indications for the use of an antipsychotic medication were. Administrative Nurse D stated she did realize dementia and psychosis were not appropriate indications for antipsychotic medications. Administrative Nurse D stated she was unsure if the facility had been working with the pharmacist and physician on correct indications for antipsychotic drug use. , Administrative Nurse D stated she expected the physician's orders to be followed. Administrative Nurse D stated the physician should be notified if a physician order was not followed, and that notification would be documented in the resident's ID notes. The facility's Consultant Pharmacist policy last revised 03/24/24 documented the consultant pharmacist agreed to render the required service in accordance with local, state, and federal laws, regulations, guidelines, facility policies and procedures, community standards of practice, and professional standards of practice. Reviewing the medication regimen (drug regimen review) of each elder in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review and findings in the elder's clinical record. Communicating potential or actual problems detected related to medication therapy orders to the responsible physician and the Director of Nursing.- The Diagnosis tab of R1's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, encounter for palliative care (a specialized form of care that focuses on improving the quality of life for people living with serious illnesses when the resident was nearing the end of life or not), dependence on wheelchair, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated 03/19/25, documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R1 was rarely or never understood. The MDS documented R1 had behaviors that fluctuated in severity. The MDS documented R1 was dependent on staff for toileting and bathing. The MDS documented R1 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) during the observation period. R1's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 documented R1 triggered for this CAA due to the use of antipsychotic medication. The CAA documented the factors that place residents at risk for a problem including the potential for side effects from psychoactive medication. The CAA documented R1 had no recent falls that were attributed to the use of the medication. The CAA documented R1 had not demonstrated any apparent side effects or adverse consequences from the current medication regimen that contains Black Box Warning (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). R1's Care Plan dated 04/30/24 documented the facility would work with the physician for a reduction in dosing when target behaviors are absent and or easily altered for specified periods, but no less than quarterly. R1's plan of care documented the facility would consider pharmacological interventions using medications other than antipsychotics, such as pain medication, by observing for lessening behavior and collaborating with the interdisciplinary team. The plan of care for R1 documented nursing was to administer a medication regimen as prescribed by the physician and notify the physician and psychiatrist for increased sedation, an increase in behavioral symptoms, unresponsiveness to environmental interventions, or an increase in side effects. R1's plan of care documented the facility would attempt gradual dose reduction (GDR) for antipsychotic medications per physician orders as recommended by the pharmacy consultant. R1's plan of care documented a GDR was being attempted, and staff will provide physical activities for R1 to participate in and help control the number of stimuli in her immediate environment. R1's EMR under Orders documented the following physician's order: Quetiapine fumarate (antipsychotic) 25 milligrams (mg) oral tablet give 0.5 tablet by mouth every evening for severe dementia with agitation, dated 07/24/24. A review of the CP's Monthly Medication Reviews (MMR) from 04/2024 to 04/2025 revealed the Pharmacist did identify R1's quetiapine and made recommendations for the inappropriate indication of use related to R1's quetiapine medication. Upon request, the facility was unable to provide a risk vs benefit for the use of quetiapine for dementia with agitation. On 06/04/25 at 09:32 AM, R1 sat at the dining room table, visiting with peers. On 06/04/25 at 11:20 AM, Licensed Nurse (LN) I stated he was unsure what an appropriate indication for an antipsychotic medication was. LN I stated he did know there needed to be an indication from the physician for the use of the medication. On 06/04/25 at 01:13 PM, Administrative Nurse D stated she was unsure what all the indications for the use of an antipsychotic medication were. Administrative Nurse D stated she did realize dementia (a progressive mental disorder characterized by failing memory and confusion) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality) were not appropriate indications for antipsychotic medications. Administrative Nurse D stated she was unsure if the facility had been working with the pharmacist and physician on correct indications for antipsychotic drug use. The facility's Consultant Pharmacist policy last revised on 03/24/24 documented the consultant pharmacist agreed to render the required service by local, state, and federal laws, regulations, and guidelines, facility policies and procedures, community standards of practice, and professional standards of practice. Reviewing the medication regimen (drug regimen review) of each elder in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review and findings in the elder's clinical record. Communicating potential or actual problems detected related to medication therapy orders to the responsible physician and the Director of Nursing.

The facility identified a census of 65 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician's order for Resident (R) 50's hypotension (low blood pressure) medication) was administered. This deficient practice placed R50 at risk for unnecessary medications and adverse side effects. Findings included: - R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), tachycardia (rapid heartbeat greater than 100 beats per minute), hypotension, hemiplegia (paralysis of one side of the body), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) The Annual Minimum Data Set (MDS) dated 12/25/24 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R50 had received antidepressant (a class of medications used to treat mood disorders) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Quarterly MDS dated 03/12/25 documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R50 had received antipsychotic medication and antidepressant medication during the observation period. R50's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/03/25 documented he was at risk for adverse side effects of psychotropic medications. R50's Care Plan, dated 04/16/24, documented staff provided medication and treatments per the physician's orders. The plan of care documented the staff would monitor for side effects of his medications and notify the physician. R50's EMR under the Orders tab revealed the following physician orders: Midodrine (hypotensive) five milligrams (mg) tablet, give one tablet by mouth three times a day for hypotension as needed. Administer for systolic blood pressure (SBP - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less than (<) 130 millimeters (mm) of mercury (Hg) or diastolic blood pressure (DBP - minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 60 mmHg, not to exceed three times a day as needed, ordered on 02/11/25 and discontinued on 05/06/25. Review of EMR under Vitals tab revealed from 03/01/25 to 05/06/25 (67 days) documented blood pressure was within the physician-ordered parameters for administration of Midodrine on the following dates (50 opportunities): 03/01/25, 03/02/25, 03/05/25, 03/07/25, 03/09/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25, 03/17/25, 03/18/25, 03/19/25, 03/20/25, 03/21/25, 03/24/25, 03/25/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 04/01/25, 04/02/25, 04/03/25, 04/04/25, 04/05/25, 04/08/25, 04/09/25, 04/10/25, 04/13/25, 04/14/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, 04/20/25, 04/21/25, 04/22/25, 04/23/25, 04/24/25, 04/25/25, 04/28/25, 04/29/25, 04/30/25, 05/01/25, 05/02/25, 05/03/25, 05/04/25, 05/05/25, and 05/06/25. The clinical record lacked documentation the physician was notified. Review of R50's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 03/01/25 to 05/06/25 revealed Midodrine was administered on 03/30/25. On 06/04/25 at 08:46 AM, R50 sat upright on the side of his bed as he watched TV in his room. On 06/04/25 at 01:00 PM, Licensed Nurse (LN) H stated the nurse or the certified nurse aide (CMA) would obtain the blood pressure and the pulse before administering any medication that required vital signs. LN H stated the nurse was responsible to ensure the medication was given as ordered by the physician. LN H stated the CMA would notify the nurse if a resident's vital signs were outside the normal or physician-ordered parameters. LN H stated the physician should be notified if that was ordered and the notification would be documented in the interdisciplinary (ID) notes, along with the physician's response. On 06/04/25 at 01:13 PM, Administrative Nurse D stated she expected the physician's orders to be followed. Administrative Nurse D stated the physician should be notified if a physician order was not followed, and that notification would be documented in the resident's interdisciplinary notes. The facility's Physician Orders for Medication and Treatments policy dated 10/20/23 documented all medications would be administered as ordered by a healthcare professional authorized by the state to order medications.

The facility identified a census of 64 residents. The sample included 16 residents, with three reviewed for specialized diets. Based on observation, record review, and interviews, the facility failed to follow Resident (R) 19's physician's order to provide Ensure supplementation 30 minutes after her meals. This deficient practice placed R19 at risk for potential risk related to impaired nutrition and weight loss. Findings Included: The Medical Diagnosis section within R19's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), anxiety (cognitive or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and speech/language deficits. R19's Quarterly Minimum Data Set (MDS) completed 04/02/25 noted a Brief Interview for Mental Status (BIMS) of zero, indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS indicated she required substantial to maximal assistance from staff to eat her meals. The MDS indicated she was at risk for skin breakdown and pressure ulcers but had no wounds. The MDS indicated she had pressure-reducing devices for her bed and wheelchair. The MDS noted she had a repositioning program and nutritional interventions to prevent pressure ulcers. The MDS noted she weighed 122 pounds (lbs). R19's Functional Ability Care Area Assessment (CAA) completed 01/09/25 indicated she required assistance from staff for her Activities of Daily Living (ADL)related to her medical diagnoses. The CAA noted she had confusion due to a decline in her cognition. The CAA noted she required maximum assistance from one to two staff for bed mobility. The CAA noted she was not always able to express her needs. R19's Nutrition CAA completed 01/09/25 indicated she was at risk for malnutrition and weight loss due to her medical diagnosis. The CAA indicated that the facility was to provide her with a diet as prescribed and implemented interventions to reduce the risk. R19's Care Plan initiated on 01/22/25 indicated she was at risk for impaired decision-making, ADL deficits, falls, and weight loss related to her cognitive impairments and medical diagnoses. The plan noted she required extensive assistance from staff for bed mobility, transfers, bathing, dressing, toileting, and wheelchair mobility. The plan noted that R19 required assistance from one staff while eating her meals. The plan instructed staff to encourage her to have meals in the dining room so she had supervision and cues to eat food during meals. The plan instructed staff to provide feeding assistance by mimicking actions to help her with self-feeding during meals. The plan indicated she was not to be left in her room alone while eating. The plan indicated she had a pressure-reducing low air-loss mattress on her bed. R19's EMR under Physician's Orders revealed an order (dated 02/10/22) that instructed staff to administer one carton of Ensure (supplemental nutrition to prevent weight loss) by mouth 30 minutes after each meal for protein-calorie malnutrition. R19's EMR under Assessments revealed a Nutrition Risk Assessment completed 05/29/25. The assessment indicated that R19 required supervision during meals. The assessment noted she required partial to maximal assistance during mealtimes with feeding. The assessment revealed she was provided Ensure supplementation three times daily. On 06/02/25 at 09:30 AM, R19 rested in her bed. R19's bedside table was positioned over her chest. R19 lay flat on her back (supine position) with the shoulders and neck propped upward to her bedside table. R19's breakfast meal was uncovered and untouched. R19's Ensure supplement was left with her breakfast meal. On 06/02/25 at 09:56 AM, R19 remained asleep in the same position but her Ensure supplement bottle was empty and rested downward in her lap. R19's push-button call light rested on the bed underneath her bed next to the wall. R19's breakfast meal remained untouched. R19's low air-loss mattress control panel was set to 200 lbs. On 06/03/25 at 09:20 AM, R19 rested in her bed. R19's bedside table was positioned over her chest. R19 lay flat on her back with the shoulders and neck propped upward to her bedside table. R19's food was untouched and uncovered. R19's Ensure supplement was served with her meal. On 06/03/25 at 09:32 AM, R19 lay in her bed and ate her breakfast meal in her room. Staff were not present as she consumed her breakfast meal. R19's call light was under her bed near the back wall. On 06/04/25 at 09:37 AM, R19's breakfast was served to her in her room. R19's Ensure supplement was given to her with her breakfast. Staff stayed in the room as she ate her meal and consumed her Ensure during her meal. On 06/04/25 at 11:25 AM, Licensed Nurse (LN) J stated supplements were provided with the meals based on the resident's dietary orders. She stated staff were expected to follow the diet and specific needs of the residents. She stated if ordered to wait 30 minutes after each meal, staff were expected to wait the full thirty minutes before offering the ensure. On 06/04/25 at 12:50 PM, Dietary Staff CC stated staff were to hold the Ensure supplement until 30 minutes after R19's meal to ensure she consumed her meal before being given a supplement. He stated the facility wanted to focus on meal consumption before supplements were offered. On 06/04/25 at 01:13 PM, Administrative Nurse D stated staff were expected to follow the dietary orders based on the specific timeframe outlined by the order. She stated staff were expected to wait 30 minutes after R19's meals to offer the Ensure supplement. The facility's Special Diets policy (undated) indicated the facility would provide dietary supplementation to residents at risk for weight loss and malnutrition. The policy indicated the facility would follow the guidance of the medical and dietician.

The facility identified a census of 65 residents. Based on record review and interviews, the facility failed to ensure that direct care staff had received the required in-service education for nurse aide training. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 06/03/25, a review of the provided training for facility staff Certified Nurses Aid (CNA) M, CNA N, and Certified Medication Aide (CMA) R and CMA S revealed the following: CNA M's facility-provided credentialing file lacked evidence of the required 12 hours of nurse aid in-service training. CNA N's facility-provided credentialing file lacked evidence of the required 12 hours of nurse aid in-service training. CMA R's facility-provided credentialing file lacked evidence of the required 12 hours of nurse aid in-service training. CMA S's facility-provided credentialing file lacked evidence of the required 12 hours of nurse aid in-service training. On 06/03/25 at 02:56 PM, Administrative Staff A stated the nurse aide in-services had been the responsibility of the facility scheduler previously, but it had been noticed that CNAs and CMA's had not completed the required number of yearly educations. Administrative Staff A stated that the director of nursing (DON) was now responsible to ensure the nursing staff completed the required number of hours of education/training yearly. The facility policy CNA Required Training and In-services last revised on 05/05/25 documented that all direct care staff was required to attend twelve (12) hours of continuing education and demonstrate competency annually, including but not limited to: o Infection Control, including bloodborne pathogens and Antibiotic Stewardship o Health Insurance Portability and Accountability Act (HIPAA) and confidentiality o Resident rights and facility responsibilities o Prevention of abuse, neglect, exploitation, and mistreatment of residents o Compliance and ethics o Advance directives and the Patient Self-Determination Act o Emergency preparedness o Quality Assurance/Performance Improvement (QAPI) o Communication o Safety and hazard training program o Behavioral Health including but not limited to Trauma-Informed Care and Substance Use Disorder as identified in Facility Assessment o Non-Pharmacological Interventions

The facility identified a census of 65 residents. The sample included 16 residents, with four medication rooms and six medication carts. Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff failed to ensure the medication carts were locked when the cart was not within the nurses' view. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 06/02/25 at 10:38 AM, on hall 600 the treatment cart containing residents' treatment supplies and as-needed (PRN) creams. Licensed nurse (LN) G stated the treatment cart should be locked and secured when staff walk away. The medication cart was out of LN G's view. On 06/04/25 at 01:01 PM, Administrative Nurse D stated the expectation of the facility was the medication carts should be locked if the cart was out of the nurse's view. The facility's Medication Labeling and Storage policy revised on 12/20/23 documented medications were labeled and stored in accordance with facility requirements and State and Federal laws. All drug containers would be labeled, and drug labels must be clear, consistent, legible, and in compliance with State and Federal requirements. There would be a standard method for appropriately and safely labeling medications dispensed to all residents. Only the provider pharmacy could modify or change prescription labels. All drugs and biologicals would be stored securely and appropriately following manufacturer recommendations and State and Federal Regulations as appropriate.

