Every finding on record at Wakefield Care and Rehab

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.Findings included:- On 09/09/25 at 09:00 AM, observation in the kitchen revealed a three-door refrigerator had the following:An unlabeled, undated container of steak fry casserole.An unlabeled, undated plastic bag with salad and cheese.A three-door refrigerator located in the dry storage room had an unlabeled, undated plastic bag with sliced ham and lacked a backup thermometer.On 09/09/25 at 11:15 AM, Certified Dietary Manager (CDM) BB verified the above observations, stated there should be a backup thermometer in the dry storage refrigerator, and staff should label and date all food items before placing them in the refrigerators.On 09/10/25 at 11:30 AM, observation in the kitchen revealed the following:The pipes, approximately 4 feet long, located underneath the sink in the dishwasher area where the dirty dishes enter the dishwasher, had numerous different-sized areas of brownish stains. The 13 vents, approximately six inches (in) by 4 in, located underneath the ceiling air conditioner, had a gray fuzzy substance in them.On 09/10/25 at 11:35 AM, CDM BB verified the above findings and stated the kitchen staff were responsible for cleaning them.The Kitchen Cleaning Schedule had tasks listed for staff to complete daily, weekly, and monthly.The facility's Sanitation Policy, revised 10/24, documented all kitchen, kitchen areas, and dining areas shall be kept clean and free from rubbish.The facility's Food Safety Policy, revised 10/24, documented all foods stored in the refrigerator or freezer would be covered, labeled, and dated.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to include a hospice (a program that gives special care to people who are near the end of life) service visit frequency, medications, medical equipment, and preferences for Resident (R) 38. This deficient practice placed the resident at risk of not receiving resident-directed end-of-life care.Findings included:- R38's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), shortness of breath, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, major depressive disorder (major mood disorder that causes persistent feelings of sadness), low back pain, demoralization (loss of hope) and apathy (lack of interest), adjustment disorder (excessive reactions to stress involving negative thoughts), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), cardiomegaly (enlarged heart), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and fractures (broken bone) of the upper right humerus (upper arm bone) and the neck of the right femur (thigh bone) with delayed healing.R38's Significant Change Minimum Data Set (MDS), dated [DATE], documented that R38 had severe cognitive impairment, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and was dependent on staff for functional abilities. R38 received scheduled pain medication, as-needed pain medication, and non-medication interventions for moderate pain. The MDS further documented that R38 had a condition or disease that may result in a life expectancy of less than six months and received hospice care.The Psychosocial Well-Being Care Area Assessment (CAA), dated 06/30/25, documented that R38 received hospice service, had a broken hip that was not healing, and was not a candidate for surgical interventions due to his heart failure. R38's nutritional needs were not being met due to skipping meals and minimal intake. The CAA further documented that R38 had been readying for end of life for the past two years.R38's Care Plan dated 07/21/25, documented R38 was on hospice for Parkinson's disease and delayed healing of his right femur fracture. The Care Plan included the name of the hospice provider, the telephone number, and directed staff to follow orders for symptom control. The Care Plan lacked specifics of delegation of hospice staff services, visit frequency, medications, medical equipment, and personal hygiene supplies. The Physician Order dated 06/16/25 directed staff to admit R38 to hospice for Parkinson's disease and the fracture to the right femur with delayed healing.The Progress Note dated 06/06/25 at 10:44 AM documented that the hospice provider wanted to meet with R38 and his representatives to explain in detail what hospice could provide.The Progress Note dated 06/11/25 at 12:18 PM documented that the hospice provider would admit R38 to hospice.On 09/09/25 at 8:01 AM, R38 remained in bed, wearing oxygen, eyes closed, and the room was quiet and dark.On 09/10/25 at 09:05 AM, Certified Medication Aide (CMA) R reported that the hospice service provided certain medications for R38, and CMA R would ask the nurse on duty about services and medication for R38. CMA R also stated that the facility provided incontinence products and personal care for hospice residents, and she was not aware of where she would look to find specifics related to the hospice and the facility responsible for supplies needed to care for R38.On 09/10/25 at 09:09 AM, Administrative Nurse F reported that hospice provided a list of medications they would supply to R38, and the hospice nurse would come to see the resident twice a week, unless the resident was actively dying, and then the hospice nurse would come daily. Administrative Nurse F stated that a hospice aide usually did not come because the facility's staff met his personal needs. Administrative Nurse F reported that staff lacked a list of supplies furnished by hospice for R38.On 09/10/25 at 10:44 AM, Administrative Nurse D reported the facility's Care Plan lacked specifics related to the hospice provider provided and what the facility was responsible for in the end-of-life care and services for R38.The facility's Hospice Program policy, dated 10/2024, documented promoting continuity of care, collaborating with the hospice, nursing home, and resident/representative on a coordinated care plan to ensure the resident receives all necessary care and services. Although the hospice provider retains primary responsibility for the provision of the following hospice care and services, including but not limited to providing medical direction, nursing, counseling, medical supplies, durable medical equipment, and all other services that are necessary for the care of the resident's terminal illness and related conditions.

The facility had a census of 45 residents. The sample included 12 residents, with two reviewed for hospitalization. Based on record review and interview, the facility failed to provide the resident or her representative with the bed hold policy when Resident (R) 1 was transferred to the hospital. This placed the residents at risk for uninformed care choices. Findings included:- R1's Electronic Medical Record (EMR) documented the resident had a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing).R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R1 required partial to moderate staff assistance with lower body dressing, putting on and or taking off footwear, showering, supervision with oral hygiene, toileting hygiene, upper body dressing, lying to sitting position, ambulation less than 150 feet (ft), and picking up objects off the floor. R1 required setup assistance with eating and sitting to lying position, independent with transfers.R1's Care Plan, revised 08/13/25, documented R1 had COPD and instructed staff to administer medication and breathing treatments as the physician ordered. The plan instructed staff to educate R1 on the importance of quitting smoking, encourage her to comply with fluid restriction, and diet. The plan documented R1 had a history of leaving her oxygen tubing and nebulizer mask in her bed, on her end table, or on the floor, and instructed staff to remind R1 of the importance of keeping these items bagged. The plan instructed staff to monitor R1 for signs or symptoms of shortness of breath, lethargy, pain, and sputum production. R1's Progress Notes dated 07/31/25 at 05:09 AM documented the resident was transferred to the hospital.R1's clinical record lacked evidence that either R1, or her representative was notified of the bed hold policy. On 09/09/25 at 02:00 PM, observation revealed R1 sat in a chair in her room, with no signs or symptoms of respiratory distress.On 09/10/25 at 01:10 PM, Social Service Designee (SSD) X stated that when residents are transferred to the hospital, the nurse on duty at that time is responsible for notifying the resident or representative of the bed hold policy. On 09/10/25 at 01:36 PM, Administrative Nurse D stated the nurse was responsible for providing the bed-hold policy to the resident or representative unless it was an emergency, then SSD X should follow up on providing it.Upon request, the facility failed to provide a bed-hold policy.

The facility had a census of 42 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to employ a certified dietary manager, placing the residents at risk for unmet nutritional needs. Findings included: - On 11/13/23 at 08:05AM, initial observation of the kitchen revealed dietary staff prepared breakfast. On 11/13/23 at 08:15AM, Dietary Staff (DS) BB verified she was not a certified dietary manager. On 11/14/23 at 1:00PM, Administrative Staff A verified the dietary manager was not certified. The facility Food Service Staffing policy dated 10/2023, stated the facility will employ a certified dietary manager to oversee the day-to-day operation of food service to the residents. The facility failed to employ a certified dietary manager, placing the residents at risk for unmet nutritional needs.

The facility had a census of 42 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise, update, and individualize the care plans for Resident (R) 27 who received insulin (a hormone to regulate blood sugar) and R39, who had pain. This deficient practice placed the residents at risk for inadequate and inappropriate care related to uncommunicated care needs. Findings included: - R27's Electronic Medical Record (EMR) documented diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R27 received insulin injections weekly. R27's Care Plan lacked update or revision for assessment and monitoring for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) or for the use of the insulin. On 11/14/23 at 10:00AM, observation revealed R27 sat in his wheelchair near the nurse's desk. On 11/16/23 at 10:45AM, Administrative Nurse D verified R27 had a diagnosis of diabetes mellitus and received insulin weekly. Administrative Nurse D verified R27's care plan lacked interventions for assessment of hypo/hyperglycemia and the weekly insulin injections. The facility's Care Plan policy, dated 09/2023, stated a care plan was developed for each resident that included measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs and were consistent with the resident's desires and preferences. The care plan was to be revised, reviewed, and updated with changes in a residents care. The facility failed to update R27's care plan placing him at risk for inadequate care due to uncommunicated care needs. 32358 - R39's Electronic Medical Record (EMR) documented R39 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), low back pain, and neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). R39's Quarterly Minimum Data Set (MDS), dated [DATE], documented R39 had a Brief Interview of Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The MDS documented R39 required moderate staff assistance with personal hygiene, and toileting. R39 required set up assistance with the rest of her activities of daily living (ADLs). The MDS documented R39 received no scheduled pain or as needed pain (PRN) medications and had no indicators of pain during the observation period. R39's Care Plan, revised 08/25/23, lacked a section regarding pain management. On 11/16/23 at 08:14 AM, observation revealed R39 sat at the dining room table. R39grimaced, held her right hand on her right hip and stated to Certified Medication Aide (CMA) M it hurt. CMA M told R39 she would tell her nurse. Further observation revealed CMA M went to the nurse's station and reported to the nurse, came back to the resident and told R39 she would give R39 some pain medication when she administered the resident's other morning medications. R39 replied ok, and continued to grimace and hold her right hand on her right hip. Further observation revealed at 08:31 AM, R39 stood up from table and ambulated without assistance to the social service office, then ambulated out of the office, with her hand on her right hip. R39 grimaced and held onto Social Services X's hand. R39 reported she had pain to Social Services X's in that area and stopped walking occasionally as Social Services X's assisted her to a recliner by the nurse's station. Social Services X gave R39 a photo album. Observation revealed Social Services X's reported to CMA M that R39 had pain, and CMA M replied she would administer Tylenol to R39 with the resident's other morning pills. Further observation revealed CMA M continued to administer other residents' medications in the dining room. CMA M did not offer R39 any non-pharmacological (non-medicinal) pain interventions. R39 continued to grimace and hold her right hand on her right hip. At 08:47 AM, CMA M began placing R39's morning medications in a medication cup. R39 again asked for something for pain in her right hip, and CMA M asked R39 to sit in the recliner until she had all of R39's medications ready. At 08:55 AM (41 minutes after the initial report of pain), CMA M administered two Tylenol, 325milligram (mg), tablets to R39 with her other medications. On 11/16/23 at 09:07 AM, R39 ambulated with Licensed Nurse (LN) H in the hall to a recliner by the nurse's station with her right hand on her right hip. R39 grimaced and stated ooh, that hurts when she sat down in the recliner. LN H handed R39 a photo album and did not address R39's report of pain. On 11/16/23 at 09:19AM, R39 sat in a recliner by the nurse's station. R39 had her right hand on her right hip, and verbalized to staff she was having pain. R39 then stood up and ambulated down the hall. CMA M redirected R39 back to the recliner, and R39 again verbalized pain. Further observation revealed CMA M told R39 she needed to sit still in the recliner and give the pain medication time to work. CMA M did not ask R39 her pain level or offer non-pharmacological interventions for pain. On 11/20/23 at 09:44 AM, LN G stated if a resident reported they had pain, she would assess the pain level and immediately see what she could do to alleviate the pain. On 11/16/23 at 11:51 AM, Administrative Nurse E verified R39's care plan lacked a section regarding pain and stated it should have one. The facility's Care Plan policy, dated 09/2023, stated a care plan was developed for each resident that included measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs and were consistent with the resident's desires and preferences. The care plan was to be revised, reviewed, and updated with changes in a residents care. The facility failed to update R39's care plan. This placed her at risk for inadequate care due to uncommunicated care needs.