The facility had a census of 66 residents. The sample included 18 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide supervision for one sampled resident, Resident (R) 31, who fell in the facility courtyard and fractured (broken) her right arm and right middle finger. The facility further failed to ensure a safe environment for R50, who fell in his room and fractured his nasal bone, fractured his lumbar transverse process (the bony projection on either side of your spine), sustained a laceration (cut) to his left eye, and bruising to his right side. These failures placed the residents at risk for further falls and related injury. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of malignancy neoplasm of the colon (colon cancer), confusional arousal (when a sleeping person appears to wake up, but their behavior is unusual or strange), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R31 had a Brief Mental Status Score (BIMs) of 14, which indicated intact cognition. The MDS further documented R31 required extensive assistance of one staff for toileting and limited assistance of one staff for bed mobility, ambulation, dressing, and personal hygiene. The assessment documented R31 had unsteady balance, upper functional impairment on one side, and had no falls. R31's Fall Risk Assessments, dated 10/31/22, 11/12/22, 02/14/23, 04/27/23, 07/31/23, 08/03/23, and 09/22/23, documented R31 was at risk for falls. R31's Care Plan, dated 08/03/23, initiated on 11/12/22, directed staff to educated R31 on the use of the call light system, assess for appropriate assistive device for mobility and transfers on admission, quarterly, and as needed. The update, dated, 08/03/23, directed staff to keep personal items within reach, ensure her call light was within reach, assist R31 to put her shoes on properly. The update, dated 09/22/23, directed staff to assign a staff member to monitor and assist residents while outside and coming in and out of the patio door. The Fall Investigation, dated 09/22/23, documented, on 09/22/23 at 01:10 PM, R31's friend was coming in from the courtyard and R31 sat in a chair in the dining room, near the door to the courtyard. R31 got up when her friend was at the courtyard door to open it for her, and at the same time her friend moved, when she had previously had a hand on the door, the door opened more quickly than anticipated, and R31 tripped over the threshold going outside. The investigation documented R31 landed face first on the concrete, with her head landing in the mulch of the landscaping, hurting her middle finger and right wrist. The investigation documented R31 was sent to the emergency room for evaluation, and it was determined she had a fracture to her right middle finger and a fractured right wrist. The intervention for the fall documented team members would be assigned to the residents when they are going outside so the staff would be there to safely assist them in and out. The Nurse's Note, dated 09/25/23 at 02:40 PM, documented R31 returned from the hospital with her right arm in a splint and wrapped with an ace wrap, her fingers warm to the touch with mild swelling. On 10/17/23 at 11:42 AM, observation revealed R31 independently ambulated with a walker in the dining room. On 10/17/23 at 09:30 AM Certified Nurse Aide (CNA) M stated R31 was independent with transfers and ambulation and had some recent falls which resulted in a fracture of her arm. On 10/19/23 at 10:16 AM, Licensed Nurse (LN) H stated staff were not going outside with residents until R31 had her fall with a fracture. LN H stated staff now were assigned to make sure if a resident went outside, staff would be aware and could help residents go in and out of the doors. LN H stated she was not really sure what happened with R31 because she was helping other residents. She stated her understanding was that the resident who was outside with R31 took a tissue box and put it in the doorway so the door would not shut and somehow when R31 tried to help the other resident come inside, R31 lost her balance and fell in the courtyard. On 10/18/23 at 10:46 AM, Administrative Nurse D stated R31's daughter took R31 and another resident outside in the courtyard; when she brought R31 back inside, she took a tissue box and propped the door open so the other resident could come inside when she was ready. Administrative Nurse D further stated when R31 was at a dining room table, she saw her friend having trouble getting the door open, so she got up and pushed on the door while the other resident was pulled on the door, and R31 lost her balance and fell . Administrative Nurse D stated that even though R31's daughter placed the tissue box in the door, it was the nursing staff responsibility to make sure the residents were safe outside and could safely get back inside. On 10/18/23 at 04:00 PM, Administrative Staff A stated all families had door cards so they could get in and out of the facility when there was not a receptionist at the front door. Administrative Staff A said R31's daughter used her card to open the courtyard door and did not notify staff that she left the other resident outside, the family member also propped the courtyard door open. The facility's Fall Management policy, dated 01/20/22, documented, residents are assessed for risk for falls by a licensed nurse and interventions are placed in the plan of care, and staff would ensure resident's rooms are free from hazards that could cause a fall. The policy documented staff would attempt to identify the cause of the fall and documented in nursing notes and seek to identify all that contributed to the fall. The facility failed to provide adequate supervision to prevent accidents and hazards for R31 who attempted to assist another resident inside from the courtyard and had a fall which resulted in a fractured right arm and middle finger. This placed the resident at risk for further falls and pain. - R50's Electronic Medical Record (EMR) documented diagnoses of repeated falls, confusional arousal (when a sleeping person appears to wake up, but their behavior is unusual or strange), muscle spasms, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) dated , 05/06/23, documented R50 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation; and supervision and one staff assistance for personal hygiene. The MDS further documented R50 had unsteady balance, lower impairment functional impairment on both sides, and had no falls. The Quarterly MDS, dated [DATE], documented R50 had a BIMs score of 13, which indicated intact cognition and required extensive assistance of one staff for bed mobility, toileting, dressing, personal hygiene. R50 did not ambulate. The assessment further documented R50 had unsteady balance, lower functional impairment on both sides, and had no falls. The Fall Risk Assessments, dated 05/02/23, 05/08/23, 06/18/23, 07/21/23, 08/29/23, 09/07/23, and 10/03/23, documented R50 was at risk for falls. The Care Plan, dated 10/03/23, initiated on 06/26/23, directed staff to keep his walker within arm's reach, cue and assist to the bathroom after all meals, remind him to call for assistance, and place a sign on his wall to remind him to call for assistance. The update, dated, 07/27/23, directed staff to switch out his call light necklace to his wrist, so he could locate it better. The update, dated 08/29/23, directed staff to ensure his bed was at the standard height. The update, dated 09/03/23, directed staff to ensure R50 wore nonskid socks. The update, dated 09/07/23, directed staff to ensure resident wore nonskid socks and place anti-slip traction to tape on the floor to the right and left of the bed. The update, dated 09/30/23, directed staff to rearrange R50's room to improve safety and do hourly checks as R50 was cognitively impaired and confused. The update, dated 10/03/23, directed staff to ensure the light in his room was adequate, family members educated to call for assistance with R50 required assistance, remind R50 to call for assistance, educated R50 on the bed controls and how to use them, educated R50 to call for assistance when he wants to get out of bed, and remind R50 to wear nonskid socks. The Fall Investigation, dated 06/17/23 at 10:50 PM, documented staff found R50 between the bed and the recliner. R50 had raised the bed too high, tried to get into the bed and fell . The Fall Investigation, dated 07/22/23 at 03:00 AM, documented R50 was on the floor beside the foot of the bed, naked and had a dry incontinence brief lying beside him. The investigation further documented R50 had periods of confusion and was known to disrobe and rummage through his belongings, and directed staff to monitor R50 during rounds for evidence he was restless. The Fall Investigation, dated 07/28/23 at 11:45 PM, documented R50 was on the floor and directed staff to change his call light necklace to his wrist so he could locate it better. The Fall Investigation, dated 08/20/23 at 08:07 PM, documented R50 was in his room on his hands and knees, he had attempted to transfer himself from his wheelchair to his bed and had adjusted the height of the bed and it was too high for him to transfer. The investigation documented the control to his bed was moved as he was unable to demonstrate his ability to utilize the controls appropriately and orange tape was in place to clearly indicated the appropriate height of the bed to aide in a safe transfer. The Fall Investigation. dated 08/29/23 at 03:50 AM, documented R50 was found on his floor, naked with a dry incontinence brief beside him, he stated he slipped while he tried to get into bed. The investigation further documented the bed was at standard height at 11:50 PM, and at the time of his fall, the bed was in a low position. The investigation documented staff were educated on why the bed was at standard position at night. The Nurse's Note, dated 09/28/23 at 10:07 PM, documented on 09/27/23 and 9/28/23, R50 was very restless and tried to stand several times without locking his wheelchair, and tried to pull down his pants several times. R50 stated he did not know what he wanted, would be calm for short periods of time, then became restless again, and required one on one (1:1) with the nurse. The Fall Investigation, dated 09/30/23 at 10:30 PM, documented R50 was on the floor in his room, he stated he did not know what happened and had been toileted around 09:15 PM. The investigation further documented R50 had a laceration above his left eye which measured 0.1 centimeter (cm) by 0.2 cm, and some bruises on the right ribs. R50 complained of pain all over and went to the emergency room for evaluation. The investigation documented R50 sustained a fractured nasal bone, and a fracture of the lumbar transverse process, and a facial laceration. The Nurse's Note, dated 10/03/23 at 06:44 PM, documented R50 had bruises to his face and arms, and education was provided on fall prevention and education on how to use the call light system, to demonstrate back to staff, and he was unable to use the call light system. On 10/17/23 at 09:30 AM, observation revealed Certified Nurse Aide (CNA) M pushed R50's wheelchair into the bathroom, instructed him to use the wheelchair arms to push up, stand, and grab onto the grab bars by the toilet. Further observation revealed, CNA M did not use a gait belt and R50 was very unsteady and could not follow her instructions. CNA M instructed him to turn to the left, he would turn to the right, and after multiple times cuing, he was able to turn to the left as instructed so she could assist him with toileting. On 10/17/23 at 09:30 AM, CNA M stated, she did not use a gait belt on R50 because he was a standby assist so she did not need to. CNA M stated R50 did have a lot of falls and were instructed to make sure his bed was the standard height, nonskid strips beside his bed, try to assist him with toileting every two hours, and get him up first in the morning. On 10/19/23 at 10:00 AM, Licensed Nurse (LN) H stated R50 was getting better, he had been confused for a while, was impulsive, and liked to get up on his own. On 10/19/23 at 10:46 AM, Administrative Nurse D stated staff were to use a gait belt with R50 as he was a fall risk and was impulsive. Administrative Nurse D further stated she felt the fall with the fractures was because R50 had a lot of clutter in his room and he fell over it. The facility's Fall Management policy, dated 01/20/22, documented residents are assessed for risk for falls by a licensed nurse and interventions are placed in the plan of care. The staff would ensure resident's rooms are free from hazards that could cause a fall. The policy documented staff would attempt to identify the cause of the fall and documented in nursing notes and seek to identify all that contributed to the fall. The facility failed to ensure that interventions in place to prevent falls were adequately implemented by staff consistently to prevent falls for R50, who had a fall with major injury. This placed the resident at risk for further falls and related complications.

The facility had a census of 66 residents. The sample included 18 residents, with six reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement preventative measure to prevent facility acquired pressure ulcers for three sampled residents. As a result, Resident (R) 26 developed facility acquired deep tissue injuries (DTI-localized areas of tissue damage of necrosis that develop because of pressure) to his right heel and his right and left outer malleolus (a bony projection on either side of the ankle), a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer on his left heel, and a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open)on his left buttocks (the fleshy round parts that form the lower rear area). The facility further failed to prevent and adequately monitor and treat facility aquired pressure injuries for R17 and R3. This deficient practice also placed the residents at risk for further skin breakdown, pain, and infections. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), hereditary ataxia (motor incoordination resulting from dysfunction of the cerebellum and its connections), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Admission Minimum Data Set) (MDS), dated [DATE], documented R26 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R26 was dependent upon two staff for transfers, toileting, and required extensive assistance of two staff for bed mobility, and dressing. The MDS further documented R26 was at risk for pressure ulcers, had a pressure relieving device for his bed and chair, and had no skin breakdown. The Quarterly MDS, dated [DATE], documented R26 had a BIMS score of 11 which indicated moderately impaired cognition. R26 was dependent upon two staff for transfers, dressing, toileting, and required extensive assistance of two staff for bed mobility. The MDS further documented R26 was at risk for pressure ulcers, had a pressure relieving device for his bed and chair, and had no skin breakdown. The Braden Scale Assessment, (a formal assessment for predicting pressure ulcer risk), dated 05/23/23, 06/12/23, 08/04/23, 08/08/23, and 08/15/23, documented R26 was at risk for pressure ulcers. R26's Care Plan, initiated on 08/15/23 documented R26 was at risk for pressure ulcers and directed staff to complete a Braden scale assessment quarterly and as needed with condition change, inspect the skin when dressing, bathing, and toileting, and keep R26's skin clean and dry using a protective skin barrier cream with each brief change. The plan directed staff to use a pressure relieving air mattress and chair cushion and reposition him every 2-3 hours while in bed and when sitting up as needed. The update, dated 08/29/23, documented R26 had a blister on his left heel and right heel, and directed staff to place heel protectors on the resident when in bed. An intervention dated 09/20/23 documented R26 had a Stage 2 pressure ulcer to his left heel and a DTI to his right heel, treatment orders were in place, and he was seen by a wound doctor. It directed staff to place the heel protectors on every morning after R26 was transferred with the mechanical lift and administer Prostat (a supplement) twice a day to aid in wound healing. An update, dated 10/06/23, documented R26 had a new pressure area to his left malleolus and the certified nurse aides were instructed not to put booties on tight and to leave the strap loose. The Nurse's Note, dated 08/28/23 at 03:42 PM, documented R26 had a fluid filled blister to his left heel which measured 2.0 centimeters (cm) by 2.0 cm and was most likely caused by friction. The nursing staff would apply Skin-prep (liquid skin protectant) daily, cover with a bordered gauze dressing, and discuss heel protectors when in bed. The Nurse's Note, dated 08/29/23, documented the hospice aide found a fluid filled blister to R26's right heel which was like the left heel which measured 2.5 cm by 2.0 cm, most likely caused by friction. The note documented nursing staff would apply Skin-prep daily and cover with a bordered gauze dressing; staff would see if hospice would provide another pair of heel protectors for when R26 was in both bed and wheelchair. The Skin Assessment, dated 09/01/23, documented R26 had a facility acquired Stage 2 fluid filled blister on his left heel which measured 3.8 cm by 3.6 cm by 0.1 cm. The staff applied Skin-prep and covered the area with a bordered gauze. The Skin Assessment, dated 09/11/23, documented R26 had a Stage 2 pressure injury to his left heel which measured 2.8 cm by 3.2 cm by 0.1 cm. The staff applied Skin-prep and covered the area with a bordered gauze. The Physician Order, dated 09/14/23, directed staff to cleanse the open left heel wound with wound cleanser and apply Aquacel ag (an antimicrobial dressing), cover with a ABD pad (large pad to absorb drainage), and change daily. The Physician Order, dated 09/15/23, directed staff to cleanse the left wound with wound cleanser, Skin-prep the edges of the wound, and cover with a bordered dressing. The Skin Assessment, dated 09/18/23 documented R26 had a Stage 2 pressure injury to his left heel which measured 3.0 cm by 3.3 cm by 0.2 cm. The Skin Assessment, dated 09/18/23, documented R26 had a deep tissue injury to his right heel which measured 2.0 cm by 3.1 cm. The staff applied Skin-prep and a dry dressing. The Weekly Skin Assessment, dated 09/25/23, documented R26's left heel measure 2.0 cm by 3.3 cm by 0.1 cm, and staff to applied Skin-prep the edges of the wound and cover with a dry dressing. The Skin Assessment, dated 10/02/23, documented R26's left heel measured 2.0 cm by 3.1 cm by 0.1 cm. The staff applied Skin-prep to the edges of the wound and covered with a dry dressing. The Skin Assessment, dated 10/02/23, documented R26's right heel had a deep tissue injury which measured 1.9 cm by 2.8 cm and staff were to apply Skin-prep and a dry dressing. The Nurse's Note, dated 10/06/23, documented the physician removed the blister to R26's left heel and directed staff to apply Xeroform (a non-adherent primary dressing that maintains a moist wound environment) to the left heel wound, cover with a bordered gauze dressing, and change the dressing daily. The note further directed staff to stop Skin-prep to the right heel and just cover the area with bordered gauze, and change the dressing on Monday, Wednesday, and Fridays. The note further documented R26 developed a dark purple area to his left outer malleolus due to his heel protectors being too tight. Staff were Skin-prep the area and cover with a silicone dressing to be changed on Monday, Wednesday, and Fridays, and educate staff not to put the heel protectors on tight. The Skin Assessment, dated 10/09/23, documented R26 had a deep tissue injury to his left outer malleolus, which measured 1.1 cm by 1.3 cm, and staff applied Skin-prep to the area. The Nurse's Note, dated 10/17/23, documented a new order from the physician for zinc ointment, twice a day, to be applied to R26's coccyx (small triangular bone at the base of the spine) and buttocks, for breakdown prevention. The Skin Assessment, date 10/18/23, documented staff found a new dark purple area to R26's right outer malleolus. The staff applied Skin-prep and covered the area with a foam dressing. On 10/17/23 at 11:21 AM, observation during personal cares revealed R26 had an area on his left buttock that was approximately 5 cm by 2 cm, light pink and a small, darkened area near the center of the wound. On 10/17/23 at 02:15 PM, observation revealed Licensed Nurse (LN) H washed her hands, donned clean gloves, removed the soiled dressing from R26's left outer malleolus. LN H said the wound was caused by a heel protector strap that was put on too tight. The area was approximately the size of a quarter and had a scab on it. Further observation revealed LN H changed gloves, cleansed the wound with wound cleanser, placed Xeroform on the wound, and covered it with a dry dressing. On 10/18/23 at 07:15 AM, LN H washed her hand, donned clean gloves, removed the soiled dressing from the left inner heel. The area was approximately the size of a quarter, had a scab over the wound. LN H cleansed the area with wound cleanser and placed Xeroform on the wound and covered it with a dry dressing. Continued observation revealed LN H took R26's right sock off and removed the soiled dressing off of his right heel. The area was approximately the size of a quarter and had a scab over top of it. Observation revealed a dark purple area over the right outer malleolus, and LN H stated she did not know the resident had the dark purple area. LN H cleansed the right heel ulcer with wound cleanser and placed a dry dressing over it. LN H wiped the right outer malleolus with wound cleanser, applied Skin-prep, and placed a dry dressing over it. On 10/19/23 at 09:00 AM, observation revealed R26 sat in his wheelchair. He wore bilateral heel protectors, but his right malleolus was resting on the foot pedal out of his heel protector. On 10/17/23 at 11:21 AM, CNA M stated the area on R26's buttock had not been there the day before and said she had never seen any type of dressing on it. CNA M stated R26 would tell staff when he wanted to lay down and had already been up in the wheelchair since 06:30 AM, without repositioning. On 10/17/23 at 11:30 AM, LN H stated the area on R26's buttock was scar tissue and when the CNAs provide personal cares, they rubbed the area too hard. LN H said that caused the top layer of the scar tissue to rub off. LN H stated staff were not putting any dressings on the scarring in order to prevent breakdown. LN H stated she would talk with hospice to ask for a Roho cushion (pressure relief cushion made of soft, flexible air cells) for R26's wheelchair. On 10/18/23 at 07:15 AM, LN H stated the pressure areas on R26's heels were from friction and verified R26 was not wearing heel protectors prior to the breakdown. LN H stated R26 had ataxia and would cause him to have spasms and his legs would move a lot, like frog legs. LN H stated she felt that the heel protectors did not stay in place due to the resident's movement of his legs, and that was how the right malleolus broke down. LN H stated R26 slept with socks on at night, so the CNAs would not have seen the new area on his right malleolus. On 10/19/23 at 10:46 AM, Administrative Nurse D stated there should have been interventions in place to prevent the breakdown on R26's feet. Administrative Nurse D said R26 should be laid down more often to prevent further breakdown. The facility's Wound Management Policy and Procedure, dated 09/12/23, documented the facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individuals clinical condition demonstrates they are unavoidable. The facility failed to implement interventions to prevent pressure ulcers for R26, and failed to ensure cares were delivered in a manner to prevent injury or wound worsening which resulted in a facility acquired DTI, a Stage 2 and Stage 1 pressure ulcers. This also placed the resident at risk for further breakdown. 27168 - R17 's Electronic Medical Record (EMR) listed diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) edema (swelling resulting from an excessive accumulation of fluid in the body tissue,) and heart failure. R17's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R17 required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had one unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer that was not present on admission. The Pressure Ulcer Care Area Assessment (CAA), dated 08/28/23, documented the resident required extensive assistance and had bowel and bladder incontinence that placed her at risk for impaired skin integrity. The CAA documented staff provide incontinent care as needed, skin inspection, and the use of a pressure reducing mattress. R17's Care Plan, dated 8/28/23, documented staff would apply moisture barrier cream with each brief change and provide a pressure relieving chair cushion. The plan directed staff to reposition the resident from side to side every two hours when in bed and shift weight from side to side every two hours when sitting in the chair. The Braden Scale Assessment for predicting pressure ulcer risk, dated 08/23/23 documented a score of 13.0, which indicated a high risk. The Physician Order, dated 08/28/23 ordered the staff to obtain weekly skin assessments by a licensed nurse. The Tissue Analytics Wound Evaluation, dated 10/17/23, documented the date of onset was 10/17/23 and the wound was identified as an unstageable pressure ulcer, facility acquired, to the right buttocks. The wound measured 1.0 cm x 1.05 cm by 0.1 cm depth. The current treatment was listed as wound cleanser, Skin-Prep and a foam dressing three times a week and as needed. The evaluation documented the wound as New. The evaluation lacked any further description of the wound. The Tissue Analytics Wound Evaluation, dated 10/19/23, documented R17 had one open area on her right gluteal (buttock) area, measuring 1.0 cm by 1.5 cm by 0.10 cm. The area was listed as an unstageable pressure ulcer, facility acquired. The Physician Order, dated 09/13/22, documented staff would place the resident on an up/down schedule, three times a day the resident may be up for an hour with meals and may attend activities and at other times must by lying on a low air loss mattress. The Physician Order, dated 10/06/23, documented for staff to apply Desitin (a barrier ointment relieves irritated skin and protects skin and helps seal out wetness) daily defense 13% cream, two grams, topically two times a day, for wound prevention to the bottom and any reddened areas. On 10/17/23 at 08:50 AM, R17 laid in bed on her back. Licensed Nurse (LN) K, and Certified Nurse Aide (CNA) P positioned R17 on her left side. LN K cleansed the open area on R71's right buttock with wound cleanser. The wound appeared as a one-inch reddened round area with approximately three-quarters of an inch open. LN K applied Desitin cream to the buttocks and open area. Continued observation revealed the area was red and open and the Desitin would not cover the area. LN K stated she would contact the physician for a new wound treatment order due to the Desitin not covering or protecting the open area. On 10/19/23 at 09:00 AM, Administrative Nurse E verified R71 developed a facility acquired pressure ulcer on her right buttock. Administrative Nurse E reported the resident recently had a decline in condition and had increased loose stools which may have contributed to the open areas. The Wound Management, policy dated 09/12/23, documented the facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individuals clinical condition demonstrates they are unavoidable. Ant resident with a wound receives treatment and services consistent with the resident's goals of treatment. The goal as one of promoting healing and preventing infections unless a resident's preferences and medically condition necessities palliative care as the primary focus. The facility failed to monitor the effectiveness of interventions to prevent the worsening of an unstageable facility acquired pressure ulcer for R17, placing the resident at risk for further skin breakdown. - R3's Electronic Medical Record (EMR) listed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion,) tremors (involuntary, quivering movement,) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and aphasia (condition with disordered or absent language function.) R3's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition. The MDS documented R3 required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had two unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcers, not present on admission. R3's Care Plan, dated 08/28/23, documented the resident had limited physical mobility due to general weakness and cognitive decline. The care plan documented the resident required extensive assist of one to two staff for bed mobility and required total dependence of two staff for transfers with a Hoyer lift (total body mechanical lift). The Braden Scale Assessment for predicting pressure ulcer risk, dated 08/01/23 documented a score of 15.0, which indicated a mild risk. The Physician Order, dated 07/21/23 directed staff to apply Skin-prep twice daily to the residents left lateral foot and left great toe. The Physician Verbal Order, on 10/04/23 directed the nurse to cleanse the left heel wound with wound cleanser and apply Skin-prep to the peri wound intact skin before dressing three times a week. The resident's family was notified of the new skin injury. The Wound Evaluation, dated 10/06/23 (two days after the physician gave a verbal order for the wound) documented R3 had one open area on her left heel, measuring 1.9 centimeters (cm) by 2.4 cm by 0.3 cm depth. The evaluation documented the wound as a new Stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure wound, which was facility acquired. R3 had an additional open area on her left great toe, measuring 0.7 cm by 0.5 cm by 0.2 cm. The evaluation documented the wound was a new, unstageable pressure ulcer, also facility acquired. The facility lacked any more Wound Evaluation measurements after 10/06/23 until exit date 10/19/23. On 10/17/23 at 08:10 AM, observation revealed Licensed Nurse (LN) K, and Certified Nurse Aide (CNA) P positioned R3 on her right side. LN K removed the old dressing on R3's left heel, cleansed the left heel open area with wound cleanser, applied Skin-prep, then placed a Polymen (non-adhesive dressing that will cleanse, fill, absorb and moisten wounds throughout the healing process) film island dressing over the open area. Continued observation revealed LN K removed the old dressing from R3's left great medial toe, cleansed with wound cleanser, applied Skin-prep, and then applied a Mepilex (absorbent, bordered foam dressing) dressing over the wound. The resident had pressure relieving boots. On 10/17/23 at 10:00 AM LN K verified the resident had recently developed the open area on her left great toe and staff thought it was caused from the Podous boot (lightweight plastic shell with a liner to help treat and prevent lower extremity disorders. LN K stated the left heel wound was from the heel opening on the Podous boot. On 10/19/23 at 09:20 AM, Administrative Nurse D verified the resident developed the facility acquired Stage 3 pressure ulcer on her left heel and a facility acquired unstageable pressure ulcer on the left medial great toe. Administrative Nurse D verified the resident did have Podous boots, and the areas developed from the use of the boot. The Wound Management, policy dated 09/12/23, documented the facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individuals clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. The goal as one of promoting healing and preventing infections unless a resident's preferences and medically condition necessities palliative care as the primary focus. The facility failed to prevent the development of a Stage 3 facility acquired left heel pressure ulcer, and an unstageable facility acquired, left great toe pressure ulcer for R3 and failed to monitor to promote healing placing the resident at risk for further skin breakdown.

The facility had a census of 66 residents. The sample included 18 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) possessed the qualifying education, training, experience as well as certification required to fulfill the role, placing the residents at risk of unidentified and untreated infections. Findings included: - On the survey form Department Heads filled out by the facility, the facility identified the IP as Certified Medication Aide (CMA) R. On 10/18/23 at 11:08 AM, Certified Medication Aide (CMA) R identified self as the facility IP. CMA R provided a transcript of Nursing Home Infection Preventionist Training Course (Web-Based) completion of two continuing education units (CEU) dated 05/17/23. Participating via phone, Consultant GG stated she was the consultant which worked mostly off site, and made occasional onsite visits to support CMA R in the role of IP. On 10/19/23 at 11:33 AM, the facility provided Licensed Nurse (LN) J's proof of completion of the Nursing Home Infection Preventionist Training Course (Web-Based). LN J reported working two days a week with one day designated as the wound nurse and one day working with CMA R for infection control. LN J was also responsible for the facility's immunizations. The facility's Infection Preventionist policy, dated 10/18/22, documented the qualifications and position requirement must possess current, unencumbered, active licensure in an applied clinical science including but not limited to: Nursing, Medical Technology, Microbiology, Epidemiology, or other related field or other appropriate educational degree. The policy further documented IP must work in the facility for substantial time to complete with Infection Prevention duties. The facility failed to ensure CMA R, the staff person designated as the IP, had the qualifying education, training, experience and certification required to fulfill the role, placing the residents at risk of unidentified and untreated infection.

The facility had a census of 66 residents. Based on interview and record review, the facility failed to submit accurate staffing information through Payroll Based Journaling (PBJ) to the Centers for Medicare and Medicaid Services (CMS). This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - Review of the facility's submission of payroll data to CMS revealed no data had been submitted as required by CMS for Fiscal Year (FY) 2022 Quarter 4. On 10/19/23 at 11:41 AM, Administrative Staff A provided email information related to the PBJ submission for quarter 4 that the information was submitted with errors. Administrative Staff A stated the facility tried to resubmit the information but since it was past the submission deadline, it was not possible to resubmit the correct information. The facility's Mandatory Submission of Staffing Information policy, dated 11/22/22, documented the facility Administrator was responsible to ensure the person assigned to submission and the person to complete the task in the absence of the primary submitter are appropriately trained and demonstrate competency in the submission process including but not limited to: complete data for the entire reporting period including hours paid for all required staff each day, provision of accurate data, provision of data by the required deadline, and submission of the required staffing information based on payroll data in a uniform format. The facility failed to submit accurate PBJ information to CMS for FY 2022 Quarter 4. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to act upon the concerns of the resident council group concerning issues of care and life in the facility. This placed the residents at risk of decreased quality of care and services. Findings included: - The monthly Resident Council meetings recorded the following: In September 2023, the residents voiced concerns over staffing and the desire for more consistent staff. Other concerns included the residents did not always get a menu in advance, and the kitchen ran out of orange juice and cranberry juice. In August 2023, the residents voiced concerns again over staffing and the desire for more consistent staff. Further concerns again included residents did not always get a menu in advance and did not get the food they ordered. In July 2023, the residents voiced concerns over staffing again, and the desire for more consistent staff. Further concerns included late meals, and unavailable food items with no alternatives. In June 2023, the council concerns remained over the lack of staffing and the desire for more consistent staff. Further concerns included the hamburgers and hot dogs were burnt, the chicken was overcooked, and the facility continued to run out of staples like juices and brown sugar. No May 2023 meeting was noted. In April 2024, the council concerns remained over the lack of staffing and the desire for more consistent staff. In March 2023, the council voiced concerns over staff were always on their cell phones. Additional concerns included breakfast and lunch were not always on time. In February 2023, the residents voiced concerns about the nursing staff were always on cell phones. Additional concerns included the call light response time needed work. In January 2023, the council voiced concerns over staffing and having to wait for staff. Call light response time remained a concern as well. No December 2023 meeting was noted. In November 2024, the residents voiced concerns over staffing and the desire for more consistent staff and the need for more staff. Additional concerns included nursing staff were on cell phones, and the eggs were rubbery. Residents wanted more fruit. In October 2014, the residents voiced concern over staffing. Additional concerns included the Salisbury chopped steak was tough and the hamburgers were burnt and lacked flavor. On 10/19/23 at 02:00 PM Administrative Staff A verified awareness of the resident council's continued concerns from month to month and stated staffing was on ongoing issue. Administrative Staff A stated the facility had a new management company for dining to help with the food concerns and understood the ongoing issues. The facility Resident Council policy, dated 11/23/15, documented each resident would be encouraged to organize, meet, participate in Resident Council and a designated staff would provide assistance and respond to written request that result from the group meetings, and shall listen to the views and act upon the recommendations and grievances of such groups concerning proposed policy and operational decisions affecting resident care and life in the facility. The facility failed to act promptly upon the concerns of the resident council groups concerning issues of care and life in the facility, which placed the residents who resided in the facility at risk for decreased quality of life.