The facility had a census of 42 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure adequate pain management was provided to Resident (R)39 when R39 reported pain in her right hip area. This placed the resident at risk for unrelieved pain. Findings included: - R39's Electronic Medical Record (EMR) documented R39 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), low back pain, and neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). R39's Quarterly Minimum Data Set (MDS), dated [DATE], documented R39 had a Brief Interview of Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The MDS documented R39 required moderate staff assistance with personal hygiene, and toileting. R39 required set up assistance with the rest of her activities of daily living (ADLs). The MDS documented R39 received no scheduled pain or as needed pain (PRN) medications and had no indicators of pain during the observation period. R39's Care Plan, revised 08/25/23, lacked a section regarding pain management. On 11/16/23 at 08:14 AM, observation revealed R39 sat at the dining room table. R39 grimaced, held her right hand on her right hip and stated to Certified Medication Aide (CMA) M it hurts. CMA M told R39 she would tell her nurse. Further observation revealed CMA M went to the nurse's station and reported to the nurse, came back to the resident and told R39 she would give R39 some pain medication when she administered the resident's other morning medications. R39 replied ok, and continued to grimace and hold her right hand on her right hip. Further observation revealed at 08:31 AM, R39 stood up from table and ambulated without assistance to the social service office, then ambulated out of the office, with her hand on her right hip. R39 grimaced and held onto Social Services X's hand. R39 reported she had pain to Social Services X's in that area and stopped walking occasionally as Social Services X's assisted her to a recliner by the nurse's station. Social Services X gave R39 a photo album. Observation revealed Social Services X's reported to CMA M that R39 had pain, and CMA M replied she would administer Tylenol to R39 with the resident's other morning pills. Further observation revealed CMA M continued to administer other residents' medications in the dining room. Staff did not offer R39 any non-pharmacological (non-medicinal) pain interventions. R39 continued to grimace and hold her right hand on her right hip. At 08:47 AM, CMA M began placing R39's morning medications in a medication cup. R39 again asked for something for pain in her right hip, and CMA M asked R39 to sit in the recliner until she had all of R39's medications ready. At 08:55 AM (41 minutes after the initial report of pain), CMA M administered two Tylenol, 325milligram (mg), tablets to R39 with her other medications. On 11/16/23 at 09:07 AM, R39 ambulated with Licensed Nurse (LN) H in the hall to a recliner by the nurse's station with her right hand on her right hip. R39 grimaced and stated ooh, that hurts when she sat down in the recliner. LN H handed R39 a photo album and did not address R39's report of pain. On 11/16/23 at 09:19AM, R39 sat in a recliner by the nurse's station. R39 had her right hand on her right hip, and verbalized to staff she was having pain. R39 then stood up and ambulated down the hall. CMA M redirected R39 back to the recliner, and R39 again verbalized pain. Further observation revealed CMA M told R39 she needed to sit still in the recliner and give the pain medication time to work. CMA M did not ask R39 her pain level or offer non-pharmacological interventions for pain. On 11/20/23 at 09:44 AM, LN G stated if a resident reported they had pain, she would assess the pain level and immediately see what she could do to alleviate the pain. On 11/16/23 at 11:51 AM, Administrative Nurse E stated if R39 had pain, staff should immediately look at R39's Medication Administration Record (MAR) to see if R39 had a PRN pain medication available. The facility's Pain Assessment and Management Policy, revised 10/2022, documented the pain management program was based on a facility-wide commitment to resident comfort. The policy documented pain management was a multidisciplinary care process that included the following: Assessing the potential for pain. Effectively recognizing the presence of pain. Identifying the characteristics of pain. Addressing the underlying causes of the pain. Identifying and using specific strategies for different levels and sources of pain. Monitoring for the effectiveness of interventions. Modifying approaches as necessary. The facility failed to ensure adequate pain management was provided to R39 when R39 reported right hip pain. This placed the resident at risk for unrelieved pain.

The facility identified a census of 43 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff identified a situation of abuse and mistreatment and failed to immediately report to the facility administrator (LNHA). On 08/14/23 at approximately 07:30 AM Certified Medication Aide (CMA) R entered Resident(R) 1's room and offered the resident a shower. R1 stated she would like a shower but requested assistance to the bathroom first. CMA R asked Licensed Nurse (LN) G to assist with toileting R1, who required extensive assistance from two staff for toileting and transfer. CMA R and LN G assisted R1 onto the toilet, CMA R stayed in the bathroom with the resident, and LN G stepped back into the resident's room. LN G then became frustrated with waiting, entered the bathroom, grabbed R1 by the arm, and by the gait belt around R1's waist and attempted to pull R1 off the toilet while stating she had other residents to take care of. R1 resisted saying she still need to void. CMA R asked LN G to leave the room. LN G proceeded to leave the bathroom and as she did, she flung R1's wheelchair out of the way and the wheelchair struck R1 in the right leg. LN G exited the room and slammed the door. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 required extensive assistance of two staff for all activities of daily living except for eating. The Activity of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/21/22, documented R1 had a diagnosis of Huntington's disease and required extensive assistance of two staff for all activities of daily living except eating. The Huntington's Disease Care Plan, revised 05/04/23, directed staff to provide R1 with a calm approach and utilize redirection as needed. The care plan directed staff to provide R1 with active listening and implement problem solving skills when R1 was calm and able to communicate effectively and appropriately. The Performance Review, dated March 2023, documented LN G had the following areas that required improvement in her employment as a licensed nurse at the facility: LN G lost her temper too easily, LN G did not start her workdays in a positive manner, and LN G announced things to others in the open. Development actions prescribed included LN G needed a way to catch herself prior to losing her temper, LN G needed to try not to set her whole day up for failure, and LN G needed to understand not everyone needed to hear about call-ins or others short comings. The Performance Review documented LN G was occasionally disruptive and discourteous, slow to help others, exhibited less than adequate responsiveness and courteousness to patients, and would occasionally ignore problems. The Witness Statement, dated 08/15/23, documented CMA R went into R1's room. R1 told CMA R she needed to use the bathroom first. CMA R told R1 to give her a moment to try and find another staff to assist getting R1 onto the toilet. CMA R looked out into the hall and saw LN G and asked if LN G would help her to transfer R1 to the toilet. CMA R stated after she and LN G transferred R1 to the toilet, CMA R stayed in the bathroom with R1 and LN G waited in R1's room. CMA R stated after around two minutes R1 had not gone to the bathroom and LN G was getting visibly frustrated. LN G stated to R1 since she had not gone to the bathroom yet R1 needed to get off of the toilet because LN G had stuff to do. CMA R stated R1 said, No, and was upset with LN G. R1 stated she still needed to use the bathroom. CMA R stated she tried to diffuse the situation by telling R1 maybe she could try to go to the bathroom later or maybe R1 could pee in the shower, not ideal but it would be okay. R1 did not like that idea and CMA R assured R1 they could wait. LN G said, No she needs to get up now. R1 said, No. LN G then began to pull on R1's arm and the gait belt. LN G told R1 she needed to get off of the toilet in a loud frustrated voice. R1 resisted and stated, No I still need to pee. I will tell my kids. CMA R then told LN G to leave the room and CMA R would find someone else to help transfer R1 off of the toilet. LN G then proceeded to [NAME] R1's wheelchair out of her way causing the wheelchair to hit R1's right calf and knee. LN G left and slammed the door on the way out. The Facility Incident Report, dated 08/18/23, documented R1 was on her way to be showered. They were leaving R1's room and R1 stated she had to go to the restroom. CMA M and LN G helped R1 onto the stool in R1's room. R1 sat on the stool for a few minutes and did not go. LN G told her that she needed to help other residents and if R1 could not go now then she needed to get up and try again later. R1 stated she could get herself off of the toilet. LN G stated no that was not safe and LN G took R1's arm and started pulling to help her to stand up. R1 resisted and LN G became frustrated and used an inappropriate firm authoritative voice to get R1 to comply. To deescalate the situation, CMA M told LN G that she would stay with R1, and LN G could go on to the next resident. As LN G was leaving, LN G pushed the wheelchair out of her way, and it ran into the leg of R1. R1 then sat on the toilet a while longer and went to the bathroom and was then escorted to the shower room. On 08/21/23, at 09:30 AM, R1 sat at the breakfast table in her wheelchair and watched other residents and staff. R1 had spastic movements. On 08/21/23 at 09:45 AM, R1 stated LN G told her that she was going to get off of the toilet and grabbed her arm. R1 told LN G that she was not done. R1 told LN G not to treat her like that. R1 stated LN G pushed her wheelchair out of the way and the wheelchair hit her leg. R1 stated she was scared of LN G but since LN G was gone, she was sleeping much better. On 08/21/23 at 10:30 AM, CMA S stated LN G was easily frustrated and when LN G started to get frustrated LN G would get loud. CMA S stated she would pull LN G into the office and ask LN G what was going on and allow her to vent. On 08/21/23 at 10:45 AM, Administrative Nurse D stated a couple of weeks ago, LN G was voicing her frustration regarding a resident being needy in an open area of the facility where others could hear her, and Administrative Nurse D took LN G to the office and told her it was inappropriate to express her feelings about a resident's wants where anyone could hear. Administrative Nurse D reported LN G may have had some personal stressors which factored in but stated the incident was unanticipated. On 08/21/23 at 11:00 AM, Administrative Staff A stated CMA R did not report the incident until about 03:00 PM when her shift was over; CMA R stated she did not report it because she did not want to make the working relationship between her and LN G strained or uncomfortable. Administrative Staff A stated he expected all staff to report allegations of abuse and neglect to him immediately and that all staff had been re-educated on the abuse policy. On 08/21/23 at 11:30 AM, CMA R stated that LN G got frustrated easily when she was on shift and staff walked on eggshells around her. CMA R stated LN G did not act appropriately with R1 on the day of the incident. CMA R said LN G went into the bathroom and grabbed R1's arm roughly and then grabbed the gait belt and pulled R1 half-way off of the toilet trying to get R1 to stand up. CMA R stated she had to scoot R1 back onto the toilet to keep her from falling off the toilet. CMA R stated she did not report the incident with R1 and LN G until after her shift was over, then she reported it to social services at the facility. CMA R stated she knew now that the incident should have been reported immediately to protect R1 and the other residents in the facility. The facility's Abuse Prevention Program, revised August 2022, documented residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The facility failed to ensure staff identified a situation of abuse and mistreatment and failed to immediately report to the facility administrator (LNHA). On 08/16/23 the facility completed corrective actions which included an all-staff in-service on preventing abuse, neglect and exploitation and reporting abuse. The facility provided staff training on CARES Values. The corrective actions were completed prior to the onsite survey therefore the deficient practice was cited as past noncompliance at a scope and severity of K.