The facility identified a census of 44 residents. The expanded sample included 20 residents. Based on observation, interview, and record review, the facility failed to protect residents from abuse while investigating episodes of resident to resident sexual abuse. On 01/23/20, Resident (R) 9 entered the room of a cognitively impaired female resident, who was unable to consent to physical relations. R9 held the resident's hand and attempted to touch her belly and kiss her. The facility to implement interventions to protect all cognitively impaired female residents while the facility investigated the allegation. On 02/23/2020, the same male resident entered the room of another cognitively impaired resident, who was unable to consent to physical relations, and touched her on the chest and/or breast area. The facility again failed to implement interventions aimed at protecting all cognitively impaired female resident while the occurrence was investigated. This deficient practice placed all cognitively impaired female residents on both health care units in immediate jeopardy on 01/23/2020. The immediate jeopardy was removed on 03/12/2020 when the facility implemented measures to prevent further episodes of sexual abuse and protect residents at risk. Findings included: - R9's Electronic Medical Record (EMR), recorded [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] recorded R9 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact. R9 had no behaviors, but he hallucinated (sensing things while awake that appear to be real, but the mind created). He used a wheelchair for mobility and required limited assistance of one person for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/23/19 documented R9 had occasional instances of short-term memory loss. The CAA for Activities of Daily Living (ADLs) recorded R9 was alert with forgetfulness. He made his needs known and scored 13 on his BIMS assessment. He propelled himself in his wheelchair and required reminders on safety. He had significant changes with mood, weight loss, and incontinence. The CAA recorded he verbalized changes in his mood. The CAA for Behaviors documented R9 had increased anxiety and weight loss related to his possible discharge. R9's care plan titled Cognitive Loss/Dementia, dated 01/06/20, documented R9 had impaired decision and cognitive deficits related to [MEDICAL CONDITION] and dementia. It directed staff to provide daily orientation to routines, activity schedules, and therapy. It further directed staff to use environmental cues as needed for memory. The Psychosocial Well-being care plan, dated 01/06/2020, directed staff to remind and redirect R9 as needed if at any time he approached any female resident or current companion that it is always to be consensual and that at no time is it appropriate to touch or initiate contact without permission and verbal agreement and understanding from the female. The Behavior Problems care plan, dated 01/06/2020, documented R9 had impaired behavior related to making inappropriate sexual comments and gestures. It directed staff to intervene as necessary to ensure safety of the resident and others. It directed staff to remind him of the importance of being respectful and all acts should be consensual. It further directed staff to remind him he was not to initiate contact of any sort with others without permission and understanding of companion. Staff were to help redirect him. The care plan directed staff to remind R9 that inappropriate touching and sexual comments were unacceptable and to redirect. The Facility Investigation included a note, dated 01/23/20 at 07:01 PM, copied from R41's EMR which recorded a statement copied from a witness statement written by Certified Nurse Aid (CNA) O. The note documented CNA O took R41 to her room around 05:30 PM. CNA O walked past R41's room a few minutes later and observed a male resident in her room. CNA O entered the room and asked why the male resident was in the room. R41 answered the male resident was in there to kiss her. CNA O observed the residents holding hands. CNA O asked the nurse if the male resident was supposed to be in there and the nurse said no. CNA O then went to R41's room and removed the male resident from the room. The male resident went back to the dining room. At that time, R41 told CNA O the male resident was trying to touch her belly. CNA O reported the incident to the nurse. The note further recorded that at 6:00 PM R41 walked to the nurse's station and asked if she could have a room, pointing to a room. The note recorded LN J told R41 where her room was. R41 stated she did not want to go to her room because people keep telling her what to do. LN G documented R41 had a look of worry or concern on her face. LN J told R41 she could stay in an empty room near the nurse and escorted R41 into an empty room. The note documented notification of the occurrence to R41's representative. A note dated 01/23/20 at 06:59 PM, in R9's EMR, under the Interdisciplinary (ID) Notes tab, recorded CNA O took R41 to her room around 05:30 PM. A few minutes later, CNA O observed R9 in R41's room. When CNA O asked why R9 was in the room, R41 stated R9 was in there to kiss her. CNA O observed R9 and R41 holding hands. CNA O asked the nurse if R9 was supposed to be in the room with R41 and the nurse stated no. CNA O returned to the room and removed R9 from the room. At that time, R41 stated R9 tried to touch her belly. CNA O remained in R41's room until R9 returned to the dining room. CNA O then reported the whole incident to the nurse. The note documented the female resident (R41) was cognitively impaired with advanced dementia. R9 stated he was in R41's room and he did hold her hand but denied anything further. Staff notified R9's Durable Power of Attorney (DPOA). A note, dated 01/31/20, in R9's EMR, under the ID Notes tab, documented on 01/23/20 R9 was reported to be in another female resident's room. Staff redirected R9 as the female resident was cognitively impaired. R9 visited with the floor nurse that same evening regarding the incident. The confused female resident voiced concerns about other people coming to her room and telling her what to do. She requested a room change and staff redirected her with reassurance. Staff reported the event to both resident's DPOAs. Documentation on 01/27/20 indicated the social worker and Vice President (VP) Healthcare Services visited with R9 to discuss the incident on 01/23/20. R9 reported R41 kissed him. R9 reported he was not concerned about the incident because he was not the one soliciting it. Staff re-educated R9 about consent and the fact that not all of the residents at the facility were able to provide true consent due to certain conditions, referring to R41's cognitive impairment related to dementia. R9 verbalized understanding. The note recorded the Care Plan had been updated with interventions which included education for R9 on recognizing difference in consents from female counterpart and asking staff for guidance and support as needed. It also recorded staff were to monitor resident interactions related to appropriateness with female residents and document as needed. Review of R9's care plan revealed an intervention initiated on 01/28/2020 which directed staff to monitor resident interaction related to appropriateness with female residents. It further directed R9 was educated on recognizing differences in consents from female counter part and directed R9 to ask staff for guidance and support as needed. The facility investigations, clinical records and documents provided lacked evidence interventions were put in place regarding protection of female residents from R9 during the investigative process. R9's EMR recorded a note, dated 02/23/20 under the ID Notes tab documented R9 entered a female resident's room, R195, without her permission. R9 explained that R195 invited him to come in and waved him to come into her room. The note recorded R9 admitted that once he was in the room R195 asked him to leave so he left. R9 reported to staff at that time he observed R195 in the hallway earlier and he thought she seemed lost. The note documented staff encouraged R9 to speak with the nurses prior to entering any rooms. A notarized Witness Statement signed by Certified Medication Aid (CMA) S documented on 02/23/20 at about 01:00 PM, CMA S observed R195 in the hallway heading towards R195's room. CMA S documented R9 followed behind R195, heading towards the same direction. CMA S documented a few hours later, R195 approached CMA S and reported that R9 was trying to follow her into her room and she stopped him. CMA S documented R195 appeared to be very worried and CMA S calmed R195, provided reassurance, and then reported the incident to the nurse. A notarized Witness Statement signed by CNA P documented on 02/23/20 at 03:40 PM R195 and her representative called CNA P to complain very unhappy because R9 tried to get into R195's room and tried to touch her in an inappropriate way. CNA P documented she did not witness the interaction. A notarized Witness Statement signed by LN K documented on 02/23/2020 she received report from a CMA that R9 had followed R195 into her room at approximately 02:05 PM. LN K visited with R195 in her room. She observed R195 seated in the recliner and R195's family member had just arrived as well. LN K documented R195 had just told her family member about the incident. R195 reported R9 went into her room, but R195 did not feel scared and R9 left when asked to leave. LN K documented R195's family member reported he did not want repercussions for R9 but did want the facility to make sure R9 would not enter R195's room again. A notarized Witness Statement signed by Administrative Staff B documented on 02/24/20 R195's representative stated she needed to talk to Social Services LL about an incident that occurred over the weekend when a resident entered R195's room and touched R195 inappropriately on the chest. A notarized Witness Statement signed by Social Service LL documented on 02/24/20 she received a request to visit R195 and R195's family member regarding a male resident entering (R195)'s room on 02/23/20, touching her sexually. Social Services LL documented she informed social services of the issue and then went to R195's room. R195 stated to Social Services LL she was so sorry for the trouble but did not want any other residents to experience unwanted touch from the male resident. Social Services LL documented R195 told her R195 entered her room in the afternoon, but though R195 was uncertain of the time. Social Services LL documented R195 said a man followed her in, reached out, touched her breast. R195 reported she took the man's hand and put it back where it belonged. Social Services LL documented Social Services X and Y were in R195's room at that point and took notes. R195 stated she would like to go home instead of staying one more night in case the male resident returned. The facility Report of Complaint or Grievance form, signed by Social Services X and dated 02/24/20 documented an incident on or about 02/23/20 at 02:00 PM involving R9 and R195. The reporting party was R195 and her representative. The report recorded at approximately 02:45 PM Social Services X received notice from Administrative Staff B that R195's representative called and stated there was an incident on the weekend when a resident went into R195's room and touched R195 inappropriately on the chest. The report documented Social Services X, Social Service Y, and Social Service LL met with R195 and her representative in R195's room for further investigation. R 195 stated another resident went into her room shortly after lunch. R195 initially stated the resident walked into her room, but upon further questioning R195 was unable to remember if the resident walked using a walker, a wheelchair, or other. R195's representative stated R195's family member was present just after the incident reported R195 reported the resident was in a wheelchair. R195 stated the resident placed his hand above her breast. R195 also reported that the resident went back to her room after R195's family member arrived and R195 identified the male resident to her family member as the resident who entered her room previously. The report documented Social Services X contacted R195's family member for statement. R195's family member reported to Social Services X that he arrived at the facility shortly after the incident and R195 stood in her room doorway. R195 looked rattled and attempted to phone someone. R195's family member asked what happened and R195 said a gentleman followed her and came into her room. R195 told her family member the man got too close to her and she pushed his hand away. The report documented R195's family member stated R195 continued to appear rattled for the following three-hour visit. He reported the male resident went by R195's room in his wheelchair and R195 identified the male resident as the man who entered her room. The family member stated he reported this to the staff. He also reported R195 chose to eat her dinner in her room. The family member reported R195 stated she wished she could lock her room. R195 requested her family member call her later in the evening to check on her. The family member called later that night. He reported R195 stated at that time her room door was closed and she left her light on. The report documented the family member reported R195 made the decision to discharge a day early. Review of R9's care plan revealed an intervention was implemented on 02/23/2020 which documented R9 was encouraged to check in with staff before accepting invitations from other female residents to go into their room. The Facility Investigation,, clinical records and facility documentation of the occurrence lacked evidence interventions were implemented in order to protect the cognitively impaired female residents accessible to R9 from sexual abuse during the investigative process. On 03/10/20 at 12:20 PM R9 sat in his wheelchair between two female residents, also in wheelchairs. He spoke to the resident on his right. On 03/11/20 at 11:05 AM R9 sat in his wheelchair, alone, in the common room, and read the newspaper. No staff were observed in the area. On 03/12/20 at 12:11 PM CMA R stated staff received education and in-services regarding abuse through an electronic training website. She stated she had training on abuse but was uncertain when she last completed the training. CMA R stated the staff received specific information on how to care for residents in a shift to shift verbal report as well as a Care Sheet. She said the Care Sheet had specific information about how the residents transferred and toileted. She stated she did not think resident's specific behaviors were listed on the Care Sheet. CMA R said the staff monitored for behaviors and documented any behavior and what intervention staff used for the behavior in their charting system. CMA R stated she was aware of an occurrence between R9 and another female resident on 02/23/20 but did not witness it herself. CMA R stated she was not aware of any interventions related to R9's sexually inappropriate behaviors towards other residents and or steps to prevent a sexually inappropriate interaction. She stated staff were told when and if an incident occurred but were not trained on what to do to prevent it or what to do if it occurred. On 03/12/20 at 12:22 PM CNA N stated staff received education and training on abuse and various other topics via online training. He stated he was unsure when the last time he received the training, but he felt it had been recently and stated they received training often. CNA N said the staff knew how to care for the residents by the Care Sheets and by report from the nurses. He said the care sheets tell things about how a resident transfer, if they needed help toileting and things like that. He said the nurses let the staff know about any resident behaviors and staff would document the behaviors in the charting system. CNA N stated he had not witnessed any behaviors from R9 but was aware there had been previous incidents. CNA N stated he thought most of the incidents had been with the short stay residents, who come and go. CNA N stated R9 was supposed to let staff know where he was at all times but R9 was pretty independent in his wheelchair and could take himself to the different units. The only time R9 needed help were the times R9 was tired or wore out. CNA N stated he had no memory or knowledge of the incident that occurred on 02/23/20. CNA N stated he had not received any specific training on preventing R9's sexually inappropriate behaviors towards other residents. He said he was not aware of any specific interventions related to the sexual behaviors. On 03/12/220 at 01:01 PM LN I stated staff received training on abuse, neglect, and exploitation. LN I reported they received updates and information about residents' needs through verbal report. He stated if a resident had behaviors, this would be reported in verbal report between nurses. The nurses would then do a huddle to let the direct care staff know how to care for the residents and the behaviors. LN I said residents with behaviors have the behaviors listed on the electronic Treatment Administration Record (eTAR). LN I stated R9 had a history of [REDACTED]. LN I stated there were no specific interventions he was aware of regarding R9's behaviors. LN I stated if they saw R9 behaving in a sexually inappropriate manner, staff were to intervene, stop the behavior, report it to the facility administrative staff, R9's family, and the physician. LN I stated there were no specific intervention that he was aware of for the prevention of sexually inappropriate behaviors by R9. He said staff try to be aware of where R9 is and communicate with the other staff members if R9 was in activities. Staff reminded R9 to report to staff if he was leaving the unit. LN I stated R9 could be forgetful at times. On 03/12/2020 at 01:20 PM LN G stated she was familiar with R9. R9 visited residents on her unit frequently. LN G stated she was aware of R9's behaviors and impulses. She said R9 did have some issues controlling his sexual impulses. LN G stated R9 moved around the facility in his wheelchair independently. LN G stated she felt that R9 had too much freedom perhaps, considering his inability to control his impulses. She stated staff did try to stay aware of where he was and what he was doing. LN G stated she was unaware of any specific training or interventions put into place as a result of risk presented by R9's behaviors. She said all interventions would be on the care plan and she had not looked at R9's care plan for a long time. She did say that though R9 spent a great deal of time on her unit, she did not receive verbal or written report when changes occurred with R9 or when incidents or behaviors occurred. On 03/12/20 at 02:11 PM Administrative Nurse D stated staff notified her about the occurrence on 01/23/20 between R9 and R41 via email. She said she emailed back to the facility to find out if an investigation had been started. Staff informed her Administrative Staff A was aware and he initiated the investigation. Administrative Nurse D said facility staff met with R9 and reeducated him. Facility staff explained to R9 not all residents had ability to consent to physical contact. They educated R9 on consensual guidance and R9 was to check with staff prior to touching any residents. Administrative Nurse D stated this was not the first resident to resident occurrence of sexually inappropriate behavior involving R9, but it was the first since Administrative D had been in her position so she thought the prior incident may have been more than a year ago. Regarding the incident on 01/23/20, Administrative Nurse D stated she did not think R9 touching R41's belly and holding her hand with R41 seemed like sexual abuse. She stated R41 was friendly and very touchy feely and R41 changed her statement. Administrative Nurse D did say that sexually inappropriate behaviors would be determined by the person receiving the touching and the person's perception of the touching. She also stated R9 had a documented history of sexual behaviors. Administrative Nurse D stated if R41 had any signs of emotional distress or signs that something occurred, she would have viewed the situation differently. Regarding the occurrence on 02/23/20, Administrative Nurse D stated she called the resident to resident incident to the state agency on 02/26/20. Administrative Nurse D reviewed the witness statements and confirmed one of the statements alleged R9 touched R195's breast. Administrative Nurse D also confirmed that according to the documentation, it appeared R195 had a negative psychosocial impact related to the event. Administrative Nurse D stated staff received abuse training on the online training site last year and it was due again and scheduled on the training site. Administrative Nurse D stated R9 had unrestricted access to both healthcare units in the building where he resided. She reported staff tried to keep track of his whereabouts, though she was unable to find documentation related to continuous staff monitoring in the investigation report, EMR, and/or care plan. Administrative Nurse D reported staff had not received any specific resident-centered training on prevention and intervention related to R9's specific behaviors. After reviewing the care plan interventions for R9 implemented after each episode of abuse, Administrative Nurse D stated the interventions did seem redundant and was unable to provide documentation regarding the monitoring and effectiveness of the interventions. Administrative Nurse D verified R9 had unrestricted movement between the two health acre units at the facility. She said staff tried to always be aware of R9's location but she was unable to provide documentation of staff's continuous monitoring of R9. On 03/12/20 at 03:00 PM Administrative Staff A reported she was out of the facility for the occurrence on 01/23/20. She became aware of it on 01/27/20. She stated she read the report and knew the female resident involved. Administrative Staff A said no one actually saw what happened and the reports were very unclear as to what happened. Regarding the occurrence on 02/23/20, Administrative Staff A stated she was out of the facility at the time of the situation. She stated it should have been reported to the state agency sooner and the person in change at the facility during the incident should have recognized the allegation regarding the touching of R195's breast and acted accordingly. Administrative Staff A stated R9 had repeated behaviors regarding sexual inappropriateness in the past. She said there were no recent resident to resident behaviors, but he had been inappropriate with staff on many occasions. She said facility staff educated R9 and redirected him in regard to the sexual inappropriateness with staff on repeated occasions, but R9 continued to deny the behaviors. She further stated she felt the behaviors towards staff and inappropriate behaviors towards residents should be viewed differently since she felt R9 had the ability to understand the teaching about consensual relationships. She stated she felt R9 viewed the other female residents as potential sexual partners. Administrative Staff D stated she was uncertain what the facility did at the time of the incident to protect the other residents. She said she was informed staff would monitor his location hourly and she felt it was documented somewhere, perhaps on paper. Administrative Staff A stated the ID team had discussed possible interventions such as one to one monitoring for R9 but R9 lacked the funds for such measures. She stated there was no way for her to know if R9 had constant supervision. Administrative Staff A reported facility staff has received abuse training in the last calendar year and the training was scheduled again in the next month or so. The facility policy Abuse and Neglect effective 07/18/16 recorded the facility had the responsibility to ensure each resident had the right to be free from verbal, sexual, physical, and mental abuse. The policy recorded the facility would identify events, occurrences, patterns, and trends of potential or suspected abuse of residents. The policy further documented staff would protect residents from harm during an investigation of alleged abuse. The facility failed to implement measures to protect residents while investigating allegations and /or suspected sexual resident to resident abuse. The deficient practice placed all cognitively impaired female residents on both health care units in Immediate Jeopardy. The Immediate Jeopardy was determined to first exist on 01/23/2020 and was removed on 03/12/2020 at 05:43 PM when the facility implemented the following: All nursing staff were required to read and sign the Abuse, Neglect, and Exploitation policy before beginning his/her shift at the facility. Nursing staff were assigned additional online training regarding the reporting of abuse. R9's care plan was updated to include one to one caregiver and all interventions to address and prevent inappropriate sexual behaviors towards other residents. Care plan interventions for R9 were printed and shared with nursing staff to assure knowledge of all interventions to prevent R9 from entering other resident's rooms or having inappropriate sexual contact with other residents. CNA worksheets were updated to reflect R9s risk for sexually inappropriate behavior and the related interventions. A one to one caregiver was confirmed for R9 each day, for each shift. The deficient practice remained at a scope and severity of an E.