The facility identified a census of 43 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from abuse and mistreatment. On 08/14/23 at approximately 07:30 AM Certified Medication Aide (CMA) R entered Resident(R) 1's room and offered the resident a shower. R1 stated she would like a shower but requested assistance to the bathroom first. CMA R asked Licensed Nurse (LN) G to assist with toileting R1, who required extensive assistance from two staff for toileting and transfer. CMA R and LN G assisted R1 onto the toilet, CMA R stayed in the bathroom with the resident, and LN G stepped back into the resident's room. LN G then became frustrated with waiting, entered the bathroom, grabbed R1 by the arm, and by the gait belt around R1's waist and attempted to pull R1 off the toilet while stating she had other residents to take care of. R1 resisted saying she still need to void. CMA R asked LN G to leave the room. LN G proceeded to leave the bathroom and as she did, she flung R1's wheelchair out of the way and the wheelchair struck R1 in the right leg. LN G exited the room and slammed the door. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 required extensive assistance of two staff for all activities of daily living except for eating. The Activity of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/21/22, documented R1 had a diagnosis of Huntington's disease and required extensive assistance of two staff for all activities of daily living except eating. The Huntington's Disease Care Plan, revised 05/04/23, directed staff to provide R1 with a calm approach and utilize redirection as needed. The care plan directed staff to provide R1 with active listening and implement problem solving skills when R1 was calm and able to communicate effectively and appropriately. The Performance Review, dated March 2023, documented LN G had the following areas that required improvement in her employment as a licensed nurse at the facility: LN G lost her temper too easily, LN G did not start her workdays in a positive manner, and LN G announced things to others in the open. Development actions prescribed included LN G needed a way to catch herself prior to losing her temper, LN G needed to try not to set her whole day up for failure, and LN G needed to understand not everyone needed to hear about call-ins or others short comings. The Performance Review documented LN G was occasionally disruptive and discourteous, slow to help others, exhibited less than adequate responsiveness and courteousness to patients, and would occasionally ignore problems. The Witness Statement, dated 08/15/23, documented CMA R went into R1's room. R1 told CMA R she needed to use the bathroom first. CMA R told R1 to give her a moment to try and find another staff to assist getting R1 onto the toilet. CMA R looked out into the hall and saw LN G and asked if LN G would help her to transfer R1 to the toilet. CMA R stated after she and LN G transferred R1 to the toilet, CMA R stayed in the bathroom with R1 and LN G waited in R1's room. CMA R stated after around two minutes R1 had not gone to the bathroom and LN G was getting visibly frustrated. LN G stated to R1 since she had not gone to the bathroom yet R1 needed to get off of the toilet because LN G had stuff to do. CMA R stated R1 said, No, and was upset with LN G. R1 stated she still needed to use the bathroom. CMA R stated she tried to diffuse the situation by telling R1 maybe she could try to go to the bathroom later or maybe R1 could pee in the shower, not ideal but it would be okay. R1 did not like that idea and CMA R assured R1 they could wait. LN G said, No she needs to get up now. R1 said, No. LN G then began to pull on R1's arm and the gait belt. LN G told R1 she needed to get off of the toilet in a loud frustrated voice. R1 resisted and stated, No I still need to pee. I will tell my kids. CMA R then told LN G to leave the room and CMA R would find someone else to help transfer R1 off of the toilet. LN G then proceeded to [NAME] R1's wheelchair out of her way causing the wheelchair to hit R1's right calf and knee. LN G left and slammed the door on the way out. The Facility Incident Report, dated 08/18/23, documented R1 was on her way to be showered. They were leaving R1's room and R1 stated she had to go to the restroom. CMA M and LN G helped R1 onto the stool in R1's room. R1 sat on the stool for a few minutes and did not go. LN G told her that she needed to help other residents and if R1 could not go now then she needed to get up and try again later. R1 stated she could get herself off of the toilet. LN G stated no that was not safe and LN G took R1's arm and started pulling to help her to stand up. R1 resisted and LN G became frustrated and used an inappropriate firm authoritative voice to get R1 to comply. To deescalate the situation, CMA M told LN G that she would stay with R1, and LN G could go on to the next resident. As LN G was leaving, LN G pushed the wheelchair out of her way, and it ran into the leg of R1. R1 then sat on the toilet a while longer and went to the bathroom and was then escorted to the shower room. On 08/21/23, at 09:30 AM, R1 sat at the breakfast table in her wheelchair and watched other residents and staff. R1 had spastic movements. On 08/21/23 at 09:45 AM, R1 stated LN G told her that she was going to get off of the toilet and grabbed her arm. R1 told LN G that she was not done. R1 told LN G not to treat her like that. R1 stated LN G pushed her wheelchair out of the way and the wheelchair hit her leg. R1 stated she was scared of LN G but since LN G was gone, she was sleeping much better. On 08/21/23 at 10:30 AM, CMA S stated LN G was easily frustrated and when LN G started to get frustrated LN G would get loud. CMA S stated she would pull LN G into the office and ask LN G what was going on and allow her to vent. On 08/21/23 at 10:45 AM, Administrative Nurse D stated a couple of weeks ago, LN G was voicing her frustration regarding a resident being needy in an open area of the facility where others could hear her, and Administrative Nurse D took LN G to the office and told her it was inappropriate to express her feelings about a resident's wants where anyone could hear. Administrative Nurse D reported LN G may have had some personal stressors which factored in but stated the incident was unanticipated. On 08/21/23 at 11:00 AM, Administrative Staff A stated CMA R did not report the incident until about 03:00 PM when her shift was over; CMA R stated she did not report it because she did not want to make the working relationship between her and LN G strained or uncomfortable. Administrative Staff A stated he expected all staff to report allegations of abuse and neglect to him immediately and that all staff had been re-educated on the abuse policy. On 08/21/23 at 11:30 AM, CMA R stated that LN G got frustrated easily when she was on shift and staff walked on eggshells around her. CMA R stated LN G did not act appropriately with R1 on the day of the incident. CMA R said LN G went into the bathroom and grabbed R1's arm roughly and then grabbed the gait belt and pulled R1 half-way off of the toilet trying to get R1 to stand up. CMA R stated she had to scoot R1 back onto the toilet to keep her from falling off the toilet. CMA R stated she did not report the incident with R1 and LN G until after her shift was over, then she reported it to social services at the facility. CMA R stated she knew now that the incident should have been reported immediately to protect R1 and the other residents in the facility. The facility's Abuse Prevention Program, revised August 2022, documented residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The facility failed to ensure residents remained free from abuse and mistreatment. This deficient practice placed R1 in immediate jeopardy. On 08/16/23 the facility completed corrective actions which included an all-staff in-service on preventing abuse, neglect and exploitation and reporting abuse. The facility provided staff training on CARES Values. The corrective actions were completed prior to the onsite survey therefore the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility identified a census of 40 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to provide activities of daily living (ADL) assistance with the appropriate number of staff in order to prevent accidents for Resident (R)1. On 11/25/22 Licensed Nurse (LN) G provided incontinence care to R1 without secondary staff assistance when LN G lost her balance, let go of R1causing R1 to fall to the floor, face first. As a result, R1 sustained a laceration to her left eyebrow and a large, complicated tongue laceration, despite not having any teeth, which required suturing by a specialized physician. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), protein calorie malnutrition, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 was severely cognitively impaired and had short- and long-term memory loss. The MDS further documented R1 was totally dependent on two staff for toileting and bathing. R1 was totally dependent on one staff for personal hygiene and locomotion on and off the unit. R1 required extensive assistance from two staff for bed mobility, transfer, and dressing. The Fall Care Area Assessment (CAA), dated 03/22/22, documented R1 was at risk for falls due to poor balance and strength during transfers and transitioning and R1 needed assistance of two staff and a full body lift. The ADL CAA did not trigger. The ADL Care Plan, revised 04/22/22, documented R1 required one to two staff for bed mobility and two staff for toileting. The Communication to Physician Note, dated 10/23/22, documented R1's dementia was continuing to cause her to decline in functioning and R1's blood pressure medication had to be held for three days. The Nursing Note, dated 11/10/22 documented R1 was oriented to herself only and staff anticipated all of her needs. The note included R1 was harder and harder to keep awake and when R1 was awake, it was difficult for her to hold her head up. Nursing noted that for the past few weeks R1 preferred to be in bed asleep rather than be out of bed, for any reason. The note documented R1's decline had become very apparent to the nursing staff. The Nursing Note, dated 11/11/22, documented R1 struggled to swallow liquids and was letting the liquids run out of her mouth or hold it in her cheeks. R1's decline was documented as being increasingly noticeable. The Nursing Note, dated 11/16/22, documented R1 had not taken in enough food to measure. R1 appeared to pocket food in her cheeks or chew the same bite for over five minutes and then refused to swallow. The staff were constantly having to wake up R1 or ask R1 to hold up her head so she could drink. The Nursing Note, dated 11/20/22 documented R1 struggled to hold her head up and was not swallowing even with verbal cues from staff. The Nursing Note, dated 11/25/22, documented a call for help was heard from R1's room. When the nurse entered R1's room, she saw LN G on the floor on her knees and R1 lying face down on the floor beside her bed with a pool of blood around her. LN G reported she had been changing R1 [providing peri-care and changing incontinence brief] by herself and had rolled R1 towards the edge of the bed. LN G then fell backwards and R1 rolled out of bed. A complete body check was performed. R1 had a deep laceration to the left side of her nose and two other areas to the left side of her head. The areas were cleansed, and pressure was applied. R1's range of motion was within normal limits. The staff notified R1's primary care physician of the fall and received orders to send R1 to the emergency room for evaluation and treatment. The emergency room Note, dated 11/25/22, documented R1 sustained a laceration to the bridge of her nose and a significant laceration to her tongue despite not having any teeth. R1 would be transferred to a higher level of care due to acute injury and the need for an Ear, Nose, and Throat (ENT) doctor to suture R1's tongue. The Hospital Physical Therapy Note, dated 11/26/22, documented R1 required total assistance of two staff for right and left rolling and was dependent for peri-cares of cleansing during the session, with extreme fatigue on exertion noted. R1 exhibited poor trunk and head control, decreased strength, decreased endurance, limited range of motion, incoordination, inability to execute purposeful movements, lack of coordination of muscle movement, poor safety awareness, decreased attention, inability to follow directions, poor balance, and impaired cognition. On 01/11/23 at 10:00 AM, Certified Medication Aide (CMA) R stated R1 required assistance of two staff for bed mobility and incontinence care because when staff rolled her, she was flaccid and had no muscle control. CMA R stated when she assisted R1 with incontinence care, there were always two staff performing the task. On 01/11/23 at 10:15 AM, Certified Nurse Aide (CNA) M stated R1 needed to have two staff assist her with incontinence care because when staff rolled R1, R1 did not have any control of her body and did not assist in any way. On 01/11/23 at 10:30 AM, CNA N stated when she assisted R1 with bed mobility or incontinence care two staff were needed to perform cares safely. On 01/11/23 at 11:00 AM, LN H stated R1 required one to two staff assistance with bed mobility and incontinence care depending on how R1 was doing each day, how awake R1 was, whether R1 could follow directions, but most of the time two staff assisted R1 for safety reasons. On 01/11/23 at 01:30 PM, Administrative Nurse D verified if LN G had used two staff to provide incontinent care to R1, R1 would not have fallen. Administrative Nurse D verified R1's MDS documented R1 required extensive assistance of two staff for bed mobility and was totally dependent on two staff for toileting. The facility's Managing Falls and Fall Risk, dated October 2022, documented staff will identify interventions related to a resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. Factors that may result in a fall include but are not limited to: acute changes in condition, functional impairments, and cognitive impairment. The facility failed to provide ADL care with the appropriate number of staff in order to prevent accidents for R1 which resulted in R1 falling out of bed onto her face. As a result, she sustained injuries that required her to be transferred to a higher level of care for treatment to receive sutures in her tongue.

The facility had a census of 40 residents. The sample included 13 residents with one reviewed for positioning. Based on observation, record review, and interview, the facility failed to ensure staff provided the required positioning and offloading devices, and failed to ensure appropriate wheelchair positioning for Resident (R) 36. This placed R36 at increased risk for pain, contractures (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement) and further skin breakdown. Findings included: - The electronic medical record (EMR) documented R36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated [DATE], documented R36 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, dressing, personal hygiene, and dependent upon two staff for transfers and toileting. R36 had upper functional impairment on one side, lower functional impairment on both sides, had one Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous (under the skin) tissue layer), one Stage 4 pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone), and one unstageable pressure ulcer (full thickness tissue loss in which the actual depth of the ulcer cannot be seen due to dead tissue). The resident had a turning and repositioning program, pressure relieving devices for bed and chair, nutrition and hydration interventions to manage skin problems, and pressure ulcer care. The Activity of Daily Living (ADL) Care Plan, dated 03/10/22, directed staff to turn and reposition R36 every two hours and as needed, and directed two staff for assistance with bed mobility. It directed staff to place a pillow behind the residents back and between his knees; utilize one to two positioning wedges in the bed to help with off loading and promote wound healing. It further directed R36 needed blue heel protector boots to lower legs and feet at all times but R36 often refused. On 04/07/22 at 12:28 PM, observation revealed R36 sat in a Broda chair (a positioning chair), leaned to the left, with no pillow under or between his legs. Further observation revealed R36's feet had nonskid socks on and they rested against the back of the foot rest. On 04/11/22 at 12:00 PM, observation revealed R36 sat in his Broda chair and leaned to the left. R36's left arm was positioned at his side between his side and the foam cushion on the resident's left arm rest. There was no pillow behind his back or under his legs or feet. R36's knees were together, his left foot and ankle had an ace wrap and gripper socks, and the foot rest not elevated. Staff did not assist the resident with repositioning. On 04/12/22 at 01:41 PM, observation revealed R36 sat in his Broda chair in the dining room. The resident leaned to his left and his head hung over the side of his head rest, making his face look straight down. R36 had on the heel protection boots but his right leg kept falling off the foot rest and hung down unsupported. R36 did not have a pillow between his legs or behind his back. On 04/13/22 at 08:22 AM, Therapy Consultant GG stated they last saw R36 for therapy in February. The facility ordered a Broda chair for the resident when he was admitted . Therapy Consultant GG stated R36 did tend to lean to the left but if he was leaning more than he should, staff were educated to reposition him or lay him down in bed. Therapy Consultant GG stated she discussed with the facility using two to three wedge cushions to keep R36 off his left side to prevent further skin breakdown. On 04/11/22 at 03:31 PM, Certified Nurse Aide (CNA) M stated R36 was repositioned every two hours and he could be repositioned in the Broda chair. On 04/12/22 at 02:45 PM, Administrative Nurse D verified R36 should be positioned better in the Broda chair and should have a pillow between his knees. The facility's Repositioning policy, dated May 2021, documented the guidelines for the assessment of resident repositioning needs was to aid in the development of an individualized care plan for repositioning to promote comfort for all bed and chair bound residents and to prevent skin breakdown, promote circulation, and provide pressure relief for residents. The facility failed to provide the necessary cares and services to ensure appropriate wheelchair positioning, positioning devices, and off-loading for R36, placing the resident at risk for pain and further skin breakdown.

The facility had a census of 40 residents. The sample included 13 residents, with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure staff implemented interventions placed to promote healing and prevent worsening of a Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer), a Stage 4 pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone), and a suspected deep tissue injury (an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) for Resident (R)36. This placed the resident at risk for further skin breakdown and delayed healing. Findings included: - The electronic medical record (EMR) documented R36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, dated [DATE], documented R36 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, dressing, personal hygiene, and dependent upon two staff for transfers and toileting. R36 had upper functional impairment on one side, lower functional impairment on both sides, had one Stage 3 pressure ulcer, one Stage 4 pressure ulcer, and one unstageable pressure ulcer. The resident was provided a turning and repositioning program, pressure relieving devices for bed and chair, nutrition and hydration interventions to manage skin problems, and pressure ulcer care. The Pressure Ulcer Care Area Assessment (CAA), dated 11/24/21, documented R36 was at risk for pressure ulcers but did not have any skin breakdown at this time. The Pressure Ulcer Care Plan initiated on 12/01/21, directed staff to assess skin weekly and as needed, apply a cushion to the wheelchair. It further directed a low loss air mattress and turn and reposition every two hours and as needed. It listed an intervention dated 12/01/21 to monitor R36's palm guard/splint areas for redness every day and night shift for contracture to the left hand. R36's Care Plan recorded R36 had limited physical mobility and needed assistance due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It listed an intervention dated 12/01/21 which directed R36 required assistance of two staff members for bed mobility. It recorded an intervention dated 12/01/21 which directed R36 required use of a Hoyer lift (mechanical lift) and two staff member for transfers. The Care Plan listed a new intervention dated 01/19/22 which directed staff to place a pillow to R36's back and between his knees and place pressure reducing boots to both feet when R36 was in bed. The Wound Clinic Report, dated 03/11/22, directed staff to pad the wheelchair arms with padding to promote healing. The Wound Clinic Report, dated 03/18/22, directed staff to pad both arms on R36's wheelchair with padding such as pool noodles and secure the padding to keep pressure off the resident's elbows; apply Prevalon (cushioned bottom boot that floats the heel off surfaces, helping to reduce pressure) blue heel protector boots to each lower leg/foot. On 04/07/22 at 12:28 PM, observation revealed R36 seated in a Broda chair (a positioning chair), leaned to the left, no pillow under or between his legs, and a foam pad on the left arm of the Broda chair, which his left elbow rested on. Further observation revealed the resident's feet had nonskid socks on and they rested against the back of the footrest. On 04/11/22 at 08:35 AM, observation revealed R36 laid in bed, eyes closed with no Prevalon boots on the resident's feet. On 04/11/22 at 12:00 PM, observation revealed R36 in his Broda chair and he leaned to the left. R36's left arm was positioned at his side between his side and the foam cushion on the resident's left arm rest. No pillow behind his back or under his legs or feet. The resident's knees were together, and his left foot/ankle had an ace wrap on, gripper socks and footrest not elevated. Staff did not assist the resident with repositioning. On 04/11/22 at 03:05 PM, observation revealed R36 in his Broda chair, in the living room area watching television. The resident yelled for assistance and staff did not check on the resident. At 03:23 PM, R36 hollered for help and was getting anxious and continued to holler for assistance. At 03:31 PM, Certified Nurse Aide (CNA) N and CNA M took the resident to his room to lay him down in his bed. CNA M placed a lift sling under R36's right knee, CNA M lifted R36's knee up to adjust the sling and the resident said ouch, my knee popped, can I get a pain pill? CNA M told R36 she would check to see if he could get a pain pill. CNA M and CNA N had trouble adjusting the sling to be able to hook the sling to the lift. CNA M continued to pull on the sling underneath the resident which caused the resident to yell Ouch!. CNA N asked the resident if he was ok. R36 stated, No, I'm just suffering! CNA M and CNA N continued to adjust the sling until they were able to hook the sling to the lift. R36 was transferred to his bed and staff positioned the resident on his back, with his feet lying directly on the mattress, did not place the wedge cushion, nor offer the Prevalon boots before leaving R36's room. On 04/12/22 at 01:41 PM, observation revealed R36 seated in his Broda chair in the dining room. The resident leaned to his left and his head hung over the side of his head rest, making his face look straight down. R36 had on the Prevalon boots, his right leg kept falling off the footrest and would just hang down. R36 did not have a pillow between his legs or behind his back. On 04/11/22 at 03:31 PM, CNA M stated staff reposition R36 frequently and stated she did not offer the boots or the pillow under his legs because he would be getting up for supper. CNA M further stated prior to his skin breakdown, staff just repositioned him every two hours. On 04/13/22 at 08:22 AM, Therapy Consultant GG stated they had last seen R36 for therapy in February. The facility had ordered a Broda chair for the resident when he was admitted . Consultant GG stated R36 did tend to lean to the left but if he was leaning more that he should, staff were educated to reposition him or lay him down in bed. Consultant GG stated she had discussed with the facility to use 2-3 wedge cushions to keep him off the left side to prevent further breakdown. On 04/12/22 at 02:54 PM, Administrative Nurse D stated staff should offer the Prevalon boots to R36 when he was in bed and should follow the care plan to prevent further breakdown. On 04/12/22 at 03:00 PM, Wound Consultant HH stated the physician would expect the facility to follow all recommendations that were given to them from the wound clinic to prevent further breakdown. The facility's Prevention of Pressure Injuries policy, dated May 2021, documented staff identify specific risk factors, establish goals and prevention interventions with the resident, representatives and physician s input to establish goals and approaches to identify co-morbities, risk factors associated with pressure injuries. The risk factors increase with impaired mobility and decreased functional ability. The resident should be repositioned at least every two hours and more frequently as needed, use special mattress that contained foam, air, gel, or water as indication. Consider offloading pressure hourly if the head of the bed was greater than 30 degrees. The policy documented to utilize pillows or wedges to keep body prominences from touching each other, float heels when in bed and place a pillow from knee to ankle. The facility failed to provide the care planned pressure ulcer interventions for R36 to prevent skin breakdown, placing the resident at risk for further skin breakdown and delayed wound healing.