The facility identified a census of 44 residents. The expanded sample included 20 residents. Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse. On 01/23/20, Resident (R) 9 entered the room of a cognitively impaired female resident, who was unable to consent to physical relations. R9 held the resident's hand and attempted to touch her belly and kiss her . On 02/23/2020, the same male resident entered the room of another cognitively impaired resident, who was unable to consent to physical relations, and touched her on the chest and/or breast area. Both interactions created an environment of fear on the part of the female residents and/or their representatives. The facility transferred R41 to another unit and the R195 and/or her representative chose to discharge from the facility, ending her Medicare Part A benefit early, as a result of the resident to resident abuse. This deficient practice placed all cognitively impaired female residents on both health care units in immediate jeopardy on 02/23/2020. The immediate jeopardy was removed on 03/12/2020 when the facility implemented measures to prevent further episodes of sexual abuse. Findings included: - R9's Electronic Medical Record (EMR), recorded [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] recorded R9 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact. R9 had no behaviors, but he hallucinated (sensing things while awake that appear to be real, but the mind created). He used a wheelchair for mobility and required limited assistance of one person for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/23/19 documented R9 had occasional instances of short-term memory loss. The CAA for Activities of Daily Living (ADLs) recorded R9 was alert with forgetfulness. He made his needs known and scored 13 on his BIMS assessment . He propelled himself in his wheelchair and required reminders on safety. He had significant changes with mood, weight loss, and incontinence. The CAA recorded he verbalized changes in his mood. The CAA for Behaviors documented R9 had increased anxiety and weight loss related to his possible discharge. R9's care plan titled Cognitive Loss/Dementia, dated 01/06/20, documented R9 had impaired decision and cognitive deficits related to [MEDICAL CONDITION] and dementia. It directed staff to provide daily orientation to routines, activity schedules, and therapy. It further directed staff to use environmental cues as needed for memory. The Psychosocial Well-being care plan, dated 01/06/2020, directed staff to remind and redirect R9 as needed if at any time he approached any female resident or current companion that it is always to be consensual and that at no time is it appropriate to touch or initiate contact without permission and verbal agreement and understanding from the female. The Behavior Problems care plan, dated 01/06/2020, documented R9 had impaired behavior related to making inappropriate sexual comments and gestures. It directed staff to intervene as necessary to ensure safety of the resident and others. It directed staff to remind him of the importance of being respectful and all acts should be consensual. It further directed staff to remind him he was not to initiate contact of any sort with others without permission and understanding of companion. Staff were to help redirect him. The care plan directed staff to remind R9 that inappropriate touching and sexual comments were unacceptable and to redirect. The Facility Investigation included a note, dated 01/23/20 at 07:01 PM, copied from R41's EMR which recorded a statement copied from a witness statement written by Certified Nurse Aid (CNA) O. The note documented CNA O took R41 to her room around 05:30 PM. CNA O walked past R41's room a few minutes later and observed a male resident in her room. CNA O entered the room and asked why the male resident was in the room. R41 answered the male resident was in there to kiss her. CNA O observed the residents holding hands. CNA O asked the nurse if the male resident was supposed to be in there and the nurse said no. CNA O then went to R41's room and removed the male resident from the room. The male resident went back to the dining room. At that time, R41 told CNA O the male resident was trying to touch her belly. CNA O reported the incident to the nurse. The note further recorded that at 6:00 PM R41 walked to the nurse's station and asked if she could have a room, pointing to a room. The note recorded LN J told R41 where her room was. R41 stated she did not want to go to her room because people keep telling her what to do. LN G documented R41 had a look of worry or concern on her face. LN J told R41 she could stay in an empty room near the nurse and escorted R41 into an empty room. The note documented notification of the occurrence to R41's representative. A note dated 01/23/20 at 06:59 PM, in R9's EMR, under the Interdisciplinary (ID) Notes tab, recorded CNA O took R41 to her room around 05:30 PM. A few minutes later, CNA O observed R9 in R41's room. When CNA O asked why R9 was in the room, R41 stated R9 was in there to kiss her. CNA O observed R9 and R41 holding hands. CNA O asked the nurse if R9 was supposed to be in the room with R41 and the nurse stated no. CNA O returned to the room and removed R9 from the room. At that time, R41 stated R9 tried to touch her belly. CNA O remained in R41's room until R9 returned to the dining room. CNA O then reported the whole incident to the nurse. The note documented the female resident (R41) was cognitively impaired with advanced dementia. R9 stated he was in R41's room and he did hold her hand, but denied anything further. Staff notifiedR9's Durable Power of Attorney (DPOA). A note, dated 01/31/20, in R9's EMR, under the ID Notes tab, documented on 01/23/20 R9 was reported to be in another female resident's room. Staff redirected R9 as the female resident was cognitively impaired. R9 visited with the floor nurse that same evening regarding the incident. The confused female resident voiced concerns about other people coming to her room and telling her what to do. She requested a room change and staff redirected her with reassurance. Staff reported the event to both resident's DPOAs. Documentation on 01/27/20 indicated the social worker and Vice President (VP) Healthcare Services visited with R9 to discuss the incident on 01/23/20. R9 reported R41 kissed him. R9 reported he was not concerned about the incident because he was not the one soliciting it. Staff re-educated R9 about consent and the fact that not all of the residents at the facility were able to provide true consent due to certain conditions, referring to R41's cognitive impairment related to dementia. R9 verbalized understanding. The note recorded the Care Plan had been updated with interventions which included education for R9 on recognizing difference in consents from female counterpart and asking staff for guidance and support as needed. It also recorded staff were to monitor resident interactions related to appropriateness with female residents and document as needed. A note, dated 02/06/20 , in R41's EMR under ID Notes recorded R41 transferred to a different building on that date. R9's EMR recorded a note, dated 02/23/20 under the ID Notes tab documented R9 entered a female resident's room, R195, without her permission. R9 explained that R195 invited him to come in and waved him to come into her room. The note recorded R9 admitted that once he was in the room R195 asked him to leave so he left. R9 reported to staff at that time he observed R195 in the hallway earlier and he thought she seemed lost. The note documented staff encouraged R9 to speak with the nurses prior to entering any rooms. A notarized Witness Statement signed by Certified Medication Aid (CMA) S documented on 02/23/20 at about 01:00 PM, CMA S observed R195 in the hallway heading towards R195's room. CMA S documented R9 followed behind R195, heading towards the same direction. CMA S documented a few hours later, R195 approached CMA S and reported that R9 was trying to follow her into her room and she stopped him. CMA S documented R195 appeared to be very worried and CMA S calmed R195, provided reassurance, and then reported the incident to the nurse. A notarized Witness Statement signed by CNA P documented on 02/23/20 at 03:40 PM R195 and her representative called CNA P to complain very unhappy because R9 tried to get into R195's room and tried to touch her in an inappropriate way. CNA P documented she did not witness the interaction. A notarized Witness Statement signed by LN K documented on 02/23/2020 she received report from a CMA that R9 had followed R195 into her room at approximately 02:05 PM. LN K visited with R195 in her room. She observed R195 seated in the recliner and R195's family member had just arrived as well. LN K documented R195 had just told her family member about the incident. R195 reported R9 went into her room, but R195 did not feel scared and R9 left when asked to leave. LN K documented R195's family member reported he did not want repercussions for R9 but did want the facility to make sure R9 would not enter R195's room again. A notarized Witness Statement signed by Administrative Staff B documented on 02/24/20 R195's representative stated she needed to talk to Social Services LL about an incident that occurred over the weekend when a resident entered R195's room and touched R195 inappropriately on the chest. A notarized Witness Statement signed by Social Service LL documented on 02/24/20 she received a request to visit R195 and R195's family member regarding a male resident entering (R195)'s room on 02/23/20, touching her sexually. Social Services LL documented she informed social services of the issue and then went to R195's room. R195 stated to Social Services LL she was so sorry for the trouble but did not want any other residents to experience unwanted touch from the male resident. Social Services LL documented R195 told her R195 entered her room in the afternoon, but though R195 was uncertain of the time. Social Services LL documented R195 said a man followed her in, reached out, touched her breast. R195 reported she took the man's hand and put it back where it belonged. Social Services LL documented Social Services X and Y were in R195's room at that point and took notes. R195 stated she would like to go home instead of staying one more night in case the male resident returned. The facility Report of Complaint or Grievance form, signed by Social Services X and dated 02/24/20 documented an incident on or about 02/23/20 at 02:00 PM involving R9 and R195. The reporting party was R195 and her representative. The report recorded at approximately 02:45 PM Social Services X received notice from Administrative Staff B that R195's representative called and stated there was an incident on the weekend when a resident went into R195's room and touched R195 inappropriately on the chest. The report documented Social Services X, Social Service Y, and Social Service LL met with R195 and her representative in R195's room for further investigation. R 195 stated another resident went into her room shortly after lunch. R195 initially stated the resident walked into her room, but upon further questioning R195 was unable to remember if the resident walked using a walker, a wheelchair, or other. R195's representative stated R195's family member was present just after the incident reported R195 reported the resident wasin a wheelchair. R195 stated the resident placed his hand above her breast. R195 also reported that the resident went back to her room after R195's family member arrived and R195 identified the male resident to her family member as the resident who entered her room previously. The report documented Social Services X contacted R195's family member for statement. R195's family member reported to Social Services X that he arrived at the facility shortly after the incident and R195 stood in her room doorway. R195 looked rattled and attempted to phone someone. R195's family member asked what happened and R195 said a gentleman followed her and came into her room. R195 told her family member the man got too close to her and she pushed his hand away. The report documented R195's family member stated R195 continued to appear rattled for the following three-hour visit. He reported the male resident went by R195's room in his wheelchair and R195 identified the male resident as the man who entered her room. The family member stated he reported this to the staff. He also reported R195 chose to eat her dinner in her room. The family member reported R195 stated she wished she could lock her room. R195 requested her family member call her later in the evening to check on her. The family member called later that night. He reported R195 stated at that time her room door was closed and she left her light on. The report documented the family member reported R195 made the decision to discharge a day early. The Facility Investigation included a copy of an email sent from Social Services Y to Social Services X on 02/24/20 at 04:06 PM. The email documented an observation in which Social Services Y walked R195 and her family member out to the car. Social Services Y documented an occurrence in which R195 saw R9 at the double doors and stated, I can't go that way, I can't go that way. Social Services Y documented she wanted to alert Social Services X to R195's reaction to seeing R9 in the hall. The EMR for R195, under the ID Notes documented a late entry note on 02/25/20, corrected on 02/27/20, by Social Services X. The note recorded Social Services X met with R195 and her representative. R195 explained how another resident entered her room and touched her without her consent. The note recorded R195 and her representative made the decision for R195 to discharge on that date (one day early) due to R195's concerns the other resident may return to her room. On 03/10/20 at 12:20 PM R9 sat in his wheelchair between two female residents, also in wheelchairs. He spoke to the resident on his right. On 03/11/20 at 11:05 AM R9 sat in his wheelchair, alone, in the common room, and read the newspaper. No staff were observed in the area. On 03/12/20 at 12:11 PM CMA R stated staff received education and in-services regarding abuse through an electronic training website. She stated she had training on abuse but was uncertain when she last completed the training. CMA R stated the staff received specific information on how to care for residents in a shift to shift verbal report as well as a Care Sheet. She said the Care Sheet had specific information about how the residents transferred and toileted. She stated she did not think resident's specific behaviors were listed on the Care Sheet. CMA R said the staff monitored for behaviors and documented any behavior and what intervention staff used for the behavior in their charting system. CMA R stated she was aware of an occurrence between R9 and another female resident on 02/23/20 but did not witness it herself. On 03/12/20 at 12:22 PM CNA N stated staff received education and training on abuse and various other topics via online training. He stated he was unsure when the last time he received the training, but he felt it had been recently and stated they received training often. CNA N said the staff knew how to care for the residents by the Care Sheets and by report from the nurses. He said the care sheets tell things about how a resident transfer, if they needed help toileting and things like that. He said the nurses let the staff know about any resident behaviors and staff would document the behaviors in the charting system. CNA N stated he had not witnessed any behaviors from R9, but was aware there had been previous incidents. CNA N stated he thought most of the incidents had been with the short stay residents, who come and go. CNA N stated R9 was supposed to let staff know where he was at all times but R9 was pretty independent in his wheelchair and could take himself to the different units. The only time R9 needed help were the times R9 was tired or wore out. CNA N stated he had no memory or knowledge of the incident that occurred on 02/23/20. On 03/12/220 at 01:01 PM LN I stated staff received training on abuse, neglect, and exploitation. LN I reported they received updates and information about residents' needs through verbal report. He stated if a resident had behaviors, this would be reported in verbal report between nurses. The nurses would then do a huddle to let the direct care staff know how to care for the residents and the behaviors. LN I said residents with behaviors have the behaviors listed on the electronic Treatment Administration Record (eTAR). LN I stated R9 had a history of [REDACTED]. LN I stated there were no specific interventions he was aware of regarding R9's behaviors. LN I stated if they saw R9 behaving in a sexually inappropriate manner, staff were to intervene, stop the behavior, report it to the facility administrative staff, R9's family, and the physician. LN I stated there were no specific intervention that he was aware of for the prevention of sexually inappropriate behaviors by R9. On 03/12/20 at 02:11 PM Administrative Nurse D stated staff notified her about the occurrence on 01/23/20 between R9 and R41 via email. She said she emailed back to the facility to find out if an investigation had been started. Staff informed her Administrative Staff A was aware and he initiated the investigation. Administrative Nurse D said facility staff met with R9 and reeducated him. Facility staff explained to R9 not all residents had ability to consent to physical contact. They educated R9 on consensual guidance and R9 was to check with staff prior to touching any residents. Administrative Nurse D stated this was not the first resident to resident occurrence of sexually inappropriate behavior involving R9, but it was the first since Administrative D had been in her position so she thought the prior incident may have been more than a year ago. Regarding the incident on 01/23/20, Administrative Nurse D stated she did not think R9 touching R41's belly and holding her hand with R41 seemed like sexual abuse. She stated R41 was friendly and very touchy feely and R41 changed her statement. Administrative Nurse D did say that sexually inappropriate behaviors would be determined by the person receiving the touching and the person's perception of the touching. She also stated R9 had a documented history of sexual behaviors. Administrative Nurse D stated if R41 had any signs of emotional distress or signs that something occurred, she would have viewed the situation differently. Regarding the occurrence on 02/23/20, Administrative Nurse D stated she called the resident to resident incident to the state agency on 02/26/20. Administrative Nurse D reviewed the witness statements and confirmed one of the statements alleged R9 touched R195's breast. Administrative Nurse D also confirmed that according to the documentation, it appeared R195 had a negative psychosocial impact related to the event. Administrative Nurse D stated staff received abuse training on the online training site last year and it was due again and scheduled on the training site. Administrative Nurse D stated R9 had unrestricted access to both healthcare units in the building where he resided. She reported staff tried to keep track of his whereabouts, though she was unable to find documentation related to continuous staff monitoring in the investigation report, EMR, and/or care plan. Administrative Nurse D reported staff had not received any specific resident-centered training on prevention and intervention related to R9's specific behaviors. On 03/12/20 at 03:00 PM Administrative Staff A reported she was out of the facility for the occurrence on 01/23/20. She became aware of it on 01/27/20. She stated she read the report and knew the female resident involved. Administrative Staff A said no one actually saw what happened and the reports were very unclear as to what happened. Regarding the occurrence on 02/23/20, Administrative Staff A stated she was out of the facility at the time of the situation. She stated it should have been reported to the state agency sooner and the person in change at the facility during the incident should have recognized the allegation regarding the touching of R195's breast and acted accordingly. Administrative Staff A stated R9 had repeated behaviors regarding sexual inappropriateness in the past. She said there were no recent resident to resident behaviors, but he had been inappropriate with staff on many occasions. She said facility staff educated R9 and redirected him in regard to the sexual inappropriateness with staff on repeated occasions, but R9 continued to deny the behaviors. She further stated she felt the behaviors towards staff and inappropriate behaviors towards residents should be viewed differently since she felt R9 had the ability to understand the teaching about consensual relationships. She stated she felt R9 viewed the other female residents as potential sexual partners. Administrative Staff D stated she was uncertain what the facility did at the time of the incident to protect the other residents. She said she was informed staff would monitor his location hourly and she felt it was documented somewhere, perhaps on paper. Administrative Staff A said the local law enforcement agency was not notified because R195's family did not desire law enforcement intervention. She further stated the facility should have reported the incident within two hours. She reported she was aware the facility was not allowed to delay reporting in order to further investigate but since she was not present for the occurrence, she could only go by what was reported to her by nursing. Administrative Staff A stated the ID team had discussed possible interventions such as one to one monitoring for R9 but R9 lacked the funds for such measures. She stated there was no way for her to know if R9 had constant supervision. Administrative Staff A reported facility staff has received abuse training in the last calendar year and the training was scheduled again in the next month or so . The facility policy Abuse and Neglect effective 07/18/16 recorded the facility had the responsibility to ensure each resident had the right to be free from verbal, sexual, physical, and mental abuse. The policy recorded the facility would identify events, occurrences, patterns, and trends of potential or suspected abuse of residents. The policy further documented staff would protect residents from harm during an investigation of alleged abuse. The facility failed to prevent occurrences of sexual resident to resident abuse when the facility failed to prevent an alert and oriented resident from inappropriately touching two cognitively impaired females. The first incident occurred on 01/23/20 and the second on 02/23/20. The deficient practice placed all cognitively impaired female residents on both health care units in Immediate Jeopardy. The Immediate Jeopardy was determined to first exist on 02/23/2020 and was removed on 03/12/2020 at 05:43 PM when the facility implemented the following: All nursing staff were required to read and sign the Abuse, Neglect, and Exploitation policy before beginning his/her shift at the facility. Nursing staff were assigned additional online training regarding the reporting of abuse. R9's care plan was updated to include one to one caregiver and all interventions to address and prevent inappropriate sexual behaviors towards other residents. Care plan interventions for R9 were printed and shared with nursing staff to assure knowledge of all interventions to prevent R9 from entering other resident's rooms or having inappropriate sexual contact with other residents. CNA worksheets were updated to reflect R9s risk for sexually inappropriate behavior and the related interventions. A one to one caregiver was confirmed for R9 each day, for each shift. The deficient practice remained at a scope and severity of a G.