The facility had a census of 40 residents. The sample included 13 residents, with one reviewed for pain. Based on observation, record review, and interview, the facility failed to administer pain medication in a timely manner to Resident (R) 36, who had a Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer), a Stage 4 pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone), and a suspected deep tissue injury (an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). This placed R36 at risk for further pain and discomfort. Findings included: - The electronic medical record (EMR) documented R36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated [DATE], documented R36 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, dressing, personal hygiene, and dependent upon two staff for transfers and toileting. The resident had moderate pain and received scheduled pain medication. The Pain Care Area Assessment did not trigger. The Pain Care Plan, dated 03/10/22, directed staff to administer as needed analgesics (medication that relieve different types of pain) as ordered by the physician, assess for pain every shift and as needed, and anticipate and meet R36's needs. Reposition the resident, distract with television or talking about topics of R36's choice, hold his hand, offer food and/or drinks, and rotate sites when changing the [MEDICATION(S)] patch (a patch that is used to treat severe pain). The Pain Assessment,dated 02/19/22, documented R36 was at risk for pain and had severe, constant pain all over. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/11/22 at 03:31 PM, observation revealed R36 sat in his Broda chair (a positioning chair). Certified Nurse Aide (CNA) M placed a lift sling under R36's right knee, CNA M lifted R36's knee up to adjust the sling and the resident said ouch, my knee popped, can I get a pain pill? CNA M told R36 she would check to see if he could get a pain pill. CNA M and CNA N had trouble adjusting the sling to be able to hook the sling to the lift. CNA M continued to pull on the sling underneath the resident which caused the resident to yell Ouch!. CNA N asked the resident if he was ok. R36 stated, No, I'm just suffering! CNA M and CNA N continued to adjust the sling until they were able to hook the sling to the lift. On 04/12/22 at 10:15 AM, observation revealed R36 lying in bed. Licensed Nurse (LN) G and Administrative Nurse E explained to R36 that they were going to do his wound care and began to position R36 for wound care. LN G started to lift R36's left arm and he hollered OW, that hurts, can I get a pain pill? Administrative Nurse E asked him if he had been given his morning medications, and he stated No! Administrative Nurse E stated the resident had pain medication available but she did not know what exact medication nor when R1 was ordered to receive it. LN G asked R36 to roll to the left and grab the positioning rail with his right hand. R36 hollered Ouch, that hurts my ankle! Administrative Nurse E asked CNA O to tell Certified Medication Aide (CMA) R that R36 requested pain medication and his water pitcher. CMA R brought in a water pitcher, pills in a small plastic cup, and a [MEDICATION(S)] patch. CMA R told Administrative Nurse E where to place the patch and left the room. Administrative Nurse E asked the resident his level of pain and started to administer the medication to the resident. Administrative Nurse E stated she did not know what the medications in the cup were except that they were the resident's morning medications. R36 took the medications and LN G continued with wound care. LN G looked at R36's foot, checked capillary refill (time taken for color to return after [NAME] was applied) and began to unwrap the ace bandage to rewrap it looser. R36 hollered ouch, your hurting me! After LN G rewrapped the resident's foot, she took a slipper sock and started to put in on the resident's foot. LN G noticed it was too small to fit over his wrapped foot; R36 again yelled Ow, Ow and stated it was hurting all the way up to his knee. LN G continued to try to put the sock on R36's foot. Administrative Nurse E removed the resident's shirt to look at a healed area on R36's rear left shoulder. LN G used wound cleanser on the resident's shoulder and applied skin prep (liquid protective film or barrier) to the area. R36 laid in bed with his left leg bent and the left knee underneath his right knee. Administrative Nurse E directed LN G to apply the resident's prevalon boots (pressure relieving boots) while he was in bed. LN G applied R36's right boot, then attempted to put on the left boot while the left leg was still under the right leg. R36 yelled Ow Ow, Ow! LN G was able to reposition the resident's left leg to put on his left boot . On 04/12/22 at 10:45 AM, Administrative Nurse E stated R36 had [CONDITION(S)] (dysfunction of one or more peripheral nerves, typically causing numbness or weakness) and often hollered out and they tried to be extra careful when moving him. On 04/12/22 at 11:00 AM, CMA R stated R36 received his [MEDICATION(S)], muscle spasm, and anxiety medications. CMA R stated she was behind on her medication administration and R36 should have received his pain medication two hours earlier. She stated she should have administered the resident's pain medication that she had prepared, and it was not standard practice to allow another staff member to administer the medications. On 04/12/22 at 02:54 PM, Administrative Nurse D stated R36 should have received his medications on time and CMA R should have administered the medications she had prepared. The facility's Pain Assessment and Management policy, dated May 2021, documented staff identify and develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. The staff review the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff review the resident's treatment record or recent nurse's notes to identify any situations or interventions when an increase in the resident's pain may be anticipated, for example treatments such as wound care or dressing changes, turning and repositioning. The facility failed to administer pain medication in a timely to R36, who had pain during repositioning and wound care. This placed the resident at risk for further pain and discomfort.

The facility had a census of 40 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure staff possessed the appropriate competencies to safely administer medications per the standards of practice when a licensed nurse administered Resident (R)36 medications without verifying the medication, route, and/or dosage. This placed the resident at risk for medication errors. Findings Included: - On 04/12/22 at 10:20 AM, observation revealed Administrative Nurse E asked Certified Nurse Aide (CNA) O to tell Certified Medication Aide (CMA) R that R36 requested pain medication and his water pitcher. CMA R brought in a water pitcher, pills in a small plastic cup, and a [MEDICATION(S)] patch. CMA R told Administrative Nurse E where to place the patch and left the room. Administrative Nurse E asked the resident his level of pain and started to administer the medication to R36. Administrative Nurse E stated she did not know what the medications in the cup were except that they were the resident's morning medications. Administrative Nurse E administered the medications to R36. On 04/12/22 at 11:00 AM, CMA R stated R36 received his [MEDICATION(S)], muscle spasm, and anxiety medications. CMA R stated she was behind on her medication administration and R36 should have received his pain medication two hours earlier. She stated she should have administered the resident's pain medication that she had prepared, and it was not standard practice to allow another staff member to administer the medications she had prepared. On 04/12/22 at 02:54 PM, Administrative Nurse D stated R36 should have received his medications on time and CMA R should have administered the medications she had prepared. Administrative Nurse D stated Administrative Nurse E and CMA R had taken the medication administration competency test in December of 2021 and would take it again in July of 2022. On 04/13/22 at 11:15 AM, Administrative Nurse E stated she knew that she should not have administered the medications to R36 since she had not prepared the medications. On 04/13/22 at 01:00 PM, CMA S stated it was not standard practice to prepare medications and then another staff member administer the medications. On 04/13/22 at 01:05 PM, CMA T stated if she prepared the medication, she would administer the medication. On 04/13/22 at 01:15 PM, LN H stated staff are not to administer medications someone else prepared. The facility's Administering Medications policy, dated May 2021, documented the individual administering the medication must check the label three times to assure the right medication, right dosage, right time, and right route of administration before giving the medication. The facility failed to ensure staff possessed the appropriate competencies to safely administer medications per the standards of practice when a licensed nurse administered R36 medications without verifying the medication, route, and/or dosage. This placed the resident at risk for medication errors.

The facility had a census of 41 resident. Based on observation, record review, and interview, the facility failed to use gloved hands when staff picked up food and assisted residents with eating, and failed to properly clean the blender between preparing different pureed (a paste or thick liquid suspension usually made from cooked food ground finely) food items. Findings included: - On 10/01/20 at 08:15 AM, observation revealed Certified Medication Aide (CMA) R sat at the counter on Resident (R) 22's left side and assisted the resident with her breakfast meal. Observation revealed CMA R stood up, ambulated to the activity director room, picked up a ponytail holder, and with ungloved hands placed his hair up into a ponytail on his head. Observation revealed CMA R returned to the dining room counter, sat in the chair to the left of R22, picked up a slice of her toast with his left ungloved hand, and gave R22 a bite. On 10/01/20 at 08:39 AM, observation revealed Licensed Nurse (LN) G propelled R22 in her wheelchair back to her food on the counter, picked up a piece of R22's toast with her ungloved hands, and placed the toast in R22's mouth. On 10/01/20 at 09:05 AM, observation revealed Certified Nurses Aide (CNA) M picked up a piece of bacon in her ungloved hand and placed the bacon up to R27's mouth. On 10/01/20 at 11:05 AM, observation revealed Dietary Staff (DS) BB placed two (1/3 cup) portions of mixed vegetables in a blender, added thickener and vegetable juice , and blended the vegetables to a pudding consistency. Observation revealed DS BB rinsed the blender lid and container in hot water several times then placed 1/3 cup of ground country fried steak, 1/3 cup of gravy, and an unmeasured amount of milk in the blender and blended to consistency of mashed potatoes. Observation revealed DS BB rinsed the blender container and lid several times with hot water then placed a roll into the blender, added unmeasured milk, and blended to a consistency of mashed potatoes, topped with unmeasured butter, and placed it on the plate with the other food items. On 10/05/20 12:18 PM, observation revealed CMA S placed her ungloved hand on R35's sandwich and cut off the crust with a butter knife in her right hand. On 10/01/20 at 11:05 AM, DS CC stated staff always rinse the blender between food items in the same way and she was unaware the blender were supposed to be sanitized between different foods. On 10/05/20 at 01:48 PM, Administrative Nurse D stated staff should not use their ungloved hands to pick up food items. The facility's Preventing Foodborne Illness-Food Handling F812 policy, dated November 2017, documented that all employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. All food service equipment and utensils will be sanitized according to current guidelines and manufacturer's recommendations. The facility failed to ensure dietary staff cleansed and sanitized the blender container between pureed food items and failed to ensure staff wore gloves when they assisted residents eat their food, placing the residents at risk for foodborne illness.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation and interview, the facility failed to display staffing information in a prominent place accessible to residents and visitors when the facility posted staffing hours inside the nurse's station charting room not readily available in a readable format. Findings included: - On 09/29/20 at 10:00 AM, observation revealed no visible posting of nursing staff hours. On 09/30/20 at 10:30 AM, observation revealed no visible posting of nursing staff hours. On 10/01/20 at 10:01 AM, License Nurse (LN) G stated staffing hours were kept on a clip board in a file [MEDICATION NAME] on top of a desk inside the nurse's charting room. On 10/01/20 at 02:40 AM, Administrative Nurse D verified the staffing hours were kept in the nurse's station on a clip board inside the nurses charting room, but should be posted on the wall outside the nurse's charting room. The facility's Posting Direct Care Daily Staffing Numbers policy, dated January 2020, documented the facility will post in a prominent location (assessable to residents and visitors), on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The facility failed to display daily staffing information in a readable format visible to staff and visitors, placing residents and visitors at risk for being uninformed of nursing staff hours.

The facility had a census of 41 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide an appropriate end date for one as needed (PRN) antianxiety medication (class of medications that calm and relax people with excessive mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension) for one of six sampled residents, Resident (R) 87. Findings included: - R87's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), physical and verbal behavioral symptoms directed towards others, behavioral symptoms not directed toward others, and rejection of care one to three days during the look back period. The MDS documented the resident required supervision with all activities of daily living (ADLs) except toilet use which required limited assistance. The MDS documented the resident received insulin (medication used to treat people who produce little or no insulin), antipsychotic (class of medications used to treat a major mental disorder characterized by a gross impairment in reality and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and diuretic (medication to promote the formation and excretion of urine) medications seven days during the look back period. The Risk for Adverse Reaction Care Plan, dated 08/20/20, directed staff to administer the resident [MEDICATION NAME] (antianxiety medication) and monitor for side effects of increased risk for falls, Central Nervous System (CNS-nerve tissues that control the activities of the body) and respiratory depression (a breathing disorder characterized by slow and ineffective breathing). The care plan documented the physician reviewed and evaluated the resident's medications. The Physician order [REDACTED]. The order lacked an end date for the medication. On 09/30/20 at 09:30 AM, observation revealed the resident ambulated independently from her room to the dining room table, sat in a chair, and visited with the resident across the table. On 10/05/20 at 01:38 PM, Administrative Nurse D verified the resident's [MEDICATION NAME], 0.5 mg order had no end date and stated the facility used the mega rule which allowed the facility to not apply an end date to the resident's PRN [MEDICATION NAME]. The nurse practitioner saw the resident every one to two weeks through tele medicine (the process of providing health care from a distance through technology, often using video conferencing), but could not produce documentation regarding the mega rule. The facility's Unnecessary Drugs, [MEDICAL CONDITION] Use policy, dated January 2020, documented the facility would limit PRN orders for antianxiety drugs to 14 days. This may be extended beyond the 14 days through documentation in the medical record by the practitioner as to why this should occur. The facility failed to provide an appropriate end date for R87's PRN [MEDICATION NAME], placing the resident at risk for receiving unnecessary [MEDICAL CONDITION] medications.

The facility had a census of 41 residents. The sample included 12 residents with one reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide meals and assistance to Resident (R) 23 in a prompt and conducive manner. Findings included: - R23's Physician order [REDACTED]. or hopeless, and physical that can occur because of having a hard time coping) with depressed mood, and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment, required extensive assistance of one staff for eating, and loss of liquid and solids from her mouth when eating or drinking. The MDS documented the resident held food in mouth and cheeks or residual food in mouth after meals and coughed or choked during meals or swallowing medication. The MDS further documented the resident had impaired range of motion on one side of upper body, significant weight loss, and received a mechanically altered diet. The Nutritional Status Care Area Assessment (CAA), dated 09/24/20, documented R23 had a 10% weight loss, not on a prescribed weight loss regimen, and received a mechanically altered diet. The CAA documented the resident received nectar thick liquids, supplements, poor appetite, liked cranberry juice, and directed staff to try to find foods the resident would accept. The Nutritional Care Plan, dated 08/27/20, instructed staff to provide the resident a fortified pureed diet with nectar thick liquids and a supplement three time a day. The care plan further documented the resident liked diet coke, hot cereal with brown sugar, lemon and tapioca pudding, and family reported she was not a picky eater. The POS, dated 09/21/20, directed staff to provide the resident a supplement three times a day, pureed diet, and nectar thick liquids. The Nutritional Assessment, dated 09/14/20, by Consultant (C) GG, documented a loss of nine lbs. in one month and intake of 0-25% of pureed and nectar thick liquids. C GG recommended a pureed diet, increased nectar thickened liquid amounts, and increased supplement amounts. C GG further recommended speech therapy and a goal to maintain weight of 111 pounds or more. On 09/30/20 at 11:26 AM, observation revealed R23 entered the dining room with walker and two staff. At 12:03 PM, continue observation revealed the resident sat with her eyes closed at the desk in the dining room, no food or fluids present. At 12:17 PM, continued observation revealed staff woke the resident and informed her the kitchen was preparing her food, then staff brought R23 a cup of red nectar thick liquid with a sippy lid and handles on each side and unwrapped silverware . The resident picked up each piece of silverware separately and made motion as if taking a bite. At 12:21 PM, continued observation revealed staff delivered pureed food and placed it in front of the resident. Certified Medication Aide (CMA) R offered the resident a bite of pudding and R23 pushed CMA R's hand away. (55 minutes to receive the meal) On 10/01/20 at 09:22 AM, observation revealed CMA T ambulated R23 to the dining room, provided the resident with a nectar thick supplement drink and hot tea in cups with sipper lids and handles. Continued observation revealed staff encouraged the resident to drink, but did not stay to assist her. At 09:38 AM, continued observation revealed the resident sat with her eyes closed, no food provided. At 09:57 AM, continued observation revealed staff moved the resident's chair to the end of the table to adhere to social distancing of another resident seated at the table, no food provided, and staff stated to each other the kitchen had been notified of resident being in the dining room. At 10:15 AM, continued observation revealed R23 slept at the table. At 10:24 AM, continued observation revealed one staff assisted the resident to the bathroom with her walker. After toileting, staff alerted the resident had not received a breakfast meal, so staff returned R23 to the table, provided her pudding, and attempted to give the resident bites, but she did not eat and closed her eyes. At 10:44 AM, continued observation revealed staff transferred R23 to a recliner in the commons area. (62 minutes until toileted and returned to dining room) On 10/05/20 at 10:53 AM, CMA T reported R23 required assistance and encouragement of one staff with eating, and at times would try to feed herself. CMA T stated the resident had a poor appetite and received a pureed diet with nectar thick liquids. CMA T stated the resident ate better later in the day and when staff sat with her one on one in her room. On 10/05/20 at 11:09 AM, LN H reported it was difficult to get the resident to eat, the resident ate in the dining room with her back to the room of residents so she did not get distracted. On 10/05/20 at 01:31 PM Dietary Staff (DS) CC stated when R23 was brought to the dining room staff were to let dietary know she was ready for her meal. DS CC stated the residents should not have to wait 30 minutes to be served the meal or assisted to eat. On 10/05/20 at 02:30 PM, Administrative Nurse D stated the resident should be served promptly, assisted in the dining room, and a 30-minute wait was too long. The facility's Nutrition (Impaired)/ Unplanned Weight Loss Clinical Protocol policy, dated February 2020, documented residents with functional impairment most likely need some form of assistance with eating, to ensure food is served to the resident in a conducive dining. The facility failed to provide R23 meals and assistance within 45 minutes of being placed in the dining room, placing the resident at risk for poor nutrition and weight loss.

The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to provide food prepared by methods that conserved nutritive value, flavor and appearance for one of two residents who received pureed meals, Resident (R) 23. Findings included: - On 10/01/20 at 11:05 AM, observation during pureed food preparation revealed Dietary Staff (DS) BB, with DS CC overlooking, placed 2/3 cup of mixed vegetables into the blender, added two teaspoons (tsp) of thickener, and blended. DS BB stated the mixture was not the right consistency, added 2/3 cup of juice from the mixed vegetables in the steam table, and blended to a pudding consistency. DS BB placed the mixture onto a plate and placed it on the counter beside the steam table. Observation revealed DS BB placed 1/3 cup of ground country fried steak into the blender, added 1/3 cup of gravy, and blended. DS BB stated the mixture was not the right consistency, poured unmeasured milk into the mixture, and blended to mashed potato consistency, and placed the mixture on the plate with the pureed mixed vegetable. Further observation revealed DS BB placed a bread roll into a blender, added unmeasured milk, and blended the mixture to mashed potato consistency. DS BB placed an unmeasured amount of the mixture on the plate with the other pureed food items, leaving some of the pureed mixture in the blender. On 10/01/20 at 11:15 AM, DS BB verified the above finding, obtained a plastic-coated sheet of paper titled, Puree Recipes, this is only to be used as a back-up for recipes on production sheets, and stated she used that document. On 10/01/20 at 11:16 AM, DS CC verified DS BB had not followed a recipe and brought out a white binder, stated DS BB should have followed the pureed recipe in the binder, and measured each item she placed in the blender. On 10/01/20 at 11:17 AM, DS BB stated she was unaware the kitchen had a recipe book. The facility's Standardized Recipes policy, dated February 2020, documented standardized recipes shall be developed and used in the preparation of foods. The food services manager will maintain the recipe file and make it available to food services staff as necessary. The facility failed to follow a recipe when preparing R23's pureed meal, placing the resident at risk for impaired nutrition.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide necessary care and treatment for [REDACTED]. Findings included: - Resident #8's admission (MDS) Minimum Data Set assessment, dated 1/21/2019, documented the resident had severe impaired cognition, independent for bed mobility, transfers, toilet use, and had venous and arterial ulcers. The (CAA) Care Area Assessment for pain, dated 1/23/2019, recorded the resident had arterial and diabetic wounds, and his/her hygiene care and skin integrity were risk factors with the resident. The 1/11/2019 care plan directed staff to change the resident's UNNA (a special gauze bandage, impregnated with zinc, [MEDICATION NAME], or [MEDICATION NAME] that becomes rigid when it dries, approximately 4 inches by 10 yards long), boot on his/her left lower extremity every Friday, and as needed due to chronic venous ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) and inflammation of his/her left lower extremity, which could be used for the treatment of [REDACTED]. The 3/01/2019 physicians order directed the nurse to change the UNNA boot to the resident's left lower extremity on Fridays, place [MEDICATION NAME] AG (a sterile dressing with silver used to cover a wound and prevent infection) to open wound, apply UNNA boot, wrap with gauze-kling and stabilize with coban (a self-adherent compression bandage used for protection and swelling control). The 3/14/2019 at 3:50 PM, nurse's notes recorded the resident returned from the physician's office with orders to continue with the current care on the resident's left lower extremity, and follow up with the physician in 6 weeks. The 3/22/2019 at 11:09 AM, nurse's notes documented the nurse changed the resident's left lower leg dressing and noted the wound was yellow and purple colored, with yellow drainage, and odor noted. The 3/29/2019 at 4:55 AM, nurse's notes documented the resident's left lower leg dressing was changed last night due to leaking foul smelling greenish/yellowish drainage, when the dressing was removed. Continued observation revealed the leg was macerated (softening and breaking down of the skin resulting from prolonged exposure to moisture), cleansed with wound cleanser, the resident requested to leave the leg open to air, and staff respected his/her wishes. The nurse placed (ABD) abdominal gauze pads to absorb drainage from the wounds, and tape around his/her leg to prevent his/her pants from rubbing on the wound of his/her leg. The resident called his/her relative and explained he/she had drainage coming from his/her wound, the relative called the facility and requested the resident be seen at the emergency room first thing in the morning. The 4/01/2019 at 3:59 AM, nurse's notes documented the resident's wound had a large amount of watery green drainage, the nurse placed an ABD pad wrapped with gauze to the resident's heel and bottom of foot to absorb any drainage. The 4/03/2019 at 9:18 AM, nurse's notes documented the nurse removed the left lower leg dressing and observed green drainage with a foul odor with dark purple skin and multiple open areas. On 4/03/2019 at 9:00 AM, observation revealed Nurse H removed the UNNA boot from the resident's left lower extremity, cleansed the wound with normal saline gauze, and patted dry. Continued observation revealed the leg had yellowish/green drainage, and Nurse H applied calcium alginate over the three open areas on the top of the resident's shin and back of the calf. Continued observation revealed Nurse H applied the UNNA boot dressing, secured with a 4 inch gauze wrap, applied two 6 inch ABDs for drainage and absorption, then applied a 4 inch kling dressing, secured with coban. On 4/03/2019 at 9:00 AM, Nurse H verified the resident was admitted to the facility in (MONTH) after left leg vein surgery. Nurse H stated the resident was on antibiotics, and after the antibiotics were finished the resident started developing the drainage and foul odor from the wounds. Nurse H verified he/she sent a fax to the physician over the weekend, (MONTH) 31, and requested to obtain a culture or a different wound treatment, but had not received correspondence back as of 4/03/2019. The 7/01/2013 Wound Care Management policy documented to choose the appropriate option and secure a physician order, specifying type, size, and amount of all dressings utilized. The facility utilized zinc with a [MEDICATION NAME] compression bandage system (UNNA Boot) and follow the following procedure: The nurse scrubbed the skin surface of wound bed tissue vigorously with normal saline gauze, or skin integrity wound cleanser. Allow the area around the wound to dry. Apply honey dressing to ulcerated areas. Apply UNNA boot bandage, start just above the toes and wrap up in a spiral, stopping just below the back of the knee. Change every 5-7 days or when drainage strikes through the dressing. If no improvement in 14 days, notify the physician for further evaluation. The facility failed to provide Resident #8 with adequate treatment for [REDACTED].