The facility identified a census of 44 residents. The expanded sample included 20 residents. Based on observation, record review, and interviews, the facility failed to provide the care needed to maintain Resident (R)9's highest practicable level of psychosocial well-being when the facility failed to implement and monitor effectiveness of specific, person centered interventions to address R9's increased depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) resulting from an involuntary discharge notice issued to R9 by the facility. Findings included: - R9's electronic medical record (EMR), recorded [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] recorded R9 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The MDS, under the Mood section, recorded a total severity score of zero which indicated no symptoms of depression. The MDS documented R9 had no behaviors. The MDS recorded R9 received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) and antipsychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions) seven of the seven look back days. R9 had occasional pain, which he rated at a two on a zero to ten scale with ten being the worst. The MDS recorded a weight of 179 pounds (lbs.) with no weight loss. The MDS documented R9 had no plan to discharge to the community and preferred not to be asked about discharge with each assessment. The Significant Change MDS dated [DATE] recorded R9 had a BIMS score of 13 which indicated he was cognitively intact. The MDS, under the Mood section, recorded a total severity score of four which indicated depression as evidenced by R9 felt down, depressed, and hopeless. He also had a poor appetite, felt tired and/or lacked energy, and felt bad about himself. He had little interest or pleasure in doing things. The MDS documented R9 had no behaviors, but he hallucinated (sensing things while awake that appear to be real, but the mind created). The MDS recorded R9 received an antidepressant, antianxiety and antipsychotic seven of the seven look back days. R9 had occasional pain, which he rated at a five on a zero to ten scale with ten being the worst. The MDS recorded a weight of 170 lbs. and indicated R9 had unintentional weight loss. The MDS documented R9 had no plan to discharge to the community. The question regarding the resident's goal for discharge was left blank. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/23/19 documented R9 had occasional instances of short-term memory loss. The CAA for Activities of Daily Living (ADLs) recorded R9 was alert with forgetfulness. He made his needs known and scored 13 on his BIMS assessment. He propelled himself self in his wheelchair and required reminders on safety. He had significant changes with mood, weight loss, and incontinence. The CAA recorded he verbalized changes in his mood. The CAA for Behaviors documented R9 had increased anxiety and weight loss related to his possible discharge. The CAA for Mood recorded R9 had increased anxiety and sadness. The Nutritional Status CAA documented R9 had a significant weight loss. The Psychosocial Well-being CAA documented R9 reported stress and anxiety. The Activities CAA documented R9 felt more tired lately and needed more help and reminders regarding programs. R9's care plan titled Cognitive Loss/Dementia, dated 01/06/20, documented R9 had impaired decision and cognitive deficits related to [MEDICAL CONDITION] and dementia. It directed staff to provide daily orientation to routines, activity schedules, and therapy. It further directed staff to use environmental cues as needed for memory. The Behavior Problems care plan, dated 01/06/20, documented R9 had impaired behavior related to making inappropriate sexual comments and gestures. It directed staff to intervene as necessary to ensure safety of resident and others. It directed staff to remind him of the importance of being respectful and all acts should be consensual. It further directed staff to remind him he was not to initiate contact of any sort with others without permission and understanding of the companion. Staff were to help redirect him. The care plan directed staff to remind R9 that inappropriate touching and sexual comments were unacceptable and to redirect. The Psychosocial Well-being care plan, dated 01/06/20, documented R9's well bring was important to him and he wanted to be able to share an intimate relationship with a willing female resident. It directed staff to remind and redirect R9 as needed if at any time he approached any female resident or current companion that it is always to be consensual and that at no time is it appropriate to touch or initiate contact without permission and verbal agreement and understanding from the female. It further directed to provide R9 emotional support and validate his feelings and/or concerns as needed. It directed staff to facilitate development of consensual relationship with fell ow resident and promote one on one time. The care plan directed staff to assist the resident when he chose to have alone time with his consensual companion. It recorded staff were to encourage family involvement and support as needed and continue to educate regarding safety. The Mood State care plan, dated 01/06/20 documented R9 had a mood problem related to depression as evidenced by R9 self-report. It directed staff to administer R9's antidepressant medication and monitor for adverse effects. It further directed staff to observe and document effectiveness of mood enhancement medications, to monitor behaviors, and observe for patterns or triggers. The Mood State care plan recorded R9 had an alteration in mood related to anxiety. It directed staff to provide reassurance and comfort, give clear concise explanations of procedures, and to assist with decision making. The care plan recorded R9 had ineffective coping related to stress as evidenced by R9's self-reports of increased anxiety and difficulty making decisions. It directed staff to assess and document specific stressors, stimuli, and triggers. It directed to provide opportunities to express concerns, fears, feelings and expectations. The care plan directed staff to explore R9's attitudes and feelings about required lifestyle changes and to reduce stimuli in his environment that could be interpreted as threatening. It directed staff to administer mediations as ordered and to teach R9 the use of relaxation, exercise, and diversional activities as methods to cope with stress. The Discharge Planning care plan, dated 01/06/20, recorded R9 needed 24-hour supervision and required long term care environment. It directed staff to encourage R9 to move about the facility as long as he had no exit seeking behaviors and to make care choices as he was able. It further directed staff to orient R9 to facility layout and provide orientation to routine and daily scheduling including meals, programs, and therapy. It directed staff to identify self and role when approaching the resident . The Care Plan lacked interventions which identified specific or suspected triggers and lacked direction to staff regarding person-centered measures aimed at relieving R9's self-reported stress, anxiety, and depression. The care plan lacked interventions which directed staff on how to provide resident specific support in the event of anxiety, stress, and/or depression. R9's EMR documented a 30 Day Notice of Involuntary Discharge issued to R9 and his representative on 11/5/19. A note, under the Interdisciplinary Note (ID) Note tab, dated 11/06/19 recorded Administrative Staff A met with R9 to discuss the 30 Day Notice of Involuntary Discharge provided to him. R9 asked Administrative Staff A what he could do to change that final decision. Administrative Staff A suggested to R9 that he do all he could to control behaviors that resulted in inappropriate verbalizations and/or physical contact with staff members. A note, under the ID Note tab dated 11/14/19 documented R9 requested to speak with Social Service X. He asked for an update to the notice of discharge. Social Service X provided the update. R9 again asked about timeline for the process and Social Service X explained that it would be open ended until determination of a decision. The note documented Social Service X provided active listening as R9 had concerns he upset his family. R9 stated he was thankful for the support he received. Social Service X encouraged R9 to feel free to contact her as needed whenever R9 had questions or felt the need to talk. Social Service X encouraged R9 to continue self-care. A note, under the ID Note tab, dated 11/17/19 documented LN L asked R9 how he was doing. R9 stated that he was doing well, and asked LN L to come to R9's room and visit. LN L informed R9 LN L had to go see another resident. R9 voiced understanding and propelled himself back to his room. The note lacked documentation LN L followed up with R9 to assess R9's needs. The note lacked documentation staff provided comfort and/or visitation to R9 as R9 requested. A behavioral health Progress Note under the consults tab, dated 11/19/19 documented R9 was seen for the goal of reducing stress and anxiety. The session content recorded health concerns and situational circumstances. The note recorded the recommendation to staff to continue to provide comfort and support. A note, under the ID Note tab, dated 11/25/19 recorded R9 extended his hand to CNA Q, as if to shake it, and stated Hi, my name is (R9). The note recorded CNA Q responded she knew R9's name. R9 then asked CNA Q my place or yours? CNA Q told R9 that comment was not appropriate. CNA Q asked R9 if he wanted to go to his room and R9 responded no I just want you to come to my room. CNA Q stated again that's not appropriate. CNA Q then asked R9 if she could help him with something, and R9 responded I just want to spend time with you. CNA Q excused herself from R9. The note lacked documentation staff followed up with comfort, support, or offered R9 individualized time as R9 requested. The note lacked evidence the nurse assessed R9's well-being or needs at that time. A late entry note, under the ID note tab, dated 12/01/19 documented Social Services X and Administrative Nurse D met with R9 to review the comments he made to CNA Q on 11/25/19. The note documented R9 did not remember making the comment and stated, if you say this happened, then I guess it did. Social Service X and Administrative Nurse D reminded R9 that it was important to try not to make these types of comments and why. R9 stated he was sorry for the incident. Social Service X then provided reassurance that updates would be provided about the discharge investigation. A note under the ID Note tab dated 12/01/19 documented R9 remained in bed the whole day, asleep. R9 did not get up to eat at all. R9 was only up to toilet and take medications. R9 denied any discomforts. No inappropriate behaviors observed or reported. A note under the ID Note tab, dated 12/11/19 documented Social Service X met with R9 prior to his doctor's appointment. The note recorded R9 looked haggard and when asked how he was doing, he stated, I'm tired. I didn't sleep well last night. At least I don't think I did. Social Service X checked with R9 about his mood and R9 said, I really can't tell you. Social Service X offered suggestions for how R9 might feel and R9 agreed he felt anxious and scared. Social Service X provided reassurance that this was normal, and this was also part of the reason for the multiple doctor appointments. The note recorded R9 seemed more confused and had difficulty speaking or finding words to express himself. The note documented Social Service X met with R9 later in the day. R9 was in bed, but awake. R9 told Social Service X he had a headache and had been in bed off and on all afternoon. Social Service X reminded R9 of self-care strategies discussed previously and then encouraged him to have a good dinner since he had not eaten much that day. A note under the ID Note tab dated 12/12/19 documented R9 expressed to LN J feeling increased anxiety. R9 stated he needed something to calm him down. The note recorded notification of the physicianand obtained a new order for an antianxiety medication. The note recorded LN J notified Social Service X and Administrative Nurse D to follow up with R9 the next day. A note under the ID Note tab dated 12/13/19 documented Social Service X met with R9 to check on him following his difficulty the previous day with increased anxiety. R9 stated he had a bad day and was in bed resting. When asked why it was a bad day, R9 said he had been nervous all day. The note recorded Social Service X also notified R9 that the pre-hearing (regarding the involuntary discharge) scheduled for 12/27/19 had been rescheduled for 1/3/20. Social Service X explained to R9 there would be another facility there to meet him on Tuesday 12/17/19 and Social Service X would be present for support. A note under the ID Note tab dated 12/17/19 documented R9 complained of increased anxiety and increased tremors. Staff administered As needed medication and R9 reported he felt better. A note under the ID Note tab dated 12/18/19 recorded on 12/17/19 Social Service X met with representatives from a nursing center regarding possible placement as needed depending on outcome of R9's discharge appeal. Social Service X reminded R9 about the reason for the meeting and R9 was willing to meet. Social Service X made a follow up visit to R9 on 12/18/19 and reminded R9 why the other facility staff met with him. R9 stated understanding, but also stated he did not want to move. Social Service X reminded R9 of pre-hearing date of 01/03/2020. Social Service X asked R9 how he felt and R9 indicated he had some increased anxiety, but staff had been helpful when R9 asked. Social Service X reminded R9 to continue self-care activities as possible and notify staff if he had questions or needed support. A nutrition alert note under ID Note tab dated 12/29/19 documented R9's weight at168.6 lbs. The note recorded R9 continued weight loss and inadequate oral intake . An unlocked note under the ID Note tab dated 12/31/19 documented Social Service X met with R9. The note lacked further information. A note under the ID Note tab dated 01/01/20 recorded R9 refused to get up. R9 did not want to eat and stated he just felt tired. R9 called to use the bathroom and took all of his medications. R9 denied any needs and nursing staff offered R9 food and fluids. A note under the ID Note tab dated 01/02/20 documented Administrative Staff A met with R9 in his room and reminded him that tomorrow was the prehearing conference. The note recorded R9 immediately reacted with acknowledgement and understanding of what was being referred to. Administrative Staff A asked R9 if he wished to be present for the phone conference. R9 stated, No, I don't think so, I am not really feeling strong enough. A note under the ID Note tab dated 01/02/20 recorded R9 refused to eat and was tired all the time from walking around. It further recorded staff voiced concerns that R9 lacked motivation, even with strong encouragement. The note recorded R9 voiced he had no appetite lately, but would try to eat that night. A note under the ID Note tab dated 01/07/20 recorded R9 stopped Social Service X in the hallway to report that R9 had a rough 24 hours. R9 shared that he felt weak, tired, had heartburn last night, and generally didn't feel well. When asked why he felt that way, he responded, I'm not sure. R9 also stated he felt jittery. Social Service X assisted R9 to see the charge nurse and requested the nurse check on R9. Social Service X also spoke with the Behavioral Health Therapist . The note recorded the therapist would see R9 that day and weekly. A note under the ID Note tab dated 01/29/20 recorded R9 complained of increased anxiety. Staff administered medication for the anxiety. R9 went to bed & refused to eat the evening meal. The note documented R9 stated he felt better, but still declined to eat at that time. A Nutrition Alert under the ID Note tab dated 01/31/20 recorded R9 weighed 168.6 lbs. The note recorded R9 had some anxiety noted and had a pattern of not eating well when he had increased anxiety. A note under the ID Note tab dated 02/04/20 documented R9 called Social Service X and requested a visit. During the meeting, R9 voiced concerns that he did not understand why he was given the discharge notice. Social Service X again revisited the concerns as they were noted by staff and comments that R9 made to staff. R9 stated, If I did this, I certainly didn't do it with any malice or intent. He also stated that these comments must have been made off the cuff. The note documented R9 questioned why anyone would be threatened by anything he said. Social Service X reviewed past incidents with R9 and reminded R9 those incidents had been discussed with him. The note documented Social Service X confirmed that R9 apologized to some of the people who made the reports. R9 indicated he did not remember this. Social Service X reviewed recent correspondence after the pre-hearing was held and agreed to follow up in regard to what R9 could expect with the hearing scheduled for 3/13/20. A Behavioral Health Progress Note under the consults tab, dated 02/04/20 documented R9 was seen for the goal of reducing anxiety and depression. The note recorded the session content consisted of situational circumstances and the unknown or not knowing or understanding pending legal matters. The note recorded R9 reported worry and anxiety as soon as he awoke and panic attacks in the afternoons. The note documented recommendation to staff to continue comfort and support. A note under the ID Note tab dated 02/04/20 recorded R9 complained of increased anxiety two times during the shift and requested as needed medication. R9 reported the medication was effective. A note under the ID Note tab dated 02/17/20 recorded Social Service X met with R9 at R9's request. R9 continued to report he had no idea why he received the notice of discharge and shared his anxiety about it was increasing. Social Services X again reminded R9 of the reports that were made regarding his comments to staff. He stated again he did not remember making the comments. R9 also stated he had increased anxiety about the hearing and wondered what to expect, whether he had to be present, and what to expect from the decision. The note documented