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 14 sampled residents. (#32) Findings included: - Resident #32's quarterly (MDS) Minimum Data Set assessment, dated 2/24/19, recorded the resident had severely impaired cognition with inattention and disorganized thinking. The MDS also recorded the resident required extensive staff assistance with all (ADLs) Activities of Daily Living and used a wheelchair for mobility. The 7/30/18 admission (CAA) Care Area Assessment for falls recorded the resident was a high risk for falls due to his/her weakness, immobility and severely impaired cognition. The 3/15/19 care plan recorded the resident was at risk for falls due to weakness, immobility, and poor safety awareness, The care plan directed staff to transfer the resident with a sit to stand lift (assistive device provides support for person to stand), and transport the resident in his/her wheelchair. On 4/01/19 at 11:11 AM, observation revealed the resident sat in a wheelchair with no foot pedals, and his/her feet rested on the floor. Continued observation revealed the resident had a pressure relief boot on his/her left foot, a sock on his/her right foot, and the resident's feet slid on the floor, when staff pushed the resident's wheelchair to the dining room. Multiple observations, during the 4 day survey process, revealed staff pushed the resident's wheelchair, and the resident's feet slid on the floor. On 4/03/19 at 11:02 AM, Nurse G stated the resident was a fall risk due to severely impaired cognition and limited mobility, and was dependent on staff to push his/her wheelchair. On 4/04/19 at 8:00 AM, Administrative Nurse D stated the resident was a fall risk, and dependent on staff for his/her wheelchair mobility. Administrative Nurse D stated staff should place foot pedals on the resident's wheelchair to prevent an accident or injury. The facility's Positioning Policy, dated 5/2011, directed staff to position residents to ensure comfort and safety. The facility failed to provide adequate supervision and assistive devices to prevent accidents for Resident #32, placing the resident at risk for falls and injuries.

The facility had a census of 29 residents. The sample included 15 residents of which 1 was reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide necessary care and treatment to prevent the development of a pressure ulcer for 1 of 1 sampled resident. Resident #6 developed an avoidable, stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone tendon, or muscle are not exposed) on his/her left medial malleolus (the bump on the inner side of the ankle). Findings included: - Resident #6's physician order [REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 8/26/2017, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 6, indicating severely impaired cognition. The MDS documented the resident required extensive assistance of two staff with bed mobility, transfers, dressing and toilet use. The MDS indicated the resident was at risk for pressure ulcers, had no current pressure ulcers, staff provided skin ulcer treatment, pressure relieving devices to the bed and chair, and on a turning and repositioning program. The quarterly MDS assessment, dated 11/26/2017, recorded the resident had a BIMS score of 9, indicating moderate cognitive impairment, and the resident required the same assistance as the 8/26/2017 MDS. The MDS indicated the resident was at the risk for pressure ulcers, and had no pressure ulcers. The MDS documented staff provided interventions of a pressure relieving device to bed, chair, and a turning and repositioning program. The 8/26/2017 (CAA) Care Area Assessment summary for skin/pressure ulcers indicated the resident was frequently incontinent of bowel and required staff assistance with bed mobility and transfers. The CAA documented the resident had no pressure wounds. The 11/17/2016 care plan instructed the staff to assist the resident to reposition in the morning, in the evening, nighttime, and as needed. The care plan directed the staff to assist the resident to a position of comfort, utilizing pillows and appropriate positioning devices. The 12/21/2017 care plan instructed the staff to assist the resident to turn and reposition every 2-3 hours while in bed, and to assist the resident out of the bed, into a wheelchair, for 2-3 hours a day, as tolerated. The care plan directed staff to float the resident's heels while in bed, and apply a lower extremity positioning device on the leg rest while in the wheelchair. The 9/06/2017 (RD) registered dietician assessment documented the nursing staff reported the resident weighed 127(#) pounds. The dietician documented the resident lost weight and recommended the physician order [REDACTED]. The 10/26/2017 at 10:48 AM, nurse's note documented the facility requested an order from the physician, for a douderm (extra thin dressing, that provides a moist wound environment that helps with healing the wound) dressing to the resident's right inner ankle every three days, after cleansing with wound cleanser, patting dry, and applying skin prep (a liquid film-forming dressing that, upon application to the skin, forms a protective cover to help reduce friction during the removal of tapes and films). The 10/26/2017 weekly wound assessment documented the right ankle wound measured, 1.0 (cm) centimeters by 1.0 cm by 0.0 cm, redness surrounding the open area, and staff cleansed with wound cleanser, patted dry, and applied skin prep around the open area. The 11/03/2017 at 1:03 PM (7 days after the original request on 10/26/2017), nurse's note documented the nurse contacted the physician's office and left a message for the physician's nurse to call the facility for wound care orders the facility had prior requested, and would await a phone call. The 11/16/2017, weekly wound assessment (21 days after the last wound assessment) documented the resident's right ankle open area with redness, measured 1.2 cm by 0.8 cm, and no measurable depth. The 11/18/2017 at 11:14 AM, nurse's note documented the duoderm dressing on the resident's right inner ankle peeled away and exposed the stage II pressure ulcer. The area had a small amount of thick, foul-smelling, tan drainage, edges red, and swollen. The center of the wound revealed a white elevated area with scattered black tissue, and red tissue through the wound bed. The note documented staff applied wound cleanser and duoderm treatment, and the nurse documented the area was very painful for the resident. The nurse's note lacked documentation staff notified the physician of the resident's wound status and pain. The 11/19/2017 weekly wound assessment documented the right ankle, open area measured 2 cm x 1.6 cm, and no measurable depth. The wound had light cream color thick drainage, with slight foul odor, very tender to touch, and the resident rated his/her pain at an 8 on a 1-10 (1 being the least amount of pain and 10 being the worst pain) scale. The 11/27/2017 at 10:55 AM, (8 days after staff noted wound status changes), nurse's note documented the nurse contacted the physician regarding the resident's right inner ankle wound. The physician ordered the nurse to cleanse the area with wound cleanser, pat dry, apply collagen (fibers that stimulate tissue growth), and cover with foam protective dressing, twice daily, until healed. The 12/14/2017 at 4:17 PM, nurse's note documented the resident had a stage III pressure ulcer to the right medial malleolus, the previous treatment was ineffective, and staff notified the physician. The notes documented the physician ordered staff to change the treatment to hydrogel (a dressing that contains a gel in the form of a sheet that can take the shape of the wound) dressing every day, continue with pressure reducing mattress, turn and repositioning program, cushion to the wheelchair, out of the bed for 2 hours at a time, leg rest positioned, and to float heels when in bed. The 12/14/2017 weekly wound assessment (25 days after the last assessment) documented the resident's stage III right ankle wound measured, 1.3 cm by 2.0 cm x 0.2 cm (the notes documented the wound had increased from a stage II to a stage III) and staff notified the physician. The 12/15/2017 at 11:00 AM, nurse's note documented the nurse cleansed the resident's right medial malleolus with wound cleanser, patted dry, applied skin prep to the periwound (the tissue surrounding the wound itself), applied hydrogel dressing, and covered with a foam dressing, daily. The 12/21/2017 weekly wound assessment documented the resident's right ankle wound measured, 1.3 cm 1.8 cm by 0.2 cm, staff floated the resident's heels when in bed, the wound was healing slowly, without signs of infection. The 12/27/2017 wound assessment documented the resident's ankle wound measured, 1.4 cm x 2.2 cm x 0.2 cm, and the size had increased slightly from the previous week. The 12/27/2017 at 11:11 AM, nurse's note documented the right medial malleolus wound increased in size, with [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissue)noted to the right foot. The nurse requested a treatment change to [MEDICATION NAME] (a dressing that releases silver at a controlled level for broad spectrum antimicrobial action) gel dressing every 3 days, and as needed, and requested a vascular (vessels of the body, arteries and veins) study to assess pressure wound verses vascular ulcer. The 12/29/2017 at 4:32 PM, nurse's note documented the physician ordered Prostat (ready to drink liquid that contains 17 grams of protein, plus added vitamins and minerals) 30 (cc) cubic centimeters, twice a day, to assist with wound healing. The 1/02/2018 weekly wound assessment documented the resident's right ankle wound measured, 1.4 cm by 2.0 cm by 0.2 cm, and was healing slowly. The 1/08/2018 weekly wound assessment documented the resident's stage III right ankle wound, measured, 1.3 cm by 1.6 cm by 0.2 cm. The 1/15/2018 weekly wound assessment documented the ankle wound was unstageable and measured 3.0 cm by 4.5 cm, depth undetermined, increase in overall wound size, and the resident had an increase in unrelieved pain. The 1/24/2018 weekly wound assessment documented the right ankle wound, measured, 1.2 by 0.8 cm, with a small creamed colored center. The 1/29/2018 physician's orders [REDACTED]. The 2/01/2018 weekly wound assessment documented the right ankle open area measured, 2.5 cm by 1.9 cm by 0.3 cm depth, the wound was a dark brown color with small spots of cream colored drainage. The 2/05/2018 weekly wound assessment documented the ankle wound measured, 3.0 cm by 4.5 cm, depth undetermined, and the resident had an increase in unrelieved pain. The 2/08/2018 at 11:10 AM, nurse's note documented the resident had an upcoming appointment at the wound clinic on 2/15/2018, for consultation. The note documented the physician decided to refer the resident to the wound clinic prior to the venous study. The notes documented the staff continued pressure reduction to the area on the resident's inner ankle. The 2/10/2018 at 3:53 PM, nurse's note documented the resident had an appointment on 1/31/2018, at a local foot clinic, and the physician recommended heel protectors. The 2/11/2018 at 11:03 AM, nurse's note documented the resident's open area to the right inner ankle, measured 1.2 cm by 2.5 cm by 0.3 cm, and the resident complained of severe pain with the dressing change. On 2/08/2018 at 2:45 PM, observation revealed Nurse G peeled the top half of the dressing back and revealed the right medial malleolus wound, the skin open approximately 3.0 cm by 4.0 cm with brownish macerated area. The resident stated ouch and expressed discomfort when the nurse removed part of the dressing. Observation revealed the staff placed a pillow between the resident's legs, but did not have a pressure relieving boot on. On 2/13/2018 at 1:00 PM, observation revealed the resident sat in a wheelchair in the dining room, socks on his/her feet, but no pressure relieving boot on his/her right foot. On 2/12/2018 at 11:00 AM, Nurse Aide O verified the resident complained of discomfort in his/her right foot and staff applied a pressure relieving boot when the resident was up in the wheelchair, and not when he/she was in bed. On 2/12/2018 at 3:20 PM, Nurse G verified the resident had a long standing [MEDICAL CONDITION] diagnosis, and had the potential for skin breakdown. Nurse G verified staff should ensure the resident wore the pressure relieving boot on his/her right foot in bed, and when up in the wheelchair. On 2/12/2018 at 2:40 PM, Administrative Nurse D verified the resident developed a facility acquired pressure ulcer on his/her right medial malleolus, and had an upcoming appointment at the wound clinic for continued treatment. Administrative Nurse D verified the resident had a [DIAGNOSES REDACTED]. Administrative Nurse D verified the lack of physician notification and skin assessments every week. The facility's 7/01/2013 Prevention and Management of wounds policy directed the staff to identify residents at risk and the facility would provide appropriate care and treatment for [REDACTED]. The nurse would identify the impairment and stage if indicated, identify the appropriate treatment and interventions, notify the physician, notify the family or responsible party, document the physician order, complete the treatment recording the wound module or on paper, indicate interventions on the resident's care plan, update nurse aide plan of care in the Kiosk (electronic charting system) as needed, and recognize factors contributing to pressure, resident needs and behaviors. The facility failed to develop and implement timely and effective interventions, to prevent the development of Resident #6's stage III right ankle pressure ulcer. The facility lacked consistent weekly wound assessments, physician notification of wound changes, placing the resident at risk for further pressure ulcer decline and development of additional pressure ulcers.