Social Service X reviewed self-care activities with R9 and encouraged him to continue a normal routine when possible and seek support as needed A note under the ID Note tab dated 03/02/20 documented Social Service X received a phone call from R9. R9 asked What is next in all of this? Social Service X confirmed R9 was talking about the upcoming hearing. Social Service X reminded R9 the hearing remained scheduled for 3/13/2020. R9 asked if there was anything he could do at that time and Social Service X recommended R9 contact his family representative for further options if available. Social Service X offered to visit R9, but R9 declined. A note under the ID Note tab dated 03/03/20 recorded R9 complained of increased anxiety. The note recorded staff administered medication with effectiveness noted. A note under the ID Note tab dated 03/10/20 at 04:50 PM recorded R9 suffered increased anxiety related to having a very stressful day. Staff received new orders for antianxiety medication administered the medication. R9 ate supper and rested in his room for the rest of the shift. During observation and interview with R9 on 03/10/20 at 05:10 PM, R9 agreed to talk with the surveyor. R9 laid back on his bed. He appeared restless and uncomfortable as evidenced by frequent weight shifting and repositioning. R9 stated he liked the facility, his nurses, and the other residents at the facility. He reported he had been feeling very anxious and scared for several months because of the notice. He also said he had been feeling tired and disinterested. He expressed concern in speaking about the notice or about his feelings and stated that in the past, when he spoke about things it caused problems. R9 verbalized he did not want to cause any issues. He stated he would answer any questions and do what he needed to do, but did not really want to talk or think about the discharge and how it made him feel. R9 shared he felt uncertain about the future and uncertain about what may happen if he lost the appeal. He stated, I guess they just shuffle me off to another nursing home. R9 stated he did not remember if he discussed these feelings with anyone in the facility. R9 then said that if they say I did, then I guess I did. R9 verbalized he had been having trouble remembering things and getting things right. He again expressed concern about saying anything and stated he did not want to say the wrong thing. R9 said that happened in the past and it had come back to bite him. R9 became tearful, and stated he felt very blah and was just stressed over the hearing on Friday. He then requested to end the interview. On 03/12/20 at 12:11 PM CMA R stated R9 had been depressed and crying. CMA R said she had not received any specific instruction or training regarding R9 recent change in mood. She said she just reported it to the nurse when she observed it. CMA R stated she was aware there had been talk about R9's specific behaviors, but she had not really witnessed it. The nurse informed staff that there was an occurrence involving R9. Social services usually dealt with those type of behaviors. CMA R stated there had been a big change in R9 and it was usually more noticeable after they take him off to talk to him. She clarified they were management people. After those times, he usually did not want to come out of his room, like he was embarrassed. CMA R stated she did not know what else they do for the behaviors. She stated she only knew they take him off and talk to him. CMA R said she administered medications, so she knew R9 was on some medications for his anxiety. CMA R said R9 started asking for more anxiety medication. She stated once in a while R9 would ask for a pain pill, due to a bad headache. She said she was not sure if he was using his pain medication more than before. CAM R stated she would not say R9 had more pain, he was just sad now. CMA R stated facility staff were not doing anything new to help him with his emotional support and the changes in his mood. On 03/12/20 at 12:22 PM CNA N stated he worked with R9 almost every day he worked. CNA N stated he was not sure what he was supposed to say regarding the situation with R9. CNA N stated he had not really witnessed any behaviors from R9, but was aware from other staff that there had been occurrences. CNA N said R9 was forgetful, but that was common from all the residents. CNA N stated the staff were all very fond of R9 and loved him. CNA N said the whole situation that happened with R9, with the discharge, had really messed with R9 emotionally. CNA N stated R9 would cry and be upset frequently, which was not normal for R9. CNA N stated he was aware of a few incidents of inappropriate behavior R9 had towards staff and a few other residents. CNA N said R9 was redirectable, but if R9 was redirected the wrong way, he would have what CNA N called a bad day. CNA N stated he knew when R9 had a bad day because R9 would not want to get out of bed. CNA N said on R9's bad days R9 would repeatedly apologize to the staff. CNA N said he was unaware of any specific interventions regarding R9's behavior and mood changes. CNA N stated staff had not received any special training or new interventions regarding the changes in R9's mood or behaviors. On 03/12/20 at 01:01 PM LN I stated staff had not received any specific training or instructions regarding caring for R9's mood or behaviors. LN I stated R9 had bad days, and on those bad days R9 talked about being anxious and nervous. LN I said R9 would go back to bed. LN I reported R9 had been more tearful recently. On 03/12/20 at 01:20 PM LN G stated staff had not received any specific training or information related to R9. LN G stated staff were very worried about him. R9 was nervous and anxious all the time. LN G stated that began when he received the notice of eviction. LN G said R9 seemed a bit better now, but she was sure he was probably still upset. LN G said staff had not received any communication regarding interventions or supporting needs when the facility issued the notice. LN G said there should have been an in-service or some training to direct staff about what was going on. On 03/16/20 at 03:00 PM Social Service X stated since R9 received the discharge notice he reported increased anxiety. Social Service X said R9 started calling her to check and look for updates. She said one day the previous week he called three or four times in one day. R9 wanted to know if there was anything else he could do to stop the discharge. Social Service X stated she spent a lot of time communicating with R9 and also encouraged R9 to talk to his family. Social Service X stated she thought R9 was active in programs (activities) with no change from his normal routine. She said R9 was more tired recently and took more naps. Social Service X stated increased sleeping and napping could be a sign of depression. She said R9 had anxiety before, but it had certainly heightened due to the recent events. She stated she discussed multiple non-pharmacological interventions with R9 and made suggestions, but R9 was usually not interested. Social Service X stated she had done some informal training with some of the staff regarding R9's mood and behaviors. She said she asked staff to monitor and check on R9 frequently. The facility policy Behavior Assessment, Intervention and Monitoring dated 01/2019 documented the facility would thoroughly evaluate new and changing behavioral symptoms in order to identify underlying causes and address modifiable factors. It listed examples of emotional, psychiatric and/or psychological stressors. Examples listed included, depression, boredom, loneliness, and fear. The policy directed interventions would be individualized and part of an overall care environment that strove to understand, prevent, or relive the resident's distress. The facility failed to provide individualized care and interventions to respond to R9's mental health needs. The facility failed to identify and apply person-centered interventions to alleviate the acute stress, anxiety, and depression for R9 after he received an involuntary discharge notice. The deficient practice resulted in R9's impaired psychosocial well-being at the level of harm as evidenced by increased anxiety, increased need for antianxiety medication, depression, guilt, and weight loss .

The facility reported a census of 53 residents. The sample of 18 included 1 reviewed for pain management. Based on observation, interview and record review, the facility failed to ensure adequate pain management for the 1 (#10) resident reviewed for pain. The facility failed to implement adequate interventions to reduce the resident's pain with movements of the resident's tightened muscles in the left arm and leg. The resident experienced severe pain expressed by the resident's facial grimaces, yelling out, and refusal with yelling out, during assistance with upper extremity dressing and with range of motion services. Findings included: - Resident #10's electronic admission notes, documented the resident admitted on [DATE], with [DIAGNOSES REDACTED]. The annual MDS (minimum data set) dated 3/26/18, revealed the resident had severely impaired cognition, required extensive assistance of 1 staff for bed mobility, dressing and toileting and total assistance of 2 staff for transfers, did not walk, and had impairment in range of motion ability on 1 side both upper and lower extremities. The resident used a wheelchair for mobility. The resident received scheduled pain medications, had no non-pharmacological pain interventions, and received no PRN medications for pain. The resident's care plan, dated 3/26/18, instructed the staff the resident required 2 staff for bed mobility; transferred with mechanical lift with 2 staff; required extensive assistance for dressing; used a wheelchair handrest for the left hand for support for all times for weakness; participated in a restorative aide program 3 times per week for the upper and lower extremities; and had physical therapy/occupational therapy/speech therapy to evaluation and to treat as indicated. The resident had a potential for pain related to chronic shoulder pain and the plan instructed the staff to provide [MEDICATION NAME] as ordered and assess for untoward side effects. Assess pain level as evidenced by reported pain, restlessness, pupil dilation, perspiration and changes in vital signs from baseline data. Report uncontrolled pain to provider, pain assessment every shift report any changes to PCP (primary care physician). Review of the resident's ETAR from 6/1-19/18 revealed the staff documented their initials only and no pain scale or observations related to pain. A Physician order, dated 3/17/17, instructed the staff to administer Tylenol 325 mg (milligrams), give 650 mgs, po (by mouth), PRN (as needed) every 4 hours for left shoulder pain. A Physician order, dated 3/30/17, instructed the staff to administer Tylenol, 500 mg., 2 tablets, (total of 1000 mgs), PO, BID (twice a day), for pain to the left shoulder. Administration times scheduled for morning and bedtime. A Physician order, dated 3/30/17, instructed the staff to administer [MEDICATION NAME] (to treat moderate to severe pain), 50 mgs, 1 tablet, po, every 6 hours PRN, as needed for pain to the left shoulder. A Physician order, dated 9/22/17, instructed the staff to complete a pain assessment every shift and to document it on the ETAR (electronic treatment administration record). Staff were to use a pain scale/observations to assess the resident's pain every shift. Review of the resident's EMARs (electronic medication administration records) for the months of (MONTH) through (MONTH) 19/18, revealed the facility staff administered the routine scheduled Tylenol 1000 mgs twice a day as ordered. However the facility staff did not administer the physician ordered as needed, [MEDICATION NAME] pain medication. The staff did administer the resident Tylenol 650 mg PRN, on one occasion, on 2/7/18 at 12:16 AM. The medication staff documented for the PRN, nurse notified given for pain. The documentation lacked an area of pain or a pain scale/observations. Review of the ETARs (electronic treatment administration record), from 1/1/18 through 6/19/18, revealed the facility staff placed their initials for each shift to complete a pain assessment as ordered. However, the ETARs contained no documentation of any shifts with the resident experiencing pain, as reported by the facility direct care staff. Nurses notes, dated 5/23/18 at 2:33 PM, documented the resident refused his/her restorative program today. On 6/19/18 11:38 AM, restorative staff E, worked with restorative exercises/stretches to the resident's right lower leg/foot. Then staff E did exercises/stretches to the resident's left leg/foot, noted as slower with stiffness. Staff E then lifted the resident's lower legs to place a pillow under the resident's legs and the resident complained of pain. Staff E then slightly lifted the resident's left arm from the special arm/hand rest on the wheelchair. The resident made facial grimaces of pain and stated, No, No, No. Staff E stopped the resident's exercises on the left arm and explained at times, he/she had to stop the exercises due to the resident's pain. Staff E verified he/she stopped the restorative exercises when it hurt the resident too much. Stated she stopped sometimes when it hurt the resident too much. When questioned, if staff E ever had the nurse provide pain medications or non-pharmacological interventions such as warm packs prior to providing the resident with the exercises to help ease the resident's pain and staff E explained the staff never did that because he/she thought the resident received routine medication for the pain. At 11:55 AM, staff E reported he/she did report to the licensed nurse staff D just now that the resident had pain, but the nurse explained the resident received Tylenol routinely in the mornings. On 6/20/18 at 9:30 AM, observation revealed direct care staff H entered the resident's room and awakened the resident for the day. As staff H lifted the resident's left arm to place it into the sleeve of the resident's shirt, the resident yelled out it hurts. The resident used small jerky motions of the left arm, with complaints of pain, while staff H continued to bend/lift the arm into the shirt sleeve. Staff H informed the resident he/she would get some pain medication soon and asked where he/she hurt. the resident explained pain in his/her arms/legs and was very upset with staff H related to the pain in his/her arm and the dressing with bending it. Staff H verified the resident's pain in the left arm with dressing as a usual process when getting the resident dressed. When asked if staff H ever reported to the charge nurse the resident's pain, staff H stated he/she thought the resident did receive something for pain but this was the usual process. Direct care staff E, present in the room explained he/she would not be completing any restorative services for the resident today as he/she completed it yesterday. On 6/20/18 at 1:00 PM, questioning of licensed nursing staff D, who worked the resident's unit on 6/19/18 and on 6/20/18, was asked if any of the staff from yesterday or today, reported the resident having pain. Staff D explained the restorative aide did tell him/her yesterday (6/19/18) that the resident was having pain but the resident was on routine medications. The a question about the ETAR, physician order [REDACTED]. Licensed nursing staff D explained the resident's pain was only documented in the notes, if the resident had any signs/reports of pain, so the staff would document the resident's pain by exception. At this time, review of the nurses notes for 6/19/18, lacked any mention of the resident's pain reported to the nurse by the restorative staff during exercises. Further review of nurses notes, dated 6/20/18 at 10:15 AM, documented by licensed nursing staff D documented, Resident pleasant and cooperative with staff and cares. Has no signs/symptoms of pain or discomfort noted at this time . assistance with transfers using Hoyer lift and 1 assistance with ADLs (activities of daily living) . Observation on 6/21/18 at 8:40 AM, revealed the resident dressed and lying on the bed. Direct care staff H called for another staff to assist with using a mechanical lift to transfer the resident into the wheelchair. Staff H explained, yes, the resident's left arm and leg usually hurt him/her to get dressed and it did this morning also. Staff H explained he/she was usually the one to assist the resident to dress in the morning and it did bother the resident to put on the shirt sleeves. On 6/21/18 at 9:00 AM, staff H propelled the resident in the wheelchair to the dining room area. The medication staff present in the dining room explained the resident did not received any of his/her morning medications yet this morning. On 6/21/18 at 3:00 PM, interview and review of the resident's medical record, with administrative licensed nursing staff B, verified the facility staff failed to identify the resident's ongoing pain and to manage the resident's pain, with non-pharmacological and/or medications for the resident's pain with movement in the left arm/hand. The facility's 10/20/17, policy and procedure for pain- clinical protocol, instructed the staff for assessment and recognition . 4.) The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care, ambulation, or repositioning . Treatment/Management . 3.) The staff will evaluate and report how much and how often the individual asks for PRN pain medication. b.) If there are more than occasional [MEDICATION NAME] requests, and depending on the success of non-pharmacological interventions, the physician will consider changing to regular administration of at least one [MEDICATION NAME] with another medication for PRN use, increasing the standing dose of an existing [MEDICATION NAME], or switching to another [MEDICATION NAME] . The facility failed to recognize and maintain this resident's ongoing pain experiences, which occurred with any movements in the left arm and also reported pain in the left leg. The staff failed to provide a pain maintenance program to prevent the dependent resident's pain, either with medication or non-pharmacological interventions, for this resident who cried out in pain, revealed facial grimaces and refused cares at times, due to the pain.