The facility had a census of 29 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to offer a snack program and monitor supplement intake for Resident #14, who had a severe weight loss (greater than 10% in 6 months) of 30.2# or 21.18% in 6 months. Findings included: - Review of Resident #14's physician order [REDACTED]. Its extreme form is characterized by severe weight loss), anorexia (lack or loss of appetite), bulimia {(eating disorder characterized by binge eating followed by purging (vomiting or taking laxatives)}, and cachexia (wasting syndrome characterized by loss of weight, [MEDICAL CONDITION], fatigue, weakness, and significant loss of appetite). The quarterly (MDS) Minimum Data Set assessment, dated 12/23/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 8 (moderately impaired cognition). The MDS recorded the resident required set up assistance and supervision with eating, weighed 118 (lbs.) pounds and had a recent weight loss. The annual (CAA) Care Area Assessment for nutrition, dated 06/26/17, recorded the resident weighed 138 pounds, gained weight the past 3 months, and continued to eat independently without difficulty. The CAA also stated the resident was malnourished, when admitted from the hospital, and had a history of [REDACTED]. The 12/28/17 care plan recorded the resident was at risk for altered nutrition due to the [DIAGNOSES REDACTED]. The care plan directed staff to provide the resident with a mechanical altered diet (finely chopped or soft foods) and encourage food and fluid intake. The care plan directed staff to provide the resident with supplements as ordered by the physician and chocolate milk at meals. The weight record recorded the following weights: 08/04/17 - 142.6 lbs. 09/01/17 - 139.2 lbs. 10/10/17 - 139.2 lbs. 11/01/17 - 127.0 lbs. 12/07/17 - 118.0 lbs. 01/08/18 - 114.4 lbs. 02/06/18 - 112.4 lbs. (30.2 lbs. or 21.18% weight loss in 6 months) The 10/18/17 nutrition assessment recorded the resident weighed 133 lbs., had a recent weight loss, but remained within the weight range goal of 133 lbs. to 143 lbs. The assessment recorded the resident ate independently, average meal intake was 50%, and staff provided 2 Cal supplement (high calorie drink) to the resident 3 times a day. The 11/16/17 physician's orders [REDACTED]. The 12/04/17 at 11:58 AM, nurse's note recorded the resident refused the 2 Cal supplement because the supplement made him/her sick. The 12/11/17 at 7:47 PM, nurse's note recorded the resident refused the 2 Cal supplement because the supplement makes him/her vomit. Review of the resident's medical record revealed, from 11/16/17 to 01/11/18 (when the supplement was discontinued), staff documented 27 nurse's notes that the resident refused the supplement due to the supplement made him/her sick or vomit. The 12/11/17 nutrition assessment recorded the resident weighed 118 lbs., had a significant weight loss and continued on 2 Cal supplement. The assessment recorded the (RD) Registered Dietician recommended [MEDICATION NAME] medication (antidepressant and appetite stimulant) to improve the resident's appetite. The 01/03/18 facility's fax to the physician (30 days after staff noted on 12/04/17 the supplement made the resident sick) recorded the resident consistently refused the 2 Cal supplement with meals and at bedtime. The physician ordered staff to discontinue the scheduled supplement and offer the supplement to the resident (prn) as needed. The 01/05/18 facility's fax to the physician recorded the resident continued to lose weight and refused breakfast due to concerns about his/her weight. The physician ordered staff to provide the resident with (CIB) Carnation Instant Breakfast (increased calorie supplement) every day. The 01/08/18 at 1:30 PM, nurse's note recorded the resident weighed 114 lbs., refused to eat breakfast and staff offered the resident Carnation Instant Breakfast. The 01/16/18 at 9:52 AM, nurse's note recorded the resident remained in bed in the mornings and staff provided CIB supplement every day for breakfast. The note recorded the resident frequently refused meals due to concerns for his/her weight and nursing notified the dietary department. The 01/20/18 nurse's note recorded staff provided the resident CIB supplement at breakfast, because the resident continued to refuse the prescribed supplement. The note recorded the resident spent most of the day in bed, and came out to dining room for lunch and supper. The 01/23/18 weight change note recorded the resident lost 25.6 lbs (18.3%) in 180 days. The note recorded the resident recently started on [MEDICATION NAME] for appetite stimulant and received magic cup milk shake (increased calorie supplement) with all meals. The 02/08/18 nutrition assessment recorded the resident weighed 112 lbs, had significant weight loss, and continued to lose weight while on scheduled [MEDICATION NAME] medication. The assessment recorded the resident continued to sleep through breakfast and the Registered Dietician recommended magic cups (increased calorie supplement) with meals and restart 2 Cal supplement with chocolate syrup added. The 30 day (01/14/18 to 02/12/18) meal intake record documented the following information: refused meals - 11 times consumed 0-25% - 24 times consumed 25-50% - 4 times consumed 50-75% - 12 times consumed 75-100% - 28 times The 30 day (01/14/18 to 02/12/18) snack intake record lacked documentation the staff provided snacks to the resident. Review of the resident's medical record lacked evidence of documentation staff monitored the resident's supplement intake. The resident's medical record also lacked documentation staff offered the resident food preferences for meals or snacks. On 02/12/18 at 11:27 AM, observation revealed the resident walked independently with a walker and 1 staff assistance to the dining room. Continued observation revealed staff served the magic cup supplement with the meal, the resident ate and drank independently, and consumed approximately 50% of the supplement and 75% of the meal. On 02/12/18 at 3:08 PM, observation revealed staff in the hall passing snacks to the residents in their rooms. Continued observation revealed the resident resting in bed, and staff passed by the resident's room without offering the resident a snack. On 02/12/18 at 2:10 PM, Nurse H stated the resident had a recent weight loss and received supplements for added calories. Nurse H stated the facility had no system to monitor the resident's supplement intake and the resident refused supplements at times. Nurse H stated the resident frequently did not eat breakfast and refused snacks. On 02/12/18 at 3:10 PM, Nurse Aide O stated the resident slept until late in the morning and frequently refused any food or drinks for breakfast. Nurse Aide O stated staff do not offer the resident snacks because the resident consistently refused snacks or to eat any food in his/her room. On 02/12/18 at 4:01 PM, Nurse Aide N stated the resident spent most of the day in bed and usually only came out for lunch and supper. Nurse Aide N stated the (CNA) Certified Nurse Aide recorded the resident's meal and snack intake on the computer, but the resident always refused snacks. Nurse Aide N was not aware if staff offered the resident food preferences for snacks. On 02/13/18 at 8:21 AM, Nurse Aide M stated the resident had a history of [REDACTED]. On 02/13/18 at 9:30 AM, Nurse G stated the resident had a recent significant weight loss and a history of mental problems related to nutrition. Nurse G stated staff tried several different nutritional supplements to prevent the resident's weight loss, and the facility had no system to monitor the resident's supplement intake. Nurse G stated the resident refused his/her nutritional supplements at times, and frequently refused breakfast and snacks. Nurse G stated he/she was not aware, if staff offered the resident food or snack preferences. On 02/13/18 at 1:28 PM, Administrative Nurse D stated the resident had mental problems related to nutrition and a recent significant weight loss. Administrative Nurse D stated staff tried multiple nutritional supplements to prevent the resident's weight loss and the facility had no system to monitor the resident's supplement intake. Administrative Nurse D stated the resident refused meals (usually breakfast) and supplements at times and consistently did not participate the facility's snack program. On 02/15/18 at 3:10 PM, Registered Dietician GG stated staff had not informed him/her the facility had no system to monitor the resident's nutritional supplement intake. Registered Dietician GG stated he/she was not aware the resident frequently refused breakfast, nutritional supplements and snacks. The facility's Nutritional Policy, dated 03/09/15, directed staff to provide nutritional supplements to the residents to prevent weight loss, and to document the supplement intake on the (MAR) Medication Administration Record. The policy also directed staff to offer the residents with weight loss between meal and bedtime snacks and record the intake per facility protocol. The facility failed to offer a snack program, monitor supplement intake, and seek physician involvement when the resident refused physician ordered supplements, for Resident #14, who had a severe weight loss of 30.2 lbs. in 6 months.

¿The facility identified a census of 26 residents with 3 residents sampled. Based on observation, interview, and record review, the facility failed to provide adequate supervision to protect (gender) residents from known incidents of resident-to-resident sexual abuse from resident (#1), which placed 18 (gender) residents in immediate jeopardy. Findings included: - Resident #1's readmission Minimum Data Set (MDS) assessment dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 14, which identified the resident with intact cognition and independent with all his/her activities of daily living. The cognitive Care Are assessment dated [DATE] documented the resident was alert, oriented, and had no confusion or disorientation. The quarterly MDS dated [DATE] recorded the resident with a BIMS score of (15), and independent with all his/her activities of daily living. The resident's behavior care plan dated 11/10/15, documented he/she sometimes exhibited sexually inappropriate behavior with inappropriate touching. The care plan directed staff to quietly attempt to re-direct the resident, reminding him/her that the behavior was not appropriate and to treat the resident with dignity and respect regardless of any behaviors. Interventions added to the care plan on 2/26/16 directed staff to remind the resident not to enter other resident's rooms, monitor the resident's interactions with other residents, consult with psychological services and the resident could interact with other residents in the common area. The care plan lacked evidence of the intervention 15-minute checks. A care conference meeting note dated, 2/25/16, recorded the resident was alert, oriented, had intact short- and long-term memory, and impaired decision-making skills. A previous care plan dated 3/19/13, discontinued on 6/10/13, directed the resident and (gender) residents were to be in common areas with staff present. The resident was not to be in (gender) resident's rooms alone. Nursing Note (NN) dated 2/12/15 at 9:18 P.M. documented the resident was alert and oriented to person, place and time. The resident was independent with all activities of daily living. Staff observed the resident putting his/her hands on direct care staff, and trying to hug them in inappropriate area. Staff directed the resident that unless there was a medical reason, then he/she was not to touch the staff. NN dated 2/13/16 at 8:58 P.M., recorded staff observed resident behaviors of inappropriate physical contact with staff, grabbing arms, and trying to hug staff member from the back. NN dated 2/24/16 timed 5:30 P.M., documented a physician order [REDACTED]. The facility reported investigation documented on 2/24/16 at approximately 5:40 P.M., direct care staff O reported an allegation from resident #2, that resident #1 came into his/her room, sat on the bed, pulled down his/her gown and patted him/her on the chest area. The investigation recorded administrative nursing staff D assessed resident #2 without an injury and reminded the resident to use the call light if anyone entered his/her room. Nursing staff implemented 15-minute checks on the resident #1 and his/her location and he/she was not to enter any (gender) resident's rooms until further notice. NN dated 2/24/16 at 9:47 P.M., documented staff continued 15-minute visual checks on the resident. NN dated 2/25/16 at 8:10 A.M. documented the physician ordered an antibiotic for the resident's urinary tract infection. Observation on 3/1/16 at 8:10 A.M. revealed a cut-through passage between halls 1 and 2, which allowed individuals to walk unobserved between halls, without going around the nursing office or centralized medication cart storage. Observation on 3/1/16 at 8:20 A.M. revealed the resident lay in bed watching television. The resident reported he/she walked down to the dining room for breakfast and back and was independent with most daily chores. Observation on 3/1/16 at 11:48 A.M., the resident finished eating lunch and walked independently down the hallway to his/her room as nursing staff observed from the medication carts. Review of the facility provided 15-minute check sheet, started 2/24/16 at 6:00 P.M. continued with documentation each quarter hour of the resident's location and staff initials. On 3/1/16 at 8:10 A.M. resident #2 reported resident #1 came into his/her room, sat on the bed and pulled down his/her night gown on the left side. Resident #2 pulled up the nightgown and then resident #1 pulled it down again and massaged his/her left chest. Resident #2 reported now the other resident was not allowed on this hall or in resident #2's room. Resident #2 reported the staff kept his/her curtain partially closed and the other resident was not to be near his/her door, but you don't know . On 3/1/16 at 9:00 A.M., administrative staff A reported staff placed the resident on 15-minute checks after the reported resident-to-resident event on 2/24/16. Administrative staff D revealed the resident attempted to touch or kiss staff member's hands or touch staff member's legs. The resident was advised this was not appropriate behavior. Administrative staff A was not aware of any inappropriate events in the past. On 3/1/16 at 11:30 A.M., direct care staff P reported staff observed and documented the location of the resident every 15 minutes and all staff watched for the location of the resident. On 3/1/16 at 11:45 A.M. administrative licensed staff D revealed the staff reported resident #2's allegation a (gender) came into his/her room and touched him/her on the chest. The resident reported sometimes resident #1 held or patted his/her hand in the dining room. Staff placed resident #1 on 15-minute checks to monitor his/her whereabouts and the resident resided on different hallways. On 3/1/16 at 12:10 P.M. licensed nursing staff G revealed during a conversation with resident #2 on 2/24/16, the resident was upset and reported another resident sat on the edge of his/her bed and pulled down his/her gown, twice, and began to rub his/her chest. Licensed nursing staff G reported he/she had seen the resident walking in the hall arm and arm once with an unsampled (gender) resident. During an interview on 3/1/16 at 12:20 P.M., direct care staff O revealed he/she entered resident #2's room on 2/24/16 at approximately 5:20 P.M. to give the resident his/her medications. (According to the quarterly MDS dated [DATE], documented resident #2 with a BIMS score of (7), which indicated severe cognitive impairment and required extensive assistance from staff for all activities of daily living.) Resident #2 reported that (gender) resident came into his/her room and pulled down the front of his/her night gown (twice) and massaged him/her here (and pointed to the chest area). The resident reported the incident happened approximately 20 minutes before. Direct care staff O continued that he/she spoke with resident #1, who confirmed he/she had gone into a (gender) resident's room earlier in the day. Resident #1 denied touching resident #2's chest area, and stated he/she would not do that. Direct care staff O reminded it was not appropriate for resident #1 to go into other (gender) resident rooms and he/she could visit with residents in the common areas. Direct care staff O reported on 2/24/16, he/she saw the resident at approximately 5:00 P.M. leaving the dining room. Direct care staff O reported the administrative nursing staff D initiated 15-minute checks, and staff passed on the information with peer-to-peer report. The direct care staff worksheet documented the 15-minute checks. On 3/1/16 at 1:30 P.M., licensed nursing staff H reported staff observed and documented 15-minute checks on the resident and his/her whereabouts and to redirect from the hall where resident #2 lived. On 3/1/16 at 12:55 P.M. social services staff X reported a process was in place to get the resident a mental health appointment. The resident had a common behavior of holding hands with (gender) residents. On 3/1/16 at 1:00 P.M., administrative nursing staff E reported the physician ordered an antibiotic for the resident's urinary tract infection, which could have caused his/her behavior. In an interview on 3/2/16 at 11:19 A.M. direct care staff N revealed he/she saw resident #1 walk out of resident #2's room, on 2/24/16 between 4:30 P.M. and 5:00 P.M. Approximately 10 minutes later resident #2 reported a (gender) came into his/her room, pulled down his/her gown and started messing with his/her left chest. Direct care staff N asked if it was resident #1, as this was the resident observed coming out of resident #2's room. Resident #2 reported, yes. The facility provided policy Protection from Abuse dated 2/26/15 recorded all residents in the Living Center was free from sexual abuse according to the outline in the nursing home abuse prevention plan. The social services staff ensured that all involved resident parties were protected from further abuse, trauma due to injury, and investigational retaliation. The facility provided policy Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation dated 2/12/16 documented, the executive director and director of nursing services identified, intervened, and corrected situation in which abuse, neglect or misappropriation for resident property was more likely to occur. For resident protection, the director of nursing or his/her designee removed a resident suspected of being the subject of an alleged violation to an environment where the resident's safety was protected. If the suspected perpetrator was another resident, the director of nursing or designee separated the residents so they do not have access to each other until the circumstances of the alleged incident were determined. During the investigation, the medical record was reviewed to determine the resident's past history, condition, and its relevance to the alleged violation. The center made reasonable efforts to determine the cause of the alleged violation and took corrective action consistent with the investigation findings and to eliminate any ongoing changes to the resident. The director of nursing or designee initiated a care plan to reflect the resident's condition and measures taken to prevent recurrence, where appropriate. The facility takes appropriate to prevent recurrence of the incident. The facility failed to protect the residents in the facility from resident #1's unwanted sexual advances, identified with a past history of sexual advances when the staff failed to provide adequate supervision to protect the (gender) residents in the facility from unwelcome sexual advances on 2/24/16, with resident #2, a cognitively impaired dependent resident, which placed the (gender) residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on March 3, 2016 at 4:30 P.M. when: 1) The facility immediately stationed a staff member to observe the resident one-on-one, 24-hours per day, in place on 3/1/16 at 2:05 P.M. 2) The facility identified all (gender) residents had the potential to be affected. 3) The facility provided education to all staff on duty on 3/1/16 and additional staff would be in-serviced before they were allowed to work. Education included: a review of the policy on Abuse, Neglect, and Exploitation of residents, the process to report to the charge nurse and director of nursing services (DNS) and executive director all allegations immediately, and the process used for the investigation and how to immediately protect residents. 4) The facility will monitor the resident continually while he/she was in the facility. 5) The social services visits daily with the (gender) residents to check for any concerns. 6) The interdisciplinary team will review actions daily in stand up and in QAPI (quality assurance performance improvement) meeting. The deficient practice remained at the scope and severity of an E.