The facility identified a census of 77 residents. The sample included three residents reviewed for elopement risk (the risk of a resident leaving the facility without staff's knowledge). Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement timely interventions to prevent the elopement and ultimately, a fall with injury, for one resident (#1). The resident eloped from the facility on 7/9/17, was found in the facility driveway by a pharmacy delivery person, who saw the resident step off the curb of the sidewalk and fall into the driveway. This deficient practice placed cognitively impaired resident #1 in immediate jeopardy. Findings included: The clinical record documented the facility admitted resident #1 on 7/28/16 with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. The resident used a walker and wheelchair for mobility, but did not exhibit wandering behavior. The quarterly MDS dated [DATE] documented a BIMS score of 5, which indicated severely impaired cognition. The resident used a walker and wheelchair for mobility, did not exhibit wandering behavior, and had two or more falls with no injury. The Care Area assessment dated [DATE] for Activities of Daily Living (ADLs) and Falls documented the resident had dementia, a history of multiple falls, and required staff assistance for most ADLs. The care plan dated 8/16/16 documented the resident required assistance with ADLs and directed staff to frequently check the resident at night because he/she would get up unassisted. A revision on 11/8/16 directed staff to provide supervision on and off the unit. A revision on 5/11/17 documented the resident had impaired decision-making and memory deficits related to dementia. On 7/11/17, staff revised the care plan with the following interventions: the resident had a non-injury fall on 7/9/17 related to hazardous wandering and staff applied a Wanderguard (a bracelet that set off an alarm when residents wearing one attempt to exit the building without an escort) to the resident. A revision dated 7/10/17 documented staff discontinued the Wanderguard as staff transferred the resident to a secured unit, and directed staff to round on the resident every hour to offer toileting and check on the resident's pain level, position, and ensure his/her personal effects were within reach. The Elopement Risk Form dated 5/12/17 documented the resident was ambulatory, confused or disoriented, demonstrated an unawareness of safety needs, had a history of [REDACTED]. The Elopement Risk Form documented a score of 14, which indicated the resident was a wander risk and directed staff to implement a safety plan. Review of the clinical record from 6/28/17 to 7/9/17 lacked documentation the resident was monitored for elopement. A progress note dated 2/25/17 at 10:25 P.M. documented the resident wandered in the hallway between resident rooms and the dining room, looking for his/her friend. A social service note dated 6/7/17 at 2:28 P.M. documented the resident had a decline in cognition, increased restlessness, impaired memory, lacked understanding of his/her limitations, and was a fall risk. The resident required constant reassurance by staff so that he/she did not get up unattended for safety reasons. The resident could ambulate with assistance but due to vision and safety, did not walk alone. The resident frequently thought he/she needed to be somewhere and was often with staff at programs or in common areas. The family was not supportive of moving the resident to a secured unit, but was aware if he/she did attempt elopement, he/she would require a secured unit. According to the note, the resident was not an elopement risk. A progress note dated 7/7/17 at 5:04 A.M. documented the resident was up most of the night, wandered in the hallway, and staff found him/her near the main entrance of the facility at 3:30 A.M. A progress note dated 7/9/17 at 9:20 P.M. by licensed nursing staff H documented the resident was found outside in front of the building by the pharmacy delivery person at approximately 8:40 P.M. The pharmacy delivery person stated he/she saw the resident step off the curb, take a couple of steps, stumble, and fall. The resident stated his/her left side, hand, wrist, head, and back hurt. The resident was last seen by staff at 8:00 P.M. when he/she pushed the call light and was found by staff in the bathroom. Staff toileted the resident then assisted him/her back to bed. Staff did not start neurological checks because the resident was sent to the hospital. The resident did not have any bruises and would need to be evaluated for a Wanderguard. A progress note dated 7/10/17 at 1:28 A.M. documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. A progress note dated 7/10/17 at 8:27 A.M. documented staff obtained a physician order [REDACTED]. A progress note dated 7/10/17 at 9:21 A.M. documented staff obtained a physician order [REDACTED]. Review of the progress notes from 7/10/17 through 7/18/17 documented the resident remained on fall follow-up monitoring and behavior monitoring. Review of the facility investigation dated 7/13/17 regarding the events that occurred on 7/9/17 documented the resident activated his/her call light at approximately 7:40 P.M. Direct care staff O toileted the resident, then assisted him/her back to bed. The staff person assigned to the resident was direct care staff P, who was provided care to another resident at that time. Direct care staff P stated the resident usually sat in the chairs in the hallway and often got up without assistance. The facility witness statement dated 7/13/17 by direct care staff Q regarding the events that occurred on 7/9/17 documented he/she was passing medications when the nurse called and asked him/her to look outside the window. Direct care staff Q observed the resident on the ground, obtained the vital signs machine, and went outside with licensed nursing staff H. When staff Q and licensed nursing staff H went outside, security staff was outside with the resident. Staff H notified the house supervisor and the resident was taken to the hospital by ambulance. Review of the undated and untimed handwritten interview of direct care staff P by administrative nursing staff D regarding the events that occurred on 7/9/17 documented he/she put the resident to bed after dinner. At approximately 8:00 P.M., the resident was asleep and staff P was busy assisting other residents to bed. Direct care staff P stated the resident usually came out of his/her room at night and walked around with his/her walker. Staff P indicated he/she observed the resident by the double doors on another date. Review of the SMARTcare (the facility's electronic door alarm monitoring system) log documented the art gallery door opened at 8:41 P.M. On 7/18/17 at 1:15 P.M., the resident sat in his/her wheelchair in the common area of the secured unit with his/her eyes closed, sleeping. On 7/18/17 at 3:45 P.M., administrative staff B, administrative staff C, and administrative nursing staff D reviewed the camera monitoring system for 7/9/17. On 7/9/17 at 8:41 PM, the pharmacy delivery person exited the main entrance and walked to his/her car, which was parked in the driveway. Also at 8:41 P.M., the resident exited the art gallery door (near the main entrance) and ambulated with his/her wheeled walker on the sidewalk. At 8:42 P.M., the resident stepped off the curb with his/her right foot, fell backward, and hit the ground in the driveway. At that time, the pharmacy delivery person ran to the resident's side, then ran to the phone inside the main entrance and notified security. The resident turned him/herself on his/her left side. At 8:44 P.M., the delivery person returned to the resident's side and an unsampled resident in assisted living came outside to help. At 8:45 P.M., the facility security guard exited the facility to attend to the resident and used his/her cell phone to call additional staff. At 8:48 P.M., licensed nursing staff H and direct care staff Q exited the facility with a vital signs machine and attended to the resident. At 8:54 P.M., the ambulance arrived. The resident followed commands during his/her transfer to the gurney, and transported to the hospital. On 7/18/17 at 9:55 A.M., administrative nursing staff D stated the resident was not an elopement risk prior to 7/9/17 and liked to sit on the bench outside of the art gallery, which was in a public area. He/she stated on 7/9/17, the resident ambulated out of the door by the art gallery with his/her wheeled walker, walked along the sidewalk in front of the main entrance, lost his/her balance, and fell off the curb, landing in the driveway. Administrative nursing staff D stated the pharmacy delivery person exited the building and saw him/her on the ground. When they reviewed the camera, it was apparent the delivery person turned around and notified security and at the same time, facility staff that was passing medication observed the resident on the ground as he/she looked out the window. On 7/18/17 at 9:58 A.M., administrative staff C stated the exit door by the art gallery was not locked or alarmed, but any time the door was opened, an alert was sent to security. On 7/18/17 at 1:15 P.M., resident #1 stated he/she could not remember walking outside, thought it would be easy to propel his/her wheelchair, but stated he/she hurt too much to try. The remainder of the interview could not be completed due to the resident's impaired cognition. On 7/18/17 at 1:52 P.M., licensed nursing staff I stated residents should be assessed for elopement at admission, quarterly, and as needed if they exhibited new exit-seeking behaviors. Licensed nursing staff I stated an elopement risk assessment score of greater than four indicated the resident was at risk for elopement, should be closely monitored by staff when they were out of their room to ensure they did not exit the building, and staff should place interventions on the care plan to prevent elopement. He/she stated the resident was an elopement risk because he/she could ambulate independently, was confused, and staff did not leave him/her unattended in common areas. On 7/18/17 at 3:00 P.M., direct care staff O stated the resident normally walked by him/herself with a walker and at times would walk in areas off the unit. He/she stated the resident had confusion and would go toward the exit doors. Direct care staff O stated on 7/9/17, he/she toileted the resident at approximately 7:40 P.M., then assisted him/her back to bed. Direct care staff O stated he/she did not observe the resident leave the unit. On 7/18/17 at 4:00 P.M., administrative staff B stated the resident used to live in assisted living and he/she enjoyed sitting on the benches outside the main entrance. He/she stated it was possible the resident was walking toward the bench when he/she fell . On 7/18/17 at 5:58 P.M., direct care staff Q stated the resident frequently ambulated all over the unit and walked independently with his/her walker. He/she stated staff monitored the resident's whereabouts when they did rounds and if he/she was in a common area, staff tried to keep a close eye on him/her. Direct care staff Q stated the resident walked off the unit on a previous date and was found by the exit doors near the art gallery. Direct care staff Q stated on 7/9/17, he/she was passing medications to another resident when licensed nursing staff H called him/her and asked him/her to look outside the window. Staff Q observed the resident lying in the driveway and stated the security staff and pharmacy delivery person were at the resident's side. Direct care staff Q and licensed nursing staff H went outside to attend to the resident, called 911, and stated the resident did not appear to be in pain. On 7/18/17 at 6:45 P.M., administrative nursing staff D stated residents who were at risk for elopement and/or had a Wanderguard should be identified on the nurse and direct care staff report sheets. He/she stated if the calculated score on the elopement risk form was four or greater, a safety plan should be developed and interventions should be placed on the care plan. Licensed nursing staff D stated he/she had not yet assessed the staff's competency regarding interpretation of the risk score or implementation of appropriate monitoring and interventions. The facility's undated Wandering Unsafe Resident policy documented the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for resident who were at risk for elopement. The staff would identify residents who were at risk for harm because of unsafe wandering, including elopement. The staff would assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan would indicate the resident was at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan would be included. The facility's Elopement policy dated July 2015 documented nursing personnel must report and investigate all reports of missing residents. Prior to admission to the facility, the resident would be assessed to determine if they were an elopement risk. The resident would be housed in the most appropriate unit to prevent elopement. External doors would be checked by security daily. Residents that do not reside on the secured unit would be assessed quarterly to determine if they were a wander risk. If it was determined they were at risk, a wander bracelet would be applied to either wrist, ankle, or assistive device. The wander alerts would activate an alarm when the resident in question tried to leave the unit. The function and placement would be checked daily by nursing staff. Staff would be in-serviced on hire and annually on elopement and procedure. The facility failed to provide supervision and implement timely interventions to this cognitively impaired resident who eloped from the facility on 7/9/17 and was assessed as an elopement risk. The resident fell while outside and sustained a compression fracture to his/her back. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 7/25/17 at 8:00 A.M. by initiating the following: The facility would ensure the safety of all residents who were at risk for elopement or have hazardous wandering behaviors that place them at risk by taking the following immediate actions: All residents would be assessed for elopement risk. An elopement assessment would be performed on all residents by a licensed nurse immediately, under the direction of the Director of Nursing (DON) or House Supervisor. Assessments were completed and reviewed on all residents on 7/18/17. All licensed nursing staff who performed the Elopement Risk Assessments would have re-education on how to perform and score the Elopement Risk Assessment. The DON or Assistant Director of Nursing (ADON) would initiate training staff immediately and training would be completed by 7/25/17 at 8:00 A.M. or before. The DON/ADON or designee would provide re-training for all licensed nurses on the completion of the Elopement Assessment and ideas for standard interventions and best practices related to exit-seeking and wandering behaviors would be shared/discussed. The DON or ADON would initiate training staff immediately and training would be completed by 7/25/17 at 8:00 A.M. or before. Nursing staff who were FMLA/LOA/PTO would be required to have the training prior to returning to work by the DON/ADON or designee Residents who were at risk for elopement/hazardous wandering would have an appropriate intervention in place (based on scoring on the Elopement Assessment), including placement of a Wanderguard, or other less restrictive interventions All nursing staff would have access to Wanderguard bracelets and ensure that residents have orders for a Wanderguard, orders for the Wanderguard would show to the electronic Treatment Administration Record (eTAR) for nurse daily documentation. The licensed nurse would perform daily shift checks to ensure placement and function of the Wanderguard was documented on the eTAR, implemented by July 19, 2017. The policies related to Elopement, Wandering Unsafe Resident, and Missing Resident Policy would be reviewed and updated as indicated. The COO and or designee will perform and complete the task by 7/20/17. All Staff would be re-trained immediately by Department Directors on Policies related Elopement Prevention/Identification and what actions to take in the event that they would come across a confused resident with wandering or exit-seeking behaviors. All new associates would be trained upon hire at New Hire General Orientation and as needed on Elopement Policies, Wandering Unsafe Resident, and Missing Resident Policies by a Clinical Team Member assigned to New Hire General Orientation. The Interdisciplinary Treatment Team would meet at least monthly and as needed to discuss care transitions. Members are as listed: The Director of Assisted Living and Primary Care Nurse, Social Services Director and or designee, Memory Care Coordinator Suites 1/MC-AL, DON/ADON, Admissions Coordinator, and COO-Ad Hoc member. Audits would be performed to ensure the Plan of Correction was in place as approved. The DON or designee would perform random audits of 10 nursing staff weekly to demonstrate understanding of the policies and procedures related to use of the Wanderguard placement and function. The direct care staff worksheets would be checked nightly by the House Supervisor to ensure that any resident who had a Wanderguard was listed on the worksheet. The COO or designee would schedule/perform monthly elopement drills, alternating on each shift, so that quarterly each shift would have at a minimum three Elopement Drills per year. The Elopement Drills would begin August 1, 2017. Elopement drills would be performed to test knowledge of policy and procedure. Clinical staff would set off the wander alert and time the response during the drill, policies would be discussed and ideas related to any challenges that staff may have had related to equipment, resident behaviors, and any other pertinent feedback. Exit-Seeking drills would also be a clinical scenario and role-play of a resident with moderate dementia and staff would be asked to role-play interventions and discuss What to do in the Moment. Audits and results from Elopement Drills would be discussed at quarterly QAPI meetings The deficient practice remained at a scope and severity of D.