¿The facility identified a census of 26 residents with 3 residents sampled. Based on observation, interview, and record review, the facility failed to keep resident #2 free from resident-to-resident sexual abuse from resident (#1). Findings included: - Resident #1's readmission Minimum Data Set (MDS) assessment dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 14, which identified the resident with intact cognition and independent with all his/her activities of daily living. The cognitive Care Are assessment dated [DATE] documented the resident was alert, oriented, and had no confusion or disorientation. The quarterly MDS dated [DATE] recorded the resident with a BIMS score of (15), and independent with all his/her activities of daily living. The resident's behavior care plan dated 11/10/15, documented he/she sometimes exhibited sexually inappropriate behavior with inappropriate touching. The care plan directed staff to quietly attempt to re-direct the resident, reminding him/her that the behavior was not appropriate and to treat the resident with dignity and respect regardless of any behaviors. Interventions added to the care plan on 2/26/16 directed staff to remind the resident not to enter other resident's rooms, monitor the resident's interactions with other residents, consult with psychological services and the resident could interact with other residents in the common area. The care plan lacked evidence of the intervention 15-minute checks. A care conference meeting note dated, 2/25/16, recorded the resident was alert, oriented, had intact short- and long-term memory, and impaired decision-making skills. A previous care plan dated 3/19/13, discontinued on 6/10/13, directed the resident and (gender) residents were to be in common areas with staff present. The resident was not to be in (gender) resident's rooms alone. NN (Nursing Note) dated 2/12/16 at 9:18 P.M. documented the resident was alert and oriented to person, place and time. The resident was independent with all activities of daily living. Staff observed the resident putting his/her hands on direct care staff, and trying to hug them in inappropriate area. Staff directed the resident that unless there was a medical reason, then he/she was not to touch the staff. NN dated 2/13/16 at 8:58 P.M., recorded staff observed resident behaviors of inappropriate physical contact with staff, grabbing arms, and trying to hug staff member from the back. NN dated 2/24/16 timed 5:30 P.M., documented a physician order [REDACTED]. The facility reported investigation documented on 2/24/16 at approximately. 5:40 P.M., direct care staff O reported an allegation from resident #2, that resident #1 came into his/her room, sat on the bed, pulled down his/her gown and patted him/her on the chest area. The investigation recorded administrative nursing staff D assessed resident #2 without an injury and reminded the resident to use the call light if anyone entered his/her room. Nursing staff implemented 15-minute checks on the resident #1 and his/her location and he/she was not to enter any resident's room until further notice. NN dated 2/24/16 at 9:47 P.M., documented staff continued 15-minute visual checks on the resident. NN dated 2/25/16 at 8:10 A.M. documented the physician ordered an antibiotic for the resident's urinary tract infection. NN dated 2/29/16 at 10:49 P.M., recorded staff continued 15-minute checks, notified the state agency and local police department, and social services initiated the process of obtaining a psychological referral for the resident #1. Observation on 3/1/16 at 8:10 A.M. revealed a cut-through passage between halls 1 and 2, which allowed individuals to walk unobserved between halls, without going around the nursing office or centralized medication cart storage. Observation on 3/1/16 at 8:20 A.M. revealed the resident lay in bed watching television. The resident reported he/she walked down to the dining room for breakfast and back and was independent with most daily chores. Observation on 3/1/16 at 11:48 A.M., the resident finished eating lunch and walked independently down the hallway to his/her room as nursing staff observed from the medication carts. Review of the facility provided 15-minute check sheet, started 2/24/16 at 6:00 P.M. continued with documentation each quarter hour of the resident's location and staff initials. On 3/1/16 at 8:10 A.M. resident #2 reported resident #1 came into his/her room, sat on the bed and pulled down his/her night gown on the left side. Resident #2 pulled up the nightgown and then resident #1 pulled it down again and massaged his/her left chest. Resident #2 reported now the other resident was not allowed on this hall or in resident #2's room. Resident #2 reported the staff kept his/her curtain partially closed and the other resident was not to be near his/her door, but you don't know . On 3/1/16 at 9:00 A.M., administrative staff A reported staff placed the resident on 15-minute checks after the reported resident-to-resident event on 2/24/16. Administrative staff D revealed the resident attempted to touch or kiss staff member's hands or touch staff member's legs. The resident was advised this was not appropriate behavior. Administrative staff A was not aware of any inappropriate events in the past. On 3/1/16 at 11:30 A.M., direct care staff P reported staff observed and documented the location of the resident every 15 minutes and all staff watched for the location of the resident. On 3/1/16 at 11:45 A.M. administrative licensed staff D revealed the staff reported resident #2's allegation a (gender) came into his/her room and touched him/her on the chest. The resident reported sometimes resident #1 held or patted his/her hand in the dining room. Staff placed resident #1 on 15-minute checks to monitor his/her whereabouts and the resident resided on different hallways. On 3/1/16 at 12:10 P.M. licensed nursing staff G revealed during a conversation with resident #2 on 2/24/16, the resident was upset and reported another resident sat on the edge of his/her bed and pulled down his/her gown, twice, and began to rub his/her chest. Licensed nursing staff G reported he/she had seen the resident walking in the hall arm and arm once with an unsampled (gender) resident. During an interview on 3/1/16 at 12:20 P.M., direct care staff O revealed he/she entered resident #2's room on 2/24/16 at approximately 5:20 P.M. to give the resident his/her medications. (According to the quarterly MDS dated [DATE], documented resident #2 with a BIMS score of (7), which indicated severe cognitive impairment and required extensive assistance from staff for all activities of daily living.) Resident #2 reported that (gender) resident came into his/her room and pulled down the front of his/her night gown (twice) and massaged him/her here (and pointed to the chest area). The resident reported the incident happened approximately 20 minutes before. Direct care staff O continued that he/she spoke with resident #1, who confirmed he/she had gone into a (gender) resident's room earlier in the day. Resident #1 denied touching resident #2's chest area, and stated he/she would not do that. Direct care staff O reminded it was not appropriate for resident #1 to go into other (gender) resident rooms and he/she could visit with residents in the common areas. Direct care staff O reported on 2/24/16, he/she saw the resident at approximately 5:00 P.M. leaving the dining room. Direct care staff O reported the administrative nursing staff D initiated 15-minute checks, and staff passed on the information with peer-to-peer report. The direct care staff worksheet documented the 15-minute checks. On 3/1/16 at 1:30 P.M., licensed nursing staff H reported staff observed and documented 15-minute checks on the resident and his/her whereabouts and to redirect from the hall where resident #2 lived. On 3/1/16 at 12:55 P.M. social services staff X reported a process was in place to get the resident a mental health appointment. The resident had a common behavior of holding hands with (gender) residents. On 3/1/16 at 1:00 P.M., administrative nursing staff E reported the physician ordered an antibiotic for the resident's (#1) urinary tract infection, which could have caused his/her behavior. In an interview on 3/2/16 at 11:19 A.M. direct care staff N revealed he/she saw resident #1 walk out of resident #2's room, on 2/24/16 between 4:30 P.M. and 5:00 P.M. Approximately 10 minutes later resident #2 reported a (gender) came into his/her room, pulled down his/her gown and started messing with his/her left chest. Direct care staff N asked if it was resident #1, as this was the resident observed coming out of resident #2's room. Resident #2 reported, yes. The facility provided policy Protection from Abuse dated 2/26/15 recorded all residents in the Living Center was free from sexual abuse according to the outline in the nursing home abuse prevention plan. The social services staff ensured that all involved resident parties were protected from further abuse, trauma due to injury, and investigational retaliation. The facility provided policy Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation dated 2/12/16 documented, the executive director and director of nursing services identified, intervened, and corrected situation in which abuse, neglect or misappropriation for resident property was more likely to occur. For resident protection, the director of nursing or his/her designee removed a resident suspected of being the subject of an alleged violation to an environment where the resident's safety was protected. If the suspected perpetrator was another resident, the director of nursing or designee separated the residents so they do not have access to each other until the circumstances of the alleged incident were determined. During the investigation, the medical record was reviewed to determine the resident's past history, condition, and its relevance to the alleged violation. The center made reasonable efforts to determine the cause of the alleged violation and took corrective action consistent with the investigation findings and to eliminate any ongoing changes to the resident. The director of nursing or designee initiated a care plan to reflect the resident's condition and measures taken to prevent recurrence, where appropriate. The facility takes appropriate to prevent recurrence of the incident. The facility failed to keep resident #2, a cognitively impaired dependent resident, free from resident #1's avoidable unwanted sexual advances.

The facility had a census of 26 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to provide social services for 1 of 15 sampled residents (#19) who lost a family member. - Findings included: Resident #19's medical record indicated [DIAGNOSES REDACTED]. On 8/26/10 at 10:00 AM, observation revealed the resident tearful over the loss of their spouse. Further observation revealed the resident expressed wanting to be with their husband. On 8/26/10 at 2:35 PM, observation revealed the resident seated in a chair in the lobby. Further observation revealed the resident became tearful and expressed loss of their spouse and trying to be happy again. On 8/26/10 at 2:50 PM, observation revealed a nurse aide approached the resident and invited them to Bingo and the resident declined. On 8/30/10 at 8:01 AM, observation revealed the resident seated at the dining room table. Further observation revealed the resident became tearful as the Surveyor greeted the resident and they talked about the day. Further observation of the resident revealed the resident quickly replaced the tearfulness with a stern look. On 8/31/10 at 11:15 AM, observation revealed the resident seated at the dining room table with a splint in place on their right hand. Further observation revealed the resident denied any discomfort with the splint and with discussion of the splint helping the resident, the resident became tearful and unable to verbally express their self. The admission (MDS) Minimum Data Set assessment 2.0, dated 12/29/09, indicated the resident had short term memory loss and modified independence with decision making skills. The MDS indicated the resident had moods and behaviors that included negative statements, self deprecation, crying and tearfulness. The MDS indicated the resident required limited to extensive assistance of 1 staff with their activities of daily living. The MDS indicated the resident did not receive an antianxiety or antidepressant medication. The Resident Assessment Protocol (RAPs), dated 12/29/09, for the resident's psychosocial well-being indicated the resident exhibited moods such as tearfulness and crying and the moods were easily altered through 1:1 interaction with the staff and family. The RAPs further indicated the resident did not receive an antianxiety or antidepressant medication. The quarterly MDS, dated [DATE], indicated the resident had short term memory loss and moderately impaired decision making skills. The MDS inidicated the resident had mood/behaviors that included crying, tearfulness and repetitive physical movement. The 6/7/10 (no time), nurse's notes indicated the resident weepy and tearful related to their concern for their husband in the hospital. The nurse's notes indicated the staff contacted the physician related to the resident's anxiety status. The 6/9/10 at 4:05 AM, nurse's notes indicated the resident mourning the loss of their husband this AM. The nurse's note indicated the resident cried often and stated "I want to be with my husband". The nurse's notes indicated the staff followed up with the physician and received an order for [REDACTED]. The 6/8/10 care plan directed the staff to allow and encourage the resident to verbalize their fears and concerns. The care plan further directed the staff to monitor the resident for crying, verbalizations of sadness or frustration, decreased participation in activities and decreased appetite. The care plan directed the staff to contact the resident's family for increased visits when the resident expressed sadness or loneliness. The care plan directed the staff to encourage the resident to leave their room for activities of their choice. The care plan indicated the resident exhibited tearfulness related to their grieving process over the death of their spouse. The care plan directed the staff to give the resident time to express their feelings, provide 1:1 as needed and administer Xanax (an anxiety medication) 0.25 milligrams every 6 hours as needed for anxiety. The 4/11/10 social service note indicated they spoke to the resident in regards to their crying on several occasions. The social service notes indicated during the visit, while outside the building, the resident appeared to be happy then displayed a moment of crying. Further review of the social service note did not indicate interventions for the resident's crying. Review of the resident's record revealed no further social service notes from 4/11/10 to 8/9/10, including during the time of the resident's loss of their spouse on 6/9/10. The 8/9/10 social service note indicated the resident still not over the loss of their husband. The social service note indicated the resident crying and unhappy. The end of the social service noted indicated the resident's needs were met. On 8/31/10 at 9:00 AM, interview with the resident revealed the resident voiced difficulty with the loss of their husband and agreed social worker visits would help them. On 8/31/10 at 10:00 AM, Nurse S verified the facility social service designee did not provide needed support to the resident during the loss of their spouse as care planned. The facility failed to support resident #19's individual needs during the grieving process.